Armenia - Demographic and Health Survey - 2017

Publication date: 2017

Armenia Demographic and Health Survey 2015-16 A rm enia 2015-16 D em ographic and H ealth S urvey Armenia Demographic and Health Survey 2015-16 National Statistical Service Yerevan, Armenia Ministry of Health Yerevan, Armenia The DHS Program ICF Rockville, Maryland USA August 2017 The 2015-16 Armenia Demographic and Health Survey (2015-16 ADHS) was implemented by the National Statistical Service and the Ministry of Health from December 8, 2015, to April 5, 2016. The funding for the ADHS was provided by the United States Agency for International Development (USAID), the United Nations Population Fund (UNFPA), the Joint United Nations Programme on HIV/AIDS (UNAIDS), and the United Nations Children’s Fund (UNICEF). ICF provided technical assistance through The DHS Program, a USAID- funded project providing support and technical assistance in the implementation of population and health surveys in countries worldwide. Additional information about the 2015-16 ADHS may be obtained from the National Statistical Service of the Republic of Armenia, Republic Avenue, 3 Government House, 0010, Yerevan, Republic of Armenia; Telephone: 374-11-524-213; Fax: 374-11-521-921; E-mail: info@armstat.am; Internet: http://www.armstat.am. 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; E-mail: info@DHSprogram.com; Internet: www.DHSprogram.com. Recommended citation: National Statistical Service [Armenia], Ministry of Health [Armenia], and ICF. 2017. Armenia Demographic and Health Survey 2015-16. Rockville, Maryland, USA: National Statistical Service, Ministry of Health, and ICF. Contents • iii CONTENTS TABLES AND FIGURES . ix PREFACE . xv ACKNOWLEDGEMENTS . xvii MILLENNIUM DEVELOPMENT GOAL INDICATORS . xix SUSTAINABLE DEVELOPMENT GOAL INDICATORS . xxi MAP OF ARMENIA . xxii 1 INTRODUCTION AND SURVEY METHODOLOGY . 1 1.1 Geography and Population . 1 1.1.1 Geography . 1 1.1.2 Population . 1 1.2 Systems for Collecting Demographic and Health Data . 2 1.3 Health Care System Updates in Armenia . 2 1.4 Objectives and Organization of the Survey . 4 1.5 Sample Design and Implementation . 5 1.6 Questionnaires . 5 1.7 Anthropometry and Anemia Testing . 6 1.8 Pretest . 7 1.9 Training of Field Staff . 8 1.10 Fieldwork and Data Processing . 8 1.11 Response Rates . 9 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION . 11 2.1 Housing Characteristics . 12 2.1.1 Drinking Water . 12 2.1.2 Sanitation Facility . 14 2.1.3 Household Characteristics . 15 2.2 Secondhand Smoke Exposure . 15 2.3 Household Possessions . 16 2.4 Wealth Quintiles . 16 2.5 Hand Washing . 17 2.6 Household Population by Age and Sex . 18 2.7 Household Size and Composition . 20 2.8 Children’s Living Arrangements and Orphanhood . 20 2.9 Educational Attainment of Household Members. 21 2.10 Child Protection . 25 2.10.1 Birth Registration . 26 2.10.2 Child Discipline . 26 2.11 Poverty Benefits . 29 3 BACKGROUND CHARACTERISTICS OF RESPONDENTS . 31 3.1 Background Characteristics of Respondents . 31 3.2 Educational Attainment of Respondents . 32 3.3 Exposure to Mass Media and Internet . 34 3.3.1 Mass Media . 35 3.3.2 Internet Usage . 36 3.4 Employment . 38 iv • Contents 3.5 Occupation . 41 3.6 Women’s Employment Characteristics . 44 3.7 Employment Abroad . 45 4 MARRIAGE AND SEXUAL ACTIVITY . 47 4.1 Marital Status . 47 4.2 Age at First Marriage and Sexual Intercourse . 48 4.2 Age at First Sexual Intercourse . 50 4.3 Recent Sexual Activity . 51 5 FERTILITY . 55 5.1 Current Fertility . 55 5.2 Fertility Differentials by Background Characteristics . 56 5.3 Fertility Trends . 57 5.3.1 Retrospective Data . 57 5.3.2 Comparison with Prior ADHS Surveys . 58 5.4 Children Ever Born and Living . 58 5.5 Birth Intervals . 59 5.6 Postpartum Amenorrhea, Abstinence, and Insusceptibility . 61 5.7 Menopause . 61 5.8 Age at First Birth . 62 5.9 Teenage Pregnancy and Motherhood . 63 6 FERTILITY PREFERENCES . 65 6.1 Fertility Preferences . 65 6.2 Ideal Number of Children . 68 6.3 Fertility Planning . 70 6.4 Wanted and Unwanted Fertility . 71 7 CONTRACEPTION . 73 7.1 Knowledge of Contraceptive Methods . 73 7.2 Current Use of Contraception . 75 7.3 Current Use by Background Characteristics . 76 7.4 Source of Family Planning . 78 7.5 Informed Choice . 79 7.6 Discontinuation within 12 Months of Use . 80 7.7 Knowledge of the Fertile Period . 82 7.8 Need for Family Planning . 83 7.9 Future Use of Contraception . 86 7.10 Exposure to Family Planning Messages in the Mass Media . 87 7.11 Contact of Nonusers with Family Planning Providers . 89 7.12 Exposure to Reproductive Health Messages . 90 8. ABORTION . 91 8.1 Pregnancy Outcomes . 92 8.2 Lifetime Experience with Induced Abortion . 94 8.3 Rates of Induced Abortion . 95 8.4 Trends in Induced Abortion . 97 8.5 Use of Contraceptive Methods before Abortion . 98 8.6 Reasons for Abortion . 99 Contents • v 9 REPRODUCTIVE HEALTH . 101 9.1 Antenatal Care . 102 9.1.1 Antenatal Care Provider . 102 9.1.2 Number and Timing of ANC Visits . 103 9.1.3 Folate and Iron Supplements . 103 9.1.4 Antenatal Care Content . 104 9.1.5 Ultrasound Tests . 105 9.2 Assistance and Medical Care at Delivery . 106 9.2.1 Place of Delivery. 106 9.2.2 Assistance at Delivery . 107 9.2.3 Caesarian Deliveries . 107 9.2.4 Payment for Delivery . 109 9.3 Postnatal Care for the Mother . 111 9.3.1 Timing of Postnatal Checkups for the Mother . 111 9.3.2 Type of Provider of Postnatal Checkups for the Mother . 112 9.4 Postnatal Care for the Newborn . 112 9.4.1 Timing of Postnatal Care for Newborns . 112 9.4.2 Type of Provider of Postnatal Care for Newborns . 114 9.4.3 Content of Postnatal Care for Newborns . 114 9.5 Problems in Accessing Health Care . 115 9.6 Travel to Nearest Health Clinic . 117 10 HEALTH INSURANCE, USE OF TOBACCO, KNOWLEDGE AND ATTITUDES ABOUT TUBERCULOSIS . 119 10.1 Health Insurance . 119 10.2 Use of Tobacco . 122 10.3 Tuberculosis . 124 10.3.1 Knowledge and Attitudes about Tuberculosis . 124 10.3.2 Knowledge of Tuberculosis Symptoms . 128 10.3.3 Knowledge of Organs Affected by Tuberculosis . 131 10.3.4 Misconceptions about How Tuberculosis is Spread . 132 11 CHILD HEALTH . 135 11.1 Child’s Weight and Size at Birth . 135 11.2 Vaccination Coverage. 137 11.3 Trends in Vaccination Coverage . 141 11.4 Acute Respiratory Infection . 142 11.5 Fever . 142 11.6 Diarrhea . 143 11.7 Knowledge of ORS Packets . 146 11.8 Disposal of Children’s Stools . 146 11.9 Childhood Mortality . 147 12 NUTRITION . 149 12.1 Nutritional Status of Children . 150 12.1.1 Measurement of Nutritional Status among Young Children . 150 12.1.2 Levels of Child Malnutrition . 151 12.1.3 Trends in Children’s Nutritional Status . 156 12.2 Breastfeeding and Supplementation . 157 12.2.1 Initiation of Breastfeeding . 157 12.2.2 Breastfeeding Status by Age . 159 12.2.3 Duration of Breastfeeding . 161 12.2.4 Types of Complementary Foods . 161 vi • Contents 12.3 Infant and Young Child Feeding (IYCF) Practices . 163 12.4 Household Iodized Salt Consumption . 166 12.5 Micronutrient Intake in Children . 167 12.6 Nutritional Status of Women . 169 12.7 Micronutrient Intake among Mothers . 171 12.8 Anemia . 173 12.8.1 Anemia Prevalence in Women . 174 12.8.2 Anemia Prevalence in Children . 176 12.8.3 Knowledge about Anemia . 178 13 HIV/AIDS AND SEXUALLY TRANSMITTED INFECTIONS . 189 13.1 Knowledge of HIV/AIDS and Methods of HIV Prevention . 190 13.2 Misconceptions about HIV Transmission and Comprehensive Knowledge of AIDS . 192 13.3 Knowledge of Prevention of Mother-to-Child Transmission of HIV . 193 13.4 Discriminatory Attitudes towards People Living with HIV . 194 13.5 Higher-Risk Sex . 196 13.5.1 Multiple Partners and Higher-Risk Sexual Intercourse. 196 13.5.2 Transactional Sex . 198 13.6 Coverage of Prior HIV Testing . 199 13.7 Self-Reported Sexually Transmitted Infections . 202 13.8 Prevalence of Medical Injections. 204 13.9 HIV/AIDS-Related Knowledge and Behavior among Youth . 206 13.9.1 HIV/AIDS-Related Knowledge among Young Adults . 206 13.9.2 Age at First Sex among Youth . 206 13.9.3 Abstinence and Premarital Sex . 208 13.9.4 Multiple Sexual Partners and Condom Use among Young People . 208 13.9.5 Recent HIV Tests among Youth . 209 14 DOMESTIC VIOLENCE . 211 14.1 Measurement of Violence . 211 14.1.1 Use of Valid Measures of Violence . 211 14.1.2 Ethical Considerations . 213 14.2 Experience of Physical Violence . 213 14.3 Experience of Sexual Violence . 215 14.4 Experience of Different Forms of Violence . 215 14.5 Violence during Pregnancy . 216 14.6 Marital Control by Spouse . 216 14.7 Forms of Spousal Violence . 218 14.8 Spousal Violence by Background Characteristics . 219 14.9 Violence by Spousal Characteristics and Women’s Empowerment Indicators . 221 14.10 Recent Spousal Violence by Any Husband . 222 14.11 Onset of Spousal Violence . 224 14.12 Physical Consequences of Spousal Violence . 224 14.13 Violence by Women against Their Husband . 225 14.14 Help-seeking Behavior by Women Who Experience Violence . 227 15 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES . 229 15.1 Employment and Cash Earnings . 230 15.2 Control Over Cash Earnings and Relative Magnitude of Women’s Earnings . 231 15.3 Ownership of Assets, Bank Accounts, and Mobile Phones . 234 15.4 Women’s Participation in Decision Making . 243 Contents • vii 15.5 Attitudes toward Wife Beating . 246 15.6 Attitudes toward and Ability to Negotiate Safer Sex with Husbands . 249 15.7 Indicators of Women’s Empowerment . 251 15.8 Contraceptive Use by Women’s Status . 252 REFERENCES . 255 APPENDIX A SAMPLE DESIGN . 259 A.1 Introduction . 259 A.2 Sample Frame . 259 A.3 Sample Design and Implementation . 261 A.4 Sample Probabilities and Sample Weights . 262 A.5 Survey Implementation. 263 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 267 APPENDIX C DATA QUALITY TABLES . 285 APPENDIX D PERSONS INVOLVED IN THE 2015-16 ARMENIA DEMOGRAPHIC AND HEALTH SURVEY . 291 APPENDIX E QUESTIONNAIRES . 295 Tables and Figures • ix TABLES AND FIGURES 1 INTRODUCTION AND SURVEY METHODOLOGY . 1 Table 1.1 Results of the household and individual interviews . 9 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION . 11 Table 2.1 Household drinking water . 13 Table 2.2 Availability of water . 13 Table 2.3 Household sanitation facilities . 14 Table 2.4 Household characteristics . 15 Table 2.5 Household possessions . 16 Table 2.6 Wealth quintiles . 17 Table 2.7 Hand washing . 18 Table 2.8 Household population by age, sex, and residence . 19 Table 2.9 Household composition . 20 Table 2.10 Children's living arrangements and orphanhood . 21 Table 2.11.1 Educational attainment of the female household population . 23 Table 2.11.2 Educational attainment of the male household population . 23 Table 2.12 School attendance ratios . 24 Table 2.13 Birth registration of children under age 5 . 26 Table 2.14 Child discipline . 28 Table 2.15 Poverty benefits . 29 Figure 2.1 Population pyramid . 19 Figure 2.2 Age-specific attendance rates in the de facto population age 5-24 . 25 3 BACKGROUND CHARACTERISTICS OF RESPONDENTS . 31 Table 3.1 Background characteristics of respondents . 32 Table 3.2.1 Educational attainment: Women . 33 Table 3.2.2 Educational attainment: Men . 34 Table 3.3.1 Exposure to mass media: Women . 35 Table 3.3.2 Exposure to mass media: Men . 36 Table 3.4.1 Internet usage: Women . 37 Table 3.4.2 Internet usage: Men. 38 Table 3.5.1 Employment status: Women . 39 Table 3.5.2 Employment status: Men . 40 Table 3.6.1 Occupation: Women . 42 Table 3.6.2 Occupation: Men . 43 Table 3.7 Type of employment . 44 Table 3.8 Respondent’s employment abroad . 45 Figure 3.1 Employment status . 41 4 MARRIAGE AND SEXUAL ACTIVITY . 47 Table 4.1 Current marital status . 48 Table 4.2 Age at first marriage . 49 Table 4.3 Median age at first marriage by background characteristics . 49 Table 4.4 Age at first sexual intercourse . 50 Table 4.5 Median age at first sexual intercourse by background characteristics . 51 Table 4.6.1 Recent sexual activity: Women. 52 Table 4.6.2 Recent sexual activity: Men . 53 x • Tables and Figures 5 FERTILITY . 55 Table 5.1 Current fertility . 56 Table 5.2 Fertility by background characteristics . 57 Table 5.3 Trends in age-specific fertility rates . 57 Table 5.4 Trends in fertility . 58 Table 5.5 Children ever born and living . 59 Table 5.6 Birth intervals . 60 Table 5.7 Postpartum amenorrhea, abstinence and insusceptibility . 61 Table 5.8 Menopause . 61 Table 5.9 Age at first birth . 62 Table 5.10 Median age at first birth . 62 Table 5.11 Teenage pregnancy and motherhood . 63 Figure 5.1 Trends in age-specific fertility rates . 58 6 FERTILITY PREFERENCES . 65 Table 6.1 Fertility preferences according to number of living children . 66 Table 6.2.1 Desire to limit childbearing: Women . 67 Table 6.2.2 Desire to limit childbearing: Men . 67 Table 6.3 Ideal number of children according to number of living children . 69 Table 6.4 Mean ideal number of children according to background characteristics . 70 Table 6.5 Fertility planning status . 71 Table 6.6 Wanted fertility rates . 71 Figure 6.1 Trends in fertility desires among married women . 68 7 CONTRACEPTION . 73 Table 7.1 Knowledge of contraceptive methods . 74 Table 7.2 Current use of contraception according to age . 75 Table 7.3 Current use of contraception according to background characteristics . 76 Table 7.4 Trends in the current use of contraception . 77 Table 7.5 Source of modern contraception methods . 79 Table 7.6 Informed choice . 80 Table 7.7 Twelve-month contraceptive discontinuation rates . 81 Table 7.8 Reasons for discontinuation . 82 Table 7.9 Knowledge of fertile period . 82 Table 7.10 Need and demand for family planning among currently married women . 85 Table 7.11 Future use of contraception . 86 Table 7.12.1 Exposure to family planning messages: Women . 87 Table 7.12.2 Exposure to family planning messages: Men. 88 Table 7.13 Contact of nonusers with family planning providers . 89 Table 7.14 Exposure to reproductive health messages . 90 Figure 7.1 Trends in contraceptive use among currently married women . 78 Figure 7.2 Trends in unmet need for family planning . 86 8. ABORTION . 91 Table 8.1 Pregnancy outcome by background characteristics . 92 Table 8.2 Lifetime experience with induced abortion. 94 Table 8.3 Induced abortion rates . 95 Table 8.4 Induced abortion rates by background characteristics . 96 Table 8.5 Trends in age-specific abortion rates . 98 Table 8.6 Use of contraception before pregnancy. 98 Table 8.7 Reason for abortion . 99 Figure 8.1 Trends in induced abortion by urban-rural residence, Armenia 2000-2016 . 93 Figure 8.2 Age-specific fertility rates and abortion rates, 2015-16 . 96 Tables and Figures • xi Figure 8.3 Trends in age-specific abortion rates, 2000-2016 . 97 9 REPRODUCTIVE HEALTH . 101 Table 9.1 Antenatal care . 102 Table 9.2 Number of antenatal care visits and timing of first visit . 103 Table 9.3 Components of antenatal care . 104 Table 9.4 Ultrasound testing during antenatal care . 105 Table 9.5 Place of delivery . 106 Table 9.6 Assistance during delivery . 107 Table 9.7 Caesarean section . 108 Table 9.8 Access to free delivery services . 110 Table 9.9 Payment for delivery of the last birth . 110 Table 9.10 Timing of first postnatal checkup for the mother . 111 Table 9.11 Timing of first postnatal checkup for the newborn . 113 Table 9.12 Type of provider of first postnatal checkup for the newborn . 114 Table 9.13 Content of postnatal care for newborns . 115 Table 9.14 Problems in accessing health care . 116 Table 9.15 Travel to the nearest clinic . 117 Figure 9.1 Mother’s duration of stay in the health facility after giving birth . 109 Figure 9.2 Type of provider of postnatal care for the mother . 112 10 HEALTH INSURANCE, USE OF TOBACCO, KNOWLEDGE AND ATTITUDES ABOUT TUBERCULOSIS . 119 Table 10.1.1 Health insurance coverage: Women . 120 Table 10.1.2 Health insurance coverage: Men . 121 Table 10.2.1 Use of tobacco: Women . 122 Table 10.2.2 Use of tobacco: Men . 123 Table 10.3 Average number of cigarettes smoked daily: Men . 124 Table 10.4.1 Knowledge and attitudes concerning tuberculosis: Women . 126 Table 10.4.2 Knowledge and attitudes concerning tuberculosis: Men. 127 Table 10.5.1 Knowledge of symptoms of tuberculosis: Women . 129 Table 10.5.2 Knowledge of symptoms of tuberculosis: Men . 130 Table 10.6.1 Knowledge about organs that can be affected by tuberculosis: Women . 131 Table 10.6.2 Knowledge about organs that can be affected by tuberculosis: Men . 132 Table 10.7.1 Misconceptions about tuberculosis transmission: Women . 133 Table 10.7.2 Misconceptions about tuberculosis transmission: Men . 134 Figure 10.1 Knowledge of tuberculosis . 125 11 CHILD HEALTH . 135 Table 11.1 Child's size and weight at birth . 136 Table 11.2 Vaccinations by source of information . 138 Table 11.3 Vaccinations by background characteristics . 140 Table 11.4 Prevalence and treatment of symptoms of ARI . 142 Table 11.5 Prevalence and treatment of fever . 143 Table 11.6 Prevalence of diarrhea . 144 Table 11.7 Feeding practices during diarrhea . 144 Table 11.8 Diarrhea treatment . 145 Table 11.9 Knowledge of ORS packets . 146 Table 11.10 Disposal of children's stools. 147 Figure 11.1 Trends in vaccination coverage among children 18-29 months . 141 xii • Tables and Figures 12 NUTRITION . 149 Table 12.1 Nutritional status of children . 153 Table 12.2 Initial breastfeeding . 158 Table 12.3 Breastfeeding status according to age . 159 Table 12.4 Median duration of breastfeeding . 161 Table 12.5 Foods and liquids consumed by children in the day or night preceding the interview . 162 Table 12.6 Infant and young child feeding (IYCF) practices . 164 Table 12.7 Presence of iodized salt in household . 167 Table 12.8 Micronutrient intake among children . 168 Table 12.9 Nutritional status of women . 170 Table 12.10 Micronutrient intake among mothers . 172 Table 12.11 Folate or multivitamins intake among mothers . 173 Table 12.12 Prevalence of anemia in women . 175 Table 12.13 Prevalence of anemia in children . 177 Table 12.14 Knowledge of anemia . 179 Table 12.15.1 Knowledge of symptoms of anemia: Women . 181 Table 12.15.2 Knowledge of symptoms of anemia: Men . 182 Table 12.16.1 Knowledge about what may cause anemia: Women . 183 Table 12.16.2 Knowledge about what may cause anemia: Men . 184 Table 12.17.1 What person can eat or drink to prevent anemia: Women . 185 Table 12.17.2 What person can eat or drink to prevent anemia: Men . 186 Table 12.18 Attitudes about drinking tea or coffee during meal time in relation to anemia . 187 Figure 12.1 Nutritional status of children by age . 155 Figure 12.2 Trends in nutritional status of children under age 5, 2005-2016 . 157 Figure 12.3 Infant feeding practices by age . 160 Figure 12.4 IYCF Indicators on breastfeeding status . 161 Figure 12.5 IYCF indicators on minimum acceptable diet . 166 Figure 12.6 Trends in nutritional status of women age 15-49 . 171 Figure 12.7 Trends in anemia status among women age 15-49, 2000-2016 . 176 Figure 12.8 Trends in anemia status among children age 6-59 months, 2000-2016 . 178 13 HIV/AIDS AND SEXUALLY TRANSMITTED INFECTIONS . 189 Table 13.1 Knowledge of HIV or AIDS . 190 Table 13.2 Knowledge of HIV prevention methods . 191 Table 13.3 Comprehensive knowledge about HIV . 193 Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV . 194 Table 13.5 Discriminatory attitudes towards people living with HIV . 195 Table 13.6 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: Men . 197 Table 13.7 Payment for sexual intercourse and condom use at last paid sexual intercourse . 198 Table 13.8.1 Coverage of prior HIV testing: Women . 200 Table 13.8.2 Coverage of prior HIV testing: Men . 201 Table 13.9 Self-reported prevalence of sexually transmitted infections (STIs) and STI symptoms . 203 Table 13.10 Prevalence of medical injections. 205 Table 13.11 Comprehensive knowledge about HIV among young people . 206 Table 13.12 Age at first sexual intercourse among young people . 207 Table 13.13 Premarital sexual intercourse among young people . 208 Table 13.14 Recent HIV tests among young people . 209 Figure 13.1 Women seeking advice or treatment for STIs . 204 Figure 13.2 Trends in age at first sexual intercourse . 207 Figure 13.3 Multiple sexual partners and higher-risk sex among young people . 209 Tables and Figures • xiii 14 DOMESTIC VIOLENCE . 211 Table 14.1 Experience of physical violence . 214 Table 14.2 Experience of sexual violence. 215 Table 14.3 Experience of different forms of violence . 215 Table 14.4 Experience of violence during pregnancy . 216 Table 14.5 Marital control exercised by husbands . 217 Table 14.6 Forms of spousal violence . 218 Table 14.7 Spousal violence by background characteristics . 220 Table 14.8 Spousal violence by husband's characteristics and empowerment indicators . 221 Table 14.9 Frequency of physical or sexual violence . 223 Table 14.10 Experience of spousal violence by duration of marriage . 224 Table 14.11 Injuries to women due to spousal violence . 224 Table 14.12 Violence by women against their spouse . 225 Table 14.13 Violence by women against their husband according to the husband’s characteristics and empowerment indicators . 226 Table 14.14 Help seeking to stop violence . 228 15 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES . 229 Table 15.1 Employment and cash earnings of currently married women and men . 230 Table 15.2.1 Control over women's cash earnings and relative magnitude of women's cash earnings . 232 Table 15.2.2 Control over men's cash earnings . 233 Table 15.3 omen's control over their own earnings and over those of their husbands . 234 Table 15.4.1 Ownership of assets: Women . 235 Table 15.4.2 Ownership of assets: Men . 236 Table 15.5.1 Ownership of title or deed for house: Women . 237 Table 15.5.2 Ownership of title or deed for house: Men . 238 Table 15.6.1 Ownership of title or deed for land: Women . 239 Table 15.6.2 Ownership of title or deed for land: Men . 240 Table 15.7.1 Ownership and use of bank accounts and mobile phones: Women . 241 Table 15.7.2 Ownership and use of bank accounts and mobile phones: Men. 242 Table 15.8 Participation in decision making . 243 Table 15.9.1 Women's participation in decision making by background characteristics . 244 Table 15.9.2 Men's participation in decision making by background characteristics . 246 Table 15.10.1 Attitude toward wife beating: Women . 247 Table 15.10.2 Attitude toward wife beating: Men . 248 Table 15.11 Attitudes toward negotiating safer sexual relations with husband . 250 Table 15.12 Ability to negotiate sexual relations with husband . 251 Table 15.13 Indicators of women's empowerment . 252 Table 15.14 Current use of contraception by women's empowerment . 253 Table 15.15 Ideal number of children and unmet need for family planning by women's empowerment . 254 Figure 15.1 Number of decisions in which currently married women participate . 245 APPENDIX A SAMPLE DESIGN . 259 Table A.1 Households . 260 Table A.2 Enumeration areas . 260 Table A.3 Sample allocation of enumeration areas and households . 261 Table A.4 Sample allocation of completed interviews with women and men . 262 Table A.5 Sample implementation: Women . 264 Table A.6 Sample implementation: Men . 265 xiv • Tables and Figures APPENDIX B ESTIMATES OF SAMPLING ERRORS . 267 Table B.1 List of selected indicators for sampling errors, Armenia 2015-16 . 269 Table B.2 Sampling errors: Total sample, Armenia 2015-16 . 270 Table B.3 Sampling errors: Urban sample, Armenia 2015-16 . 271 Table B.4 Sampling errors: Rural sample, Armenia 2015-16 . 272 Table B.5 Sampling errors: Yerevan sample, Armenia 2015-16 . 273 Table B.6 Sampling errors: Aragatsotn sample, Armenia 2015-16 . 274 Table B.7 Sampling errors: Ararat sample, Armenia 2015-16 . 275 Table B.8 Sampling errors: Armavir sample, Armenia 2015-16 . 276 Table B.9 Sampling errors: Gegharkunik sample, Armenia 2015-16. 277 Table B.10 Sampling errors: Lori sample, Armenia 2015-16 . 278 Table B.11 Sampling errors: Kotayk sample, Armenia 2015-16 . 279 Table B.12 Sampling errors: Shirak sample, Armenia 2015-16 . 280 Table B.13 Sampling errors: Syunik sample, Armenia 2015-16 . 281 Table B.14 Sampling errors: Vayots Dzor sample, Armenia 2015-16 . 282 Table B.15 Sampling errors: Tavush sample, Armenia 2015-16 . 283 APPENDIX C DATA QUALITY TABLES . 285 Table C.1 Household age distribution . 285 Table C.2.1 Age distribution of eligible and interviewed women . 286 Table C.2.2 Age distribution of eligible and interviewed men . 286 Table C.3 Completeness of reporting . 287 Table C.4 Births by calendar years . 287 Table C.5 Reporting of age at death in days . 288 Table C.6 Reporting of age at death in months . 288 Table C.7 Nutritional status of children based on the NCHS/CDC/WHO International Reference Population . 289 Table C.8 Vaccinations by background characteristics for children age 18-29 months . 290 Preface • xv PREFACE he 2015-16 Armenia Demographic and Health Survey (2015-16 ADHS) is a nationally representative sample survey designed to provide information on population and health issues in Armenia. The ADHS was conducted by the National Statistical Service (NSS) and the Ministry of Health (MOH) of the Republic of Armenia from December 8, 2015, through April 5, 2016. ICF provided technical support for the survey through The DHS Program. The DHS Program is funded by the United States Agency for International Development (USAID) to assist countries worldwide in obtaining information on key population and health indicators. USAID/Armenia provided funding for the survey. The United Nations Children’s Fund (UNICEF)/Armenia, United Nations Population Fund (UNFPA)/Armenia, and Joint United Nations Program on HIV/AIDS (UNAIDS)/Armenia supported the survey through in-kind contributions. The primary objective of the 2015-16 ADHS project is to provide up-to-date estimates of key demographic and health indicators. Specifically, the ADHS collected information on fertility and abortion levels, marriage, fertility preferences, awareness and use of family planning methods, breastfeeding practices, nutrition, maternal and child health, childhood mortality, domestic violence against women, child discipline, awareness and behavior regarding HIV/AIDS and other sexually transmitted infections (STIs), and other health-related issues such as smoking, tuberculosis, and anemia. The 2015-16 ADHS is a follow- up survey to the 2000, 2005, and 2010 ADHS surveys and provides updated estimates of key demographic and health indicators. The 2015-16 ADHS results are intended to provide the information needed to evaluate existing social programs and to design new strategies for improving health and health services for the people of Armenia. They also contribute to the international database on demographic and health-related indicators. T Acknowledgments • xvii ACKNOWLEDGMENTS he National Statistical Service of the Republic of Armenia and the Ministry of Health of the Republic of Armenia wish to express their appreciation to those involved in the implementation of the 2015- 16 Armenia Demographic and Health Survey (2015-16 ADHS) and the preparation of this report. Particular thanks go to:  U.S. Agency for International Development (USAID/Armenia), for providing the funding for organizing and conducting the 2015-16 ADHS.  ICF for providing technical support, training of fieldwork staff, consultations, recommendations, and analyses of the data collected.  United Nations Children’s Fund (UNICEF)/Armenia, Joint United Nations Program on HIV/AIDS (UNAIDS)/Armenia, and United Nations Population Fund (UNFPA)/Armenia for providing technical, financial, and administrative support.  The technical staff of the ADHS, the input of field staff and data quality teams, and the valuable contribution of all experts and organizations, whose joint efforts ensured the effective implementation of the survey.  Finally, to 7,893 households, 6,116 women, and 2,755 men, whose honest participation made it possible to obtain the reliable information collected in the 2015-16 ADHS. Mr. Gagik Gevorgyan National Director, ADHS Member of the State Council on Statistics of RA Mr. Sergey Khachatryan National Director for Medical Affairs, ADHS Deputy Minister of Health T Millennium Development Goal Indicators • xix MILLENNIUM DEVELOPMENT GOAL INDICATORS Goals and Indicators Value Male Female Total 1. Eradicate extreme poverty and hunger 1.8 Prevalence of underweight children under age 51 3.2 2.0 2.6 2. Achieve universal primary education 2.1 Net enrollment ratio in primary education2 98.1 97.2 97.7 3. Promote gender equality and empower women 3.1a Ratio of girls to boys in primary education3 na na 0.99 3.1b Ratio of girls to boys in secondary education3 na na 1.29 3.1c Ratio of girls to boys in tertiary education3 na na 1.31 4. Reduce child mortality 4.3 Proportion of 1-year-old children immunized against measles4 94.2 91.3 92.8 5. Improve maternal health 5.2 Proportion of births attended by skilled health personnel5 na na 99.8 5.3 Contraceptive prevalence rate6 na 57.1 na 5.4 Adolescent birth rate7 na 24 na 5.5a Antenatal care coverage: at least one visit by skilled health professional na 99.6 na 5.5b Antenatal care coverage: at least four visits by any provider na 96.0 na 5.6 Unmet need for family planning na 12.5 na 6. Combat HIV/AIDS, malaria and other diseases 6.2 Condom use at last high-risk sex: youth age 15-248 86.3a 0.0 43.1b 6.3 Percentage of population age 15-24 with comprehensive knowledge of HIV/AIDS9 12.5a 20.2 16.4b 7. Ensure environmental sustainability Urban Rural Total 7.8 Percentage of population using an improved drinking water source10 98.9 97.0 98.1 7.9 Percentage of population with access to improved sanitation11 96.1 48.6 76.6 na = Not applicable 1 Proportion of children age 0-59 months who are below -2 standard deviations (SD) from the median of the WHO Child Growth Standards in weight-for-age 2 Based on reported attendance, not enrollment 3 Based on reported net attendance, not gross enrollment, among 6-9-year-olds for primary, 10-17-year-olds for secondary, 18-24- year-olds for tertiary education 4 In Armenia, the measles vaccinations are given at the age of 12 months. The values presented in the table are for children age 24- 35 months who have been vaccinated at any time before the survey against measles. 5 Among births in the 5-year period before the survey 6 Use of any contraceptive method among married or in-union women age 15-49 7 Age-specific fertility rates for women age 15-19 corresponding to the 3-year period before the survey 8 High-risk sex is defined as sexual intercourse with a non-marital, non-cohabiting partner. It is expressed as a percentage of men and women age 15-24 who had high-risk sex in the past 12 months. 9 A person is considered to have comprehensive knowledge about HIV/AIDS when s/he knows that consistent use of a condom during sexual intercourse and having just one HIV-negative and faithful partner can reduce the chances of getting HIV, knows that a healthy- looking person can have HIV, and rejects the two most common misconceptions about HIV, i.e., that HIV can be transmitted by mosquito bites and that a person can get HIV by kissing someone who has HIV. 10 Percentage of de-jure population whose main source of drinking water is a household connection (piped), public standpipe, borehole, protected dug well or spring, or rainwater collection 11 Percentage of de-jure population with access to flush toilet, ventilated improved pit latrine, traditional pit latrine with a slab, or composting toilet and does not share its facility with other households a Restricted to men in sub-sample of households selected for the male interview b The total is calculated as the simple arithmetic mean of the percentages in the columns for male and females Sustainable Development Goal Indicators • xxi SUSTAINABLE DEVELOPMENT GOAL INDICATORS Sustainable Development Goal Indicators Armenia 2015-16 Indicator Sex Total Male Female 2. Zero hunger 2.2.1 Prevalence of stunting among children under 5 years of age 10.9 7.8 9.4 2.2.2 Prevalence of malnutrition among children under 5 years of age 18.1 17.7 17.8 a) Prevalence of wasting among children under 5 years of age 3.6 5 4.2 b) Prevalence of overweight among children under 5 years of age 14.5 12.7 13.6 3. Good health and well-being 3.1.2 Proportion of births attended by skilled health personnel na na 99.8 3.7.1 Proportion of women of reproductive age (aged 15-49 years) who have their need for family planning satisfied with modern methods na 40.2 na 3.7.2 Adolescent birth rates per 1,000 women a) Girls aged 10-14 years1 na na na b) Women aged 15-19 years2 na 24 na 3.a.1 Age-standardized prevalence of current tobacco use among persons aged 15 years and older3 61.4 1.2 31.3a 3.b.1 Proportion of the target population covered by all vaccines included in their national programme4 88.0 84.7 86.4 5. Gender equality 5.2.1 Proportion of ever-partnered women and girls aged 15 years and older subjected to physical, sexual or psychological violence by a current or former intimate partner in the previous 12 months5,6 a) Physical violence na 3.5 na b) Sexual violence na 0.3 na c) Psychological violence na na na 5.3.1 Proportion of women aged 20-24 years who were married or in a union before age 15 and before age 18 a) before age 15 na 0.0 na b) before age 18 na 5.3 na 5.b.1 Proportion of individuals who own a mobile telephone7 98.8 96.7 97.8a Residence Total 6. Clean water and sanitation Urban Rural 6.1.1 Proportion of the population using safely managed drinking water services8 98.9 97 98.1 6.2.1 Proportion of population using safely managed sanitation services, including a handwashing facility with soap and water9 96.1 48.6 76.6 7. Affordable clean energy 7.1.1 Proportion of population with access to electricity10 100.0 100.0 100.0 7.1.2 Proportion of population with primary reliance on clean fuels and technology11 99.7 92.0 96.9 Sex Total 8. Decent work and economic growth Male Female 8.10.2 Proportion of adults (15 years and older) with an account at a bank or other financial institution or with a mobile-money-service provider7 20.7 19.3 20.0a 16. Peace, justice, and strong institutions 16.2.1 Percentage of children aged 1-17 years who experienced any physical punishment and/or psychological aggression by caregivers in the past month12 70.8 66.8 68.9 16.9.1 Proportion of children under 5 years of age whose births have been registered with a civil authority 98.9 98.5 98.7 17. Partnerships for the goals 17.8.1 Proportion of individuals using the Internet7 88.9 85.3 87.1a na = Not applicable 1 Equivalent to the age-specific fertility rate for girls age 10-14 for the 3-year period preceding the survey, expressed in terms of births per 1,000 girls age 10-14 2 Equivalent to the age-specific fertility rate for women age 15-19 for the 3-year period preceding the survey, expressed in terms of births per 1,000 women age 15-19 3 Data are not age-standardized and are available for women and men age 15-49 only. 4 Data are presented for children age 12-23 months who received all vaccinations appropriate for their age that are included in the national program: BCG, hepatitis B (birth dose), three doses of DPT-HEPB-HIB, three doses of oral polio vaccine, and two doses of rotavirus vaccine (excluding the recently introduced pneumococcal vaccine). 5 Data are available for women age 15-49 who have ever been in union only. 6 In the DHS, psychological violence is termed emotional violence. 7 Data are available for women and men age 15-49 who have used the internet in the past 12 months. 8 Measured as the percentage of population using an improved water source: the percentage of de jure population whose main source of drinking water is a household connection (piped), public tap or standpipe, tubewell or borehole, protected dug well, protected spring, or rainwater collection. Households using bottled water for drinking are classified as using an improved or unimproved source according to their water source for cooking and handwashing. 9 Measured as the percentage of population using an improved sanitation facility: the percentage of de jure population whose household has a flush or pour flush toilet to a piped water system, septic tank or pit latrine; ventilated improved pit latrine; pit latrine with a slab; or composting toilet and does not share this facility with other households. 10 Measured as the percentage of households with access to electricity. 11 Measured as the percentage of the households using clean fuel for cooking. 12 Data are available for children age 1-14 only. a The total is calculated as the simple arithmetic mean of the percentages in the columns for males and females xxii • Map of Armenia Introduction and Survey Methodology • 1 INTRODUCTION AND SURVEY METHODOLOGY 1 he 2015-16 Armenia Demographic and Health Survey (ADHS) was implemented by the National Statistical Service (NSS) and Ministry of Health (MOH) of the Republic of Armenia. Data collection took place from 8 December 2015 to 5 April 2016. ICF provided technical assistance through The DHS Program, which is funded by the United States Agency for International Development (USAID) and offers support and technical assistance for population and health surveys in countries worldwide. Other agencies and organizations that facilitated the successful implementation of the survey through technical or financial support were the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), and the Joint United Nations Programme on HIV/AIDS (UNAIDS). 1.1 GEOGRAPHY AND POPULATION 1.1.1 Geography The Republic of Armenia (RA) is situated in the western part of Asia and occupies the northeastern part of the Armenian plateau between the Caucasus and Nearest Asia (the inter-river territory between the middle flows of the rivers Kur and Araxes). The country borders with Georgia in the north, with Azerbaijan in the east, with Iran in the south, and with Turkey in the west and southwest. The area of the country is 29,743 square km, 68.8 percent of which is agricultural, 11.2 percent is forest, 11.3 percent is protected territory, and 8.7 percent is other types of land. The highest elevation in the country is the peak of Mt. Aragats (4,090 m), the lowest point is the underflow region of the Debed River (375 m). The largest lake is Lake Sevan, which is located 1,900 m above sea level. The surface of the lake is 1,276 square km. The longest rivers are the Araxes (192 km in the territory of RA, with a total length of 1,072 km) and the Akhuryan (186 km). The climate in Armenia is dry and continental, with cold winters and hot summers. The country is subdivided into 10 regions (marz), and the capital city of Yerevan (NSS 2016a). 1.1.2 Population The First National Population Census of the Republic of Armenia after independence took place from 10-19 October 2001. As of 10 October 2001, the de facto population number in Armenia was 3,002,594 and the de jure population was 3,213,011 (NSS 2013). The most recent census prior to ADHS 2015-16 was conducted from 12-21 October 2011. According to the 2011 Census results, the de facto population in Armenia was 2,871,771 and the de jure population was 3,018,854 (NSS 2013). The de jure population of RA as of 1 April 2016, is 2,994,400, with 1,904,700 urban and 1,089,700 rural (NSS 2016b). More than half of the urban population (1,073,400) was living in the capital city, Yerevan. Men and women comprised 47.7 percent and 52.3 percent, respectively, of the permanent population in Armenia in 2016. The average age of the population was 36.1; it was 34.2 for men and 37.8 for women (NSS 2016d). As of early 2016, 20.8 percent of the permanent population was age 15 or younger, 66.3 percent was age 16-62, and 12.9 percent was age 63 or older. One of the existing problems of the demographic distribution is the ageing of the population, a process that greatly accelerated in Armenia during the post-Soviet period. Population ageing or demographic ageing is the result of long-lasting demographic changes, mainly changes in population reproduction, fertility, mortality, and their correlates and also partially the result of migration as well. By the demographic ageing scale set by the UN, if the share of the population age 65 is more than 7 percent, then this population is considered to be ageing. In early 2016, the share of the RA population age 65 and older was 11.0 percent. T 2 • Introduction and Survey Methodology 1.2 SYSTEMS FOR COLLECTING DEMOGRAPHIC AND HEALTH DATA The National Statistical Service (NSS) of RA is responsible for conducting a nationwide census every 10 years and for providing information about the current population using data from the national registration system. The 2001 census results were published during 2002-2004, and the 2011 census results during 2012-2014. Data on births, deaths, marriages, and divorces are provided by the Civil Status Acts Registration offices of the Ministry of Justice. Administrative data on internal and external migration of the population are provided by the Passport and Visa Department of RA police, and are based on the data from an electronic database, which is, in turn, based on the administrative records of registration of residency. The NSS handles statistical processing and analysis of the obtained administrative data, and publishes the preliminary data in the monthly report “Socio-Economic Situation of RA,” while final data by specific characteristics are published in a number of different annual reports of RA, including “The Demographic Handbook of Armenia,” “Men and Women in Armenia,” “Statistical Yearbook,” and others, all are available at the official website of the NSS of RA. Data on health are collected by the Ministry of Health through administrative statistical reporting forms filled in and provided by the health facilities. The collected information is then passed to the NSS. The NSS compiles and analyzes the data for the country level and publishes monthly, quarterly and annual reports and various publications. Based on compiled health data, the Ministry of Health publishes annual and quarterly thematic repots, such as “Health Indicators of the Population and Efficiency of Healthcare Resources in Armenia.” The country statistics are available at the World Health Organization (WHO) website through the Global Health Observatory, the WHO’s gateway to health-related statistics for its member states. 1.3 HEALTH CARE SYSTEM UPDATES IN ARMENIA Principles of health care policy Soon after regaining its independence Armenia began to reform the health care system. The country has recognized health and health care as a fundamental human right over the past 2 decades, and a number of major reforms have been carried out. These include decentralizing management and organizational structure, privatizing a number of health facilities, centralizing public financing activities, strengthening primary health care (PHC), and reforming the public health care system. The need for continuous reform to the health care system is conditioned by the new health challenges emerging both in the world and in Armenia. In particular, the balance between communicable and non- communicable diseases (NCDs) has changed, and NCDs are now the primary cause of mortality. The main directions of development in the health care system in Armenia arise from the provisions of the Actions Plan of RA Government and the comprehensive policy of “Health 2020,” adopted by the World Health Organization (WHO-EURO 2013). They are directed towards:  Ensuring universal health care coverage, that is, maximum access to health care and services for all the population groups  Maintaining and improving public health  Increasing the efficiency of management in the health care system  Maintaining the principle of social justice and equality, and formation of a stable and “people- centered” health care system The improvement of the quality of medical services is one of the key issues among current health care system priorities. According to the requirements of RA Government Protocol Decision № 40 “On the Concept of Health Care Service Quality Assessment and Approval of the List of Activities for Realization of the Concept” (14 October 2010), and in order to improve the quality of health care and services in the primary health care circle, a complex package of quality ensuring practical measures (methods, procedures, Introduction and Survey Methodology • 3 registration-reporting forms) has been put into use in 139 large health facilities throughout all the regions and the capital city of Yerevan. In Armenia health care services are provided in the outpatient (ambulatory) and inpatient (specialized) levels. Inpatient health care is provided at multiprofile, monoprofile, or specialized hospitals (including maternity homes and children’s hospitals). Outpatient health care is provided by urban polyclinics, health centers, rural ambulatory facilities, and feldsher-accoucher posts. At present there are 85 urban polyclinics, 255 rural ambulatory facilities and health centers, and 617 feldsher-accoucher posts in Armenia. Maternal and Child Health Armenia, as a member of the United Nations, has made the well-being and health of the mother and child a priority at the national level. This emphasis is reflected in the strategic documents of the RA government, particularly those of the Ministry of Health. They are the following:  The strategic program of prospective development for 2014-2025 of RA (GoA 2014a)  The national policy on the improvement of reproductive health and the implementation of an action plan for 2016-2020 (GoA 2016a)  The national policy on the improvement of child and adolescent health and the implementation of an action plan for 2015-2020 (GoA 2016b)  The concept of improvement of child nutrition and the implementation of an action plan for 2015-2020 (GoA 2014b)  The national breastfeeding promotion program and the implementation of an action plan for 2016-2020  The national program on immunization for 2016-2020 These documents reflect the current status of reproductive, maternal, and child health care issues in the country. They define the policies and goals aimed at improving women's and children's health and nutrition, and at reducing maternal and child mortality. Within the framework of the above mentioned policies and programs, the activities aimed at the protection of maternal and child health are considered as priorities of the Ministry of Health. Free delivery care vouchers and state certificates for free child health care have been in use since their respective introductions in 2008 and 2011. Additional financial contributions within these programs resulted in a three-to-four-fold rise in the wages of health workers, which significantly contributed to truly free and affordable delivery services for the population. Financing of the Health Care System Historically, the state budget was the primary financing source of the health care system. Currently, the health care system is financed by both local and international sources. The main local sources are the state budget and out-of-pocket payment. The international financing sources are generally in the form of humanitarian aid and special grants for the implementation of international projects. Grants received from abroad and from international organizations are mainly directed to the implementation of projects aimed at HIV/AIDS prevention, improvement of immunization coverage, and improvements in reproductive, maternal, and child health. The state budget is still the main source of financing. The funding for health care is determined as the final state budget is prepared. Budget allocations to health facilities are administered by the Ministry of Health on a contract basis, according to the principles of a limited budget. The primary health care (PHC) budget is financed according to per capita financing, whereas hospital-level facilities are financed according to the cost of each hospital case presented for reimbursement. The financing for medicine, medical equipment, and other health programs is also organized on a contract basis. State expenditures on the health 4 • Introduction and Survey Methodology care system are not sufficient to support the system and therefore do not meet the health needs of the population. Furthermore, the use of the given financial resources is not efficient. Taking into account the low level of state expenditures on the health care system, the RA government increases financing each year. Serious steps have been taken to reform the structure of the financing system. These have aimed at reducing non-official payment and introducing objective criteria for reimbursement. One valuable future program will be the introduction of compulsory health (medical) insurance, which is considered a way to add financial resources to the health care system, make health care more affordable for the population, promote principles of social justice, and increase the purposeful use of resources and the efficiency of medical services. Family planning policies Good reproductive health forms the basis of every family, the entire society, and the well-being and prosperity of a country. The status of reproductive health guarantees stable economic and social development. Investments in this sector are viewed as investments in the future. Family planning is the key component of reproductive health. The state and society must create proper conditions and take appropriate measures to ensure the birth of healthy children, to provide the prerequisites for education of the growing generation, and to support the reproduction of the population. Family planning has a broad impact on sexual and reproductive health, because it enables women to exercise their right of choice and to control their fertility. It reduces maternal and fetal morbidity and mortality, and lowers the transmission of sexually transmitted infections, including HIV. Family planning increases gender equality and gives opportunities for women to get an education, find a job, and fully engage in society. At present, according to Armenian law, induced abortions are permitted only in the first trimester of the pregnancy, a 12-week period (GoA 2004). In the case of medical or social indications, induced abortions may be done up to 22 weeks of gestation. Contraceptives once were provided free, and the services necessary for their prescription were charged to patients. In 2006, gynecological services were included among those services provided at no cost, in accord with the government’s principle of guaranteed, free primary health care. Because of the high concentration of estrogens in the early contraceptive pills and the frequency of serious complications, the Ministry of Health of the Soviet Union forbade their use and dissemination in 1974 under the “Side Effects and Complications of Oral Contraceptives” order. Today, the concentration of estrogens in the contraceptive pills of the new generation has been reduced, providing safety of use and medical efficiency. The use of modern contraceptive methods, including pills, has been permitted by the RA, as a part of the legislation on reproductive health and reproductive rights” (National Assembly of RA 2002). For the first time in 2015 some funds were allocated from within the state budget (National Assembly of RA 2014) for the purchase of modern contraceptive methods and for the dissemination of these methods among couples in socially insecure families. 1.4 OBJECTIVES AND ORGANIZATION OF THE SURVEY The 2015-16 Armenia Demographic and Health Survey (2015-16 ADHS) is the fourth in a series of nationally representative sample surveys designed to provide information on population and health issues. It is conducted in Armenia under the worldwide Demographic and Health Surveys program. Specifically, the objective of the 2015-16 ADHS is to provide current and reliable information on fertility and abortion levels, marriage, sexual activity, fertility preferences, awareness and use of family planning methods, breastfeeding practices, nutritional status of young children, childhood mortality, maternal and child health, domestic Introduction and Survey Methodology • 5 violence against women, child discipline, awareness and behavior regarding AIDS and other sexually transmitted infections (STIs), and other health-related issues such as smoking, tuberculosis, and anemia. The survey obtained detailed information on these issues from women of reproductive age and, for certain topics, from men as well. The 2015-16 ADHS results are intended to provide information needed to evaluate existing social programs and to design new strategies to improve the health of and health services for the people of Armenia. Data are presented by region (marz) wherever sample size permits. The information collected in the 2015-16 ADHS will provide updated estimates of basic demographic and health indicators covered in the 2000, 2005, and 2010 surveys. The long-term objective of the survey includes strengthening the technical capacity of major government institutions, including the NSS. The 2015-16 ADHS also provides comparable data for long- term trend analysis because the 2000, 2005, 2010, and 2015-16 surveys were implemented by the same organization and used similar data collection procedures. It also adds to the international database of demographic and health–related information for research purposes. 1.5 SAMPLE DESIGN AND IMPLEMENTATION The sample was designed to produce representative estimates of key indicators at the national level, for Yerevan, and for total urban and total rural areas separately. Many indicators can also be estimated at the regional (marz) level. The sampling frame used for the 2015-16 ADHS is the Armenia Population and Housing Census, which was conducted in Armenia in 2011 (APHC 2011). The sampling frame is a complete list of enumeration areas (EAs) covering the whole country, a total number of 11,571 EAs, provided by the National Statistical Service (NSS) of Armenia, the implementing agency for the 2015-16 ADHS. This EA frame was created from the census data base by summarizing the households down to EA level. A representative probability sample of 8,749 households was selected for the 2015-16 ADHS sample. The sample was selected in two stages. In the first stage, 313 clusters (192 in urban areas and 121 in rural areas) were selected from a list of EAs in the sampling frame. In the second stage, a complete listing of households was carried out in each selected cluster. Households were then systematically selected for participation in the survey. Appendix A provides additional information on the sample design of the 2015-16 Armenia DHS. Because of the approximately equal sample size in each marz, the sample is not self-weighting at the national level, and weighting factors have been calculated, added to the data file, and applied so that results are representative at the national level. All women age 15-49 who were either permanent residents of the households in the 2015-16 ADHS sample or visitors present in the household on the night before the survey were eligible to be interviewed. Interviews were completed with 6,116 women. In addition, in a subsample of one-half of all households selected for the survey, all men age 15-49 were eligible to be interviewed if they were either permanent residents or visitors present in the household on the night before the survey. Interviews were completed with 2,755 men. Anemia testing was performed in each household among eligible women age 15-49 who consented. With the parent’s or guardian’s consent, children age 6-59 months were also tested for anemia in each household. Height and weight information was collected from eligible women age 15-49 and children age 0-59 months in all households. In addition, a subsample of one eligible woman in each household was randomly selected to be asked additional questions about domestic violence. 1.6 QUESTIONNAIRES Five questionnaires were used for the 2015-16 ADHS: the Household Questionnaire, the Woman’s Questionnaire, the Man’s Questionnaire, the Biomarker Questionnaire, and the Fieldworker Questionnaire. 6 • Introduction and Survey Methodology These questionnaires, based on The DHS Program’s standard Demographic and Health Survey questionnaires, were adapted to reflect the population and health issues relevant to Armenia. Input was solicited from various stakeholders representing government ministries and agencies, nongovernmental organizations, and international donors. After all questionnaires were finalized in English, they were translated into Armenian. They were pretested in September-October 2015. The Household Questionnaire was used to list all usual members of and visitors to the selected households and to collect information on the socioeconomic status of the household. The first part of the questionnaire collected, for each household member or visitor, information on age, sex, educational attainment, and relationship to the head of household. This information provided basic demographic data for Armenian households. It also was used to identify the women and men who were eligible for an individual interview (that is, women and men age 15-49). In the second part of the Household Questionnaire, there were questions on housing characteristics (for example, the flooring material, the source of water, and the type of toilet facilities), on ownership of a variety of consumer goods, and on other aspects of the socioeconomic status of the household. In addition, the Household Questionnaire was used to obtain information on each child’s birth registration, collect information about child discipline from one randomly selected child age 1-14 per household, and identify women age 15-49 and children under age 5 who were eligible for height and weight measurements and hemoglobin testing. The Woman’s Questionnaire obtained information from women age 15-49 on the following topics:  Background characteristics  Pregnancy history, reasons for any abortions, and child mortality  Knowledge, attitudes, and use of contraception  Antenatal, delivery, and postnatal care  Vaccinations of children under age 3  Episodes of diarrhea and respiratory illness of children under age 5  Breastfeeding and weaning practices  Marriage and recent sexual activity  Fertility preferences  Knowledge of and attitudes toward AIDS and other sexually transmitted diseases  Woman’s work and husband’s background characteristics  Domestic violence  Knowledge, attitudes, and behavior related to other health issues (for example, tuberculosis, anemia, and smoking) The Man’s Questionnaire was administered to all men age 15-49 in the subsample of households selected for the male survey (every second household). The Man’s Questionnaire collected much of the same information as the Woman’s Questionnaire, but was shorter because it did not contain a detailed reproductive history or questions about child health or domestic violence. In addition, the Biomarker Questionnaire was used to record the results of the informed consent procedures, as well as the anthropometry measurements and hemoglobin testing results, for consenting respondents. For the first time, the Fieldworker Questionnaire was used in the ADHS. This questionnaire was created to serve as a tool in conducting analyses of data quality. The questionnaire was distributed and collected by the NSS after final selection of fieldworkers was done and before fieldworkers entered the field. Fieldworkers filled out a 2-page self-administered questionnaire on their general background characteristics. 1.7 ANTHROPOMETRY AND ANEMIA TESTING The 2015-16 ADHS incorporated two biomarkers: anthropometry and anemia testing. Data related to the coverage of the biomarker component, the anthropometric measures, and the result of the anemia Introduction and Survey Methodology • 7 testing was directly recorded in the Biomarker Questionnaire. The protocol for anemia testing was reviewed and approved by the National Center for AIDS Prevention of the Ministry of Health and the Institutional Review Board of ICF. Anthropometry In all households, height and weight measurements were recorded for children age 0-59 months and women age 15-49 years. Weight measurements were obtained using lightweight, electronic Seca scales with a digital screen and the mother/child function. Height measurements were carried out with measuring boards provided by UNICEF1. Children younger than age 24 months were measured lying down (recumbent) on the board, while standing height was measured for older children. Anemia Testing Blood specimens were collected for anemia testing from all children age 6-59 months and all women age 15-49 years who voluntarily consented to the testing. Blood samples consisted of a drop of blood taken from a finger prick (or a heel prick, for young children with small fingers) and collected in a microcuvette. Hemoglobin analysis was carried out on site using a battery-operated portable HemoCue® analyzer, which produces a result in less than one minute. Results were given verbally and in writing. Parents of children with a hemoglobin level below 7 g/dl were instructed to take the child to a health facility for follow-up care. Likewise, nonpregnant women and pregnant women were referred for follow-up care if their hemoglobin level was below 7 g/dl and 9 g/dl, respectively. All households in which anthropometry and/or anemia testing was conducted were given a brochure explaining the causes and prevention of anemia. 1.8 PRETEST Eleven women and four men participated in a training to pretest the ADHS survey questionnaires over a three-week period from September 16 through October 7, 2015. Twelve days of classroom training was provided. The training was led in Armenian by the in-country ADHS core team and was supported by The DHS Program staff. Senior subject specialists from the MOH attended the sessions to provide technical background on different topics included in the questionnaires. In addition, seven women were recruited as health investigators for the pretest. Classroom training for these women was conducted at the National Institute of Health (NIH) from 22-30 September 2015. Biomarker training was led by staff from the DHS Program and the NIH. Before going for the field practice, to make sure that the health investigators had enough practical experience to measure women and children, a standardization exercise was organized in the classroom. 1 Portable baby/child/adult length-height measuring board, UNICEF supply catalogue number S0114540. 8 • Introduction and Survey Methodology The pretest fieldwork was conducted on 1-7 October 2015. A total of 87 interviews with households were completed, as well as 81 interviews of women and 24 interviews of men. All interviews were conducted in Armenian. Approximately 77 women and 55 children were measured and tested for anemia after obtaining informed consent. Following the pretest fieldwork, a debriefing session was held with the pretest field staff, and modifications to the questionnaires were made based on lessons drawn from the exercise. 1.9 TRAINING OF FIELD STAFF The main survey training, which was conducted by NSS, MOH, and the DHS Program staff, was held during a 3-week period in November and was attended by all supervisors, field editors, interviewers, and quality control personnel, a total of 104 people (85 women and 19 men). The training included lectures, demonstrations, practice interviews in small groups, and examinations. All field staff received training in anthropometric measurement and participated in 2 days of field practice. Health investigators were trained separately. Fifteen health investigators (13 women, 2 men) attended the training; all of them were skilled health professionals. The classroom training of the health investigators was conducted at the National Institute of Health (NIH). The biomarker portion of the training was conducted by the NIH/MOH and the DHS Program staff and included classroom instruction focusing on anthropometry measurements, anemia testing, and recording of biomarker information in the Biomarker Questionnaire. The training was divided into three sessions following the DHS biomarker curriculum: class- room training on anthropometry and anemia, in-class standardization of tests and practice sessions, and field practice with interviewers. 1.10 Fieldwork and Data Processing Thirteen teams collected the survey data; each team consisted of four female interviewers, a male interviewer, a field editor, a health investigator, and a team supervisor. Fieldwork started on 8 December 2015 in most regions and stopped from 31 December 2015 until 7 January 2016 for the New Year and Orthodox Christmas holidays. Fieldwork resumed on 8 January 2016, and was completed by 5 April 2016. Fieldwork monitoring was an integral part of the ADHS. Senior ADHS technical staff from NSS and NIH visited teams regularly to review the work and monitor data quality. Representatives from The DHS Program and USAID/Armenia also visited teams to monitor data collection and to observe the anemia testing and height and weight measurements of women and children under age 5. The processing of the 2015-16 ADHS data began shortly after fieldwork commenced. All completed questionnaires were edited immediately by field editors while still in the field and checked by the supervisors before being dispatched to the data processing center at the NSS central office in Yerevan. These completed questionnaires were edited and entered by 15 data processing personnel specially trained for this task. All data were entered twice for 100 percent verification. Data were entered using the CSPro computer package. The concurrent processing of the data was an advantage because the senior ADHS technical staff were able to advise field teams of problems detected during the data entry. In particular, tables were generated to check various data quality parameters. Moreover, the double entry of data enabled easy comparison and identification of errors and inconsistencies. As a result, specific feedback was given to the teams to improve performance. The data entry and editing phase of the survey was completed in June 2016. Introduction and Survey Methodology • 9 1.11 RESPONSE RATES Table 1.1 shows response rates for the 2015-16 ADHS. A total of 8,749 households were selected in the sample, of which 8,205 were occupied at the time of the fieldwork. The main reason for the difference is that some of the dwelling units that were occupied during the household listing operation were either vacant or the household was away for an extended period at the time of interviewing. The number of occupied households successfully interviewed was 7,893, yielding a household response rate of 96 percent. The household response rate in urban areas (96 percent) was nearly the same as in rural areas (97 percent). In these households, a total of 6,251 eligible women were identified; interviews were completed with 6,116 of these women, yielding a response rate of 98 percent. In one-half of the households, a total of 2,856 eligible men were identified, and interviews were completed with 2,755 of these men, yielding a response rate of 97 percent. Among men, response rates are slightly lower in urban areas (96 percent) than in rural areas (97 percent), whereas rates for women are the same in urban and in rural areas (98 percent). The 2015-16 ADHS achieved a slightly higher response rate for households than the 2010 ADHS (NSS 2012). The increase is only notable for urban households (96 percent in 2015-16 compared with 94 percent in 2010). Response rates in all other categories are very close to what they were in 2010. Table 1.1 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Armenia 2015-16 Result Residence Total Urban Rural Household interviews Households selected 5,369 3,380 8,749 Households occupied 5,017 3,188 8,205 Households interviewed 4,806 3,087 7,893 Household response rate1 95.8 96.8 96.2 Interviews with women age 15-49 Number of eligible women 3,631 2,620 6,251 Number of eligible women interviewed 3,545 2,571 6,116 Eligible women response rate2 97.6 98.1 97.8 Interviews with men age 15-49 Number of eligible men 1,587 1,269 2,856 Number of eligible men interviewed 1,522 1,233 2,755 Eligible men response rate2 95.9 97.2 96.5 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents Housing Characteristics and Household Population • 11 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION 2 his chapter presents a demographic and socioeconomic profile of the households in the 2015-16 ADHS, including information on the age, sex, place of residence, and educational status of household members; housing characteristics; and the ownership of durable goods. Information on child birth registration and child discipline is also presented. Knowledge about the characteristics of respondents and their households helps in understanding and interpreting the findings of the survey and also in assessing the representativeness of the survey. T Key Findings  The average household has 3.5 members.  All households have electricity.  A majority of households (77 percent) use improved, not shared sanitation facilities.  Nearly all households (98 percent) obtain drinking water from an improved source.  Almost all households (97 percent) have soap and water available at the place that household members use for handwashing.  Most dwellings have some type of flooring, mostly parquet or polished wood, or wood/planks.  More than 9 in 10 households use gas for cooking and have a specific place for cooking inside the house. Natural gas is the most common fuel used for cooking in both urban and rural households (92 percent and 70 percent, respectively).  Eight percent of rural households use solid fuels for cooking versus less than 1 percent of urban households.  Virtually all Armenian households have a television, 97 percent have a refrigerator, and 93 percent have a washing machine. Most households also have a mobile telephone (96 percent).  Possession of a computer has increased from 29 percent of households in 2010 to 69 percent in 2015-16. Ownership among rural households has been especially rapid, increasing from 12 percent in 2010 to 62 percent in 2015-16.  The median number of completed years of schooling is 9.9 years among females and 9.7 years among males.  School attendance among youth is widespread but not universal; 96 percent of the basic school-age population and 56 percent of the high-school-age population attend school.  There is almost no gender gap in basic and high school attendance, but girls are slightly more likely to attend school than boys.  Seven in ten children age 1-14 experienced some form of psychological or physical punishment during the 30 days preceding the survey: 19 percent experienced only non-violent discipline; 65 percent experienced psychological aggression, and 38 percent of children experienced some form of physical punishment. Four percent experienced severe physical punishment. 12 • Housing Characteristics and Household Population A household is defined as a person or group of related and unrelated persons who live together in the same dwelling unit(s) or on connected premises, who acknowledge one adult member as head of the household, and who have common arrangements for cooking and eating their food. The questionnaire for the 2015-16 ADHS distinguishes between the de jure population (persons who usually live in the household) and the de facto population (persons who stayed the night before the interview in the household). According to the 2015-16 ADHS data, the differences between these populations are small. Tabulations for the household data presented in this chapter are based primarily on the de facto population. Throughout the report, because of the way the sample was designed, the number of cases in some regions may appear small in the tables; this is because they are weighted to make the regional distribution nationally representative. To identify results that may be based on numbers too small to ensure statistical reliability, percentages based on 25 to 49 unweighted cases are shown within parentheses, and percentages based on fewer than 25 unweighted cases are suppressed. 2.1 HOUSING CHARACTERISTICS There is a strong correlation between the socioeconomic condition of a household and the vulnerability of its members, especially children, to common diseases. The amenities and assets available to households are important in determining the general socioeconomic status of the population. To assess the socioeconomic conditions under which the population lives, respondents were asked to give specific information about their household environment. They answered questions about the household’s access to electricity, type of water source, sanitation facilities, floor material, and ownership of durable goods. Tables 2.1 through 2.6 present major housing characteristics by urban-rural residence. 2.1.1 Drinking Water The source of drinking water is an indicator of whether it is suitable for drinking. Table 2.1 provides information on the source of drinking water, the amount of time it takes to obtain the water, and the type of treatment of water used for drinking. The table shows the results separately for households and for the de jure population living in those households. Overall, the 2015-16 ADHS shows that most households (98 percent) in Armenia have access to an improved source of drinking water, with the large majority (96 percent) reporting that their drinking water is piped directly into the dwelling, yard, or plot (Table 2.1). Only 3 percent of rural households and 1 percent of urban households rely on an unimproved source for drinking water, mainly water obtained from a tanker truck/cart. The small number of households that do not obtain their drinking water on the premises spend less than 30 minutes going to get water. Because households may use more than one method to treat water to make it safe to drink, water treatment is shown in Table 2.1 as the percentages of households and of the de jure population using specific treatment methods rather than a percent distribution. Because almost all households rely on piped water, which presumably comes from a public source where it is treated, it is not surprising that water is not treated further in most households (94 percent). At the household level, the most frequently used method for treating water is boiling (4 percent). Overall, 5 percent of households use an appropriate treatment method— boiling, bleaching, straining, filtering, or solar disinfecting. Interruptions to the supply of water may lead households to use unimproved sources for drinking water. Most households in Armenia do not have problems with lack of access to water. Only 8 percent of households using piped water or water from a borehole or dug well reported that water was not available from their usual source for at least 1 day in the 2 weeks prior to the survey (Table 2.2). Housing Characteristics and Household Population • 13 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, Armenia 2015-16 Characteristic Households Population Urban Rural Total Urban Rural Total Source of drinking water Improved source 99.0 97.3 98.3 98.9 97.0 98.1 Piped into dwelling/ yard/ plot 98.7 92.5 96.4 98.6 92.2 96.0 Public tap/standpipe 0.1 1.1 0.5 0.1 1.1 0.5 Tube well/borehole 0.0 0.6 0.2 0.0 0.8 0.3 Protected dug well 0.0 0.6 0.2 0.0 0.5 0.2 Protected spring 0.1 2.5 1.0 0.1 2.3 1.0 Unimproved source 1.0 2.7 1.7 1.1 3.0 1.9 Unprotected spring 0.0 0.2 0.1 0.0 0.2 0.1 Tanker truck/cart with small tank 1.0 2.4 1.6 1.1 2.8 1.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 Time to obtain drinking water (round trip) Water on premises 98.8 95.6 97.6 98.7 95.5 97.4 Less than 30 minutes 0.9 2.6 1.5 0.9 2.5 1.6 30 minutes or longer 0.0 0.6 0.2 0.0 0.7 0.3 Don't know/missing 0.3 1.2 0.7 0.3 1.4 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment prior to drinking1 Boiled 5.4 2.8 4.4 6.2 3.2 5.0 Bleach/chlorine added 0.0 0.1 0.0 0.0 0.1 0.0 Strain through cloth 0.1 0.1 0.1 0.1 0.1 0.1 Ceramic, sand, or other filter 0.9 1.0 1.0 1.1 1.4 1.2 Solar disinfection 0.1 0.0 0.0 0.0 0.0 0.0 Let it stand and settle 0.8 0.3 0.6 0.7 0.3 0.5 Other 0.8 0.0 0.5 0.9 0.0 0.5 No treatment 92.2 95.6 93.5 91.3 94.7 92.7 Percentage using an appropriate treatment method2 6.4 3.8 5.4 7.3 4.6 6.2 Number 4,924 2,969 7,893 16,482 11,475 27,958 1 Respondents may report multiple treatment methods, so the sum of treatment may exceed 100 percent. 2 Appropriate water treatment methods include boiling, bleaching, filtering, and solar disinfecting. Table 2.2 Availability of water Among households and de jure population using piped water or water from a tube well or borehole, percentage with lack of availability of water in the last 2 weeks, according to residence, Armenia 2015-16 Availability of water in last 2 weeks Households Population Urban Rural Total Urban Rural Total Not available for at least 1day 8.1 8.1 8.1 8.6 8.2 8.4 Available with no interruption of at least 1 day 91.0 90.7 90.9 90.8 91.0 90.9 Don't know 0.9 1.2 1.0 0.6 0.8 0.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number using piped water or water from a tube well/borehole 4,868 2,798 7,666 16,281 10,800 27,081 14 • Housing Characteristics and Household Population 2.1.2 Sanitation Facility A household’s toilet/latrine facility is classified as hygienic if it is used only by household members (i.e., not shared) and if the type of facility effectively separates human waste from human contact. The types of facilities that are most likely to accomplish this are toilets that flush or pour flush into a piped sewer system/septic tank/pit latrine, and pit latrines with a slab. A household’s sanitation facility is classified as unhygienic if it is shared with other households or if it does not effectively separate human waste from human contact. Table 2.3 shows the proportion of households and of the de jure population with access to hygienic sanitation facilities (that is, those with access to improved, unshared facilities), shared facilities, and non-improved facilities. The 2015-16 ADHS found that 77 percent of households in Armenia use improved sanitation facilities that are not shared with another household (Table 2.3), which is lower than the percentage using improved, unshared facilities at the time of the 2010 ADHS (80 percent) 1 . Flush toilets are widespread in urban areas (95 percent), while pit latrines without a slab or open pits are the most prevalent type of toilet facility in rural areas (47 percent). Table 2.3 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, Armenia 2015-16 Type and location of toilet/ latrine facility Households Population Urban Rural Total Urban Rural Total Improved, not shared facility Flush/pour flush to piped sewer system 94.8 27.1 69.3 94.8 28.2 67.5 Flush/pour flush to septic tank 0.3 4.8 2.0 0.3 5.7 2.5 Pit latrine with slab 0.9 14.8 6.2 1.0 14.7 6.6 Total 96.0 46.7 77.4 96.1 48.6 76.6 Shared facility1 Flush/pour flush to piped sewer system 0.6 0.1 0.4 0.5 0.1 0.3 Total 0.6 0.1 0.4 0.5 0.2 0.4 Unimproved facility Flush/pour flush not to sewer/septic tank/pit latrine 0.8 5.6 2.6 0.9 5.5 2.8 Pit latrine without slab/open pit 2.5 47.4 19.4 2.4 45.8 20.2 Missing 0.1 0.0 0.0 0.1 0.0 0.0 Total 3.4 53.1 22.1 3.4 51.3 23.0 Location of toilet facility In own dwelling 94.4 34.6 71.9 94.1 36.7 70.6 In own yard/plot 5.4 65.1 27.9 5.7 63.0 29.2 Elsewhere 0.2 0.3 0.2 0.2 0.2 0.2 Missing 0.0 0.0 0.0 0.0 0.1 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 4,924 2,969 7,893 16,482 11,475 27,958 1 Facilities that would be considered improved if they were not shared by two or more households 1 It should be noted, that unlike in the 2010 ADHS, the 2015-16 ADHS Household Questionnaire did not include the coding category for toilets that flush to a pit latrine. Housing Characteristics and Household Population • 15 2.1.3 Household Characteristics Table 2.4 presents the distribution of households by housing characteristics, according to residence. All households in Armenia have electricity (Table 2.4). More than 9 in 10 households use gas for cooking and have a specific place for cooking inside the house. Natural gas is the most common fuel used for cooking among both urban and rural households (92 and 70 percent, respectively). Eight percent of rural households rely on biomass fuels, primarily wood, for cooking. The use of biomass fuels may contribute to indoor air pollution, which has been shown to have adverse health effects (Fullerton et al. 2008). Slightly more than one-quarter of households (28 percent) have three or more rooms used for sleeping, and 42 percent have two rooms. Urban households are more likely than rural households to have only one room for sleeping (34 percent versus 22 percent). Virtually all households have a finished floor. Parquet or polished wood is the most common flooring material in both urban areas (77 percent) and rural areas (52 percent). Most rural households (87 percent) have stone walls with lime or cement. The majority of urban households have either stone (51 percent) or cement blocks for walls (39 percent). Shingles, or schiefer, are the most common roofing material in both urban and rural areas (45 and 74 percent, respectively), while taule roofing is used almost exclusively in urban areas (31 percent). Urban and rural households show a similar preference for metal roofing (21 and 24 percent, respectively). 2.2 SECONDHAND SMOKE EXPOSURE Secondhand smoke (SHS) causes health risks in children and adults who do not smoke. Pregnant women exposed to SHS have a higher risk of giving birth to a low- birth-weight baby (Windham et al. 1999). Children who are exposed to SHS are at increased risk for respiratory and ear infections and poor lung development (US Department of Health and Human Services 2006). The 2015-16 ADHS collected information on smoking inside the home to assess the percentage of households in which there is exposure to secondhand smoke. The last panel in Table 2.4 shows percent distribution of households by frequency of smoking inside the home. In over half of the households in Armenia, someone smokes inside the house on a daily basis, compared with just over one-third of households where no one smokes inside the house. Rural households (60 percent) are slightly more likely to report Table 2.4 Household characteristics Percent distribution of households by housing characteristics, percentage using solid fuel for cooking, and percent distribution by frequency of smoking in the home, according to residence, Armenia 2015-16 Housing characteristic Residence Total Urban Rural Electricity Yes 100.0 100.0 100.0 No 0.0 0.0 0.0 Total 100.0 100.0 100.0 Flooring material Earth/sand 0.4 0.2 0.3 Wood planks 11.7 36.0 20.8 Parquet/polished wood/laminate 76.5 51.9 67.2 Vinyl/linoleum 3.0 2.3 2.7 Ceramic/marble tiles 3.4 3.3 3.4 Cement 1.3 4.1 2.3 Carpet 3.5 2.3 3.1 Missing 0.2 0.0 0.1 Total 100.0 100.0 100.0 Main wall material No walls 0.0 0.0 0.0 Dirt 0.0 0.0 0.0 Stone with mud 6.0 8.2 6.8 Uncovered adobe 0.1 0.0 0.0 Plywood 0.0 0.0 0.0 Reused wood 0.0 0.0 0.0 Cement/monolith 3.2 0.8 2.3 Stone with lime/cement 50.6 86.6 64.1 Bricks 0.7 2.5 1.4 Cement blocks or panels 38.9 1.4 24.8 Covered adobe 0.0 0.1 0.0 Wood planks/ shingles 0.4 0.2 0.3 Other 0.1 0.1 0.1 Total 100.0 100.0 100.0 Main roof material No roof 0.1 0.0 0.1 Wood planks 0.0 0.1 0.1 Metal 20.7 23.5 21.7 Wood 0.1 0.3 0.2 Calamine/cement fiber 3.0 1.4 2.4 Ceramic tiles 0.1 0.5 0.3 Cement 0.1 0.5 0.2 Roofing shingles/schiefer 44.8 73.6 55.6 Taule (tarred roofing paper) 31.0 0.1 19.4 Missing 0.1 0.0 0.1 Total 100.0 100.0 100.0 Rooms used for sleeping One 34.1 22.2 29.6 Two 44.3 37.5 41.8 Three or more 21.5 40.0 28.4 Missing 0.2 0.3 0.2 Total 100.0 100.0 100.0 Place for cooking In the house 99.5 95.2 97.9 In a separate building 0.4 4.7 2.0 Outdoors 0.1 0.0 0.1 Missing 0.0 0.0 0.0 Total 100.0 100.0 100.0 Cooking fuel Electricity 2.8 2.2 2.6 LPG 4.5 19.4 10.1 Natural gas 92.1 70.2 83.9 Biogas 0.3 0.2 0.3 Wood 0.3 7.1 2.9 Animal dung 0.0 0.8 0.3 Total 100.0 100.0 100.0 Percentage using solid fuel for cooking1 0.3 8.0 3.2 Frequency of smoking in the home Daily 49.5 59.7 53.4 Weekly 4.5 4.7 4.6 Monthly 1.8 1.8 1.8 Less than monthly 3.9 2.3 3.3 Never 40.3 31.5 37.0 Total 400.8 412.8 405.3 Number 4,924 2,969 7,893 LPG = Liquefied petroleum gas 1 Includes wood and animal dung 16 • Housing Characteristics and Household Population someone smokes on a daily basis and less likely to say no one ever smokes inside the house (32 percent) than urban households (50 and 40 percent, respectively). A comparison of the 2010 and 2015-16 ADHS results indicates that there has been virtually no change either in the proportion of households in which members are exposed to smoking on a daily basis (55 percent and 53 percent, respectively) or in the proportion of households in which no one smokes (38 percent and 37 percent, respectively). 2.3 HOUSEHOLD POSSESSIONS The availability of durable goods is an approximate measure of household socioeconomic status. Moreover, particular goods have specific benefits: having access to a radio or a television exposes household members to innovative ideas; a refrigerator prolongs the wholesomeness of foods; and a means of transportation allows greater access to many services away from the local area. Table 2.5 provides information on household ownership of durable goods (e.g., radios, televisions, phones, computers, or refrigerators) and means of transportation (e.g., bicycles, motorcycles, or automobiles). Virtually all Armenian households have a television, 97 percent have a refrigerator, and 93 percent have a washing machine. Most households also have a mobile telephone (96 percent), and 69 percent have a computer. Virtually all households own common household furnishings like a table, sofa, and bed. Thirty-nine percent of households own a car or truck. Urban households are more likely than rural households to own most of the household effects shown in Table 2.5, although the differences in ownership rates are not large for many goods. Rural households are notably more likely to own a car or truck than urban households (48 percent and 34 percent, respectively). As expected, they are also much more likely to own agricultural land and farm animals than urban households. Household ownership of most durable goods has increased since the 2010 ADHS. Particularly noteworthy is the rapid growth in computer ownership. Around 7 in 10 households owned a computer in 2015-16 compared with 29 percent at the time of the 2010 ADHS. The increase in computer ownership among rural households has been especially rapid, from 12 percent in 2010 to 62 percent in 2015-16. The proportion of households owning a mobile phone also increased, from 87 percent in 2010 to 96 percent in 2015-16. On the other hand, there was a sharp drop in the percentage of households owning a non-mobile telephone, from 78 percent in 2010 to 58 percent in 2015-16. The drop in ownership of non-mobile phones was especially large among rural households, from 56 percent in 2010 to 25 percent in 2015-16. 2.4 WEALTH QUINTILES The wealth index is a measure that has been tested in a number of countries in relation to inequities in household income, use of health services, and health outcomes (Rutstein et al. 2000; Rutstein and Johnston 2004). Its construction takes into account urban-rural differences in household and dwelling characteristics Table 2.5 Household possessions Percentage of households possessing various household effects, means of transportation, agricultural land and livestock/farm animals by residence, Armenia 2015-16 Possession Residence Total Urban Rural Household effects Radio 7.8 2.4 5.8 Television 99.6 99.5 99.5 Mobile phone 96.5 96.0 96.3 Non-mobile phone 77.7 25.2 57.9 Computer 72.7 62.2 68.7 Refrigerator 97.9 95.2 96.9 Washing machine 94.2 90.5 92.8 Vacuum cleaner 80.3 62.1 73.4 Video camera camcorder 21.7 12.4 18.2 Table 99.9 99.8 99.9 Chair 100.0 99.8 99.9 Sofa 99.3 98.4 99.0 Bed 99.9 99.9 99.9 Wall unit/buffet 95.4 95.6 95.5 Air conditioner 13.9 6.5 11.1 DVD player 35.4 35.2 35.3 Satellite antenna 26.4 40.6 31.8 Freezer 10.0 6.7 8.8 Sewing machine 42.6 40.0 41.6 Carpet 93.9 92.2 93.3 Internet connection 72.7 62.2 68.8 Means of transport Bicycle 7.2 11.0 8.6 Animal drawn cart 0.2 0.8 0.4 Motorcycle/scooter 0.2 0.3 0.2 Car/truck 34.1 47.7 39.2 Boat with a motor 0.2 0.3 0.3 Ownership of agricultural land 13.0 84.2 39.7 Ownership of farm animals1 4.1 56.1 23.7 Number of households 4,924 2,969 7,893 1 Milk cows or bulls; cattle; horses, donkeys, or mules; goats; sheep; pigs; rabbits; other animals with fur; chickens or other poultry; or beehives Housing Characteristics and Household Population • 17 (Rutstein 2008). Each household is assigned a score based on the assets the household owns, 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, each with the same number of individuals. At the national level, approximately 20 percent of the population is in each wealth quintile. Table 2.6 shows the distribution of the de jure household population across the five wealth quintiles, for urban and rural areas and by region. These distributions indicate the degree to which wealth is evenly (or unevenly) distributed among geographic areas. For example, 82 percent of the rural population is in the lowest and second-lowest wealth quintiles. In contrast, 64 percent of the urban population is in the two highest wealth quintiles. Considering the regional distributions, around 7 in 10 residents in Aragatsotn, Ararat, and Armavir are in the lowest two wealth quintiles compared with only 4 percent of residents in Yerevan. Table 2.6 also shows the Gini coefficient of wealth in Armenia, which indicates the concentration of wealth, with 0 representing an exactly equal distribution (everyone having the same amount of wealth) and 1 representing a totally unequal distribution (one person having all the wealth). The overall Gini coefficient is 0.05, suggesting a relatively equal distribution of wealth at the national level. The lowest Gini coefficient is seen in Yerevan (0.02), where nearly half of the population (47 percent) is in the highest wealth quintile. The highest Gini coefficients—that is, the least equitable distributions of wealth—are observed in Armavir (0.19) and Vayots Dzor (0.12). Table 2.6 Wealth quintiles Percent distribution of the de jure population by wealth quintiles, and the Gini coefficient, according to residence and region, Armenia 2015-16 Residence/region Wealth quintile Total Number of persons Gini coefficient Lowest Second Middle Fourth Highest Residence Urban 3.9 6.9 25.4 32.1 31.7 100.0 16,482 0.04 Rural 43.1 38.8 12.3 2.6 3.2 100.0 11,475 0.03 Region Yerevan 1.5 2.4 17.0 32.3 46.8 100.0 8,558 0.02 Aragatsotn 30.7 40.4 17.4 9.1 2.4 100.0 1,451 0.06 Ararat 40.1 33.3 13.2 8.3 5.1 100.0 2,623 0.08 Armavir 42.9 27.5 15.1 10.4 3.9 100.0 2,550 0.19 Gegharkunik 27.4 25.9 29.5 12.6 4.6 100.0 2,208 0.05 Lori 28.5 20.6 25.5 20.0 5.3 100.0 1,942 0.08 Kotayk 16.4 26.0 21.2 19.8 16.7 100.0 3,019 0.10 Shirak 18.0 23.8 25.2 20.0 13.0 100.0 2,377 0.09 Syunik 19.0 28.2 26.7 15.5 10.6 100.0 1,295 0.06 Vayots Dzor 27.6 24.4 19.2 16.6 12.2 100.0 578 0.12 Tavush 28.6 29.5 23.0 12.6 6.3 100.0 1,357 0.07 Total 20.0 20.0 20.0 20.0 20.0 100.0 27,958 0.05 2.5 HAND WASHING Washing hands with soap and water is the most hygienic way to wash. However, hand washing with a non-soap cleaning agent such as ash or sand is an improvement over not using any cleansing agent. In the 2015-16 ADHS, the household respondents were asked to show the interviewer where household members most often wash their hands, and the interviewer recorded if water, soap, and a non-soap cleaning agent were available at that location. A hand washing station was observed in 96 percent of households interviewed in the ADHS (Table 2.7). Among households where a place for hand washing was observed, 97 percent had soap and water available at the time of interview. Only 2 percent of households in Armenia had soap alone, and less than 1 percent did not have water, soap, or another cleansing agent available. Households in the lowest wealth quintile (90 percent) and households in Armavir (91 percent) were least likely to have water and soap or another cleansing agent available. 18 • Housing Characteristics and Household Population Table 2.7 Hand washing Percentage of households in which the place most often used for washing hands was observed, and among households in which the place for hand washing was observed, percent distribution by availability of water, soap and other cleansing agents, Armenia 2015-16 Background characteristic Percentage of households in which place for washing hands was observed1 Number of house- holds Among households where place for hand washing was observed, percentage with: Number of households with place for hand washing observed Soap and water2 Water and cleansing agent3 other than soap only Water only Soap but no water4 Cleansing agent other than soap only3 No water, no soap, no other cleansing agent Missing Total Residence Urban 97.2 4,924 98.4 0.0 0.6 0.5 0.0 0.1 0.5 100.0 4,788 Rural 94.5 2,969 93.4 0.0 2.2 3.5 0.2 0.7 0.0 100.0 2,806 Region Yerevan 96.8 2,480 98.7 0.0 0.2 0.3 0.0 0.0 0.8 100.0 2,401 Aragatsotn 89.8 387 92.5 0.0 3.3 3.0 0.0 1.1 0.0 100.0 347 Ararat 96.7 682 95.1 0.1 3.1 0.8 0.2 0.6 0.1 100.0 659 Armavir 93.6 633 90.6 0.0 0.5 8.5 0.0 0.5 0.0 100.0 592 Gegharkunik 96.2 601 91.9 0.0 3.5 3.8 0.0 0.7 0.1 100.0 579 Lori 99.1 645 97.5 0.0 0.5 1.9 0.0 0.0 0.0 100.0 639 Kotayk 98.1 799 95.7 0.0 2.2 0.3 0.5 1.0 0.3 100.0 784 Shirak 93.8 685 98.4 0.0 0.3 1.2 0.0 0.0 0.2 100.0 643 Syunik 100.0 448 99.9 0.0 0.0 0.1 0.0 0.0 0.0 100.0 448 Vayots Dzor 95.5 167 98.5 0.0 1.5 0.0 0.0 0.0 0.0 100.0 160 Tavush 93.5 366 97.7 0.0 1.1 0.8 0.0 0.4 0.0 100.0 342 Wealth quintile Lowest 91.4 1,700 89.8 0.0 3.3 5.4 0.3 1.1 0.1 100.0 1,554 Second 97.0 1,452 96.2 0.0 1.7 1.7 0.0 0.3 0.1 100.0 1,409 Middle 97.4 1,791 98.1 0.0 0.6 0.6 0.1 0.2 0.5 100.0 1,744 Fourth 98.3 1,558 99.2 0.0 0.2 0.1 0.0 0.0 0.5 100.0 1,531 Highest 97.4 1,392 99.5 0.0 0.0 0.0 0.0 0.0 0.5 100.0 1,355 Total 96.2 7,893 96.5 0.0 1.2 1.6 0.1 0.3 0.3 100.0 7,594 1 Includes fixed and mobile place 2 Soap includes soap or detergent in bar, liquid, powder or paste form. This column includes households with soap and water only as well as those that had soap and water and another cleansing agent. 3 Cleansing agents other than soap include locally available materials such as ash, mud, or sand. 4 Includes households with soap only as well as those with soap and another cleansing agent 2.6 HOUSEHOLD POPULATION BY AGE AND SEX Age and sex are important demographic variables and form the primary basis of demographic classification in vital statistics, censuses, and surveys. They are also important variables in the study of mortality, fertility, and nuptiality. Table 2.8 shows how the de facto household population is distributed by 5-year age groups, according to urban-rural residence and sex. The 2015-16 ADHS results indicate that, as expected, women outnumber men in Armenia. Overall, there were only 89 men for every 100 women in the de facto population in the households interviewed in the survey. The gender disparity is much more pronounced in urban areas than in rural areas (83 and 98 men per 100 women, respectively). Among the population under age 15, there are more males than females. The opposite pattern is consistently observed among the population age 50 and over, a result of higher mortality among men than women. The age structure shown in Figure 2.1 is typical of an older population characterized by low fertility. Over two-thirds of the population is in the 15-64 age group, also referred to as the economically active population. The dependency ratio, which is the ratio of the non-productive population (persons under age 15 and age 65 and over) to the economically active population, is 48, which represents a slight increase over the dependency ratio of 45 at the time of the 2010 ADHS. The increase reflects the aging of the population, which characterizes countries in which fertility has fallen below the replacement level. Housing Characteristics and Household Population • 19 Table 2.8 Household population by age, sex, and residence Percent distribution of the de facto household population by 5-year age groups, according to sex and residence, Armenia 2015-16 Age Urban Rural Total Male Female Total Male Female Total Male Female Total <5 7.0 5.4 6.1 7.3 5.6 6.4 7.1 5.5 6.3 5-9 7.8 5.4 6.5 6.8 6.3 6.5 7.4 5.8 6.5 10-14 7.4 5.4 6.3 7.3 5.7 6.5 7.4 5.5 6.4 15-19 5.5 4.6 5.0 5.3 6.2 5.7 5.4 5.2 5.3 20-24 6.1 6.3 6.2 8.8 7.1 7.9 7.2 6.6 6.9 25-29 7.5 8.1 7.8 8.8 7.6 8.2 8.0 7.9 8.0 30-34 7.8 7.3 7.5 7.5 6.9 7.2 7.7 7.1 7.4 35-39 7.1 6.3 6.7 5.1 6.2 5.6 6.2 6.2 6.2 40-44 5.6 5.5 5.5 4.8 5.8 5.3 5.2 5.6 5.4 45-49 4.5 5.0 4.8 6.0 5.2 5.6 5.2 5.1 5.1 50-54 7.0 8.6 7.9 9.1 10.1 9.6 7.9 9.2 8.6 55-59 7.6 9.3 8.5 8.2 7.8 8.0 7.8 8.7 8.3 60-64 6.6 7.2 6.9 4.9 5.3 5.1 5.9 6.5 6.2 65-69 4.9 5.5 5.2 2.9 3.6 3.3 4.0 4.8 4.4 70-74 2.4 3.0 2.7 1.6 2.2 1.9 2.0 2.7 2.4 75-79 2.8 4.0 3.5 3.0 4.2 3.6 2.9 4.1 3.5 80 + 2.5 3.1 2.8 2.8 4.2 3.5 2.6 3.5 3.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of persons 7,466 8,955 16,421 5,624 5,758 11,382 13,089 14,713 27,803 Figure 2.1 Population pyramid 8 6 4 2 0 2 4 6 8 <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 + Percent Age Male Female ADHS 2015-16 20 • Housing Characteristics and Household Population 2.7 HOUSEHOLD SIZE AND COMPOSITION Table 2.9 presents the percent distribution of households in the 2015-16 ADHS sample by sex of the head of the household and by mean household size. These characteristics are important because they are often associated with differences in household socioeconomic levels. For example, female-headed households are frequently poorer than households headed by males. In addition, the size and composition of the household affects the allocation of financial and other resources among household members, which in turn influences the overall well-being of these individuals. Household size is also associated with crowding in the dwelling, which can lead to unfavorable health conditions. The average household size at the time of the 2015-16 ADHS had fallen to 3.5 persons, compared with 4.3 persons in at the time of the 2000 ADHS. The majority of households are headed by males, with one-third (33 percent) headed by females. The rate of households run by women is slightly lower than that reported in the 2010 ADHS; this reverses an upward trend in which the proportion of female- headed households increased from 29 percent at the time of the 2000 ADHS to 37 percent in 2010. The average household size in rural areas is larger than in urban areas (3.9 compared with 3.3 members). On the other hand, households in urban areas are more likely than those in rural areas to be headed by a woman (37 percent compared with 28 percent). Information on households with foster children and orphans also was collected in the 2015-16 ADHS. Foster children are defined here as children under age 18 living in households with neither their mother nor their father present, while orphans are children with one or both parents dead. Table 2.9 shows that only a small proportion of households (2 percent) include orphans or foster children under age 18. 2.8 CHILDREN’S LIVING ARRANGEMENTS AND ORPHANHOOD Table 2.10 presents information on living arrangements and orphanhood for children under age 18. The majority of children under age 18 (86 percent) live with both parents, 11 percent live with their mother only, 1 percent live with their father only, and 1 percent live with neither of their biological parents. The table also provides data on the extent of orphanhood, that is, the proportion of children who have lost one or both parents. Three percent of children under age 18 have lost one or both parents. Two percent of children under age 18 have lost their fathers, while less than 1 percent have lost their mothers. Very few children under age 18 are reported to have lost both parents. Table 2.9 Household composition Percent distribution of households by sex of head of household and by household size; mean size of households; and percentage of households with orphans and foster children under age 18, according to residence, Armenia 2015-16 Characteristic Residence Total Urban Rural Household headship Male 63.5 72.4 66.8 Female 36.5 27.6 33.2 Total 100.0 100.0 100.0 Number of usual members 1 16.6 12.8 15.2 2 21.9 16.9 20.0 3 16.8 15.1 16.1 4 19.1 17.6 18.6 5 12.6 15.7 13.7 6 8.8 13.4 10.5 7 2.6 5.3 3.6 8 0.8 1.8 1.1 9+ 0.8 1.5 1.0 Total 100.0 100.0 100.0 Mean size of households 3.3 3.9 3.5 Percentage of households with orphans and foster children under 18 Double orphans 0.1 0.0 0.1 Single orphans1 1.3 1.0 1.2 Foster children2 0.7 0.7 0.7 Orphans and/or foster children 2.0 1.6 1.9 Number of households 4,924 2,969 7,893 Note: Table is based on de jure household members, that is, 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 father are alive. Housing Characteristics and Household Population • 21 Differentials in fosterhood and orphanhood by background characteristics are generally not large. Older children are less likely than younger children to live with both parents. This results from increases with age in both proportions of children who are fostered and children who are orphaned. Shirak and Yerevan have the lowest proportions of children living with both parents (77 percent and 82 percent, respectively). These regions also report the highest proportions of children who live only with their mothers but whose fathers are alive (18 percent for Shirak and 12 percent for Yerevan). Greater employment-driven outmigration from these regions may be a factor in both patterns. Table 2.10 Children's living arrangements and orphanhood Percent distribution of de jure children under age 18 by living arrangements and survival status of parents, the percentage of children not living with a biological parent, and the percentage of children with one or both parents dead, according to background characteristics, Armenia 2015-16 Background characteristic 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 Both alive Only father alive Only mother alive Both dead Missing infor- mation on father/ mother Father alive Father dead Mother alive Mother dead Age 0-4 91.3 8.0 0.4 0.1 0.1 0.1 0.0 0.0 0.0 0.1 100.0 0.1 0.5 1,743 <2 92.4 7.3 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 100.0 0.0 0.3 724 2-4 90.4 8.5 0.5 0.2 0.1 0.2 0.0 0.0 0.0 0.1 100.0 0.2 0.6 1,019 5-9 86.9 9.7 1.3 0.7 0.2 0.8 0.2 0.0 0.1 0.1 100.0 1.1 1.8 1,807 10-14 82.9 9.6 3.8 1.3 0.5 1.3 0.3 0.0 0.0 0.3 100.0 1.6 4.6 1,781 15-17 82.9 10.7 2.5 0.8 0.6 2.1 0.0 0.0 0.3 0.2 100.0 2.4 3.4 988 Sex Male 85.9 9.6 2.2 0.6 0.3 0.8 0.2 0.0 0.1 0.2 100.0 1.1 2.8 3,366 Female 86.8 9.0 1.7 0.8 0.3 1.1 0.1 0.0 0.0 0.1 100.0 1.2 2.1 2,953 Residence Urban 83.3 11.8 2.4 0.7 0.3 1.0 0.2 0.0 0.1 0.1 100.0 1.3 3.0 3,662 Rural 90.5 6.0 1.3 0.8 0.3 0.9 0.0 0.0 0.0 0.2 100.0 0.9 1.7 2,657 Region Yerevan 82.3 12.1 2.8 0.9 0.2 1.1 0.3 0.0 0.2 0.0 100.0 1.6 3.6 1,900 Aragatsotn 93.2 4.3 1.6 0.3 0.2 0.1 0.0 0.0 0.0 0.3 100.0 0.1 1.8 311 Ararat 90.9 5.6 2.1 0.6 0.0 0.6 0.2 0.0 0.0 0.0 100.0 0.8 2.3 600 Armavir 84.8 9.9 1.9 0.7 0.5 1.6 0.0 0.0 0.0 0.6 100.0 1.6 2.4 640 Gegharkunik 91.4 4.6 2.7 0.0 0.8 0.4 0.0 0.0 0.1 0.0 100.0 0.6 3.6 467 Lori 87.7 9.4 1.0 0.0 0.5 1.4 0.0 0.0 0.0 0.2 100.0 1.4 1.4 309 Kotayk 89.7 7.9 0.8 0.7 0.4 0.1 0.1 0.0 0.0 0.2 100.0 0.3 1.3 772 Shirak 77.0 17.5 2.5 1.2 0.4 1.4 0.0 0.0 0.0 0.0 100.0 1.4 2.9 568 Syunik 88.9 7.0 1.2 0.7 0.0 2.3 0.0 0.0 0.0 0.0 100.0 2.3 1.2 281 Vayots Dzor 94.7 3.5 1.1 0.0 0.0 0.7 0.0 0.0 0.0 0.0 100.0 0.7 1.1 128 Tavush 91.9 4.4 0.1 1.8 0.2 0.7 0.0 0.0 0.0 0.8 100.0 0.7 0.4 344 Wealth quintile Lowest 86.3 8.9 2.7 1.2 0.1 0.4 0.1 0.0 0.0 0.3 100.0 0.5 2.8 1,287 Second 88.8 6.7 1.3 0.6 0.4 1.9 0.0 0.0 0.0 0.3 100.0 1.9 1.8 1,201 Middle 82.8 11.8 2.4 0.7 0.5 0.8 0.7 0.0 0.2 0.1 100.0 1.7 3.8 1,189 Fourth 86.1 10.4 1.5 0.6 0.2 1.0 0.0 0.0 0.0 0.2 100.0 1.0 1.8 1,211 Highest 87.5 9.1 1.7 0.6 0.3 0.7 0.0 0.0 0.1 0.0 100.0 0.8 2.2 1,431 Total <15 87.0 9.1 1.8 0.7 0.2 0.7 0.2 0.0 0.0 0.2 100.0 0.9 2.3 5,331 Total <18 86.3 9.4 1.9 0.7 0.3 0.9 0.1 0.0 0.1 0.2 100.0 1.2 2.5 6,319 Note: Table is based on de jure members, that is, 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 2.9 EDUCATIONAL ATTAINMENT OF HOUSEHOLD MEMBERS Education is important because it helps individuals make informed decisions that influence their health and well-being. Armenia’s educational system has undergone several stages of restructuring over the past decade, making the analysis of educational data across a wide range of ages challenging.2 The current school system has been in place since 2007. The system consists of primary school (grades 1 through 4 for students age 6-9), middle school (grades 5 through 9 for students age 10-14), and high school (grades 10 2 The Armenian educational system before 2007 consisted of primary school (grades 1-3, age 7-9), middle school (grades 4-8, age 10-14), and high school (grades 9-10, ages 15-16). Education of at least 8 grades was compulsory. Students who had completed at least 8 grades were eligible for secondary-special education. Since 2005, age 6 years and 6 months has become the mandatory age of school enrollment. Before 2005, when children were allowed to enter school at age 6 or 7, the majority of children would start school at age 7. 22 • Housing Characteristics and Household Population through 12 for students age 15-17). Primary and middle school (grades 1 through 9) together constitute what is referred to as basic education. In the constitution of Armenia basic education is declared to be mandatory. Primary, middle, and high school together (or grades 1 through 12) constitute what is referred to as a standard school or secondary education. In this report, respondents who have attended or completed grades 1 through 9 are presented as having attained basic education, and those who, in addition to basic school, have attended or completed high school are presented as having attained secondary education. Students who have completed a minimum of nine grades may enroll in specialized secondary education, which provides training for careers that require mid-level qualifications, such as nurses, midwives, musicians, technicians, and others. The course of study for specialized secondary education can be completed in 3-5 years depending on the number of grades. Upon graduation students receive a secondary- special education degree, which recognizes a level that is somewhat higher than secondary education but lower than higher education. University and postgraduate education provides training for a higher level of specialist. Students who have completed secondary education or secondary-special education may enroll in a university. Tables 2.11.1 and 2.11.2 present information on the educational attainment of the Armenian population age 6 and older. Virtually all Armenians have gone to school. The proportions of the female and male populations with no education are negligible (less than 1 percent each) in most age groups, with the highest levels observed among those age 6 to 9 (reflecting some who have not yet started school) and those age 65 and older. Overall, more than 9 in 10 women and men age 6 and over have attended secondary school, and more than 4 in10 women and around one-third of men have a secondary-special or higher education. The median number of years of schooling is 9.9 years for women and 9.7 years for men. Individuals residing in urban areas have substantially higher rates of secondary-special and higher education than those residing in rural areas. Individuals in Yerevan are around twice as likely to have at least some higher education compared with those in other regions. Wealth status has a strong positive relationship with education; 43 percent of women in the highest wealth quintile have at least some higher education compared with 6 percent of women in the lowest quintile. The corresponding proportions for men are 40 percent and 6 percent, respectively. Data on net attendance ratios (NARs) and gross attendance ratios (GARs) by school level, sex, residence, region, and wealth quintile are shown in Table 2.12. The NAR indicates participation in basic education (primary and middle school) for the population age 6-14 and high school for the population age 15-17. The GAR measures participation at each level of schooling among those of any age from 6 to 24. The GAR is nearly always higher than the NAR for the same level because the GAR includes participation by those who may be older or younger than the official age range for that level.3 A NAR of 100 percent would indicate that all children in the official age range for the level are attending education at that level. The GAR can exceed 100 percent if there is significant over-age or under-age participation at a given level of schooling. In Armenia, attendance among school-age household members is high. The overall NAR for basic education is 96, indicating that, among children who should be attending basic education, 96 percent are currently doing so. The NAR for basic education in 2015-16 is slightly higher than the NAR at the time of the 2010 ADHS (92 percent). The basic school NARs are virtually the same for females and males. Differences in basic school attendance by residence, region, and wealth quintile are not large, with the NAR lowest in Shirak (91 percent) and highest in the highest wealth quintile (98 percent). The basic school GAR is 101 percent. A comparison of the NAR and GAR indicates that approximately 5 percent of students attending basic school are either under age or over age for their grade level. 3 Students who are over age for a given level of schooling may have started school over age, may have repeated one or more grades in school, or may have dropped out of school and later returned. Housing Characteristics and Household Population • 23 Table 2.11.1 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, Armenia 2015-16 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 Secondary special Higher Don't know/ missing Total Number Median years completed Age 6-9 6.7 93.0 0.3 0.0 0.0 0.0 0.0 0.0 100.0 693 0.6 10-14 0.3 7.3 20.0 72.4 0.0 0.0 0.0 0.0 100.0 813 5.0 15-19 0.1 0.0 0.0 46.1 21.5 16.2 16.1 0.0 100.0 770 10.3 20-24 0.2 0.0 0.0 2.9 31.9 16.4 48.6 0.0 100.0 969 12.5 25-29 0.1 0.2 0.2 3.7 34.3 20.4 41.0 0.0 100.0 1,161 12.3 30-34 0.1 0.0 0.1 4.6 42.1 22.5 30.7 0.0 100.0 1,052 11.4 35-39 0.0 0.2 0.0 6.6 43.7 22.9 26.6 0.0 100.0 919 10.0 40-44 0.3 0.0 0.0 4.3 42.3 28.6 24.4 0.0 100.0 825 11.2 45-49 0.3 0.0 0.0 5.6 40.2 30.9 23.0 0.0 100.0 746 11.2 50-54 0.2 0.1 0.1 5.3 46.8 25.6 21.7 0.1 100.0 1,353 9.9 55-59 0.1 0.1 0.2 6.4 44.6 28.5 20.1 0.0 100.0 1,281 10.0 60-64 0.3 0.4 0.2 9.6 40.3 27.5 21.7 0.0 100.0 949 10.0 65+ 1.1 2.7 3.6 22.7 38.0 15.0 16.8 0.1 100.0 2,219 9.5 Residence Urban 0.5 4.8 1.4 11.3 28.8 22.3 30.9 0.0 100.0 8,376 11.3 Rural 1.0 6.9 2.6 18.7 44.4 16.2 10.3 0.0 100.0 5,374 9.5 Region Yerevan 0.3 4.9 1.3 9.9 23.0 20.3 40.4 0.0 100.0 4,409 12.2 Aragatsotn 0.2 6.2 0.9 13.1 52.5 14.9 12.1 0.0 100.0 697 9.6 Ararat 0.5 7.4 2.7 20.9 40.9 15.3 12.3 0.0 100.0 1,232 9.5 Armavir 1.5 6.5 2.0 19.2 38.8 19.4 12.7 0.0 100.0 1,181 9.6 Gegharkunik 1.8 6.3 3.2 18.2 49.9 11.7 8.9 0.0 100.0 1,105 9.5 Lori 0.5 4.1 1.8 16.5 41.0 21.7 14.4 0.0 100.0 978 9.7 Kotayk 0.7 7.0 2.2 12.9 36.2 22.3 18.5 0.1 100.0 1,452 9.8 Shirak 0.7 4.6 1.2 12.1 36.8 24.8 19.8 0.0 100.0 1,154 9.9 Syunik 0.5 3.8 2.0 16.0 39.9 20.6 17.2 0.0 100.0 627 9.8 Vayots Dzor 0.2 6.0 3.0 12.3 41.0 24.4 13.1 0.0 100.0 278 9.7 Tavush 1.0 7.0 1.6 18.0 29.9 27.5 15.0 0.0 100.0 635 9.8 Wealth quintile Lowest 1.1 7.4 3.1 23.1 45.9 13.2 6.1 0.0 100.0 2,705 9.4 Second 0.8 5.8 2.1 14.3 42.9 19.3 14.8 0.0 100.0 2,667 9.7 Middle 0.6 4.0 1.3 13.9 39.6 22.6 18.0 0.1 100.0 2,810 9.8 Fourth 0.5 5.1 1.2 9.8 27.0 24.2 32.3 0.0 100.0 2,832 11.6 Highest 0.2 6.0 1.6 10.1 19.6 20.0 42.6 0.0 100.0 2,735 12.3 Total 0.7 5.6 1.8 14.2 34.9 19.9 22.9 0.0 100.0 13,750 9.9 1 Completed 4 grade at the primary level 2 Completed grade 12 or completed more than 9 years of schooling and has a secondary school attestat Table 2.11.2 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, Armenia 2015-16 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 Secondary special Higher Don't know/ missing Total Number Median years completed Age 6-9 6.8 93.1 0.1 0.0 0.0 0.0 0.0 0.0 100.0 764 0.8 10-14 0.2 6.3 19.2 74.3 0.0 0.0 0.0 0.0 100.0 967 5.2 15-19 0.5 0.0 0.0 49.8 20.7 16.0 13.0 0.0 100.0 706 10.0 20-24 0.2 0.1 0.2 9.6 44.9 10.7 34.3 0.0 100.0 948 10.9 25-29 0.2 0.4 0.0 10.2 43.7 11.5 33.8 0.1 100.0 1,050 9.9 30-34 0.5 0.1 0.0 11.3 44.5 9.4 34.1 0.1 100.0 1,003 9.8 35-39 0.2 0.3 0.2 11.2 51.4 12.5 24.1 0.1 100.0 814 9.7 40-44 0.2 0.0 0.0 7.3 47.9 19.1 25.4 0.0 100.0 686 9.9 45-49 0.0 0.0 0.0 8.5 46.8 25.3 19.4 0.1 100.0 674 9.9 50-54 0.2 0.5 0.1 6.7 50.6 21.8 20.1 0.0 100.0 1,038 9.8 55-59 0.0 0.1 0.2 8.1 42.3 25.1 24.2 0.1 100.0 1,025 10.0 60-64 0.3 0.4 0.1 6.9 45.6 22.8 23.9 0.0 100.0 773 9.9 65+ 0.4 1.3 2.5 20.7 37.2 15.7 22.1 0.0 100.0 1,512 9.7 Residence Urban 0.6 7.1 1.6 13.7 30.8 16.2 30.0 0.0 100.0 6,830 9.9 Rural 0.8 6.3 2.3 22.8 45.1 12.2 10.5 0.0 100.0 5,130 9.5 Region Yerevan 0.3 7.1 1.6 12.1 24.6 15.0 39.4 0.0 100.0 3,531 11.4 Aragatsotn 0.2 6.5 1.7 17.5 49.0 9.6 15.3 0.2 100.0 662 9.5 Ararat 0.8 6.7 2.7 23.4 40.3 12.4 13.6 0.0 100.0 1,141 9.5 Armavir 0.8 8.5 2.6 28.2 37.0 12.5 10.4 0.0 100.0 1,117 9.3 Gegharkunik 1.0 6.3 2.2 18.3 54.7 6.2 11.2 0.0 100.0 1,025 9.5 Lori 0.9 5.0 1.4 15.8 49.1 16.2 11.2 0.4 100.0 837 9.6 Kotayk 1.1 6.6 1.9 17.1 38.5 16.6 18.2 0.0 100.0 1,242 9.7 Shirak 1.2 5.9 2.1 16.6 37.9 18.5 17.7 0.0 100.0 984 9.7 Syunik 0.2 5.8 1.7 16.6 44.8 14.7 16.3 0.0 100.0 593 9.6 Vayots Dzor 0.3 6.8 1.2 14.8 37.2 25.1 14.6 0.0 100.0 251 9.8 Tavush 0.8 7.9 2.0 24.6 28.9 20.9 14.8 0.0 100.0 578 9.6 Wealth quintile Lowest 1.0 7.4 2.9 27.8 45.1 10.2 5.5 0.2 100.0 2,421 9.3 Second 0.8 5.5 1.7 18.8 44.3 14.0 14.8 0.0 100.0 2,499 9.6 Middle 0.8 6.8 1.5 16.6 40.0 16.1 18.1 0.0 100.0 2,354 9.7 Fourth 0.2 6.6 1.7 12.3 31.3 17.0 31.0 0.0 100.0 2,353 10.0 Highest 0.6 7.6 1.8 11.9 22.9 15.2 40.0 0.0 100.0 2,334 11.6 Total 0.7 6.8 1.9 17.6 36.9 14.5 21.7 0.0 100.0 11,961 9.7 1 Completed 4 grade at the primary level 2 Completed grade 12 or completed more than 9 years of schooling and has a secondary school attestat 24 • Housing Characteristics and Household Population The NAR is much lower at the high school level: only 56 percent of students age 15-17 who should be attending high school are in school. While it is low, a comparison with the NAR in 2010 (45 percent) indicates that high school attendance improved substantially in the period between the two surveys. High school attendance ratios are higher among females than males (62 percent and 51 percent, respectively). Surprisingly, both the NAR and GAR at the high school level are slightly higher among students living in rural areas than among those living in urban areas. The high school NAR and GAR are also lower in Yerevan than in other regions. The high school GAR is 64 percent. A comparison of the NAR and GAR indicates that approximately 8 percent of students are either under age or over age for their grade level. Syunik has the highest proportion of high school age students who are either under age or over age for their grade level (21 percent). Table 2.12 School attendance ratios Net attendance ratios (NARs) and gross attendance ratios (GARs) for the de facto household population, by sex and level of schooling; and the Gender Parity Index (GPI), according to background characteristics, Armenia 2015-16 Background characteristic Net attendance ratio1 Gross attendance ratio2 Male Female Total Gender Parity Index3 Male Female Total Gender Parity Index3 BASIC SCHOOL Residence Urban 97.5 95.5 96.6 0.98 102.5 100.1 101.4 0.98 Rural 95.5 96.1 95.8 1.01 100.4 100.3 100.4 1.00 Region Yerevan 99.5 95.5 97.6 0.96 104.3 101.3 102.9 0.97 Aragatsotn 95.9 95.4 95.6 0.99 104.4 97.5 101.2 0.93 Ararat 96.9 98.0 97.5 1.01 102.2 101.7 102.0 1.00 Armavir 96.0 98.3 96.9 1.02 101.0 102.2 101.5 1.01 Gegharkunik 96.2 93.5 95.0 0.97 99.9 96.4 98.2 0.97 Lori 95.1 95.0 95.0 1.00 97.9 99.4 98.6 1.01 Kotayk 95.8 96.1 95.9 1.00 101.0 100.3 100.7 0.99 Shirak 94.8 94.8 94.8 1.00 101.9 101.4 101.7 1.00 Syunik 91.1 91.5 91.3 1.00 96.6 94.6 95.6 0.98 Vayots Dzor 97.8 94.4 96.2 0.97 101.6 100.6 101.1 0.99 Tavush 94.0 97.7 95.6 1.04 96.3 100.4 98.1 1.04 Wealth quintile Lowest 95.7 96.1 95.8 1.00 100.8 100.1 100.5 0.99 Second 95.8 95.5 95.7 1.00 101.7 100.0 100.9 0.98 Middle 96.0 94.9 95.5 0.99 99.7 98.5 99.2 0.99 Fourth 97.7 94.9 96.4 0.97 102.8 99.8 101.4 0.97 Highest 98.1 97.0 97.5 0.99 103.3 102.1 102.7 0.99 Total 96.7 95.7 96.2 0.99 101.7 100.2 101.0 0.99 HIGH SCHOOL Residence Urban 44.0 53.8 48.7 1.22 49.7 62.6 55.9 1.26 Rural 60.6 71.7 66.1 1.18 70.7 78.3 74.4 1.11 Region Yerevan 36.5 49.8 43.0 1.36 37.0 58.3 47.4 1.58 Aragatsotn 64.9 61.2 63.6 0.94 72.6 68.4 71.2 0.94 Ararat 51.8 68.0 59.7 1.31 64.3 74.9 69.5 1.16 Armavir 51.8 47.4 49.9 0.92 57.1 50.9 54.4 0.89 Gegharkunik 69.0 76.4 73.2 1.11 78.1 83.5 81.2 1.07 Lori 59.0 65.7 62.3 1.11 68.1 82.7 75.3 1.21 Kotayk 51.0 71.0 60.3 1.39 62.2 77.2 69.2 1.24 Shirak 52.9 57.4 55.0 1.08 67.5 59.6 63.8 0.88 Syunik 64.7 78.9 72.3 1.22 86.8 99.2 93.4 1.14 Vayots Dzor 67.1 80.8 73.7 1.20 69.8 92.8 80.9 1.33 Tavush 61.3 77.0 69.7 1.26 76.7 79.9 78.4 1.04 Wealth quintile Lowest 61.1 77.7 69.3 1.27 70.1 85.2 77.6 1.21 Second 56.3 64.2 60.0 1.14 64.1 72.4 68.0 1.13 Middle 56.4 53.3 54.8 0.95 69.9 56.4 62.8 0.81 Fourth 43.4 57.6 49.3 1.33 47.8 71.4 57.7 1.49 Highest 41.3 56.8 49.2 1.38 45.7 64.0 55.1 1.40 Total 51.3 61.9 56.4 1.21 58.9 69.7 64.1 1.18 1 The NAR for basic school is the percentage of the basic-school age (6-14 years) population that is attending basic school (grades 1-9). The NAR for high school is the percentage of the high-school age (15-17) population that is attending high school (grades 10-12). By definition the NAR cannot exceed 100 percent. 2 The GAR for basic school is the total number of basic school students, expressed as a percentage of the official basic-school- age population. The GAR for high school is the total number of high school students, expressed as a percentage of the official high-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 basic school is the ratio of the basic school NAR(GAR) for females to the NAR(GAR) for males. The Gender Parity Index for high school is the ratio of the high school NAR(GAR) for females to the NAR(GAR) for males. Housing Characteristics and Household Population • 25 The gender parity index (GPI), or the ratio of the female to the male NAR or GAR at the basic and high school levels, is an indicator of the magnitude of the gender gap in attendance ratios. If there is no gender difference, the GPI will equal one. The GPI will be closer to zero if the disparity is in favor of males. If the gender gap favors females, the GPI will exceed one. Table 2.12 shows the GAR GPI is 0.99 for the basic level, which indicates that there is no gender gap at the basic level. At the high school level, the GPI is 1.18, indicating a gender gap favoring females at the high school level. Figure 2.2 presents the age-specific attendance rates (ASAR) for the population age 5-24, by sex. The ASAR indicates that almost all youths of basic school age (6-14) attend school, with virtually no differences by gender. Among the high-school-age population (15-17), attendance ratios begin to decline, with a particularly sharp decline at age 17 among males. One possible explanation is that the requirement to serve in the military at age 18 keeps some young men out of school once they have completed the secondary level. Figure 2.2 Age-specific attendance rates in the de facto population age 5-24 2.10 CHILD PROTECTION In 1989, Armenia became a signatory to the Convention on the Rights of the Child, a document that recognizes that all children have the right to be protected from any harm, including abuse, neglect, and economic exploitation (UN 1989). Armenia ratified the Convention on the Rights of the Child in 1992. In 2003, the Armenia adopted the National Plan of Action for Protection of Children’s Rights, which is an integral part of the country’s child welfare reforms. Information obtained in the 2015-16 ADHS allows for an assessment of two topics that bear on the protection of Armenia’s children: birth registration and child discipline. 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Percent Age (years) Male Female ADHS 2015-16 26 • Housing Characteristics and Household Population 2.10.1 Birth Registration In Armenia, birth registration is recognized as a child’s right. The registration of a birth involves the inscription of the facts of the birth into an official log in the registrar’s office. A birth certificate is issued at the time of registration or later as proof that the birth was registered. The certificate establishes a child’s legal identity, which is important not only during childhood, e.g., to gain access to school, but later in life when the child seeks to marry, vote, or inherit property. In the 2015-16 ADHS, birth registration information was collected in the Household Questionnaire for children under age 5. Table 2.13 gives the percentage of children under age 5 whose births were officially registered and the percentage who had a birth certificate at the time of the survey. Not all children who are registered may have a birth certificate because some certificates may have been lost or were never issued. However, all children with a certificate have been registered. Birth registration is virtually universal in Armenia, with 99 percent of births in the 5 years preceding the survey registered. Practically all births have a certificate. Only small variations are found across subgroups of children, with children in Armavir and Ararat regions the least likely to have a birth certificate (96 percent and 97 percent, respectively). 2.10.2 Child Discipline The manner in which parents and caretakers discipline children can have long-term consequences for their physical and psychological development and well-being. To identify the types of child disciplinary methods used in Armenia, questions on child discipline were asked about one randomly selected child age 1-14 in each household.4 The questions were addressed to the household respondent. Questions referred to practices that may have been used to discipline the child during the 30 days prior to the interview. Specifically, questions asked whether anyone in the household had taken away the child’s privileges, forbade something the child liked, or did not allow the child to leave the house; explained why some behavior was wrong; shook the child; shouted, yelled, or screamed at the child; gave the child something else to do; spanked, hit, or slapped the child on the bottom with a bare hand; hit on the bottom or elsewhere on the body with something like a belt, hairbrush, stick, or other hard object; called the child dumb, lazy, or a similar name; hit or slapped on the face, head, or ears; hit or slapped on the hand, arm, or leg; or beat the child over and over as hard as possible. 4 If several children age 1-14 were listed in the household schedule, only one child per household was randomly selected for administration of the questions on child discipline. If one child age 1-14 was listed in the household schedule, the questions on child discipline were administered about this child. If none of the children listed in the household schedule were age 1-14, the questions on child discipline were not administered. Table 2.13 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, Armenia 2015-16 Background characteristic Children whose births are registered Percentage registered Number of children Percentage who had birth certificate Percentage who did not have birth certificate Age <2 98.6 0.1 98.7 724 2-4 98.7 0.0 98.7 1,019 Sex Male 98.7 0.1 98.9 930 Female 98.5 0.0 98.5 813 Residence Urban 99.0 0.1 99.1 1,009 Rural 98.1 0.0 98.1 734 Region Yerevan 99.0 0.0 99.0 499 Aragatsotn 97.8 0.0 97.8 64 Ararat 96.5 0.0 96.5 174 Armavir 96.0 0.0 96.0 195 Gegharkunik 100.0 0.0 100.0 80 Lori 98.8 0.0 98.8 98 Kotayk 99.6 0.4 100.0 249 Shirak 99.5 0.0 99.5 182 Syunik 100.0 0.0 100.0 64 Vayots Dzor 100.0 0.0 100.0 37 Tavush 100.0 0.0 100.0 98 Wealth quintile Lowest 98.1 0.0 98.1 340 Second 97.4 0.0 97.4 341 Middle 99.7 0.0 99.7 325 Fourth 99.3 0.3 99.7 311 Highest 98.8 0.0 98.8 427 Total 98.6 0.1 98.7 1,743 Housing Characteristics and Household Population • 27 Table 2.14 shows that 7 in 10 children age 1-14 experienced some form of psychological or physical punishment during the 30 days preceding the survey. Approximately one-fifth of children (19 percent) experienced only non-violent discipline. Psychological aggression was more common than physical punishment; about two-thirds of children (65 percent) experienced psychological aggression while 38 percent of children experienced some form of physical punishment. Four percent experienced severe physical punishment. Violent methods were used almost as often to discipline girls (67 percent) as boys (71 percent). Very young children experienced violence less often than children age 3-14; nevertheless, some type of violent method was used to discipline half of 1- and 2-year-old children. Violent disciplinary methods were almost as common among urban (68 percent) as rural children (71 percent). Children from Syunik and Vayots Dzor were least likely to have experienced any violent disciplinary method (56 percent and 59 percent, respectively). In contrast, some type of violent method was used to discipline around 8 in 10 children in Aragatsotn and Lori. Lack of education tends to be positively associated with the use of violent disciplinary methods, especially psychological aggression. Seventy-two percent of children whose head of household had only basic education experienced some form of psychological aggression during the month before the survey compared with 58 percent of children whose head of household had a higher education. The use of violent methods to discipline children tends to decline with the wealth quintile. The relationship between the use of severe physical punishment and both education and wealth is marked. Severe methods were used to discipline 8 percent of children whose head of household had only basic education compared with only 2 percent of children whose head of household had secondary special or higher education. Similarly, the percentage experiencing severe physical punishment decreased from 8 percent among children in the lowest wealth quintile to 2 percent among children in the fourth and fifth quintiles. 28 • Housing Characteristics and Household Population Table 2.14 Child discipline Percentage of children age 1-14 by child disciplinary methods experienced during the month before the survey, according to background characteristics, Armenia 2015-16 Background characteristic Percentage of children age 1-14 years who experienced: Number of children age 1-14 years Only non- violent discipline1 Psychological aggression2 Physical punishment Any violent discipline method5 Any3 Severe4 Age 1-2 12.0 41.5 33.0 0.9 50.1 394 3-4 15.1 67.9 53.4 1.2 74.7 375 5-9 17.3 72.0 41.1 4.0 74.9 1,081 10-14 23.8 65.8 30.6 6.6 67.7 1,030 Sex Male 16.7 67.2 39.0 4.5 70.8 1,515 Female 20.7 62.7 36.6 3.7 66.8 1,365 Residence Urban 21.0 63.7 37.2 2.7 67.6 1,677 Rural 15.3 67.0 38.8 6.2 70.7 1,203 Region Yerevan 22.0 63.7 41.8 1.9 68.9 870 Aragatsotn 17.9 70.4 49.4 9.6 78.6 138 Ararat 7.2 69.0 34.4 9.6 70.4 295 Armavir 14.2 62.9 33.2 2.9 65.0 287 Gegharkunik 13.9 68.4 57.1 20.0 74.7 203 Lori 14.2 76.7 44.8 2.1 79.3 142 Kotayk 17.8 70.1 24.3 0.7 71.2 353 Shirak 18.9 59.4 35.6 1.5 62.7 261 Syunik 34.4 51.9 15.1 0.8 56.2 121 Vayots Dzor 26.3 52.6 36.8 1.7 59.4 58 Tavush 26.6 62.5 41.4 0.8 66.3 153 Education of head of household No education * * * * * 5 Basic 12.4 72.1 40.9 7.7 73.6 359 Secondary 17.6 66.8 37.6 4.8 71.0 1,370 Secondary special 19.2 64.2 37.2 1.9 66.8 552 Higher 24.4 57.7 37.0 2.3 63.1 593 Wealth quintile Lowest 12.2 69.6 43.1 8.0 73.1 595 Second 17.9 65.2 35.4 4.2 69.3 538 Middle 18.3 66.0 36.8 4.2 69.0 547 Fourth 23.9 61.0 33.2 2.4 64.9 543 Highest 20.9 63.4 39.8 2.0 68.0 657 Total 18.6 65.1 37.8 4.1 68.9 2,880 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases. Total includes one child with missing information on education of head of household. 1Only non-violent discipline: (1) providing an affirmative response to one or both of the following: took away child’s privileges, forbade something the child liked, or did not allow the child to leave the house or explained why some behavior was wrong, or gave the child something else to do; and (2) a negative response to all of the following: shook the child; shouted, yelled, or screamed at the child; spanked, hit, or slapped the child on the bottom with a bare hand; hit the child on the bottom or elsewhere on the body with something like a belt, hairbrush, stick, or other hard object; called the child dumb, lazy, or similar name; hit or slapped the child on the face, head, or ears; hit or slapped the child on the hand, arm, or leg; or beat the child over and over as hard as possible. 2 Psychological aggression: providing an affirmative answer to one or both of the following: shouted, yelled, or screamed at the child or called the child dumb, lazy, or similar name. 3 Any physical punishment: providing an affirmative response to any of the following: shook the child; spanked, hit, or slapped the child on the bottom with a bare hand; hit the child on the bottom or elsewhere on the body with something like a belt, hairbrush, stick, or other hard object; hit or slapped the child on the face, head, or ears; hit or slapped the child on the hand, arm, or leg; or beat the child over and over as hard as possible. 4 Severe physical punishment: providing an affirmative response to one or both of the following: hit or slapped the child on the face, head, or ears; or beat the child over and over as hard as possible. 5 Any violent discipline method (MICS indicator 8.3 - Violent discipline): providing an affirmative response to any of the following: shook the child; shouted, yelled, or screamed at the child; spanked, hit, or slapped the child on the bottom with a bare hand; hit the child on the bottom or elsewhere on the body with something like a belt, hairbrush, stick, or other hard object; called the child dumb, lazy, or similar name; hit or slapped the child on the face, head, or ears; hit or slapped the child on the hand, arm, or leg; or beat the child over and over as hard as possible. Housing Characteristics and Household Population • 29 2.11 POVERTY BENEFITS The government of Armenia provides a number of benefits to assist poor families. According to the Law on State Benefits, there are 10 types of benefits financed from the state budget: a family benefit, a social benefit, an emergency benefit, a lump-sum benefit at childbirth, a child-care leave benefit (under age 2), a temporary disability benefit, an old-age benefit, a disability benefit, a survivor benefit, and a funeral benefit. In ADHS 2015-16 respondents were asked about two types of benefits: a family benefit and an emergency benefit. To provide information on the coverage of these benefits, the 2015-16 ADHS included questions on whether or not households received any of the following benefits in the 6 months before the survey: (1) a monthly cash benefit, that is, the poverty family benefit; (2) an emergency benefit, a cash benefit available to families four times per year. The respondents were also asked to report if any member of their household received a government “order” to cover the costs of health services for which fees are charged. The ADHS questionnaire also included a question to determine if households that had not received any of the benefits during the 6 months prior to the survey had registered or updated their registration in the family benefit program in the 6-month period before the survey. Table 2.15 shows that 14 percent of households interviewed in the ADHS had received at least one of the family benefits during the 6 months prior to the survey. Eleven percent of households received a monthly cash benefit, 3 percent received a government order to cover health care costs, and 1 percent received an emergency cash benefit. Virtually no households received all three benefits. Among the households not receiving benefits, 3 percent had registered or updated their registration in the family benefit program database. Overall, one in six households either received benefits or were registered in the family benefit database in the 6 months before the survey. Table 2.15 Poverty benefits Percentages of households receiving a poverty family benefit, an emergency benefit in the past 6 months or a government order for any health services that are otherwise not free; percentages receiving all three types of poverty family benefits and none of the poverty family benefits in the 6 months prior to the survey; and, among households receiving no poverty family benefits, percentage that registered or updated their registration in the family benefit program database in the s6months prior to the survey, according to selected background characteristics, Armenia 2015-16 Background characteristic Percent- age of households receiving a poverty family benefit1 Percent- age of households receiving an emergency benefit2 Percent- age of house-holds receiving a government order to any health services that are otherwise not free3 Percent- age of households receiving at least one of the family benefits Percent- age of households receiving all three of the family benefits Percent- age of households received none of the family benefits Number of house- holds Among households receiving none of the family benefits: Percentage registering or updating registration in the family benefit program database Number of households not receiving benefits Residence Urban 8.5 0.9 2.0 10.8 0.1 89.2 4,924 2.3 4,390 Rural 15.4 1.1 3.3 18.9 0.0 81.1 2,969 2.7 2,408 Region Yerevan 3.8 0.2 1.9 5.6 0.1 94.4 2,480 2.3 2,340 Aragatsotn 10.1 0.6 0.1 10.9 0.0 89.1 387 1.7 345 Ararat 8.9 0.6 0.2 9.3 0.0 90.7 682 0.9 618 Armavir 8.8 0.7 3.8 12.4 0.0 87.6 633 5.7 554 Gegharkunik 23.1 2.8 8.5 31.1 0.3 68.9 601 5.2 414 Lori 17.0 0.5 0.5 17.3 0.2 82.7 645 0.2 533 Kotayk 13.6 0.6 1.2 15.1 0.0 84.9 799 1.7 678 Shirak 21.2 0.6 1.3 22.5 0.0 77.5 685 2.4 531 Syunik 7.4 6.5 7.7 20.8 0.0 79.2 448 0.1 355 Vayots Dzor 12.5 0.0 4.4 16.1 0.0 83.9 167 3.4 140 Tavush 18.5 0.6 2.5 21.0 0.0 79.0 366 5.9 289 Wealth quintile Lowest 20.6 1.9 3.2 24.5 0.1 75.5 1,700 3.3 1,284 Second 12.8 1.1 2.2 15.7 0.0 84.3 1,452 2.4 1,224 Middle 10.8 1.2 3.1 14.1 0.3 85.9 1,791 3.0 1,539 Fourth 6.9 0.4 1.8 8.6 0.0 91.4 1,558 1.7 1,423 Highest 2.8 0.1 1.8 4.5 0.0 95.5 1,392 1.9 1,329 Total 11.1 1.0 2.5 13.9 0.1 86.1 7,893 2.5 6,798 1 A poverty family benefit’ that is, a monthly cash benefit 2 An emergency benefit; that is, a cash benefit up to four times per year 3 A government order to cover the cost of any health services that are not free (for example, an operation board) 30 • Housing Characteristics and Household Population Rural households were almost twice as likely as urban households to have received at least one of the family benefits. Gegharkunik (31 percent) had the highest proportion of households receiving one family benefits and Yerevan the lowest (6 percent). Households receiving family benefits were largely concentrated in the bottom three wealth quintiles, with one in four households in the lowest quintile receiving benefits. Background Characteristics of Respondents • 31 BACKGROUND CHARACTERISTICS OF RESPONDENTS 3 his chapter gives a demographic and socioeconomic profile of respondents in the 2015-16 ADHS sample. Information on the basic characteristics of women and men interviewed in the survey is essential to interpret the findings on reproduction, health, and women’s status that are presented in final chapters of the report. The distribution of the respondents by their various demographic and socioeconomic characteristics can be compared to the likelihood of occurrence in the general population and, thus, offer a means of assessing the representativeness of the ADHS sample. The main background characteristics, described in detail here and used in subsequent chapters on reproduction and health, are as follows: age at the time of the survey, marital status, residence, education, and wealth quintile. This chapter also includes information on exposure to mass media and employment. 3.1 BACKGROUND CHARACTERISTICS OF RESPONDENTS As noted in Chapter 1, all women age 15-49 who were usual residents or present in the household on the night before the interviewer’s visit were eligible to be interviewed in the 2015-16 ADHS. Men age 15-49 were interviewed in every second household. To avoid double counting the respondents, the tables in this report are, in most cases, based on the de facto population, that is, those who stayed in the household the night before the interview. Table 3.1 presents the distribution of interviewed women and men age 15-49 by selected background characteristics. The age distribution shows that 45 percent of the women and a similar percentage of the men (46 percent) are under age 30. About one-quarter of both women and men are age 40-49. Nearly two-thirds of the women (64 percent) and more than half of the men (55 percent) are married or living together. Because men tend to marry later in life than women do, more men (43 percent) than women (30 percent) have never been married. Six percent of women and two percent of men are divorced, separated, or widowed. T Key Findings:  Virtually all women and men age 15-49 have at least a secondary education, and 31 percent of women and 27 percent of men have some higher education.  More than 9 in 10 women and men in Armenia are exposed to some form of mass media, primarily television, at least once per week.  Internet usage is almost as widespread; 91 percent of women and 89 percent of men access the Internet at least once per week.  More than 7 in 10 men and 4 in 10 women report they were employed in the 12 months prior to the survey. 32 • Background Characteristics of Respondents Table 3.1 Background characteristics of respondents Percent distribution of women and men age 15-49 by selected background characteristics, Armenia 2015-16 Background characteristic Women Men Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted number Age 15-19 11.9 725 743 12.5 345 346 20-24 15.2 928 922 17.0 467 450 25-29 18.0 1,099 1,076 16.9 464 477 30-34 16.5 1,007 1,005 15.5 427 434 35-39 14.2 867 874 13.6 376 373 40-44 12.8 784 782 12.6 346 341 45-49 11.5 706 714 12.0 330 334 Marital status Never married 29.9 1,830 1,747 43.2 1,190 1,179 Married 63.3 3,870 3,973 49.4 1,361 1,368 Living together 0.4 25 25 5.3 145 159 Divorced/separated 4.3 262 244 2.0 56 46 Widowed 2.1 128 127 0.1 3 3 Residence Urban 59.8 3,657 3,545 56.5 1,558 1,522 Rural 40.2 2,459 2,571 43.5 1,197 1,233 Region Yerevan 32.7 2,001 1,055 30.2 833 440 Aragatsotn 5.2 315 453 5.8 159 228 Ararat 9.0 552 597 10.5 290 313 Armavir 9.6 586 642 9.7 268 284 Gegharkunik 7.8 478 551 8.5 235 268 Lori 5.8 355 337 6.7 184 164 Kotayk 11.1 678 659 10.8 299 288 Shirak 8.3 510 536 7.3 201 191 Syunik 3.9 238 383 3.8 104 174 Vayots Dzor 1.9 119 405 2.0 56 186 Tavush 4.6 283 498 4.6 126 219 Education No education 0.1 5 5 0.2 5 6 Basic 6.5 396 406 13.1 360 379 Secondary 40.0 2,444 2,580 45.4 1,250 1,293 Secondary special 22.2 1,360 1,444 14.6 403 422 Higher 31.2 1,910 1,681 26.7 736 655 Wealth quintile Lowest 17.7 1,081 1,137 19.0 523 536 Second 20.3 1,242 1,358 21.2 583 626 Middle 18.7 1,142 1,324 18.9 521 608 Fourth 21.0 1,287 1,293 20.5 566 565 Highest 22.3 1,365 1,004 20.4 562 420 Total 100.0 6,116 6,116 100.0 2,755 2,755 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. Three-fifths of the respondents live in urban areas. The majority live in Yerevan. Outside of Yerevan, the largest proportions of respondents are found in Kotayk, Ararat, and Armavir, each with around 10 percent of the total sample. The regions with the smallest proportions of respondents are Vayots Dzor and Syunik. Male and female respondents are universally well educated, with 93 percent of the women and 87 percent of the men having at least some secondary education. Thirty-one percent of the women and just over a quarter of the men have some higher education. 3.2 EDUCATIONAL ATTAINMENT OF RESPONDENTS Education provides people with the knowledge and skills to lead a better quality of life. Educational attainment has been found to be closely associated with the health of women and children as well as with the reproductive behavior of women and men. Background Characteristics of Respondents • 33 Tables 3.2.1 and 3.2.2 show the distribution of women and men age 15-49 by highest level of schooling1 attended or completed and the median number of years of schooling completed, according to background characteristics. Education has been almost universal in Armenia for some time, and almost all women and men have completed at least some secondary education. More than a fifth of women and 15 percent of men have secondary special education. Three in 10 women and more than one-quarter of the men have had at least some university education. 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, Armenia 2015-16 Background characteristic Highest level of schooling Total Median years completed Number of women No education Some primary Completed primary1 Some secondary Completed secondary2 Secondary special Higher Age 15-24 0.0 0.2 0.1 23.0 25.9 16.4 34.3 100.0 11.0 1,653 15-19 0.0 0.3 0.0 48.6 18.2 16.9 16.0 100.0 10.1 725 20-24 0.0 0.2 0.1 3.0 32.0 16.1 48.6 100.0 11.9 928 25-29 0.1 0.6 0.1 3.7 33.9 20.7 40.9 100.0 12.3 1,099 30-34 0.1 0.2 0.1 5.2 41.6 22.6 30.2 100.0 11.5 1,007 35-39 0.0 0.3 0.0 6.6 43.7 22.6 26.9 100.0 10.0 867 40-44 0.3 0.0 0.0 4.4 42.5 28.3 24.6 100.0 11.2 784 45-49 0.0 0.2 0.0 5.8 40.2 30.6 23.1 100.0 11.3 706 Residence Urban 0.0 0.3 0.0 6.5 26.6 24.9 41.7 100.0 12.2 3,657 Rural 0.2 0.2 0.1 15.0 50.6 18.3 15.6 100.0 9.8 2,459 Region Yerevan 0.0 0.2 0.0 5.7 20.3 22.0 51.8 100.0 12.7 2,001 Aragatsotn 0.0 0.0 0.0 7.7 57.4 15.4 19.5 100.0 9.9 315 Ararat 0.0 0.3 0.2 12.9 51.8 16.2 18.6 100.0 9.9 552 Armavir 0.5 1.1 0.2 19.6 41.2 19.7 17.7 100.0 9.8 586 Gegharkunik 0.0 0.0 0.0 12.7 56.7 17.3 13.3 100.0 9.8 478 Lori 0.0 0.0 0.0 7.4 43.3 23.1 26.2 100.0 11.1 355 Kotayk 0.0 0.4 0.0 9.9 36.5 26.5 26.8 100.0 11.0 678 Shirak 0.2 0.2 0.0 8.6 39.6 25.3 26.0 100.0 11.0 510 Syunik 0.2 0.0 0.0 13.1 36.6 28.7 21.3 100.0 10.9 238 Vayots Dzor 0.0 0.0 0.0 10.6 40.2 29.6 19.6 100.0 10.3 119 Tavush 0.3 0.0 0.0 13.9 32.3 32.0 21.5 100.0 11.1 283 Wealth quintile Lowest 0.1 0.4 0.1 21.0 53.2 16.1 9.0 100.0 9.7 1,081 Second 0.1 0.1 0.1 9.6 47.6 20.8 21.6 100.0 10.0 1,242 Middle 0.0 0.4 0.0 9.2 41.4 25.4 23.6 100.0 10.7 1,142 Fourth 0.2 0.4 0.0 5.6 25.5 26.7 41.6 100.0 12.2 1,287 Highest 0.0 0.0 0.0 6.0 18.2 21.6 54.2 100.0 12.8 1,365 Total 0.1 0.3 0.0 9.9 36.2 22.2 31.2 100.0 11.3 6,116 1 Completed 4 grade at the primary level 2 Completed 12 grade at the secondary level or completed more than 9 years of schooling and has a secondary school attestat Although virtually all female respondents have attended secondary school, differences in attendance at higher levels of education are evident by background characteristics. For example, 42 percent of urban women have some higher education compared with only 16 percent of rural women. There also is considerable variation by region: the largest proportion of highly educated women is found in Yerevan (52 percent), and the smallest proportion in Gegharkunik (13 percent). Attainment of higher education is closely related to wealth status; more than half of the women in the highest wealth quintile (54 percent) have some university education compared with less than 1 in 10 women in the lowest quintile. Differences in the proportion of men attaining higher education are similar to those among women (Table 3.2.2). Thirty-seven percent of urban men have some higher education compared with 14 percent of rural men. As with women, there is considerable variation by region. Yerevan residents have a clear 1 As reported in Chapter 2, Armenia’s educational system has undergone several stages of restructuring. Since 2007, basic education has consisted of grades 1-9 instead of grades 1-8 as in the previous system; high school consists of grades 10-12 instead of grades 9-10 as in the previous system. The two levels together (basic education and high school) are referred to as secondary education (grades 1 through 12 in the new system versus grades 1 through 10 in the old system). 34 • Background Characteristics of Respondents educational advantage over the rest of the country: nearly half of the men in Yerevan (47 percent) have some university education compared with 10 percent of men in Armavir and 12 percent in Gegharkunik. Wealth status is positively associated with education; half of men in the highest wealth quintile have some higher education compared with 5 percent of men in the lowest wealth quintile. 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, Armenia 2015-16 Background characteristic Highest level of schooling Total Median years completed Number of men No education Some primary Completed primary1 Some secondary Completed secondary2 Secondary special Higher Age 15-24 0.2 0.6 0.0 28.8 31.4 13.4 25.7 100.0 10.4 813 15-19 0.4 0.1 0.0 53.1 18.2 14.4 13.9 100.0 10.1 345 20-24 0.0 0.9 0.0 10.9 41.1 12.6 34.5 100.0 10.9 467 25-29 0.0 1.1 0.0 12.2 40.8 11.7 34.2 100.0 9.9 464 30-34 0.4 0.1 0.0 12.9 45.8 10.2 30.6 100.0 9.8 427 35-39 0.7 0.3 0.3 12.9 50.0 13.2 22.7 100.0 9.7 376 40-44 0.0 0.0 0.0 7.1 52.2 17.9 22.8 100.0 9.8 346 45-49 0.0 0.0 0.0 9.3 42.4 26.0 22.3 100.0 10.0 330 Residence Urban 0.2 0.1 0.0 11.1 33.6 18.2 36.8 100.0 11.2 1,558 Rural 0.2 0.8 0.1 23.1 52.2 10.0 13.6 100.0 9.6 1,197 Region Yerevan 0.0 0.0 0.0 7.7 28.1 17.0 47.2 100.0 12.0 833 Aragatsotn 0.0 0.0 0.0 12.7 55.7 9.4 22.2 100.0 9.8 159 Ararat 0.0 0.6 0.0 22.2 51.1 9.4 16.7 100.0 9.6 290 Armavir 0.4 1.5 0.5 33.9 44.5 8.7 10.4 100.0 9.4 268 Gegharkunik 0.0 0.9 0.0 17.0 64.2 6.0 11.9 100.0 9.7 235 Lori 0.0 1.2 0.0 14.0 53.7 12.5 18.6 100.0 9.8 184 Kotayk 0.0 0.0 0.0 20.0 39.2 19.5 21.3 100.0 9.9 299 Shirak 1.7 0.0 0.0 18.4 38.7 18.4 22.8 100.0 9.9 201 Syunik 0.0 0.0 0.0 16.4 40.1 22.4 21.2 100.0 9.9 104 Vayots Dzor 0.0 0.8 0.0 8.2 44.6 21.9 24.4 100.0 10.0 56 Tavush 0.7 0.7 0.0 20.7 36.1 22.6 19.3 100.0 9.9 126 Wealth quintile Lowest 0.5 0.9 0.2 30.2 53.7 8.9 5.4 100.0 9.4 523 Second 0.3 1.1 0.0 17.6 51.5 11.9 17.7 100.0 9.7 583 Middle 0.0 0.0 0.0 15.6 44.0 16.3 24.1 100.0 9.9 521 Fourth 0.0 0.0 0.0 10.7 36.8 17.1 35.4 100.0 11.0 566 Highest 0.2 0.1 0.0 8.4 22.9 18.8 49.7 100.0 12.4 562 Total 15-49 0.2 0.4 0.0 16.3 41.7 14.6 26.7 100.0 9.9 2,755 1 Completed 4 grade at the primary level 2 Completed 12 grade at the secondary level or completed more than 9 years of schooling and has a secondary school attestat A comparison of the median years of schooling among women and men in the 2010 ADHS and 2015-16 ADHS shows educational attainment increased only modestly for women between the surveys, from 11.2 to 11.3 years, and remained stable at 9.9 years among men. The proportion of women with some higher education also increased only slightly in the period between the 2010 and 2015-16 ADHS surveys, from 30 to 31 percent. Among men, the proportion with some higher education actually dropped from 30 percent in 2010 (NSS et al. 2012) to 27 percent in 2015-16. 3.3 EXPOSURE TO MASS MEDIA AND INTERNET Access to information is essential to increase people’s knowledge and awareness of what happens around them. The 2015-16 ADHS collected information relating to the respondent’s access to mass media, including print and broadcast media, as well as usage of the Internet. This information can help program managers plan the dissemination of information on health, family planning, nutrition, and other topics. Background Characteristics of Respondents • 35 3.3.1 Mass Media In the survey, exposure to media was assessed by asking how often respondents read a newspaper or magazine, watched television, or listened to the radio. The results indicate that more than 9 in 10 Armenian women watch television at least once a week, just over a quarter read a newspaper or magazine, and 15 percent listen to the radio (Table 3.3.1). In general, men report a slightly lower level of exposure to television and newspapers or magazines and a higher level of exposure to radio than women (Table 3.3.2). Eighty-nine percent of men watch television, 22 percent read a newspaper or magazine, and 24 percent listen to the radio at least once a week. Overall, around one in eight women and men are exposed to all three types of media on a weekly basis, while 10 percent of men and 6 percent of women are not regularly exposed to any of the three types of media. Among both women and men, media exposure rates are highest among urban residents, those living in Yerevan, those with higher education, and those in the highest wealth quintile. Table 3.3.1 Exposure to mass media: Women Percentage of women age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Armenia 2015-16 Background characteristic Reads a newspaper or magazine 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 25.4 90.4 14.6 9.8 8.3 725 20-24 27.1 93.3 16.9 12.9 6.0 928 25-29 28.5 93.9 17.9 13.7 5.5 1,099 30-34 26.9 94.2 17.8 13.0 5.7 1,007 35-39 28.1 94.3 13.9 11.4 5.1 867 40-44 26.5 94.3 13.4 10.4 4.7 784 45-49 27.1 93.4 10.1 7.1 5.8 706 Residence Urban 33.7 94.6 20.9 15.8 4.5 3,657 Rural 17.4 91.8 7.0 5.1 7.8 2,459 Region Yerevan 41.3 96.9 30.4 23.8 2.5 2,001 Aragatsotn 15.5 86.9 4.2 3.8 12.7 315 Ararat 15.9 97.2 15.7 10.1 1.8 552 Armavir 18.0 97.8 7.2 5.5 2.0 586 Gegharkunik 3.6 65.7 0.3 0.0 32.7 478 Lori 8.7 87.3 2.5 1.5 12.1 355 Kotayk 26.4 97.8 14.0 10.0 1.5 678 Shirak 18.4 95.8 11.3 7.3 3.9 510 Syunik 29.4 97.7 6.0 4.5 2.0 238 Vayots Dzor 37.0 98.0 2.1 1.6 1.1 119 Tavush 56.1 95.4 2.3 1.6 3.7 283 Education Basic 10.5 91.0 6.3 2.8 8.1 396 Secondary 14.5 91.7 8.8 5.1 8.0 2,444 Secondary special 26.8 94.8 11.4 8.1 4.5 1,360 Higher 47.1 95.4 28.3 24.0 3.5 1,910 Wealth quintile Lowest 11.5 92.0 4.9 2.5 7.8 1,081 Second 22.2 93.1 9.3 7.2 6.3 1,242 Middle 25.3 91.0 14.9 10.9 8.2 1,142 Fourth 29.4 93.8 17.3 11.9 4.9 1,287 Highest 43.6 96.9 27.5 22.7 2.8 1,365 Total 27.2 93.5 15.3 11.5 5.8 6,116 Note: Total includes 5 (weighted) women with no education. Looking at the trends in exposure to specific media between the 2010 and 2015-16 ADHS surveys, the greatest change was in the proportion of women reading a newspaper or magazine at least once a week, which dropped from 45 percent in 2010 to 27 percent in 2015-16. Men also were less likely to have regular exposure to newspapers or magazines in 2015-16 compared with 2010 (30 percent and 22 percent, respectively). The level of exposure to radio and television also changed between 2010 and 2015-16. Among women, the percentage listening to the radio at least once per week declined from 20 percent in 2010 to 15 percent in 2015-16 while, among men, regular exposure to radio broadcasts increased from 18 percent to 24 36 • Background Characteristics of Respondents percent. Considering television exposure, the percentage of men watching television at least once per week dropped from 96 percent in 2010 to 89 percent in 2015-16, while the percentage of women regularly exposed to television broadcasts remained essentially stable (93 percent in 2010 and 94 percent in 2015-16). Overall, the proportion of women who accessed none of the three mass media on a weekly basis remained stable at 6 percent between 2010 and 2015-16 while the proportion of men who did not access any of the three media rose from 3 percent to 10 percent. Table 3.3.2 Exposure to mass media: Men Percentage of men age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Armenia 2015-16 Background characteristic Reads a newspaper or magazine 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 12.2 87.4 10.0 6.4 12.5 345 20-24 17.2 87.2 16.7 8.1 12.3 467 25-29 22.4 89.8 23.3 11.5 9.1 464 30-34 23.5 88.8 27.0 13.6 10.5 427 35-39 28.6 89.9 34.8 19.0 8.5 376 40-44 24.3 87.2 23.9 13.4 12.0 346 45-49 28.8 91.4 32.1 18.0 8.1 330 Residence Urban 27.5 92.2 30.1 17.5 6.9 1,558 Rural 15.4 84.3 15.6 6.3 15.0 1,197 Region Yerevan 35.5 97.6 40.6 27.1 1.6 833 Aragatsotn 12.1 98.7 4.6 1.0 1.3 159 Ararat 12.6 93.4 9.7 4.9 5.6 290 Armavir 26.3 99.0 53.9 21.3 0.7 268 Gegharkunik 0.7 2.9 0.0 0.0 96.4 235 Lori 3.7 98.9 8.2 2.0 1.1 184 Kotayk 17.6 99.4 22.4 5.7 0.6 299 Shirak 27.6 85.6 14.7 4.5 9.8 201 Syunik 10.5 98.8 3.6 1.2 1.2 104 Vayots Dzor 16.8 93.9 6.2 4.2 5.7 56 Tavush 42.7 99.7 14.8 13.0 0.0 126 Education Basic 8.0 90.4 17.2 4.0 9.4 360 Secondary 13.0 83.6 17.1 6.7 15.8 1,250 Secondary special 19.5 94.7 25.1 9.7 4.5 403 Higher 46.5 93.5 37.9 28.7 5.2 736 Wealth quintile Lowest 12.9 87.5 16.6 6.0 12.1 523 Second 17.0 86.2 16.9 7.3 12.8 583 Middle 17.9 82.9 19.0 8.8 16.8 521 Fourth 26.1 91.9 24.9 14.4 7.3 566 Highest 36.5 95.0 40.8 26.1 3.7 562 Total 22.2 88.8 23.8 12.6 10.4 2,755 Note: Total includes 5 (weighted) men with no education. 3.3.2 Internet Usage Changes in the level of exposure to various mass media may relate at least in part to the rapid growth in computer ownership among Armenian households between the 2010 and 2015-16 ADHS surveys (see Chapter 2). Increased access to the Internet, which accompanied computer ownership, affected usage of traditional mass media. Tables 3.4.1 and 3.4.2 present information from the 2015-16 ADHS on the extent to which respondents accessed the Internet. Background Characteristics of Respondents • 37 Overall, a large majority of women and men reported that they had ever used the Internet (87 percent and 91 percent, respectively), and most women and men had used it at some point in the 12 months prior to the survey (85 percent and 89 percent, respectively). Overall, among respondents who had used the Internet in the 12 months before the survey, around 90 percent reported that they were online at least once a week during the month before the survey; 70 percent of women and 61 percent of men reported use almost every day during the month. Table 3.4.1 Internet usage: Women Percentage of women age 15-49 who have ever used the Internet, and percentage who have used the Internet in the past 12 months; and among women who have used the Internet in the past 12 months, percent distribution by frequency of Internet use in the past month, according to background characteristics, Armenia 2015-16 Background characteristic Ever used the Internet Used the Internet in the past 12 months Number of women Among women who have used the Internet in the past 12 months, percentage who, in the past month, used Internet: Number of women Almost every day Less than every day but at least once a week Less than once a week Not at all Missing Total Age 15-19 93.7 93.1 725 85.1 10.2 4.6 0.2 0.0 100.0 675 20-24 94.8 93.4 928 83.4 10.9 5.7 0.1 0.0 100.0 867 25-29 91.1 89.9 1,099 76.7 17.1 5.8 0.4 0.0 100.0 988 30-34 89.5 87.5 1,007 65.5 24.1 10.2 0.1 0.0 100.0 881 35-39 81.5 80.2 867 63.1 25.6 10.1 1.2 0.0 100.0 695 40-44 81.4 79.8 784 54.6 32.1 13.1 0.1 0.0 100.0 625 45-49 71.3 69.3 706 52.6 29.7 16.8 0.8 0.2 100.0 489 Residence Urban 92.9 91.9 3,657 75.2 18.3 6.2 0.3 0.0 100.0 3,360 Rural 77.8 75.6 2,459 61.3 24.5 13.7 0.5 0.0 100.0 1,860 Region Yerevan 95.1 94.5 2,001 76.9 17.4 5.4 0.3 0.0 100.0 1,891 Aragatsotn 83.1 77.7 315 63.4 26.2 9.8 0.6 0.0 100.0 245 Ararat 79.5 78.4 552 66.3 23.8 9.6 0.3 0.0 100.0 433 Armavir 73.9 71.5 586 70.3 18.8 10.9 0.0 0.0 100.0 419 Gegharkunik 82.4 81.1 478 41.4 37.5 20.5 0.6 0.0 100.0 388 Lori 87.1 84.8 355 63.9 22.8 11.7 1.3 0.3 100.0 301 Kotayk 86.2 84.7 678 67.3 18.4 13.6 0.7 0.0 100.0 574 Shirak 84.2 81.7 510 75.6 18.5 5.6 0.3 0.0 100.0 417 Syunik 92.2 91.4 238 80.8 16.6 2.5 0.0 0.0 100.0 218 Vayots Dzor 88.4 87.9 119 68.4 21.4 10.2 0.0 0.0 100.0 105 Tavush 81.4 81.1 283 76.3 16.5 7.3 0.0 0.0 100.0 229 Education Basic 65.2 62.8 396 59.1 25.4 15.3 0.1 0.0 100.0 249 Secondary 80.0 77.7 2,444 59.9 25.9 13.4 0.7 0.0 100.0 1,899 Secondary special 89.4 88.4 1,360 66.3 23.9 9.6 0.2 0.0 100.0 1,203 Higher 98.4 97.8 1,910 84.9 12.0 2.9 0.2 0.0 100.0 1,867 Wealth quintile Lowest 62.9 59.7 1,081 55.0 24.6 19.0 1.3 0.0 100.0 645 Second 84.8 82.9 1,242 65.2 23.7 10.8 0.3 0.0 100.0 1,029 Middle 88.8 87.1 1,142 65.9 24.1 9.7 0.4 0.0 100.0 994 Fourth 95.6 95.2 1,287 75.2 19.2 5.3 0.3 0.1 100.0 1,225 Highest 97.7 97.2 1,365 80.5 14.4 5.1 0.0 0.0 100.0 1,327 Total 86.8 85.3 6,116 70.3 20.5 8.8 0.4 0.0 100.0 5,220 Note: Total includes five (weighted) women with no education. Among women and men, both the likelihood that an individual had ever used the Internet and had used the Internet in the 12 months before the survey decreased with age. Ever use and use in the 12 months before the survey was lower among rural than urban residents and among women living in Armavir and men living in Vayots Dzor compared with those living in other regions. Such use rose with increasing education and wealth. Among those who had used the Internet in the 12 months before the survey, the likelihood that use was infrequent during the month before the survey, (i.e., less than once a week or not at all), was greatest for women in Gegharkunik (21 percent) and in the lowest wealth quintile (19 percent) and for men in Aragatsotn (28 percent) and Ararat (21 percent) and in the lowest wealth quintile (19 percent). 38 • Background Characteristics of Respondents Table 3.4.2 Internet usage: Men Percentage of men age 15-49 who have ever used the Internet, and percentage who have used the internet in the past 12 months; and among men who have used the Internet in the past 12 months, percent distribution by frequency of Internet use in the past month, according to background characteristics, Armenia 2015-16 Background characteristic Ever used the Internet Used the internet in the past 12 months Number of men Among men who have used the Internet in the past 12 months, percentage who, in the past month, used Internet: Number of men Almost every day Less than every day but at least once a week Less than once a week Not at all Missing Total Age 15-19 95.5 95.2 345 76.0 18.3 5.6 0.0 0.0 100.0 329 20-24 96.3 95.2 467 72.5 21.2 5.4 0.9 0.0 100.0 445 25-29 94.1 93.5 464 66.8 24.3 8.5 0.3 0.0 100.0 434 30-34 91.2 89.9 427 64.6 22.4 12.5 0.5 0.0 100.0 384 35-39 89.6 87.0 376 52.0 33.3 13.6 0.5 0.5 100.0 327 40-44 86.9 83.1 346 43.1 38.5 17.6 0.9 0.0 100.0 287 45-49 75.8 74.1 330 36.3 45.9 16.0 1.8 0.0 100.0 244 Residence Urban 94.4 93.5 1,558 66.7 24.2 8.5 0.4 0.1 100.0 1,456 Rural 85.4 83.0 1,197 52.5 32.7 13.9 1.0 0.0 100.0 994 Region Yerevan 94.0 93.4 833 67.5 24.1 8.2 0.2 0.0 100.0 778 Aragatsotn 78.5 77.9 159 27.7 43.9 28.4 0.0 0.0 100.0 124 Ararat 86.9 77.8 290 49.6 25.7 20.5 4.2 0.0 100.0 225 Armavir 76.4 76.4 268 67.3 28.1 4.6 0.0 0.0 100.0 204 Gegharkunik 94.7 93.2 235 25.0 57.7 17.3 0.0 0.0 100.0 219 Lori 94.4 91.9 184 60.2 22.5 16.8 0.6 0.0 100.0 170 Kotayk 94.1 94.1 299 67.9 24.1 6.3 1.1 0.6 100.0 281 Shirak 97.3 97.3 201 74.1 20.7 5.2 0.0 0.0 100.0 196 Syunik 92.2 89.8 104 70.1 27.0 2.5 0.5 0.0 100.0 94 Vayots Dzor 75.8 75.4 56 46.8 39.3 13.9 0.0 0.0 100.0 42 Tavush 93.1 92.8 126 91.2 4.8 4.0 0.0 0.0 100.0 116 Education Basic 80.4 78.4 360 53.0 30.8 16.0 0.2 0.0 100.0 282 Secondary 89.5 87.2 1,250 50.3 34.5 14.2 0.8 0.2 100.0 1,090 Secondary special 90.2 89.1 403 60.9 28.9 9.5 0.7 0.0 100.0 359 Higher 97.9 97.4 736 80.2 15.4 3.9 0.5 0.0 100.0 717 Wealth quintile Lowest 77.3 74.0 523 49.1 31.4 18.5 1.1 0.0 100.0 387 Second 90.4 87.8 583 57.3 31.1 10.6 1.0 0.0 100.0 512 Middle 92.0 91.0 521 55.9 32.4 11.3 0.4 0.0 100.0 474 Fourth 95.0 94.8 566 66.8 22.7 9.9 0.6 0.0 100.0 537 Highest 97.0 96.2 562 71.5 22.5 5.4 0.2 0.3 100.0 540 Total 90.5 88.9 2,755 60.9 27.7 10.7 0.6 0.1 100.0 2,450 Note: Total includes five (weighted) men with no education. 3.4 EMPLOYMENT In the 2015-16 ADHS, respondents were asked about their employment status at the time of the survey as well as their continuity of employment in the 12 months prior to the survey. The measurement of women’s employment can be especially difficult, because some of the activities that women do, especially work on family farms, family businesses, or in the informal sector, are often not perceived by women themselves as employment and hence are not reported as such. To avoid underestimating employment, respondents were asked several questions to probe for their employment status and to ensure complete coverage of employment in both the formal and informal sectors. Tables 3.5.1 and 3.5.2 show the percent distribution of female and male respondents by employment status, according to background characteristics. Respondents are considered “employed” if they were currently working at the time of the survey (that is, if they had worked in the past 7 days). Thirty-four percent of women reported being currently employed and 6 percent were employed in the 12 months preceding the survey but not working at the time of the survey. As expected, employment was more common among men than women (Figure 3.1). Fifty-six percent of men reported they were employed at the time of the survey and 16 percent had worked in the 12 months prior to the survey but were not employed at the time of the survey. Background Characteristics of Respondents • 39 Table 3.5.1 Employment status: Women Percent distribution of women age 15-49 by employment status, according to background characteristics, Armenia 2015-16 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Missing/ don’t know Total Number of women Currently employed1 Not currently employed Age 15-19 2.5 1.4 96.0 0.1 100.0 725 20-24 19.9 4.2 75.9 0.0 100.0 928 25-29 34.7 6.3 58.9 0.0 100.0 1,099 30-34 34.4 6.7 58.9 0.1 100.0 1,007 35-39 44.7 8.7 46.6 0.0 100.0 867 40-44 50.5 9.2 40.2 0.0 100.0 784 45-49 51.5 7.8 40.7 0.0 100.0 706 Marital status Never married 28.6 3.3 68.0 0.1 100.0 1,830 Married or living together 34.3 7.5 58.2 0.0 100.0 3,895 Divorced/separated/ widowed 56.0 8.7 35.3 0.0 100.0 390 Number of living children 0 29.8 3.6 66.6 0.0 100.0 2,120 1-2 35.4 6.8 57.8 0.0 100.0 2,990 3-4 39.2 10.5 50.3 0.0 100.0 966 5+ (25.7) (15.6) (58.7) (0.0) 100.0 39 Residence Urban 37.9 2.7 59.4 0.0 100.0 3,657 Rural 28.2 11.8 60.0 0.0 100.0 2,459 Region Yerevan 41.5 1.8 56.6 0.0 100.0 2,001 Aragatsotn 27.3 0.9 71.8 0.0 100.0 315 Ararat 37.3 13.6 49.0 0.1 100.0 552 Armavir 36.0 17.0 47.0 0.0 100.0 586 Gegharkunik 32.4 15.4 52.3 0.0 100.0 478 Lori 15.1 1.1 83.6 0.3 100.0 355 Kotayk 33.5 8.2 58.3 0.0 100.0 678 Shirak 17.7 4.4 77.8 0.0 100.0 510 Syunik 39.3 3.8 56.9 0.0 100.0 238 Vayots Dzor 34.9 2.9 62.2 0.0 100.0 119 Tavush 29.1 2.3 68.6 0.0 100.0 283 Education Basic 22.2 8.6 69.3 0.0 100.0 396 Secondary 23.6 9.3 67.1 0.0 100.0 2,444 Secondary special 37.2 5.6 57.1 0.0 100.0 1,360 Higher 47.4 2.6 49.9 0.1 100.0 1,910 Wealth quintile Lowest 22.6 13.7 63.7 0.0 100.0 1,081 Second 31.6 9.4 58.9 0.1 100.0 1,242 Middle 31.6 5.2 63.2 0.1 100.0 1,142 Fourth 39.5 3.2 57.4 0.0 100.0 1,287 Highest 41.9 1.8 56.2 0.0 100.0 1,365 Total 34.0 6.4 59.6 0.0 100.0 6,116 Note: Figures in parentheses are based on 25-49 unweighted cases. Total includes five (weighted) women with no education. 1 Currently employed is defined as having done work in the past 7 days and 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. Current employment among both women and men generally increased with age, education, and wealth quintile. Divorced, separated, or widowed women were substantially more likely to be employed at the time of the survey than currently or never-married women. Among men, those who were currently married were more likely to be currently employed than those who were formerly married or especially those who were never-married. Urban residents were more likely to be currently employed than rural residents. Considering regional differences, the proportion of women who were currently employed was highest in Yerevan (42 percent) and Syunik (39 percent) and lowest in Lori (15 percent) and Shirak (18 percent). Among men, the highest proportions currently employed were found in Ararat (76 percent), Syunik (72 percent), and Kotayk (71 percent), and the lowest proportion was in Shirak (31 percent). 40 • Background Characteristics of Respondents Table 3.5.2 Employment status: Men Percent distribution of men age 15-49 by employment status, according to background characteristics, Armenia 2015-16 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of men Currently employed1 Not currently employed Age 15-19 4.2 5.7 90.1 100.0 345 20-24 34.9 16.0 49.1 100.0 467 25-29 63.7 18.8 17.5 100.0 464 30-34 73.5 17.4 9.2 100.0 427 35-39 72.4 14.8 12.8 100.0 376 40-44 71.2 17.8 11.0 100.0 346 45-49 68.4 18.5 13.1 100.0 330 Marital status Never married 33.7 14.2 52.1 100.0 1,190 Married or living together 72.6 16.4 11.0 100.0 1,506 Divorced/separated/ widowed (59.9) (30.9) (9.1) 100.0 59 Number of living children 0 37.5 14.3 48.1 100.0 1,321 1-2 71.5 17.0 11.5 100.0 1,100 3-4 75.0 16.3 8.8 100.0 322 Residence Urban 58.8 10.4 30.8 100.0 1,558 Rural 51.4 22.7 25.9 100.0 1,197 Region Yerevan 59.7 6.9 33.4 100.0 833 Aragatsotn 43.8 18.0 38.2 100.0 159 Ararat 75.9 7.9 16.2 100.0 290 Armavir 59.5 22.6 17.9 100.0 268 Gegharkunik 32.5 49.0 18.4 100.0 235 Lori 34.6 26.4 39.0 100.0 184 Kotayk 70.7 9.9 19.4 100.0 299 Shirak 30.7 23.3 46.0 100.0 201 Syunik 71.5 0.4 28.1 100.0 104 Vayots Dzor 64.8 9.7 25.5 100.0 56 Tavush 48.0 14.3 37.7 100.0 126 Education Basic 44.8 17.7 37.5 100.0 360 Secondary 51.4 21.7 26.9 100.0 1,250 Secondary special 59.3 15.4 25.3 100.0 403 Higher 66.1 5.0 28.9 100.0 736 Wealth quintile Lowest 49.5 24.0 26.5 100.0 523 Second 51.6 20.4 28.0 100.0 583 Middle 51.8 17.7 30.5 100.0 521 Fourth 58.0 10.9 31.0 100.0 566 Highest 66.4 6.2 27.4 100.0 562 Total 55.6 15.7 28.7 100.0 2,755 Note: Figures in parentheses are based on 25-49 unweighted cases. Total includes 13 (weighted) men with five or more living children and 5 (weighted) men with no education. 1 Currently employed is defined as having done work in the past 7 days and 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. The proportions of women and men who had worked in the 12 months prior to the survey but were not currently employed also varied by background characteristics. As expected, given the seasonality of agricultural employment, it was higher in rural than in urban areas among both women (12 percent and 3 percent, respectively) and men (23 percent and 10 percent, respectively). Looking at the regional patterns, the proportion that had been employed in the 12 months prior to the survey but were not currently working was highest among men in Gegharkunik (49 percent) and among women in Armavir (17 percent). Although the relationship was not uniform, the proportion tended to decrease with increasing education and wealth among both women and men. Background Characteristics of Respondents • 41 Figure 3.1 Employment status 3.5 OCCUPATION Respondents who indicated that they had worked at any time in the 12 months prior to the survey were asked about the kind of work that they did. Their responses were recorded verbatim and then coded into occupation groups after questionnaires were sent to the central office. Information on occupation not only allows for an evaluation of the source of income for both women and men but also has implications for women’s empowerment. Tables 3.6.1 and 3.6.2 show the occupational profiles of male and female respondents who were employed in the 12 months preceding the survey, according to background characteristics. The majority of employed women were working in professional, technical, or managerial (42 percent) or in sales and services (23 percent) positions, and about one-fifth worked in agriculture. Among employed men, 21 percent held professional, technical, or managerial jobs, 27 percent worked in sales and services, more than one-third were employed as manual laborers, either skilled (28 percent) or unskilled (6 percent), and 13 percent worked in agriculture. 34 6 60 56 16 29 Currently employed Not currently employed, but worked in last 12 months Did not work in last 12 months Percentage Women Men ADHS 2015-16 42 • Background Characteristics of Respondents Table 3.6.1 Occupation: Women Percent distribution of women age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Armenia 2015-16 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Agriculture Missing Total Number of women Age 15-19 (14.4) (0.0) (33.4) (10.0) (1.0) (41.2) (0.0) 100.0 28 20-24 48.6 8.3 27.5 4.1 1.6 8.8 1.2 100.0 224 25-29 50.5 4.7 22.8 5.6 1.3 14.9 0.3 100.0 451 30-34 43.3 3.9 21.3 5.1 4.1 21.5 0.8 100.0 413 35-39 42.9 2.1 21.3 6.8 4.3 21.6 1.1 100.0 463 40-44 32.3 2.3 27.3 9.2 4.8 24.1 0.0 100.0 468 45-49 39.2 2.8 18.9 9.1 4.0 25.3 0.7 100.0 419 Marital status Never married 54.9 5.9 27.8 4.0 0.9 6.1 0.4 100.0 585 Married or living together 38.8 3.0 18.7 7.3 4.3 27.4 0.5 100.0 1,629 Divorced/separated/ widowed 31.5 2.0 39.9 11.2 4.2 9.9 1.4 100.0 252 Number of living children 0 52.9 5.6 28.1 5.1 0.9 6.9 0.6 100.0 708 1-2 42.2 3.5 23.1 7.8 3.5 19.2 0.7 100.0 1,262 3-4 26.3 0.9 15.5 7.3 6.9 42.5 0.6 100.0 480 Residence Urban 53.8 4.6 29.0 7.5 1.7 2.4 0.8 100.0 1,484 Rural 23.8 1.9 13.9 6.0 6.1 47.9 0.3 100.0 982 Region Yerevan 59.7 3.8 27.9 6.6 0.9 0.3 0.8 100.0 868 Aragatsotn 40.1 2.6 15.6 8.5 1.5 31.6 0.0 100.0 89 Ararat 34.0 0.6 22.6 10.8 3.7 27.3 1.1 100.0 281 Armavir 19.0 3.9 11.5 3.5 8.8 52.9 0.4 100.0 311 Gegharkunik 18.8 2.9 13.0 1.6 4.1 59.6 0.0 100.0 228 Lori 47.8 3.2 36.4 6.4 0.0 3.6 2.7 100.0 57 Kotayk 34.0 4.7 24.7 11.8 7.1 17.6 0.0 100.0 283 Shirak 55.6 8.0 26.3 4.4 1.0 4.7 0.0 100.0 113 Syunik 41.6 3.0 28.9 10.4 2.2 14.0 0.0 100.0 102 Vayots Dzor 39.0 2.2 23.5 12.1 11.1 10.3 1.8 100.0 45 Tavush 39.8 4.0 24.7 3.7 0.8 25.7 1.3 100.0 89 Education Basic 5.3 0.0 21.4 8.0 15.7 49.6 0.0 100.0 122 Secondary 6.4 1.3 34.6 9.2 6.1 41.8 0.6 100.0 804 Secondary special 40.8 5.0 28.2 7.6 2.6 15.3 0.6 100.0 583 Higher 77.2 5.1 10.3 4.5 0.2 2.0 0.7 100.0 956 Wealth quintile Lowest 10.9 1.7 16.6 6.2 9.7 54.6 0.3 100.0 392 Second 33.5 2.6 15.8 7.0 4.3 36.5 0.3 100.0 509 Middle 34.2 5.2 31.0 8.9 2.8 17.3 0.7 100.0 420 Fourth 53.8 4.4 28.3 8.0 1.2 3.5 0.9 100.0 548 Highest 63.9 3.7 22.9 4.9 1.3 2.5 0.8 100.0 597 Total 41.9 3.6 23.0 6.9 3.5 20.5 0.6 100.0 2,466 Note: Figures in parentheses are based on 25-49 unweighted cases. Total includes 1 (weighted) woman with no education and 16 women with5 or more living children. Background Characteristics of Respondents • 43 Table 3.6.2 Occupation: Men Percent distribution of men age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Armenia 2015-16 Background characteristic Professional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Agriculture Missing Total Number of men Age 15-19 (7.8) (1.5) (30.8) (10.8) (24.3) (24.8) (0.0) 100.0 34 20-24 13.9 0.8 19.6 35.3 7.9 16.7 5.8 100.0 238 25-29 21.2 1.6 26.3 26.8 5.7 15.0 3.4 100.0 383 30-34 22.6 1.2 30.6 26.4 5.5 8.7 5.1 100.0 388 35-39 22.6 0.4 28.1 31.0 5.8 8.1 4.0 100.0 328 40-44 19.9 1.1 30.0 26.8 7.0 12.7 2.6 100.0 308 45-49 23.6 0.6 26.8 23.8 3.7 18.9 2.6 100.0 287 Marital status Never married 19.1 1.0 23.0 29.7 6.4 17.0 3.7 100.0 570 Married or living together 21.4 0.9 29.0 27.2 5.8 11.7 4.0 100.0 1,341 Divorced/separated/ widowed (21.0) (4.4) (31.2) (21.3) (12.2) (9.9) (0.0) 100.0 53 Number of living children 0 20.1 0.9 23.1 30.0 6.3 15.7 3.9 100.0 685 1-2 21.6 1.3 30.7 26.6 5.5 10.5 3.8 100.0 973 3-4 20.1 0.5 27.4 25.4 7.4 15.2 3.9 100.0 294 Residence Urban 30.2 1.4 32.5 25.1 5.0 1.4 4.4 100.0 1,078 Rural 9.2 0.6 21.1 30.9 7.6 27.5 3.2 100.0 887 Region Yerevan 37.1 2.1 33.2 19.9 4.6 0.3 2.8 100.0 555 Aragatsotn 17.5 1.0 28.4 23.4 1.7 26.3 1.7 100.0 98 Ararat 13.5 0.7 26.9 27.0 6.0 23.0 2.9 100.0 243 Armavir 12.0 0.2 19.0 19.0 8.0 37.8 3.8 100.0 220 Gegharkunik 6.4 0.0 17.8 41.7 5.7 26.3 2.2 100.0 192 Lori 17.2 0.0 28.2 36.1 6.9 6.7 4.9 100.0 113 Kotayk 18.9 1.1 30.6 34.4 8.9 3.3 2.8 100.0 241 Shirak 15.9 1.1 24.6 47.3 2.1 3.2 5.8 100.0 109 Syunik 18.0 0.8 22.9 30.1 10.8 5.9 11.5 100.0 75 Vayots Dzor 13.7 2.0 26.6 15.2 23.5 9.4 9.5 100.0 42 Tavush 15.2 0.0 30.1 25.6 1.8 18.6 8.8 100.0 78 Education Basic 5.1 0.0 19.6 30.1 14.3 28.7 2.3 100.0 225 Secondary 7.2 0.1 28.8 36.3 7.1 17.6 2.9 100.0 913 Secondary special 12.0 2.8 38.9 30.4 6.2 5.5 4.2 100.0 301 Higher 56.2 2.1 21.3 10.3 1.1 3.2 5.8 100.0 524 Wealth quintile Lowest 4.4 0.3 18.7 31.1 8.9 33.8 2.7 100.0 384 Second 10.6 0.7 25.0 33.1 7.3 19.5 3.9 100.0 420 Middle 16.8 0.4 30.7 30.7 6.8 9.0 5.6 100.0 362 Fourth 31.1 1.2 29.1 27.0 5.0 2.0 4.7 100.0 390 Highest 40.1 2.4 33.3 17.1 2.9 1.7 2.4 100.0 408 Total 20.7 1.0 27.3 27.7 6.2 13.2 3.8 100.0 1,965 Note: Figures in parentheses are based on 25-49 unweighted cases. Total includes 13 (weighted) men with 5 or more living children and 1 (weighted) man with no education. 44 • Background Characteristics of Respondents As expected, the proportions of both women and men who worked in professional, technical, and managerial occupations were higher in urban than in rural areas. The proportions in these occupations also rose rapidly with both increasing education and wealth. Men and especially women with basic education and those in the lowest wealth quintile were most likely to be working in agriculture. 3.6 WOMEN’S EMPLOYMENT CHARACTERISTICS As with education, employment can be a source of empowerment for women, particularly employment that involves cash earnings. Table 3.7 shows the percent distribution of women who were employed in the 12 months preceding the survey by type of earnings and employer, and continuity of employment, according to type of employment (agricultural or nonagricultural). Overall, 74 percent of employed women earn cash only, 12 percent were paid in cash and in kind, and 14 percent either received only in-kind payment or were not paid at all. Virtually all women who worked in nonagricultural jobs (95 percent) were paid in cash. On the other hand, women who worked in agricultural positions most often did not receive any cash payments for the work they did; more than half were paid either in kind only (33 percent) or not paid at all (22 percent). Table 3.7 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), Armenia 2015-16 Employment characteristic Agricultural work Nonagricultural work Total Type of earnings Cash only 4.5 94.5 73.9 Cash and in-kind 40.6 3.4 11.9 In-kind only 33.0 0.1 7.6 Not paid 21.9 2.1 6.6 Total 100.0 100.0 100.0 Type of employer Employed by family member 14.2 4.2 6.5 Employed by nonfamily member 4.2 88.4 69.1 Self-employed 81.6 7.4 24.4 Total 100.0 100.0 100.0 Continuity of employment All year 48.4 94.4 83.9 Seasonal 51.6 5.2 15.8 Occasional 0.0 0.3 0.2 Missing 0.0 0.1 0.1 Total 100.0 100.0 100.0 Number of women employed during the last 12 months 564 1,887 2,466 Note: Total includes women with missing information on type of employment who are not shown separately. Women who work in agriculture were mainly either self-employed (82 percent) or employed by a family member (14 percent), while the majority of women employed in nonagricultural jobs were employed by nonfamily members (88 percent). More than 8 in 10 working women were employed throughout the year, while 16 percent had seasonal jobs. As expected, the ADHS results confirm that continuity of employment is more assured for women engaged in nonagricultural work; more than half of women employed in agricultural occupations had seasonal jobs compared with 5 percent of women in nonagricultural occupations. Background Characteristics of Respondents • 45 3.7 EMPLOYMENT ABROAD Armenia is a country that regularly experiences an outflow of citizens, particularly men, in search of employment. The 2015-16 ADHS collected information about recent employment abroad as a proxy indicator for labor migration. To obtain this information, all women and men age 15-49 were asked whether they had worked abroad during the 3 years preceding the survey for 3 or more months at a time. In addition, currently married women and men age 15-49 in the 2015-16 ADHS were asked whether their spouses were working abroad during the 3 years preceding the survey for 3 or more months at a time. Table 3.8 shows the percentages of women and men age 15-49 who worked abroad during the 3 years preceding the survey for 3 or more months at a time, by background characteristics. Overall, 1 percent of women and 12 percent of men reported that they had worked abroad at some point in the 3 years preceding the 2105-16 ADHS for 3 or more months at a time. The rates of employment abroad among women and men have not changed much over the past 5 years since the 2010 ADHS when 3 percent of women and 11 percent of men reported they had worked abroad. Marked differences were evident by background characteristics in the likelihood that men had worked abroad (Table 3.8). Eighteen percent of rural men had worked abroad compared with 8 percent of urban men. Considering regional differences, men in Shirak (26 percent), Lori (27 percent) and Gegharkunik (31 percent) were the most likely to have worked abroad, while men in Syunik (1 percent) were the least likely. Men with secondary special or less education were more than twice as likely as men with higher education to have worked abroad. Similarly, men in the lowest wealth quintiles were more than twice as likely to have recently worked abroad as men in the two highest quintiles. Finally, although few currently married women themselves had worked abroad recently, 22 percent reported that their spouse had worked abroad in the 3 years prior to the 2015-16 ADHS. Among currently married men only 1 percent reported that their wife had worked abroad during the referenced period (data not shown). Table 3.8 Respondent’s employment abroad Percentage of women and men 15-49 who worked abroad during the 3 years before the survey for 3 or more months at a time, by background characteristics, Armenia 2015-16 Background characteristic Women Men Worked abroad1 Number of women Worked abroad1 Number of men Age 15-24 1.0 1,653 6.6 813 25-29 0.9 1,099 17.5 464 30-39 1.7 1,874 13.5 802 40-49 1.5 1,490 13.4 676 Marital status Never married 1.2 1,830 8.6 1,190 Married/living together 1.3 3,895 15.0 1,506 Divorced/separated/ widowed 2.2 390 (8.4) 59 Residence Urban 1.7 3,657 7.8 1,558 Rural 0.7 2,459 17.7 1,197 Region Yerevan 2.5 2,001 3.0 833 Aragatsotn 0.0 315 2.0 159 Ararat 0.5 552 3.2 290 Armavir 1.0 586 18.8 268 Gegharkunik 0.4 478 30.9 235 Lori 0.8 355 26.9 184 Kotayk 1.0 678 16.1 299 Shirak 1.9 510 25.5 201 Syunik 0.0 238 1.1 104 Vayots Dzor 0.0 119 6.3 56 Tavush 0.8 283 16.0 126 Education Basic 1.0 396 12.5 360 Secondary 0.8 2,444 16.0 1,250 Secondary special 1.5 1,360 13.0 403 Higher 1.9 1,910 5.0 736 Wealth quintile Lowest 0.8 1,081 16.0 523 Second 0.6 1,242 16.8 583 Middle 1.3 1,142 16.5 521 Fourth 1.1 1,287 6.8 566 Highest 2.6 1,365 5.1 562 Total 1.3 6,116 12.1 2,755 Note: Figures in parentheses are based on 25-49 unweighted cases. Total includes five (weighted) women and five (weighted) men with no education. 1 Employment abroad refers to working abroad during the past 3 years before the survey for 3 or more months at a time. Marriage and Sexual Activity • 47 MARRIAGE AND SEXUAL ACTIVITY 4 his chapter presents 2015-16 ADHS data on marriage and sexual activity. If couples have the biological capacity to reproduce, the social environment in which they live largely determines whether they will have children and, if so, how many and how often. In Armenia, sexual activity usually takes place within marriage; therefore, marriage is a primary indicator of a woman’s sustained exposure to the risk of pregnancy. More direct measures of exposure are age at first sexual intercourse and the frequency of intercourse. Although postpartum amenorrhea, abstinence, and menopause also influence fertility, their impact is reviewed in the next chapter. None of these determining factors are independent; they interact and influence each other to affect fertility levels and trends. Their contribution varies from person to person, from region to region, and from time to time. 4.1 MARITAL STATUS Table 4.1 shows the percent distribution of all women and men age 15-49 by their marital status at the time of the survey, according to age. The term married refers to legal or formal marriage (civil or religious), while living together refers to informal unions. In subsequent tables, these two categories are merged and referred to collectively as currently married. Persons who are divorced, separated, or widowed are considered to be formerly married. T Key Findings  Approximately two-thirds of women age 15-49 (64 percent) and more than half of men age 15-49 (55 percent) are currently married or living together with a partner. Thirty percent of women and 43 percent of men have never been married; 4 percent of women and 2 percent of men are divorced or separated; and 2 percent of women but virtually no men are widowed.  Most Armenian women and men marry at least once during their lifetime; the proportion who have never married decreases rapidly with age, dropping to 6 percent among women age 45-49 and 4 percent among men age 45-49.  Less than 1 percent of women age 25-49 married for the first time before age 15, and only 13 percent married before age 18.  The percentage of women age 25-49 who were married by age 18 decreases from 21 percent among those age 40-44 to 5 percent among those age 20-24.  Men in Armenia marry on average 5 years later than women. The median age at first marriage among women age 30-49 is 20.9 years, compared with 25.9 years among men in the same age group.  Women in Armenia generally initiate sexual intercourse around the time of their first marriage. In contrast, men age 30-49 initiate intercourse 4.7 years before their first marriage.  Fifty-seven percent of women were sexually active within the 4 weeks before the survey, and an additional 6 percent were active within the 12 months before the survey although not in the month before the survey; corresponding figures for men are 64 percent and 9 percent. 48 • Marriage and Sexual Activity Table 4.1 Current marital status Percent distribution of women and men age 15-49 by current marital status, according to age, Armenia 2015-16 Age Marital status Total Percentage of respondents currently in union Number of respondents Never married Married Living together Divorced Separated Widowed WOMEN 15-19 95.2 4.6 0.0 0.2 0.0 0.0 100.0 4.6 725 20-24 60.1 39.2 0.1 0.2 0.2 0.1 100.0 39.3 928 25-29 27.4 69.1 0.2 2.4 0.5 0.4 100.0 69.2 1,099 30-34 12.5 81.5 0.5 4.1 0.8 0.6 100.0 82.0 1,007 35-39 8.2 81.4 0.4 6.3 1.5 2.2 100.0 81.8 867 40-44 5.2 81.1 0.4 6.3 1.3 5.6 100.0 81.5 784 45-49 6.0 78.1 1.5 6.3 0.6 7.5 100.0 79.6 706 Total 29.9 63.3 0.4 3.6 0.7 2.1 100.0 63.7 6,116 MEN 15-19 100.0 0.0 0.0 0.0 0.0 0.0 100.0 0.0 345 20-24 87.9 8.6 2.6 0.4 0.4 0.0 100.0 11.2 467 25-29 55.1 40.1 4.3 0.3 0.2 0.0 100.0 44.4 464 30-34 21.6 67.3 8.1 2.0 0.5 0.5 100.0 75.4 427 35-39 13.5 77.3 8.0 0.7 0.2 0.3 100.0 85.3 376 40-44 6.0 82.2 7.1 3.5 1.1 0.0 100.0 89.3 346 45-49 4.4 82.6 7.3 4.2 1.5 0.0 100.0 90.0 330 Total 43.2 49.4 5.3 1.5 0.5 0.1 100.0 54.7 2,755 According to the 2015-16 ADHS, more than three-fifths of women (64 percent) and more than half of men (55 percent) are married or living together with a partner. Four percent of women and 2 percent of men are either divorced or separated, while 2 percent of women but virtually no men are widowed. The proportion of women currently married increases with age, peaking at 82 percent among women age 30-44, and then declining slightly among the oldest women. Among women age 45-49, only 6 percent have never married, 80 percent are married or cohabiting with a man, 7 percent are divorced or separated, and 8 percent are widowed. Men, in comparison with women, are more likely to have never married (43 percent versus 30 percent). This difference is largely explained by the tendency of men to marry at later ages. For example, 11 percent of men age 20-24 are in union compared with 39 percent of women of the same age. Marriage patterns have remained largely stable over the past decade in Armenia. The proportions reported as ever married varied only slightly between the 2005, 2010, and 2015-16 ADHS surveys among both women (69 percent, 68 percent, and 70 percent, respectively) and men (58 percent, 55 percent, and 57 percent, respectively). 4.2 AGE AT FIRST MARRIAGE AND SEXUAL INTERCOURSE Marriage is an important demographic and social indicator; it generally marks the point in a person’s life when parenthood becomes socially acceptable. Information on age at first marriage was obtained in the 2015-16 ADHS by asking all ever-married respondents the month and year they started living together with their first spouse. Table 4.2 shows the proportions of women and men who first married by specific exact ages and the median age at first marriage among women age 25-49 and women and men age 30-49. The median age at first marriage is not shown for men age 25-49 because less than 50 percent of men married for the first time before reaching age 25. The results in Table 4.2 show that more than one-third of women age 25-49 had married by age 20, and 73 percent had married by age 25. The median age at first marriage among women age 25-49 was 21.4 years. An examination of cohort differences in the median age at first marriage among women age 25-49 indicates that younger women married more than 2 years later than older women; the median age at first marriage among women age 25-29 was 22.9 years compared with 20.6 years among women age 45-49. Marriage and Sexual Activity • 49 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, Armenia 2015-16 Current age Percentage first married by exact age: Percentage never married Number of respondents Median age at first marriage 15 18 20 22 25 WOMEN 15-19 0.0 na na na na 95.2 725 a 20-24 0.0 5.3 19.1 na na 60.1 928 a 25-29 0.2 7.6 23.9 41.7 63.3 27.4 1,099 22.9 30-34 0.1 11.1 32.4 52.4 69.5 12.5 1,007 21.7 35-39 0.7 16.0 39.5 56.7 73.6 8.2 867 21.0 40-44 0.2 20.6 51.4 67.6 81.1 5.2 784 19.9 45-49 0.0 14.0 43.0 65.6 82.6 6.0 706 20.6 25-49 0.2 13.3 36.7 55.3 72.9 13.0 4,463 21.4 30-49 0.2 15.2 40.9 59.8 76.0 8.3 3,364 20.9 MEN 15-19 0.0 na na na na 100.0 345 a 20-24 0.0 0.4 1.6 na na 87.9 467 a 25-29 0.0 0.3 0.9 7.7 26.9 55.1 464 a 30-34 0.0 0.5 2.4 11.2 35.4 21.6 427 26.3 35-39 0.0 0.9 3.5 13.0 41.7 13.5 376 26.1 40-44 0.0 0.5 4.5 15.1 37.8 6.0 346 26.6 45-49 0.0 0.5 2.8 21.3 52.1 4.4 330 24.7 25-49 0.0 0.5 2.7 13.1 37.9 22.3 1,942 a 30-49 0.0 0.6 3.3 14.8 41.3 12.0 1,478 25.9 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 percent of the women or men began living with their spouse or partner for the first time before reaching the beginning of the age group Unlike women, very few men age 25-49 had married by age 20 (3 percent), and only 38 percent had married by age 25. The majority of men marry between ages 25 and 30, with nearly 90 percent of men age 30-49 reporting they had married. The tendency of men to delay marriage to much older ages than women is further evidenced by the 5-year difference between the median ages at first marriage among men and women age 30-49 (25.9 years and 20.9 years, respectively). The median ages at first marriage among women age 25-49 and women and men age 30-49 are shown by background characteristics in Table 4.3. The median age at first marriage is lower in rural areas than in urban areas for both women and men age 30-49. Considering regional differentials, Yerevan has by far the highest median age at first marriage among women (22.4), while Yerevan and Aragatsotn have the highest median ages among men (26.8 years and 27.1 years, respectively). The median age at first marriage rises with increasing education among women and men. However, education clearly has a much stronger influence on age at first marriage among women than men. On average, women age 30-49 with higher education married more than 5 years later than women with basic education (23.8 years and 18.5 years, respectively). In contrast, men age 30-49 with higher education married less than 2 years 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 30-49, according to background characteristics, Armenia 2015-16 Background characteristic Women age Men age 25-49 30-49 30-49 Residence Urban 22.3 21.9 26.4 Rural 20.1 19.7 25.3 Region Yerevan 22.8 22.4 26.8 Aragatsotn 21.0 20.3 27.1 Ararat 21.3 21.0 25.7 Armavir 20.0 19.6 25.5 Gegharkunik 20.1 19.8 25.4 Lori 21.3 20.8 25.3 Kotayk 20.7 20.4 25.3 Shirak 21.0 20.5 26.3 Syunik 20.8 20.4 26.6 Vayots Dzor 20.2 20.0 26.2 Tavush 20.4 19.9 24.6 Education No education * * * Basic 18.8 18.5 25.5 Secondary 19.9 19.7 25.6 Secondary special 21.2 20.9 25.9 Higher 24.1 23.8 27.2 Wealth quintile Lowest 20.3 19.9 25.8 Second 20.4 20.0 25.5 Middle 20.8 20.2 25.8 Fourth 22.4 21.7 26.6 Highest 22.7 22.4 26.1 Total 21.4 20.9 25.9 Note: The age at first marriage is defined as the age at which the respondent began living with her/his first spouse/partner. An asterisk indicates that a figure is based on fewer than 25 cases and has been suppressed. 50 • Marriage and Sexual Activity later than men with basic education (27.2 years and 25.5 years, respectively). Among women, wealth is directly related to the age at first marriage; the median age at first marriage increases steadily among women age 30-49, from 19.9 years in the lowest quintile to 22.4 years in the highest quintile. The relationship between wealth and age at marriage is not as strong among men, but men in the fourth and the highest wealth quintiles report marrying somewhat later on average (26.6 years and 26.1 years, respectively) than men in the lowest three quintiles (between 25.5 years and 25.8 years). With regard to recent trends in the age at first marriage, the median age at first marriage among women age 25-49 increased from 21.1 years in 2010 to 21.4 years in 2015-16, while the median age at first marriage among men age 30-49 increased from 25.8 in 2010 to 25.9 in 2015-16. 4.2 AGE AT FIRST SEXUAL INTERCOURSE Age at first marriage is sometimes seen as a proxy for a woman’s first exposure to intercourse, but the two events need not occur at the same time. Because women and men may engage in sexual relations prior to marriage, age at first sexual intercourse is a more reliable indicator of a woman’s exposure to the risk of pregnancy than age at first marriage. In the 2015-16 ADHS, women and men were asked how old they were when they first had sexual intercourse. Table 4.4 shows the proportion of women and men who first had sex by specific exact ages and the median ages at first intercourse. Overall, the 2015-16 ADHS results indicate that, among Armenian women, the reported age at first marriage and age at first intercourse correspond closely. Among all women age 25-49, for example, the median age at first intercourse was 21.2 years, only very slightly lower than the median age at first marriage (21.4 years). The very close correspondence between the age at first intercourse and the age at first marriage may be in part a result of women’s unwillingness to report premarital sexual activity due to the strong cultural norms against such behavior. Table 4.4 Age at first sexual intercourse Percentage of women and men age 15-49 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, Armenia 2015-16 Current age Percentage who had first sexual intercourse by exact age: Percentage who never had intercourse Number of respondents Median age at first intercourse 15 18 20 22 25 WOMEN 15-19 0.0 na na na na 95.2 725 a 20-24 0.2 5.9 19.6 na na 59.9 928 a 25-29 0.2 8.1 25.0 42.1 64.3 27.0 1,099 22.8 30-34 0.1 11.7 33.3 52.9 70.0 12.1 1,007 21.7 35-39 0.7 16.8 40.4 57.3 74.7 8.2 867 20.9 40-44 0.5 21.2 51.9 68.2 81.4 5.1 784 19.9 45-49 0.0 15.4 44.2 66.9 83.6 5.9 706 20.4 20-49 0.2 11.1 30.6 na na 29.6 5,265 a 25-49 0.3 14.1 37.6 56.0 73.6 12.8 4,463 21.2 30-49 0.3 16.0 41.8 60.6 76.7 8.2 3,364 20.7 15-24 0.1 na na na na 75.4 1,653 a MEN 15-19 1.0 na na na na 87.5 345 a 20-24 1.0 14.9 31.8 na na 39.9 467 a 25-29 0.7 15.5 35.4 65.0 87.6 7.5 464 21.1 30-34 0.8 15.9 33.6 58.9 83.4 3.3 427 21.3 35-39 0.8 19.2 37.0 59.3 84.2 3.4 376 21.1 40-44 0.3 11.1 28.0 57.5 84.3 1.7 346 21.5 45-49 0.9 14.4 37.3 66.4 88.9 0.5 330 20.9 20-49 0.8 15.3 33.8 na na 10.6 2,410 a 25-49 0.7 15.4 34.3 61.5 85.6 3.6 1,942 21.2 30-49 0.7 15.3 34.0 60.3 85.0 2.3 1,478 21.2 15-24 1.0 na na na na 60.1 813 a na = Not applicable due to censoring a = Omitted because less than 50 percent of the respondents had sexual intercourse for the first time before reaching the beginning of the age group Marriage and Sexual Activity • 51 Unlike women, it is common for Armenian men to report having sexual intercourse before marriage. For example, although very few men age 30-49 were married by age 20 (just 3 percent), one-third of men said they had had sexual intercourse for the first time by that age. The median age at first sexual intercourse among men age 30-49 is more than 4 years younger than the median age at first marriage (21.2 years and 25.9 years, respectively). Table 4.5 shows the median age at first sexual intercourse for women and men in the age groups 25-49 and 30-49 by background characteristics. Looking at the results for the women, differentials in the median age at first intercourse within subgroups closely parallel the differentials observed in the median ages at first marriage; the highest median ages at first sex were observed among women in urban areas, women in Yerevan, women with at least some higher education, and women in the highest wealth quintile. In contrast, the median age at first intercourse is lower among men in urban areas than among men in rural areas and generally declines with increasing education and wealth. 4.3 RECENT SEXUAL ACTIVITY In the absence of contraceptive use, the frequency of sexual intercourse is a direct determinant of pregnancy; therefore, information about the frequency of sexual activity is a useful indicator of exposure to pregnancy. The 2015-16 ADHS asked women and men the timing of their last sexual intercourse. Tables 4.6.1 and 4.6.2 show the percent distributions for women and men age 15-49 by how long ago their last sexual intercourse occurred. Respondents were considered to be sexually active if they had sexual intercourse at least once in the 4 weeks prior to the survey. In the 4 weeks preceding the survey, 57 percent of women were sexually active. Six percent of women had sexual intercourse in the year preceding the survey, but not in the month before the survey, and another 7 percent reported they last had sexual intercourse more than a year before. At the time of the survey, 30 percent of all female respondents had never had sexual intercourse. The proportion of women who were recently sexually active increases with age to a peak at 76 percent among women age 30-34 and then declines to 67 percent among women age 45-49. Only 4 percent of women age 15-19 reported recent sexual activity; the majority (95 percent) have never had sexual intercourse. As expected, marital status is closely related to the frequency of sexual activity. Among currently married women, 90 percent reported they had had intercourse within the month before the interview. As previously noted, almost no women reported sexual activity outside of marriage: virtually all never-married women reported that they had never had intercourse. Table 4.5 Median age at first sexual intercourse by background characteristics Median age at first sexual intercourse among women and men age 25-49 and age 30-49, according to background characteristics, Armenia 2015-16 Background characteristic Women age Men age 25-49 30-49 25-49 30-49 Residence Urban 22.2 21.7 20.8 20.9 Rural 20.0 19.6 21.7 21.7 Region Yerevan 22.8 22.3 20.1 20.2 Aragatsotn 20.9 20.2 23.7 23.8 Ararat 21.3 20.9 21.1 21.1 Armavir 19.8 19.5 18.8 18.8 Gegharkunik 20.0 19.7 22.3 22.3 Lori 21.3 20.8 22.0 22.0 Kotayk 20.6 20.3 21.8 22.1 Shirak 20.9 20.4 17.9 17.9 Syunik 20.8 20.4 a 25.8 Vayots Dzor 20.2 20.0 24.2 24.1 Tavush 20.3 19.8 23.9 23.4 Education No education * * * * Basic 18.6 18.3 21.0 21.1 Secondary 19.8 19.6 21.4 21.4 Secondary special 21.2 20.8 21.2 21.4 Higher 23.9 23.7 20.9 20.8 Wealth quintile Lowest 20.2 19.8 21.5 21.7 Second 20.3 19.9 21.5 21.5 Middle 20.7 20.1 21.4 21.6 Fourth 22.3 21.6 21.3 21.3 Highest 22.6 22.4 20.0 20.1 Total 21.2 20.7 21.2 21.2 Note: An asterisk indicates that a figure is based on fewer than 25 cases and has been suppressed. a = Omitted because less than 50 percent of the respondents had intercourse for the first time before reaching the beginning of the age group 52 • Marriage and Sexual Activity Table 4.6.1 Recent sexual activity: Women Percent distribution of women age 15-49 by timing of last sexual intercourse, according to background characteristics, Armenia 2015-16 Background characteristic Timing of last sexual intercourse Never had sexual intercourse Total Number of women Within the past 4 weeks Within 1 year1 One or more years Missing Age 15-19 4.0 0.8 0.0 0.0 95.2 100.0 725 20-24 35.6 3.6 0.8 0.2 59.9 100.0 928 25-29 62.7 6.7 3.4 0.2 27.0 100.0 1,099 30-34 76.1 5.3 6.5 0.1 12.1 100.0 1,007 35-39 74.5 5.8 11.3 0.1 8.2 100.0 867 40-44 73.0 6.9 14.7 0.2 5.1 100.0 784 45-49 66.7 11.1 16.1 0.2 5.9 100.0 706 Marital status Never married 0.4 0.1 0.1 0.0 99.3 100.0 1,830 Married or living together 89.7 8.1 2.1 0.1 0.0 100.0 3,895 Divorced/separated/widowed 0.9 8.2 90.1 0.8 0.0 100.0 390 Marital duration2 0-4 years 89.1 9.7 1.0 0.2 0.0 100.0 698 5-9 years 90.9 7.5 1.4 0.2 0.0 100.0 772 10-14 years 91.9 6.0 2.1 0.0 0.0 100.0 694 15-19 years 92.4 5.5 2.0 0.2 0.0 100.0 565 20-24 years 88.5 8.4 3.0 0.1 0.0 100.0 560 25+ years 85.0 11.5 3.3 0.2 0.0 100.0 545 Married more than once 83.1 9.7 7.3 0.0 0.0 100.0 61 Employment abroad (past 3 years)3 Yes 45.4 10.6 16.3 0.0 27.7 100.0 81 No 57.4 5.6 7.0 0.1 29.8 100.0 6,035 Spousal employment abroad reported by currently married women4 Respondent worked abroad herself * * * * * 100.0 18 Spouse worked abroad 72.6 20.0 7.4 0.0 0.0 100.0 834 Both worked abroad (66.6) (20.8) (12.7) (0.0) (0.0) 100.0 32 None worked abroad 94.7 4.7 0.5 0.2 0.0 100.0 2,998 Not currently married 0.5 1.6 16.0 0.1 81.9 100.0 2,221 Missing * * * * * 100.0 13 Residence Urban 54.3 5.9 8.7 0.1 31.0 100.0 3,657 Rural 61.7 5.4 4.8 0.2 27.8 100.0 2,459 Region Yerevan 50.8 5.8 9.4 0.1 33.9 100.0 2,001 Aragatsotn 55.3 1.3 4.8 1.3 37.2 100.0 315 Ararat 62.1 2.8 6.6 0.0 28.6 100.0 552 Armavir 60.1 8.1 7.6 0.2 24.0 100.0 586 Gegharkunik 59.2 2.7 4.0 0.1 34.0 100.0 478 Lori 53.5 5.7 5.5 0.0 35.3 100.0 355 Kotayk 62.9 6.6 6.4 0.0 24.1 100.0 678 Shirak 55.0 11.8 8.2 0.0 25.0 100.0 510 Syunik 69.4 2.1 5.4 0.0 23.1 100.0 238 Vayots Dzor 64.8 7.5 4.0 0.0 23.7 100.0 119 Tavush 69.0 4.9 3.9 0.2 21.9 100.0 283 Education No education * * * * * 100.0 5 Basic 45.2 6.1 7.4 0.3 41.0 100.0 396 Secondary 61.0 6.0 7.8 0.2 25.0 100.0 2,444 Secondary special 62.1 7.4 7.7 0.1 22.6 100.0 1,360 Higher 51.6 4.0 5.8 0.0 38.5 100.0 1,910 Wealth quintile Lowest 58.1 5.4 8.6 0.2 27.8 100.0 1,081 Second 61.0 5.2 4.3 0.2 29.3 100.0 1,242 Middle 56.2 6.7 8.6 0.1 28.3 100.0 1,142 Fourth 55.6 5.5 6.6 0.2 32.1 100.0 1,287 Highest 55.8 5.7 7.8 0.1 30.6 100.0 1,365 Total 57.3 5.7 7.1 0.1 29.7 100.0 6,116 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 cases and has been suppressed. 1 Excludes women who had sexual intercourse within the last 4 weeks 2 Excludes women who are not currently married 3 Employment abroad refers to working abroad during the past 3 years before the survey for 3 or more months at a time. 4 Information is based on currently married women’s report of their own and their husband’s employment abroad for a period of 3 or more months at any time in the 3 years before the survey. Marriage and Sexual Activity • 53 Table 4.6.2 Recent sexual activity: Men Percent distribution of men age 15-49 by timing of last sexual intercourse, according to background characteristics, Armenia 2015-16 Background characteristic Timing of last sexual intercourse Never had sexual intercourse Total Number of men Within the past 4 weeks Within 1 year1 One or more years Missing Age 15-19 3.7 7.6 1.2 0.0 87.5 100.0 345 20-24 34.7 14.9 10.5 0.0 39.9 100.0 467 25-29 65.8 15.8 9.9 1.0 7.5 100.0 464 30-34 80.5 10.1 5.7 0.4 3.3 100.0 427 35-39 87.7 4.7 3.9 0.3 3.4 100.0 376 40-44 89.3 3.9 3.9 1.2 1.7 100.0 346 45-49 91.8 3.7 3.4 0.7 0.5 100.0 330 Marital status Never married 24.5 16.5 11.8 0.4 46.9 100.0 1,190 Married or living together 96.5 2.8 0.1 0.6 0.0 100.0 1,506 Divorced/separated/widowed (33.4) (30.8) (35.8) (0.0) (0.0) 100.0 59 Marital duration2 0-4 years 94.7 5.0 0.0 0.3 0.0 100.0 317 5-9 years 95.8 3.9 0.0 0.4 0.0 100.0 331 10-14 years 97.4 2.1 0.0 0.5 0.0 100.0 291 15-19 years 98.4 0.5 0.0 1.1 0.0 100.0 252 20-24 years 96.1 2.1 0.6 1.2 0.0 100.0 182 25+ years 99.7 0.3 0.0 0.0 0.0 100.0 83 Married more than once 94.3 3.5 0.0 2.2 0.0 100.0 51 Residence Urban 66.1 9.4 6.1 0.5 17.9 100.0 1,558 Rural 61.4 9.1 5.7 0.6 23.2 100.0 1,197 Region Yerevan 69.3 8.8 6.5 0.0 15.4 100.0 833 Aragatsotn 54.8 4.8 16.0 0.2 24.2 100.0 159 Ararat 55.8 11.2 11.4 0.0 21.5 100.0 290 Armavir 83.1 5.2 0.4 0.0 11.3 100.0 268 Gegharkunik 50.1 15.8 3.7 0.0 30.4 100.0 235 Lori 47.1 10.3 8.1 7.3 27.3 100.0 184 Kotayk 68.7 10.4 4.6 0.0 16.4 100.0 299 Shirak 70.7 15.4 1.9 0.0 12.0 100.0 201 Syunik 55.6 4.2 0.0 0.0 40.2 100.0 104 Vayots Dzor 54.5 6.3 3.6 0.5 35.0 100.0 56 Tavush 60.0 2.1 4.2 0.0 33.6 100.0 126 Education No education * * * * * 100.0 5 Basic 52.6 9.3 6.2 0.3 31.6 100.0 360 Secondary 63.9 8.6 5.5 0.7 21.3 100.0 1,250 Secondary special 68.4 9.0 4.9 0.7 17.0 100.0 403 Higher 67.7 10.8 7.0 0.2 14.3 100.0 736 Wealth quintile Lowest 62.1 9.3 6.7 0.6 21.3 100.0 523 Second 60.1 9.7 5.8 0.6 23.8 100.0 583 Middle 62.0 10.8 6.0 0.4 20.8 100.0 521 Fourth 68.1 7.3 5.0 0.7 18.9 100.0 566 Highest 67.8 9.5 6.1 0.2 16.4 100.0 562 Total 64.1 9.3 5.9 0.5 20.2 100.0 2,755 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 cases and has been suppressed. 1 Excludes men who had sexual intercourse within the last 4 weeks 2 Excludes men who are not currently married Employment abroad was related to the likelihood of recent sexual activity among currently married women. Those whose spouse had worked abroad were less likely to have been sexually active within the 4- week period before the survey than married women who reported they and their spouse had never worked abroad (73 percent and 95 percent, respectively). Recent sexual activity was lowest among the small number of married women who reported that both they and their spouse had worked abroad (66 percent). 54 • Marriage and Sexual Activity Overall, men are more likely to report having had recent sexual intercourse than women (Table 4.6.2). Sixty-four percent had sexual intercourse in the 4 weeks preceding the survey; 9 percent had sexual intercourse in the past year, although not in the previous 4 weeks; 6 percent had sex one or more years ago and 20 percent have never had sexual intercourse. Among men under age 30, the likelihood a man has been recently sexually active increases sharply with age, from 4 percent among men age 15-19 to 66 percent among those age 25-29. Among men age 30 and older, 80 percent or more reported they had sex in the month preceding the interview. As expected, men who are currently married or living with a woman are most likely to have had recent sexual intercourse: 97 percent compared with 25 percent of never married men and one-third of the small number of formerly married men. Fertility • 55 FERTILITY 5 ertility is one of the three principal components of population dynamics, the others being mortality and migration. This chapter looks at a number of fertility indicators, including levels, patterns, and trends in current and cumulative fertility; children ever born and living; the length of birth intervals; the age at which women initiate childbearing; and teenage fertility. Postpartum amenorrhea, abstinence from sexual relations, and menopause are also presented in this chapter. Postpartum amenorrhea and sexual abstinence affect the duration of a woman’s insusceptibility to pregnancy, which in turn affects birth spacing. Menopause is important because it marks the end of a woman’s period of exposure to the risk of pregnancy. All women interviewed in the 2015-16 ADHS were asked for a complete reproductive history. Each woman was first asked about the total number of pregnancies that had ended in live births, stillbirths, miscarriages, and induced abortions. After obtaining these aggregate data, an event-by-event pregnancy history was collected. For each pregnancy, the month and year in which the pregnancy ended and the result of the pregnancy were recorded. Information was collected about all pregnancies the respondent had in the order in which they occurred, starting with her first one. For each pregnancy that resulted in a live birth, information was collected on the sex of the child, its survival status, and its current age (for surviving children) or age at death (for deceased children). In addition, the duration was recorded for each pregnancy ending during the 5-year period preceding the survey. 5.1 CURRENT FERTILITY The data collected in the pregnancy history were used to calculate two of the most widely used measures of current fertility: the total fertility rate (TFR) and its component age-specific fertility rates. The TFR is interpreted as the number of children the average woman would bear in her lifetime if she experienced the currently observed age-specific fertility rates throughout her reproductive years. The fertility rates refer to the 3-year period before the survey (i.e., approximately from February 2013 to February 2016). F Key Findings:  The total fertility rate for the 3 years prior to the 2015-16 ADHS was 1.7 births per woman.  Three prior ADHS surveys in 2000, 2005, and 2010 also reported total fertility rates of 1.7 births per woman, indicating that fertility in Armenia has been stable for more than 15 years.  Women are delaying childbearing to later ages. Almost 60 percent of childbearing at the time of the 2000 ADHS was concentrated among women age 15-24, but only a little more than 40 percent of childbearing took place in those age groups at the time of the 2015-16 ADHS.  Short birth intervals may adversely affect maternal health and children’s chances of survival. More than one fifth of non-first births in the 5-year period before the 2015-16 ADHS took place within 24 months of a previous birth, and 11 percent occurred within 18 months of the older sibling.  Childbearing at a young age also places the mother and child at increased risk. The proportion of teenagers who are already mothers or pregnant with their first child is higher in rural than urban areas (6 percent versus 1 percent, respectively). 56 • Fertility According to the results of the 2015-16 ADHS, the TFR is 1.7 children per woman (Table 5.1). The ADHS estimate is identical to the TFR of 1.7 births per woman reported by the National Statistical Service of Armenia for 2014 (NSS 2015), the year that falls in the middle of the 3-year period used to calculate the 2015-16 ADHS TFR.1 Thus, both sources confirm that childbearing in Armenia is substantially below replacement-level fertility, which is 2.1 children per woman. The age pattern presented in Table 5.1, displays fertility as highest in the 20-24 age group (124 births per 1,000 women), followed closely by the 25-29 age group (116 births per 1,000 women). Births to women in these age groups account for almost 70 percent of the total fertility rate. Table 5.1 also shows that the urban TFR is slightly lower than the rural rate (1.7 births per woman versus 1.8 births per woman) although, given sampling variability, this difference is not statistically significant. Among both urban and rural women, fertility rates are highest in the 20-24 and 25-29 age groups. Teenage fertility is lower among urban women than among rural women (11 births per 1,000 women versus 39 births per 1,000 women). Urban women also tend to delay childbearing to older ages more often than rural women; births to women age 30 and older account for 28 percent of the total urban TFR compared with 19 percent of the rural TFR. 5.2 FERTILITY DIFFERENTIALS BY BACKGROUND CHARACTERISTICS Table 5.2 presents differentials by background characteristics in three fertility measures: the total fertility rate, the percentage of women age 15-49 who are currently pregnant, and the mean number of children ever born among women age 40-49. Caution should be exercised in interpreting differences in the three measures between subgroups since some of the differences may be due simply to sampling variability, particularly where subgroups include comparatively small numbers of respondents.2 The TFR varies markedly by region. The rate is lowest in Aragatsotn and Gegharkunik (each 1.1 births per woman) and highest in Tavush (2.4 births per woman). The TFR declines with the level of education, from 2.8 births per woman among those with only basic education to 1.6 births per woman among those with at least some higher education. Wealth is also generally negatively associated with the TFR, which drops from 2 births per woman in the lowest wealth quintile to 1.4 births in the fourth quintile before rising to 1.9 births in the highest quintile. The percentage of women who are pregnant provides another measure of current fertility, although it is subject to some error as women may not recognize or report all first trimester pregnancies. Table 5.2 shows that 3 percent of women reported being pregnant at the time of the survey, with only minor differences across subgroups of women. 1 The data on which the ADHS rate and the annual rate reported by the NSS are based differ. Whereas the ADHS rates are based on information on live births collected from the complete pregnancy history of the de facto population of women (those who stayed the night before the interview in the household) for the 3 years preceding the survey, the official government rate is based on births among the de jure population of women (those who usually live in the household) registered in 2014. 2 Sampling errors and confidence intervals are presented in Appendix B for all of the fertility measures included in Table 5.2 at the national, urban and rural, and regional levels. Table 5.1 Current fertility Age-specific and total fertility rates, the general fertility rate, and the crude birth rate for the 3 years preceding the survey, according to residence, Armenia 2015-16 Age group Residence Total Urban Rural 15-19 11 39 24 20-24 108 148 124 25-29 119 112 116 30-34 58 49 55 35-39 31 15 25 40-44 3 4 4 45-49 2 0 1 TFR(15-49) 1.7 1.8 1.7 GFR 62 67 64 CBR 12.7 13.2 12.9 Note: Age-specific fertility rates are per 1,000 women. Rates for age group 45-49 may be slightly biased due to truncation. Rates are for the period 1-36 months prior to interview. TFR: Total fertility rate expressed per woman GFR: General fertility rate expressed per 1,000 women age 15-44 CBR: Crude birth rate, expressed per 1,000 population Fertility • 57 The last column in Table 5.2 shows the mean number of children ever born to women age 40-49. This is an indicator of cumulative fertility; it reflects the fertility performance of older women who are nearing the end of their reproductive period and thus represents completed fertility. If fertility had remained stable over time, the two fertility measures, TFR and children ever born, would be equal. The findings show that the mean number of children ever born to women age 40-49 (2.2 children per woman) is higher than the TFR for the 3 years preceding the survey (1.7 children per woman), indicating a decline in fertility of around half a child over the past 30 years. In general, comparisons of the TFR and the mean children ever born measures indicate that fertility has declined by less than one birth over the past three decades in most subgroups. Exceptions to this pattern are Aragatsotn and Gegharkunik, with implied fertility declines of 1.4 births and 1.3 births, respectively, and the basic education subgroup with an implied increase of 0.3 births. 5.3 FERTILITY TRENDS Using data from the 2015-16 ADHS, two approaches can be used to explore fertility trends in Armenia. The first method uses retrospective data on the childbearing patterns among the ADHS respondents to examine changes in age-specific fertility rates during the 20 years prior to survey. The second method compares the total and age-specific fertility rates from the 2015-16 ADHS with the results of the 2000, 2005, and 2010 ADHS surveys (NSS 2001; NSS 2006; NSS 2012). 5.3.1 Retrospective Data Table 5.3 uses information from the retrospective pregnancy histories obtained in the ADHS respondents to examine trends in age-specific fertility rates for successive five-year periods before the survey. Because women age 50 and older were not interviewed in the survey, the rates are successively truncated as the number of years before the survey increases. The results in Table 5.3 indicate that age-specific fertility declined sharply among women under age 25 over the past 20 years. The decline was most rapid among women age 15-19, with fertility dropping by more than half, from 58 births per 1,000 women in the period 15 to 19 years before the survey to 25 births per 1,000 women in the period 0-4 years before the survey. Fertility among women age 20-24 also decreased over the period from 173 births per 1,000 women in the period 15- 19 years before the survey to 126 births per 1,000 women in the period 0-4 years before the survey, a decrease of 27 percent. Unlike the pattern among younger women, age-specific fertility generally rose among women age 25-49. Although this suggests a trend toward delaying childbearing to older ages, the increases among women age 30 and over were modest so that childbearing remains heavily concentrated among women age 20-29. Table 5.2 Fertility by background characteristics Total fertility rate for the 3 years preceding the survey, percentage of women age 15-49 currently pregnant, and mean number of children ever born to women age 40-49, according to background characteristics, Armenia 2015-16 Background characteristic Total fertility rate Percentage of women age 15-49 currently pregnant Mean number of children ever born to women age 40-49 Residence Urban 1.7 2.6 2.0 Rural 1.8 3.2 2.6 Region Yerevan 1.6 2.3 1.9 Aragatsotn 1.1 1.6 2.5 Ararat 1.9 2.9 2.3 Armavir 2.2 3.5 2.6 Gegharkunik 1.1 1.7 2.4 Lori 1.5 3.7 2.1 Kotayk 2.1 4.3 2.3 Shirak 1.9 3.3 2.4 Syunik 2.0 2.8 2.3 Vayots Dzor 1.9 3.7 2.6 Tavush 2.4 2.8 2.8 Education Basic 2.8 1.6 2.5 Secondary 1.9 2.7 2.4 Secondary special 1.7 2.8 2.1 Higher 1.6 3.4 1.9 Wealth quintile Lowest 2.0 2.1 2.6 Second 1.7 2.8 2.5 Middle 1.7 3.4 2.1 Fourth 1.4 2.7 2.0 Highest 1.9 3.1 1.9 Total 1.7 2.8 2.2 Note: Total fertility rates are for the period 1-36 months prior to interview. Totals include 5 women with no education for which indicators are not shown separately. Table 5.3 Trends in age-specific fertility rates Age-specific fertility rates for five-year periods preceding the survey, according to mother’s age at the time of the birth, Armenia 2015-16 Mother’s age at birth Number of years preceding survey 0-4 5-9 10-14 15-19 15-19 25 31 40 58 20-24 126 141 163 173 25-29 110 116 104 101 30-34 52 52 41 [47] 35-39 21 14 [17] 40-44 3 [4] 45-49 [1] Note: Age-specific fertility rates are per 1,000 women. Estimates in brackets are truncated. Rates exclude the month of interview. 58 • Fertility 5.3.2 Comparison with Prior ADHS Surveys Table 5.4 shows total and age-specific fertility rates for the four ADHS surveys conducted between 2000 and 2015-16. The TFR was 1.7 per woman in all of the surveys indicating that the overall level of fertility has remained stable in Armenia for more than 15 years. However, an examination of the age-specific fertility rates shows that there has been a shift away from childbearing among women age 15-24 to older ages, particularly the late 20s (Figure 5.1). Thus, while almost 60 percent of childbearing at the time of the 2000 ADHS was concentrated among women age 15-24, only a little more than 40 percent of childbearing at the time of the 2015-16 ADHS took place in those age groups. Table 5.4 Trends in fertility Age-specific and total fertility rates (TFR) for the three-year period preceding several surveys, according to mother’s age at the time of the birth, Armenia 2000-2016 Age 2000 ADHS (1997-2000) 2005 ADHS (2002-2005) 2010 ADHS (2007-2010) 2015-16 ADHS (2013-2016) 15-19 50 30 28 24 20-24 149 148 140 124 25-29 88 107 102 116 30-34 35 37 42 55 35-39 16 16 24 25 40-44 3 4 5 4 45-49 0 0 0 1 TFR 15-49 1.7 1.7 1.7 1.7 Note: Age-specific fertility rates are per 1,000 women. Rates for age group 45-49 may be slightly biased due to truncation. Rates are for the period 1-36 months prior to interview. Figure 5.1 Trends in age-specific fertility rates 5.4 CHILDREN EVER BORN AND LIVING Table 5.5 shows the distribution of all women and currently married women by number of children ever born. The marked differences between the results for currently married women and for all women at the younger ages are due to the comparatively large numbers of never-married women who have had no births. Data on the number of children ever born reflect the accumulation of births to women over the past three decades and therefore have limited reference to current fertility levels. However, the information is 0 50 100 150 200 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Births per 1,000 women Age group 2000 ADHS 2005 ADHS 2010 ADHS 2015-16 ADHS Fertility • 59 useful in looking at how average family size varies across age groups and for looking at the level of primary infertility. Table 5.5 indicates that the average woman in Armenia had given birth to 1.4 children at the time of the 2015-16 ADHS. A comparison with the average number of surviving children indicates that virtually all of the children ever born are still alive. Reflecting the natural family-building process, the number of children that women have borne increases directly with age from an average of less than one child among women age 15-24 to an average of 2.3 births among women 45-49. The percentage of currently married women age 45-49 who have no births provides an indirect indicator of primary infertility since voluntary childlessness is rare in Armenia. Table 5.5 shows that 1 percent of currently married women age 45-49 have never had a live birth, suggesting that primary infertility affects comparatively few women in Armenia. Table 5.5 Children ever born and living Percent distribution of all women and currently married women age 15-49 by number of children ever born, mean number of children ever born and mean number of living children, according to age group, Armenia 2015-16 Age group Number of children ever born Total Number of women Mean number of children ever born Mean number of living children 0 1 2 3 4 5 6+ ALL WOMEN 15-19 97.5 2.5 0.0 0.0 0.0 0.0 0.0 100.0 725 0.03 0.03 20-24 69.5 19.5 10.0 0.9 0.0 0.0 0.0 100.0 928 0.42 0.42 25-29 34.9 26.4 31.4 5.9 0.9 0.4 0.0 100.0 1,099 1.13 1.12 30-34 16.5 15.0 49.3 17.2 1.6 0.3 0.1 100.0 1,007 1.74 1.72 35-39 9.8 11.8 50.9 21.6 4.6 1.1 0.3 100.0 867 2.04 2.00 40-44 9.7 9.9 45.9 27.2 5.3 1.1 0.8 100.0 784 2.16 2.10 45-49 7.8 8.4 44.4 29.4 7.6 2.0 0.4 100.0 706 2.28 2.23 Total 34.6 14.4 33.5 14.0 2.7 0.7 0.2 100.0 6,116 1.39 1.36 CURRENTLY MARRIED WOMEN 15-19 (45.0) (55.0) (0.0) (0.0) (0.0) (0.0) (0.0) 100.0 33 (0.55) (0.55) 20-24 23.9 48.5 25.3 2.3 0.0 0.0 0.0 100.0 365 1.06 1.05 25-29 10.7 34.6 44.4 8.4 1.3 0.6 0.0 100.0 761 1.57 1.55 30-34 4.3 14.9 58.2 20.2 1.9 0.4 0.1 100.0 826 2.02 2.00 35-39 1.6 8.2 58.1 25.6 4.9 1.3 0.3 100.0 709 2.29 2.25 40-44 3.4 7.4 50.0 31.2 5.9 1.4 0.7 100.0 639 2.36 2.32 45-49 1.4 4.9 48.9 33.6 8.3 2.5 0.5 100.0 562 2.52 2.46 Total 6.7 18.4 49.2 20.8 3.7 1.0 0.3 100.0 3,895 2.01 1.97 Note: Figures in parentheses are based on 25-49 unweighted cases. 5.5 BIRTH INTERVALS A birth interval is defined as the length of time between two live births. Research has shown that short birth intervals may adversely affect maternal health and children’s chances of survival. Children born within 36 months of a previous birth, especially if the interval between the births is less than two years, are at increased risk of health problems and death at an early age (Rutstein and Winter, 2014; WHO, 2006; Conde-Agudelo et al., 2006). Longer birth intervals, on the other hand, contribute to the improved health status of both mother and child. Table 5.6 shows the percent distribution of non-first births, i.e., second and higher-order births, in the five years prior to the survey by the number of months since the previous birth. Six in ten of non-first births occurred at the recommended interval of at least 36 months after a prior birth. The median birth interval was 41.6 months, which was 4.4 months longer than the median birth interval reported in the 2010 ADHS (37.2 months). Despite the increase in the average birth interval, the results in Table 5.6 indicate that a substantial proportion of non-first births still take place at too short an interval; more than one fifth (23 percent) of non-first births in the five-year period before the 2015-16 ADHS took place within 24 months of a previous birth, and 11 percent occurred within 18 months of previous birth. 60 • Fertility Table 5.6 Birth intervals Percent distribution of non-first births in the 5 years preceding the survey by number of months since preceding birth, and median number of months since preceding birth, according to background characteristics, Armenia 2015-16 Background characteristic Months since preceding birth Total Number of non-first births Median number of months since preceding birth 7-17 18-23 24-35 36-47 48-59 60+ Age 20-29 17.2 14.9 24.6 22.2 11.7 9.4 100.0 477 32.5 30-39 3.6 9.6 11.9 10.2 15.3 49.4 100.0 415 59.4 40-49 (4.7) (5.9) (2.6) (3.3) (10.9) (72.7) 100.0 31 (104.5) Sex of preceding birth Male 11.8 12.5 19.2 15.8 12.3 28.4 100.0 461 39.3 Female 9.6 11.9 17.1 16.6 14.3 30.5 100.0 462 44.6 Survival of preceding birth Living 10.7 12.1 18.0 16.2 13.4 29.6 100.0 908 41.8 Dead * * * * * * 100.0 15 * Birth order 2-3 10.8 12.2 18.9 16.2 13.1 28.8 100.0 870 41.2 4-6 6.3 13.6 6.5 14.6 17.8 41.2 100.0 50 54.7 7+ * * * * * * 100.0 3 * Residence Urban 8.7 11.9 15.6 16.0 14.3 33.5 100.0 525 45.7 Rural 13.4 12.6 21.5 16.4 12.0 24.2 100.0 398 37.4 Region Yerevan 8.6 11.8 12.7 16.9 14.6 35.4 100.0 262 49.0 Aragatsotn (5.1) (8.7) (28.1) (20.3) (13.5) (24.2) 100.0 31 (37.9) Ararat 9.6 14.5 19.9 14.3 10.4 31.4 100.0 97 42.1 Armavir 14.6 14.5 20.9 12.6 14.3 23.0 100.0 97 36.0 Gegharkunik 9.5 6.9 20.9 12.0 9.2 41.5 100.0 44 51.3 Lori 16.5 19.5 23.1 10.3 16.3 14.3 100.0 56 34.0 Kotayk 7.7 10.3 13.0 19.2 16.5 33.3 100.0 140 47.7 Shirak 17.3 10.2 24.5 20.7 9.6 17.7 100.0 83 35.0 Syunik 11.8 8.2 27.3 11.8 6.4 34.5 100.0 34 37.5 Vayots Dzor 7.1 14.0 20.6 19.6 12.6 26.1 100.0 22 43.6 Tavush 12.3 14.1 19.9 16.2 12.8 24.6 100.0 56 37.5 Education Basic 13.6 15.2 15.6 17.4 13.1 25.1 100.0 65 39.4 Secondary 12.7 10.5 21.1 11.7 12.1 31.9 100.0 384 41.2 Secondary special 8.0 12.8 18.9 17.7 13.3 29.3 100.0 190 43.1 Higher 9.1 13.3 14.3 20.9 15.0 27.4 100.0 284 42.2 Wealth quintile Lowest 14.9 16.0 18.1 14.1 12.5 24.4 100.0 193 36.6 Second 11.0 12.1 24.3 17.3 11.9 23.4 100.0 181 37.5 Middle 11.2 8.0 20.9 14.4 11.2 34.2 100.0 157 43.1 Fourth 11.1 14.8 12.5 17.8 14.5 29.3 100.0 154 43.1 Highest 6.4 10.3 15.4 17.1 15.6 35.3 100.0 238 50.3 Total 10.7 12.2 18.1 16.2 13.3 29.5 100.0 923 41.6 Note: First-order births are excluded. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates a figure is based on fewer than 25 unweighted cases and has been suppressed. In general, younger women are more likely to have births that are too closely spaced than older women. For example, 57 percent of non-first births to women age 20-29 were spaced less than the recommended interval of at least than 36 months apart, and 32 percent took place less than 24 months after a prior birth. On the other hand, among births to mothers age 30-39, only 25 percent were spaced less than 36 months apart, and only 13 percent occurred less than 24 months after a prior birth. Birth intervals are related to residence. The median birth interval in urban areas is 45.7 months compared with 37.4 months in rural areas, and only a little more than one-third of urban births were spaced less than 36 months after a prior birth compared with almost half of rural births. Birth intervals also vary widely across regions, with the longest in Gegharkunik (51.3 months) and the shortest in Lori (34.0 months). Both education and wealth are associated with birth intervals. For example, 44 percent of births to mothers with basic education occur less than 36 months after their older sibling compared with 37 percent of births to mothers with higher education. Half of births in the lowest wealth quintile were spaced less than the recommended interval of at least 36 months after a prior birth compared with around one-third of births in the highest quintile. Fertility • 61 5.6 POSTPARTUM AMENORRHEA, ABSTINENCE, AND INSUSCEPTIBILITY Postpartum amenorrhea refers to the interval between childbirth and the return of menstruation. During this period, the risk of pregnancy is reduced. The duration of reduced risk of conception largely depends on two factors: the length and intensity of breastfeeding, which tends to suppress the resumption of ovulation, and the length of time before the resumption of sexual intercourse. Women who are either amenorrheic or abstaining (or both) are considered insusceptible to the risk of pregnancy. Among births that occurred in the three years preceding the survey, the percentage of mothers who were postpartum amenorrheic, abstaining, or insusceptible at the time of the survey is shown in Table 5.7. At the time of the survey, 11 percent of women who had given birth during the three years preceding the survey were amenorrheic, and 7 percent were abstaining. Overall, 14 percent of these women were insusceptible to the risk of pregnancy. During the first year after birth, there was a rapid decline in postpartum amenorrhea, from 84 percent during the first 2 to 3 months after birth to 33 percent of women 4 to 5 months after giving birth and to just 6 percent of women 10 to 11 months after birth. Postpartum abstinence also declined rapidly after birth; only 20 percent of women were abstaining after 2 to 3 months and just 4 percent were abstaining after 10 to 11 months. Overall, the median duration of insusceptibility after birth was 3 months. Because a few women in Armenia are amenorrheic or abstain for a very long time, the mean durations are higher than the median duration for amenorrhea, abstinence, and insusceptibility. 5.7 MENOPAUSE For women age 30 and older, the risk of pregnancy declines as increasing proportions of women become menopausal. Although the onset of menopause is difficult to determine for an individual woman, the proportion of women who are menopausal can be estimated for the population as a whole. Table 5.8 shows the percentage of women age 30 and older who are menopausal, that is, who are not pregnant or postpartum amenorrheic and who have not menstruated for six months or more in the period preceding the survey. According to the 2015-16 ADHS, 8 percent of women age 30 to 49 are menopausal. As expected, the proportion of women who are menopausal increases with age, from 1 percent of women age 30-34 to 37 percent of women age 48-49. Table 5.7 Postpartum amenorrhea, abstinence and insusceptibility Percentage of births in the 3 years preceding the survey for which mothers are postpartum amenorrheic, abstaining, and insusceptible, according to number of months since birth, and median and mean durations, Armenia 2015-16 Months since birth Percentage of births for which the mother is: Number of births Amenorrheic Abstaining Insusceptible1 <2 (83.7) (71.3) (91.5) 28 2-3 54.4 19.9 62.2 58 4-5 32.8 5.4 34.9 62 6-7 23.3 7.1 27.6 77 8-9 6.6 8.7 11.8 62 10-11 5.9 3.6 9.4 55 12-13 2.7 3.5 6.2 50 14-15 3.4 5.1 8.5 61 16-17 0.0 3.5 3.5 60 18-19 2.4 1.5 3.8 57 20-21 0.0 1.3 1.3 59 22-23 5.5 3.8 5.5 54 24-25 3.2 7.6 7.6 58 26-27 1.3 0.0 1.3 51 28-29 4.1 3.9 8.0 68 30-31 0.0 0.0 0.0 53 32-33 0.0 2.7 2.7 48 34-35 0.0 2.2 2.2 55 Total 11.2 6.7 14.4 1,016 Median 2.6 1.5 3.3 na Mean 4.9 3.4 6.1 na Note: Estimates are based on status at the time of the survey. Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable 1 Includes births for which mothers are either still amenorrheic or still abstaining (or both) following birth Table 5.8 Menopause Percentage of women age 30-49 who are menopausal, according to age, Armenia 2015-16 Age Percentage menopausal1 Number of women 30-34 1.1 1,007 35-39 2.8 867 40-41 6.2 344 42-43 6.0 293 44-45 13.6 308 46-47 17.5 270 48-49 37.4 274 Total 7.9 3,364 1 Percentage of all women who are not pregnant and not postpartum amenorrheic whose last menstrual period occurred six or more months preceding the survey 62 • Fertility 5.8 AGE AT FIRST BIRTH The age at which childbearing typically begins has important demographic consequences for society as a whole as well as for the health and welfare of mother and child. Table 5.9 shows the percentages of women age 15-49 that have given birth by specific exact ages, according to current age. Median age at first birth is presented in the last column of the table. For women under age 25, the median age at first birth is not shown because less than 50 percent of women in those ages had given birth at the time of the survey. Table 5.9 Age at first birth Percentage of women age 15-49 who gave birth by specific exact ages, percentage who have never given birth, and median age at first birth, according to current age, Armenia 2015-16 Current age Percentage who gave birth by exact age Percentage who have never given birth Number of women Median age at first birth 15 18 20 22 25 15-19 0.0 na na na na 97.5 725 a 20-24 0.0 1.0 9.6 na na 69.5 928 a 25-29 0.0 2.5 14.1 29.9 53.8 34.9 1,099 24.4 30-34 0.0 4.0 17.8 39.4 61.8 16.5 1,007 23.2 35-39 0.3 7.2 25.5 45.3 64.0 9.8 867 22.6 40-44 0.0 6.8 30.8 55.9 73.9 9.7 784 21.4 45-49 0.0 3.1 24.2 50.1 76.2 7.8 706 22.0 20-49 0.0 4.0 19.6 na na 26.2 5,391 a 25-49 0.1 4.6 21.7 42.8 64.6 17.2 4,463 22.8 na = Not applicable due to censoring a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group The 2015-16 ADHS findings indicate that childbearing among Armenian women begins relatively late. Seven in ten women age 20-24 and more than one-third of women age 25-29 have never given birth. Women age 35 and over are much more likely than younger women to have begun childbearing in their early twenties. For example, among women age 45-49, 24 percent had become a mother before age 20, while only 10 percent of women age 20-24 gave birth to their first child before that age. The median age at first birth ranges from a low of 21.4 years among women age 40-44 to 24.4 years among women age 25-29. The median age at first birth cannot be computed for women age 15- 19 and age 20-24 because less than half of these women had a live birth before the beginning of the age group. However, recent trends in the initiation of childbearing among young women can be assessed by comparing the proportion of women in these age groups that had given birth in the 2015-16 ADHS with similar results from the 2010 ADHS. The comparisons indicate that, in 2015-16, 3 percent of women age 15-19 had had their first birth, which represents only a slight drop from the already low proportion of women age 15-19 who had initiated childbearing in 2010 (4 percent). Among women age 20-24, there also was only a small decline between 2010 and 2015-16 in the percentage who had had their first birth (33 percent and 31 percent, respectively). Table 5.10 shows the median age at first birth among women age 25-49, by background characteristics. The median age at first birth for urban women is more than two years older than for rural women (23.8 years compared with 21.4 years). Considering the regional patterns, the highest median age at first birth is observed in Yerevan (24.5 years) and the lowest in Gegharkunik (21.4 years). Education and wealth status are positively Table 5.10 Median age at first birth Median age at first birth among women age 25-49 years, according to background characteristics, Armenia 2015-16 Background characteristic Women age 25-49 Residence Urban 23.8 Rural 21.4 Region Yerevan 24.5 Aragatsotn 22.4 Ararat 22.8 Armavir 21.5 Gegharkunik 21.4 Lori 22.7 Kotayk 22.1 Shirak 22.5 Syunik 22.5 Vayots Dzor 21.5 Tavush 21.9 Education Basic 20.3 Secondary 21.3 Secondary special 22.7 Higher a Wealth quintile Lowest 21.6 Second 21.8 Middle 22.4 Fourth 23.8 Highest 24.2 Total 22.8 a = Omitted because less than 50 percent of women had a birth before reaching the beginning of the age group Total includes 5 women (unweighted) with no education for which median age at first birth is not shown separately. Fertility • 63 related to the age at which women initiate childbearing. The median age at first birth is 20.3 years for women with basic education compared with 22.7 years among women with secondary-special education. Similarly, women living in the poorest households begin childbearing more than two and a half years earlier on average than women living in the wealthiest households (21.6 years and 24.2 years, respectively). Finally, information on the age at which women marry (see Chapter 4) and the age at which they give birth provides an insight into which how long couples typically delayed childbearing after marriage. A comparison of the median ages at first marriage and first birth among all women age 25-49 (21.4 years and 22.8 years, respectively) indicates that women in Armenia had their first birth on average just under 18 months after they marry. 5.9 TEENAGE PREGNANCY AND MOTHERHOOD It is well known that adolescent pregnancy, early childbearing, and motherhood have negative socioeconomic and health consequences. Adolescent mothers are more likely to have complications during pregnancy and labor, which result in higher morbidity and mortality for themselves and their children. Moreover, childbearing during the teenage years frequently has adverse social consequences, particularly with respect to female educational attainment, because women who become mothers in their teens are more likely to curtail education.3 Table 5.11 shows that, overall, 4 percent of women age 15-19 (teenagers) had begun childbearing, with 3 percent reporting they were already mothers, and 1 percent pregnant with their first child. In terms of trends, the rate of teenage pregnancy and motherhood in 2015-16 was slightly lower than the level observed in the 2010 ADHS (5 percent). Considering the variation by background characteristics, none of the 15-year- old women in the ADHS sample had begun childbearing. Among women age 16-19, the proportion that started childbearing rises rapidly from one percent or less among those ages 16 and 17 to 12 percent among 19-year-olds. The proportion of teenagers who had begun childbearing was higher in rural areas than in urban areas (6 percent and 1 percent, respectively). Looking at regional differences, teenage childbearing was highest in Armavir (12 percent). With respect to educational attainment, 4 to 5 percent of teenagers with basic or secondary education had begun childbearing compared with less than one percent of teenagers with some higher education. Similarly, the proportion of teenagers who had begun childbearing decreased from 6 percent in the lowest wealth quintile to less than one percent in the highest quintile. 3 The legal age for marriage of women in Armenia is 18. Table 5.11 Teenage pregnancy and motherhood Percentage of women age 15-19 who have had a live birth or who are pregnant with their first child, and percentage who have begun childbearing, by background characteristics, Armenia 2015-16 Background characteristic Percentage of women age 15-19 who: Percentage who have begun childbearing Number of women Have had a live birth Are pregnant with first child Age 15 0.0 0.0 0.0 137 16 0.0 0.4 0.4 156 17 0.4 0.7 1.1 156 18 4.8 0.8 5.5 135 19 8.0 3.5 11.6 140 Residence Urban 0.9 0.3 1.2 386 Rural 4.4 2.0 6.3 339 Region Yerevan 1.0 0.5 1.5 216 Aragatsotn (3.2) (0.0) (3.2) 31 Ararat 1.0 0.0 1.0 63 Armavir 8.1 3.8 11.8 72 Gegharkunik 4.0 0.0 4.0 78 Lori (0.0) (0.0) (0.0) 37 Kotayk 1.1 1.1 2.2 82 Shirak 5.4 3.9 9.3 56 Syunik 0.0 0.0 0.0 35 Vayots Dzor 1.5 1.8 3.4 17 Tavush 4.0 1.5 5.6 39 Education Basic 2.3 1.8 4.1 133 Secondary 3.4 1.2 4.6 354 Secondary special 2.5 1.0 3.5 122 Higher 0.2 0.0 0.2 116 Wealth quintile Lowest 4.5 1.6 6.1 150 Second 3.1 1.8 4.9 154 Middle 3.2 0.7 3.9 138 Fourth 1.8 0.8 2.6 130 Highest 0.0 0.4 0.4 153 Total 2.5 1.1 3.6 725 Figures in parentheses are based on 25-49 unweighted cases. Fertility Preferences • 65 FERTILITY PREFERENCES 6 nformation on fertility preferences is of considerable importance to family planning program administrators because it allows them to assess the need for contraception, whether for spacing or limiting of births, and to evaluate the extent of unwanted and mistimed pregnancies. Data on fertility preferences can also be useful as an indicator of the direction that future fertility patterns may take. This chapter presents information on whether and when married women and men want more children, ideal family size, whether recent births were wanted at the time they occurred, and what the theoretical fertility rate would be if all unwanted births were prevented. 6.1 FERTILITY PREFERENCES In the 2015-16 ADHS, women and men were asked whether they wanted to have another child and, if so, how soon. Table 6.1 shows fertility preferences among currently married women and men by the number of living children they already had at the time of the survey (including any current pregnancy). The majority of married Armenian women wish to control their future fertility. Over half (54 percent) do not want to have any more children or are sterilized. Only about one-quarter want to have a child in the future. The desire to limit fertility markedly increases by number of living children. For example, 70 percent of married women with no children say they want to have a child soon; only 3 percent of these women do not want to have any children. On the other hand, 6 in 10 women with two children say that they do not want any more, as do more than 8 in 10 women with three or more children. Men’s fertility preferences, in general, are similar to women’s. However, a lower proportion of married men than women report that they want no more children (48 percent versus 54 percent), and a much higher percentage of men than women report that they are undecided about their desire for more children (21 percent versus 11 percent). Men are also much less likely than women to admit that they cannot have another child. I Key Findings  About half of married women (54 percent) and men (48 percent) want no more children.  The ideal number of children wanted by women is 2.6 and by men is 2.7.  Overall, 92 percent of births were wanted at the time of conception, 6 percent were reported as mistimed (wanted later), and 2 percent were unwanted.  The total wanted fertility rate is 1.7 children per woman, identical to the actual fertility rate of 1.7 children per woman. 66 • Fertility Preferences Table 6.1 Fertility preferences according to number of living children Percent distribution of currently married women and currently married men age 15-49 by desire for children, according to number of living children, Armenia 2015-16 Desire for children Number of living children Total 15-49 0 1 2 3 4+ WOMEN1 Have another soon2 69.7 26.3 5.3 0.9 0.0 11.2 Have another later3 0.0 38.7 8.7 1.4 1.7 12.0 Have another, undecided when 2.5 7.2 2.4 1.4 0.6 3.0 Undecided 2.9 6.9 15.8 7.9 4.5 11.4 Want no more 3.0 8.8 60.4 80.1 77.9 52.8 Sterilized4 0.0 0.7 0.4 1.2 2.8 0.7 Declared infecund 21.9 11.2 7.1 7.2 12.5 8.8 Missing 0.0 0.2 0.0 0.0 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 195 719 2,009 811 161 3,895 MEN5 Have another soon2 76.8 30.1 6.0 3.1 0.6 14.2 Have another later3 0.0 27.5 6.9 1.1 1.4 9.7 Have another, undecided when 16.2 19.9 2.1 0.0 0.0 6.2 Undecided 2.6 13.2 24.6 25.2 17.9 20.8 Want no more 0.5 7.8 59.7 69.9 73.4 47.8 Sterilized4 0.0 0.3 0.1 0.4 0.0 0.2 Declared infecund 3.8 0.8 0.4 0.1 0.0 0.6 Missing 0.0 0.4 0.3 0.0 6.7 0.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 80 323 768 274 60 1,506 1 The number of living children includes the current pregnancy. 2 Wants next birth within 2 years 3 Wants to delay next birth for 2 or more years 4 Includes both female and male sterilization 5 The number of living children includes one additional child if respondent’s wife is pregnant. Table 6.2.1 shows the percentage of currently married women who want no more children or are sterilized, by number of living children and background characteristics. Women in urban and rural areas are equally likely to want no more children. Differences between urban and rural women become more evident if one compares groups of women based on the number of living children that they already have. For example, urban mothers are more likely than rural mothers to want to stop childbearing at all parities, except for those with only one child. Women in Gegharkunik, Vayots Dzor, and Yerevan are the most likely to want no more children, whereas those in Aragatsotn and Kotayk are the least likely to want to stop childbearing. Married women with higher education are the least likely to want no more children; however, that is likely because they tend to be younger and have fewer children. Differences by education according to the number of living children are very small. There is little relationship between desire to stop childbearing and women’s wealth status. Table 6.2.2 shows the percentage of currently married men who want no more children, who are sterilized, or who declared that their wife/partner is sterilized, by number of living children and background characteristics. There is no strong relationship between desire to stop childbearing and residence, education, or wealth. Fertility Preferences • 67 Table 6.2.1 Desire to limit childbearing: Women Percentage of currently married women age 15-49 who want no more children, by number of living children, according to background characteristics, Armenia 2015-16 Background characteristic Number of living children1 Total 0 1 2 3+ Residence Urban 3.7 9.4 64.1 84.1 53.3 Rural 1.5 9.7 55.3 79.1 53.8 Region Yerevan (5.7) 10.3 69.4 92.3 56.8 Aragatsotn * 0.0 39.6 71.1 41.5 Ararat * 12.4 53.9 74.8 49.2 Armavir * 7.0 59.4 82.4 56.7 Gegharkunik * 7.7 79.0 89.9 68.4 Lori * (31.1) 61.3 (62.2) 52.7 Kotayk * 4.7 45.8 67.5 42.4 Shirak * 9.0 64.2 79.1 54.0 Syunik * (0.0) 55.9 83.6 52.6 Vayots Dzor * (8.3) 56.8 87.3 57.0 Tavush * 3.3 48.2 88.7 51.0 Education Basic * (21.4) 56.0 78.7 59.8 Secondary 4.3 11.3 59.9 81.6 56.6 Secondary special (2.8) 9.5 65.1 77.4 56.2 Higher 2.2 6.7 58.4 85.5 44.8 Wealth quintile Lowest (3.4) 12.3 53.0 76.6 54.0 Second (0.0) 10.8 58.7 78.1 53.7 Middle (7.3) 11.1 62.2 86.6 53.7 Fourth (0.0) 5.7 65.9 81.1 51.7 Highest (4.7) 9.0 61.9 88.2 54.3 Total 3.0 9.5 60.8 81.2 53.5 Note: Women who have been sterilized or whose husband has been sterilized are considered to want no more children. Total includes 4 (weighted) women with no education. A figure in parentheses is based on 25-49 unweighted cases; an asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 The number of living children includes the current pregnancy. Table 6.2.2 Desire to limit childbearing: Men Percentage of currently married men age 15-49 who want no more children, by number of living children, according to background characteristics, Armenia 2015-16 Background characteristic Number of living children1 Total 0 1 2 3+ Residence Urban 0.0 7.1 59.9 69.9 46.4 Rural (1.8) 9.4 59.6 71.7 50.1 Education Basic * (6.6) 50.8 65.5 45.5 Secondary (0.0) 7.0 62.7 71.1 49.5 Secondary special * (13.2) 70.4 70.7 57.6 Higher * 8.4 50.4 74.8 40.1 Wealth quintile Lowest * 10.8 50.6 69.7 45.6 Second * 9.1 63.6 68.1 50.5 Middle * 7.8 73.2 79.8 53.0 Fourth * 3.4 65.8 76.0 49.4 Highest * 9.6 48.6 64.6 42.3 Total 0.5 8.0 59.8 70.9 48.0 Note: Men who have been sterilized or who state in response to the question about desire for children that their wife has been sterilized are considered to want no more children. Total includes 3 (weighted) men with no education. A figure in parentheses is based on 25-49 unweighted cases; an asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 The number of living children includes one additional child if respondent’s wife is pregnant. 68 • Fertility Preferences With regard to trends in fertility preference, the proportion of married women who say that they want to stop childbearing has decreased steadily in the past 15 years, from 74 percent in 2000 to 71 percent in 2005, to 58 percent in 2010, and to 54 percent in 2015-16 (Figure 6.1). However, an increase is seen in the percentage of women who say that they cannot conceive (from 3 percent in 2005 to 9 percent in 2015- 16) or who are undecided about whether they want to have another child or about when to have it (6 percent in 2005 and 14 percent in 2015-16), as well as smaller increases in the proportions who want to have another child either soon or later (NSS et al. 2001, NSS et al. 2006, NSS et al. 2012). Figure 6.1 Trends in fertility desires among married women 6.2 IDEAL NUMBER OF CHILDREN In the 2015-16 ADHS, respondents were asked what they considered the ideal family size to be. This information was obtained by asking each respondent one of two questions. Respondents who had no children were asked, “If you could choose exactly the number of children to have in your whole life, how many would that be?” For respondents who had children, the question was, “If you could go back to the time you did not have any children and could choose exactly the number of children to have in your whole life, how many would that be?” Responses to these questions are meant to be independent of the number of children that a respondent already has. However, there is typically a correlation between the actual number of children that respondents have and their reported ideal. This correlation may occur because respondents who want larger families have more children or because respondents adjust their ideal family size to match their actual family size (rationalization). The percent distribution of women and men age 15-49 by ideal number of children is detailed in Table 6.3, according to the number of living children. Virtually all Armenian women want at least some children. Almost half of all women (47 percent) say that two children are ideal, and 33 percent say that three children are ideal. One in seven women (14 percent) states that she prefers to have four or more children. Overall, the mean ideal number of children is 2.6 among all women and 2.7 among currently married women. There is a positive correlation between the actual and ideal number of children. Among all women, the mean ideal number of children increases from 2.3 among women with no children to 3.9 among women with four or more children. 8 9 6 74 3 9 11 5 71 4 10 13 11 58 8 11 12 14 54 9 Have another soon Have another later Undecided Want no more Infecund Percentage of currently married women 2000 ADHS 2005 ADHS 2010 ADHS 2015-16 ADHS Fertility Preferences • 69 In general, Armenian men want the same number of children as women. Forty-seven percent of men say that two children are ideal, 34 percent say that three children are ideal, and 15 percent say that four or more children are ideal. Overall, the mean ideal number of children among all men is 2.7 children, and among currently married men is 2.8 children. As there is for women, there is a positive correlation between the actual and ideal number of children among men. Table 6.3 Ideal number of children according to number of living children Percent distribution of women and men age 15-49 by ideal number of children, and mean ideal number of children for all respondents and for currently married respondents, according to the number of living children, Armenia 2015-16 Ideal number of children Number of living children Total 0 1 2 3 4+ WOMEN1 0 1.8 0.2 0.2 0.1 0.0 0.7 1 6.9 5.2 0.5 1.0 0.2 3.4 2 55.7 51.8 51.8 13.3 12.2 46.6 3 21.9 34.1 34.3 56.4 15.8 32.7 4 8.6 7.4 12.0 24.9 55.9 13.3 5 0.5 0.3 0.3 1.2 7.7 0.7 6+ 0.0 0.1 0.1 0.7 6.5 0.3 Non-numeric responses 4.6 0.9 0.7 2.4 1.7 2.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 2,053 892 2,139 858 175 6,116 Mean ideal number of children for:2 All women 2.3 2.5 2.6 3.1 3.9 2.6 Number of women 1,958 884 2,124 837 172 5,974 Currently married women 2.4 2.5 2.6 3.2 3.9 2.7 Number of currently married women 189 712 1,994 792 158 3,845 MEN3 0 1.0 0.0 0.1 0.0 0.0 0.5 1 3.0 0.9 0.3 0.0 0.0 1.6 2 56.7 55.5 43.1 10.7 6.2 46.8 3 27.0 36.7 39.0 52.1 4.4 33.7 4 7.6 5.4 15.3 33.8 65.9 13.5 5 0.9 0.7 1.0 3.1 19.3 1.5 6+ 0.2 0.0 0.3 0.3 4.2 0.3 Non-numeric responses 3.6 0.7 0.9 0.0 0.0 2.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,281 337 794 283 61 2,755 Mean ideal number of children for:2 All men 2.4 2.5 2.8 3.3 4.1 2.7 Number of men 1,235 334 786 283 61 2,699 Currently married men 2.6 2.5 2.8 3.3 4.1 2.8 Number of currently married men 80 321 761 274 60 1,497 1 The number of living children includes current pregnancy for women. 2 Means are calculated excluding respondents who gave non-numeric responses. 3 The number of living children includes one additional child if respondent’s wife is pregnant. The data do not indicate any substantial change in ideal family size among women since 2000; the mean number of children considered ideal was 2.7 among all women in 2000, 2.6 in 2005, 2.5 in 2010, and 2.6 in 2015-16 (NSS et al. 2001, NSS et al. 2006, NSS et al. 2012). Similarly, there has been almost no change in the mean ideal family size among men over the past 10 years (2.8 in 2005, 2.7 in 2010, and 2.7 in 2015-16). Table 6.4 shows the mean ideal number of children by background characteristics. In general, there are no significant variations in the mean ideal number of children. However, the mean ideal number of children among both women and men increases slightly with age. It tends to decline slightly with increasing education and wealth. 70 • Fertility Preferences Table 6.4 Mean ideal number of children according to background characteristics Mean ideal number of children for all women and men age 15-49 by background characteristics, Armenia 2015-16 Women Men Background characteristic Mean Number of women1 Mean Number of men1 Age 15-19 2.4 675 2.5 321 20-24 2.5 899 2.5 460 25-29 2.6 1,081 2.5 455 30-34 2.6 988 2.6 423 35-39 2.6 858 2.7 370 40-44 2.7 774 3.0 340 45-49 2.8 700 2.9 330 Residence Urban 2.5 3,595 2.6 1,528 Rural 2.7 2,380 2.7 1,171 Region Yerevan 2.5 1,995 2.6 829 Aragatsotn 2.7 314 2.7 159 Ararat 2.6 552 2.6 289 Armavir 2.7 528 3.0 266 Gegharkunik 2.7 475 2.9 234 Lori 2.5 320 2.5 157 Kotayk 2.6 652 2.7 285 Shirak 2.5 499 2.4 201 Syunik 2.5 238 2.3 104 Vayots Dzor 2.6 119 2.8 51 Tavush 2.8 281 2.7 126 Education Basic 2.7 368 2.8 345 Secondary 2.7 2,388 2.7 1,222 Secondary special 2.6 1,335 2.6 403 Higher 2.5 1,876 2.5 725 Wealth quintile Lowest 2.8 1,040 2.8 514 Second 2.6 1,203 2.7 570 Middle 2.6 1,113 2.6 509 Fourth 2.6 1,265 2.6 552 Highest 2.5 1,354 2.6 555 Total 2.6 5,974 2.7 2,699 Note: Totals include 5 women and 5 men (weighted) with no education. 1 Number who gave a numeric response 6.3 FERTILITY PLANNING In the 2015-16 ADHS, women were asked a series of questions about each of their children born in the 5 years preceding the survey—and, if pregnant, asked about their current pregnancy—to determine if their pregnancies were wanted then (planned), wanted later (mistimed), or not wanted (unplanned). Table 6.5 shows the percent distribution of births in the 5 years preceding the survey by whether the birth was wanted then, wanted later, or not wanted. About 92 percent of the births in the past 5 years were wanted at the time of conception. Six percent of births were wanted later, and 2 percent of births were not wanted at all at the time of conception. These proportions suggest that over the past 15 years, there has been a notable improvement in the level of planned births in Armenia. The percentage of births that were unwanted decreased from 8 percent in 2000 to 7 percent in 2005, and to 1 percent in 2010, before increasing very slightly to 2 percent in 2015-16. In turn, the proportion of births that were wanted at the time of conception has increased from 83 percent in 2000 to 92 percent in 2015-16 (NSS et al. 2001, NSS et al. 2006, NSS et al. 2012). Fertility Preferences • 71 There is a relationship between planning status and birth order. For example, while 98 percent of first births were wanted at the time of conception, 8 percent of fourth and higher order births were not wanted at all. Younger women were more likely than older women to want their births at the time they were conceived, while older women were more likely than younger women to have wanted no more children. Table 6.5 Fertility planning status Percent distribution of births to women age 15-49 in the 5 years preceding the survey (including current pregnancies), by planning status of the birth, according to birth order and mother’s age at birth, Armenia 2015-16 Planning status of birth Total Number of births Birth order and mother’s age at birth Wanted then Wanted later Wanted no more Missing Birth order 1 98.2 1.6 0.1 0.1 100.0 809 2 88.6 10.4 0.8 0.2 100.0 693 3 86.5 7.2 6.3 0.0 100.0 284 4+ 86.5 5.6 7.9 0.0 100.0 60 Mother’s age at birth <20 97.7 2.3 0.0 0.0 100.0 108 20-24 92.4 7.2 0.1 0.3 100.0 697 25-29 93.6 5.9 0.5 0.1 100.0 656 30-34 89.7 5.9 4.4 0.0 100.0 278 35-39 88.9 1.1 10.0 0.0 100.0 93 40-44 * * * * 100.0 13 45-49 * * * * 100.0 2 Total 92.4 5.9 1.6 0.1 100.0 1,846 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 6.4 WANTED AND UNWANTED FERTILITY Table 6.6 provides information on total “wanted” fertility rates and total fertility rates for the 3 years preceding the survey, by background characteristics. Unwanted births are defined as births that exceed the number considered ideal. Women who did not report a numeric ideal family size were assumed to want all their births. The total wanted fertility rate represents the level of fertility that would have prevailed in the 3 years preceding the survey if all unwanted births were prevented. A comparison of the total wanted fertility and total fertility rate suggests the potential demographic impact of the elimination of unwanted births. In Armenia, because of the low level of unwanted childbearing, there is no difference between the observed total fertility rate (1.7 children per woman) and the wanted total fertility rate (1.7 children per woman). Differences between desired and actual fertility are very small by background characteristics. Table 6.6 Wanted fertility rates Total wanted fertility rates and total fertility rates for the 3 years preceding the survey, by background characteristics, Armenia 2015-16 Background characteristic Total wanted fertility rates Total fertility rate Residence Urban 1.6 1.7 Rural 1.8 1.8 Region Yerevan 1.5 1.6 Aragatsotn 1.0 1.1 Ararat 1.9 1.9 Armavir 2.1 2.2 Gegharkunik 0.9 1.1 Lori 1.5 1.5 Kotayk 2.0 2.1 Shirak 1.7 1.9 Syunik 2.0 2.0 Vayots Dzor 1.7 1.9 Tavush 2.3 2.4 Education Basic 2.5 2.8 Secondary 1.8 1.9 Secondary special 1.6 1.7 Higher 1.6 1.6 Wealth quintile Lowest 1.9 2.0 Second 1.7 1.7 Middle 1.6 1.7 Fourth 1.4 1.4 Highest 1.9 1.9 Total 1.7 1.7 Note: Rates are calculated based on births to women age 15-49 in the period 1-36 months preceding the survey. The total fertility rates are the same as those presented in Table 5.2. Total includes five women with no education. Contraception • 73 CONTRACEPTION 7 amily planning refers to a conscious effort by a couple to limit or space the number of children they have through the use of contraceptive methods. The efficacy of family planning depends on people’s knowledge of contraceptive methods and on the availability of methods to meet the varying needs of a wide spectrum of potential users. Availability of methods, in turn, depends on the quality and quantity of service providers and on financial and technical resources. According to the legislation on reproductive health and rights adopted by the parliament of Armenia in 2002, use of contraception, including voluntary sterilization, is legal in Armenia. This chapter presents the 2015-16 ADHS findings on contraceptive knowledge, use, sources, met and unmet need for family planning, and exposure to media messages about family planning. The information is particularly useful for policymakers, program managers, international and national nongovernmental organizations, and researchers in population and family planning. The information provides a means to assess the success of the Armenian family planning program. Although the focus is on women, some results from the male survey are presented because men play an important role in realizing women’s reproductive goals. Comparisons are made with findings from previous surveys to evaluate trends over the past 15 years in Armenia. 7.1 KNOWLEDGE OF CONTRACEPTIVE METHODS Acquiring knowledge about fertility control is an important step toward gaining access to and then using a suitable contraceptive method in a timely and effective manner. The 2015-16 ADHS collected information on knowledge and use of contraception. To obtain these data, interviewers read aloud the name of each contraceptive method and asked respondents if they had heard of the method; if not, the F Key Findings  Knowledge of contraception is widespread in Armenia, with 97 percent of women and 99 percent of men having heard of at least one method.  The contraceptive prevalence rate has fluctuated over the last 15 years, decreasing from 61 percent of currently married women in 2000 to a low of 53 percent in 2005 before increasing to 57 percent in 2015-16.  Use of modern methods has increased since 2000, but are used by only 28 percent of currently married women.  Use of withdrawal has decreased slightly over time, but is still the most commonly used contraceptive method (25 percent of married women).  Only about one-third of modern contraceptive users (primarily IUD users) obtain their contraceptives from the public sector, while two-thirds (primarily pill and condom users) depend on private medical sources.  Eighty-seven percent of modern contraceptive users were informed of the side effects or health problems associated with the method they used; 85 percent were told what to do if they experienced side effects, and 72 percent were told about other methods available.  Half of women know that they are most fertile midway between two menstrual periods.  Only 13 percent of currently married women have an unmet need for family planning services, half for spacing and half for limiting births. 74 • Contraception interviewers read a description of the method. Non-pregnant women were asked if they (or their partners) were currently using any method to delay or avoid getting pregnant. All women were asked about any periods of contraceptive use in the 5 years before the survey (contraceptive calendar). For analytical purposes, contraceptive methods are grouped into two types: modern and traditional. Modern methods include female sterilization, male sterilization, pill, intrauterine device (IUD), injectables, implants, male condom, lactational amenorrhea method (LAM), and emergency contraception. Traditional methods include periodic abstinence (rhythm method), withdrawal, and folk methods. Table 7.1 shows that knowledge of contraception is high among women and men. Almost all respondents know at least one method (97 percent of women and 99 percent of men); knowledge is slightly higher among currently married respondents than among all respondents. The mean number of methods known is a rough indicator of the breadth of knowledge of family planning methods. On average, currently married women, who have the greatest exposure to the risk of pregnancy, know almost eight methods. Knowledge of a modern method is nearly universal. More than nine out of every ten married women have heard about the male condom, the IUD, and the pill. However, other modern methods are less well-known. For example, only about two-thirds of married women are aware of female sterilization and less than half have heard about injectables and emergency contraception. Awareness of male sterilization (37 percent) and implants (24 percent) is substantially lower. Withdrawal is the most widely known traditional method (94 percent) among currently married women. Table 7.1 Knowledge of contraceptive methods Percentage of all respondents, currently married respondents, and sexually active unmarried respondents age 15-49 who have heard of any contraceptive method, according to specific method, Armenia 2015-16 Women Men Method All women Currently married women Sexually active unmarried women1 All men Currently married men Sexually active unmarried men1 Any method 97.4 99.8 * 99.3 99.8 100.0 Any modern method 97.2 99.7 * 99.3 99.7 100.0 Female sterilization 57.4 64.7 * 58.8 66.7 51.6 Male sterilization 32.5 36.8 * 45.8 53.1 43.6 Pill 89.1 93.5 * 74.3 81.7 81.2 IUD 87.9 94.8 * 75.4 85.4 68.8 Injectables 43.1 47.7 * 41.0 46.4 40.6 Implants 21.2 24.3 * 24.3 29.3 23.3 Male condom 96.3 99.1 * 99.2 99.6 100.0 Emergency contraception 40.1 46.4 * 46.0 52.5 43.7 Lactational amenorrhea (LAM) 60.5 74.1 * 26.0 37.3 18.4 Other modern method 0.2 0.3 * 0.2 0.1 1.4 Any traditional method 83.3 96.3 * 90.9 97.5 89.9 Rhythm 70.3 82.1 * 45.4 55.3 34.4 Withdrawal 78.2 93.5 * 90.3 96.8 89.7 Other traditional 1.1 1.4 * 0.1 0.0 0.4 Mean number of methods known by respondents 6.8 7.6 * 6.3 7.0 6.0 Number of respondents 6,116 3,895 11 2,755 1,506 311 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Had last sexual intercourse within 30 days before the survey. Similar to women, currently married men are most aware of the male condom (100 percent), the IUD (85 percent), and the pill (82 percent). Men are more likely than women to know of some methods, especially those in which they are directly involved such as male sterilization, condoms, and withdrawal, but less likely to have heard of the pill, the IUD, LAM, and the rhythm method. Married men know an average of seven contraceptive methods, which is slightly less than married women. The percentage of currently married women and currently married men who know of at least one method of contraception does not vary by background characteristics. Knowledge of any method and of a modern method is virtually universal (data not shown). Contraception • 75 In the past 15 years, contraceptive knowledge has remained consistently high in Armenia. The level of awareness of specific methods among currently married women and men has increased over the past 5 years. Knowledge of female and male sterilization, implants, LAM1, and emergency contraception has increased, while knowledge of injectables has decreased. Overall, the mean number of methods known by currently married Armenian women and men has remained roughly stable since 2010 (7.7 and 6.8 methods for women and men, respectively, in 2010, compared with 7.6 and 7.0 methods for women and men, respectively, in 2015-16). 7.2 CURRENT USE OF CONTRACEPTION This section presents information on the prevalence of current contraceptive use among women age 15-49. The level of current use is a measure of actual contraceptive practice at the time of the survey. Table 7.2 shows the percent distribution of all women and currently married women by the contraceptive method they are currently using, disaggregated by age group. Table 7.2 Current use of contraception according to age Percent distribution of all women and currently married women age 15-49 by contraceptive method currently used, according to age, Armenia 2015-16 Any method Any modern method Modern method Any tradi- tional method Traditional method Not current- ly using Total Number of women Age Female sterili- zation Pill IUD Inject- ables Male condom LAM Other Rhythm With- drawal Other ALL WOMEN 15-19 1.5 1.0 0.0 0.0 0.0 0.0 0.6 0.4 0.0 0.5 0.1 0.3 0.0 98.5 100.0 725 20-24 16.9 9.0 0.0 1.0 1.6 0.0 5.2 1.3 0.0 7.9 0.6 7.2 0.1 83.1 100.0 928 25-29 38.5 20.4 0.1 1.5 5.4 0.0 12.4 0.8 0.3 18.1 2.9 15.1 0.1 61.5 100.0 1,099 30-34 54.7 29.8 0.5 2.4 9.7 0.5 16.2 0.5 0.1 24.9 2.9 21.5 0.5 45.3 100.0 1,007 35-39 54.5 26.7 0.8 3.0 9.7 0.0 13.1 0.0 0.1 27.8 3.4 23.9 0.5 45.5 100.0 867 40-44 49.9 21.8 0.6 2.4 8.5 0.3 10.0 0.1 0.0 28.1 5.2 22.6 0.3 50.1 100.0 784 45-49 34.0 13.0 1.6 1.5 4.0 0.0 5.9 0.0 0.0 21.0 1.7 19.3 0.0 66.0 100.0 706 Total 36.7 18.1 0.5 1.7 5.7 0.1 9.6 0.5 0.1 18.6 2.5 15.9 0.2 63.3 100.0 6,116 CURRENTLY MARRIED WOMEN 15-19 (32.4) (21.9) (0.0) (0.0) (0.0) (0.0) (14.0) (7.8) (0.0) (10.5) (3.1) (7.4) (0.0) (67.6) 100.0 33 20-24 42.5 22.4 0.0 2.1 3.9 0.0 13.2 3.2 0.0 20.1 1.6 18.2 0.4 57.5 100.0 365 25-29 55.0 28.8 0.1 2.1 7.7 0.0 17.3 1.1 0.4 26.1 4.2 21.8 0.1 45.0 100.0 761 30-34 66.4 36.0 0.6 2.9 11.8 0.6 19.5 0.6 0.1 30.4 3.6 26.3 0.6 33.6 100.0 826 35-39 66.2 32.2 1.0 3.7 11.8 0.0 15.5 0.0 0.1 34.0 4.2 29.3 0.6 33.8 100.0 709 40-44 60.9 26.6 0.8 2.9 10.3 0.4 12.1 0.1 0.0 34.4 6.3 27.7 0.4 39.1 100.0 639 45-49 41.7 15.4 1.7 1.9 4.6 0.0 7.2 0.0 0.0 26.4 2.1 24.3 0.0 58.3 100.0 562 Total 57.1 28.0 0.7 2.6 8.9 0.2 14.7 0.7 0.1 29.2 3.8 25.0 0.3 42.9 100.0 3,895 Note: If more than one method is used, only the most effective method is considered in this tabulation. Figures in parentheses are based on 25-49 unweighted cases. LAM = Lactational amenorrhea method. Results show that 57 percent of married women of reproductive age are using a method of contraception. Among married women, use of traditional methods (29 percent) is slightly more common than use of modern methods (28 percent). The most widely used method among currently married women by far, is withdrawal (25 percent), followed by the male condom (15 percent), and the IUD (9 percent). The use of any contraceptive method rises rapidly with age, peaking at 66 percent among currently married women age 30-39 and then declining to 42 percent among women age 45-49. As expected, contraceptive use is lower among all women (37 percent) than among married women (57 percent) because the former includes women who are not married and who are not sexually active, and are not in need of family planning. 1 In 2000 and 2015-16 ADHS, if a woman did not recognize the term “lactational amenorrhea method” when she was asked if she had ever heard of the method, a description of LAM was read to her, while in the 2005 and 2010 ADHS, the description was not read to her. 76 • Contraception 7.3 CURRENT USE BY BACKGROUND CHARACTERISTICS Table 7.3 presents information by background characteristics on the current use of contraceptives by currently married women. In general, women in Armenia do not begin to use contraception until they have had at least one child. Use of any contraception among married women is similar among urban and rural women (57 percent and 58 percent, respectively). However, urban women are markedly more likely to be using a modern method than rural women (32 percent and 23 percent, respectively). Table 7.3 Current use of contraception according to background characteristics Percent distribution of currently married women age 15-49 by contraceptive method currently used, according to background characteristics, Armenia 2015-16 Background characteristic Any method Any modern method Modern method Any tradi- tional method Traditional method Not current- ly using Total Number of women Female sterili- zation Pill IUD Inject- ables Male condom LAM Other Rhythm With- drawal Other Number of living children 0 2.3 0.2 0.0 0.0 0.2 0.0 0.0 0.0 0.0 2.1 0.5 1.6 0.0 97.7 100.0 261 1-2 60.3 31.4 0.5 3.0 10.0 0.3 16.7 0.8 0.2 28.9 4.3 24.1 0.4 39.7 100.0 2,690 3-4 64.1 26.1 1.2 2.5 8.4 0.0 13.5 0.4 0.0 38.1 3.6 34.3 0.2 35.9 100.0 908 5+ (46.7) (23.9) (7.2) (0.0) (5.0) (0.0) (5.4) (6.3) (0.0) (22.7) (0.0) (22.7) (0.0) (53.3) 100.0 36 Residence Urban 56.5 31.9 0.7 3.0 9.5 0.3 17.4 0.8 0.2 24.5 4.9 19.3 0.4 43.5 100.0 2,221 Rural 58.1 22.7 0.7 2.2 8.1 0.0 11.2 0.6 0.0 35.3 2.5 32.5 0.3 41.9 100.0 1,674 Region Yerevan 58.4 40.1 0.9 4.1 11.0 0.6 22.3 1.0 0.2 18.3 6.3 11.6 0.4 41.6 100.0 1,140 Aragatsotn 63.0 35.3 0.0 7.8 8.7 0.0 17.8 1.0 0.0 27.7 0.9 26.8 0.0 37.0 100.0 187 Ararat 66.1 34.7 1.8 0.8 13.4 0.0 18.1 0.5 0.0 31.4 4.4 26.9 0.1 33.9 100.0 360 Armavir 59.7 22.4 0.5 2.3 5.0 0.0 14.6 0.0 0.0 37.3 0.8 35.6 0.9 40.3 100.0 405 Gegharkunik 69.7 19.3 0.0 2.1 9.7 0.0 5.4 1.9 0.2 50.5 2.4 47.7 0.4 30.3 100.0 298 Lori 60.0 13.4 0.0 2.4 8.0 0.0 3.0 0.0 0.0 46.6 1.5 44.2 0.9 40.0 100.0 214 Kotayk 55.6 23.2 0.5 0.8 8.8 0.0 12.1 1.0 0.0 32.4 3.9 28.5 0.0 44.4 100.0 476 Shirak 40.6 18.7 0.0 2.6 7.1 0.0 8.7 0.3 0.0 22.0 6.5 15.5 0.0 59.4 100.0 349 Syunik 20.8 13.1 0.3 0.3 1.2 0.0 10.8 0.4 0.0 7.7 1.3 6.4 0.0 79.2 100.0 172 Vayots Dzor 68.5 13.4 0.3 0.3 4.8 0.0 7.6 0.4 0.0 55.1 0.7 54.4 0.0 31.5 100.0 87 Tavush 60.3 26.8 2.5 1.9 8.8 0.0 12.1 0.3 1.2 33.6 1.1 31.4 1.0 39.7 100.0 208 Education Basic 59.0 20.5 0.0 0.8 4.9 0.0 13.6 1.1 0.0 38.5 1.9 35.7 0.9 41.0 100.0 205 Secondary 58.1 24.1 1.0 2.3 7.5 0.1 12.4 0.8 0.1 34.0 2.7 31.0 0.3 41.9 100.0 1,669 Secondary special 56.4 28.4 0.6 2.0 11.1 0.2 13.9 0.2 0.3 28.0 3.8 23.7 0.5 43.6 100.0 953 Higher 55.9 35.3 0.5 4.1 9.9 0.2 19.3 1.1 0.2 20.6 6.0 14.4 0.2 44.1 100.0 1,064 Wealth quintile Lowest 58.6 21.1 0.7 2.2 7.5 0.0 10.2 0.5 0.0 37.6 2.5 34.7 0.4 41.4 100.0 695 Second 56.8 24.6 0.6 2.1 8.2 0.0 12.7 0.6 0.3 32.2 2.3 29.6 0.3 43.2 100.0 834 Middle 54.4 25.2 0.5 2.1 7.5 0.3 13.2 1.3 0.2 29.2 2.4 26.6 0.3 45.6 100.0 721 Fourth 55.2 30.3 0.6 2.5 9.0 0.0 17.3 0.8 0.1 24.9 4.9 19.6 0.4 44.8 100.0 790 Highest 60.4 37.2 1.0 4.2 11.8 0.5 19.2 0.5 0.0 23.2 6.7 16.2 0.4 39.6 100.0 855 Total 57.1 28.0 0.7 2.6 8.9 0.2 14.7 0.7 0.1 29.2 3.8 25.0 0.3 42.9 100.0 3,895 Note: If more than one method is used, only the most effective method is considered in this tabulation. Figures in parentheses are based on 25-49 unweighted cases. Total includes 4 (weighted) women with no education. LAM = Lactational amenorrhea method. There is considerable variation in contraceptive use by region. Gegharkunik and Vayots Dzor have the highest contraceptive prevalence rates (70 percent and 69 percent, respectively), while Syunik has the lowest (21 percent). With modern methods, Yerevan has the highest use with 40 percent. There have been large, erratic changes in contraceptive use by region since 2010, with use of traditional methods (primarily withdrawal) increasing dramatically in Gegharkunik and declining precipitously in Syunik. It is not clear if these trends are valid or an anomaly, and further investigation is needed. Contraception • 77 Although overall contraceptive use actually decreases slightly as the education of the woman increases, use of modern methods increases with educational attainment. Women with higher levels of education are almost twice as likely to use a modern method as women with only basic education (35 percent compared with 21 percent). This difference is due primarily to the increased use of IUDs and the male condom. The overall contraceptive prevalence rate does not vary uniformly with wealth quintile. However, modern contraceptive use increases markedly as household wealth increases, from 21 percent among married women in the lowest wealth quintile to 37 percent among those in the highest wealth quintile. Use of any contraceptive method has increased slightly over the past 10 years, from 53 percent of currently married women in 2005 to 55 percent in 2010 and 57 percent in 2015-16, although the levels are not as high as they were in 2000, when 61 percent of married women were using a method of contraception (Table 7.4 and Figure 7.1). After an initial decline from 22 percent of married women in 2000 to 20 percent in 2005, use of modern methods increased to 27 percent in 2010 and 28 percent in 2015-16. Use of traditional methods declined considerably, from 38 percent 2 of married women in 2000 to 28 percent in 2010, before rising slightly to 29 percent in 2015-16. Table 7.4 Trends in the current use of contraception Percent distribution of currently married women age 15-49 by contraceptive method currently used, according to several surveys. Method 2000 ADHS 2005 ADHS 2010 ADHS 2015-16 ADHS Any method 60.5 53.1 54.9 57.1 Any modern method 22.3 19.5 27.2 28.0 Female sterilization 2.7 0.6 0.2 0.7 Pill 1.1 0.8 1.5 2.6 IUD 9.4 9.4 9.6 8.9 Male condom 6.9 8.1 14.6 14.7 Other modern method 2.2 0.6 1.3 1.0 Any traditional method 38.2a 33.6 27.7 29.2 Rhythm 4.8 3.8 2.4 3.8 Withdrawal 31.9 27.7 24.5 25.0 Other 1.5 2.1 0.8 0.3 Not currently using 39.5 46.9 45.1 42.9 Total 100.0 100.0 100.0 100.0 Number of women 4,125 4,044 3,626 3,895 a Includes “other” traditional methods, such as folk methods. This estimate differs from the 36.7 percent published in the 2000 ADHS final report, because “folk method” was not included in the “any traditional method” category in that report. 2 This estimate differs from the 36.7 percent published in the 2000 ADHS final report because “folk method” was not included in the “any traditional method” category in the 2000 report tabulation but was included in the 2005 and 2010 report tabulations. 78 • Contraception Figure 7.1 Trends in contraceptive use among currently married women Compared with data from DHS surveys conducted in the past 10 years in other countries of the former Soviet Union and in Albania, use of a modern contraceptive method among married women age 15-49 in Armenia (28 percent) appears to be higher than that in Albania (11 percent in 2008-09), Azerbaijan (14 percent in 2006), and Tajikistan (26 percent in 2012), but lower than in Ukraine (48 percent in 2007) and the Kyrgyz Republic (34 percent in 2012). Armenia has a high percentage of currently married women using a traditional method (29 percent) compared with those reported in Tajikistan (2 percent), the Kyrgyz Republic (3 percent), and Ukraine (19 percent), although their rates are lower than those reported in neighboring Azerbaijan (37 percent) (ICF 2015a). 7.4 SOURCE OF FAMILY PLANNING Information on where women obtain their modern contraceptive methods is useful for family planning managers and those who implement logistics planning. In the 2015-16 ADHS, women who reported that they were currently using a modern method of contraception were asked where they obtained the method the last time they acquired it. Interviewers recorded the name of the source or facility because respondents may not always be able to accurately categorize a source as public or private. Supervisors and editors then verified and coded this information to improve the accuracy. Table 7.5 shows that almost two-thirds of users of modern methods received their method from the private sector, with the overwhelming majority being from pharmacies; only one-third of users received their method from the public sector, primarily from maternity homes and government hospitals. The source is heavily dependent on the method. Almost all users of female sterilization and the IUD reported obtaining their method from government sources (98 percent and 94 percent, respectively), while almost all users of the pill and male condom reported obtaining their method from private sources (96 percent and 98 percent, respectively). There has been little change since 2010 in the public-private distribution of methods. 61 22 3 1 9 7 38 5 32 53 20 1 1 9 8 34 4 28 55 27 0 2 10 15 28 2 25 57 28 1 3 9 15 29 4 25 ANY METHOD Any modern method Female sterilization Pill IUD Male condom Any traditional method Rhythm Withdrawal Percentage of currently married women 2000 ADHS 2005 ADHS 2010 ADHS 2015-16 ADHS Percent Contraception • 79 Table 7.5 Source of modern contraception methods Percent distribution of users of modern contraceptive methods age 15-49 by most recent source of method, according to method, Armenia 2015-16 Source Female sterilization Pill IUD Male condom Total Public sector (97.9) 4.5 94.0 1.7 35.0 Government hospital (58.8) 1.8 38.6 0.1 14.8 Maternity home (31.8) 0.3 48.5 0.2 16.9 Diagnostic center (0.0) 0.6 0.5 0.2 0.3 Woman consultation (0.0) 1.9 4.4 0.3 1.8 Polyclinic (0.0) 0.0 1.4 0.2 0.6 Ambulatory/family doctor’s office (0.0) 0.0 0.4 0.6 0.4 Other public (7.3) 0.0 0.1 0.0 0.2 Private medical sector (2.1) 95.5 6.0 98.0 64.8 Private hospital (2.1) 0.9 3.4 0.0 1.3 Maternity home (0.0) 0.0 1.3 0.0 0.4 Diagnostic center (0.0) 0.0 0.7 0.0 0.2 Woman consultation (0.0) 2.4 0.0 0.0 0.2 Polyclinic (0.0) 0.0 0.0 0.3 0.2 FAP (0.0) 0.0 0.0 0.2 0.1 Pharmacy (0.0) 92.2 0.6 97.4 62.3 Other source (0.0) 0.0 0.0 0.3 0.2 Friend/relative (0.0) 0.0 0.0 0.3 0.2 Total 100.0 100.0 100.0 100.0 100.0 Number of women 29 105 349 586 1,081 Note: Total includes users of other modern methods but excludes lactational amenorrhea method (LAM). Figures in parentheses are based on 25-49 unweighted cases. In the 2015-16 ADHS, women who were using an IUD were asked if they received the IUD free of charge the most recent time they obtained one or if they paid for it. Results indicate that only 3 percent of IUD users received the IUD for free (data not shown). Women were also asked if they knew of a place where they could obtain a method of contraception free of charge. Only 3 percent of all women and 4 percent of currently married women said they knew of a place to obtain a free contraceptive method (data not shown). 7.5 INFORMED CHOICE Informed choice is an important aspect of family planning services. Family planning clients have the right to information about their contraceptive method. Providers are required to inform all users of contraceptive methods about (1) the potential side effects of their method, (2) what they should do if they encounter side effects or signs of a problem, and (3) alternative methods of family planning. Current users of modern methods who are well informed about the side effects and problems associated with methods and know of a range of method options are better able to make an informed choice about the method they prefer. This information improves the quality of care and compliance by assisting users to cope with side effects and decreasing unnecessary discontinuation of temporary methods. Current users of selected modern contraceptive methods were asked whether, at the time they adopted the particular method, they were informed about the possible side effects or problems that might be encountered with the method. Table 7.6 shows the percentage of current users of modern methods who were informed about possible side effects or problems with the method used; what to do if they experienced side effects or problems; and other methods available for use. These are described below by method type and the initial source of the method. 80 • Contraception Table 7.6 Informed choice Among current users of modern methods age 15-49 who started the last episode of use within the 5 years before the survey, the percentage who were informed about possible side effects or problems of that method, the percentage who were informed about what to do if they experienced side effects, and the percentage who were informed about other methods available for use, according to method and initial source, Armenia 2015-16 Method/source Among women who started last episode of modern contraceptive method within 5 years before the survey: Percentage who were informed about side effects or problems of method used Percentage who were informed about what to do if side effects experienced Percentage who were informed by a health or family planning worker of other methods that could be used Number of women Method Pill 68.8 65.9 82.5 62 IUD 94.5 92.5 67.8 167 Initial source of method1 Public sector 92.9 90.9 70.9 172 Government hospital 92.6 92.6 85.0 74 Maternity home 94.9 90.3 56.2 74 Private medical sector 74.2 71.7 76.4 71 Pharmacy 76.2 73.1 72.3 58 Total 87.2 85.1 72.3 243 Note: Total includes 7 (weighted) users of female sterilization and 7 users of injectables not shown separately. 1 Source at start of current episode of use. Almost nine in ten modern contraceptive users reported that they were informed about side effects (87 percent) and were told what to do if they did experience such side effects (85 percent). The percentage of currently married women informed of side effects and told what to do if they experience side effects has increased from 69 percent and 62 percent of women in 2010. Furthermore, 72 percent of currently married women in 2015-16 reported that they were informed about other methods of contraception, an increase from 49 percent in 2010. The IUD users are more likely than pill users to be informed about side effects and what to do if they experience side effects. However, the IUD users are less likely than pill users to be informed of alternative methods available for use. Women who obtain their methods from public sources are more likely to be informed about methods than those who use private sources. For example, over 90 percent of women who obtained their method from the public sector were informed about side effects or problems of the method used and about what to do if they experienced side effects, compared with less than three- quarters of women who obtained their method from the private sector. This relationship may be due to the types of methods obtained at public and private sources. The main methods obtained from public sources are the IUD and female sterilization, while the main methods obtained from private sources are pills and condoms, methods that have fewer side effects. This mix of methods may also explain why women who obtain their methods from the private sector (primarily pills and condoms) are somewhat more likely than women who obtained their method from a public source (primarily IUDs and female sterilization) to be informed about other methods available for use. 7.6 DISCONTINUATION WITHIN 12 MONTHS OF USE Reproductive goals can only be realized if contraceptive methods are used consistently and correctly. A major concern among family planning program workers is the rate at which contraceptive users discontinue their methods. To obtain information on contraceptive discontinuation, all segments of contraceptive use in the 5-year period before the survey were recorded in the “calendar” section of the Woman’s Questionnaire, as well as the reason for any discontinuation. In analyzing these data, the month of interview and the two preceding months are ignored in order to avoid the bias that may be introduced by unrecognized pregnancies. Contraception • 81 Table 7.7 shows contraceptive discontinuation rates within 12 months of starting use among women age 15-49. Overall, 32 percent of women who started using a contraceptive method in the 5 years before the survey discontinued use within 12 months of adopting the method. The one-year discontinuation rate is lowest among users of the IUD (2 percent), highest among users of LAM (99 percent) and withdrawal (30 percent), and intermediate among users of condoms (17 percent). Almost one-third of the discontinuation rate is due to a desire to use a more effective method. Table 7.7 Twelve-month contraceptive discontinuation rates Among women age 15-49 who started an episode of contraceptive use within the 5 years before the survey, the percentage of episodes discontinued within 12 months, according to reason for discontinuation and specific method, Armenia 2015-16 Method Method failure Desire to become pregnant Other fertility related reasons2 Side effects/ health reasons Wanted more effective method Other method related reasons3 Other reasons Any reason4 Switched to another method5 Number of episodes of use6 IUD (0.8) (0.4) (0.0) (0.3) (0.0) (0.0) (0.5) (2.0) (0.5) 234 Male condom 3.0 4.3 6.2 0.4 0.8 1.1 0.8 16.5 2.3 560 Lactational amenorrhea (LAM) 4.1 4.2 4.6 0.8 63.4 16.0 5.8 99.0 74.1 279 Withdrawal 9.7 5.5 10.9 0.0 2.9 0.0 1.0 30.0 2.6 1,026 Other1 (7.4) (6.1) (5.5) (2.8) (2.4) (0.9) (0.4) (25.6) (6.2) 271 All methods 6.4 4.6 7.3 0.6 9.5 2.4 1.4 32.2 11.6 2,377 Note: Figures are based on life table calculations using information on episodes of use that began 3-62 months before the survey. Figures in parentheses are based on 125-249 unweighted women using the method during the first month of the life table. 1 Includes pills, injectables, emergency contraception and rhythm. 2 Includes infrequent sex/husband away, difficult to get pregnant/menopausal, and marital dissolution/separation. 3 Includes lack of access/too far, costs too much, and inconvenient to use. 4 Reasons for discontinuation are mutually exclusive and add to the total given in this column. 5 The episodes of use included in this column are a subset of the discontinued episodes included in the discontinuation rate. A woman is considered to have switched to another method if she used a different method in the month after discontinuation or if she gave “wanted a more effective method” as the reason for discontinuation and started another method within 2 months of discontinuation. 6 Number of episodes of use includes both episodes of use that were discontinued during the period of observation and episodes of use that were not discontinued during the period of observation. According to definition of the method, it is impossible to use LAM for longer than 6 months. Effective use of LAM means that a woman is exclusively or predominantly breastfeeding, is less than 6 months postpartum, is postpartum amenorrheic, and knows to use another contraceptive method when any of the previous criteria do not pertain. Therefore, a 12-month discontinuation rate for LAM is expected to be high, but it is not expected to be 100 percent. Since figures in Table 7.7 are based on life table calculation with information on episodes of use that began 3-62 months before the survey, a small number of LAM users could be legitimate users of the method at the time of the interview if they began their episode of use 3-5 months before the survey. The 12-month discontinuation rate is higher for LAM than for any other method—99 percent of LAM users who started an episode of use in the 5 years before the survey were no longer using this method at the time of the interview. Sixty-three percent of LAM users said they discontinued the method because they wanted a more effective method. As expected, most LAM users who discontinued use of the method (74 percent) switched to another method. Table 7.8 shows the distribution of discontinuations of all contraceptive methods during the 5 years before the survey by reason for discontinuation. The desire to become pregnant is the most commonly cited reason for discontinuing use, accounting for slightly over one-quarter (27 percent) of all discontinuations. Almost as common is method failure (accidental pregnancy or becoming pregnant while using), which accounts for 24 percent of discontinuations. Other common reasons for discontinuing contraceptive use are infrequent sex or the absence of their partner (17 percent) and the desire to use a more effective method (15 percent). 82 • Contraception Table 7.8 Reasons for discontinuation Percent distribution of discontinuations of contraceptive methods in the 5 years before the survey by main reason stated for discontinuation, according to specific method, Armenia 2015-16 Reason Pill IUD Male condom LAM Rhythm Withdrawal All methods Became pregnant while using 13.1 3.4 16.7 4.1 40.8 34.4 24.1 Wanted to become pregnant 15.8 44.9 46.1 4.6 35.0 26.1 27.1 Husband disapproved 0.0 0.0 4.1 4.8 2.9 3.8 3.5 Wanted a more effective method 8.4 0.0 4.5 61.4 12.4 7.7 15.3 Side effects/health concerns 29.4 33.6 0.9 1.0 0.0 0.0 3.6 Lack of access/too far 1.8 0.0 0.0 0.0 0.0 0.0 0.1 Cost too much 0.0 0.0 2.2 0.2 0.0 0.2 0.5 Inconvenient to use 5.1 1.9 2.0 16.7 0.9 0.1 3.4 Up to God/fatalistic 0.0 0.0 0.0 0.4 0.0 0.1 0.2 Difficult to get pregnant/ menopausal 5.1 6.7 1.5 0.9 1.2 2.1 2.3 Infrequent sex/husband away 18.9 5.2 18.6 4.1 4.1 23.2 17.1 Marital dissolution/separation 1.4 0.0 1.0 0.2 0.0 0.3 0.4 Other 0.9 0.7 0.5 0.3 0.0 0.4 0.4 Missing 0.0 3.5 2.0 1.4 2.6 1.6 1.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of discontinuations 67 91 259 239 91 781 1,546 Note: All methods includes 2 weighted users of injectables, 4 users of emergency contraception, and 13 users of other methods. LAM = Lactational amenorrhea method. Reasons for discontinuing contraceptive use vary depending on the method. For example, users of rhythm and withdrawal have the highest levels of discontinuations due to method failure; 41 percent of those discontinuing use of the rhythm method and 34 percent of those discontinuing use of withdrawal said that it was due to becoming pregnant while using the method. The main reason for discontinuing use of condoms (46 percent) and the IUD (45 percent) is the desire to get pregnant. Side effects and health concerns are the most commonly cited reason for discontinuing use of the pill, reported by 29 percent of women, while LAM users discontinued their method because they wanted a more effective method (61 percent) or because they found it inconvenient to use (17 percent). The low efficacy of the rhythm method and withdrawal is evidenced by the high failure rate of these methods during use. As previously noted, withdrawal is the most popular method of contraception in Armenia. This method is used by 25 percent of currently married women and accounts for almost half of all contraceptive use. It is striking that a method with such a high failure rate is used by such a substantial proportion of Armenian women who are trying to control their fertility. 7.7 KNOWLEDGE OF THE FERTILE PERIOD A basic knowledge of the physiology of reproduction is especially useful for the successful practice of coitus-related methods such as withdrawal, condoms, vaginal methods, and those fertility-awareness methods collectively referred to as periodic abstinence, rhythm, or the calendar method. Knowledge of the fertile period in a woman’s menstrual cycle is particularly critical in the case of the rhythm method, and the successful practice of natural family planning depends on an understanding of when a woman is most likely to conceive. Table 7.9 Knowledge of fertile period Percent distribution of women age 15-49 by knowledge of the fertile period during the ovulatory cycle, according to current use of the rhythm method, Armenia 2015-16 Perceived fertile period Users of rhythm method Nonusers of rhythm method All women Just before her menstrual period begins 5.4 3.1 3.2 During her menstrual period 0.0 0.1 0.1 Right after her menstrual period has ended 13.4 19.5 19.3 Halfway between two menstrual periods 77.2 48.9 49.6 Other 0.0 0.1 0.1 No specific time 3.2 2.3 2.3 Don’t know 0.8 25.9 25.3 Total 100.0 100.0 100.0 Number of women 150 5,966 6,116 Contraception • 83 The 2015-16 ADHS included a question designed to obtain information on the respondent’s understanding of when a woman is most likely to become pregnant during her menstrual cycle. All women were asked, “From one menstrual period to the next, are there certain days when a woman is more likely to become pregnant?” If the answer was “yes,” the women were further asked whether that time was just before her period begins, during her period, right after her period ended, or halfway between two periods. Table 7.9 shows the results for all women age 15-49 and for those who reported they are currently using the rhythm method. Half of all women age 15-49 correctly identified the fertile period as occurring halfway between two periods. However, one-quarter of women said that they did not know when a woman is most likely to become pregnant. Knowledge of the fertile period is higher among users of the rhythm method; 77 percent were able to correctly identify the fertile period. Knowledge of the fertile period has improved since 2010. Overall, the proportion of women who know that they are most likely to get pregnant if they have sexual intercourse halfway between two menstrual periods increased from 32 percent in 2010 to 50 percent in 2015-16. Among users of the rhythm method, the percentage of women who can correctly identify the fertile period has slightly increased from 71 percent in 2010 to 77 percent in 2015-16. 7.8 NEED FOR FAMILY PLANNING Maternal health care services focus on defining the size of the population of women who have a potential need for family planning services and identifying women whose need for contraception is unmet. Unmet need for family planning refers to fecund women who are not using contraception but who wish to postpone the next birth (spacing) or stop childbearing altogether (limiting). Specifically, women are considered to have unmet need for spacing if they are:  At risk of becoming pregnant, not using contraception, and either do not want to become pregnant within the next 2 years, or are unsure if or when they want to become pregnant  Pregnant with a mistimed pregnancy  Postpartum amenorrheic for up to 2 years after a mistimed birth and not using contraception Women are considered to have unmet need for limiting if they are:  At risk of becoming pregnant, not using contraception, and want no (more) children  Pregnant with an unwanted pregnancy  Postpartum amenorrheic for up to 2 years after an unwanted birth and not using contraception. Women who are classified as infecund have no unmet need because they are not at risk of becoming pregnant. Women who are using contraception are considered to have met need. Women using contraception who say they want no (more) children are considered to have met need for limiting, and women who are using contraception and say they want to delay having a child, or are unsure if or when they want a/another child, are considered to have met need for spacing. 84 • Contraception Unmet need, total demand, percentage of demand satisfied, and percentage of demand satisfied by modern methods are defined as follows:  Unmet need: the sum of unmet need for spacing plus unmet need for limiting  Total demand for family planning: the sum of unmet need plus total contraceptive use  Percentage of demand satisfied: total contraceptive use divided by the sum of unmet need plus total contraceptive use  Percentage of demand satisfied by modern methods: use of modern contraceptive methods divided by the sum of unmet need plus total contraceptive use The definition of unmet need for family planning has been revised to make levels of unmet need comparable over time and across surveys (Bradley et al. 2012). The aspect of the change in the definition that has the largest impact on levels of unmet need is the removal of information collected from the contraceptive calendar, which has not been included in all DHS surveys across countries. Previously, in surveys that included a calendar, women who were pregnant or postpartum amenorrheic resulting from contraceptive failure were not considered to have unmet need, even if their last pregnancy/birth was unwanted or mistimed. In contrast, if the survey did not collect information on contraceptive failure in the calendar, all pregnant and postpartum amenorrheic women whose last pregnancy/birth was unwanted or mistimed were considered to have unmet need. To make the definition of unmet need comparable in both types of surveys, the new definition does not take information on contraceptive failure into account for any woman when assigning unmet need status. Removing contraceptive failure from the calculation can result in a small increase in the estimated level of unmet need by moving some women who were in the failure category into the unmet need category. The revised definition was employed in determining the women who have an unmet need for family planning (Table 7.10). Table 7.10 presents information on unmet need, met need, and the total demand for family planning services among currently married women, by background characteristics. Overall, 13 percent of currently married women have an unmet need for family planning, evenly split between unmet need for spacing (6 percent) and unmet need for limiting (6 percent). Over half of women (57 percent) have a met need for family planning because they are currently using a method. If all currently married women who say they want to space or limit their children were to use a family planning method, the contraceptive prevalence rate would increase to 70 percent (total demand for family planning). Currently, 82 percent of the family planning needs of currently married women are being met, with less than half of that need met by modern methods (40 percent). The total demand for family planning is comprised more heavily of the demand to limit births (45 percent), with only 25 percent of the demand for spacing purposes. Unmet need is highest among married women age 20-24 (20 percent). There are only minor differences in unmet need by residence, education, and wealth quintile. However, unmet need varies considerably by region, ranging from only 5 percent among married women in Aragatsotn to 22 percent of women in Shirak. Contraception • 85 Table 7.10 Need and demand for family planning among currently married women Percentage of currently married women age 15-49 with unmet need for family planning, percentage with met need for family planning, total demand for family planning, and percentage of the demand for family planning that is satisfied, according to background characteristics, Armenia 2015-16 Background characteristic Unmet need for family planning Met need for family planning (currently using) Total demand for family planning1 Percentage of demand satisfied2 Percentage of demand satisfied by modern methods3 Number of women For spacing For limiting Total For spacing For limiting Total For spacing For limiting Total Age 15-19 (9.3) (0.0) (9.3) (28.1) (4.3) (32.4) (37.4) (4.3) (41.7) (77.7) (52.5) 33 20-24 19.4 1.1 20.4 36.2 6.3 42.5 55.6 7.4 63.0 67.6 35.6 365 25-29 12.3 3.3 15.6 38.0 17.0 55.0 50.3 20.3 70.6 77.9 40.9 761 30-34 5.9 4.2 10.1 25.9 40.5 66.4 31.8 44.7 76.5 86.8 47.1 826 35-39 2.6 8.7 11.2 9.2 57.0 66.2 11.8 65.6 77.5 85.5 41.6 709 40-44 0.8 7.7 8.5 2.6 58.4 60.9 3.4 66.1 69.5 87.7 38.2 639 45-49 0.0 13.1 13.1 0.8 40.9 41.7 0.8 54.0 54.8 76.2 28.0 562 Residence Urban 6.2 7.4 13.6 19.7 36.7 56.5 26.0 44.1 70.1 80.5 45.6 2,221 Rural 6.0 5.0 11.0 17.5 40.6 58.1 23.5 45.5 69.0 84.1 32.9 1,674 Region Yerevan 6.0 7.1 13.1 19.6 38.8 58.4 25.6 45.9 71.5 81.6 56.1 1,140 Aragatsotn 2.7 1.7 4.5 23.9 39.1 63.0 26.6 40.8 67.4 93.4 52.4 187 Ararat 5.7 1.9 7.7 21.3 44.9 66.1 27.0 46.8 73.8 89.6 47.1 360 Armavir 5.8 5.4 11.2 17.1 42.5 59.7 22.9 48.0 70.8 84.2 31.6 405 Gegharkunik 2.8 4.7 7.5 9.9 59.8 69.7 12.7 64.5 77.3 90.3 24.9 298 Lori 7.7 4.3 12.0 16.5 43.5 60.0 24.3 47.8 72.1 83.3 18.6 214 Kotayk 7.8 7.2 15.0 26.5 29.1 55.6 34.3 36.3 70.6 78.7 32.9 476 Shirak 7.5 14.7 22.2 14.5 26.1 40.6 22.1 40.8 62.9 64.6 29.7 349 Syunik 9.4 7.9 17.3 9.2 11.6 20.8 18.7 19.5 38.1 54.6 34.3 172 Vayots Dzor 1.2 4.3 5.5 20.6 48.0 68.5 21.8 52.2 74.0 92.6 18.1 87 Tavush 7.6 4.3 11.8 20.1 40.2 60.3 27.7 44.5 72.2 83.6 37.1 208 Education Basic 6.8 6.7 13.5 14.1 44.9 59.0 20.9 51.6 72.5 81.4 28.3 205 Secondary 5.9 6.1 12.0 17.2 40.9 58.1 23.1 47.0 70.2 82.8 34.3 1,669 Secondary special 5.7 6.2 11.9 16.3 40.1 56.4 22.0 46.4 68.3 82.5 41.6 953 Higher 6.8 6.8 13.6 24.4 31.5 55.9 31.2 38.3 69.5 80.4 50.8 1,064 Wealth quintile Lowest 6.8 5.9 12.7 17.2 41.4 58.6 24.0 47.3 71.3 82.2 29.5 695 Second 6.4 5.3 11.7 17.4 39.4 56.8 23.8 44.7 68.5 82.9 35.9 834 Middle 6.3 7.3 13.6 18.1 36.3 54.4 24.4 43.6 68.0 80.0 37.0 721 Fourth 5.8 5.9 11.7 18.4 36.8 55.2 24.3 42.6 66.9 82.5 45.3 790 Highest 5.5 7.5 13.0 22.3 38.1 60.4 27.8 45.6 73.4 82.3 50.6 855 Total 6.1 6.4 12.5 18.8 38.4 57.1 24.9 44.7 69.6 82.1 40.2 3,895 Note: Numbers in this table correspond to the revised definition of unmet need described in Bradley et al. 2012. Figures in parentheses are based on 25-49 unweighted cases. Total includes 4 (weighted) women with no education. 1 Total demand is the sum of unmet need and met need. 2 Percentage of demand satisfied is met need divided by total demand. 3 Modern methods include female sterilization, male sterilization, pill, IUD, injectables, implants, male condom, emergency contraception, lactational amenorrhea method (LAM), and other modern methods. A comparison with the 2000, 2005, and 2010 ADHS shows that unmet need has decreased somewhat, especially since 2005 (Figure 7.2).3 The change is entirely due to a decrease in unmet need for limiting births. The total demand for family planning has remained fairly steady since 2005 at about 70 percent of married women. 3 All numbers in Figure 7.2 have been recalculated with the revised definition of unmet need and differ from numbers published in the final reports for each previous survey. 86 • Contraception Figure 7.2 Trends in unmet need for family planning 7.9 FUTURE USE OF CONTRACEPTION The needs and practices of women in contraception change as they mature through their reproductive years. Currently married women who were not using contraception at the time of the survey were asked whether they intended to use family planning methods in the future. The results are presented in Table 7.11. Table 7.11 Future use of contraception Percent distribution of currently married women age 15-49 who are not using a contraceptive method by intention to use in the future, according to number of living children, Armenia 2015-16 Intention Number of living children1 Total 0 1 2 3 4+ Intends to use 25.2 33.6 20.0 14.9 9.3 22.4 Unsure 39.8 37.2 30.4 26.4 17.0 31.8 Does not intend to use 34.6 28.6 49.4 58.7 73.7 45.5 Missing 0.3 0.6 0.2 0.0 0.0 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 189 400 707 297 75 1,669 1 Includes current pregnancy. Twenty-two percent of all currently married nonusers stated that they intend to use a contraceptive method at some time in the future, almost identical to the 23 percent reported in the 2010 ADHS, but lower than the 29 percent reported in the 2005 ADHS. One-third (34 percent) of nonusers with one child say they intend to use a contraceptive method in the future. These women are more likely to intend to use a contraceptive method in the future than women with no children and women with two or more living children. Except among those with no children, the more children a woman has, the more likely she is to say she does not intend to use a method in the future. 18 19 14 13 2000 ADHS 2005 ADHS 2010 ADHS 2015-16 ADHS Percent Note: Estimates for all years are based on the revised definition of unmet need. Contraception • 87 7.10 EXPOSURE TO FAMILY PLANNING MESSAGES IN THE MASS MEDIA The mass media provide an opportunity to communicate family planning information to a broad spectrum of the population. Information on the level of exposure to such media is important for programmers and planners to effectively target population subgroups for information, education, and communication campaigns. To assess the extent to which media serve as sources of family planning messages, respondents were asked whether they had heard or seen a message about family planning on the radio or television, in newspapers or magazines, on a mobile phone, or on the Internet in the few months before the survey. Exposure to family planning messages among women and men age 15-49 are shown in Table 7.12.1 for women and in Table 7.12.2 for men. Table 7.12.1 Exposure to family planning messages: Women Percentage of women age 15-49 who heard or saw a family planning message on radio, on television, in a newspaper or magazine, on a mobile phone, or on the Internet in the past few months, according to background characteristics, Armenia 2015-16 Women Background characteristic Radio Television Newspaper/ magazine Mobile phone Internet None of these five media sources Number of women Age 15-19 1.7 15.1 8.7 3.6 21.0 72.6 725 20-24 2.6 18.6 11.5 3.3 26.9 66.3 928 25-29 4.3 23.5 12.0 3.6 28.6 62.7 1,099 30-34 3.1 27.6 10.4 3.7 27.6 60.2 1,007 35-39 2.8 25.9 9.1 3.6 25.8 61.8 867 40-44 2.3 20.9 9.5 3.1 21.9 67.9 784 45-49 1.4 20.7 10.2 1.9 15.8 72.4 706 Residence Urban 3.6 23.5 13.1 4.2 30.1 61.2 3,657 Rural 1.4 20.1 6.2 2.0 16.3 72.4 2,459 Region Yerevan 5.4 20.6 14.2 4.7 33.9 60.2 2,001 Aragatsotn 0.5 14.3 5.3 3.4 23.4 70.7 315 Ararat 1.3 16.7 5.0 1.1 8.0 77.2 552 Armavir 0.0 3.2 0.3 0.0 5.7 92.0 586 Gegharkunik 0.0 16.5 4.0 0.4 14.8 76.4 478 Lori 0.6 18.3 5.4 1.6 17.3 74.7 355 Kotayk 4.7 26.9 14.3 0.0 25.6 58.6 678 Shirak 1.8 28.2 8.4 1.7 21.5 66.0 510 Syunik 2.4 67.8 19.2 21.4 55.4 20.0 238 Vayots Dzor 0.0 17.6 5.6 3.8 20.3 71.8 119 Tavush 0.0 46.7 25.2 6.5 35.6 44.5 283 Education Basic 0.5 6.8 2.4 1.8 6.5 88.0 396 Secondary 1.2 19.0 4.9 2.2 14.7 73.7 2,444 Secondary special 2.4 26.7 11.1 3.2 27.5 61.3 1,360 Higher 5.4 26.1 18.4 5.1 38.9 53.8 1,910 Wealth quintile Lowest 0.6 12.8 4.1 1.3 10.9 81.0 1,081 Second 1.9 24.5 7.8 2.3 18.7 67.0 1,242 Middle 1.6 24.7 8.8 2.8 23.3 65.2 1,142 Fourth 3.2 22.7 13.5 3.6 31.1 60.7 1,287 Highest 5.6 24.7 15.8 6.0 35.6 57.4 1,365 Total 2.7 22.1 10.3 3.3 24.5 65.7 6,116 Note: Total includes 5 women with no education. Among women, the Internet is the most common source of information on family planning. One- quarter of all female respondents accessed contraceptive information through the Internet in the few months before the survey. Almost as many women (22 percent) saw a family planning message on the television. Newspapers and magazines are not common sources of family planning messages (10 percent). Women are least likely to report the radio as a source; only 3 percent of women heard a family planning message on the radio in the months before the survey. 88 • Contraception Table 7.12.2 Exposure to family planning messages: Men Percentage of men age 15-49 who heard or saw a family planning message on radio, on television, in a newspaper or magazine, on a mobile phone, or on the Internet in the past few months, according to background characteristics, Armenia 2015-16 Background characteristic Men Radio Television Newspaper/ magazine Mobile phone Internet None of these five media sources Number of men Age 15-19 0.0 6.1 0.8 2.0 13.7 81.9 345 20-24 0.5 10.2 1.0 1.5 20.2 76.0 467 25-29 2.5 18.0 3.7 1.8 26.2 65.8 464 30-34 3.8 18.0 3.7 2.6 20.7 70.4 427 35-39 4.0 13.3 5.7 1.5 16.7 74.6 376 40-44 3.6 19.0 3.6 2.5 17.3 73.6 346 45-49 3.8 15.9 3.1 3.0 13.0 75.8 330 Residence Urban 3.6 12.9 3.6 1.6 20.0 73.6 1,558 Rural 1.2 16.4 2.4 2.8 17.2 73.8 1,197 Region Yerevan 3.1 6.1 2.9 0.1 16.7 80.6 833 Aragatsotn 0.0 30.6 3.3 0.0 33.4 56.2 159 Ararat 0.4 2.4 0.4 0.0 8.6 91.4 290 Armavir 0.5 4.0 2.9 0.5 11.6 86.6 268 Gegharkunik 0.5 25.7 0.8 1.3 23.4 64.4 235 Lori 0.7 5.1 0.0 0.0 7.2 89.9 184 Kotayk 5.3 9.0 0.4 0.0 4.8 84.3 299 Shirak 11.6 62.6 18.4 11.0 56.9 15.4 201 Syunik 0.0 23.2 3.7 29.2 44.7 37.7 104 Vayots Dzor 0.7 36.5 0.8 0.0 9.2 58.8 56 Tavush 0.0 10.0 1.2 0.0 15.8 78.9 126 Education Basic 1.1 7.4 0.3 2.3 10.0 84.6 360 Secondary 1.7 14.9 2.3 1.9 15.3 75.7 1,250 Secondary special 6.1 16.8 3.0 3.3 17.8 72.5 403 Higher 2.8 15.8 5.6 1.8 29.5 65.5 736 Wealth quintile Lowest 0.8 11.1 1.0 1.2 12.3 80.6 523 Second 1.9 18.0 2.5 2.9 18.8 71.1 583 Middle 2.3 17.5 4.2 2.9 18.3 73.1 521 Fourth 3.5 14.6 4.5 2.3 22.9 69.7 566 Highest 4.1 10.8 3.1 1.3 21.0 74.3 562 Total 2.6 14.4 3.1 2.1 18.8 73.6 2,755 Note: Total includes 5 men with no education. Men are less likely than women to have seen or heard a family planning message during the few months before the survey; this is true for every type of source. For example, 22 percent of women say they saw a family planning message on the television in the few months before the survey, while only 14 percent of men say they did. Overall, almost three-quarters of men were not exposed to a family planning message from any of the five specified sources (compared to two-thirds of women). As with women, the Internet is the most common source of messages on family planning for men (19 percent). Exposure to family planning messages is related to place of residence, level of education, and household wealth. Women living in rural areas, women with lower levels of education, and those living in poorer households are less likely to have been exposed to family planning messages than urban dwellers, women with higher levels of education, and those living in economically advantaged households. Differentials by residence, education, and wealth are less pronounced among men than women. Regional differences in exposure to family planning messages are considerable. Among women, Armavir is the region with the highest proportion of respondents who were not exposed to a family planning message from any of the five specified sources (92 percent). Among men, Ararat has the highest proportion who were not exposed to any message (91 percent). Women living in Syunik and men living in Shirak were the most likely to have heard a family planning message. Men age 15-19 report the lowest exposure to family planning messages in the media. Contraception • 89 Exposure to family planning messages has decreased considerably since 2010. For example, the proportion of women who saw a family planning message on television in the few months before the survey decreased from 51 percent in 2010 to 22 percent in 2015-16. Similarly, the proportion who saw a message in a newspaper or magazine declined from 32 percent to 10 percent. Decreases are also seen for men. 7.11 CONTACT OF NONUSERS WITH FAMILY PLANNING PROVIDERS To determine whether nonusers of family planning in Armenia have had an opportunity to receive information about family planning from providers, women who were not using contraception were asked whether they had attended a health facility in the past year for any reason and, if so, whether a staff person at that facility spoke to them about family planning methods. These questions help to assess the level of so- called “missed opportunities” to inform women about contraception. The results are shown in Table 7.13. Table 7.13 Contact of nonusers with family planning providers Among women age 15-49 who are not using contraception, the percentage who during the past 12 months visited a health facility, the percentage who visited a health facility and discussed family planning with any staff member, and the percentage who visited a health facility but did not discuss family planning, according to background characteristics, Armenia 2015-16 Background characteristic Percentage of women who visited a health facility Percentage of women who visited a health facility in the past 12 months and who: Number of women Discussed family planning with any staff member Did not discuss family planning Age 15-19 16.2 0.3 15.9 714 20-24 31.7 3.2 28.5 771 25-29 50.8 5.9 44.9 676 30-34 55.6 5.6 50.0 456 35-39 46.8 3.8 43.0 394 40-44 42.3 2.1 40.2 393 45-49 41.2 2.1 39.2 466 Residence Urban 44.0 2.9 41.1 2,384 Rural 30.3 3.7 26.6 1,487 Region Yerevan 47.4 1.6 45.7 1,321 Aragatsotn 27.0 4.1 22.9 197 Ararat 21.4 3.8 17.6 312 Armavir 29.3 2.2 27.0 344 Gegharkunik 23.8 1.4 22.4 270 Lori 25.5 0.0 25.5 227 Kotayk 55.6 11.0 44.5 412 Shirak 34.1 2.3 31.8 368 Syunik 46.4 5.3 41.1 202 Vayots Dzor 40.2 4.4 35.8 60 Tavush 37.5 2.9 34.5 157 Education Basic 22.1 1.4 20.7 273 Secondary 34.7 2.6 32.1 1,468 Secondary special 44.6 3.8 40.8 819 Higher 43.1 3.9 39.2 1,308 Wealth quintile Lowest 27.3 2.8 24.5 674 Second 31.5 3.9 27.7 765 Middle 40.9 4.0 36.9 742 Fourth 43.7 3.7 40.0 843 Highest 47.6 1.9 45.7 847 Total 38.7 3.2 35.5 3,870 Note: Total includes 2 (weighted) women with no education. 90 • Contraception Less than four in ten nonusers (39 percent) visited a health facility during the 12 months before the survey. Overall, among women not using a method of contraception, 36 percent visited a health facility and had no discussions about family planning with a health professional. Only 3 percent visited a health facility and discussed family planning. Although there are differences by background characteristics in the proportion of nonusers who visited a health facility, differences in the proportions who discussed family planning are minor. 7.12 EXPOSURE TO REPRODUCTIVE HEALTH MESSAGES Similar to the questions about family planning methods, the 2015-16 ADHS also included questions about reproductive health messages on the Internet. Respondents were asked whether they had read information about reproductive health on the Internet in the few months before the survey. Exposure to reproductive health messages among women and men age 15-49 is shown in Table 7.14. Among women, only about one in five accessed information about reproductive health on the Internet in the few months before the survey. Urban women and women in Syunik are the most likely to have read about reproductive health on the Internet. The proportion of women who obtained information on the Internet increases steadily as education and wealth quintile increase. Men are less likely than women to have read information about reproductive health on the Internet in the few months before the survey (9 percent). Differences by background characteristics among men are similar to those among women, but much less pronounced. Also, men in Aragatsotn are the most likely to say they obtained reproductive health information on the Internet. Table 7.14 Exposure to reproductive health messages Percentage of women and men age 15-49 who read information about reproductive health on the Internet in the past few months, according to background characteristics, Armenia 2015-16 Background characteristic Women Men Percentage of women Number of women Percentage of men Number of men Age 15-19 9.4 725 3.8 345 20-24 22.7 928 9.8 467 25-29 26.6 1,099 12.8 464 30-34 28.1 1,007 9.4 427 35-39 24.6 867 7.3 376 40-44 20.9 784 8.1 346 45-49 16.6 706 6.9 330 Residence Urban 26.7 3,657 10.3 1,558 Rural 15.1 2,459 6.3 1,197 Region Yerevan 26.8 2,001 12.8 833 Aragatsotn 13.5 315 26.2 159 Ararat 11.5 552 2.7 290 Armavir 7.0 586 2.4 268 Gegharkunik 14.2 478 9.7 235 Lori 19.0 355 2.0 184 Kotayk 26.5 678 2.7 299 Shirak 19.4 510 8.1 201 Syunik 52.5 238 8.2 104 Vayots Dzor 31.0 119 14.5 56 Tavush 31.5 283 5.4 126 Education Basic 6.7 396 2.6 360 Secondary 13.3 2,444 4.8 1,250 Secondary special 23.8 1,360 7.4 403 Higher 35.2 1,910 18.7 736 Wealth quintile Lowest 8.7 1,081 4.5 523 Second 17.4 1,242 5.5 583 Middle 21.6 1,142 8.1 521 Fourth 25.6 1,287 12.2 566 Highest 33.8 1,365 12.5 562 Total 22.1 6,116 8.6 2,755 Note: Total includes 5 (weighted) women and 5 men with no education. Abortion • 91 ABORTION 8 nformation about induced abortion was collected in the 2015-16 ADHS through a detailed reproductive history. Women were first asked about the number of pregnancies, if any, that had ended in stillbirths, miscarriages, or induced abortions. A complete pregnancy history was then obtained. In the pregnancy history, the woman was asked to report the outcome of each pregnancy, i.e., whether the pregnancy ended in a live birth, a stillbirth, a miscarriage, or an induced abortion. The manner of collecting information in the pregnancy history differed from the procedure used in the three previous ADHS surveys. In the 2015-16 ADHS, respondents were asked to list pregnancies in chronological order, beginning with the first pregnancy and ending with the most recent pregnancy. In earlier ADHS surveys, the respondent was asked to list pregnancies in reverse order, beginning with the most recent pregnancy and ending with the first pregnancy. To decrease underreporting of induced abortions, the question on the pregnancy outcome asked women to include abortions that may have been induced by cytotec or a similar abortion medication. Although no direct question was asked, interviewers in the 2015-16 ADHS were specifically trained to record abortions that may have been performed by the women at home or elsewhere using herbs with an abortive effect.1 At the end of the pregnancy history, interviewers were also required to check the consistency between the aggregate data collected at the outset of the reproductive section and the number of events reported in the pregnancy history. 1 In the 2000 ADHS, respondents were asked separately about “self-induced abortions” and “induced abortions”. However, only 37 women in the 2000 ADHS sample reported inducing an abortion themselves. Thus, the distinction between self-induced and medically induced abortions was dropped from the question on pregnancy outcomes in the 2005, 2010, and 2015-16 ADHS questionnaires. I Key Findings  Nearly one in four pregnancies in the three-year period before the survey ended in an abortion.  The total induced abortion rate (TAR) during the period was 0.6 abortions per woman, little changed from the 2010 ADHS when the rate was 0.8 abortions per woman; however substantially lower than the rates found on the 2000 and 2005 ADHS surveys (2.6 and 1.8 abortions per woman, respectively).  The TAR among rural women (0.8) is twice the rate among urban women (0.4). The Gegharkunik region had the highest TAR among regions (1.4), followed closely by Armavir (1.2).  Half of women who had an induced abortion in the 3-year period before the survey were using some form of contraception at the time they became pregnant, mainly traditional methods.  About two-thirds of abortions were performed because of a desire to stop childbearing. Other reasons included concerns about the mother’s health (7 percent) and the risk of birth defects (8 percent), sex selection (8 percent), and a lack of economic resources (6 percent). 92 • Abortion 8.1 PREGNANCY OUTCOMES Table 8.1 shows the percent distribution of pregnancy outcomes that occurred during the 3-year period before the survey (approximately February 2013 to February 2016). Nearly seven in ten pregnancies resulted in a live birth (69 percent), and about one in four resulted in an abortion (23 percent). Eight percent of pregnancies miscarried, and less than 1 percent resulted in stillbirths. Table 8.1 Pregnancy outcome by background characteristics Percent distribution of pregnancies ending in the three years before the survey by type of outcome, according to background characteristics, Armenia 2015-16. Background characteristics Pregnancy outcome Total Number of pregnancies Live birth Induced abortion Miscarriage Stillbirth Age at pregnancy outcome <20 84.7 5.9 9.4 0.0 100.0 64 20-24 77.6 12.3 9.9 0.2 100.0 479 25-34 65.2 26.6 7.5 0.7 100.0 811 35-44 51.6 42.1 5.4 0.9 100.0 140 45-49 * * * * 100.0 2 Pregnancy order First 90.6 2.3 6.7 0.4 100.0 423 Second 82.4 5.3 12.1 0.2 100.0 392 Third 65.3 24.2 9.7 0.7 100.0 271 Fourth 45.2 49.6 3.8 1.4 100.0 161 Fifth or higher 29.0 65.2 5.3 0.5 100.0 249 Residence Urban 72.4 18.7 8.6 0.3 100.0 827 Rural 64.3 27.4 7.5 0.8 100.0 669 Region Yerevan 77.8 14.8 7.1 0.3 100.0 401 Aragatsotn 79.6 10.4 4.6 5.4 100.0 41 Ararat 78.4 18.9 2.7 0.0 100.0 137 Armavir 57.2 30.7 11.5 0.6 100.0 211 Gegharkunik 42.1 56.7 1.2 0.0 100.0 100 Lori 65.5 22.5 10.8 1.3 100.0 82 Kotayk 67.0 23.8 8.7 0.5 100.0 210 Shirak 64.2 23.5 12.3 0.0 100.0 156 Syunik 92.8 3.9 3.3 0.0 100.0 39 Vayots Dzor 77.6 10.0 12.4 0.0 100.0 27 Tavush 67.6 19.2 11.9 1.4 100.0 91 Education Basic 68.8 27.9 3.3 0.0 100.0 99 Secondary 64.1 27.0 8.0 0.9 100.0 625 Secondary special 65.3 25.8 8.9 0.0 100.0 311 Higher 77.7 12.9 8.9 0.5 100.0 459 Wealth quintile Lowest 61.3 30.1 7.6 1.0 100.0 318 Second 65.4 24.3 9.7 0.5 100.0 318 Middle 68.9 21.4 9.7 0.0 100.0 274 Fourth 73.1 21.2 4.6 1.1 100.0 247 Highest 75.4 16.0 8.4 0.2 100.0 339 Total 68.7 22.6 8.1 0.5 100.0 1,496 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Total includes 2 (weighted) women with no education. The proportion of pregnancies that ended in an induced abortion rises dramatically with the woman’s age. Six percent of teenage pregnancies ended in abortion, compared with 12 percent of pregnancies among women age 20-24, 27 percent among women age 25-34, and 42 percent among women age 35-44. There is an even steeper increase in the proportion of pregnancies ending in abortion by pregnancy order; only 2 percent of first order and 5 percent of second-order pregnancies ended in an abortion compared to 24 percent of third-order pregnancies, 50 percent of fourth-order pregnancies, and 65 percent of fifth-or-higher-order pregnancies. Pregnancies among rural women were somewhat more likely to have ended in an induced abortion than pregnancies among urban women (27 percent versus 19 percent). The proportion of pregnancies that ended in induced abortions also varies by region, from a low of 4 percent in Syunik to a high of 57 percent Abortion • 93 in Gegharkunik. Since regional results are based on a small number of pregnancies, these findings should be viewed with caution. Women with basic education only had the highest percentage of pregnancies resulting in induced abortions (28 percent), closely followed by women with secondary-special and secondary education (26-27 percent). In comparison, only 13 percent of pregnancies among women with higher than secondary education resulted in an induced abortion. There also is a negative relationship between abortion and wealth status; three in ten pregnancies among mothers in the lowest wealth quintile resulted in abortion (30 percent) compared with16 percent of pregnancies among women in the highest wealth quintile. Figure 8.1 shows that the proportion of pregnancies ending in induced abortion steadily declined over the past 16 years, from 55 percent in 2000, 45 percent in 2005, 29 percent in 2010, and 23 percent in 2015-16. Conversely, the proportion of pregnancies ending in live births has increased from 38 percent in 2000, 48 percent in 2005, 63 percent in 2010, and 69 percent in 2015-16 (NSS et al. 2001; NSS et al. 2006; NSS et al. 2012). Over the past 6 years, there is some shift in pregnancy outcome by urban-rural residence. For example, the proportion of pregnancies that ends in induced abortion declined from 29 percent in 2010 to 19 percent in 2015-16 among urban women. This represented a 34 percent decrease since 2010, with no similar changes reported by rural women (28 percent in 2010 and 27 percent in 2015-16). Figure 8.1 Trends in induced abortion by urban-rural residence, Armenia 2000-2016 54 56 55 42 49 45 29 28 29 19 27 23 Urban Rural Total Percent 2000 ADHS 2005 ADHS 2010 ADHS 2015-16 ADHS 94 • Abortion 8.2 LIFETIME EXPERIENCE WITH INDUCED ABORTION Table 8.2 shows the number of abortions that are experienced over women’s lifetimes. Statistics are based on all women age 15-49, irrespective of their exposure to the risk of pregnancy. Table 8.2 Lifetime experience with induced abortion Percentage of women who have had at least 1 induced abortion, and among these women, percent distribution by number of abortions, and the mean number of abortions, according to background characteristics, Armenia 2015-16 Background Characteristics Percentage of women with an induced abortion Number of women Among women who had an abortion, percent distribution by number of abortion Total Mean number of abortions Number of women with abortions 1 2-3 4-5 6+ Age <20 0.2 725 * * * * 100.0 1.0 2 20-24 2.4 928 (73.9) (23.3) (0.0) (2.8) 100.0 1.4 23 25-34 21.9 2,106 54.0 38.0 5.1 2.9 100.0 1.8 461 35+ 45.4 2,357 31.9 51.3 11.6 5.2 100.0 2.4 1,070 Number of living children 0 0.3 2,120 * * * * 100.0 2.6 7 1 10.9 899 69.2 26.5 2.4 1.9 100.0 1.5 98 2-3 46.1 2,924 37.8 48.6 9.8 3.8 100.0 2.2 1,348 4+ 59.7 172 27.7 44.3 12.9 15.2 100.0 3.2 103 Marital status Never married 0.0 1,830 * * * * 100.0 10.0 1 Currently married 37.2 3,895 38.3 47.7 9.5 4.5 100.0 2.2 1,450 Formerly married 27.0 390 50.4 36.4 9.0 4.3 100.0 2.2 105 Residence Urban 21.8 3,657 47.0 41.0 8.3 3.8 100.0 2.1 797 Rural 30.8 2,459 30.8 53.1 10.8 5.3 100.0 2.4 758 Region Yerevan 18.7 2,001 56.6 36.2 4.5 2.7 100.0 1.8 373 Aragatsotn 26.9 315 50.2 49.0 0.4 0.4 100.0 1.6 85 Ararat 26.5 552 39.9 51.1 8.4 0.6 100.0 1.9 147 Armavir 34.6 586 24.7 49.0 16.4 9.9 100.0 2.9 202 Gegharkunik 35.2 478 17.6 56.0 17.5 8.8 100.0 2.9 168 Lori 23.6 355 36.6 37.1 16.9 9.3 100.0 2.7 84 Kotayk 34.1 678 32.3 52.8 10.4 4.4 100.0 2.3 231 Shirak 28.5 510 36.4 52.6 8.6 2.4 100.0 2.1 146 Syunik 9.0 238 (56.4) (38.8) (2.3) (2.4) 100.0 1.8 21 Vayots Dzor 17.9 119 50.2 46.3 3.5 0.0 100.0 1.7 21 Tavush 27.0 283 45.2 47.8 4.6 2.4 100.0 2.0 77 Education Basic 29.4 396 26.6 47.2 16.8 9.4 100.0 2.9 116 Secondary 30.5 2,444 32.1 52.0 10.8 5.0 100.0 2.3 746 Secondary special 29.4 1,360 45.1 43.7 6.8 4.5 100.0 2.1 400 Higher 15.2 1,910 54.3 38.2 6.2 1.3 100.0 1.8 290 Wealth quintile Lowest 30.0 1,081 32.3 49.8 10.3 7.6 100.0 2.6 324 Second 28.8 1,242 30.9 53.5 12.4 3.2 100.0 2.3 357 Middle 26.5 1,142 36.9 46.6 10.6 5.9 100.0 2.3 303 Fourth 21.3 1,287 48.1 39.7 9.4 2.8 100.0 2.0 274 Highest 21.8 1,365 50.4 42.7 4.1 2.8 100.0 1.9 298 Total 25.4 6,116 39.1 46.9 9.5 4.5 100.0 2.2 1,555 Note: Currently married includes respondents in consensual union (living together). Formerly married includes divorced, separated, and widowed respondents. 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. Total includes 5 (weighted) women with no education. Approximately one-quarter of Armenian women age 15-49 have ever had an induced abortion (25 percent). As expected, a woman’s likelihood of having had an abortion increases rapidly with age, from 2 percent among women age 20-24 years to 22 percent among women age 25-34 and 45 percent among women age 35 and older. There is a positive relationship between having had an induced abortion and the number of living children. Less than 1 percent of women with no living children have had an abortion, compared with 11 percent of women with one child, 46 percent of women with two to three children, and 60 percent of women with four or more children. Abortion • 95 Marital disruptions are associated with a lower level of induced abortion; 37 percent of currently married women have ever had an abortion compared with 27 percent of women who are divorced, separated, or widowed. Rural women are more likely to have ever had an abortion than urban women (31 and 22 percent, respectively). Gegharkunik, Armavir, and Kotayk had the highest percentages of women ever having had an abortion (34-35 percent) and Syunik (9 percent) the lowest. Fifteen percent of women with higher education have ever had an abortion, about half the level observed among women with less education (29-31 percent). The proportion of women ever having had an induced abortion generally decreases with the wealth quintile. Among women who have ever had an abortion, 39 percent had only one abortion, nearly half (47 percent) reported two to three abortions, while 14 percent reported having four or more abortions. Overall, among women who have had an abortion, the mean number of abortions per woman is 2.2. 8.3 RATES OF INDUCED ABORTION Table 8.3 shows rates of induced abortion for the 3- year period before the 2015-16 ADHS survey (approximately February 2013 to February 2016). Three types of rates are presented: age-specific abortion rates, the total abortion rate, and the general abortion rate. Age-specific abortion rates (ASARs), which are shown per 1,000 women, express the number of abortions among women of a given age, divided by the total number of women in that age group. The total abortion rate (TAR), which is expressed per woman, is a summary measure of the age-specific rates. The TAR is interpreted as the number of abortions a woman would have in her lifetime if she experienced the currently observed age-specific rates during her childbearing years. The general abortion rate (GAR) is the number of abortions divided by the number of women age 15- 44 and expressed per 1,000 women. Table 8.3 shows that the total abortion rate during the 3 years prior to the 2015-16 ADHS was 0.6 abortions per woman. At the national level, age-specific abortion rates peaked among women age 25-29 and declined in the older age groups. Table 8.3 also shows that the TAR for rural women is almost twice as high as that for urban women (0.8 versus 0.4). With age, abortion rates are higher among rural women than among urban women for all age groups, with the gap is especially wide among women age 25-29 and 30-34. Figure 8.2 examines differences in the age pattern of fertility and abortion during the 3-year period prior to the 2015-16 ADHS. Age-specific abortion rates were substantially lower than the fertility rates for women under age 40 but were virtually the same as the fertility rates among older women (Figure 8.2). Table 8.3 Induced abortion rates Age-specific induced abortion rates (per 1,000 women), total abortion rates (TAR), and general abortion rates (GAR), for the 3-year period before the survey, by residence, Armenia 2015-16 Age group Residence Total Urban Rural 15-19 2 2 2 20-24 17 24 19 25-29 30 63 42 30-34 20 45 29 35-39 15 19 16 40-44 8 10 9 45-49 0 0 0 TAR(15-49)1 0.4 0.8 0.6 TAR(15-44) 0.4 0.8 0.6 GAR2 16.0 28.0 21.0 1 Total abortion rate (TAR) expressed per woman. 2 General abortion rate (GAR) = number of abortions divided by number of women (15-44), expressed per 1,000 women. 96 • Abortion Figure 8.2 Age-specific fertility rates and abortion rates, 2015-16 Table 8.4 presents differences in two measures of abortion levels by background characteristics. The first column shows the total abortion rate during the 3-year period before the 2015-16. The second column shows the mean number of abortions ever performed among women age 40-49. The latter measure is an indicator of cumulative terminations that reflects the lifetime abortion experience of older women who are nearing the end of their reproductive period. The TAR varied markedly by region, ranging from 0.1 abortions per woman in Syunik to 1.4 in Gegharkunik. Women with higher education and those from the wealthier households had among the lowest TARs. A comparison of the TARs with the mean abortion rates among women age 40-49 indicate the direction of changes in abortion levels over the past several decades in Armenia. Because the mean number of abortions among older women is subject to recall problems, the comparisons may understate the true magnitude of the changes over time. The mean number of abortions ever performed among women age 40-49 (1.3 abortions per woman) is more than twice as high as the TAR (0.6 abortions per woman); this indicates that there has been a substantial decline in abortions over the past 30 years. The decline in abortions appears to be shared by all subgroups, but is particularly evident among women with the lowest educational attainment and among residents of Lori, Armavir, and Kotayk. For these women, the difference between the TAR and the mean number of abortions is 1.0 to 1.3 abortions per woman. 0 20 40 60 80 100 120 140 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age Groups Rates per 1,000 women Fertility rates Abortion rates 2015-16 ADHS Table 8.4 Induced abortion rates by background characteristics Total induced abortion rates for the 3 years before the survey and mean number of abortions among women age 40-49, by background characteristics, Armenia 2015-16 Background characteristic Total abortion rate for women 15-49 Mean number of abortions among women age 40-49 Residence Urban 0.4 1.0 Rural 0.8 1.7 Region Yerevan 0.3 0.8 Aragatsotn 0.2 0.9 Ararat 0.5 1.2 Armavir 1.2 2.4 Gegharkunik 1.4 1.9 Lori 0.5 1.8 Kotayk 0.7 1.9 Shirak 0.7 1.5 Syunik 0.1 0.3 Vayots Dzor 0.3 0.7 Tavush 0.7 1.1 Education Basic 0.9 1.9 Secondary 0.8 1.5 Secondary special 0.6 1.1 Higher 0.3 0.9 Wealth quintile Lowest 0.9 1.6 Second 0.7 1.6 Middle 0.6 1.3 Fourth 0.4 1.0 Highest 0.4 1.0 Total 0.6 1.3 Abortion • 97 8.4 TRENDS IN INDUCED ABORTION Comparisons with Previous Surveys Insight into the trends in induced abortion since 2000 in Armenia can be obtained by comparing the total abortion rates reported in the four ADHS surveys conducted between 2000 and 2015-16. The TAR decreased steadily during that period from a high of 2.6 abortions per woman at the time of the 2000 ADHS to 1.8 abortions in 2005 and 0.8 abortions in 2010 before reaching 0.6 abortions in the 2015-16 ADHS. Figure 8.3 shows that the decline was shared by every age group. The decline in the prevalence of induced abortion over the past 16 years is also reflected in the changes in lifetime abortion measures since 2000. For example, almost half (47 percent) of all respondents in the 2000 ADHS had had an induced abortion, compared with 37 percent in the 2005 ADHS, 31 percent in the 2010 ADHS and 25 percent in the 2015-16 ADHS. Women age 40-49 had an average of 2.8 abortions in 2000, compared with 1.7 in 2005, 1.6 in 2010, and 1.3 in 2015-16. Figure 8.3 Trends in age-specific abortion rates, 2000-2016 0 20 40 60 80 100 120 140 160 180 200 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Age Groups Rates per 1,000 women 2000 ADHS 2005 ADHS 2010 ADHS 2015-16 ADHS 98 • Abortion Retrospective Data Another approach to understanding abortion trends is to examine changes in the age-specific abortion rates of the 2015-16 ADHS respondents over time. Table 8.5 shows the age-specific abortion rates for 5-year periods before the 2015-16 ADHS survey. Because women age 50 and above were not interviewed in the survey, the rates are successively truncated as the number of years before the survey increases. The changes in abortion rates over time reported by the 2015-16 ADHS respondents are consistent with trends observed in the comparisons with the 2000, 2005, and 2010 ADHS survey results. For example, the age- specific abortion rate for women age 25-29 declined by almost 40 percent, from 74 abortions per 1,000 women in the period 10-14 years before the survey to 45 abortions per 1,000 women in the period 0-4 years before the survey. The most rapid decline in the age-specific rates was observed for women age 30- 34; the abortion rate decreased by nearly 50 percent in this age group, from 60 abortions per 1,000 women in the period 10 to 14 years before the survey to 32 abortions per 1,000 women in the period 0-4 years before the survey. 8.5 USE OF CONTRACEPTIVE METHODS BEFORE ABORTION Information from the reproductive calendar included in the ADHS in Table 8.6 explored how induced abortions related to women’s contraceptive behavior during the 3-year period before the survey. This information is of particular interest to both family planning counselors and abortion providers because a woman who had an abortion was either not using a method of contraception at the time of conception or was using (perhaps incorrectly) a method that had failed. Slightly more than half of women who had an induced abortion were using a method of contraception at the time they became pregnant (51 percent). This suggests that almost half of the abortions resulted from contraceptive failure. The majority of contraceptive failures occurred when the woman was using a traditional method; 36 percent of induced abortions occurred among women who said they were using withdrawal and 4 percent among those who used rhythm. Although many abortions are related to contraceptive failure, the ADHS results show that nearly half of the pregnancies resulting in induced abortion occurred among women who were not using any method of contraception. Access to and use of more reliable methods of contraception would reduce the number of unwanted pregnancies and the incidence of induced abortions, and would improve the reproductive health of women in Armenia. Table 8.5 Trends in age-specific abortion rates Age-specific induced abortion rates for 5-year periods before the survey, by woman's age at the time of the abortion, Armenia 2015-16 Woman's age at the time of the abortion Number of years before survey 0-4 5-9 10-14 15-19 15-19 1 3 1 5 20-24 22 31 34 53 25-29 45 68 74 111 30-34 32 44 60 [85] 35-39 18 28 [45] 40-44 8 [9] 45-49 [0] Note: Age-specific induced abortion rates are per 1,000 women. Estimates in brackets are truncated. Table 8.6 Use of contraception before pregnancy Percent distribution of pregnancy outcomes in the three years before the survey, by contraceptive method used at the time of conception, Armenia 2015-16 Contraceptive method Pregnancy outcome All pregnancies Live birth Induced abortion Miscarriage No method used 92.0 49.1 81.5 81.4 Any method 8.0 50.9 18.5 18.6 Any modern method 2.0 10.2 1.4 3.8 Pill 0.3 1.0 0.0 0.4 IUD 0.1 0.6 0.0 0.2 Male condom 1.1 8.0 1.4 2.7 Lactational amenorrhea (LAM) 0.5 0.4 0.0 0.4 Emergency contraception 0.0 0.2 0.0 0.1 Any traditional method 6.0 40.7 17.1 14.8 Rhythm 0.8 4.3 1.3 1.6 Withdrawal 5.2 36.3 15.9 13.2 Total 100.0 100.0 100.0 100.0 All pregnancies 1,028 338 122 1,496 Note: Total includes 8 stillbirths that are not shown separately. Abortion • 99 8.6 REASONS FOR ABORTION Table 8.7 presents the primary reasons for having an abortion in the 3 years before the survey. About two-thirds of abortions (65 percent) were performed because the women did not want to have any more children. Fifteen percent of abortions were performed because of concerns about maternal health (7 percent) or risk of birth defects (8 percent). Sex selection was cited as a reason for 8 percent of abortions, while socioeconomic reasons or other reasons were each cited for 6 percent. Table 8.7 Reason for abortion Percent distribution of induced abortion in the 3 years before the survey by the most important reason for the abortion, according to selected background characteristics, Armenia 2015-16 Background Characteristics Reason for abortion Total Number of abortion Health of mother Risk of birth defects Sex selection Poverty Unwanted child Un- married Other Don't remember Missing Age 15-19 * * * * * * * * * 100.0 2 20-24 (2.4) (26.0) (0.0) (0.0) (64.9) (0.0) (6.7) (0.0) (0.0) 100.0 27 25-29 8.5 7.6 13.0 3.1 59.1 0.0 7.9 0.8 0.0 100.0 120 30-34 2.9 0.7 2.9 12.4 76.3 0.0 4.7 0.0 0.0 100.0 111 35+ 12.1 11.4 9.3 1.8 59.6 0.8 3.3 1.7 0.0 100.0 79 Education Basic (4.2) (5.2) (8.0) (17.2) (65.5) (0.0) (0.0) (0.0) (0.0) 100.0 28 Secondary 4.4 5.2 5.3 4.0 70.5 0.0 10.5 0.0 0.0 100.0 169 Secondary special 4.5 10.4 5.4 7.7 69.6 0.8 0.0 1.7 0.0 100.0 80 Higher 19.3 13.7 17.9 2.1 43.4 0.0 2.1 1.6 0.0 100.0 59 Wealth quintile Lowest 2.3 5.3 11.0 8.7 66.4 0.0 4.8 1.4 0.0 100.0 96 Second 8.0 6.1 2.8 1.6 77.6 0.0 2.6 1.2 0.0 100.0 77 Middle 3.3 9.3 11.0 0.0 75.3 1.1 0.0 0.0 0.0 100.0 58 Fourth 1.6 9.2 7.4 4.7 70.1 0.0 7.0 0.0 0.0 100.0 52 Highest (23.0) (12.1) (5.7) (12.6) (30.5) (0.0) (16.0) (0.0) (0.0) 100.0 54 Total 7.0 7.9 7.7 5.6 65.4 0.2 5.6 0.7 0.0 100.0 338 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 to 49 unweighted cases. Total includes 2 women (weighted) with no education. Reproductive Health • 101 REPRODUCTIVE HEALTH 9 eproductive and maternal health care in Armenia is implemented through an extensive system of feldsher1-accoucher posts (FAPs), ambulatory facilities, polyclinics, and hospitals. The network of ambulatory health care is organized by geographical regions and offered through women’s consultation clinics and rural health facilities. Obstetric care is provided at hospital obstetric-gynecological departments, regional delivery hospitals located in urban areas, and republican centers for specialized (tertiary) care. Under the state Basic Benefits Package (BBP), a set of limited reproductive health services is free of charge for all people, and broader services are free for certain vulnerable groups. This chapter presents findings in several areas of importance to reproductive and maternal health: antenatal, delivery, and postnatal care; access to free delivery care; costs for delivery services; problems in accessing health care; and travel time to nearest clinic. These data are of great value in identifying subgroups of women who utilize or receive specific health services and are useful in developing plans to improve service delivery. 1 A feldsher is a health professional trained in nursing and midwifery with extended training in clinical diagnosis. R Key Findings  All women who gave birth in the 5 years before the survey received antenatal care (ANC) from a skilled provider for their most recent birth; 94 percent received care during their first trimester of pregnancy.  Virtually all women who gave birth in the 5 years before the survey reported that during the pregnancy of their most recent birth, their blood pressure was measured and they received urine, blood, and ultrasound tests. Nutritional supplements are less common; only 40 percent of women took iron supplements and 45 percent took folate supplements or multi-vitamins during pregnancy.  Ninety-nine percent of live births in the 5 years before the survey took place in a health facility and100 percent were assisted by a skilled provider.  Almost one in five births in Armenia is delivered by caesarean section.  Among women who gave birth in the 2 years before the survey, 97 percent received a postnatal checkup from a skilled provider within the first 2 days after birth.  Among women who had a birth in the 2 years before the survey, 98 percent of their newborns received a postnatal check-up from a skilled provider in the first 2 days after birth.  More than half of women age 15-49 report that having money for treatment is a serious problem in obtaining health care, while one-quarter say that not wanting to go alone is a problem. 102 • Reproductive Health 9.1 ANTENATAL CARE The survival and well-being of both mother and child are closely associated with the health care that a mother receives during pregnancy and delivery. In this chapter, antenatal care (ANC) is described according to the type of provider, number of ANC visits, stage of pregnancy at the first visit, and services and information provided during a visit, including the use of ultrasound. 9.1.1 Antenatal Care Provider Table 9.1 shows that all women in Armenia (just under 100 percent) receive antenatal care (ANC) from a skilled provider. This is an increase from 92 percent in the 2000 ADHS, 93 percent in the 2005 ADHS, and 99 percent in the 2010 ADHS (NSS 2001, NSS 2006, NSS 2012). Practically all women who received ANC saw a doctor (99 percent), while only 1 percent saw a nurse/midwife. The role of the nurse, midwife, or feldsher in providing ANC is gradually diminishing at 9 percent in 2000, 3 percent in 2005, and less than 1 percent in 2010 and 2015-16.2 Table 9.1 Antenatal care Percent distribution of women age 15-49 who had a live birth in the 5 years before the survey by antenatal care (ANC) provider during pregnancy for the most recent birth and the percentage receiving ANC from a skilled provider for the most recent birth, according to background characteristics, Armenia 2015-16 Background characteristic Antenatal care provider Number of women Doctor Nurse/ midwife Missing No ANC Total Percentage receiving antenatal care from a skilled provider1 Mother’s age at birth <20 100.0 0.0 0.0 0.0 100.0 100.0 63 20-34 98.7 0.8 0.1 0.4 100.0 99.6 1,207 35-49 97.3 2.7 0.0 0.0 100.0 100.0 92 Birth order 1 98.8 1.1 0.1 0.0 100.0 99.9 495 2-3 99.0 0.6 0.0 0.4 100.0 99.6 818 4-5 (91.4) (5.9) (0.0) (2.7) (100.0) (97.3) 45 6+ * * * * * * 3 Residence Urban 99.3 0.5 0.1 0.1 100.0 99.9 794 Rural 97.8 1.5 0.0 0.7 100.0 99.3 568 Region Yerevan 100.0 0.0 0.0 0.0 100.0 100.0 398 Aragatsotn 100.0 0.0 0.0 0.0 100.0 100.0 51 Ararat 97.6 0.9 0.4 1.1 100.0 98.5 140 Armavir 96.7 2.3 0.0 1.0 100.0 99.0 147 Gegharkunik 86.8 10.4 0.0 2.8 100.0 97.2 65 Lori 98.6 1.4 0.0 0.0 100.0 100.0 76 Kotayk 100.0 0.0 0.0 0.0 100.0 100.0 200 Shirak 100.0 0.0 0.0 0.0 100.0 100.0 130 Syunik 100.0 0.0 0.0 0.0 100.0 100.0 46 Vayots Dzor 99.1 0.9 0.0 0.0 100.0 100.0 30 Tavush 100.0 0.0 0.0 0.0 100.0 100.0 78 Education Basic 98.0 0.0 0.0 2.0 100.0 98.0 70 Secondary 98.0 1.2 0.1 0.6 100.0 99.3 533 Secondary special 98.8 1.2 0.0 0.0 100.0 100.0 286 Higher 99.5 0.5 0.0 0.0 100.0 100.0 472 Wealth quintile Lowest 97.0 1.9 0.0 1.1 100.0 98.9 252 Second 98.6 1.4 0.0 0.0 100.0 100.0 275 Middle 98.1 1.1 0.0 0.8 100.0 99.2 253 Fourth 99.2 0.5 0.2 0.0 100.0 99.8 250 Highest 100.0 0.0 0.0 0.0 100.0 100.0 331 Total 98.7 0.9 0.0 0.3 100.0 99.6 1,361 Note: If more than one source of ANC was mentioned, only the provider with the highest qualifications is considered in this tabulation. Figures in parentheses are based on 25-49 unweighted cases; an asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Skilled provider includes doctor, nurse, midwife, and feldsher. A feldsher is a health professional trained in nursing and midwifery with extended training in clinical diagnosis. 2 If more than one source of ANC was mentioned by a respondent, only the provider with the highest qualifications was considered in the tabulations. Reproductive Health • 103 There are only small variations in provider use across subgroups of women. The most notable differences are by region. In Gegharkunik, only 87 percent of women saw a doctor, 10 percent saw a nurse or midwife for ANC, and 3 percent had no ANC. 9.1.2 Number and Timing of ANC Visits The prevention of complications during pregnancy and delivery and the successful outcome of the pregnancy for both mother and child are associated with the quality of ANC, the number of visits, and the timing of the first visit. The Ministry of Health has adopted the World Health Organization (WHO) guidelines of at least four to six ANC visits for a normal pregnancy and the first visit by 12 weeks of gestation. Progress in access to quality ANC over time is seen in the increase of women who made four or more ANC visits for their most recent birth. Table 9.2 shows that 96 percent of women who had a live birth in the 5 years before the survey had four or more ANC visits during pregnancy for the most recent birth. This represents a steady increase from the levels recorded in 2000 (65 percent), 2005 (71 percent), and 2010 (93 percent). Although there is some urban-rural differential in the percentage of women making four or more ANC visits in 2015-16 (98 and 94 percent, respectively), the gap is much smaller than that reported in prior ADHS surveys (82 and 45 percent, respectively, in 2000). Overall, 94 percent of women make their first ANC visit in the first trimester. Urban women are slightly more likely than rural women to have their first examination in the first trimester (95 percent compared with 92 percent). 9.1.3 Folate and Iron Supplements Women are advised to take folate tablets or multivitamins before or during pregnancy to guard against birth defects such as fetal neural tube anomalies. They are also advised to take iron supplements during pregnancy because maternal anemia is a principal cause of both maternal and neonatal mortality. Table 9.3 shows that while only 16 percent of women with a live birth in the past 5 years took folate tablets or multivitamins immediately before the pregnancy, 45 percent took folate supplements during the pregnancy. Forty percent of women took iron tablets or syrup during pregnancy for their last birth, an increase from the 29 percent in the 2010 ADHS. Table 9.2 Number of antenatal care visits and timing of first visit Percent distribution of women age 15-49 who had a live birth in the 5 years before the survey by number of antenatal care (ANC) visits for the most recent live birth, and by the timing of the first visit, and among women with ANC, median months pregnant at first visit, according to residence, Armenia 2015-16 Background characteristic Residence Total Urban Rural Number of ANC visits None 0.1 0.7 0.3 1 0.2 0.3 0.2 2-3 1.0 3.5 2.1 4+ 97.8 93.6 96.0 Don’t know/missing 1.0 1.9 1.3 Total 100.0 100.0 100.0 Number of months pregnant at time of first ANC visit No antenatal care 0.1 0.7 0.3 <4 94.6 92.3 93.6 4-5 4.9 5.9 5.4 6-7 0.1 0.7 0.3 8+ 0.3 0.0 0.2 Don’t know/missing 0.0 0.3 0.1 Total 100.0 100.0 100.0 Number of women 794 568 1,361 Median months pregnant at first visit (for those with ANC) 2.9 3.0 2.9 Number of women with ANC 793 563 1,357 104 • Reproductive Health Table 9.3 Components of antenatal care Among women age 15-49 with a live birth in the 5 years before the survey, the percentage who took iron tablets or syrup and tablets or syrup and folate tables or multivitamins during the pregnancy of the most recent birth, and among women receiving antenatal care (ANC) for the most recent live birth in the 5 years before the survey, the percentage receiving specific antenatal services, according to background characteristics, Armenia 2015-16 Background characteristic Among women with a live birth in the past 5 years, the percentage who immediately before the pregnancy of their last birth took folate tablets or multivitamins Among women with a live birth in the past five years, the percentage who during the pregnancy of their last birth: Among women who received antenatal care for their most recent birth in the past 5 years, the percentage with selected services Took iron tablets or syrup Took folate tablets or multivitamins Number of women with a live birth in the past five years Blood pressure measured Urine sample taken Blood sample taken Number of women with ANC for their most recent birth Mother’s age at birth <20 10.0 29.1 30.8 63 100.0 100.0 100.0 63 20-34 16.0 39.5 46.3 1,207 99.8 99.8 99.8 1,202 35-49 20.6 53.5 41.7 92 99.1 98.2 99.1 92 Birth order 1 19.9 42.2 47.3 495 99.4 99.4 99.4 495 2-3 13.8 38.4 44.7 818 99.9 99.8 99.9 815 4-5 (15.0) (42.6) (36.2) 45 (100.0) (100.0) (100.0) 44 6+ * * * 3 * * * 3 Residence Urban 18.3 42.6 49.5 794 99.8 99.8 99.8 793 Rural 13.0 36.3 39.5 568 99.6 99.4 99.6 563 Region Yerevan 17.1 42.8 48.0 398 100.0 100.0 100.0 398 Aragatsotn 29.1 70.2 57.2 51 100.0 100.0 100.0 51 Ararat 9.6 44.7 19.6 140 98.7 98.1 98.7 139 Armavir 12.3 31.2 42.4 147 99.4 99.4 99.4 146 Gegharkunik 17.0 25.9 45.9 65 100.0 100.0 100.0 63 Lori 11.7 51.0 67.4 76 100.0 100.0 100.0 76 Kotayk 10.9 35.8 56.0 200 99.6 99.6 99.6 200 Shirak 12.8 19.0 30.3 130 100.0 100.0 100.0 130 Syunik 63.7 92.0 90.3 46 100.0 100.0 100.0 46 Vayots Dzor 14.6 27.4 39.3 30 99.2 99.2 99.2 30 Tavush 15.5 33.4 27.0 78 100.0 100.0 100.0 78 Education Basic 16.0 39.7 38.7 70 100.0 98.9 100.0 69 Secondary 14.3 37.0 40.0 533 99.7 99.7 99.7 530 Secondary special 15.8 38.3 43.2 286 99.4 99.4 99.4 286 Higher 18.3 44.4 53.6 472 99.9 99.9 99.9 472 Wealth quintile Lowest 11.7 31.6 34.1 252 99.4 99.1 99.4 249 Second 15.2 42.1 42.1 275 99.6 99.6 99.6 275 Middle 18.1 40.0 47.3 253 100.0 100.0 100.0 251 Fourth 19.2 42.1 46.2 250 99.7 99.7 99.7 250 Highest 16.2 42.8 54.3 331 99.9 99.9 99.9 331 Total 16.1 40.0 45.3 1,361 99.7 99.7 99.7 1,357 Note: Figures in parentheses are based on 25-49 unweighted cases; an asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Older women and urban women are more likely than other women to have taken folate and iron supplements. Differences by education and wealth levels are not uniform. However, women in the lowest wealth quintile are the least likely to have taken either folate or iron supplements. Prominent differentials are shown by region. For example, the proportion of women who took iron supplements during the pregnancy of their most recent birth ranges from 19 percent in Shirak to 92 percent in Syunik. The proportion of women who took folate or multivitamins during pregnancy ranges from 20 percent in Ararat to 90 percent in Syunik. 9.1.4 Antenatal Care Content In Armenia, standard ANC includes the testing of urine and blood samples and blood pressure measurement. The 2015-16 ADHS respondents who received ANC for their most recent birth in the past 5 years were asked whether they had received each service during at least one of the ANC visits (Table 9.3). The content of ANC is important in judging its value. Pregnancy complications are an important source of maternal and child mortality and morbidity and thus, tests for complications should be routinely included in ANC. Reproductive Health • 105 Virtually all women who had a live birth in the 5 years before the survey in Armenia received all of the specified procedures during an ANC visit for their most recent birth, including blood pressure measurement and analysis of urine and blood samples. 9.1.5 Ultrasound Tests In addition to urine and blood testing, prenatal ultrasound tests can also provide indications of certain problems with pregnancy. Women interviewed in the 2015-16 ADHS who received ANC for their most recent birth in the past 5 years were asked whether they had had an ultrasound test during any of their ANC visits. Results show that 99 percent of women had at least one ultrasound test during the pregnancy (Table 9.4). Among those who said they had at least one ultrasound test, the vast majority (77 percent) said they had three or more ultrasound tests. Table 9.4 Ultrasound testing during antenatal care Among women receiving antenatal care (ANC) for the most recent live birth in the 5 years before the survey, the percentage receiving an ultrasound examination of the fetus, and among them, the percentage with one, two or three ultrasounds and the median number months of pregnancy at the first ultrasound test, according to background characteristics, Armenia 2015-16 Background characteristic Had at least one ultrasound test Number of women with ANC for their most recent birth Among women with ANC who received an ultrasound test for their most recent birth in the past 5 years, the percentage with one, two or three ultrasound tests and the median number months of pregnancy at the first ultrasound test Number of women who received an ultrasound test One ultrasound test Two ultrasound tests Three or more ultrasound tests Don’t know/ Missing Median number months of pregnancy at first ultrasound Age at pregnancy outcome <20 97.5 58 2.8 17.7 77.8 1.8 3.7 57 20-24 99.1 459 5.6 18.0 75.9 0.4 3.5 455 25-34 99.7 742 4.0 18.0 77.5 0.5 3.4 740 35-44 100.0 96 2.4 18.9 78.7 0.0 3.4 96 45-49 * 2 * * * * * 2 Birth order 1 98.8 495 3.9 16.0 79.5 0.6 3.4 489 2-3 99.8 815 4.7 19.3 75.6 0.5 3.5 813 4-5 (100.0) 44 (2.8) (19.4) (77.8) (0.0) (3.7) 44 6+ * 3 * * * * * 3 Sex of last birth Male 99.5 723 3.8 19.1 76.5 0.5 3.4 719 Female 99.4 633 5.0 16.8 77.7 0.5 3.5 630 Residence Urban 99.9 793 2.2 16.4 81.1 0.4 3.4 792 Rural 98.8 563 7.5 20.4 71.4 0.7 3.5 556 Region Yerevan 100.0 398 1.1 9.6 88.5 0.8 3.2 398 Aragatsotn 100.0 51 0.0 9.7 84.9 5.4 4.3 51 Ararat 95.6 139 27.9 29.2 42.9 0.0 4.2 133 Armavir 99.0 146 0.9 16.2 82.4 0.4 3.4 144 Gegharkunik 100.0 63 3.7 16.1 80.2 0.0 3.9 63 Lori 100.0 76 2.7 41.6 55.7 0.0 3.6 76 Kotayk 100.0 200 2.1 17.9 80.0 0.0 3.4 200 Shirak 100.0 130 4.3 16.4 79.3 0.0 3.2 130 Syunik 100.0 46 0.0 39.3 60.7 0.0 3.5 46 Vayots Dzor 99.2 30 2.9 13.8 82.3 0.9 3.5 30 Tavush 100.0 78 1.4 21.4 77.2 0.0 3.3 78 Education Basic 97.9 69 8.2 22.5 69.3 0.0 3.5 67 Secondary 99.2 530 6.0 22.3 70.7 1.1 3.6 525 Secondary special 99.6 286 4.2 18.0 77.3 0.4 3.4 285 Higher 99.9 472 2.1 12.7 85.3 0.0 3.3 471 Wealth quintile Lowest 98.4 249 7.9 25.9 65.2 1.1 3.6 245 Second 98.9 275 7.8 19.3 72.6 0.4 3.5 272 Middle 100.0 251 1.9 18.5 78.3 1.2 3.4 251 Fourth 100.0 250 2.4 18.3 79.3 0.0 3.4 250 Highest 99.8 331 2.3 10.7 87.1 0.0 3.3 331 Total 99.4 1,357 4.4 18.0 77.1 0.5 3.4 1,349 Note: Figures in parentheses are based on 25-49 unweighted cases; an asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 106 • Reproductive Health Although there are no meaningful differences by background characteristics in the proportion of women who have at least one ultrasound test during pregnancy, women who are better educated and in the higher wealth quintiles are more likely to have three or more ultrasound tests. Urban women and those who live in Yerevan are also more likely to have three or more ultrasound tests during pregnancy than rural women and those living in other regions. The median number of months of pregnancy at the time of the first ultrasound test is 3.4, which means that most women are tested around the end of the first trimester or the beginning of the second. 9.2 ASSISTANCE AND MEDICAL CARE AT DELIVERY Hygienic conditions during delivery and supervision of delivery by trained medical staff reduce the risk of infections and ensure that the complications of delivery are effectively handled. The 2015-16 ADHS collected information on the place of delivery for all children born in the 5 years before the survey and the type of medical staff assisting during delivery. In addition, there were questions about payment for delivery. 9.2.1 Place of Delivery Table 9.5 shows that almost all births (99 percent) occurred in a health facility. The proportion of births in a health facility increased from 91 percent in 2000 to 97 percent in 2005 and 99 percent in both 2010 and 2015-16. Almost all births take place in public sector facilities, with less than 4 percent in private facilities. There are only minor differentials by background characteristics, with the only exception the relatively high proportion of births in Armavir that take place in private facilities (14 percent). Table 9.5 Place of delivery Percent distribution of live births in the 5 years before the survey by place of delivery and percentage delivered in a health facility, according to background characteristics, Armenia 2015-16 Background characteristic Health facility Home Other Missing Total Percentage delivered in a health facility Number of births Public sector Private sector Mother’s age at birth <20 94.2 4.6 0.0 0.0 1.2 100.0 98.8 99 20-34 95.8 3.5 0.2 0.1 0.4 100.0 99.3 1,475 35-49 97.7 2.3 0.0 0.0 0.0 100.0 100.0 98 Birth order 1 94.8 4.4 0.3 0.0 0.4 100.0 99.3 741 2-3 96.5 2.9 0.0 0.1 0.5 100.0 99.3 876 4-5 100.0 0.0 0.0 0.0 0.0 100.0 100.0 51 6+ * * * * * * * 4 Residence Urban 96.4 2.6 0.2 0.1 0.7 100.0 99.0 962 Rural 95.1 4.7 0.0 0.1 0.2 100.0 99.8 710 Region Yerevan 96.7 2.9 0.4 0.0 0.0 100.0 99.6 475 Aragatsotn 95.1 3.8 0.5 0.0 0.5 100.0 98.9 61 Ararat 95.6 4.4 0.0 0.0 0.0 100.0 100.0 168 Armavir 85.0 14.0 0.0 0.3 0.6 100.0 99.0 190 Gegharkunik 99.2 0.0 0.0 0.0 0.8 100.0 99.2 77 Lori 97.9 2.1 0.0 0.0 0.0 100.0 100.0 99 Kotayk 96.7 2.6 0.0 0.0 0.7 100.0 99.3 239 Shirak 97.6 0.0 0.0 0.0 2.4 100.0 97.6 168 Syunik 100.0 0.0 0.0 0.0 0.0 100.0 100.0 61 Vayots Dzor 99.0 0.0 0.0 1.0 0.0 100.0 99.0 37 Tavush 100.0 0.0 0.0 0.0 0.0 100.0 100.0 99 Mother’s education Basic 99.3 0.7 0.0 0.0 0.0 100.0 100.0 95 Secondary 96.0 3.8 0.0 0.0 0.3 100.0 99.7 670 Secondary special 97.8 1.7 0.1 0.3 0.1 100.0 99.5 346 Higher 93.9 4.7 0.3 0.0 1.0 100.0 98.6 562 Wealth quintile Lowest 95.3 4.4 0.0 0.1 0.2 100.0 99.7 324 Second 95.8 3.8 0.0 0.0 0.4 100.0 99.6 338 Middle 95.1 3.5 0.0 0.2 1.2 100.0 98.6 305 Fourth 98.0 1.3 0.0 0.0 0.7 100.0 99.3 299 Highest 95.3 4.0 0.6 0.0 0.1 100.0 99.4 406 Total 95.9 3.5 0.1 0.1 0.5 100.0 99.3 1,672 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that have been suppressed. Reproductive Health • 107 9.2.2 Assistance at Delivery Assistance at delivery by a health professional is universal in Armenia (Table 9.6). A doctor attended 96 percent of live births during the 5 years before the survey, while a nurse or midwife attended 3 percent. There are no significant variations across groups of women in the proportion of births assisted by a skilled provider. However, relative to other regions, the role of nurses and midwives in assisting deliveries is more prominent in Gegharkunik (14 percent) and Lori (11 percent). Table 9.6 Assistance during delivery Percent distribution of live births in the 5 years before the survey by person providing assistance during delivery, percentage of birth assisted by a skilled provider, according to background characteristics, Armenia 2015-16 Person providing assistance during delivery Percentage delivered by a skilled provider1 Number of births Background characteristic Doctor Nurse/ midwife Relative/ other Don’t know/ missing Total Mother’s age at birth <20 97.7 2.3 0.0 0.0 100.0 100.0 99 20-34 96.3 3.5 0.0 0.2 100.0 99.8 1,475 35-49 97.0 3.0 0.0 0.0 100.0 100.0 98 Birth order 1 96.7 3.0 0.0 0.3 100.0 99.7 741 2-3 96.4 3.5 0.0 0.1 100.0 99.9 876 4-5 92.4 7.6 0.0 0.0 100.0 100.0 51 6+ * * * * * * 4 Residence Urban 96.2 3.5 0.0 0.3 100.0 99.7 962 Rural 96.6 3.3 0.1 0.0 100.0 99.9 710 Region Yerevan 94.9 4.7 0.0 0.5 100.0 99.5 475 Aragatsotn 100.0 0.0 0.0 0.0 100.0 100.0 61 Ararat 100.0 0.0 0.0 0.0 100.0 100.0 168 Armavir 93.8 6.2 0.0 0.0 100.0 100.0 190 Gegharkunik 84.8 14.4 0.0 0.8 100.0 99.2 77 Lori 89.3 10.7 0.0 0.0 100.0 100.0 99 Kotayk 100.0 0.0 0.0 0.0 100.0 100.0 239 Shirak 99.4 0.6 0.0 0.0 100.0 100.0 168 Syunik 100.0 0.0 0.0 0.0 100.0 100.0 61 Vayots Dzor 97.5 1.6 1.0 0.0 100.0 99.0 37 Tavush 100.0 0.0 0.0 0.0 100.0 100.0 99 Mother’s education Basic 98.5 1.5 0.0 0.0 100.0 100.0 95 Secondary 95.6 4.3 0.0 0.1 100.0 99.9 670 Secondary special 97.6 2.3 0.1 0.0 100.0 99.9 346 Higher 96.3 3.3 0.0 0.4 100.0 99.6 562 Wealth quintile Lowest 95.6 4.1 0.1 0.2 100.0 99.7 324 Second 96.8 3.2 0.0 0.0 100.0 100.0 338 Middle 98.8 1.2 0.0 0.0 100.0 100.0 305 Fourth 97.0 2.2 0.0 0.8 100.0 99.2 299 Highest 94.4 5.6 0.0 0.0 100.0 100.0 406 Total 96.4 3.4 0.0 0.2 100.0 99.8 1,672 Note: If the respondent mentioned more than one person attending during delivery, only the most qualified person is considered in this tabulation. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Skilled provider includes doctor, nurse, midwife, and feldsher. 9.2.3 Caesarian Deliveries Table 9.7 presents information on the extent of caesarean section delivery (C-section). Access to C-section surgery is a measure of access to emergency care for childbirth complications. In Appropriate Technology for Birth (1985), based on the evidence available at that time, the WHO concluded that the caesarean section delivery rate should not exceed 10-15 percent. The recent WHO Statement on Caesarean Section Rates (2015), based on the available data, concluded that at population level, C-section rates above 10 percent are not associated with reductions in maternal and newborn mortality rates (WHO 2015b). 108 • Reproductive Health Table 9.7 Caesarean section Percentage of live births in the 5 years before the survey delivered by Caesarian section (C-section), percentage delivered by C-section that was planned before the onset of labor pains, and percentage delivered by C-section that was decided after the onset of labor pains, according to background characteristics, Armenia 2015-16 Background characteristic Percentage delivered by C-section Timing of decision to conduct C-section Number of births Decided before onset of labor pains Decided after onset of labor pains Mother’s age at birth <20 8.1 5.2 2.8 99 20-34 18.0 15.1 2.9 1,475 35-49 27.5 25.0 2.6 98 Birth order 1 19.6 15.4 4.2 741 2-3 17.0 15.1 1.9 876 4-5 11.5 11.5 0.0 51 6+ * * * 4 Residence Urban 20.1 17.4 2.8 962 Rural 15.0 12.0 3.0 710 Region Yerevan 23.1 20.0 3.1 475 Aragatsotn 6.5 3.3 3.3 61 Ararat 14.6 13.8 0.7 168 Armavir 19.3 15.0 4.3 190 Gegharkunik 0.8 0.8 0.0 77 Lori 12.8 12.8 0.0 99 Kotayk 21.4 18.7 2.7 239 Shirak 13.7 8.0 5.8 168 Syunik 13.5 12.4 1.0 61 Vayots Dzor 14.5 11.0 3.4 37 Tavush 24.9 20.7 4.2 99 Mother’s education Basic 15.2 13.8 1.4 95 Secondary 13.9 11.0 2.9 670 Secondary special 20.4 17.7 2.7 346 Higher 21.8 18.5 3.2 562 Wealth quintile Lowest 16.7 13.1 3.7 324 Second 16.5 14.1 2.4 338 Middle 16.5 12.8 3.7 305 Fourth 19.2 16.5 2.8 299 Highest 20.4 18.2 2.1 406 Total 18.0 15.1 2.9 1,672 Note: The question on C-section is asked only of women who delivered in a health facility. In this table, it is assumed that women who did not give birth in health facility did not have a C-section. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. In Armenia, almost one in five births (18 percent) are delivered by C-section. This represents a steady increase from 7 percent in 2000, 9 percent in 2005, and 13 percent in 2010. Caesarean deliveries increase with the woman’s age, education, and wealth quintile. First births are more likely to be delivered by C-section than higher order births. Women living in urban areas are slightly more likely than rural women to deliver by caesarean section (20 and 15 percent, respectively). Delivery by caesarean section varies widely across regions, ranging from 1 percent in Gegharkunik to 25 percent in Tavush. In almost all cases, the decision have a C-section was made before the onset of labor (15 percent), as opposed to after the onset of labor (3 percent). Figure 9.1 presents the mother’s duration of stay in the health facility after giving birth. Almost 9 in 10 women (86 percent) who had a vaginal delivery spent 3 or more days at the health facility, while 13 percent stayed for 1-2 days. For those mothers who had a caesarean delivery, 98 percent spent at least three days at the health facility. Reproductive Health • 109 Figure 9.1 Mother’s duration of stay in the health facility after giving birth 9.2.4 Payment for Delivery In 2008, as part of broader reproductive health care reforms, Armenia introduced vouchers that entitled pregnant women to receive free delivery care services. In the 2015-16 ADHS, women who gave birth in a health facility in the 5 years before the survey were asked whether they had a delivery voucher, whether they were eligible for free delivery and medicine, and whether they were asked to pay for any of the services they received during delivery. Table 9.8 shows that women had a delivery voucher for 99 percent of births, that they were eligible to receive free hospital care for 98 percent of births, and eligible for free medicine during delivery for 89 percent of births. Women said they were charged for delivery services for only 13 percent of births. There are only slight variations in the extent of eligibility for free services by background characteristics. Eligibility for free medicines during delivery appears to be particularly low in the Aragatsotn region and relatively high for births to rural women and those with less education. Mothers in the Kotayk region were the most likely to be charged for delivery. In the 2015-16 ADHS, the small number of women who said they were charged for delivery services were further asked how much they paid for various services during delivery for their most recent birth in the past 5 years. The results are presented in Table 9.9. Among those who were charged for any delivery service, almost all paid money for the service; only 12 percent said that they did not pay any money for any delivery service. About 2 in 5 women (43 percent) paid 51,000 drams or more. Women are most likely to pay for delivery and other expenses and less likely to pay for laboratory services and medicines. The median amount paid for all delivery services is 59, 231 drams. 1 0 13 2 86 98 Vaginal birth Caesarean birth Percentage <24 hours 1-2 days 3+ days ADHS 2015-16 110 • Reproductive Health Table 9.8 Access to free delivery services Percentage of live births in the 5 years before the survey who had a delivery voucher, who were eligible for free hospital care and for free medicine during delivery, and who were charged for delivery, according to background characteristics, Armenia 2015-16 Background characteristic Among births that occurred in the 5 years before the survey, the percentage who: Had a delivery voucher Were eligible for free hospital care during delivery Were eligible for free medicine during delivery Were charged/paid for delivery Number of births Mother’s age at birth <20 99.7 96.1 91.0 10.7 99 20-34 99.1 98.0 88.8 13.5 1,475 35-49 96.6 96.6 80.3 6.8 98 Residence Urban 99.1 98.2 85.9 12.2 962 Rural 98.8 97.2 92.0 14.1 710 Region Yerevan 99.5 99.1 79.6 9.4 475 Aragatsotn 99.4 97.2 56.8 2.2 61 Ararat 98.4 98.4 94.2 13.4 168 Armavir 99.7 100.0 96.7 12.6 190 Gegharkunik 99.2 99.2 94.7 21.8 77 Lori 97.6 98.7 98.7 9.8 99 Kotayk 98.3 99.5 93.1 30.1 239 Shirak 98.2 85.4 83.8 2.8 168 Syunik 100.0 100.0 100.0 6.5 61 Vayots Dzor 98.6 99.3 92.4 13.5 37 Tavush 99.6 99.6 98.4 13.0 99 Education Basic 97.8 97.8 96.6 10.5 95 Secondary 98.9 97.6 88.3 12.0 670 Secondary special 99.4 97.9 89.5 12.3 346 Higher 99.0 97.9 86.7 14.9 562 Wealth quintile Lowest 98.5 97.1 92.4 12.3 324 Second 99.3 97.9 91.8 13.2 338 Middle 99.3 98.3 91.9 12.6 305 Fourth 98.7 95.8 85.1 13.4 299 Highest 99.1 99.3 82.6 13.4 406 Total 99.0 97.8 88.5 13.0 1,672 Table 9.9 Payment for delivery of the last birth Among women who were charged for delivery of the most recent birth in the 5 years before the survey, percent distribution by whether they paid for delivery and amount paid; and the median amount paid, according to type of service, Armenia 2015-16 Payment for delivery and amount paid Payment for any delivery service Payment for delivery by type of service Laboratory Medicine Delivery Other expenses Paid money and knows the amount 79.3 13.3 10.4 48.5 45.4 1,000-5,000 Armenian drams 0.6 0.7 0.0 1.3 0.6 6,000-10,000 Armenian drams 0.2 1.6 1.3 0.2 1.6 11,000-25,000 Armenian drams 6.3 5.1 4.1 2.6 7.7 26,000-50,000 Armenian drams 28.8 3.1 2.7 14.0 20.7 51,000+ Armenian drams 43.4 2.7 2.2 30.4 14.8 Paid money and does not know amount 8.8 12.7 14.0 12.0 12.6 Paid no money 11.9 74.0 75.6 39.5 42.1 Total 100.0 100.0 100.0 100.0 100.0 Number of women 175 175 175 175 175 Median Paid (Armenian dram)1 59,231 22,428 24,753 59,848 39,682 1 Among women who reported the amount they paid; one US dollar is about 486 Armenian drams. For the first column, the median is calculated by summing the amounts the woman paid for all delivery services. Reproductive Health • 111 9.3 POSTNATAL CARE FOR THE MOTHER The postnatal period is defined as the time between the delivery of the placenta and 42 days after delivery. Postnatal care provides an opportunity to treat complications arising from the delivery as well as to provide the mother with important information on how to care for herself and her child. Because many maternal deaths occur during the first few days after delivery, the timing of postnatal care is important. 9.3.1 Timing of Postnatal Checkups for the Mother Table 9.10 presents information on the timing of the first postnatal checkup after the most recent birth for women who gave birth in the 2 years before the survey. The data show that 97 percent of these women received a postnatal checkup in the first 2 days after birth. Three in five women (60 percent) receive a checkup within 4 hours after delivery. Differences by background characteristics are very small. Table 9.10 Timing of first postnatal checkup for the mother Among women age 15-49 giving birth in the 2 years before the survey, the percent distribution of the mother’s first postnatal check-up for the last live birth by time after delivery, and percentage of women with a live birth in the 2 years before the survey who received a postnatal checkup in the first 2 days after giving birth, according to background characteristics, Armenia 2015-16 Background characteristic Time after delivery of mother’s first postnatal checkup1 No postnatal checkup2 Total Percentage of women with a postnatal checkup in the first 2 days after birth1 Number of women Less than 4 hours 4-23 hours 1-2 days 3-6 days 7-41 days Don’t know/ missing Mother’s age at birth <20 (57.0) (10.2) (32.8) (0.0) (0.0) (0.0) (0.0) (100.0) (100.0) 36 20-34 59.5 13.7 23.8 0.9 0.1 0.5 1.6 100.0 97.0 579 35-49 (70.5) (6.8) (22.7) (0.0) (0.0) (0.0) (0.0) (100.0) (100.0) 52 Birth order 1 57.7 14.9 25.5 1.1 0.0 0.0 0.8 100.0 98.1 278 2-3 61.5 12.3 23.0 0.6 0.1 0.8 1.8 100.0 96.7 367 4+ * * * * * * * * * 21 Residence Urban 60.5 13.8 23.4 1.1 0.1 0.2 1.0 100.0 97.6 391 Rural 59.8 11.9 25.3 0.4 0.0 0.8 1.8 100.0 97.0 275 Region Yerevan 58.7 15.9 24.2 1.2 0.0 0.0 0.0 100.0 98.8 190 Aragatsotn (10.5) (19.4) (70.1) (0.0) (0.0) (0.0) (0.0) (100.0) (100.0) 22 Ararat 55.5 21.8 22.8 0.0 0.0 0.0 0.0 100.0 100.0 65 Armavir 49.0 4.6 45.4 1.0 0.0 0.0 0.0 100.0 99.0 79 Gegharkunik (30.6) (24.9) (38.2) (0.0) (0.0) (6.3) (0.0) (100.0) (93.7) 28 Lori (28.7) (17.9) (47.9) (2.9) (0.0) (0.0) (2.6) (100.0) (94.5) 36 Kotayk 87.8 2.9 6.4 0.8 0.0 1.1 1.1 100.0 97.0 103 Shirak 60.6 18.5 12.2 0.0 0.0 0.0 8.7 100.0 91.3 65 Syunik (95.4) (4.6) (0.0) (0.0) (0.0) (0.0) (0.0) (100.0) (100.0) 24 Vayots Dzor (60.6) (16.1) (10.8) (2.5) (0.0) (0.0) (10.1) (100.0) (87.4) 13 Tavush 78.2 6.8 14.1 0.0 0.9 0.0 0.0 100.0 99.1 43 Education Basic (59.3) (11.5) (29.2) (0.0) (0.0) (0.0) (0.0) (100.0) (100.0) 39 Secondary 59.0 11.2 26.7 1.0 0.0 0.4 1.6 100.0 97.0 266 Secondary special 62.4 10.0 24.9 0.2 0.0 0.8 1.7 100.0 97.2 133 Higher 60.4 17.0 20.0 1.0 0.2 0.3 1.2 100.0 97.4 229 Wealth quintile Lowest 53.4 11.3 31.0 0.7 0.0 0.9 2.7 100.0 95.7 117 Second 61.7 13.2 23.8 0.0 0.0 0.0 1.3 100.0 98.7 141 Middle 66.9 10.7 19.9 0.3 0.0 1.4 0.8 100.0 97.6 126 Fourth 60.0 10.9 23.5 3.4 0.3 0.0 1.8 100.0 94.5 122 Highest 58.6 17.3 23.5 0.0 0.0 0.0 0.6 100.0 99.4 161 Total 60.2 13.0 24.2 0.8 0.1 0.4 1.4 100.0 97.4 666 Note: Figures in parentheses are based on 25-49 unweighted cases; an asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Includes women who received a checkup from a doctor, midwife, nurse, feldsher, or traditional birth attendant. 2 Includes women who received a checkup after 41 days. 112 • Reproductive Health 9.3.2 Type of Provider of Postnatal Checkups for the Mother Figure 9.2 shows the type of health care provider who performed the postnatal checkup for the mother for the most recent birth in the 2 years before the survey. Almost all were examined by a doctor (95 percent), with only 3 percent examined by a nurse or midwife and another 3 percent receiving no postnatal care within the first 2 days after giving birth. Figure 9.2 Type of provider of postnatal care for the mother 9.4 POSTNATAL CARE FOR THE NEWBORN 9.4.1 Timing of Postnatal Care for Newborns Table 9.11 shows that 98 percent of births in the 2 years before the survey received a postnatal checkup within 2 days after birth, almost twice the level in 2010 (50 percent)3. Only 30 percent of births received a postnatal check within 1 hour after birth; however, 50 percent were checked 1-3 hours after birth. Differences by background characteristics in both the coverage and timing of postnatal care are minor; differences by region in the timing of postnatal care are hampered by the small numbers of cases. 3 When comparing the 2015-16 ADHS postnatal checkup data to the previous surveys, it should be noted that the questions on postnatal care for the newborn have been modified to obtain a better sense of coverage of postnatal care. In the 2015-16 ADHS, for a facility birth, women were asked whether someone checked on the health of her baby and the timing of the first check while still in the facility. Women were also asked if the baby had a check on his/her health in the 2 months after they left the facility and the timing of the first post-discharge check. For the 2010 ADHS and earlier surveys, for a facility birth, women were asked if the baby had a checkup on his/her health in the 2 months after birth and the timing of the first check without specifying whether still in the facility or after they left the facility. Doctor 95% Nurse/midwife 3% No postnatal care 3% ADHS 2015-16 Percentage of women who gave birth in the previous 2 years Reproductive Health • 113 Table 9.11 Timing of first postnatal checkup for the newborn Percent distribution of last births in the 2 years before the survey by time after birth of first postnatal checkup, and the percentage of births with a postnatal checkup in the first two days after birth, according to background characteristics, Armenia 2015-16 Background characteristic Time after birth of newborn’s first postnatal checkup1 No postnatal checkup2 Total Percentage of births with a postnatal checkup in the first 2 days after birth1 Number of births Less than 1 hour 1-3 hours 4-23 hours 1-2 days 3-6 days Don’t know/ missing Mother’s age at birth <20 (23.6) (55.9) (4.8) (15.8) (0.0) (0.0) (0.0) (100.0) (100.0) 36 20-34 30.1 50.2 8.8 8.9 0.2 1.7 0.1 100.0 97.9 579 35-49 (38.8) (45.7) (12.3) (3.2) (0.0) (0.0) (0.0) (100.0) (100.0) 52 Birth order 1 29.4 54.5 6.0 9.9 0.0 0.0 0.3 100.0 99.7 278 2-3 31.6 46.8 11.4 7.2 0.3 2.7 0.0 100.0 97.0 367 4+ * * * * * * * * * 21 Residence Urban 32.6 49.8 9.0 6.6 0.3 1.5 0.2 100.0 98.0 391 Rural 27.3 50.7 8.5 12.0 0.0 1.5 0.0 100.0 98.5 275 Region Yerevan 27.0 56.0 11.2 4.6 0.0 1.2 0.0 100.0 98.8 190 Aragatsotn (0.0) (48.2) (10.8) (41.0) (0.0) (0.0) (0.0) (100.0) (100.0) 22 Ararat 16.2 68.2 12.8 2.0 0.0 0.8 0.0 100.0 99.2 65 Armavir 0.0 50.3 11.3 38.5 0.0 0.0 0.0 100.0 100.0 79 Gegharkunik (2.0) (40.1) (38.9) (14.8) (0.0) (4.1) (0.0) (100.0) (95.9) 28 Lori (81.7) (12.2) (0.0) (0.0) (2.9) (3.3) (0.0) (100.0) (93.8) 36 Kotayk 84.2 11.6 2.0 1.1 0.0 1.1 0.0 100.0 98.9 103 Shirak 7.5 75.5 6.2 5.1 0.0 4.5 1.2 100.0 94.3 65 Syunik (15.2) (84.8) (0.0) (0.0) (0.0) (0.0) (0.0) (100.0) (100.0) 24 Vayots Dzor (10.2) (75.9) (5.9) (8.1) (0.0) (0.0) (0.0) (100.0) (100.0) 13 Tavush 33.5 63.6 0.9 0.0 0.0 2.1 0.0 100.0 97.9 43 Mother’s education Basic (33.8) (49.9) (9.9) (6.4) (0.0) (0.0) (0.0) (100.0) (100.0) 39 Secondary 27.2 47.6 9.6 13.9 0.0 1.6 0.0 100.0 98.4 266 Secondary special 38.2 51.4 2.3 5.7 0.0 1.7 0.6 100.0 97.7 133 Higher 29.1 52.4 11.4 5.1 0.5 1.5 0.0 100.0 98.0 229 Wealth quintile Lowest 27.1 47.4 8.9 15.1 0.0 1.6 0.0 100.0 98.4 117 Second 26.5 53.9 8.4 10.4 0.0 0.8 0.0 100.0 99.2 141 Middle 38.4 43.4 6.4 8.0 0.0 3.1 0.6 100.0 96.3 126 Fourth 29.7 56.6 6.8 3.5 0.9 2.7 0.0 100.0 96.5 122 Highest 30.6 49.4 12.4 7.5 0.0 0.0 0.0 100.0 100.0 161 Total 30.4 50.2 8.8 8.8 0.2 1.5 0.1 100.0 98.2 666 Note: Figures in parentheses are based on 25-49 unweighted cases; an asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Includes newborns who received a checkup from a doctor, midwife, nurse, feldsher, or traditional birth attendant. 2 Includes newborns who received a checkup after 41 days. 114 • Reproductive Health 9.4.2 Type of Provider of Postnatal Care for Newborns Table 9.12 shows that the vast majority of births receive a postnatal checkup from a doctor (88 percent), while 10 percent receive postnatal care from a nurse or midwife. Births that are more likely to receive postnatal care from a doctor include urban births and those whose mothers are better educated and in the higher wealth quintiles. Interpretation of differences by region is hampered by the small number of births. Table 9.12 Type of provider of first postnatal checkup for the newborn Percent distribution of last births in the 2 years before the survey by type of provider of the newborn’s first postnatal health check during the 2 days after the last live birth, according to background characteristics, Armenia 2015-16 Background characteristic Type of health provider of newborn’s first postnatal checkup Total Number of births Doctor Nurse/ midwife No postnatal checkup in the first 2 days after birth Mother’s age at birth <20 (83.8) (16.2) (0.0) (100.0) 36 20-34 88.8 9.2 2.1 100.0 579 35-49 (88.3) (11.7) (0.0) (100.0) 52 Birth order 1 90.0 9.7 0.3 100.0 278 2-3 87.8 9.2 3.0 100.0 367 4+ * * * * 21 Residence Urban 91.5 6.5 2.0 100.0 391 Rural 84.1 14.5 1.5 100.0 275 Region Yerevan 95.5 3.3 1.2 100.0 190 Aragatsotn (90.8) (9.2) (0.0) (100.0) 22 Ararat 93.2 6.0 0.8 100.0 65 Armavir 57.7 42.3 0.0 100.0 79 Gegharkunik (79.0) (16.8) (4.1) (100.0) 28 Lori (91.6) (2.3) (6.2) (100.0) 36 Kotayk 91.0 7.9 1.1 100.0 103 Shirak 92.6 1.7 5.7 100.0 65 Syunik (100.0) (0.0) (0.0) (100.0) 24 Vayots Dzor (62.5) (37.5) (0.0) (100.0) 13 Tavush 97.9 0.0 2.1 100.0 43 Mother’s education Basic (84.8) (15.2) (0.0) (100.0) 39 Secondary 84.6 13.7 1.6 100.0 266 Secondary special 93.3 4.4 2.3 100.0 133 Higher 90.7 7.3 2.0 100.0 229 Wealth quintile Lowest 83.2 15.2 1.6 100.0 117 Second 83.5 15.7 0.8 100.0 141 Middle 90.2 6.1 3.7 100.0 126 Fourth 92.3 4.2 3.5 100.0 122 Highest 92.3 7.7 0.0 100.0 161 Total 88.4 9.8 1.8 100.0 666 Note: Figures in parentheses are based on 25-49 unweighted cases; an asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 9.4.3 Content of Postnatal Care for Newborns Table 9.13 shows information on the types of care given within 2 days after birth for the most recent birth in the 2 years before the survey. Mothers report that the umbilical cord was examined for almost all births (99 percent), while for 98 percent of births, the baby’s temperature was measured. Almost all new mothers were counseled about breastfeeding (96 percent), while 89 percent were observed breastfeeding their newborns. Eighty-seven percent of mothers said they received counseling about danger signs for newborns. All but a tiny fraction of babies were reported by the mother to have been weighed at birth (100 percent). Virtually all births received at least two types of care and almost 4 in 5 births (79 percent) received all six types of care (data not shown separately). Differences by background characteristics are small. Reproductive Health • 115 Table 9.13 Content of postnatal care for newborns Among last births in the 2 years before the survey, percentage for whom selected functions were performed within 2 days after birth and percentage with at least two signal functions performed within 2 days after birth, according to background characteristics, Armenia 2015-16 Background characteristic Among last births in the 2 years before the survey, percentage for whom the selected function was performed within 2 days after birth: Number of births Cord examined Temperature measured Counseling on danger signs Counseling on breastfeeding Observation of breastfeeding Weighed1 Percentage with at least two signal functions performed during the 2 days after birth Mother’s age at birth <20 (98.2) (95.1) (86.2) (97.4) (92.7) (100.0) (100.0) 36 20-34 99.2 97.8 85.6 95.1 88.7 99.5 99.4 579 35-49 (100.0) (98.1) (96.1) (98.8) (86.8) (100.0) (100.0) 52 Birth order 1 99.0 97.1 87.8 95.3 92.0 99.4 99.7 278 2-3 99.3 98.0 85.4 95.3 86.5 99.6 99.3 367 4-5 * * * * * * * 19 6+ * * * * * * * 2 Residence Urban 99.0 98.2 88.1 94.6 87.3 99.6 99.1 391 Rural 99.5 97.0 84.2 96.7 90.9 99.5 100.0 275 Region Yerevan 99.2 99.2 91.5 95.3 88.4 100.0 99.2 190 Aragatsotn (100.0) (90.9) (84.7) (95.5) (89.3) (100.0) (100.0) 22 Ararat 100.0 98.8 80.5 90.3 90.0 97.1 100.0 65 Armavir 98.2 100.0 82.3 100.0 92.6 100.0 100.0 79 Gegharkunik (100.0) (100.0) (76.7) (100.0) (83.5) (100.0) (100.0) 28 Lori (96.7) (96.7) (62.9) (84.5) (81.9) (100.0) (96.7) 36 Kotayk 100.0 100.0 99.0 99.2 89.1 100.0 100.0 103 Shirak 98.8 85.9 78.9 97.3 94.6 98.8 98.8 65 Syunik (97.4) (100.0) (91.7) (88.4) (79.9) (100.0) (100.0) 24 Vayots Dzor (100.0) (100.0) (92.5) (94.5) (94.5) (100.0) (100.0) 13 Tavush 100.0 98.0 84.0 94.7 84.3 99.0 100.0 43 Mother’s education Basic (96.3) (100.0) (77.8) (97.1) (84.2) (100.0) (100.0) 39 Secondary 99.3 97.1 85.1 96.5 91.5 99.1 99.6 266 Secondary special 99.4 97.3 85.3 96.4 88.7 99.4 99.4 133 Higher 99.3 98.1 90.3 93.4 86.5 100.0 99.3 229 Wealth quintile Lowest 98.8 97.8 77.8 96.3 86.6 100.0 100.0 117 Second 99.6 97.3 87.2 96.4 91.4 99.3 100.0 141 Middle 99.4 97.2 90.4 96.1 90.4 99.4 99.4 126 Fourth 99.0 98.1 84.9 93.9 88.9 100.0 99.0 122 Highest 99.1 98.0 90.2 94.7 86.7 99.1 99.1 161 Total 99.2 97.7 86.5 95.5 88.8 99.5 99.5 666 Note: Figures in parentheses are based on 25-49 unweighted cases; an asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Captures newborns who were weighed “at birth.” May exclude some newborns were weighed during the 2 days after birth. 9.5 PROBLEMS IN ACCESSING HEALTH CARE Many factors can prevent women from accessing medical advice or treatment for themselves. The 2015-16 ADHS included questions on the type of barriers women may face in accessing health care for themselves. All women were asked if the following factors would be a big problem for them in obtaining medical advice or treatment if they were sick: obtaining permission to go for treatment, having money for treatment, traveling the distance to the health facility, and feeling concerned about going alone to the facility. Table 9.14 shows that almost two in three women considered at least one of these issues to be potentially a serious problem in accessing health care for themselves. Women most frequently cited the lack of money to pay for treatment (55 percent). One in four women (25 percent) cited not wanting to go alone as a potential barrier. Nine percent of women said that distance to a health facility is a problem. Obtaining permission to go to a doctor is the least often cited issue (4 percent). 116 • Reproductive Health Table 9.14 Problems in accessing health care Percentage of women age 15-49 who reported that they have serious problems in accessing health care for themselves when they are sick, by type of problem, according to background characteristics, Armenia 2015-16 Background characteristic Problems in accessing health care Getting permission to go for treatment Getting money for treatment Distance to health facility Not wanting to go alone At least one problem accessing health care Number of women Age 15-19 6.3 45.3 9.1 50.8 67.9 725 20-34 4.3 53.4 9.7 26.2 62.3 3,034 35-49 3.6 60.1 8.7 14.4 65.3 2,357 Number of living children 0 5.3 47.6 8.0 35.5 63.2 2,120 1-2 3.4 58.4 8.8 18.8 64.0 2,990 3-4 4.6 59.9 12.8 18.0 65.4 966 5+ (10.1) (81.1) (18.7) (31.0) (89.6) 39 Marital status Never married 5.5 47.1 8.0 36.6 63.1 1,830 Married or living together 3.7 57.1 9.8 19.9 63.5 3,895 Divorced/separated/ widowed 4.4 71.6 9.0 14.4 74.7 390 Employed last 12 months Not employed 4.2 56.6 9.8 29.1 66.9 3,650 Employed for cash 4.4 53.3 7.6 18.1 60.6 2,115 Employed not for cash 4.8 49.7 13.4 15.9 55.9 351 Residence Urban 3.3 54.4 5.6 21.7 63.6 3,657 Rural 5.8 56.0 14.7 28.8 64.8 2,459 Region Yerevan 3.7 57.4 6.1 24.0 68.5 2,001 Aragatsotn 13.6 72.9 25.1 23.0 73.7 315 Ararat 2.7 54.8 14.5 32.8 64.6 552 Armavir 0.0 40.4 5.6 12.2 42.5 586 Gegharkunik 15.4 45.5 16.1 36.9 60.2 478 Lori 0.0 44.0 0.2 21.4 55.0 355 Kotayk 0.5 56.0 1.6 24.2 64.5 678 Shirak 3.0 65.9 9.5 23.2 73.4 510 Syunik 5.1 64.2 13.2 13.8 67.1 238 Vayots Dzor 11.2 49.1 17.3 26.7 54.4 119 Tavush 4.4 52.1 21.7 33.8 68.5 283 Education Basic 6.2 62.4 16.2 36.0 74.4 396 Secondary 5.4 62.1 11.3 27.7 70.1 2,444 Secondary special 2.5 60.0 8.6 20.9 67.2 1,360 Higher 3.7 41.0 5.7 20.7 52.2 1,910 Wealth quintile Lowest 5.7 65.1 18.9 30.7 71.5 1,081 Second 5.2 55.2 10.9 24.5 62.3 1,242 Middle 4.4 55.9 8.4 23.7 65.3 1,142 Fourth 3.9 54.6 5.1 23.7 65.3 1,287 Highest 2.6 46.6 4.7 21.3 57.8 1,365 Total 4.3 55.0 9.2 24.5 64.1 6,116 Note: Total includes 5 women with no education. The proportion of women who cite at least one problem in accessing health care for themselves has remained more or less stable over the past 5 years, declining from 66 percent in 2010 to 64 percent in 2015-16. However, the proportion who cite distance to a health facility as an obstacle has declined from 19 percent to 9 percent, and the proportion who say that not wanting to go alone is a problem has declined from 33 percent to 25 percent since 2010. Women who are divorced, separated, or widowed are somewhat more likely to report at least one potential problem than those who never married or are currently married. Women who were not employed were more likely than others to have encountered at least one obstacle in accessing health care. Women from Aragatsotn and Shirak are the most likely to mention at least one potential obstacle, while women from Armavir are the least likely to have an obstacle in getting health care for themselves. The proportion of women who mention at least one problem accessing health care generally declines with increasing education and wealth. Reproductive Health • 117 9.6 TRAVEL TO NEAREST HEALTH CLINIC The 2015-16 ADHS obtained information on the mode of transportation and the travel time to the clinic or health facility usually used by household members. The information provides insights into how households access health care and the potential travel burdens they may face in obtaining care. Table 9.15 shows that slightly more than half of households report that members walk to the clinic or health facility they typically use; 29 percent travel in a car or taxi, and 15 percent rely on public transportation. A large majority of households (89 percent) say that it takes less than 30 minutes to travel to their usual clinic or health facility. Virtually no households say that it takes more than 1 hour to travel to the clinic or health facility. The proportion reporting it takes less than 30 minutes to travel to the clinic or health facility is higher if members walk (93 percent) than if they use public transportation (82 percent) (data not shown separately). Households are the least likely to report that members walk to their usual clinic or health facility in Aragatsotn (35 percent) and Lori (30 percent) (Table 9.15). Public transport is used most often in households in Lori (37 percent). The Lori and Gegharkunik regions have the highest proportions of households reporting that it requires 30 minutes or more to travel to their usual clinic or health facility (18 percent and 17 percent, respectively). The proportion of households reporting it takes members 30 minutes or more to travel to their usual clinic or health facility varies from a high of 12 percent in the lowest wealth quintile to 6 percent in the highest quintile. Table 9.15 Travel to the nearest clinic Percent distribution of households by usual method to travel to the nearest clinic or health facility usually used by household members and percent distribution of households by the approximate time to travel to the nearest clinic or health facility in minutes, according to background characteristics, Armenia 2015-16 Background characteristic Usual mode of transportation Time to get to the nearest clinic in minutes Number of house- holds Foot Car/taxi Public transport Missing Total <30 30-60 >60 Don't know Missing Total Residence Urban 52.2 27.3 19.8 0.7 100.0 90.0 9.0 0.3 0.7 0.0 100.0 4,924 Rural 60.8 30.5 7.9 0.8 100.0 88.1 10.7 0.3 0.8 0.1 100.0 2,969 Region Yerevan 53.5 21.8 23.8 0.9 100.0 89.8 9.0 0.3 0.9 0.0 100.0 2,480 Aragatsotn 35.0 56.8 5.4 2.9 100.0 86.4 10.8 0.0 2.9 0.0 100.0 387 Ararat 57.2 38.3 4.4 0.2 100.0 97.9 1.9 0.0 0.2 0.0 100.0 682 Armavir 67.1 28.4 4.3 0.2 100.0 94.0 5.3 0.1 0.2 0.4 100.0 633 Gegharkunik 52.0 40.6 6.2 1.2 100.0 81.4 17.1 0.3 1.2 0.0 100.0 601 Lori 30.1 31.1 37.4 1.4 100.0 79.3 18.2 1.1 1.4 0.0 100.0 645 Kotayk 60.1 27.0 12.6 0.3 100.0 93.4 6.2 0.1 0.3 0.0 100.0 799 Shirak 65.5 21.3 13.1 0.1 100.0 85.2 14.5 0.1 0.1 0.0 100.0 685 Syunik 72.6 18.1 9.3 0.0 100.0 94.2 5.8 0.0 0.0 0.0 100.0 448 Vayots Dzor 67.6 32.4 0.0 0.0 100.0 96.6 3.4 0.0 0.0 0.0 100.0 167 Tavush 60.7 29.8 9.1 0.4 100.0 85.0 13.4 1.3 0.4 0.0 100.0 366 Wealth quintile Lowest 62.9 24.3 11.6 1.3 100.0 86.2 12.1 0.4 1.3 0.1 100.0 1,700 Second 53.8 34.8 11.0 0.4 100.0 88.4 10.8 0.3 0.4 0.1 100.0 1,452 Middle 54.4 27.3 17.5 0.8 100.0 88.0 10.9 0.3 0.8 0.0 100.0 1,791 Fourth 52.9 28.1 18.2 0.8 100.0 91.2 7.6 0.4 0.8 0.0 100.0 1,558 Highest 52.1 29.2 18.5 0.2 100.0 93.6 6.0 0.1 0.2 0.0 100.0 1,392 Total 55.4 28.5 15.4 0.7 100.0 89.3 9.6 0.3 0.7 0.0 100.0 7,893 Health Insurance, use of Tobacco, Knowledge and Attitudes about Tuberculosis • 119 HEALTH INSURANCE, USE OF TOBACCO, KNOWLEDGE AND ATTITUDES ABOUT TUBERCULOSIS 10 his chapter includes information on health insurance coverage, use of tobacco, and knowledge and attitudes about tuberculosis. 10.1 HEALTH INSURANCE In 1998, the government of Armenia introduced the first state Basic Benefits Package (BBP) and established the State Health Agency as the purchaser of publicly financed health care services. The BBP is a publicly funded package of basic medical services, which are free for the entire population, and broader services, which are free for certain vulnerable groups. The services and population groups covered under the BBP are reviewed annually by the government in response to financial and political requirements. The fluctuation of services covered under the BBP over the years has caused confusion and uncertainty for both service providers and patients. The government is attempting to standardize the BBP and its review process. Voluntary health insurance that is provided through an employer or purchased independently does not play a significant role in the Armenian health system and is unaffordable for most citizens (Richardson 2013). The 2015-16 ADHS asked all respondents whether or not they were covered by a health insurance plan. The level of health insurance coverage is very low: only 7 percent of women and 8 percent of men reported having any type of health insurance (Tables 10.1.1 and 10.1.2). Most women and men who have health insurance coverage indicate that they have the BBP (5 percent and 6 percent, respectively). The BBP is a government-sponsored program that provides specific health services including primary health care to a limited segment of the Armenian population who are considered poor and vulnerable. Only 2 percent of men and women report being covered by private plans, primarily through their employers. While fewer than one in ten women and men have health insurance, coverage levels are better than at the time of the 2010 ADHS when only 1 percent of women and 2 percent of men had health insurance. Coverage levels for both women and men are lowest among those under age 25, those with secondary or less education, and those in the lowest wealth quintile. Among women, coverage levels are highest in Syunik (21 percent). Men are the most likely to report having insurance in Syunik (24 percent) and Vayots Dzor (19 percent). T Key Findings:  Fewer than one in ten women and men has any form of health insurance.  Men are much more likely to smoke tobacco products than women (61 percent versus 1 percent).  More than eight in ten women and men have heard about tuberculosis, but fewer than ten percent are aware of multidrug-resistant TB.  Most individuals who know about TB also are not aware that it may affect organs in the body other than the lungs. 120 • Health Insurance, use of Tobacco, Knowledge and Attitudes about Tuberculosis Table 10.1.1 Health insurance coverage: Women Percentage of women age 15-49 with specific types of health insurance coverage, according to background characteristics, Armenia 2015-16 Background characteristic Basic Benefits Package Employer based insurance Privately purchased commercial insurance None Number of women Age 15-19 0.6 0.3 0.3 98.8 725 20-24 2.8 1.2 0.1 95.9 928 25-29 4.9 2.6 0.2 92.4 1,099 30-34 4.9 1.4 0.0 93.7 1,007 35-39 7.9 1.7 0.5 90.0 867 40-44 5.8 3.6 0.4 90.2 784 45-49 7.2 2.5 0.2 90.1 706 Residence Urban 5.1 2.4 0.3 92.3 3,657 Rural 4.6 1.2 0.1 94.1 2,459 Region Yerevan 4.7 1.4 0.4 93.6 2,001 Aragatsotn 5.4 2.2 0.1 92.3 315 Ararat 8.4 0.5 0.2 90.8 552 Armavir 3.1 2.1 0.0 94.7 586 Gegharkunik 3.3 1.2 0.1 95.3 478 Lori 4.7 0.0 0.3 95.1 355 Kotayk 5.1 1.8 0.0 93.2 678 Shirak 4.9 0.7 0.2 94.2 510 Syunik 2.8 17.9 0.2 79.3 238 Vayots Dzor 6.7 2.7 0.0 90.8 119 Tavush 5.9 0.3 0.0 93.9 283 Education Basic 0.7 0.4 0.0 98.9 396 Secondary 0.6 0.5 0.0 98.9 2,444 Secondary special 3.9 1.7 0.2 94.2 1,360 Higher 12.0 4.2 0.5 83.4 1,910 Wealth quintile Lowest 1.9 0.4 0.0 97.6 1,081 Second 5.8 1.9 0.1 92.2 1,242 Middle 4.3 2.1 0.1 93.5 1,142 Fourth 6.1 2.8 0.4 90.8 1,287 Highest 5.7 2.1 0.4 91.8 1,365 Total 4.9 1.9 0.2 93.0 6,116 Note: Total includes 5 (weighted) women with no education. Health Insurance, use of Tobacco, Knowledge and Attitudes about Tuberculosis • 121 Table 10.1.2 Health insurance coverage: Men Percentage of men age 15-49 with specific types of health insurance coverage, according to background characteristics, Armenia 2015-16 Background characteristic Basic Benefits Package Employer based insurance Privately purchased commercial insurance Other None Number of men Age 15-19 0.0 0.4 0.4 0.1 99.1 345 20-24 3.6 0.6 0.0 0.1 95.8 467 25-29 6.3 1.3 0.1 0.0 92.4 464 30-34 9.9 2.3 0.0 0.0 87.9 427 35-39 9.8 2.0 0.1 0.0 88.2 376 40-44 6.2 1.8 0.0 0.4 91.6 346 45-49 7.3 1.8 0.1 0.1 90.7 330 Residence Urban 7.2 1.5 0.1 0.1 91.1 1,558 Rural 4.9 1.3 0.0 0.1 93.8 1,197 Region Yerevan 4.9 0.6 0.0 0.0 94.5 833 Aragatsotn 7.5 0.6 0.2 0.0 91.7 159 Ararat 8.1 0.8 0.0 0.0 91.1 290 Armavir 3.1 2.3 0.5 0.6 93.6 268 Gegharkunik 2.8 1.0 0.0 0.0 96.2 235 Lori 9.4 0.0 0.0 0.0 90.6 184 Kotayk 4.3 2.7 0.0 0.0 93.1 299 Shirak 8.0 0.4 0.0 0.0 91.6 201 Syunik 16.9 7.0 0.0 0.0 76.0 104 Vayots Dzor 5.9 10.1 0.8 1.8 82.1 56 Tavush 9.6 0.3 0.0 0.0 90.1 126 Education Basic 1.7 0.7 0.0 0.0 97.6 360 Secondary 2.6 0.9 0.1 0.2 96.3 1,250 Secondary special 8.6 0.4 0.0 0.0 90.9 403 Higher 13.3 3.2 0.1 0.1 83.4 736 Wealth quintile Lowest 2.5 0.9 0.0 0.3 96.4 523 Second 6.7 0.7 0.1 0.0 92.5 583 Middle 5.9 2.3 0.1 0.0 91.7 521 Fourth 7.8 1.4 0.2 0.2 90.5 566 Highest 7.7 1.9 0.0 0.0 90.3 562 Total 6.2 1.4 0.1 0.1 92.2 2,755 Note: Total includes 5 (weighted) men with no education. 122 • Health Insurance, use of Tobacco, Knowledge and Attitudes about Tuberculosis 10.2 USE OF TOBACCO Smoking is a known risk factor for cardiovascular disease. Smoking also causes lung cancer, emphysema, and other respiratory illnesses. Smoking may also have an effect on individuals who are exposed to second-hand smoke. For example, inhaling second-hand smoke may adversely affect children’s growth and cause childhood illness, especially respiratory diseases. Since the mid-1990s, a number of tobacco control measures have been put into effect in Armenia. Advertising of tobacco products is banned in the mass media. However, there is no control over the broadcast of foreign television programs in Armenia. Legislation requires health warnings as well as tar and nicotine content labeling on cigarette cartons. In addition, the sale of cigarettes to minors under age 18 years has been prohibited. Smoking is restricted in public areas, government and health facilities, restaurants and bars, indoor workplaces and offices, and on public transportation. To measure the extent of smoking among Armenian adults, women and men who were interviewed in the 2015-16 ADHS were asked if they currently smoke cigarettes or use other forms of tobacco. Tables 10.2.1 and 10.2.2 show the distribution of women and men who smoke cigarettes or use other tobacco. Overall, a very small proportion of women interviewed in the 2015-16 ADHS reported that they currently smoke cigarettes (1 percent), and virtually no women say they use other forms of tobacco (Table 10.2.1). It is possible that some female respondents were reluctant to report that they smoke tobacco because traditional Armenian attitudes discourage women smoking. Urban dwellers, women residing in Yerevan, women age 35-49, women with some higher education, and women in the highest two wealth quintiles are the most likely to smoke (2 to 3 percent). Among the women who smoke cigarettes, fewer than half report that they smoke every day and, among the small number of daily smokers, around half say they smoke an average of 6 or more cigarettes each day (data not shown). Smoking is considerably more common among men (Table 10.2.2). Sixty-one percent of men report that they use tobacco, with virtually all saying that they smoke cigarettes. This proportion is slightly lower that the proportion who reported tobacco use in 2010 ADHS (64 percent). Almost all men who use tobacco are regular smokers; 59 percent of all men say they are daily smokers while 2 percent report they smoke only occasionally. More than two-thirds of men who are daily smokers reported they smoke an average of 15-24 cigarettes per day, and 23 percent smoke more than 25 cigarettes per day (Table 10.3). Table 10.2.1 Use of tobacco: Women Percentage of women age 15-49 who smoke various tobacco products, according to background characteristics, Armenia 2015-16 Background characteristic Percentage who smoke:1 Number of women Cigarettes2 Other type of tobacco3 Any type of tobacco Age 15-19 0.1 0.0 0.1 725 20-24 0.2 0.0 0.2 928 25-29 0.8 0.2 0.8 1,099 30-34 1.1 0.2 1.1 1,007 35-39 2.0 0.0 2.0 867 40-44 2.0 0.0 2.0 784 45-49 3.1 0.5 3.1 706 Residence Urban 2.0 0.2 2.0 3,657 Rural 0.1 0.0 0.1 2,459 Region Yerevan 3.0 0.4 3.0 2,001 Aragatsotn 0.3 0.1 0.3 315 Ararat 0.3 0.0 0.3 552 Armavir 0.2 0.0 0.2 586 Gegharkunik 0.5 0.0 0.5 478 Lori 0.0 0.0 0.0 355 Kotayk 0.8 0.0 0.8 678 Shirak 0.0 0.0 0.0 510 Syunik 1.1 0.3 1.1 238 Vayots Dzor 0.2 0.0 0.2 119 Tavush 0.4 0.0 0.4 283 Education Basic 1.6 0.6 1.6 396 Secondary 0.8 0.1 0.8 2,444 Secondary special 1.3 0.1 1.3 1,360 Higher 1.8 0.1 1.8 1,910 Wealth quintile Lowest 0.0 0.0 0.0 1,081 Second 0.2 0.1 0.2 1,242 Middle 1.3 0.2 1.3 1,142 Fourth 2.1 0.3 2.1 1,287 Highest 2.3 0.1 2.3 1,365 Total 1.2 0.1 1.2 6,116 Note: Total includes 5 (weighted) women with no education. 1 Includes daily and occasional (less than daily) use. 2 Includes manufactured cigarettes. 3 Includes cigars, cheroots and cigarillos, and water pipes. Health Insurance, use of Tobacco, Knowledge and Attitudes about Tuberculosis • 123 Table 10.2.2 shows that the proportion of men who use tobacco increases rapidly with age, from 16 percent of men age 15-19 to around half of men age 20-24, nearly two-thirds of men age 25-29, and more than 70 percent among men age 35-49. Men are only slightly more likely to use tobacco in urban than in rural areas (63 percent and 59 percent, respectively). Men in Syunik are least likely to use tobacco (38 percent), while those in Yerevan and Aragatsotn are the most likely to use tobacco (71 percent and 78 percent, respectively). Table 10.2.2 Use of tobacco: Men Percentage of men age 15-49 who smoke various tobacco products, and the percent distribution of men by smoking frequency, according to background characteristics, Armenia 2015-16 Background characteristic Percentage who smoke:1 Smoking frequency Total Number of men Cigarettes2 Other type of tobacco3 Any type of tobacco Daily smoker Occasional smoker4 Non- smoker Age 15-19 15.5 0.0 15.5 13.3 2.2 84.5 100.0 345 20-24 51.3 0.3 51.3 48.4 2.9 48.7 100.0 467 25-29 67.1 0.0 67.1 64.8 2.3 32.9 100.0 464 30-34 73.8 0.3 73.8 72.1 1.7 26.2 100.0 427 35-39 73.1 0.0 73.1 71.2 1.9 26.9 100.0 376 40-44 73.9 0.0 73.9 72.9 1.4 25.7 100.0 346 45-49 73.2 0.0 73.2 71.7 1.5 26.8 100.0 330 Residence Urban 63.2 0.0 63.2 61.8 1.5 36.7 100.0 1,558 Rural 59.1 0.2 59.1 56.4 2.7 40.9 100.0 1,197 Region Yerevan 70.5 0.0 70.5 70.0 0.5 29.5 100.0 833 Aragatsotn 77.9 0.0 77.9 71.6 6.3 22.1 100.0 159 Ararat 58.3 0.0 58.3 51.5 6.8 41.7 100.0 290 Armavir 59.4 0.5 59.4 56.5 2.8 40.6 100.0 268 Gegharkunik 53.6 0.5 53.6 52.9 0.7 46.4 100.0 235 Lori 51.8 0.0 51.8 51.2 1.2 47.5 100.0 184 Kotayk 61.2 0.0 61.2 59.7 1.6 38.8 100.0 299 Shirak 55.2 0.0 55.2 54.7 0.5 44.8 100.0 201 Syunik 37.8 0.0 37.8 35.8 2.1 62.2 100.0 104 Vayots Dzor 58.4 0.0 58.4 56.6 1.8 41.6 100.0 56 Tavush 51.8 0.0 51.8 50.6 1.3 48.2 100.0 126 Education Basic 53.2 0.0 53.2 52.4 0.8 46.8 100.0 360 Secondary 64.2 0.2 64.2 61.9 2.4 35.8 100.0 1,250 Secondary special 62.3 0.0 62.3 60.3 2.3 37.4 100.0 403 Higher 60.0 0.0 60.0 58.0 1.9 40.0 100.0 736 Wealth quintile Lowest 63.3 0.5 63.3 60.5 2.7 36.7 100.0 523 Second 58.3 0.0 58.3 54.5 3.7 41.7 100.0 583 Middle 59.6 0.0 59.6 58.8 0.8 40.4 100.0 521 Fourth 59.3 0.0 59.3 58.0 1.5 40.5 100.0 566 Highest 66.7 0.0 66.7 65.4 1.3 33.3 100.0 562 Total 61.4 0.1 61.4 59.4 2.0 38.5 100.0 2,755 Note: Total includes 5 (weighted) men with no education. 1 Includes daily and occasional (less than daily) use. 2 Includes manufactured cigarettes. 3 Includes cigars, cheroots and cigarillos, pipes full of tobacco, and water pipes. 4 Occasional refers to less often than daily use. 124 • Health Insurance, use of Tobacco, Knowledge and Attitudes about Tuberculosis Table 10.3 Average number of cigarettes smoked daily: Men Among men age 15-49 who smoke cigarettes daily, percent distribution by average number of cigarettes smoked per day, according to background characteristics, Armenia 2015-16 Background characteristic Percent distribution of men who smoke cigarettes by number of cigarettes on average each day Total Number of men who smoke cigarettes daily <5 5-9 10-14 15-24 ≥25 Don’t know/ missing Age 15-19 (0.0) (3.8) (33.8) (51.9) (10.4) (0.0) (100.0) 46 20-24 1.2 1.5 9.2 77.6 10.5 0.0 100.0 226 25-29 0.9 1.4 5.0 72.7 20.0 0.0 100.0 301 30-34 0.2 1.0 4.5 67.7 26.6 0.0 100.0 308 35-39 1.3 0.9 4.7 67.0 26.1 0.0 100.0 268 40-44 0.4 0.4 4.9 64.1 30.2 0.0 100.0 252 45-49 0.5 1.3 5.6 65.2 27.4 0.0 100.0 236 Residence Urban 0.6 0.8 6.5 70.4 21.8 0.0 100.0 962 Rural 0.9 1.7 6.1 65.9 25.4 0.0 100.0 675 Region Yerevan 0.3 0.4 5.9 75.5 18.0 0.0 100.0 583 Aragatsotn 0.0 0.0 2.6 65.6 31.8 0.0 100.0 114 Ararat 0.0 0.8 7.0 68.9 23.4 0.0 100.0 149 Armavir 2.1 3.9 11.3 63.2 19.4 0.0 100.0 151 Gegharkunik 0.0 0.0 0.5 95.2 4.3 0.0 100.0 124 Lori 1.1 1.0 4.9 55.2 37.8 0.0 100.0 95 Kotayk 2.7 3.2 5.1 60.4 28.7 0.0 100.0 178 Shirak 1.1 0.9 6.4 54.3 37.3 0.0 100.0 110 Syunik 0.0 0.0 24.3 51.8 23.9 0.0 100.0 37 Vayots Dzor 0.0 0.0 1.4 29.8 68.8 0.0 100.0 32 Tavush 0.0 3.0 11.2 66.1 19.7 0.0 100.0 63 Education Basic 0.5 3.3 6.3 67.0 22.9 0.0 100.0 189 Secondary 0.7 0.9 6.8 65.8 25.9 0.0 100.0 773 Secondary special 0.4 0.9 8.0 67.0 23.7 0.0 100.0 243 Higher 1.1 0.9 4.4 75.3 18.4 0.0 100.0 427 Wealth quintile Lowest 1.8 2.5 6.6 62.4 26.6 0.0 100.0 317 Second 0.4 0.3 5.0 66.7 27.6 0.0 100.0 318 Middle 0.2 0.8 6.7 70.4 21.8 0.0 100.0 307 Fourth 0.2 1.0 7.5 64.7 26.5 0.0 100.0 328 Highest 1.0 1.0 5.7 77.2 15.1 0.0 100.0 367 Total 0.7 1.1 6.3 68.5 23.3 0.0 100.0 1,637 Note: Figures in parentheses are based on 25-49 unweighted cases. Total includes 4 (weighted) men with no education. 10.3 TUBERCULOSIS Tuberculosis (TB) is a serious health concern in Armenia. In 2015, the incidence of tuberculosis was estimated to be 41 per 100,000, while the incidence of multi-drug-resistant tuberculosis was 8.9 per 100,000. This indicated that more than one-fifth of new TB cases are resistant to standard first-line drug treatment (WHO 2017). Information on the population’s level of TB knowledge and attitudes is crucial for designing effective communication strategies that educate the public about TB and reduce the spread of the disease. To obtain this information, the 2015-16 ADHS included a series of questions to assess the overall level of awareness of tuberculosis, attitudes about the disease, and knowledge about the modes of transmission, symptoms, and the possibility that tuberculosis could be cured. 10.3.1 Knowledge and Attitudes about Tuberculosis Tables 10.4.1 and 10.4.2 present the percentages of women and men age 15-49 who had heard about tuberculosis, and, among those who know about tuberculosis, the percentages who are aware that tuberculosis is spread through the air by coughing or sneezing, who believe that tuberculosis can be cured, and who would want to keep it a secret if a family member had tuberculosis. More than eight in ten women and men say they have heard of tuberculosis, showing that awareness of the disease is widespread in Armenia but not universal. Figure 10.1 shows that, while overall awareness of the disease is common among women and men, only 10 percent of women and 8 percent of men have heard of the multi-drug resistant form of TB. Health Insurance, use of Tobacco, Knowledge and Attitudes about Tuberculosis • 125 Figure 10.1 Knowledge of tuberculosis Tables 10.4.1 and 10.4.2 show that the majority of women and men in all subgroups have heard of TB. The percentage of women who have heard about TB is lowest in the Gegharkunik region (57 percent), in the 15-19 age group (64 percent), and among those who have only basic education (65 percent). Men are least likely to have heard about TB if they are in the 15-19 age group (60 percent), or live in the Gegharkunik (40 percent) and Lori (37 percent) regions. The majority of women and men age 15-49 who have heard about tuberculosis correctly believe that the disease is spread through the air when an infected individual coughs or sneezes (85 percent and 88 percent, respectively). Women and men with only basic education (67 percent and 75 percent, respectively), women living in the Armavir region (72 percent), and men living in the Lori, Shirak, and Vayots Dzor regions (66 percent, 68 percent, and 69 percent respectively) were among the least likely to report that coughing and sneezing can spread TB. Almost seven in ten men but only six in ten women who know about tuberculosis think that the disease can be cured. Regional differences in the proportion believing that TB can be cured are especially marked. For example, only slightly more than one quarter of women in Gegharkunik believe a person with TB can be cured compared with eight in ten or more women in Ararat and Tavush. Around one quarter of men in Lori think TB is curable compared with 92 percent in Aragatsotn. Only a minority of women and men age 15-49 say they would want to keep it secret if a family member had TB. This suggests that most individuals in Armenia do not believe there is stigma associated with the disease. Among those individuals who would want to keep a family member’s TB status secret, women outnumber men; one in four women would hide a family member’s TB status compared with 16 percent of men. Differences in the proportion who would want to keep a family member’s TB a secret are especially marked by region. Women in Lori are least likely and women in Ararat are most likely to express concern about keeping a family member’s TB status secret (3 percent and 49 percent, respectively). Among men, 10 percent or less express a concern about keeping a family member’s TB a secret in all regions except Armavir (36 percent), Ararat (44 percent), and Gegharkunik (96 percent). 86 10 84 8 Heard about TB Heard about multidrug- resistant TB Percentage Women Men ADHS 2015-16 126 • Health Insurance, use of Tobacco, Knowledge and Attitudes about Tuberculosis Table 10.4.1 Knowledge and attitudes concerning tuberculosis: Women Percentage of women age 15-49 who have heard of tuberculosis (TB), and among women who have heard of TB, the percentages who report that TB is spread through the air when an infected person coughs or sneezes, the percentage who believe that TB can be cured, and the percentage who would want to keep secret that a family member has TB, according to background characteristics, Armenia 2015-16 Background characteristic Percentage of women who have heard of TB Number of women Among women who have heard of TB, the percentage who: Report that TB is spread through the air when an infected person coughs or sneezes Believe that TB can be cured Would want a family member’s TB kept secret Number of women who have heard of tuberculosis Age 15-19 64.0 725 77.1 53.7 23.9 464 20-24 81.0 928 84.8 57.9 21.4 752 25-29 89.6 1,099 85.0 59.5 26.1 985 30-34 91.2 1,007 84.6 60.3 24.8 919 35-39 90.8 867 87.0 64.9 20.8 787 40-44 92.0 784 86.9 63.2 27.4 721 45-49 92.2 706 87.5 61.5 26.1 651 Residence Urban 88.7 3,657 86.6 63.9 23.1 3,245 Rural 82.7 2,459 82.7 55.0 26.5 2,033 Region Yerevan 89.2 2,001 86.5 65.8 26.3 1,785 Aragatsotn 82.4 315 94.3 37.4 30.9 260 Ararat 89.7 552 91.8 83.3 48.9 496 Armavir 80.1 586 72.1 43.9 5.8 469 Gegharkunik 56.5 478 81.7 27.2 25.4 270 Lori 79.4 355 80.8 45.4 2.5 282 Kotayk 94.7 678 81.6 52.2 15.7 643 Shirak 91.7 510 87.3 71.2 20.9 468 Syunik 96.8 238 95.8 69.0 30.7 230 Vayots Dzor 93.4 119 68.6 54.2 7.1 111 Tavush 93.3 283 87.1 80.2 43.6 264 Education Basic 65.1 396 67.0 45.4 30.2 258 Secondary 82.4 2,444 80.7 50.9 27.1 2,015 Secondary special 90.7 1,360 86.8 64.3 23.9 1,233 Higher 92.6 1,910 91.6 71.0 20.7 1,769 Wealth quintile Lowest 78.7 1,081 77.2 49.5 22.6 851 Second 86.3 1,242 85.6 58.6 27.3 1,071 Middle 85.3 1,142 84.2 56.6 24.2 974 Fourth 88.9 1,287 87.3 64.5 23.8 1,144 Highest 90.8 1,365 88.8 69.0 23.7 1,239 Total 86.3 6,116 85.1 60.5 24.4 5,278 Note: Total includes 5 (weighted) women with no education. Health Insurance, use of Tobacco, Knowledge and Attitudes about Tuberculosis • 127 Table 10.4.2 Knowledge and attitudes concerning tuberculosis: Men Percentage of men age 15-49 who have heard of tuberculosis (TB), and among men who have heard of TB, the percentages who report that TB is spread through the air when an infected person coughs or sneezes, the percentage who believe that TB can be cured, and the percentage who would want to keep secret that a family member has TB, according to background characteristics, Armenia 2015-16 Background characteristic Percentage of men who have heard of TB Number of men Among men who have heard of TB, the percentage who: Report that TB is spread through the air when an infected person coughs or sneezes Believe that TB can be cured Would want a family member’s TB kept secret Number of men who have heard of tuberculosis Age 15-19 60.2 345 81.5 56.3 9.0 208 20-24 82.1 467 84.8 63.8 20.5 384 25-29 85.3 464 88.7 71.3 18.4 396 30-34 87.9 427 90.6 74.9 14.0 375 35-39 90.5 376 88.9 69.4 14.5 340 40-44 88.4 346 91.3 69.4 11.7 306 45-49 93.0 330 89.6 73.1 16.7 307 Residence Urban 87.4 1,558 90.0 64.5 8.5 1,362 Rural 79.6 1,197 85.7 75.4 25.5 953 Region Yerevan 93.1 833 93.9 59.0 2.1 775 Aragatsotn 96.5 159 96.1 91.8 0.7 154 Ararat 91.4 290 89.4 67.9 44.3 265 Armavir 93.2 268 75.0 77.5 36.1 249 Gegharkunik 40.2 235 97.0 51.3 96.1 94 Lori 37.2 184 65.6 27.4 2.5 69 Kotayk 90.3 299 94.1 86.2 3.1 270 Shirak 93.7 201 67.9 78.8 9.6 189 Syunik 86.7 104 99.3 80.8 4.7 90 Vayots Dzor 76.5 56 68.6 86.2 9.3 43 Tavush 93.4 126 89.2 57.0 6.2 117 Education Basic 79.8 360 74.5 65.3 26.0 287 Secondary 76.1 1,250 87.3 64.5 20.5 951 Secondary special 91.2 403 89.2 65.9 10.3 368 Higher 95.9 736 94.7 78.3 7.1 706 Wealth quintile Lowest 77.0 523 82.1 72.8 29.4 403 Second 82.0 583 88.2 74.4 21.0 478 Middle 79.9 521 86.4 66.9 17.5 416 Fourth 88.4 566 89.1 63.1 10.5 501 Highest 92.0 562 93.6 68.4 2.7 517 Total 84.0 2,755 88.2 69.0 15.5 2,315 Note: Total includes 5 (weighted) men with no education. 128 • Health Insurance, use of Tobacco, Knowledge and Attitudes about Tuberculosis 10.3.2 Knowledge of Tuberculosis Symptoms Respondents in the 2015-16 ADHS were asked to identify symptoms that would lead them to think that a person had TB. All symptoms or signs mentioned by respondents mentioned were recorded. The results in Tables 10.5.1 and 10.5.2 indicate that more than eight in ten women and men in Armenia who know about TB identify coughing as a symptom of the disease. Most of these women and men cite coughing alone without any other signs of illness. However, one-third of women and 39 percent of men mention coughing with sputum and 12 percent of women and 23 percent of men cite a cough that lasts several weeks as symptoms of TB. Slightly more than one-third of women and men mention blood in sputum, 28 percent of women and 17 percent of men cite fever, and 11 percent of men and 10 percent of women consider weight loss as symptoms of TB. Other symptoms such as loss of appetite, pain in the chest, or tiredness/fatigue were identified by 10 percent or less of women and men. Overall, 10 percent of women and 8 percent of men who have heard about tuberculosis are not able to name any TB symptom. The percentages of women and men who are not able to identify any TB symptoms generally decline with age and with increasing education and wealth. With regional differences, the percentages who are unable to identify any TB symptoms are highest among women in Armavir (25 percent) and Vayots Dzor (22 percent) and among men in Shirak (41 percent) and Vayots Dzor (38 percent). Health Insurance, use of Tobacco, Knowledge and Attitudes about Tuberculosis • 129 Table 10.5.1 Knowledge of symptoms of tuberculosis: Women Among women age 15-49 who have heard of tuberculosis (TB), the percentage identifying specific symptoms as signs that would lead them to think a person has tuberculosis, according to background characteristics, Armenia 2015-16 Background characteristic Non- specific coughing Cough- ing with sputum Cough- ing for several weeks Any coughing Fever Blood in sputum Loss of appetite Night sweating Pain in chest Tired- ness/ fatigue Weight loss Lethargy Other Don’t know Number of women who have heard of TB Age 15-19 63.6 23.9 8.8 78.8 21.0 24.0 10.7 2.8 5.0 7.1 7.7 2.0 1.6 16.1 464 20-24 62.9 32.9 10.3 82.9 25.9 35.2 7.3 4.3 5.8 7.2 10.5 1.4 0.3 11.7 752 25-29 61.9 34.5 11.7 83.3 26.6 35.0 9.5 5.8 7.9 7.7 12.9 2.2 0.7 10.2 985 30-34 64.6 35.1 13.3 85.5 28.2 36.0 10.5 5.5 8.1 7.1 10.6 1.6 1.0 10.4 919 35-39 65.8 38.1 13.3 87.5 30.6 38.0 9.2 5.8 6.1 8.0 10.4 2.0 0.6 8.1 787 40-44 62.6 31.9 11.7 85.2 28.3 38.9 11.0 6.0 5.2 8.2 7.0 3.5 1.2 8.0 721 45-49 68.5 32.0 12.2 86.4 30.6 38.0 11.0 3.4 6.2 8.1 11.6 4.2 0.1 6.6 651 Residence Urban 68.1 33.3 10.7 85.4 26.8 37.8 7.9 4.5 6.2 8.2 11.2 2.4 0.9 8.6 3,245 Rural 57.9 33.4 13.7 83.0 28.9 32.1 12.8 5.9 7.2 6.7 9.0 2.3 0.5 12.0 2,033 Region Yerevan 72.8 32.2 10.0 84.9 23.0 40.0 6.9 3.7 6.2 9.4 12.8 1.7 0.9 7.9 1,785 Aragatsotn 45.2 45.8 19.8 88.5 20.0 54.2 28.8 12.0 14.3 6.3 13.9 2.6 0.0 0.1 260 Ararat 60.5 48.6 18.2 93.7 38.3 27.3 13.8 1.8 1.6 2.3 11.1 0.0 0.0 1.7 496 Armavir 58.0 12.1 6.7 71.9 23.5 11.7 7.8 5.6 0.3 7.0 7.0 1.3 0.9 24.5 469 Gegharkunik 38.9 37.3 22.2 81.2 32.4 54.1 10.5 14.3 7.0 8.2 12.8 1.9 0.5 8.9 270 Lori 61.3 23.2 16.8 82.3 33.0 27.4 6.8 2.5 2.6 4.3 2.9 0.7 0.5 13.5 282 Kotayk 56.7 38.5 7.0 81.7 34.0 24.5 4.2 3.6 9.0 6.4 8.1 3.6 1.5 14.7 643 Shirak 69.3 36.1 5.5 85.0 17.8 54.3 11.2 1.3 7.2 6.5 5.6 3.7 0.5 11.4 468 Syunik 71.4 42.7 21.6 98.3 34.2 40.0 16.1 5.8 10.3 11.4 12.3 5.3 0.0 0.4 230 Vayots Dzor 63.4 25.7 7.1 76.2 20.4 10.4 7.1 6.1 8.1 5.7 6.9 0.9 0.0 21.7 111 Tavush 74.1 22.1 14.2 86.2 42.0 35.9 16.4 14.1 14.5 13.8 14.6 8.1 1.7 8.1 264 Education Basic 55.3 27.6 9.7 74.4 21.4 23.6 9.8 4.2 4.2 2.8 7.0 2.6 0.4 21.1 258 Secondary 60.0 29.7 12.5 81.0 24.7 31.1 9.3 4.5 5.5 5.8 7.7 2.3 0.7 13.7 2,015 Secondary special 65.0 33.2 11.7 86.2 28.1 36.5 11.1 6.1 8.0 8.7 10.5 2.3 0.7 7.9 1,233 Higher 69.6 38.4 11.6 88.9 31.5 41.8 9.4 5.0 7.1 9.7 13.8 2.5 0.9 5.3 1,769 Wealth quintile Lowest 57.7 29.3 13.1 79.4 26.8 26.6 10.4 5.2 3.7 5.8 8.1 1.6 0.6 15.6 851 Second 58.4 36.3 14.3 85.1 29.9 35.0 13.0 5.2 7.2 7.1 9.3 2.4 0.4 10.0 1,071 Middle 62.5 30.6 13.1 83.3 27.8 35.8 9.5 5.2 7.9 7.7 11.0 2.8 0.8 10.0 974 Fourth 67.1 33.3 9.8 86.8 26.6 37.1 9.3 4.5 7.3 6.9 10.0 2.6 1.3 7.4 1,144 Highest 72.2 35.7 9.7 86.3 26.9 40.7 7.4 5.1 6.2 10.1 12.7 2.3 0.6 8.2 1,239 Total 64.2 33.3 11.8 84.5 27.6 35.6 9.8 5.0 6.5 7.6 10.4 2.4 0.8 9.9 5,278 Note: Total includes 2 (weighted) women with no education. 130 • Health Insurance, use of Tobacco, Knowledge and Attitudes about Tuberculosis Table 10.5.2 Knowledge of symptoms of tuberculosis: Men Among men age 15-49 who have heard of tuberculosis (TB), the percentage identifying specific symptoms as signs that would lead them to think a person has tuberculosis, according to background characteristics, Armenia 2015-16 Background characteristic Non- specific coughing Cough- ing with sputum Cough- ing for several weeks Any Cough- ing Fever Blood in sputum Loss of appetite Night sweating Pain in chest Tired- ness/ fatigue Weight loss Lethargy Other Don’t know Number of men who have heard of TB Age 15-19 63.7 26.8 15.9 79.0 12.7 23.5 3.5 1.9 1.8 7.6 9.2 2.7 0.0 17.9 208 20-24 55.3 41.4 18.6 85.3 20.6 32.2 6.7 4.3 6.5 9.9 9.1 1.8 0.3 10.4 384 25-29 60.4 40.0 24.1 87.1 14.4 35.2 8.1 7.7 8.2 7.9 11.2 0.8 0.5 7.7 396 30-34 57.8 40.0 23.4 86.7 15.5 33.6 5.6 6.1 4.2 8.4 11.4 2.2 0.2 8.6 375 35-39 62.5 37.3 23.8 89.1 16.3 38.6 6.7 4.8 9.1 10.3 11.3 1.6 0.4 4.4 340 40-44 61.3 38.2 28.9 91.0 15.8 38.8 9.8 9.3 7.3 11.8 13.1 3.3 0.7 5.5 306 45-49 54.2 41.9 25.5 89.4 19.1 42.0 9.0 7.2 9.4 9.5 13.7 2.0 0.0 5.3 307 Residence Urban 65.3 38.9 17.5 89.1 15.3 31.1 6.7 5.6 5.5 7.5 9.5 2.1 0.5 5.8 1,362 Rural 50.1 38.4 31.1 84.3 18.3 41.2 7.9 6.8 8.9 12.1 13.9 1.8 0.1 11.4 953 Region Yerevan 75.8 46.1 10.5 95.8 14.6 22.3 4.5 4.2 2.9 4.5 3.9 1.8 0.5 1.6 775 Aragatsotn 61.8 85.4 79.6 97.0 43.8 30.5 1.9 3.7 0.2 1.5 0.2 1.1 0.0 2.4 154 Ararat 23.4 52.4 30.0 88.7 6.4 21.3 8.4 8.1 6.9 0.2 2.0 3.5 0.0 9.9 265 Armavir 73.9 24.7 0.0 91.8 2.2 19.7 2.3 0.0 0.0 1.8 4.2 0.3 0.3 4.8 249 Gegharkunik 2.6 56.4 55.8 97.5 26.9 93.1 9.0 44.9 12.3 18.9 8.3 6.0 0.0 0.7 94 Lori 55.6 20.9 11.9 82.2 18.2 28.3 1.5 0.0 0.0 3.7 10.5 0.0 0.0 7.0 69 Kotayk 80.3 13.6 38.3 87.9 34.7 72.1 25.3 13.7 25.9 53.5 67.9 2.2 1.1 6.9 270 Shirak 44.2 15.2 6.6 49.3 5.9 33.7 0.6 0.0 12.6 3.0 0.5 1.6 0.0 41.1 189 Syunik 70.9 47.9 17.5 87.2 30.7 37.3 5.5 0.7 3.5 3.1 6.0 4.3 0.0 0.0 90 Vayots Dzor 51.9 15.3 6.5 62.3 13.7 16.5 1.6 1.5 0.6 1.1 21.7 0.0 0.0 37.7 43 Tavush 10.1 20.1 48.1 65.6 3.5 72.4 13.6 0.3 7.7 1.0 1.3 1.3 0.0 13.7 117 Education Basic 55.3 26.4 17.4 81.9 12.8 24.6 4.7 3.9 2.2 5.6 10.8 0.7 0.3 15.2 287 Secondary 56.8 35.9 27.1 86.7 17.4 35.8 7.9 5.4 7.4 10.0 11.0 1.5 0.1 8.6 951 Secondary special 56.7 32.2 25.6 86.1 16.1 37.4 7.8 7.8 7.2 10.9 11.7 2.2 0.3 8.4 368 Higher 64.9 50.9 18.8 90.4 17.1 37.9 7.0 6.9 7.8 9.4 11.7 2.9 0.7 4.3 706 Wealth quintile Lowest 51.8 34.6 23.9 84.8 13.2 32.9 5.6 4.5 5.1 6.8 9.1 0.7 0.0 12.4 403 Second 52.2 39.6 32.7 85.1 22.0 40.4 7.9 6.3 7.7 11.2 13.6 2.7 0.2 11.0 478 Middle 48.9 40.1 25.5 83.7 16.4 43.5 6.5 6.6 8.3 11.3 12.9 1.5 0.7 8.5 416 Fourth 65.0 35.4 20.7 90.0 12.0 33.3 9.7 7.0 5.9 10.7 11.9 2.5 0.6 4.4 501 Highest 73.5 43.0 14.0 90.7 18.6 27.6 6.0 5.8 7.2 6.8 9.1 2.2 0.2 5.3 517 Total 59.1 38.7 23.1 87.1 16.5 35.3 7.2 6.1 6.9 9.4 11.3 2.0 0.3 8.1 2,315 Note: Total includes 3 (weighted) men with no education. Health Insurance, use of Tobacco, Knowledge and Attitudes about Tuberculosis • 131 10.3.3 Knowledge of Organs Affected by Tuberculosis To further assess a respondent’s knowledge of the disease, the 2015-16 ADHS included a question about the organs of the body that may be affected by TB. Tables 10.6.1 and 10.6.2 show that only 23 percent of women and 18 percent of men believe correctly that TB can affect any organ in the body. The majority of both women and men age 15-49 think that TB affects the lungs (66 percent of women and 77 percent of men). Ten percent of women and 5 percent of men are not able to identify any organs that TB affects. Among both women and men, the proportions who correctly believe that any organ in the body may be affected by TB are lowest in the 15-19 age group and generally increase with increasing education and household wealth. Table 10.6.1 Knowledge about organs that can be affected by tuberculosis: Women Among women age 15-49 who have heard of TB, the percentage who report that TB can affect the lungs, and percentage who report that TB can affect any organs and the percentage who don’t know which organs can be affected by TB, according to background characteristics, Armenia 2015-16 Background characteristic Among women who have heard of TB, the percentage who: Report that TB can affect lungs Believe that TB can affect any organs Don’t know which organs can be affected by TB Number of women who have heard of TB Age 15-19 67.7 13.6 18.0 464 20-24 67.5 20.6 11.9 752 25-29 65.7 23.9 10.0 985 30-34 63.2 25.5 10.8 919 35-39 64.4 26.9 8.1 787 40-44 65.7 24.6 8.5 721 45-49 68.7 23.5 7.8 651 Residence Urban 64.3 25.3 9.6 3,245 Rural 68.3 20.1 11.5 2,033 Region Yerevan 64.5 23.5 10.7 1,785 Aragatsotn 89.9 7.1 3.0 260 Ararat 63.4 31.0 5.6 496 Armavir 62.7 15.2 22.1 469 Gegharkunik 62.5 30.9 6.6 270 Lori 72.7 13.4 13.6 282 Kotayk 61.7 25.7 12.4 643 Shirak 66.6 24.1 9.3 468 Syunik 61.2 38.7 0.2 230 Vayots Dzor 67.6 13.8 18.6 111 Tavush 70.0 24.2 5.8 264 Education Basic 65.4 9.2 25.4 258 Secondary 70.8 15.8 13.1 2,015 Secondary special 66.0 25.7 8.0 1,233 Higher 60.3 32.2 6.6 1,769 Wealth quintile Lowest 69.7 14.5 15.6 851 Second 68.0 22.5 9.3 1,071 Middle 67.6 21.4 10.7 974 Fourth 63.9 27.6 8.4 1,144 Highest 61.8 27.6 9.1 1,239 Total 65.9 23.3 10.3 5,278 Note: Total includes 2 (weighted) women with no education. 132 • Health Insurance, use of Tobacco, Knowledge and Attitudes about Tuberculosis Table 10.6.2 Knowledge about organs that can be affected by tuberculosis: Men Among men age 15-49 who have heard of TB, the percentage who report that TB can affect the lungs, and percentage who report that TB can affect any organs and the percentage who don’t know which organs can be affected by TB, according to background characteristics, Armenia 2015-16 Background characteristic Among men who have heard of TB, the percentage who: Report that TB can affect lungs Believe that TB can affect any organs Don’t know which organs can be affected by TB Number of men who have heard of TB Age 15-19 79.2 11.4 9.3 208 20-24 77.8 16.0 5.6 384 25-29 78.8 17.2 3.5 396 30-34 76.6 18.3 5.0 375 35-39 77.1 19.6 2.9 340 40-44 76.3 18.8 4.1 306 45-49 73.7 23.6 2.8 307 Residence Urban 77.0 18.4 4.1 1,362 Rural 77.1 17.6 5.1 953 Region Yerevan 80.7 16.7 1.8 775 Aragatsotn 70.9 26.1 3.0 154 Ararat 83.8 13.3 2.9 265 Armavir 79.2 15.0 5.3 249 Gegharkunik 8.7 91.3 0.0 94 Lori 78.9 10.8 10.3 69 Kotayk 85.1 10.8 4.0 270 Shirak 69.1 14.1 16.7 189 Syunik 81.2 13.7 5.2 90 Vayots Dzor 72.4 2.4 25.2 43 Tavush 87.8 11.8 0.4 117 Education Basic 81.5 10.4 8.1 287 Secondary 79.2 16.0 4.7 951 Secondary special 79.3 14.7 4.9 368 Higher 71.1 25.9 2.6 706 Wealth quintile Lowest 79.1 14.8 5.8 403 Second 75.6 18.2 6.1 478 Middle 76.8 19.1 3.6 416 Fourth 76.8 20.3 2.9 501 Highest 77.2 17.5 4.4 517 Total 77.1 18.1 4.5 2,315 Note: Total includes 3 (weighted) men with no education. 10.3.4 Misconceptions about How Tuberculosis is Spread The ADHS respondents who had heard about tuberculosis were asked to identify ways in which the disease is spread from one person to another. All modes of transmission that respondents mentioned in response to the question were recorded. The results presented in Tables 10.7.1 and 10.7.2 highlight the most common misconceptions about how the disease is spread. Women and men were most likely to think incorrectly that TB can be spread through sharing utensils; 21 percent of women and 12 percent of men believe that TB is spread in this manner. Ten percent of women and 8 percent share a misconception that a person can contract the disease through touching a person with TB. Six percent or less of women and men share other misconceptions about how TB is spread including through food, sexual contact, or mosquito bites. Health Insurance, use of Tobacco, Knowledge and Attitudes about Tuberculosis • 133 Table 10.7.1 Misconceptions about tuberculosis transmission: Women Among women age 15-49 who have heard of tuberculosis (TB), the percentage who report various misconceptions about ways tuberculosis is spread, according to background characteristics, Armenia 2015-16 Background characteristic Through sharing utensils Through touching a person with TB Through food Through sexual contact Through mosquito bites Other Don’t know Number of women who have heard of TB Age 15-19 13.3 7.6 3.8 5.0 1.8 0.0 19.5 464 20-24 16.7 8.9 4.2 2.4 1.4 0.0 12.3 752 25-29 20.5 9.4 5.4 2.4 1.4 0.0 11.3 985 30-34 21.1 10.4 4.1 4.5 0.9 0.0 11.7 919 35-39 20.1 10.3 5.8 4.4 1.2 0.0 9.6 787 40-44 23.1 10.6 7.7 3.9 0.9 0.1 10.3 721 45-49 26.7 13.1 6.0 4.3 2.0 0.1 7.9 651 Residence Urban 19.8 10.0 5.5 2.9 1.2 0.0 10.2 3,245 Rural 21.5 10.2 5.1 5.1 1.5 0.0 13.4 2,033 Region Yerevan 14.8 8.4 5.2 0.9 0.3 0.0 10.0 1,785 Aragatsotn 8.5 4.0 7.9 1.0 0.0 0.0 3.1 260 Ararat 12.0 2.3 3.9 21.3 0.0 0.0 6.7 496 Armavir 26.5 15.4 0.8 0.4 0.2 0.0 23.3 469 Gegharkunik 13.2 23.3 1.3 4.6 0.8 0.0 12.0 270 Lori 20.4 10.3 4.2 3.1 0.4 0.0 15.1 282 Kotayk 36.6 7.8 6.9 0.6 7.4 0.1 15.4 643 Shirak 18.9 13.0 6.4 0.8 0.0 0.0 10.0 468 Syunik 48.3 9.9 7.1 14.3 5.2 0.0 2.6 230 Vayots Dzor 17.0 2.5 18.0 0.0 0.0 0.5 23.4 111 Tavush 23.9 23.1 6.6 3.5 0.3 0.1 7.6 264 Education Basic 12.9 5.7 3.4 3.2 1.2 0.0 28.2 258 Secondary 18.4 9.7 6.4 5.5 1.3 0.0 14.8 2,015 Secondary special 23.3 11.6 4.8 3.5 1.3 0.0 9.9 1,233 Higher 22.1 10.2 4.8 2.0 1.3 0.1 6.1 1,769 Wealth quintile Lowest 16.8 7.5 5.0 2.0 0.5 0.0 19.0 851 Second 22.8 11.1 5.5 8.1 2.3 0.0 10.3 1,071 Middle 20.8 11.2 4.8 3.7 1.3 0.0 12.0 974 Fourth 22.3 8.9 5.9 2.6 1.5 0.1 9.0 1,144 Highest 19.1 11.2 5.3 2.1 0.9 0.0 9.0 1,239 Total 20.5 10.1 5.3 3.7 1.3 0.0 11.4 5,278 Note: Total includes 2 (weighted) women with no education. 134 • Health Insurance, use of Tobacco, Knowledge and Attitudes about Tuberculosis Table 10.7.2 Misconceptions about tuberculosis transmission: Men Among men age 15-49 who have heard of tuberculosis (TB), the percentage who report various misconceptions about ways tuberculosis is spread, according to background characteristics, Armenia 2015-16 Background characteristic Through sharing utensils Through touching a person with TB Through food Through sexual contact Through mosquito bites Other Don’t know Number of men who have heard of TB Age 15-19 7.2 1.6 2.4 1.1 0.2 0.0 15.9 208 20-24 10.2 8.2 5.0 4.9 0.0 0.0 10.6 384 25-29 11.5 11.4 6.4 6.0 0.6 0.5 7.9 396 30-34 11.1 7.1 7.6 3.6 0.3 0.0 9.0 375 35-39 16.6 7.4 7.5 4.9 0.0 0.0 7.3 340 40-44 15.9 7.4 6.9 5.0 0.4 0.0 7.3 306 45-49 13.7 9.9 7.3 5.5 0.0 0.0 6.1 307 Residence Urban 9.7 5.2 5.6 3.6 0.0 0.1 8.3 1,362 Rural 16.4 12.0 7.4 6.1 0.5 0.1 9.5 953 Region Yerevan 6.2 1.6 3.7 0.3 0.0 0.0 5.5 775 Aragatsotn 1.7 1.3 7.2 14.6 0.2 0.0 3.2 154 Ararat 14.6 5.7 0.9 0.2 0.0 0.0 6.5 265 Armavir 18.0 5.7 3.2 0.0 0.0 0.0 8.3 249 Gegharkunik 18.5 9.0 1.7 15.4 0.0 0.0 0.0 94 Lori 5.0 0.0 5.7 3.0 0.0 0.0 31.4 69 Kotayk 35.6 43.7 23.6 15.4 0.0 0.8 5.4 270 Shirak 4.3 7.0 10.7 8.8 2.5 0.0 29.7 189 Syunik 22.6 0.0 1.4 7.1 0.0 0.0 0.7 90 Vayots Dzor 12.7 3.0 2.0 0.9 0.0 0.0 31.4 43 Tavush 2.5 0.6 4.9 0.0 0.0 0.0 10.8 117 Education Basic 11.8 9.0 3.5 1.6 0.1 0.0 17.8 287 Secondary 13.5 8.1 6.8 5.1 0.2 0.1 9.7 951 Secondary special 14.5 9.8 9.5 5.8 0.3 0.3 9.1 368 Higher 10.2 6.6 5.4 4.6 0.2 0.0 3.7 706 Wealth quintile Lowest 14.5 9.6 4.8 5.0 0.3 0.3 12.4 403 Second 15.4 11.2 8.1 5.1 0.2 0.0 7.7 478 Middle 12.8 9.2 7.5 6.2 0.4 0.0 9.6 416 Fourth 11.5 6.5 6.3 5.0 0.2 0.2 9.8 501 Highest 8.8 4.2 5.1 2.3 0.0 0.0 5.6 517 Total 12.4 8.0 6.4 4.6 0.2 0.1 8.8 2,315 Total includes 3 (weighted) men with no education. Child Health • 135 CHILD HEALTH 11 his chapter presents findings about child health, including characteristics of the neonate (birth weight and size), the vaccination status of young children, and treatment practices among children suffering from three childhood illnesses: acute respiratory infection (ARI), fever, and diarrhea. Since appropriate sanitary practices can help prevent and reduce the severity of diarrheal disease, information is provided on the disposal of children’s fecal matter. These results from the 2015-16 ADHS are expected to assist policymakers and program managers in formulating appropriate strategies and interventions to improve the health of children in Armenia. These indicators are based on data collected from mothers of children born in the 5 years before the survey. 11.1 CHILD’S WEIGHT AND SIZE AT BIRTH Birth weight or size at birth is an important indicator of children’s vulnerability to childhood illnesses and their chances of survival. Children whose birth weight is less than 2.5 kilograms, or children reported to be “very small” or “smaller than average,” are considered to have a higher than average mortality risk. For births in the 5 years before the survey, the birth weight was recorded in the questionnaire if the weight was available from child health cards kept at home or from mother’s recall. Because birth weight may not be known for all babies, the mother’s estimate of the baby’s size at birth was also obtained. Table 11.1 presents information on size at birth and weight, according to background characteristics. Only 1 percent of babies were reported by the mother to have been very small at birth and only 7 percent were smaller than average. Babies who were very small or smaller than average at birth are more likely to be those born to women under age 20 and those born to women with only a basic education. Birth weight was obtained for 99 percent of all births in the 5 years before the survey. Of those babies weighed, only 6 percent weighed less than 2.5 kilograms. Newborns of mothers under age 20 and those born to mothers with only basic education were more likely than other newborns to weigh less than 2.5 kilograms. T Key Findings  By mothers’ estimates, 9 percent of children born alive in the 5 years before the survey were very small or smaller than average at birth. Among infants with a birth weight reported, 6 percent weighed less than 2.5 kg.  Almost 9 in 10 children age 24-35 months (89 percent) had received all basic vaccinations at the time of the survey; 73 percent of this age group had received all vaccinations recommended by the Armenia Ministry of Health except pneumococcal (BCG, HepB at birth, MMR, three doses of DPT-HepB-Hib, a fourth dose of DPT, four doses of polio, and two doses of rotavirus).  Only 1 percent of children under age 5 experienced symptoms of an acute respiratory infection (ARI) in the 2 weeks before the survey, while 9 percent had fever and 4 percent had diarrhea in the same time period. 136 • Child Health Table 11.1 Child's size and weight at birth Percent distribution of live births in the 5 years before the survey by mother's estimate of baby's size at birth, percentage of live births in the 5 years before the survey that have a reported birth weight, and among live births in the 5 years before the survey with a reported birth weight, percentage less than 2.5 kg, according to background characteristics, Armenia 2015-16 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 0.8 19.7 79.6 0.0 100.0 99.6 99 12.2 99 20-34 1.4 6.5 91.9 0.3 100.0 99.4 1,475 5.8 1,467 35-49 2.9 9.3 87.8 0.0 100.0 98.0 98 5.9 96 Birth order 1 0.9 7.8 91.0 0.3 100.0 99.3 741 5.4 736 2-3 2.0 6.6 91.2 0.2 100.0 99.6 876 6.9 872 4-5 0.0 11.9 88.1 0.0 100.0 97.5 51 2.5 50 6+ * * * * 100.0 * 4 * 4 Residence Urban 1.7 7.1 90.9 0.2 100.0 99.6 962 7.0 958 Rural 1.0 7.8 90.8 0.4 100.0 99.0 710 5.0 703 Region Yerevan 1.8 4.9 93.3 0.0 100.0 100.0 475 6.3 475 Aragatsotn 0.0 2.2 97.8 0.0 100.0 100.0 61 5.2 61 Ararat 2.0 9.1 87.0 1.9 100.0 96.5 168 6.7 162 Armavir 1.6 12.1 86.2 0.0 100.0 99.7 190 6.1 189 Gegharkunik 0.0 6.5 92.7 0.8 100.0 99.2 77 1.6 76 Lori 0.0 12.9 87.1 0.0 100.0 100.0 99 8.8 99 Kotayk 0.0 8.1 91.9 0.0 100.0 100.0 239 4.2 239 Shirak 1.2 4.0 94.7 0.0 100.0 98.9 168 7.8 166 Syunik 4.4 6.0 89.7 0.0 100.0 99.1 61 8.7 61 Vayots Dzor 6.3 7.1 85.9 0.6 100.0 99.4 37 9.2 37 Tavush 1.7 11.0 86.8 0.4 100.0 99.2 99 5.6 98 Mother's education Basic 1.4 13.2 85.4 0.0 100.0 100.0 95 10.0 95 Secondary 1.4 8.6 89.3 0.7 100.0 98.8 670 6.2 662 Secondary special 1.3 5.7 93.0 0.0 100.0 99.7 346 4.5 345 Higher 1.6 6.0 92.4 0.0 100.0 99.7 562 6.5 560 Wealth quintile Lowest 2.1 9.3 88.4 0.2 100.0 99.0 324 7.7 321 Second 0.6 8.6 90.4 0.3 100.0 99.3 338 6.9 336 Middle 0.5 4.8 94.7 0.0 100.0 99.7 305 3.4 304 Fourth 1.0 9.6 89.4 0.0 100.0 99.5 299 4.9 298 Highest 2.6 5.2 91.5 0.7 100.0 99.3 406 7.4 403 Total 1.4 7.4 90.9 0.3 100.0 99.4 1,672 6.2 1,662 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Based on either a written record or the mother's recall. Child Health • 137 11.2 VACCINATION COVERAGE Armenia’s Ministry of Health has adopted the World Health Organization (WHO) guidelines for childhood immunizations that call for all children to receive the following: a BCG vaccination against tuberculosis; three doses of DPT to prevent diphtheria, pertussis, and tetanus; three doses of polio vaccine; and a measles vaccine, with all but the last to be given during the first year of life. In Armenia, protection against measles is given in the form of an MMR vaccination at 12 months to protect against measles, mumps, and rubella. In addition to these standard recommendations, since 1999, the Ministry of Health has recommended that children receive three doses of the hepatitis B vaccine, with the first dose given at birth. The pentavalent vaccine “DPT/Hep-B/Hib,” which was introduced in September 2009, has replaced the DPT vaccine and is to be given on the same schedule as DPT. The pentavalent vaccine contains, in addition to DPT, the hepatitis B vaccine (Hep-B) and a vaccine against Haemophilus influenza type B (Hib). The 2015-16 ADHS also collected information on the coverage of three doses of pneumococcal vaccine introduced in the routine immunizations for children in Armenia in September 2014 and two doses of the rotavirus vaccine introduced in 2012. Information on vaccination coverage was collected in the 2015-16 ADHS for all children under age 3. In Armenia, child health cards (MOH form 112) and vaccination forms (MOH form 63) are maintained in the local health care facilities. Vaccination certificates (cards kept by the child’s parents or guardian) were made available in 1995. In this survey, data were collected from both sources, when available. A mother who did not have a vaccination certificate was asked to recall her child’s immunizations. She was also asked for consent for survey personnel to obtain vaccination records for the child from the health facility where he/she received the vaccinations. After all the interviews in a cluster were completed, the supervisor visited the local clinic to record information from the health cards of the children in the sample. Information on vaccinations by source of information is shown in Table 11.2. In this report, results are shown for children age 12-23 months, since most vaccines are given to children during infancy and this age group provides the most up-to-date coverage data. However, because children in Armenia receive the measles vaccine at age 12 months, results are also shown for children age 24-35 months. Overall, for more than 9 in 10 children, the immunization data reported here are based on the health facility cards or vaccination certificates (96 percent of children age 12-23 months and 92 percent of children age 24-35 months). While most of the data in Table 11.2 are based on health facility cards or vaccination certificates kept at home, the data are based on the mother’s recall for children for whom a facility card or a vaccination certificate was not located. 138 • Child Health Table 11.2 Vaccinations by source of information Percentage of children age 12-23 months and children age 24-35 months who received specific vaccines at any time before the survey, by source of information (vaccination card or mother's report), and percentage who received specific vaccines by the appropriate age, Armenia 2015-16 Source of information Children age 12-23 months Children age 24-35 months Vaccination card1 Mother's report Either source Vaccinated by appropriate age2,3 Vaccination card1 Mother's report Either source Vaccinated by appro- priate age3,4 BCG 95.5 3.5 99.0 99.0 92.4 6.8 99.2 99.2 HepB (birth dose)5 94.4 3.5 97.9 97.9 91.3 6.8 98.2 98.2 Within 1 day of birth 79.1 na na na 75.2 na na na After 1 day of birth 13.1 na na na 14.5 na na na DPT-HepB-Hib 1 95.0 3.5 98.5 97.7 91.1 5.4 96.4 94.5 2 92.1 3.5 95.6 94.2 89.9 4.8 94.6 92.8 3 90.1 2.6 92.7 90.4 88.3 4.3 92.6 87.4 DPT 4 na na na na 77.0 0.9 77.9 74.4 Polio 1 94.3 3.5 97.8 97.8 92.4 6.5 98.9 96.1 2 93.3 3.5 96.8 96.2 91.4 6.5 97.9 95.0 3 90.6 2.6 93.2 92.0 89.7 5.9 95.6 91.3 4 na na na na 79.0 1.2 80.1 75.7 Pneumococcal 1 59.1 2.6 61.6 61.2 23.7 3.1 26.8 25.5 2 55.5 2.2 57.7 57.3 21.1 3.1 24.2 23.0 3 50.3 1.2 51.5 50.5 15.6 1.9 17.5 17.5 Rotavirus 1 90.0 2.6 92.6 92.6 87.7 4.7 92.4 92.4 2 87.7 2.4 90.2 89.2 84.0 3.3 87.3 85.6 Measles, mumps and rubella (MMR) na na na na 87.4 5.4 92.8 91.2 All basic vaccinations6 na na na na 85.8 3.2 88.9 83.6 All age appropriate vaccinations7 84.2 2.2 86.4 84.4 71.7 0.9 72.6 67.1 No vaccinations 0.3 0.3 0.6 na 0.0 0.6 0.6 na Number of children 325 13 338 338 310 25 335 335 na = Not applicable. BCG = Bacille Calmette-Guerin. DPT = Diphtheria-pertussis-tetanus. HepB = Hepatitis B. Hib = Haemophilus influenza type b. DPT-HepB-Hib is sometimes referred to as Pentavalent. 1 Vaccination card, booklet or other home-based record or a facility based record. 2 Received by age 12 months. 3 For children whose vaccination information is based on the mother’s report, date of vaccination is not collected. The proportions of vaccinations given during the first and second years of life are assumed to be the same as for children with a written record of vaccination. 4 Received by age 12 months for all vaccines except DPT4, Polio4, and measles, mumps and rubella (MMR), which were received by age 24 months. 5 For children whose vaccination information is based on the mother's report, children reported to have received hepatitis B (birth dose) received the vaccine within 24 hours after birth. For children whose vaccination information is based on the written record of vaccination, children are considered to have received hepatitis B (birth dose) if this vaccine is recorded on their card, regardless of when the dose was administered. 6 Basic vaccinations are defined as: BCG, three doses of DPT-HepB-Hib, three doses of oral polio vaccine, and one dose of measles, mumps, and rubella (MMR). 7 Age-appropriate vaccinations are defined as: for children 12-23 months: BCG, HepB (birth dose), three doses of DPT-HepB-Hib, three doses of oral polio vaccine, and two doses of rotavirus vaccine (excludes pneumococcal vaccines) and for children 24-35 months, all of these plus one dose of DPT4, a fourth dose of polio, and one dose of measles, mumps and rubella (MMR). Child Health • 139 Table 11.2 shows, based on data from either source (health card or mother’s recall), that 89 percent of children age 24-35 months have received all the basic WHO-recommended vaccinations, which include BCG, three doses of DPT-HepB-Hib, three doses of polio, and at least one dose of measles, mumps, and rubella (MMR). Almost all these children (84 percent) received these basic vaccinations at the appropriate age. With the additional vaccinations recommended by the MOH (including the hepatitis B vaccine at birth, the two doses of rotavirus vaccine, and for children age 24-35 months, a fourth dose of DPT and a fourth dose of polio)1, coverage is somewhat lower, with 73 percent of children age 24-35 months receiving all and 67 percent receiving them by the appropriate age. Table 11.3 shows rates of vaccination coverage for children age 12-23 and 24-35 months by background characteristics. Almost all children age 12-23 months (98-99 percent) had received vaccinations for BCG, hepatitis B at birth, and the first doses of DPT-HepB-Hib and polio. The proportions of children receiving the second and third doses of DPT-HepB-Hib and polio are slightly lower—93 percent of children completed the required three doses of the DPT-HepB-Hib and polio vaccines. Ninety percent of children age 12-23 months received both doses of the rotavirus vaccine and 52 percent received all three doses of the pneumococcal vaccine. The relatively low coverage for the latter vaccine is expected since the vaccine was only introduced in September 2014. Thus, among children age 12-23 months, 86 percent have received all the age-appropriate vaccinations excluding the recently introduced pneumococcal vaccine. 1 Since the pneumococcal vaccine regimen was only introduced in 2014, it has been ignored in calculating the summary statistics. 14 0 • C hi ld H ea lth Ta bl e 11 .3 V ac ci na ti o ns b y ba ck gr o un d ch ar ac te ri st ic s P er ce nt ag e of c hi ld re n ag e 12 -2 3 m on th s an d ch ild re n ag e 24 -3 5 m on th s w ho r ec ei ve d sp ec ifi c va cc in es a t an y tim e be fo re t he s ur ve y (a cc or di ng t o a va cc in at io n ca rd o r th e m ot he r's r ep or t) , pe rc en ta ge w ith a ll ba si c va cc in at io ns , a nd p er ce nt ag e w ith a ll ag e ap pr op ria te v ac ci na tio ns , b y ba ck gr ou nd c ha ra ct er is tic s, A rm en ia 2 01 5- 16 B ac kg ro un d ch ar ac te ris tic C hi ld re n ag e 12 -2 3 m on th s C hi ld re n ag e 24 -3 5 m on th s: B C G H ep B (b irt h do se )1 D P T -H ep B -H ib P ol io P ne um oc oc ca l R ot av iru s A ll ag e ap pr op ria te va cc in - at io ns 2 N o va cc in - at io ns N um be r of c hi l- dr en M ea sl es , m um ps an d ru be lla (M M R ) D P T 4 P ol io 4 A ll ba si c va cc in - at io ns 3 A ll ag e ap pr op ria te va cc in - at io ns 4 N um be r of ch ild re n 1 2 3 1 2 3 1 2 3 1 2 S ex M al e 99 .3 98 .4 98 .7 97 .4 93 .4 98 .3 97 .9 93 .4 64 .2 58 .5 51 .3 94 .0 91 .3 88 .0 0. 7 17 4 94 .2 74 .2 76 .5 87 .9 68 .3 17 3 Fe m al e 98 .7 97 .3 98 .2 93 .6 91 .9 97 .2 95 .5 93 .0 58 .9 56 .9 51 .7 91 .1 89 .0 84 .7 0. 6 16 4 91 .3 81 .8 84 .0 90 .0 77 .2 16 2 B ir th o rd er 1 99 .3 97 .6 98 .6 95 .7 92 .3 97 .2 97 .2 92 .6 64 .6 61 .4 56 .4 91 .6 89 .7 85 .0 0. 3 14 8 91 .1 74 .7 76 .9 87 .5 71 .4 13 9 2- 3 98 .6 97 .9 98 .5 95 .3 93 .3 98 .3 96 .4 93 .3 61 .8 57 .1 49 .5 93 .7 90 .6 87 .3 0. 9 17 3 94 .0 80 .1 81 .7 89 .7 73 .4 18 6 4- 5 * * * * * * * * * * * * * * * 15 * * * * * 10 6+ * * * * * * * * * * * * * * * 2 * * * * * 1 R es id en ce U rb an 99 .1 97 .1 98 .5 93 .4 90 .9 98 .0 96 .2 91 .8 59 .8 55 .2 49 .3 91 .6 89 .0 84 .0 0. 9 19 3 91 .5 73 .6 75 .3 85 .8 69 .4 18 7 R ur al 98 .9 98 .9 98 .4 98 .4 95 .1 97 .5 97 .5 95 .1 64 .0 61 .1 54 .4 94 .0 91 .7 89 .6 0. 2 14 6 94 .5 83 .4 86 .1 92 .9 76 .7 14 8 M ot h er 's ed uc at io n B as ic * * * * * * * * * * * * * * * 27 * * * * * 22 S ec on da ry 99 .1 98 .4 97 .2 95 .3 92 .1 96 .6 96 .6 92 .2 59 .1 56 .0 48 .1 92 .0 88 .7 85 .0 0. 9 13 6 91 .7 79 .2 81 .0 90 .5 71 .1 12 9 S ec on da ry sp ec ia l 97 .5 96 .1 98 .7 94 .3 94 .3 98 .7 94 .3 94 .3 71 .3 62 .7 59 .6 96 .8 91 .4 88 .8 1. 3 64 95 .1 78 .9 80 .1 87 .9 75 .7 66 H ig he r 99 .5 99 .0 99 .5 95 .6 92 .7 98 .1 97 .6 93 .0 60 .8 57 .7 52 .5 90 .3 90 .0 86 .6 0. 0 11 1 93 .0 74 .9 77 .0 87 .7 71 .2 11 8 W ea lt h q ui nt ile Lo w es t 99 .1 95 .7 98 .4 98 .4 97 .0 99 .1 99 .1 97 .6 66 .8 65 .0 59 .2 94 .9 93 .8 88 .4 0. 9 67 92 .1 83 .6 91 .1 90 .1 78 .8 74 S ec on d 98 .8 98 .8 97 .6 97 .6 91 .4 97 .6 97 .6 91 .4 73 .2 66 .8 57 .2 93 .3 90 .3 85 .7 0. 0 63 95 .9 88 .3 90 .3 93 .5 80 .1 62 M id dl e 97 .8 96 .5 97 .8 94 .7 91 .0 92 .9 92 .9 91 .4 47 .4 45 .5 42 .5 92 .4 90 .5 87 .8 2. 2 68 92 .9 79 .6 78 .2 88 .9 74 .6 60 Fo ur th 10 0. 0 98 .9 98 .0 88 .3 87 .4 99 .1 93 .1 89 .1 57 .0 51 .3 43 .7 93 .1 86 .7 84 .0 0. 0 57 92 .8 80 .4 82 .4 88 .7 80 .4 53 H ig he st 99 .4 99 .4 10 0. 0 97 .3 95 .2 10 0. 0 10 0. 0 95 .2 63 .6 59 .4 53 .6 90 .0 89 .3 85 .9 0. 0 83 91 .1 62 .7 63 .1 84 .8 55 .6 86 T ot al 99 .0 97 .9 98 .5 95 .6 92 .7 97 .8 96 .8 93 .2 61 .6 57 .7 51 .5 92 .6 90 .2 86 .4 0. 6 33 8 92 .8 77 .9 80 .1 88 .9 72 .6 33 5 N ot e: C hi ld re n ar e co ns id er ed to h av e re ce iv ed th e va cc in e if it w as e ith er w rit te n on th e ch ild 's v ac ci na tio n ca rd o r re po rt ed b y th e m ot he r. F or c hi ld re n w ho se v ac ci na tio n in fo rm at io n is b as ed o n th e m ot he r’s r ep or t, da te o f va cc in at io n is n ot c ol le ct ed . T he p ro po rt io ns o f v ac ci na tio ns g iv en d ur in g th e fir st a nd s ec on d ye ar s of li fe a re a ss um ed to b e th e sa m e as fo r c hi ld re n w ith a w rit te n re co rd o f v ac ci na tio n. B C G = B ac ill e C al m et te -G ue rin . D P T = D ip ht he ria -p er tu ss is -t et an us . H ep B = H ep at iti s B . H ib = H ae m op hi lu s in flu en za ty pe b . D P T -H ep B -H ib is s om et im es r ef er re d to a s P en ta va le nt . 1 Fo r ch ild re n w ho se v ac ci na tio n in fo rm at io n is b as ed o n th e m ot he r's r ep or t, ch ild re n re po rte d to h av e re ce iv ed H ep B ( bi rth d os e) r ec ei ve d th e va cc in e w ith in 2 4 ho ur s af te r bi rth . F or c hi ld re n w ho se v ac ci na tio n in fo rm at io n is b as ed o n th e w rit te n re co rd o f v ac ci na tio n, c hi ld re n ar e co ns id er ed to h av e re ce iv ed h ep at iti s B ( bi rt h do se ) i f t hi s va cc in e is r ec or de d on th ei r ca rd , r eg ar dl es s of w he n th e do se w as a dm in is te re d. 2 A ge -a pp ro pr ia te v ac ci na tio ns fo r th os e ag e 12 -2 3 m on th s: B C G , H ep B ( bi rth d os e) , t hr ee d os es o f D P T -H ep B -H ib , t hr ee d os es o f o ra l p ol io v ac ci ne , t w o do se s of r ot av iru s va cc in e at a ny ti m e be fo re th e su rv ey ( ex cl ud es pn eu m oc oc ca l v ac ci ne s) . 3 B as ic v ac ci na tio ns a re d ef in ed a s: B C G , t hr ee d os es o f D P T -H ep B -H ib , t hr ee d os es o f o ra l p ol io v ac ci ne , a nd o ne d os e of m ea sl es , m um ps a nd r ub el la ( M M R ) va cc in e at a ny ti m e be fo re th e su rv ey 4 A ge -a pp ro pr ia te v ac ci na tio ns fo r th os e ag e 24 -3 5 m on th s: B C G , H ep B ( bi rt h do se ), th re e do se s of D P T -H ep B -H ib , a fo ur th d os e of D P T v ac ci ne , f ou r do se s of o ra l p ol io v ac ci ne , t w o do se s of r ot av iru s va cc in e, a nd o ne do se o f m ea sl es , m um ps , a nd r ub el la ( M M R ) v ac ci ne a t a ny ti m e be fo re th e su rv ey ( ex cl ud es p ne um oc oc ca l v ac ci ne s) . 140 • Child Health Child Health • 141 With children age 24-35 months, Table 11.3 shows that 93 percent of children received one dose of the MMR vaccine, 78 percent received the fourth dose of DPT, and 80 percent received the fourth dose of polio vaccine; 89 percent of children age 24-35 months have received all the basic recommended vaccinations, while 73 percent have received all the vaccinations recommended by the Ministry of Health (not including the pneumococcal vaccines). Differences in immunization coverage by sex are minimal, although a higher percentage of girls than boys age 24-35 months have received all the MOH-recommended vaccinations (77 percent versus 68 percent). This gender difference is due to the lower coverage among boys for the fourth doses of DPT and polio. Surprisingly, vaccination coverage is generally lower among urban than rural children. For example, 86 percent of urban children age 24-35 months have received all the basic WHO-recommended vaccinations, compared with 93 percent of rural children. There is no clear association between vaccination coverage and either the mother’s education or the household wealth quintile. 11.3 TRENDS IN VACCINATION COVERAGE In the 2015-16 ADHS, rates of vaccination coverage were calculated separately for children age 12-23 months and 24-35 months to allow for examination of the receipt of vaccines appropriate for the two age groups. However, for the 2010 ADHS, data were presented for children age 18-29 months. For comparison purposes, data from the 2015-16 ADHS survey were re-calculated for the same age group as in the 2010 ADHS, or 18-29 months (Appendix C, Table C.8). The results indicate that vaccination coverage has decreased slightly over the past 5 years for all basic vaccinations among children age 18-29 months. Although 92 percent were fully immunized with the basic vaccines by the date of the interview in 2010, only 89 percent were fully immunized in 2015-16 (Figure 11.1). The coverage levels for most of the individual vaccines have also decreased slightly. Figure 11.1 Trends in vaccination coverage among children 18-29 months 92 100 99 96 95 99 97 95 95 89 99 97 96 93 99 98 95 94 All* BCG DPT1 DPT2 DPT3 Polio 1 Polio 2 Polio 3 MMR Percentage of children age 18-29 months with specific vaccines 2010 ADHS 2015-16 ADHS * Includes BCG, MMR, and 3 doses of DPT and polio 142 • Child Health 11.4 ACUTE RESPIRATORY INFECTION Acute respiratory infection (ARI) is among the leading causes of childhood morbidity and mortality throughout the world. Among acute respiratory diseases, pneumonia is the most serious for young children. Early diagnosis and treatment with antibiotics can prevent a large number of deaths caused by ARIs. In the 2015-16 ADHS, the prevalence of ARIs was estimated by asking mothers whether their children under age 5 had been ill with a cough accompanied by fast, short, rapid, or difficult breathing, which was chest-related, in the 2 weeks before the survey. These symptoms are consistent with ARIs. The morbidity data are subjective because they are based on a mother’s perception of illness without validation by medical personnel. Table 11.4 shows the percentage of children under age 5 who had a cough with symptoms of ARI. From mothers’ reports, it was estimated that only 1 percent of children under age 5 had symptoms of ARI in the 2 weeks before the survey. Prevalence of symptoms of ARI is higher among children living in Ararat region than in other regions. Differences in ARI prevalence by other characteristics are minimal. Due to the small number of children with symptoms of ARI in the 2 weeks before the survey, it is not meaningful to examine treatment behavior. 11.5 FEVER Fever is a symptom of malaria in malaria endemic areas. However, because Armenia is not in a malaria endemic region, fever is regarded as a sign of childhood infections other than malaria, such as ARIs, and throat and ear infections. To obtain information about the frequency of fever, mothers were asked (for each child under age 5) whether the child had had a fever in the 2 weeks before the survey. Table 11.5 shows the percentage of children with fever, by selected background characteristics. Nine percent of all children under age 5 were reported to have had a fever in the 2 weeks before the survey. Fever is most common among children age 36-47 months (11 percent) and least common, at 6 percent, among the youngest children (under 6 months). There are large regional differences in the prevalence of fever, with the highest prevalence occurring in Ararat region (20 percent) and the lowest prevalence in Syunik region (3 percent). The prevalence of fever tends to decrease as mother’s education and wealth quintile increase. Almost three-quarters of children with a fever (72 percent) were taken to a health facility or provider for treatment, and 4 percent were given antibiotics (data not shown). Differences in treatment of fever by background characteristics are not large, and are hampered by small numbers in most categories. Table 11.4 Prevalence and treatment of symptoms of ARI Among children under age 5, the percentage who had symptoms of acute respiratory infection (ARI) in the 2 weeks before the survey, according to background characteristics, Armenia 2015-16 Background characteristic Among children under age five: Percentage with symptoms of ARI1 Number of children Age in months <6 1.1 177 6-11 2.3 180 12-23 0.6 338 24-35 1.1 335 36-47 1.4 309 48-59 2.2 324 Sex Male 1.4 888 Female 1.4 776 Residence Urban 0.7 958 Rural 2.3 705 Region Yerevan 0.0 475 Aragatsotn 0.0 61 Ararat 9.6 166 Armavir 0.8 188 Gegharkunik 0.0 76 Lori 0.7 98 Kotayk 0.8 239 Shirak 0.0 167 Syunik 0.0 61 Vayots Dzor 1.5 36 Tavush 2.6 97 Mother's education Basic 2.3 93 Secondary 1.9 664 Secondary special 0.4 344 Higher 1.3 562 Wealth quintile Lowest 2.1 323 Second 3.0 333 Middle 1.6 303 Fourth 0.6 299 Highest 0.0 406 Total 1.4 1,663 1 Symptoms of ARI is defined as rapid breathing which was chest- related and/or difficult breathing which was chest-related. Child Health • 143 Table 11.5 Prevalence and treatment of fever Among children under age 5, the percentage who had a fever in the 2 weeks before the survey, by background characteristics, Armenia 2015-16 Background characteristic Percentage with fever Number of children Age in months <6 6.0 177 6-11 9.7 180 12-23 8.9 338 24-35 9.2 335 36-47 11.1 309 48-59 9.1 324 Sex Male 8.5 888 Female 9.9 776 Residence Urban 8.2 958 Rural 10.5 705 Region Yerevan 5.6 475 Aragatsotn 8.4 61 Ararat 20.3 166 Armavir 8.9 188 Gegharkunik 4.0 76 Lori 13.4 98 Kotayk 10.4 239 Shirak 9.3 167 Syunik 3.3 61 Vayots Dzor 3.9 36 Tavush 11.3 97 Mother's education Basic 11.4 93 Secondary 10.9 664 Secondary special 7.5 344 Higher 7.8 562 Wealth quintile Lowest 10.3 323 Second 12.3 333 Middle 8.6 303 Fourth 6.5 299 Highest 8.1 406 Total 9.2 1,663 11.6 DIARRHEA Dehydration caused by severe diarrhea is a major cause of death among young children. A simple and effective response to dehydration is a prompt increase in the child’s fluid intake through some form of oral rehydration therapy (ORT). This may include the use of a solution prepared from commercially produced packets of oral rehydration salts (ORS) or a homemade mixture usually prepared from sugar, salt, and water. Increasing the amount of any other liquids given to a child during a diarrheal episode is another means of preventing dehydration. In the 2015-16 ADHS, mothers were asked if each of their children under age 5 had diarrhea during the 2-week period before the survey. If a child had diarrhea, the mother was asked what actions were taken to treat the diarrhea and what feeding practices were followed during the diarrheal episode. 144 • Child Health Table 11.6 shows the percentages of children under age 5 who had diarrhea at some time during the 2-weeks before the survey. It is important to note that the prevalence figures may involve some reporting error because they are based on the mothers’ subjective assessments of their child’s illness. Because there are seasonal variations in the pattern of diarrheal illnesses, the percentages in Table 11.6 may represent the prevalence of diarrhea at the time of the 2015-16 ADHS (December 2015- early April 2016) and not the situation at other times of the year in Armenia. Among children under age 5, only 4 percent were reported by their mothers to have been ill with diarrhea during the 2-week period before the ADHS interview. Children age 6-35 months were slightly more likely to suffer from diarrhea than older children or those under age 6 months. Diarrheal episodes were most common among children living in the Aragatsotn and Shirak regions and least common among those in Yerevan. Diarrhea prevalence among children decreases as mother’s education level and wealth quintile increase. Mothers are encouraged to continue normal feeding of children with diarrhea and to increase the amount of fluids given to the child. These practices help to reduce dehydration and minimize the adverse consequences of diarrhea on the child’s nutritional status. Mothers interviewed in the 2015-16 ADHS were asked whether they gave the child less, the same amount, or more fluids and foods than usual when their child had diarrhea. Table 11.7 shows the percent distribution of children under age 5 who had diarrhea in the 2 weeks before the survey by feeding practices. It is important to remember that only 4 percent of children under age 5 were reported to have had diarrhea in the 2 weeks before the survey, so the findings about treatments are based on small number of cases and should be interpreted with caution. Table 11.7 Feeding practices during diarrhea Percent distribution of children under age 5 who had diarrhea in the 2 weeks before the survey by amount of liquids and food offered compared with normal practice, Armenia 2015-16 Amount of liquids given Amount of food given Number of children with diarrhea More Same as usual Some- what less Much less Don't know/ missing Total More Same as usual Some- what less Much less None Never gave food Total Total 38.9 47.4 7.8 3.8 2.2 100.0 3.4 55.9 34.4 2.8 1.6 1.9 100.0 63 Note: It is recommended that children should be given more liquids to drink during diarrhea and food should not be reduced. Table 11.6 Prevalence of diarrhea Percentage of children under age 5 who had diarrhea in the 2 weeks before the survey, by background characteristics, Armenia 2015-16 Background characteristic Percentage with diarrhea Number of children Age in months <6 1.7 177 6-11 5.3 180 12-23 4.9 338 24-35 4.7 335 36-47 3.2 309 48-59 2.7 324 Sex Male 4.5 888 Female 3.0 776 Toilet facility1 Improved, not shared 3.2 1,299 Non-improved 5.9 352 Shared2 /missing * 12 Residence Urban 2.6 958 Rural 5.4 705 Region Yerevan 0.4 475 Aragatsotn 8.8 61 Ararat 5.7 166 Armavir 6.4 188 Gegharkunik 1.5 76 Lori 2.2 98 Kotayk 5.6 239 Shirak 8.4 167 Syunik 1.7 61 Vayots Dzor 3.9 36 Tavush 1.5 97 Mother's education Basic 6.2 93 Secondary 5.0 664 Secondary special 4.5 344 Higher 1.5 562 Wealth quintile Lowest 5.6 323 Second 4.2 333 Middle 4.7 303 Fourth 3.3 299 Highest 1.7 406 Total 3.8 1,663 1 See Table 2.3 for definition of categories 2 Facilities that would be considered improved if they were not shared by two or more households Child Health • 145 Only 39 percent of children with diarrhea were given more to drink than usual, 47 percent were given the same amount as usual, and 12 percent were given somewhat less or much less than usual. The proportion of children with diarrhea who received more to drink than usual has decreased substantially in the past 5 years, from 65 percent in 2010 to 39 percent in 2015-16. Food intake is curtailed more than fluid intake during episodes of diarrhea. Only 3 percent of children with diarrhea were given more to eat than usual, 56 percent were given the same amount of food as usual, 34 percent were given somewhat less food than usual, and 3 percent were given much less food than usual. Table 11.8 shows the percentage of children with diarrhea who were taken to a health facility or provider for treatment, the percentage who received ORT, and the percentage who were given other treatments. Overall, 41 percent of children with diarrhea were taken to a health facility or provider for treatment of diarrhea. Table 11.8 Diarrhea treatment Among children under age 5 who had diarrhea in the 2 weeks before the survey, percentage for whom advice or treatment was sought from a health facility or provider; percentage given fluid from an ORS packet, homemade fluids (HF), ORS or HF, zinc, ORS and zinc, ORS or increased fluids, oral rehydration therapy (ORT), continued feeding and ORT, and other treatments; and percentage given no treatment, Armenia 2015-16 Percentage for whom advice or treatment was sought from a health facility or provider1 Percentage of children with diarrhea who were given: Miss- ing No treat- ment Number of chil- dren with diarrhea Fluid from ORS packets Home fluids (HF) Either ORS or HF Zinc ORS and zinc ORS or in- creased fluids ORT (ORS, HF, or in- creased fluids) Continued feeding and ORT2 Anti- biotic drugs Anti- motility drugs Intra- venous solution Home remedy/ other Total 40.6 36.9 24.5 48.8 3.7 2.0 36.9 66.4 63.1 18.3 19.5 0.0 7.8 4.1 18.3 63 ORS = Oral rehydration salts. 1 Excludes pharmacy, shop, market, traditional practitioner, and itinerant drug peddler. 2 Continued feeding includes children who were given more, same as usual, or somewhat less food during the diarrhea episode. Oral rehydration therapy, which involves giving children with diarrhea a solution prepared from oral rehydration salts (ORS) or recommended home fluids (HF)—usually a homemade sugar-salt-water solution—is a simple and effective response to diarrheal illness. According to the 2015-16 ADHS, half of children with diarrhea (49 percent) were treated with either ORS (37 percent) or HF (25 percent). Two in three children (66 percent) were treated with ORS, HF, or increased liquids. Antibiotics are generally not recommended for use in treating non-bloody diarrhea in young children. According to the 2015-16 ADHS, 18 percent of children were given antibiotics, 20 percent were given anti-motility drugs, and 4 percent were given a zinc supplement to treat the diarrhea. Eight percent of children were given a home remedy to treat the diarrhea. Eighteen percent of children were given no treatment. Seeking treatment for diarrhea from a health provider has remained roughly stable in the past 5 years; however, the use of ORS packets and particularly, the use of home fluids (HF) for treatment of diarrhea, have decreased considerably. According to the 2010 ADHS, 90 percent of children with diarrhea received ORS, HF, or increased fluids, compared with only 66 percent in the 2015-16 ADHS. The use of antibiotics to treat diarrhea has increased (12 percent in 2010 compared with 18 percent in 2015-16), but the use of anti-motility drugs has remained almost the same (18 percent in 2010 compared with 20 percent in 2015-16). The use of home remedies has decreased over the past 5 years from 26 percent in 2010 to 8 percent in 2015-16. 146 • Child Health 11.7 KNOWLEDGE OF ORS PACKETS As mentioned earlier, a prompt increase in a child’s fluid intake is a simple and effective means to prevent diarrhea from developing into a life-threatening illness. Oral rehydration therapy (ORT) may include the use of a solution prepared from packets of oral rehydration salts (ORS). To ascertain how widespread knowledge of ORS is in Armenia, female respondents were asked if they knew about ORS packets. Table 11.9 shows the percentage of women who gave birth in the 5 years before the survey who know about ORS packets for treatment of diarrhea, by background characteristics. More than 4 in 5 Armenian mothers of young children know about ORS packets (83 percent). Younger mothers are slightly less likely to know about ORS packets than older mothers. By region, the proportion of mothers who know about ORS packets ranges from 70 percent in the Armavir region to 100 percent in the Syunik region. Knowledge of ORS packets increases with level of education of the mother, from only 59 percent of mothers with basic education to 88-89 percent of mothers with secondary special or higher education. Knowledge of ORS packets has increased somewhat in the past 5 years, from 75 percent of mothers in 2010 to 83 percent in 2015-16. 11.8 DISPOSAL OF CHILDREN’S STOOLS Poor hygiene, which includes improper disposal of fecal matter, contributes to the spread of disease, including diarrhea. Table 11.10 shows the percent distribution of youngest children under age 2 living with the mother by the way in which the child’s stools are disposed, according to background characteristics and the type of toilet facilities in the household. The most common method of disposing of young children’s stools is throwing them into the garbage (55 percent), followed by rinsing the stools into a toilet or latrine (33 percent) and having the child use a toilet or latrine (11 percent). Overall, 43 percent of children under age 2 have their stools disposed of safely. Older children are more likely than younger children to have their stools disposed of safely. Differences by urban-rural residence and by mother’s education and wealth quintile are notably small. Differences by region in children’s stool disposal are difficult to interpret due to small numbers of children in some regions. There has been a steep decrease in the past 5 years in the proportion of young children’s stools that are disposed of safely. In the 2010 ADHS, data were tabulated for children under 5, whereas in the 2015-16 ADHS, the table refers to children under 2. However, re-calculating data for 2010 indicates that the proportion of children under age 2 whose stools are disposed of safely has decreased from about 75 percent to only 43 percent in 2015-16. Table 11.9 Knowledge of ORS packets Percentage of women age 15-49 with a live birth in the 5 years before the survey who know about ORS packets for treatment of diarrhea by background characteristics, Armenia 2015-16 Background characteristic Percentage of women who know about ORS packets Number of women Age 15-19 * 18 20-24 73.7 279 25-34 84.6 890 35-49 88.2 173 Residence Urban 83.3 794 Rural 81.6 568 Region Yerevan 80.8 398 Aragatsotn 86.1 51 Ararat 92.8 140 Armavir 70.4 147 Gegharkunik 82.5 65 Lori 74.5 76 Kotayk 90.8 200 Shirak 70.5 130 Syunik 100.0 46 Vayots Dzor 83.6 30 Tavush 90.1 78 Education Basic 58.7 70 Secondary 77.5 533 Secondary special 88.8 286 Higher 88.2 472 Wealth quintile Lowest 75.7 252 Second 86.7 275 Middle 78.6 253 Fourth 88.0 250 Highest 83.4 331 Total 82.6 1,361 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. ORS = Oral rehydration salts Child Health • 147 Table 11.10 Disposal of children's stools Percent distribution of youngest children under age 2 living with the mother by the manner of disposal of the child's last fecal matter, and percentage of children whose stools are disposed of safely, according to background characteristics, Armenia 2015-16 Background characteristic Manner of disposal of children's stools Total Percentage of children whose stools are disposed of safely1 Number of children Child used toilet or latrine Put/rinsed into toilet or latrine Put/rinsed into drain or ditch Thrown into garbage Missing Age of child in months 0-1 (0.0) (36.8) (0.9) (62.2) (0.0) 100.0 (36.8) 41 2-3 1.0 20.7 2.7 75.5 0.0 100.0 21.8 57 4-5 2.4 23.9 0.8 72.9 0.0 100.0 26.3 73 6-8 2.8 42.8 0.0 54.4 0.0 100.0 45.6 86 9-11 7.7 26.2 1.0 65.0 0.0 100.0 34.0 91 12-17 16.7 30.9 3.3 48.7 0.4 100.0 47.7 165 18-23 21.3 40.3 1.6 36.8 0.0 100.0 61.6 148 6-23 14.0 34.9 1.8 49.1 0.1 100.0 48.9 490 Toilet facility2 Improved, not shared 11.0 33.3 0.7 55.0 0.1 100.0 44.2 531 Shared3 * * * * * 100.0 * 5 Unimproved 8.6 29.7 6.2 55.4 0.0 100.0 38.3 125 Residence Urban 9.3 34.4 0.2 55.9 0.2 100.0 43.8 390 Rural 12.7 30.0 3.9 53.4 0.0 100.0 42.7 272 Region Yerevan 6.3 42.1 0.0 51.6 0.0 100.0 48.4 190 Aragatsotn (4.5) (25.8) (4.6) (65.1) (0.0) 100.0 (30.3) 22 Ararat 0.0 15.8 0.0 84.2 0.0 100.0 15.8 65 Armavir 5.4 30.4 6.0 57.3 0.8 100.0 35.8 75 Gegharkunik (15.0) (66.5) (4.0) (14.5) (0.0) 100.0 (81.5) 28 Lori (41.2) (45.8) (0.0) (13.0) (0.0) 100.0 (87.0) 36 Kotayk 4.8 24.0 0.0 71.2 0.0 100.0 28.8 103 Shirak 21.4 13.5 1.6 63.5 0.0 100.0 34.9 64 Syunik (25.0) (60.9) (7.4) (6.7) (0.0) 100.0 (86.0) 24 Vayots Dzor (25.1) (37.6) (14.1) (23.2) (0.0) 100.0 (62.7) 13 Tavush 16.7 21.7 0.0 61.6 0.0 100.0 38.4 42 Mother's education Basic (8.7) (39.8) (3.7) (47.7) (0.0) 100.0 (48.5) 39 Secondary 13.3 30.5 2.9 53.1 0.2 100.0 43.8 264 Secondary special 11.1 31.0 1.4 56.5 0.0 100.0 42.1 132 Higher 7.8 34.8 0.1 57.2 0.0 100.0 42.6 227 Wealth quintile Lowest 15.3 28.2 5.7 50.8 0.0 100.0 43.6 115 Second 10.0 28.1 1.3 60.6 0.0 100.0 38.1 139 Middle 13.8 34.3 2.0 49.9 0.0 100.0 48.1 125 Fourth 9.7 32.6 0.4 56.8 0.5 100.0 42.3 122 Highest 6.3 38.4 0.0 55.3 0.0 100.0 44.7 161 Total 10.7 32.6 1.7 54.9 0.1 100.0 43.3 662 Note: Total includes 1 child for whom type of toilet facility is missing. Figures in parentheses are based on 25-49 unweighted cases; an asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Children's stools are considered to be disposed of safely if the child used a toilet or latrine, if the fecal matter was put/rinsed into a toilet or latrine, or if it was buried. 2 See Table 2.3 for definition of categories. 3 Facilities that would be considered improved if they were not shared by two or more households. 11.9 CHILDHOOD MORTALITY In the 2015-16 ADHS, data on infant and child mortality were collected in the reproductive history section of the Woman’s Questionnaire. Only 16 under-five deaths (unweighted) were reported by women out of total of 1,724 live births in the period 0-4 years prior to the survey. The small number of deaths reported in the ADHS is a reflection of fact that child mortality has been steadily falling in Armenia (NSS, 2015). However, the small number of deaths makes it impossible to derive reliable estimates of child mortality rates from the survey. Consequently, a decision has been made not to present mortality estimates in this report. Users are also cautioned not to consider the preliminary childhood mortality estimates presented in the ADHS Key Indicators report (NSS et al., 2016) as reliable estimates of child mortality levels in Armenia. Nutrition • 149 NUTRITION 12 ood nutrition is a prerequisite for national development and individual wellbeing. Although problems related to poor nutrition affect the entire population, women and children are especially vulnerable because of their unique physiology and socioeconomic characteristics. In children, the period from birth to age 2 is especially important for optimal growth, health, and development. Unfortunately, this period is often marked by protein-energy and micronutrient deficiencies that interfere with optimal physical growth and cognitive development. Illnesses such as diarrhea and acute respiratory infections, which are common in young children, also contribute to nutritional deficiencies (Black et al. 2008). Malnutrition in adults results in reduced productivity, increased susceptibility to infections, slow recovery from illness, and for women, increased risk of adverse pregnancy outcomes (Cesar et al. 2008). A woman with poor nutritional status (indicated by a low body mass index, short stature, anemia, or other micronutrient deficiencies) has a heightened risk of experiencing obstructed labor, having a baby with low birth weight, and dying from postpartum hemorrhage. Morbidity, in general, is high for both the woman and her baby. Numerous socioeconomic and cultural factors influence patterns of feeding and nutritional status. To assess nutritional status in the 2015-16 ADHS, health investigators took height, weight, and hemoglobin measurements of all children under age 5 and all women age 15-49 in the household. In addition, data were collected from women on feeding practices for infants and young children, including breastfeeding, introduction of solid and semi-solid foods, diversity of foods, and frequency of feeding. Information was also collected on the use of iron supplements for both women and children. Cooking salt was also tested for the presence of iodine. This chapter uses these data to assess several aspects of the nutritional status of children and women in Armenia. The chapter includes the nutritional status of women and children under age 5 based on the anthropometric data (height and weight) collected during the survey; infant and young child feeding practices including breastfeeding, complementary feeding patterns, and the prevalence of bottle-feeding; micronutrient intake among mothers and children; iodization of salt used in the household; prevalence of anemia in women and children, and knowledge of anemia among women and men. A summary indicator that describes the quality of infant and young child (age 6-23 months) feeding practices (IYCF) is also included. G Key Findings  Nine percent of children under age 5 are stunted (short for their age); 4 percent of the children are wasted (thin for their height); 3 percent are underweight (thin for their age), and 14 percent are overweight/obese (heavy for their height).  Almost all children (97 percent) are breastfed at some point in their life and 45 percent of infants under 6 months are exclusively breastfed.  Only one-quarter (25 percent) of children age 6-23 months meet the minimum acceptable dietary standards.  Sixteen percent of children 6-59 months are anemic; 13 percent of women age 15-49 are anemic.  Forty-five percent of women age 15-49 are overweight/obese.  All households used iodized salt for cooking. 150 • Nutrition 12.1 NUTRITIONAL STATUS OF CHILDREN The 2015-16 ADHS collected data on the nutritional status of children by measuring the height and weight of all children under age 5 in the interviewed households. The nutritional status assessment helps to identify subgroups of children that face increased risk of faltered growth. 12.1.1 Measurement of Nutritional Status among Young Children All children listed in the household questionnaire who were born in January 2010 or later were eligible for height and weight measurement. Thus, height and weight measurements were collected from children whose mothers may not have been interviewed in the survey. Weight was measured with lightweight scales with digital screens manufactured by SECA (878). Height measurements were carried out with measuring boards provided by UNICEF1. Recumbent length was recorded for children under age 2. Standing height was measured for all other children. Based on these measurements, three internationally accepted indices were constructed to reflect the nutritional status of children:  Height-for-age (the measure to assess stunting)  Weight-for-height (the measure to assess wasting and overweight)  Weight-for-age (the measure to assess underweight) For the 2015-16 ADHS, the nutritional status of children was calculated using growth standards published by the World Health Organization (WHO) in 2006. These growth standards were generated from data collected in the WHO Multicentre Growth Reference Study (WHO Multicentre Growth Reference Study Group 2006). Use of a standard reference population as a point of comparison facilitates the examination of differences in the anthropometric status of subgroups in a population and of changes in nutritional status over time. Each of the three nutritional status indicators described here is expressed in standard deviation (SD) units from the median of the WHO Child Growth Standards. The height-for-age is a measure of linear growth retardation and cumulative growth deficits. Children whose height-for-age Z-score is below minus two standard deviations (-2 SD) from the median of the reference population are considered short for their age (stunted), or chronically undernourished. Children who are below minus three standard deviations (-3 SD) are considered severely stunted. Stunting of a child’s growth may result from failure to receive adequate nutrition over a long period, sustained improper feeding practices, or the effects of repeated episodes of illness. Height-for-age represents a measure of the outcome of malnutrition in a population over a long period and does not vary appreciably with the season of data collection. The weight-for-height index measures body mass in relation to body height or length and describes current nutritional status. The index allows for identification of children who show evidence of recent substantial weight loss, usually from acute shortage of food, severe disease, or both. Children whose weight-for-height Z-score is below minus two standard deviations (-2 SD) from the median of the reference population are considered thin (wasted) or acutely undernourished. Children whose weight-for- height Z-score is below minus three standard deviations (-3 SD) from the reference population median are considered severely wasted. Wasting represents the failure to receive adequate nutrition during the period immediately before the survey and usually shows marked seasonal patterns associated with changes in food availability or disease prevalence. Wasting may result from recent episodes of illness, particularly diarrhea, improper feeding practices, or acute food shortage. 1 Portable baby/child/adult length-height measuring board, UNICEF supply catalogue number S0114540. Nutrition • 151 Weight-for-age is a composite index of height-for-age and weight-for-height that takes into account acute and chronic malnutrition. Children whose weight-for-age Z-score is below minus two standard deviations (-2 SD) from the median of the reference population are classified as underweight. Children whose weight-for-age Z-score is below minus three standard deviations (-3 SD) from the reference population median are considered severely underweight. Overweight and obesity are becoming problems for children in many countries. Children whose weight-for-height Z-score is more than two standard deviations (+2 SD) above the median of the reference population are considered overweight. Mean Z-scores are also calculated for each of the nutritional indices. The mean Z-score describes the nutritional status of the entire population in question without the use of a cut-off. A mean Z-score of less than 0 (a negative mean value) on any of the indices suggests that the status of the children in the survey population (or in a subgroup of the survey population) on that index is, on average, below that of the WHO Growth Standards reference population. 12.1.2 Levels of Child Malnutrition In the survey, children under age 5 in the household were eligible for height and weight measurements. Of the 1,740 children eligible for measurement (age 0-59 months at the time of the survey), height measurements were missing for 7 percent of the children and weight measurements were missing for 6 percent of the children because the child was not present, the parents refused, or the child was ill. Another 8-10 percent of the children were considered to have implausibly high or low values for their height or weight measures. The following analysis focuses on the children for whom complete and plausible anthropometric and age data were collected. Table 12.1 shows the percentage of these children classified as malnourished, according to height-for-age, weight-for-height, and weight-for-age indices, by demographic and other background characteristics. Height-for-age (stunting) The results of data collection show that 9 percent of children under age 5 are stunted or chronically malnourished (height-for-age below -2 SD); 4 percent of children are severely stunted (Table 12.1). Analysis of stunting by age groups shows that stunting is highest (17 percent) among children age 6-8 months and declines rapidly in the second year of age to the lowest (5 percent) among children age 24-35 months, and then oscillates between the 10 and 6 percent among older children (Figure 12.1). Male children are slightly more likely to be stunted than female children (11 percent compared with 8 percent). There is little difference in the level of stunting by birth interval, size at birth, or mother’s nutritional status. However, differences by urban-rural residence, mother’s education, and wealth are considerable. Stunting is more common in rural areas, with rural children twice as likely to be stunted as their urban counterparts (13 and 6 percent, respectively). In general, children born to mothers with less education are more likely to be stunted. For example, children born to mothers with basic education are more than twice as likely to be stunted as children born to mothers with secondary special or higher education. Stunting is more common in the lowest to middle wealth quintile categories (12 percent) than in the fourth and highest wealth quintile wealth categories (6 percent each). There is substantial regional variation in the prevalence of stunted children, ranging from a low of 4 percent in Yerevan to a high of 20 percent in Shirak. 152 • Nutrition Weight-for-height (wasting) Four percent of children under age 5 are wasted (weight-for-height below -2 SD). With differentials by age, wasting is highest in children under age 6 months and age 36-47 months (6 percent each) and lowest (0 percent) in children age 18-23 months. There is little difference in the level of wasting by sex or birth interval. Female and male children are almost equally likely to be wasted. Children who are small or very small at birth are more likely to be wasted than children who are of average size or larger at birth. Wasting in children is more prevalent in Aragatsotn (23 percent), Ararat (13 percent), and Gegharkunik (11 percent) than in other regions (5 percent or less). Weight-for-age (underweight) Overall, 3 percent of children are underweight (weight-for-age below -2 SD). Peak levels of low weight-for-age are found among children less than 9 months old. Children living in Aragatsotn have a higher prevalence of underweight than their counterparts (14 percent compared with 5 percent or less). N ut rit io n • 1 53 Ta bl e 12 .1 N u tr iti o na l s ta tu s of c hi ld re n P er ce nt ag e of c hi ld re n un de r f5 y ea rs c la ss ifi ed a s m al no ur is he d ac co rd in g to th re e an th ro po m et ric in di ce s of n ut rit io na l s ta tu s: h ei gh t- fo r- ag e, w ei gh t- fo r- he ig ht , a nd w ei gh t-f or -a ge , a cc or di ng to b ac kg ro un d ch ar ac te ris tic s, A rm en ia 2 01 5- 16 B ac kg ro un d ch ar ac te ris tic H ei gh t-f or -a ge 1 W ei gh t-f or -h ei gh t W ei gh t-f or -a ge P er ce nt ag e be lo w -3 S D P er ce nt ag e be lo w -2 S D 2 M ea n Z- sc or e (S D ) N um be r of c hi ld re n P er ce nt ag e be lo w -3 S D P er ce nt ag e be lo w -2 S D 2 P er ce nt ag e ab ov e +2 S D M ea n Z- sc or e (S D ) N um be r of ch ild re n P er ce nt ag e be lo w -3 S D P er ce nt ag e be lo w -2 S D 2 P er ce nt ag e ab ov e +2 S D M ea n Z- sc or e (S D ) N um be r of ch ild re n A ge in m o nt hs <6 4. 2 15 .4 -0 .3 15 0 1. 7 6. 3 11 .2 0. 3 15 3 1. 9 7. 5 4. 3 -0 .1 16 3 6- 8 14 .6 16 .9 -0 .0 75 0. 0 1. 6 12 .2 0. 7 75 2. 4 7. 8 8. 1 0. 4 80 9- 11 7. 5 11 .8 -0 .3 85 2. 7 5. 4 12 .6 0. 8 85 0. 0 0. 8 3. 8 0. 4 86 12 -1 7 4. 7 12 .8 -0 .1 16 1 0. 0 2. 1 16 .7 0. 9 15 9 0. 0 0. 4 12 .2 0. 7 16 7 18 -2 3 4. 2 9. 5 -0 .4 15 7 0. 0 0. 0 18 .6 1. 1 15 7 0. 0 0. 0 10 .6 0. 7 16 6 24 -3 5 1. 4 5. 4 0. 2 33 0 2. 2 5. 1 11 .9 0. 6 32 6 0. 0 1. 0 7. 1 0. 5 33 0 36 -4 7 3. 2 9. 7 -0 .3 30 4 2. 1 6. 1 14 .8 0. 6 29 9 0. 8 4. 0 4. 5 0. 3 30 5 48 -5 9 2. 0 6. 2 -0 .2 31 1 1. 8 4. 2 12 .2 0. 4 30 1 1. 1 2. 3 7. 4 0. 2 31 4 S ex M al e 4. 4 10 .9 -0 .2 83 3 1. 2 3. 6 14 .5 0. 7 82 2 1. 0 3. 2 7. 7 0. 3 85 4 Fe m al e 2. 9 7. 8 -0 .0 74 0 1. 9 5. 0 12 .7 0. 6 73 3 0. 4 2. 0 6. 5 0. 4 75 5 B ir th in te rv al in m on th s3 Fi rs t b irt h4 4. 4 9. 7 -0 .2 68 4 1. 2 3. 2 12 .3 0. 6 67 8 0. 9 2. 6 7. 1 0. 4 70 3 <2 4 3. 1 10 .2 -0 .3 19 5 0. 5 5. 1 19 .4 0. 8 19 1 0. 0 3. 3 9. 7 0. 4 19 7 24 -4 7 3. 0 9. 7 -0 .2 31 5 1. 6 4. 6 12 .4 0. 6 30 9 0. 8 1. 1 7. 0 0. 3 31 7 48 + 3. 2 8. 2 0. 0 36 7 2. 6 5. 5 13 .6 0. 5 36 5 0. 5 3. 7 5. 9 0. 4 38 0 S iz e at b ir th 3 V er y sm al l * * * 19 (7 .2 ) (1 2. 4) (8 .7 ) 0. 0 22 (1 9. 5) (3 3. 0) (0 .0 ) 1. 5 23 S m al l 3. 0 10 .9 -0 .2 11 5 3. 5 7. 1 8. 3 0. 4 11 5 0. 6 3. 6 6. 7 0. 2 11 7 A ve ra ge o r la rg er 3. 5 8. 9 -0 .1 1, 42 2 1. 3 3. 8 14 .1 0. 7 1, 40 3 0. 4 2. 1 7. 2 0. 4 1, 45 3 M ot h er 's n u tr iti on al s ta tu s5 T hi n (B M I< 18 .5 ) 6. 3 8. 9 -0 .2 71 1. 9 1. 9 14 .2 0. 5 70 1. 3 1. 3 9. 4 0. 3 73 N or m al ( B M I 1 8. 5- 24 .9 ) 3. 7 10 .5 -0 .2 82 1 1. 2 4. 4 13 .7 0. 6 81 3 0. 8 2. 9 7. 2 0. 4 83 8 O ve rw ei gh t/o be se ( B M I ≥ 2 5) 3. 7 8. 1 -0 .1 53 2 2. 2 4. 4 14 .3 0. 7 52 5 0. 5 2. 5 6. 8 0. 4 54 9 R es id en ce U rb an 2. 4 6. 2 -0 .1 87 6 1. 5 3. 3 11 .5 0. 6 87 7 0. 5 2. 3 5. 4 0. 4 90 7 R ur al 5. 3 13 .4 -0 .2 69 7 1. 5 5. 5 16 .4 0. 7 67 9 0. 9 3. 1 9. 4 0. 4 70 2 R eg io n Y er ev an 1. 5 3. 5 0. 0 41 9 1. 4 1. 4 11 .4 0. 6 42 0 0. 0 1. 9 4. 7 0. 5 44 1 A ra ga ts ot n 11 .0 18 .1 0. 2 65 10 .1 22 .9 10 .3 -0 .4 61 4. 4 14 .3 6. 5 -0 .2 65 A ra ra t 7. 9 13 .7 0. 8 16 1 2. 7 13 .4 35 .9 1. 0 14 7 1. 1 2. 8 34 .8 1. 2 16 4 A rm av ir 1. 5 9. 7 -0 .4 18 5 0. 7 2. 2 13 .1 0. 7 18 7 1. 0 4. 8 1. 7 0. 2 19 1 G eg ha rk un ik 6. 7 9. 9 0. 6 75 3. 5 10 .6 12 .3 0. 2 73 0. 0 0. 0 11 .7 0. 6 74 Lo ri 0. 0 5. 6 -0 .2 69 0. 0 1. 2 10 .8 0. 7 69 0. 0 0. 0 6. 1 0. 3 69 K ot ay k 1. 8 7. 7 -0 .5 24 5 0. 0 1. 1 4. 9 0. 6 24 4 0. 0 1. 2 0. 8 0. 1 24 6 S hi ra k 8. 6 19 .5 -0 .7 16 9 1. 7 5. 1 18 .4 0. 7 17 0 1. 1 2. 4 4. 3 0. 1 17 2 S yu ni k 3. 9 12 .3 -0 .5 62 1. 1 2. 6 12 .2 0. 4 62 2. 0 4. 4 1. 5 -0 .1 63 V ay ot s D zo r 3. 8 11 .5 -0 .5 37 0. 0 2. 2 18 .9 0. 9 36 0. 7 1. 5 6. 8 0. 4 37 T av us h 1. 8 7. 4 -0 .5 86 0. 0 0. 0 7. 8 0. 8 86 1. 0 1. 0 4. 5 0. 3 87 (C on tin ue d… ) Nutrition • 153 15 4 • N ut rit io n Ta bl e 12 .1 –C o nt in ue d B ac kg ro un d ch ar ac te ris tic H ei gh t-f or -a ge 1 W ei gh t-f or -h ei gh t W ei gh t-f or -a ge P er ce nt ag e be lo w -3 S D P er ce nt ag e be lo w -2 S D 2 M ea n Z- sc or e (S D ) N um be r of c hi ld re n P er ce nt ag e be lo w -3 S D P er ce nt ag e be lo w -2 S D 2 P er ce nt ag e ab ov e +2 S D M ea n Z- sc or e (S D ) N um be r of ch ild re n P er ce nt ag e be lo w -3 S D P er ce nt ag e be lo w -2 S D 2 P er ce nt ag e ab ov e +2 S D M ea n Z- sc or e (S D ) N um be r of ch ild re n M ot h er 's e d uc at io n6 B as ic 5. 5 17 .3 -0 .3 91 1. 2 5. 7 24 .4 0. 8 89 0. 0 3. 1 7. 7 0. 2 91 S ec on da ry 4. 0 10 .6 -0 .2 64 0 1. 3 5. 9 14 .2 0. 6 63 2 0. 7 2. 7 7. 9 0. 3 65 0 S ec on da ry s pe ci al 3. 8 8. 2 -0 .2 32 7 0. 6 1. 6 13 .6 0. 7 32 1 1. 2 1. 6 6. 3 0. 4 33 2 H ig he r 3. 0 7. 3 -0 .1 51 0 2. 4 3. 7 11 .0 0. 6 50 9 0. 4 3. 1 6. 7 0. 4 53 3 W ea lt h q ui nt ile Lo w es t 3. 2 12 .0 -0 .2 31 5 1. 1 6. 1 16 .8 0. 6 30 9 1. 4 4. 9 9. 5 0. 2 31 5 S ec on d 3. 9 11 .5 -0 .1 32 5 2. 7 5. 6 16 .1 0. 6 31 9 0. 5 1. 6 12 .0 0. 5 33 3 M id dl e 7. 1 11 .5 -0 .3 30 0 1. 0 4. 3 15 .1 0. 7 29 3 0. 3 1. 8 6. 3 0. 4 30 2 Fo ur th 2. 7 6. 2 -0 .2 26 4 0. 6 2. 3 12 .5 0. 7 26 6 0. 8 2. 0 3. 7 0. 4 27 4 H ig he st 1. 9 5. 9 -0 .0 36 9 1. 8 2. 8 8. 5 0. 5 36 8 0. 5 2. 8 4. 1 0. 3 38 4 T ot al 3. 7 9. 4 -0 .1 1, 57 3 1. 5 4. 2 13 .6 0. 6 1, 55 5 0. 7 2. 6 7. 2 0. 4 1, 60 9 N ot e: T ab le is b as ed o n ch ild re n w ho s ta ye d in t he h ou se ho ld o n th e ni gh t be fo re t he in te rv ie w . E ac h of t he in di ce s is e xp re ss ed in s ta nd ar d de vi at io n un its ( S D ) fr om t he m ed ia n of th e W H O C hi ld G ro w th S ta nd ar ds a do pt ed in 2 00 6. T he in di ce s in th is ta bl e ar e N O T c om pa ra bl e to th os e ba se d on th e pr ev io us ly u se d N C H S /C D C /W H O r ef er en ce . T ab le is b as ed o n ch ild re n w ith v al id d at es o f bi rth ( m on th a nd y ea r) a nd v al id m ea su re m en t o f b ot h he ig ht a nd w ei gh t. Fi gu re s in pa re nt he se s ar e ba se d on 2 5- 49 u nw ei gh te d ca se s. T ot al in cl ud es 3 c as es w ith m is si ng in fo rm at io n on c hi ld re n’ s si ze a t b irt h an d 5 ch ild re n w ho se m ot he rs h av e no e du ca tio n. 1 R ec um be nt le ng th is m ea su re d fo r c hi ld re n un de r ag e 2, o r i n th e fe w c as es w he n th e ag e of th e ch ild is u nk no w n an d th e ch ild is le ss th an 8 5 cm ; s ta nd in g he ig ht is m ea su re d fo r al l o th er c hi ld re n. 2 In cl ud es c hi ld re n w ho a re b el ow - 3 st an da rd d ev ia tio ns (S D ) f ro m th e W H O C hi ld G ro w th s ta nd ar ds p op ul at io n m ed ia n. 3 E xc lu de s ch ild re n w ho se m ot he rs w er e no t i nt er vi ew ed . 4 Fi rs t- bo rn tw in s (t rip le ts , e tc .) ar e co un te d as fi rs t b irt hs b ec au se th ey d o no t h av e a pr ev io us b irt h in te rv al . 5 E xc lu de s ch ild re n w ho se m ot he rs w er e no t w ei gh ed a nd m ea su re d, c hi ld re n w ho se m ot he rs w er e no t i nt er vi ew ed , a nd c hi ld re n w ho se m ot he rs a re p re gn an t o r ga ve b irt h w ith in th e pa st 2 m on th s. M ot he r's n ut rit io na l s ta tu s in te rm s of B M I (B od y M as s In de x) is p re se nt ed in T ab le 1 2. 9. 6 F or w om en w ho a re n ot in te rv ie w ed , i nf or m at io n is ta ke n fr om th e H ou se ho ld Q ue st io nn ai re . E xc lu de s ch ild re n w ho se m ot he rs a re n ot li st ed in th e H ou se ho ld Q ue st io nn ai re . 154 • Nutrition Nutrition • 155 Overweight Table 12.1 also shows the proportion of children who are more than 2 standard deviations above the reference median. These children are considered to be heavy for their height. Fourteen percent of children under age 5 are overweight (weight-for-height above +2 SD units). This indicates that overweight is more of a concern than underweight among Armenian children. Although differences are small, levels of overweight-for-height are higher among boys (15 percent) than girls (13 percent), and higher among rural children (16 percent) than urban children (12 percent). Children living in Ararat (36 percent) are more likely to be overweight than children living in other regions (5-19 percent). Children born to mothers with only basic education are more likely to be overweight (24 percent) than children born to more educated mothers (11-14 percent, respectively). The proportion of children who are overweight declines steadily as wealth quintile increases. Figure 12.1 Nutritional status of children by age The nutritional status of children varies with age, as shown in Figure 12.1. After being stable in the first 6-7 months of life at a high of 15-16 percent, the prevalence of stunting steadily declines with age from 8 months through the first 2 years of life before increasing again in the third and fourth years. The levels of wasting and underweight peak at 6-10 months when complementary food is typically introduced in addition to breast milk. After age 12 months, both wasting and underweight levels remain low, before increasing again after the second year of age. 0 5 10 15 20 25 30 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 Percent Age (months) Stunted Wasted Underweight Note: Stunting reflects chronic malnutrition; wasting reflects acute malnutrition; underweight reflects chronic or acute malnutrition or a combination of both. Plotted values are smoothed by a five-month moving ADHS 2015-16 156 • Nutrition 12.1.3 Trends in Children’s Nutritional Status The nutritional status of Armenian children as measured by the 2015-16 ADHS can be compared with data from two previous DHS surveys conducted in Armenia in 2005 and 20102. Figure 12.2 depicts trends in children’s nutritional status between the 2005 and 2015-16 ADHSs, according to stunting, wasting, underweight, and overweight categories. Figure 12.2 shows that stunting decreased from 18-19 percent in 2005 and 2010, to 9 percent in 2015-16. Levels of wasting have not changed since 2005. The proportion of underweight children has decreased by almost half from 5 percent in 2010 to 3 percent in 2015-16. The proportion of overweight children (weight-for-height above +2 SD units) increased from 11 percent in 2005 to 15 percent in 2010, but has not changed over the last 5 years (14 percent in 2015-16). Further investigation is needed to better understand the reasons that may underlie the improvements in the rates of stunting and, to a lesser degree, of underweight in 2015-16 ADHS survey compared to the levels observed in the 2005 and 2010 ADHS surveys. The stunting values for children under age 2 are similar among children under age 24 months across the three surveys (14 percent in 2005 ADHS, 17 percent in 2010 ADHS, 13 percent in 2015-16 ADHS). Stunting among children age 24-59 months is markedly high in 2010 (21 percent) than in the 2015-16 ADHS (7 percent) and 2005 ADHS (12 percent). Factors that may have contributed include differences in the equipment utilized for collecting the height measures3, as well as in the timing of the fieldwork in the three surveys4. Sampling variability also plays a role. However, the comparisons of the 2005-2010 ADHS nutrition status information with the 2015-16 ADHS findings suggest that, as was true in the earlier ADHS surveys, Armenian children continue to be more likely to experience stunting and overweight than to be underweight or wasted. 2 The 2000 ADHS data on children’s nutritional status are not used in this trend analysis because anthropometric measurements were restricted to children born to women who were interviewed. The 2005, 2010, and 2015-16 ADHS surveys included height and weight measurements of all children born in the 5 years before the survey and listed in the Household Questionnaire, irrespective of the interview status of their mother. The levels of stunting, wasting, and underweight shown in Figure 12.2 differ from the data published in the 2005 ADHS survey report (NSS et al. 2006), which were derived using the National Center for Health Statistics (NCHS) reference standards. In order to assess trends in nutrition status, the 2005 ADHS nutrition indicators were re-calculated with the 2006 WHO Child Growth Standards. 3 The 2015-16 ADHS survey employed portable baby/child/adult length-height measuring boards (UNICEF supply catalogue number S0114540) and the 2005 ADHS survey employed Shorr boards. Locally constructed height boards were used in the 2010 ADHS. 4 The 2015-16 ADHS was conducted in the height of winter while the two earlier surveys were conducted largely in the fall. Because of the timing of the 2015-16 ADHS, it was more difficult to fully undress children for the anthropometric measurement, which may have contributed to differences in the nutrition indicators between the 2015- 16 ADHS and the earlier surveys. Although it was not preferable to conduct the fieldwork in the height of winter, the ADHS data collection commenced in December 2015 in order to expeditiously provide the MOH with the ADHS anemia testing results. The MOH needed the data on anemia prevalence to advocate for a flour fortification program proposed to the parliament that would prevent and control anemia in Armenia. Nutrition • 157 Figure 12.2 Trends in nutritional status of children under age 5, 2005-2016 12.2 BREASTFEEDING AND SUPPLEMENTATION 12.2.1 Initiation of Breastfeeding Early initiation of breastfeeding is encouraged for a number of reasons. Mothers benefit from early suckling because it stimulates breast milk production and facilitates the release of oxytocin, which helps the uterus to contract and reduces postpartum blood loss. The first breast milk contains colostrum, which is highly nutritious and has antibodies that protect the newborn from diseases. Prelacteal feeding (giving something other than breast milk in the first three days of life) is generally discouraged because it may inhibit breastfeeding and expose the newborn infant to illness. The importance and necessity of breastfeeding has been well recognized in Armenia since the 1993 adoption of the State Program on Breastfeeding by the Ministry of Health. In conjunction with the state program, reforms occurred in maternity hospitals as part of the Baby Friendly Hospital Initiative (BFHI). Examples of these reforms include establishing immediate contact between mother and newborn after delivery, initiating early breastfeeding (in the first 30 to 60 minutes after birth), allowing the mother and newborn to stay in the same hospital room, breastfeeding the baby on demand, and other Baby Friendly practices. The BFHI Program has expanded since 2000, but has not changed since 2010 when 22 maternity hospitals and 10 polyclinics had earned Baby Friendly status. Table 12.2 presents the breastfeeding status of all last-born children born in the 2 years5 before the survey by background characteristics. The table shows the percentage of children according to whether they were ever breastfed, when they started breastfeeding, and whether they were fed anything other than breast milk prior to the commencement of breastfeeding. Breastfeeding is almost universal in Armenia; 97 percent of last-born children born in the 2 years before the survey were breastfed at some point in their life. 5 For the 2000 and 2005 ADHS surveys, the initiation of breastfeeding indicators were reported for all children born in the 5 years before the survey. Initiation of breastfeeding within 1 hour and within 1 day of birth was calculated among the children who were ever-breastfed, whereas the 2010 and 2015-16 results are based on last-born children who were born in the 2 years before the survey. Hence, caution should be observed when comparing the figures in this table with the results published in the final reports for previous ADHS surveys. 18 5 4 11 19 4 5 15 9 4 3 14 Stunting (height-for-age) Wasting (weight-for-height) Underweight (weight-for-age) Overweight Percent 2005 ADHS 2010 ADHS 2015-16 ADHS Note: The data for all three surveys are based on the WHO Child Growth standards adopted in 2006. 158 • Nutrition Overall, 41 percent of last-born children were breastfed within 1 hour after birth, and 86 percent were breastfed within 1 day after birth. Table 12.2 Initial breastfeeding Among last-born children who were born in the 2 years before the survey, the percentage who were ever breastfed and the percentages who started breastfeeding within 1 hour and within 1 day of birth; and among last-born children born in the 2 years before the survey who were ever breastfed, the percentage who received a prelacteal feed, according to background characteristics, Armenia 2015-16 Background characteristic Among last-born children born in the past 2 years: Among last-born children born in the past 2 years who were ever breastfed: Percentage ever breastfed Percentage who started breastfeeding within 1 hour of birth Percentage who started breastfeeding within 1 day of birth1 Number of last- born children Percentage who received a prelacteal feed2 Number of last- born children ever breastfed Sex Male 97.0 40.3 84.8 337 11.5 327 Female 96.0 41.5 86.4 329 10.7 316 Residence Urban 96.7 35.3 84.8 391 13.1 378 Rural 96.1 48.7 86.7 275 8.2 265 Region Yerevan 96.8 34.9 87.2 190 14.2 184 Aragatsotn (100.0) (67.8) (86.2) 22 (13.6) 22 Ararat 91.6 74.4 91.6 65 7.9 59 Armavir 94.0 16.3 59.1 79 5.6 74 Gegharkunik (98.0) (59.5) (98.0) 28 (0.0) 27 Lori (100.0) (20.1) (97.4) 36 (0.0) 36 Kotayk 99.0 27.4 83.6 103 17.2 102 Shirak 97.6 65.8 94.5 65 4.7 63 Syunik (100.0) (37.5) (97.2) 24 (4.9) 24 Vayots Dzor (92.2) (27.9) (83.8) 13 (25.1) 12 Tavush 93.1 54.0 84.4 43 21.8 40 Mother's education Basic (89.4) (34.3) (73.5) 39 (8.7) 35 Secondary 96.8 43.5 86.5 266 7.5 258 Secondary special 97.9 41.8 89.5 133 15.8 130 Higher 96.5 38.4 84.3 229 12.9 221 Wealth quintile Lowest 94.8 45.2 83.0 117 8.3 111 Second 96.5 50.7 83.5 141 9.0 136 Middle 97.2 36.3 81.1 126 13.9 122 Fourth 98.0 36.0 86.1 122 14.5 119 Highest 96.0 36.4 92.3 161 10.0 155 Total 96.5 40.9 85.6 666 11.1 643 Note: Table is based on last-born children born in the 2 years before the survey regardless of whether the children are living or dead at the time of interview. Figures in parentheses are based on 25-49 unweighted cases. 1 Includes children who started breastfeeding within 1 hour of birth. 2 Children given something other than breast milk during the first 3 days of life. Differences in early initiation of breastfeeding are small by sex of the child. Children in rural areas are more likely to start breastfeeding during the first hour after birth than children in urban areas. Almost half (49 percent) of children in rural areas started breastfeeding within 1 hour of birth compared with over one-third of children in urban areas (35 percent). However, this difference is almost gone within the next 24 hours, with 87 percent of children in rural areas and 85 percent in urban areas initiating breastfeeding within 1 day of birth. Children born to mothers with secondary special education and children from households in the highest wealth quintile are more likely to begin breastfeeding within 1 day of birth compared with children born to mothers with other levels education or wealth. Among last-born children under age 2 who were ever breastfed, 11 percent received a prelacteal feed (something other than breast milk during the first three days of life). Children born in urban areas were more likely to receive a prelacteal feed than children born in rural areas (13 percent and 8 percent, respectively). Regional variations in prelacteal feeding are notable but are hampered by the small number of children in some regions. There is no clear relationship between prelacteal feeding and the mother’s education or wealth quintile. Comparisons with data from the 2000, 2005 and 2010 ADHSs indicate that the percentage of children who were breastfed within 1 hour of birth has markedly increased over the past 15 years (25 percent in 2000, 32 percent in 2005, 36 percent in 2010, and 41 percent in 2015-16, with the sharpest Nutrition • 159 increase observed during the period between the 2000 ADHS and the 2005 ADHS6. The percentage of children who started breastfeeding within 1 day of birth also increased rapidly, from 70 percent in 2000 to 78 percent in 2005, 84 percent in 2010, and 86 percent in 2015-16 (ICF 2015b). 12.2.2 Breastfeeding Status by Age Breast milk is the optimal source of nutrients for infants. Children who are exclusively breastfed receive only breast milk. Exclusive breastfeeding is recommended during the first 6 months of a child’s life because it limits exposure to disease agents and provides all the nutrients that are required for a baby. As the infant grows, breast milk alone no longer provides sufficient nourishment, and other liquids and foods need to be added to a child’s diet. The 2015-16 ADHS collected data on infant and young child feeding for all last-born children under age 2 living with their mothers, using a 24-hour recall method. Table 12.3 shows the percent distribution of youngest children under age 2 living with the mother by breastfeeding status, and the percentage of children under age 2 using a bottle with a nipple, according to age in months.7 Figure 12.3 illustrates breastfeeding practices by age in Armenia. The results presented in Table 12.3 and Figure 12.3 show that 85 percent of children under age 6 months in Armenia are breastfed. The duration of breastfeeding, however, is not long; at age 12-17 months, 69 percent of infants are no longer breastfed. By age 18-23 months, 74 percent of children have been weaned. Table 12.3 Breastfeeding status according to age Percent distribution of youngest children under age 2 who are living with their mother by breastfeeding status and percentage currently breastfeeding; and the percentage of all children under age 2 using a bottle with a nipple, according to age in months, Armenia 2015-16 Age in months Not breast- feeding Breastfeeding status Total Percentage currently breast- feeding Number of youngest children under age 2 living with the mother Percentage using a bottle with a nipple Number of all children under age 2 Exclusively breastfed Breast- feeding and consuming plain water only Breast- feeding and consuming non milk liquids1 Breast- feeding and consuming other milk Breast- feeding and consuming comple- mentary foods 0-1 (6.9) (79.7) (4.7) (2.9) (1.0) (4.8) (100.0) (93.1) 41 (8.6) 42 2-3 11.4 57.2 9.8 0.4 8.0 13.1 100.0 88.6 57 24.9 60 4-5 22.3 14.8 20.6 2.8 4.0 35.5 100.0 77.7 73 53.6 75 6-8 29.1 6.7 1.3 0.0 0.0 62.9 100.0 70.9 86 53.5 87 9-11 29.1 0.7 0.0 0.7 0.0 69.5 100.0 70.9 91 66.6 94 12-17 69.2 0.4 0.0 0.0 0.0 30.4 100.0 30.8 165 56.3 170 18-23 73.6 0.0 0.0 0.0 0.0 26.4 100.0 26.4 148 50.1 169 0-3 9.5 66.6 7.7 1.5 5.1 9.6 100.0 90.5 99 18.2 101 0-5 15.0 44.5 13.2 2.0 4.6 20.7 100.0 85.0 172 33.3 177 6-9 28.0 5.1 0.9 0.0 0.0 66.0 100.0 72.0 124 56.1 126 12-15 64.0 0.6 0.0 0.0 0.0 35.4 100.0 36.0 109 56.9 113 12-23 71.3 0.2 0.0 0.0 0.0 28.5 100.0 28.7 313 53.2 338 20-23 78.4 0.0 0.0 0.0 0.0 21.6 100.0 21.6 82 44.7 97 Note: Breastfeeding status refers to a "24-hour" period (yesterday and last night). Children who are classified as breastfeeding and consuming plain water only consumed no liquid or solid supplements. The categories of not breastfeeding, exclusively breastfed, breastfeeding and consuming plain water, non-milk liquids, other milk, and complementary foods (solids and semi-solids) are hierarchical and mutually exclusive, and their percentages add to 100 percent. Thus children who receive breast milk and non-milk liquids and who do not receive other milk and who do not receive complementary foods are classified in the non-milk liquid category even though they may also get plain water. Any children who get complementary food are classified in that category as long as they are breastfeeding as well. Figures in parentheses are based on 25-49 unweighted cases. 1 Non-milk liquids include juice, juice drinks, clear broth, or other liquids. Contrary to recommended practices, supplementation of breast milk with other liquids or foods starts at an early age, with just under half (45 percent) of children under age 6 months exclusively breastfed. In addition to breast milk, 13 percent of children under age 6 months consume plain water, 5 6 In order to assess trends in early initiation of breastfeeding, the 2000 ADHS and 2005 ADHS initiation of breastfeeding indicators have been re-calculated for all last-born children born in the 2 years before the survey. 7 When comparing the total results of the 2015-16 ADHS to the 2000 and 2005 surveys, it should be noted that in 2015-16, the table on breastfeeding status by age is restricted to the youngest children under age 2 living with their mothers instead of the youngest children under age 3 living with their mothers (as in the 2005 ADHS report) and instead of all children under age 3 (as in the 2000 ADHS report). 160 • Nutrition percent consume other milk, 2 percent consume non-milk liquids, and 21 percent consume complementary foods. Use of bottles with a nipple for infant feeding is widespread in Armenia. Twenty-five percent of children age 2-3 months are bottle fed. This proportion increases with age and peaks at 67 percent among children age 9-11 months before declining. For the younger children (2-3 months old), the use of a bottle with a nipple for feeding has decreased by 12 percentage points since the 2010 ADHS, from 37 percent in 2010 to 25 percent in 2015-16; for children age 9-11 months, it has decreased by 9 percentage points, from 76 percent in 2010 to 67 percent in 2015. Since 2010, the proportion of children under age 6 months who were breastfeeding at the time of the survey has decreased slightly from 89 percent in 2010 to 85 percent in 2015-16. Exclusive breastfeeding, as recommended by the Ministry of Health, shows improvement in this age group (35 percent in 2010 compared with 45 percent in 2015-16). The proportion of children under age 6 months who received complementary foods in addition to breast milk has increased from 17 percent in 2010 to 21 percent in this survey. The pattern of weaning at an early age has not changed. Among children age 6-8 months, 29 percent are not breastfed, which remains unchanged since 2010. Sixty-three percent of children age 6-8 months received breast milk and complementary foods in 2015-16, which indicated an increase of 15 percentage points since 2010 (48 percent). Figure 12.3 Infant feeding practices by age Figure 12.4 shows 2015-16 ADHS results for key infant and young child feeding (IYCF) practices. As noted above, 45 percent of children under age 6 months are exclusively breastfed, and 90 percent of children age 6-8 months are given a timely introduction of complementary foods. More than three in ten children (36 percent) are still breastfeeding at age 1, and a little more than two in ten children are still breastfeeding at age 2 (22 percent). Forty-three percent of Armenian children age 0-23 months are given age-appropriate breastfeeding. This includes exclusive breastfeeding for children under 6 months and continued breastfeeding plus complementary foods for children age 6-23 months. Sixty percent of children under 6 months are predominantly breastfed. This percentage includes children who are exclusively breastfed, plus those who receive breast milk and only plain water or non-milk liquids such as juice. Finally, 50 percent of children under age 2 are bottle fed. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% <2 2-3 4-5 6-7 8-9 10-11 12-13 14-15 16-17 18-19 20-21 22-23 Age group in months Not breastfeeding Complementary foods Other milk Non-milk liquids/juice Plain water only Exclusively breastfed ADHS 2015-16 Nutrition • 161 Figure 12.4 IYCF Indicators on breastfeeding status 12.2.3 Duration of Breastfeeding Table 12.4 shows the median duration of breastfeeding by sex and residence. The estimates of median and mean durations of breastfeeding are based on current status data, which is the proportion of children born in the 3 years before the survey who were breastfed at the time of the survey. The median duration of any breastfeeding in Armenia is 11.9 months. However, the median durations of exclusive and predominant breastfeeding (breastfeeding plus plain water, water-based liquids, or juice) are shorter (2.2 months and 3.4 months, respectively). The mean durations of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding are longer (13.2 months, 3.6 months, and 4.4 months, respectively). These figures indicate that the Ministry of Health’s official recommendation of exclusive breastfeeding for 6 months has not been reached. Nevertheless, the median duration of any breastfeeding has increased, from 10.5 months in the 2005 ADHS to 10.9 months in the 2010 ADHS, and 11.9 months in the current survey. 12.2.4 Types of Complementary Foods As mentioned, it is recommended that complementary feeding (giving solid or semi-solid foods to infants in addition to breast milk) start at age 6 months, because at this age, breast milk is no longer sufficient to maintain the child’s growth (WHO 2008). In the 2015-16 ADHS, women who had at least one child living with them who was born in 2013 or later were asked questions about the types of liquids and foods such as fortified baby food, meat, and eggs their youngest child had consumed during the day or night before the interview. Data based on responses to these questions are subject to a number of 45 15 36 90 22 43 60 50 Exclusive breastfeeding under age 6 months Exclusive breastfeeding at age 4-5 months Continued breastfeeding at 1 year Introduction of solid, semi-solid, or soft foods (6-8 months) Continued breastfeeding at 2 years Age-appropriate breastfeeding (0-23 months) Predominant breastfeeding (0-5 months) Bottle feeding (0-23 months) Percentage of children ADHS 2015-16 Table 12.4 Median duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children born in the 3 years before the survey, according to sex and residence, Armenia 2015-16 Background characteristic Median duration (months) of breastfeeding among children born in the past three years1 Any breast- feeding Exclusive breast- feeding Predominant breast- feeding2 Sex Male 12.4 (2.1) 3.2 Female 11.7 * 3.6 Residence Urban 12.1 (2.0) 3.1 Rural 11.5 2.7 3.8 Total 11.9 (2.2) 3.4 Mean for all children 13.2 3.6 4.4 Note: Median and mean durations are based on the distributions at the time of the survey of the proportion of births by months since birth. Includes children living and deceased at the time of the survey. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 1 It is assumed that non-last-born children and last-born children not currently living with the mother are not currently breastfeeding. 2 Either exclusively breastfed or received breast milk and plain water, and/or non-milk liquids only. 162 • Nutrition limitations. First, the mother may have had difficulty in recalling all the foods and liquids her child consumed. In addition, a mother may not have been able to report fully on a child’s intake of food and liquids if the child was fed by other individuals during the period. Despite these limitations, the information collected on the types of foods and liquids consumed by young children is useful in assessing timely, appropriate complementary feeding. Table 12.5 provides information on the types of foods and liquids given to the youngest children under age 2 living with their mother, on the day and night before the interview, according to the child’s age and breastfeeding status.8 The results show that, for many breastfeeding children, foods and liquids other than breast milk are being consumed earlier than the recommended age of 6 months. For example, on the day before the survey interview, 15 percent of breastfeeding children age 2-3 months were given solid or semi-solid food, 10 percent received other animal milk, 6 percent received fortified baby foods, and 5 percent each received liquids other than plain water, foods made from grains, and foods made from roots and tubers in addition to breast milk. Table 12.5 Foods and liquids consumed by children in the day or night preceding the interview Percentage of youngest children under age 2 who are living with the mother by type of foods consumed in the day or night before the interview, according to breastfeeding status and age, Armenia 2015-16 Age in months Liquids Solid or semi-solid foods Any solid or semi- solid food Number of children under age 2 Infant formula Other milk1 Other liquids2 Fortified baby foods Foods made from grains3 Fruits and vege- tables rich in vitamin A4 Other fruits and vege- tables Food made from roots and tubers Food made from legumes and nuts Meat, fish, poultry Eggs Cheese, yogurt, other milk product BREASTFEEDING CHILDREN 0-1 (2.1) (1.1) (3.1) (5.2) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (5.2) 38 2-3 1.5 10.1 5.4 6.4 4.9 2.5 0.0 4.9 0.0 0.0 0.0 5.9 14.8 51 4-5 2.3 12.2 13.1 21.0 18.2 9.8 13.9 11.6 2.0 2.6 1.1 14.4 45.7 57 6-8 6.8 10.9 44.0 11.3 65.3 36.6 55.0 46.7 0.0 10.1 4.6 39.3 88.7 61 9-11 0.7 22.2 61.0 16.5 78.4 40.3 56.9 75.6 0.0 38.2 15.6 52.6 98.0 65 12-17 5.0 18.0 75.2 3.8 92.1 56.2 79.7 84.9 4.3 44.7 25.4 67.6 98.8 51 18-23 (10.7) (26.9) (62.8) (13.4) (92.8) (46.5) (65.0) (82.4) (6.1) (57.3) (24.6) (77.0) (100.0) 39 0-5 2.0 8.5 7.8 11.8 8.8 4.7 5.4 6.2 0.8 1.0 0.4 7.7 24.3 146 6-11 3.7 16.7 52.8 14.0 72.0 38.5 56.0 61.6 0.0 24.6 10.3 46.2 93.5 125 6-23 5.3 18.8 59.9 11.5 80.5 44.1 63.2 70.8 2.1 35.3 16.4 56.8 95.9 215 Total 3.9 14.7 38.8 11.6 51.5 28.2 39.8 44.7 1.6 21.4 10.0 36.9 66.9 362 NONBREASTFEEDING CHILDREN 0-1 * * * * * * * * * * * * * 3 2-3 * * * * * * * * * * * * * 7 4-5 * * * * * * * * * * * * * 16 6-8 * * * * * * * * * * * * * 25 9-11 (0.0) (57.1) (71.1) (13.4) (94.4) (43.0) (67.5) (80.9) (0.0) (37.7) (8.6) (71.8) (100.0) 26 12-17 1.4 44.8 74.0 5.7 96.3 49.2 72.2 83.1 5.5 58.4 23.3 66.1 100.0 114 18-23 6.7 43.7 77.2 4.0 96.5 50.8 84.2 82.9 10.5 62.5 30.0 74.8 99.2 109 0-5 (11.5) (58.9) (17.2) (25.9) (18.8) (3.8) (29.8) (18.8) (0.0) (5.1) (3.3) (36.0) (59.8) 26 6-11 (8.2) (56.8) (58.0) (20.7) (77.1) (36.1) (51.5) (66.5) (2.6) (27.4) (14.1) (59.0) (96.4) 51 6-23 4.8 46.6 72.3 7.8 92.8 47.4 73.1 79.9 7.0 54.2 24.2 68.2 99.0 274 Total 5.3 47.7 67.5 9.4 86.4 43.6 69.3 74.7 6.4 50.0 22.4 65.5 95.6 300 Note: Breastfeeding status and food consumed refer to a “24-hour" period (yesterday and last night). Figures in parentheses are based on 25-49 unweighted cases. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Other milk includes fresh, tinned and powdered cow or other animal milk. 2 Doesn't include plain water. Includes juice, juice drinks, clear broth, or other non-milk liquids. 3 Includes fortified baby food. 4 Includes fruits and vegetables such as red sweet pepper, pumpkin or squash, carrots, dark green leafy vegetables, ripe or dried apricots, dried peaches, cantaloupe melon, and other locally grown fruits and vegetables that are rich in vitamin A, 8 When comparing the total results of the 2015-16 ADHS to 2000 and 2005 surveys, it should be noted that in 2015-16 the table on foods and liquids consumed by children on the day or night before the interview are restricted to the youngest children under age 2 living with their mothers, instead of the youngest children under age 3 living with their mothers (as in the 2005 ADHS report) and instead of all children under age 3 (as in the 2000 ADHS report). In addition, the wording of questions in the 2015-16 and 2010 surveys differed from those in 2005 and 2000, and questions about foods made with oil, fat, or butter were not asked. Nutrition • 163 After children reach age 6 months, they should be fed small quantities of solid and semi-solid foods, while continuing to breastfeed. The results in Table 12.5 suggest that these guidelines are not being observed in a small proportion of children age 6 months and older. For example, 89 percent of breastfed children age 6-8 months received any solid or semi-solid food on the day before the interview. Among breastfeeding children age 9-11 months, almost all (98 percent) were given any solid or semi-solid food on the day before the interview. Table 12.5 shows that, as expected, foods made from grains are the staple in the diet of young children. Over four-fifths of breastfeeding children age 6-23 months (81 percent) consume foods made from grains (including fortified baby foods), 71 percent consume foods made from roots and tubers, 57 percent receive cheese, yogurt, or other milk products, 35 percent eat meat, fish, or poultry, and 16 percent consume eggs. In addition to being breastfed, 5 percent of these children also receive infant formula, and 19 percent receive other milk. Forty-four percent of breastfeeding children consume fruits and vegetables rich in vitamin A, and 63 percent consume other fruits and vegetables. Overall in Armenia, 96 percent of breastfed children age 6-23 months are receiving solid or semi-solid foods. Consumption of complementary foods is generally higher among non-breastfeeding children than breastfeeding children. Almost all (99 percent) of non-breastfeeding children age 6-23 months received solid or semi-solid foods. Ninety-three percent of non-breastfeeding children age 6-23 months received foods made from grains; 80 percent ate foods made from roots or tubers, and 68 percent were given cheese, yogurt, or other milk products. Almost half (47 percent) of non-breastfeeding children older than 6 months consumed fruits and vegetables rich in vitamin A and 73 percent ate other fruits and vegetables. Consumption of meat, fish, poultry (54 percent), and eggs (24 percent) is higher among non-breastfeeding children than among breastfeeding children. 12.3 INFANT AND YOUNG CHILD FEEDING (IYCF) PRACTICES Infant and young child feeding (IYCF) practices include initiating timely feeding of solid or semi- solid foods at age 6 months and increasing the amount and variety of foods and frequency of feeding as the child gets older, while maintaining frequent breastfeeding. Guidelines have been established for IYCF practices for children age 6-23 months (PAHO/WHO 2003; WHO 2005; WHO 2008). Although breastfeeding is recommended for infants up to age 2, the guidelines include standards for assessing feeding practices for non-breastfeeding children as well as breastfed children, since it is recognized that children may stop breastfeeding before reaching age 2, for various reasons (WHO 2005). The IYCF guidelines include recommendations for both dietary diversity and the frequency of feeding. With dietary diversity, studies have shown that plant-based complementary foods by themselves are insufficient to meet the child’s needs for certain micronutrients (WHO and UNICEF 1998). Therefore, it is recommended that meat, poultry, fish, or eggs be eaten daily or as often as possible. It is also important to pay attention to the types of fruits and vegetables a child consumes, since vegetarian diets may not meet children’s nutrient requirements in the absence of supplements or fortified products. In particular, children should consume fruits and vegetables rich in vitamin A on a daily basis. Children’s diets also should include an adequate fat content, because fat provides essential fatty acids, facilitates absorption of fat-soluble vitamins (such as vitamin A), and enhances dietary energy density and palatability. Taking these factors into account, the IYCF guidelines for minimum dietary diversity call for feeding the child food from at least four of the following seven food groups: grains, roots, and tubers; legumes and nuts; dairy products (milk, yogurt, cheese); flesh foods (meat, fish, poultry, and liver/organ meat); eggs; vitamin A-rich fruits and vegetables; and other fruits and vegetables. Consumption of food from at least four food groups means that the child has a high likelihood of consuming at least one animal source of food and at least one fruit or vegetable in addition to a staple food (grains, roots, or tubers) (WHO 2008). 164 • Nutrition In addition to dietary diversity, frequency of feeding is important to ensure that children meet their nutrient and caloric requirements. The minimum feeding frequencies are based on the energy needs from complementary foods estimated from age-specific total daily energy requirements. The guidelines differ for breastfeeding and non-breastfeeding children. Since meal frequency is considered a proxy for energy intake from foods other than breast milk, the feeding frequency indicator for non-breastfeeding children includes both milk feeds and solid/semi-solid feeds (WHO 2008). The recommended number of feedings is as follows:  Breastfeeding infants age 6-8 months should be fed meals of complementary foods two to three times per day, with one to two snacks as desired; breastfeeding children age 9-23 months should be fed meals three to four times per day, with one to two snacks.  Non-breastfeeding children 6-23 months should receive milk products at least twice a day to ensure that they meet their calcium needs. Non-breastfeeding children also should be fed meals four to five times per day, with one to two snacks as desired (WHO 2005). Table 12.6 presents the results of the 2015-16 ADHS on IYCF practices for breastfed and non- breastfed children living with their mothers. The recommendations include children for whom feeding practices meet minimum standards for:  Food diversity (the number of food groups consumed)  Feeding frequency (the number of times the child is fed)  Consumption of breast milk or other types of milk or milk products Table 12.6 Infant and young child feeding (IYCF) practices Percentage of youngest children age 6-23 months living with their mother who are fed according to three IYCF feeding practices based on breastfeeding status, number of food groups, and times they are fed during the day or night before the survey, according to background characteristics, Armenia 2015-16 Background characteristic Among breastfed children age 6-23 months, percentage fed: Among non-breastfed children age 6-23 months, percentage fed: Among all children age 6-23 months, percentage fed: 4+ food groups1 Minimum meal frequency2 Both 4+ food groups and minimum meal frequency Number of breastfed children age 6-23 months Milk or milk products3 4+ food groups1 Minimum meal frequency4 With 3 IYCF practices5 Number of non- breastfed children age 6-23 months Breast- milk, milk, or milk products6 4+ food groups1 Minimum meal frequency7 With 3 IYCF practices Number of all children age 6-23 months Age in months 6-8 20.2 69.7 16.3 61 * * * * 25 91.0 24.7 69.6 13.0 86 9-11 36.0 64.1 26.1 65 (46.4) (45.4) (68.2) (5.6) 26 84.4 38.7 65.3 20.2 91 12-17 47.3 72.7 40.4 51 49.5 62.5 66.9 21.0 114 65.1 57.8 68.7 27.0 165 18-23 (53.1) (72.2) (39.6) 39 57.0 67.3 82.6 27.8 109 68.3 63.5 79.9 30.9 148 Sex Male 39.7 69.7 33.2 109 57.4 59.0 81.1 21.0 129 76.9 50.2 75.9 26.6 238 Female 34.8 68.7 25.0 106 50.9 61.4 66.7 20.6 146 71.6 50.2 67.5 22.5 252 Residence Urban 37.3 64.2 27.1 125 56.0 64.6 75.7 24.7 156 75.5 52.5 70.6 25.8 280 Rural 37.4 76.1 32.0 91 51.3 54.6 70.5 15.5 118 72.4 47.1 72.9 22.7 209 Mother's education Basic * * * 13 * * * * 16 (80.0) (36.8) (73.5) (9.4) 29 Secondary 37.4 68.2 30.9 90 57.4 52.5 77.2 21.6 108 76.7 45.7 73.2 25.8 198 Secondary special (29.1) (72.1) (22.1) 43 39.0 62.9 63.6 15.0 58 65.2 48.4 67.2 18.0 101 Higher 49.2 70.1 36.8 69 57.6 66.7 73.5 24.0 92 75.8 59.2 72.0 29.5 162 Wealth quintile Lowest (33.8) (71.3) (28.6) 35 47.4 64.0 73.5 15.1 53 68.3 52.0 72.6 20.5 89 Second 36.1 75.0 29.4 53 62.7 50.3 75.7 16.8 53 81.3 43.2 75.4 23.1 107 Middle 42.7 67.3 37.4 44 47.4 57.7 70.2 15.4 49 72.2 50.6 68.8 25.8 93 Fourth (29.3) (62.3) (18.2) 37 44.3 67.4 61.3 21.2 50 68.3 51.0 61.8 19.9 87 Highest (42.9) (68.2) (30.5) 46 63.7 61.8 82.7 31.7 69 78.1 54.3 76.9 31.2 115 Total 37.3 69.2 29.2 215 53.9 60.3 73.5 20.8 274 74.2 50.2 71.6 24.5 490 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 1 Food groups: a. infant formula, milk other than breast milk, cheese or yogurt or other milk products; b. foods made from grains, roots, and tubers, including porridge and fortified baby food from grains; c. vitamin A-rich fruits and vegetables; d. other fruits and vegetables; e. eggs; f. meat, poultry, fish, and shellfish (and organ meats); g. legumes and nuts. 2 For breastfed children, minimum meal frequency is receiving solid or semi-solid food at least twice a day for infants 6-8 months and at least three times a day for children 9-23 months. 3 Includes two or more feedings of commercial infant formula, fresh, tinned, and powdered animal milk, and yogurt. 4 For non-breastfed children age 6-23 months, minimum meal frequency is receiving solid or semi-solid food or milk feeds at least four times a day. 5 Non-breastfed children age 6-23 months are considered to be fed with a minimum standard of three Infant and Young Child Feeding Practices if they receive other milk or milk products at least twice a day, receive the minimum meal frequency, and receive solid or semi-solid foods from at least four food groups not including the milk or milk products food group. 6 Breastfeeding, or not breastfeeding and receiving two or more feedings of commercial infant formula, fresh, tinned and powdered animal milk, and yogurt. 7 Children are fed the minimum recommended number of times per day according to their age and breastfeeding status as described in footnotes 2 and 4. Nutrition • 165 Breastfed children are considered to be fed in accordance with the minimum IYCF standards if they consume at least four food groups and receive foods at least twice per day for children age 6-8 months and at least three times per day for children age 9-23 months. Table 12.6 shows that among breastfed children age 6-23 months, 37 percent were given food from at least four food groups in the 24 hours before the survey, and 69 percent were fed the recommended minimum number of times. About three in ten breastfed children (29 percent) fall into both categories, in which their feeding practices meet minimum standards with respect to food diversity and feeding frequency. Non-breastfed children age 6-23 months are considered to be fed with a minimum standard of three IYCF practices if they receive commercial infant formula, animal milk, or milk products at least twice a day, receive solid or semi-solid food or milk feeds at least four times a day, and receive solid or semi-solid foods from at least four food groups, not including the milk/milk product group. Among non-breastfed children age 6-23 months, 54 percent are given milk or milk products, 60 percent are given food from at least four food groups, and 74 percent are fed four or more times per day. However, only about one in five (21 percent) non-breastfeeding children are fed in accordance with all three IYCF practices. Table 12.6 shows that among all children age 6-23 months, nearly three-quarters (74 percent) are given breast milk or other milk products, 72 percent are fed the recommended number of times a day, and one-half receive foods from the recommended number of food groups for their age. Only one-quarter (25 percent) are being fed in accordance with all three of the IYCF recommendations of consuming breast milk or other milk products, having the minimum dietary diversity, and having the minimum meal frequency. Feeding practices are generally more likely to comply with minimum standards for older children. Children age 18-23 months (31 percent) are the most likely to be fed according to the IYCF practices, while those age 6-8 months (13 percent) are the least likely. Some slight differences are seen in feeding practices by sex and residence. Boys and children residing in urban areas are slightly more likely to be fed according to all three IYCF practices. The relationships between infant and child feeding practices and mother’s education or mother’s wealth status are not clear, although children born to mothers with higher education and in the highest wealth quintile households are more likely to be fed appropriately in accordance with all three IYCF practices than other children. Figure 12.5 shows the percentage of youngest children age 6-23 months living with the mother fed according to a minimum standard of acceptable feeding practices and by breastfeeding status. In terms of overall feeding practices, a higher proportion of breastfeeding children meet the minimum requirements (29 percent) than non-breastfeeding children (21 percent). There has been a decrease in the proportion of children age 6-23 months fed according to all three IYCF practices between 2010 and 2015-16 (32 percent in 2010 to 25 percent in 2015-16). 166 • Nutrition Figure 12.5 IYCF indicators on minimum acceptable diet 12.4 HOUSEHOLD IODIZED SALT CONSUMPTION Salt used in the household is the most common vehicle for iodine fortification to prevent the public health concerns of iodine deficiency disorders (IDD). In Armenia, the government developed and adopted national laws to prevent and reduce the prevalence of iodine deficiency among its citizens through universal salt iodization. In February 2004, the Government of Armenia passed a decree that required mandatory iodization of all salt for human consumption. Import of non-iodized salt was also banned (UNICEF 2005). To assess the use of iodized salt in Armenia, the 2015-16 ADHS included salt testing at the household level using the MBI rapid test kit for salt fortified with potassium iodate, which was required because in Armenia, salt is commonly iodized with potassium iodate. The MBI rapid test kit provides a qualitative indication of the presence or absence of iodine. To perform the test, interviewers asked households to provide a teaspoon of the salt that the household used for cooking. A recheck solution was used when the salt showed no change in color. Table 12.7 shows the proportion of households with iodized salt according to background characteristics. Overall, salt was tested in 99 percent of households and virtually all the tested households were found to use salt with at least some iodine. According to the WHO, a country’s salt iodization program is on a good track to eliminating iodine deficiency when 90 percent of households use iodized salt. 37 69 29 60 74 21 50 72 25 IYCF 5: Minimum dietary diversity IYCF 6: Minimum meal frequency IYCF 7: Minimum acceptable diet Percent Among breastfed children Among non-breastfed children Among all children 6-23 months ADHS 2015-16 Nutrition • 167 Table 12.7 Presence of iodized salt in household Among all households, the percentage with salt tested for iodine content and the percentage with no salt in the household; and among households with salt tested, the percent distribution by level of iodine in salt (parts per million or ppm) and the percentage with iodized salt, according to background characteristics, Armenia 2015-16 Background characteristic Among all households, percentage Among households with tested salt: With salt tested With no salt in the household Number of households None (0 ppm) Inadequate (<15 ppm) Adequate (15+ ppm) Total Percentage with iodized salt Number of households Residence Urban 99.1 0.9 4,924 0.2 0.8 99.0 100.0 99.8 4,879 Rural 99.7 0.3 2,969 0.3 1.5 98.1 100.0 99.7 2,959 Region Yerevan 98.7 1.3 2,480 0.0 0.4 99.6 100.0 100.0 2,449 Aragatsotn 99.6 0.4 387 0.0 7.8 92.2 100.0 100.0 385 Ararat 99.2 0.8 682 0.0 0.2 99.8 100.0 100.0 676 Armavir 99.9 0.1 633 0.3 0.5 99.2 100.0 99.7 632 Gegharkunik 99.8 0.2 601 0.0 0.8 99.2 100.0 100.0 600 Lori 100.0 0.0 645 0.0 0.0 100.0 100.0 100.0 645 Kotayk 98.9 1.1 799 0.0 0.4 99.6 100.0 100.0 790 Shirak 99.1 0.9 685 2.1 4.8 93.1 100.0 97.9 679 Syunik 100.0 0.0 448 0.0 0.0 100.0 100.0 100.0 448 Vayots Dzor 100.0 0.0 167 0.4 0.2 99.5 100.0 99.6 167 Tavush 99.8 0.2 366 0.0 0.3 99.7 100.0 100.0 365 Wealth quintile Lowest 99.4 0.6 1,700 0.2 1.3 98.4 100.0 99.8 1,690 Second 99.5 0.5 1,452 0.3 1.4 98.3 100.0 99.7 1,444 Middle 99.0 1.0 1,791 0.1 1.9 98.1 100.0 99.9 1,774 Fourth 99.6 0.4 1,558 0.3 0.4 99.2 100.0 99.7 1,551 Highest 99.0 1.0 1,392 0.1 0.3 99.6 100.0 99.9 1,378 Total 99.3 0.7 7,893 0.2 1.1 98.7 100.0 99.8 7,838 Although the presence of any iodine is most commonly accepted to define iodized salt, the test kits used in the ADHS allow classification on whether the salt contains at least 15 parts per million (ppm) of iodine, which constitutes the adequate amount of iodization.9 Using this criterion, 99 percent of the tested households had adequately iodized salt. These results show substantial improvement in use of iodized salt since the 2000 ADHS. 12.5 MICRONUTRIENT INTAKE IN CHILDREN Micronutrient deficiencies are major contributors to childhood morbidity and mortality. Children can receive micronutrients from foods, food fortification, and direct supplementation. Table 12.8 shows indicators used to measure children’s intake of several key micronutrients. Table 12.8 also presents information about the proportion of children age 6-59 months who live in households that use iodized salt. Vitamin A is an essential micronutrient for the immune system and plays an important role in maintaining the epithelial tissue in the body. Vitamin A deficiency can increase the severity of infections, such as measles and diarrheal diseases in children, and can slow recovery from illness. Vitamin A is found in breast milk, other milks, liver, eggs, fish, butter, carrots, pumpkins, yellow-orange sweet potatoes, and dark green leafy vegetables. Periodic dosing (usually every 6 months) with vitamin A supplements is one way to ensure that children at risk do not develop vitamin A deficiency. Iron is essential for cognitive development. Low iron intake can also contribute to anemia. Iron requirements are greatest between the ages of 6 and 12 months, when growth is extremely rapid. The 2015-16 ADHS collected information on the consumption of foods rich in vitamin A and foods rich in iron. Household salt samples were also tested for iodine levels. Table 12.8 shows that over two-thirds of children age 6-23 months living with their mother consumed foods rich in vitamin A in the 24 hours before the survey (69 percent), and half (52 percent) 9 Recent laboratory studies suggest that rapid tests kits may be reliable only to distinguish between the presence and absence of iodine in salt, but not to determine whether salt is adequately iodized (Gorstein et al. 2016). 168 • Nutrition consumed foods rich in iron. There is a steady increase with age in the proportion of children who eat foods rich in vitamin A and iron. With foods rich in vitamin A, the proportion rises from 46 percent of children age 6-8 months to 77 percent of those age 12-17 months, and remains unchanged among children age 18-23 months. A similar pattern is observed for foods rich in iron, with consumption highest among children age 18-23 months (66 percent). Children who are not breastfeeding are more likely to receive vitamin A-rich and iron-rich foods than breastfeeding children. There are no major differentials in the percentages of children who consumed foods rich in vitamin A or iron in past 24 hours, by urban-rural residence. Mother’s education is positively associated with children consuming these foods that provide important micronutrients. Table 12.8 Micronutrient intake among children Among youngest children age 6-23 months who are living with their mother, the percentages who consumed vitamin A-rich and iron-rich foods in the 24 hours before the survey, and among all children 6-59 months, the percentages who were given iron supplements in the past 7 days, and among all children age 6-59 months who live in households in which salt was tested for iodine, the percentage who live in households with iodized salt, according to background characteristics, Armenia 2015-16 Background characteristic Among youngest children age 6-23 months living with the mother: Among all children age 6-59 months: Among children age 6-59 months living in households in which salt was tested Percentage who consumed foods rich in vitamin A in past 24 hours1 Percentage who consumed foods rich in iron in past 24 hours2 Number of children Percentage given iron supplements in past 7 days3 Number of children Percentage living in households with iodized salt4 Number of children Age in months 6-8 45.7 17.8 86 0.8 87 100.0 87 9-11 66.0 45.5 91 0.0 94 100.0 92 12-17 76.8 61.6 165 1.8 170 98.8 170 18-23 76.5 66.2 148 0.6 169 100.0 169 24-35 na na na 0.6 335 99.7 332 36-47 na na na 2.6 309 100.0 309 48-59 na na na 1.4 324 99.7 320 Sex Male 68.7 51.7 238 1.2 787 99.6 785 Female 69.7 52.9 252 1.4 700 99.9 694 Breastfeeding status Breastfeeding 63.6 43.9 215 0.6 239 99.5 238 Not breastfeeding 73.7 59.0 274 1.4 1,248 99.8 1,241 Mother's age at birth 15-19 * * 8 * 11 * 11 20-29 68.9 52.7 326 0.9 939 99.6 932 30-39 69.3 51.1 148 2.0 501 100.0 500 40-49 * * 7 (1.7) 35 (100.0) 35 Residence Urban 70.4 52.2 280 1.7 845 99.9 840 Rural 67.7 52.5 209 0.8 641 99.5 639 Region Yerevan 68.8 47.9 142 1.4 425 100.0 423 Aragatsotn * * 15 1.1 54 100.0 54 Ararat 54.2 46.7 53 0.0 154 100.0 154 Armavir 71.7 59.4 57 1.1 168 99.3 168 Gegharkunik * * 17 0.0 65 100.0 65 Lori * * 23 0.0 85 100.0 85 Kotayk 81.7 41.1 74 1.0 209 100.0 208 Shirak (55.2) (44.5) 47 0.0 149 98.1 145 Syunik (77.9) (77.9) 18 14.2 55 100.0 55 Vayots Dzor (63.9) (51.6) 10 1.6 34 100.0 34 Tavush 79.1 75.0 33 0.5 88 100.0 88 Mother's education Basic (57.7) (45.9) 29 0.0 83 100.0 83 Secondary 64.6 48.5 198 1.4 598 99.7 598 Secondary special 67.3 52.4 101 1.2 313 99.7 311 Higher 78.1 58.1 162 1.4 493 99.8 487 Wealth quintile Lowest 69.8 54.2 89 0.9 296 99.4 295 Second 59.7 46.2 107 1.0 300 99.6 299 Middle 71.6 54.3 93 0.4 271 100.0 270 Fourth 68.1 54.5 87 2.3 264 99.6 262 Highest 76.8 53.3 115 1.8 356 100.0 354 Total 69.2 52.3 490 1.3 1,486 99.7 1,479 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable. 1 Includes meat (and organ meat), fish, poultry, eggs, red sweet pepper, pumpkin, yellow squash, carrots, dark green leafy vegetables, mango, ripe or dried apricots, dried peaches, cantaloupe melon and other locally grown fruits and vegetables that are rich in vitamin A. 2 Includes meat (including organ meat), fish, poultry and eggs. 3 Based on mother's recall. 4 Excludes children in households in which salt was not tested. Nutrition • 169 The 2015-16 ADHS also collected information on iron supplementation. In the 2015-16 ADHS, mothers were asked if their children under age 5 had taken an iron tablet in the seven days before the survey. Only 1 percent of children age 6-59 months received an iron supplement in the seven days before the survey. Consumption of iron supplements is highest in Syunik region at 14 percent. Differences in iron supplementation by other background characteristics are small. Fortified salt that contains 15 parts of iodine per million of salt (15 ppm) is considered adequate for the prevention of iodine deficiency (ICCIDD, UNICEF, and WHO 2001). Table 12.8 shows that at the national level, virtually all children live in households that use iodized salt. 12.6 NUTRITIONAL STATUS OF WOMEN Low pre-pregnancy BMI and short stature of women are risk factors for poor birth outcomes and delivery complications. In developing countries, maternal underweight is the leading risk factor for preventable death and diseases (The World Health Report WHO 2002). The prevalence of overweight women and men is a growing concern in developing countries, and is associated with a wide range of health problems such as diabetes, heart disease, and poor birth outcomes for women. In many countries, chronic energy deficiency of adults is still a problem which leads to low work productivity and reduced resistance to illness. Using the same equipment employed to measure children (UNICEF measuring boards and SECA digital scales), the 2015-16 ADHS obtained the height and weight measurements for women age 15-49. The data are used to derive two measures of women’s nutritional status: height and body mass index (BMI). Given the relationship between maternal stature and pelvic size, women’s height can be useful in predicting the risk of difficulties in delivery. The risk of giving birth to low-weight babies is higher among women of small stature. The cut-off point at which mothers are considered at risk because of short stature normally falls between 140 and 150 centimeters. The BMI is used to measure thinness or obesity, and is defined as weight in kilograms divided by height in meters squared (kg/m2). A BMI of less than 18.5 is used to define thinness or acute undernutrition, while BMI of 25 or above usually indicates overweight and a BMI of 30 or above indicates obesity. Table 12.9 presents nutritional status of women. Of a total of 6,116 women age 15-49, 96 percent were measured for height and 93 percent have a BMI calculated. The table excludes women for whom there was no information on height and/or weight and women for whom a BMI could not be estimated because they were pregnant or had given birth in the previous two months. Overall, less than 1 percent of women fall below 145 centimeters in height, the mid-range of the cut-off for risk of giving birth to low-weight babies. Over half of women have a normal BMI (51 percent), while 4 percent are undernourished or thin (BMI less than 18.5), and 45 percent are overweight or obese (BMI 25 or higher). The mean BMI for women age 15-49 is 25.3, which falls in the overweight BMI classification. Differences in BMI levels by background characteristics are apparent. Women in their teens or 20s are more likely than women in older age groups to be thin or undernourished (7-8 percent versus 1 percent). In contrast, the proportion of women who are overweight increases with age: among women age 40-49, 45 percent are overweight and 35 percent are obese. Differences by urban-rural residence are small; women in rural areas (46 percent) are almost as likely as urban women (44 percent) to be overweight or obese. By region, the proportion of undernourished women does not vary considerably (1-7 percent), with the proportion of overweight women ranging from 23 percent in Tavush to 45 percent in the Aragatsotn region. Obesity is more common among women from Tavush (27 percent), Armavir (23 percent) and Vayots Dzor (21 percent) than among women from other regions (9-19 percent). Women with higher education are less likely to be obese compared with women with lower education (10 percent compared 170 • Nutrition with 16-20 percent). There are no major differences in the prevalence of overweight/obesity by wealth quintile. Compared with data from the 2000 and 2005 ADHSs, the percentage of non-pregnant women age 15-49 who are thin (BMI <18.5) has not changed and remains stable at about 4 percent. The percentage of women who are overweight or obese (BMI ≥25.0) has increased somewhat, from 42 percent each in 2000 and 2005 to 45 percent in 2015-16 (Figure 12.6). Table 12.9 Nutritional status of women Among women age 15-49, percentage with height under 145 cm, mean Body Mass Index (BMI), and percentage with specific BMI levels, according to background characteristics, Armenia 2015-16 Background characteristic Height Body Mass Index1 Mean Body Mass Index (BMI) Normal Thin Overweight/obese Number of women 18.5-24.9 (total normal) <18.5 (total thin) 17.0-18.4 (mildly thin) <17 (moderately and severely thin) ≥25.0 (total over- weight or obese) 25.0-29.9 (over- weight) ≥30.0 (obese) Percent- age below 145 cm Number of women Age 15-19 1.7 701 21.6 82.2 8.2 6.3 1.9 9.6 7.0 2.6 689 20-29 0.4 1,941 23.1 71.0 6.6 5.1 1.6 22.4 17.8 4.5 1,796 30-39 0.5 1,801 26.0 45.5 1.2 1.1 0.2 53.3 38.6 14.7 1,758 40-49 0.5 1,434 28.9 19.4 0.6 0.5 0.0 80.1 45.3 34.8 1,432 Residence Urban 0.3 3,474 25.1 51.6 4.1 3.3 0.9 44.3 30.6 13.7 3,366 Rural 1.0 2,402 25.5 51.2 2.9 2.2 0.7 45.9 28.8 17.1 2,308 Region Yerevan 0.1 1,884 25.1 51.4 3.8 3.1 0.7 44.8 32.4 12.3 1,835 Aragatsotn 1.8 312 26.4 40.4 0.9 0.8 0.1 58.7 45.4 13.3 306 Ararat 0.3 539 25.0 53.6 2.7 2.3 0.5 43.6 27.5 16.1 519 Armavir 1.2 584 26.4 44.9 3.7 2.7 0.9 51.4 28.9 22.5 561 Gegharkunik 0.8 472 24.8 60.4 1.0 1.0 0.0 38.6 25.1 13.5 461 Lori 1.4 300 25.5 48.1 3.9 2.5 1.4 48.0 33.8 14.1 287 Kotayk 0.2 670 25.3 53.3 3.5 2.6 0.9 43.2 27.4 15.8 632 Shirak 0.2 507 24.0 56.9 7.3 6.1 1.1 35.8 26.6 9.3 486 Syunik 1.9 235 25.3 53.8 4.0 2.5 1.5 42.2 23.7 18.6 228 Vayots Dzor 1.2 113 25.9 47.1 5.0 4.6 0.4 47.9 27.1 20.8 107 Tavush 1.7 261 26.5 46.4 4.1 2.4 1.7 49.5 22.9 26.6 251 Education Basic 2.0 382 25.3 51.0 5.6 4.4 1.2 43.4 23.7 19.7 371 Secondary 0.8 2,374 25.6 49.5 3.0 2.3 0.7 47.4 31.0 16.4 2,298 Secondary special 0.5 1,313 25.9 46.0 3.9 3.5 0.5 50.1 31.7 18.4 1,269 Higher 0.1 1,803 24.5 58.0 3.7 2.7 1.0 38.2 28.4 9.8 1,732 Wealth quintile Lowest 1.3 1,054 25.3 51.9 3.8 2.9 0.9 44.3 27.9 16.4 1,026 Second 0.7 1,214 25.5 51.0 2.3 1.8 0.6 46.7 29.8 16.9 1,170 Middle 0.7 1,103 25.3 51.5 4.0 2.6 1.4 44.5 29.4 15.1 1,058 Fourth 0.4 1,205 25.2 51.9 3.6 3.1 0.5 44.5 30.5 14.1 1,172 Highest 0.2 1,300 25.1 51.0 4.4 3.8 0.6 44.7 31.4 13.3 1,250 Total 0.6 5,876 25.3 51.4 3.6 2.8 0.8 45.0 29.9 15.1 5,675 Note: The Body Mass Index (BMI) is expressed as the ratio of weight in kilograms to the square of height in meters (kg/m2). Total includes 5 (weighted) women with no education. 1 Excludes pregnant women and women with a birth in the previous 2 months. Nutrition • 171 Figure 12.6 Trends in nutritional status of women age 15-49 12.7 MICRONUTRIENT INTAKE AMONG MOTHERS Adequate micronutrient intake by women has important benefits for women and their children. Breastfeeding children benefit from micronutrient supplementation that mothers receive, especially vitamin A. Iron supplementation during pregnancy can reduce the likelihood of anemia. Iodine deficiency is related to a number of adverse pregnancy outcomes including abortion, stillbirth, fetal brain damage, and congenital malformation. The 2015-16 ADHS collected information from women age 15-49 who had given birth during the 5 years before the survey on their use of iron, folic acid, or multivitamin supplements during pregnancy. To obtain the information on iron supplementation, women were asked if they had been given or bought iron tablets or syrup during pregnancy for their most recent birth. If they responded affirmatively, they were asked about the number of days that they took the tablets or syrup. A similar set of questions was asked to obtain information on folic acid or multivitamin supplementation. Table 12.10 shows that approximately six in ten women did not take any iron tablets or syrup during pregnancy for their most recent birth in the 5 years before the survey. Most of the women who took iron supplements did so for fewer than 60 days; only 5 percent of women said they took iron supplements for 90 days or more. Iron supplementation during pregnancy is more common among women age 40-49, women in urban areas, women in the Syunik and Aragatsotn regions, and those with higher education. Mothers in the lowest wealth quintile (28 percent) are less likely than mothers in the other wealth quintiles to have received iron supplements (38-41 percent). Table 12.10 also shows that virtually all women age 15-49 with a child born in the past 5 years live in a household with iodized salt. 4 42 5 42 4 45 Undernutrition (chronic energy deficiency) Overnutrition (overweight/obese) 2000 ADHS 2005 ADHS 2015-16 ADHS Percent 172 • Nutrition Table 12.10 Micronutrient intake among mothers Among women age 15-49 with a child born in the 5 years before the survey, percent distribution by number of days they took iron tablets or syrup during the pregnancy of the last child, and among women age 15-49 with a child born in the 5 years before the survey and who live in households that were tested for iodized salt, percentage who live in households with iodized salt, according to background characteristics, Armenia 2015-16 Background characteristic Number of days women took iron tablets or syrup during pregnancy of last birth Number of women Among women with a child born in the last five years, who live in households that were tested for iodized salt Percentage living in house- holds with iodized salt1 Number of women None <60 60-89 90+ Don't know/ missing Total Age 15-19 * * * * * * 18 * 18 20-29 59.0 29.7 2.8 4.1 4.4 100.0 833 99.4 828 30-39 56.7 30.1 2.4 5.5 5.4 100.0 476 100.0 475 40-49 (55.3) (36.4) (0.0) (4.8) (3.5) 100.0 34 100.0 34 Residence Urban 55.4 30.2 2.9 7.0 4.4 100.0 794 99.8 790 Rural 62.2 29.2 2.3 1.0 5.3 100.0 568 99.5 565 Region Yerevan 55.5 27.9 2.5 10.5 3.6 100.0 398 100.0 395 Aragatsotn 27.3 68.3 1.9 0.0 2.5 100.0 51 100.0 51 Ararat 48.2 30.2 7.0 1.8 12.8 100.0 140 100.0 140 Armavir 67.6 21.7 0.2 4.2 6.3 100.0 147 98.7 147 Gegharkunik 74.1 12.6 0.0 0.0 13.4 100.0 65 100.0 65 Lori 44.2 43.1 3.2 1.5 7.9 100.0 76 100.0 76 Kotayk 64.2 31.1 1.9 1.3 1.5 100.0 200 100.0 199 Shirak 81.0 17.6 0.0 0.7 0.8 100.0 130 97.8 127 Syunik 6.9 64.3 14.4 12.0 2.5 100.0 46 100.0 46 Vayots Dzor 72.6 22.1 3.6 1.8 0.0 100.0 30 100.0 30 Tavush 65.5 29.0 1.1 0.5 3.8 100.0 78 100.0 78 Education Basic 56.3 29.5 4.5 3.0 6.6 100.0 70 100.0 70 Secondary 61.0 28.2 2.7 3.0 5.1 100.0 533 99.6 533 Secondary special 60.2 27.4 2.3 4.6 5.5 100.0 286 99.7 284 Higher 54.2 33.1 2.5 6.4 3.8 100.0 472 99.6 468 Wealth quintile Lowest 66.2 24.8 2.8 0.4 5.7 100.0 252 99.3 251 Second 55.7 31.9 1.8 3.9 6.7 100.0 275 99.6 274 Middle 57.7 29.6 4.0 3.9 4.8 100.0 253 100.0 252 Fourth 56.1 30.8 3.7 5.0 4.3 100.0 250 99.3 249 Highest 56.3 31.2 1.5 8.3 2.8 100.0 331 100.0 329 Total 58.2 29.8 2.7 4.5 4.8 100.0 1,361 99.7 1,355 1 Excludes women in households where salt was not tested. Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. Table 12.11 shows that supplementation with folic acid or multivitamins is slightly more common than iron supplementation. Approximately five in ten women did not take any folic acid tablets or multivitamins during pregnancy for their most recent birth in the 5 years before the survey. Most of the women who took folate or multivitamin supplements did so for fewer than 60 days; only 4 percent took a supplement for 60-89 days, and 6 percent took folic acid or multivitamins for 90 days or more. Folic acid and multivitamin supplementation during pregnancy is more common among women age 20-29, women in urban areas, women in the Syunik and Lori regions, and those with more education and wealth. Sixteen percent of women took folic acid or multivitamin supplements immediately prior to pregnancy for their most recent birth in the 5 years before the survey. Folate or multivitamin supplementations before pregnancy is substantially more common among women residing in Syunik (64 percent) and Aragatsotn (29 percent), compared with the 10-17 percent among women from other regions (data not shown). Nutrition • 173 Table 12.11 Folate or multivitamins intake among mothers Among women age 15-49 with a child born in the past 5 years, the percent distribution by number of days they took folate tablets or multivitamins during the pregnancy of the last child, according to background characteristics, Armenia 2015-16 Background characteristic Among women with a child born in the last five years, number of days women took folate tablets or multivitamins during pregnancy of last birth Total Number of women None <60 60-89 90+ Don't know/ missing Age 15-19 * * * * * * 18 20-29 49.9 34.1 4.4 6.2 5.5 100.0 833 30-39 53.7 32.9 3.3 5.4 4.7 100.0 476 40-49 (62.2) (18.2) (6.4) (7.8) (5.4) 100.0 34 Residence Urban 47.2 33.9 5.1 8.6 5.3 100.0 794 Rural 58.1 32.0 2.5 2.0 5.4 100.0 568 Region Yerevan 48.6 30.4 3.4 12.5 5.1 100.0 398 Aragatsotn 42.8 41.7 6.1 7.5 1.9 100.0 51 Ararat 70.1 16.0 1.2 1.3 11.4 100.0 140 Armavir 56.3 30.0 3.0 5.2 5.4 100.0 147 Gegharkunik 48.8 28.5 0.0 0.0 22.7 100.0 65 Lori 25.9 58.4 7.8 0.0 8.0 100.0 76 Kotayk 43.5 49.3 2.6 3.7 0.9 100.0 200 Shirak 69.1 23.8 3.7 2.0 1.4 100.0 130 Syunik 9.7 48.5 30.0 10.4 1.4 100.0 46 Vayots Dzor 60.7 33.2 3.5 1.7 0.9 100.0 30 Tavush 73.0 21.9 1.3 1.1 2.6 100.0 78 Education Basic 56.5 26.2 7.9 2.0 7.4 100.0 70 Secondary 56.1 30.8 3.0 3.1 7.0 100.0 533 Secondary special 54.6 31.5 4.6 5.1 4.2 100.0 286 Higher 44.3 37.8 4.2 9.9 3.8 100.0 472 Wealth quintile Lowest 61.2 28.3 2.1 0.4 8.0 100.0 252 Second 57.0 30.7 3.1 3.7 5.5 100.0 275 Middle 49.1 32.8 6.7 5.7 5.7 100.0 253 Fourth 50.3 32.2 5.8 6.3 5.4 100.0 250 Highest 43.3 39.7 2.8 11.5 2.8 100.0 331 Total 51.7 33.1 4.0 5.8 5.3 100.0 1,361 12.8 ANEMIA Anemia is a condition characterized by a reduction in the red blood cell volume and a decrease in the concentration of hemoglobin in the blood. Hemoglobin is necessary for transporting oxygen to tissues and organs in the body. Approximately 1.62 billion people or about one-quarter of the global population are affected by anemia (WHO and CDC 2008). Globally in 2011, about 43 percent of children, 38 percent of pregnant women, and 29 percent of all women of reproductive age had anemia. About half of cases of anemia are due to iron deficiency (WHO 2015a). Iron deficiency, in turn, is largely due to an inadequate dietary intake of bioavailable iron, increased iron requirements during rapid growth periods, such as pregnancy and infancy, and increased blood loss due to hookworm or schistosome infestation. Nutritional anemia includes the anemic burden due to deficiency in iron plus deficiencies in folate, vitamins B and B12, and certain trace elements involved with red blood cell production. Anemia in children is associated with impaired mental and physical development, increased mortality, and morbidity. Anemia can be a particularly serious problem for pregnant women, because it leads to premature delivery and low birth weight. 174 • Nutrition Determining anemia levels among women and their children under age 5 was one component of the ADHS. Anemia levels were determined by measuring the level of hemoglobin in the blood, a decreased concentration of which characterizes anemia. Hemoglobin concentration was measured using the Hb301+ analyzer by HemoCue. For the hemoglobin measurement, capillary blood was taken with a finger prick using sterile, disposable instruments. The first two drops of blood were wiped off with a sterile gauze pad, and the third drop was used for anemia testing. As described in Chapter 1, medically trained personnel on each 2015-16 ADHS interviewing team performed the testing procedures on eligible, consenting respondents. After the test, hemoglobin concentration levels were reported back to the respondent or parents/responsible adults. In the case of severe anemia, a written referral that recommended immediate follow up with a health professional was provided. 12.8.1 Anemia Prevalence in Women In addition to causing weakness, frequent tiredness, and lowered resistance to disease, anemia can be a particularly serious problem for pregnant women, and can lead to premature delivery and low birth weight. All women age 15 to 49 in households interviewed in the 2015-16 ADHS were offered an anemia test. Before participating in the survey, each respondent was read a consent statement that informed her of her right not to participate in the anemia testing. Each woman was asked if she would give permission for the collection of a blood droplet from her and her children. Ninety-three percent of eligible women participated in the hemoglobin measurement. Levels of anemia were classified as severe, moderate, and mild based on the hemoglobin concentration in the blood, according to criteria developed by WHO (DeMaeyer et al. 1989). Because hemoglobin levels vary by altitude, the measurements were adjusted based on altitude measurements taken in each cluster. Levels of anemia were classified as follows:  Mild: hemoglobin concentration 10.0-10.9 g/dl  Moderate: hemoglobin concentration 7.0-9.9 g/dl  Severe: hemoglobin concentration less than 7.0 g/dl Table 12.12 presents the prevalence of anemia in women age 15-49 based on hemoglobin levels adjusted for altitude and smoking status using the formulas recommended by CDC (CDC 1998). Thirteen percent of women in Armenia suffer from some degree of anemia; most of these (12 percent of all women) have mild anemia, 1 percent have moderate anemia, and almost none have severe anemia. Table 12.12 shows that anemia rates generally decrease with age. The prevalence of anemia is somewhat higher among breastfeeding women (16 percent) than among pregnant women (11 percent), or among women who are neither pregnant nor breastfeeding (13 percent). Women in Gegharkunik are the most likely to be anemic (39 percent) compared with women in other regions (7-14 percent). The prevalence of anemia decreases with education, from 17 percent of women with basic education to 11 percent among women with higher education. A comparison of the three ADHS surveys of 2015-16, 2005, and 2000 (Figure 12.7) indicates that prevalence of anemia among women age 15-49 has returned to levels observed in 2000. Nutrition • 175 Table 12.12 Prevalence of anemia in women Percentage of women age 15-49 with anemia, according to background characteristics, Armenia 2015-16 Background characteristic Not pregnant Anemia status by hemoglobin level Any Mild Moderate Severe Number of women <12.0 g/dl 10.0-11.9 g/dl 7.0-9.9 g/dl <7.0 g/dl Pregnant <11.0 g/dl 10.0-10.9 g/dl 7.0-9.9 g/dl <7.0 g/dl Age 15-19 17.2 16.6 0.4 0.3 686 20-29 13.7 12.9 0.8 0.0 1,894 30-39 11.1 10.2 0.7 0.2 1,770 40-49 14.1 10.8 3.1 0.2 1,419 Number of children ever born 0 15.1 14.5 0.4 0.1 1,972 1 11.5 10.6 0.6 0.3 813 2-3 12.8 10.8 1.9 0.2 2,775 4-5 14.2 10.3 3.9 0.0 197 6+ * * * * 12 Maternity status Pregnant 11.2 9.8 1.3 0.0 156 Breastfeeding 16.1 15.6 0.5 0.0 351 Neither 13.3 11.8 1.3 0.2 5,261 Using IUD Yes 11.9 10.2 1.6 0.1 322 No 13.5 12.1 1.3 0.2 5,448 Smoking status Smokes cigarettes/ tobacco (18.5) (13.4) (5.1) (0.0) 36 Does not smoke 13.4 12.0 1.3 0.2 5,733 Residence Urban 12.9 11.4 1.4 0.2 3,381 Rural 14.2 12.9 1.1 0.1 2,388 Region Yerevan 11.9 10.4 1.4 0.1 1,812 Aragatsotn 14.2 14.1 0.1 0.0 308 Ararat 9.0 8.9 0.1 0.0 539 Armavir 7.4 6.3 0.9 0.2 580 Gegharkunik 39.2 37.8 1.1 0.4 468 Lori 13.8 10.2 2.9 0.7 299 Kotayk 12.6 10.9 1.7 0.0 662 Shirak 11.3 9.8 1.4 0.2 504 Syunik 10.4 8.9 1.5 0.0 232 Vayots Dzor 9.6 7.5 1.1 1.1 113 Tavush 9.5 7.2 2.4 0.0 253 Education Basic 17.3 15.6 1.2 0.5 380 Secondary 14.9 13.4 1.3 0.2 2,340 Secondary special 13.4 11.2 2.1 0.1 1,296 Higher 10.7 9.9 0.7 0.1 1,748 Wealth quintile Lowest 13.9 12.0 1.6 0.3 1,047 Second 14.4 13.1 1.2 0.1 1,196 Middle 14.1 12.4 1.6 0.2 1,092 Fourth 13.6 11.9 1.5 0.2 1,175 Highest 11.4 10.8 0.6 0.0 1,260 Total 13.4 12.0 1.3 0.2 5,769 Note: Prevalence is adjusted for altitude and for smoking status if known using formulas in CDC 1998. Total includes 5 (weighted) women with no education. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 176 • Nutrition Figure 12.7 Trends in anemia status among women age 15-49, 2000-2016 12.8.2 Anemia Prevalence in Children Table 12.13 presents anemia prevalence for children age 6-59 months. The results are based on tests of 1,349 (weighted) children who were present at the time of testing, whose parents consented to their being tested, and whose hemoglobin results represented plausible data. These children represented 85 percent of the 1,582 (weighted) children eligible for testing. Table 12.13 presents the prevalence of anemia in children age 6-69 months based on hemoglobin levels adjusted for altitude. The results in Table 12.13 indicate that overall, one in six children age 6 to 59 months (16 percent) have some level of anemia. Almost all children who suffer from anemia are mildly anemic (11 percent of all children) or moderately anemic (4 percent of all children). Less than 1 percent of children age 6-59 months are severely anemic. As Table 12.13 shows, anemia prevalence declines with age. Anemia is more prevalent among children under age 24 months than among older children with a peak prevalence of 35 percent observed among children age 9-11 months. Children age 48-59 months are five times less likely to be anemic than children age 12-17 months (6 percent and 31 percent, respectively). Anemia is almost equally prevalent in boys and girls (16 and 15 percent, respectively). Children in rural areas (18 percent) are slightly more likely than urban children (14 percent) to be anemic. Differences in the prevalence of anemia by maternal education or wealth are small. Unlike the 2015-16 or 2005 surveys, the 2000 ADHS restricted hemoglobin measurement to children whose mothers were interviewed with the Woman’s Individual Questionnaire. Therefore, in order to compare the 2015-16 and 2005 estimates of anemia prevalence to the 2000 estimates, 2015-16 and 2005 estimates were recalculated, restricting the estimates to children age 6-59 months, whose mothers were interviewed with the Woman’s Questionnaire. 12 10 2 0.3 21 17 3 0.5 13 12 1 0.2 Any anemia Mild Moderate Severe Percent 2000 ADHS 2005 ADHS 2015-16 ADHS Note: 2005 anemia estimates have been re-calculated to reflect corrections that were made to the 2005 ADHS altitude data. Nutrition • 177 Table 12.13 Prevalence of anemia in children Percentage of children age 6-59 months classified as having anemia, according to background characteristics, Armenia 2015-16 Background characteristic Anemia status by hemoglobin level Any anemia (<11.0 g/dl) Mild anemia (10.0-10.9 g/dl) Moderate anemia (7.0-9.9 g/dl) Severe anemia (< 7.0 g/dl) Number of children age 6-59 months Age in months 6-8 24.4 15.8 8.6 0.0 66 9-11 34.7 20.6 14.1 0.0 77 12-17 30.5 20.2 8.2 2.0 155 18-23 21.7 15.4 6.3 0.0 142 24-35 13.0 10.4 2.3 0.3 309 36-47 10.4 8.6 1.8 0.0 299 48-59 6.3 3.8 1.8 0.7 301 Sex Male 15.8 11.7 3.5 0.6 718 Female 15.4 10.2 4.9 0.3 631 Residence Urban 13.6 9.9 3.0 0.7 721 Rural 18.0 12.3 5.5 0.1 628 Region Yerevan 10.4 6.9 1.9 1.6 331 Aragatsotn 11.5 9.7 1.8 0.0 58 Ararat 10.3 9.7 0.0 0.5 159 Armavir 7.4 5.3 2.1 0.0 172 Gegharkunik 48.8 41.7 7.1 0.0 64 Lori 33.6 19.5 14.1 0.0 52 Kotayk 20.2 11.9 8.3 0.0 207 Shirak 21.4 13.5 7.9 0.0 153 Syunik 9.8 6.6 3.2 0.0 53 Vayots Dzor 15.1 10.6 4.5 0.0 34 Tavush 11.2 9.8 1.4 0.0 66 Mother's education1 Basic 16.6 10.1 6.5 0.0 82 Secondary 18.9 13.5 5.3 0.1 571 Secondary special 13.4 8.8 3.5 1.1 280 Higher 12.6 9.5 2.6 0.5 411 Wealth quintile Lowest 18.8 14.7 3.9 0.3 285 Second 14.4 8.6 5.8 0.0 292 Middle 19.9 12.8 6.2 0.8 250 Fourth 13.8 9.2 3.6 0.9 219 Highest 11.6 9.7 1.6 0.4 302 Total 15.6 11.0 4.2 0.4 1,349 Note: Table is based on children who stayed in the household on the night before the interview and who were tested for anemia. Prevalence of anemia, based on hemoglobin levels, is adjusted for altitude using formulas in CDC, 1998. Hemoglobin in grams per deciliter (g/dl). 1 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire. 178 • Nutrition Figure 12.8 compares anemia data from the 2000, 2005 and 2015-16 ADHS surveys. Children are much less likely to be anemic in 2015-16 than at the time of the two earlier ADHS surveys. The downward trend is especially marked with the rates of moderate anemia. Figure 12.8 Trends in anemia status among children age 6-59 months, 2000-2016 12.8.3 Knowledge about Anemia Although anemia levels among women and children have fallen, anemia continues to be a serious health concern in Armenia. A flour fortification program is being proposed to the parliament to prevent and control anemia in Armenia. Information on the population’s level of anemia knowledge is crucial for designing effective communication strategies to educate the public about anemia. To obtain this information, the 2015-16 ADHS included a series of questions in the Woman’ and Man’s questionnaires to assess the overall level of awareness of anemia and the extent of knowledge about symptoms and ways to prevent and control anemia. Anemia Knowledge Table 12.14 presents the percentages of women and men age 15-49 who had heard about anemia. Nearly eight in ten women (78 percent) and five in ten men (55 percent) say they have heard of anemia, showing that awareness of the disease is widespread in Armenia but not universal. The percentage of women who have heard about anemia is lowest in the Gegharkunik region (42 percent), in the 15-19 age group (57 percent), and among those who have only basic education (46 percent). Men are least likely to have heard about anemia if they are in the 15-19 age group (30 percent), are rural residents (44 percent), or live in the Lori (11 percent), Syunik (25 percent), Shirak (30 percent), and Gegharkunik (32 percent) regions. Among both women and men, the proportions who have heard about anemia generally increase with increasing education and household wealth. Knowledge of Anemia Symptoms Respondents in the 2015-16 ADHS who had heard about anemia were asked to mention symptoms that would lead them to think that a person had anemia. All the symptoms or signs that respondents mentioned were recorded. 24 14 10 0.4 33 15 17 1 16 11 4 0.5 Any anemia Mild Moderate Severe Percent 2000 ADHS 2005 ADHS 2015-16 ADHS Note: The estimates are restricted to children born to mothers who were interviewed. The 2005 ADHS anemia estimates have been re-calculated to reflect corrections that were made to the 2005 ADHS altitude data. Nutrition • 179 Table 12.14 Knowledge of anemia Percentage of women and men age 15-49 who have heard of anemia, according to background characteristics, Armenia 2015-16 Background characteristic Women Men Percentage who have heard of anemia Number of women Percentage who have heard of anemia Number of men Age 15-19 57.1 725 30.1 345 20-24 73.0 928 43.2 467 25-29 81.2 1,099 52.3 464 30-34 81.5 1,007 60.9 427 35-39 83.4 867 65.9 376 40-44 83.6 784 65.4 346 45-49 83.9 706 66.3 330 Residence Urban 83.4 3,657 62.3 1,558 Rural 70.1 2,459 44.3 1,197 Region Yerevan 87.5 2,001 78.8 833 Aragatsotn 66.8 315 52.5 159 Ararat 75.5 552 73.8 290 Armavir 59.3 586 51.7 268 Gegharkunik 41.5 478 31.5 235 Lori 67.8 355 10.7 184 Kotayk 84.6 678 30.4 299 Shirak 90.0 510 25.4 201 Syunik 94.6 238 77.2 104 Vayots Dzor 84.9 119 49.2 56 Tavush 89.1 283 51.6 126 Education Basic 45.7 396 35.1 360 Secondary 70.9 2,444 47.3 1,250 Secondary special 84.9 1,360 54.8 403 Higher 89.3 1,910 76.5 736 Wealth quintile Lowest 63.9 1,081 41.1 523 Second 76.2 1,242 47.1 583 Middle 74.7 1,142 49.1 521 Fourth 84.4 1,287 63.4 566 Highest 88.0 1,365 70.5 562 Total 78.1 6,116 54.5 2,755 Note: Total includes 5 (weighted) women and 5 (weighted) men with no education. The results in Tables 12.15.1 and 12.15.2 indicate that nearly three-quarters of women (72 percent) and two-thirds of men (66 percent) in Armenia who know about anemia identify pale skin as a symptom of the disease. Approximately half of women and men mention weakness, two-fifths of women and about one-fifth of men mention dizziness/lightheadedness, one-fifth of women and one-quarter of men cite tiredness/fatigue, and one-fifth of women and one-tenth of men consider headache as symptom of anemia. Shortness of breath and frequent infections are mentioned by 7 percent or less of women and men. Two percent or less of women and men mentioned other symptoms or said that anemia does not have any visible signs. Overall, 10 percent of women and 8 percent of men who have heard about anemia are not able to identify any anemia symptoms. The percentages of women and men who are not able to identify any anemia symptoms generally decline with age and with increasing education and wealth. Considering regional differences, the percentages who are unable to identify any anemia symptoms are highest among women in the Armavir (30 percent), Vayots Dzor (23 percent) and Lori (22 percent) regions and among men in Vayots Dzor (68 percent) and Tavush (33 percent) regions. Causes of Anemia The ADHS respondents who had heard about anemia were asked to identify what may cause anemia; all causes that respondents mentioned in response to the question were recorded. The results presented in Tables 12.16.1 and 12.16.2 highlight the most common answers about potential causes of anemia. 180 • Nutrition About half of women and men age 15-49 who have heard about anemia correctly believe that lack of iron in food (49 percent and 55 percent, respectively) or poor nutrition (58 percent women and 55 percent men) may cause anemia. About three in ten women and two in ten men cite blood loss or trauma as causes of anemia. Hereditary anemia was mentioned by 14 percent of women and 9 percent of men. Overall, 13 percent of women and 8 percent of men who have heard about anemia are not able to name any cause of anemia. Anemia Prevention The ADHS respondents who had heard about anemia were also asked to identify what person can eat or drink to prevent anemia; all answers that respondents mentioned in response to the question were recorded. The results presented in Tables 12.17.1 and 12.17.2. Around three in ten women and men age 15-49 who have heard about anemia mentioned eating iron rich foods without specifying the type of food. With regard to specific foods, more than six in ten women and men believe that consumption of red meat/any meat/any organ meat can prevent anemia. Other foods that were frequently mentioned by women as preventing anemia include beetroot (43 percent), vegetables/red fruits or vegetables (25 percent), and green apples (21 percent). Men were somewhat more likely than women to mention vegetables/red fruits or vegetables (29 percent) but less likely to cite eating beetroot (15 percent) or green apples (15 percent) as a means of preventing anemia. Eighteen percent of women and 17 percent of men said that medicine with iron can prevent anemia. Less than 10 percent of women and men mentioned factors like taking any vitamins, taking vitamin C/vitamin B12, or eating vitamin C-rich food as ways to prevent anemia. Overall, 12 percent of women and 11 percent of men who have heard about anemia were not able to cite any action a person can take to prevent anemia. Nutrition • 181 Table 12.15.1 Knowledge of symptoms of anemia: Women Among women age 15-49 who have heard of anemia, the percentage identifying specific symptoms as signs that would lead them to think a person has anemia, by background characteristics, Armenia 2015-16 Background characteristic Pale skin Weakness Tiredness/ fatigue Shortness of breath Headache Dizziness or light- headed- ness Frequent infections No visible signs Other Don't know Number of women who heard of anemia Age 15-19 62.9 39.2 18.9 5.5 19.2 33.7 5.1 1.3 3.4 15.4 414 20-24 70.0 45.9 21.9 3.4 19.0 39.7 5.3 1.4 1.4 12.0 678 25-29 73.9 43.9 20.2 5.3 19.9 40.4 4.8 1.2 2.1 9.7 893 30-34 74.5 47.9 23.0 4.2 17.9 40.2 3.0 1.3 2.0 9.0 821 35-39 75.0 45.6 21.1 5.7 18.5 40.4 4.5 0.8 1.4 9.2 723 40-44 72.6 45.6 20.2 5.6 19.3 37.4 5.7 1.0 2.0 7.3 655 45-49 73.1 47.9 24.2 4.3 19.2 42.1 4.5 1.9 2.4 7.5 593 Residence Urban 73.1 47.4 22.6 3.9 18.3 40.8 5.1 0.7 2.6 8.7 3,052 Rural 71.1 42.1 19.5 6.5 20.2 37.1 3.8 2.2 1.0 11.6 1,725 Region Yerevan 71.1 50.8 24.5 3.6 18.6 42.3 4.4 0.2 4.1 8.1 1,751 Aragatsotn 64.4 50.6 19.9 18.9 15.3 59.0 1.5 0.0 0.0 0.4 211 Ararat 86.3 45.7 25.3 5.6 22.5 14.1 2.1 5.6 0.0 2.5 417 Armavir 48.1 29.3 6.5 0.5 23.6 30.8 1.0 0.4 0.4 29.9 347 Gegharkunik 57.4 53.0 29.1 6.8 21.8 53.6 4.7 12.6 0.0 6.6 198 Lori 61.0 18.1 21.1 5.2 29.3 39.5 1.5 0.0 2.4 22.1 241 Kotayk 74.5 39.7 10.7 1.5 11.1 49.9 13.5 0.2 1.0 10.1 574 Shirak 80.7 45.4 18.0 6.0 14.7 36.1 0.7 0.2 0.2 10.5 459 Syunik 87.9 63.4 33.4 8.4 12.5 10.1 9.5 1.9 0.0 1.4 225 Vayots Dzor 62.7 34.4 9.7 0.7 25.0 44.5 1.9 0.0 0.3 23.4 101 Tavush 90.9 47.8 34.7 8.1 29.8 52.8 4.7 0.0 4.3 3.2 252 Education Basic 65.9 38.7 14.7 3.1 19.6 29.5 1.7 3.1 2.0 20.4 181 Secondary 68.0 38.6 17.6 4.9 17.3 35.7 3.8 1.9 1.8 12.0 1,734 Secondary special 73.9 45.7 23.9 5.2 19.2 40.1 5.1 0.8 1.6 9.0 1,155 Higher 76.4 53.0 24.5 4.7 20.5 44.0 5.4 0.7 2.5 6.8 1,705 Wealth quintile Lowest 66.8 39.3 15.2 4.6 17.8 34.8 2.1 2.6 1.4 15.2 691 Second 74.1 42.8 21.1 8.5 21.5 35.4 4.8 2.0 1.0 8.8 946 Middle 72.8 45.7 23.4 4.4 18.4 39.4 4.9 1.6 1.7 8.8 853 Fourth 71.7 47.3 22.2 4.2 17.5 39.5 5.5 0.3 2.7 9.4 1,085 Highest 74.5 49.2 23.2 3.1 19.5 45.4 4.9 0.4 2.8 8.3 1,202 Total 72.4 45.5 21.4 4.8 19.0 39.5 4.6 1.2 2.0 9.7 4,777 Note: Total includes 1 (weighted) woman with no education. 182 • Nutrition Table 12.15.2 Knowledge of symptoms of anemia: Men Among men age 15-49 who have heard of anemia, the percentage identifying specific symptoms as signs that would lead them to think a person has anemia, by background characteristics, Armenia 2015-16 Background characteristic Pale skin Weakness Tiredness/ fatigue Shortness of breath Headache Dizziness or light- headed- ness Frequent infections No visible signs Other Don't know Number of men who heard of anemia Age 15-19 68.5 50.7 24.6 2.4 5.0 23.8 4.0 1.7 0.0 6.0 104 20-24 68.0 58.2 18.5 4.1 11.4 18.1 6.1 1.6 1.1 6.6 202 25-29 67.6 57.2 22.8 4.1 8.6 19.7 7.0 2.4 0.4 7.3 243 30-34 58.2 58.8 28.0 5.1 8.4 14.9 7.8 1.3 0.0 10.1 260 35-39 65.0 57.4 23.2 5.1 11.6 19.2 4.7 2.5 0.8 7.5 247 40-44 68.9 58.1 23.9 7.1 18.6 22.2 8.6 2.3 0.9 7.7 226 45-49 66.3 56.3 29.9 4.1 6.8 18.5 8.1 2.1 0.2 11.2 219 Residence Urban 65.3 62.2 24.9 4.2 11.0 19.0 5.0 1.2 0.5 6.7 970 Rural 66.3 48.1 23.8 5.8 9.4 19.1 10.2 3.4 0.5 11.2 531 Region Yerevan 61.8 71.5 26.4 2.6 11.9 18.3 2.7 0.0 0.6 4.7 657 Aragatsotn 59.1 94.6 90.4 16.8 4.7 7.1 1.9 0.0 0.0 2.7 84 Ararat 54.0 49.7 4.9 2.8 1.0 4.2 5.6 9.8 0.0 8.9 214 Armavir 94.7 12.8 3.8 3.2 2.8 3.5 0.0 0.0 0.0 5.1 138 Gegharkunik 45.6 63.6 47.7 5.0 36.8 78.0 13.4 0.0 0.0 0.0 74 Lori * * * * * * * * * * 20 Kotayk 84.4 43.6 32.5 12.6 17.0 61.5 45.8 6.5 3.5 13.4 91 Shirak (75.4) (46.0) (22.6) (3.3) (8.0) (8.6) (1.7) (0.0) (0.0) (18.9) 51 Syunik 100.0 39.9 19.9 14.2 25.2 7.5 8.8 0.8 0.0 0.0 80 Vayots Dzor 14.6 17.0 6.9 0.0 0.0 14.1 2.4 8.8 1.6 67.7 28 Tavush 55.1 51.2 8.1 1.9 2.3 19.7 15.0 0.0 0.0 33.4 65 Education Basic 68.9 40.5 22.8 7.0 6.2 11.9 5.0 2.3 2.4 10.3 126 Secondary 58.3 54.7 23.9 3.6 10.6 19.7 5.2 2.0 0.1 10.6 591 Secondary special 65.8 53.7 22.9 3.9 8.6 18.6 12.7 2.0 1.9 9.9 221 Higher 72.6 65.0 26.3 5.8 11.9 20.2 6.7 1.9 0.0 4.8 563 Wealth quintile Lowest 70.4 38.1 18.1 4.0 8.2 12.9 6.2 3.7 0.0 11.5 215 Second 64.1 51.4 28.3 7.3 7.9 17.6 11.4 3.7 0.8 11.2 275 Middle 62.4 55.7 27.3 3.9 9.3 22.8 7.6 2.0 0.8 9.9 256 Fourth 63.2 60.0 26.2 2.3 9.2 19.2 5.6 1.0 0.8 6.1 359 Highest 68.5 70.1 22.1 6.2 15.2 20.9 4.6 0.8 0.1 5.4 396 Total 65.7 57.2 24.5 4.8 10.4 19.1 6.8 2.0 0.5 8.3 1,501 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. N ut rit io n • 1 83 Ta bl e 12 .1 6. 1 K n ow le dg e ab ou t w ha t m ay c au se a n em ia : W om en A m on g w om en a ge 1 5- 49 w ho h av e he ar d of a ne m ia , t he p er ce nt ag e w ho r ep or t v ar io us c au se s of a ne m ia , b y ba ck gr ou nd c ha ra ct er is tic s, A rm en ia 2 01 5- 16 B ac kg ro un d ch ar ac te ris tic La ck o f iro n in fo od P oo r nu tr iti on E at in g br ea d on ly H er e- di ta ry an em ia B lo od lo ss o r tra um a A bo rti on M en st ru - at io n P re g- na nc y D el iv er y E nv iro n- m en t po llu tio n Le ad po is on U nc le an po llu te d w at er D is ea se s In fe ct io n M os - qu ito s/ m al ar ia P ar a- si te s W ro ng bl oo d tra ns - fu si on In je c- tio ns O th er D on 't kn ow N um be r of w om en w ho he ar d of an em ia A ge 15 -1 9 44 .7 50 .6 7. 3 12 .8 20 .6 4. 1 4. 5 6. 2 3. 9 0. 6 0. 0 0. 5 6. 5 3. 0 0. 0 1. 3 2. 5 0. 5 1. 3 22 .1 41 4 20 -2 4 45 .7 55 .7 5. 3 13 .4 26 .4 6. 6 4. 7 8. 0 7. 0 0. 8 0. 0 0. 3 7. 8 4. 2 0. 1 1. 5 2. 6 0. 5 1. 1 16 .9 67 8 25 -2 9 49 .6 57 .6 5. 4 13 .3 31 .4 8. 5 7. 2 8. 6 6. 0 0. 8 0. 0 0. 2 8. 2 5. 3 0. 2 0. 9 2. 1 0. 6 1. 1 12 .5 89 3 30 -3 4 52 .6 58 .6 5. 6 15 .1 28 .3 6. 4 5. 8 7. 2 7. 4 0. 7 0. 0 0. 1 8. 9 5. 2 0. 7 1. 2 2. 9 0. 9 1. 6 12 .5 82 1 35 -3 9 51 .3 59 .0 3. 3 14 .2 32 .3 6. 7 4. 6 5. 6 6. 9 0. 6 0. 1 0. 1 7. 2 4. 0 0. 2 0. 3 2. 1 0. 8 1. 6 12 .5 72 3 40 -4 4 50 .1 58 .9 4. 4 13 .9 29 .5 5. 4 2. 8 6. 5 6. 3 0. 6 0. 0 0. 2 9. 4 5. 9 0. 3 0. 4 2. 3 0. 0 2. 6 10 .2 65 5 45 -4 9 45 .6 60 .4 5. 1 17 .3 30 .4 8. 0 5. 3 7. 2 5. 1 0. 3 0. 0 0. 1 9. 7 4. 0 0. 1 1. 1 2. 8 0. 5 2. 0 10 .7 59 3 R es id en ce U rb an 49 .5 60 .2 5. 1 15 .1 31 .1 7. 4 6. 4 6. 3 6. 6 0. 9 0. 0 0. 2 7. 7 5. 4 0. 3 1. 4 2. 8 0. 6 2. 1 11 .5 3, 05 2 R ur al 48 .1 53 .1 5. 0 12 .8 25 .1 5. 6 3. 0 8. 6 5. 6 0. 2 0. 1 0. 2 9. 4 3. 4 0. 2 0. 2 1. 9 0. 5 0. 7 16 .8 1, 72 5 R eg io n Y er ev an 47 .8 63 .6 5. 2 17 .7 32 .5 8. 8 8. 6 5. 4 7. 2 1. 0 0. 0 0. 2 4. 1 7. 1 0. 2 2. 0 3. 8 0. 7 3. 2 9. 8 1, 75 1 A ra ga ts ot n 52 .5 32 .0 4. 2 22 .9 20 .3 0. 9 0. 3 0. 6 0. 2 0. 0 0. 6 0. 6 1. 0 5. 0 0. 6 0. 0 4. 3 0. 0 0. 0 21 .3 21 1 A ra ra t 59 .6 55 .7 3. 7 26 .0 22 .2 5. 0 1. 5 3. 0 3. 7 0. 0 0. 0 0. 0 0. 7 0. 6 0. 0 0. 0 1. 0 0. 0 0. 0 5. 2 41 7 A rm av ir 33 .1 50 .6 0. 7 1. 8 21 .0 4. 4 2. 8 7. 2 2. 1 0. 4 0. 0 0. 0 4. 7 0. 0 0. 0 0. 0 0. 4 0. 0 0. 0 33 .5 34 7 G eg ha rk un ik 78 .4 44 .4 0. 3 14 .3 19 .7 16 .8 7. 5 20 .2 27 .0 0. 0 0. 0 0. 5 20 .1 1. 8 0. 0 0. 0 5. 7 0. 6 0. 3 8. 5 19 8 Lo ri 48 .6 48 .4 2. 9 1. 9 14 .6 2. 9 2. 9 5. 8 0. 4 0. 0 0. 0 0. 0 8. 7 0. 2 1. 2 0. 0 0. 9 0. 9 0. 6 27 .4 24 1 K ot ay k 37 .2 63 .9 5. 1 5. 1 29 .4 2. 1 1. 0 14 .1 4. 6 0. 2 0. 0 0. 2 31 .2 8. 7 0. 0 1. 1 0. 3 0. 6 1. 6 15 .9 57 4 S hi ra k 38 .9 48 .6 2. 0 14 .0 44 .0 13 .5 6. 1 3. 1 4. 7 0. 0 0. 0 0. 2 2. 5 0. 8 0. 0 0. 2 1. 0 0. 0 1. 0 13 .0 45 9 S yu ni k 87 .5 63 .9 16 .6 21 .3 15 .6 1. 7 1. 4 5. 8 7. 8 4. 2 0. 0 0. 6 17 .8 2. 3 1. 9 1. 1 2. 8 1. 6 0. 0 2. 2 22 5 V ay ot s D zo r 29 .0 40 .8 4. 1 20 .0 34 .3 0. 8 5. 8 2. 0 0. 8 0. 0 0. 0 0. 0 9. 5 7. 6 0. 0 0. 0 3. 5 1. 0 0. 0 32 .7 10 1 T av us h 54 .1 73 .5 14 .7 6. 1 35 .9 4. 3 5. 3 16 .9 11 .6 0. 0 0. 0 0. 0 1. 4 5. 5 0. 0 0. 0 3. 0 1. 5 1. 7 5. 7 25 2 E du ca ti o n B as ic 38 .1 52 .6 4. 1 9. 1 21 .0 2. 2 4. 1 3. 9 3. 4 0. 0 0. 0 0. 0 6. 0 6. 2 0. 3 0. 0 1. 7 0. 0 0. 0 26 .8 18 1 S ec on da ry 41 .6 53 .2 4. 6 12 .7 23 .2 5. 6 3. 4 5. 7 5. 3 0. 3 0. 0 0. 2 8. 0 3. 1 0. 2 0. 0 2. 1 0. 6 1. 7 18 .9 1, 73 4 S ec on da ry sp ec ia l 49 .6 58 .5 5. 4 14 .9 31 .8 7. 1 4. 2 7. 7 5. 8 0. 5 0. 1 0. 1 9. 2 5. 6 0. 2 1. 2 1. 9 0. 6 0. 9 11 .8 1, 15 5 H ig he r 57 .3 62 .1 5. 5 16 .1 33 .7 8. 2 7. 7 8. 6 7. 8 1. 2 0. 0 0. 3 8. 3 5. 4 0. 3 1. 7 3. 4 0. 6 2. 2 7. 5 1, 70 5 W ea lt h qu in til e Lo w es t 39 .6 52 .7 4. 1 7. 6 24 .9 5. 0 2. 8 6. 1 4. 0 0. 4 0. 0 0. 1 5. 6 3. 0 0. 3 0. 0 1. 7 0. 4 0. 5 22 .2 69 1 S ec on d 52 .8 53 .7 6. 2 17 .4 25 .2 5. 3 3. 8 9. 3 5. 8 0. 3 0. 0 0. 3 10 .7 3. 8 0. 2 0. 2 1. 7 0. 5 0. 8 12 .7 94 6 M id dl e 47 .1 57 .3 4. 9 10 .1 29 .4 7. 0 5. 5 7. 8 6. 9 0. 7 0. 0 0. 1 9. 9 2. 6 0. 3 0. 4 1. 7 0. 6 1. 1 14 .3 85 3 Fo ur th 48 .4 59 .3 5. 7 14 .3 30 .7 4. 8 5. 1 5. 5 4. 7 0. 6 0. 0 0. 3 8. 9 5. 4 0. 2 1. 3 3. 0 0. 5 2. 2 12 .2 1, 08 5 H ig he st 53 .2 62 .3 4. 3 18 .6 32 .4 10 .5 7. 4 7. 1 8. 9 1. 0 0. 1 0. 2 6. 3 7. 0 0. 3 2. 0 3. 6 0. 8 2. 7 9. 4 1, 20 2 T ot al 49 .0 57 .7 5. 1 14 .3 29 .0 6. 7 5. 2 7. 1 6. 3 0. 6 0. 0 0. 2 8. 3 4. 7 0. 2 0. 9 2. 5 0. 6 1. 6 13 .4 4, 77 7 N ot e: T ot al in cl ud es 1 ( w ei gh te d) w om an w ith n o ed uc at io n. Nutrition • 183 18 4 • N ut rit io n Ta bl e 12 .1 6. 2 K n ow le dg e ab ou t w ha t m ay c au se a n em ia : M en A m on g m en a ge 1 5- 49 w ho h av e he ar d of a ne m ia , t he p er ce nt ag e w ho r ep or t v ar io us c au se s of a ne m ia , b y ba ck gr ou nd c ha ra ct er is tic s, A rm en ia 2 01 5- 16 B ac kg ro un d ch ar ac te ris tic La ck o f iro n in fo od P oo r nu tr iti on E at in g br ea d on ly H er e- di ta ry an em ia B lo od lo ss o r tra um a A bo rti on M en st ru - at io n P re g- na nc y D el iv er y E nv iro n- m en t po llu tio n Le ad po is on U nc le an po llu te d w at er D is - ea se s In fe ct io n M os qu i- to s/ m al ar ia P ar a si te s W ro ng bl oo d tra ns - fu si on In je c- tio ns O th er D on 't kn ow N um be r of m en w ho he ar d of an em ia A ge 15 -1 9 47 .7 43 .7 8. 1 5. 3 13 .1 2. 3 1. 1 0. 0 6. 2 7. 0 1. 2 7. 9 1. 1 10 .4 5. 9 1. 6 10 .5 1. 6 0. 0 9. 4 10 4 20 -2 4 53 .5 51 .8 8. 0 6. 6 20 .0 1. 8 1. 1 0. 9 5. 3 7. 9 2. 1 8. 2 3. 0 4. 6 3. 7 0. 0 4. 4 0. 7 0. 0 10 .0 20 2 25 -2 9 61 .6 51 .1 10 .4 9. 6 19 .2 2. 4 1. 7 1. 8 8. 4 9. 7 0. 7 2. 9 4. 2 5. 8 3. 7 0. 8 8. 2 2. 5 0. 9 5. 6 24 3 30 -3 4 52 .3 54 .4 11 .7 6. 9 15 .4 1. 9 2. 0 2. 5 6. 0 7. 1 3. 3 5. 2 2. 8 4. 0 3. 9 0. 0 9. 2 3. 7 0. 0 11 .3 26 0 35 -3 9 53 .9 60 .8 13 .7 11 .9 18 .6 2. 3 1. 9 2. 7 5. 1 5. 6 3. 3 6. 6 3. 6 9. 0 2. 9 0. 0 7. 7 5. 0 0. 0 5. 8 24 7 40 -4 4 53 .4 56 .0 8. 8 12 .8 24 .0 2. 5 2. 1 5. 4 12 .9 4. 4 1. 1 8. 7 4. 0 9. 8 5. 7 0. 0 8. 5 3. 5 0. 0 8. 6 22 6 45 -4 9 57 .7 55 .3 10 .8 6. 7 20 .6 2. 3 3. 9 3. 2 7. 9 5. 6 1. 3 3. 1 4. 0 8. 8 9. 9 0. 0 3. 6 2. 0 0. 0 8. 6 21 9 R es id en ce U rb an 50 .7 57 .6 8. 8 6. 4 18 .8 1. 5 1. 5 2. 0 6. 3 8. 1 2. 1 8. 1 3. 0 6. 7 7. 5 0. 4 9. 4 4. 4 0. 2 6. 7 97 0 R ur al 62 .5 47 .9 13 .5 13 .5 19 .4 3. 4 3. 1 3. 6 9. 6 4. 1 1. 7 1. 7 4. 3 8. 1 0. 2 0. 0 3. 6 0. 2 0. 0 11 .4 53 1 R eg io n Y er ev an 45 .2 65 .2 7. 1 4. 4 18 .5 0. 7 1. 1 1. 6 4. 5 10 .1 2. 4 11 .4 2. 1 6. 5 10 .9 0. 5 11 .2 6. 2 0. 3 3. 8 65 7 A ra ga ts ot n 93 .4 85 .0 78 .9 2. 4 17 .9 0. 4 0. 4 0. 0 0. 4 0. 0 0. 0 0. 0 0. 0 0. 4 0. 0 0. 0 0. 0 0. 4 0. 0 2. 7 84 A ra ra t 39 .4 44 .7 3. 9 24 .4 8. 7 0. 0 0. 0 4. 8 2. 9 7. 1 3. 0 4. 3 2. 2 21 .7 0. 0 0. 0 3. 8 0. 0 0. 0 15 .2 21 4 A rm av ir 84 .0 13 .6 0. 9 0. 0 29 .8 0. 9 1. 9 2. 6 5. 2 0. 0 4. 6 0. 0 0. 5 0. 0 0. 5 0. 0 9. 2 0. 5 0. 0 7. 2 13 8 G eg ha rk un ik 95 .9 5. 7 3. 3 42 .0 28 .8 36 .9 25 .6 15 .9 90 .5 0. 0 0. 0 0. 0 21 .6 0. 0 2. 5 0. 0 11 .5 2. 2 0. 0 1. 6 74 Lo ri * * * * * * * * * * * * * * * * * * * * 20 K ot ay k 44 .5 74 .9 0. 0 3. 4 10 .3 0. 0 0. 0 1. 1 0. 0 16 .5 1. 0 3. 1 3. 3 0. 0 0. 0 0. 0 4. 5 0. 0 0. 0 15 .6 91 S hi ra k (4 3. 9) (3 5. 4) (1 .9 ) (0 .0 ) (1 0. 2) (0 .0 ) (2 .1 ) (0 .0 ) (2 .1 ) (0 .0 ) (0 .0 ) (0 .0 ) (6 .2 ) (4 .2 ) (0 .0 ) (0 .0 ) (2 .1 ) (0 .0 ) (0 .0 ) (2 6. 8) 51 S yu ni k 96 .0 52 .9 37 .1 8. 9 4. 6 0. 0 0. 0 0. 0 0. 0 3. 2 0. 0 0. 8 2. 2 0. 0 0. 0 0. 0 2. 2 0. 8 0. 0 0. 0 80 V ay ot s D zo r 5. 6 24 .3 0. 0 27 .7 26 .9 0. 0 1. 4 5. 5 1. 0 0. 0 0. 0 0. 0 7. 9 0. 9 0. 0 0. 0 0. 0 0. 0 0. 0 58 .7 28 T av us h 44 .4 87 .3 3. 2 0. 0 56 .7 0. 0 0. 0 0. 0 1. 2 0. 0 0. 0 0. 0 9. 2 24 .9 0. 0 0. 0 0. 0 0. 0 0. 0 4. 4 65 E du ca ti o n B as ic 46 .6 44 .0 11 .8 10 .2 13 .8 0. 9 1. 6 2. 6 3. 5 2. 9 2. 6 0. 0 3. 8 10 .4 0. 0 0. 0 6. 0 0. 0 0. 0 15 .7 12 6 S ec on da ry 50 .2 51 .6 10 .3 11 .1 20 .4 4. 2 2. 7 2. 9 11 .3 4. 9 1. 0 5. 5 3. 5 7. 4 3. 2 0. 3 4. 5 2. 5 0. 0 10 .4 59 1 S ec on da ry sp ec ia l 52 .8 61 .1 9. 3 6. 1 23 .3 0. 0 1. 1 3. 0 4. 3 4. 1 0. 3 4. 8 2. 7 7. 5 1. 7 0. 9 8. 8 2. 8 0. 0 9. 1 22 1 H ig he r 62 .4 56 .5 10 .9 7. 4 17 .1 1. 3 1. 8 2. 0 5. 7 10 .5 3. 5 8. 0 3. 6 6. 2 9. 2 0. 0 10 .0 4. 0 0. 4 4. 3 56 3 W ea lt h qu in til e Lo w es t 61 .1 39 .2 10 .1 10 .5 15 .7 1. 6 2. 3 3. 8 7. 1 2. 4 0. 0 1. 3 4. 6 7. 0 0. 5 0. 0 6. 0 0. 5 0. 0 15 .2 21 5 S ec on d 62 .0 52 .7 13 .3 12 .8 22 .0 4. 5 2. 3 2. 4 9. 3 4. 6 2. 7 2. 3 4. 2 9. 5 0. 0 0. 0 2. 3 0. 0 0. 0 9. 9 27 5 M id dl e 50 .8 54 .3 12 .8 12 .1 14 .2 3. 5 2. 7 2. 8 11 .8 10 .0 2. 3 4. 4 3. 8 7. 3 3. 1 0. 0 5. 8 2. 8 0. 8 7. 9 25 6 Fo ur th 47 .7 56 .4 10 .3 5. 3 21 .1 1. 3 1. 9 2. 8 5. 8 4. 2 1. 3 6. 9 3. 0 5. 0 5. 7 1. 0 9. 2 3. 8 0. 0 8. 5 35 9 H ig he st 55 .7 61 .4 7. 4 6. 4 20 .0 0. 9 1. 4 1. 7 5. 1 10 .7 2. 9 10 .8 2. 4 7. 6 11 .4 0. 0 10 .8 5. 6 0. 0 3. 8 39 6 T ot al 54 .9 54 .2 10 .5 8. 9 19 .0 2. 2 2. 1 2. 6 7. 5 6. 7 2. 0 5. 9 3. 4 7. 2 5. 0 0. 2 7. 3 2. 9 0. 1 8. 4 1, 50 1 N ot e: A n as te ris k de no te s a fig ur e ba se d on fe w er th an 2 5 un w ei gh te d ca se s th at h as b ee n su pp re ss ed . F ig ur es in p ar en th es es a re b as ed o n 25 -4 9 un w ei gh te d ca se s. 184 • Nutrition N ut rit io n • 1 85 Ta bl e 12 .1 7. 1 W h at p er so n ca n ea t o r dr in k to p re ve n t a ne m ia : W om en A m on g w om en a ge 1 5- 49 w ho h av e he ar d of a ne m ia , t he p er ce nt ag e w ho r ep or t v ar io us fo od s an d dr in ks a p er so n ca n co ns um e to p re ve nt a ne m ia , b y ba ck gr ou nd c ha ra ct er is tic s, A rm en ia 2 01 5- 16 B ac kg ro un d ch ar ac te ris tic R ed m ea t/a ny m ea t/ or ga n m ea t Iro n ric h fo od A ny fru its G re en ap pl es B ee t- ro ot A ny ve ge ta - bl es /r ed fru its o r ve ge ta bl es A ny ju ic e T ea o r co ffe e V ita m in " C " ric h fo od s V ita m in C / vi ta m in B 12 A ny vi ta m in s Iro n co nt ai ni ng ta bl et s/ ca ps ul es / sy ru p/ m ed ic in e O th er D on 't kn ow N um be r of w om en w ho h ea rd of a ne m ia A ge 15 -1 9 53 .9 25 .5 4. 9 23 .2 38 .7 20 .9 3. 5 0. 8 7. 5 9. 9 9. 0 13 .5 5. 1 20 .5 41 4 20 -2 4 60 .5 28 .0 6. 5 19 .0 40 .9 21 .9 2. 1 0. 0 7. 5 7. 9 7. 2 15 .6 4. 2 16 .3 67 8 25 -2 9 69 .3 26 .9 6. 3 22 .1 43 .5 25 .0 2. 7 0. 4 6. 7 7. 5 6. 6 21 .2 5. 4 10 .6 89 3 30 -3 4 69 .7 33 .2 7. 7 21 .6 40 .7 26 .3 2. 9 0. 2 6. 1 7. 7 6. 5 22 .1 4. 7 11 .5 82 1 35 -3 9 67 .9 29 .8 7. 5 24 .1 45 .3 24 .7 2. 8 0. 4 7. 0 9. 5 5. 5 16 .6 4. 3 11 .8 72 3 40 -4 4 66 .4 28 .2 6. 1 16 .3 45 .8 28 .6 2. 9 0. 2 6. 7 7. 1 8. 0 15 .1 7. 9 9. 4 65 5 45 -4 9 72 .3 25 .9 8. 4 19 .5 44 .0 27 .5 3. 4 0. 4 7. 1 5. 9 6. 4 16 .4 6. 4 8. 6 59 3 R es id en ce U rb an 66 .0 29 .0 6. 7 23 .0 41 .0 23 .8 3. 2 0. 4 7. 1 8. 7 7. 2 19 .7 7. 6 10 .7 3, 05 2 R ur al 67 .5 27 .7 7. 1 17 .0 46 .3 27 .7 2. 2 0. 3 6. 5 6. 4 6. 3 14 .2 1. 6 14 .9 1, 72 5 R eg io n Y er ev an 63 .4 30 .3 5. 8 26 .2 40 .2 20 .4 3. 1 0. 2 7. 8 10 .4 7. 1 22 .6 12 .1 9. 2 1, 75 1 A ra ga ts ot n 69 .8 37 .8 3. 6 6. 5 25 .7 12 .8 0. 7 0. 0 8. 7 5. 2 18 .1 6. 0 0. 2 6. 1 21 1 A ra ra t 70 .8 36 .4 1. 0 28 .5 51 .9 27 .0 0. 0 0. 0 2. 1 3. 4 1. 2 10 .1 0. 0 9. 4 41 7 A rm av ir 53 .8 15 .8 3. 0 9. 1 32 .6 13 .7 0. 0 0. 0 8. 1 3. 3 1. 3 11 .0 1. 5 32 .0 34 7 G eg ha rk un ik 65 .6 55 .0 10 .7 7. 9 10 .8 36 .8 1. 1 2. 3 13 .0 18 .6 15 .0 66 .7 0. 0 9. 4 19 8 Lo ri 45 .6 23 .7 8. 6 13 .1 39 .0 8. 0 0. 6 0. 5 2. 9 10 .9 7. 4 13 .3 1. 1 23 .1 24 1 K ot ay k 69 .1 21 .3 7. 3 11 .5 68 .0 43 .4 1. 0 0. 0 2. 9 6. 7 3. 8 15 .2 2. 1 13 .3 57 4 S hi ra k 71 .7 23 .1 8. 5 18 .8 38 .2 25 .6 5. 4 0. 6 5. 9 1. 7 10 .8 2. 0 1. 0 14 .9 45 9 S yu ni k 96 .1 21 .0 6. 5 27 .5 24 .3 29 .7 2. 4 0. 3 8. 7 5. 7 4. 2 22 .5 0. 5 0. 8 22 5 V ay ot s D zo r 53 .8 16 .0 1. 4 6. 5 46 .9 11 .3 3. 7 0. 0 4. 0 18 .1 6. 2 12 .6 2. 4 28 .4 10 1 T av us h 80 .4 34 .8 25 .8 42 .2 70 .3 48 .4 14 .6 0. 7 14 .2 6. 3 8. 6 13 .5 7. 0 3. 5 25 2 E du ca ti o n B as ic 58 .8 20 .5 7. 7 19 .2 42 .6 17 .8 3. 1 0. 9 4. 4 6. 8 4. 6 8. 1 1. 3 25 .4 18 1 S ec on da ry 62 .7 24 .7 7. 3 17 .0 42 .4 26 .0 2. 7 0. 2 5. 2 6. 2 6. 9 12 .5 3. 6 16 .4 1, 73 4 S ec on da ry sp ec ia l 68 .9 28 .1 7. 0 20 .1 43 .8 25 .4 3. 8 0. 4 7. 9 6. 6 7. 5 16 .5 6. 4 10 .2 1, 15 5 H ig he r 69 .7 33 .5 6. 3 25 .5 42 .7 25 .0 2. 4 0. 3 8. 2 10 .5 6. 6 24 .9 6. 9 7. 8 1, 70 5 W ea lt h q ui nt ile Lo w es t 60 .7 22 .3 7. 2 13 .1 42 .4 23 .4 1. 6 0. 2 5. 8 5. 2 5. 7 8. 3 3. 6 19 .0 69 1 S ec on d 71 .2 31 .3 6. 5 21 .6 48 .5 27 .8 2. 4 0. 2 6. 8 7. 4 6. 2 16 .8 1. 8 11 .5 94 6 M id dl e 65 .8 27 .5 7. 8 17 .7 38 .2 29 .3 4. 1 0. 3 7. 0 6. 5 8. 2 16 .5 5. 0 12 .2 85 3 Fo ur th 66 .1 28 .5 5. 5 22 .7 40 .4 23 .3 3. 6 0. 6 5. 8 6. 8 8. 4 18 .1 6. 5 11 .9 1, 08 5 H ig he st 67 .2 30 .7 7. 5 25 .5 44 .3 23 .0 2. 3 0. 2 8. 4 11 .6 5. 9 24 .5 8. 6 9. 0 1, 20 2 T ot al 66 .5 28 .5 6. 9 20 .9 42 .9 25 .2 2. 8 0. 3 6. 9 7. 8 6. 9 17 .7 5. 4 12 .2 4, 77 7 N ot e: T ot al in cl ud es 1 ( w ei gh te d) w om an w ith n o ed uc at io n. Nutrition • 185 18 6 • N ut rit io n Ta bl e 12 .1 7. 2 W h at p er so n ca n ea t o r dr in k to p re ve n t a ne m ia : M en A m on g m en a ge 1 5- 49 w ho h av e he ar d of a ne m ia , t he p er ce nt ag e w ho r ep or t v ar io us fo od s an d dr in ks a p er so n ca n co ns um e to p re ve nt a ne m ia , b y ba ck gr ou nd c ha ra ct er is tic s, A rm en ia 2 01 5- 16 B ac kg ro un d ch ar ac te ris tic R ed m ea t/ an y m ea t/ or ga n m ea t Iro n ric h fo od A ny fru its G re en ap pl es B ee tr oo t A ny ve ge ta - bl es /r ed fru its o r ve ge ta bl es A ny ju ic e T ea o r co ffe e V ita m in " C " ric h fo od s V ita m in C / vi ta m in B 12 A ny vi ta m in s Iro n co nt ai ni ng ta bl et s/ ca ps ul es / sy ru p/ m ed ic in e O th er D on 't kn ow N um be r of m en w ho he ar d of an em ia A ge 15 -1 9 56 .6 20 .0 5. 8 9. 9 17 .3 24 .8 5. 7 1. 7 3. 3 13 .4 9. 6 15 .1 4. 7 9. 9 10 4 20 -2 4 64 .6 32 .4 8. 5 15 .7 12 .1 27 .8 2. 3 3. 4 7. 7 3. 0 12 .7 17 .0 2. 4 12 .4 20 2 25 -2 9 56 .4 31 .6 13 .1 15 .9 12 .0 29 .0 3. 4 2. 7 7. 7 9. 9 8. 8 18 .3 0. 6 10 .2 24 3 30 -3 4 63 .8 31 .0 14 .5 13 .6 14 .4 32 .7 3. 5 0. 4 12 .3 4. 1 8. 5 13 .5 1. 1 11 .0 26 0 35 -3 9 67 .4 29 .7 10 .0 15 .2 17 .3 28 .9 6. 8 3. 5 8. 9 6. 1 6. 9 22 .1 4. 1 7. 3 24 7 40 -4 4 60 .3 33 .2 12 .6 20 .2 19 .3 28 .3 7. 0 2. 3 12 .8 8. 6 8. 1 21 .3 3. 1 12 .6 22 6 45 -4 9 64 .5 26 .1 13 .6 12 .6 14 .4 26 .0 4. 2 2. 1 9. 1 1. 3 8. 5 12 .3 2. 9 12 .6 21 9 R es id en ce U rb an 57 .5 26 .9 11 .5 11 .7 17 .2 26 .3 5. 8 0. 8 9. 1 7. 3 12 .2 13 .8 3. 5 11 .5 97 0 R ur al 71 .3 35 .5 12 .0 21 .3 11 .4 33 .0 2. 6 5. 0 9. 8 4. 0 2. 8 23 .6 0. 6 9. 7 53 1 R eg io n Y er ev an 51 .5 23 .0 10 .6 8. 6 17 .9 20 .7 7. 6 0. 0 9. 9 8. 6 16 .8 7. 0 5. 0 11 .2 65 7 A ra ga ts ot n 97 .7 52 .4 25 .2 24 .2 1. 6 20 .1 0. 0 0. 0 0. 4 1. 2 0. 4 0. 0 0. 0 2. 3 84 A ra ra t 60 .4 11 .5 3. 2 28 .1 9. 3 25 .7 6. 8 16 .2 1. 1 0. 0 4. 0 29 .1 0. 0 9. 6 21 4 A rm av ir 71 .7 44 .8 6. 6 11 .4 8. 3 29 .8 1. 5 0. 0 0. 4 0. 4 0. 7 11 .6 0. 5 7. 6 13 8 G eg ha rk un ik 92 .2 83 .4 6. 0 9. 9 6. 4 84 .9 0. 0 0. 0 38 .2 34 .3 1. 7 90 .0 0. 0 0. 0 74 Lo ri * * * * * * * * * * * * * * 20 K ot ay k 79 .7 34 .2 58 .2 20 .7 26 .8 74 .1 2. 3 0. 0 26 .4 0. 0 9. 3 45 .2 0. 0 15 .6 91 S hi ra k (1 8. 5) (4 4. 6) (1 .6 ) (3 1. 7) (3 .7 ) (0 .0 ) (0 .0 ) (0 .0 ) (4 .0 ) (4 .2 ) (0 .0 ) (2 .2 ) (0 .0 ) (2 6. 5) 51 S yu ni k 99 .3 28 .7 0. 0 25 .3 24 .2 4. 7 0. 0 0. 0 0. 0 3. 0 2. 5 28 .9 0. 0 0. 0 80 V ay ot s D zo r 28 .2 10 .1 13 .7 3. 8 30 .6 18 .8 3. 7 0. 0 1. 7 0. 9 2. 6 6. 1 15 .4 56 .3 28 T av us h 57 .9 31 .7 10 .2 10 .9 21 .9 58 .4 0. 0 0. 0 26 .1 4. 2 0. 6 2. 1 0. 0 12 .3 65 E du ca ti o n B as ic 62 .2 18 .8 3. 0 17 .2 16 .8 23 .4 5. 6 5. 7 6. 5 4. 6 3. 3 15 .6 0. 0 18 .6 12 6 S ec on da ry 61 .2 29 .0 11 .7 15 .1 12 .3 31 .4 3. 1 2. 6 8. 7 7. 2 5. 7 19 .6 2. 6 16 .0 59 1 S ec on da ry sp ec ia l 66 .7 25 .2 9. 7 14 .9 22 .1 27 .5 5. 6 2. 1 8. 6 5. 0 6. 5 16 .4 4. 6 9. 9 22 1 H ig he r 61 .9 35 .2 14 .4 14 .7 15 .0 27 .3 5. 7 1. 4 11 .0 5. 8 14 .3 15 .6 2. 1 4. 1 56 3 W ea lt h q ui nt ile Lo w es t 66 .5 29 .9 9. 0 16 .9 9. 5 26 .5 3. 3 3. 1 6. 2 3. 1 1. 9 21 .2 0. 2 10 .1 21 5 S ec on d 73 .6 34 .9 14 .0 20 .9 12 .2 32 .7 3. 2 6. 4 9. 8 2. 8 3. 1 23 .3 0. 3 9. 9 27 5 M id dl e 63 .6 31 .5 12 .1 13 .1 12 .4 33 .4 4. 0 2. 2 9. 2 8. 0 8. 3 20 .8 0. 7 11 .1 25 6 Fo ur th 57 .7 27 .2 10 .1 14 .9 17 .7 25 .0 4. 5 0. 6 7. 6 8. 6 8. 7 12 .2 4. 1 15 .7 35 9 H ig he st 55 .8 28 .0 12 .7 11 .6 19 .7 27 .1 6. 9 0. 6 12 .5 6. 7 17 .0 13 .4 4. 9 7. 4 39 6 T ot al 62 .4 29 .9 11 .7 15 .1 15 .1 28 .6 4. 7 2. 3 9. 4 6. 1 8. 8 17 .3 2. 5 10 .9 1, 50 1 N ot e: A n as te ris k de no te s a fig ur e ba se d on fe w er th an 2 5 un w ei gh te d ca se s th at h as b ee n su pp re ss ed . F ig ur es in p ar en th es es a re b as ed o n 25 -4 9 un w ei gh te d ca se s. 186 • Nutrition Nutrition • 187 Awareness about drinking tea or coffee during meal time can promote anemia The burden of anemia is primarily due to deficiency in iron. Iron deficiency, in turn, is largely due to an inadequate dietary intake of bioavailable iron. Tea, and to a lesser extent coffee, contain tannins that inhibit the absorption of nonheme iron if taken with or shortly after the meal (DeMaeyer et al. 1989). To assess awareness of the population about the inhibitory effect of tea and coffee on iron absorption, the 2015-16 ADHS respondents who had heard about anemia were further asked if they think that drinking tea or coffee during a meal can promote anemia. Table 12.18 Attitudes about drinking tea or coffee during meal time in relation to anemia Among women and men age 15-49 who have heard of anemia, the percent distribution by belief that drinking tea or coffee during a meal promotes anemia, according to background characteristics, Armenia 2015-16 Background characteristic Women Men Believes drinking tea or coffee promotes anemia: Believes drinking tea or coffee promotes anemia: Yes No Don't know Number of women who heard of anemia Yes No Don't know Number of men who heard of anemia Age 15-19 17.1 24.4 58.5 414 4.8 28.0 67.2 104 20-24 17.7 18.8 63.5 678 7.4 19.5 73.1 202 25-29 16.3 21.5 62.2 893 11.0 22.7 66.3 243 30-34 20.1 22.8 57.0 821 8.3 19.0 72.7 260 35-39 19.3 22.6 58.1 723 8.7 20.7 70.5 247 40-44 16.5 25.8 57.7 655 9.6 22.7 67.7 226 45-49 20.6 23.3 56.0 593 11.0 19.2 69.9 219 Residence Urban 18.0 23.7 58.4 3,052 9.1 23.5 67.4 970 Rural 18.7 20.6 60.7 1,725 8.9 16.9 74.2 531 Region Yerevan 16.3 26.1 57.6 1,751 9.1 24.0 66.9 657 Aragatsotn 7.2 14.2 78.6 211 18.7 1.5 79.8 84 Ararat 18.0 31.9 50.1 417 13.1 14.1 72.8 214 Armavir 12.3 19.0 68.7 347 7.8 12.8 79.4 138 Gegharkunik 28.4 13.1 58.4 198 1.6 0.8 97.5 74 Lori 16.1 13.3 70.6 241 * * * 20 Kotayk 21.4 14.2 64.3 574 4.9 17.0 78.1 91 Shirak 9.1 22.5 68.4 459 (1.7) (31.5) (66.8) 51 Syunik 40.2 25.0 34.8 225 6.9 75.3 17.8 80 Vayots Dzor 23.9 9.2 66.9 101 14.1 16.7 69.2 28 Tavush 31.8 32.6 35.5 252 4.9 21.4 73.7 65 Education Basic 18.6 22.8 58.6 181 9.0 18.6 72.4 126 Secondary 12.1 21.8 66.1 1,734 5.0 18.7 76.4 591 Secondary special 21.5 21.6 56.9 1,155 6.7 21.5 71.8 221 Higher 22.3 23.9 53.8 1,705 14.2 24.2 61.6 563 Wealth quintile Lowest 18.0 15.2 66.7 691 9.7 12.0 78.3 215 Second 18.4 24.9 56.7 946 7.9 20.0 72.1 275 Middle 19.1 21.0 59.9 853 6.5 22.3 71.2 256 Fourth 15.5 24.2 60.3 1,085 7.0 20.5 72.6 359 Highest 20.2 24.6 55.3 1,202 13.0 26.8 60.2 396 Total 18.3 22.6 59.2 4,777 9.0 21.2 69.8 1,501 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. Total includes 1 (weighted) woman with no education. Table 12.18 shows that slightly more women believe that drinking tea or coffee during a meal does not promote anemia than think it has that effect (23 percent and 18 percent, respectively). Men are also more likely to feel that drinking tea or coffee during a meal does not promote anemia than to think that it can have that effect (21 percent and 9 percent, respectively). Overall, however, most women and men are not sure if drinking tea or coffee during a meal plays a role in promoting anemia (59 percent and 70 percent, respectively). HIV/AIDS and Sexually Transmitted Infections • 189 HIV/AIDS AND SEXUALLY TRANSMITTED INFECTIONS 13 cquired immune deficiency syndrome (AIDS) is caused by a human immunodeficiency virus (HIV) that weakens the immune system, making the body susceptible to and unable to recover from other diseases. HIV/AIDS is an international pandemic, with cases reported from every country. The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that in 2015, 36.7 million people worldwide were living with HIV and an estimated 2.1 million people became newly infected. Due to the substantial scale-up of antiretroviral therapy (ART) over the past few years, the annual number of new HIV infections worldwide has fallen by 6 percent since 2010. Despite these signs of progress, only 46 percent of adults living with HIV were obtaining treatment in 2015 (UNAIDS 2016a). Armenia has a low HIV prevalence overall, with a concentrated epidemic specifically affecting people who inject drugs, migrant workers, men who have sex with men, and sex workers (WHO-EURO 2015). In 2015, an estimated 3,600 of the country’s residents were living with HIV, of whom fewer than two out of five were aware of their status and only one-third were linked to care (UNAIDS 2016b; WHO- A Key Findings  Awareness of AIDS is very widespread in Armenia; 89 percent of women and 88 percent of men age 15-49 have heard of HIV or AIDS.  Nevertheless, comprehensive knowledge about HIV is low: only 25 percent of women and 21 percent of men know that use of condoms and having just one uninfected faithful partner can reduce the chances of getting HIV, know that a healthy-looking person can have HIV, and reject the two most common local misconceptions about HIV transmission.  About half of women and men age 15-49 know that HIV can be transmitted from a mother to her child by breastfeeding; about one- quarter of women and one-fifth of men know that the risk of mother-to- child transmission can be reduced by a mother taking special drugs during pregnancy.  Discriminatory attitudes towards people living with HIV are common. For example, over half of women and more than two-thirds of men age 15-49 say they would not buy fresh vegetables from a shopkeeper who has HIV.  High-risk sexual behavior appears to be rare in Armenia. No women and only 5 percent of men age 15-49 reported having two or more sexual partners in the 12 months before the survey.  Mean numbers of lifetime sexual partners among Armenian women and men age 15-49 are 1.1 and 4.0, respectively.  Ten percent of men said they had paid for sexual intercourse in the past 12 months; among these men, 84 percent reported using a condom during their most recent paid sexual intercourse.  Fifteen percent of women and 2 percent of men have ever been tested for HIV.  Five percent of women and 1 percent of men reported having a sexually transmitted infection (STI) or symptoms of an STI in the 12 months preceding the survey. 190 • HIV/AIDS and Sexually Transmitted Infections EURO 2015). According to the Armenian National Center for AIDS Prevention (NCAP), the estimated HIV prevalence in the 15-49 age group is 0.2 percent (NCAP 2016). The 2015-16 ADHS collected information from women and men on knowledge and attitudes regarding HIV/AIDS, as well as on sexual behavior and the prevalence of symptoms of sexually transmitted infections (STIs). This chapter summarizes information on knowledge, perceptions, and behaviors at the national level and within geographic and socioeconomic subgroups of the population. 13.1 KNOWLEDGE OF HIV/AIDS AND METHODS OF HIV PREVENTION Table 13.1 shows the percentages of women and men age 15-49 who have heard of HIV or AIDS, by background characteristics. Knowledge of AIDS in Armenia continues to be very high. Almost 9 in 10 women and men (89 percent of women and 88 percent of men) reported that they have heard of Table 13.1 Knowledge of HIV or AIDS Percentage of women and men age 15-49 who have heard of HIV or AIDS, according to background characteristics, Armenia 2015-16 Background characteristic Women Men Have heard of HIV or AIDS Number of women Have heard of HIV or AIDS Number of men Age 15-24 82.0 1,653 70.0 813 15-19 73.6 725 63.4 345 20-24 88.6 928 74.9 467 25-29 92.3 1,099 91.8 464 30-39 92.8 1,874 95.4 802 40-49 91.0 1,490 96.2 676 Marital status Never married 83.6 1,830 76.3 1,190 Ever had sex * 12 88.3 631 Never had sex 83.5 1,818 62.6 559 Married/living together 91.6 3,895 96.3 1,506 Divorced/separated/widowed 93.7 390 (89.5) 59 Employment abroad1 Worked abroad 96.3 81 94.4 334 Did not work abroad 89.3 6,035 86.5 2,419 Spousal employment abroad2 Only respondent worked abroad * 18 96.0 220 Only spouse worked abroad2 86.7 834 * 10 Both worked abroad (94.6) 32 * 6 Neither worked abroad 92.9 2,998 96.2 1,264 Residence Urban 94.0 3,657 89.6 1,558 Rural 82.4 2,459 84.7 1,197 Region Yerevan 97.3 2,001 89.4 833 Aragatsotn 64.0 315 77.1 159 Ararat 92.8 552 84.4 290 Armavir 91.0 586 95.1 268 Gegharkunik 50.4 478 68.8 235 Lori 89.4 355 75.1 184 Kotayk 97.7 678 100.0 299 Shirak 87.4 510 87.9 201 Syunik 96.7 238 91.4 104 Vayots Dzor 94.3 119 90.5 56 Tavush 92.4 283 96.7 126 Education Basic 71.6 396 78.1 360 Secondary 83.7 2,444 85.3 1,250 Secondary special 93.5 1,360 91.9 403 Higher 97.6 1,910 93.7 736 Wealth quintile Lowest 79.9 1,081 84.1 523 Second 86.3 1,242 86.0 583 Middle 87.5 1,142 84.8 521 Fourth 94.6 1,287 92.0 566 Highest 96.3 1,365 89.9 562 Total 89.4 6,116 87.5 2,755 Note: Total includes 2 men with missing information about employment abroad, 13 women and 7 men with missing information about spousal employment abroad, and 5 women and 5 men with no education. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 1 “Employment abroad” refers to working abroad during the three years before the survey for three or more months at a time. 2 Currently married respondents only; information on spouse’s employment abroad is based on respondent’s report. HIV/AIDS and Sexually Transmitted Infections • 191 HIV/AIDS, a slight decrease from the figures reported in the 2010 ADHS (96 percent among both women and men) (NSS et al. 2012). Awareness of AIDS is somewhat lower among the youngest and least educated respondents and among those who have never had sex, those who have not worked abroad, and those in the lowest wealth quintile. Additionally, women and men living in Gegharkunik region (50 percent and 69 percent, respectively) are considerably less likely than respondents in other regions to have heard of AIDS. AIDS prevention programs focus their messages and efforts on safe sexual practices, specifically on proper condom use (using a condom at every sexual intercourse) and staying faithful to one uninfected partner who has no other partners. Table 13.2 shows the percentages of women and men who gave positive responses when asked prompted questions on these two specific ways of avoiding HIV infection. Overall, more than three-quarters of women and men agree that people can reduce their chances of getting HIV by limiting sex to one uninfected partner (79 percent of women and 77 percent of men) and by using condoms (76 percent of women and 78 percent of men). Just over 7 in 10 women (72 percent) and men (73 percent) mentioned both using condoms and limiting sex to one uninfected partner. Table 13.2 Knowledge of HIV prevention methods Percentage of women and men age 15-49 who, in response to prompted questions, say that people can reduce the risk of getting HIV by using condoms every time they have sexual intercourse and by having one sex partner who is not infected and has no other partners, according to background characteristics, Armenia 2015-16 Background characteristic Women Men Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner1,2 Number of women Using condoms1 Limiting sexual intercourse to one uninfected partner2 Using condoms and limiting sexual intercourse to one uninfected partner1,2 Number of men Age 15-24 65.4 69.0 61.1 1,653 62.3 58.4 55.3 813 15-19 52.6 56.5 47.5 725 55.4 49.2 46.9 345 20-24 75.4 78.8 71.6 928 67.3 65.2 61.5 467 25-29 80.8 84.4 78.0 1,099 84.2 85.1 82.1 464 30-39 79.8 82.6 75.8 1,874 85.6 84.2 79.6 802 40-49 78.9 81.6 75.1 1,490 84.8 84.3 78.8 676 Residence Urban 81.9 84.4 77.8 3,657 80.9 76.1 72.5 1,558 Rural 66.9 71.0 63.5 2,459 74.9 77.6 72.9 1,197 Employment abroad3 Worked abroad 86.4 85.3 79.8 81 84.1 83.5 80.5 334 Did not work abroad 75.7 78.9 71.9 6,035 77.5 75.9 71.7 2,419 Region Yerevan 87.5 89.3 83.5 2,001 83.3 73.1 70.2 833 Aragatsotn 53.0 50.5 49.1 315 74.1 75.9 72.9 159 Ararat 84.1 81.5 77.6 552 72.1 79.8 68.9 290 Armavir 68.9 81.3 68.4 586 89.7 92.8 88.3 268 Gegharkunik 42.7 46.8 41.3 478 63.4 67.5 62.2 235 Lori 79.6 80.6 75.4 355 45.9 45.0 39.9 184 Kotayk 87.4 89.2 84.5 678 99.0 100.0 99.0 299 Shirak 70.3 75.8 66.1 510 86.0 85.9 84.4 201 Syunik 45.2 59.2 39.3 238 31.7 33.4 28.0 104 Vayots Dzor 78.9 82.1 74.2 119 78.5 80.9 76.7 56 Tavush 75.5 77.7 68.5 283 92.9 89.0 85.8 126 Education Basic 46.4 45.8 39.7 396 68.5 68.8 64.3 360 Secondary 67.5 71.3 62.9 2,444 75.4 73.7 69.7 1,250 Secondary special 80.9 84.2 77.7 1,360 81.8 76.7 73.2 403 Higher 89.2 92.3 86.5 1,910 86.3 86.2 81.7 736 Wealth quintile Lowest 62.8 66.7 58.1 1,081 72.1 76.8 70.0 523 Second 71.3 74.3 67.4 1,242 77.8 78.0 74.3 583 Middle 70.1 74.9 66.4 1,142 75.0 72.1 68.8 521 Fourth 84.5 86.4 80.9 1,287 82.7 78.8 75.4 566 Highest 87.0 89.5 83.7 1,365 83.2 77.7 74.4 562 Total 75.9 79.0 72.0 6,116 78.3 76.8 72.7 2,755 Note: Total includes 2 men with missing information about employment abroad and 5 women and 5 men with no education. 1 Using condoms every time they have sexual intercourse 2 Partner who has no other partners 3 “Employment abroad” refers to working abroad during the three years before the survey for three or more months at a time. 192 • HIV/AIDS and Sexually Transmitted Infections As Table 13.2 shows, young women and men age 15-24 are somewhat less knowledgeable than older respondents about the various modes of prevention. Urban women are more aware of both specified HIV prevention methods than rural women (78 percent versus 64 percent), while there is no difference among men: 73 percent of both urban and rural men are aware of both HIV prevention methods. Women and men who worked abroad in the past three years for three or more months (80 percent and 81 percent, respectively) are more likely to be aware of safe sexual practices than those who did not work abroad (72 percent among both women and men). Among women, knowledge of both specified HIV prevention methods ranges from 39 percent in Syunik region to 85 percent in Kotayk region, while among men it ranges from 28 percent in Syunik region to 99 percent in Kotayk region. There is a strong positive relationship between the respondent’s educational background and knowledge of ways to prevent getting HIV. For example, 40 percent of women and 64 percent of men with a basic education say that the risk of getting HIV can be reduced by using condoms and limiting sex to one uninfected partner, as compared with 87 percent of women and 82 percent of men with a higher education. There is a similar relationship among women between wealth and knowledge of HIV prevention measures; only 58 percent of women in the lowest wealth quintile are aware of both prevention methods, compared with 84 percent of those in the highest wealth quintile. Among men, however, the relationship is weak and not consistent. Overall, awareness of these two HIV prevention methods at the national level has changed little during the past five years. The proportion of respondents who say that using condoms and limiting sexual intercourse to only one uninfected partner can reduce the risk of getting HIV increased from 69 percent in 2010 to 72 percent in 2015-16 among women and decreased from 80 percent in 2010 to 73 percent in 2015-16 among men (NSS et al. 2012). 13.2 MISCONCEPTIONS ABOUT HIV TRANSMISSION AND COMPREHENSIVE KNOWLEDGE OF AIDS In addition to knowing effective ways to avoid contracting HIV, it is also useful to be able to identify incorrect beliefs about AIDS to eliminate misconceptions. Misconceptions about AIDS and HIV transmission are among the factors that result in discrimination and stigmatization. Common misconceptions about AIDS include the idea that HIV-positive people always appear ill and the belief that HIV can be transmitted through mosquito bites, by kissing someone who has HIV, by sharing food with someone who has HIV, and by shaking hands with someone who has HIV. Respondents in the 2015-16 ADHS who had heard of HIV or AIDS were asked about these five misconceptions, and the results are presented in Table 13.3. The findings indicate that many Armenian adults lack accurate knowledge about the ways in which HIV can and cannot be transmitted. For example, only 60 percent of women and 64 percent of men know that a healthy-looking person can have HIV. Particularly critical is the fact that only 49 percent of women and 35 percent of men know that HIV cannot be transmitted by kissing a person who has the virus and only half of women and men know that HIV cannot be transmitted through mosquito bites. Two-thirds of women and almost 6 in 10 men know that HIV cannot be contracted by sharing food with a person who has HIV. Somewhat higher proportions of respondents know that HIV cannot be transmitted by shaking hands with a person who has HIV (75 percent of women and 64 percent of men). Table 13.3 provides an assessment of the level of comprehensive knowledge of HIV/AIDS prevention and transmission. Comprehensive knowledge is defined as (1) knowing that both condom use and limiting sexual partners to one HIV-negative person can reduce the chances of transmitting HIV/AIDS, (2) being aware that a healthy-looking person can have HIV, and (3) rejecting the two most common local misconceptions in Armenia—namely, that HIV can be transmitted through mosquito bites and by kissing someone infected with HIV. The ADHS results indicate that only one in four women (25 percent) and just over one in five men (21 percent) in Armenia have comprehensive knowledge of HIV/AIDS and Sexually Transmitted Infections • 193 HIV/AIDS prevention and transmission. As is the case with individual aspects of HIV/AIDS transmission, young respondents age 15-19 and men age 20-24 are less likely than older respondents to have comprehensive knowledge of AIDS. Over the past 10 years, levels of comprehensive knowledge about HIV/AIDS have fluctuated. The percentage of women who have comprehensive knowledge about HIV/AIDS decreased from 26 percent in 2005 to 20 percent in 2010 and then increased to 25 percent in 2015-16. The percentage also fluctuated among men, from 24 percent in 2005 to 16 percent in 2010 and 21 percent in 2015-16 (NSS et al. 2006; NSS et al. 2012). Table 13.3 Comprehensive knowledge about HIV Percentage of women and men age 15-49 who say that a healthy-looking person can have HIV and who, in response to prompted questions, correctly reject local misconceptions about transmission or prevention of HIV, and the percentage with comprehensive knowledge about HIV, according to age, Armenia 2015-16 Age Percentage of respondents who say that: Percentage who say that a healthy-looking person can have HIV and who reject the two most common local misconceptions1 Percentage with comprehensive knowledge about HIV2 Number of respondents A healthy-looking person can have HIV HIV cannot be transmitted by mosquito bites HIV cannot be transmitted by kissing a person who has HIV A person cannot become infected by sharing food with a person who has HIV HIV cannot be transmitted by shaking hands with a person who has HIV WOMEN 15-24 51.8 45.5 42.4 60.2 67.1 23.1 20.2 1,653 15-19 43.1 35.9 33.6 51.7 59.1 17.7 14.7 725 20-24 58.6 53.0 49.3 66.9 73.4 27.3 24.5 928 25-29 64.3 54.2 53.3 72.8 78.1 29.1 27.4 1,099 30-39 62.9 53.1 52.3 72.9 79.0 29.5 27.7 1,874 40-49 63.2 49.7 49.5 70.8 76.2 25.0 22.9 1,490 Total 15-49 60.2 50.4 49.1 68.9 75.0 26.6 24.5 6,116 MEN 15-24 49.3 34.5 22.0 40.8 48.1 13.5 12.5 813 15-19 43.3 27.9 15.0 30.7 41.7 8.9 8.9 345 20-24 53.8 39.5 27.1 48.2 52.8 16.9 15.2 467 25-29 68.4 55.2 39.0 61.8 67.0 24.2 23.5 464 30-39 71.3 58.4 40.8 64.1 72.8 27.0 24.8 802 40-49 69.4 59.1 41.6 65.6 70.7 25.9 23.2 676 Total 63.9 51.0 35.1 57.2 64.0 22.3 20.6 2,755 1 Two most common local misconceptions involve transmission by mosquito bites and by kissing a person who has HIV. 2 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting HIV, knowing that a healthy-looking person can have HIV, and rejecting the two most common local misconceptions about transmission or prevention of HIV. 13.3 KNOWLEDGE OF PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV Increasing the level of general knowledge about transmission of HIV from mother to child and reducing the risk of transmission by use of antiretroviral drugs are critical to the prevention of mother-to- child transmission (MTCT) of HIV. To assess MTCT knowledge, respondents in the 2015-16 ADHS were asked if HIV can be transmitted from a mother to her baby during pregnancy, delivery, or breastfeeding and whether they know of any special drugs a mother with HIV can take to reduce the risk of transmission to the baby. Table 13.4 shows that while almost 7 in 10 women and men know that HIV can be transmitted from mother to child during pregnancy, less than 6 in 10 know that it can be transmitted during delivery and only around 5 in 10 know of the risk of mother-to-child transmission of HIV during breastfeeding. Less than half of respondents are aware of all three means of MTCT (48 percent of women and 44 percent of men). Knowledge of antiretroviral therapy to prevent MTCT of HIV is very limited in Armenia. Only 27 percent of women and 20 percent of men say they know that the risk of mother-to-child transmission can be reduced by the mother taking special drugs. Respondents age 15-19 are considerably less likely than older respondents to know that HIV can be transmitted by breastfeeding or that the risk of MTCT can be reduced by the mother taking special drugs. 194 • HIV/AIDS and Sexually Transmitted Infections Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV Percentage of women and men age 15-49 who know that HIV can be transmitted from mother to child during pregnancy, during delivery, by breastfeeding, and by all three means, and percentage who know that the risk of mother-to-child transmission (MTCT) of HIV can be reduced by the mother taking special drugs, according to age, Armenia 2015-16 Age Percentage who know that HIV can be transmitted from mother to child: Percentage who know that the risk of MTCT can be reduced by mother taking special drugs Number of respondents During pregnancy During delivery By breastfeeding By all three means WOMEN 15-24 55.7 45.1 44.1 37.0 19.9 1,653 15-19 42.0 33.0 31.8 25.5 15.7 725 20-24 66.4 54.6 53.7 45.9 23.1 928 25-29 72.8 63.0 61.2 53.1 28.6 1,099 30-39 74.0 65.2 61.1 53.4 31.0 1,874 40-49 73.3 61.9 57.5 50.0 28.9 1,490 Total 68.7 58.6 55.7 48.1 27.0 6,116 MEN 15-24 49.1 34.0 26.7 24.5 9.9 813 15-19 39.6 21.8 18.1 15.8 3.8 345 20-24 56.1 43.1 33.0 31.0 14.3 467 25-29 73.8 60.9 52.8 48.6 22.3 464 30-39 78.5 66.5 58.2 54.3 25.3 802 40-49 81.9 70.9 56.0 53.6 26.1 676 Total 69.9 57.1 47.5 44.4 20.4 2,755 Although knowledge about MTCT of HIV in Armenia is rather limited, there has been improvement over the past five years. For example, the proportion of respondents who know that HIV can be transmitted from a mother to a child during breastfeeding increased from 44 percent in 2010 to 56 percent in 2015-16 among women and from 35 to 48 percent among men. Similarly, knowledge that MTCT can be reduced by the mother taking special drugs increased between 2010 and 2015-16, from 17 to 27 percent among women and from 9 to 20 percent among men (NSS et al. 2012). 13.4 DISCRIMINATORY ATTITUDES TOWARDS PEOPLE LIVING WITH HIV Knowledge and beliefs about AIDS can affect how people treat those they know to be living with HIV. Widespread stigma and discrimination in a population can adversely affect people’s willingness to be tested for HIV as well as their adherence to antiretroviral therapy. Reduction of stigma and discrimination in a population is, thus, an important impetus to the success of programs targeting HIV/AIDS prevention and control. In the 2015-16 ADHS, several questions were posed to respondents to assess the level of stigma associated with HIV and AIDS. Respondents were asked if they think children living with HIV should be allowed to attend school with children who do not have HIV. They were also asked if they would buy fresh vegetables from a shopkeeper or vendor if they knew that the person had HIV. Table 13.5 shows the percentages of women and men who express discriminatory attitudes toward people with HIV, by background characteristics. The results show a high level of discriminatory attitudes towards people living with HIV among Armenian adults. They also indicate that men are considerably more likely than women to have such attitudes. For example, just over one-third of women do not think that children with HIV should be able to attend school with HIV-negative children, as compared with well over half of men (36 percent and 56 percent, respectively). Similarly, 53 percent of women and 69 percent of men say they would not buy fresh vegetables from a shopkeeper who has HIV. Taken together, almost 6 in 10 women and 3 in 4 men hold one or both of these discriminatory attitudes. HIV/AIDS and Sexually Transmitted Infections • 195 Table 13.5 Discriminatory attitudes towards people living with HIV Among women and men age 15-49 who have heard of HIV or AIDS, percentage who do not think that children living with HIV should be able to attend school with children who are HIV negative, percentage who would not buy fresh vegetables from a shopkeeper who has HIV, and percentage with discriminatory attitudes towards people living with HIV, according to background characteristics, Armenia 2015-16 Background characteristic Women Men Percentage who do not think that children living with HIV should be able to attend school with children who are HIV negative Percentage who would not buy fresh vegetables from a shopkeeper who has HIV Percentage with discriminatory attitudes towards people living with HIV1 Number of women who have heard of HIV or AIDS Percentage who do not think that children living with HIV should be able to attend school with children who are HIV negative Percentage who would not buy fresh vegetables from a shopkeeper who has HIV Percentage with discriminatory attitudes towards people living with HIV1 Number of men who have heard of HIV or AIDS Age 15-24 34.9 50.4 55.0 1,356 52.4 66.6 72.8 569 15-19 38.4 52.0 57.0 534 46.5 66.6 72.5 219 20-24 32.6 49.3 53.6 822 56.1 66.5 73.0 350 25-29 34.3 53.6 57.3 1,014 55.5 66.5 72.2 426 30-39 35.9 52.1 56.3 1,740 57.5 70.1 74.8 765 40-49 38.0 54.4 59.5 1,356 56.2 70.2 73.8 650 Marital status Never married 32.8 48.9 53.2 1,530 52.7 65.1 71.0 908 Ever had sex * * * 12 54.4 63.3 69.9 557 Never had sex 33.1 49.3 53.6 1,519 49.9 68.0 72.8 350 Married/living together 37.3 54.5 58.8 3,569 57.4 71.1 75.2 1,450 Divorced/separated/ widowed 34.4 48.0 54.6 366 (57.9) (60.9) (74.1) 53 Employment abroad2 Worked abroad 30.9 49.1 50.0 78 70.0 82.5 85.2 315 Did not work abroad 35.9 52.6 57.1 5,387 53.4 66.5 71.8 2,092 Spousal employment abroad3 Only respondent worked abroad * * * 16 70.5 84.6 88.0 211 Only spouse worked abroad3 40.2 58.0 61.5 723 * * * 10 Both worked abroad (29.6) (45.9) (45.9) 31 * * * 6 Neither worked abroad 36.9 53.9 58.5 2,786 55.0 68.9 73.2 1,217 Residence Urban 33.4 51.8 55.5 3,438 49.3 66.2 71.7 1,396 Rural 40.0 53.7 59.4 2,027 64.2 72.1 76.3 1,014 Region Yerevan 31.1 52.4 56.0 1,946 33.4 58.5 64.4 745 Aragatsotn 35.6 67.0 71.3 202 1.8 2.9 3.7 123 Ararat 32.7 21.0 39.6 513 78.6 82.0 89.8 245 Armavir 33.7 41.0 41.4 533 37.1 45.3 49.8 255 Gegharkunik 61.3 77.7 81.8 241 96.3 98.9 98.9 162 Lori 61.2 77.1 79.1 318 83.0 77.6 86.3 139 Kotayk 28.9 66.4 68.7 663 84.6 86.7 94.0 299 Shirak 30.5 31.9 36.3 446 66.1 85.6 87.4 177 Syunik 37.2 47.6 49.9 230 82.7 84.3 88.8 95 Vayots Dzor 48.1 69.7 75.1 112 49.8 64.7 68.2 51 Tavush 48.1 71.3 73.2 261 47.6 89.0 90.3 121 Education Basic 36.0 53.1 58.2 284 62.3 70.9 75.9 281 Secondary 44.3 57.8 63.6 2,045 61.0 72.9 78.1 1,065 Secondary special 33.8 52.0 56.2 1,272 53.4 69.3 75.2 371 Higher 28.0 47.0 50.0 1,864 45.7 60.7 64.8 690 Wealth quintile Lowest 39.2 52.1 56.3 864 62.4 68.5 73.5 440 Second 38.8 51.9 58.7 1,071 62.9 71.3 75.6 502 Middle 38.5 56.1 59.9 999 62.8 75.2 80.3 442 Fourth 33.0 52.2 56.7 1,217 45.7 66.3 72.3 521 Highest 31.9 51.0 53.9 1,314 46.4 62.8 67.2 505 Total 35.9 52.5 57.0 5,465 55.6 68.6 73.6 2,410 Note: Total includes 2 men with missing information about employment abroad, 13 women and 7 men with missing information about spousal employment abroad, and 2 women and 3 men with no education. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 1 Percentage who do not think that children living with HIV should be able to attend school with children who are HIV negative or would not buy fresh vegetables from a shopkeeper who has HIV 2 “Employment abroad” refers to working abroad during the three years before the survey for three or more months at a time. 3 Currently married respondents only; information on spouse’s employment abroad is based on respondent’s report. 196 • HIV/AIDS and Sexually Transmitted Infections For the most part, variations in the extent of discriminatory attitudes towards people with HIV are not large. Although the proportions of women and men who have discriminatory attitudes are lowest among those with a higher education and those in the highest wealth quintile, there is no uniform pattern by either education or wealth. Whereas working abroad is associated with a decrease in discriminatory attitudes among women, it is associated with an increase among men. Differences by age and marital status are very small, and rural residents are only slightly more likely than urban residents to hold discriminatory attitudes. However, there are large variations in attitudes by region. For example, the proportion of women with discriminatory attitudes towards people with HIV varies from 36 percent in Shirak to 82 percent in Gegharkunik. Among men, the proportion ranges from 4 percent in Aragatsotn to a high of 99 percent in Gegharkunik. 13.5 HIGHER-RISK SEX Limiting the number of sexual partners and having protected sex are crucial to combating HIV/AIDS and other sexually transmitted infections (STIs). Condom use is an important tool in the fight. The 2015-16 ADHS included questions on respondents’ sexual partners over their lifetime and during the 12 months preceding the survey. Men were asked an additional question: whether they paid anyone for sex during the 12 months preceding the interview. Information on the use of condoms at last sexual intercourse with each type of partner was collected from both women and men. Because the questions were sensitive, some respondents may have been reluctant to provide information on recent sexual behavior. 13.5.1 Multiple Partners and Higher-Risk Sexual Intercourse Table 13.6 shows (1) the percentage of all men age 15-49 who had sexual intercourse with more than one partner in the past 12 months; (2) the percentage of men with more than one partner who reported using a condom at last intercourse; (3) the percentage of men who had sex in the past 12 months who had sex with a non-marital, non-cohabiting partner; (4) the percentage of men who had sex with a non-marital, non-cohabiting partner in the past 12 months who used a condom during the last such episode; and (5) among men who ever had sex, the mean number of sexual partners during their lifetime, by background characteristics.1 The table shows that 5 percent of all men age 15-49 reported having had more than one sexual partner in the 12 months preceding the survey, a decrease from the figure reported in 2010 (15 percent). The proportion of men with more than one partner in the previous 12 months is slightly higher among men age 25-29 than among older or younger men. It is also higher among men in Armavir (18 percent) and Kotayk (12 percent). The percentage of men who had more than one partner in the past 12 months varies erratically according to education and wealth. Sixty-two percent of men who had more than one sexual partner in the past 12 months used a condom during their last sexual intercourse. Among those with more than one sexual partner, never- married men were more likely than married men to have had protected sex in the past 12 months, and rural men were less likely than urban men to have done so. Among men who had sexual intercourse in the 12 months before the survey, 29 percent said they had sex with a person they were not married to or living with. As expected, this proportion is highest among men who have never been married and among younger men. It is also relatively higher among men in Armavir. 1 The data for women are not presented because close to 0 percent of women age 15-49 reported having had more than one partner in the past 12 months and less than 1 percent of women who had sex in the 12 months before the survey reported having sex with a non-marital, non-cohabiting partner in the past 12 months. Among all women who ever had sex, the mean number of lifetime partners was 1.1. HIV/AIDS and Sexually Transmitted Infections • 197 Table 13.6 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: Men Among all men age 15-49, percentage who had sexual intercourse with more than one sexual partner in the past 12 months; among those having more than one partner in the past 12 months, percentage reporting that a condom was used during last intercourse; among men who had sexual intercourse in the past 12 months, percentage who had intercourse in the past 12 months with a non-marital, non-cohabiting partner; among men age 15-49 who had sexual intercourse in the past 12 months with a non-marital, non-cohabiting partner, percentage who used a condom during last sexual intercourse with such a partner; and among men who ever had sexual intercourse, mean number of sexual partners during their lifetime, according to background characteristics, Armenia 2015-16 Background characteristic All men Men who had 2+ partners in the past 12 months Men who had sexual intercourse in the past 12 months Men who had intercourse in the past 12 months with a non- marital, non-cohabiting partner1 Men who ever had sexual intercourse2 Percentage who reported using a condom during last sexual intercourse with a non- marital, non- cohabiting partner1 Number of men Mean number of sexual partners in lifetime Number of men Percentage who had 2+ partners in the past 12 months Number of men Percentage who reported using a condom during last sexual intercourse Number of men Percentage who had intercourse in the past 12 months with a non- marital, non- cohabiting partner1 Number of men Age 15-24 2.8 813 * 22 79.4 271 85.9 215 2.8 310 15-19 1.3 345 * 4 (100.0) 39 (100.0) 39 (2.6) 43 20-24 3.9 467 * 18 76.0 232 82.8 176 2.9 267 25-29 7.9 464 (77.9) 37 46.7 379 75.6 177 4.0 392 30-39 6.8 802 (52.6) 54 17.5 734 86.6 128 4.0 691 40-49 5.4 676 (43.6) 36 9.8 637 84.7 63 4.8 601 Marital status Never married 5.9 1,190 93.8 71 98.6 487 81.8 481 3.9 563 Married or living together 5.1 1,506 33.9 77 5.2 1,495 94.7 77 4.1 1,375 Divorced/separated/ widowed (3.7) 59 * 2 (65.6) 38 * 25 (3.8) 56 Employment abroad3 Worked abroad 7.0 334 (33.2) 23 30.5 307 60.3 94 4.5 281 Did not work abroad 5.2 2,419 67.9 126 28.6 1,711 87.1 489 4.0 1,711 Residence Urban 5.1 1,558 67.2 80 29.3 1,177 85.7 345 4.3 1,167 Rural 5.8 1,197 56.9 70 28.1 844 78.7 238 3.7 827 Region Yerevan 4.5 833 * 38 31.5 650 92.1 205 4.6 678 Aragatsotn 0.0 159 * 0 25.8 95 (100.0) 24 1.3 89 Ararat 3.9 290 * 11 22.4 194 (74.9) 44 3.9 226 Armavir 17.6 268 (52.3) 47 47.7 236 92.2 113 7.5 163 Gegharkunik 0.8 235 * 2 23.6 155 (15.7) 37 2.6 164 Lori 1.1 184 * 2 18.6 106 * 20 1.3 70 Kotayk 11.8 299 (42.2) 35 30.2 236 95.7 71 3.8 249 Shirak 5.4 201 * 11 34.7 173 75.2 60 5.7 177 Syunik 3.1 104 * 3 12.4 62 * 8 1.3 60 Vayots Dzor 0.0 56 * 0 2.1 34 * 1 1.6 36 Tavush 0.5 126 * 1 1.3 78 * 1 1.4 83 Education Basic 5.0 360 * 18 28.6 223 81.7 64 4.7 215 Secondary 4.8 1,250 50.2 60 24.5 905 77.8 221 3.8 868 Secondary special 5.9 403 * 24 25.8 312 83.1 80 4.3 310 Higher 6.5 736 (75.6) 48 37.6 578 88.2 217 4.0 599 Wealth quintile Lowest 6.4 523 (69.2) 33 29.0 373 83.9 108 4.0 358 Second 5.0 583 (46.8) 29 28.6 407 75.6 116 3.7 401 Middle 7.0 521 (65.1) 36 32.3 380 75.5 123 3.7 363 Fourth 4.0 566 * 22 29.8 426 88.2 127 4.3 414 Highest 5.0 562 * 28 25.1 434 91.3 109 4.4 457 Total 5.4 2,755 62.4 150 28.8 2,021 82.8 583 4.0 1,994 Note: Total includes 2 men with missing information about employment abroad and 5 men with no education. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 1 A person who was not his wife and did not live with him 2 Means are calculated excluding respondents who gave non-numeric responses. 3 “Employment abroad” refers to working abroad during the three years before the survey for three or more months at a time. 198 • HIV/AIDS and Sexually Transmitted Infections Among men who reported having sex with a non-marital, non-cohabiting partner in the previous 12 months, 83 percent said they used a condom during the most recent such episode. Condom use with non-marital partners is higher among married men than never-married men (95 percent and 82 percent, respectively) and higher among men who did not work abroad in the past three years than those who worked abroad (87 percent and 60 percent, respectively). It is also higher among urban men and shows a slight tendency to increase with increasing education and wealth. Men who have ever been sexually active report having an average (mean number) of 4.0 lifetime sexual partners, about four times the average number of lifetime sexual partners reported by sexually active women (1.1 partners) (data not shown). Men’s mean number of sexual partners increases with age and is slightly higher among those who worked abroad than among those who did not; it is also higher among urban men than rural men. Men in Armavir have the highest mean number of lifetime partners (7.5). The mean number of lifetime sexual partners reported by men has decreased since 2010, from 5.8 to 4.0 (NSS et al. 2012). 13.5.2 Transactional Sex Transactional sex is the exchange of sex for money, favors, or gifts. Transactional sex is associated with a high risk of contracting HIV and other sexually transmitted infections because of compromised power relations and the likelihood of having multiple partners as a result. Male respondents in the 2015-16 ADHS were asked whether they had ever paid money in exchange for sex and whether they had done so in the 12 months preceding the survey. The findings are presented in Table 13.7. Table 13.7 Payment for sexual intercourse and condom use at last paid sexual intercourse Percentage of men age 15-49 who ever paid for sexual intercourse and percentage reporting payment for sexual intercourse in the past 12 months, and among them, the percentage reporting that a condom was used the last time they paid for sexual intercourse, according to age, Armenia 2015-16 Age Among all men: Among men who paid for sex in the past 12 months: Percentage who ever paid for sexual intercourse Percentage who paid for sexual intercourse in the past 12 months Number of men Percentage reporting condom use at last paid sexual intercourse Number of men 15-24 17.4 13.6 813 91.2 111 15-19 7.7 7.4 345 * 25 20-24 24.6 18.2 467 88.6 85 25-29 36.0 13.2 464 73.5 61 30-39 31.0 6.6 802 83.8 53 40-49 25.9 7.9 676 82.6 53 Total 26.6 10.1 2,755 84.2 278 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Among men age 15-49, 27 percent reported having ever paid for sexual intercourse. The percentage who ever paid for sex is highest among men age 25-29 (36 percent). One in 10 men reported paying for sexual intercourse in the 12 months before the survey. It is encouraging that 84 percent of men who paid for sex in the 12 months before the survey said they used a condom during the most recent paid sexual intercourse. HIV/AIDS and Sexually Transmitted Infections • 199 13.6 COVERAGE OF PRIOR HIV TESTING For people who are HIV negative, knowledge of their HIV status helps in making specific decisions that will reduce the risk of getting HIV, lead to safer sex practices, and enable them to remain disease free. For those who are HIV positive, knowledge of their HIV status allows them to take action to protect their sexual partners, to access treatment, and to plan for the future. In the 2015-16 ADHS, respondents were asked whether they had ever been tested for HIV. If they had been tested, they were asked when they were most recently tested, whether they had received the results of their last test, and where they had been tested. If they had never been tested, they were asked if they knew a place where they could go to be tested. Tables 13.8.1 and 13.8.2 show that 48 percent of women and 45 percent of men age 15-49 know where to get an HIV test, an increase from the figures reported in 2010 (43 percent and 35 percent, respectively) (NSS et al. 2012). Knowledge about where to get an HIV test is more common among respondents age 25-49, ever-married respondents, urban respondents, and women in Kotayk and men in Tavush. Interestingly, women who worked abroad in the past three years are more likely to know where to get an HIV test than women who did not work abroad; however, the relationship is reversed among men, with higher levels of knowledge among those who did not work abroad. Knowledge of a place for HIV testing services increases dramatically with increasing education and wealth among both women and men. The proportions of respondents who have ever been tested are much smaller; only 15 percent of women and 2 percent of men age 15-49 have ever been tested for HIV, and 12 percent of women and 1 percent of men have been tested and received the results. The proportions of respondents who were tested in the 12 months before the survey and received the results of their most recent test are even smaller: only 3 percent of women and less than 1 percent of men. The proportion of women ever tested for HIV is lowest among those age 15-19 (2 percent) and highest among those age 25-29 (28 percent). Currently married women (21 percent) are more likely to have had an HIV test than those who have never been married (2 percent) and those who were previously married (12 percent). There are sizeable regional variations in HIV testing. The proportion of women who have ever been tested for HIV ranges from 0 percent in Gegharkunik to 27 percent in Syunik. Women’s likelihood of having been tested for HIV increases slightly as education and wealth increase. In general, variations in the proportion of men ever tested for HIV by background characteristics are not pronounced; men who worked abroad in the three years prior to the survey (9 percent) and men in Shirak (8 percent) were most likely to have been tested. 200 • HIV/AIDS and Sexually Transmitted Infections Table 13.8.1 Coverage of prior HIV testing: Women Percentage of women age 15-49 who know where to get an HIV test, percent distribution of women age 15-49 by testing status and by whether they received the results of the last test, the percentage of women ever tested, and the percentage of women age 15-49 who were tested in the past 12 months and received the results of the last test, according to background characteristics, Armenia 2015-16 Background characteristic Percentage who know where to get an HIV test Percent distribution of women by testing status and by whether they received the results of the last test Total Percentage ever tested Percentage who have been tested for HIV in the past 12 months and received the results of the last test Number of women Ever tested and received results Ever tested, did not receive results Never tested1 Age 15-24 35.6 7.0 2.5 90.5 100.0 9.5 3.0 1,653 15-19 25.9 1.5 0.5 98.0 100.0 2.0 0.6 725 20-24 43.2 11.3 4.0 84.7 100.0 15.3 4.9 928 25-29 57.2 21.9 5.5 72.5 100.0 27.5 5.5 1,099 30-39 53.6 14.5 3.5 81.9 100.0 18.1 2.7 1,874 40-49 48.5 6.0 1.0 93.0 100.0 7.0 2.2 1,490 Marital status Never married 36.5 1.5 0.1 98.4 100.0 1.6 0.8 1,830 Ever had sex * * * * 100.0 * * 12 Never had sex 36.2 1.4 0.1 98.5 100.0 1.5 0.6 1,818 Married/living together 52.8 16.8 4.4 78.8 100.0 21.2 4.4 3,895 Divorced/separated/ widowed 55.7 9.3 2.6 88.1 100.0 11.9 2.1 390 Employment abroad2 Worked abroad 67.1 14.6 1.6 83.8 100.0 16.2 0.0 81 Did not work abroad 47.9 11.7 3.0 85.3 100.0 14.7 3.2 6,035 Spousal employment abroad3 Only respondent worked abroad * * * * 100.0 * * 18 Only spouse worked abroad3 44.1 14.5 2.2 83.3 100.0 16.7 3.4 834 Both worked abroad (74.6) (22.6) (2.0) (75.4) 100.0 (24.6) (0.0) 32 Neither worked abroad 55.0 17.5 5.1 77.5 100.0 22.5 4.8 2,998 Residence Urban 53.4 13.6 2.7 83.7 100.0 16.3 3.4 3,657 Rural 40.3 9.0 3.3 87.6 100.0 12.4 2.9 2,459 Region Yerevan 58.2 15.0 1.7 83.3 100.0 16.7 2.9 2,001 Aragatsotn 22.5 0.4 0.0 99.6 100.0 0.4 0.1 315 Ararat 59.6 12.5 7.2 80.3 100.0 19.7 2.9 552 Armavir 47.8 14.6 3.3 82.0 100.0 18.0 2.7 586 Gegharkunik 11.0 0.0 0.0 100.0 100.0 0.0 0.0 478 Lori 19.7 7.8 1.0 91.3 100.0 8.7 3.0 355 Kotayk 67.5 15.3 6.0 78.6 100.0 21.4 7.8 678 Shirak 46.0 14.8 0.8 84.5 100.0 15.5 4.9 510 Syunik 45.9 10.6 16.0 73.4 100.0 26.6 3.0 238 Vayots Dzor 27.9 4.5 0.3 95.2 100.0 4.8 1.6 119 Tavush 50.4 9.0 0.5 90.5 100.0 9.5 1.9 283 Education Basic 29.2 8.6 3.5 87.9 100.0 12.1 2.8 396 Secondary 37.7 8.2 3.3 88.5 100.0 11.5 2.1 2,444 Secondary special 50.8 12.8 2.5 84.7 100.0 15.3 3.6 1,360 Higher 63.6 16.2 2.9 81.0 100.0 19.0 4.3 1,910 Wealth quintile Lowest 32.8 8.7 3.0 88.3 100.0 11.7 2.4 1,081 Second 45.8 9.0 3.4 87.6 100.0 12.4 2.5 1,242 Middle 43.8 11.8 2.8 85.4 100.0 14.6 3.5 1,142 Fourth 52.6 12.6 2.8 84.6 100.0 15.4 4.2 1,287 Highest 61.8 15.8 2.9 81.2 100.0 18.8 3.2 1,365 Total 48.1 11.7 3.0 85.3 100.0 14.7 3.2 6,116 Note: Total includes 13 women with missing information about spousal employment abroad and 5 women with no education. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 1 Includes “don’t know/missing” 2 “Employment abroad” refers to working abroad during the three years before the survey for three or more months at a time. 3 Currently married respondents only; information on spouse’s employment abroad is based on respondent’s report. HIV/AIDS and Sexually Transmitted Infections • 201 Table 13.8.2 Coverage of prior HIV testing: Men Percentage of men age 15-49 who know where to get an HIV test, percent distribution of men age 15-49 by testing status and by whether they received the results of the last test, the percentage of men ever tested, and the percentage of men age 15-49 who were tested in the past 12 months and received the results of the last test, according to background characteristics, Armenia 2015-16 Background characteristic Percentage who know where to get an HIV test Percent distribution of men by testing status and by whether they received the results of the last test Total Percentage ever tested Percentage who have been tested for HIV in the past 12 months and received the results of the last test Number of men Ever tested and received results Ever tested, did not receive results Never tested1 Age 15-24 31.9 0.7 0.5 98.8 100.0 1.2 0.3 813 15-19 25.9 0.2 0.0 99.8 100.0 0.2 0.2 345 20-24 36.3 1.1 0.9 98.0 100.0 2.0 0.3 467 25-29 51.2 2.2 0.5 97.3 100.0 2.7 0.5 464 30-39 49.5 1.7 0.1 98.2 100.0 1.8 0.4 802 40-49 52.4 1.3 0.1 98.6 100.0 1.4 0.6 676 Marital status Never married 37.1 0.9 0.1 99.0 100.0 1.0 0.2 1,190 Ever had sex 47.7 1.7 0.2 98.1 100.0 1.9 0.4 631 Never had sex 25.2 0.1 0.0 99.9 100.0 0.1 0.0 559 Married/living together 51.7 1.8 0.5 97.7 100.0 2.3 0.6 1,506 Divorced/separated/ widowed (48.8) (0.0) (0.0) (100.0) 100.0 (0.0) (0.0) 59 Employment abroad2 Worked abroad 38.4 7.0 1.9 91.1 100.0 8.9 1.6 334 Did not work abroad 46.3 0.6 0.1 99.3 100.0 0.7 0.2 2,419 Spousal employment abroad3 Only respondent worked abroad 43.3 6.6 2.3 91.1 100.0 8.9 2.1 220 Only spouse worked abroad3 * * * * 100.0 * * 10 Both worked abroad * * * * 100.0 * * 6 Neither worked abroad 53.4 1.0 0.2 98.8 100.0 1.2 0.3 1,264 Residence Urban 53.5 0.8 0.4 98.8 100.0 1.2 0.2 1,558 Rural 34.6 2.1 0.2 97.7 100.0 2.3 0.7 1,197 Region Yerevan 69.7 0.0 0.0 100.0 100.0 0.0 0.0 833 Aragatsotn 8.2 0.6 0.0 99.4 100.0 0.6 0.6 159 Ararat 58.1 0.0 0.0 100.0 100.0 0.0 0.0 290 Armavir 8.2 4.1 0.0 95.9 100.0 4.1 1.8 268 Gegharkunik 9.9 0.0 0.0 100.0 100.0 0.0 0.0 235 Lori 12.3 0.5 1.0 98.5 100.0 1.5 0.0 184 Kotayk 60.0 3.5 0.7 95.8 100.0 4.2 0.6 299 Shirak 46.1 6.4 1.1 92.5 100.0 7.5 1.8 201 Syunik 19.8 0.0 2.1 97.9 100.0 2.1 0.0 104 Vayots Dzor 24.3 1.7 0.0 98.3 100.0 1.7 0.0 56 Tavush 89.9 0.7 0.0 99.3 100.0 0.7 0.0 126 Education Basic 28.0 2.2 0.6 97.3 100.0 2.7 0.4 360 Secondary 35.6 1.2 0.4 98.4 100.0 1.6 0.5 1,250 Secondary special 51.1 1.8 0.2 97.9 100.0 2.1 0.3 403 Higher 67.4 1.1 0.1 98.8 100.0 1.2 0.4 736 Wealth quintile Lowest 27.5 1.1 0.0 98.9 100.0 1.1 0.4 523 Second 37.5 2.7 0.1 97.2 100.0 2.8 1.2 583 Middle 40.2 1.9 1.1 97.0 100.0 3.0 0.1 521 Fourth 54.6 0.6 0.3 99.0 100.0 1.0 0.4 566 Highest 65.4 0.6 0.0 99.4 100.0 0.6 0.0 562 Total 45.3 1.4 0.3 98.3 100.0 1.7 0.4 2,755 Note: Total includes 2 men with missing information about employment abroad, 7 men with missing information about spousal employment abroad, and 5 men with no education. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 1 Includes “don’t know/missing” 2 “Employment abroad” refers to working abroad during the three years before the survey for three or more months at a time. 3 Currently married respondents only; information on spouse’s employment abroad is based on respondent’s report. 202 • HIV/AIDS and Sexually Transmitted Infections 13.7 SELF-REPORTED SEXUALLY TRANSMITTED INFECTIONS Sexually transmitted infections are closely associated with HIV because they increase the likelihood of contracting HIV and involve similar risk factors. In the 2015-16 ADHS, all respondents who ever had sexual intercourse were asked if they had had an STI or symptoms of an STI (including a bad- smelling/abnormal genital discharge and a genital sore or ulcer) in the 12 months preceding the survey. It is important to note that these data are likely to underestimate the true prevalence of STIs for a number of reasons. First, if symptoms are not obvious or prolonged, they may not be recognized as an STI. Furthermore, health care may not be sought for STIs because of the embarrassment or the presumed stigma associated with such infections, and they may go undiagnosed. Finally, even if people know they have an STI, they may be reluctant to report the infection during an interview. Table 13.9 shows that less than 1 percent of women and men reported having an STI in the past 12 months. These results suggest some underreporting of STIs. When asked whether they had experienced an abnormal genital discharge or genital sores or ulcers in the past 12 months, 5 percent and 1 percent of women, respectively, and less than 1 percent each of men reported that they had. To the extent that women may report a normal genital discharge as abnormal, this may be an overestimate of any serious STIs among women. Overall, 5 percent of women reported having had an STI, genital discharge, or genital sore or ulcer in the 12 months before the survey, about midway between the figure of 3 percent reported in 2010 and the 8 percent figure reported in 2005 (NSS et al. 2006; NSS et al. 2012). Among men, the self-reported prevalence of STIs and STI symptoms is less than 1 percent, similar to the prevalence in 2005 (less than 1 percent) and 2010 (2 percent). Among women, the prevalence of STIs or their symptoms increases slightly with age and decreases slightly as educational level and wealth quintile increase. Rural women and women whose husbands worked abroad are more likely than their counterparts to report having had an STI or an STI symptom (8 percent each). Women in Ararat, Aragatsotn, and Shirak are more likely than women in other regions to report having had an STI or a symptom of an STI in the 12 months before the survey. There are no substantial variations by background characteristics in the prevalence of STIs or STI symptoms among men. HIV/AIDS and Sexually Transmitted Infections • 203 Table 13.9 Self-reported prevalence of sexually transmitted infections (STIs) and STI symptoms Among women and men age 15-49 who ever had sexual intercourse, the percentage reporting having an STI and/or symptoms of an STI in the past 12 months, according to background characteristics, Armenia 2015-16 Background characteristic Women Men Percentage of women who reported having in the past 12 months: Number of women who ever had sexual intercourse Percentage of men who reported having in the past 12 months: Number of men who ever had sexual intercourse STI Bad- smelling/ abnormal genital discharge Genital sore or ulcer STI/genital discharge/ sore or ulcer STI Bad- smelling/ abnormal discharge from penis Genital sore or ulcer STI/ abnormal discharge from penis/ sore or ulcer Age 15-24 0.3 2.1 0.7 2.4 407 0.6 0.6 0.0 0.6 324 15-19 (0.0) (0.0) (0.0) (0.0) 35 (4.5) (4.5) (0.0) (4.5) 43 20-24 0.3 2.3 0.8 2.6 372 0.0 0.0 0.0 0.0 281 25-29 0.9 3.8 0.9 4.1 802 0.7 0.0 0.0 0.7 428 30-39 0.9 4.4 0.9 5.2 1,681 0.4 0.5 0.3 0.9 776 40-49 0.9 6.1 1.9 6.3 1,408 0.0 0.2 0.0 0.2 668 Marital status Never married * * * * 12 0.8 0.3 0.0 0.8 631 Married or living together 0.9 4.6 1.3 5.1 3,895 0.1 0.3 0.2 0.4 1,506 Divorced/separated/ widowed 0.0 4.8 0.5 4.8 390 (3.1) (0.0) (0.0) (3.1) 59 Employment abroad1 Worked abroad 2.4 3.7 0.0 3.7 59 0.0 0.0 0.0 0.0 322 Did not work abroad 0.8 4.6 1.2 5.1 4,239 0.4 0.4 0.2 0.7 1,872 Spousal employment abroad2 Only respondent worked abroad * * * * 18 0.0 0.0 0.0 0.0 220 Only spouse worked abroad2 1.1 7.1 2.1 7.8 834 * * * * 10 Both worked abroad (0.0) (0.0) (0.0) (0.0) 32 * * * * 6 Neither worked abroad 0.8 4.0 1.1 4.5 2,998 0.1 0.4 0.2 0.5 1,264 Residence Urban 0.6 2.9 0.6 3.3 2,523 0.3 0.2 0.0 0.3 1,278 Rural 1.2 7.1 2.1 7.7 1,775 0.4 0.5 0.3 0.9 918 Region Yerevan 0.6 1.5 0.0 1.9 1,322 0.6 0.3 0.0 0.6 705 Aragatsotn 1.0 8.8 5.6 11.3 198 1.1 0.3 0.3 1.1 120 Ararat 1.1 12.0 5.1 12.0 394 0.3 0.5 0.0 0.8 227 Armavir 1.2 1.9 0.6 2.5 445 0.0 1.0 0.5 1.5 237 Gegharkunik 1.4 7.7 0.0 7.7 315 0.0 0.0 0.0 0.0 164 Lori 0.0 2.1 0.0 2.1 230 0.0 0.0 0.0 0.0 133 Kotayk 1.6 4.3 1.9 5.3 515 0.4 0.0 0.0 0.4 250 Shirak 0.5 10.3 1.6 10.5 383 0.6 0.6 0.6 0.6 177 Syunik 0.0 0.0 0.3 0.3 183 0.0 0.0 0.0 0.0 62 Vayots Dzor 1.2 3.2 0.3 3.8 91 0.6 0.6 0.6 0.6 37 Tavush 0.4 5.4 0.5 5.7 221 0.0 0.0 0.0 0.0 83 Education Basic 0.3 6.4 2.7 7.1 234 0.0 0.4 0.0 0.4 246 Secondary 1.0 6.3 1.4 6.7 1,833 0.5 0.4 0.3 0.9 982 Secondary special 0.7 3.9 1.2 4.5 1,053 0.6 0.6 0.0 0.6 334 Higher 0.9 2.2 0.6 2.8 1,175 0.2 0.0 0.0 0.2 631 Wealth quintile Lowest 0.6 6.9 2.3 7.5 780 0.2 0.3 0.3 0.8 411 Second 0.9 6.5 1.8 6.8 878 0.2 0.5 0.0 0.7 444 Middle 0.8 6.1 1.3 6.4 818 0.1 0.1 0.1 0.1 413 Fourth 0.8 2.9 0.2 3.4 874 1.1 0.4 0.0 1.1 458 Highest 0.9 1.3 0.6 2.1 948 0.3 0.3 0.3 0.3 470 Total 0.8 4.6 1.2 5.1 4,298 0.4 0.3 0.1 0.6 2,196 Note: Total includes 2 men with missing information about employment abroad, 13 women and 7 men with missing information about spousal employment abroad, and 4 women and 3 men with no education. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 1 “Employment abroad” refers to working abroad during the three years before the survey for three or more months at a time. 2 Currently married respondents only; information on spouse’s employment abroad is based on respondent’s report. 204 • HIV/AIDS and Sexually Transmitted Infections If respondents reported an STI or an STI symptom (i.e., genital discharge or sore/ulcer) in the past 12 months, they were asked questions about their actions in response to the infection or symptom. Figure 13.1 shows that more than 6 in 10 of the women (62 percent) who reported having had an STI or STI symptoms in the past 12 months sought advice or treatment from a clinic, hospital, or health professional.2 More than one-third (35 percent) of women did not solicit any advice or seek treatment. Figure 13.1 Women seeking advice or treatment for STIs 13.8 PREVALENCE OF MEDICAL INJECTIONS Respondents in the 2015-16 ADHS were asked how many injections they had from a doctor, nurse, pharmacist, dentist, or other health worker in the 12 months preceding the survey. If they had had such a medical injection, they were asked if the syringe and needle were taken from a new, unused package for the most recent injection. It should be noted that injections that are self-administered (e.g., insulin for diabetes) are not considered medical injections for this analysis. Table 13.10 shows the percentages of women and men age 15-49 who received a medical injection in the past 12 months, the average number of injections, and whether or not the syringe and needle used were taken from an unopened package. The data show that 12 percent of women and 17 percent of men report having received an injection from a health worker in the 12 months preceding the survey, with an average of 1.2 injections for both women and men. Older women and, to a lesser extent, older men are more likely than younger women and men to report getting an injection. The proportion of women who had a medical injection in the 12 months before the survey is twice as high in Tavush (19 percent) as in Syunik and Aragatsotn (8 percent each). Among men, the regional variation is even larger, ranging from less than 1 percent in Ararat to 36 percent in Armavir. Prevalence of medical injections among women and men is not strongly related to either education or wealth. When asked whether the syringe used in the last medical injection came from a new, unopened package, 98 percent of women and 96 percent of men responded positively. The proportion of women who reported receiving a medical injection in the 12 months before the survey has decreased slightly over the past five years, from 14 percent in 2010 to 12 percent in 2015-16. Among men, however, there has been a sizeable increase, from 8 percent to 17 percent (NSS et al. 2012). 2 There were too few men who reported having had an STI or an STI symptom to show information about treatment. 62 6 2 35 Clinic/hospital/private doctor/other health professional Advice or medicine from shop/pharmacy Advice or treatment from any other source No advice or treatment Percentage ADHS 2015-16 HIV/AIDS and Sexually Transmitted Infections • 205 Table 13.10 Prevalence of medical injections Percentage of women and men age 15-49 who received at least one medical injection in the last 12 months, the average number of medical injections per person in the last 12 months, and among those who received a medical injection, the percentage of last medical injections for which the syringe and needle were taken from a new, unopened package, by background characteristics, Armenia 2015-16 Women Men Background characteristic Percentage who received a medical injection in the last 12 months Average number of medical injections per person in the last 12 months Number of women For last injection, syringe and needle taken from a new, unopened package Number of women receiving medical injections in the last 12 months Percentage who received a medical injection in the last 12 months Average number of medical injections per person in the last 12 months Number of men For last injection, syringe and needle taken from a new, unopened package Number of men receiving medical injections in the last 12 months Age 15-24 7.2 0.5 1,653 98.1 119 13.6 0.7 813 98.9 111 15-19 5.0 0.2 725 (93.6) 36 15.1 0.7 345 99.5 52 20-24 9.0 0.6 928 100.0 83 12.6 0.7 467 98.4 59 25-29 14.2 1.4 1,099 98.1 156 15.3 0.9 464 96.8 71 30-39 12.5 1.4 1,874 97.6 235 17.5 1.4 802 97.3 141 40-49 15.5 1.8 1,490 98.5 231 19.8 1.6 676 91.8 134 Marital status Never married 5.3 0.3 1,830 97.6 98 15.0 0.9 1,190 96.5 179 Ever had sex * * 12 * 2 17.8 1.0 631 95.5 112 Never had sex 5.2 0.3 1,818 97.6 95 11.9 0.8 559 98.2 67 Married/living together 15.1 1.6 3,895 98.0 590 17.9 1.4 1,506 96.1 270 Divorced/separated/ widowed 13.6 1.5 390 100.0 53 (13.3) (0.8) 59 * 8 Employment abroad1 Worked abroad 16.4 1.3 81 * 13 16.1 1.2 334 98.0 54 Did not work abroad 12.1 1.2 6,035 98.2 728 16.7 1.2 2,419 95.7 403 Spousal employment abroad2 Only respondent worked abroad * * 18 * 5 17.9 1.5 220 (97.3) 39 Only spouse worked abroad2 16.0 1.5 834 99.2 134 * * 10 * 4 Both worked abroad (19.9) (1.8) 32 * 6 * * 6 * 0 Neither worked abroad 14.8 1.6 2,998 97.8 445 17.8 1.4 1,264 95.8 225 Residence Urban 12.2 1.2 3,657 97.9 447 18.2 1.3 1,558 94.6 283 Rural 12.0 1.3 2,459 98.3 294 14.5 1.1 1,197 98.3 173 Region Yerevan 11.4 1.0 2,001 96.1 229 19.4 1.3 833 91.1 161 Aragatsotn 8.1 0.7 315 (100.0) 26 31.5 1.7 159 100.0 50 Ararat 10.3 1.2 552 100.0 57 0.7 0.0 290 * 2 Armavir 10.4 1.4 586 97.5 61 35.8 2.3 268 98.0 96 Gegharkunik 8.5 1.2 478 (100.0) 41 5.8 0.7 235 * 14 Lori 15.6 1.2 355 100.0 55 21.7 1.2 184 (97.4) 40 Kotayk 16.7 1.9 678 100.0 113 13.9 1.6 299 (100.0) 42 Shirak 13.9 1.1 510 97.0 71 12.8 0.8 201 * 26 Syunik 7.7 1.1 238 (100.0) 18 2.5 0.8 104 * 3 Vayots Dzor 13.9 1.1 119 100.0 17 18.7 1.4 56 (91.4) 11 Tavush 18.6 1.8 283 96.6 53 10.5 0.6 126 * 13 Education Basic 9.6 0.9 396 (94.2) 38 14.8 1.2 360 97.1 53 Secondary 10.9 1.2 2,444 97.9 267 17.1 1.3 1,250 93.8 214 Secondary special 15.3 1.7 1,360 98.5 208 14.5 0.9 403 95.1 58 Higher 11.9 1.0 1,910 98.5 228 17.8 1.1 736 99.5 131 Wealth quintile Lowest 10.9 1.2 1,081 96.3 117 17.6 1.4 523 98.6 92 Second 13.0 1.4 1,242 100.0 162 14.4 1.0 583 98.3 84 Middle 11.6 1.1 1,142 98.5 133 15.3 0.9 521 97.4 80 Fourth 12.1 1.3 1,287 98.4 156 19.3 1.5 566 92.1 109 Highest 12.7 1.1 1,365 96.8 173 16.3 1.1 562 94.7 92 Total 12.1 1.2 6,116 98.1 741 16.6 1.2 2,755 96.0 457 Note: Medical injections are those given by a doctor, nurse, pharmacist, dentist, or other health worker. Total includes 2 men with missing information about employment abroad, 13 women and 7 men with missing information about spousal employment abroad, and 5 women and 5 men with no education. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 1 “Employment abroad” refers to working abroad during the three years before the survey for three or more months at a time. 2 Currently married respondents only; information on spouse’s employment abroad is based on respondent’s report. 206 • HIV/AIDS and Sexually Transmitted Infections 13.9 HIV/AIDS-RELATED KNOWLEDGE AND BEHAVIOR AMONG YOUTH This section addresses knowledge of HIV/AIDS issues and related sexual behavior among youth age 15-24. This age group is of particular interest for HIV/AIDS programs. The period between initiation of sexual activity and marriage is often a time of sexual experimentation, and it may also involve risky behaviors. The survey collected data on comprehensive knowledge of HIV/AIDS transmission and prevention among youth. Information was also gathered on issues such as age at sexual debut, premarital sex, higher-risk sexual behavior, condom use, and HIV testing. 13.9.1 HIV/AIDS-Related Knowledge among Young Adults Young respondents in the 2015-16 ADHS were asked the same set of questions as older respondents about whether condom use and limiting the number of sexual partners to one uninfected partner can help protect against getting HIV and whether a healthy-looking person can have HIV (see Table 13.3). Table 13.11 shows the level of comprehensive knowledge among young people, that is, the proportion of youth who, in response to prompted questions, answer in the affirmative that people can reduce their chances of getting HIV by having sex with only one uninfected faithful partner and by using condoms consistently, who know that a healthy-looking person can have HIV, and who know that HIV cannot be transmitted by mosquito bites or by kissing someone who has HIV. Only 20 percent of young women and 13 percent of young men have comprehensive knowledge about HIV/AIDS. Comprehensive knowledge about HIV/AIDS increases with the age of the respondent. It does not vary between respondents who have been married and those who have never been married. Urban youth are more likely than those in rural areas to have comprehensive knowledge about HIV/AIDS. The proportion of young women and men with comprehensive knowledge about HIV increases dramatically as educational level increases. 13.9.2 Age at First Sex among Youth Information from the 2015-16 ADHS can be used to look at the timing of the initiation of sexual activity among youth. Table 13.12 shows the proportions of young women and men in the 15-24 age cohort who had sex before age 15 and before age 18. Overall, almost no women and only 1 percent of men age 15-24 in Armenia report having had sex by age 15 (Table 13.12). By age 18, however, 6 percent of women and 16 percent of men age 18-24 have had their sexual debut. Table 13.11 Comprehensive knowledge about HIV among young people Percentage of young women and young men age 15-24 with comprehensive knowledge about HIV, according to background characteristics, Armenia 2015-16 Women age 15-24 Men age 15-24 Background characteristic Percentage with compre- hensive knowledge of HIV1 Number of women Percentage with compre- hensive knowledge of HIV1 Number of men Age 15-19 14.7 725 8.9 345 15-17 11.9 450 7.2 261 18-19 19.3 275 14.1 85 20-24 24.5 928 15.2 467 20-22 23.0 506 13.1 247 23-24 26.4 422 17.5 221 Marital status Never married 20.5 1,249 12.5 756 Ever had sex * 2 16.0 267 Never had sex 20.5 1,247 10.5 489 Ever married 19.4 405 13.3 56 Residence Urban 24.9 928 15.6 438 Rural 14.3 725 8.9 374 Education Basic 6.7 163 4.5 139 Secondary 10.7 651 8.9 354 Secondary special 26.1 272 9.1 109 Higher 32.2 567 25.8 209 Total 20.2 1,653 12.5 813 Note: Total includes 1 man with no education. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Comprehensive knowledge means knowing that consistent use of condoms during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting HIV, knowing that a healthy-looking person can have HIV, and rejecting the two most common local misconceptions about transmission or prevention of HIV. The components of comprehensive knowledge are presented in Tables 13.2 and 13.3. HIV/AIDS and Sexually Transmitted Infections • 207 Differences in age at initiation of sexual relations by residence are not uniform. Among women age 18-24, those in rural areas are more likely to have had sex before age 18 than those in urban areas. However, among men, the reverse is true: urban men are slightly more likely to have had sex before age 18 than rural men. The proportion of young women and young men age 18-24 who had sex by age 18 tends to decrease as educational level increases, although the relationship is stronger among women than men. Table 13.12 Age at first sexual intercourse among young people Percentage of young women and young men age 15-24 who had sexual intercourse before age 15 and percentage of young women and young men age 18-24 who had sexual intercourse before age 18, according to background characteristics, Armenia 2015-16 Background characteristic Women age 15-24 Women age 18-24 Men age 15-24 Men age 18-24 Percentage who had sexual intercourse before age 15 Number of women Percentage who had sexual intercourse before age 18 Number of women Percentage who had sexual intercourse before age 15 Number of men Percentage who had sexual intercourse before age 18 Number of men Age 15-19 0.0 725 na na 1.0 345 na na 15-17 0.0 450 na na 1.1 261 na na 18-19 0.0 275 5.7 275 0.8 85 21.8 85 20-24 0.2 928 5.9 928 1.0 467 14.9 467 20-22 0.3 506 5.8 506 1.0 247 16.6 247 23-24 0.0 422 6.1 422 1.0 221 12.9 221 Residence Urban 0.1 928 3.0 675 1.8 438 17.6 287 Rural 0.1 725 9.6 529 0.0 374 14.1 265 Education Basic 1.0 163 (28.5) 40 0.9 139 24.2 59 Secondary 0.0 651 10.8 406 1.9 354 14.7 220 Secondary special 0.0 272 5.5 203 0.0 109 18.1 77 Higher 0.0 567 0.8 554 0.0 209 14.1 195 Total 0.1 1,653 5.9 1,204 1.0 813 15.9 552 Note: Total includes 1 man with no education. Figures in parentheses are based on 25-49 unweighted cases. na = Not applicable Figure 13.2 shows that there has been very little change in age at first sexual intercourse since 2010. The percentage of young women age 18-19 who initiated sexual intercourse before age 18 has decreased slightly, from 8 percent in 2010 to 6 percent in 2015-16. The percentage of men age 18-19 who had sex before age 18 has remained stable at 22 percent (NSS et al. 2012). Figure 13.2 Trends in age at first sexual intercourse 0 0 8 22 0 1 6 22 Percentage of women 15-19 who had sexual intercourse before exact age 15 Percentage of men 15-19 who had sexual intercourse before exact age 15 Percentage of women 18-19 who had sexual intercourse before exact age 18 Percentage of men 18-19 who had sexual intercourse before exact age 18 Percent 2010 ADHS 2015-16 ADHS 208 • HIV/AIDS and Sexually Transmitted Infections 13.9.3 Abstinence and Premarital Sex As noted, the period between sexual initiation and marriage is often a time of sexual experimentation. Premarital sex and the length of the interval between sexual initiation and marriage are among the factors contributing to the spread of HIV. Table 13.13 shows the percentages of never-married young women and men age 15-24 who have never had sexual intercourse. Almost all never-married young women report that they have never had sex, and there are no differentials by age, residence, or education. Table 13.13 Premarital sexual intercourse among young people Among never-married women and men age 15-24, percentage who have never had sexual intercourse, according to background characteristics, Armenia 2015-16 Background characteristic Never-married women age 15-24 Never-married men age 15-24 Percentage who have never had sexual intercourse Number of women Percentage who have never had sexual intercourse Number of men Age 15-19 100.0 690 87.5 345 15-17 100.0 446 94.4 261 18-19 100.0 244 66.4 85 20-24 99.7 558 45.4 411 20-22 100.0 346 53.2 237 23-24 99.1 212 34.7 174 Residence Urban 99.7 739 59.1 415 Rural 100.0 509 71.4 341 Education Basic 100.0 138 79.7 131 Secondary 100.0 454 73.0 326 Secondary special 100.0 195 61.0 101 Higher 99.6 460 42.3 197 Total 99.8 1,249 64.6 756 Note: Total includes 1 man with no education. Overall, 65 percent of never-married young men age 15-24 report that they have never had sex. The proportion of never-married young men who have never had sex drops rapidly with increasing age and education. For example, 94 percent of never-married men age 15-17 have never had sex, as compared with 35 percent of men age 23-24. Similarly, 80 percent of young men with a basic education have never had sex, compared with 42 percent of those with a higher education. Young men in urban areas (59 percent) are considerably less likely than those in rural areas (71 percent) to have never had sex. 13.9.4 Multiple Sexual Partners and Condom Use among Young People In many societies, young adulthood is a time of sexual experimentation. Multiple partnerships and sexual experiences with non-marital partners can expose people to sexually transmitted infections such as HIV. In the 2015-16 ADHS, young women and men were asked the same set of questions as older respondents regarding the number and types of sexual partners they had in the 12 months before the survey. Figure 13.3 shows information for young women and men age 15-24 as to the proportion with more than one sexual partner in the past 12 months, the proportion who had sex with a non-marital partner, and, among them, the proportion using a condom at the last sexual intercourse. As was the case in the 2010 ADHS, no young women age 15-24 reported having multiple sexual partners in the 12 months before the survey (NSS et al. 2012). Less than 1 percent of young women who had had sexual intercourse in the 12 months before the survey said they had sex with a non-marital, non- cohabiting partner in that time frame. HIV/AIDS and Sexually Transmitted Infections • 209 Only 3 percent of young men reported having had more than one sexual partner in the 12 months preceding the survey, a steep decline from the 16 percent figure reported in 2010. Differences by background characteristics are minimal (data not shown). Among young men who had sexual intercourse in the 12 months before the survey, 79 percent said they had sex with a non-marital, non-cohabiting partner (i.e., not a wife or live-in partner). Of those who had non-marital sex, 86 percent said they used a condom the last time they had sex. Figure 13.3 Multiple sexual partners and higher-risk sex among young people 13.9.5 Recent HIV Tests among Youth Individuals’ knowledge of their own HIV status can provide motivation to practice safer sexual practices. People who learn that they do not have HIV may decide to take precautions in the future so as not to contract the virus, and those who learn that they are carrying the virus may decide to take precautions to avoid transmitting the virus to others. Only 10 percent of young women and 1 percent of young men reported that they had ever been tested for HIV (see Tables 13.8.1 and 13.8.2). The fact that many young people in Armenia are not sexually active may explain these low percentages. Consequently, Table 13.14 presents results on coverage of HIV testing among sexually active young women and men age 15-24, focusing on those who may be more motivated to get tested. Overall, 11 percent of young women and less than 1 percent of young men who had sexual intercourse in the 12 months before the survey were recently tested for HIV and received the results. In general, the numbers are too small to reach meaningful conclusions on variations in testing coverage by the background characteristics shown in Table 13.14. 0 1 0 3 79 86 Among all age 15-24, percentage who had 2+ partners in the past 12 months Among those who had sex in last 12 months, percentage who had sex with a non-marital partner Among those who had sex in the last 12 months with a non-marital partner, percentage using a condom at last sex Percent Women Men 2015-16 ADHS Table 13.14 Recent HIV tests among young people Among young women and young men age 15-24 who have had sexual intercourse in the past 12 months, the percentage who were tested for HIV in the past 12 months and received the results of the last test, according to background characteristics, Armenia 2015-16 Background characteristic Women age 15-24 who have had sexual intercourse in the past 12 months: Men age 15-24 who have had sexual intercourse in the past 12 months: Percentage who have been tested for HIV in the past 12 months and received the results of the last test Number of women Percentage who have been tested for HIV in the past 12 months and received the results of the last test Number of men Age 15-19 (9.9) 35 (1.7) 39 15-17 * 3 * 14 18-19 (8.9) 31 * 25 20-24 10.5 363 0.7 232 20-22 9.4 157 0.0 96 23-24 11.4 206 1.2 136 Marital status Never married * 2 0.7 215 Ever married 10.5 396 1.2 56 Total 10.5 398 0.8 271 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. Domestic Violence • 211 DOMESTIC VIOLENCE 14 Key Findings  Six percent of women age 15-49 have experienced physical violence at least once since age 15, and 3 percent experienced physical violence in the 12 months prior to the survey.  One percent of women age 15-49 report having experienced sexual violence at least once in their lifetime.  Among ever-married women age 15-49, 14 percent report having experienced physical, sexual, or emotional violence from their spouse, and 8 percent report experiencing such violence in the past 12 months.  Among ever-married women who have experienced spousal violence (physical or sexual), 40 percent reported experiencing physical injuries.  Twenty-nine percent of women who have experienced physical or sexual violence by anyone have sought assistance to stop the violence. ender-based violence is defined as any act that results in, or is likely to result in, physical, sexual, or psychological harm or suffering among women, including threats of such acts and coercion or arbitrary deprivations of liberty, whether occurring in public or in private life (United Nations 1993; United Nations 1996; WHO 2016). Domestic violence against women, a major form of gender- based violence, has negative health consequences, especially for the reproductive health of women and the physical, emotional, and mental health of their children. The 2015-16 ADHS included a domestic violence module administered to women age 15-49 to assess the prevalence and correlates of women’s experience of domestic violence in Armenia. 14.1 MEASUREMENT OF VIOLENCE Collecting valid, reliable, and ethical data on domestic violence poses particular challenges because what constitutes violence or abuse varies across cultures and among individuals. In addition, a culture of silence usually surrounds the experience of domestic violence and can affect reporting. Assuring the safety of respondents and interviewers when asking about domestic violence in a familial setting, protecting women who disclose violence, and reducing the risk of double victimization of respondents as they relive their experiences are all specific ethical concerns. 14.1.1 Use of Valid Measures of Violence In the 2015-16 ADHS, information was obtained from ever-married women on violence committed by their current and former husbands and by others. Information was collected from never- married women on violence committed by anyone. Since international research shows that intimate partner violence is one of the most common forms of violence, especially against women, information on spousal violence was measured in more detail than violence committed by other perpetrators. These measurements were made using a shortened, modified version of the Conflict Tactics Scale (Strauss 1990). Specifically, violence by the current husband/partner among currently married women and by the most recent husband/partner among formerly married women was measured by asking all ever-married women the following set of questions. G 212 • Domestic Violence Does (did) your (last) husband/partner ever: (a) Push you, shake you, or throw something at you? (b) Slap you? (c) Twist your arm or pull your hair? (d) Punch you with his fist or with something that could hurt you? (e) Kick you, drag you, or beat you up? (f) Try to choke you or burn you on purpose? (g) Threaten or attack you with a knife, gun, or other weapon? (h) Physically force you to have sexual intercourse with him even when you did not want to? (i) Physically force you to perform any other sexual acts you did not want to? (j) Force you with threats or in any other way to perform sexual acts you did not want to? For every question that a woman answered “yes,” she was asked about the frequency of the act in the 12 months preceding the survey (often, sometimes, or not at all). A yes answer to one or more of items (a) to (g) above constitutes evidence of physical violence, and a yes answer to item (h), (i), or (j) constitutes evidence of sexual violence. Similarly, emotional violence among ever-married women was measured with the following questions. Does (did) your (last) husband/partner ever: (a) Say or do something to humiliate you in front of others? (b) Threaten to hurt or harm you or someone you care about? (c) Insult you or make you feel bad about yourself? This approach of asking about specific acts to measure different forms of violence has the advantage of not being affected by different understandings of what constitutes a summary term such as “violence.” By including a wide range of acts, this approach has the additional advantage of giving the respondent multiple opportunities to disclose any experience of violence. In addition to these questions asked only of ever-married respondents, all women were asked about physical and sexual violence from persons other than the current or most recent husband/partner. Respondents who answered yes to this question were asked who committed violence against them and the frequency of such violence during the 12 months preceding the survey. Respondents who reported experiencing different forms of violence were asked for the perpetrators of the violence. Although this approach to questioning is generally considered to be optimal, the possibility of underreporting of violence, particularly sexual violence, cannot be entirely ruled out in any survey, and this survey is no exception. Domestic Violence • 213 14.1.2 Ethical Considerations In recognition of the challenges in collecting data on violence, the 2015-16 ADHS interviewers were specially trained on the sensitivity around asking about domestic violence; additionally, they were trained to ensure privacy when asking this module of questions and on how to build rapport with the respondent. Rapport with the respondent, confidentiality, and privacy are all keys to building respondents’ confidence so that they can safely share their experiences with the interviewer. Also, placement of questions about violence at the end of the questionnaire provides time for the interviewer to develop a certain degree of intimacy that should further encourage respondents to share their experiences of violence, if any. In addition, the following protections were built into the survey in keeping with the World Health Organization’s ethical and safety recommendations for research on domestic violence (WHO 2001): 1. To maintain confidentiality, only one woman per household was administered the questions on violence. The random selection of one woman was done through a simple selection procedure based on the Kish grid, which was built into the Household Questionnaire (Kish 1965). 2. As a means of obtaining additional consent beyond the initial consent provided at the start of the interview, the respondent was informed that the questions could be sensitive and was reassured regarding the confidentiality of her responses. 3. The violence module was implemented only if privacy could be obtained. The interviewers were instructed to skip the module, thank the respondent, and end the interview if they could not ensure privacy. As a result of the various precautions and restrictions, a total of 4,592 women age 15-49 (3,208 ever-married women) completed the domestic violence module. Specially constructed weights were used to adjust for the selection of only one woman per household in order to ensure that the subsample of women administered the domestic violence module was nationally representative. Note that for the remainder of this chapter the term “husband” refers to any man living with a respondent in either a formal or an informal marital union. 14.2 EXPERIENCE OF PHYSICAL VIOLENCE Table 14.1 shows the percentages of women who have experienced physical violence since age 15 and the percentages who experienced violence during the 12 months preceding the survey, by background characteristics. Six percent of women have experienced physical violence since age 15, and 3 percent experienced physical violence in the 12 months preceding the survey. Overall, 1 percent of women reported that they had experienced physical violence often in the past 12 months and 2 percent said they had experienced physical violence sometimes during the same period. The percentage of women who have experienced physical violence since age 15 increases with age; no women in the 15-19 age group reported experiencing violence, as compared with 10 percent of women in the 40-49 age group. A similar pattern is observed by women’s number of children. Women’s experience of violence varies greatly by region, from a low of 0 percent in Syunik and 1 percent in Tavush to a high of 18 percent in Aragatsotn. Thirty-five percent of women who are divorced, separated, or widowed have experienced physical violence since age 15, compared with 6 percent of currently married women. The percentage of women who have experienced physical violence since age 15 tends to decline with increasing education and wealth. Almost all of the women who reported experiencing any physical violence since age 15 are currently or formerly married. Thus, it is not surprising that the majority of reported perpetrators of violence are current husbands (60 percent) and former husbands (39 percent). Former boyfriends, mothers- in-law, and siblings were also mentioned as perpetrators by 1 percent each of women (data not shown). 214 • Domestic Violence Table 14.1 Experience of physical violence Percentage of women age 15-49 who have ever experienced physical violence since age 15 and percentage who have experienced physical violence during the 12 months preceding the survey, by background characteristics, Armenia 2015-16 Background characteristic Percentage who have ever experienced physical violence since age 151 Percentage who have experienced physical violence in the past 12 months Number of women Often Sometimes Often or sometimes2 Age 15-19 0.0 0.0 0.0 0.0 534 20-24 1.2 0.1 0.9 1.0 724 25-29 4.1 0.1 1.6 1.7 827 30-39 8.5 0.7 2.8 3.5 1,399 40-49 9.7 1.2 2.7 3.8 1,109 Residence Urban 5.2 0.5 1.6 2.1 2,741 Rural 6.8 0.6 2.4 3.0 1,851 Region Yerevan 4.6 0.3 1.7 2.0 1,522 Aragatsotn 17.5 1.2 12.4 13.6 241 Ararat 13.0 1.7 1.8 3.5 421 Armavir 2.2 0.4 0.3 0.7 442 Gegharkunik 4.3 0.0 1.1 1.1 365 Lori 10.1 1.1 3.7 4.8 224 Kotayk 6.1 0.0 1.1 1.1 513 Shirak 3.4 1.3 1.1 2.4 381 Syunik 0.0 0.0 0.0 0.0 181 Vayots Dzor 8.6 0.0 1.3 1.3 91 Tavush 1.2 0.2 0.5 0.7 211 Marital status Never married 0.1 0.0 0.1 0.1 1,384 Married or living together 5.8 0.4 2.2 2.6 2,923 Divorced/separated/widowed 35.0 4.9 7.9 12.8 285 Number of living children 0 0.4 0.0 0.0 0.0 1,600 1-2 8.5 0.7 2.9 3.7 2,219 3-4 9.5 0.7 2.8 3.6 737 5+ (14.7) (8.3) (5.0) (13.3) 35 Employment Employed for cash 7.1 0.8 1.5 2.3 1,606 Employed not for cash 5.7 0.4 0.4 0.8 260 Not employed 5.1 0.4 2.3 2.7 2,726 Education Basic 8.6 1.0 1.1 2.0 300 Secondary 7.6 0.5 2.6 3.2 1,810 Secondary special 6.6 0.8 2.4 3.2 1,020 Higher 2.6 0.3 0.9 1.2 1,458 Wealth quintile Lowest 9.0 1.1 3.4 4.5 812 Second 5.9 0.4 1.6 1.9 930 Middle 8.0 0.8 2.3 3.2 860 Fourth 3.5 0.2 1.0 1.2 956 Highest 3.7 0.3 1.6 1.9 1,034 Total 5.9 0.5 1.9 2.5 4,592 Note: Total includes 4 women with no education. Figures in parentheses are based on 25-49 unweighted cases. 1 Includes violence in the past 12 months. For women who were married before age 15 and who reported physical violence, the violence could have occurred before age 15. 2 Includes women who report physical violence in the past 12 months but for whom frequency is not known Domestic Violence • 215 14.3 EXPERIENCE OF SEXUAL VIOLENCE Table 14.2 shows the percentage of women who have experienced sexual violence ever and in the past 12 months, according to background characteristics. The results show that 1 percent of women age 15-49 have ever experienced sexual violence, and for a minority of them, the violence occurred in the past 12 months. Women’s experience of sexual violence increases with age, with 2 percent of women age 40-49 reporting such violence. As with physical violence, formerly married women are much more likely to report sexual violence than currently married women (6 percent versus 1 percent). Experience of sexual violence is most common in Aragatsotn (4 percent) and in Ararat and Lori (2 percent each). As with reports of physical violence, almost all women reporting sexual violence were currently or formerly married, and the reported perpetrators were either current or former husbands or boyfriends (data not shown). 14.4 EXPERIENCE OF DIFFERENT FORMS OF VIOLENCE Table 14.3 presents information on the experience of various forms of violence among women age 15-49. Overall, 6 percent of women reported that they have experienced either physical or sexual violence or both. Five percent have experienced physical violence only, less than 1 percent have experienced sexual violence only, and 1 percent have experienced both physical and sexual violence. The percentage of women who have experienced physical or sexual violence increases sharply with age. Table 14.2 Experience of sexual violence Percentage of women age 15-49 who have ever experienced sexual violence and percentage who have experienced sexual violence in the 12 months preceding the survey, by background characteristics, Armenia 2015-16 Background characteristic Percentage who have experienced sexual violence: Number of women Ever1 In the past 12 months Age 15-19 0.0 0.0 534 20-24 0.1 0.1 724 25-29 0.4 0.3 827 30-39 1.2 0.4 1,399 40-49 1.8 0.6 1,109 Residence Urban 0.8 0.2 2,741 Rural 1.0 0.4 1,851 Region Yerevan 0.5 0.2 1,522 Aragatsotn 3.7 0.9 241 Ararat 1.9 1.3 421 Armavir 0.4 0.1 442 Gegharkunik 0.6 0.3 365 Lori 1.8 0.3 224 Kotayk 1.2 0.1 513 Shirak 0.0 0.0 381 Syunik 0.0 0.0 181 Vayots Dzor 1.0 0.0 91 Tavush 0.6 0.4 211 Marital status Never married 0.1 0.0 1,384 Married or living together 0.7 0.3 2,923 Divorced/separated/widowed 6.3 1.8 285 Employment Employed for cash 1.4 0.7 1,606 Employed not for cash 0.4 0.0 260 Not employed 0.6 0.1 2,726 Number of living children 0 0.2 0.0 1,600 1-2 1.2 0.4 2,219 3-4 1.3 0.4 737 5+ (1.4) (1.4) 35 Education Basic 2.1 0.7 300 Secondary 0.9 0.3 1,810 Secondary special 1.5 0.6 1,020 Higher 0.1 0.0 1,458 Wealth quintile Lowest 1.4 0.5 812 Second 1.1 0.6 930 Middle 1.1 0.2 860 Fourth 0.4 0.1 956 Highest 0.4 0.2 1,034 Total 0.9 0.3 4,592 Note: Total includes 4 women with no education. Figures in parentheses are based on 25-49 unweighted cases. 1 Includes violence in the past 12 months Table 14.3 Experience of different forms of violence Percentage of women age 15-49 who have ever experienced different forms of violence by current age, Armenia 2015-16 Age Physical violence only Sexual violence only Physical and sexual violence Physical or sexual violence Number of women 15-19 0.0 0.0 0.0 0.0 534 15-17 0.0 0.0 0.0 0.0 321 18-19 0.1 0.0 0.0 0.1 212 20-24 1.1 0.0 0.1 1.2 724 25-29 3.8 0.1 0.3 4.2 827 30-39 7.5 0.1 1.0 8.6 1,399 40-49 8.0 0.1 1.7 9.8 1,109 Total 5.1 0.1 0.8 5.9 4,592 216 • Domestic Violence 14.5 VIOLENCE DURING PREGNANCY Respondents who had ever been pregnant were asked specifically whether they had ever experienced physical violence while pregnant. Table 14.4 shows that 1 percent of women who had ever been pregnant experienced physical violence during pregnancy. This percentage increases with age, from less than 1 percent among women age 20-24 to 2 percent among women age 40-49. Eight percent of formerly married women report having experienced physical violence when they were pregnant, as compared with 1 percent of currently married women. Experience of violence during pregnancy is most common, at 3 percent each, in Ararat, Lori, and Kotayk. Violence during pregnancy tends to decline with increasing wealth but does not vary consistently with education. 14.6 MARITAL CONTROL BY SPOUSE Attempts by husbands to closely control and monitor their wives’ behavior may be important warning signs and correlates of violence in a relationship. A series of questions were included in the 2015-16 ADHS to elicit the degree of marital control exercised by husbands over their wives. Controlling behaviors most often manifest themselves in terms of extreme possessiveness, jealousy, and attempts to isolate women from their family and friends. To determine the degree of marital control by husbands, ever-married women were asked whether their current or former husband or partner exhibited each of the following controlling behaviors: (1) he is jealous or gets angry if she talks to other men, (2) he frequently accuses her of being unfaithful, (3) he does not permit meetings with female friends, (4) he tries to limit contact with her family, and (5) he insists on knowing where she is at all times. Because the concentration of such behaviors is more significant than the display of any single behavior, the proportion of respondents whose husbands display at least three of the specified behaviors is highlighted. Table 14.5 shows the percentage of ever-married women whose current husbands display each of the listed behaviors by selected background characteristics. Table 14.4 Experience of violence during pregnancy Among women age 15-49 who have ever been pregnant, percentage who have ever experienced physical violence during pregnancy, by background characteristics, Armenia 2015-16 Background characteristic Percentage who experienced violence during pregnancy Number of women who have ever been pregnant Age 15-19 * 21 20-24 0.4 242 25-29 0.4 568 30-39 1.4 1,218 40-49 1.5 1,019 Residence Urban 1.2 1,779 Rural 1.2 1,290 Region Yerevan 0.5 943 Aragatsotn 1.3 144 Ararat 3.1 300 Armavir 0.5 317 Gegharkunik 0.0 224 Lori 3.0 127 Kotayk 2.5 382 Shirak 1.1 276 Syunik 0.0 131 Vayots Dzor 1.2 66 Tavush 0.7 159 Marital status Never married * 1 Married or living together 0.5 2,803 Divorced/separated/ widowed 8.2 265 Number of living children 0 2.0 77 1-2 1.1 2,219 3-4 1.3 737 5+ (1.4) 35 Education Basic 1.5 171 Secondary 1.1 1,309 Secondary special 2.3 759 Higher 0.2 826 Wealth quintile Lowest 1.6 569 Second 1.4 641 Middle 1.6 578 Fourth 1.1 591 Highest 0.3 690 Total 1.2 3,069 Note: Total includes 4 women with no education. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. Domestic Violence • 217 Table 14.5 Marital control exercised by husbands Percentage of ever-married women age 15-49 whose husbands/partners have ever demonstrated specific types of controlling behaviors, by background characteristics, Armenia 2015-16 Background characteristic Percentage of women whose husband/partner: Is jealous or angry if she talks to other men Frequently accuses her of being unfaithful Does not permit her to meet her female friends Tries to limit her contact with her family Insists on knowing where she is at all times Displays 3 or more of the specific behaviors Displays none of the specific behaviors Number of ever-married women Age 15-19 (36.9) (0.0) (3.1) (0.0) (38.2) (3.1) (57.5) 27 20-24 36.9 0.5 8.1 3.0 39.3 6.2 49.5 278 25-29 42.5 1.7 8.1 2.8 42.5 8.0 43.6 610 30-39 37.1 3.5 8.3 3.9 39.5 8.3 49.0 1,248 40-49 29.1 2.3 7.3 2.7 34.5 7.3 56.9 1,045 Residence Urban 36.6 3.0 7.0 3.7 39.1 7.6 48.6 1,872 Rural 34.0 1.8 9.2 2.5 37.5 7.8 53.5 1,337 Region Yerevan 36.9 3.2 5.2 3.2 41.6 7.0 45.8 995 Aragatsotn 69.9 4.3 18.6 6.5 59.2 18.3 19.8 146 Ararat 44.1 2.5 17.7 5.4 50.5 14.4 39.3 306 Armavir 20.0 0.8 2.6 0.7 14.5 1.5 76.1 336 Gegharkunik 43.7 3.7 16.0 3.3 38.4 17.0 47.5 236 Lori 51.1 2.2 8.4 4.3 48.3 7.8 39.5 132 Kotayk 36.5 1.7 3.3 2.0 42.8 3.3 49.4 393 Shirak 30.4 2.9 12.9 5.5 49.4 8.8 42.1 288 Syunik 9.8 0.6 0.7 0.7 4.1 1.5 89.4 141 Vayots Dzor 50.3 3.1 6.7 4.4 41.2 7.9 44.9 68 Tavush 10.1 1.7 4.4 1.0 17.6 2.4 76.6 168 Marital status Married or living together 33.4 0.8 6.5 1.8 36.9 5.3 52.0 2,923 Divorced/separated/ widowed 56.8 20.5 21.9 17.5 53.7 31.8 36.2 285 Number of living children 0 33.0 1.8 5.1 1.6 34.9 4.4 53.6 217 1-2 36.9 2.8 7.6 3.5 40.1 7.7 48.6 2,219 3-4 32.3 1.9 9.1 2.8 34.5 8.0 55.4 737 5+ (29.8) (4.4) (17.6) (4.4) (32.8) (14.5) (59.8) 35 Employment Employed for cash 35.7 3.9 7.5 3.9 39.5 8.6 50.9 1,181 Employed not for cash 24.0 2.2 8.1 2.2 21.4 6.2 65.9 241 Not employed 36.9 1.6 8.1 2.9 40.0 7.3 48.4 1,786 Education Basic 36.2 2.2 11.7 5.6 40.3 12.4 51.6 175 Secondary 37.8 2.4 10.1 3.3 38.4 9.2 49.7 1,361 Secondary special 34.9 3.0 7.7 3.4 38.3 7.0 50.2 787 Higher 32.4 2.3 3.9 2.4 38.3 5.0 52.0 881 Wealth quintile Lowest 31.6 3.3 10.6 4.4 35.4 9.4 56.2 586 Second 36.8 1.1 8.9 2.3 41.0 7.4 49.7 664 Middle 38.8 3.5 9.0 4.0 39.5 9.6 48.3 608 Fourth 36.0 2.1 7.2 2.5 37.8 6.8 47.9 633 Highest 34.2 2.8 4.4 3.0 38.1 5.6 51.5 717 Woman afraid of husband/partner Afraid most of the time (81.2) (58.1) (61.0) (62.7) (76.9) (72.7) (17.0) 41 Sometimes afraid 71.0 7.9 26.2 11.1 65.0 28.3 20.5 452 Never afraid 28.9 0.8 4.0 1.0 33.4 3.2 56.2 2,714 Total 35.5 2.5 7.9 3.2 38.4 7.7 50.6 3,208 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Total includes 4 women with no education and 1 woman with missing information on fear of husband/partner. Figures in parentheses are based on 25-49 unweighted cases. 218 • Domestic Violence The main controlling behaviors women experienced from their husbands were that the husband insisted on knowing where they were at all times (38 percent), was jealous or angry if they talked to other men (36 percent), and did not permit them to meet their female friends (8 percent). Overall, 8 percent of ever-married women say that their husbands display three or more of these controlling behaviors, and 51 percent say that their husbands display none of the specified behaviors. Women living in Aragatsotn (18 percent) and Gegharkunik (17 percent) and divorced, separated, or widowed women (32 percent) are more likely than most other women to report that their husbands display at least three controlling behaviors. In general, more educated and wealthier women are less likely than less educated and poorer women to report having a husband who displays at least three of the controlling behaviors. Having a husband who displays three or more controlling behaviors is highly correlated with women being afraid of their husband. Only 3 percent of women who are never afraid of their husband say that their husband displays three or more controlling behaviors, as compared with 28 percent of women who are sometimes afraid of their husband. 14.7 FORMS OF SPOUSAL VIOLENCE Different types of spousal violence are not mutually exclusive, and women may report experiencing multiple forms of violence. Table 14.6 shows the percentage of ever-married women age 15- 49 who have experienced various forms of violence by their spouse over the course of the marriage and in the 12 months preceding the survey. Note that respondents who are currently married reported on violence by their current spouse, and respondents who are widowed, divorced, or separated reported on violence by their most recent spouse. The lower panel of the table provides information on violence by any husband as opposed to only the current or most recent husband. Table 14.6 Forms of spousal violence Percentage of ever-married women age 15-49 who have experienced various forms of violence ever or in the 12 months preceding the survey committed by their husband/partner, Armenia 2015-16 Type of violence Ever In the past 12 months Often Sometimes Often or sometimes Spousal violence committed by current or most recent husband/partner Physical violence Any physical violence 8.0 0.8 2.7 3.5 Pushed her, shook her, or threw something at her 5.8 0.6 2.0 2.7 Slapped her 6.5 0.7 2.0 2.7 Twisted her arm or pulled her hair 3.2 0.4 0.8 1.3 Punched her with his fist or with something that could hurt her 2.1 0.4 0.4 0.7 Kicked her, dragged her, or beat her up 1.5 0.4 0.2 0.6 Tried to choke her or burn her on purpose 0.5 0.2 0.0 0.2 Threatened her or attacked her with a knife, gun, or other weapon 0.5 0.1 0.1 0.2 Sexual violence Any sexual violence 1.1 0.2 0.1 0.3 Physically forced her to have sexual intercourse with him when she did not want to 1.1 0.2 0.1 0.3 Physically forced her to perform any other sexual acts she did not want to 0.4 0.1 0.1 0.2 Forced her with threats or in any other way to perform sexual acts she did not want to 0.4 0.1 0.1 0.2 Emotional violence Any emotional violence 11.4 1.3 5.1 6.4 Said or did something to humiliate her in front of others 5.7 0.8 2.2 3.0 Threatened to hurt or harm her or someone she cared about 1.5 0.3 0.4 0.8 Insulted her or made her feel bad about herself 10.5 1.2 4.6 5.8 Any form of physical and/or sexual violence 8.1 0.8 2.7 3.5 Any form of emotional and/or physical and/or sexual violence 14.0 1.6 6.0 7.6 Spousal violence committed by any husband/partner Physical violence 8.2 na na 3.5 Sexual violence 1.1 na na 0.3 Physical and/or sexual violence 8.2 na na 3.5 Number of ever-married women 3,208 3,208 3,208 3,208 na = Not available Domestic Violence • 219 Eight percent of ever-married women reported ever experiencing physical violence committed by their current or most recent husband, 1 percent reported sexual violence, and 11 percent reported emotional violence. Overall, 8 percent of women have ever experienced spousal physical and/or sexual violence, and 14 percent have experienced at least one of the three forms of spousal violence. Six percent of women reported experiencing spousal emotional violence in the past 12 months, and 4 percent and less than 1 percent reported spousal physical violence and spousal sexual violence, respectively, in the past 12 months. Overall, 8 percent of women experienced spousal physical, sexual, or emotional violence in the past 12 months. The most common forms of spousal violence reported by ever-married women are being insulted or made to feel bad about themselves (11 percent), being slapped (7 percent), being pushed or shaken or having something thrown at them (6 percent), and being humiliated in front of others (6 percent). About 1 percent each of women reported being threatened or attacked with a gun or other weapon or being choked or burned on purpose. Some women have been married or partnered more than once. When previous husbands are included as perpetrators, the percentage of ever-married women who report having ever experienced physical and/or sexual violence by any husband remains almost unchanged at 8 percent. 14.8 SPOUSAL VIOLENCE BY BACKGROUND CHARACTERISTICS Table 14.7 shows the percentages of ever-married women age 15-49 who have experienced spousal emotional, physical, or sexual violence from their current or most recent husband by selected background characteristics. Overall, 14 percent of ever-married women have experienced at least one form of spousal violence. Women’s experience of at least one form (physical, sexual, or emotional) of spousal violence increases with age, from 6 percent among women age 20-24 to 17 percent among women age 40-49; experience of violence also increases sharply with women’s number of living children. Eleven percent of currently married women report experiencing spousal violence, as compared with 43 percent of divorced, separated, or widowed women. While no women in Syunik report spousal violence, almost one in three (32 percent) women report spousal violence in Ararat. Women with a higher education and those in the top two wealth quintiles are less likely to have experienced at least one form of spousal violence than women with less education and poorer women. 220 • Domestic Violence Table 14.7 Spousal violence by background characteristics Percentage of ever-married women age 15-49 who have ever experienced emotional, physical, or sexual violence committed by their husband/partner, by background characteristics, Armenia 2015-16 Background characteristic Emotional violence Physical violence Sexual violence Physical and sexual Physical and sexual and emotional Physical or sexual Physical or sexual or emotional Number of ever- married women Age 15-19 (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) 27 20-24 5.0 2.7 0.3 0.3 0.3 2.7 5.6 278 25-29 8.4 5.2 0.4 0.4 0.4 5.2 10.0 610 30-39 12.9 9.3 1.1 1.0 1.0 9.3 15.7 1,248 40-49 13.3 9.9 1.7 1.7 1.5 9.9 16.8 1,045 Residence Urban 11.1 7.2 1.0 0.9 0.8 7.2 13.0 1,872 Rural 11.8 9.2 1.2 1.2 1.2 9.2 15.3 1,337 Region Yerevan 10.2 6.8 0.7 0.6 0.5 6.9 11.9 995 Aragatsotn 13.6 28.2 5.6 5.6 5.1 28.2 28.6 146 Ararat 23.3 17.8 2.1 2.1 2.1 17.8 31.5 306 Armavir 4.7 2.9 0.3 0.3 0.3 2.9 5.9 336 Gegharkunik 13.6 6.7 0.5 0.5 0.5 6.7 15.8 236 Lori 17.0 15.3 3.0 3.0 3.0 15.3 19.9 132 Kotayk 16.4 7.0 1.3 1.3 1.3 7.0 17.6 393 Shirak 5.3 4.2 0.0 0.0 0.0 4.2 5.6 288 Syunik 0.0 0.0 0.0 0.0 0.0 0.0 0.0 141 Vayots Dzor 23.6 10.7 1.3 1.3 1.3 10.7 24.3 68 Tavush 3.5 1.3 0.1 0.1 0.1 1.3 3.5 168 Marital status Married or living together 8.8 5.5 0.6 0.6 0.6 5.5 11.2 2,923 Divorced/separated/widowed 37.6 34.3 5.8 5.4 4.9 34.7 42.7 285 Number of living children 0 3.8 1.5 0.5 0.5 0.5 1.5 3.8 217 1-2 11.4 8.2 1.1 1.0 0.9 8.2 14.1 2,219 3-4 12.9 9.2 1.2 1.2 1.2 9.2 15.9 737 5+ (24.6) (14.7) (0.0) (0.0) (0.0) (14.7) (25.2) 35 Employment Employed for cash 12.7 9.5 1.6 1.5 1.4 9.5 16.1 1,181 Employed not for cash 8.4 6.2 0.4 0.4 0.4 6.2 11.2 241 Not employed 10.9 7.4 0.8 0.8 0.8 7.4 12.9 1,786 Education Basic 19.0 14.4 2.9 2.9 1.9 14.4 24.4 175 Secondary 13.4 9.8 1.0 1.0 0.9 9.8 16.5 1,361 Secondary special 10.4 7.8 1.8 1.7 1.7 8.0 13.5 787 Higher 7.7 4.3 0.1 0.1 0.1 4.3 8.5 881 Wealth quintile Lowest 16.0 12.3 1.6 1.6 1.5 12.3 20.9 586 Second 10.7 7.8 1.2 1.2 1.2 7.8 13.6 664 Middle 13.3 10.8 1.4 1.2 1.0 11.0 16.0 608 Fourth 8.5 4.8 0.6 0.6 0.6 4.8 9.9 633 Highest 9.0 5.3 0.6 0.6 0.6 5.3 10.5 717 Total 11.4 8.0 1.1 1.0 1.0 8.1 14.0 3,208 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Total includes 4 women with no education. Figures in parentheses are based on 25-49 unweighted cases. Domestic Violence • 221 14.9 VIOLENCE BY SPOUSAL CHARACTERISTICS AND WOMEN’S EMPOWERMENT INDICATORS Table 14.8 presents information on ever-married women age 15-49 who have experienced emotional, physical, or sexual violence committed by their current or most recent husband according to their husband’s characteristics and women’s empowerment indicators. Table 14.8 Spousal violence by husband's characteristics and empowerment indicators Percentage of ever-married women age15-49 who have ever experienced emotional, physical, or sexual violence committed by their husband/partner, by husband's characteristics and empowerment indicators, Armenia 2015-16 Background characteristic Emotional violence Physical violence Sexual violence Physical and sexual Physical and sexual and emotional Physical or sexual Physical or sexual or emotional Number of ever- married women Husband's/partner's education1 Basic 17.2 7.2 0.0 0.0 0.0 7.2 19.3 294 Secondary 10.0 7.1 1.0 1.0 1.0 7.1 13.0 1,377 Secondary special 7.3 4.9 0.7 0.7 0.7 4.9 9.9 491 Higher 4.3 2.2 0.0 0.0 0.0 2.2 5.6 752 Husband's/partner's alcohol consumption Does not drink alcohol 4.9 3.7 0.2 0.2 0.2 3.7 6.8 1,170 Drinks alcohol but is never drunk 6.3 3.1 0.3 0.3 0.3 3.1 6.8 833 Is sometimes drunk 17.6 11.2 1.7 1.6 1.4 11.3 21.1 1,080 Is often drunk 52.0 54.0 8.2 8.2 8.2 54.0 67.9 124 Missing 37.3 33.9 5.7 5.4 4.8 34.2 42.3 289 Spousal education difference1 Husband has more education 4.4 4.1 0.3 0.3 0.3 4.1 7.0 595 Wife has more education 9.0 4.8 0.7 0.7 0.7 4.8 10.8 950 Both have equal education 10.6 6.5 0.7 0.7 0.7 6.5 13.2 1,372 Neither has any education * * * * * * * 2 Spousal age difference1 Wife older 8.8 9.2 0.4 0.4 0.4 9.2 11.0 127 Wife same age 9.0 5.7 2.0 2.0 2.0 5.7 11.3 216 Wife 1-4 years younger 9.6 4.5 0.6 0.6 0.6 4.5 11.6 1,246 Wife 5-9 years younger 7.5 5.1 0.3 0.3 0.3 5.1 9.5 1,053 Wife 10 or more years younger 9.9 9.5 0.7 0.7 0.4 9.5 15.3 281 Number of marital control behaviors displayed by husband/partner2 0 3.0 2.9 0.2 0.2 0.2 2.9 4.6 1,625 1-2 14.2 8.3 0.9 0.8 0.7 8.3 17.7 1,338 3-4 46.2 36.5 5.3 5.3 5.0 36.5 51.6 218 5 (88.8) (76.8) (27.5) (27.5) (27.5) (76.8) (88.8) 27 Number of decisions in which women participate3 0 14.1 17.1 1.5 1.5 1.5 17.1 21.1 57 1-2 14.8 5.1 0.3 0.3 0.3 5.1 16.0 625 3 7.0 5.3 0.7 0.7 0.6 5.3 9.6 2,241 Number of reasons for which wife beating is justified4 0 10.6 7.0 0.9 0.9 0.8 7.0 12.8 2,850 1-2 20.9 19.7 3.1 3.1 2.8 19.7 29.3 229 3-4 8.3 7.6 1.4 1.4 1.4 7.6 10.2 116 5 * * * * * * * 14 Woman's father beat mother Yes 26.8 24.6 4.2 4.2 4.2 24.6 32.4 180 No 8.9 6.1 0.8 0.8 0.7 6.1 11.0 2,589 Don't know/missing 19.6 12.9 1.3 1.3 1.1 12.9 23.8 439 Woman afraid of husband/partner Afraid most of the time (88.2) (93.1) (29.2) (29.2) (29.2) (93.1) (98.8) 41 Sometimes afraid 33.9 28.1 3.9 3.9 3.4 28.1 40.8 452 Never afraid 6.4 3.4 0.2 0.1 0.1 3.4 8.2 2,714 Total 11.4 8.0 1.1 1.0 1.0 8.1 14.0 3,208 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Total includes 5 women whose husbands/partners have no education, 4 women with missing information on husband’s/partner’s education, 1 woman with missing information on spousal age difference, 1 woman with missing information on husband’s/partner’s alcohol consumption, and 1 woman with missing information on fear of husband/partner. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 1 Includes only currently married women 2 According to the wife's report. See Table 14.5 for list of behaviors. 3 According to the wife's report. Includes only currently married women. See Table 15.9.1 for list of decisions. 4 According to the wife's report. See Table 15.10.1 for list of reasons. 222 • Domestic Violence Spousal violence is higher among women whose husbands have only a basic education (19 percent) than among women whose husbands have a higher education (6 percent). Women in couples where the spouses have an equal amount of education are more likely to experience spousal violence (13 percent) than women whose husbands have more education (7 percent). Also, women who are much younger than their husbands—at least 10 or more years younger—are more likely to experience spousal violence (15 percent) than women who are closer in age to their husbands (10 to 12 percent). Spousal violence increases sharply with the number of controlling behaviors displayed by the husband. Among women whose husbands exhibit 3-4 types of controlling behaviors, more than half (52 percent) have experienced one or more forms of violence. In contrast, only 5 percent of women whose husbands display none of the controlling behaviors have experienced any form of spousal violence. There is no clear association between women’s experience of violence and the number of reasons they give for which wife beating is justified; however, women who do not participate in any household decisions are twice as likely as women who participate in all three specified decisions to experience spousal violence (21 percent versus 10 percent). The intergenerational effects of domestic violence are very evident in Armenia: women whose father beat their mother are much more likely to experience any type of violence by their husband than women whose father did not beat their mother (32 percent versus 11 percent). Finally, women who are afraid of their husband sometimes are much more likely to experience spousal violence than women who are never afraid (41 percent versus 8 percent). 14.10 RECENT SPOUSAL VIOLENCE BY ANY HUSBAND Table 14.9 shows the percentage of ever-married women who have experienced physical or sexual violence by any husband (current, most recent, or previous) in the past 12 months, by background characteristics. Overall, 4 percent of women experienced physical or sexual violence by any husband in the past 12 months. The percentage of women who have experienced recent physical or sexual violence by any husband ranges from a high of 22 percent in Aragatsotn and 8 percent in Lori to a low of 0 percent in Syunik and tends to decline with increasing wealth. Twelve percent of women who are sometimes afraid of their husband reported experiencing spousal physical or sexual violence in the past 12 months, as compared with 1 percent of women who are never afraid of their husband. Domestic Violence • 223 Table 14.9 Frequency of physical or sexual violence Percentage of ever-married women who have experienced physical or sexual violence by any husband/partner in the past 12 months, by background characteristics, Armenia 2015-16 Background characteristic Percentage of women who have experienced physical or sexual violence in the past 12 months from any husband/ partner Number of ever-married women Age 15-19 (0.0) 27 20-24 2.4 278 25-29 2.3 610 30-39 4.0 1,248 40-49 4.1 1,045 Residence Urban 3.1 1,872 Rural 4.1 1,337 Region Yerevan 3.1 995 Aragatsotn 21.9 146 Ararat 4.8 306 Armavir 0.9 336 Gegharkunik 1.7 236 Lori 8.1 132 Kotayk 1.5 393 Shirak 3.1 288 Syunik 0.0 141 Vayots Dzor 1.8 68 Tavush 0.9 168 Marital status Married or living together 2.6 2,923 Divorced/separated/ widowed 13.2 285 Number of living children 0 0.0 217 1-2 3.7 2,219 3-4 3.6 737 5+ (13.3) 35 Employment Employed for cash 3.2 1,181 Employed not for cash 0.9 241 Not employed 4.1 1,786 Education Basic 3.5 175 Secondary 4.2 1,361 Secondary special 4.3 787 Higher 1.8 881 Wealth quintile Lowest 6.2 586 Second 2.6 664 Middle 4.6 608 Fourth 1.8 633 Highest 2.8 717 Woman afraid of husband/partner Afraid most of the time (49.1) 41 Sometimes afraid 12.0 452 Never afraid 1.4 2,714 Total 3.5 3,208 Note: Any husband/partner includes all current, most recent, and former husbands/partners. Total includes 4 women with no education and 1 woman with missing information on fear of husband/partner. Figures in parentheses are based on 25-49 unweighted cases. 224 • Domestic Violence 14.11 ONSET OF SPOUSAL VIOLENCE To obtain information on the onset of marital violence, the 2015-16 ADHS asked currently married women who have been married only once how long after marriage the onset of spousal violence occurred, if ever. Table 14.10 shows that the majority of women (95 percent) have never experienced spousal physical or sexual violence. Overall, 1 percent of currently married women experienced violence in the first two years of marriage, and 4 percent experienced it in the first five years of marriage. These data suggest that, for a considerable percentage of women who have experienced spousal physical or sexual violence, the violence began relatively early in their marriage. Table 14.10 Experience of spousal violence by duration of marriage Among currently married women age 15-49 who have been married only once, the percentage who first experienced physical or sexual violence committed by their current husband/partner by specific exact years since marriage, according to marital duration, Armenia 2015-16 Years since marriage Percentage who first experienced spousal physical or sexual violence by exact marital duration: Percentage who have not experienced sexual or physical violence Number of currently married women who have been married only once Before marriage 2 years 5 years 10 years <2 0.0 na na na 98.9 203 2-4 0.0 0.8 na na 99.0 310 5-9 0.0 0.5 3.1 na 96.4 582 10+ 0.1 1.5 4.4 5.7 92.6 1,735 Total 0.0 1.2 3.5 4.4 94.6 2,830 na=Not applicable 14.12 PHYSICAL CONSEQUENCES OF SPOUSAL VIOLENCE In the 2015-16 ADHS, ever-married women were asked whether they had sustained any injury as a result of physical or sexual violence inflicted by their spouse. Thirty-eight percent of women who reported ever having experienced spousal physical or sexual violence suffered cuts, bruises, or aches; 11 percent had eye injuries, sprains, dislocations, or burns; and 4 percent had deep wounds, broken bones, broken teeth, or other serious injuries (Table 14.11). Overall, 40 percent of women who had ever experienced spousal physical or sexual violence suffered one or more of these injuries. The prevalence of all forms of injury is even higher among women who experienced violence in the past 12 months. Table 14.11 Injuries to women due to spousal violence Percentage of ever-married women age 15-49 who have experienced specific types of spousal violence by types of injuries resulting from the violence, according to the type of violence and whether they experienced the violence ever and in the 12 months preceding the survey, Armenia 2015-16 Type of violence Cuts, bruises, or aches Eye injuries, sprains, dis- locations, or burns Deep wounds, broken bones, broken teeth, or any other serious injury Any of these injuries Number of ever-married women who have ever experienced any physical or sexual violence Experienced physical violence1 Ever2 38.0 10.9 4.0 40.4 258 Past 12 months 40.5 16.8 6.6 43.7 112 Experienced sexual violence Ever2 (56.0) (16.1) (13.5) (56.0) 34 Past 12 months * * * * 10 Experienced physical or sexual violence1 Ever2 37.8 10.9 4.0 40.2 259 Past 12 months 40.2 16.6 6.5 43.3 113 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 1 Excludes women who reported violence only in response to a direct question on violence during pregnancy 2 Includes in the past 12 months Domestic Violence • 225 14.13 VIOLENCE BY WOMEN AGAINST THEIR HUSBAND In cases of domestic violence, either person, the husband or the wife, can be the initiator of the violence. In the 2015-16 ADHS, ever-married women were asked whether they had ever initiated physical violence against their current or most recent husband when he was not already hitting or beating them. Table 14.12 shows the percentages of ever-married women age 15-49 who reported initiating physical violence against their husbands ever and in the 12 months prior to the survey by women’s background characteristics. Table 14.13 shows the percentages of women initiating physical violence by husbands’ characteristics and women’s empowerment indicators. Table 14.12 Violence by women against their spouse Percentage of ever-married women age 15-49 who have committed physical violence against their current or most recent husband/partner when he was not already beating or physically hurting them, ever and in the past 12 months, according to women's own experience of spousal violence and background characteristics, Armenia 2015-16 Background characteristic Percentage who committed physical violence against their husband/partner Number of ever-married women Ever1 Past 12 months Woman's experience of spousal physical violence Ever1 2.8 1.8 258 In the past 12 months 5.0 3.3 112 Never 0.3 0.1 2,950 Age 15-19 (3.6) (3.6) 27 20-24 0.0 0.0 278 25-29 0.3 0.3 610 30-39 0.7 0.4 1,248 40-49 0.3 0.1 1,045 Residence Urban 0.4 0.2 1,872 Rural 0.5 0.3 1,337 Region Yerevan 0.4 0.0 995 Aragatsotn 2.4 2.4 146 Ararat 0.4 0.1 306 Armavir 1.6 1.0 336 Gegharkunik 0.0 0.0 236 Lori 0.5 0.5 132 Kotayk 0.0 0.0 393 Shirak 0.3 0.3 288 Syunik 0.0 0.0 141 Vayots Dzor 0.0 0.0 68 Tavush 0.0 0.0 168 Marital status Married or living together 0.3 0.2 2,923 Divorced/separated/widowed 2.0 1.3 285 Employment Employed for cash 0.7 0.3 1,181 Employed not for cash 0.4 0.4 241 Not employed 0.3 0.2 1,786 Number of living children 0 0.0 0.0 217 1-2 0.6 0.3 2,219 3-4 0.3 0.2 737 5+ (0.0) (0.0) 35 Education Basic 2.2 1.8 175 Secondary 0.1 0.1 1,361 Secondary special 1.1 0.4 787 Higher 0.1 0.1 881 Wealth quintile Lowest 0.6 0.6 586 Second 0.7 0.2 664 Middle 0.5 0.4 608 Fourth 0.2 0.2 633 Highest 0.4 0.0 717 Total 0.5 0.3 3,208 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Total includes 4 women with no education. Figures in parentheses are based on 25-49 unweighted cases. 1 Includes in the past 12 months 226 • Domestic Violence Table 14.13 Violence by women against their husband according to the husband’s characteristics and empowerment indicators Percentage of ever-married women age 15-49 who have committed physical violence against their current or most recent husband/partner when he was not already beating or physically hurting them, ever and in the past 12 months, according to their husband’s characteristics, Armenia 2015-16 Background characteristic Percentage who committed physical violence against their husband/partner Number of ever- married women Ever1 Past 12 months Husband's/partner's education2 Basic 0.6 0.3 294 Secondary 0.4 0.1 1,377 Secondary special 0.3 0.3 491 Higher 0.1 0.1 752 Husband's/partner's alcohol consumption Does not drink alcohol 0.0 0.0 1,170 Drinks alcohol but is never drunk 0.7 0.4 833 Sometimes drunk 0.3 0.1 1,080 Often drunk 4.9 3.1 124 Spousal education difference2 Husband has more education 0.1 0.1 595 Wife has more education 0.6 0.2 950 Both have equal education 0.2 0.2 1,372 Neither has any education * * 2 Missing 1.9 1.3 289 Spousal age difference2 Wife older 0.0 0.0 127 Wife same age 0.8 0.0 216 Wife 1-4 years younger 0.4 0.2 1,246 Wife 5-9 years younger 0.2 0.2 1,053 Wife 10 or more years younger 0.3 0.3 281 Number of marital control behaviors displayed by husband/partner3 0 0.4 0.3 1,625 1-2 0.3 0.1 1,338 3-4 1.2 1.0 218 5 (6.3) (6.3) 27 Number of decisions in which women participate4 0 0.0 0.0 57 1-2 0.0 0.0 625 3 0.4 0.2 2,241 Number of reasons for which wife beating is justified5 0 0.5 0.2 2,850 1-2 1.0 1.0 229 3-4 0.0 0.0 116 5 * * 14 Woman’s father beat mother Yes 1.7 0.2 180 No 0.4 0.2 2,589 Don't know/missing 0.6 0.6 439 Woman afraid of husband/partner Afraid most of the time (10.0) (10.0) 41 Sometimes afraid 1.0 0.3 452 Never afraid 0.3 0.1 2,714 Total 0.5 0.3 3,208 Note: Husband/partner refers to the current husband/partner for currently married women and the most recent husband/partner for divorced, separated, or widowed women. Total includes 5 women whose husbands/partners have no education, 4 women with missing information on husband’s/partner’s education, 1 woman with missing information on spousal age difference, 1 woman with missing information on husband’s/partner’s alcohol consumption, and 1 woman with missing information on fear of husband/partner. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 1 Includes in the past 12 months 2 Includes only currently married women 3 According to the wife's report. See Table 14.5 for list of behaviors. 4 According to the wife's report. Includes only currently married women. See Table 15.9.1 for list of decisions. 5 According to the wife's report. See Table 15.10.1 for list of reasons. Domestic Violence • 227 One percent of women reported that they had ever initiated physical violence against their husbands, and less than 1 percent had done so in the past 12 months. Women who had been physically abused by their current or most recent husband ever (3 percent) or in the past 12 months (5 percent) were more likely to have initiated spousal violence than women who had never experienced spousal violence (less than 1 percent). By region, women’s use of violence against their husbands is highest at 2 percent in Aragatsotn and Armavir. Notably, initiation of spousal violence by women, although still very low, is higher among those whose father beat their mother (2 percent) than among those whose father did not beat their mother (less than 1 percent). 14.14 HELP-SEEKING BEHAVIOR BY WOMEN WHO EXPERIENCE VIOLENCE Table 14.14 shows the percent distribution of women age 15-49 who have ever experienced physical or sexual violence committed by anyone according to whether they have ever sought help to stop the violence and, if not, whether they told anyone about the violence. Overall, 3 in 10 women (29 percent) who have experienced any type of physical or sexual violence from anyone sought help to stop the violence. Forty percent of women never sought help and never told anyone, and 29 percent never sought help but told someone. Rural women (24 percent) are less likely than urban women (34 percent) to have sought help. Help seeking tends to increase with increasing education but does not vary consistently with wealth. Women who are employed for cash are more likely than those who are not employed to have ever sought help. Most women who experienced physical or sexual violence and sought help went to their families for help: 82 percent sought help from their own families and 22 percent from their husbands’ families. Neighbors were the next most common source of help (3 percent). Two percent each of women sought help from friends and lawyers (data not shown). 228 • Domestic Violence Table 14.14 Help seeking to stop violence Percent distribution of women age 15-49 who have ever experienced physical or sexual violence by their help-seeking behavior, according to type of violence and background characteristics, Armenia 2015-16 Background characteristic Sought help to stop violence Never sought help but told someone Never sought help, never told anyone Missing/ don't know Total Number of women who have ever experi- enced any physical or sexual violence Type of violence experienced Physical only 27.2 30.3 39.9 2.5 100.0 232 Sexual only * * * * 100.0 3 Physical and sexual (43.5) (19.0) (37.5) (0.0) 100.0 37 Age 15-19 * * * * 100.0 0 20-24 * * * * 100.0 9 25-29 (38.4) (24.9) (32.2) (4.5) 100.0 34 30-39 33.1 35.1 29.7 2.0 100.0 121 40-49 22.6 24.0 51.8 1.7 100.0 109 Residence Urban 34.0 27.3 37.5 1.1 100.0 144 Rural 24.3 30.1 42.3 3.3 100.0 128 Region1 Yerevan (24.8) (32.7) (42.4) (0.0) 100.0 70 Aragatsotn 23.3 22.8 53.9 0.0 100.0 42 Ararat 26.5 35.2 36.3 1.9 100.0 56 Armavir * * * * 100.0 10 Gegharkunik * * * * 100.0 17 Lori (39.4) (13.2) (47.4) (0.0) 100.0 23 Kotayk (48.5) (20.7) (20.9) (9.9) 100.0 31 Shirak * * * * 100.0 13 Vayots Dzor (26.3) (22.0) (51.7) (0.0) 100.0 8 Tavush * * * * 100.0 3 Marital status Never married * * * * 100.0 2 Married or living together 17.5 33.8 45.3 3.4 100.0 170 Divorced/separated/widowed 50.2 19.8 30.0 0.0 100.0 101 Number of living children 0 * * * * 100.0 7 1-2 30.8 25.4 41.8 1.9 100.0 190 3-4 20.4 40.0 36.5 3.1 100.0 70 5+ * * * * 100.0 5 Employment Employed for cash 35.9 29.6 33.9 0.6 100.0 118 Employed not for cash * * * * 100.0 15 Not employed 27.0 25.9 44.1 3.0 100.0 140 Education Basic (21.4) (43.3) (35.2) (0.0) 100.0 27 Secondary 21.9 34.9 41.4 1.7 100.0 139 Secondary special 39.6 21.0 36.9 2.5 100.0 69 Higher (44.0) (9.4) (42.2) (4.4) 100.0 38 Wealth quintile Lowest 32.9 24.2 39.5 3.4 100.0 74 Second 24.0 28.8 41.6 5.6 100.0 55 Middle 31.6 28.2 39.9 0.3 100.0 71 Fourth (32.2) (36.3) (31.5) (0.0) 100.0 34 Highest (24.3) (30.8) (44.9) (0.0) 100.0 38 Total 29.4 28.6 39.8 2.1 100.0 272 Note: Women can report more than one source from which they sought help. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 1 Syunik is not included because no women in Syunik reported physical or sexual violence. Women’s Empowerment • 229 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 15 Key Findings  Forty-two percent of currently married women are employed, up from 36 percent at the time of the 2010 ADHS. Currently married men are more than twice as likely as currently married women to be employed (89 percent).  Two-thirds of currently married women who are employed work for cash only, down from 72 percent at the time of the 2010 ADHS. Among women who earn cash, 28 percent say that they themselves mainly decide how their cash earnings are used and 67 percent say that they make this decision jointly with their husband.  About half of women (48 percent) own a house alone or jointly with someone else, and 16 percent own land. The corresponding percentages among men are 72 percent and 35 percent. Most women and men who own either asset have a title deed for the asset and have their name on the title deed.  About one in five women and men have a bank account that they use. Mobile phone ownership is virtually universal in Armenia.  A large majority of married women either make specified household decisions themselves or participate in these decisions jointly with their husbands. About three out of four women participate either alone or jointly in all three decisions asked about.  Ten percent of women and 23 percent of men agree that wife beating is justified in at least one of five specified situations.  Modern contraceptive use is higher among women who participate in one or more household decisions and who do not agree with any reason for wife beating. he study of women’s status and empowerment—important in its own right—takes on special significance in the context of promoting demographic change and improving health outcomes. Women are the ones who bear children and are typically the primary caregivers, particularly for children. This makes women the prime targets of maternal and child health and nutrition programs. Women’s empowerment and control over decisions and resources are likely to play an important role in their ability to access and utilize these and other developmental programs and achieve their own and their family’s demographic and health goals. The 2015-16 ADHS collected data specific to women’s empowerment from both women and men age 15-49. Specifically, information was collected on receipt of cash earnings, the magnitude of a woman’s earnings relative to those of her husband/partner,1 and women’s and men’s control over the use of their own earnings. Women were also asked about the use of their husband’s earnings. Information was collected from both women and men on ownership of a house, agricultural or non-agricultural land, and a mobile phone. Additionally, respondents were asked about their use of an account at a bank or other financial institution and use of their mobile phone for financial transactions. The survey also collected data on women’s and men’s participation in household decision making, their attitudes toward wife beating, and their attitudes 1 In the remainder of this chapter, the term “husband” refers to any man living with a respondent in either a formal or informal marital union. T 230 • Women’s Empowerment toward women’s right to negotiate safer sexual relations with their husband. Finally, women were asked about their own ability to negotiate safer sex with their spouse. Information collected from women is summarized in two indices of women’s empowerment. The first index is based on the number of household decisions in which a woman participates, and the second is based on the number of reasons for which a woman justifies wife beating. The ranking of women on these two indices is then related to selected demographic and health outcomes, including contraceptive use. 15.1 EMPLOYMENT AND CASH EARNINGS In the 2015-16 ADHS, respondents were asked a number of questions to determine their employment status at the time of the survey and their continuity of employment in the 12 months prior to the survey. They were also asked about the type of payment they received for their work. Table 15.1 shows the percentage of currently married women and men who were employed at any time during the 12 months preceding the survey and the percent distribution of those employed at any time in the 12 months preceding the survey by the type of earnings they received (cash, in-kind, or both). Table 15.1 Employment and cash earnings of currently married women and men Percentage of currently married women and men age 15-49 who were employed at any time in the past 12 months and percent distribution of currently married women and men employed in the past 12 months by type of earnings, according to age, Armenia 2015-16 Age Among currently married respondents: Percent distribution of currently married respondents employed in the past 12 months, by type of earnings Total Number of respondents Percentage employed in past 12 months Number of respondents Cash only Cash and in-kind In-kind only Not paid Missing/ don't know WOMEN 15-19 (7.2) 33 * * * * * * 2 20-24 16.3 365 75.7 6.2 14.9 3.2 0.0 100.0 59 25-29 30.1 761 73.0 13.3 8.7 5.0 0.0 100.0 229 30-34 36.8 826 68.0 13.1 11.9 7.0 0.0 100.0 304 35-39 49.9 709 61.3 16.4 11.0 11.2 0.0 100.0 354 40-44 57.0 639 66.2 16.2 8.1 9.5 0.0 100.0 364 45-49 56.2 562 58.9 16.1 12.6 12.5 0.0 100.0 316 Total 41.8 3,895 65.3 14.9 10.7 9.1 0.0 100.0 1,629 MEN 15-19 * * * * * * * * 0 20-24 83.0 52 (82.0) (10.7) (2.5) (4.8) (0.0) (100.0) 43 25-29 87.9 206 85.6 7.1 4.9 2.3 0.0 100.0 181 30-34 91.3 322 90.6 8.0 1.0 0.1 0.3 100.0 294 35-39 90.2 320 91.7 5.0 3.2 0.1 0.0 100.0 289 40-44 90.1 309 87.0 10.1 1.3 1.6 0.0 100.0 278 45-49 86.0 297 81.5 14.5 1.0 3.0 0.0 100.0 255 Total 89.0 1,506 87.4 9.0 2.1 1.4 0.1 100.0 1,341 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. According to the 2015-16 ADHS, 42 percent of currently married women were employed at any time in the preceding 12 months, up from 36 percent at the time of the 2010 ADHS (NSS et al. 2012). The likelihood of being employed increases sharply with age; this is likely because younger women may still be completing their education. By age 40-49, well over half of all currently married women are employed. Among women who were employed in the preceding 12 months, two-thirds received only cash for their work, down from 72 percent in 2010. About 1 in 10 (9 percent) women did not receive any payment at all; 15 percent received cash and in-kind earnings for their work, and 11 percent received in-kind earnings only. Women’s Empowerment • 231 Currently married men are much more likely to be employed than currently married women (89 percent versus 42 percent). Employed men are also more likely than women to be paid in cash only (87 percent versus 65 percent) and less likely to work with no pay (1 percent versus 9 percent). Only 9 percent of men employed in the preceding 12 months received cash and in-kind payment, and 2 percent were paid in-kind only. 15.2 CONTROL OVER CASH EARNINGS AND RELATIVE MAGNITUDE OF WOMEN’S EARNINGS In addition to access to paid employment, control over cash earnings is another important dimension of empowerment. Currently married employed women who earn cash for their work were asked who the main decision maker is with regard to the use of their earnings and the relative magnitude of their earnings compared with their husbands’ earnings. This information may provide some insight into women’s empowerment within the family and the extent of their control over household resources and other decision making. Table 15.2.1 shows the percent distribution of currently married women who received cash earnings in the past 12 months, according to the person who mainly decides about the use of their earnings and their perception of the magnitude of their earnings relative to those of their husbands. Twenty-eight percent of women say that they themselves mainly decide how their cash earnings are used. The majority of women (67 percent) indicate that the decision is made jointly with their husbands. Only 3 percent of women say that the decision is made mainly by their husbands. The likelihood that a currently married woman is the main decision maker regarding the use of her cash earnings tends to increase somewhat with age, suggesting that older women are more empowered than younger women; the likelihood declines somewhat with women’s number of living children. In terms of residence, women in urban areas (31 percent) are more likely than women in rural areas (22 percent) to mainly decide themselves how their cash earnings are used. Decision making alone by women on the use of their cash earnings varies widely across regions, ranging from 13 percent in Ararat to 41 percent in Armavir. The percentage of women who mainly decide themselves how their cash earnings are used varies inconsistently with education and wealth. Table 15.2.1 also shows that about two-thirds of women (65 percent) earn less than their husbands and that one in five (20 percent) earn about the same amount as their husbands. Only 8 percent earn more than their husbands. Six percent of women say that their husbands have no cash earnings. The proportion of women who earn more than their husbands does not vary uniformly with most background characteristics but does increase with increasing education. Notably, the distributions of currently married employed women by the person who mainly decides about the use of their earnings and by their earnings relative to those of their husband are virtually identical to the corresponding distributions in the 2010 ADHS. Currently married men age 15-49 who receive cash earnings were asked who decides how their cash earnings are spent. Additionally, currently married women age 15-49 whose husbands receive cash earnings were asked who decides how the husband’s earnings are spent. Table 15.2.2 shows that two-thirds (65 percent) of currently married men who receive cash earnings report that they decide jointly with their wives how their earnings will be used, and almost one in five (17 percent) say that decisions on how their earnings are used are mainly made by their wives. Less than one in eight men (13 percent) say that they mainly make the decisions themselves. 232 • Women’s Empowerment Table 15.2.1 Control over women's cash earnings and relative magnitude of women's cash earnings Percent distribution of currently married women age 15-49 who received cash earnings for employment in the 12 months preceding the survey by person who decides how wife's cash earnings are used and by whether she earned more or less than her husband, according to background characteristics, Armenia 2015-16 Background characteristic Person who decides how wife's cash earnings are used: Total Wife's cash earnings compared with husband's cash earnings: Total Number of women Mainly wife Wife and husband jointly Mainly husband Other Missing More Less About the same Husband has no earnings Don't know/ missing Age 15-19 * * * * * * * * * * * 100.0 2 20-24 25.8 69.0 0.0 5.2 0.0 100 10.6 70.0 8.7 10.7 0.0 100.0 49 25-29 24.3 71.3 1.3 3.0 0.0 100 5.6 72.4 16.7 4.4 0.9 100.0 198 30-34 25.8 65.8 5.8 2.5 0.0 100 5.4 67.3 23.0 2.8 1.4 100.0 246 35-39 23.2 70.1 3.1 2.7 0.8 100 8.4 70.0 14.5 5.0 2.0 100.0 275 40-44 31.3 64.4 2.7 1.4 0.1 100 7.8 62.1 23.1 6.0 1.1 100.0 300 45-49 34.5 61.8 3.2 0.5 0.0 100 13.9 53.3 23.5 8.1 1.1 100.0 237 Number of living children 0 32.0 64.8 2.1 1.1 0.0 100 9.1 64.9 18.6 6.8 0.6 100.0 97 1-2 28.2 67.2 2.6 1.8 0.2 100 7.8 64.0 21.0 5.7 1.5 100.0 897 3-4 25.8 65.9 5.1 3.1 0.2 100 10.1 67.8 16.8 4.4 1.0 100.0 304 5+ * * * * * * * * * * * 100.0 9 Residence Urban 31.2 65.5 1.7 1.5 0.2 100 8.2 64.3 20.0 6.5 1.0 100.0 834 Rural 22.0 68.7 5.8 3.3 0.3 100 8.7 66.0 19.6 4.0 1.7 100.0 473 Region Yerevan 32.8 64.6 1.7 0.9 0.0 100 9.3 59.6 23.7 6.9 0.5 100.0 455 Aragatsotn 24.0 69.5 5.4 0.0 1.1 100 15.5 61.7 19.7 2.0 1.1 100.0 30 Ararat 13.0 76.9 6.4 3.4 0.3 100 8.1 66.4 22.2 2.1 1.1 100.0 169 Armavir 41.3 54.0 3.8 0.0 0.8 100 5.8 74.0 12.3 6.1 1.8 100.0 144 Gegharkunik 20.0 62.7 11.4 5.3 0.6 100 4.7 74.8 13.0 4.7 2.8 100.0 109 Lori (16.5) (83.5) (0.0) (0.0) (0.0) (100) (14.3) (51.5) (20.3) (10.5) (3.4) 100.0 37 Kotayk 29.1 66.5 0.0 4.3 0.0 100 2.8 76.8 17.2 2.6 0.7 100.0 149 Shirak 36.7 53.9 1.7 7.6 0.0 100 17.9 54.5 21.4 6.2 0.0 100.0 64 Syunik 17.7 80.6 0.8 0.9 0.0 100 7.2 72.4 14.3 5.4 0.7 100.0 69 Vayots Dzor 23.6 76.4 0.0 0.0 0.0 100 10.8 53.6 25.4 5.5 4.7 100.0 31 Tavush 22.9 74.1 3.0 0.0 0.0 100 11.5 47.6 22.7 13.5 4.6 100.0 49 Education Basic (18.4) (63.7) (15.6) (2.2) (0.0) (100) (4.0) (65.7) (19.5) (7.8) (3.0) 100.0 48 Secondary 22.7 67.6 5.4 4.3 0.0 100 7.0 65.2 20.2 7.0 0.7 100.0 384 Secondary special 34.3 62.4 1.1 1.5 0.7 100 8.7 67.3 15.5 6.7 1.9 100.0 347 Higher 28.1 69.1 1.7 1.0 0.1 100 9.5 63.2 22.4 3.7 1.2 100.0 527 Wealth quintile Lowest 21.9 66.3 10.0 1.4 0.4 100 6.5 63.9 21.0 6.1 2.4 100.0 167 Second 24.5 68.2 4.4 2.3 0.7 100 8.6 68.4 17.9 3.2 1.9 100.0 260 Middle 23.0 70.1 2.4 4.4 0.2 100 7.3 62.9 21.5 7.4 0.8 100.0 223 Fourth 33.9 62.2 1.3 2.6 0.0 100 10.3 64.1 16.4 8.1 1.1 100.0 313 Highest 30.9 67.6 1.0 0.5 0.0 100 7.9 65.0 22.7 3.7 0.7 100.0 342 Total 27.8 66.7 3.1 2.1 0.2 100 8.3 65.0 19.8 5.6 1.3 100.0 1,306 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. Women’s Empowerment • 233 Table 15.2.2 Control over men's cash earnings Percent distributions of currently married men age 15-49 who receive cash earnings and of currently married women age 15-49 whose husbands receive cash earnings, by person who decides how husband's cash earnings are used, according to background characteristics, Armenia 2015-16 Background characteristic Men Women Person who decides how husband's cash earnings are used: Total Number of men Person who decides how husband's cash earnings are used: Total Number of women Mainly wife Husband and wife jointly Mainly husband Other Missing Mainly wife Husband and wife jointly Mainly husband Other Missing Age 15-19 * * * * * 0.0 0 (3.6) (68.0) (15.2) (13.2) (0.0) 100.0 28 20-24 (13.5) (52.2) (14.0) (20.4) (0.0) 100.0 40 2.1 73.6 14.3 9.3 0.7 100.0 334 25-29 16.4 62.6 13.7 7.3 0.0 100.0 168 2.7 75.7 12.1 9.3 0.1 100.0 718 30-34 15.2 61.6 15.3 7.9 0.0 100.0 290 5.0 76.6 12.2 6.2 0.1 100.0 787 35-39 17.7 63.1 16.3 2.9 0.0 100.0 279 8.6 81.4 7.6 2.4 0.0 100.0 670 40-44 15.9 68.0 12.5 3.4 0.2 100.0 270 6.8 83.7 8.3 1.2 0.0 100.0 605 45-49 17.9 72.7 8.4 1.0 0.0 100.0 245 7.8 82.7 8.9 0.5 0.0 100.0 524 Number of living children 0 16.4 58.0 16.8 8.9 0.0 100.0 99 4.8 72.8 15.1 7.3 0.0 100.0 236 1-2 15.5 67.0 13.1 4.4 0.0 100.0 907 5.4 79.6 9.8 5.0 0.1 100.0 2,533 3-4 20.6 61.3 13.5 4.4 0.2 100.0 275 6.3 78.9 11.0 3.7 0.1 100.0 862 5+ * * * * * 100.0 12 (11.7) (77.9) (9.3) (1.1) (0.0) 100.0 34 Residence Urban 12.6 74.0 11.5 1.9 0.0 100.0 755 6.5 79.8 10.5 3.0 0.2 100.0 2,096 Rural 22.0 52.9 16.0 9.0 0.1 100.0 538 4.4 78.0 10.3 7.3 0.0 100.0 1,569 Region Yerevan 2.1 91.9 5.9 0.0 0.0 100.0 387 8.7 79.1 10.7 1.4 0.2 100.0 1,083 Aragatsotn 2.2 78.4 19.4 0.0 0.0 100.0 59 9.9 74.6 15.5 0.0 0.0 100.0 181 Ararat 34.0 56.5 9.5 0.0 0.0 100.0 148 1.6 70.0 21.8 6.0 0.6 100.0 339 Armavir 1.3 33.5 42.8 22.4 0.0 100.0 142 7.8 85.5 6.4 0.4 0.0 100.0 379 Gegharkunik 0.0 71.8 1.5 26.7 0.0 100.0 112 2.2 65.7 19.9 12.1 0.0 100.0 289 Lori 0.0 85.1 13.9 1.0 0.0 100.0 70 9.8 79.2 7.8 3.2 0.0 100.0 183 Kotayk 88.4 4.8 6.3 0.5 0.0 100.0 170 2.5 78.8 4.7 14.0 0.0 100.0 468 Shirak 1.1 48.5 50.3 0.0 0.0 100.0 76 3.5 83.1 4.9 8.4 0.0 100.0 331 Syunik 0.0 100.0 0.0 0.0 0.0 100.0 50 2.7 91.6 2.8 2.8 0.0 100.0 164 Vayots Dzor 1.4 84.8 13.7 0.0 0.0 100.0 24 3.9 86.2 9.6 0.4 0.0 100.0 82 Tavush 0.0 98.9 0.0 0.0 1.1 100.0 55 2.4 85.8 11.1 0.7 0.0 100.0 168 Education Basic 24.9 45.4 19.7 10.0 0.0 100.0 136 5.1 74.8 15.4 4.8 0.0 100.0 182 Secondary 17.5 62.2 13.4 6.8 0.1 100.0 599 4.7 76.9 11.9 6.5 0.1 100.0 1,555 Secondary special 15.5 68.4 14.8 1.4 0.0 100.0 214 6.4 79.9 9.5 4.1 0.0 100.0 897 Higher 12.0 76.6 9.7 1.7 0.0 100.0 343 6.5 82.1 8.2 3.0 0.2 100.0 1,028 Wealth quintile Lowest 16.6 49.7 21.3 12.4 0.0 100.0 228 5.7 75.7 13.5 5.1 0.0 100.0 629 Second 23.7 56.9 14.0 5.4 0.0 100.0 251 4.2 80.2 9.8 5.7 0.0 100.0 794 Middle 15.5 66.6 12.5 5.4 0.0 100.0 231 4.5 79.0 9.8 6.6 0.2 100.0 675 Fourth 18.3 68.0 11.0 2.7 0.0 100.0 274 5.8 80.5 10.4 3.2 0.0 100.0 743 Highest 9.6 80.0 9.8 0.4 0.2 100.0 308 7.7 79.0 9.2 3.8 0.3 100.0 825 Total 16.5 65.2 13.4 4.9 0.0 100.0 1,293 5.6 79.0 10.4 4.8 0.1 100.0 3,665 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. Total for men includes 1 man with no education and total for women includes 4 women with no education. 234 • Women’s Empowerment There are a few distinct patterns with respect to who decides how men’s earnings are used. Older men are somewhat more likely than younger men to make joint decisions with their wives on how to use their cash earnings; for example, 73 percent of men age 45-49 make joint decisions with their wives, as compared with 63 percent of men age 25-29. Men in rural areas (53 percent) are less likely than those in urban areas (74 percent) to make joint decisions with their wives on how to use their cash earnings. Among regions, the percentage of men who make joint decisions with their wives ranges from 5 percent in Kotayk to 100 percent in Syunik. Joint decision making about men’s earnings increases sharply as men’s education and household wealth increase. Table 15.2.2 shows that 79 percent of currently married women age 15-49 whose husbands receive cash earnings report that their husbands decide jointly with them how the husbands’ cash earnings will be used. Six percent of women report that they mainly decide how their husbands’ cash earnings are used, and 10 percent say that their husbands mainly make this decision. Thus, women’s reports on decision making about the use of their husbands’ earnings differ somewhat from the reports of men about the use of their own earnings, particularly with respect to joint decision making. Table 15.3 shows, for currently married women who earned cash in the past 12 months, the person who decides how their cash earnings are used and, for all currently married women whose husbands earned cash in the past 12 months, the person who decides how their husbands’ cash earnings are used, according to the magnitude of women’s earnings relative to their husbands’ earnings. This table indicates whether women’s control over the use of their own and their husbands’ earnings varies by whether they earn more or less than their husbands. Women who earn less than their husbands are more likely than women who earn an equal amount to be the main decision maker about their own cash earnings (30 percent versus 18 percent). However, women who earn about the same as their husbands are somewhat more likely than other women to jointly make decisions about the use of their own earnings as well as the use of their husbands’ earnings. Table 15.3 Women's control over their own earnings and over those of their husbands Percent distribution of currently married women age 15-49 with cash earnings in the last 12 months by person who decides how the wife's cash earnings are used, and percent distribution of currently married women age 15-49 whose husbands have cash earnings by person who decides how the husband's cash earnings are used, according to the relation between wife's and husband's cash earnings, Armenia 2015-16 Women's earnings relative to husband's earnings Person who decides how wife's cash earnings are used: Total Number of women Person who decides how husband's cash earnings are used: Total Number of women Mainly wife Wife and husband jointly Mainly husband Other Missing Mainly wife Wife and husband jointly Mainly husband Other Missing More than husband 26.0 70.9 0.9 2.2 0.0 100.0 109 7.7 86.1 6.2 0.0 0.0 100.0 109 Less than husband 30.0 64.4 3.2 2.4 0.0 100.0 849 8.7 79.1 9.3 2.9 0.0 100.0 849 Same as husband 17.6 78.8 2.3 1.2 0.0 100.0 259 4.8 89.6 4.2 1.3 0.0 100.0 259 Husband has no cash earnings or did not work 41.9 50.5 4.8 2.8 0.0 100.0 73 na na na na na na 0 Woman worked but has no cash earnings na na na na na na 0 1.2 88.0 5.2 5.6 0.0 100.0 308 Woman did not work na na na na na na 0 5.0 76.2 12.5 6.1 0.2 100.0 2,124 Total1 27.8 66.7 3.1 2.1 0.2 100.0 1,306 5.6 79.0 10.4 4.8 0.1 100.0 3,665 na = Not applicable 1 Includes cases where a woman does not know whether she earned more or less than her husband 15.3 OWNERSHIP OF ASSETS, BANK ACCOUNTS, AND MOBILE PHONES Asset ownership, particularly of land and a house, has many beneficial effects for households including protection against financial ruin. For women, asset ownership is a source of financial empowerment, and for married women, it can provide economic protection in the case of marital dissolution or abandonment. Information on women’s asset ownership can provide important insights into women’s status and demographic and health outcomes. The 2015-16 ADHS asked women and men if they own agricultural or non-agricultural land or a house (the one they were in at the time of the interview or any other), alone or jointly. If respondents are the Women’s Empowerment • 235 sole owners of the asset (they do not share ownership with anyone), then they own the asset “alone.” If respondents own the asset with someone else, they are classified as owning the asset “jointly only.” If they own more than one asset, and some assets are owned alone and some jointly with someone else, they are classified in the “alone and jointly” category. Finally, respondents who do not own the specific asset, either alone or jointly, are included in the “does not own” category. Additionally, women and men who owned either asset were asked if they had a title deed for the asset and whether their name was on the deed. Tables 15.4.1 and 15.4.2 show the percent distributions of women and men age 15-49, respectively, by ownership of a house and land, according to background characteristics. Less than half of women in Armenia (48 percent) own a house, down sharply from 72 percent in the 2010 ADHS. The majority of women who own a house do so jointly. House ownership, alone or jointly, increases with age from 30 percent among women age 15-19 to 72 percent among women age 45-49. House ownership does not vary substantially by urban or rural residence but varies greatly by region: 81 percent of women in Gegharkunik own a house, either alone or jointly, as compared with only 20 percent in Shirak. Women with only a basic education are less likely (32 percent) than women with any type of secondary or higher education to own a house alone or jointly (48-50 percent). There is no clear relationship between women’s house ownership and wealth. Table 15.4.1 Ownership of assets: Women Percent distribution of women age 15-49 by ownership of housing and land, according to background characteristics, Armenia 2015-16 Background characteristic Percentage who own a house: Per- centage who do not own a house Total Percentage who own land: Per- centage who do not own land Total Number of women Alone Jointly Alone and jointly Alone Jointly Alone and jointly Age 15-19 0.0 28.9 0.7 70.4 100.0 0.0 9.1 0.5 90.3 100.0 725 20-24 0.8 35.9 1.4 61.9 100.0 0.8 9.5 0.6 89.2 100.0 928 25-29 1.6 36.8 1.6 60.1 100.0 0.9 9.4 0.4 89.2 100.0 1,099 30-34 3.3 40.7 2.3 53.7 100.0 1.1 13.3 0.9 84.7 100.0 1,007 35-39 6.7 47.4 1.6 44.3 100.0 1.3 16.3 0.9 81.6 100.0 867 40-44 8.2 50.8 4.5 36.5 100.0 3.1 17.5 1.8 77.6 100.0 784 45-49 13.6 53.0 5.6 27.8 100.0 4.9 19.1 2.0 74.0 100.0 706 Residence Urban 6.2 37.9 2.2 53.7 100.0 0.8 4.0 0.3 94.9 100.0 3,657 Rural 2.0 46.9 2.8 48.3 100.0 2.8 26.7 2.0 68.5 100.0 2,459 Region Yerevan 7.3 35.6 1.3 55.7 100.0 0.8 0.8 0.0 98.5 100.0 2,001 Aragatsotn 2.3 67.4 6.2 24.1 100.0 2.5 41.7 8.5 47.3 100.0 315 Ararat 3.8 63.0 2.6 30.6 100.0 3.3 31.9 1.1 63.7 100.0 552 Armavir 2.2 20.7 0.0 77.0 100.0 3.4 6.2 0.0 90.3 100.0 586 Gegharkunik 3.5 73.4 3.9 19.2 100.0 2.5 58.3 1.0 38.2 100.0 478 Lori 5.6 47.1 2.7 44.5 100.0 0.3 0.3 0.0 99.4 100.0 355 Kotayk 3.6 43.5 2.4 50.4 100.0 2.0 10.2 0.6 87.2 100.0 678 Shirak 2.5 12.3 5.0 80.2 100.0 0.9 1.5 1.3 96.3 100.0 510 Syunik 2.0 49.9 3.8 44.3 100.0 0.8 12.4 2.5 84.2 100.0 238 Vayots Dzor 3.1 48.2 0.0 48.6 100.0 0.4 14.5 0.0 85.0 100.0 119 Tavush 1.8 33.0 2.8 62.4 100.0 1.3 14.3 1.6 82.9 100.0 283 Education Basic 2.8 27.5 1.7 68.1 100.0 2.0 11.3 0.5 86.3 100.0 396 Secondary 3.3 43.9 2.7 50.0 100.0 2.2 18.9 1.4 77.4 100.0 2,444 Secondary special 5.2 40.4 2.3 52.1 100.0 1.4 12.6 0.9 85.0 100.0 1,360 Higher 5.9 42.3 2.2 49.6 100.0 0.9 6.6 0.5 92.0 100.0 1,910 Wealth quintile Lowest 3.1 39.4 2.2 55.3 100.0 3.3 22.4 1.2 73.1 100.0 1,081 Second 1.8 48.5 3.5 46.2 100.0 2.6 25.0 2.5 69.8 100.0 1,242 Middle 4.9 39.3 1.6 54.2 100.0 1.7 14.2 0.4 83.8 100.0 1,142 Fourth 5.9 40.4 2.8 50.9 100.0 0.5 4.5 0.5 94.5 100.0 1,287 Highest 6.5 39.8 1.9 51.9 100.0 0.3 2.3 0.3 97.1 100.0 1,365 Total 4.5 41.5 2.4 51.5 100.0 1.6 13.1 1.0 84.3 100.0 6,116 Note: Total includes 5 women with no education. 236 • Women’s Empowerment Table 15.4.2 Ownership of assets: Men Percent distribution of men age 15-49 by ownership of housing and land, according to background characteristics, Armenia 2015-16 Background characteristic Percentage who own a house: Per- centage who do not own a house Total Percentage who own land: Per- centage who do not own land Missing Total Number of men Alone Jointly Alone and jointly Alone Jointly Alone and jointly Age 15-19 0.7 52.2 0.6 46.5 100.0 0.3 23.7 0.3 75.7 0.0 100.0 345 20-24 0.7 54.8 0.9 43.6 100.0 1.1 28.7 0.2 69.9 0.0 100.0 467 25-29 5.8 66.0 0.3 27.8 100.0 3.0 34.3 0.1 62.7 0.0 100.0 464 30-34 10.6 59.5 0.5 29.4 100.0 7.3 29.1 0.4 63.2 0.0 100.0 427 35-39 25.0 56.0 1.1 17.9 100.0 10.4 23.4 0.9 65.1 0.3 100.0 376 40-44 31.7 52.9 1.2 14.3 100.0 13.4 23.2 1.1 62.2 0.0 100.0 346 45-49 37.1 51.4 2.9 8.7 100.0 22.8 19.4 1.0 56.8 0.0 100.0 330 Residence Urban 15.2 54.0 0.7 30.1 100.0 3.3 9.1 0.0 87.5 0.1 100.0 1,558 Rural 13.9 60.0 1.4 24.7 100.0 13.5 49.3 1.2 36.1 0.0 100.0 1,197 Region Yerevan 17.4 49.9 0.2 32.4 100.0 2.3 0.5 0.0 97.2 0.0 100.0 833 Aragatsotn 21.1 67.9 1.0 9.9 100.0 20.8 65.3 0.6 13.3 0.0 100.0 159 Ararat 10.4 81.7 1.8 6.0 100.0 9.0 60.3 0.4 30.3 0.0 100.0 290 Armavir 19.4 2.9 0.0 77.8 100.0 10.6 1.0 0.0 88.4 0.0 100.0 268 Gegharkunik 20.9 76.4 2.1 0.5 100.0 22.7 75.4 1.4 0.5 0.0 100.0 235 Lori 13.5 15.9 0.0 70.6 100.0 6.9 0.6 0.0 92.5 0.0 100.0 184 Kotayk 1.4 94.8 0.0 3.8 100.0 1.0 52.8 0.0 45.8 0.4 100.0 299 Shirak 13.3 79.0 0.4 7.3 100.0 4.8 25.7 0.0 69.4 0.0 100.0 201 Syunik 12.7 48.1 3.3 35.9 100.0 9.1 4.7 0.6 85.6 0.0 100.0 104 Vayots Dzor 11.8 20.9 17.3 50.0 100.0 9.2 11.3 14.2 65.3 0.0 100.0 56 Tavush 13.9 62.0 0.0 24.2 100.0 9.7 37.1 0.3 52.9 0.0 100.0 126 Education Basic 10.2 49.2 1.5 39.1 100.0 8.6 28.9 0.3 61.8 0.3 100.0 360 Secondary 16.3 57.8 0.7 25.2 100.0 9.7 33.7 0.5 56.2 0.0 100.0 1,250 Secondary special 18.4 52.0 1.8 27.8 100.0 8.0 19.0 0.9 72.1 0.0 100.0 403 Higher 11.9 60.8 0.8 26.5 100.0 3.7 17.5 0.5 78.3 0.0 100.0 736 Wealth quintile Lowest 13.9 48.9 0.7 36.5 100.0 13.4 38.8 0.3 47.5 0.0 100.0 523 Second 15.5 60.7 1.6 22.2 100.0 13.7 47.5 1.1 37.7 0.0 100.0 583 Middle 12.5 59.9 1.1 26.4 100.0 5.4 32.5 0.8 61.3 0.0 100.0 521 Fourth 13.9 56.6 0.9 28.6 100.0 3.7 9.7 0.3 86.2 0.2 100.0 566 Highest 17.2 56.4 0.6 25.8 100.0 2.3 4.9 0.1 92.7 0.0 100.0 562 Total 14.6 56.6 1.0 27.8 100.0 7.7 26.6 0.5 65.2 0.0 100.0 2,755 Note: Total includes 5 men with no education. Women are less likely to own land than a house; about 16 percent of women own land, either alone or jointly. As with house ownership, land ownership among women has declined since 2010, when 39 percent of women owned land. Land ownership increases somewhat with age: 10 percent of women age 15- 19 own land, as compared with 26 percent of women age 45-49. As expected, women living in rural areas, where more land is available and is necessary for farming, are more likely to own land (32 percent) than women in urban areas (5 percent). Land ownership, either alone or jointly, is lowest among women in Lori and Yerevan (1-2 percent) and highest among women in Gegharkunik (62 percent). The percentage of women who own land decreases with increasing education and wealth, implying that those at the highest levels of education and wealth are least likely to own land. For example, 27 percent of women in the lowest wealth quintile own land, compared with 3 percent of women in the highest wealth quintile. Table 15.4.2 shows that about 7 in 10 men (72 percent) own a house, as compared with less than half of women (48 percent). More than half of men (57 percent) own a house jointly. House ownership among men increases rapidly with age, from 53 percent among those age 15-19 to 91 percent among those age 45-49. House ownership, either alone or jointly, is lowest among men in Armavir (22 percent) and highest among men in Gegharkunik (99 percent). House ownership does not vary uniformly with men’s education or wealth. Women’s Empowerment • 237 Thirty-five percent of men, compared with only 16 percent of women, own land. Twenty-seven percent of men own land jointly. Land ownership tends to increase with age but not linearly. As observed for women, rural men are much more likely (64 percent) than urban men (12 percent) to own land. Land ownership, either jointly or alone, ranges from 3 percent among men in Yerevan to almost 100 percent among men in Gegharkunik. Men at lower levels of wealth are more likely to own land than wealthier men. Tables 15.5.1 and 15.5.2 show the percent distributions of women and men age 15-49 who own a house, respectively, by whether there is a title or deed for the house they own and whether their name is on the title or deed, according to background characteristics. Most men and women who own a house have a title or deed for the house. Eighty-six percent of women and 93 percent of men who own a house have their name on the title or deed for the house; however, these proportions are not fully comparable because 7 percent of women who own a house do not know whether their name is on the title or deed or are missing data on one or more of the questions about the title or deed, as compared with less than 1 percent of men. Table 15.5.1 Ownership of title or deed for house: Women Among women age 15-49 who own a house, percent distribution by whether the house owned has a title or deed and whether or not the woman's name appears on the title or deed, according to background characteristics, Armenia 2015-16 Background characteristic House has a title or deed and: Does not have a title/deed Don't know/ missing1 Total Number of women who own a house2 Woman's name is on title/deed Woman's name is not on title/deed Age 15-19 66.1 1.0 3.6 29.3 100.0 214 20-24 77.5 3.0 4.7 14.7 100.0 354 25-29 86.1 2.0 4.2 7.8 100.0 438 30-34 88.7 4.2 4.0 3.1 100.0 466 35-39 88.2 3.2 4.0 4.7 100.0 483 40-44 90.0 1.7 4.5 3.7 100.0 498 45-49 94.2 0.6 3.3 1.9 100.0 510 Residence Urban 90.6 1.4 2.0 5.9 100.0 1,692 Rural 80.8 3.5 6.8 8.9 100.0 1,272 Region Yerevan 93.9 0.0 0.6 5.5 100.0 885 Aragatsotn 51.7 3.0 19.5 25.7 100.0 239 Ararat 96.4 1.4 1.4 0.8 100.0 384 Armavir 95.2 1.0 2.3 1.5 100.0 134 Gegharkunik 65.1 11.2 5.5 18.2 100.0 386 Lori 94.0 0.0 1.1 4.9 100.0 197 Kotayk 93.6 2.7 1.2 2.6 100.0 336 Shirak 92.9 1.1 5.1 0.9 100.0 101 Syunik 93.9 0.4 5.2 0.5 100.0 133 Vayots Dzor 98.0 0.0 0.4 1.6 100.0 61 Tavush 73.7 0.0 18.7 7.6 100.0 106 Education Basic 83.5 4.6 5.1 6.8 100.0 126 Secondary 84.4 2.5 4.8 8.3 100.0 1,222 Secondary special 84.8 2.6 5.7 6.9 100.0 651 Higher 90.5 1.5 1.9 6.2 100.0 963 Wealth quintile Lowest 79.7 4.0 6.2 10.1 100.0 483 Second 83.0 2.5 7.7 6.9 100.0 668 Middle 84.5 3.2 3.8 8.6 100.0 523 Fourth 90.4 1.7 2.0 5.9 100.0 632 Highest 92.6 0.8 1.0 5.7 100.0 657 Total 86.4 2.3 4.0 7.2 100.0 2,963 Note: Total includes 1 woman with no education. 1 Includes women whose house has a title/deed, but they do not know if their name is on it (or this information is missing), and women who do not know if the house has a deed/title (or this information is missing) 2 Includes alone, joint, or alone and joint ownership 238 • Women’s Empowerment Table 15.5.2 Ownership of title or deed for house: Men Among men age 15-49 who own a house, percent distribution by whether the house owned has a title or deed and whether or not the man's name appears on the title or deed, according to background characteristics, Armenia 2015-16 Background characteristic House has a title or deed and: Does not have a title/deed Don't know/ missing1 Total Number of men who own a house2 Man's name is on title/deed Man's name is not on title/ deed Age 15-19 89.9 0.0 9.2 0.9 100.0 185 20-24 89.7 0.0 10.3 0.0 100.0 263 25-29 88.4 0.1 11.1 0.4 100.0 335 30-34 90.7 0.5 8.8 0.0 100.0 301 35-39 96.6 0.0 3.4 0.0 100.0 308 40-44 95.7 0.2 4.1 0.0 100.0 297 45-49 95.5 0.0 4.4 0.1 100.0 301 Residence Urban 96.0 0.1 3.8 0.1 100.0 1,089 Rural 88.3 0.1 11.4 0.2 100.0 901 Region Yerevan 98.8 0.0 1.2 0.0 100.0 563 Aragatsotn 27.5 0.2 72.2 0.0 100.0 143 Ararat 97.4 0.0 2.3 0.3 100.0 272 Armavir 88.0 0.0 12.0 0.0 100.0 59 Gegharkunik 97.1 0.0 2.4 0.5 100.0 234 Lori (94.0) (0.0) (6.0) (0.0) (100.0) 54 Kotayk 98.1 0.4 1.2 0.3 100.0 288 Shirak 99.4 0.0 0.6 0.0 100.0 187 Syunik 99.2 0.0 0.0 0.8 100.0 67 Vayots Dzor 82.8 4.1 13.1 0.0 100.0 28 Tavush 97.3 0.0 2.7 0.0 100.0 95 Education Basic 91.0 0.0 8.4 0.6 100.0 219 Secondary 90.9 0.1 8.9 0.1 100.0 935 Secondary special 96.7 0.1 2.9 0.3 100.0 291 Higher 93.5 0.3 6.1 0.2 100.0 541 Wealth quintile Lowest 87.7 0.1 11.9 0.3 100.0 332 Second 89.2 0.0 10.5 0.3 100.0 454 Middle 90.4 0.1 9.4 0.1 100.0 384 Fourth 95.4 0.3 4.0 0.2 100.0 404 Highest 98.9 0.1 0.9 0.0 100.0 417 Total 92.5 0.1 7.2 0.2 100.0 1,990 Note: Figures in parentheses are based on 25-49 unweighted cases. Total includes 4 men with no education. 1 Includes men whose house has a title/deed, but they do not know if their name is on it (or this information is missing), and men who do not know if the house has a deed/title (or this information is missing) 2 Includes alone, joint, or alone and joint ownership Women’s Empowerment • 239 Similarly, Tables 15.6.1 and 15.6.2 show the percent distributions of women and men age 15-49 who own land, respectively, by whether there is a title or deed for the land they own and whether their name is on the title or deed, according to background characteristics. As in the case of house ownership, most women and men who own land have a title or deed and have their name on the deed (75 percent of women and 86 percent of men who own land). Again, women are much more likely than men to not know whether their name is on the deed or to be missing other information regarding the deed, making comparisons difficult. Table 15.6.1 Ownership of title or deed for land: Women Among women age 15-49 who own land, percent distribution by whether the land owned has a title or deed and whether or not the woman's name appears on the title or deed, according to background characteristics, Armenia 2015-16 Background characteristic Land has a title or deed and: Does not have a title/deed Don't know/ missing1 Total Number of women who own land2 Woman's name is on title/deed Woman's name is not on title/deed Age 15-19 57.0 4.2 5.8 33.0 100.0 70 20-24 55.6 8.7 5.4 30.3 100.0 101 25-29 72.0 5.9 7.6 14.4 100.0 119 30-34 77.4 7.1 5.6 9.9 100.0 154 35-39 76.6 2.5 8.5 12.3 100.0 160 40-44 80.8 3.9 7.4 7.8 100.0 175 45-49 86.6 1.3 7.1 5.1 100.0 184 Residence Urban 71.2 5.4 6.7 16.7 100.0 187 Rural 76.2 4.2 7.0 12.6 100.0 775 Region Yerevan * * * * 100.0 31 Aragatsotn 46.2 5.1 19.2 29.5 100.0 166 Ararat 97.0 1.8 0.6 0.6 100.0 201 Armavir (98.8) (0.0) (0.0) (1.2) 100.0 57 Gegharkunik 69.4 9.6 2.2 18.9 100.0 295 Lori * * * * 100.0 2 Kotayk 93.3 2.3 1.2 3.2 100.0 87 Shirak * * * * 100.0 19 Syunik 72.5 0.0 20.6 6.9 100.0 38 Vayots Dzor 94.9 1.9 3.2 0.0 100.0 18 Tavush 61.2 0.0 32.1 6.6 100.0 48 Education Basic 79.8 6.2 4.3 9.7 100.0 54 Secondary 76.6 4.2 4.9 14.4 100.0 552 Secondary special 71.9 4.3 13.6 10.3 100.0 204 Higher 73.3 4.9 6.4 15.4 100.0 152 Wealth quintile Lowest 75.4 5.6 6.4 12.6 100.0 291 Second 75.8 3.7 7.9 12.6 100.0 375 Middle 76.9 4.4 5.1 13.6 100.0 185 Fourth 66.0 1.3 9.7 23.0 100.0 71 Highest (77.0) (8.4) (5.5) (9.1) 100.0 40 Total 75.2 4.4 6.9 13.4 100.0 962 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. 1 Includes women whose land has a title/deed, but they do not know if their name is on it (or this information is missing), and women who do not know if the land has a deed/title (or this information is missing) 2 Includes alone, joint, or alone and joint ownership 240 • Women’s Empowerment Table 15.6.2 Ownership of title or deed for land: Men Among men age 15-49 who own land, percent distribution by whether the land owned has a title or deed and whether or not the man's name appears on the title or deed, according to background characteristics, Armenia 2015-16 Background characteristic House has a title or deed and: Does not have a Title/deed Don't know/ missing1 Total Number of men who own land2 Man's name is on title/deed Man's name is not on title/deed Age 15-19 79.0 0.0 19.6 1.5 100.0 84 20-24 77.1 0.8 21.2 0.8 100.0 141 25-29 81.4 0.0 17.7 0.9 100.0 173 30-34 86.4 0.0 13.6 0.0 100.0 157 35-39 91.3 0.8 7.9 0.0 100.0 130 40-44 89.8 0.0 10.2 0.0 100.0 131 45-49 93.9 0.0 6.1 0.0 100.0 143 Residence Urban 83.7 0.0 15.5 0.8 100.0 193 Rural 86.2 0.3 13.2 0.3 100.0 765 Region Yerevan * * * * * 23 Aragatsotn 27.5 0.0 72.5 0.0 100.0 138 Ararat 96.2 0.0 2.7 1.1 100.0 202 Armavir (93.3) (0.0) (6.7) (0.0) (100.0) 31 Gegharkunik 96.2 0.5 2.8 0.5 100.0 234 Lori * * * * * 14 Kotayk 98.7 0.7 0.7 0.0 100.0 161 Shirak 98.2 0.0 1.8 0.0 100.0 62 Syunik * * * * * 15 Vayots Dzor 90.2 0.0 9.8 0.0 100.0 20 Tavush 97.4 0.0 1.9 0.7 100.0 59 Education Basic 87.9 0.8 10.4 0.9 100.0 136 Secondary 84.2 0.2 15.2 0.4 100.0 548 Secondary special 89.1 0.0 10.5 0.4 100.0 113 Higher 86.6 0.0 13.4 0.0 100.0 160 Wealth quintile Lowest 86.4 0.0 13.5 0.2 100.0 275 Second 85.3 0.3 13.6 0.8 100.0 363 Middle 83.0 0.0 17.0 0.0 100.0 202 Fourth 89.2 0.0 10.0 0.8 100.0 77 Highest (92.0) (2.8) (5.2) (0.0) (100.0) 41 Total 85.7 0.2 13.6 0.4 100.0 958 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. Total includes 1 man with no education. 1 Includes men whose land has a title/deed, but they do not know if their name is on it (or this information is missing), and men who do not know if the land has a deed/title (or this information is missing) 2 Includes alone, joint, or alone and joint ownership Women’s Empowerment • 241 In the 2015-16 ADHS, women and men were also asked about their ownership of a mobile phone and, if they owned a mobile phone, whether they used the phone for any financial transactions. Additionally, women and men were asked if they have an account in a bank or other financial institution that they themselves use. Tables 15.7.1 and 15.7.2 show the percentages of women and men age 15-49 who have a bank account that they use and who own a mobile phone, respectively, according to background characteristics. These tables also provide percentages of mobile phone owners who use the phone for financial transactions. Table 15.7.1 Ownership and use of bank accounts and mobile phones: Women Percentage of women age 15-49 who use an account in a bank or other financial institution and percentage who own a mobile phone, and among women who own a mobile phone, percentage who use it for financial transactions, according to background characteristics, Armenia 2015-16 Background characteristic Use a bank account Own a mobile phone Number of women Use mobile phone for financial transactions Number of women who own a mobile phone Age 15-19 4.5 93.6 725 28.7 679 20-24 14.4 97.5 928 35.6 905 25-29 19.1 97.7 1,099 34.2 1,073 30-34 21.3 97.1 1,007 29.9 977 35-39 24.6 98.0 867 26.4 850 40-44 26.7 96.4 784 23.7 755 45-49 23.5 95.9 706 23.0 677 Residence Urban 24.2 98.6 3,657 33.3 3,606 Rural 12.0 94.0 2,459 23.1 2,310 Region Yerevan 26.3 99.0 2,001 33.2 1,981 Aragatsotn 16.2 99.4 315 35.4 313 Ararat 21.3 97.2 552 28.0 537 Armavir 12.0 89.8 586 22.3 526 Gegharkunik 8.8 90.6 478 9.8 433 Lori 7.4 97.7 355 65.2 347 Kotayk 16.2 96.7 678 34.0 656 Shirak 14.1 98.1 510 4.9 501 Syunik 28.3 98.2 238 45.3 234 Vayots Dzor 24.4 97.2 119 23.9 116 Tavush 23.2 96.5 283 18.3 273 Education Basic 3.1 88.7 396 15.3 352 Secondary 6.6 95.3 2,444 20.8 2,329 Secondary special 18.5 97.7 1,360 26.6 1,330 Higher 39.5 99.7 1,910 44.3 1,904 Wealth quintile Lowest 7.3 89.6 1,081 22.4 969 Second 15.8 97.1 1,242 24.4 1,205 Middle 14.1 97.5 1,142 26.5 1,113 Fourth 23.3 99.1 1,287 35.8 1,275 Highest 32.5 99.2 1,365 34.9 1,354 Total 19.3 96.7 6,116 29.3 5,917 Note: Total for all women age 15-49 includes 5 women with no education and total for women who have a mobile phone includes 3 women with no education. 242 • Women’s Empowerment Table 15.7.2 Ownership and use of bank accounts and mobile phones: Men Percentage of men age 15-49 who use an account in a bank or other financial institution and percentage who own a mobile phone, and among men who own a mobile phone, percentage who use it for financial transactions, according to background characteristics, Armenia 2015-16 Background characteristic Use a bank account Own a mobile phone Number of men Use mobile phone for financial transactions Number of men who own a mobile phone Age 15-19 3.7 97.1 345 8.2 335 20-24 12.1 99.4 467 15.6 464 25-29 23.3 99.9 464 20.8 464 30-34 26.8 98.3 427 24.2 420 35-39 27.0 98.5 376 23.8 370 40-44 28.9 99.4 346 23.4 344 45-49 23.5 98.3 330 22.9 324 Residence Urban 22.0 99.0 1,558 23.4 1,543 Rural 19.1 98.4 1,197 15.2 1,178 Region Yerevan 11.5 99.7 833 24.9 830 Aragatsotn 15.5 98.7 159 12.2 157 Ararat 12.9 98.3 290 4.6 285 Armavir 29.8 95.9 268 3.7 257 Gegharkunik 12.0 97.7 235 26.0 230 Lori 19.7 97.8 184 17.1 180 Kotayk 29.8 100.0 299 42.4 299 Shirak 28.4 99.5 201 9.9 200 Syunik 53.6 98.2 104 29.1 102 Vayots Dzor 45.4 98.2 56 2.3 55 Tavush 33.0 99.7 126 18.8 125 Education Basic 10.5 97.4 360 8.3 351 Secondary 14.7 98.6 1,250 14.9 1,233 Secondary special 21.9 98.6 403 20.2 398 Higher 35.5 99.9 736 33.6 736 Wealth quintile Lowest 13.3 97.3 523 8.2 509 Second 20.7 99.2 583 17.2 578 Middle 24.4 98.4 521 21.4 513 Fourth 22.3 99.9 566 26.8 566 Highest 22.7 98.9 562 24.9 555 Total 20.7 98.8 2,755 19.9 2,721 Note: Total for all men age 15-49 includes 5 men with no education and total for men who have a mobile phone includes 4 men with no education. About one in five women and men in Armenia have a bank account that they use. Ownership and use of a bank account tends to increase with age for both women and men. Among men, use of a bank account does not vary substantially by rural-urban residence, but rural women are only half as likely (12 percent) as urban women to have a bank account that they use (24 percent). Possession of a bank account increases with increasing education among both women and men. In Armenia, virtually all women (97 percent) and men (99 percent) age 15-49 have a mobile phone, and there are only minimal variations in these proportions by background characteristics. However, mobile phone usage for financial transactions is very limited. Only 29 percent of women and 20 percent of men who own a mobile phone use the phone for financial transactions. Urban women and men are somewhat more likely to conduct financial transactions on their mobile phone, and use of mobile phones for financial transactions tends to increase with increasing education and wealth. Notably, 44 percent of women and 34 percent of men with a higher education use their mobile phones for financial transactions. Use of mobile phones for financial transactions varies greatly by region among both women and men. Use of a mobile phone for this purpose is highest among women in Lori (65 percent) and among men in Kotayk (42 percent). Women’s Empowerment • 243 15.4 WOMEN’S PARTICIPATION IN DECISION MAKING To assess women’s decision-making autonomy within the household, the 2015-16 ADHS collected information on currently married women’s participation in three different types of decisions: on their own health care, on making major household purchases, and on visits to the women’s family, friends, or relatives. Having a final say in the decision-making process reflects a high degree of autonomy. Women are considered a participant in a decision if they usually make that decision alone or jointly with their husbands. The ability of women to make decisions that affect their own lives is an essential aspect of empowerment and will have consequences with respect to fulfilling health and demographic goals. Table 15.8 shows the percent distribution of currently married women and currently married men according to the person in the household who usually makes the decisions concerning these matters. Twenty- eight percent of women are the main decision makers about their own health care, 68 percent decide jointly with their husband, and 4 percent have no say in this decision. Fourteen percent of currently married women decide mainly themselves about major household purchases, two-thirds (67 percent) decide jointly with their husbands, and 17 percent have no say. Decisions about visits to the woman’s family or relatives are also mostly made jointly (80 percent), with 13 percent of women making this decision by themselves. Table 15.8 Participation in decision making Percent distribution of currently married women and currently married men age 15-49 by person who usually makes decisions about various issues, Armenia 2015-16 Decision Mainly wife Wife and husband jointly Mainly husband Someone else Other Missing Total Number WOMEN Own health care 28.0 68.0 2.6 1.3 0.0 0.1 100.0 3,895 Major household purchases 13.6 66.6 7.4 10.1 2.3 0.1 100.0 3,895 Visits to her family or relatives 12.5 79.8 3.4 3.4 0.7 0.2 100.0 3,895 MEN Own health care 15.7 59.3 23.1 0.6 1.2 0.2 100.0 1,506 Major household purchases 18.4 61.2 6.0 6.3 7.7 0.3 100.0 1,506 Currently married men were asked who usually makes decisions about their own health care and about large household purchases. Table 15.8 shows that 23 percent of men are the main decision makers about their own health care and 6 percent are the main decision makers about major household purchases, while about three in five decide jointly with their wives (59 percent and 61 percent, respectively). For 16 percent and 18 percent of men, respectively, decisions about their own health care and about major household purchases are mainly made by their wives or someone else. A comparison of women’s and men’s participation in decisions about their own health care and major household purchases suggests that women in Armenia are somewhat more likely to participate in these decisions than men. Table 15.9.1 shows how women’s participation in decision making varies by their background characteristics. As mentioned above, a large majority of married women either make household decisions themselves or participate in the decisions jointly with their husbands. Overall, more than 9 in 10 women have a say in decisions about their own health care (96 percent) or visits to their family and friends (92 percent), while 80 percent are involved in decision making about major household purchases. About three out of four currently married women (77 percent) participate in all three specified household decisions, while only 2 percent report having no say in any of the three decisions (Figure 15.1). 244 • Women’s Empowerment Table 15.9.1 Women's participation in decision making by background characteristics Percentage of currently married women age 15-49 who usually make specific decisions either alone or jointly with their husband, according to background characteristics, Armenia 2015-16 Background characteristic Specific decisions All three decisions None of the three decisions Number of women Woman's own health care Making major household purchases Visits to her family or relatives Age 15-19 (91.9) (60.2) (83.8) (57.2) 1.8 33 20-24 90.7 59.5 84.4 56.0 6.4 365 25-29 95.7 70.9 91.0 68.3 2.0 761 30-34 96.7 78.3 91.1 75.2 1.9 826 35-39 96.9 86.2 94.3 82.5 1.2 709 40-44 95.6 90.1 95.2 86.1 1.4 639 45-49 98.0 91.8 95.8 89.4 1.2 562 Employment (last 12 months) Not employed 95.5 76.5 90.7 73.4 2.5 2,266 Employed for cash 96.1 84.8 94.9 81.3 1.6 1,306 Employed not for cash 98.7 88.0 93.9 85.4 0.3 322 Number of living children 0 94.0 70.4 87.6 66.5 3.8 261 1-2 96.3 79.3 93.0 76.4 1.6 2,690 3-4 95.7 85.8 91.6 82.2 2.8 908 5+ (90.3) (82.4) (97.6) (76.1) 0.0 36 Residence Urban 96.9 82.9 93.7 80.1 1.7 2,221 Rural 94.7 76.7 90.6 73.0 2.5 1,674 Region Yerevan 97.4 84.4 95.0 81.6 1.3 1,140 Aragatsotn 97.9 89.9 85.8 79.4 0.5 187 Ararat 87.0 53.6 81.2 47.3 6.4 360 Armavir 99.2 90.8 97.9 89.6 0.5 405 Gegharkunik 88.1 62.4 81.4 60.2 8.6 298 Lori 99.1 76.1 96.7 74.7 0.0 214 Kotayk 98.2 80.7 95.4 80.1 1.0 476 Shirak 98.5 84.2 94.2 82.0 0.6 349 Syunik 92.9 92.1 89.2 80.1 1.5 172 Vayots Dzor 97.8 90.7 95.4 88.6 0.5 87 Tavush 96.1 82.7 94.6 81.3 1.3 208 Education Basic 92.9 77.1 88.3 70.6 3.0 205 Secondary 94.6 76.7 90.5 73.9 3.1 1,669 Secondary special 96.9 83.5 93.1 79.8 1.3 953 Higher 97.8 83.5 95.3 80.8 0.9 1,064 Wealth quintile Lowest 94.3 74.9 89.8 71.9 3.7 695 Second 94.5 79.2 91.0 75.5 2.2 834 Middle 96.2 80.1 93.0 77.3 1.7 721 Fourth 97.6 84.4 93.2 80.1 1.2 790 Highest 97.1 82.0 94.4 79.8 1.6 855 Total 96.0 80.3 92.3 77.1 2.0 3,895 Note: Figures in parentheses are based on 25-49 unweighted cases. Total includes 1 woman with missing information on employment and 4 women with no education. Women’s Empowerment • 245 Figure 15.1 Number of decisions in which currently married women participate There is a strong correlation between currently married women’s age and their participation in decision making. The percentage of women participating in all three decisions increases with age, from 56 percent among women age 20-24 to 89 percent among women age 45-49. Women with no children are less likely (67 percent) than women with children, particularly women with 3-4 children (82 percent), to participate in all three decisions. The proportion of currently married women participating in all three decisions varies widely among regions, ranging from 47 percent in Ararat to 90 percent in Armavir. Women’s education and wealth have a positive association with their participation in household decisions. Table 15.9.2 shows that a large majority of married men (82 percent) participate alone or jointly with their wives in making decisions about their own health care, while only 67 percent participate in making decisions about major household purchases. Only two-thirds of currently married men participate in both decisions, and 16 percent report having no say in either of the decisions. The percentage of men participating in both specified decisions increases with age and number of children and is much higher among men in urban areas (72 percent) than among men in rural areas (57 percent). There are large differences in the proportion of currently married men participating in both decisions across regions, with very few men in Kotayk (3 percent) and almost all men in Aragatsotn (99 percent) participating in both decisions. The proportion of men who participate in both decisions does not vary in a clear pattern by wealth but does increase with increasing education, from 52 percent among men with a basic education to 74 percent among men with a higher education. 2 4 17 77 0 1 2 3 Number of decisions Percent of women ADHS 2015-16 246 • Women’s Empowerment Table 15.9.2 Men's participation in decision making by background characteristics Percentage of currently married men age 15-49 who usually make specific decisions either alone or jointly with their wife, according to background characteristics, Armenia 2015-16 Background characteristic Specific decisions Both decisions Neither of the two decisions Number of men Man's own health Making major household purchases Age 20-24 74.0 41.3 41.3 26.0 52 25-29 80.6 63.2 60.8 17.0 206 30-34 81.5 63.6 61.9 16.8 322 35-39 82.3 68.5 66.6 15.8 320 40-44 85.4 69.8 68.5 13.2 309 45-49 82.9 74.5 73.3 16.0 297 Employment (last 12 months) Not employed 93.8 71.5 69.7 4.4 165 Employed for cash 81.0 67.0 65.4 17.4 1,293 Employed not for cash 80.4 57.1 57.1 19.6 47 Number of living children 0 80.2 60.1 58.7 18.4 120 1-2 83.3 66.8 65.2 15.1 1,061 3-4 79.4 71.1 69.3 18.8 313 5+ * * * * 13 Residence Urban 86.7 73.7 71.9 11.5 859 Rural 76.7 58.6 57.4 22.1 648 Region Yerevan 97.1 85.4 84.0 1.5 446 Aragatsotn 99.5 98.6 98.6 0.5 71 Ararat 68.0 59.6 58.8 31.1 151 Armavir 87.2 56.6 55.8 12.0 159 Gegharkunik 93.7 86.3 83.3 3.3 118 Lori 100.0 68.9 68.9 0.0 94 Kotayk 10.7 4.7 2.8 87.4 186 Shirak 94.7 70.9 66.4 0.7 119 Syunik 98.9 97.0 95.9 0.0 55 Vayots Dzor 92.3 78.6 75.3 4.4 34 Tavush 99.2 57.8 57.0 0.0 76 Education Basic 71.2 55.0 51.9 25.6 174 Secondary 82.9 65.5 64.2 15.8 717 Secondary special 82.3 67.9 66.6 16.4 240 Higher 86.5 75.7 74.2 12.0 372 Wealth quintile Lowest 79.7 57.9 55.9 18.4 280 Second 78.0 62.2 61.9 21.6 306 Middle 82.8 73.0 70.9 15.1 267 Fourth 82.0 65.5 65.0 17.5 319 Highest 88.7 76.7 73.7 8.3 335 Total 82.4 67.2 65.6 16.0 1,506 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Total includes 1 man with missing information on employment and 3 men with no education. 15.5 ATTITUDES TOWARD WIFE BEATING Wife beating is a form of physical violence that degrades women’s humanity and is a violation of women’s human rights. Furthermore, this form of violence lowers a woman’s self-esteem and her image in society, leading to her disempowerment. Acceptance of this practice reflects women’s low status and the perception that men are superior to women. The 2015-16 ADHS collected information on attitudes toward wife beating. Women and men were asked whether a husband is justified in beating his wife under a series of circumstances: if the wife burns the food, argues with him, goes out without telling him, neglects the children, and refuses to have sexual intercourse with him. Women who perceive that a husband is justified in hitting or beating his wife for any Women’s Empowerment • 247 of the mentioned reasons may believe that they are lower in status, both absolutely and relative to men. Such a stereotypical perception could act as a barrier to taking advantage of social and economic opportunities. This in turn may negatively affect women’s quality of life and general well-being. Tables 15.10.1 and 15.10.2 show acceptance of wife beating by women and men, respectively, in each of the five circumstances listed above. They also show the percentages of women and men who agree with wife beating for at least one of the specified circumstances. Table 15.10.1 Attitude toward wife beating: Women Percentage of all women age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, according to background characteristics, Armenia 2015-16 Background characteristic Husband is justified in hitting or beating his wife if she: Percentage who agree with at least one specified reason Number of women Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Age 15-19 0.4 4.8 5.1 7.2 0.6 8.7 725 20-24 0.2 5.4 4.5 7.0 0.7 8.7 928 25-29 0.4 6.0 4.9 8.2 0.7 9.5 1,099 30-34 0.4 7.0 6.3 9.7 1.0 11.3 1,007 35-39 0.3 6.4 5.7 8.6 0.6 10.1 867 40-44 0.7 6.1 4.6 9.2 1.2 10.8 784 45-49 0.2 7.1 5.8 10.4 0.5 11.7 706 Employment (last 12 months) Not employed 0.2 5.2 4.2 7.6 0.6 9.1 3,648 Employed for cash 0.6 6.1 4.6 7.6 1.1 9.1 2,115 Employed not for cash 0.3 16.0 19.8 24.4 0.6 26.2 351 Number of living children 0 0.2 4.7 4.7 6.7 0.5 8.2 2,120 1-2 0.3 5.5 4.2 8.3 0.5 9.5 2,990 3-4 0.9 10.5 9.1 13.4 2.1 15.8 966 5+ (0.0) (16.4) (13.8) (17.8) (0.0) (19.3) 39 Marital status Never married 0.3 4.7 5.0 6.8 0.5 8.4 1,830 Married or living together 0.4 7.1 5.7 9.9 0.9 11.4 3,895 Divorced/separated/ widowed 0.3 3.2 2.5 3.8 0.8 5.3 390 Residence Urban 0.1 3.4 2.5 5.4 0.5 6.3 3,657 Rural 0.8 10.2 9.3 13.4 1.2 15.7 2,459 Region Yerevan 0.0 0.7 0.3 1.6 0.3 2.2 2,001 Aragatsotn 0.3 18.6 23.2 32.2 0.7 40.2 315 Ararat 0.0 3.1 1.1 3.1 0.3 5.7 552 Armavir 0.1 1.5 0.2 1.9 0.1 2.2 586 Gegharkunik 3.4 33.2 38.3 40.0 5.1 41.2 478 Lori 0.0 0.9 1.0 7.6 0.0 7.8 355 Kotayk 0.3 2.8 1.5 6.9 0.7 7.3 678 Shirak 0.0 4.1 0.4 1.6 0.0 4.9 510 Syunik 0.0 0.3 0.0 2.8 0.3 2.8 238 Vayots Dzor 1.5 33.9 12.0 31.1 2.6 39.9 119 Tavush 0.0 11.4 7.3 16.9 0.6 17.4 283 Education Basic 0.1 5.3 5.4 9.4 1.5 12.0 396 Secondary 0.9 9.2 8.7 12.6 1.2 14.4 2,444 Secondary special 0.0 5.1 4.2 7.5 0.4 8.5 1,360 Higher 0.0 3.0 1.6 4.2 0.3 5.3 1,910 Wealth quintile Lowest 0.9 9.4 7.5 11.4 1.5 14.3 1,081 Second 0.5 8.2 8.0 12.7 0.9 14.5 1,242 Middle 0.4 8.4 7.9 10.5 0.7 11.9 1,142 Fourth 0.0 3.4 2.6 6.1 0.2 6.9 1,287 Highest 0.1 2.2 1.2 3.5 0.6 4.2 1,365 Total 0.4 6.1 5.2 8.6 0.8 10.1 6,116 Note: Figures in parentheses are based on 25-49 unweighted cases. Total includes 2 women with missing information on employment and 5 women with no education. 248 • Women’s Empowerment Table 15.10.2 Attitude toward wife beating: Men Percentage of all men age 15-49 who agree that a husband is justified in hitting or beating his wife for specific reasons, according to background characteristics, Armenia 2015-16 Background characteristic Husband is justified in hitting or beating his wife if she: Percentage who agree with at least one specified reason Number of men Burns the food Argues with him Goes out without telling him Neglects the children Refuses to have sexual intercourse with him Age 15-19 0.7 14.0 14.2 19.0 0.7 24.7 345 20-24 0.6 16.9 13.4 18.7 1.2 23.9 467 25-29 0.8 16.9 10.3 16.0 1.3 23.2 464 30-34 0.5 16.7 10.7 17.3 1.6 22.7 427 35-39 0.9 12.2 8.2 15.2 2.8 19.7 376 40-44 0.4 20.9 14.2 20.0 2.2 25.1 346 45-49 0.6 14.9 11.2 14.0 1.9 18.1 330 Employment (last 12 months) Not employed 0.7 12.2 8.7 16.0 1.5 20.7 790 Employed for cash 0.6 17.0 12.3 17.0 1.5 22.2 1,874 Employed not for cash 1.0 31.7 26.3 31.5 6.0 47.0 90 Number of living children 0 0.9 15.8 12.9 17.2 1.3 22.9 1,321 1-2 0.4 15.8 9.7 17.0 2.1 22.2 1,100 3-4 0.5 18.0 13.5 17.9 1.4 22.2 322 5+ * * * * * * 13 Marital status Never married 1.0 16.0 12.9 17.2 1.4 23.2 1,190 Married or living together 0.4 15.8 10.3 16.5 1.5 21.3 1,506 Divorced/separated/ widowed (0.0) (27.5) (22.5) (33.7) (9.1) (42.3) 59 Residence Urban 0.7 9.5 7.1 12.0 1.2 15.1 1,558 Rural 0.7 24.7 17.7 23.9 2.2 32.3 1,197 Region Yerevan 0.2 1.3 1.0 3.1 0.9 3.8 833 Aragatsotn 0.0 3.1 3.3 3.7 0.0 4.3 159 Ararat 0.0 0.8 0.8 0.2 0.0 1.2 290 Armavir 1.4 28.5 13.9 12.1 2.1 34.5 268 Gegharkunik 0.3 77.3 99.0 97.7 6.4 100.0 235 Lori 0.4 2.5 0.4 9.5 0.0 9.9 184 Kotayk 0.0 14.9 4.7 17.1 0.3 22.7 299 Shirak 4.5 33.4 3.5 38.0 6.2 50.9 201 Syunik 2.3 2.3 5.5 7.8 3.0 10.4 104 Vayots Dzor 0.0 22.3 13.8 18.8 0.4 24.2 56 Tavush 0.3 29.1 1.2 12.2 0.0 31.3 126 Education Basic 1.0 22.0 13.6 17.8 2.4 30.3 360 Secondary 0.6 20.2 16.3 22.8 2.2 27.9 1,250 Secondary special 0.6 13.0 6.8 14.1 1.5 18.9 403 Higher 0.6 8.1 5.8 9.1 0.5 11.9 736 Wealth quintile Lowest 0.5 22.6 16.3 19.1 2.3 29.2 523 Second 1.2 23.2 15.0 23.1 1.8 30.6 583 Middle 0.4 19.5 17.5 24.7 2.8 28.8 521 Fourth 1.0 10.2 5.9 11.9 0.9 15.6 566 Highest 0.2 5.5 4.4 7.6 0.4 9.3 562 Total 0.7 16.1 11.7 17.2 1.6 22.6 2,755 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. Total includes 1 man with missing information on employment and 5 men with no education. Women’s Empowerment • 249 Among women age 15-49, agreement with specific reasons justifying wife beating ranges from a low of less than 1 percent if she burns the food to a high of 9 percent if she neglects the children. Agreement with each reason justifying wife beating is higher among men than women and ranges from a low of 1 percent if she burns the food to 17 percent if she neglects the children. Overall, 10 percent of women and 23 percent of men agree that wife beating is justified for at least one of the specified situations. Whether women believe a husband is justified in wife beating for any of the specified reasons increases marginally with age and number of children and is relatively high among women who are employed but do not earn cash (26 percent). Agreement with at least one reason is more than twice as high among women in rural areas (16 percent) as among women in urban areas (6 percent). In addition, women who have never been married (8 percent) and those who were previously married (5 percent) are less likely than currently married women (11 percent) to believe that there are occasions when wife beating is justified. Attitudes toward wife beating vary considerably across regions, with acceptance of wife beating ranging from 2 to 3 percent in Yerevan, Armavir, and Syunik to 40 to 41 percent in Gegharkunik, Aragatsotn, and Vayots Dzor. Acceptance of wife beating among women tends to vary inversely with education and wealth. The percentage of men who believe a husband is justified in beating his wife for any of the specified reasons varies inconsistently with age, and men who are employed but do not earn cash are much more likely to justify wife beating (47 percent) than unemployed men or men employed for cash (21-22 percent). Similar to women, men in rural areas (32 percent) are more likely than those in urban areas (15 percent) to agree with at least one specified justification for wife beating. Men in Ararat (1 percent) are least likely to agree with at least one specified reason, while men in Gegharkunik are most likely (100 percent) to do so. As observed for women, the percentage of men who agree with at least one of the specified reasons that justify wife beating is highest among the least educated and poorest men. There has been virtually no change in attitudes toward wife beating among either women or men since the 2010 ADHS, suggesting little or no change in gender attitudes. The proportions of women (9 percent) and men (20 percent) who agreed with at least one of the specified reasons that justify wife beating in 2010 are both marginally lower than the corresponding proportions in 2015-16 (10 percent and 23 percent). 15.6 ATTITUDES TOWARD AND ABILITY TO NEGOTIATE SAFER SEX WITH HUSBANDS The 2015-16 ADHS asked women and men if they believe that a wife is justified in refusing to have sexual intercourse with her husband if she knows he has sexual intercourse with other women and that a woman is justified in asking that they use a condom if she knows that her husband has a sexually transmitted infection (STI). Believing in a woman’s right to refuse sex for any reason and believing in her right to request condom use if she perceives the need for it are both important for negotiating safer sex with husbands. Safer sex protects women and their partners against many diseases, and the ability to have safer sex is an important aspect of women’s empowerment. Table 15.11 shows that 85 percent of women and 73 percent of men age 15-49 agree that a woman can refuse to have sexual intercourse with her husband if she knows that he has sex with other women; also, 87 percent of women and 93 percent of men agree that a woman can ask that they use a condom if she knows that her husband has an STI. In general, attitudes among women favoring women’s right to negotiate safer sex with their husbands tend to increase with increasing age, education, and wealth, and these attitudes are more common in urban than rural areas. Ever-married women are more likely to hold favorable attitudes than never-married women. Although agreement varies by region, a majority of women in all regions favor these rights of women for negotiating safer sex. Notably, agreement with a woman’s right to refuse sexual intercourse with her husband if she knows he has sex with other women is lowest at 61 percent in Tavush, and agreement with a woman’s right to ask that they use a condom if she knows that her husband has an STI is lowest at 72 percent in Gegharkunik and Syunik. 250 • Women’s Empowerment Table 15.11 Attitudes toward negotiating safer sexual relations with husband Percentage of women and men age 15-49 who believe that a woman is justified in refusing to have sexual intercourse with her husband if she knows that he has sexual intercourse with other women, and percentage who believe that a woman is justified in asking that they use a condom if she knows that her husband has a sexually transmitted infection (STI), according to background characteristics, Armenia 2015-16 Background characteristic Women Men Woman is justified in: Number of women Woman is justified in: Number of men Refusing to have sexual intercourse with her husband if she knows he has sex with other women Asking that they use a condom if she knows that her husband has an STI Refusing to have sexual intercourse with her husband if she knows he has sex with other women Asking that they use a condom if she knows that her husband has an STI Age 15-24 73.4 75.7 1,653 64.0 86.0 813 15-19 63.0 64.7 725 57.8 81.5 345 20-24 81.5 84.3 928 68.5 89.4 467 25-29 87.3 89.7 1,099 72.9 95.8 464 30-39 89.6 91.7 1,874 76.3 95.1 802 40-49 88.4 91.6 1,490 78.4 96.3 676 Marital status Never married 73.7 75.4 1,830 66.2 87.9 1,190 Ever had sex * 100.0 12 69.5 93.9 631 Never had sex 73.8 75.2 1,818 62.5 81.2 559 Married/living together 89.1 91.8 3,895 77.5 96.6 1,506 Divorced/separated/ widowed 89.2 93.3 390 (75.6) (95.9) 59 Residence Urban 89.4 91.6 3,657 70.6 92.5 1,558 Rural 77.3 80.1 2,459 75.2 93.2 1,197 Region Yerevan 95.0 96.6 2,001 65.3 92.9 833 Aragatsotn 81.0 84.2 315 84.5 97.1 159 Ararat 84.9 84.8 552 80.9 94.4 290 Armavir 77.1 79.2 586 94.9 95.8 268 Gegharkunik 70.1 71.6 478 96.1 97.9 235 Lori 90.1 89.8 355 64.9 73.3 184 Kotayk 84.5 92.5 678 47.1 98.7 299 Shirak 81.7 82.2 510 97.4 97.8 201 Syunik 74.4 71.9 238 69.0 69.1 104 Vayots Dzor 82.8 88.7 119 52.5 92.0 56 Tavush 61.2 73.5 283 38.8 94.0 126 Education Basic 59.2 65.0 396 72.0 89.3 360 Secondary 81.0 83.5 2,444 74.6 93.1 1,250 Secondary special 88.0 89.3 1,360 71.4 91.3 403 Higher 92.1 94.7 1,910 70.2 95.0 736 Wealth quintile Lowest 73.8 75.8 1,081 78.4 92.4 523 Second 81.8 84.0 1,242 74.7 93.1 583 Middle 83.7 87.0 1,142 71.6 93.0 521 Fourth 88.2 90.5 1,287 74.8 93.1 566 Highest 92.8 95.3 1,365 63.7 92.5 562 Total 84.5 87.0 6,116 72.6 92.8 2,755 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. Figures in parentheses are based on 25-49 unweighted cases. Total includes 5 women with no education. Men’s attitudes towards a woman’s right to negotiate safer sex generally vary less by background characteristics than attitudes among women. Rural men appear to have more favorable attitudes towards a woman’s right to negotiate safer sex than urban men, and the wealthiest men appear less likely than most other men to have these attitudes. Only 39 percent of men in Tavush agree with a woman’s right to refuse sexual intercourse with her husband if she knows he has sex with other women, and agreement with this right is also below 50 percent in Kotayk. By contrast, agreement with a woman’s right to ask that they use a condom if she knows that her husband has an STI is high in most regions, with the lowest percentage among men in Syunik (69 percent). Women’s Empowerment • 251 In addition to asking about women’s and men’s attitudes regarding a wife’s right to negotiate safer sex with her husband, the 2015-16 ADHS asked currently married women about their own ability to negotiate safer sex. In particular, currently married women age 15-49 were asked if they can say no to their husband if they do not want to have sexual intercourse and if they can ask their husband to use a condom. Table 15.12 shows the percentages of currently married women who said yes to each of these questions by background characteristics. Overall, less than half of currently married women (48 percent in each case) report that they can say no to their husband if they do not want to have sexual intercourse and that they can ask their husband to use a condom. Only 17 percent of currently married women age 15-24 say yes to each of the two questions about their ability to negotiate safer sex; however, this proportion tends to rise sharply with age. Among women age 40-49, 63 percent report that they can say no to their husband if they do not want to have sex, and 59 percent say that they can ask their husband to use a condom. The rural-urban differential in women’s ability to negotiate safer sex with their husband is very small, with urban women only slightly more likely than rural women to say yes to either question. Women’s ability to negotiate safer sex with their husband increases with increasing wealth but varies inconsistently with education; women with a secondary special education are most likely to say yes to both questions, and women with a basic education are least likely to do so. The percentage of women who report that they are able to say no to their husband if they do not want to have sexual intercourse ranges from a high of 55 percent in Tavush and Lori to a low of 31 percent in Gegharkunik, while the percentage of women who say that they can ask their husband to use a condom varies from a high of 61 percent in Tavush to a low of 28 percent in Gegharkunik. 15.7 INDICATORS OF WOMEN’S EMPOWERMENT The two sets of empowerment indicators, namely women’s participation in making household decisions and their attitudes toward wife beating, are summarized in two separate indices. The first index shows the number of decisions (see Table 15.9.1 for the list of decisions) in which women participate alone or jointly with their husbands. This index ranges in value from 0 to 3 and is positively related to women’s empowerment. It reflects the degree of decision-making control that women are able to exercise in areas that affect their own lives and environments. The second indicator, which ranges in value from 0 to 5, is the total number of reasons (see Table 15.10.1 for the list of reasons) for which the woman feels that a husband is justified in beating his wife. A lower score on this indicator is interpreted as reflecting a greater sense of entitlement and self-esteem and higher status. Table 15.12 Ability to negotiate sexual relations with husband Percentage of currently married women age 15-49 who can say no to their husband if they do not want to have sexual intercourse, and percentage who can ask their husband to use a condom, according to background characteristics, Armenia 2015-16 Background characteristic Percentage who can say no to their husband if they do not want to have sexual intercourse Percentage who can ask their husband to use a condom Number of women Age 15-24 16.7 17.2 1,653 15-19 3.4 3.4 725 20-24 27.2 27.9 928 25-29 50.7 53.0 1,099 30-39 61.7 62.2 1,874 40-49 63.2 59.1 1,490 Residence Urban 49.6 49.7 3,657 Rural 45.4 44.5 2,459 Region Yerevan 51.3 50.7 2,001 Aragatsotn 33.0 30.8 315 Ararat 47.2 49.1 552 Armavir 49.5 47.9 586 Gegharkunik 31.2 28.2 478 Lori 54.7 48.0 355 Kotayk 43.8 52.2 678 Shirak 52.0 54.3 510 Syunik 53.8 35.7 238 Vayots Dzor 49.4 47.9 119 Tavush 55.1 60.9 283 Education Basic 31.2 24.0 396 Secondary 46.9 47.2 2,444 Secondary special 54.9 55.0 1,360 Higher 47.8 47.9 1,910 Wealth quintile Lowest 42.8 39.9 1,081 Second 45.3 45.8 1,242 Middle 47.3 46.2 1,142 Fourth 47.7 49.6 1,287 Highest 55.1 54.8 1,365 Total 47.9 47.6 6,116 Note: Total includes 5 women with no education. 252 • Women’s Empowerment Table 15.13 shows how these indicators relate to each other among currently married women. In general, the expectation is that women who participate in making household decisions are also more likely to have gender-egalitarian beliefs. The data show that there is the expected positive relationship between the number of decisions in which women participate and the proportion who disagree with all of the reasons justifying a husband beating his wife. Table 15.13 shows that 72 percent of women who do not participate in any of the household decisions disagree with all of the given reasons for a husband beating his wife, as compared with 89 percent of women who participate in all three decisions. The second panel in Table 15.13 shows that participation in all household decisions declines as the number of justifications for wife beating increases, from 78 percent among women who agree with none of the reasons justifying wife beating to 66 percent among women who agree with three to four reasons. The number of cases of women agreeing with all five reasons is too small to allow any conclusion. 15.8 CONTRACEPTIVE USE BY WOMEN’S STATUS A woman’s ability to control her fertility and use a method of contraception is likely to be affected by her sense of empowerment and belief in her ability to control her sexual life and fertility. A woman who feels that she is unable to control other aspects of her life may be less likely to feel that she can make decisions regarding fertility. Table 15.14 shows the relationship of each of the two empowerment indices with current use of contraceptive methods among currently married women age 15-49. The data indicate that there is a positive association between the two empowerment indices and contraceptive use. For example, the proportion of married women who are using any method of contraception is lower among those who do not participate in household decision making (44 percent) than among those who participate in one or more decisions (57-58 percent). Use of modern methods follows the same pattern: 16 percent of women who do not participate in any of the household decisions are using a modern method, as compared with 28-30 percent of women who participate in at least one decision. The relationship between contraceptive use and the empowerment indicator based on attitudes toward wife beating is more complex. Women who agree with 3-4 reasons for wife beating are much more likely than women who do not agree with any reason to use a traditional method. By contrast, modern contraception use is much higher among women who do not agree with any reason for wife beating (29 percent) than among women who agree with 3-4 reasons (18 percent). This suggests that while modern contraceptive use varies positively according to women’s empowerment, use of traditional methods may be inversely related to empowerment. Table 15.13 Indicators of women's empowerment Percentage of currently married women age 15-49 who participate in all decision making and the percentage who disagree with all of the reasons justifying wife beating, according to value on each of the indicators of women's empowerment, Armenia 2015-16 Empowerment indicator Percentage who participate in all decision making Percentage who disagree with all reasons justifying wife beating Number of women Number of decisions in which women participate1 0 na 71.9 79 1-2 na 87.4 814 3 na 89.4 3,002 Number of reasons for which wife beating is justified2 0 77.7 na 3,452 1-2 76.4 na 278 3-4 66.3 na 153 5 * na 12 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. na = Not applicable 1 See Table 15.9.1 for the list of decisions. 2 See Table 15.10.1 for the list of reasons. Women’s Empowerment • 253 Table 15.15 shows how unmet need for family planning varies by the two empowerment indicators. As was the case with contraceptive use, the relationship of the empowerment indicators with unmet need is nuanced and needs to be interpreted with care. Unmet need is higher among women who do not participate in any of the three household decisions (20 percent) than among women who participate in one or more decisions (12 percent); it is also higher among women who do not agree with any reason for wife beating than among women who do. The latter result is more consistent with the idea that women who are more empowered may be more desirous of controlling their fertility, and, if they are not able to access family planning, they will have a higher level of unmet need. In keeping with the idea of more empowered women desiring fewer children, Table 15.15 also shows that the mean ideal number of children is lower among women who participate in at least one household decision (2.7 children) and among women who do not agree with any reason for wife beating (2.6 children) than among women who do not participate in any decisions (3.0 children) and who agree with one or more reasons for wife beating (2.8 to 3.0 children). Table 15.14 Current use of contraception by women's empowerment Percent distribution of currently married women age 15-49 by current contraceptive method, according to selected indicators of women's status, Armenia 2015-16 Empowerment indicator Any method Any modern method1 Modern methods Any traditional method Not currently using Total Number of women Female sterili- zation Tem- porary modern female methods2 Male condom Number of decisions in which women participate3 0 43.7 15.5 1.1 5.6 8.8 28.2 56.3 100.0 79 1-2 58.2 30.1 0.7 14.2 15.2 28.1 41.8 100.0 814 3 57.2 27.7 0.7 12.3 14.7 29.5 42.8 100.0 3,002 Number of reasons for which wife beating is justified4 0 55.8 28.7 0.7 12.8 15.2 27.1 44.2 100.0 3,452 1-2 65.3 25.9 0.2 12.5 13.2 39.4 34.7 100.0 278 3-4 71.5 18.1 0.4 9.0 8.6 53.4 28.5 100.0 153 5 * * * * * * * 100.0 12 Total 57.1 28.0 0.7 12.6 14.7 29.2 42.9 100.0 3,895 Note: If more than one method is used, only the most effective method is considered in this tabulation. An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Female sterilization, male sterilization, pill, IUD, injectables, implants, male condom, female condom, emergency contraception, lactational amenorrhea method (LAM), and other modern methods 2 Pill, IUD, injectables, implants, female condom, emergency contraception, lactational amenorrhea method, and other modern methods 3 See Table 15.9.1 for the list of decisions. 4 See Table 15.10.1 for the list of reasons. 254 • Women’s Empowerment Table 15.15 Ideal number of children and unmet need for family planning by women's empowerment Mean ideal number of children for women age 15-49 and percentage of currently married women age 15-49 with an unmet need for family planning, according to indicators of women's empowerment, Armenia 2015-16 Empowerment indicator Mean ideal number of children1 Number of women Percentage of currently married women with an unmet need for family planning2 Number of currently married women For spacing For limiting Total Number of decisions in which women participate3 0 3.0 79 14.0 5.6 19.6 79 1-2 2.7 803 8.7 3.6 12.2 814 3 2.7 2,963 5.3 7.1 12.4 3,002 Number of reasons for which wife beating is justified4 0 2.6 5,361 6.5 6.7 13.1 3,452 1-2 2.8 384 3.6 5.5 9.1 278 3-4 3.0 213 2.6 1.3 4.0 153 5 * 17 * * * 12 Total 2.6 5,974 6.1 6.4 12.5 3,895 Note: An asterisk denotes a figure based on fewer than 25 unweighted cases that has been suppressed. 1 Mean excludes respondents who gave non-numeric responses. 2 Figures for unmet need correspond to the revised definition described in Bradley et al. 2012. 3 Restricted to currently married women. See Table 15.9.1 for the list of decisions. 4 See Table 15.10.1 for the list of reasons. In societies where health care is widespread, such as in Armenia, women’s status may not affect their access to health services. In other societies, however, increased empowerment among women is likely to increase their ability to seek out and use health services to better meet their reproductive health goals, including the goal of safe motherhood. As a woman becomes more empowered, she is more likely to have a say in the number and spacing of children she desires. However, in Armenia, almost all women received antenatal care or delivery care from health personnel for their most recent birth in the five years preceding the survey, and almost all births were delivered at a health facility (see Chapter 9). 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World Health Organization (WHO). 2015b. “WHO Statement on Caesarean Section Rates.” Reproductive Health Matters 23(45):149-150. 258 • References World Health Organization (WHO). 2016. Violence against Women: Intimate Partner and Sexual Violence against Women. Fact sheet. Accessed in September 2016. http://www.who.int/mediacentre/factsheets/fs239/en/. World Health Organization (WHO). 2017. Armenia Tuberculosis 2015. https://extranet.who.int/sree/ Reports?op=Replet&name=%2FWHO_HQ_Reports%2FG2%2FPROD%2FEXT%2FTBCountryProfile&I SO2=AM&LAN=EN&outtype=html. World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC). 2008. Worldwide Prevalence of Anaemia 1993–2005: WHO Global Database on Anaemia. Edited by Bruno de Benoist, Erin McLean, Ines Egli, and Mary Cogswell. Geneva, Switzerland: WHO and Atlanta, GA, USA: (CDC). Accessed on 12 December 2016. http://www.who.int/nutrition/publications/micronutrients/anaemia_iron_deficiency/9789241596657/en/. World Health Organization (WHO) and UNICEF. 1998. Complementary Feeding of Young Children in Developing Countries: A Review of Current Scientific Knowledge. Geneva, Switzerland: WHO and UNICEF. WHO Multicentre Growth Reference Study Group. 2006. WHO Child Growth Standards: Length/Height- for-Age, Weight-for-Age, Weight-for-Length, Weight-for-Height and Body Mass Index-for-Age: Methods and Development. Geneva, Switzerland: World Health Organization. World Health Organization, Regional Office for Europe (WHO-EURO). 2013. Health 2020. A European Policy Framework and Strategy for the 21st Century. WHO Regional Office for Europe, Copenhagen, Denmark. http://www.euro.who.int/en/health-topics/health-policy/health-2020-the-european-policy-for- health-and-well-being/publications/2013/health-2020.-a-european-policy-framework-and-strategy-for-the- 21st-century-2013. World Health Organization, Regional Office for Europe (WHO-EURO). 2015. HIV Programme Review in Armenia (2015). http://www.euro.who.int/en/health-topics/communicable- diseases/hivaids/publications/2015/hiv-programme-review-in-armenia-2015. No authors listed. 1985. “Appropriate Technology for Birth.” Lancet 326 (8452): 436-437. Appendix A • 259 SAMPLE DESIGN APPENDIX A A.1 INTRODUCTION he 2015-16 Armenia Demographic and Health Survey (2015-16 ADHS) is the fourth DHS survey conducted in Armenia, following those carried out in 2000, 2005, and 2010. A nationally representative sample of 8,764 households was selected for the 2015-16 ADHS from 313 clusters. All women age 15-49 who were usual members of the selected households or who stayed the night before the survey in the households were eligible for the survey interview. The main objectives of the interviews with women were to provide up-to-date information on fertility and fertility preferences, abortions, awareness and use of family planning methods, maternal and child health, and knowledge and attitudes regarding HIV/AIDS and other sexually transmitted infections (STIs). In addition, the ADHS collected domestic violence data from one randomly selected woman age 15-49 in each household. The survey also collected information on several biomarkers for women as well as for young children. All women age 15-49 living in the households sampled for the 2015-16 ADHS were asked to provide a few drops of blood from a finger prick for on-the-spot anemia testing, and parents or guardians of all children age 6-59 months living in the interviewed households were asked for permission to test the children for anemia. All women age 15-49 and all children age 0-59 months were also eligible for collection of anthropometric indicators (height and weight). Finally, a male survey was simultaneously conducted in a subsample of one-half of the households selected for the 2015-16 ADHS. All men age 15-49 who were usual members of the selected households or who stayed the night before the survey in the households were eligible for the male survey, which collected information on men’s demographic status and knowledge and attitudes regarding family planning methods and HIV/AIDS and other STIs. A.2 SAMPLE FRAME Armenia is divided into 10 marz (regions). Each marz is in turn sub-divided into communities, and each community is sub-divided into settlements. The capital city of Yerevan, considered a special region, is sub-divided into 12 urban districts. The 2015-16 ADHS was designed to produce representative results for the country as a whole, for urban and rural areas separately at the national level, for the city of Yerevan, and for each of the 10 administrative regions (marz). Table A.1 shows the distribution of residential households at the time of the census by region and by type of residence (urban and rural). The regional share of households varies from 2 percent for Vayots Dzor to 34 percent for Yerevan. In Armenia, 65 percent of residential households are in urban areas, and, among urban households, more than half are in Yerevan. By region, the percentage of households that are urban varies from 24 percent in Aragatsotn to 100 percent in Yerevan. T 260 • Appendix A Table A.1 Households Distribution of residential households in the sampling frame by region and residence, Armenia 2015-16 Region Number of households in the frame Percent urban Percentage of total households in the frame Urban Rural Total Yerevan 271,125 na 271,125 100.0 33.8 Aragatsotn 8,303 26,507 34,810 23.9 4.3 Ararat 19,670 47,982 67,652 29.1 8.4 Armavir 23,722 41,506 65,228 36.4 8.1 Gegharkunik 20,805 33,878 54,683 38.0 6.8 Lori 50,651 31,680 82,331 61.5 10.2 Kotayk 43,107 28,029 71,136 60.6 8.9 Shirak 40,126 27,358 67,484 59.5 8.4 Syunik 25,370 12,670 38,040 66.7 4.7 Vayots Dzor 5,555 8,801 14,356 38.7 1.8 Tavush 14,927 21,556 36,483 40.9 4.5 Armenia 523,361 279,967 803,328 65.1 100.0 na = Not applicable Source: 2011 APHC The sampling frame used in the survey was provided by the National Statistical Service (NSS) of Armenia, the implementing agency for the 2015-16 ADHS. The frame, which is based on the 2011 Armenia Population and Housing Census (2011 APHC), includes a complete list of census enumeration areas (EAs). For each EA, the frame includes basic identification information such as region and other administrative designations. Each EA in the frame is also classified into one of the two types of residence, urban or rural. In rural areas, an EA is a natural village, a segment of a large village, or a group of small villages; in urban areas, an EA is a street or a city block. In addition, the frame includes the number of residential households in the EA, which served as the measure of size for the EA during sample selection. At the time of the census, cartographical materials were prepared for each EA that delineated its geographical location, boundaries, main access routes, and landmarks in or outside the EA that could be used to help to identify it. The NSS EA frame was not linked to these cartographic materials, which were maintained by another institution. Because of the lack of EA maps, the complete list of residential households with household addresses recorded in the population census was used to identify the selected EAs during the 2015-16 ADHS household listing operation. Table A.2 presents the number of EAs in the 2015-16 ADHS sampling frame and the average number of residential households in each EA, by region and by type of residence. Of the total of 11,571 EAs, 6,613 are in urban areas and 4,958 are in rural areas. Overall, each EA has an average of 69 households, with EAs in urban areas averaging 79 households and those in rural areas averaging 56 households. Table A.2 Enumeration areas Distribution of enumeration areas in the sampling frame and the average number of residential households per enumeration area, by region and residence, Armenia 2015-16 Region Number of enumeration areas in frame Average number of residential households in enumeration area Urban Rural Total Urban Rural Total Yerevan 3,522 na 3,522 77 na 77 Aragatsotn 116 483 599 72 55 58 Ararat 257 813 1,070 77 59 63 Armavir 317 800 1,117 75 52 58 Gegharkunik 278 652 930 75 52 59 Lori 560 450 1,010 90 70 82 Kotayk 474 524 998 91 53 71 Shirak 527 500 1027 76 55 66 Syunik 323 238 561 79 53 68 Vayots Dzor 70 156 226 79 56 64 Tavush 169 342 511 88 63 71 Armenia 6,613 4,958 11,571 79 56 69 na = Not applicable Source: 2011 APHC Appendix A • 261 A.3 SAMPLE DESIGN AND IMPLEMENTATION The sample for the 2015-16 ADHS was a stratified sample selected in two stages. Stratification was achieved by separating each region into urban and rural areas. In total, 21 sampling strata were created, since Yerevan has only urban areas. Samples were selected independently in each stratum via a two-stage selection procedure. Implicit stratification and proportional allocation were achieved by sorting the sampling frame within each sampling stratum according to administrative units before sample selection. In the first stage, a total of 313 EAs were selected with probability proportional to EA size. The sample selected at the second stage was fixed at 28 households per EA, resulting in a total sample of 8,764 households. Table A.3 shows the allocation of EAs and households selected by region and residence. Among the 313 EAs, 192 came from urban areas and 121 came from rural areas. With regard to the household sample, 5,376 households were from urban areas and 3,388 from rural areas. Table A.3 Sample allocation of enumeration areas and households Sample allocation of enumeration areas and households by region, according to residence, Armenia 2015-16 Region Allocation of enumeration areas Allocation of households Urban Rural Total Urban Rural Total Yerevan 48 0 48 1,344 0 1,344 Aragatsotn 11 12 23 308 336 644 Ararat 14 14 28 392 392 784 Armavir 15 13 28 420 364 784 Gegharkunik 14 12 26 392 336 728 Lori 18 13 31 504 364 868 Kotayk 17 12 29 476 336 812 Shirak 17 12 29 476 336 812 Syunik 15 10 25 420 280 700 Vayots Dzor 10 12 22 280 336 616 Tavush 13 11 24 364 308 672 Armenia 192 121 313 5,376 3,388 8,764 Table A.4 shows the expected number of completed interviews with women and men by region and residence. The allocations were based on information from the 2010 ADHS. In the 2010 ADHS, household response rates were 87 percent in urban areas and 92 percent in rural areas. The average number of women age 15-49 per household was 0.86 in urban areas and 1.02 in rural areas. Women’s individual response rates were 97 percent in urban areas and 99 percent in rural areas. The average number of men age 15-49 per household was 0.72 in urban areas and 0.85 in rural areas. Men’s individual response rates were 96 percent in urban areas and 97 percent in rural areas. The sample allocation for the 2015-16 ADHS involved a power allocation with small adjustments because of the large regional size variations. As detailed in Table A.4, the 2015-16 ADHS was expected to achieve about 7,000 completed interviews with women age 15-49, with a minimum sample of 514 for the region of Vayots Dzor and a maximum sample of 976 for the city of Yerevan. The expected number of completed interviews with men age 15-49 was 2,839, 1,569 in urban areas and 1,270 in rural areas. The regional sample sizes for the 2015- 16 ADHS are small relative to DHS surveys in other countries, where a minimum of 800 interviews with women per region is generally recommended. With the 2015-16 ADHS sample size, adequate survey precision for women’s indicators at the regional level is expected to be at the 10% level or above. 262 • Appendix A Table A.4 Sample allocation of completed interviews with women and men Sample allocation of expected number of completed interviews with women and men by region, according to residence, Armenia 2015-16 Region Women 15-49 Men 15-49 Urban Rural Total Urban Rural Total Yerevan 976 0 976 392 0 392 Aragatsotn 224 310 534 90 126 216 Ararat 284 362 646 114 147 261 Armavir 305 337 642 123 136 259 Gegharkunik 284 310 594 114 126 240 Lori 365 337 702 147 136 283 Kotayk 346 310 656 139 126 265 Shirak 346 310 656 139 126 265 Syunik 305 259 564 123 105 228 Vayots Dzor 204 310 514 82 126 208 Tavush 265 285 550 106 116 222 Armenia 3,904 3,130 7,034 1,569 1,270 2,839 Note: Male surveys were conducted in half of the households selected for interviews with women. A household listing operation was carried out in all of the selected EAs before the main survey. The listing operation consisted of visiting each of the 313 selected EAs to draw a location map and a detailed sketch map and to record on the household listing forms the address and the name of the head of the household for all residential households found in the EA. The resulting list of households served as the sampling frame for the selection of households in the second stage. In the second stage, a fixed number of 28 households was selected from each of the EAs included. No replacements and no changes in the pre- selected households were allowed in the implementing stages to prevent bias. The interviewers were asked to make at least two to three callbacks for households that could not be interviewed during the first visit in order to keep the nonresponse rate low. A.4 SAMPLE PROBABILITIES AND SAMPLE WEIGHTS Because of the non-proportional allocation of the sample to the different regions and to urban and rural areas, and because of the differences in response rates, analysis of the 2015-16 ADHS requires that the data be weighted to ensure the representation of the survey results at the national level as well as at the domain levels. Because the 2015-16 ADHS sample was a two-stage stratified cluster sample, sampling weights were based on sampling probabilities calculated separately for each sampling stage and for each cluster. P1hi: first-stage sampling probability of selecting the ith EA in stratum h P2hi: second-stage sampling probability within the ith EA (household selection) The following describes the calculation of the probabilities of selection in the first stage. In cases where the ADHS cluster was an entire EA, let ah be the number of EAs selected in stratum h, Mhi the total number of households according to the sampling frame in the ith EA, and M hi the total number of households in stratum h. The probability of selecting the ith EA in the 2015-16 ADHS sample is calculated as follows: M M a = P hi hih 1hi  The following describes the calculation of the probabilities of selection in the second stage. Appendix A • 263 Let hiL be the number of households listed in the household listing operation in cluster i in stratum h, and let hig be the number of households selected in that cluster. The selection probability for each household in the cluster is calculated as follows: hi hi hi L g P 2 The overall selection probability for each household in cluster i of stratum h is the product of the first- and second-stage selection probabilities: hihihi PPP 21  The design weight for each household in cluster i of stratum h is the inverse of its overall selection probability: hihi PW /1 A spreadsheet containing all of the sampling parameters and selection probabilities was prepared to facilitate the calculation of the design weights. The design weights were adjusted for nonresponse to obtain sampling weights for households and for women and men. In turn, the sampling weights were normalized so that, at the national level, the total number of weighted cases would be equal to the total number of unweighted cases. The normalized weights are relative weights that are valid for estimating means, proportions, and ratios but not for estimating population totals and pooled data. In addition, the number of cases obtained by applying the normalized weights has no direct relation with survey precision because it is relative; therefore, especially for oversampled areas, the number of weighted cases will be much smaller than the number of unweighted cases, which is directly related to survey precision. Four sets of general weights were calculated for the 2015-16 ADHS:  one set for all households selected for the survey  one set for women  one set for households selected for the male survey  one set for men In addition, there were two sets of special weights that applied to the subsample of women age 15- 49 selected randomly for the domestic violence module and the subsample of children age 1-14 selected for the child discipline module. A.5 SURVEY IMPLEMENTATION Tables A.5 and A.6 show the results of the household and individual interviews by residence and region. 26 4 • A pp en di x A Ta bl e A .5 S am pl e im pl em en ta tio n: W om en P er ce nt d is tri bu tio n of h ou se ho ld s an d el ig ib le w om en b y re su lts o f t he h ou se ho ld a nd in di vi du al in te rv ie w s, a nd h ou se ho ld , e lig ib le w om en ’s , a nd o ve ra ll w om en ’s r es po ns e ra te s, a cc or di ng to u rb an -r ur al re si de nc e an d re gi on (u nw ei gh te d) , A rm en ia 2 01 5- 16 R es ul t R es id en ce R eg io n To ta l U rb an R ur al Y er ev an A ra ga ts ot n A ra ra t A rm av ir G eg ha rk un ik Lo ri K ot ay k S hi ra k S yu ni k V ay ot s D zo r Ta vu sh S el ec te d ho us eh ol ds C om pl et ed (C ) 89 .5 91 .3 93 .2 86 .3 92 .7 87 .6 92 .7 78 .7 92 .9 86 .8 96 .9 88 .5 95 .8 90 .2 H ou se ho ld p re se nt b ut n o co m pe te nt re sp on de nt at h om e (H P ) 1. 4 1. 1 0. 3 0. 0 0. 6 1. 3 0. 0 1. 5 1. 8 4. 3 0. 0 4. 7 0. 0 1. 3 P os tp on ed (P ) 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 R ef us ed (R ) 2. 5 1. 9 2. 2 0. 2 1. 5 2. 1 0. 0 9. 4 1. 8 3. 2 0. 1 0. 5 1. 6 2. 3 D w el lin g no t f ou nd (D N F) 0. 1 0. 0 0. 3 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 H ou se ho ld a bs en t ( H A ) 5. 6 5. 0 3. 1 11 .8 4. 7 7. 6 5. 9 9. 4 3. 2 4. 0 2. 3 6. 3 2. 5 5. 3 D w el lin g va ca nt /a dd re ss no t a d w el lin g (D V ) 0. 5 0. 2 0. 8 0. 5 0. 0 0. 4 0. 7 0. 5 0. 0 0. 9 0. 3 0. 0 0. 0 0. 4 D w el lin g de st ro ye d (D D ) 0. 1 0. 0 0. 1 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 2 0. 0 0. 0 0. 0 0. 0 O th er (O ) 0. 4 0. 5 0. 0 1. 2 0. 4 1. 0 0. 7 0. 5 0. 2 0. 6 0. 4 0. 0 0. 0 0. 4 To ta l 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 N um be r o f s am pl ed ho us eh ol ds 5, 36 9 3, 38 0 1, 34 0 64 4 78 4 77 6 72 8 86 8 81 2 80 9 70 0 61 6 67 2 8, 74 9 H ou se ho ld re sp on se ra te (H R R )1 95 .8 96 .8 97 .0 99 .8 97 .7 96 .3 10 0. 0 87 .8 96 .2 92 .0 99 .9 94 .5 98 .3 96 .2 E lig ib le w om en C om pl et ed (E W C ) 97 .6 98 .1 99 .4 99 .8 99 .5 98 .2 99 .5 83 .6 98 .4 96 .9 99 .5 99 .8 97 .5 97 .8 N ot a t h om e (E W N H ) 0. 4 0. 5 0. 0 0. 0 0. 0 0. 2 0. 0 2. 2 1. 0 1. 3 0. 0 0. 0 1. 2 0. 5 P os tp on ed (E W P ) 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 2 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 R ef us ed (E W R ) 1. 6 1. 1 0. 2 0. 0 0. 3 1. 1 0. 4 13 .6 0. 3 1. 6 0. 0 0. 0 1. 2 1. 4 P ar tly c om pl et ed (E W P C ) 0. 1 0. 1 0. 2 0. 2 0. 0 0. 0 0. 2 0. 0 0. 0 0. 2 0. 3 0. 0 0. 2 0. 1 In ca pa ci ta te d (E W I) 0. 2 0. 2 0. 2 0. 0 0. 2 0. 6 0. 0 0. 2 0. 3 0. 0 0. 3 0. 2 0. 0 0. 2 O th er (E W O ) 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 To ta l 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 N um be r o f w om en 3, 63 1 2, 62 0 1, 06 1 45 4 60 0 65 4 55 4 40 3 67 0 55 3 38 5 40 6 51 1 6, 25 1 E lig ib le w om en re sp on se ra te (E W R R )2 97 .6 98 .1 99 .4 99 .8 99 .5 98 .2 99 .5 83 .6 98 .4 96 .9 99 .5 99 .8 97 .5 97 .8 O ve ra ll w om en re sp on se ra te (O R R )3 93 .5 95 .0 96 .5 99 .6 97 .2 94 .5 99 .5 73 .4 94 .6 89 .2 99 .3 94 .2 95 .8 94 .1 1 U si ng th e nu m be r o f h ou se ho ld s fa lli ng in to s pe ci fic re sp on se c at eg or ie s, th e ho us eh ol d re sp on se ra te (H R R ) i s ca lc ul at ed a s: 1 00 * C _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ C + H P + P + R + D N F 2 Th e el ig ib le w om en ’s re sp on se ra te (E W R R ) i s eq ui va le nt to th e pe rc en ta ge o f i nt er vi ew s co m pl et ed (E W C ). 3 Th e ov er al l w om en ’s re sp on se ra te (O W R R ) i s ca lc ul at ed a s: O W R R = H R R * E W R R /1 00 264 • Appendix A A pp en di x A • 2 65 Ta bl e A .6 S am pl e im pl em en ta tio n: M en P er ce nt d is tri bu tio n of h ou se ho ld s an d el ig ib le m en b y re su lts o f t he h ou se ho ld a nd in di vi du al in te rv ie w s, a nd h ou se ho ld , e lig ib le m en ’s , a nd o ve ra ll m en ’s r es po ns e ra te s, a cc or di ng to u rb an -r ur al r es id en ce an d re gi on (u nw ei gh te d) , A rm en ia 2 01 5- 16 R es ul t R es id en ce R eg io n To ta l U rb an R ur al Y er ev an A ra ga ts ot n A ra ra t A rm av ir G eg ha rk un ik Lo ri K ot ay k S hi ra k S yu ni k V ay ot s D zo r Ta vu sh S el ec te d ho us eh ol ds C om pl et ed (C ) 89 .4 91 .1 93 .4 85 .4 93 .4 87 .9 93 .7 78 .8 91 .1 84 .2 97 .1 89 .6 95 .8 90 .1 H ou se ho ld p re se nt b ut n o co m pe te nt re sp on de nt at h om e (H P ) 1. 5 1. 1 0. 6 0. 0 0. 8 1. 0 0. 0 1. 2 1. 7 5. 9 0. 0 3. 9 0. 0 1. 3 P os tp on ed (P ) 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 R ef us ed (R ) 2. 6 2. 2 2. 1 0. 3 1. 5 1. 0 0. 0 10 .4 2. 7 4. 5 0. 3 0. 3 2. 1 2. 5 D w el lin g no t f ou nd (D N F) 0. 1 0. 0 0. 3 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 H ou se ho ld a bs en t ( H A ) 5. 6 4. 9 3. 0 13 .0 3. 8 8. 8 6. 0 7. 8 4. 4 3. 2 2. 0 6. 2 2. 1 5. 3 D w el lin g va ca nt /a dd re ss no t a d w el lin g (D V ) 0. 4 0. 3 0. 6 0. 3 0. 0 0. 3 0. 3 0. 9 0. 0 1. 2 0. 3 0. 0 0. 0 0. 4 D w el lin g de st ro ye d (D D ) 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 2 0. 0 0. 0 0. 0 0. 0 O th er (O ) 0. 3 0. 5 0. 0 0. 9 0. 5 1. 0 0. 0 0. 9 0. 0 0. 7 0. 3 0. 0 0. 0 0. 4 To ta l 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 N um be r o f s am pl ed ho us eh ol ds 2, 68 4 1, 68 9 67 0 32 2 39 2 38 7 36 4 43 4 40 6 40 4 35 0 30 8 33 6 4, 37 3 H ou se ho ld re sp on se ra te (H R R )1 95 .5 96 .5 96 .9 99 .6 97 .6 97 .7 10 0. 0 87 .2 95 .4 89 .0 99 .7 95 .5 97 .9 95 .9 E lig ib le m en C om pl et ed (E M C ) 95 .9 97 .2 98 .4 99 .1 98 .1 97 .6 99 .3 78 .8 98 .3 91 .0 10 0. 0 97 .4 98 .2 96 .5 N ot a t h om e (E M N H ) 0. 4 0. 1 0. 0 0. 0 0. 3 0. 0 0. 0 0. 5 0. 3 2. 4 0. 0 0. 0 0. 0 0. 3 P os tp on ed (E M P ) 0. 1 0. 1 0. 0 0. 4 0. 0 0. 0 0. 0 0. 5 0. 0 0. 0 0. 0 0. 0 0. 0 0. 1 R ef us ed (E M R ) 2. 9 1. 9 1. 1 0. 4 1. 3 0. 7 0. 7 17 .8 0. 7 6. 7 0. 0 0. 5 0. 9 2. 5 P ar tly c om pl et ed (E M P C ) 0. 4 0. 3 0. 4 0. 0 0. 0 1. 0 0. 0 1. 9 0. 0 0. 0 0. 0 0. 5 0. 0 0. 4 In ca pa ci ta te d (E M I) 0. 3 0. 5 0. 0 0. 0 0. 3 0. 7 0. 0 0. 5 0. 7 0. 0 0. 0 1. 6 0. 9 0. 4 O th er (E M O ) 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 To ta l 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 10 0. 0 N um be r o f m en 1, 58 7 1, 26 9 44 7 23 0 31 9 29 1 27 0 20 8 29 3 21 0 17 4 19 1 22 3 2, 85 6 E lig ib le m en re sp on se ra te (E M R R )2 95 .9 97 .2 98 .4 99 .1 98 .1 97 .6 99 .3 78 .8 98 .3 91 .0 10 0. 0 97 .4 98 .2 96 .5 O ve ra ll m en re sp on se ra te (O R R )3 91 .6 93 .7 95 .4 98 .8 95 .8 95 .4 99 .3 68 .8 93 .7 81 .0 99 .7 93 .0 96 .1 92 .5 1 U si ng th e nu m be r o f h ou se ho ld s fa lli ng in to s pe ci fic re sp on se c at eg or ie s, th e ho us eh ol d re sp on se ra te (H R R ) i s ca lc ul at ed a s: 1 00 * C _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ C + H P + P + R + D N F 2 Th e el ig ib le m en ’s re sp on se ra te (E M R R ) i s eq ui va le nt to th e pe rc en ta ge o f i nt er vi ew s co m pl et ed (E M C ). 3 Th e ov er al l m en ’s re sp on se ra te (O M R R ) i s ca lc ul at ed a s: O M R R = H R R * E M R R /1 00 Appendix A • 265 Appendix B • 267 ESTIMATES OF SAMPLING ERRORS Appendix B he estimates from a sample survey are affected by two types of errors: (1) nonsampling errors and (2) sampling errors. Nonsampling errors are the results of mistakes made in implementing data collection and data processing, such as failure to locate and interview the correct household, misunderstanding of the questions on the part of either the interviewer or the respondent, and data entry errors. Although numerous efforts were made during the implementation of the 2015-16 Armenia Demographic and Health Survey (ADHS) to minimize this type of error, nonsampling errors are impossible to avoid and difficult to evaluate statistically. Sampling errors, on the other hand, can be evaluated statistically. The sample of respondents selected in the 2015-16 ADHS is only one of many samples that could have been selected from the same population, using the same design and expected size. Each of these samples would yield results that differ somewhat from the results of the actual sample selected. Sampling errors are a measure of the variability between all possible samples. Although the degree of variability is not known exactly, it can be estimated from the survey results. A sampling error is usually measured in terms of the standard error for a particular statistic (mean, percentage, etc.), which is the square root of the variance. The standard error can be used to calculate confidence intervals within which the true value for the population can reasonably be assumed to fall. For example, for any given statistic calculated from a sample survey, the value of that statistic will fall within a range of plus or minus two times the standard error of that statistic in 95 percent of all possible samples of identical size and design. If the sample of respondents had been selected as a simple random sample, it would have been possible to use straightforward formulas for calculating sampling errors. However, the 2015-16 ADHS sample is the result of a multi-stage stratified design, and, consequently, it was necessary to use more complex formulae. Programs developed through SAS computer software were used to calculate sampling errors for the 2015-16 ADHS. The programs used the Taylor linearization method of variance estimation for means or proportions and the Jackknife repeated replication method for variance estimation of more complex statistics such as fertility and mortality rates. The Taylor linearization method treats any percentage or average as a ratio estimate, r = y/x, where y represents the total sample value for variable y, and x represents the total number of cases in the group or subgroup under consideration. The variance of r is computed using the formula given below, with the standard error being the square root of the variance:                         H h h h m i hi h h h m z z m m f x rvarrSE h 1 2 1 2 2 2 1 1 1 )()( in which hihihi rxyz  , and hhh rxyz  T 268 • Appendix B where h represents the stratum which varies from 1 to H, mh is the total number of clusters selected in the hth stratum, yhi is the sum of the weighted values of variable y in the ith cluster in the hth stratum, xhi is the sum of the weighted number of cases in the ith cluster in the hth stratum, and fh is the sampling fraction of PSU in the hth stratum. The Jackknife repeated replication method derives estimates of complex rates from each of several replications of the parent sample and calculates standard errors for these estimates using simple formulae. Each replication considers all but one cluster in the calculation of the estimates. Pseudo-independent replications are thus created. In the 2015-16 ADHS, there were 313 nonempty clusters. Hence, 313 replications were created. The variance of a rate r is calculated as follows: SE r var r k k r r i k i 2 1 21 1 ( ) ( ) ( ) ( )      in which )()1( ii rkkrr  where r is the estimate computed from the full sample of 313 clusters, r(i) is the estimate computed from the reduced sample of 312 clusters (ith cluster excluded), and k is the total number of clusters. In addition to the standard error, the SAS programs calculate the design effect (DEFT) for each estimate. DEFT is defined as the ratio between the standard error using the given sample design and the standard error that would result if a simple random sample had been used. A DEFT value of 1.0 indicates that the sample design is as efficient as a simple random sample, while a value greater than 1.0 indicates the increase in the sampling error due to the use of a more complex and less statistically efficient design such as multistage and cluster selection. The relative error and confidence limits for the estimates are also computed by the SAS programs. Sampling errors for the 2015-16 ADHS are calculated for selected variables considered to be of primary interest for the women’s survey and for the men’s survey. The results are presented in this appendix for Armenia as a whole, for urban and rural areas, and for each of the 11 regions. For each variable, the type of statistic (mean, proportion, or rate) and the base population are given in Table B.1. Tables B.2 through B.15 present the value of the statistic (R), its standard error (SE), the number of unweighted (N) and weighted (WN) cases, the design effect (DEFT), the relative standard error (SE/R), and the 95 percent confidence limits (R±2SE) for each variable. In the tables, the DEFT is shown as undefined (i.e., not applicable) when the standard error considering a simple random sample is zero (when the estimate is close to 0 or 1). In the case of the total fertility rate, the number of unweighted cases is not relevant, as there is no known unweighted value for woman-years of exposure to childbearing. The confidence interval (e.g., as calculated for currently married women currently using a modern contraceptive method) can be interpreted as follows: the overall percentage of currently married women currently using a modern contraceptive method is 28 percent, and the standard error is 0.009 (rounded). Therefore, to obtain the 95 percent confidence limits, one adds and subtracts twice the standard error to the sample estimate, that is, 28±2×0.009. There is a high probability (95 percent) that the true percentage of currently married women currently using a modern method is between 26 percent and 30 percent (rounded). For the total sample, the value of the design effect (DEFT), averaged over all variables for the women’s survey, is 1.21. This means that, due to multistage clustering of the sample, the average standard error is increased by a factor of 1.21 over that in an equivalent simple random sample. Appendix B • 269 Table B.1 List of selected indicators for sampling errors, Armenia 2015-16 Variable Estimate Base population WOMEN Urban residence Proportion All women 15-49 Secondary education or higher Proportion All women 15-49 Never married/in union Proportion All women 15-49 Currently married/in union Proportion All women 15-49 Married before age 20 Proportion Women 25-49 Had sexual intercourse before age 18 Proportion Women 25-49 Currently pregnant Proportion All women 15-49 Children ever born Mean All women 15-49 Children surviving Mean All women 15-49 Children ever born to women age 40-49 Mean Women 40-49 Know any contraceptive method Proportion Currently married women 15-49 Know a modern method Proportion Currently married women 15-49 Currently using any method Proportion Currently married women 15-49 Currently using a modern method Proportion Currently married women 15-49 Currently using pill Proportion Currently married women 15-49 Currently using IUD Proportion Currently married women 15-49 Currently using condoms Proportion Currently married women 15-49 Currently using injectables Proportion Currently married women 15-49 Currently using female sterilization Proportion Currently married women 15-49 Using public sector source Proportion Currently married women 15-49 currently using a modern method Want no more children Proportion Currently married women 15-49 Want to delay next birth at least 2 years Proportion Currently married women 15-49 Ideal number of children Mean All women 15-49 Mothers received antenatal care for last birth Proportion Women with at least one live birth in 5 years before survey Births with skilled attendant at delivery Proportion Births occurring 1-59 months before survey Had diarrhea in the past 2 weeks Proportion Children under 5 Treated with ORS Proportion Children under 5 Sought medical treatment for diarrhea Proportion Children under 5 with diarrhea in past 2 weeks Vaccination card seen (children age 12-23 months) Proportion Children 12-23 months Received BCG vaccination Proportion Children 12-23 months Received HepB vaccination at birth Proportion Children 12-23 months Received DPT-HepB-Hib vaccination (third dose) Proportion Children 12-23 months Received polio vaccination (third dose) Proportion Children 12-23 months Received rotavirus vaccination (second dose) Proportion Children 12-23 months Received all vaccinations appropriate for a child age 12-23 months Proportion Children 12-23 months Vaccination card seen (children age 24-35 months) Proportion Children 24-35 months Received measles, mumps, and rubella (MMR) vaccination Proportion Children 24-35 months Received DPT vaccination (fourth dose) Proportion Children 24-35 months Received polio vaccination (fourth dose) Proportion Children 24-35 months Received all basic vaccinations appropriate for children age 24-35 months Proportion Children 24-35 months Received all vaccinations appropriate for a child age 24-35 months Proportion Children 24-35 months Height-for-age (-2SD) Proportion Children under 5 who were measured Weight-for-height (-2SD) Proportion Children under 5 who were measured Weight-for-age (-2SD) Proportion Children under 5 who were measured Prevalence of anemia (children age 6-59 months) Proportion All children 6-59 months who were tested Prevalence of anemia (women age 15-49) Proportion All women 15-49 who were tested Body mass index (BMI) < 18.5 Proportion All women 15-49 who were measured Body mass index (BMI) ≥ 25 Proportion All women 15-49 who were measured Ever experienced any physical violence since age 15 Proportion All women 15-49 Ever experienced any sexual violence Proportion All women 15-49 Ever experienced any physical or sexual violence by husband/partner Proportion All ever-married women 15-49 Ever experienced any physical or sexual violence by husband/partner in the last 12 months Proportion All ever-married women 15-49 Total fertility rate (3 years) Rate Woman-years of exposure to childbearing Total abortion rate (3 years) Rate Woman-years of exposure to childbearing MEN Urban residence Proportion All men 15-49 Secondary education or higher Proportion All men 15-49 Never married/in union Proportion All men 15-49 Currently married/in union Proportion All men 15-49 Had sexual intercourse before age 18 Proportion Men 25-49 Want no more children Proportion Currently married men 15-49 Want to delay next birth at least 2 years Proportion Currently married men 15-49 Ideal number of children Mean All men 15-49 Had 2+ sexual partners in past 12 months Proportion All men 15-49 Abstinence among youth (never had sex) Proportion Never-married men 15-24 Paid for sexual intercourse in past 12 months Proportion All men 15-49 270 • Appendix B Table B.2 Sampling errors: Total sample, Armenia 2015-16 Variable Value (R) Standard error (SE) Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE WOMEN Urban residence 0.598 0.010 6,116 6,116 1.621 0.017 0.578 0.618 Secondary or higher education 0.934 0.006 6,116 6,116 1.847 0.006 0.923 0.946 Never married (never in union) 0.299 0.006 6,116 6,116 1.107 0.022 0.286 0.312 Currently married (in union) 0.637 0.007 6,116 6,116 1.126 0.011 0.623 0.651 Married before age 20 0.367 0.009 4,451 4,463 1.257 0.025 0.349 0.385 Had sexual intercourse before age 18 0.141 0.006 4,451 4,463 1.197 0.044 0.128 0.153 Currently pregnant 0.028 0.003 6,116 6,116 1.208 0.090 0.023 0.034 Children ever born 1.385 0.016 6,116 6,116 0.996 0.011 1.354 1.417 Children surviving 1.360 0.015 6,116 6,116 0.994 0.011 1.330 1.390 Children ever born to women age 40-49 2.216 0.033 1,496 1,490 1.157 0.015 2.150 2.282 Know any contraceptive method 0.998 0.001 3,998 3,895 1.099 0.001 0.996 0.999 Know a modern method 0.997 0.001 3,998 3,895 1.040 0.001 0.995 0.999 Currently using any method 0.571 0.009 3,998 3,895 1.194 0.016 0.553 0.590 Currently using a modern method 0.280 0.009 3,998 3,895 1.209 0.031 0.263 0.297 Currently using pill 0.026 0.003 3,998 3,895 1.287 0.124 0.020 0.033 Currently using IUD 0.089 0.006 3,998 3,895 1.328 0.067 0.077 0.101 Currently using condoms 0.147 0.006 3,998 3,895 1.112 0.042 0.135 0.160 Currently using injectables 0.002 0.001 3,998 3,895 1.946 0.732 0.000 0.004 Currently using female sterilization 0.007 0.002 3,998 3,895 1.195 0.226 0.004 0.010 Using public sector source 0.350 0.018 999 1,081 1.198 0.052 0.314 0.387 Want no more children 0.535 0.009 3,998 3,895 1.146 0.017 0.517 0.553 Want to delay next birth at least 2 years 0.120 0.006 3,998 3,895 1.208 0.052 0.107 0.132 Ideal number of children 2.596 0.013 5,972 5,974 1.152 0.005 2.570 2.622 Mothers received antenatal care for last birth 0.996 0.002 1,396 1,361 1.113 0.002 0.992 1.000 Births with skilled attendant at delivery 0.998 0.001 1,724 1,672 1.325 0.001 0.995 1.000 Had diarrhea in the past 2 weeks 0.038 0.005 1,710 1,663 1.028 0.131 0.028 0.048 Treated with ORS 0.369 0.066 68 63 1.045 0.179 0.237 0.502 Sought medical treatment for diarrhea 0.406 0.066 68 63 1.030 0.163 0.274 0.539 Vaccination card seen (children age 12-23 months) 0.962 0.011 345 338 1.046 0.011 0.940 0.983 Received BCG vaccination 0.990 0.004 345 338 0.780 0.004 0.982 0.998 Received HepB vaccination at birth 0.979 0.007 345 338 0.901 0.007 0.965 0.993 Received DPT-HepB-Hib vaccination (third dose) 0.927 0.015 345 338 1.044 0.016 0.898 0.956 Received polio vaccination (third dose) 0.932 0.014 345 338 1.059 0.015 0.903 0.961 Received rotavirus vaccination (second dose) 0.902 0.020 345 338 1.258 0.022 0.861 0.942 Received all vaccinations appropriate for a child age 12- 23 months 0.864 0.022 345 338 1.195 0.026 0.820 0.908 Vaccination card seen (children age 24-35 months) 0.926 0.019 332 335 1.338 0.020 0.888 0.964 Received measles, mumps, and rubella (MMR) vaccination 0.779 0.029 332 335 1.282 0.037 0.721 0.837 Received DPT vaccination (fourth dose) 0.801 0.029 332 335 1.318 0.036 0.743 0.859 Received polio vaccination (fourth dose) 0.928 0.016 332 335 1.150 0.017 0.896 0.960 Received all basic vaccinations appropriate for children age 24-35 months 0.889 0.020 332 335 1.164 0.022 0.850 0.929 Received all vaccinations appropriate for a child age 24- 35 months 0.726 0.030 332 335 1.226 0.041 0.666 0.786 Height-for-age (-2SD) 0.094 0.009 1,593 1,573 1.181 0.094 0.076 0.112 Weight-for-height (-2SD) 0.042 0.006 1,572 1,555 1.132 0.141 0.030 0.054 Weight-for-age (-2SD) 0.026 0.005 1,620 1,609 1.140 0.174 0.017 0.036 Prevalence of anemia (children age 6-59 months) 0.156 0.011 1,371 1,349 1.099 0.071 0.134 0.179 Prevalence of anemia (women age 15-49) 0.134 0.008 5,807 5,769 1.690 0.057 0.119 0.150 Body mass index (BMI) < 18.5 0.036 0.003 5,688 5,675 1.286 0.088 0.030 0.043 Body mass index (BMI) ≥ 25 0.450 0.008 5,688 5,675 1.206 0.018 0.434 0.466 Ever experienced any physical violence since age 15 0.059 0.005 4,592 4,592 1.409 0.083 0.049 0.068 Ever experienced any sexual violence 0.009 0.002 4,592 4,592 1.143 0.180 0.006 0.012 Ever experienced any physical/sexual violence by husband/partner 0.081 0.007 3,540 3,208 1.470 0.083 0.067 0.094 Ever experienced any physical or sexual violence by husband/partner in the last 12 months 0.035 0.004 3,540 3,208 1.296 0.114 0.027 0.043 Total fertility rate (last 3 years) 1.746 0.064 17,661 17,681 1.242 0.037 1.618 1.874 Total abortion rate (last 3 years) 0.588 0.050 17,661 17,681 1.144 0.085 0.488 0.688 MEN Urban residence 0.565 0.012 2,755 2,755 1.273 0.021 0.541 0.590 Secondary or higher education 0.867 0.010 2,755 2,755 1.610 0.012 0.846 0.888 Never married (in union) 0.432 0.011 2,755 2,755 1.123 0.025 0.411 0.453 Currently married (in union) 0.547 0.011 2,755 2,755 1.174 0.020 0.524 0.569 Had first sexual intercourse before age 18 0.154 0.013 1,959 1,942 1.540 0.082 0.128 0.179 Want no more children 0.480 0.018 1,527 1,506 1.403 0.037 0.444 0.516 Want to delay birth at least 2 years 0.097 0.009 1,527 1,506 1.155 0.090 0.079 0.114 Ideal number of children 2.659 0.023 2,695 2,699 1.377 0.009 2.612 2.705 Had 2+ sexual partners in past 12 months 0.054 0.006 2,755 2,755 1.416 0.113 0.042 0.067 Abstinence among never-married youth (never had sex) 0.646 0.022 738 756 1.247 0.034 0.602 0.690 Paid for sexual intercourse in past 12 months 0.101 0.010 2,755 2,755 1.744 0.099 0.081 0.121 Appendix B • 271 Table B.3 Sampling errors: Urban sample, Armenia 2015-16 Variable Value (R) Standard error (SE) Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE WOMEN Urban residence 1.000 0.000 3,545 3,657 na 0.000 1.000 1.000 Secondary or higher education 0.963 0.004 3,545 3,657 1.152 0.004 0.956 0.970 Never married (never in union) 0.313 0.009 3,545 3,657 1.095 0.027 0.296 0.330 Currently married (in union) 0.607 0.009 3,545 3,657 1.120 0.015 0.589 0.626 Married before age 20 0.288 0.012 2,645 2,729 1.332 0.041 0.265 0.312 Had sexual intercourse before age 18 0.099 0.007 2,645 2,729 1.220 0.072 0.085 0.113 Currently pregnant 0.026 0.004 3,545 3,657 1.332 0.137 0.019 0.033 Children ever born 1.263 0.019 3,545 3,657 0.999 0.015 1.225 1.301 Children surviving 1.248 0.019 3,545 3,657 0.999 0.015 1.211 1.285 Children ever born to women age 40-49 1.973 0.041 870 894 1.200 0.021 1.890 2.056 Know any contraceptive method 0.999 0.001 2,233 2,221 0.849 0.001 0.998 1.000 Know a modern method 0.999 0.001 2,233 2,221 0.806 0.001 0.997 1.000 Currently using any method 0.565 0.013 2,233 2,221 1.206 0.022 0.539 0.590 Currently using a modern method 0.319 0.013 2,233 2,221 1.273 0.039 0.294 0.345 Currently using pill 0.030 0.005 2,233 2,221 1.393 0.168 0.020 0.040 Currently using IUD 0.095 0.009 2,233 2,221 1.475 0.096 0.077 0.114 Currently using condoms 0.174 0.009 2,233 2,221 1.122 0.052 0.156 0.192 Currently using injectables 0.003 0.002 2,233 2,221 1.916 0.729 0.000 0.008 Currently using female sterilization 0.007 0.002 2,233 2,221 1.190 0.296 0.003 0.011 Using public sector source 0.324 0.024 631 710 1.307 0.075 0.275 0.372 Want no more children 0.533 0.012 2,233 2,221 1.148 0.023 0.508 0.557 Want to delay next birth at least 2 years 0.135 0.009 2,233 2,221 1.233 0.066 0.117 0.153 Ideal number of children 2.526 0.017 3,476 3,595 1.217 0.007 2.492 2.561 Mothers received antenatal care for last birth 0.999 0.001 804 794 0.768 0.001 0.996 1.000 Births with skilled attendant at delivery 0.997 0.002 979 962 1.370 0.002 0.992 1.000 Had diarrhea in the past 2 weeks 0.026 0.005 971 958 0.869 0.180 0.017 0.036 Treated with ORS 0.542 0.105 31 25 1.010 0.193 0.333 0.752 Sought medical treatment for diarrhea 0.343 0.097 31 25 0.965 0.282 0.150 0.537 Vaccination card seen (children age 12-23 months) 0.962 0.014 195 193 1.037 0.015 0.933 0.990 Received BCG vaccination 0.991 0.005 195 193 0.787 0.005 0.980 1.000 Received HepB vaccination at birth 0.971 0.011 195 193 0.937 0.012 0.949 0.994 Received DPT-HepB-Hib vaccination (third dose) 0.909 0.021 195 193 1.031 0.024 0.866 0.951 Received polio vaccination (third dose) 0.918 0.021 195 193 1.058 0.023 0.876 0.960 Received rotavirus vaccination (second dose) 0.890 0.030 195 193 1.327 0.034 0.830 0.950 Received all vaccinations appropriate for a child age 12- 23 months 0.840 0.032 195 193 1.226 0.039 0.776 0.905 Vaccination card seen (children age 24-35 months) 0.899 0.031 180 187 1.406 0.034 0.837 0.961 Received measles, mumps, and rubella (MMR) vaccination 0.736 0.044 180 187 1.347 0.059 0.649 0.823 Received DPT vaccination (fourth dose) 0.753 0.045 180 187 1.396 0.060 0.663 0.844 Received polio vaccination (fourth dose) 0.915 0.024 180 187 1.169 0.026 0.867 0.963 Received all basic vaccinations appropriate for children age 24-35 months 0.858 0.031 180 187 1.201 0.036 0.797 0.919 Received all vaccinations appropriate for a child age 24- 35 months 0.694 0.044 180 187 1.278 0.064 0.606 0.782 Height-for-age (-2SD) 0.062 0.009 885 876 1.048 0.142 0.044 0.080 Weight-for-height (-2SD) 0.033 0.007 881 877 1.115 0.215 0.019 0.047 Weight-for-age (-2SD) 0.023 0.006 909 907 1.114 0.249 0.012 0.034 Prevalence of anemia (children age 6-59 months) 0.136 0.015 743 721 1.119 0.110 0.106 0.166 Prevalence of anemia (women age 15-49) 0.129 0.011 3,315 3,381 1.805 0.082 0.108 0.150 Body mass index (BMI) < 18.5 0.041 0.005 3,280 3,366 1.333 0.112 0.032 0.051 Body mass index (BMI) ≥ 25 0.443 0.011 3,280 3,366 1.273 0.025 0.421 0.465 Ever experienced any physical violence since age 15 0.052 0.007 2,715 2,741 1.667 0.137 0.038 0.066 Ever experienced any sexual violence 0.008 0.002 2,715 2,741 1.164 0.255 0.004 0.012 Ever experienced any physical/sexual violence by husband/partner 0.072 0.010 2,055 1,872 1.741 0.138 0.053 0.092 Ever experienced any physical or sexual violence by husband/partner in the last 12 months 0.031 0.006 2,055 1,872 1.463 0.181 0.020 0.042 Total fertility rate (last 3 years) 1.656 0.082 10,258 10,578 1.353 0.049 1.492 1.820 Total abortion rate (last 3 years) 0.450 0.056 10,258 10,578 1.162 0.124 0.338 0.562 MEN Urban residence 1.000 0.000 1,522 1,558 na 0.000 1.000 1.000 Secondary or higher education 0.926 0.008 1,522 1,558 1.199 0.009 0.910 0.942 Never married (in union) 0.420 0.016 1,522 1,558 1.235 0.037 0.389 0.451 Currently married (in union) 0.551 0.017 1,522 1,558 1.302 0.030 0.518 0.584 Had first sexual intercourse before age 18 0.173 0.019 1,111 1,119 1.682 0.111 0.135 0.211 Want no more children 0.464 0.028 854 859 1.621 0.060 0.409 0.520 Want to delay birth at least 2 years 0.107 0.013 854 859 1.228 0.121 0.081 0.133 Ideal number of children 2.591 0.035 1,495 1,528 1.531 0.013 2.521 2.660 Had 2+ sexual partners in past 12 months 0.051 0.007 1,522 1,558 1.310 0.144 0.037 0.066 Abstinence among never-married youth (never had sex) 0.591 0.033 385 415 1.294 0.055 0.526 0.656 Paid for sexual intercourse in past 12 months 0.095 0.014 1,522 1,558 1.857 0.147 0.067 0.123 na=Not applicable 272 • Appendix B Table B.4 Sampling errors: Rural sample, Armenia 2015-16 Variable Value (R) Standard error (SE) Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE WOMEN Urban residence 0.000 0.000 2,571 2,459 na na 0.000 0.000 Secondary or higher education 0.892 0.013 2,571 2,459 2.171 0.015 0.865 0.918 Never married (never in union) 0.278 0.010 2,571 2,459 1.138 0.036 0.258 0.299 Currently married (in union) 0.681 0.011 2,571 2,459 1.158 0.016 0.660 0.702 Married before age 20 0.490 0.014 1,806 1,734 1.185 0.028 0.463 0.518 Had sexual intercourse before age 18 0.206 0.011 1,806 1,734 1.194 0.055 0.184 0.229 Currently pregnant 0.032 0.004 2,571 2,459 1.019 0.111 0.025 0.039 Children ever born 1.567 0.027 2,571 2,459 1.013 0.017 1.514 1.620 Children surviving 1.527 0.026 2,571 2,459 1.009 0.017 1.476 1.578 Children ever born to women age 40-49 2.581 0.047 626 596 1.052 0.018 2.486 2.675 Know any contraceptive method 0.996 0.002 1,765 1,674 1.183 0.002 0.993 1.000 Know a modern method 0.994 0.002 1,765 1,674 1.107 0.002 0.990 0.998 Currently using any method 0.581 0.014 1,765 1,674 1.171 0.024 0.553 0.608 Currently using a modern method 0.227 0.011 1,765 1,674 1.096 0.048 0.206 0.249 Currently using pill 0.022 0.004 1,765 1,674 1.052 0.168 0.014 0.029 Currently using IUD 0.081 0.007 1,765 1,674 1.032 0.083 0.067 0.094 Currently using condoms 0.112 0.009 1,765 1,674 1.143 0.077 0.095 0.129 Currently using injectables 0.000 0.000 1,765 1,674 na na 0.000 0.000 Currently using female sterilization 0.007 0.002 1,765 1,674 1.199 0.348 0.002 0.011 Using public sector source 0.402 0.026 368 371 1.027 0.065 0.349 0.454 Want no more children 0.538 0.014 1,765 1,674 1.139 0.025 0.511 0.565 Want to delay next birth at least 2 years 0.100 0.008 1,765 1,674 1.144 0.082 0.083 0.116 Ideal number of children 2.702 0.019 2,496 2,380 1.048 0.007 2.664 2.740 Mothers received antenatal care for last birth 0.993 0.004 592 568 1.199 0.004 0.984 1.000 Births with skilled attendant at delivery 0.999 0.001 745 710 0.619 0.001 0.998 1.000 Had diarrhea in the past 2 weeks 0.054 0.010 739 705 1.140 0.181 0.034 0.073 Treated with ORS 0.253 0.078 37 38 1.113 0.307 0.098 0.409 Sought medical treatment for diarrhea 0.449 0.088 37 38 1.065 0.195 0.274 0.624 Vaccination card seen (children age 12-23 months) 0.961 0.017 150 146 1.059 0.017 0.928 0.994 Received BCG vaccination 0.989 0.006 150 146 0.771 0.007 0.976 1.000 Received HepB vaccination at birth 0.989 0.006 150 146 0.771 0.007 0.976 1.000 Received DPT-HepB-Hib vaccination (third dose) 0.951 0.018 150 146 1.020 0.019 0.916 0.987 Received polio vaccination (third dose) 0.951 0.018 150 146 1.013 0.019 0.915 0.986 Received rotavirus vaccination (second dose) 0.917 0.025 150 146 1.101 0.027 0.868 0.967 Received all vaccinations appropriate for a child age 12- 23 months 0.896 0.027 150 146 1.105 0.031 0.841 0.950 Vaccination card seen (children age 24-35 months) 0.960 0.017 152 148 1.079 0.018 0.926 0.994 Received measles, mumps, and rubella (MMR) vaccination 0.834 0.033 152 148 1.116 0.040 0.767 0.901 Received DPT vaccination (fourth dose) 0.861 0.030 152 148 1.065 0.034 0.802 0.921 Received polio vaccination (fourth dose) 0.945 0.020 152 148 1.103 0.021 0.904 0.985 Received all basic vaccinations appropriate for children age 24-35 months 0.929 0.022 152 148 1.064 0.024 0.885 0.973 Received all vaccinations appropriate for a child age 24- 35 months 0.767 0.038 152 148 1.105 0.049 0.692 0.843 Height-for-age (-2SD) 0.134 0.016 708 697 1.281 0.123 0.101 0.167 Weight-for-height (-2SD) 0.055 0.010 691 679 1.133 0.182 0.035 0.075 Weight-for-age (-2SD) 0.031 0.007 711 702 1.167 0.241 0.016 0.046 Prevalence of anemia (children age 6-59 months) 0.180 0.017 628 628 1.074 0.092 0.147 0.213 Prevalence of anemia (women age 15-49) 0.142 0.011 2,492 2,388 1.509 0.074 0.121 0.163 Body mass index (BMI) < 18.5 0.029 0.004 2,408 2,308 1.153 0.137 0.021 0.036 Body mass index (BMI) ≥ 25 0.459 0.011 2,408 2,308 1.092 0.024 0.437 0.481 Ever experienced any physical violence since age 15 0.068 0.006 1,877 1,851 1.026 0.087 0.056 0.080 Ever experienced any sexual violence 0.010 0.003 1,877 1,851 1.123 0.253 0.005 0.016 Ever experienced any physical/sexual violence by husband/partner 0.092 0.008 1,485 1,337 1.096 0.089 0.076 0.109 Ever experienced any physical or sexual violence by husband/partner in the last 12 months 0.041 0.006 1,485 1,337 1.093 0.137 0.030 0.053 Total fertility rate (last 3 years) 1.841 0.101 7,402 7,103 1.073 0.055 1.638 2.043 Total abortion rate (last 3 years) 0.812 0.087 7,402 7,103 1.138 0.107 0.638 0.986 MEN Urban residence 0.000 0.000 1,233 1,197 na na 0.000 0.000 Secondary or higher education 0.791 0.021 1,233 1,197 1.833 0.027 0.749 0.834 Never married (in union) 0.447 0.014 1,233 1,197 0.955 0.030 0.420 0.474 Currently married (in union) 0.541 0.014 1,233 1,197 0.972 0.026 0.513 0.569 Had first sexual intercourse before age 18 0.127 0.014 848 823 1.245 0.112 0.099 0.156 Want no more children 0.501 0.020 673 648 1.024 0.039 0.461 0.540 Want to delay birth at least 2 years 0.083 0.011 673 648 1.015 0.130 0.061 0.104 Ideal number of children 2.747 0.030 1,200 1,171 1.177 0.011 2.688 2.806 Had 2+ sexual partners in past 12 months 0.058 0.010 1,233 1,197 1.540 0.177 0.038 0.079 Abstinence among never-married youth (never had sex) 0.714 0.028 353 341 1.176 0.040 0.657 0.770 Paid for sexual intercourse in past 12 months 0.108 0.014 1,233 1,197 1.587 0.130 0.080 0.136 na=Not applicable Appendix B • 273 Table B.5 Sampling errors: Yerevan sample, Armenia 2015-16 Variable Value (R) Standard error (SE) Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE WOMEN Urban residence 1.000 0.000 1,055 2,001 na 0.000 1.000 1.000 Secondary or higher education 0.973 0.005 1,055 2,001 0.955 0.005 0.963 0.982 Never married (never in union) 0.344 0.013 1,055 2,001 0.887 0.038 0.318 0.370 Currently married (in union) 0.570 0.014 1,055 2,001 0.928 0.025 0.542 0.598 Married before age 20 0.248 0.018 790 1,498 1.201 0.074 0.211 0.285 Had sexual intercourse before age 18 0.085 0.011 790 1,498 1.070 0.125 0.064 0.107 Currently pregnant 0.023 0.006 1,055 2,001 1.194 0.239 0.012 0.034 Children ever born 1.174 0.028 1,055 2,001 0.816 0.024 1.118 1.230 Children surviving 1.169 0.028 1,055 2,001 0.822 0.024 1.113 1.225 Children ever born to women age 40-49 1.858 0.061 267 505 0.983 0.033 1.736 1.980 Know any contraceptive method 1.000 0.000 601 1,140 na 0.000 1.000 1.000 Know a modern method 1.000 0.000 601 1,140 na 0.000 1.000 1.000 Currently using any method 0.584 0.019 601 1,140 0.968 0.033 0.545 0.623 Currently using a modern method 0.401 0.022 601 1,140 1.091 0.054 0.357 0.444 Currently using pill 0.041 0.009 601 1,140 1.133 0.224 0.023 0.059 Currently using IUD 0.110 0.017 601 1,140 1.300 0.151 0.076 0.143 Currently using condoms 0.223 0.016 601 1,140 0.967 0.074 0.190 0.256 Currently using injectables 0.006 0.004 601 1,140 1.374 0.721 0.000 0.015 Currently using female sterilization 0.009 0.004 601 1,140 0.985 0.421 0.001 0.017 Using public sector source 0.304 0.036 243 460 1.215 0.118 0.232 0.376 Want no more children 0.568 0.020 601 1,140 1.000 0.036 0.527 0.608 Want to delay next birth at least 2 years 0.153 0.015 601 1,140 0.999 0.096 0.123 0.182 Ideal number of children 2.526 0.026 1,051 1,995 1.038 0.010 2.473 2.579 Mothers received antenatal care for last birth 1.000 0.000 209 398 na 0.000 1.000 1.000 Births with skilled attendant at delivery 0.995 0.005 250 475 1.071 0.005 0.986 1.000 Had diarrhea in the past 2 weeks 0.004 0.004 250 475 0.999 1.002 0.000 0.012 Treated with ORS 1.000 0.000 1 2 na 0.000 1.000 1.000 Sought medical treatment for diarrhea 0.000 0.000 1 2 na na 0.000 0.000 Vaccination card seen (children age 12-23 months) 0.965 0.024 51 99 0.931 0.025 0.917 1.000 Received BCG vaccination 1.000 0.000 51 99 na 0.000 1.000 1.000 Received HepB vaccination at birth 1.000 0.000 51 99 na 0.000 1.000 1.000 Received DPT-HepB-Hib vaccination (third dose) 0.903 0.036 51 99 0.867 0.039 0.832 0.974 Received polio vaccination (third dose) 0.903 0.036 51 99 0.867 0.039 0.832 0.974 Received rotavirus vaccination (second dose) 0.870 0.053 51 99 1.141 0.061 0.764 0.977 Received all vaccinations appropriate for a child age 12- 23 months 0.848 0.055 51 99 1.107 0.065 0.737 0.958 Vaccination card seen (children age 24-35 months) 0.881 0.050 56 109 1.164 0.057 0.781 0.981 Received measles, mumps, and rubella (MMR) vaccination 0.667 0.070 56 109 1.107 0.104 0.528 0.806 Received DPT vaccination (fourth dose) 0.681 0.073 56 109 1.135 0.107 0.535 0.826 Received polio vaccination (fourth dose) 0.909 0.037 56 109 0.975 0.041 0.834 0.983 Received all basic vaccinations appropriate for children age 24-35 months 0.846 0.047 56 109 0.992 0.056 0.751 0.941 Received all vaccinations appropriate for a child age 24- 35 months 0.629 0.069 56 109 1.044 0.109 0.491 0.766 Height-for-age (-2SD) 0.035 0.012 208 419 0.933 0.332 0.012 0.059 Weight-for-height (-2SD) 0.014 0.008 209 420 1.015 0.590 0.000 0.030 Weight-for-age (-2SD) 0.019 0.009 220 441 1.035 0.498 0.000 0.038 Prevalence of anemia (children age 6-59 months) 0.104 0.026 163 331 1.052 0.247 0.052 0.155 Prevalence of anemia (women age 15-49) 0.119 0.019 955 1,812 1.766 0.156 0.082 0.156 Body mass index (BMI) < 18.5 0.038 0.007 966 1,835 1.196 0.194 0.023 0.053 Body mass index (BMI) ≥ 25 0.448 0.018 966 1,835 1.126 0.040 0.412 0.484 Ever experienced any physical violence since age 15 0.046 0.012 791 1,522 1.603 0.261 0.022 0.069 Ever experienced any sexual violence 0.005 0.003 791 1,522 1.113 0.579 0.000 0.010 Ever experienced any physical/sexual violence by husband/partner 0.069 0.018 555 995 1.628 0.254 0.034 0.104 Ever experienced any physical or sexual violence by husband/partner in the last 12 months 0.031 0.010 555 995 1.289 0.305 0.012 0.050 Total fertility rate (last 3 years) 1.551 0.134 3,054 5,789 1.245 0.086 1.283 1.819 Total abortion rate (last 3 years) 0.317 0.073 3,054 5,789 1.119 0.229 0.172 0.463 MEN Urban residence 1.000 0.000 440 833 na 0.000 1.000 1.000 Secondary or higher education 0.960 0.011 440 833 1.187 0.011 0.938 0.983 Never married (in union) 0.426 0.025 440 833 1.066 0.059 0.376 0.477 Currently married (in union) 0.535 0.027 440 833 1.118 0.050 0.482 0.588 Had first sexual intercourse before age 18 0.168 0.033 311 586 1.534 0.195 0.102 0.233 Want no more children 0.403 0.048 238 446 1.504 0.119 0.307 0.499 Want to delay birth at least 2 years 0.111 0.021 238 446 1.030 0.189 0.069 0.153 Ideal number of children 2.593 0.057 438 829 1.331 0.022 2.479 2.707 Had 2+ sexual partners in past 12 months 0.045 0.012 440 833 1.209 0.266 0.021 0.069 Abstinence among never-married youth (never had sex) 0.521 0.050 123 235 1.094 0.095 0.422 0.620 Paid for sexual intercourse in past 12 months 0.108 0.025 440 833 1.665 0.229 0.058 0.157 na=Not applicable 274 • Appendix B Table B.6 Sampling errors: Aragatsotn sample, Armenia 2015-16 Variable Value (R) Standard error (SE) Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE WOMEN Urban residence 0.202 0.016 453 315 0.856 0.080 0.169 0.234 Secondary or higher education 0.939 0.042 453 315 3.654 0.044 0.856 1.000 Never married (never in union) 0.373 0.027 453 315 1.170 0.071 0.320 0.427 Currently married (in union) 0.593 0.030 453 315 1.309 0.051 0.533 0.654 Married before age 20 0.418 0.040 335 228 1.477 0.095 0.339 0.498 Had sexual intercourse before age 18 0.099 0.025 335 228 1.509 0.249 0.050 0.149 Currently pregnant 0.016 0.005 453 315 0.944 0.354 0.005 0.026 Children ever born 1.348 0.067 453 315 1.099 0.050 1.214 1.482 Children surviving 1.335 0.065 453 315 1.070 0.048 1.206 1.465 Children ever born to women age 40-49 2.452 0.086 109 74 1.019 0.035 2.280 2.624 Know any contraceptive method 1.000 0.000 262 187 na 0.000 1.000 1.000 Know a modern method 0.998 0.002 262 187 0.684 0.002 0.995 1.000 Currently using any method 0.630 0.033 262 187 1.112 0.053 0.563 0.696 Currently using a modern method 0.353 0.023 262 187 0.762 0.064 0.308 0.398 Currently using pill 0.078 0.015 262 187 0.927 0.197 0.048 0.109 Currently using IUD 0.087 0.019 262 187 1.072 0.215 0.049 0.124 Currently using condoms 0.178 0.022 262 187 0.932 0.124 0.134 0.222 Currently using injectables 0.000 0.000 262 187 na na 0.000 0.000 Currently using female sterilization 0.000 0.000 262 187 na na 0.000 0.000 Using public sector source 0.248 0.045 86 64 0.971 0.183 0.157 0.339 Want no more children 0.415 0.044 262 187 1.456 0.107 0.326 0.504 Want to delay next birth at least 2 years 0.061 0.021 262 187 1.389 0.337 0.020 0.103 Ideal number of children 2.688 0.051 452 314 1.128 0.019 2.586 2.790 Mothers received antenatal care for last birth 1.000 0.000 71 51 na 0.000 1.000 1.000 Births with skilled attendant at delivery 1.000 0.000 84 61 na 0.000 1.000 1.000 Had diarrhea in the past 2 weeks 0.088 0.030 84 61 1.005 0.338 0.029 0.148 Treated with ORS 0.245 0.186 7 5 1.204 0.760 0.000 0.617 Sought medical treatment for diarrhea 0.346 0.167 7 5 0.977 0.482 0.012 0.680 Vaccination card seen (children age 12-23 months) 1.000 0.000 12 9 na 0.000 1.000 1.000 Received BCG vaccination 1.000 0.000 12 9 na 0.000 1.000 1.000 Received HepB vaccination at birth 1.000 0.000 12 9 na 0.000 1.000 1.000 Received DPT-HepB-Hib vaccination (third dose) 0.961 0.039 12 9 0.716 0.041 0.882 1.000 Received polio vaccination (third dose) 0.961 0.039 12 9 0.716 0.041 0.882 1.000 Received rotavirus vaccination (second dose) 0.961 0.039 12 9 0.716 0.041 0.882 1.000 Received all vaccinations appropriate for a child age 12- 23 months 0.922 0.079 12 9 1.032 0.085 0.764 1.000 Vaccination card seen (children age 24-35 months) 1.000 0.000 15 10 na 0.000 1.000 1.000 Received measles, mumps, and rubella (MMR) vaccination 0.933 0.048 15 10 0.725 0.051 0.837 1.029 Received DPT vaccination (fourth dose) 0.933 0.048 15 10 0.725 0.051 0.837 1.029 Received polio vaccination (fourth dose) 1.000 0.000 15 10 na 0.000 1.000 1.000 Received all basic vaccinations appropriate for children age 24-35 months 0.968 0.034 15 10 0.714 0.035 0.900 1.035 Received all vaccinations appropriate for a child age 24- 35 months 0.906 0.053 15 10 0.690 0.059 0.799 1.013 Height-for-age (-2SD) 0.181 0.052 84 65 1.202 0.289 0.076 0.286 Weight-for-height (-2SD) 0.229 0.053 80 61 1.180 0.230 0.123 0.335 Weight-for-age (-2SD) 0.143 0.044 85 65 1.194 0.305 0.056 0.231 Prevalence of anemia (children age 6-59 months) 0.115 0.051 76 58 1.456 0.446 0.012 0.217 Prevalence of anemia (women age 15-49) 0.142 0.020 439 308 1.227 0.143 0.102 0.183 Body mass index (BMI) < 18.5 0.009 0.005 438 306 1.044 0.513 0.000 0.019 Body mass index (BMI) ≥ 25 0.587 0.042 438 306 1.797 0.072 0.503 0.672 Ever experienced any physical violence since age 15 0.175 0.022 339 241 1.081 0.128 0.131 0.220 Ever experienced any sexual violence 0.037 0.012 339 241 1.160 0.321 0.013 0.061 Ever experienced any physical/sexual violence by husband/partner 0.282 0.031 230 146 1.030 0.108 0.221 0.344 Ever experienced any physical or sexual violence by husband/partner in the last 12 months 0.219 0.028 230 146 1.010 0.126 0.164 0.274 Total fertility rate (last 3 years) 1.144 0.224 1,331 929 1.195 0.196 0.696 1.591 Total abortion rate (last 3 years) 0.151 0.064 1,331 929 1.028 0.422 0.023 0.278 MEN Urban residence 0.199 0.017 228 159 0.638 0.085 0.166 0.233 Secondary or higher education 0.877 0.058 228 159 2.626 0.066 0.761 0.993 Never married (in union) 0.539 0.038 228 159 1.143 0.070 0.463 0.614 Currently married (in union) 0.445 0.038 228 159 1.144 0.085 0.369 0.520 Had first sexual intercourse before age 18 0.017 0.011 159 111 1.075 0.642 0.000 0.040 Want no more children 0.084 0.031 100 71 1.101 0.366 0.023 0.145 Want to delay birth at least 2 years 0.062 0.025 100 71 1.033 0.405 0.012 0.112 Ideal number of children 2.741 0.047 227 159 0.861 0.017 2.648 2.834 Had 2+ sexual partners in past 12 months 0.000 0.000 228 159 na na 0.000 0.000 Abstinence among never-married youth (never had sex) 0.707 0.077 67 47 1.366 0.109 0.553 0.861 Paid for sexual intercourse in past 12 months 0.008 0.007 228 159 1.106 0.810 0.000 0.021 na=Not applicable Appendix B • 275 Table B.7 Sampling errors: Ararat sample, Armenia 2015-16 Variable Value (R) Standard error (SE) Number of cases Design effect (DEFT) Relative error (SE/R) Confidence limits Un- weighted (N) Weighted (WN) R-2SE R+2SE WOMEN Urban residence 0.269 0.025 597 552 1.367 0.092 0.220 0.319 Secondary or higher education 0.885 0.025 597 552 1.943 0.029 0.834 0.936 Never married (never in union) 0.286 0.023 597 552 1.216 0.079 0.241 0.331 Currently married (in union) 0.651 0.025 597 552 1.254 0.038 0.602 0.700 Married before age 20 0.355 0.028 445 407 1.240 0.079 0.299 0.411 Had sexual intercourse before age 18 0.133 0.013 445 407 0.820 0.100 0.106 0.159 Currently pregnant 0.029 0.007 597 552 1.009 0.239 0.015 0.043 Children ever born 1.454 0.049 597 552 0.981 0.034 1.356 1.552 Children surviving 1.424 0.049 597 552 1.012 0.035 1.325 1.523 Children ever born to women age 40-49 2.286 0.085 134 128 0.897 0.037 2.116 2.456 Know any contraceptive method 1.000 0.000 395 360 na 0.000 1.000 1.000 Know a modern method 1.000 0.000 395 360 na 0.000 1.000 1.000 Currently using any method 0.661 0.024 395 360 0.992 0.036 0.614 0.709 Currently using a modern method 0.347 0.033 395 360 1.360 0.094 0.282 0.413 Currently using pill 0.008 0.005 395 360 1.057 0.576 0.000 0.018 Currently using IUD 0.134 0.014 395 360 0.806 0.103 0.106 0.162 Currently using condoms 0.181 0.025 395 360 1.300 0.139 0.131 0.232 Currently using injectables 0.000 0.000 395 360 na na 0.000 0.000 Currently using female sterilization 0.018 0.009 395 360 1.311 0.484 0.001 0.036 Using public sector source 0.411 0.036 135 125 0.850 0.088 0.339 0.483 Want no more children 0.492 0.019 395 360 0.759 0.039 0.454 0.531 Want to delay next birth at least 2 years 0.084 0.018 395 360 1.302 0.216 0.048 0.121 Ideal number of children 2.584 0.028 597 552 0.913 0.011 2.528 2.641 Mothers received antenatal care for last birth 0.985 0.011 160 140 1.113 0.011 0.963 1.000 Births with skilled attendant at delivery 1.000 0.000 193 168 na 0.000 1.000 1.000 Had diarrhea in the past 2 weeks 0.057 0.018 191 166 1.000 0.321 0.020 0.093 Treated with ORS 0.838 0.152 10 9 1.310 0.182 0.534 1.000 Sought medical treatment for diarrhea 0.797 0.157 10 9 1.236 0.198 0.482 1.000 Vaccination card seen (children age 12-23 months) 0.988 0.012 47 43 0.752 0.012 0.964 1.000 Received BCG vaccination 0.988 0.012 47 43 0.752 0.012 0.964 1.000 Received HepB vaccination at birth 0.974 0.018 47 43 0.756 0.018 0.939 1.000 Received DPT-HepB-Hib vaccination (third dose) 0.916 0.042 47 43 1.029 0.046 0.832 0.999 Received polio vaccination (third dose) 0.885 0.048 47 43 1.035 0.054 0.789 0.982 Received rotavirus vaccination (second dose) 0.856 0.053 47 43 1.025 0.062 0.750 0.961 Received all vaccinations appropriate for a child age 12- 23 months 0.842 0.053 47 43 0.999 0.064 0.735 0.949 Vaccination card seen (children age 24-35 months) 1.000 0.000 41 39 na 0.000 1.000 1.000 Received measles, mumps, and rubella (MMR) vaccination 0.811 0.054 41 39 0.897 0.066 0.703 0.918 Received DPT vaccination (fourth dose) 0.826 0.059 41 39 1.010 0.071 0.709 0.943 Received polio vaccination (fourth dose) 0.935 0.040 41 39 1.050 0.042 0.856 1.014 Received all basic vaccinations appropriate for children age 24-35 months 0.935 0.040 41 39 1.050 0.042 0.856 1.014 Received all vaccinations appropriate for a child age 24- 35 months 0.649 0.074 41 39 1.014 0.114 0.501 0.797 Height-for-age (-2SD) 0.137 0.037 179 161 1.360 0.272 0.062 0.211 Weight-for-height (-2SD) 0.134 0.028 164 147 1.044 0.210 0.078 0.191 Weight-for-age (-2SD) 0.028 0.012 182 164 0.963 0.429 0.004 0.052 Prevalence of anemia (children age 6-59 months) 0.103 0.025 172 159 1.099 0.247 0.052 0.153 Prevalence of anemia (women age 15-49) 0.090 0.014 586 539 1.143 0.151 0.063 0.117 Body mass index (BMI) < 18.5 0.027 0.007 563 519 1.014 0.256 0.013 0.041 Body mass index (BMI) ≥ 25 0.436 0.020 563 519 0.961 0.046 0.396 0.477 Ever experienced any physical violence since age 15 0.130 0.017 464 421 1.060 0.127 0.097 0.163 Ever experienced any sexual violence 0.019 0.008 464 421 1.318 0.437 0.002 0.036 Ever experienced any physical/sexual violence by husband/partner 0.178 0.024 372 306 1.231 0.138 0.129 0.226 Ever experienced any physical or sexual violence by husband/partner in the last 12 months 0.048 0.018 372 306 1.638 0.379 0.012 0.084 Total fertility rate (last 3 years) 1.949 0.209 1,748 1,614 1.159 0.107 1.531 2.368 Total abortion rate (last 3 years) 0.527 0.133 1,748 1,614 1.198 0.252 0.262 0.792 MEN Urban residence 0.268 0.032 313 290 1.272 0.119 0.205 0.332 Secondary or higher education 0.791 0.054 313 290 2.340 0.069 0.683 0.900 Never married (in union) 0.466 0.022 313 290 0.781 0.047 0.422 0.510 Currently married (in union) 0.520 0.022 313 290 0.791 0.043 0.475 0.565 Had first sexual intercourse before age 18 0.085 0.017 235 217 0.959 0.206 0.050 0.119 Want no more children 0.303 0.029 170 151 0.829 0.097 0.245 0.362 Want to delay birth at least 2 years 0.008 0.005 170 151 0.778 0