Cambodia - Demographic and Health Survey - 2006

Publication date: 2006

Cambodia Demographic and Health Survey 2005 National Institute of Public Health and National Institute of Statistics Phnom Penh, Cambodia ORC Macro Calverton, Maryland, USA December 2006 The analysis and preparation of this report on the Cambodia Demographic and Health Survey was achieved through the joint efforts of: Darith Hor, NIS/MoP Sovanratnak Sao, DGH/MoH Vonthanak Saphonn, NIPH/MoH Kia Reinis, ORC Macro Keith Purvis, ORC Macro Kaye Mitchell, ORC Macro Bernard Barrère, ORC Macro Ruilin Ren, ORC Macro Rathavuth Hong, ORC Macro Noah Bartlett, ORC Macro Kiersten Johnson, ORC Macro Joy Fishel, ORC Macro Sri Poedjastoeti, ORC Macro Monica Kothari, ORC Macro Erica Nybro, ORC Macro Andrew Inglis, ORC Macro Sidney Moore, ORC Macro John Chang, ORC Macro See Appendix D for a list of contributors to the implementation of the CDHS. The 2005 Cambodia Demographic and Health Survey (2005 CDHS) is part of the worldwide MEASURE DHS project which is funded by the United States Agency for International Development (USAID). The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID. Additional information about the 2005 CDHS may be obtained from the National Institute of Public Health (#2, Kim Il Sung Blvd, Phnom Penh, Cambodia. Telephone: 855-23-880345, Fax: 855-23-880346, Email: usa@camnet.com.kh) or National Institute of Statistics (#386, Monivong Blvd, Phnom Penh, Cambodia. Telephone/Fax: 855-23-213-650, Email: hdarith@nis.gov.kh). Additional information about the DHS project may be obtained from ORC Macro, 11785 Beltsville Drive, Calverton, MD 20705 USA; Telephone: 301-572-0200, Fax: 301-572-0999, E-mail: reports@orcmacro.com, Internet: http://www.measuredhs.com. Suggested citation: National Institute of Public Health, National Institute of Statistics [Cambodia] and ORC Macro. 2006. Cambodia Demographic and Health Survey 2005. Phnom Penh, Cambodia and Calverton, Maryland, USA: National Institute of Public Health, National Institute of Statistics and ORC Macro. Contents | iii CONTENTS TABLES AND FIGURES . ix FOREWORD .xvii ACKNOWLEDGMENTS . xix SUMMARY OF FINDINGS .xxiii CHAPTER 1 INTRODUCTION 1.1 Geodemography, History, And Economy .1 1.2 Health Status And Policy .2 1.3 Objective and Survey Organization .3 1.4 Sample Design .3 1.5 Questionnaires.5 1.6 Training and Fieldwork .6 1.7 Data Processing.8 1.8 Sample Coverage .8 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2.1 Characteristics of the Household Population .9 2.2 Education of the Household Population .11 2.3 Housing Characteristics .17 2.4 Household Possessions.22 2.5 Household Wealth.22 2.6 Birth Registration.24 CHAPTER 3 UTILIZATION OF HEALTH SERVICES FOR ACCIDENT, ILLNESS, OR INJURY 3.1 Accidental Death or Injury .27 3.2 Physical Impairment.30 3.3 Prevalence and Severity of Illness or Injury .31 3.4 Treatment Sought for Illness or Injury .32 3.5 Utilization of Health Care Facilities .34 3.6 Cost for Health Care .35 CHAPTER 4 RESPONDENT CHARACTERISTICS 4.1 Characteristics of Survey Respondents.41 4.2 Educational Attainment and Literacy .43 4.3 Access to Mass Media .47 4.4 Employment .49 4.5 Knowledge and attitudes concerning tuberculosis.56 4.6 Use of Tobacco.58 iv │ Contents CHAPTER 5 FERTILITY 5.1 Current Fertility Levels and Differentials .61 5.2 Fertility Trends .63 5.3 Children Ever Born and Living.66 5.4 Birth Intervals.67 5.5 Age at First Birth.69 5.6 Teenage Pregnancy and Motherhood.70 CHAPTER 6 PRACTICE OF ABORTION 6.1 Number of Induced Abortions.73 6.2 Abortion in the Past Five Years .75 CHAPTER 7 FAMILY PLANNING 7.1 Knowledge of Contraceptive Methods.79 7.2 Ever Use of Contraceptive Methods .81 7.3 Current Use of Contraceptive Methods .82 7.4 Number of Children at First Use of Contraception.85 7.5 Use of Social Marketing Brands .85 7.6 Knowledge of Fertile Period .86 7.7 Timing of Sterilization .87 7.8 Source of Family Planning Methods .87 7.9 Cost of Family Planning Methods .89 7.10 Informed Choice.89 7.11 Future Use of Contraception .91 7.12 Reasons for Not Intending to Use a Contraceptive Method in the Future.91 7.13 Preferred Method of Contraception for Future Use .92 7.14 Exposure to Family Planning Messages .92 7.15 Contact of Nonusers with Family Planning Providers .93 7.16 Husband's Knowledge of Wife's Use of Contraception.95 CHAPTER 8 OTHER PROXIMATE DETERMINANTS OF FERTILITY 8.1 Marital Status .97 8.2 Age at First Marriage .98 8.3 Age at First Sexual Intercourse.100 8.4 Recent Sexual Activity .103 8.5 Postpartum Amenorrhea, Abstinence, and Insusceptibility.106 8.6 Termination of Exposure to Pregnancy .108 CHAPTER 9 FERTILITY PREFERENCES 9.1 Desire for More Children .109 9.2 Need for Family Planning Services.111 9.3 Ideal Family Size .113 9.4 Fertility Planning .114 Contents | v CHAPTER 10 ADULT AND MATERNAL MORTALITY 10.1 Data Quality Issues .117 10.2 Adult Mortality .118 10.3 Maternal Mortality .119 CHAPTER 11 INFANT AND CHILD MORTALITY 11.1 Assessment of Data Quality .121 11.2 Levels and Trends in Childhood Mortality .122 11.3 Socioeconomic Differentials in Childhood Mortality.125 11.4 Demographic Differentials in Mortality.127 11.5 High-Risk Fertility Behavior .128 CHAPTER 12 CAUSES OF DEATH AMONG INFANTS AND YOUNG CHILDREN 12.1 Introduction.131 12.2 Cause of Death Reported by the Mother.131 12.3 Symptoms Prior to Death .133 12.4 Possible Cause of Death on the Basis of Symptoms .133 CHAPTER 13 MATERNAL HEALTH 13.1 Antenatal Care .137 13.2 Childbirth and Delivery.143 13.3 Postnatal Care and Practices.146 13.4 Perceived Problems in Accessing Women’s Health Care .148 CHAPTER 14 CHILD HEALTH 14.1 Child’s Size at Birth .151 14.2 Immunization of Children .153 14.3 Acute Respiratory Infection .155 14.4 Fever.157 14.5 Diarrhea .159 14.6 Feeding Practices .161 14.7 Knowledge of ORS Packets .163 14.8 Stool Disposal .163 CHAPTER 15 NUTRITION OF CHILDREN AND WOMEN 15.1 Nutritional Status of Children .165 15.2 Initiation of Breastfeeding.169 15.3 Breastfeeding Status by Age.171 15.4 Duration and Frequency of Breastfeeding .173 15.5 Types of Complementary Foods .175 15.6 Infant and Young Child Feeding (IYCF) Practices .176 15.7 Prevalence of Anemia in Children .178 15.8 Micronutrient Intake among Children.180 15.9 Use of Iodized Salt .182 vi │ Contents 15.10 Nutritional Status of Women.183 15.11 Foods Consumed by Mothers.186 15.12 Prevalence of Anemia in Women.187 15.13 Micronutrient Intake among Mothers .189 CHAPTER 16 MALARIA 16.1 Introduction.191 16.2 Malaria Prevention.191 16.3 Malaria Diagnosis and Treatment .195 CHAPTER 17 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR 17.1 Knowledge of HIV/AIDS and of Transmission and Prevention Methods .197 17.1.1 Awareness of AIDS .197 17.1.2 HIV Prevention Methods .197 17.1.3 Knowledge about Transmission.200 17.1.4 Knowledge of Mother-to-Child Transmission.203 17.2 Stigma Associated with AIDS and Attitudes Related to HIV/AIDS .205 17.3 Attitudes towards Negotiating Safer Sex and Educating Youth about Condom Use .208 17.4 Higher-Risk Sex .211 17.4.1 Multiple Sexual Partners and Higher-Risk Sex .211 17.4.2 Paid Sex .214 17.5 Testing for HIV .216 17.6 Reports of Recent Sexually Transmitted Infections .221 17.7 Injections.223 17.8 HIV/AIDS-Related Knowledge and Behavior Among Youth .226 17.8.1 Knowledge about HIV/AIDS and Source for Condoms .226 17.8.2 Age at First Sex and Condom Use at First Sexual Intercourse.227 17.8.3 Recent Sexual Activity.231 17.8.4 Higher-Risk Sex .233 17.8.5 Drunkenness during Sexual Intercourse .235 17.8.6 HIV Testing.237 CHAPTER 18 HIV PREVALENCE AND ASSOCIATED FACTORS 18.1 HIV Testing Protocol.239 18.2 Coverage of HIV Testing in the CDHS.241 18.3 HIV Prevalence.245 18.4 HIV Prevalence Among Youth.252 18.5 HIV Prevalence by Other Characteristics Related to HIV Risk.254 18.6 HIV Prevalence Among Couples .255 CHAPTER 19 CHILDREN AT RISK 19.1 Orphanhood and Children’s Living Arrangements.257 19.2 School Attendance.258 19.3 Basic Material Needs .259 19.4 Separation of Siblings.260 Contents | vii 19.5 Succession Planning.261 19.6 Dispossession of Property .263 CHAPTER 20 WOMEN’S STATUS AND EMPOWERMENT 20.1 Marriage Patterns.265 20.2 Interspousal Communication .268 20.3 Decisionmaking within Households .269 20.4 Attitudes toward Gender Roles .271 20.5 Support from Birth Family.276 20.6 Financial Empowerment .276 20.7 Involvement with Civil Society .278 CHAPTER 21 DOMESTIC VIOLENCE 21.1 Approach to Violence Measurement.284 21.2 Women’s Experience of Violence since Age 15 and Recent Violence in the 12 Months Preceding the Survey.285 21.3 Violence during Pregnancy .287 21.4 Marital Control .288 21.5 Interspousal Violence.290 21.6 Experience of Forced Sex at Sexual Initiation .297 21.7 Help-Seeking Behavior by Women Who Have Experienced Violence.297 REFERENCES . 299 APPENDIX A SAMPLE IMPLEMENTATION .301 APPENDIX B ESTIMATES OF SAMPLING ERRORS.319 APPENDIX C DATA QUALITY TABLES .345 APPENDIX D PERSONS INVOLVED IN THE 2005 CAMBODIA DEMOGRAPHIC AND HEALTH SURVEY.351 APPENDIX E QUESTIONNAIRES .355 Tables and Figures | ix TABLES AND FIGURES Page CHAPTER 1 INTRODUCTION Table 1.1 Results of the household and individual interviews.8 Figure 1.1 Implementation of Survey Instruments and Modules .5 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS Table 2.1 Household population by age, sex, and residence.10 Table 2.2 Population by age according to selected sources .11 Table 2.3 Household composition.11 Table 2.4 Educational attainment of household population .12 Table 2.5 School attendance ratios .14 Table 2.6 Grade repetition and dropout rates.16 Table 2.7 Household drinking water.18 Table 2.8 Household sanitation facilities.20 Table 2.9 Housing characteristics.21 Table 2.10 Household possessions .22 Table 2.11 Wealth quintiles.24 Table 2.12 Birth registration of children under age five .25 Figure 2.1 Population pyramid .10 Figure 2.2 Age-specific attendance rates .15 CHAPTER 3 UTILIZATION OF HEALTH SERVICES FOR ACCIDENT, ILLNESS, OR INJURY Table 3.1 Injury or death in an accident .28 Table 3.2 Injury and death in an accident by type of accident .29 Table 3.3 Physical impairment.30 Table 3.4 Prevalence and severity of illness or injury in previous 30 days.32 Table 3.5 Percentage of ill or injured population who sought treatment.33 Table 3.6 Percentage of ill or injured population who sought treatment.34 Table 3.7 Distribution of cost for health care .36 Table 3.8 Expenditures for health care.37 Table 3.9 Source of money spent on health care .39 Figure 3.1 Percentage of household members ill or injured seeking treatment by order of treatment and sector of health care .35 CHAPTER 4 RESPONDENT CHARACTERISTICS Table 4.1 Background characteristics of respondents .42 Table 4.2.1 Educational attainment: women .44 x | Tables and Figures Table 4.2.2 Educational attainment: men .45 Table 4.3 Literacy: women.46 Table 4.4.1 Exposure to mass media: women.47 Table 4.4.2 Exposure to mass media: men.49 Table 4.5.1 Employment status: women .50 Table 4.5.2 Employment status: men.52 Table 4.6.1 Occupation: women.53 Table 4.6.2 Occupation: men .54 Table 4.7 Type of employment.55 Table 4.8 Knowledge and attitude concerning tuberculosis: women.57 Table 4.9 Use of tobacco: women.59 Figure 4.1 Women’s Employment Status in the Past 12 Months.51 CHAPTER 5 FERTILITY Table 5.1 Current fertility .61 Table 5.2 Fertility by background characteristics .63 Table 5.3.1 Trends in age-specific fertility rates.64 Table 5.3.2 Trends in age-specific and total fertility rates .65 Table 5.4 Children ever born and living.66 Table 5.5 Birth intervals.68 Table 5.6 Age at first birth .69 Table 5.7 Median age at first birth .70 Table 5.8 Teenage pregnancy and motherhood.71 Figure 5.1 Trends in fertility.65 CHAPTER 6 PRACTICE OF ABORTION Table 6.1 Number of induced abortions .74 Table 6.2 Pregnancy duration at the time of abortion .76 Table 6.3 Place of abortion.76 Table 6.4 Persons who helped with abortion .77 Figure 6.1 Distribution of number of abortions for women who report having an induced abortion .75 CHAPTER 7 FAMILY PLANNING Table 7.1 Knowledge of contraceptive methods .79 Table 7.2 Knowledge of contraceptive methods by background characteristics .80 Table 7.3 Ever use of contraception.81 Table 7.4 Current use of contraception by age .82 Table 7.5 Current use of contraception by background characteristics .83 Table 7.6 Number of children at first use of contraception .85 Table 7.7 Use of social marketing brand pills and condoms .86 Table 7.8 Knowledge of fertile period.87 Table 7.9 Timing of sterilization.87 Table 7.10 Source of modern contraceptive methods.88 Tables and Figures | xi Table 7.11 Cost of modern contraceptive methods.89 Table 7.12 Informed choice .90 Table 7.13 Future use of contraception .91 Table 7.14 Reason for not intending to use contraception in the future .91 Table 7.15 Preferred method of contraception for future use.92 Table 7.16 Exposure to family planning messages .93 Table 7.17 Contact of nonusers with family planning providers .94 Table 7.18 Husband/partner's knowledge of women's use of contraception .95 CHAPTER 8 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 8.1 Current marital status .97 Table 8.2 Age at first marriage .98 Table 8.3.1 Median age at first marriage: women .99 Table 8.3.2 Median age at first marriage: men. 100 Table 8.4 Age at first sexual intercourse . 101 Table 8.5.1 Median age at first sexual intercourse: women. 102 Table 8.5.2 Median age at first sexual intercourse: men. 103 Table 8.6.1 Recent sexual activity: women. 104 Table 8.6.2 Recent sexual activity: men. 105 Table 8.7 Postpartum amenorrhea, abstinence and insusceptibility. 106 Table 8.8 Median duration of amenorrhea, postpartum abstinence and postpartum insusceptibility. 107 Table 8.9 Menopause. 108 CHAPTER 9 FERTILITY PREFERENCES Table 9.1 Fertility preferences by number of living children . 109 Table 9.2 Desire to limit childbearing . 110 Table 9.3 Need and demand for family planning among currently married women . 112 Table 9.4 Ideal number of children . 113 Table 9.5 Mean ideal number of children. 114 Table 9.6 Fertility planning status. 115 Table 9.7 Wanted fertility rates. 116 CHAPTER 10 ADULT AND MATERNAL MORTALITY Table 10.1 Data on siblings . 117 Table 10.2 Sibship size and sex ratio of siblings . 118 Table 10.3 Adult mortality rates. 119 Table 10.4 Direct estimates of maternal mortality . 120 CHAPTER 11 INFANT AND CHILD MORTALITY Table 11.1 Early childhood mortality rates . 122 Table 11.2 Early childhood mortality rates by socioeconomic characteristics. 126 Table 11.3 Early childhood mortality rates by demographic characteristics. 127 Table 11.4 High-risk fertility behavior . 129 Figure 11.1 Trends in childhood mortality, 2000 and 2005 CDHS . 123 xii | Tables and Figures Figure 11.2 Trends in infant mortality . 124 Figure 11.3 Trends in child mortality . 124 Figure 11.4 Trends in under-five mortality . 125 Figure 11.5 Infant mortality by mother’s background characteristics . 126 Figure 11.6 Infant mortality by selected demographic characteristics . 128 CHAPTER 12 CAUSES OF DEATH AMONG INFANTS AND YOUNG CHILDREN Table 12.1 Causes of death among infants and young children . 131 Table 12.2 Infant and child deaths diagnosed by a health worker . 132 Table 12.3 Symptoms during illness that led to death . 133 Table 12.4 Possible diagnosis established from symptoms. 134 Table 12.5 Multiple diagnoses . 135 CHAPTER 13 MATERNAL HEALTH Table 13.1 Antenatal care. 138 Table 13.2 Number of antenatal care visits and timing of first visit . 139 Table 13.3 Components of antenatal care . 140 Table 13.4 Tetanus toxoid injections . 142 Table 13.5 Place of delivery . 144 Table 13.6 Assistance during delivery . 145 Table 13.7 Timing of first postnatal checkup. 147 Table 13.8 Type of provider of first postnatal checkup. 148 Table 13.9 Problems in accessing health care . 149 CHAPTER 14 CHILD HEALTH Table 14.1 Child's weight and size at birth. 152 Table 14.2 Vaccinations by source of information. 153 Table 14.3 Vaccinations by background characteristics . 154 Table 14.4 Prevalence and treatment of symptoms of ARI . 156 Table 14.5 Prevalence and treatment of fever. 158 Table 14.6 Prevalence of diarrhea . 159 Table 14.7 Diarrhea treatment . 160 Table 14.8 Feeding practices during diarrhea . 162 Table 14.9 Knowledge of ORS packets or pre-packaged liquids. 163 Table 14.10 Disposal of children's stools. 164 Figure 14.1 Trends in vaccination coverage by 12 months of age (among children 12-23 months) . 155 CHAPTER 15 NUTRITION OF CHILDREN AND WOMEN Table 15.1 Nutritional status of children . 167 Table 15.2 Initial breastfeeding. 170 Table 15.3 Breastfeeding status by age . 172 Table 15.4 Median duration and frequency of breastfeeding . 174 Table 15.5 Foods and liquids consumed by children in the day or night preceding the interview . 175 Tables and Figures | xiii Table 15.6 Infant and young child feeding (IYCF) practices . 177 Table 15.7 Prevalence of anemia in children . 179 Table 15.8 Micronutrient intake among children . 181 Table 15.9 Iodization of household salt . 183 Table 15.10 Nutritional status of women . 185 Table 15.11 Foods consumed by mothers in the day or night preceding the interview. 187 Table 15.12 Prevalence of anemia in women . 188 Table 15.13 Micronutrient intake among mothers . 190 Figure 15.1 Nutritional status of children by age . 168 Figure 15.2 Trends in nutritional status of children under five years . 169 Figure 15.3 Among last-born children born in the five years preceding the survey who ever received a prelacteal liquid, the percentage who received various types of liquids. 171 Figure 15.4 Infant feeding practices by age . 173 Figure 15.5 Infant and young child feeding (ICYF) practices . 178 Figure 15.6 Trends in anemia status among children age 6-59 months . 180 Figure 15.7 Trends in nutritional status among women age 15-49 . 186 Figure 15.8 Trends in anemia status among women age 15-49. 189 CHAPTER 16 MALARIA Table 16.1 Household possession of mosquito nets . 192 Table 16.2 Use of mosquito nets by children . 193 Table 16.3 Use of mosquito nets by women . 195 Table 16.4 Prevalence and prompt treatment of children with fever . 196 CHAPTER 17 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR Table 17.1 Knowledge of AIDS. 197 Table 17.2 Knowledge of HIV prevention methods. 198 Table 17.3.1 Comprehensive knowledge about AIDS: women . 201 Table 17.3.2 Comprehensive knowledge about AIDS: men . 202 Table 17.4 Knowledge of prevention of mother-to-child transmission of HIV. 204 Table 17.5.1 Accepting attitudes toward those living with HIV/AIDS: women. 206 Table 17.5.2 Accepting attitudes toward those living with HIV/AIDS: men. 207 Table 17.6 Attitudes toward negotiating safer sexual relations with husband . 209 Table 17.7 Adult support of education about condom use to prevent AIDS . 210 Table 17.8.1 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: women . 212 Table 17.8.2 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months: men . 213 Table 17.9 Payment for sexual intercourse and condom use at last paid sexual intercourse: men. 215 Table 17.10.1 Coverage of prior HIV testing: women . 217 Table 17.10.2 Coverage of prior HIV testing: men. 218 Table 17.11 Pregnant women counseled and tested for HIV. 220 Table 17.12 Self-reported prevalence of sexually-transmitted infections (STIs) and STI symptoms . 222 xiv | Tables and Figures Table 17.13 Prevalence of medical injections . 224 Table 17.14 Comprehensive knowledge about AIDS and of a source of condoms among youth . 227 Table 17.15 Age at first sexual intercourse among youth. 228 Table 17.16 Condom use at first sexual intercourse among youth. 230 Table 17.17 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth. 232 Table 17.18.1 Higher-risk sexual intercourse among youth and condom use at last higher-risk intercourse in the past 12 months: women . 233 Table 17.18.2 Higher-risk sexual intercourse among youth and condom use at last higher-risk intercourse in the past 12 months: men . 234 Table 17.19 Drunkenness during sexual intercourse among youth. 236 Table 17.20 Recent HIV tests among youth . 237 Figure 17.1 Perceptions and beliefs about abstinence and faithfulness . 199 Figure 17.2 women and men seeking treatment for STIs. 223 Figure 17.3 Type of facility where last medical injection was received . 225 Figure 17.4 Percentage whose last injection was given with a syringe and Needle taken from a new, unopened package . 225 Figure 17.5 Abstinence, being faithful, and condom use (ABC) among young women and men . 235 CHAPTER 18 HIV PREVALENCE AND ASSOCIATED FACTORS Table 18.1.1 Coverage of HIV testing by residence and region: all respondents . 242 Table 18.1.2 Coverage of HIV testing by sex, according to residence and region: women and men . 243 Table 18.2 Coverage of HIV testing by selected background characteristics . 244 Table 18.3.1 HIV prevalence by age: women . 245 Table 18.3.2 HIV prevalence by age: men. 245 Table 18.3.3 HIV prevalence by age: total women and men. 246 Table 18.4.1 HIV prevalence by socioeconomic characteristics: women. 247 Table 18.4.2 HIV prevalence by socioeconomic characteristics: men . 248 Table 18.4.3 HIV prevalence by socioeconomic characteristics: women and men . 249 Table 18.5 HIV prevalence by demographic characteristics . 250 Table 18.6 HIV prevalence by sexual behavior . 251 Table 18.7 HIV prevalence among young people by background characteristics . 253 Table 18.8 HIV prevalence among young people by sexual behavior. 254 Table 18.9 HIV prevalence by other characteristics. 255 Table 18.10 Prior HIV testing by HIV status . 255 Table 18.11 HIV prevalence among couples. 256 Figure 18.1 HIV testing algorithm . 240 CHAPTER 19 CHILDREN AT RISK Table 19.1 Children’s living arrangements and orphanhood . 258 Table 19.2 School attendance by survivorship of parents . 259 Table 19.3 Possession of basic material needs by orphanhood status . 260 Table 19.4 Orphans not living with siblings. 261 Table 19.5 Succession planning. 262 Tables and Figures | xv Table 19.6 Widows dispossessed of assets and valuables . 263 CHAPTER 20 WOMEN’S STATUS AND EMPOWERMENT Table 20.1 Choice of spouse . 266 Table 20.2 Differences in age and education between spouses. 267 Table 20.3 Spousal communication. 268 Table 20.4 Household decisionmaking. 269 Table 20.5 Women’s participation in household decisionmaking. 270 Table 20.6 Gender-related attitudes . 272 Table 20.7 Women's agreement with reasons justifying a husband beating his wife . 273 Table 20.8 Women's agreement with reasons for refusing to have sexual relations with husband. 275 Table 20.9 Birth family interaction and support . 276 Table 20.10 Ownership of assets . 277 Table 20.11 Economic autonomy. 278 Table 20.12 Involvement in civil society . 279 Table 20.13 Knowledge of issues and laws concerning women's rights. 281 CHAPTER 21 DOMESTIC VIOLENCE Table 21.1 Experience of beatings or physical mistreatment . 286 Table 21.2 Perpetrators of violence . 287 Table 21.3 Violence during pregnancy . 288 Table 21.4 Marital control exercised by husband. 289 Table 21.5 Marital violence . 291 Table 21.6 Frequency of spousal violence . 293 Table 21.7 Onset of spousal violence . 294 Table 21.8 Physical consequences of spousal violence. 295 Table 21.9 Spousal violence, women's status, and spousal characteristics. 296 Table 21.10 Experienced force at sexual initiation . 297 Table 21.11 Help-seeking behavior among all women who have experienced violence. 298 Figure 21.1 Percentage of ever-married women who have experienced different forms of violence from their husband ever and in the past 12 months . 292 APPENDIX A SAMPLE IMPLEMENTATION Table A.1 Distribution of the villages by province and type of residence (sampling frame) . 302 Table A.2 Population distribution by study domain and type of residence (sampling frame) . 302 Table A.3 Sample allocation of complete women interviews according to study domain and by type of residence. 303 Table A.4 Sample distribution according to study domain and by type of residence . 304 Table A.5 Sample distribution of men survey according to study domain and by type of residence. 305 xvi | Tables and Figures Table A.6 Sample implementation: women . 311 Table A.7 Sample implementation: men. 313 Table A.8 Coverage of HIV testing among interviewed women by social and demographic characteristics . 315 Table A.9 Coverage of HIV testing among interviewed men by social and demographic characteristics . 316 Table A.10 Coverage of HIV testing among interviewed women by sexual behavior characteristics . 317 Table A.11 Coverage of HIV testing among interviewed men by sexual behavior characteristics . 318 APPENDIX B ESTIMATES OF SAMPLING ERRORS Table B.1 List of selected variables for sampling errors . 321 Table B.2 Sampling errors for national sample . 322 Table B.3 Sampling errors for urban sample. 323 Table B.4 Sampling errors for rural sample. 324 Table B.5 Sampling errors for Banteay Mean Chey province . 325 Table B.6 Sampling errors for Kampong Cham province . 326 Table B.7 Sampling errors for Kampong Chhnang province. 327 Table B.8 Sampling errors for Kampong Speu province. 328 Table B.9 Sampling errors for Kampong Thom province. 329 Table B.10 Sampling errors for Kandal province. 330 Table B.11 Sampling errors for Kratie province . 331 Table B.12 Sampling errors for Phnom Penh province . 332 Table B.13 Sampling errors for Prey Veng province. 333 Table B.14 Sampling errors for Pursat province. 334 Table B.15 Sampling errors for Siem Reap province. 335 Table B.16 Sampling errors for Svay Rieng province. 336 Table B.17 Sampling errors for Takeo province. 337 Table B.18 Sampling errors for Otdar Mean Chey province . 338 Table B.19 Sampling errors for Battambang/Krong Pailin provinces . 339 Table B.20 Sampling errors for Kampot/Krong Kep provinces. 340 Table B.21 Sampling errors for Krong Preah Sihanouk/Kaoh Kong provinces . 341 Table B.22 Sampling errors for Preah Vihear/Steung Treng provinces . 342 Table B.23 Sampling errors for Mondol Kiri/Rattanak Kiri provinces . 343 APPENDIX C DATA QUALITY TABLES Table C.1 Household age distribution . 345 Table C.2.1 Age distribution of eligible and interviewed women . 346 Table C.2.2 Age distribution of eligible and interviewed men. 346 Table C.3 Completeness of reporting . 347 Table C.4 Births by calendar years . 347 Table C.5 Reporting of age at death in days . 348 Table C.6 Reporting of age at death in months. 349 Foreword | xvii FOREWORD We would like to introduce the Cambodia Demographic and Health Survey 2005 that is the second survey of this type conducted successfully in Cambodia. This survey is sponsored by USAID, ADB using a grant from DFID, UNFPA, UNICEF, and CDC/GAP. Technical assistance was provided by ORC Macro. The National Institute of Public Health (NIPH), Directorate General for Health, Ministry of Health, and the National Institute of Statistics (NIS) of the Ministry of Planning, were the project implementation agencies. This main report includes information on demography, family planning, maternal mortality, infant and child mortality, domestic violence, women’s status and health related information such as breastfeeding, antenatal care, children’s immunization, childhood diseases, and HIV/AIDS. The questionnaires (household, man and woman questionnaires) are designed to evaluate the nutritional status of mothers and children and to measure the prevalence of HIV and anemia. The 2005 CDHS findings are expected to be used by policymakers and program managers to evaluate the Cambodian demographic and health status in order to formulate appropriate population and health policies and programs in Cambodia. The programs of reproductive health and child health and health facilities need to be expanded and improved. We would like to thank USAID, ADB, DFID, UNFPA, UNICEF, and CDC/GAP for sponsoring this survey project and ORC Macro for providing technical assistance. We gratefully acknowledge the support and encouragement extended by HE. San Sy Than, Director General, National Institute of Statistics, Dr. Ung Sam An, Director, National Institute of Public Health, Mr. Hor Darith, CDHS Survey Coordinator and Director of Census and Survey Department, NIS/MOP, Mr. Tith Vong, CDHS Survey Coordinator and Director, Social Statistics Department, NIS/MOP, Dr. Sao Sovanratnak, CDHS Survey Coordinator and Deputy Director, Planning and Health Information Department, MOH, Dr Saphonn Vonthanak, CDHS Survey Coordinator and Deputy Director, National Institute of Public Health, MOH, and other members of the 2005 CDHS Executive Committee and Technical Committee who contributed to the survey activities. We express our sincere thanks to all persons involved in the survey implementation, analysis of the results and report writing for the 2005 CDHS and especially to NIS, NIPH, and Macro staff who contributed in making the survey a success. Prof. Eng Huot Ouk Chay Secretary of State Secretary of State for Minister of Health for Senior Minister Minister of Planning Acknowledgments | xix ACKNOWLEDGMENTS The 2005 Cambodia Demographic and health Survey (CDHS 2005) represents the continuing commitment and efforts in Cambodia to obtain data on population and health. The survey also reflects the interest in obtaining information on maternal health, child health and anemia and HIV prevalence. The CDHS 2005 was sponsored by USAID, ADB using a grant from DFID, UNFPA, UNICEF, and CDC/GAP and it was implemented by the National Institute of Public Health (NIPH), Ministry of Health and the National Institute of Statistics (NIS) of the Ministry of Planning. This survey could not have been implemented without the active support and the efforts of many institutions and individuals. The active support and guidance of Excellencies Secretaries of State, HE. Prof. Eng Huot, Ministry of Health and HE. Ouk Chay, Ministry of Planning, are acknowledged with deep gratitude. We also gratefully acknowledge the representatives of USAID, DFID, UNFPA, UNICEF, and CDC/GAP and their staff for their support and valuable comments throughout the survey activities. Our deep appreciation also goes to the ORC Macro team led by Mr. Bernard Barrère and his colleague Dr. Kia Reinis and others and they are acknowledged with gratitude for their support to facilitate and ensure the survey a success. We would like to express our appreciation for all team leaders, field editors, and interviewers from NIS, NIPH, and central and local offices of Ministry of Planning and Ministry of Health whose dedicated efforts ensured the quality and timeliness of the survey and to all respondents for contributing their time and for giving the required information, enabling us to produce high-quality data for the country. Finally, we would like to thank Dr. Saphonn Vonthanak, CDHS Survey Coordinator and Deputy Director of the National Institute of Public Health, MoH, Dr. Sao Sovanratnak, CDHS Survey Coordinator and Deputy Director, Planning and Health Information Department, Mr. Buth Sokhal, Head of NIPH Laboratory Bureau, Mr. Hor Darith, CDHS Survey Coordinator and Director of Census and Survey Department, NIS, and Mr. Tith Vong, CDHS Survey Coordinator and Director, Social Statistics Department, NIS. Excellency San Sy Than Dr. Ung Sam An Director General Director National Institute of Statistics National Institute of Public Health Summary of Findings | xxi SUMMARY OF FINDINGS The 2005 Cambodia Demographic and Health Survey (CDHS) is a nationally repre- sentative sample of 16,823 women and 6,731 men age 15-49. The 2005 CDHS is the second comprehensive survey conducted in Cambodia as part of the worldwide Demographic and Health Surveys (DHS) projects. The primary purpose of the CDHS is to provide the policymakers and planners with updated and reliable data on fer- tility, family planning, infant, child and maternal mortality, maternal and child health, nutrition, malaria, knowledge of HIV/AIDS, prevalence of HIV, women’s status and domestic violence. The 2005 CDHS is the first survey in Cambodia to provide population-based prevalence estimates for HIV. FERTILITY Survey results indicate that there has been a decline in the total fertility rate, from 4.0 births per woman in 2000 to 3.4 births per woman in 2005. Fertility continues to be lower in urban areas (2.8 births per woman) than rural areas (3.5 births per woman). There is a substantial differential in fertility by region ranging from a low of 2.5 births per woman in Phnom Penh to a high of 5.2 births per woman in Mondol Kiri/ Rattanak Kiri. Both education and wealth have an effect on fertility. Women with secondary or higher education have 1.7 children less than women with no education and women living in the lowest wealth quintile have twice as many children as those living in the highest wealth quintile. Women (age 25-49) begin having children at a median age of 22.0. Women living in urban areas have their first birth about one year later than women living in rural areas. Age at first birth is lowest in Mondol Kiri/Rattanak Kiri (20.7 years) and highest in Kampong Chhnang (23.3 years). Women with secondary and higher education begin childbearing at a slightly higher age than those with less education. Teenage childbearing is quite rare in Cambodia—only 8 percent of young women age 15-19 have begun childbearing. Marriage and sexual initiation patterns are important determinants of fertility levels. Sixty percent of women interviewed are currently married. Women get married at a median age of 20.1. The median age at first marriage has been stable for the past 20 years. Women generally begin having sexual intercourse at about the same time as their first marriage, at the median age of 20.4. Women in urban areas wait about one year longer to get married and initiate sexual activity than those living in rural areas. Women with higher levels of education also tend to marry and initiate sex later than those with lower levels of education. Men marry at a median age of 22.1 and initiate sex slightly before marriage, at a median age of 21.5. The interval between births is relatively long in Cambodia. The median number of months since the preceding birth is 36.8. Eighteen per- cent of nonfirst births occur within 24 months of a previous birth, while 30 percent occur 24 to 35 months after a previous birth. Thirty-one per- cent occur 36 to 59 months after a previous birth and 21 percent occur more than 60 months after a previous birth. More than half (56 percent) of currently mar- ried Cambodian women do not want any more children. Another 23 percent would like to wait at least two years before their next child. On average, Cambodian women would like 3.3 chil- dren. About 8 percent of women have ever had an induced abortion. Among those who have had an induced abortion, 44 percent have had more than one. Four percent of women have had an abor- tion in the past five years. These abortions most frequently took place at a private health facility or at someone’s home. In almost 80 percent of cases, a doctor, nurse, midwife or other health worker assisted with the abortion. FAMILY PLANNING Almost all women are familiar with at least some methods of contraception. The daily con- traceptive pill, the male condom, and xxii | Summary of Findings injectables are known by over 90 percent of married women. About half of women know at least one traditional method of family planning. Almost two-thirds of currently married women have ever used a contraceptive method in their lifetime. Forty percent of married women are currently using a contraceptive method; 27 percent are using a modern method and 13 percent are using a traditional method. Use of contraception has increased substantially since 2000 when only 19 percent of married women were using a modern method. This is due pri- marily to the increase in use of the pill (from 5 percent to 11 percent). Use of modern methods of contraception is higher in urban areas than rural areas (31 percent compared with 27 percent). Almost one-third of women with secondary or higher education use a modern method compared with 22 percent of those with no schooling. Use of modern methods is highest in Otdar Mean Chey (35 percent) and lowest in Mondol Kiri/Rattanak Kirk (19 per- cent). Women access their contraception from a variety of sources. Pill and male condom users obtain their method from the public sector (pri- marily health centers) and other non-medical sources, such as shops and community distribu- tors. Eighty-four percent of injectable users rely on the public sector (health centers) and the private medical sector. Just over half of currently married women say that they intend to use family planning in the future. The daily pill and injectables are the two methods most favored for future use. One-quarter of currently married women have an unmet need for family planning. That is, they do not want any more children or want to wait at least two years before their next birth but are not using a method of contraception. The unmet need for limiting (16 percent) is higher than the unmet need for spacing (9 percent). Unmet need is especially high among women in the lowest wealth quintile and women with no education. Currently 40 percent of the total need for family planning is being met. CHILD HEALTH The 2005 CDHS data show a remarkable decline in childhood mortality. Currently there are 66 infant deaths for every 1,000 live births and 83 under-five deaths for every 1,000 live births. In 2000, infant mortality was 95 and under-five mortality was 124. This represents a decrease of over 30 percent. Still, one in every 12 Cambodian children dies before reaching age 5. Four-fifths of these deaths occur in the first year of life. Childhood mortality varies throughout Cam- bodia. It is much higher in rural areas (under-five mortality of 111) than in urban areas (under-five mortality of 76). Under-five mortality ranges from a high of 165 in Mondol Kiri/Rattanak Kiri to a low of 52 in Phnom Penh. Wealth and edu- cation are strongly linked with childhood death. Children whose mothers are in the lowest wealth quintile have a three times greater risk of death than those whose mothers are in the highest wealth quintile. Under-five mortality is also much higher for those whose mothers have re- ceived no schooling (136) than those whose mothers have attended secondary or higher levels of school (53). Survival of infants and children is also strongly influenced by the sex of the child, mother’s age at birth, birth order, and birth inter- val. Male children are more likely to die than female children. Childhood mortality is also highest among children whose mothers are over 40 years of age at birth. Childhood mortality in- creases with birth order- that is, first, second, and third children are at less risk of death than fourth, fifth, sixth or seventh children. Finally, children who are born less than 2 years after a sibling are at a much increased risk of infant and childhood death than those born 2 or more years after a sibling. Two-thirds of children age 12-23 months have received all the basic recommended vacci- nations (BCG, three doses of DPT and polio, and measles). In 2000, only 40 percent of children had received all of these vaccinations. Over 90 percent have received BCG, DPT 1, and polio 1, while fewer receive the second and third doses of DPT or polio and only 77 percent received the measles vaccine. Seven percent of children have received no vaccinations at all. Summary of Findings | xxiii Vaccination coverage increases with household wealth and mother’s education. Vaccination coverage is highest in Battambang/Krong Pailin (82 percent) and lowest in lowest in Mondol Kirk/Rattanak Kiri (35 percent). Diagnosis and treatment of childhood dis- eases are essential to reducing mortality. Among children who had symptoms of acute respiratory infection in the 2 weeks before the survey, 48 percent were taken to a health facility or pro- vider. Forty-three percent of children with fever received this same treatment. Only 37 percent of children with diarrhea were taken to a health provider. Thirty-six percent of children with diar- rhea were treated with either oral rehydration therapy or recommended home fluids. Only 38 percent of children with diarrhea were given more fluids than usual during illness. The 2005 CDHS collected information on ownership and use of mosquito nets. The data show that while almost all (96 percent) of house- holds own a mosquito net, only 5 percent own an insecticide-treated net. The large majority (88 percent) of children under five slept under a mosquito net the night before the survey. Nine percent slept under an ever-treated net and 4 per- cent slept under an insecticide-treated net. Thirty-five percent of children under five had a fever in the two weeks before the survey. Fever is a major manifestation of malaria, and children with fever should be treated for malaria. However, less than 1 percent of children with fever received an antimalarial drug. MATERNAL HEALTH Antenatal care from a health professional has almost doubled since 2000. Sixty-nine percent of women who had a live birth in the five years preceding the survey received antenatal care compared with only 38 percent in 2000. Ante- natal care coverage is more common in urban areas (79 percent) than in rural areas (68 per- cent). Ninety percent of women with secondary and higher education receive antenatal care compared with only 50 percent of those with no education. Antenatal care coverage is highest in Svay Rieng (92 percent) and lowest in Mondol Kiri/Rattanak Kiri (28 percent). Forty-three per- cent of women have four or more antenatal care visits. Among those who received antenatal care, only about one-third started antenatal care in the first three months of pregnancy. Only 60 percent of those who received ante- natal care reported that they were informed of the signs of pregnancy complications. Just over two-thirds of women with a birth in the five years before the survey were protected from neonatal tetanus, either because they re- ceived two tetanus toxoid injections or because they had received injections during earlier preg- nancies. Only 22 percent of births in the five years before the survey took place in a health facility— 78 percent took place at home. Still, this marks a great improvement since 2000 when only 10 per- cent of births occurred in a health facility. Health-facility births are far more common in urban areas (50 percent) than rural areas (17 per- cent) and among women with secondary or higher education and those in the highest wealth quintile. Forty-four percent of births were assist- ed by a trained health professional (doctor, nurse or midwife). This also represents a large im- provement, as only about one-third of births re- ceived trained assistance in 2000. Seventy per- cent of births in urban areas receive assistance from a trained health provider, compared with only 39 percent in rural areas. Trained assistance at delivery is most common in Phnom Penh (86 percent of births) and least common in Preah Vihear/Steung Treng (13 percent). The 2005 CDHS reports a maternal mortality rate of 472 deaths per 100,000 live births. This is comparable to the figure reported in 2000. BREASTFEEDING AND NUTRITION Almost all Cambodian children are breast- fed. About one-third begin breastfeeding within an hour of birth, while two-thirds begin breastfeeding within a day of birth. Children are breastfed for an average of 21.6 months, but they are exclusively breastfed for only 4.1 months. Sixty percent of infants under six months are exclusively breastfed as recommended by WHO. The CDHS includes biomarker testing for anemia as well as information on micronutrient intake. More than 60 percent of children age 6-59 months have some degree of anemia. The xxiv | Summary of Findings anemia is moderate or severe in 33 percent of cases. The majority of children age 6-35 months had consumed foods rich in vitamin A and iron in the day before the survey. Thirty-five percent of children age 6-59 months had received vita- min A supplements in the 6 months before the survey. Only 2 percent had received iron supple- ments in the week before the survey. Almost three-quarters of households had adequately iodized salt. The nutritional status of children has im- proved in the past 5 years. Currently 37 percent of children are stunted and 7 percent are wasted, compared with 45 and 15 percent in 2000. Stunting is most common in Pursat (62 percent) and least common in Phnom Penh (22 percent). In general, children with uneducated mothers and those living in the poorest households are most likely to be malnourished. Women also suffer from nutritional defi- ciencies. Forty-seven percent of women have some degree of anemia. While most women con- sume foods rich in vitamin A, only 27 percent received a vitamin A dose post-partum. Only 18 percent took iron tablets or syrup for 90 or more days during pregnancy, as recommended. Twenty percent of Cambodian women age 15-49 are considered thin, while 10 percent are overweight or obese. Underweight has remained stable over the last 5 years, while overweight has increased by 66 percent since 2000. HIV/AIDS Almost all Cambodians have heard of AIDS. More than 80 percent of women and men age 15-49 know the three major methods of prevent- ing HIV transmission: using a condom, having only one faithful, uninfected partner, and abstain- ing. Misconceptions about HIV/AIDS are still fairly common. Only sixty-nine percent of women and 60 percent of men know that a healthy-looking person can have the AIDS virus and only about two-thirds know that AIDS cannot be transmitted by mosquito bites. Almost nine in ten women know that HIV can be transmitted to an infant through breastfeeding, but only 33 percent know that this risk can be minimized if the mother takes special drugs during pregnancy. Certain behaviors put individuals at higher risk for contracting HIV. Less than 1 percent of women reported having higher-risk sex in the year before the survey, compared with 14 percent of men. Eighty-three percent of these men did report wearing a condom at last higher-risk sex. Six percent of men reported paying for sex in the year before the survey. Almost all of these men reported using a condom. HIV testing is relatively uncommon in Cam- bodia. About half of men and women know where to get an HIV test, but only 10 percent of women and 14 percent of men have ever taken an HIV test and received the results. Results from the 2005 CDHS indicate that 0.6 percent of Cambodian adults age 15-49 are infected with HIV. Prevalence is the same for women and men. HIV prevalence is three times higher in urban areas than in rural areas. HIV prevalence is three times higher among those living in the wealthiest households than those living in the poorest households. Men and women who are divorced, separated, or widowed have much higher infection rates than those who are currently married or have never been mar- ried. Men and women with 10 or more lifetime sexual partners are significantly more likely to have HIV than those with fewer partners. Inter- estingly, 40 percent of women and 44 percent of men who were HIV positive had been tested previously for HIV, while only 9 percent of HIV- negative women and 11 percent of HIV-negative men had ever taken an HIV test before. Results show a higher infection rate among women who received antenatal care in a public health facility (0.8 percent) than those who did not receive any ANC in the past 3 years (0.5 per- cent). This helps to explain the difference seen between the national sentinel surveillance rate and the DHS population-based HIV rate. The CDHS also examined children who are not living with both of their biological parents. Results show that 21 percent of children under age 18 are not living with both parents; however, in only 9 percent of cases have one or both of the parents died. Data indicate that orphans (those with one or both parents dead) are not signifi- cantly more lacking in basic needs (shoes, clothes, blankets) than non-orphans. Three- fourths of adult caregivers of children report that Summary of Findings | xxv they have made succession plans in case they should fall ill or die. WOMEN’S STATUS AND DOMESTIC VIOLENCE The 2005 CDHS includes modules on women’s status and domestic violence. Accord- ing to the data, 18 percent of women met their husbands for the first time on their wedding day. An additional 40 percent knew their husbands for less than one year before their wedding. In more than half of cases, the woman had no say in who she married. Most women have some decision- making power on issues such as visits to family and friends, daily household purchases and their own health care. Fewer than half have any say in decisions on whether or not she will work or whether to use contraception. Many Cambodians have gender-biased atti- tudes. For example, only 53 percent of women disagree with the statement “important decisions should be made by men.” Fifty-five percent of women agree that a husband has the right to beat his wife under certain circumstances. However, most women also agree that a wife has the right to refuse to have sex with her husband if she knows that he has a sexually transmitted infec- tion or that he is having sex with other women. While few women have sole ownership over land, their homes, or other valuables, most women share ownership of these items with someone else. However, only 24 percent can sell that asset without permission. About two-thirds of women control the money for at least one household item and one personal item. Twenty-two percent of ever-married women ever experienced violence since age 15. Ten percent of women have experienced violence in the year before the survey. In 44 percent of cases, the husband has been the sole perpetrator of the violence. Marital violence is not uncommon. Fourteen percent of ever-married women report that they have ever experienced physical or sexual violence by their husband. Nineteen per- cent report emotional violence. Six percent of women report that marital violence has resulted in bruises and aches; 1 percent reported that they have had an injury or broken bone as a conse- quence of marital violence. Marital violence is especially high among women whose husbands get drunk very often. It is also highest among husbands who exhibit a high degree of control over their wives. Among all women who reported ever experi- encing physical or sexual violence, 31 percent have ever sought help. In half of these cases, women seek help from their families. USE OF HEALTH SERVICES FOR ACCIDENT OR INJURY Two percent of household members were injured or killed in an accident in the year before the survey. Forty-six percent of injuries and deaths are attributed to road accidents. Sixteen percent of household members reported an ill- ness or injury in the month before the survey. Among them, 92 percent sought a first treatment, 27 percent sought a second treatment and 10 per- cent sought a third treatment. The mean cost of these treatments ranged from US $11.17 for the first treatment to US $ 7.82 for the third treatment. xxvi | Map of Cambodia Introduction | 1 INTRODUCTION 1 1.1 GEODEMOGRAPHY, HISTORY, AND ECONOMY Geodemography Cambodia is an agricultural country located in Southeast Asia. It is bounded by Thailand to the west, Laos and Thailand to the north, the gulf of Thailand to the southwest, and Vietnam to the east. It has a total land area of 181,035 square kilometers. Cambodia has a tropical climate with two distinct monsoon seasons, which set the rhythm of rural life. From November to February, the cool, dry northeastern monsoon brings little rain, whereas the southwestern monsoon carries strong winds, high humidity, and heavy rains. The mean annual temperature for Phnom Penh, the capital city, is 27°C. The 1962 census was the last official census to be conducted prior to 1998; it revealed a population of 5.7 million. The population census in 1998 recorded the number of the people in the country at 11,437,656 with an annual growth rate of 2.5 percent (National Institute of Statistics, 1999). The 2004 Inter-Censal Population Survey showed that the annual growth rate declined from 2.5 percent in 1998 to 1.81 percent in 2004, with the total population of 13.09 million (National Institute of Statistics, 2004). A large proportion of the population, 85 percent, live in rural areas, and only 15 percent live in urban areas. The population density in the country as a whole is 74 per square kilometer. More than a million inhabitants (1.044 millions) are living in Phnom Penh. The average size of the Cambodian household is 5.1. The total male to female sex ratio is 93.5. The literacy rate among adults age 15 and over is 73.6 percent. The male adult literacy rate (84.7 percent) is considerably higher than the rate of females (64.1 percent). Currently, it is estimated that approximately 34.7 percent of the total population lives below the poverty line. History Cambodia gained complete independence from France under the leadership of Prince Norodom Sihanouk on 9 November 1953. In March 1970, a military coup led by General Lon Nol overthrew Prince Sihanouk. On 17 April 1975, the Khmer Rouge ousted the Lon Nol regime and took control of the country. Under the new regime, the country was renamed Democratic Kampuchea. Nearly three million Cambodian people died during the Khmer Rouge’s radical and genocidal regime. On 7 January 1979, the revolutionary army of the National Front for Solidarity and Liberation of Cambodia defeated the Khmer Rouge regime and proclaimed the country the People’s Republic of Kampuchea and later in 1989 as the State of Cambodia. The most important political event was the free elections held in May 1993 under the close supervision of the United Nations Transitional Authority in Cambodia (UNTAC). Since then, Cambodia was proclaimed the Kingdom of Cambodia and has a system of constitutional monarchy. Another two free and fair elections took place in 1998 and 2003. Now, Cambodia is stable and well on its way to democracy and a promising future. 2 | Introduction Economy Since the 1991 Paris Peace Accord, Cambodia’s economy has made significant progress after more than two decades of political unrest. However, Cambodia still remains the poorest and least developed country in Asia, with the gross domestic product per capita estimated at approximately 1,400,000 Riel or $339 in 2005 (US$1= 4,128 Riel) (Ministry of Health, 2006). Agriculture, mainly rice production, is still the main economic activity for Cambodia. In addition, small-scale subsistence agriculture, such as fisheries, forestry, and livestock, are still the most important sector. In addition, garments factories and tourism services are also important components of foreign direct investment. 1.2 HEALTH STATUS AND POLICY Health outcomes have been improved recently. The infant mortality rate has decreased from 95 per 1,000 live births in 2000 to 66 in 2005 and the under-five mortality rate from 124 to 83 in the same period. Life expectancy at birth is 58 for male and 64 for female (Ministry of Planning, 2006). The government expenditure on health per capita is $4.09 (Ministry of Health, 2006). Despite progress made, the health status of the Cambodian people is still among the lowest in the region. To improve the health status of the Cambodian people, the Ministry of Health developed the Health Sector Strategic Plan for 2003-2007 (Ministry of Health, 2002). Its policy statement follows: • Implement sector-wide management through a common vision and effective partnerships among all stakeholders; • Provision of basic health services to the people of Cambodia with the full involvement of the community; • Provision of affordable, essential specialized hospital services; • Decentralization and de-concentration of financial, planning and administrative functions within the health sector; • Priority emphasis on prevention and control of communicable and selected chronic and non-communicable diseases, on injury, the elderly, adolescents and vulnerable groups such as the poor, and on managing public health crises; • Priority emphasis on provision of good quality care to mother and child especially essential obstetric and pediatric care; • Active promotion of healthy lifestyles and health-seeking behavior among the population; • Emphasis on quality, effective and efficient provision of health services by all health providers; • Optimization of human resources through appropriate planning, management including deployment and capacity development within the health system; • Increase promotion of effective public and private partnerships for effective and efficient basic and specialist care; • Effective use of the health information for evidence-based planning, implementation, monitoring and evaluation in the health sector; • Implementation of health financing systems to promote equitable access to priority services especially by the poor; and • Further development of appropriate health legislation to protect the health of providers and consumers. Introduction | 3 1.3 OBJECTIVE AND SURVEY ORGANIZATION The 2005 Cambodia Demographic and Health Survey (CDHS) is the second nationally representative survey conducted in Cambodia on population and health issues. It uses the same methodology as its predecessor, the 2000 Cambodia Demographic and Health Survey, allowing policymakers to use the two surveys to assess trends over time. The primary objective of the CDHS is to provide the Ministry of Health, Ministry of Planning (MOP), and other relevant institutions and users with updated and reliable data on infant and child mortality, fertility preferences, family planning behavior, maternal mortality, utilization of maternal and child health services, health expenditures, women’s status, domestic violence, and knowledge and behavior regarding HIV/AIDS and other sexually transmitted infections. This information contributes to policy decisions, planning, monitoring, and program evaluation for the development of Cambodia, at both national- and local-government levels. The long-term objectives of the survey are to technically strengthen the capacity of the National Institute of Public Health (NIPH), Ministry of Health, and the National Institute of Statistics (NIS) of MOP for planning, conducting, and analyzing the results of further surveys. The 2005 DHS survey was conducted by the National Institute of Public Health (NIPH), the Ministry of Health, and the National Institute of Statistics of the Ministry of Planning. The CDHS executive committee and technical committee were established to oversee all technical aspects of implementation. They consisted of representatives from the Ministry of Health, the National Institute of Public Health, Department of Planning and Health Information, the Ministry of Planning, the National Institute of Statistics, the U.S. Agency for International Development (USAID), Department for International Development (DFID), the United Nations Population Fund (UNFPA), and the United Nations Children’s Fund (UNICEF). Funding for the survey came from USAID, the Asian Development Bank (ADB) (under the Health Sector Support Project HSSP, using a grant from the United Kingdom, DFID), UNFPA, UNICEF, and the Centers for Disease Control/Global AIDS Program (CDC/GAP). Technical assistance was provided by ORC Macro. 1.4 SAMPLE DESIGN Creation of the 2005 CDHS sample was based on the objective of collecting a nationally representative sample of completed interviews with women and men between the ages of 15 and 49. To achieve a balance between the ability to provide estimates for all 24 provinces in the country and limiting the sample size, 19 sampling domains were defined, 14 of which correspond to individual provinces and 5 of which correspond to grouped provinces. • Fourteen individual provinces: Banteay Mean Chey, Kampong Cham, Kampong Chhnang, Kampong Speu, Kampong Thom, Kandal, Kratie, Phnom Penh, Prey Veng, Pursat, Siem Reap, Svay Rieng, Takeo, and Otdar Mean Chey; • Five groups of provinces: Battambang and Krong Pailin, Kampot and Krong Kep, Krong Preah Sihanouk and Kaoh Kong, Preah Vihear and Steung Treng, Mondol Kiri, and Rattanak Kiri. The sample of households was allocated to the sampling domains in such a way that estimates of indicators can be produced with known precision for each of the 19 sampling domains, for all of Cambodia combined, and separately for urban and rural areas of the country. The sampling frame used for 2005 CDHS is the complete list of all villages enumerated in the 1998 Cambodia General Population Census (GPC) plus 166 villages which were not enumerated during the 1998 GPC, provided by the National Institute of Statistics (NIS). It includes the entire country and consists of 13,505 villages. The GPC also created maps that delimited the boundaries of 4 | Introduction every village. Of the total villages, 1,312 villages are designated as urban and 12,193 villages are designated as rural, with an average household size of 161 households per village. The survey is based on a stratified sample selected in two stages. Stratification was achieved by separating every reporting domain into urban and rural areas. Thus the 19 domains were stratified into a total of 38 sampling strata. Samples were selected independently in every stratum, by a two stage selection. Implicit stratifications were achieved at each of the lower geographical or administrative levels by sorting the sampling frame according to the geographical/administrative order and by using a probability proportional to size selection at the first stage of selection. In the first stage, 557 villages were selected with probability proportional to village size. Village size is the number of households residing in the village. Some of the largest villages were further divided into enumeration areas (EA). Thus, the 557 CDHS clusters are either a village or an EA. A listing of all the households was carried out in each of the 557 selected villages during the months of February-April 2005. Listing teams also drew fresh maps delineating village boundaries and identifying all households. These maps and lists were used by field teams during data collection. The household listings provided the frame from which the selection of household was drawn in the second stage. To ensure a sample size large enough to calculate reliable estimates for all the desired study domains, it was necessary to control the total number of households drawn. This was done by selecting 24 households in every urban EA, and 28 households in every rural EA. The resulting over- sampling of small areas and urban areas is corrected by applying sampling weights to the data, which ensures the validity of the sample for all 38 strata (urban/rural, and 19 domains). Appendix A provides a complete description of the sample design and weighting procedures. All women age 15-49 years who were either usual residents of the selected households or visitors present in the household on the night before the survey were eligible to be interviewed. In addition, in a subsample of every second household selected for the survey, all men age 15-49 were eligible to be interviewed (if they were either usual residents of the selected households or visitors present in the household on the night before the survey). The minimum sample size is larger for women than men because complex indicators (such as total fertility and infant and child mortality rates) require larger sample sizes to achieve sampling errors of reasonable size, and these data come from interviews with women. In the 50 percent subsample, all men and women eligible for the individual interview were also eligible for HIV testing. In addition, in this subsample of households all women eligible for interview and all children under the age of five were eligible for anemia testing. These same women and children were also eligible for height and weight measurement to determine their nutritional status. Women in this same subsample were also eligible to be interviewed with the cause of death module, applicable to women with a child born since January 2002. The 50 percent subsample not eligible for the man interview was further divided into half, resulting in one-quarter subsamples. In one-quarter subsample all women age 15-49 were eligible for the woman’s status module in addition to the main interview. In this same one-quarter subsample, one woman per household was eligible for the domestic violence module. In the other one-quarter subsample, women were not eligible for the woman’s status module, nor the domestic violence module. Figure 1.1 provides a diagram of the implementation of the survey modules. Introduction | 5 1.5 QUESTIONNAIRES Three questionnaires were used: the Household Questionnaire, Woman Questionnaire, and Man Questionnaire. The content of these questionnaires was based on model questionnaires developed by the MEASURE DHS project. Technical meetings between experts and representatives of the Cambodian government and national and international organizations were held to discuss the content of the questionnaires. Inputs generated by these meetings were used to modify the model questionnaires to reflect the needs of users and relevant population, family planning, and health issues in Cambodia. Final questionnaires were translated from English to Khmer and a great deal of refinement to the translation was accomplished during the pretest of the questionnaires. The Household Questionnaire served multiple purposes: • It was used to list all of the usual members and visitors in the selected households and was the vehicle for identifying women and men who were eligible for the individual interview. • It collected basic information on the characteristics of each person listed, including age, sex, education, and relationship to the head of the household. • It collected information on characteristics of the household’s dwelling unit, ownership of various durable goods, ownership and use of mosquito nets, and testing of salt for iodine content. • It collected anthropometric (height and weight) measurements and hemoglobin levels. • It was used to register people eligible for collection of samples for later HIV testing. • It had a module on recent illness or death. Households All women/men 15-49 tested for HIV No men survey no HIV no anemia no height/weight no verbal autopsy In 25% of households Woman questionnaire includes: woman’s status domestic violence Survey among all men 15-49 In 50% of households Height & weight Anemia (all women 15-49 & children <5) In 25% of households No men survey no HIV no anemia no height/weight no verbal autopsy no woman’s status no domestic violence, Survey among all women 15-49 incl. verbal autopsy Survey among all women 15-49Survey among all women 15-49 Figure 1.1 Figure 1.1 ImplementationImplementation ofof SurveySurvey Instruments Instruments andand Modules Modules 2005 CDHS2005 CDHS 6 | Introduction • It had a module on utilization of health services. The Women’s Questionnaire covered a wide variety of topics divided into 13 sections: • Respondent Background • Reproduction, including an abortion module • Family Planning • Pregnancy Postnatal Care and Children’s Nutrition • Immunization Health and Women’s Nutrition • Cause of Death of Children (also known as Verbal Autopsy) • Marriage and Sexual Activity • Fertility Preferences • Husband’s Background and Woman’s Work • HIV AIDS and Other Sexually Transmitted Infections • Adult and Maternal Mortality • Women’s Status • Household Relations (also known as Domestic Violence) The Men’s Questionnaire was administered to all men age 15-49 years living in every second household of the 2005 CDHS sample. The Man Questionnaire collected information similar to that of the Woman Questionnaire but was shorter as it did not contain as detailed a reproductive history, or questions on maternal and child health, or nutrition. The CDHS underwent a full pretest in May 2005. Twenty four women and 23 men were trained in the administration of the CDHS survey instruments and blood collection techniques. Training and fieldwork included the Household Questionnaire, (not including anthropometry or testing of salt for iodine), the full 13 sections of the Woman Questionnaire, and the full Man Questionnaire. The training course was followed by five days of interviewing and blood collection, and a full day of interviewer debriefing. Constructive inputs of interviewers were used to refine survey instruments and logistics. Questionnaires were finalized as a result of pretest activities. 1.6 TRAINING AND FIELDWORK The goal of training was to create 19 field teams capable of collecting data for the CDHS 2005. Each team was responsible for data collection in one of the 19 survey domains (comprised of the 24 provinces). Field teams were each composed of 6 people: team leader, field editor, three female interviewers, and one male interviewer. After three weeks of training on questionnaires, data entry staff had acquired the necessary knowledge of the survey instruments and were released from training. The 122 field personnel continued on for three more weeks of training: one week for blood training, one week on miscellaneous topics, and one week of field practice. The first week of training was devoted to the Household Questionnaire. The next two weeks were devoted to 13 Sections of the Woman Questionnaire. Additional time was spent reviewing the Household Questionnaire, including the selection of women for the Household Relations Module, Consent Statements for blood collection, and conversion of ages and dates of birth between the Khmer and Gregorian calendar. Introduction | 7 One week was devoted to additional activities: the Man Questionnaire, measuring height and weight of women and children, sample implementation and household selection (logistically complicated and required two days of training), collection of Geographic Positioning System data, testing of household salt for iodine, organization of documents and materials for return to the head office. One week of main survey training was devoted to the collection of blood samples. All interviewers were designated to collect blood samples in the field, thus all interviewers were trained for blood collection procedures. While field editors and supervisors were not designated to collect blood samples in the field, they also underwent blood collection training so that all team members were fully aware of all responsibilities related to the collection of blood samples. Complete understanding of all survey activities by all team members contributed greatly to the maintenance of high data quality standards over a long period of data collection. Training in the collection of blood samples included procedures for: identifying the correct household eligible for HIV testing in the 50 percent subsample; identifying men and women within those households eligible for HIV testing; obtaining voluntary consent of respondents; safety procedures in handling blood samples; techniques in capillary blood draw; use of the HemoCue machine for field testing of hemoglobin levels to assess levels of anemia; capturing blood samples for anemia testing; capturing blood samples for laboratory testing of HIV; providing referral for respondents needing treatment for anemia; providing vouchers for VCT services; providing HIV information pamphlets; rendering the blood sample for HIV anonymous; proper storage of dried blood spots in the field; packaging of dried blood spots for transport to the laboratory; disposal of bio- hazardous waste; and recording information in the questionnaires. The five weeks of training were followed by a full week of field practice. Two supplementary days prior to launching fieldwork were required to cover fieldwork control forms, and supply teams with all necessary equipment. Each interviewer needs over 50 distinct items to perform a complete interview. Fieldwork was then launched, and teams disbursed to their assigned provinces. During the training period, the 19 CDHS team leaders were provided with the cluster information for the provinces in which they would be working in order to devise a data collection sequence for their sample points. They were best equipped to perform this task as team leaders hailed from their own provinces. They also conducted the CDHS Household Listing operation (described in sample design) and therefore were well-acquainted with the areas in which they would have to work. The progression of fieldwork by geographic location had to take into account weather conditions during rainy season. A fieldwork supervision plan was created for the six CDHS survey coordinators from NIS and NIPH and ORC Macro to conduct regular field supervision visits. Supervision visits were conducted throughout the six months of data collection and included the retrieval of questionnaires and blood samples from the field. In addition, a quality control program was run by the data processing team to detect key data collections errors for each team. Based on these data checks, regular feedback was given to each team based on their specific performance. Data collection was conducted from 9 September 2005 to 7 March 2006. 1.7 DATA PROCESSING Data entry on 19 personal computers began on 22 September 2005, just two weeks after the first interviews were being conducted. Data entry personnel attended questionnaire training of interviewers so as to become familiar with the survey instruments. Data processing personnel included a data processing chief, four assistants, 19 entry operators, and three office editors. Completed questionnaires were brought in from the field by survey coordinators and questionnaires and anonymous blood samples were logged by the office editors. Once proper accounting of 8 | Introduction questionnaires and blood samples was accomplished on a per-cluster basis, blood samples were transported to the NIPH laboratory for later testing. Questionnaire data were entered at NIS using CSPro, a program developed jointly by the United States Census Bureau, the ORC Macro MEASURE DHS program, and Serpro S.A. All questionnaires were entered twice to minimize data entry error. Data entry was completed in April 2006. Internal consistency verification and secondary editing were completed in May 2005. 1.8 SAMPLE COVERAGE All of the 557 clusters selected for the sample were surveyed in the 2005 CDHS. A total of 15,046 households were selected, of which 14,534 were identified and occupied at the time of the survey. Among these households, 14,243 completed the Household Questionnaire, yielding a response rate of 98 percent (Table 1.1). In the 14,243 households surveyed, 17,256 women age 15-49 years were identified as being eligible for the individual interview. Interviews were completed with 16,823 of these women, yielding a response rate of 98 percent. Interviews with men were conducted in every second household. A total of 7,229 men age 15-49 years were identified in the subsample of households. Of these 7,229 men, 6,731 completed the individual interview, yielding a response rate of 93 percent. Table 1.1 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence, Cambodia 2005 Residence Result Urban Rural Total Household interviews Households selected 3,288 11,758 15,046 Households occupied 3,175 11,359 14,534 Households interviewed 3,101 11,142 14,243 Household response rate 97.7 98.1 98.0 Interviews with women Number of eligible women 4,278 12,978 17,256 Number of eligible women interviewed 4,152 12,671 16,823 Eligible woman response rate 97.1 97.6 97.5 Interviews with men Number of eligible men 1,728 5,501 7,229 Number of eligible men interviewed 1,586 5,145 6,731 Eligible man response rate 91.8 93.5 93.1 Household Population and Housing Characteristics | 9 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2 This chapter provides a summary of the socioeconomic characteristics of households and respondents surveyed, including age, sex, place of residence, educational status, household facilities, and household characteristics. The profile of the households provided in this chapter will help in understanding the results of the 2005 CDHS in the following chapters. In addition, it may provide useful input for social and economic development planning. Throughout this report, numbers in the tables reflect weighted numbers. Due to the way the sample was designed, the number of weighted cases in some regions appears small, since they are weighted to make the regional distribution nationally representative. However, roughly the same number of households and women and men were interviewed in each province or group of provinces, and the number of unweighted cases is always large enough to calculate the presented estimates. Estimates based on an insufficient number of cases are shown in parentheses or not shown at all. The 2005 CDHS survey collected information from all usual residents of a selected household (de jure population) and persons who had stayed in the selected household the night before the interview (de facto population). Although the difference between these two populations is small, to avoid double counting all tables in this report refer to the de facto population unless otherwise specified. The CDHS survey used the same definition of households as the 1998 census conducted by the National Institute of Statistics. A household was defined as a person or group of related and unrelated persons who live together in the same dwelling unit(s) or in connected premises, who acknowledge one adult member as head of the household, and who have common arrangements for cooking and eating meals. 2.1 CHARACTERISTICS OF THE HOUSEHOLD POPULATION Age and Sex Composition Age and sex are important demographic variables and are 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. The effect of variations in sex composition from one population group to another should be taken into account in comparative studies of mortality. In general, a cross- classification with sex is useful for the effective analysis of all forms of data obtained in surveys. The survey collected information on age in completed years for each household member. When the age was not known, interviewers inquired further for dates of birth in the Gregorian calendar, the Khmer calendar, and a historical calendar. The age was then calculated using conversion charts specifically designed for this purpose. Table 2.1 presents the percent distribution of the household population by age, according to urban-rural residence and sex. The population spending the night before the survey in the households selected for the survey included 66,894 individuals, of which 47 percent were males and 53 percent were females. The age structure of the household population is typical of a society with a youthful population and recently declining fertility. The sex and age distribution of the population is also shown in the population pyramid in Figure 2.1. Cambodia has a broad-based pyramid structure due to half the population being under 20 years of age. 10 | Household Population and Housing Characteristics Table 2.1 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and residence, Cambodia 2005 Urban Rural Total Age Male Female Total Male Female Total Male Female Total <5 11.1 9.3 10.1 12.4 11.2 11.7 12.2 10.9 11.5 5-9 11.6 9.0 10.2 13.6 12.2 12.9 13.3 11.7 12.4 10-14 14.3 12.4 13.3 16.4 14.4 15.3 16.0 14.1 15.0 15-19 11.9 13.3 12.6 12.0 10.0 10.9 12.0 10.5 11.2 20-24 10.9 11.0 10.9 8.2 8.3 8.3 8.6 8.7 8.7 25-29 7.1 7.2 7.1 5.8 5.8 5.8 6.0 6.0 6.0 30-34 5.4 6.2 5.8 5.5 6.0 5.8 5.5 6.0 5.8 35-39 6.5 6.5 6.5 5.7 6.3 6.0 5.8 6.3 6.1 40-44 6.1 5.8 6.0 5.4 6.1 5.8 5.5 6.1 5.8 45-49 4.2 5.2 4.7 3.6 4.8 4.2 3.7 4.9 4.3 50-54 3.3 3.7 3.5 3.0 4.1 3.6 3.0 4.0 3.6 55-59 2.4 3.3 2.9 2.4 3.2 2.8 2.4 3.2 2.8 60-64 2.0 2.2 2.1 2.0 2.3 2.2 2.0 2.3 2.2 65-69 1.5 1.7 1.6 1.6 2.0 1.8 1.6 2.0 1.8 70-74 1.0 1.5 1.3 1.1 1.5 1.3 1.1 1.5 1.3 75-79 0.4 0.8 0.6 0.7 1.0 0.9 0.7 1.0 0.8 80 + 0.4 0.8 0.6 0.5 0.8 0.7 0.5 0.8 0.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 4,824 5,524 10,348 26,523 30,023 56,546 31,347 35,547 66,894 Above the age of 10 years, the pyramid follows a usual pattern of decreasing numbers as age increases. However, those age 25 to 34 are fewer than would be expected as these are the two age groups born in the decade of the 1970s. The early 1970s saw escalating civil war and in the late 70s the Khmer Rouge ruled. This period of time was characterized by few births and high infant and child mortality. CDHS 2005 Figure 2.1 Population Pyramid 80 + 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 <5 Age 0246810 0 2 4 6 8 10 Male Female Percent Household Population and Housing Characteristics | 11 Cambodia has a large dependent population of children and adolescents, although with declining fertility the proportion of the population under age 15 years has recently declined. Table 2.2 shows that children under 15 years of age account for 39 percent of the population. Fifty-seven percent of the population is in the age group 15-64, and nearly 5 percent are over 65 years of age. Table 2.2 Population by age according to selected sources Percent distribution of the de facto population by age group, according to selected sources, Cambodia 2005 Age 1998 Census1 2000 CDHS survey2 2004 CIPS3 2005 CDHS survey < 15 42.8 42.7 38.6 38.9 15-49 46.9 46.3 49.5 47.9 50-64 6.8 7.4 8.0 8.6 65 + 3.5 3.6 3.9 4.6 Total 100.0 100.0 100.0 100.0 1 General Population Census of Cambodia, 1998 (National Institute of Statistics, 1999) 2 Cambodia Demographic and Health Survey, 2000 (National Institute of Statistics and ORC Macro, 2001) 3 Cambodia Inter-censal Population Survey, 2004 (National Institute of Statistics, 2004) Household Composition Table 2.3 shows the distribution of households in the survey by the sex of the head of the household and by the number of house- hold members in urban and rural areas. House- holds in Cambodia are predominantly male- headed. However, one-quarter of households are headed by women, with 23 and 26 percent being female-headed households in rural and urban areas, respectively. The average household size is 5.0 per- sons, smaller than the 5.4 persons per household observed in the 2000 CDHS. Rural households have 4.9 persons per household on average, and are slightly smaller than urban households (5.2 persons). Households with seven or more members are more common in urban areas (26 percent) than in rural areas (20 percent). 2.2 EDUCATION OF THE HOUSEHOLD POPULATION Many behaviors, including those in the realm of reproduction, contraceptive use, child health, and proper hygiene, are affected by the education of household members. Information on the educational level of the male and female population age six and above is presented in Table 2.4. Survey results show that while the majority of Cambodians have not completed primary school, the country has experienced strong improvement in educational attainment over time. Overall, one in eight males has never attended school, while as many as one in four females has never attended school. Improvements over time have resulted in as few as 4 percent of girls and 5 percent of boys age 10-14 having never attended school at all. Table 2.3 Household composition Percent distribution of households by sex of head of household and by household size, and mean size of household, according to residence, Cambodia 2005 Residence Characteristic Urban Rural Total Household headship Male 73.6 77.0 76.5 Female 26.4 23.0 23.5 Total 100.0 100.0 100.0 Number of usual members 1 3.9 2.8 2.9 2 7.5 7.8 7.7 3 11.7 14.8 14.4 4 17.4 20.0 19.7 5 18.6 19.0 18.9 6 14.6 15.3 15.2 7 10.9 10.0 10.1 8 7.7 5.5 5.8 9+ 7.7 4.9 5.3 Total 100.0 100.0 100.0 Mean size of households 5.2 4.9 5.0 Number of households 2,066 12,177 14,243 Note: Table is based on de jure members, i.e., usual residents. 12 | Household Population and Housing Characteristics Table 2.4 Educational attainment of household population Percent distribution of the de facto female and male household population age six and over by highest level of education attended or completed and median grade completed, according to background characteristics, Cambodia 2005 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don't know/ missing Total Number Median grade FEMALE Age 6-9 32.0 67.9 0.0 0.0 0.0 0.0 0.1 100.0 3,282 0.3 10-14 4.1 76.0 12.4 7.4 0.1 0.0 0.1 100.0 4,996 3.4 15-19 8.2 34.0 15.6 39.9 1.4 0.8 0.0 100.0 3,729 5.5 20-24 16.2 46.1 9.5 21.0 4.0 3.1 0.1 100.0 3,110 3.9 25-29 21.6 48.4 6.2 20.2 2.2 1.4 0.0 100.0 2,138 3.4 30-34 17.2 51.9 7.3 20.9 1.9 0.8 0.0 100.0 2,130 3.2 35-39 20.9 50.1 6.2 20.9 1.5 0.5 0.0 100.0 2,256 3.0 40-44 35.3 54.2 2.9 6.5 0.5 0.3 0.4 100.0 2,161 1.3 45-49 29.7 58.5 3.6 7.3 0.7 0.3 0.0 100.0 1,739 1.7 50-54 33.9 52.6 4.8 7.0 0.9 0.2 0.6 100.0 1,429 1.6 55-59 43.4 44.2 6.5 4.8 0.4 0.3 0.4 100.0 1,137 0.8 60-64 57.9 32.5 3.3 5.1 0.2 0.2 0.8 100.0 820 0.0 65+ 85.1 12.2 0.8 1.4 0.0 0.0 0.5 100.0 1,888 0.0 Residence Urban 17.7 42.7 8.5 24.0 4.0 2.8 0.3 100.0 4,907 3.8 Rural 26.4 53.4 7.0 12.3 0.6 0.2 0.1 100.0 25,911 2.1 Province Banteay Mean Chey 28.1 56.0 5.8 9.4 0.3 0.0 0.3 100.0 1,221 1.6 Kampong Cham 28.2 52.7 7.6 10.6 0.5 0.1 0.1 100.0 4,014 2.2 Kampong Chhnang 23.6 55.3 6.9 13.0 0.9 0.0 0.3 100.0 1,100 2.2 Kampong Speu 23.9 58.0 6.7 10.5 0.5 0.3 0.2 100.0 1,715 1.9 Kampong Thom 21.8 58.1 6.2 11.9 1.3 0.0 0.6 100.0 1,527 2.2 Kandal 21.9 47.8 9.2 19.5 1.0 0.5 0.0 100.0 3,084 3.0 Kratie 24.6 52.4 6.8 15.2 0.9 0.0 0.1 100.0 604 2.1 Phnom Penh 13.5 39.3 10.0 27.8 5.0 4.3 0.1 100.0 2,888 4.8 Prey Veng 23.6 58.4 6.9 10.5 0.5 0.1 0.0 100.0 2,566 2.1 Pursat 28.4 53.5 6.0 11.2 0.4 0.4 0.2 100.0 938 1.9 Siem Reap 36.5 49.4 4.3 9.0 0.3 0.4 0.0 100.0 2,080 1.3 Svay Rieng 25.7 53.5 6.8 12.9 0.5 0.6 0.0 100.0 1,243 2.2 Takeo 23.3 50.2 7.8 17.4 1.0 0.2 0.2 100.0 2,160 2.8 Otdar Mean Chey 36.0 56.2 3.4 4.1 0.2 0.0 0.1 100.0 322 1.2 Battambang/Krong Pailin 20.3 53.7 7.9 16.0 1.3 0.8 0.0 100.0 2,171 2.7 Kampot/Krong Kep 22.9 53.7 8.6 13.9 0.7 0.2 0.2 100.0 1,566 2.4 Krong Preah Sihanouk/ Kaoh Kong 32.6 47.9 6.1 10.1 1.6 0.5 1.3 100.0 688 1.8 Preah Vihear/Steung Treng 32.2 57.3 3.1 7.0 0.3 0.1 0.1 100.0 546 1.0 Mondol Kiri/Rattanak Kiri 61.7 29.6 2.1 6.1 0.4 0.0 0.0 100.0 387 0.0 Total 25.0 51.7 7.3 14.1 1.1 0.7 0.2 100.0 30,817 2.3 Continued. Half of the population has had some primary schooling without having completed primary school, male and female alike. However, 27 percent of the male population has gone on to attend secondary or higher schooling, while only 16 percent of females have had secondary or higher schooling. Improvements over time have resulted in approximately 40 percent of males in their twenties and thirties having gone on to secondary school, and approximately 25 percent of females in their twenties and thirties having done so. As would be expected, higher percentages of males and females in urban areas have gone on for secondary schooling than have rural males and females. There is a great deal of regional variation in educational attainment across provinces, with approximately 20-35 percent having never been to school. The outliers are Mondol Kiri/Rattanak Kiri and Phnom Penh, where 62 percent and 14 percent have never been to school, respectively. The percent of men who have never been to school clusters around 10 to 25 percent across provinces, with the same outliers of Mondol Kiri/Rattanak Kiri and Phnom Penh, where 44 percent and 5 percent have never been to school, respectively. Household Population and Housing Characteristics | 13 Table 2.4—Continued Percent distribution of the de facto female and male household population age six and over by highest level of education attended or completed and median grade completed, according to background characteristics, Cambodia 2005 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don't know/ missing Total Number Median grade MALE Age 6-9 35.5 64.3 0.0 0.0 0.0 0.0 0.1 100.0 3,327 0.2 10-14 4.5 78.8 9.6 7.0 0.1 0.0 0.0 100.0 5,029 3.0 15-19 4.8 33.5 15.3 44.8 1.3 0.4 0.0 100.0 3,763 5.8 20-24 8.2 35.2 9.8 34.7 6.1 5.8 0.3 100.0 2,698 5.7 25-29 11.2 40.1 6.9 30.0 6.3 5.2 0.3 100.0 1,875 4.9 30-34 11.3 36.1 8.7 34.0 5.6 3.8 0.4 100.0 1,730 5.3 35-39 9.5 38.2 7.1 35.8 4.7 4.4 0.3 100.0 1,819 5.4 40-44 18.5 44.6 6.2 23.8 2.9 3.2 0.9 100.0 1,740 3.4 45-49 14.7 55.7 9.4 16.2 1.6 1.5 0.8 100.0 1,150 2.9 50-54 10.9 51.0 13.0 18.4 3.9 1.9 1.0 100.0 952 3.8 55-59 12.8 48.6 16.0 17.4 3.7 0.6 1.0 100.0 758 3.9 60-64 15.7 47.1 11.6 20.2 3.1 1.0 1.4 100.0 622 3.4 65+ 30.7 43.6 9.5 12.5 1.9 0.5 1.3 100.0 1,214 2.5 Residence Urban 8.7 37.7 8.8 29.2 7.3 7.5 0.8 100.0 4,180 5.4 Rural 14.1 52.9 8.9 21.1 1.7 0.9 0.3 100.0 22,496 3.3 Province Banteay Mean Chey 16.4 58.8 7.4 14.4 1.0 0.2 1.8 100.0 1,053 2.5 Kampong Cham 14.4 55.5 9.6 18.1 2.0 0.4 0.0 100.0 3,533 3.3 Kampong Chhnang 10.9 55.1 10.1 21.9 1.5 0.2 0.3 100.0 930 3.4 Kampong Speu 11.9 54.9 10.1 20.3 1.4 0.4 1.1 100.0 1,445 3.4 Kampong Thom 13.8 57.0 7.7 17.8 2.2 0.5 1.0 100.0 1,338 2.9 Kandal 10.0 46.9 8.7 30.0 2.6 1.8 0.0 100.0 2,713 4.4 Kratie 19.0 51.4 8.8 18.6 1.5 0.2 0.4 100.0 536 2.7 Phnom Penh 5.0 32.0 8.8 31.6 9.2 13.2 0.2 100.0 2,473 6.7 Prey Veng 8.1 55.0 10.6 24.5 1.4 0.4 0.0 100.0 2,018 3.9 Pursat 17.6 53.9 8.4 17.9 1.6 0.6 0.0 100.0 835 2.9 Siem Reap 26.1 51.7 6.3 13.1 1.3 1.2 0.4 100.0 1,759 2.3 Svay Rieng 8.6 50.4 11.1 26.6 1.4 1.9 0.0 100.0 1,115 4.1 Takeo 12.5 43.6 9.8 30.5 3.0 0.5 0.1 100.0 1,956 4.4 Otdar Mean Chey 23.8 60.6 4.3 10.1 1.1 0.1 0.2 100.0 289 2.1 Battambang/Krong Pailin 10.4 53.2 9.7 22.9 2.4 1.3 0.0 100.0 1,841 3.6 Kampot/Krong Kep 10.6 55.0 10.4 21.0 2.1 0.6 0.3 100.0 1,348 3.6 Krong Preah Sihanouk/ Kaoh Kong 17.9 45.6 6.6 20.7 2.9 1.4 4.9 100.0 619 3.2 Preah Vihear/Steung Treng 23.1 56.4 5.5 12.8 1.3 0.7 0.1 100.0 499 1.9 Mondol Kiri/Rattanak Kiri 43.8 39.6 3.6 10.9 1.2 0.8 0.1 100.0 379 0.4 Total 13.3 50.5 8.9 22.3 2.6 2.0 0.4 100.0 26,676 3.6 1 Completed grade 6 at the primary level 2 Completed grade 12 at the secondary level School Attendance Ratios Data on net attendance ratios (NARs) and gross attendance ratios (GARs) by school level, sex, residence, and province are shown in Table 2.5. The NAR indicates participation in primary schooling for the population age 6-12 and secondary schooling for the population age 13-18. The GAR measures participation at each level of schooling among those age 6-24. The GAR is nearly always higher than the NAR for the same level because the GAR included participation by those who may be older or younger than the official age range for that level. A NAR of 100 percent would indicate that all those in the official age range for the level are attending at that level. The GAR can exceed 100 percent if there is significant overage or underage participation at a given level of schooling. Overage for a given level of schooling occurs when students start school earlier, repeat one or more grades, or drop out of school and later return. 14 | Household Population and Housing Characteristics Table 2.5 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population by sex and level of schooling; and gender parity index (GPI), according to background characteristics, Cambodia 2005 Net attendance ratio1 Gross attendance ratio2 Background characteristic Male Female Total Male Female Total Gender parity index3 PRIMARY SCHOOL Residence Urban 76.6 79.5 78.0 104.9 101.9 103.4 0.97 Rural 76.3 78.0 77.1 113.7 108.8 111.2 0.96 Province Banteay Mean Chey 80.0 83.8 81.9 110.1 105.9 108.0 0.96 Kampong Cham 79.2 81.1 80.1 120.3 112.2 116.3 0.93 Kampong Chhnang 82.5 81.9 82.2 116.9 108.1 112.6 0.92 Kampong Speu 81.1 81.1 81.1 126.6 115.5 120.7 0.91 Kampong Thom 76.7 79.3 78.0 119.1 113.3 116.2 0.95 Kandal 84.4 77.3 80.7 111.8 101.3 106.4 0.91 Kratie 64.6 69.9 67.2 101.0 89.9 95.4 0.89 Phnom Penh 78.4 79.1 78.7 98.9 103.6 101.1 1.05 Prey Veng 79.9 84.8 82.3 125.2 120.8 123.0 0.97 Pursat 67.5 69.3 68.3 106.5 110.5 108.4 1.04 Siem Reap 63.9 74.0 69.1 94.6 101.1 97.9 1.07 Svay Rieng 79.3 79.3 79.3 124.4 112.9 118.7 0.91 Takeo 75.3 80.5 77.9 109.7 111.6 110.6 1.02 Otdar Mean Chey 62.7 73.1 67.7 105.3 108.5 106.8 1.03 Battambang/Krong Pailin 79.1 81.3 80.2 115.5 112.3 113.9 0.97 Kampot/Krong Kep 83.6 82.9 83.2 122.6 116.0 119.3 0.95 Krong Preah Sihanouk/ Kaoh Kong 66.2 68.7 67.5 97.4 92.8 95.1 0.95 Preah Vihear/Steung Treng 67.0 63.4 65.2 103.7 94.2 99.0 0.91 Mondol Kiri/Rattanak Kiri 30.4 27.0 28.7 55.5 41.1 48.3 0.74 Total 76.4 78.2 77.3 112.5 107.9 110.2 0.96 SECONDARY SCHOOL Residence Urban 47.0 43.3 45.0 64.1 50.2 56.6 0.78 Rural 27.0 23.3 25.2 35.6 26.7 31.3 0.75 Province Banteay Mean Chey 21.3 22.5 21.9 26.9 24.2 25.6 0.90 Kampong Cham 23.8 16.7 20.5 29.0 18.2 24.0 0.63 Kampong Chhnang 33.6 36.5 35.0 45.3 42.3 43.9 0.93 Kampong Speu 26.6 18.7 22.8 35.4 22.4 29.1 0.63 Kampong Thom 27.5 27.5 27.5 35.8 33.2 34.6 0.93 Kandal 41.1 38.0 39.6 52.1 41.4 46.9 0.79 Kratie 22.4 31.3 26.5 27.4 34.6 30.8 1.26 Phnom Penh 52.3 40.7 45.7 70.8 47.3 57.3 0.67 Prey Veng 25.9 24.1 25.0 36.5 28.4 32.5 0.78 Pursat 23.9 19.1 21.4 32.4 22.5 27.3 0.69 Siem Reap 15.7 16.9 16.3 21.9 20.7 21.3 0.95 Svay Rieng 30.9 25.0 28.1 41.6 28.5 35.5 0.68 Takeo 40.0 36.1 38.2 59.0 41.4 50.8 0.70 Otdar Mean Chey 11.9 6.8 9.4 15.2 7.8 11.5 0.51 Battambang/Krong Pailin 26.4 25.9 26.1 34.5 29.9 32.1 0.87 Kampot/Krong Kep 33.3 33.2 33.2 44.2 39.7 41.9 0.90 Krong Preah Sihanouk/ Kaoh Kong 27.4 18.3 22.9 35.2 20.6 28.0 0.58 Preah Vihear/Steung Treng 18.7 15.1 16.8 26.4 18.1 22.1 0.69 Mondol Kiri/Rattanak Kiri 11.6 7.9 9.7 16.5 9.2 12.8 0.56 Total 29.9 26.7 28.3 39.8 30.7 35.3 0.77 1 The NAR for primary school is the percentage of the primary-school age (6-12 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school age (13-18 years) population that is attending secondary school. By definition the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the official primary-school-age population. The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary-school-age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent. 3 The gender parity index for primary school is the ratio of the primary school GAR for females to the GAR for males. The gender parity index for secondary school is the ratio of the secondary school GAR for females to the GAR for males. Household Population and Housing Characteristics | 15 Of those children who should be attending primary school, 77 percent are currently doing so. In 2000, 68 percent of children who should have been attending primary school were doing so. The NAR is significantly lower at the secondary school level, but has also improved since 2000. Twenty- eight percent of secondary-school-age youths are in school at that level, an increase from 16 percent in 2000. There is little difference between the NAR of males and females at both the primary and secondary level, as the NAR has increased since 2000 among females to equal that of males. The NAR among secondary-school-age females has increased since 2000 from 12 to 27 percent. Table 2.5 also shows the Gender Parity Index (GPI) for primary and secondary school. The GPI for primary school is the ratio of the primary school GAR for females to the GAR for males. The GPI for secondary school is the ratio of the secondary school GAR for females to the GAR for males. The primary school GPI of 0.96 indicates near gender parity at the primary level, in both urban and rural areas. The GPI of 0.77 at the secondary school level reflects the fact that smaller proportions of girls attend secondary school than do boys, and the measure of gender parity varies across provinces far more greatly at the secondary school level than that at the primary school level. Figure 2.2 illustrates age-specific attendance rates, the percentage of a given age cohort who attend school, regardless of the level attended (primary, secondary, or higher). Although the minimum age for schooling in Cambodia is six, there are some children enrolled prior to this age, and only one- quarter of children age six are attending school. Boys and girls attend school in about equal proportions up to and including age 14. Up to and including age ten, the proportion of girls attending school is slightly higher than for boys, and then slightly lower than for boys up to age 14. It is after age 14 that boys are attending school at a noticeably higher proportion than girls. Grade Repetition and Dropout Rates Repetition and dropout rates describe the flow of pupils through the system at the primary level. Repetition rates indicate the percentage of pupils who attended a particular grade during the school year that started in 2003, and who again attended that same class during the following school year beginning in 2004. The dropout rate shows the percentage of pupils in a grade during the school year that started in 2003 who no longer attended school the following school year that began in 2004. Table 2.6 shows repetition and dropout rates by primary school class, according to pupils’ background characteristics. Figure 2.2 Age-specific Attendance Rates 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age 0 10 20 30 40 50 60 70 80 90 100 Percent Male Female CDHS 2005Note: Figure shows percentage of the de jure household population age 5-24 years attending school. 16 | Household Population and Housing Characteristics Table 2.6 Grade repetition and dropout rates Repetition and dropout rates for the de facto household population age 6-24 who attended primary school in the previous school year by school grade, according to background characteristics, Cambodia 2005 School grade Background characteristic 1 2 3 4 5 6 7 8 REPETITION RATE1 Sex Male 25.5 8.2 6.0 4.9 3.6 2.5 0.0 0.0 Female 25.1 6.5 4.0 2.9 1.7 1.2 0.0 0.0 Residence Urban 22.0 5.7 3.5 2.3 1.2 1.0 0.0 0.0 Rural 25.7 7.6 5.2 4.1 2.9 2.1 0.0 0.0 Province Banteay Mean Chey 18.3 4.1 1.9 1.0 0.0 3.7 - - Kampong Cham 23.2 8.4 9.8 9.0 4.8 3.1 0.0 - Kampong Chhnang 30.6 9.6 5.2 4.1 4.4 2.6 - - Kampong Speu 31.2 13.5 5.1 5.2 1.2 0.0 0.0 0.0 Kampong Thom 29.9 2.5 1.2 1.0 1.6 0.0 - 0.0 Kandal 17.2 6.3 6.8 5.1 5.1 1.6 - - Kratie 14.4 4.4 2.6 4.5 1.0 0.0 - - Phnom Penh 18.4 3.4 2.5 1.1 0.0 0.0 0.0 0.0 Prey Veng 35.3 11.4 6.6 5.4 3.1 0.0 0.0 - Pursat 8.3 5.1 1.6 0.0 0.0 0.6 0.0 0.0 Siem Reap 15.9 2.7 1.5 1.7 0.0 5.8 0.0 - Svay Rieng 23.3 2.8 1.8 2.2 0.0 5.7 - - Takeo 15.4 0.8 0.7 2.3 3.0 2.2 - - Otdar Mean Chey 10.3 1.6 5.6 0.0 2.7 2.3 - - Battambang/Krong Pailin 37.6 11.9 7.8 4.3 0.9 3.8 0.0 - Kampot/Krong Kep 40.2 12.1 2.2 2.1 4.2 0.0 - 0.0 Krong Preah Sihanouk/ Kaoh Kong 18.2 11.0 8.7 6.1 7.9 11.1 - - Preah Vihear/Steung Treng 36.6 13.6 5.2 3.0 3.5 0.0 - - Mondol Kiri/Rattanak Kiri 17.6 9.7 3.5 4.0 0.0 2.6 0.0 - Total 25.3 7.4 5.0 3.9 2.6 2.0 0.0 0.0 DROPOUT RATE2 Sex Male 0.2 0.9 0.6 2.4 2.0 3.3 2.5 0.0 Female 0.3 0.5 1.4 2.5 3.0 6.2 0.0 59.5 Residence Urban 0.3 0.7 1.2 2.6 1.5 3.2 44.4 0.0 Rural 0.3 0.7 0.9 2.4 2.7 4.8 0.0 40.1 Province Banteay Mean Chey 1.3 0.0 1.1 1.0 1.5 3.9 - - Kampong Cham 0.0 0.0 0.0 3.9 2.5 8.2 0.0 - Kampong Chhnang 0.6 1.8 1.1 4.3 2.5 6.0 - - Kampong Speu 0.0 0.0 2.3 1.8 3.3 9.4 0.0 100.0 Kampong Thom 0.5 1.3 0.0 1.4 1.1 2.9 - 0.0 Kandal 0.0 0.8 1.5 0.9 4.1 8.1 - - Kratie 0.0 2.1 4.5 5.4 6.1 6.1 - - Phnom Penh 0.0 1.7 1.3 6.3 0.8 3.2 0.0 0.0 Prey Veng 0.0 0.0 0.0 3.4 1.0 0.0 0.0 - Pursat 0.0 2.0 0.9 2.5 0.0 0.0 0.0 0.0 Siem Reap 0.5 2.0 2.2 4.2 2.6 2.7 0.0 - Svay Rieng 0.0 0.0 0.0 0.9 0.0 0.0 - - Takeo 0.0 0.0 0.0 0.6 0.0 1.9 - - Otdar Mean Chey 0.0 0.2 0.2 0.3 0.0 0.0 - - Battambang/Krong Pailin 0.9 1.5 2.8 1.7 7.3 8.9 0.0 - Kampot/Krong Kep 0.0 0.0 0.0 0.0 1.8 0.0 - 0.0 Krong Preah Sihanouk/ Kaoh Kong 0.0 0.0 0.0 1.5 4.1 3.1 - - Preah Vihear/Steung Treng 1.8 4.5 4.4 8.2 11.4 2.3 - - Mondol Kiri/Rattanak Kiri 0.0 0.0 2.8 4.7 14.2 7.5 44.4 - Total 0.3 0.7 1.0 2.5 2.5 4.5 1.6 19.8 1 The repetition rate is the percentage of students in a given grade in the previous school year who are repeating that grade in the current school year. 2 The dropout rate is the percentage of students in a given grade in the previous school year who are not attending school in the current school year. Household Population and Housing Characteristics | 17 Repetition rates for grade 1 are nearly the same for boys and girls, but boys have a slightly higher repetition rate in subsequent years of primary school. Repetition rates are slightly higher in rural areas than in urban areas. Overall, one-quarter of children repeat the first grade of primary school, and the repetition rate varies substantially across provinces. There have been great strides in education in Cambodia and the low dropout rates attest to that fact. Once children enter primary school they are likely to finish. There are a few noticeable exceptions, however, such as in Mondol Kiri/Rattanak Kiri, where 14 percent of students dropped out after the fifth grade. 2.3 HOUSING CHARACTERISTICS The type of water and sanitation facilities are important determinants of the health status of household members and particularly of children. Proper hygienic and sanitation practices can reduce exposure to and the seriousness of major childhood diseases such as diarrhea. The CDHS asked respondents about the household source of drinking water, the time required to get to the source of that water, and the type of sanitation facility used by the household. In Cambodia, the source of drinking water can vary between the dry season and the rainy season, so separate questions were asked for the different seasons. If households had more than one source of drinking water, respondents were asked to identify the most commonly used source. Water Supply Table 2.7 shows that sources of drinking water were the same during the dry and rainy seasons for three-quarters of urban households and over 60 percent of rural households. The source of drinking water is an indicator of whether it is suitable for drinking. Sources which are considered likely to be of suitable quality are listed under “Improved source,” and those which may not be of suitable quality are listed under “Non-improved source.” The categorization into improved and non- improved is proposed by WHO, UNICEF, and the Joint Monitoring Programme (JMP) for Water Supply and Sanitation. During the dry season, 43 percent of households in Cambodia consume drinking water from a non-improved source. This percent declines to 24 percent of households during the rainy season, as more households utilize rainwater for drinking water. The main source of drinking water during the rainy season is rainwater for one-third of households. Rainwater is the most common source of drinking water during the rainy season for rural households and for urban households that do not have water piped into their dwelling or property. Much of the increase in use of non-improved water sources during the dry season is due to a increased reliance on surface water. Even if water is not piped directly into the dwelling or yard, it is common for the source of water to be on the household premises, especially during the rainy season. Two-thirds of rural households and 80 percent of urban households report that their source of drinking water during the rainy season is located on the household premises. During the dry season, the percentage of households with their source of drinking water on the premises declines to 63 percent and 38 percent among urban and rural households, respectively. For those households not having a source of drinking water on the premises nor having water delivered, the majority are within a 30 minute or less roundtrip time of obtaining it. During the dry season only about 10 percent have 30 minutes or longer away from a source (or don't know), compared with the rainy season, where that number drops to just over three percent requiring 30 minutes or more (or not knowing the time required). The person to most commonly retrieve the water is an adult, either male or female in generally equal proportion. 18 | Household Population and Housing Characteristics Table 2.7 Household drinking water Percent distribution of households by source of drinking water, time to collect water (if not within residence or plot), person fetching the water, and percentage of households using various modes for treating drinking water, according to residence; and percent distribution of the de jure population by household drinking water arrangements and percentage of the de jure population living in households using various modes to treat drinking water, Cambodia 2005 Residence Urban Rural Total De jure population DRY SEASON: Source of drinking water Improved source 67.3 53.7 55.6 54.6 Piped water into dwelling/yard/plot 40.5 5.2 10.3 10.8 Public tap/standpipe 0.3 0.2 0.2 0.2 Tube well or borehole 17.4 31.9 29.8 28.7 Protected dug well 6.9 14.1 13.1 12.7 Protected spring 0.2 0.2 0.2 0.2 Rainwater 1.9 2.1 2.1 1.9 Non-improved source 25.0 45.5 42.5 43.6 Unprotected dug well 5.4 14.5 13.2 13.5 Unprotected spring 0.5 1.2 1.1 1.2 Tanker truck/cart with small tank 6.9 5.0 5.3 5.1 Surface water 12.3 24.7 22.9 23.8 Bottled water1 7.0 0.7 1.6 1.6 Improved source for cooking, washing 5.9 0.4 1.2 1.1 Unimproved source for cooking 1.1 0.3 0.4 0.5 Other sources 0.7 0.2 0.2 0.2 Total 100.0 100.0 100.0 100.0 DRY SEASON: Time to obtain drinking water (round trip) Water delivered 6.3 8.3 8.0 8.0 Water on premises 62.9 38.0 41.6 42.1 Less than 30 minutes 21.6 44.0 40.7 40.0 30 minutes or longer 3.7 7.7 7.1 7.3 Don't know 5.5 2.0 2.5 2.7 Total 100.0 100.0 100.0 100.0 DRY SEASON: Person who usually collects drinking water Adult female 15+ 8.9 21.4 19.6 18.9 Adult male 15+ 14.0 25.9 24.2 24.2 Female child under age 15 0.8 2.4 2.2 2.4 Male child under age 15 0.8 1.4 1.3 1.5 Other 6.2 2.4 2.9 2.8 Water on premises/ delivered 69.2 46.3 49.6 50.0 Total 100.0 100.0 100.0 100.0 RAINY SEASON: Source of drinking water Improved source 82.1 73.5 74.8 74.1 Piped water into dwelling/yard/plot 37.0 4.4 9.2 9.6 Public tap/standpipe 0.1 0.1 0.1 0.1 Tube well or borehole 14.3 24.3 22.8 21.9 Protected dug well 4.2 10.8 9.8 9.5 Protected spring 0.2 0.1 0.1 0.1 Rainwater 26.2 33.9 32.8 32.9 Non-improved source 11.5 25.8 23.7 24.5 Unprotected dug well 3.6 12.6 11.3 11.6 Unprotected spring 0.2 0.5 0.5 0.5 Tanker truck/cart with small tank 2.5 1.2 1.4 1.4 Surface water 5.2 11.4 10.5 10.9 Bottled water1 6.1 0.5 1.3 1.3 Improved source for cooking, washing 5.5 0.3 1.0 1.0 Unimproved source for cooking 0.6 0.2 0.2 0.3 Other sources 0.4 0.2 0.2 0.2 Total 100.0 100.0 100.0 100.0 Continued. Household Population and Housing Characteristics | 19 Nearly 60 percent of rural households boil their water prior to drinking, and three-quarters of urban households do so. Among those who do not boil their water, the most common action is to do nothing to treat the water prior to drinking. One-third of rural (36 percent) and one-fifth of urban households (20 percent) report they do nothing to treat their drinking water prior to consuming it. Overall, one-third of households do nothing to treat their water prior to drinking. Twelve percent of households allow the water to stand and settle prior to drinking. Table 2.7—Continued Percent distribution of households by source of drinking water, time to collect water (if not within residence or plot), person fetching the water, and percentage of households using various modes for treating drinking water, according to residence; and percent distribution of the de jure population by household drinking water arrangements and percentage of the de jure population living in households using various modes to treat drinking water, Cambodia 2005 Residence Urban Rural Total De jure population RAINY SEASON: Time to obtain drinking water (round trip) Water delivered 3.4 3.4 3.4 3.4 Water on premises 79.9 64.0 66.3 66.9 Less than 30 minutes 12.8 29.4 27.0 26.2 30 minutes or longer 1.3 2.3 2.2 2.1 Don't know 2.6 0.9 1.2 1.3 Total 100.0 100.0 100.0 100.0 RAINY SEASON: Person who usually collects drinking water Adult female 15+ 5.6 14.6 13.3 12.8 Adult male 15+ 7.1 14.3 13.3 12.9 Female child under age 15 0.6 1.6 1.4 1.6 Male child under age 15 0.4 0.9 0.8 0.9 Other 3.1 1.2 1.5 1.4 Water on premises/ delivered 83.2 67.3 69.6 70.3 Total 100.0 100.0 100.0 100.0 Percent where rainy and dry season drinking water sources are the same 73.3 61.8 63.4 63.1 Water treatment prior to drinking2 Boiled 76.0 57.3 60.0 59.7 Bleach/chlorine 0.1 0.1 0.1 0.1 White alum 1.7 1.0 1.1 1.2 Strained through cloth 0.7 0.3 0.4 0.4 Ceramic, sand or other filter 3.3 1.9 2.1 2.2 Solar disinfection 0.0 0.0 0.0 0.0 Stand and settle 7.4 12.2 11.5 11.8 Other 0.5 0.4 0.4 0.5 No treatment 19.6 36.3 33.9 34.4 Number 2,066 12,177 14,243 70,637 1 Because the quality of drinking water is not known, households using bottled water for drinking are classified as using an improved or non-improved source according to their water source for cooking and washing. 2 Respondents may report multiple treatment methods so the sum of treatment may exceed 100 percent. Sanitation Facilities A household’s toilet facility is classified as hygienic if it is used only by households members (is not shared by other households) and if the type of toilet effectively separates human waste from human contact. The types of facilities most likely to accomplish this are flush or pour flush into a piped sewer system/septic tank/pit latrine, ventilated, improved pit (VIP) latrine, pit latrine with a slab and a composting toilet. 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. Categories are those proposed by WHO, UNICEF, and JMP. 20 | Household Population and Housing Characteristics Table 2.8 Household sanitation facilities Percent distribution of households by type of toilet/latrine facilities, according to residence, and the percent distribution of the de jure population by type of toilet facilities, Cambodia 2005 Residence Type of toilet/ latrine facility Urban Rural Total De jure population Improved, not shared Flush/pour flush to piped sewer system 28.9 1.1 5.2 5.7 Flush/pour flush to septic tank 25.8 12.6 14.5 15.6 Flush/pour flush to a pit latrine 0.6 0.4 0.4 0.5 Ventilated improved pit (VIP) latrine 0.1 0.2 0.2 0.2 Pit latrine with a slab 0.6 1.2 1.1 1.2 Composting toilet 0.1 0.2 0.2 0.2 Not improved Any facility shared with other households 7.1 4.1 4.5 4.3 Flush/pour flush not to sewer/ septic tank/pit latrine 0.9 0.1 0.2 0.2 Pit latrine without slab/open pit 0.7 0.9 0.9 0.9 Bucket 0.2 0.1 0.1 0.1 Hanging toilet/hanging latrine 2.0 0.7 0.9 0.8 No facility/bush/field 32.3 78.1 71.4 70.1 Other 0.6 0.2 0.2 0.2 Total 100.0 100.0 100.0 100.0 Number 2,066 12,177 14,243 70,637 Households vary greatly in access to hygienic facilities by urban and rural residence, as shown in Table 2.8. The majority of households in rural areas have no toilet facility, with three out of four households reporting no toilet facility and making use of fields or bush areas. In urban areas, one in three households has no toilet facility; however, one-half of urban households does use a flush or pour toilet that is piped to a sewer or septic system. Table 2.9 presents the distribution of households by the characteristics of the dwelling in which they live. In urban areas, two out of three households live in dwellings with electricity, while in rural areas, only one in every five households has electricity. Wood planks provide the most common type of flooring material in both urban and rural areas. Four out of ten urban households live in dwellings with wood planks, followed by one-quarter who live in dwellings with ceramic tiles. In rural areas, one-half of households live in dwellings with wood plank flooring, followed by one-third who live in dwellings with palm or bamboo flooring. If there was more than one type of flooring, interviewers recorded the predominant flooring material. Most households sleep together in one room, although in urban areas, 30 percent of households use two or more rooms for sleeping. Cooking Arrangements Nine in ten rural households use firewood or straw for cooking fuel. While firewood or straw is also the most common source of fuel for cooking in urban areas, there is more variability in urban areas as to what is used for cooking fuel. Forty-four percent of urban households use firewood or straw, 30 percent use liquid petroleum or natural gas, and 25 percent use charcoal. Nearly all households do their cooking over an open fire, without a chimney to divert the smoke. One-half of urban households and one-third of rural households report that they do their cooking in the house. Household Population and Housing Characteristics | 21 Table 2.9 Housing characteristics Percent distribution of households by housing characteristics, according to residence and percent distribution of the de jure population by housing characteristics, Cambodia 2005 Residence Housing characteristic Urban Rural Total De jure population Electricity Yes 66.8 12.6 20.5 21.3 No 33.1 87.4 79.5 78.6 Total 100.0 100.0 100.0 100.0 Flooring material Earth, sand 5.4 9.0 8.5 7.7 Wood planks 40.5 49.4 48.1 50.2 Palm, bamboo 10.0 33.4 30.0 28.5 Parquet, polished wood 0.1 0.0 0.0 0.0 Vinyl, asphalt strips 0.1 0.2 0.2 0.2 Ceramic tiles 26.2 2.5 5.9 6.5 Cement tiles 9.0 0.7 1.9 1.9 Cement 8.5 4.3 4.9 4.6 Floating house 0.1 0.1 0.1 0.1 Other 0.1 0.3 0.3 0.2 Total 100.0 100.0 100.0 100.0 Rooms used for sleeping One 69.6 87.5 84.9 82.9 Two 17.9 9.6 10.8 11.9 Three or more 12.1 2.4 3.8 4.8 Total 100.0 100.0 100.0 100.0 Cooking fuel Electricity 0.6 0.1 0.2 0.2 LPG, natural gas 29.3 3.4 7.1 7.0 Biogas 0.9 0.0 0.2 0.2 Kerosene 0.1 0.0 0.0 0.0 Coal, lignite 0.0 0.0 0.0 0.0 Charcoal 25.4 4.9 7.9 8.3 Firewood, straw 43.6 91.3 84.4 84.1 Dung 0.0 0.2 0.1 0.2 Other 0.2 0.1 0.1 0.0 Total 100.0 100.0 100.0 100.0 Place for cooking In the house 55.2 35.2 38.1 36.7 In a separate building 14.5 23.7 22.3 23.6 Outdoors 20.4 25.3 24.6 25.1 Under the house 9.2 15.4 14.5 14.2 Other 0.7 0.5 0.5 0.5 Total 100.0 100.0 100.0 100.0 Number of households 2,066 12,177 14,243 70,637 Type of fire/stove among households using solid fuel1 Open fire 97.4 98.0 97.9 97.8 Open fire with chimney 0.4 0.3 0.3 0.4 Other 2.0 1.4 1.4 1.6 Total 100.0 100.0 100.0 100.0 Number of households/population using solid fuel 1,424 11,738 13,162 65,433 1 Includes coal/lignite, charcoal, wood/straw/shrubs, and animal dung 22 | Household Population and Housing Characteristics 2.4 HOUSEHOLD POSSESSIONS Information on ownership of durable goods and other possessions is presented in Table 2.10. The availability of durable consumer goods is a good indicator of household socioeconomic level, and particular goods have specific benefits. For example, radio access can increase exposure to innovative ideas, whereas transport vehicles can provide access to services out of the local area. Over one-half of all households in Cambodia own a television, an increase from one-third of all households in 2000. One in five households owns a mobile telephone, up from four percent in 2000. Ownership of mobile telephones is far more common among urban households (55 percent), but not unknown in rural households (14 percent). Ownership of transportation has increased since 2000 as well. Fifteen percent of urban households now own a car or truck, having increased from 10 percent in 2000. One-third of all households own a motorcycle, an increase from one-quarter of households in 2000. Percentage of households owning a boat remains unchanged, at nine percent. The 2005 CDHS found that nearly three-quarters of all households own some land, and that three-quarters of all households own at least one farm animal. Table 2.10 Household possessions Percentage of households and de jure population possessing various household effects, means of transportation, agricultural land and farm animals, by residence, Cambodia 2005 Residence Possessions Urban Rural Total De jure population Household effects Radio 62.8 47.3 49.6 51.2 Television 72.2 52.3 55.2 58.5 Mobile telephone 55.1 14.2 20.1 22.0 Refrigerator 15.9 0.7 2.9 3.4 Wardrobe 57.4 25.3 30.0 31.7 Sewing machine/loom 16.8 6.9 8.4 9.4 Means of transport Bicycle 58.2 70.0 68.3 72.2 Animal-drawn cart 7.1 27.0 24.1 26.5 Motorcycle/scooter 55.4 31.1 34.6 38.0 Car/truck 15.2 2.0 3.9 4.8 Boat with a motor 3.3 3.4 3.4 3.7 Boat without motor 3.7 5.7 5.4 6.0 Ownership of agricultural land 34.1 77.9 71.5 72.2 Ownership of farm animals1 37.1 79.2 73.1 75.5 Number of households/ population 2,066 12,177 14,243 70,637 1 Cattle, cows, bulls, horses, donkeys, goats, sheep, or chicken 2.5 HOUSEHOLD WEALTH In addition to standard background characteristics, many of the results in this report are shown by wealth quintiles, an indicator of the economic status of households. The CDHS did not collect data on consumption or income, but the information collected on dwelling and household characteristics, consumer goods, and assets are used as a measure of socio-economic status. The resulting wealth index is an indicator of the level of wealth that is consistent with expenditure and income measures. Household Population and Housing Characteristics | 23 Each household asset for which information is collected is assigned a weight or factor score generated through principal components analysis. The resulting asset scores are standardized in relation to a standard normal distribution with a mean of zero and a standard deviation of one. These standardized scores are then used to create the break points that define wealth quintiles. Each household is assigned a standardized score for each asset, where the score differs depending on whether or not the household owned that asset (or, in the case of sleeping arrangements, the number of people per room). These scores are summed by household, and individuals are ranked according to the total score of the household in which they reside. The sample is then divided into population quintiles, i.e., five groups with the same number of individuals in each. At the national level, approximately 20 percent of the household population is in each wealth quintile. A single asset index is developed on the basis of data from the entire country sample and used in all the tabulations presented. The reader should keep in mind that wealth quintiles are expressed in terms of quintiles of individuals in the population, rather than quintiles of individuals at risk for any one health or population indicator. For example, the quintile rates for infant mortality refer to the infant mortality rates per 1,000 live births among all people in the population quintile concerned, as distinct from quintiles of live births or newly-born infants, who constitute the only members of the population at risk of mortality during infancy. The wealth index has been compared against both poverty rates and gross domestic product per capita for India, and against expenditure data from household surveys in Nepal, Pakistan, and Indonesia (Filmer and Pritchett, 1998) and Guatemala (Rutstein 1999). The evidence from those studies suggests that the assets index is highly comparable to conventionally-measured consumption expenditures. Table 2.11 shows the distribution of the de jure household population into five wealth quintiles (five equally divided levels) based on the wealth index by residence. These distributions indicate the degree to which wealth is evenly (or unevenly) distributed across Cambodia. As expected, urban areas are wealthier than rural areas. For example, 87 percent of Phnom Penh's population falls in the highest wealth quintile. By contrast, the province with the lowest representation in the highest wealth quintile is Otdar Mean Chey, with only five percent of its population in the highest wealth quintile. 24 | Household Population and Housing Characteristics Table 2.11 Wealth quintiles Percent distribution of the de jure population by wealth quintiles according to residence and region, Cambodia 2005 Wealth quintile Residence/ province Lowest Second Middle Fourth Highest Total Number of de jure population Residence Urban 6.3 7.0 8.9 13.7 64.0 100.0 10,798 Rural 22.5 22.3 22.0 21.1 12.1 100.0 59,839 Province Banteay Mean Chey 18.0 26.1 24.2 18.7 13.1 100.0 2,881 Kampong Cham 19.5 22.5 22.2 25.0 10.8 100.0 9,242 Kampong Chhnang 32.2 25.6 20.1 15.3 6.8 100.0 2,560 Kampong Speu 21.3 22.5 28.3 20.7 7.1 100.0 3,806 Kampong Thom 40.4 20.6 16.8 11.9 10.2 100.0 3,500 Kandal 7.0 11.4 20.8 36.0 24.8 100.0 6,945 Kratie 27.0 19.6 21.7 20.6 11.1 100.0 1,481 Phnom Penh 0.1 1.3 2.6 9.4 86.6 100.0 6,188 Prey Veng 27.9 28.6 23.3 12.8 7.4 100.0 5,869 Pursat 19.0 27.5 29.1 13.6 10.8 100.0 2,102 Siem Reap 31.2 24.8 14.0 12.4 17.6 100.0 4,791 Svay Rieng 21.3 23.5 25.6 20.7 8.9 100.0 2,805 Takeo 14.4 21.0 28.5 27.0 9.0 100.0 4,841 Otdar Mean Chey 30.5 33.4 19.9 11.3 5.0 100.0 780 Battambang/Krong Pailin 18.9 17.3 16.5 24.8 22.4 100.0 5,180 Kampot/Krong Kep 17.0 22.8 25.3 24.6 10.3 100.0 3,495 Krong Preah Sihanouk/ Kaoh Kong 9.6 12.1 14.5 18.0 45.8 100.0 1,608 Preah Vihear/Steung Treng 40.2 26.6 16.8 8.4 8.0 100.0 1,440 Mondol Kiri/Rattanak Kiri 43.5 22.0 14.3 11.3 8.9 100.0 1,123 Total 20.0 20.0 20.0 20.0 20.0 100.0 70,637 2.6 BIRTH REGISTRATION The registration of births is the inscription of the facts of the birth into an official log. A birth certificate is issued as proof of the registration of the birth. Information on the registration of births was collected in the household interview by asking whether children under five years of age had a birth certificate. If the interviewer was told that the child did not have a birth certificate, the interviewer probed further to ascertain whether the child’s birth had been registered with the civil authority. One-half of children have a birth certificate and a total of two-thirds of children under age five are registered, although levels of registration vary greatly across the country, as shown in Table 2.12. Household Population and Housing Characteristics | 25 Table 2.12 Birth registration of children under age five Percentage of de jure children under five years of age whose births are registered with the civil authorities, according to background characteristics, Cambodia 2005 Percentage of children whose births are registered Background characteristic Had a birth certificate Did not have a birth certificate Total registered Number of children Age <2 43.2 12.4 55.7 3,204 2-4 61.9 12.0 73.9 4,590 Sex Male 54.5 12.2 66.7 3,872 Female 53.9 12.2 66.1 3,921 Residence Urban 60.7 10.3 71.0 1,068 Rural 53.2 12.5 65.7 6,726 Province Banteay Mean Chey 52.2 18.6 70.7 339 Kampong Cham 61.8 10.0 71.8 975 Kampong Chhnang 54.7 14.2 68.9 313 Kampong Speu 48.4 7.7 56.1 466 Kampong Thom 63.1 6.6 69.6 390 Kandal 60.4 17.5 78.0 689 Kratie 57.6 12.7 70.3 195 Phnom Penh 60.6 6.3 66.8 590 Prey Veng 49.7 14.5 64.1 618 Pursat 37.5 18.1 55.6 218 Siem Reap 54.0 25.0 79.0 647 Svay Rieng 63.5 4.4 67.9 265 Takeo 56.2 5.1 61.2 506 Otdar Mean Chey 74.7 0.9 75.6 96 Battambang/Krong Pailin 48.5 14.5 63.0 523 Kampot/Krong Kep 48.2 9.3 57.5 381 Krong Preah Sihanouk/ Kaoh Kong 56.7 9.9 66.6 198 Preah Vihear/Steung Treng 30.7 7.3 38.0 212 Mondol Kiri/Rattanak Kiri 23.9 14.1 38.0 172 Wealth quintile Lowest 45.3 14.0 59.3 2,101 Second 51.8 12.6 64.4 1,743 Middle 52.3 12.5 64.8 1,384 Fourth 62.2 10.2 72.5 1,300 Highest 66.3 10.2 76.5 1,267 Total 54.2 12.2 66.4 7,793 Utilization of Health Services for Accident, Illness, or Injury | 27 UTILIZATION OF HEALTH SERVICES FOR ACCIDENT, ILLNESS, OR INJURY 3 When the NHS 1998 was undertaken, the Ministry of Health was beginning to implement a redesigned Health Coverage Plan created to improve the accessibility and quality of government health services. The major points of the new health care plan were to create a network of health centers throughout the country delivering the “Minimum Package of Activities” services. The data collected in the 1998 NHS was considered to be a baseline of health conditions in the country before implementation of the new health coverage plan. The 2000 CDHS data were used to provide a first- round analysis of health care delivery under the new plan; the 2005 CDHS provides an update to those findings. Utilization of health services was assessed in the household questionnaire. The questions were asked to all households in the sample. First, information was collected to assess the prevalence of injuries and deaths due to accidents in the past year. Second, the respondent was asked if any household members suffered from any physical impairment. Third, the respondent was asked about the severity of illness or injury and the subsequent utilization of health services for all members of the household who had been ill or injured in the 30 days prior to the interview. 3.1 ACCIDENTAL DEATH OR INJURY All households reported on whether any household member had suffered accidental injury or death in the past 12 months preceding the day of the household interview. If anyone had been injured, the cause of the injury was recorded. The respondent to the household questionnaire was further asked whether the accident victim was alive or dead, and if dead, whether the death was the result of the reported accident. The questions were designed in this order to definitively assess the cause of injury, and the cause of death, if a death was noted. Frequency of Accidental Death or Injury Accidental injuries and deaths in Cambodia were not common (Table 3.1). Two percent of the population had suffered an injury or death by accident in the past 12 months. Accidental injuries were much more common than accidental deaths; for every 1,000 people in the population, 18 suffered an injury and for every 1,000 people in the population, one person suffered an accidental death. The percentage of the population injured in the past 12 months increases with age from 1.1 percent among children aged 0-9 years to a peak of 2.4 percent among adults aged 20-39 years. The percentage experiencing accidental injury decreases thereafter, to 2 percent among adults age 40 and above. The occurrence of accidental death does not vary by age. For all ages, only 0.1 percent or one out of one thousand persons died as the result of an accident. Males were more than twice as likely as women to be injured in an accident. Overall, 2.7 percent of men were injured in an accident in the past 12 months, compared with 1.1 percent of women. Despite the differences of accidental injuries by sex, men and women perished in accidents at the same rate (0.1 percent). While there were no substantial differences in accidental injuries by urban/rural residence, there are differences across provinces. The highest percentage of accidental injury was reported in Kampong Thom, with 4.4 percent of the household population experiencing an injury in the previous 12 months. The lowest percentage of accidental injury was in Otdar Mean Chey and Krong Preah Sihanouk/Kaoh Kong (both 0.7 percent). While Otdar Mean Chey has a low percentage of injuries, it has the highest percentage of accidental deaths (0.7 percent); otherwise, the percentage of accidental death ranges between 0.1 and 0.2 percent across provinces. 28 | Utilization of Health Services for Accident, Illness, or Injury Table 3.1 Injury or death in an accident Percentage of the de facto household population injured or killed in an accident in the past 12 months, according to background characteristics, Cambodia 2005 Result of accident Background characteristic Injured Killed Total injured or killed Total number of household members Age group 0-9 1.1 0.1 1.2 16,009 10-19 1.6 0.0 1.7 17,517 20-39 2.4 0.1 2.5 17,755 40-59 2.1 0.1 2.3 11,067 60+ 1.9 0.1 2.1 4,545 Sex Male 2.7 0.1 2.8 31,347 Female 1.1 0.1 1.2 35,547 Residence Urban 1.6 0.1 1.7 10,348 Rural 1.9 0.1 2.0 56,546 Province Banteay Mean Chey 2.3 0.1 2.4 2,686 Kampong Cham 2.3 0.2 2.5 8,729 Kampong Chhnang 2.8 0.2 3.0 2,408 Kampong Speu 2.3 0.0 2.3 3,725 Kampong Thom 4.4 0.2 4.6 3,321 Kandal 1.6 0.2 1.8 6,616 Kratie 1.9 0.1 2.0 1,367 Phnom Penh 1.4 0.1 1.5 6,071 Prey Veng 1.2 0.1 1.2 5,367 Pursat 1.7 0.1 1.8 2,030 Siem Reap 1.2 0.2 1.4 4,624 Svay Rieng 1.7 0.0 1.7 2,679 Takeo 2.1 0.0 2.1 4,722 Otdar Mean Chey 0.7 0.7 1.4 722 Battambang/Krong Pailin 1.2 0.2 1.4 4,654 Kampot/Krong Kep 0.8 0.1 0.9 3,400 Krong Preah Sihanouk/ Kaoh Kong 0.7 0.0 0.8 1,545 Preah Vihear/Steung Treng 2.6 0.0 2.6 1,285 Mondol Kiri/Rattanak Kiri 1.2 0.0 1.2 943 Total 1.8 0.1 1.9 66,894 Type of Accident Originally the question about the type of accident was created to assess the impact of landmines on the population. However, due to the large increase in the use of motorized vehicles in Cambodia, data on prevalence of road accidents was also included in the CDHS. Table 3.2 shows that road accidents account for the greatest proportion of accidental injuries and deaths. Forty-six percent of those who had been injured or killed in the previous 12 months were as a result of a road accident. Fourteen percent of injuries/deaths were the result of a fall, and 4 percent were the result of an animal bite. Four percent of injuries/deaths were the result of some form of violence, and an additional 1 percent from gun shot. Fatalities due to landmines are decreasing in relevance as a threat to safety, dropping from 3 percent of cases in the 2000 CDHS to the current level of 0.7 percent of all injuries/deaths. Twenty-six percent of injuries/deaths were from unknown causes. Utilization of Health Services for Accident, Illness, or Injury | 29 Table 3.2 Injury and death in an accident by type of accident Percent distribution of the de facto household population who were injured or killed in an accident in the past 12 months by type of accident, according to background characteristics, Cambodia 2005 Type of accident Background characteristic Landmine/ unexploded bomb Gun shot Road accident Severe burning Snake/ animal bite Fall from tree/ building Drown- ing Poisoning (chemical) Violence Other Don’t know Total Number of persons injured/ killed Age group 0-9 0.1 0.6 31.5 3.1 9.9 21.4 0.9 1.1 2.9 26.1 2.4 100.0 195 10-19 0.3 1.8 34.3 0.8 5.5 22.9 1.1 1.1 2.9 28.7 0.6 100.0 291 20-39 0.8 1.5 55.5 1.4 2.4 8.1 0.1 0.0 5.9 24.3 0.0 100.0 452 40-59 0.1 0.5 56.4 3.1 3.7 8.5 1.0 0.7 3.5 22.4 0.1 100.0 249 60+ 3.7 4.5 39.0 0.0 1.2 18.6 1.0 1.1 0.0 30.9 0.0 100.0 95 Sex Male 0.4 1.9 48.3 1.3 4.6 13.0 0.2 0.6 4.6 24.9 0.2 100.0 873 Female 1.3 0.4 41.1 2.6 3.9 16.6 1.6 0.7 2.1 28.6 1.1 100.0 426 Residence Urban 0.3 1.7 65.4 1.9 3.5 7.2 0.0 1.2 2.4 15.9 0.4 100.0 171 Rural 0.7 1.4 42.9 1.7 4.5 15.2 0.8 0.5 4.0 27.7 0.5 100.0 1,127 Province Banteay Mean Chey 0.0 0.0 56.8 0.0 5.3 16.2 1.5 1.5 0.0 18.7 0.0 100.0 63 Kampong Cham 1.3 1.3 29.2 2.3 7.4 15.0 0.0 1.0 6.0 36.4 0.0 100.0 215 Kampong Chhnang 0.0 11.5 39.8 0.0 6.4 17.5 0.0 0.0 7.9 16.8 0.0 100.0 73 Kampong Speu 0.0 0.0 41.6 2.6 1.4 10.5 0.0 2.4 2.4 37.8 1.3 100.0 86 Kampong Thom 1.5 0.0 32.6 0.0 3.3 23.5 0.0 0.6 0.7 37.8 0.0 100.0 153 Kandal 0.0 0.8 41.0 3.5 4.8 13.0 0.0 0.0 2.8 30.7 3.3 100.0 118 Kratie 2.9 0.0 53.7 2.8 4.9 7.6 0.8 0.0 0.0 27.3 0.0 100.0 27 Phnom Penh 0.0 0.0 85.7 1.8 0.0 1.7 1.7 0.0 5.9 3.2 0.0 100.0 91 Prey Veng (0.0) (0.0) (58.8) (0.0) (0.0) (5.3) (2.8) (0.0) (2.8) (30.3) (0.0) 100.0 66 Pursat 0.0 0.0 43.1 1.0 2.9 27.7 0.0 0.0 2.0 21.3 2.0 100.0 36 Siem Reap 0.0 1.4 66.3 0.0 7.5 2.1 1.9 0.0 4.0 16.8 0.0 100.0 65 Svay Rieng 1.8 2.1 59.5 5.5 3.7 14.9 1.6 0.0 1.8 9.2 0.0 100.0 46 Takeo 0.0 0.0 44.4 4.1 0.5 18.3 0.0 0.0 9.7 23.0 0.0 100.0 100 Otdar Mean Chey 18.1 5.7 9.7 1.3 4.3 9.3 0.0 0.0 1.3 48.1 2.2 100.0 10 Battambang/ Krong Pailin 0.0 4.0 56.7 0.0 4.1 14.2 0.0 3.3 1.9 15.7 0.0 100.0 64 Kampot/Krong Kep (0.0) (0.0) (44.9) (0.0) (3.4) (14.0) (3.6) (0.0) (0.0) (34.1) (0.0) 100.0 30 Krong Preah Sihanouk/ Kaoh Kong * * * * * * * * * * * 100.0 12 Preah Vihear/ Steung Treng 0.0 1.3 40.3 1.0 17.0 19.9 2.3 0.0 1.1 17.2 0.0 100.0 33 Mondol Kiri/ Rattanak Kiri 0.0 9.9 50.8 2.2 9.6 5.4 0.0 0.0 0.0 22.1 0.0 100.0 11 Total 0.7 1.4 45.9 1.7 4.4 14.2 0.7 0.6 3.8 26.1 0.5 100.0 1,298 Note: Total includes 16 people for whom information on age is not available. 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. Cause of injury/death varies by age, but road accidents are the most commonly cited source of injury/death for people of all ages, especially for those age 20-59. Animal bites account for ten percent of injuries among children aged 0-9, declining as a cause of injury as the population ages. Gunshots and landmines account for a higher percentage of injuries/deaths (5 and 4 percent, respectively) among people age 60 and above than for any other age group. Unspecified violence accounts for a greater percentage of injury/death (6 percent) among people age 20-39 as compared with people of other ages. There were other significant differences in accidental injuries and deaths in the last 12 months by sex, urban/rural residence, and province. Men were more likely than women to be injured or killed in a road accident (48 percent versus 41 percent), as a result of unspecified violence (5 percent versus 2 percent), or by gunshot (2 percent versus less than 1 percent). Not surprisingly, road accidents account for a higher percentage of injuries/deaths in urban areas (65 percent) than in the rural areas (43 percent). Falls account for a higher proportion of accidents in rural areas than in urban areas (15 percent versus 7 percent). The distribution of causes of injuries/deaths by province should be analyzed with caution due to small sample sizes in selected provinces. 30 | Utilization of Health Services for Accident, Illness, or Injury Table 3.3 Physical impairment Percentage of the de facto household population physically impaired and percent distribution of the impaired de facto household population by cause of impairment, according background characteristics, Cambodia 2005 Cause of impairment Background characteristic Physically impaired Number of household members Birth Illness Landmine Gun Road accident Other accident Total Number of impaired persons Age group 0-9 0.7 16,009 47.8 20.9 0.1 2.7 5.2 23.3 100.0 114 10-19 1.6 17,517 39.7 28.1 0.7 2.0 4.7 24.9 100.0 276 20-39 2.1 17,755 18.1 29.5 10.3 7.7 8.3 26.1 100.0 375 40-59 3.9 11,067 8.8 28.9 22.7 15.6 7.8 16.2 100.0 431 60+ 5.3 4,545 3.8 59.5 3.9 6.9 6.0 19.9 100.0 243 Sex Male 2.9 31,347 15.5 26.5 15.1 12.3 7.1 23.6 100.0 903 Female 1.5 35,547 26.0 45.2 2.1 1.9 6.4 18.3 100.0 536 Residence Urban 1.8 10,348 17.7 36.1 10.1 5.0 9.8 21.3 100.0 189 Rural 2.2 56,546 19.7 33.0 10.3 9.0 6.4 21.7 100.0 1,250 Province Banteay Mean Chey 3.2 2,686 17.1 33.8 12.8 11.7 6.9 17.8 100.0 86 Kampong Cham 1.3 8,729 (25.6) (36.6) (2.4) (7.7) (5.1) (22.7) 100.0 114 Kampong Chhnang 3.6 2,408 15.6 27.6 6.1 13.0 7.6 30.2 100.0 86 Kampong Speu 2.6 3,725 11.1 28.5 14.4 4.6 9.0 32.3 100.0 97 Kampong Thom 3.1 3,321 18.3 20.4 4.4 9.3 8.5 39.0 100.0 104 Kandal 1.5 6,616 15.8 43.2 11.6 0.0 5.5 23.8 100.0 98 Kratie 1.3 1,367 (14.2) (39.1) (10.7) (6.7) (6.5) (22.8) 100.0 18 Phnom Penh 1.6 6,071 12.1 38.2 7.5 8.8 13.3 20.2 100.0 100 Prey Veng 2.2 5,367 21.6 50.5 3.4 7.1 7.2 10.1 100.0 118 Pursat 2.9 2,030 19.6 33.5 13.2 1.7 3.0 29.0 100.0 59 Siem Reap 2.4 4,624 32.2 10.1 16.7 19.1 7.2 14.7 100.0 113 Svay Rieng 2.1 2,679 26.6 33.4 7.3 9.4 6.9 16.3 100.0 56 Takeo 3.1 4,722 21.6 38.2 4.9 10.1 4.9 20.3 100.0 148 Otdar Mean Chey 2.9 722 10.5 18.3 39.5 8.6 4.7 18.4 100.0 21 Battambang/Krong Pailin 2.2 4,654 15.7 45.1 20.4 4.0 2.5 12.4 100.0 105 Kampot/Krong Kep 1.3 3,400 (22.6) (29.3) (12.2) (8.5) (7.8) (19.6) 100.0 44 Krong Preah Sihanouk/ Kaoh Kong 1.6 1,545 20.9 21.2 15.2 8.5 11.6 22.5 100.0 25 Preah Vihear/Steung Treng 3.0 1,285 16.3 34.6 21.2 7.4 6.5 14.1 100.0 39 Mondol Kiri/Rattanak Kiri 1.2 943 (18.1) (22.9) (5.7) (15.4) (6.7) (31.2) 100.0 11 Total 2.2 66,894 19.4 33.4 10.3 8.4 6.8 21.6 100.0 1,439 Note: Figures in parentheses are based on 25-49 unweighted cases. 3.2 PHYSICAL IMPAIRMENT Questions on physical impairment include inquiring if any living household members were physically impaired, and if so what was the cause. In Cambodia, 2 percent of the population has a physical impairment (Table 3.3). Physical impairments increases with age. Persons aged 60 years and older are more likely than younger persons to have physical impairments (5 percent compared with 4 percent or less). Males are more likely (3 percent) to be impaired physically than women (1.5 per- cent). There are minor differences in physical impairments by urban/rural residence (1.8 and 2.2 per- cent respectively), although there are differences by province. The province with the highest percent of the population with physical impairments was Kampong Chhnang (4 percent). The provinces with the lowest prevalence of physical impairments (1.2-1.3 percent) were Kampong Cham, Kratie, Kampot/Krong Kep, and Mondol Kiri/Rattanak Kiri. Utilization of Health Services for Accident, Illness, or Injury | 31 Table 3.3 also shows the cause of physical impairments in Cambodia. The most common cause of impairment were illness (33 percent). Other causes of impairments were due to unspecified accidents (22 percent) and birth defects (19 percent). The causes of impairments are presented by age, sex, residence, and province. The cause of impairment varied significantly by age. Impairments at birth were most likely to be reported for children age 0-9 years (48 percent). On the other hand, other causes of impairment increased with age. For example, the percentage of the population impaired due to illness increases from 21 percent for age 0-9 to 60 percent for age 60 and older. Landmines and gunshots mostly affected persons age 40-59. Impairments caused by road accidents and other accidents varies less by age than by other causes of impairment. The cause of impairment varies by sex, residence, and province. Men were much more likely than women to have been impaired by landmines and gunshot accidents. While 15 percent of men were impaired by a landmine, only 2 percent of women suffered a similar fate. Twelve percent of men were impaired by a gunshot compared with 2 percent of women. There were less striking differences by rural/urban residence in causes of impairments. As in Table 3.2, the interpretation of the causes of physical impairment by province in Table 3.3 is complicated by the small number of cases in some provinces. 3.3 PREVALENCE AND SEVERITY OF ILLNESS OR INJURY All households were asked if any members were sick or injured at any time in the 30 days before the interview. If any members were sick, their names were recorded to ask specifically about their conditions in the questions that followed. The household questionnaire allotted space for information to be recorded for up to three household members. Interviewers were instructed to use extra questionnaires to record the information on all household members who were ill or injured. The respondent was asked to judge the illness or injury as slight, moderate, or severe. Finally questions were asked as to whether the ill or injured household member sought care, where they sought care, how much they spent on transport, and how much they spent on treatment. These questions were repeated in order to collect information on the patterns of health-care-seeking behavior. For example, a man might first seek treatment from a Kru Khmer traditional healer, but later go to a health clinic if the illness continues. Up to three health-seeking attempts were recorded in the questionnaire for each ill or injured person. Sixteen percent of household members were ill in the 30 days prior to the interview (Table 3.4). However, this percentage may under-represent the actual prevalence of morbidity and injury for two reasons. The questions were asked only about living household members at the time of the interview. Therefore, the recorded episodes of illness and injury exclude any cases that ended in the death of a household member in the 30 days prior to the interview. Furthermore, the responses are based on the 30 day recall of one respondent in the household. That respondent might not have been aware of all the illnesses or injuries that had occurred within the household. It is likely that illnesses or injuries that occurred at the beginning of the 30 day period or those that were of mild severity were forgotten and not reported. Nine-tenths of all illnesses or injuries were slight or moderate in severity. Only 2 percent of the household members experienced serious illness or injury, with those 40 years and older suffering from the most illnesses and injuries. The highest percentage of illness or injury was found among persons age 60 years and older; 10 percent had slight illness or injury, 15 percent had moderate illness or injury, and 5 percent reported serious illness or injury. There were only slight differences by sex and rural/urban residence. The highest percentage of illness or injury was found in Battambang/ Krong Pailin (33 percent). The province with the lowest percent of illness or injury is Krong Preah Sihanouk/Kaoh Kong (4 percent). 32 | Utilization of Health Services for Accident, Illness, or Injury Table 3.4 Prevalence and severity of illness or injury in previous 30 days Percent distribution of the de facto household population ill or injured in the previous 30 days by severity of illness or injury, according to background characteristics, Cambodia 2005 Severity of illness or injury Background characteristic Not ill or injured Slight Moderate Serious Total Number of household members Age group 0-9 80.6 10.7 6.9 1.9 100.0 16,009 10-19 92.3 3.9 3.1 0.8 100.0 17,517 20-39 86.2 5.5 6.5 1.8 100.0 17,755 40-59 77.0 8.7 11.2 3.1 100.0 11,067 60+ 69.5 10.4 15.3 4.8 100.0 4,545 Sex Male 85.5 6.4 6.2 1.9 100.0 31,347 Female 82.3 7.9 7.8 2.0 100.0 35,547 Residence Urban 87.7 5.9 5.0 1.5 100.0 10,348 Rural 83.1 7.4 7.4 2.1 100.0 56,546 Province Banteay Mean Chey 91.6 1.9 3.8 2.7 100.0 2,686 Kampong Cham 83.5 7.6 6.9 2.0 100.0 8,729 Kampong Chhnang 74.7 12.8 11.1 1.4 100.1 2,408 Kampong Speu 84.0 6.6 7.6 1.8 100.0 3,725 Kampong Thom 78.0 8.3 10.2 3.5 100.0 3,321 Kandal 87.2 5.1 5.0 2.7 100.0 6,616 Kratie 78.6 11.0 8.4 2.1 100.0 1,367 Phnom Penh 90.0 4.2 4.6 1.1 100.0 6,071 Prey Veng 82.4 7.6 7.5 2.5 100.0 5,367 Pursat 86.7 4.8 7.2 1.3 100.0 2,030 Siem Reap 91.3 2.7 5.0 1.1 100.0 4,624 Svay Rieng 84.2 6.9 8.1 0.8 100.0 2,679 Takeo 80.8 7.3 10.0 1.8 100.1 4,722 Otdar Mean Chey 82.0 13.1 4.3 0.6 100.0 722 Battambang/Krong Pailin 66.9 19.7 10.5 3.0 100.0 4,654 Kampot/Krong Kep 90.0 2.3 5.8 1.9 100.0 3,400 Krong Preah Sihanouk/Kaoh Kong 96.0 0.9 2.1 0.9 100.0 1,545 Preah Vihear/Steung Treng 76.7 12.1 8.2 3.0 100.0 1,285 Mondol Kiri/Rattanak Kiri 81.8 10.0 6.9 1.4 100.1 943 Total 83.8 7.2 7.0 2.0 100.0 66,894 3.4 TREATMENT SOUGHT FOR ILLNESS OR INJURY Table 3.5 presents the percentage of the ill or injured population who sought treatment according to the number of times. The type of treatment recorded in these questions include, but was not limited to, care given by medically-trained professionals. For example, if a sick child was first given a remedy by a Kru Khmer traditional healer, this was recorded as the first treatment. If the parents later observed that the child was still ill and went to a shop in the market for medicine, this was recorded as the second treatment. If the drugs did not work and the parents took the child to a doctor at a private clinic, this was recorded as the third treatment. Ninety-two percent of household members who were ill sought at least one treatment (Table 3.5). This continues the upward trend found in the NHS 1998 (86 percent) and the 2000 CDHS (89 percent). Twenty-seven percent of those ill or injured sought at least two treatments, and 10 per- cent sought at least three treatments. In general, there was a positive relationship between the severity of illness or injury and the number of times treatment is sought. Those persons with serious illnesses or injuries were more likely to seek treatment than those with moderate illnesses or injuries. These latter individuals were in turn were more likely to seek treatment than those with slight illnesses or injuries. For first time treatments, the percent seeking treatment was fairly similar (88, 94, and Utilization of Health Services for Accident, Illness, or Injury | 33 96 percent respectively for slight, moderate, and serious illness or injuries) than for second treatment (23, 27, and 40 percent respectively). For instance, 10 percent of slight illness or injury were treated three times or more compared with 16 percent of those with a serious illness or injury. There were small differences in health-seeking behavior by sex, age, and urban/rural residence. The province with the highest percentage of ill or injured persons seeking treatment is Battambang/Krong Pailin (98 percent), while the province with the lowest percentage is Mondol Kiri/Rattanak Kiri (76 percent). Table 3.5 Percentage of ill or injured population who sought treatment Percentage of household members who were ill or injured in the past 30 days who sought a first, second, and third treatment, according to background characteristics, Cambodia 2005 Treatment for illness or injury Background characteristic First treatment Second treatment Third treatment Total Severity of illness or injury Slight 87.9 23.1 9.8 4,803 Moderate 93.8 26.7 9.4 4,709 Serious 96.2 40.1 15.8 1,327 Age group 0-9 93.4 21.9 6.8 3,114 10-19 91.8 28.4 12.2 1,351 20-39 91.3 28.8 11.2 2,449 40-59 90.5 30.0 11.6 2,552 60+ 89.3 26.4 13.0 1,386 Sex Male 92.2 26.1 10.5 4,537 Female 91.0 27.2 10.3 6,314 Residence Urban 94.2 24.3 10.5 1,275 Rural 91.1 27.1 10.4 9,575 Province Banteay Mean Chey 91.6 11.4 2.4 228 Kampong Cham 88.6 30.3 10.5 1,441 Kampong Chhnang 94.6 30.4 12.9 610 Kampong Speu 90.3 17.6 4.2 595 Kampong Thom 87.4 26.1 11.4 730 Kandal 94.3 27.5 8.8 848 Kratie 88.2 37.9 16.0 293 Phnom Penh 96.0 16.6 4.2 607 Prey Veng 93.0 33.6 15.2 947 Pursat 88.4 16.4 2.6 270 Siem Reap 82.1 10.2 2.0 403 Svay Rieng 90.5 14.2 2.6 422 Takeo 89.7 21.7 5.4 909 Otdar Mean Chey 94.5 12.8 2.7 130 Battambang/Krong Pailin 98.2 42.4 22.9 1,544 Kampot/Krong Kep 95.5 33.9 14.2 339 Krong Preah Sihanouk/Kaoh Kong 95.4 22.3 1.2 61 Preah Vihear/Steung Treng 83.3 11.9 3.7 300 Mondol Kiri/Rattanak Kiri 75.8 9.5 0.7 173 Total 91.5 26.7 10.4 10,850 Note: Total includes 12 people for whom information on severity of illness is not available. 34 | Utilization of Health Services for Accident, Illness, or Injury 3.5 UTILIZATION OF HEALTH CARE FACILITIES Information on the sector and location of health care providers was collected to determine where persons who were ill or injured went for treatment. The health care providers were distinguished by public sector, private sector, and non-medical sector. Descriptions of the different types of hospitals, clinics, pharmacies, and other health venues were explained to the interviewers. During data collection if the interviewer had difficulties distinguishing among the various types, then the team supervisor or field editor would ascertain the correct designation from local sources. Table 3.6 presents the utilization of health services by type of residence (urban/rural), where small differences in the pattern of health care use can be observed. In general, the private sector was consistently the most popular, with the public sector as commonly used as the non-medical sector. Urban and rural residents seek a first, second, or third treatment in about equal proportion. Approximately nine in ten ill or injured people sought treatment, one in four went on for a second treatment, and one in ten went on for a third treatment. Table 3.6 Percentage of ill or injured population who sought treatment Percent distribution of household members who were ill or injured in the past 30 days by place of treatment, according to urban-rural residence, Cambodia 2005 Treatment Urban Rural Total Place of treatment First treatment Second treatment Third treatment First treatment Second treatment Third treatment First treatment Second treatment Third treatment Did not seek treatment 5.8 75.7 89.5 8.9 72.9 89.6 8.5 73.3 89.6 Public sector 18.6 4.6 1.8 22.0 6.0 2.1 21.6 5.9 2.0 National hospital (PP) 4.1 1.3 0.3 2.1 0.7 0.1 2.4 0.8 0.2 Provincial hospital (RH) 4.2 0.9 0.4 2.4 0.6 0.2 2.6 0.6 0.2 District hospital (RH) 1.3 0.5 0.1 3.0 0.8 0.3 2.8 0.7 0.2 Health center 7.8 1.8 0.7 13.6 3.6 1.4 13.0 3.4 1.3 Health post 0.1 0.0 0.0 0.5 0.2 0.1 0.5 0.2 0.1 Outreach 0.2 0.0 0.0 0.1 0.0 0.0 0.1 0.0 0.0 Other public 1.1 0.2 0.2 0.2 0.1 0.0 0.3 0.1 0.0 Private sector 59.9 15.1 6.3 46.7 13.1 5.0 48.2 13.3 5.2 Private hospital 1.8 0.6 0.0 0.6 0.1 0.1 0.8 0.2 0.1 Private clinic 14.8 4.2 1.7 6.3 2.3 0.6 7.3 2.5 0.8 Private pharmacy 25.1 5.8 3.1 6.6 2.3 1.0 8.7 2.7 1.3 Home/office of trained health worker/nurse 6.4 1.9 0.4 12.0 3.6 1.3 11.4 3.4 1.2 Visit of trained health worker/nurse 10.6 2.4 0.9 18.8 4.3 1.8 17.8 4.0 1.7 Other private medical 1.2 0.2 0.2 2.4 0.5 0.1 2.2 0.5 0.1 Non-medical sector 14.5 4.2 2.4 21.6 7.7 3.2 20.8 7.3 3.1 Shop/market 13.3 3.4 2.2 20.1 6.9 2.9 19.3 6.5 2.8 Kru khmer/magician 1.2 0.7 0.2 1.5 0.7 0.3 1.5 0.7 0.3 Monk/religious leader 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Traditional birth attendant 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 Other 1.2 0.3 0.1 0.8 0.2 0.1 0.8 0.2 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,275 1,275 1,275 9,575 9,575 9,575 10,850 10,850 10,850 PP = Phnom Penh RH = Referral hospital Utilization of Health Services for Accident, Illness, or Injury | 35 Within the public sector, health centers were most often used in both urban and rural areas. In fact, health centers in rural areas were twice as likely to be visited for first treatment than health centers in urban areas (14 percent compared with 8 percent). Within the private sector, private pharmacies were much more likely to be visited for first treatment in urban areas than in rural areas (25 percent compared with 7 percent), whereas trained health workers and nurses were more commonly sought out for first time treatment in rural areas than in urban areas (19 percent versus 11 percent). Within the nonmedical sector, the overwhelming choice for source of health care were shops or markets. Figure 3.1 summarizes the findings in Table 3.6. The private sector is about twice as likely to be visited for all treatments. Public sector is as popular as the non-medical sector for first, second and third treatments. 3.6 COST FOR HEALTH CARE Distribution of Cost for Health Care For each ill or injured person, the respondent was asked to state the costs expended for transportation and treatment for each visit to a health care provider. These costs are reported only for living people who have been recently ill or injured, and does not include costs incurred for people who died in the 30 days prior to interview. Costs are presented in US dollars in Table 3.7. For all treatments, 22 percent of household members spent US $1.00 or less and 33 percent spent $1.00 to $4.00. Just under 4 percent of all household members spent $50-$99.00 for the transport to and treatment of illness or injury, while only 2.5 percent of all ill or injured persons spent $100.00 or more for transport to and treatment of illness or injury. These expenditures vary by the type of spending. For transport, two out of three household members spent less than $1.00, 21 percent spent $1.00 to $4.00, and barely 6 percent spent $5.00 or more for transport. For health care, 56 percent spent up to $4.00, 15 percent spent between $5.00 and $9.00, and 11 percent spent between $10.00 and $19.00. 21 7 3 48 13 5 22 6 2 First treatment Second treatment Third treatment 0 10 20 30 40 50 60 Percent Non-medical sector Private sector Public sector Figure 3.1 Percentage of Household Members Ill or Injured Seeking Treatment by Order of Treatment and Sector of Health Care CDHS 2005 36 | Utilization of Health Services for Accident, Illness, or Injury There are small variations according to the order of treatment. For the first through third treatments, 69 to 76 percent of all ill or injured persons spent less than $1.00 for transport. For health care, these proportions are less varied, between 29 and 32 percent. Table 3.7 Distribution of cost for health care Percent distribution of household members who were ill or injured in the past 30 days and sought treatment by amount of money spent for transport and healthcare, according to number of treatments, Cambodia 2005 Treatment for illness or injury First treatment Second treatment Third treatment All treatments Amount spent for transport and health care Transport Health care Total cost Transport Health care Total cost Transport Health care Total cost Transport Health care Total cost Monetary cost $0 - $1 68.7 28.8 25.4 70.2 32.0 29.4 75.5 32.2 29.8 67.0 25.1 22.3 $1 - $4 20.5 32.3 34.3 21.3 35.7 37.5 18.2 40.5 42.7 21.0 31.4 32.6 $5 - $9 3.3 14.8 15.6 3.0 12.6 13.2 2.5 11.9 11.9 3.7 15.3 15.9 $10 - $19 0.7 10.2 11.0 0.8 7.2 7.9 0.2 6.9 7.5 1.4 11.2 12.0 $20 - $49 0.4 8.2 9.0 0.3 6.5 7.2 0.7 4.2 4.9 0.6 9.7 10.6 $50 - $99 0.1 2.5 2.7 0.1 2.1 2.5 0.1 1.1 1.3 0.1 3.5 3.7 $100+ 0.0 1.5 1.6 0.0 1.5 1.5 0.0 0.9 1.0 0.0 2.3 2.5 Nonmonetary cost In kind 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Don’t know/missing 6.3 1.6 0.4 4.3 2.4 0.8 2.8 2.3 0.9 6.1 1.5 0.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Note: All costs cited in US dollars. One US dollar = 4,000 Riels. Expenditures for Health Care Table 3.8 presents the mean cost of transport and treatment by the order of treatment and background characteristics. There is an inverse relationship between the cost and the order of treatment. As the number of treatments rise, the total cost for treatment decreases from $11.17 for the first treatment to $7.82 for the third treatment. The mean cost of transport does not follow a specific pattern; for all order of treatments the cost for transport is less than one dollar. The mean cost of transport and health care varies according to the type of health sector, severity of illness or injury, age group, sex, residence, and province. Examining transport costs by type of health sector shows that the highest mean expenditure is for “other” type of treatment; this may include going to another country such as Thailand or Vietnam, or going to trained medical professionals with specialized services. Examining health care costs by type of health sector shows that the highest mean expenditure is for the private sector, with costs barely diminishing over treatment cycles ($13.97, $12.79, and $10.21 respectively). Public sector and “other” medical sector costs drop noticeably over the same treatment cycle. Interestingly, health care costs within the various health sectors have swapped positions from the 2000 CDHS to the 2005 CDHS. In the 2000 CDHS, the public and “other” sectors vied for top spots as most expensive, whereas in the 2005 CDHS, the private sector is consistently the most expensive treatment. Overall, however, costs have dropped considerably from the 2000 CDHS, with public sector costs dropping by half (from $31.90 overall to $15.52) and private sector costs dropping by 31 percent (from $27.10 overall to $18.62). The “other” sector has dropped the most significantly, almost five-fold, from $55.90 in the 2000 CDHS to $10.94 in the 2005 CDHS. For health care costs, the most expensive total cost was for treatment within the private sector ($17.98), while the lowest was for those who sought care within the non-medical sector ($5.76). This is true for all orders of treatment. Utilization of Health Services for Accident, Illness, or Injury | 37 Table 3.8 Expenditures for health care Mean expenditures in United States dollars for transport and health care by household members who were ill or injured in the past 30 days, by order of treatments, according to background characteristics, Cambodia 2005 Treatment First treatment Second treatment Third treatment Total Background characteristic Transport Health care Total Transport Health care Total Transport Health care Total Transport Health care Total Type of health sector Public 1.76 10.81 12.23 1.90 7.90 9.48 1.29 3.70 4.81 2.36 13.59 15.52 Private 0.58 13.97 14.36 0.64 12.79 13.22 0.54 10.21 10.59 0.89 17.98 18.62 Nonmedical 0.26 2.52 2.75 0.33 3.74 4.03 0.56 4.71 5.27 0.54 5.76 6.25 Other 3.10 7.27 10.19 1.85 3.07 4.90 2.31 0.43 2.74 3.37 7.76 10.94 Severity of illness or injury Slight 0.23 2.58 2.77 0.17 1.54 1.69 0.14 1.34 1.48 0.29 3.13 3.38 Moderate 0.91 11.72 12.38 0.69 8.87 9.36 0.60 7.28 7.81 1.17 14.94 15.82 Serious 2.31 33.28 34.80 2.55 26.17 27.91 2.17 21.22 22.10 3.71 47.17 50.03 Age group 0-9 0.60 4.65 5.16 0.50 3.97 4.39 0.57 2.26 2.79 0.76 5.72 6.38 10-19 0.86 8.40 9.16 0.87 8.11 8.95 0.73 9.52 10.04 1.23 12.17 13.27 20-39 0.92 12.32 13.02 0.72 12.38 12.75 0.78 8.19 8.85 1.24 17.13 18.10 40-59 0.98 14.10 14.83 1.30 10.51 11.60 0.89 9.76 10.49 1.54 18.76 20.00 60+ 0.74 16.73 17.11 0.70 10.87 11.37 0.38 5.38 5.69 1.00 20.70 21.25 Sex Male 0.82 10.82 11.44 0.72 9.61 10.14 0.59 5.30 5.77 1.09 14.09 14.95 Female 0.81 10.33 10.97 0.92 8.84 9.59 0.78 8.65 9.33 1.18 13.91 14.87 Residence Urban 0.67 17.35 17.77 0.78 19.32 19.65 0.58 6.28 6.58 0.94 22.89 23.56 Rural 0.83 9.60 10.26 0.85 7.94 8.64 0.72 7.36 7.99 1.17 12.76 13.71 Province Banteay Mean Chey 1.16 19.25 20.04 (3.12) (17.27) (18.03) * * * 1.59 21.62 22.79 Kampong Cham 0.74 9.28 9.85 0.64 4.08 4.64 0.30 3.37 3.67 0.99 11.08 11.87 Kampong Chhnang 0.35 4.54 4.84 0.52 4.29 4.72 0.69 3.22 3.81 0.61 6.33 6.88 Kampong Speu 0.69 9.17 9.74 0.85 9.50 10.13 * * * 0.92 12.16 12.94 Kampong Thom 0.93 12.14 12.99 0.72 11.03 11.69 1.20 10.78 11.96 1.30 16.88 18.06 Kandal 0.91 9.97 10.78 1.09 14.53 15.62 (1.31) (18.23) (19.55) 1.36 15.91 17.19 Kratie 0.70 5.27 5.88 0.44 3.67 4.08 0.65 1.91 2.54 1.01 7.22 8.10 Phnom Penh 0.80 22.28 22.71 0.91 21.46 21.12 * * * 1.09 26.45 27.16 Prey Veng 0.87 11.87 12.63 0.76 8.86 9.56 0.38 4.90 5.23 1.21 15.85 16.93 Pursat 1.60 16.79 18.30 4.23 18.34 22.57 * * * 2.42 20.48 22.80 Siem Reap 1.49 27.29 28.67 (2.35) (40.49) (42.83) * * * 1.80 32.44 34.11 Svay Rieng 0.57 7.91 8.48 1.51 8.10 9.61 * * * 0.82 9.24 10.06 Takeo 1.51 7.08 7.45 1.47 8.45 8.89 (1.45) (16.06) (15.32) 1.95 9.70 10.24 Otdar Mean Chey 2.19 4.74 5.19 5.91 7.90 9.79 * * * 3.22 5.82 6.56 Battambang/Krong Pailin 0.40 7.76 8.13 0.34 8.34 8.62 0.41 5.62 6.02 0.64 12.64 13.25 Kampot/Krong Kep 0.71 6.53 7.22 0.87 5.59 6.35 (0.55) (4.57) (5.04) 1.10 9.15 10.22 Krong Preah Sihanouk/ Kaoh Kong 3.02 35.39 37.09 (4.11) (34.86) (38.88) * * * 4.27 43.61 46.60 Preah Vihear/ Steung Treng 0.59 4.81 5.32 1.08 4.00 4.99 (0.76) (2.56) (3.31) 0.77 5.48 6.17 Mondol Kiri/ Rattanak Kiri 1.97 8.82 10.73 2.84 12.22 14.86 * * * 2.35 10.50 12.77 Total 0.81 10.54 11.17 0.84 9.15 9.82 0.70 7.23 7.82 1.14 13.99 14.90 Note: Table includes only persons who paid cash or who reported no cost. All costs cited in US dollars. One US dollar = 4,000 Riels. Total includes 12 persons for whom information on severity of illness is not available. 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. 38 | Utilization of Health Services for Accident, Illness, or Injury In general, health care costs rose significantly by severity of illness or injury. The total mean costs of treatment increased from $3.13 for slight illness or injury to $47.17 for serious conditions. This follows the same trend established in the 2000 CDHS, though as noted above, overall costs have decreased since then ($4.60 for slight illness or injury to $61.70 for serious illnesses in the 2000 CDHS). Total health care costs rise by the patient’s age, ranging from $5.72 for children age 0-9 to $20.70 for people age 60 years and older. Health care expenditures by sex have become more equitable since the last CDHS, though spending patterns by sex have changed roles. In 2000, men spent less than women for total health care ($18.40 compared with $20.20), whereas in 2005, men spent more than women on total health care ($14.09 compared with $13.91). Total health care costs have remained more expensive in the urban areas than the rural areas since the 2000 CDHS, with the cost in urban areas staying the same (from $22.70 in 2000 compared with $22.89 in 2005). The cost in rural areas dropped by a third (from $18.90 in 2000 compared with $12.76 in 2005). On the other hand, transport costs have made an about face. In the 2000 CDHS, total transport costs were more than twice as expensive in urban areas than in rural areas ($3.20 compared with $1.20 respectively), whereas transport costs now are less in urban areas than in rural areas ($0.94 in versus $1.17 respectively). Health care expenditures vary greatly in Cambodia's provinces. The most expensive cost for health care is in Krong Preah Sihanouk/Kaoh Kong ($43.61) and the least expensive is in Preah Vihear/Steung Treng ($5.48). As Kaoh Kong has limited services and is located on the border with Thailand, it is possible that the high health expenditures reflect care sought across the border. As the health care system in Cambodia is a largely a fee-based system, it is important to know the source of the money used to pay for health care. One goal of the health care system is to have appropriate funding mechanisms for the population to acquire health care without deepening poverty. Table 3.9 shows that 45 percent of the money spent on health care came from wages/pocket money and 30 percent from savings. This is drastically different from the situation during the 2000 CDHS, where barely 16 percent of the money spent on health care came from wages/pocket money and 54 percent came from savings. There are small differences in the source of money spent on health care by type of health sector. In all sectors, wages/pocket money is the most common source of funding (42 percent to 65 percent), followed by savings (20 percent to 32 percent). Borrowed money with interest is the next most common source of funding for public and private sector health care (8 percent). The same is true for borrowed money without interest (6 percent). Overall, borrowed money has dropped as a total source of money since the 2000 CDHS. For example, in the 2000 CDHS, borrowed money (with interest) was cited 10.9 percent of the time, whereas in the 2005 CHDS it was cited just 7.4 percent of the time. A similar drop occurred with borrowed money (no interest), showing a drop from 8.6 percent in 2000 to 5.5 percent in 2005. Additionally, selling assets to obtain money to pay for health care dropped from 6.2 percent in 2000 to 2.7 percent in 2005. This would indicate that people are now better able to afford health care by their own means than before. The source of money for treatment varies by the severity of illness or injury, though following the same trend established in the 2000 CDHS. Wages/pocket money and savings were the most common source of money for care for the slight illnesses. With severe illnesses, the source shift to borrowed money with interest (from 3 percent for slight illness to 18 percent for severe illness) as did borrowed money without interest (from 3 percent for slight illness to 9 percent for severe illness). Utilization of Health Services for Accident, Illness, or Injury | 39 Table 3.9 Source of money spent on health care Percent distribution of the source of expenditures for transport and health care according to background characteristics, Cambodia 2005 Source of money for health care Background characteristic Wages/ pocket money Gift from relative/ friend Savings Borrowed money (no interest ) Borrowed money (with interest ) Sold assets Other Missing Total Number Type of health sector Did not seek treatment 52.1 3.2 29.7 4.5 4.7 1.1 3.6 1.0 100.0 99 Public 43.3 5.8 31.6 6.3 7.9 3.2 1.6 0.4 100.0 1,557 Private 42.3 7.0 29.7 6.1 8.4 2.9 3.6 0.1 100.0 3,776 Nonmedical 52.1 4.8 30.9 3.3 4.6 1.9 2.3 0.2 100.0 1,559 Other 64.6 3.1 20.0 4.8 4.5 0.0 3.0 0.0 100.0 58 Severity of illness or injury Slight 55.9 4.5 29.6 2.6 3.3 1.3 2.5 0.3 100.0 2,895 Moderate 41.3 6.9 31.2 6.9 7.8 2.7 3.2 0.1 100.0 3,198 Serious 24.3 8.8 29.1 9.4 18.2 7.0 2.8 0.3 100.0 950 Cost oftransport/treatment $0 - $1 56.5 4.7 32.2 1.7 2.0 1.3 1.5 0.2 100.0 1,394 $1 - $4 51.5 4.7 32.5 3.5 3.5 1.1 2.8 0.4 100.0 2,276 $5 - $9 43.6 7.4 29.8 6.7 7.2 1.6 3.5 0.2 100.0 1,141 $10 - $19 35.5 6.7 30.5 9.2 11.6 2.6 3.8 0.0 100.0 908 $20 - $49 32.5 9.3 26.5 7.6 14.5 5.9 3.8 0.0 100.0 823 $50 - $99 24.7 8.4 26.2 12.7 18.1 9.0 0.9 0.0 100.0 300 $100+ 23.2 6.7 16.0 10.5 24.8 15.5 3.4 0.0 100.0 203 Sex Male 45.6 4.9 30.5 5.7 8.1 2.6 2.3 0.3 100.0 2,849 Female 44.6 7.0 30.1 5.3 6.8 2.8 3.2 0.2 100.0 4,201 Residence Urban 61.0 5.4 21.0 4.6 4.8 1.1 1.6 0.5 100.0 864 Rural 42.8 6.3 31.6 5.6 7.7 2.9 3.0 0.2 100.0 6,186 Province Banteay Mean Chey 12.1 3.7 45.8 6.6 27.2 2.5 1.5 0.5 100.0 188 Kampong Cham 39.1 7.8 39.6 5.7 6.6 1.2 0.0 0.0 100.0 935 Kampong Chhnang 37.4 7.5 44.6 3.1 2.3 2.5 2.0 0.6 100.0 364 Kampong Speu 40.0 5.9 29.7 5.1 10.2 5.3 3.2 0.5 100.0 434 Kampong Thom 45.7 6.5 30.1 5.7 6.2 4.0 1.2 0.5 100.0 417 Kandal 51.3 13.3 22.7 4.8 4.1 2.3 1.5 0.0 100.0 621 Kratie 76.1 2.7 7.7 2.2 1.9 0.3 8.9 0.3 100.0 173 Phnom Penh 75.2 6.4 7.9 3.3 5.2 0.3 1.2 0.5 100.0 495 Prey Veng 39.9 10.4 12.0 4.5 9.6 4.9 18.7 0.0 100.0 703 Pursat 23.4 3.4 48.6 8.3 13.2 3.0 0.1 0.0 100.0 193 Siem Reap 70.4 3.6 10.5 6.7 6.4 1.3 1.1 0.0 100.0 287 Svay Rieng 33.4 1.8 40.2 13.4 8.0 2.7 0.0 0.6 100.0 311 Takeo 37.9 3.6 44.9 5.7 5.6 2.2 0.2 0.0 100.0 599 Otdar Mean Chey 81.0 3.1 1.4 2.7 10.9 0.6 0.3 0.0 100.0 93 Battambang/Krong Pailin 70.6 3.6 6.4 5.4 9.9 4.0 0.0 0.2 100.0 673 Kampot/Krong Kep 1.6 0.6 86.4 2.8 3.7 4.0 0.8 0.0 100.0 256 Krong Preah Sihanouk/ Kaoh Kong 27.7 6.4 55.9 6.0 2.9 1.1 0.0 0.0 100.0 52 Preah Vihear/Steung Treng 20.5 2.5 61.2 6.1 6.7 2.4 0.7 0.0 100.0 162 Mondol Kiri/Rattanak Kiri 2.5 0.6 77.1 11.0 5.0 2.2 0.4 1.2 100.0 95 Total 45.0 6.1 30.3 5.5 7.4 2.7 2.8 0.2 100.0 7,050 Note: Total includes 7 persons for whom information on severity of illness is not available and 5 persons for whom information on cost of treatment and transport is not available. 40 | Utilization of Health Services for Accident, Illness, or Injury The monetary costs of health care treatment shows a similar pattern as to those described above. Wages/pocket money and savings were the most important sources of money for health costs under $99.00, with the percentage from these two sources decreasing as the costs increased. Borrowed money (with interest) became the most important source of money for treatment costs of $100.00 or more, with fully 25 percent coming from this source. There were no real differences in the source of money for health care costs by virtue of the patient's sex. Urban residents were more likely than rural residents to use wages or pocket money for health care (61 percent compared with 43 percent). On the other hand, rural residents were more likely than urban residents to pay the health care with their savings (32 percent compared with 21 percent). Large differences were found in the sources of money for health care costs by province. Patients in Otdar Mean Chey were the most likely to use their wages or pocket money to pay for their health care (81 percent) and the least likely to use their savings (1.4 percent). Seam Reap was not far behind with 70 percent of health care costs being covered from wages and pocket money and 11 per- cent covered from savings. This is vastly improved from the 2000 CDHS, when these combined provinces spent only devoted 3.1 of their wages and pocket money towards health care costs yet 63 percent of their savings. Conversely, Kampot/Krong Kep had the highest reliance on savings for health care spending (86 percent) and the lowest reliance on wages/pocket money (1.6 percent). Mondol Kiri/Rattanak Kiri followed closely with a 77 percent reliance on savings and a 2.5 percent reliance on wages/pocket money. As in 2000, patients with the highest reliance on borrowed money (with interest) for health care were in Banteay Mean Chey (27 percent). It is interesting to note that patients in Prey Veng relied on “other” sources of money (19 percent) for their health care costs much more significantly than any other province. Respondent Characteristics | 41 RESPONDENT CHARACTERISTICS 4 This chapter provides a demographic and socioeconomic profile of respondents interviewed in the 2005 CDHS. Such background information is essential to the interpretation of findings and for understanding the results presented later in the report. Basic characteristics collected include age, level of education, marital status, religion, and wealth status. Exposure to mass media and literacy status were examined, and detailed information was collected on employment status, occupation, and earnings. In addition, the CDHS collected data on knowledge and attitudes concerning tuberculosis and use of tobacco. 4.1 CHARACTERISTICS OF SURVEY RESPONDENTS The background characteristics of the 16,823 women age 15-49 and the 6,731 men age 15-49 interviewed in the 2005 CDHS are shown in Table 4.1. This table is important in that it provides the background for interpreting findings presented later in the report. The distribution of the population of women and men by age reflects recent Cambodian history. Note that 21 percent of women and 25 percent of men fall into the 15-19 age group while 18 percent of women and men fall into the 20-24 age group. Significantly smaller proportions of women and men are found in the older age groups. Twelve to 13 percent of women and men fall into the five-year age groups between 25 and 44, and 10 percent of women and 8 percent of men fall into the 45-49 age group. This unusual distribution of respondents into the youngest age groups is an indicator of the demographic shocks that occurred as a result of the Khmer Rouge regime (1975-1979). Fertility declined during these years, concomitant with higher than normal mortality due to national conflict. Between one and two million people are estimated to have been killed during the reign of the Khmer Rouge. These events are reflected in the smaller than expected proportions of women and men in the 25-29 and 30-34 age groups. After the conflict subsided, there was a baby boom, represented by the high proportion of women and men in the 15-19 and 20-24 age groups. The majority of surveyed respondents (60 percent of women and 59 percent of men) are married or living together. The proportion not currently married varies by gender. Three in ten women has never married compared with four in ten men. On the other hand, women are much more likely to be divorced, separated, or widowed (8 percent) than men (2 percent). Place of residence is another characteristic that determines access to services and exposure to information pertaining to reproductive health and other aspects of life. The majority of respondents reside in rural areas, with only 18 percent of women and 17 percent of men residing in urban areas. Thirteen percent of men and women live in Kampong Cham, and 11 percent live in the capital city of Phnom Penh. Cambodians are predominantly Buddhist, while 2 percent are Muslim and less than 1 percent are Christian. The majority of Cambodians have some formal schooling. The education level of women has improved since the 2000 CDHS. The percentage of women who never attended school declined from 28 percent in the 2000 survey to 19 percent in 2005. At the same time, the percentage of women who attended any secondary school increased from 17 percent to 25 percent. However, Table 4.1 shows there are still notable differences in educational attainment of women and men. Twice as many women as men have never attended school (19 percent of women compared with 9 percent of women), and only a little over half as many women as men have attended secondary school (25 percent versus 43 percent). 42 | Respondent Characteristics Table 4.1 Background characteristics of respondents Percent distribution of women and men by selected background characteristics, Cambodia 2005 Women Men Background characteristic Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted number Age 15-19 21.4 3,601 3,646 24.7 1,662 1,710 20-24 18.1 3,045 3,020 18.2 1,222 1,182 25-29 12.2 2,051 2,104 12.3 830 848 30-34 12.4 2,082 2,035 12.0 811 754 35-39 13.2 2,229 2,247 12.7 858 862 40-44 12.6 2,112 2,080 11.8 793 786 45-49 10.1 1,703 1,691 8.2 555 589 Marital status Never married 31.8 5,352 5,186 38.7 2,606 2,576 Married 59.6 10,027 10,262 58.8 3,961 3,990 Living together 0.4 60 47 0.2 13 13 Divorced/separated 4.2 709 677 1.7 114 116 Widowed 4.0 675 651 0.6 37 36 Residence Urban 17.7 2,973 4,152 16.8 1,133 1,586 Rural 82.3 13,850 12,671 83.2 5,598 5,145 Province Banteay Mean Chey 3.9 650 779 3.8 253 294 Kampong Cham 12.6 2,116 791 12.9 870 330 Kampong Chhnang 3.3 556 804 3.5 234 345 Kampong Speu 5.2 870 923 5.2 348 366 Kampong Thom 4.8 799 899 4.9 331 362 Kandal 9.6 1,612 876 10.1 682 376 Kratie 2.0 331 854 1.9 128 317 Phnom Penh 11.3 1,896 1,105 11.0 737 423 Prey Veng 8.3 1,395 883 7.2 482 309 Pursat 2.9 480 817 3.0 202 341 Siem Reap 7.1 1,200 973 6.8 461 373 Svay Rieng 3.9 658 828 4.2 281 363 Takeo 6.5 1,102 888 7.3 491 406 Otdar Mean Chey 1.1 177 948 1.0 69 331 Battambang/Krong Pailin 7.4 1,247 1,036 6.8 456 373 Kampot/Krong Kep 5.0 839 873 4.8 321 336 Krong Preah Sihanouk/ Kaoh Kong 2.3 379 808 2.4 160 328 Preah Vihear/Steung Treng 1.8 301 873 1.7 116 347 Mondol Kiri/Rattanak Kiri 1.3 215 865 1.6 110 411 Education No schooling 19.4 3,270 3,772 9.0 606 712 Primary 55.8 9,389 9,131 48.4 3,261 3,347 Secondary and higher 24.8 4,165 3,920 42.6 2,865 2,672 Wealth quintile Lowest 17.9 3,017 3,261 16.0 1,078 1,213 Second 18.8 3,164 3,323 18.1 1,218 1,305 Middle 19.3 3,245 3,262 20.1 1,351 1,374 Fourth 19.7 3,308 3,115 21.8 1,468 1,339 Highest 24.3 4,089 3,862 24.0 1,616 1,500 Religion Buddhist 96.9 16,302 15,840 96.7 6,511 6,317 Muslim 1.7 281 315 1.5 102 116 Christian 0.6 99 104 0.9 58 49 Other/missing 0.8 141 564 0.9 61 249 Total 100.0 16,823 16,823 100.0 6,731 6,731 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. Respondent Characteristics | 43 4.2 EDUCATIONAL ATTAINMENT AND LITERACY Tables 4.2.1 and 4.2.2 present detailed distribution of educational attainment, according to background characteristics. The general pattern evident in Table 4.2.1 indicates a decrease in the proportion of women with no education from the oldest to the youngest cohorts. Women in the 40-44 age group are an exception to this trend; a higher percentage of women age 40-44 have never been to school compared with women in the 45-49 age group (35 versus 30 percent). This pattern probably occurred because women in the 40-44 age group reached school age at the time of the Khmer Rouge. Men in the 40-44 age group exhibit the same pattern. Women born during the reign of the Khmer Rouge (those currently age 25-29) are also somewhat more likely than the surrounding age groups to have no formal education. Men born during the time of the Khmer Rouge as well as those born just before (men currently age 25 to 34) are also more likely to have never attended school. The data presented in Tables 4.2.1 and 4.2.2 provide evidence of an increase in educational attainment among the youngest age cohort. For example, two in five women age 15-19 have attended some secondary school as compared with only one in five women age 20-24. Urban women are more highly educated than rural women. One-third of urban women have attended some secondary school compared with 19 percent of rural women. Table 4.2.1 shows great variation in education across provinces. Mondol Kiri and Rattanak Kiri have an exceptionally low rate of school attendance among women. Three in five women have no formal education. By contrast, only one in ten women in Phnom Penh has never attended school. The median grade attained is highest in Phnom Penh, Kandal, and Takeo (5.9, 4.5 and 4.1, respectively). Educational attainment rises dramatically with wealth quintile. Almost two in five women in the lowest quintile have no formal education (37 percent) compared with less than one in ten women in the highest wealth quintile (7 percent). The percentage of women who have attended some secondary school increases from 5 percent in the lowest wealth quintile to 41 percent in the highest. The pattern of variation in educational attainment by province and wealth among men is similar to that of women. The 2005 CDHS assessed literacy levels among women who had never been to school or who had attended only the primary level by asking them to read all or part of a sentence in whatever language the respondent was familiar. Those who had attained middle school or above were assumed to be literate. 44 | Respondent Characteristics Table 4.2.1 Educational attainment: women Percent distribution of women by highest level of schooling attained, and median grade completed, according to background characteristics, Cambodia 2005 Highest level of schooling attended or completed Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Total Number of women Median grade Age 15-19 7.9 33.7 15.5 40.6 1.5 0.9 100.0 3,601 5.6 20-24 16.0 46.5 9.6 20.7 4.1 3.1 100.0 3,045 3.9 25-29 21.5 48.8 6.1 20.1 2.2 1.3 100.0 2,051 3.3 30-34 16.4 53.0 7.1 20.8 1.9 0.8 100.0 2,082 3.1 35-39 20.9 50.3 6.0 20.9 1.3 0.5 100.0 2,229 3.0 40-44 35.3 54.8 2.9 6.2 0.5 0.3 100.0 2,112 1.3 45-49 29.7 58.7 3.4 7.4 0.7 0.1 100.0 1,703 1.7 Residence Urban 12.8 36.1 8.3 32.6 5.8 4.4 100.0 2,973 5.2 Rural 20.9 50.1 8.1 19.4 1.0 0.4 100.0 13,850 3.0 Province Banteay Mean Chey 24.7 51.4 7.5 15.5 0.9 0.0 100.0 650 2.5 Kampong Cham 22.6 51.4 8.8 16.3 0.7 0.3 100.0 2,116 2.8 Kampong Chhnang 12.8 55.9 8.1 21.3 1.8 0.1 100.0 556 3.2 Kampong Speu 21.4 52.3 7.3 17.7 0.8 0.5 100.0 870 2.8 Kampong Thom 16.1 57.3 6.0 18.4 2.2 0.1 100.0 799 2.9 Kandal 12.1 43.8 10.0 31.6 1.6 0.9 100.0 1,612 4.5 Kratie 20.9 48.6 6.7 22.0 1.7 0.1 100.0 331 2.8 Phnom Penh 9.5 33.0 9.2 35.2 6.8 6.3 100.0 1,896 5.9 Prey Veng 16.5 58.3 8.4 15.8 0.9 0.1 100.0 1,395 2.9 Pursat 24.6 47.8 8.0 18.3 0.7 0.6 100.0 480 2.7 Siem Reap 39.6 40.5 5.3 13.6 0.6 0.4 100.0 1,200 1.7 Svay Rieng 17.7 53.3 6.8 20.3 0.9 1.0 100.0 658 3.2 Takeo 14.4 45.2 9.0 29.6 1.4 0.5 100.0 1,102 4.1 Otdar Mean Chey 39.0 50.4 3.7 6.6 0.3 0.1 100.0 177 1.3 Battambang/Krong Pailin 15.1 47.1 9.6 24.5 2.4 1.3 100.0 1,247 3.8 Kampot/Krong Kep 14.3 50.8 11.0 22.3 1.3 0.3 100.0 839 3.5 Krong Preah Sihanouk/ Kaoh Kong 31.9 42.2 6.8 15.6 2.9 0.6 100.0 379 2.6 Preah Vihear/Steung Treng 24.0 59.5 5.0 10.9 0.4 0.2 100.0 301 1.7 Mondol Kiri/Rattanak Kiri 61.5 26.7 2.4 8.8 0.5 0.1 100.0 215 0.0 Wealth quintile Lowest 37.1 53.4 4.5 4.9 0.0 0.0 100.0 3,017 1.2 Second 26.6 56.2 7.3 9.6 0.2 0.1 100.0 3,164 2.2 Middle 19.2 55.1 8.5 16.6 0.5 0.1 100.0 3,245 3.0 Fourth 11.7 47.0 10.2 29.5 1.1 0.4 100.0 3,308 4.3 Highest 7.2 31.4 9.6 41.4 6.2 4.2 100.0 4,089 6.2 Total 19.4 47.6 8.2 21.8 1.9 1.1 100.0 16,823 3.3 1 Completed grade 6 at the primary level 2 Completed grade 12 at the secondary level Respondent Characteristics | 45 Table 4.2.2 Educational attainment: men Percent distribution of men by highest level of schooling attained, and median grade completed, according to background characteristics, Cambodia 2005 Highest level of schooling attended or completed Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Total Number of men Median grade Age 15-19 3.3 31.9 15.0 47.8 1.4 0.6 100.0 1,662 6.0 20-24 7.0 34.8 9.5 36.4 6.0 6.3 100.0 1,222 5.9 25-29 9.7 44.9 6.2 29.6 5.4 4.2 100.0 830 4.6 30-34 11.1 36.4 9.7 34.0 4.9 3.9 100.0 811 5.3 35-39 7.6 38.2 6.3 39.6 4.2 4.1 100.0 858 5.7 40-44 19.0 43.5 5.4 25.1 3.9 3.1 100.0 793 3.5 45-49 14.1 59.1 7.8 15.6 1.2 2.2 100.0 555 2.8 Residence Urban 4.7 24.3 6.5 42.7 9.9 12.0 100.0 1,133 7.7 Rural 9.9 42.0 10.1 34.0 2.5 1.6 100.0 5,598 4.8 Province Banteay Mean Chey 9.4 51.0 9.2 28.0 2.1 0.3 100.0 253 3.9 Kampong Cham 13.4 42.8 12.8 27.4 2.8 0.8 100.0 870 4.4 Kampong Chhnang 3.9 50.9 8.3 32.9 3.3 0.6 100.0 234 4.5 Kampong Speu 7.4 42.1 12.2 34.8 1.7 1.7 100.0 348 5.1 Kampong Thom 8.1 56.3 7.2 27.1 1.1 0.2 100.0 331 3.4 Kandal 6.2 31.4 7.6 46.3 4.7 3.7 100.0 682 6.5 Kratie 12.6 50.9 8.8 26.5 0.9 0.3 100.0 128 3.7 Phnom Penh 3.0 17.2 6.8 42.4 11.9 18.6 100.0 737 8.3 Prey Veng 5.0 41.5 11.2 39.7 2.5 0.0 100.0 482 5.4 Pursat 13.7 43.7 11.0 28.0 2.9 0.7 100.0 202 4.3 Siem Reap 24.8 42.4 7.4 21.3 1.6 2.4 100.0 461 3.3 Svay Rieng 3.1 34.3 11.6 46.4 2.1 2.6 100.0 281 6.1 Takeo 5.2 29.1 7.5 53.6 3.9 0.7 100.0 491 6.5 Otdar Mean Chey 19.7 55.9 6.4 17.0 0.6 0.4 100.0 69 2.6 Battambang/Krong Pailin 4.9 42.9 11.6 35.1 2.9 2.7 100.0 456 5.2 Kampot/Krong Kep 5.4 46.0 11.9 33.0 3.0 0.6 100.0 321 4.9 Krong Preah Sihanouk/ Kaoh Kong 9.2 34.8 9.5 39.0 3.7 3.8 100.0 160 5.8 Preah Vihear/Steung Treng 14.4 51.1 6.0 23.0 5.0 0.4 100.0 116 3.1 Mondol Kiri/Rattanak Kiri 34.5 41.2 4.2 17.5 0.8 1.8 100.0 110 2.1 Wealth quintile Lowest 22.3 54.2 9.6 13.3 0.6 0.0 100.0 1,078 2.6 Second 12.4 53.1 11.0 22.4 0.9 0.1 100.0 1,218 3.6 Middle 8.2 44.9 9.7 35.3 1.3 0.6 100.0 1,351 4.7 Fourth 4.5 33.9 10.6 46.3 3.1 1.5 100.0 1,468 6.1 Highest 2.3 17.9 6.9 50.3 10.7 12.0 100.0 1,616 8.1 Total 15-49 9.0 39.0 9.4 35.4 3.8 3.3 100.0 6,731 5.2 1 Completed grade 6 at the primary level 2 Completed grade 12 at the secondary level Table 4.3 shows that seven in ten women in Cambodia are literate. Literacy is associated with access to education. In general, the younger age groups are more likely to be literate than the older age groups. Illiteracy decreases from 38 percent among women age 45-49 to 16 percent among women age 15-19. However, illiteracy is higher among women in the 25-29 and 40-44 age groups than in the surrounding age cohorts. As seen in Table 4.2.1, these women were less likely to have attended school than the age cohorts before and after them. 46 | Respondent Characteristics Table 4.3 Literacy: women Percent distribution of women by level of schooling attended and level of literacy, and percent literate, according to background characteristics, Cambodia 2005 No schooling or primary school Background characteristic Secondary school or higher Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Total Number of women Percentage literate1 Age 15-19 43.0 30.0 11.3 15.5 0.1 0.0 0.1 100.0 3,601 84.3 20-24 27.9 29.2 13.4 29.4 0.0 0.0 0.1 100.0 3,045 70.4 25-29 23.6 27.6 12.1 36.6 0.0 0.1 0.0 100.0 2,051 63.3 30-34 23.5 31.8 13.5 31.1 0.0 0.0 0.2 100.0 2,082 68.7 35-39 22.7 31.2 16.1 29.8 0.0 0.1 0.0 100.0 2,229 70.1 40-44 7.0 28.8 19.2 44.4 0.1 0.3 0.1 100.0 2,112 55.1 45-49 8.3 32.7 20.3 37.9 0.1 0.6 0.0 100.0 1,703 61.3 Residence Urban 42.8 24.2 13.7 18.9 0.2 0.0 0.2 100.0 2,973 80.7 Rural 20.9 31.3 14.8 32.8 0.0 0.1 0.1 100.0 13,850 67.0 Province Banteay Mean Chey 16.4 39.1 9.3 35.1 0.0 0.1 0.0 100.0 650 64.8 Kampong Cham 17.2 40.5 9.1 32.8 0.0 0.3 0.1 100.0 2,116 66.8 Kampong Chhnang 23.2 39.4 9.9 26.9 0.1 0.0 0.5 100.0 556 72.5 Kampong Speu 19.1 32.4 8.0 40.4 0.0 0.1 0.0 100.0 870 59.5 Kampong Thom 20.7 40.9 10.6 27.8 0.0 0.0 0.0 100.0 799 72.2 Kandal 34.1 27.2 17.3 21.4 0.0 0.0 0.0 100.0 1,612 78.6 Kratie 23.8 41.0 3.5 30.6 0.6 0.6 0.0 100.0 331 68.3 Phnom Penh 48.3 26.0 12.7 12.5 0.3 0.0 0.2 100.0 1,896 87.0 Prey Veng 16.9 36.6 6.7 39.6 0.0 0.2 0.0 100.0 1,395 60.2 Pursat 19.6 7.2 37.3 35.8 0.0 0.1 0.0 100.0 480 64.1 Siem Reap 14.6 21.9 14.4 48.8 0.0 0.3 0.0 100.0 1,200 50.9 Svay Rieng 22.2 23.8 22.3 31.3 0.0 0.1 0.3 100.0 658 68.3 Takeo 31.4 29.2 17.6 21.5 0.0 0.2 0.0 100.0 1,102 78.2 Otdar Mean Chey 6.9 30.6 16.6 45.7 0.0 0.1 0.2 100.0 177 54.1 Battambang/Krong Pailin 28.2 22.9 31.4 17.5 0.0 0.0 0.0 100.0 1,247 82.5 Kampot/Krong Kep 23.9 25.5 16.0 34.5 0.0 0.0 0.1 100.0 839 65.4 Krong Preah Sihanouk/ Kaoh Kong 19.1 24.6 20.3 35.9 0.0 0.0 0.1 100.0 379 64.0 Preah Vihear/Steung Treng 11.5 31.9 5.6 50.8 0.1 0.0 0.0 100.0 301 49.1 Mondol Kiri/Rattanak Kiri 9.4 11.1 12.5 66.5 0.4 0.0 0.1 100.0 215 33.0 Wealth quintile Lowest 4.9 25.0 15.2 54.7 0.1 0.2 0.0 100.0 3,017 45.0 Second 10.0 30.0 16.1 43.8 0.0 0.1 0.1 100.0 3,164 56.1 Middle 17.2 34.5 15.8 32.3 0.0 0.2 0.1 100.0 3,245 67.5 Fourth 31.1 35.0 15.1 18.6 0.0 0.2 0.1 100.0 3,308 81.2 Highest 51.7 26.5 11.6 9.8 0.1 0.0 0.2 100.0 4,089 89.8 Total 24.8 30.1 14.6 30.3 0.1 0.1 0.1 100.0 16,823 69.4 1 Refers to women who attended secondary school or higher and women who can read a whole sentence or part of a sentence Four in five women residing in urban areas are literate compared with two in three of their rural counterparts. Differences in literacy across provinces are marked, with literacy being highest among women in Phnom Penh (87 percent) and lowest in Mondol Kiri and Rattanak Kiri (33 percent). Literacy levels increase along with women’s wealth status, doubling from 45 percent among women in the lowest wealth quintile to 90 percent among women in the highest wealth quintile. There has been little change in the overall illiteracy rate since the 2000 CDHS (32 percent in 2000 compared with 30 percent in 2005). However, there has been a large decrease in illiteracy in the 15-19 age group from 25 percent to 16 percent, reflecting the increase in the level of educational attainment in this cohort since the previous survey (see Table 4.2.1). Respondent Characteristics | 47 4.3 ACCESS TO MASS MEDIA The 2005 CDHS collected information on the exposure of respondents to both broadcast and print media. This information is important because it provides an indication of the exposure of women to mass media that can be used to disseminate family planning, health, and other information. Access to mass media is relatively high in Cambodia. Table 4.4.1 shows that four in five women have some weekly exposure to the mass media. Watching television is the most common way of accessing the media: 68 percent of women watch television at least once a week. Listening to the radio is also common (half of women listen at least once a week), with newspapers being the least utilized form of media (13 percent read a newspaper at least once a week). Table 4.4.1 Exposure to mass media: women Percentage of women who are exposed to specific media on a weekly basis by background characteristics, Cambodia 2005 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week All three media at least once a week No media at least once a week Number of women Age 15-19 19.4 78.1 57.1 14.1 13.5 3,601 20-24 16.4 69.4 53.6 11.8 19.0 3,045 25-29 12.6 65.9 47.2 9.0 23.6 2,051 30-34 10.7 62.4 41.6 6.6 25.9 2,082 35-39 10.9 62.6 45.2 7.8 26.0 2,229 40-44 7.5 63.0 47.5 5.5 25.7 2,112 45-49 10.3 66.5 53.5 7.4 19.9 1,703 Residence Urban 33.2 82.9 55.8 23.3 9.5 2,973 Rural 9.2 64.8 49.0 6.6 23.6 13,850 Province Banteay Mean Chey 2.9 61.8 42.1 2.1 27.0 650 Kampong Cham 4.7 61.5 38.0 2.8 27.9 2,116 Kampong Chhnang 14.4 71.1 70.2 9.7 11.2 556 Kampong Speu 8.8 67.7 52.8 6.3 20.5 870 Kampong Thom 16.6 44.8 39.8 7.7 37.4 799 Kandal 12.2 87.7 70.3 11.1 8.8 1,612 Kratie 15.9 56.0 42.4 8.6 27.5 331 Phnom Penh 39.9 92.1 54.0 27.7 4.7 1,896 Prey Veng 5.9 68.1 41.9 4.3 21.1 1,395 Pursat 8.3 54.7 58.1 4.2 22.7 480 Siem Reap 15.2 71.2 45.9 11.4 22.1 1,200 Svay Rieng 9.1 68.1 60.8 6.9 16.6 658 Takeo 7.4 69.7 43.2 5.5 22.0 1,102 Otdar Mean Chey 4.2 26.8 29.4 2.1 57.5 177 Battambang/Krong Pailin 20.5 81.9 66.0 17.7 9.8 1,247 Kampot/Krong Kep 4.5 45.3 44.8 2.6 34.2 839 Krong Preah Sihanouk/ Kaoh Kong 15.3 62.2 56.2 12.3 21.7 379 Preah Vihear/Steung Treng 7.9 9.5 36.9 2.1 56.1 301 Mondol Kiri/Rattanak Kiri 5.6 21.6 17.2 1.5 66.0 215 Education No schooling 0.4 49.0 34.3 0.1 38.6 3,270 Primary 9.6 66.9 49.8 6.3 21.2 9,389 Secondary and higher 32.2 85.3 63.7 24.2 7.3 4,165 Wealth quintile Lowest 3.0 37.1 31.0 1.4 47.9 3,017 Second 4.0 53.0 42.1 2.2 30.7 3,164 Middle 6.4 69.4 51.8 3.8 18.2 3,245 Fourth 11.0 79.5 59.4 8.1 11.4 3,308 Highest 35.8 91.9 61.9 26.9 4.0 4,089 Total 13.4 68.0 50.2 9.5 21.1 16,823 48 | Respondent Characteristics There is no strong trend in access to the three types of media by age. The youngest group of women (15-19 years old) is most likely to access each form of media, particularly television and newspaper. However, women in the oldest age group are not always the least likely to access media. Women in the 40-44 age group are least likely to read a newspaper at least once a week (8 percent) while women ages 30-34 are least likely to watch television or listen to the radio (62 percent and 42 percent, respectively). Residence, on the other hand, is associated with clear differences in media exposure. Urban women have better access to all three media sources than their rural counterparts. Due to lower literacy levels, rural women are much less likely to report that they read a newspaper at least once a week than urban women (9 percent compared with 33 percent). Among the provinces, women residing in Phnom Penh have by far the greatest exposure to all three media (28 percent), with Battambang and Krong Pailin being the next provinces most exposed to mass media with 18 percent of women using all three types of media at least once a week. Women residing in Mondol Kiri and Rattanak Kiri, Otdar Mean Chey, and Preah Vihear and Steung Treng are the least likely to be exposed to the media (66 percent, 58 percent, and 56 percent, respectively, have no weekly access to media). Media exposure increases with both the educational level and wealth quintile of the respondent. For example, 92 percent of women in the highest wealth quintile watch television at least once per week compared with 37 percent of women in the lowest wealth quintile. Regarding the printed media, 10 percent of women with primary education reported reading a newspaper at least once a week, compared with 32 percent of women with secondary and higher education. A comparison of Tables 4.4.1 and 4.4.2 shows that women are somewhat more likely than men not to access media at least once per week (21 percent of women compared with 18 percent of men). Most of this difference is explained by greater access of men to radio: 60 percent of men listen to the radio at least once per week compared with 50 percent of women. There has been an increase in exposure to the media since 2000, especially in areas outside of Phnom Penh. The proportion of women who do not access any form of media at least once a week declined from 30 percent in the 2000 CDHS to 21 percent in the 2005 survey. The greatest increase has come in the proportion of women who watch television at least once a week (56 percent in 2000 compared with 68 percent in 2005). Respondent Characteristics | 49 Table 4.4.2 Exposure to mass media: men Percentage of men who are exposed to specific media on a weekly basis by background characteristics, Cambodia 2005 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week All three media at least once a week No media at least once a week Number of men Age 15-19 10.5 78.6 64.6 8.0 12.3 1,662 20-24 15.8 72.7 61.5 13.0 16.1 1,222 25-29 14.2 65.1 54.6 11.1 23.1 830 30-34 11.6 64.0 53.5 9.3 23.5 811 35-39 13.6 62.4 56.4 9.8 21.7 858 40-44 15.9 69.5 59.4 13.1 19.6 793 45-49 14.2 70.0 64.1 12.1 16.2 555 Residence Urban 36.8 83.5 68.5 28.6 8.0 1,133 Rural 8.7 67.6 58.0 7.0 20.1 5,598 Province Banteay Mean Chey 8.1 55.2 47.7 4.0 25.8 253 Kampong Cham 0.2 43.3 19.9 0.1 46.0 870 Kampong Chhnang 19.2 78.5 80.5 15.5 4.6 234 Kampong Speu 5.6 93.0 93.4 5.4 1.0 348 Kampong Thom 11.3 69.6 54.3 8.2 17.6 331 Kandal 16.0 85.5 75.2 13.5 5.3 682 Kratie 5.7 47.4 43.9 3.5 34.2 128 Phnom Penh 48.7 94.4 81.8 41.5 1.2 737 Prey Veng 6.3 75.8 67.1 5.9 12.1 482 Pursat 5.1 57.4 56.1 3.0 26.8 202 Siem Reap 15.7 77.6 52.3 10.8 16.3 461 Svay Rieng 5.3 71.7 50.1 3.2 17.1 281 Takeo 4.7 63.5 56.7 3.1 20.4 491 Otdar Mean Chey 3.2 33.2 35.1 1.6 49.0 69 Battambang/Krong Pailin 17.0 85.2 76.5 13.9 4.2 456 Kampot/Krong Kep 4.5 73.9 75.2 3.9 11.6 321 Krong Preah Sihanouk/ Kaoh Kong 26.9 59.7 45.8 17.7 25.7 160 Preah Vihear/Steung Treng 9.3 14.4 49.4 3.2 44.2 116 Mondol Kiri/Rattanak Kiri 5.1 20.6 20.8 0.7 63.3 110 Education No schooling 0.6 46.6 34.1 0.6 41.6 606 Primary 5.8 65.3 57.0 4.5 20.8 3,261 Secondary and higher 24.8 80.9 68.4 19.7 10.0 2,865 Wealth quintile Lowest 3.0 44.5 45.1 2.0 37.2 1,078 Second 3.2 55.7 50.7 2.0 28.5 1,218 Middle 4.7 71.4 59.1 3.5 15.9 1,351 Fourth 10.3 77.7 64.3 7.6 12.3 1,468 Highest 38.2 90.8 72.7 31.5 4.3 1,616 Total 15-49 13.4 70.3 59.8 10.6 18.0 6,731 4.4 EMPLOYMENT Employment Status In the 2005 CDHS, respondents were asked a number of questions regarding their employment status, including whether they did any work in the seven days preceding the survey and, if not, whether they had worked in the 12 months before the survey. The results for women and men are presented in Tables 4.5.1 and 4.5.2. At the time of the survey, two-thirds of women (64 percent) were currently employed and an additional 15 percent were not employed but had worked sometime during the preceding 12 months (Figure 4.1). The proportions currently employed generally increase with increasing age. Women who are divorced, separated, or widowed are more likely to be employed than other women. 50 | Respondent Characteristics Table 4.5.1 Employment status: women Percent distribution of women by employment status, according to background characteristics, Cambodia 2005 Employed in the 12 months preceding the survey Background characteristic Currently employed1 Not currently employed Not employed in the 12 months preceding the survey Missing Total Number of women Age 15-19 46.5 9.9 43.1 0.5 100.0 3,601 20-24 64.5 15.5 19.6 0.4 100.0 3,045 25-29 66.4 17.0 16.2 0.3 100.0 2,051 30-34 69.5 16.0 14.2 0.2 100.0 2,082 35-39 70.3 18.0 11.5 0.2 100.0 2,229 40-44 73.1 15.4 11.2 0.2 100.0 2,112 45-49 72.9 13.0 13.9 0.2 100.0 1,703 Marital status Never married 58.2 9.0 32.4 0.4 100.0 5,352 Married or living together 65.7 17.5 16.5 0.3 100.0 10,087 Divorced/separated/widowed 75.9 15.8 8.2 0.2 100.0 1,384 Number of living children 0 59.6 10.4 29.6 0.4 100.0 6,296 1-2 64.7 17.0 17.9 0.3 100.0 4,534 3-4 68.9 16.5 14.3 0.3 100.0 3,549 5+ 68.1 18.4 13.2 0.3 100.0 2,444 Residence Urban 60.3 8.1 31.1 0.5 100.0 2,973 Rural 65.0 16.1 18.6 0.3 100.0 13,850 Province Banteay Mean Chey 52.2 20.6 24.3 2.9 100.0 650 Kampong Cham 72.6 9.8 17.6 0.0 100.0 2,116 Kampong Chhnang 73.3 14.6 11.4 0.6 100.0 556 Kampong Speu 60.8 24.7 14.6 0.0 100.0 870 Kampong Thom 63.6 12.3 24.1 0.0 100.0 799 Kandal 73.3 6.0 20.6 0.1 100.0 1,612 Kratie 54.9 13.4 31.3 0.4 100.0 331 Phnom Penh 62.2 2.9 34.8 0.1 100.0 1,896 Prey Veng 59.1 22.5 18.3 0.0 100.0 1,395 Pursat 46.1 27.9 26.0 0.0 100.0 480 Siem Reap 64.0 18.7 16.0 1.2 100.0 1,200 Svay Rieng 72.7 13.8 12.9 0.7 100.0 658 Takeo 58.6 20.7 20.4 0.3 100.0 1,102 Otdar Mean Chey 43.0 41.5 15.5 0.0 100.0 177 Battambang/Krong Pailin 68.8 11.2 20.0 0.0 100.0 1,247 Kampot/Krong Kep 63.3 18.9 17.5 0.3 100.0 839 Krong Preah Sihanouk/ Kaoh Kong 58.6 9.6 31.7 0.1 100.0 379 Preah Vihear/Steung Treng 55.7 31.3 13.0 0.0 100.0 301 Mondol Kiri/Rattanak Kiri 65.5 17.7 15.5 1.4 100.0 215 Education No schooling 65.4 20.9 13.3 0.4 100.0 3,270 Primary 66.9 16.0 16.9 0.3 100.0 9,389 Secondary and higher 57.1 6.7 35.8 0.5 100.0 4,165 Wealth quintile Lowest 62.5 23.0 14.2 0.3 100.0 3,017 Second 64.1 20.1 15.6 0.3 100.0 3,164 Middle 66.6 17.0 16.2 0.2 100.0 3,245 Fourth 66.1 12.2 21.4 0.4 100.0 3,308 Highest 62.1 4.4 33.1 0.4 100.0 4,089 Total 64.2 14.6 20.8 0.3 100.0 16,823 1 "Currently employed" is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. Respondent Characteristics | 51 Urban and rural women are roughly equally likely to be currently employed (60 percent compared with 65 percent). However, rural women are more likely than urban women to have worked in the past 12 months but not in the last seven days. As a result urban women are more likely than rural women not to have been employed at all in the 12 months preceding the survey (31 percent vs. 19 percent). Women in Kampong Cham, Kampong Chhnang, Kandal and Svay Rieng are most likely to be currently employed (73 percent). In contrast, women in Phnom Penh, Krong Preah Sihanouk and Kaoh Kong, and Kratie are most likely not to have been employed at any time in the 12 months preceding the survey (35 percent, 32 percent, and 31 percent, respectively). Women with some secondary education and those in the highest wealth quintile are least likely to have worked in the 12 months preceding the survey. The proportion of men currently employed is higher than that of women (79 percent compared with 64 percent). As with women, urban men are more likely not to have worked in the 12 months preceding the survey, as are men with secondary education or higher and those in the highest wealth quintile. The proportion of men currently employed ranges from 6 in 10 men in Pursat being currently employed, to 9 in 10 men in Kampong Cham being currently employed. Men were most likely to have worked at some point in the 12 previous months in Mondol Kiri and Rattanak Kiri and least likely to have done so in Phnom Penh. The

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