Cambodia - Demographic and Health Survey - 2015

Publication date: 2015

Cambodia Demographic and Health Survey 2014 C am bodia 2014 D em ographic and H ealth Survey Cambodia Demographic and Health Survey 2014 National Institute of Statistics Ministry of Planning Phnom Penh, Cambodia Directorate General for Health Ministry of Health Phnom Penh, Cambodia The DHS Program ICF International Rockville, Maryland, USA September 2015 The analysis of the Cambodia Demographic and Health Survey 2014 was achieved through the joint efforts of: Sok Kosal, NIS/MoP Chhay Satia, NIS/MoP They Kheam, NIS/MoP Phan Chinda, NIS/MoP Loun Mondol, DGH/MoH Lam Phirun, DGH/MoH Rathavuth Hong, ICF International Bernard Barrère, ICF International Anne Cross, ICF International Sunita Kishor, ICF International See Appendix D for a list of contributors to the implementation of the CDHS. The 2014 Cambodia Demographic and Health Survey (2014 CDHS) is part of The DHS Program, a worldwide project which assists countries in the collection of data to monitor and evaluate population, health, and nutrition programs. Funding was provided by the Royal Government of Cambodia (RGC), the United States Agency for International Development (USAID), the Australian Department of Foreign Affairs and Trade (Australia- DFAT), the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF), the Japan International Cooperation Agency (JICA), the Korean International Cooperation Agency (KOICA), and the Health Sector Support Program—Second Phase (HSSP-2). Additional information about the survey can be obtained from the National Institute of Statistics; 386 Monivong Boulevard, Sangkat Beong Keng Kang 1, Chamkar Mon, Phnom Penh, Cambodia; Telephone: (855) 23-213650; E-mail: ssythan@hotmail.com; Internet: www.nis.gov.kh and the Directorate General for Health, Ministry of Health 80 Samdech Penn Nouth Boulevard (289), Sangkat Boeungkak 2, Tuol Kork, Phnom Penh, Cambodia; Telephone: (855) 23-885970/23-884909; E-mail: webmaster@moh.gov.kh; Internet: www.moh.gov.kh. Additional information about The DHS Program can be obtained from ICF International, 530 Gaither Road, Suite 500, Rockville, MD 20850 USA; Telephone: 301-572-0200, Fax: 301-572-0999, E-mail: info@DHSprogram.com, Internet: www.DHSprogram.com. Suggested citation: National Institute of Statistics, Directorate General for Health, and ICF International, 2015. Cambodia Demographic and Health Survey 2014. Phnom Penh, Cambodia, and Rockville, Maryland, USA: National Institute of Statistics, Directorate General for Health, and ICF International. Cover photo of Angkor Wat temple ©2014 J.H. Tan. Contents • iii CONTENTS TABLES AND FIGURES . ix FOREWORD . xvii ACKNOWLEDGMENTS . xix MAP OF CAMBODIA . xx 1 INTRODUCTION . 1 1.1 Geodemography, History, and Economy . 1 1.1.1 Geodemography . 1 1.1.2 History . 2 1.1.3 Economy . 2 1.2 Health Status and Policy . 2 1.3 Objective and Survey Organization . 4 1.4 Sample Design . 4 1.5 Questionnaires . 5 1.6 Training and Fieldwork . 7 1.7 Biomarker Testing . 7 1.7.1 Anthropometric Measurement . 7 1.7.2 Hemoglobin Testing. 8 1.7.3 Micronutrient Testing . 8 1.8 Data Processing . 8 1.9 Sample Coverage . 8 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS . 11 2.1 Characteristics of the Household Population . 11 2.1.1 Age and Sex Composition . 11 2.1.2 Household Composition . 13 2.2 Education of the Household Population . 14 2.3 Housing Characteristics . 17 2.3.1 Water Supply . 18 2.3.2 Sanitation Facilities . 20 2.3.3 Hand Washing . 21 2.3.4 Flooring Material and Cooking Arrangements . 22 2.4 Household Possessions . 23 2.5 Household Wealth . 23 2.6 Birth Registration . 24 2.7 Children’s Living Arrangements, Orphanhood, and School Attendance by Survivorship of Parents . 25 2.7.1 Children’s Living Arrangements and Orphanhood . 25 2.7.2 School Attendance by Survivorship of Parents . 27 3 UTILIZATION OF HEALTH SERVICES FOR ACCIDENT, ILLNESS, OR INJURY . 29 3.1 Accidental Death or Injury . 29 3.1.1 Frequency of Accidental Death or Injury . 29 3.1.2 Type of Accident . 30 3.2 Prevalence and Severity of Illness or Injury . 32 3.3 Treatment Sought for Illness or Injury . 33 3.4 Utilization of Health Care Facilities . 34 iv • Contents 3.5 Cost for Health Care . 36 3.5.1 Distribution of Cost for Health Care . 36 3.5.2 Expenditures for Health Care . 36 3.5.3 Sources of Money for Health Care Expenditures . 38 4 DISABILITY . 41 4.1 Disability among the General Household Population . 41 4.2 Disability among Ill or Injured Household Members . 43 4.3 Disability and Employment . 44 5 RESPONDENT CHARACTERISTICS . 47 5.1 Characteristics of Survey Respondents . 47 5.2 Educational Attainment and Literacy . 49 5.3 Access to Mass Media . 52 5.4 Employment . 55 5.4.1 Employment Status . 55 5.4.2 Occupation . 57 5.4.3 Earnings, Employers, and Continuity of Employment . 59 5.5 Health Insurance . 60 5.6 Use of Tobacco . 62 6 FERTILITY . 67 6.1 Current Fertility Levels and Differentials . 67 6.2 Fertility Trends . 70 6.2.1 Comparison of Current and Cumulative Fertility Levels . 70 6.2.2 Retrospective Data . 70 6.2.3 Comparison with Previous CDHS . 71 6.3 Children Ever Born and Living . 72 6.4 Birth Intervals . 73 6.5 Age at First Birth . 75 6.6 Teenage Pregnancy and Motherhood . 76 7 PRACTICE OF ABORTION . 79 7.1 Number of Lifetime Induced Abortions . 79 7.2 Practice of Abortion in the Past Five Years . 81 7.2.1 Pregnancy Duration at the Time of Abortion . 81 7.2.2 Place of Abortion . 82 7.2.3 Persons Who Helped with the Abortion . 83 7.2.4 Method Used for the Abortion . 83 8 FAMILY PLANNING . 85 8.1 Knowledge of Contraceptive Methods . 85 8.2 Current Use of Contraceptive Methods . 86 8.3 Use of Social Marketing Brands . 89 8.4 Knowledge of Fertile Period . 90 8.5 Timing of Sterilization. 91 8.6 Source of Family Planning Methods . 91 8.7 Informed Choice . 92 8.8 Future Use of Contraception . 93 8.9 Exposure to Family Planning Messages . 94 8.10 Contact of Nonusers with Family Planning Providers . 95 Contents • v 9 OTHER PROXIMATE DETERMINANTS OF FERTILITY . 97 9.1 Marital Status . 97 9.2 Polygamy . 98 9.3 Age at First Union . 99 9.4 Age at First Sexual Intercourse . 102 9.5 Recent Sexual Activity . 105 9.6 Postpartum Amenorrhea, Abstinence, and Insusceptibility . 108 9.7 Termination of Exposure to Pregnancy . 109 10 FERTILITY PREFERENCES . 111 10.1 Desire for More Children . 111 10.2 Need and Demand for Family Planning Services . 114 10.3 Ideal Family Size . 116 10.4 Fertility Planning . 118 11 ADULT AND MATERNAL MORTALITY . 121 11.1 Data Quality Issues . 121 11.2 Adult Mortality . 123 11.3 Maternal Mortality . 123 12 INFANT AND CHILD MORTALITY . 127 12.1 Assessment of Data Quality . 128 12.2 Levels and Trends in Childhood Mortality . 128 12.3 Socioeconomic Differentials in Childhood Mortality . 129 12.4 Demographic Differentials in Mortality . 131 12.5 Perinatal Mortality . 132 12.6 High-Risk Fertility Behavior . 133 13 MATERNAL HEALTH . 137 13.1 Antenatal Care . 137 13.1.1 Source of Antenatal Care . 137 13.1.2 Components of Antenatal Care . 139 13.1.3 Tetanus Toxoid Vaccinations . 141 13.2 Childbirth and Delivery . 141 13.2.1 Place of Delivery. 142 13.2.2 Assistance at Delivery . 143 13.3 Postnatal Care and Practices . 144 13.4 Perceived Problems in Accessing Women’s Health Care . 149 14 CHILD HEALTH . 151 14.1 Child’s Size at Birth . 151 14.2 Immunization of Children . 152 14.3 Acute Respiratory Infection . 155 14.4 Fever . 157 14.5 Diarrhea . 158 14.6 Feeding Practices . 161 14.7 Knowledge of ORS Packets . 163 14.8 Stool Disposal . 163 15 EARLY CHILDHOOD EDUCATION AND DEVELOPMENT . 165 15.1 Early Childhood Education and Learning . 165 15.2 Adequate Care for Young Children . 169 15.3 Early Childhood Development . 170 vi • Contents 16 NUTRITION OF CHILDREN AND WOMEN . 173 16.1 Nutritional Status of Children . 174 16.1.1 Measurement of Nutritional Status among Young Children . 174 16.1.2 Measures of Child Nutritional Status . 175 16.1.3 Trends in Children’s Nutritional Status . 177 16.2 Initiation of Breastfeeding . 178 16.3 Breastfeeding Status by Age . 180 16.4 Duration of Breastfeeding . 181 16.5 Types of Complementary Foods . 183 16.6 Infant and Young Child Feeding (IYCF) Practices . 184 16.7 Prevalence of Anemia in Children . 187 16.8 Micronutrient Intake among Children . 189 16.9 Use of Iodized Salt . 191 16.10 Nutritional Status of Women . 192 16.11 Prevalence of Anemia in Women . 194 16.12 Micronutrient Intake among Mothers . 196 17 MICRONUTRIENTS . 199 17.1 Coverage of Micronutrient Testing . 200 17.2 Iron, Hemoglobin, and Parasitic Infections . 200 17.2.1 Anemia and Iron Status in Mothers . 201 17.2.2 Anemia and Iron Status in Children . 201 17.2.3 Intestinal Parasite Infection . 203 17.3 Vitamin and Calcium Deficiency . 203 17.3.1 Vitamin and Calcium Deficiency among Mothers . 203 17.3.2 Vitamin and Calcium Deficiency among Children . 203 17.4 Urine Iodine Concentration . 205 18 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR . 207 18.1 Knowledge of HIV/AIDS and of Transmission and Prevention Methods. 207 18.1.1 Awareness of AIDS . 207 18.1.2 HIV Prevention Methods . 208 18.1.3 Knowledge about Transmission . 210 18.1.4 Knowledge of Mother-to-Child Transmission . 213 18.2 Stigma Associated with AIDS and Attitudes Related to HIV/AIDS . 215 18.3 Attitudes towards Negotiating Safer Sex . 217 18.4 Multiple Sexual Partnerships . 218 18.5 Testing for HIV . 223 18.6 Reports of Recent Sexually Transmitted Infections . 227 18.7 Injections . 229 18.8 HIV/AIDS-Related Knowledge and Behavior among Youth . 230 18.8.1 Knowledge about HIV/AIDS and Source for Condoms . 231 18.8.2 Age at First Sex and Condom Use at First Sexual Intercourse . 232 18.8.3 Recent Sexual Activity . 234 18.8.4 Multiple Sexual Partnerships . 235 18.8.5 HIV Testing . 236 19 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES . 239 19.1 Employment and Forms of Earnings . 239 19.2 Control over Women’s and Men’s Earnings . 240 19.3 Participation in Household Decision Making . 243 19.4 Ownership of Assets . 247 19.5 Attitudes towards Wife Beating . 249 Contents • vii 19.6 Women’s Empowerment Indicators . 252 19.7 Current Use of Contraception by Women’s Status . 253 19.8 Ideal Family Size and Unmet Need by Women’s Status . 254 19.9 Reproductive Health Care and Women’s Empowerment Status . 255 20 DOMESTIC VIOLENCE . 257 20.1 Measurement of Violence . 257 20.1.1 Use of Valid Measures of Violence . 257 20.1.2 Ethical Considerations in the 2014 CDHS . 258 20.1.3 Subsample for the Violence Module . 259 20.2 Experience of Physical Violence . 259 20.3 Perpetrators of Physical Violence . 261 20.4 Experience of Sexual Violence . 262 20.5 Perpetrators of Sexual Violence . 262 20.6 Age at First Experience of Sexual Violence . 263 20.7 Experience of Different Forms of Violence . 263 20.8 Violence during Pregnancy . 264 20.9 Marital Control by Spouse . 266 20.10 Forms of Spousal Violence . 268 20.11 Spousal Violence by Background Characteristics . 269 20.12 Violence by Spousal Characteristics and Women’s Empowerment Indicators . 271 20.13 Recent Spousal Violence by Any Husband or Partner . 273 20.14 Onset of Spousal Violence . 273 20.15 Physical Consequences of Spousal Violence . 274 20.16 Violence by Women against Their Husband . 274 20.17 Help-seeking Behavior by Women Who Experience Violence . 276 REFERENCES . 279 APPENDIX A: SAMPLE IMPLEMENTATION . 281 A.1 Introduction . 281 A.2 Sampling Frame . 281 A.3 Sampling Methodology and Procedure . 282 A.4 Sampling Probabilities . 284 APPENDIX B: ESTIMATES OF SAMPLING ERRORS . 291 APPENDIX C: DATA QUALITY TABLES . 317 APPENDIX D: PERSONS INVOLVED IN THE 2014 CAMBODIA DEMOGRAPHIC AND HEALTH SURVEY . 323 APPENDIX E: QUESTIONNAIRES . 327 Tables and Figures • ix TABLES AND FIGURES 1 INTRODUCTION . 1 Table 1.1 Results of the household and individual interviews . 9 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS . 11 Table 2.1 Household population by age, sex, and residence . 12 Table 2.2 Population by age according to selected sources . 13 Table 2.3 Household composition . 13 Table 2.4.1 Educational attainment of the female household population . 14 Table 2.4.2 Educational attainment of the male household population . 15 Table 2.5 School attendance ratios . 16 Table 2.6 Household drinking water . 19 Table 2.7 Household sanitation facilities . 20 Table 2.8 Hand washing . 21 Table 2.9 Household characteristics . 22 Table 2.10 Household possessions . 23 Table 2.11 Wealth quintiles . 24 Table 2.12 Birth registration of children under age 5 . 25 Table 2.13 Children’s living arrangements and orphanhood . 26 Table 2.14 School attendance by survivorship of parents . 27 Figure 2.1 Population pyramid . 12 Figure 2.2 Age-specific attendance rates . 17 3 UTILIZATION OF HEALTH SERVICES FOR ACCIDENT, ILLNESS, OR INJURY . 29 Table 3.1 Injury or death in an accident . 30 Table 3.2 Injury or death in an accident by type of accident . 31 Table 3.3 Prevalence and severity of illness or injury in previous 30 days . 32 Table 3.4 Percentage of ill or injured population who sought treatment . 33 Table 3.5 Percentage of ill or injured population who sought treatment . 35 Table 3.6 Distribution of cost for health care . 36 Table 3.7 Expenditures for health care . 37 Table 3.8 Source of money (United States dollars) spent by persons who sought treatment for health care . 39 Figure 3.1 Percentage of ill or injured household members seeking treatment by order of treatment and sector of health care . 35 4 DISABILITY . 41 Table 4.1 Disability among the household population . 42 Table 4.2 Disability among the ill or injured population . 43 Table 4.3 Disability and employment . 44 5 RESPONDENT CHARACTERISTICS . 47 Table 5.1 Background characteristics of respondents . 48 Table 5.2.1 Educational attainment: Women . 49 Table 5.2.2 Educational attainment: Men . 50 Table 5.3.1 Literacy: Women . 51 Table 5.3.2 Literacy: Men . 52 x • Tables and Figures Table 5.4.1 Exposure to mass media: Women . 53 Table 5.4.2 Exposure to mass media: Men . 54 Table 5.5.1 Employment status: Women . 55 Table 5.5.2 Employment status: Men . 56 Table 5.6.1 Occupation: Women . 58 Table 5.6.2 Occupation: Men . 59 Table 5.7 Type of employment: Women . 60 Table 5.8.1 Health insurance coverage: Women . 61 Table 5.8.2 Health insurance coverage: Men . 62 Table 5.9.1 Use of tobacco: Women . 63 Table 5.9.2 Use of tobacco: Men . 64 6 FERTILITY . 67 Table 6.1 Current fertility . 68 Table 6.2 Fertility by background characteristics . 69 Table 6.3.1 Trends in age-specific fertility rates . 70 Table 6.3.2 Trends in fertility . 71 Table 6.4 Children ever born and living . 73 Table 6.5 Birth intervals . 74 Table 6.6 Age at first birth . 75 Table 6.7 Median age at first birth . 76 Table 6.8 Teenage pregnancy and motherhood . 77 Figure 6.1 Age-specific fertility rates for five-year periods preceding the survey . 71 Figure 6.2 Trends in age-specific fertility rates, Cambodia 2005, 2010, and 2014 . 72 7 PRACTICE OF ABORTION . 79 Table 7.1 Number of induced abortions . 80 Table 7.2 Pregnancy duration at the time of abortion . 82 Table 7.3 Place of abortion . 82 Table 7.4 Persons who helped with abortion . 83 Table 7.5 Method used for the abortion . 84 Figure 7.1 Distribution of women who have had an abortion by number of abortions . 81 8 FAMILY PLANNING . 85 Table 8.1 Knowledge of contraceptive methods . 85 Table 8.2 Knowledge of contraceptive methods by background characteristics . 86 Table 8.3 Current use of contraception by age . 87 Table 8.4.1 Current use of contraception by background characteristics . 88 Table 8.4.2 Trends in current use of contraception . 89 Table 8.5 Use of social marketing brand pills and condoms . 90 Table 8.6 Knowledge of fertile period . 91 Table 8.7 Timing of sterilization . 91 Table 8.8 Source of modern contraception methods . 92 Table 8.9 Informed choice . 93 Table 8.10 Future use of contraception . 94 Table 8.11 Exposure to family planning messages . 95 Table 8.12 Contact of nonusers with family planning providers . 96 9 OTHER PROXIMATE DETERMINANTS OF FERTILITY . 97 Table 9.1 Current marital status . 98 Table 9.2 Number of women’s co-wives . 99 Table 9.3 Age at first marriage . 100 Tables and Figures • xi Table 9.4.1 Median age at first marriage: Women . 101 Table 9.4.2 Median age at first marriage: Men . 102 Table 9.5 Age at first sexual intercourse . 103 Table 9.6.1 Median age at first intercourse: Women . 104 Table 9.6.2 Median age at first intercourse: Men . 105 Table 9.7.1 Recent sexual activity: Women . 106 Table 9.7.2 Recent sexual activity: Men . 107 Table 9.8 Postpartum amenorrhea, abstinence, and insusceptibility . 108 Table 9.9 Median duration of amenorrhea, postpartum abstinence, and postpartum insusceptibility . 109 Table 9.10 Menopause . 110 10 FERTILITY PREFERENCES . 111 Table 10.1 Fertility preferences by number of living children . 112 Table 10.2.1 Desire to limit childbearing: Women . 113 Table 10.2.2 Desire to limit childbearing: Men . 114 Table 10.3 Need and demand for family planning among currently married women . 116 Table 10.4 Ideal number of children . 117 Table 10.5 Mean ideal number of children . 118 Table 10.6 Fertility planning status . 118 Table 10.7 Wanted fertility rates . 119 11 ADULT AND MATERNAL MORTALITY . 121 Table 11.1 Completeness of information on siblings . 122 Table 11.2 Sibship size and sex ratio of siblings . 122 Table 11.3 Adult mortality rates . 123 Table 11.4 Maternal mortality . 124 Figure 11.1 Confidence intervals for maternal mortality rates, Cambodia 2005, 2010, and 2014 . 125 12 INFANT AND CHILD MORTALITY . 127 Table 12.1 Early childhood mortality rates . 129 Table 12.2 Early childhood mortality rates by socioeconomic characteristics . 130 Table 12.3 Early childhood mortality rates by demographic characteristics . 131 Table 12.4 Perinatal mortality . 133 Table 12.5 High-risk fertility behavior . 134 Figure 12.1 Trends in childhood mortality, 2000-2014 . 129 Figure 12.2 Infant mortality rates by socioeconomic characteristics . 130 Figure 12.3 Infant mortality rates by demographic characteristics . 132 13 MATERNAL HEALTH . 137 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 . 141 Table 13.5 Place of delivery . 142 Table 13.6 Assistance during delivery . 144 Table 13.7.1 Timing of first postnatal checkup . 145 Table 13.7.2 Type of provider of first postnatal checkup for the mother . 146 Table 13.8.1 Timing of first postnatal checkup for the newborn . 147 Table 13.8.2 Type of provider of first postnatal checkup for the newborn . 148 Table 13.9 Problems in accessing health care . 149 xii • Tables and Figures 14 CHILD HEALTH . 151 Table 14.1 Child’s size and weight 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 . 161 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 by age 12 months among children age 12-23 months, 2000-2014 . 155 15 EARLY CHILDHOOD EDUCATION AND DEVELOPMENT . 165 Table 15.1 Early childhood education . 166 Table 15.2 Support for learning . 167 Table 15.3 Learning materials . 168 Table 15.4 Inadequate care . 169 Table 15.5 Early Child Development Index . 171 16 NUTRITION OF CHILDREN AND WOMEN . 173 Table 16.1 Nutritional status of children . 176 Table 16.2 Initial breastfeeding . 179 Table 16.3 Breastfeeding status by age . 180 Table 16.4 Median duration of breastfeeding . 182 Table 16.5 Foods and liquids consumed by children in the day or night preceding the interview . 184 Table 16.6 Infant and young child feeding (IYCF) practices . 185 Table 16.7 Prevalence of anemia in children . 188 Table 16.8 Micronutrient intake among children . 190 Table 16.9 Presence of iodized salt in household . 192 Table 16.10 Nutritional status of women . 193 Table 16.11 Prevalence of anemia in women . 195 Table 16.12 Micronutrient intake among mothers . 197 Figure 16.1 Nutritional status of children by age . 177 Figure 16.2 Trends in nutritional status of children under age 5 . 178 Figure 16.3 Infant feeding practices by age . 181 Figure 16.4 IYCF indicators on breastfeeding status . 182 Figure 16.5 Trends in infant and young child feeding (IYCF) practices . 186 Figure 16.6 Trends in anemia status among children under age 5 . 189 Figure 16.7 Trends in nutritional status among women age 15-49 . 194 Figure 16.8 Trends in anemia status among women age 15-49 . 196 17 MICRONUTRIENTS . 199 Table 17.1 Coverage of micronutrient testing by residence . 200 Table 17.2 Anemia, iron status, and soluble transferrin receptors among mothers . 201 Table 17.3 Type of hemoglobin among mothers by residence . 201 Table 17.4 Anemia, iron status, and soluble transferrin receptors (sTfRs) among children born since January 2009 . 202 Table 17.5 Iron status among children by age . 202 Tables and Figures • xiii Table 17.6 Type of hemoglobin among children born since January 2009 by residence . 202 Table 17.7 Intestinal parasitic infection in women and children . 203 Table 17.8 Blood level of vitamins A, B12, B9, and D and calcium in mothers . 203 Table 17.9.1 Blood level of vitamins A, B12, B9, and D and calcium in children . 204 Table 17.9.2 Blood level of vitamins A, B12, B9, and D and calcium in children by age . 204 Table 17.10 Urinary iodine excretion in mothers and children by residence . 205 18 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR . 207 Table 18.1 Knowledge of AIDS . 208 Table 18.2 Knowledge of HIV prevention methods . 209 Table 18.3.1 Comprehensive knowledge about AIDS: Women . 211 Table 18.3.2 Comprehensive knowledge about AIDS: Men . 212 Table 18.4 Knowledge of prevention of mother-to-child transmission of HIV . 214 Table 18.5.1 Accepting attitudes toward those living with HIV/AIDS: Women . 215 Table 18.5.2 Accepting attitudes toward those living with HIV/AIDS: Men . 216 Table 18.6 Attitudes toward negotiating safer sexual relations with husband . 218 Table 18.7.1 Multiple sexual partners: Women . 219 Table 18.7.2 Multiple sexual partners: Men . 221 Table 18.8 Payment for sexual intercourse and condom use at last paid sexual intercourse . 222 Table 18.9.1 Coverage of prior HIV testing: Women . 224 Table 18.9.2 Coverage of prior HIV testing: Men . 225 Table 18.10 Pregnant women counseled and tested for HIV . 226 Table 18.11 Self-reported prevalence of sexually transmitted infections (STIs) and STI symptoms . 228 Table 18.12 Prevalence of medical injections . 230 Table 18.13 Comprehensive knowledge about AIDS and of a source of condoms among youth . 232 Table 18.14 Age at first sexual intercourse among young people . 233 Table 18.15 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth . 235 Table 18.16 Multiple sexual partners in the past 12 months among youth . 236 Table 18.17 Recent HIV tests among youth . 237 19 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES . 239 Table 19.1 Employment and cash earnings of currently married women and men . 240 Table 19.2.1 Control over women’s cash earnings and relative magnitude of women’s cash earnings . 241 Table 19.2.2 Control over men’s cash earnings . 242 Table 19.3 Women’s control over their own earnings and over those of their husbands . 243 Table 19.4 Participation in decision making . 244 Table 19.5.1 Women’s participation in decision making by background characteristics . 245 Table 19.5.2 Men’s participation in decision making by background characteristics . 246 Table 19.6.1 Ownership of assets: Women . 248 Table 19.6.2 Ownership of assets: Men . 249 Table 19.7.1 Attitude toward wife beating: Women . 250 Table 19.7.2 Attitude toward wife beating: Men . 252 Table 19.8 Indicators of women’s empowerment . 253 Table 19.9 Current use of contraception by women’s empowerment . 254 Table 19.10 Ideal number of children and unmet need for family planning by women’s empowerment . 254 xiv • Tables and Figures 20 DOMESTIC VIOLENCE . 257 Table 20.1 Experience of physical violence . 260 Table 20.2 Persons committing physical violence . 261 Table 20.3 Experience of sexual violence. 262 Table 20.4 Persons committing sexual violence . 263 Table 20.5 Age at first experience of sexual violence . 263 Table 20.6 Experience of different forms of violence . 264 Table 20.7 Experience of violence during pregnancy . 265 Table 20.8 Marital control exercised by husbands . 267 Table 20.9 Forms of spousal violence . 268 Table 20.10 Spousal violence by background characteristics . 270 Table 20.11 Spousal violence by husband’s characteristics and empowerment indicators . 272 Table 20.12 Physical or sexual violence in the past 12 months by any husband/partner . 273 Table 20.13 Experience of spousal violence by duration of marriage . 274 Table 20.14 Injuries to women due to spousal violence . 274 Table 20.15 Women’s violence against their spouse . 275 Table 20.16 Help seeking to stop violence . 276 Table 20.17 Sources for help to stop the violence . 277 APPENDIX A: SAMPLE IMPLEMENTATION . 281 Table A.1 Distribution of households in the sampling frame (2008 GPC, updated) by survey domain and by residence, Cambodia 2014 . 282 Table A.2 Distribution of enumeration areas in the sampling frame (2008 GPC, updated) and average size of EAs by survey domain and by residence, Cambodia 2014 . 282 Table A.3 Sample allocation of EAs and households by domain and by type of residence, Cambodia 2014 . 283 Table A.4 Sample allocation of expected number of interviews of women and men by domain and by type of residence, Cambodia 2014 . 284 Table A.5 Sample implementation: Women . 286 Table A.6 Sample implementation: Men . 288 APPENDIX B: ESTIMATES OF SAMPLING ERRORS . 291 Table B.1 List of selected variables for sampling errors, Cambodia 2014 . 293 Table B.2 Sampling errors: Total sample, Cambodia 2014 . 294 Table B.3 Sampling errors: Urban sample, Cambodia 2014 . 295 Table B.4 Sampling errors: Rural sample, Cambodia 2014 . 296 Table B.5 Sampling errors: Banteay Meanchey sample, Cambodia 2014 . 297 Table B.6 Sampling errors: Kampong Cham sample, Cambodia 2014 . 298 Table B.7 Sampling errors: Kampong Chhnang sample, Cambodia 2014 . 299 Table B.8 Sampling errors: Kampong Speu sample, Cambodia 2014 . 300 Table B.9 Sampling errors: Kampong Thom sample, Cambodia 2014 . 301 Table B.10 Sampling errors: Kandal sample, Cambodia 2014 . 302 Table B.11 Sampling errors: Kratie sample, Cambodia 2014 . 303 Table B.12 Sampling errors: Phnom Penh sample, Cambodia 2014 . 304 Table B.13 Sampling errors: Prey Veng sample, Cambodia 2014 . 305 Table B.14 Sampling errors: Pursat sample, Cambodia 2014 . 306 Table B.15 Sampling errors: Siem Reap sample, Cambodia 2014 . 307 Table B.16 Sampling errors: Svay Rieng sample, Cambodia 2014 . 308 Table B.17 Sampling errors: Takeo sample, Cambodia 2014 . 309 Table B.18 Sampling errors: Otdar Meanchey sample, Cambodia 2014 . 310 Table B.19 Sampling errors: Battambang and Pailin sample, Cambodia 2014 . 311 Table B.20 Sampling errors: Kampot and Kep sample, Cambodia 2014 . 312 Tables and Figures • xv Table B.21 Sampling errors: Preah Sihanouk and Koh Kong sample, Cambodia 2014 . 313 Table B.22 Sampling errors: Preah Vihear and Stung Treng sample, Cambodia 2014 . 314 Table B.23 Sampling errors: Mondul Kiri and Ratanak Kiri sample, Cambodia 2014 . 315 APPENDIX C: DATA QUALITY TABLES . 317 Table C.1 Household age distribution . 317 Table C.2.1 Age distribution of eligible and interviewed women . 318 Table C.2.2 Age distribution of eligible and interviewed men . 318 Table C.3 Completeness of reporting . 318 Table C.4 Births by calendar years . 319 Table C.5 Reporting of age at death in days . 319 Table C.6 Reporting of age at death in months . 320 Table C.7 Nutritional status of children based on the NCHS/CDC/WHO International Reference Population . 321 Foreword • xvii FOREWORD he 2014 Cambodia Demographic and Health Survey (2014 CDHS) is the fourth survey of its kind to be conducted successfully in Cambodia. Sponsors are the United States Agency for International Development (USAID), the Australian Department of Foreign Affairs and Trade (Australia-DFAT), United Nations Population Fund (UNFPA), United Nations Children’s Fund (UNICEF), Japan International Cooperation Agency (JICA), Korean International Cooperation Agency (KOICA) and the Health Sector Support Program-Second Phase (HSSP-2). Technical assistance is provided by ICF International. The Directorate General for Health (DGH) of the Ministry of Health and the National Institute of Statistics (NIS) of the Ministry of Planning are the project implementation agencies. This report includes information on demography, family planning, maternal mortality, infant and child mortality, and women’s health care status, including related information, such as breastfeeding, antenatal care, children’s immunization, childhood diseases, HIV/AIDS, and domestic violence. The questionnaires (Household, Man’s, and Woman’s questionnaires) are designed to evaluate the nutritional status of mothers and children and to measure the prevalence of anemia. The 2014 CDHS findings are expected to be used by policymakers and program managers to evaluate Cambodia’s demographic and health status and then to formulate appropriate population and health policies and programs. The programs of reproductive health and child health and health facilities need to be expanded and improved based on the survey findings. We would like to thank USAID, Australia-DFAT, UNFPA, UNICEF, JICA, KOICA, and HSSP2 for sponsoring this survey project and ICF International for providing technical assistance. We gratefully acknowledge the support and encouragement extended by the Minister of Health and Minister of Planning; and other members of the 2014 CDHS Executive Committee and Technical Committee who contributed to the survey activities. We express our sincere thanks to all persons involved in the implementation, analysis, and writing of the 2014 CDHS and especially thank the survey respondents, whose contributions made the survey a success. T Acknowledgments • xix ACKNOWLEDGMENTS he 2014 Cambodia Demographic and Health Survey (2014 CDHS) represents the continuing commitment and efforts in Cambodia to obtain data on population and health. The survey also reflects interest in obtaining information on maternal health, child health, and anemia prevalence. The 2014 CDHS was sponsored by the United States Agency for International Development (USAID), the Australian Department of Foreign Affairs and Trade (Australia-OF AT), United Nations Population Fund (UNFPA), United Nations Children's Fund (UNICEF), Japan International Cooperation Agency (JICA), Korean International Cooperation Agency (KOICA) and the Health Sector Support Program-Second Phase (HSSP-2). The survey was implemented by the Directorate General for Health (DGH) of the Ministry of Health (MOH) and by the National Institute of Statistics (NIS) of the Ministry of Planning (MOP). This survey could not have been completed without the active support and the efforts of many institutions and individuals. The active support and guidance of the Excellencies Secretaries of State; H.E. Prof. Eng Huot, Ministry of Health, and H.E. San Sy Than, Ministry of Planning, are acknowledged with deep gratitude. We also gratefully acknowledge the representatives of USAID, Australia-OF AT, UNFPA, UNICEF, JICA, KOICA, and HSSP-2 and their staff for their support and valuable comments throughout the survey activities. Our deep appreciation also goes to the ICF International team led by Mr. Bernard Barrère, Dr. Rathavuth Hong, and others. They are acknowledged with gratitude for their support as they facilitated the survey and ensured its success. We would like to express our appreciation for all team leaders, field editors, and interviewers from NIS, DGH, and the central and local offices of the 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 members of the 2014 CDHS Executive Committee and Technical Committee who contributed to the survey activities. T xx • Map of Cambodia Introduction • 1 INTRODUCTION 1 Key Findings • The 2014 Cambodia Demographic and Health Survey (CDHS) is a nationally representative survey of 15,825 households with 17,578 women age 15-49 and 5,190 men age 15-49. • The 2014 CDHS is the fourth Demographic and Health Survey conducted in Cambodia as part of the worldwide Demographic and Health Surveys project. • The primary purpose of the CDHS is to furnish policymakers and planners with detailed information on fertility and family planning; infant, child, adult, and maternal mortality; maternal and child health; nutrition; and knowledge of HIV/AIDS and other sexually transmitted infections. • In all selected households, women age 15-49 and children age 6-59 months were tested for anemia. 1.1 GEODEMOGRAPHY, HISTORY, AND ECONOMY 1.1.1 Geodemography ambodia is an agricultural country located in Southeast Asia. It borders with Thailand to the west, Laos and Thailand to the north, the Gulf of Thailand to the southwest, and Vietnam to the east and the south. It has a total land area of 181,035 square kilometers. Cambodia has a tropical climate with two distinct seasons that set the rhythm of rural life. From November to February, the cool, dry northeastern monsoon brings little rain, whereas from May to October 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 population 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 a population of 11.4 million 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 had declined to 1.8 percent, with a total population of 13.1 million (National Institute of Statistics, 2004). The 2008 General Population Census (GPC) showed a further decrease in the annual growth rate to 1.54, with a total population of 13.4 million (National Institute of Statistics, 2009). The proportion of the population living in rural areas is 80.5 percent; only 19.5 percent of the country’s residents live in urban areas. The population density in the country as a whole is 75 per square kilometer, with approximately 1.3 million inhabitants living in Phnom Penh. The average size of the Cambodian household is 4.7. The total male to female sex ratio is 94.7. The literacy rate among adult males is 84 percent, considerably higher than the rate among females (76 percent). Currently, it is estimated that the percentage of the total population living below the poverty line fell to 21.1 percent in 2010 and decreased further to 19.8 percent in 2011 (MOP, 2012). C 2 • Introduction 1.1.2 History Cambodia gained complete independence from France under the leadership of Prince Norodom Sihanouk on November 9, 1953. In March 1970, a military coup led by General Lon Nol overthrew Prince Sihanouk. On April 17, 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 2 million Cambodian people died during the Khmer Rouge’s radical and genocidal regime. On January 7, 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, the State of Cambodia. The country’s 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). At that time Cambodia was proclaimed the Kingdom of Cambodia, and it is a constitutional monarchy. Four additional free and fair elections took place in 1998, 2003, 2008, and 2013. Now Cambodia is stable and well on its way to democracy and a promising future. 1.1.3 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 one of the poorest and least developed countries in Asia, with the gross domestic product per capita estimated at approximately 4.4 million Riel or $1,088 in 2014 (US$1 = 4,087 Riel) (International Monetary Fund, 2011). Agriculture, mainly rice production, is still the main economic activity in Cambodia. Small-scale subsistence agriculture, such as fisheries, forestry, and livestock, is another important sector. Garment factories and tourism services are also important components of foreign direct investments. 1.2 HEALTH STATUS AND POLICY Health outcomes have improved recently. The infant mortality rate has decreased from 45 per 1,000 live births in 2010 to 27 per 1,000 live births in 2014. The under-5 mortality rate decreased from 54 per 1,000 live births to 35 per 1,000 live births in the same period. Life expectancy at birth is 67.1 years for males and 70.1 years for females (NIS, 2013). General government expenditures on health per capita increased from US$8 in 2008 to US$11 in 2010, US$13 in 2012, and US$16 in 2014 (MOH, 2015). The health status of the Cambodian people has steadily improved in a number of key areas. Nonetheless, challenges remain in many other areas. To improve the health status of the Cambodian people, the Ministry of Health developed the Health Sector Strategic Plan for 2008-2015 (Ministry of Health, 2008). Its policy direction is as follows: • Make services more responsive and closer to the public through implementation of a decentralized service delivery function and a management function guided by the national “Policy on Service Delivery” and the policy on “Decentralization and Deconcentration.” • Strengthen sector-wide governance through implementation of a sector-wide approach, focusing on increased national ownership and accountability to improved health outcomes, harmonization and alignment, greater coordination, and effective partnerships among all stakeholders. • Scale up access to and coverage of health services, especially comprehensive reproductive, maternal, newborn, and child health services, both demand and supply side, through Introduction • 3 mechanisms such as institutionalization and expansion of contracting through Special Operating Agencies, exemptions for the poor, health equity funds, and health insurance. • Implement pro-poor health financing systems, including exemptions for the poor and expansion of health equity funds, in combination with other forms of social assistance mechanisms. • Reinforce health legislation, professional ethics, and codes of conduct and strengthen regulatory mechanisms, including for the production and distribution of pharmaceuticals, drug quality control, cosmetics, and food safety and hygiene, to protect providers and consumers’ rights and their health. • Improve quality in service delivery and management through establishment of and compliance with national protocols, clinical practice guidelines, and quality standards, in particular establishment of accreditation systems. • Increase the competency and skills of the health workforce to deal with increased demands for accountability and high-quality care, including through strengthening allied technical skills and advanced technology through increased quality of training, career development, appropriate incentives, and a good working environment. • Strengthen and invest in health information systems and health research for evidence-based policy-making, planning, performance monitoring, and evaluation. • Increase investments in physical infrastructures, medical care equipment, and advanced technology, as well as in improvement of non-medical support services including management, maintenance, blood safety, and supply systems for drugs and commodities. • Promote quality of life and healthy lifestyles by raising health awareness and creating supportive environments, including through strengthening institutional structures, financial and human resources, and IEC (information, education, and communication) materials for health promotion, behavior change communication, and appropriate health-seeking practices. • Prevent and control communicable and selected chronic and noncommunicable diseases and strengthen disease surveillance systems for an effective response to emerging and reemerging diseases. • Strengthen public health interventions to deal with cross-cutting challenges, especially those related to gender, health of minorities, hygiene and sanitation, school health, environmental health risks, substance abuse/mental health, injury, occupational health, and disaster, through timely responses and effective collaboration and coordination with other sectors. • Promote effective public and private partnerships in service provision based on policy, regulation, legislation, and technical standards. • Encourage community engagement in health service delivery activities, management of health facilities, and continuous quality improvement. • Systematically strengthen institutions at all levels of the health system to implement the policy agenda listed under the previous 14 elements. 4 • Introduction 1.3 OBJECTIVE AND SURVEY ORGANIZATION The 2014 Cambodia Demographic and Health Survey (CDHS) is the fourth nationally representative survey conducted in Cambodia on population and health issues. It uses the same methodology as its predecessors, the 2000, 2005, and 2010 Cambodia Demographic and Health Surveys, allowing policymakers to use these surveys to assess trends over time. The primary objective of the CDHS is to provide the Ministry of Health (MOH), 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, 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 the national and local government levels. The long-term objectives of the survey are to build the capacity of the Ministry of Health and the National Institute of Statistics (NIS) of the Ministry of Planning for planning, conducting, and analyzing the results of further surveys. The 2014 CDHS survey was conducted by the Directorate General for Health (DGH) of 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 Ministry of Planning, the National Institute of Statistics, the U.S. Agency for International Development (USAID), the Australian Department of Foreign Affairs and Trade (Australia-DFAT), the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF), the Japan International Cooperation Agency (JICA), and the Korean International Cooperation Agency (KOICA). Funding for the survey came from USAID, Australia-DFAT, UNFPA, UNICEF, JICA, KOICA, and the Health Sector Support Program–Second Phase (HSSP-2). Technical assistance was provided by ICF International. 1.4 SAMPLE DESIGN The 2014 CDHS sample is a nationally representative sample of women and men between age 15 and 49 who completed interviews. To achieve a balance between the ability to provide estimates at the subnational level 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 Meanchey, Kampong Cham, Kampong Chhnang, Kampong Speu, Kampong Thom, Kandal, Kratie, Phnom Penh, Prey Veng, Pursat, Siem Reap, Svay Rieng, Takeo, and Otdar Meanchey • Five groups of provinces: Battambang and Pailin, Kampot and Kep, Preah Sihanouk and Koh Kong, Preah Vihear and Stung Treng, and Mondul Kiri and Ratanak Kiri The sample of households was allocated to the sampling domains in such a way that estimates of indicators could be produced with precision at the national level, as well as separately for urban and rural areas of the country and for each of the 19 sampling domains. The sampling frame used for the 2014 CDHS was derived from the list of all enumeration areas (EAs) created for the 2008 Cambodia General Population Census (GPC), provided by NIS. The list had been updated in 2012, and it excluded 241 EAs that are special settlement areas and not ordinary residential areas. It included 28,455 EAs for the entire country. The GPC also created maps that delimited the boundaries of each EA. Overall, 4,245 EAs were designated as urban and 24,210 as rural, with an average size of 99 households per EA. Introduction • 5 The survey used 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 through a two-stage selection process. Implicit stratifications were achieved at each of the lower geographical or administrative levels by sorting the sampling frame according to geographical/administrative order before sample selection and by using a probability proportional to size selection strategy at the first stage of selection. In the first stage, 611 EAs (188 in urban areas and 423 in rural areas) were selected with probability proportional to size. The size of an EA was defined as the number of households residing in the EA. Some of the largest EAs (more than 200 households) were divided into segments; only one segment was selected randomly to be included in the survey. Thus, the 611 CDHS clusters were either an EA or a segment of an EA. A listing of all households was carried out in each of the 611 clusters during the months of February through April 2014. Listing teams also drew fresh maps delineating EA 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 households were selected in the second stage. In the second stage selection, a fixed number of 24 households were selected from every urban cluster, and a fixed number of 28 households were selected from every rural cluster, through equal probability systematic sampling. Small areas and urban areas were oversampled, and this oversampling was corrected in the analysis using sampling weights to ensure the natural representation of the sample for all 38 strata (19 domains by urban or rural area). Appendix A provides a complete description of the sample design and weighting procedures. All women age 15-49 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 one-third of the households 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). This was a cost-effective strategy given that the minimum sample size required for the women’s survey was larger than that for the men’s survey because complex indicators (such as total fertility and infant and child mortality rates) require larger sample sizes to achieve a reasonable level of precision, and these data are derived from interviews with women. In the subsample of households chosen for the male interviews (one-third of the total sample), all women eligible for interviews and all children under age 5 were eligible for anemia testing. These same women and children were also eligible for height and weight measurements to determine their nutritional status. In a subsample consisting of one in every six of the selected clusters, a survey component focusing on micronutrient indicators was implemented among all eligible women age 15-49 who had children under age born since January 2009, as well as among the children themselves. Since data on micronutrient indicators are reported only at the national level and for urban and rural areas, a subsample of clusters was cost-effective, producing a sample size large enough to provide estimations with adequate precision. 1.5 QUESTIONNAIRES Four questionnaires were used in the 2014 CDHS: the Household Questionnaire, the Woman’s Questionnaire, the Man’s Questionnaire, and the Micronutrient Questionnaire. These questionnaires are based on the questionnaires developed by the worldwide Demographic and Health Surveys (DHS) Program and on the questionnaires used during the 2010 CDHS survey. To reflect relevant population and health issues in Cambodia, the questionnaires were adapted during a series of technical meetings with various stakeholders from government ministries and agencies, nongovernmental organizations, and international donors. The final drafts of the questionnaires were discussed at a stakeholders’ meeting 6 • Introduction organized by the National Institute of Statistics. The adapted questionnaires were translated from English into Khmer and pretested in February and March 2014. The Household Questionnaire was used to list all of the usual members and visitors in the selected households. Basic information was collected on the characteristics of each person listed, including age, sex, education, and relationship to the head of the household. For children under age 18, parents’ survival status was determined. The Household Questionnaire also collected information on the following topics: • Dwelling characteristics • Accidental death and injury • Physical impairment • Utilization of health services and health expenditures for recent illness and injury • Disability • Possession of iodized salt • Height and weight of women and children • Hemoglobin measurements among women and children for diagnosing anemia The Household Questionnaire was used to identify women and men eligible for an individual interview. The Woman’s Questionnaire was used to collect information from all women age 15-49 and was organized into the following sections: • Respondent background characteristics • Reproduction, including a complete birth and death history of respondents’ live births and information on abortion • Contraception • Pregnancy, postnatal care, and women’s nutrition • Immunization, health, children’s nutrition, and early childhood development • Marriage and sexual activity • Fertility preferences • Husbands’ background and women’s work • Domestic violence • HIV/AIDS and other sexually transmitted infections • Maternal mortality The Man’s Questionnaire was administered to all men age 15-49 living in one-third of the households in the CDHS sample. The Man’s Questionnaire was organized into the following sections: • Respondent background characteristics • Reproduction • Marriage and sexual activity • HIV/AIDS • Other health issues The Micronutrient Questionnaire was implemented in a subsample of one-sixth of the sampled clusters for the collection of micronutrient specimens among eligible women and children. Specimens collected included venous blood, urine, and stool samples. The CDHS underwent a full pretest before commencement of the main data collection. All aspects of data collection were pretested in February and March 2014. Forty-four women and men were trained from February 27 to March 17, 2014, in the administration of the CDHS survey instruments, taking of anthropometric measurements, and hemoglobin testing. Five days of fieldwork were followed by three days of interviewer debriefing and correction of questionnaires. Pretest fieldwork was conducted in 79 Introduction • 7 households in two rural and two urban villages. Constructive input from interviewers was used to refine the survey instruments and survey logistics. These pretest activities were used to finalize the questionnaires. The majority of pretest participants also attended the training for the main survey, with many of them serving as field editors and team leaders for the survey. 1.6 TRAINING AND FIELDWORK The goal of training was to create 19 field teams capable of collecting data for the 2014 CDHS. Each team was responsible for data collection in one of the 19 survey domains (comprising the 23 provinces and the capital city of Phnom Penh). Field teams were composed of five people (5 teams) or six people (14 teams): a team leader, a field editor, two or three female interviewers, and one male interviewer. Nineteen fully staffed field teams would require 114 field personnel, and at the end of training 109 field personnel were retained. Twenty-six days of training included four days of field practice in Kandal province. Data processing personnel (3 data processing supervisors, 10 office editors/coders, 19 data entry operators, and 5 reserves) also attended classroom training. Training began with the Household Questionnaire and was followed by the Woman’s Questionnaire. Additional time was spent reviewing the Household Questionnaire, including consent statements for hemoglobin testing, and conversion of ages and dates of birth from the Khmer calendar to the Gregorian calendar. One week was devoted to additional activities, including the Man’s Questionnaire, measurement of women’s and children’s height and weight, sample implementation and household selection, testing of household salt for iodine, and organization of documents and materials for return to the head office. After completion of training, including field practice, fieldwork was 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 so that they could devise a data collection sequence for their sample points. Team leaders were best equipped to perform this task because they hailed from their own provinces. They also conducted the CDHS household listing operation (described in Appendix A) and therefore were well acquainted with the areas in which they would be working. The progression of fieldwork by geographic location had to take into account weather conditions during the rainy season. Fieldwork supervision was carried out regularly by three CDHS survey coordinators from NIS and MOH along with an ICF Macro consultant. Supervision visits were conducted throughout the six months of data collection and included retrieval of questionnaires from the field. In addition, a quality control program was run by the data processing team to detect key data collection errors for each team. These data checks were used to provide regular feedback to each team based on its specific performance. Data collection was conducted from June 2 to December 12, 2014. The training and fieldwork for collection of stool, urine, and venous blood samples were conducted separately by UNICEF in collaboration with the Institut de Recherche pour le Développement (France) and Cambodia’s Ministry of Agriculture, Forestry, and Fisheries. Details are provided in the micronutrient chapter. 1.7 BIOMARKER TESTING 1.7.1 Anthropometric Measurement The 2014 CDHS included an anthropometric component in which children under age 5 in a subsample of two-thirds of the households were measured for height and weight. Weight measurements were taken using a lightweight, electronic SECA scale designed and manufactured under the guidance of UNICEF. The scale allowed for the weighing of very young children through an automatic mother-child adjustment that eliminates the mother’s weight while she is standing on the scale with her baby. Height measurements were carried out using a SECA measuring board, also produced under the guidance of 8 • Introduction UNICEF. Children younger than age 24 months were measured lying down (recumbent length) on the board, whereas standing height was measured for older children. Three nutritional indices were calculated using children’s age, height, and weight: height-for-age (stunting), weight-for-height (wasting), and weight-for-age (underweight). The height and weight of women age 15-49 were also measured among the two-thirds subsample of households selected in the 2014 CDHS. 1.7.2 Hemoglobin Testing Hemoglobin testing is the primary method for anemia diagnosis. The 2014 CDHS included anemia testing of children age 6 to 59 months and women age 15-49 in the two-thirds of CDHS households that were not selected for the men’s interview. A consent statement was read to the eligible respondent or, in the case of children and young unmarried women age 15-17, the parent or responsible adult. This statement explained the purpose of the test, informed the individual that the results would be made available as soon as the test was completed, and requested permission for the test to be carried out. Anemia levels were determined by measuring the level of hemoglobin in the blood; a decreased concentration characterizes anemia. The concentration of hemoglobin in the blood was measured in the field using the HemoCue system. The HemoCue instrument is a special purpose photometer designed specifically for the determination of hemoglobin levels. A capillary blood sample was taken from the palm side of the end of a finger, by puncturing with a sterile, non-reusable, self-retractable lancet. The blood drop was collected in a HemoCue microcuvette, which serves as a measuring tool, and placed in the HemoCue photometer to determine the level of hemoglobin in the blood. A pamphlet was given to each respondent explaining symptoms of anemia, prevention methods, and the individual results of the hemoglobin measurement of the respondent and any children for whom she gave permission to be measured. Each person whose hemoglobin level was lower than the recommended cutoff point (testing severely anemic) was advised to visit a health facility for follow-up with a health professional. 1.7.3 Micronutrient Testing The 2014 CDHS included a micronutrient component that was implemented in one out of six clusters selected for the main survey. In these clusters, blood, urine, and stool samples were collected by separate data collection teams from women who had had children born since January 2009 and from the children themselves. The blood/urine/stool samples were sent to several laboratories inside and outside of Cambodia. 1.8 DATA PROCESSING Completed questionnaires were returned from the field to NIS headquarters, where they were entered and edited by data processing personnel who were specially trained for this task and had also attended questionnaire training of field staff. Data processing personnel included a data processing chief, two assistants, four secondary editors and coordinators, 25 entry operators, and eight office editors. Data processing for the 2014 CDHS began on 25 personal computers on July 6, 2014, five weeks after the first interviews were conducted. Processing the data concurrently with data collection allowed for regular monitoring of team performance and data quality. Field check tables were generated regularly during the data processing to check various data quality parameters. As a result, feedback was given on a regular basis, encouraging teams to continue in areas of high quality and to correct areas of needed improvement. Feedback was individually tailored to each team. Data entry, which included 100 percent double entry to minimize keying errors, and data editing were completed on January 8, 2015. Data cleaning and finalization were completed on January 23, 2015. 1.9 SAMPLE COVERAGE All of the 611 clusters selected for the sample were surveyed in the 2014 CDHS. A total of 16,356 households were selected, of which 15,937 were found to be occupied during data collection. Among these Introduction • 9 households, 15,825 completed the Household Questionnaire, yielding a response rate of 99 percent (Table 1.1). In these interviewed households, 18,012 women were identified as eligible for the individual interview. Interviews were completed with 98 percent of these women. Of the 5,484 eligible men identified in every third household, 95 percent were successfully interviewed. There was little variation in response rates by urban-rural residence. Table 1.1 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Cambodia 2014 Residence Total Result Urban Rural Household interviews Households selected 4,512 11,844 16,356 Households occupied 4,399 11,538 15,937 Households interviewed 4,366 11,459 15,825 Household response rate1 99.2 99.3 99.3 Interviews with women age 15-49 Number of eligible women 5,842 12,170 18,012 Number of eligible women interviewed 5,667 11,911 17,578 Eligible women response rate2 97.0 97.9 97.6 Interviews with men age 15-49 Number of eligible men 1,641 3,843 5,484 Number of eligible men interviewed 1,540 3,650 5,190 Eligible men response rate2 93.8 95.0 94.6 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents Household Population and Housing Characteristics • 11 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2 Key Findings • Forty-three percent of the population in Cambodia is age 19 or younger. • Twenty-seven percent of household heads are women. • Sixty-five percent of households use an improved source of drinking water during the dry season and 84 percent during the rainy season. • Two in three households (67 percent) use an appropriate method of treating their drinking water, primarily boiling it (55 percent). • Forty-six percent of households have an improved, not shared sanitation facility. • Slightly more than half of households (56 percent) have electricity. • Nine in 10 Cambodians own a mobile phone. • Nearly three-quarters of children (73 percent) under age 5 have their birth registered. his chapter summarizes the socioeconomic characteristics of households and respondents surveyed, including age, sex, residence (urban-rural), educational status, household facilities, and household characteristics. The profile of the households provided in this chapter will help in understanding the results of the 2014 CDHS in the following chapters. In addition, it may provide useful information 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, because 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 2014 CDHS 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 used the same definition of households as the 2008 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 the head of the household, and who have common arrangements for cooking and eating meals. 2.1 CHARACTERISTICS OF THE HOUSEHOLD POPULATION 2.1.1 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. T 12 • Household Population and Housing Characteristics 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/or a historical calendar. 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 69,471 individuals, of whom 48 percent were males and 52 percent were females. The age structure of the household population is typical of a society with a young 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 relatively broad-based pyramid structure because 43 percent of the population is less than age 20. 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 2014 Urban Rural Male Female Total Age Male Female Total Male Female Total <5 10.2 8.9 9.5 12.2 10.8 11.5 11.8 10.5 11.2 5-9 10.2 8.7 9.4 13.4 11.6 12.5 12.9 11.2 12.0 10-14 9.5 9.1 9.3 12.3 11.2 11.7 11.9 10.9 11.4 15-19 9.5 8.9 9.2 9.2 7.8 8.4 9.2 7.9 8.6 20-24 10.0 10.9 10.5 8.1 7.9 8.0 8.4 8.4 8.4 25-29 9.6 9.5 9.5 7.5 7.4 7.5 7.9 7.8 7.8 30-34 9.4 9.7 9.6 7.9 8.0 7.9 8.2 8.3 8.2 35-39 4.8 4.7 4.8 5.0 5.0 5.0 4.9 5.0 5.0 40-44 5.7 5.7 5.7 5.2 5.5 5.4 5.3 5.5 5.4 45-49 5.0 5.2 5.1 4.8 5.2 5.0 4.9 5.2 5.0 50-54 5.0 4.9 5.0 4.4 5.2 4.9 4.5 5.2 4.9 55-59 3.8 4.4 4.1 2.9 4.4 3.7 3.0 4.4 3.7 60-64 2.7 3.5 3.1 2.3 3.4 2.9 2.4 3.4 2.9 65-69 1.5 2.5 2.0 1.9 2.5 2.2 1.8 2.5 2.2 70-74 1.4 1.3 1.3 1.3 1.7 1.5 1.3 1.6 1.5 75-79 0.8 1.2 1.0 0.9 1.2 1.0 0.8 1.2 1.0 80+ 0.7 1.0 0.9 0.8 1.1 1.0 0.8 1.1 0.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 5,248 5,932 11,180 27,818 30,473 58,291 33,066 36,405 69,471 Figure 2.1 Population pyramid Above the age of 10 years, the pyramid follows a typical pattern of decreasing numbers as age increases. However, the percentage of people age 35 to 44 is less than would be expected because these are the two age groups born in the decade of the 1970s. The early 1970s saw escalating civil war, and in the 8 6 4 2 0 2 4 6 8 <5 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ Percent Age Male Female CDHS 2014 Household Population and Housing Characteristics • 13 late 1970s the Khmer Rouge ruled. This period of time was characterized by few births and high mortality, including high infant and child mortality. Cambodia has a large dependent population of children and adolescents, although with decreasing fertility the proportion of the population under age 15 has recently declined. The proportion of those age 50 or older has slightly increased. Table 2.2 shows that the proportion of children under age 15 has remained constant over the past four years, with this age group accounting for 35 percent of the population. Sixty percent of the population is in the 15-64 age group, and 6 percent are age 65 or older. 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 2014 Age 1998 census1 2000 CDHS2 2004 CIPS3 2005 CDHS4 2008 census5 2010 CDHS6 2014 CDHS <15 42.8 42.7 38.6 38.9 33.7 34.5 34.5 15-49 46.9 46.3 49.5 47.9 53.4 50.5 48.4 50-64 6.8 7.4 8.0 8.6 8.6 10.0 11.5 65+ 3.5 3.6 3.9 4.6 4.3 5.0 5.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 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) 4 Cambodia Demographic and Health Survey, 2005 (National Institute of Statistics and ORC Macro, 2006) 5 General Population Census of Cambodia, 2008 (National Institute of Statistics, 2009) 6 Cambodia Demographic and Health Survey, 2010 (National Institute of Statistics, Directorate General for Health, and ICF Macro, 2011) 2.1.2 Household Composition Table 2.3 shows the distribution of households in the survey by the sex of the head of the household and the number of household members, according to urban and rural residence. Households in Cambodia are predominantly male- headed. However, 27 percent of households are headed by women (28 percent and 27 percent in urban and rural areas, respectively). The average household size is 4.6 persons, about the same as that observed in the 2010 CDHS (4.7 persons per household). Urban households have 5.0 persons per household on average and are slightly larger than rural households (4.5 persons). Table 2.3 also shows that 17 percent of households include foster and/or orphaned children. Overall, 13 percent of households have foster children, 6 percent have single orphans, and 1 percent have double orphans. The variation between rural and urban areas is small. Table 2.3 Household composition Percent distribution of households by sex of head of household and by household size, mean size of household, and percentage of households with orphans and foster children under age 18, according to residence, Cambodia 2014 Residence Total Characteristic Urban Rural Household headship Male 71.7 73.4 73.1 Female 28.3 26.6 26.9 Total 100.0 100.0 100.0 Number of usual members 1 3.2 3.4 3.4 2 8.2 9.4 9.2 3 13.5 17.0 16.5 4 20.8 24.0 23.5 5 19.6 19.5 19.6 6 13.8 12.8 12.9 7 7.9 7.4 7.5 8 5.5 3.3 3.7 9+ 7.5 3.2 3.8 Total 100.0 100.0 100.0 Mean size of households 5.0 4.5 4.6 Percentage of households with orphans and foster children under age 18 Foster children1 14.6 12.9 13.1 Double orphans 1.3 1.0 1.0 Single orphans2 4.5 5.6 5.5 Foster and/or orphan children 17.3 16.7 16.8 Number of households 2,284 13,541 15,825 Note: Table is based on de jure household members, i.e., usual residents. 1 Foster children are those under age 18 living in households with neither their mother nor their father present. 2 Includes children with one dead parent and an unknown survival status of the other parent 14 • Household Population and Housing Characteristics 2.2 EDUCATION OF THE HOUSEHOLD POPULATION Many behaviors, including those in the realms of reproduction, contraceptive use, child health, and proper hygiene, are affected by the education of household members. Information on the educational level of the female and male population age 6 and above is presented in Tables 2.4.1 and 2.4.2. Survey results show that although the majority of Cambodians have not completed primary school, the country has experienced strong improvement in educational attainment over time. Overall, 19 percent of females have never attended school, as compared with 10 percent of males. Improvements over time have resulted in only 2 percent of girls and 3 percent of boys age 10-14 having never attended school at all. Table 2.4.1 Educational attainment of the female household population Percent distribution of the de facto female household population age 6 and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Cambodia 2014 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Age 6-9 15.5 84.4 0.0 0.0 0.0 0.0 0.0 100.0 3,318 0.3 10-14 1.9 64.8 3.6 29.6 0.0 0.0 0.0 100.0 3,957 4.2 15-19 3.1 20.2 9.2 62.3 2.3 3.0 0.0 100.0 2,891 7.1 20-24 5.7 25.0 11.2 38.8 7.3 12.0 0.0 100.0 3,054 6.5 25-29 11.5 36.1 10.8 29.2 4.6 7.8 0.0 100.0 2,825 5.2 30-34 18.0 46.8 6.5 22.0 3.2 3.5 0.0 100.0 3,005 3.8 35-39 17.8 53.0 6.0 20.0 2.3 1.0 0.0 100.0 1,806 3.2 40-44 16.6 51.7 5.2 22.5 2.3 1.8 0.0 100.0 2,019 3.3 45-49 25.1 55.5 2.9 13.8 1.8 0.9 0.0 100.0 1,883 2.3 50-54 37.1 53.7 3.0 5.3 0.6 0.2 0.0 100.0 1,889 1.2 55-59 33.0 52.4 4.3 9.2 0.6 0.4 0.1 100.0 1,613 1.6 60-64 36.6 47.8 6.5 7.5 1.2 0.4 0.0 100.0 1,248 1.4 65+ 63.8 27.7 3.0 5.0 0.3 0.2 0.0 100.0 2,316 0.0 Residence Urban 10.7 35.5 5.4 31.8 5.8 10.8 0.0 100.0 5,307 5.5 Rural 20.6 50.5 5.7 20.7 1.4 1.1 0.0 100.0 26,521 2.7 Province Banteay Meanchey 19.6 52.8 4.7 19.6 2.2 1.1 0.0 100.0 1,340 2.6 Kampong Cham 19.9 51.9 6.6 19.2 1.3 1.1 0.0 100.0 3,985 2.4 Kampong Chhnang 15.3 50.3 7.0 23.0 2.5 1.9 0.0 100.0 1,218 3.2 Kampong Speu 18.7 46.7 7.1 25.4 1.2 0.9 0.1 100.0 2,027 3.5 Kampong Thom 19.1 54.0 6.0 17.5 1.7 1.6 0.0 100.0 1,589 2.5 Kandal 16.4 48.1 6.2 26.1 1.4 1.9 0.0 100.0 2,454 3.5 Kratie 20.1 55.4 5.0 17.1 1.4 1.0 0.0 100.0 903 2.2 Phnom Penh 9.9 34.6 5.0 31.7 5.5 13.3 0.0 100.0 3,135 5.7 Prey Veng 22.1 49.4 5.3 21.3 1.1 0.7 0.1 100.0 2,172 2.8 Pursat 22.5 51.1 6.5 17.0 2.0 1.0 0.0 100.0 1,239 2.3 Siem Reap 26.3 47.8 4.8 17.0 2.0 2.1 0.0 100.0 2,015 2.2 Svay Rieng 12.4 59.5 4.9 20.9 1.0 1.4 0.0 100.0 1,229 2.8 Takeo 22.7 40.0 5.1 27.5 2.7 2.0 0.0 100.0 2,023 3.6 Otdar Meanchey 28.4 45.5 5.3 18.9 1.5 0.5 0.0 100.0 509 1.9 Battambang/Pailin 16.5 47.0 5.5 25.1 2.9 2.9 0.0 100.0 2,446 3.6 Kampot/Kep 15.9 51.3 4.9 24.3 2.0 1.7 0.0 100.0 1,449 3.3 Preah Sihanouk/Koh Kong 15.8 46.2 6.8 25.2 2.3 3.6 0.0 100.0 696 3.9 Preah Vihear/Stung Treng 26.2 52.1 3.8 15.4 1.1 1.5 0.0 100.0 760 1.8 Mondul Kiri/Ratanak Kiri 33.9 43.6 4.2 16.7 0.8 0.9 0.0 100.0 639 1.2 Wealth quintile Lowest 28.9 56.8 4.3 9.6 0.3 0.1 0.0 100.0 6,013 1.4 Second 23.7 54.1 5.5 16.0 0.5 0.2 0.0 100.0 6,370 2.2 Middle 18.9 50.9 5.6 23.1 1.0 0.4 0.0 100.0 6,313 3.0 Fourth 15.0 44.7 6.8 28.2 2.9 2.5 0.0 100.0 6,507 4.0 Highest 9.2 34.8 6.0 34.5 5.7 9.9 0.0 100.0 6,625 5.7 Total 18.9 48.0 5.6 22.6 2.1 2.7 0.0 100.0 31,828 3.1 Note: Totals include 4 women with information on age missing. 1 Completed grade 6 at the primary level 2 Completed grade 12 at the secondary level Household Population and Housing Characteristics • 15 Table 2.4.2 Educational attainment of the male household population Percent distribution of the de facto male household population age 6 and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Cambodia 2014 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Age 6-9 19.3 80.6 0.0 0.0 0.0 0.0 0.0 100.0 3,486 0.1 10-14 2.5 70.8 2.4 24.2 0.0 0.0 0.0 100.0 3,930 3.8 15-19 4.7 25.2 7.9 57.6 1.8 2.7 0.0 100.0 3,053 6.7 20-24 5.1 25.2 9.7 41.0 8.0 11.0 0.0 100.0 2,770 6.7 25-29 7.3 29.6 8.4 34.5 7.9 12.2 0.1 100.0 2,602 6.3 30-34 9.7 36.2 7.7 30.4 8.1 8.0 0.0 100.0 2,698 5.4 35-39 11.5 41.6 6.7 28.6 6.8 4.8 0.0 100.0 1,634 4.7 40-44 8.6 35.9 6.5 34.8 8.5 5.8 0.0 100.0 1,746 5.7 45-49 10.3 39.3 7.3 33.6 5.6 4.0 0.0 100.0 1,606 5.1 50-54 17.7 49.3 8.4 19.3 2.7 2.6 0.0 100.0 1,496 2.9 55-59 18.8 48.6 10.0 17.4 3.5 1.6 0.0 100.0 992 3.1 60-64 16.2 47.4 11.4 21.0 2.8 1.2 0.0 100.0 791 3.5 65+ 23.4 40.5 11.8 20.4 2.5 1.3 0.1 100.0 1,572 3.6 Residence Urban 4.3 28.7 5.6 35.9 8.9 16.6 0.0 100.0 4,623 7.2 Rural 11.6 49.0 6.8 27.2 3.3 2.0 0.0 100.0 23,756 3.9 Province Banteay Meanchey 10.3 50.0 5.9 28.5 3.6 1.9 0.0 100.0 1,112 3.9 Kampong Cham 11.1 54.2 7.5 23.2 1.7 2.3 0.0 100.0 3,489 3.5 Kampong Chhnang 8.5 50.9 7.5 25.3 4.4 3.4 0.0 100.0 1,006 4.2 Kampong Speu 9.3 43.9 7.0 33.2 4.6 1.8 0.0 100.0 1,851 4.7 Kampong Thom 12.5 51.7 8.4 22.2 1.9 3.2 0.1 100.0 1,365 3.7 Kandal 8.9 45.3 6.7 32.2 4.4 2.6 0.0 100.0 2,287 4.6 Kratie 12.8 55.9 5.0 22.5 2.7 1.1 0.0 100.0 839 3.0 Phnom Penh 4.0 25.5 4.6 36.6 9.0 20.3 0.0 100.0 2,750 7.7 Prey Veng 9.8 45.9 6.8 33.4 2.3 1.6 0.1 100.0 1,922 4.5 Pursat 12.0 52.4 7.7 22.7 4.1 1.1 0.0 100.0 1,100 3.3 Siem Reap 20.1 47.9 5.1 19.3 4.5 3.0 0.1 100.0 1,807 2.7 Svay Rieng 3.8 46.4 6.3 34.5 5.3 3.7 0.0 100.0 1,053 5.0 Takeo 11.6 37.0 6.5 36.0 4.3 4.6 0.0 100.0 1,857 5.1 Otdar Meanchey 13.9 50.8 6.3 24.5 3.5 0.9 0.0 100.0 518 3.1 Battambang/Pailin 6.9 45.5 8.9 30.3 5.0 3.4 0.0 100.0 2,216 4.7 Kampot/Kep 8.3 48.0 6.8 29.9 4.4 2.7 0.0 100.0 1,245 4.3 Preah Sihanouk/Koh Kong 9.0 41.2 7.3 30.9 5.1 6.4 0.0 100.0 655 5.0 Preah Vihear/Stung Treng 19.3 55.5 3.9 16.0 2.5 2.9 0.0 100.0 651 2.3 Mondul Kiri/Ratanak Kiri 23.8 44.2 3.6 22.5 3.4 2.6 0.0 100.0 655 2.4 Wealth quintile Lowest 19.9 58.9 5.9 14.2 1.0 0.2 0.0 100.0 5,424 2.3 Second 12.9 56.3 6.9 21.6 1.5 0.8 0.0 100.0 5,669 3.2 Middle 9.5 47.4 8.0 30.5 2.9 1.7 0.0 100.0 5,614 4.3 Fourth 6.9 41.2 6.7 36.6 5.5 3.0 0.0 100.0 5,876 5.2 Highest 3.6 26.0 5.6 39.2 9.7 15.9 0.0 100.0 5,796 7.5 Total 10.4 45.7 6.6 28.7 4.2 4.4 0.0 100.0 28,379 4.3 1 Completed grade 6 at the primary level 2 Completed grade 12 at the secondary level Forty-eight percent of females and 46 percent of males in the household population have had some primary schooling without having completed primary school. However, 37 percent of the male population has gone on to attend secondary or higher schooling, compared with only 27 percent of females. Sixty-two percent of males and 68 percent of females age 15-19 have gone on to secondary school. Sixty percent of males and 58 percent of females age 20-24 have done so. As would be expected, higher percentages of males and females in urban areas than rural areas have gone on to secondary schooling. There is a great deal of variation in educational attainment across provinces. The outliers are Mondul Kiri/Ratanak Kiri and Phnom Penh, where 24 percent and 4 percent of males, respectively, and 34 percent and 10 percent of females, respectively, have never been to school. 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 includes participation by those who may be older or younger than the official age range for that level. An NAR of 100 percent would indicate that all of 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 participation 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. 16 • Household Population and Housing Characteristics Table 2.5 School attendance ratios Net attendance ratios (NARs) and gross attendance ratios (GARs) for the de facto household population by sex and level of schooling, and the gender parity index (GPI), according to background characteristics, Cambodia 2014 Net attendance ratio1 Gross attendance ratio2 Background characteristic Male Female Total Gender parity index3 Male Female Total Gender parity index3 PRIMARY SCHOOL Residence Urban 85.0 83.0 84.0 0.98 94.9 93.0 94.0 0.98 Rural 80.9 83.4 82.1 1.03 95.8 94.8 95.3 0.99 Province Banteay Meanchey 78.5 82.1 80.5 1.05 92.9 88.2 90.4 0.95 Kampong Cham 80.6 88.3 84.5 1.10 98.2 97.3 97.7 0.99 Kampong Chhnang 85.5 83.8 84.6 0.98 99.2 98.2 98.7 0.99 Kampong Speu 80.8 84.5 82.6 1.05 97.5 98.1 97.8 1.01 Kampong Thom 80.9 82.0 81.5 1.01 95.1 93.9 94.5 0.99 Kandal 77.4 81.0 79.0 1.05 87.8 87.8 87.8 1.00 Kratie 74.8 77.6 76.2 1.04 91.1 90.4 90.7 0.99 Phnom Penh 82.3 82.7 82.5 1.00 92.3 94.0 93.1 1.02 Prey Veng 87.1 79.6 83.7 0.91 98.4 92.7 95.8 0.94 Pursat 81.4 80.5 80.9 0.99 98.8 96.9 97.9 0.98 Siem Reap 78.8 82.7 80.7 1.05 88.2 92.6 90.3 1.05 Svay Rieng 87.0 88.5 87.8 1.02 98.9 96.4 97.6 0.97 Takeo 83.6 86.4 85.0 1.03 100.6 96.2 98.4 0.96 Otdar Meanchey 81.3 78.8 80.2 0.97 101.3 89.4 95.7 0.88 Battambang/Pailin 86.7 84.2 85.5 0.97 100.4 96.4 98.4 0.96 Kampot/Kep 85.0 86.9 85.9 1.02 98.2 97.1 97.6 0.99 Preah Sihanouk/Koh Kong 83.6 82.2 82.9 0.98 99.0 96.1 97.6 0.97 Preah Vihear/Stung Treng 72.6 78.5 75.5 1.08 94.5 96.2 95.3 1.02 Mondul Kiri/Ratanak Kiri 67.1 75.0 71.2 1.12 88.5 94.0 91.4 1.06 Wealth quintile Lowest 75.5 82.0 78.6 1.09 91.4 96.6 93.9 1.06 Second 81.7 82.9 82.3 1.01 96.8 97.2 97.0 1.00 Middle 82.9 83.5 83.3 1.01 97.2 93.0 95.1 0.96 Fourth 84.7 86.6 85.6 1.02 100.6 94.4 97.5 0.94 Highest 85.0 82.1 83.6 0.97 93.6 89.9 91.7 0.96 Total 81.4 83.4 82.4 1.02 95.7 94.5 95.1 0.99 SECONDARY SCHOOL Residence Urban 58.9 54.3 56.5 0.92 75.5 67.7 71.4 0.90 Rural 39.5 42.3 40.9 1.07 48.6 51.5 50.0 1.06 Province Banteay Meanchey 46.6 43.0 44.8 0.92 53.7 52.4 53.1 0.98 Kampong Cham 35.1 46.7 40.9 1.33 43.3 55.6 49.4 1.28 Kampong Chhnang 46.7 49.9 48.4 1.07 52.3 58.1 55.4 1.11 Kampong Speu 41.4 30.6 36.2 0.74 50.0 35.9 43.2 0.72 Kampong Thom 36.8 43.6 40.1 1.18 47.6 54.0 50.8 1.13 Kandal 40.8 37.9 39.3 0.93 53.1 42.5 47.9 0.80 Kratie 29.7 38.0 33.7 1.28 38.0 46.7 42.2 1.23 Phnom Penh 57.9 49.9 53.9 0.86 73.0 61.1 67.1 0.84 Prey Veng 50.8 51.5 51.1 1.01 58.8 65.5 61.9 1.11 Pursat 24.4 33.5 28.9 1.37 36.7 43.4 40.0 1.18 Siem Reap 34.6 34.9 34.8 1.01 44.1 44.3 44.2 1.00 Svay Rieng 58.0 47.3 53.2 0.82 71.5 61.9 67.3 0.87 Takeo 58.1 66.8 62.1 1.15 74.9 82.1 78.2 1.10 Otdar Meanchey 29.8 32.6 31.1 1.09 36.1 41.3 38.5 1.14 Battambang/Pailin 40.5 52.8 46.8 1.30 48.2 65.4 57.0 1.36 Kampot/Kep 47.4 54.8 50.9 1.16 59.0 66.0 62.3 1.12 Preah Sihanouk/Koh Kong 45.4 43.3 44.3 0.95 53.1 56.2 54.7 1.06 Preah Vihear/Stung Treng 21.2 27.1 24.2 1.28 28.7 34.2 31.6 1.19 Mondul Kiri/Ratanak Kiri 23.6 20.2 21.8 0.85 30.2 24.2 27.1 0.80 Wealth quintile Lowest 17.0 25.0 20.8 1.47 23.1 29.6 26.2 1.28 Second 30.7 34.4 32.5 1.12 37.2 41.8 39.4 1.12 Middle 45.9 45.6 45.8 0.99 58.5 56.3 57.4 0.96 Fourth 53.1 55.4 54.2 1.04 64.6 65.3 64.9 1.01 Highest 66.5 58.9 62.5 0.88 81.4 75.1 78.1 0.92 Total 42.4 44.3 43.3 1.05 52.6 54.2 53.4 1.03 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 NAR (GAR) for females to the NAR (GAR) for males. The gender parity index for secondary school is the ratio of the secondary school NAR (GAR) for females to the NAR (GAR) for males. Household Population and Housing Characteristics • 17 Of those children who should be attending primary school, 81 percent of females and 83 percent of males are currently doing so. In 2010, 85 percent of children who should have been attending primary school were doing so. The NAR is significantly lower at the secondary school level and at about the same level found in 2010. Forty-three percent of secondary school-age youths are in school at that level (this figure was 44 percent in 2010). Similar to 2010, there is little difference between the NAR of males and females at both the primary and the secondary level. 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 NAR/GAR for females to the NAR/GAR for males. The GPI for secondary school is the ratio of the secondary school NAR/GAR for females to the NAR/GAR for males. The primary school GPI for NAR of 1.02 indicates gender parity at the primary level, reflecting the fact that about the same proportions of girls and boys attend primary school. The GPI for NAR of 1.05 at the secondary school level indicates near parity at the secondary level. The GPIs for NAR in urban areas and rural areas indicate parity or near parity at the primary level (0.98 and 1.03, respectively). However, the GPI for NAR at the secondary level in urban areas is 0.92, reflecting the fact that a smaller proportion of girls than boys in urban areas attend secondary school. The GPI for NAR varies across provinces, and this variation is far more evident at the secondary school level than at the primary school level (Table 2.5). The GPI for GAR at the primary level (0.99) and at the secondary level (1.03) indicates near parity. The primary school GPI and the secondary school GPI for GAR follow patterns of the GPIs for NAR. Figure 2.2 illustrates age-specific attendance rates, that is, the percentage of a given age cohort attending school regardless of the level attended (primary, secondary, or higher). Although the minimum age for schooling in Cambodia is 6 years, some children enroll prior to this age, and only about three in every five children age 6 are attending school. Figure 2.2 Age-specific attendance rates Similar to 2010, boys and girls attend school in about equal proportions. Up to and including age 13, the proportion of girls attending school is slightly higher than for boys, and then it is slightly lower than for boys at age 14 to 16. From age 17 to 23, young men attend school at a noticeably higher proportion than young women. At age 24, the proportions of men and women attending school are about equal. 2.3 HOUSING CHARACTERISTICS Types of water sources and sanitation facilities are important determinants of the health status of household members and particularly of children. Proper hygienic and sanitation practices can reduce 0 10 20 30 40 50 60 70 80 90 100 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Percent Age Male Female CDHS 2014 Note: Figure shows percentage of the de jure household population age 5-24 years attending school 18 • Household Population and Housing Characteristics 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 round trip to obtain 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. 2.3.1 Water Supply Table 2.6 shows that sources of drinking water were the same during the dry and rainy seasons for 92 percent of urban households and 67 percent of rural households. The source of drinking water is an indicator of whether it is suitable for drinking. Sources that are considered likely to be of suitable quality are listed under “Improved source” and those that may not be of suitable quality are listed under “Non- improved source,” reflecting the categorizations proposed by the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), and the Joint Monitoring Programme (JMP) for Water Supply and Sanitation. During the dry season, 35 percent of households in Cambodia consume drinking water from a non-improved source. This percentage declines to 16 percent of households during the rainy season, when more households utilize rainwater for drinking water. The main source of drinking water during the rainy season is rainwater for nearly two of five households. Rainwater is the most common source of drinking water during the rainy season for rural households. 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. Seventy-five percent of households report that their source of drinking water during the rainy season is located on the household premises. The variation between urban households and rural households is insignificant. During the dry season, the percentage of households with their source of drinking water on the premises declines to 69 percent and 51 percent among urban and rural households, respectively. Among those households neither having a source of drinking water on the premises nor having water delivered, the majority are within 30 minutes or less in round trip time of obtaining it. During the dry season only 6 percent of households are 30 minutes or longer away from a source, and during the rainy season that number drops to just 2 percent requiring 30 minutes or more. Household Population and Housing Characteristics • 19 Table 2.6 Household drinking water Percent distribution of households and de jure population by source of drinking water, time to obtain drinking water, and treatment of drinking water, according to residence, Cambodia 2014 Households Population Characteristic Urban Rural Total Urban Rural Total Source of drinking water during dry season Improved source 95.0 60.1 65.2 95.1 58.8 64.5 Piped water into dwelling/yard/plot 51.7 5.7 12.3 54.0 5.7 13.3 Public tap/standpipe 1.8 0.5 0.7 1.9 0.5 0.8 Tube well or borehole 7.7 31.1 27.8 7.2 30.0 26.4 Protected dug well 1.4 4.0 3.6 1.4 4.2 3.8 Protected spring 0.2 0.3 0.3 0.2 0.3 0.3 Rainwater 5.5 10.1 9.4 4.9 9.6 8.9 Bottled water 26.7 8.4 11.0 25.7 8.4 11.1 Non-improved source 4.9 39.8 34.8 4.7 41.2 35.4 Unprotected dug well 1.6 13.4 11.7 1.5 13.8 11.9 Unprotected spring 0.1 1.3 1.1 0.1 1.3 1.1 Tanker truck/cart with small tank 1.6 3.9 3.6 1.6 3.9 3.6 Surface water 1.6 21.2 18.4 1.4 22.2 18.9 Other 0.1 0.0 0.0 0.2 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Time to obtain drinking water (round trip) Water on premises 69.1 51.3 53.9 70.4 50.9 54.0 Less than 30 minutes 27.6 39.5 37.8 26.1 39.5 37.4 30 minutes or longer 1.3 7.1 6.3 1.6 7.5 6.6 Don’t know/missing 2.0 2.1 2.1 1.9 2.1 2.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Source of drinking water during rainy season Improved source 97.6 81.4 83.7 97.5 80.6 83.3 Piped water into dwelling/yard/plot 49.9 4.7 11.2 51.9 4.6 12.1 Public tap/standpipe 1.6 0.5 0.7 1.7 0.5 0.7 Tube well or borehole 6.7 25.4 22.7 6.2 24.1 21.3 Protected dug well 1.2 2.8 2.5 1.2 2.9 2.6 Protected spring 0.2 0.2 0.2 0.1 0.2 0.2 Rainwater 13.4 40.8 36.9 12.7 41.4 36.9 Bottled water 24.7 7.0 9.6 23.6 6.9 9.5 Non-improved source 2.3 18.5 16.2 2.3 19.3 16.6 Unprotected dug well 1.1 9.3 8.1 1.1 9.5 8.2 Unprotected spring 0.0 0.7 0.6 0.0 0.8 0.7 Tanker truck/cart with small tank 0.6 0.9 0.8 0.7 0.9 0.8 Surface water 0.6 7.7 6.6 0.6 8.1 6.9 Other 0.1 0.0 0.0 0.1 0.0 0.0 Missing 0.0 0.1 0.1 0.0 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Time to obtain drinking water (round trip) during rainy season Water on premises 73.7 74.9 74.8 74.7 75.2 75.1 Less than 30 minutes 24.0 21.9 22.2 22.8 21.4 21.6 30 minutes or longer 0.8 2.1 1.9 0.9 2.3 2.1 Don’t know/missing 1.5 1.1 1.1 1.5 1.1 1.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using same water within dry and rainy season 91.5 67.3 70.8 91.7 66.2 70.2 Water treatment prior to drinking1 Boiled 56.7 54.9 55.1 56.6 54.4 54.7 Bleach/chlorine added 0.1 0.3 0.2 0.0 0.3 0.2 Strained through cloth 0.3 0.7 0.6 0.3 0.7 0.6 Ceramic, sand, or other filter 15.9 16.7 16.6 17.0 16.9 16.9 Solar disinfection 0.3 0.1 0.1 0.3 0.1 0.1 Stand and settle 0.7 5.3 4.7 0.7 5.3 4.6 Other 0.6 0.2 0.3 0.5 0.2 0.3 No treatment 30.4 30.8 30.8 29.9 31.4 31.2 Percentage using an appropriate treatment method2 68.7 67.0 67.3 69.3 66.6 67.0 Number 2,284 13,541 15,825 11,469 61,489 72,958 1 Respondents may report multiple treatment methods, so the sum of treatment may exceed 100 percent. 2 Appropriate water treatment methods include boiling, bleaching, filtering, and solar disinfecting. 20 • Household Population and Housing Characteristics Fifty-five percent of households boil their water prior to drinking. There is little variation between urban and rural areas in the proportion of households that boil their water prior to drinking. Seventeen percent of households use a ceramic, sand, or other type of filter to filter their water prior to drinking. Among those that do not boil their water, the most common action is to do nothing to treat the water prior to drinking. Overall, 31 percent of households report that they do nothing to treat their drinking water before consuming it. Drinking water without prior treatment is equally likely among urban and rural households. However, the likelihood of drinking water without prior treatment is somewhat higher than in 2010. 2.3.2 Sanitation Facilities A household’s toilet facility is classified as hygienic if it is used only by household 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 toilets that flush or pour flush into a piped sewer system, septic tank, or pit latrine; ventilated improved pit (VIP) latrines; pit latrines with a slab; and composting toilets. Households that share their toilet facility or do not effectively separate human waste from human contact are classified as unhygienic. These categories are those proposed by the WHO/UNICEF Joint Monitoring Program. Table 2.7 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Cambodia 2014 Households Population Type of toilet/latrine facility Urban Rural Total Urban Rural Total Improved, not shared facility Flush/pour flush to piped sewer system 37.4 0.7 6.0 38.8 0.7 6.7 Flush/pour flush to septic tank 45.2 37.2 38.4 45.7 38.6 39.7 Flush/pour flush to pit latrine 0.5 1.0 0.9 0.4 0.9 0.9 Ventilated improved pit (VIP) latrine 0.0 0.1 0.0 0.0 0.0 0.0 Pit latrine with slab 0.1 0.5 0.5 0.1 0.6 0.5 Composting toilet 0.0 0.2 0.2 0.0 0.3 0.2 Total 83.2 39.7 46.0 85.0 41.2 48.1 Shared facility1 Flush/pour flush to piped sewer system 2.3 0.2 0.5 1.8 0.2 0.5 Flush/pour flush to septic tank 6.1 8.7 8.3 5.5 8.3 7.9 Flush/pour flush to pit latrine 0.1 0.2 0.2 0.1 0.1 0.1 Ventilated improved pit (VIP) latrine 0.0 0.0 0.0 0.0 0.0 0.0 Pit latrine with slab 0.0 0.1 0.1 0.0 0.1 0.1 Composting toilet 0.0 0.0 0.0 0.0 0.0 0.0 Total 8.6 9.1 9.0 7.5 8.7 8.5 Non-improved facility Flush/pour flush not to sewer/septic tank/pit latrine 1.0 0.2 0.3 1.0 0.2 0.3 Pit latrine without slab/open pit 0.0 0.1 0.1 0.0 0.1 0.1 Bucket 0.0 0.1 0.1 0.0 0.1 0.1 Hanging toilet/hanging latrine 0.3 0.4 0.4 0.3 0.4 0.4 No facility/bush/field 6.9 50.4 44.1 6.2 49.3 42.5 Missing 0.0 0.0 0.0 0.0 0.0 0.0 Total 8.2 51.2 45.0 7.6 50.1 43.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 2,284 13,541 15,825 11,469 61,489 72,958 1 Facilities that would be considered improved if they were not shared by two or more households Households vary greatly in access to hygienic facilities by urban and rural residence, as shown in Table 2.7. The majority of households in rural areas have no toilet facility, with half of households (50 percent) reporting no toilet facility and making use of fields or bush areas. This figure was reported among only 7 percent of urban households. Access to hygienic facilities has improved substantially, as the percentage of households which have no facilities declined from 57 percent in 2010 to 44 percent in 2014. Household Population and Housing Characteristics • 21 2.3.3 Hand Washing Washing hands with water and soap before preparing and eating food and after leaving the toilet is a simple and inexpensive practice that protects against many diseases. During the survey, interviewers asked to see the place members of the household used for hand washing and observed whether water and soap or some other cleansing agent was available. Table 2.8 shows that interviewers observed a place for hand washing in 85 percent of households—a significant increase from 66 percent observed in 2010. Eighty percent of these households had water and soap for hand washing, and 19 percent had water only. In urban areas, nearly all households (97 percent) had a place for hand washing, as compared with 83 percent of households in rural areas. Ninety-four percent of urban households had soap and water available at a hand washing place, compared with only 77 percent of rural households. A higher percentage of households in rural areas than urban areas had water but no soap (22 percent versus 6 percent). Among the provinces, interviewers observed a place for hand washing in only 42 percent of the households in Mondul Kiri/Ratanak Kiri and 55 percent of the households in Takeo. Among households where a place for hand washing was observed, the lowest proportions with soap and water were in Takeo (59 percent) and Kandal (60 percent). The proportion of households with a place for hand washing increases with increasing wealth, from 74 percent among households in the lowest quintile to 96 percent among those in the highest quintile. Thirty percent of households in the lowest wealth quintile have water but no soap, compared with only 6 percent of households in the highest quintile. Table 2.8 Hand washing Percentage of households in which the place most often used for washing hands was observed, and among households in which the place for hand washing was observed, percent distribution by availability of water, soap, and other cleansing agents, Cambodia 2014 Percentage of households where place for washing hands was observed Number of households Among households where place for hand washing was observed, percentage with: Number of households with place for hand washing observed Background characteristic Soap and water1 Water and cleansing agent2 other than soap only Water only Soap but no water3 No water, no soap, no other cleansing agent Missing Total Residence Urban 97.1 2,284 94.1 0.0 5.7 0.0 0.1 0.0 100.0 2,217 Rural 82.6 13,541 77.0 0.1 22.0 0.2 0.8 0.0 100.0 11,189 Province Banteay Meanchey 98.3 670 94.1 0.2 5.7 0.0 0.0 0.0 100.0 658 Kampong Cham 82.0 1,997 89.4 0.1 10.2 0.2 0.0 0.0 100.0 1,638 Kampong Chhnang 83.1 608 87.2 0.0 12.8 0.0 0.0 0.0 100.0 506 Kampong Speu 99.0 973 69.8 0.0 30.2 0.0 0.0 0.0 100.0 963 Kampong Thom 97.5 801 85.3 0.1 11.5 0.5 2.5 0.0 100.0 781 Kandal 89.5 1,259 59.8 0.0 39.3 0.3 0.6 0.0 100.0 1,127 Kratie 87.9 451 70.9 0.8 26.6 0.8 1.0 0.0 100.0 397 Phnom Penh 98.8 1,293 98.5 0.0 1.4 0.0 0.0 0.0 100.0 1,278 Prey Veng 60.1 1,228 93.0 0.2 6.8 0.0 0.0 0.0 100.0 738 Pursat 96.5 611 61.8 0.0 36.8 0.0 1.4 0.0 100.0 589 Siem Reap 63.6 1,000 95.8 0.0 4.2 0.0 0.0 0.0 100.0 636 Svay Rieng 93.2 678 78.2 0.0 21.5 0.1 0.2 0.0 100.0 632 Takeo 54.9 1,011 59.1 0.1 35.3 0.3 5.3 0.0 100.0 555 Otdar Meanchey 89.9 271 89.2 0.0 10.7 0.0 0.2 0.0 100.0 244 Battambang/Pailin 96.7 1,222 60.9 0.0 37.5 0.2 1.4 0.0 100.0 1,181 Kampot/Kep 90.2 762 70.4 0.0 29.0 0.4 0.2 0.0 100.0 687 Preah Sihanouk/Koh Kong 99.8 320 98.1 0.0 1.9 0.0 0.0 0.0 100.0 319 Preah Vihear/Stung Treng 96.1 361 88.7 0.0 11.2 0.1 0.0 0.0 100.0 346 Mondul Kiri/Ratanak Kiri 41.9 309 77.3 0.4 22.2 0.0 0.0 0.1 100.0 130 Wealth quintile Lowest 73.7 3,208 68.1 0.1 30.4 0.3 1.1 0.0 100.0 2,364 Second 79.6 3,320 74.0 0.1 24.8 0.2 0.8 0.0 100.0 2,642 Middle 85.1 3,147 77.9 0.1 21.1 0.1 0.8 0.0 100.0 2,677 Fourth 90.0 3,176 82.3 0.0 16.8 0.2 0.6 0.0 100.0 2,859 Highest 96.3 2,975 94.2 0.0 5.8 0.0 0.1 0.0 100.0 2,865 Total 84.7 15,825 79.8 0.1 19.3 0.2 0.7 0.0 100.0 13,406 1 Soap includes soap or detergent in bar, liquid, powder, or paste form. This column includes households with soap and water only as well as those that had soap and water and another cleansing agent. 2 Cleansing agents other than soap include locally available materials such as ash, mud, or sand. 3 Includes households with soap only as well as those with soap and another cleansing agent 22 • Household Population and Housing Characteristics 2.3.4 Flooring Material and Cooking Arrangements Table 2.9 presents the distribution of households by dwelling characteristics. Nearly all households in urban areas (97 percent) live in dwellings with electricity, whereas in rural areas only about half of households (49 percent) have electricity. Ceramic tiles are the most common type of flooring material in urban areas, and wood planks are the most common material in rural areas. Thirty-six percent of urban households live in dwellings with ceramic tiles, followed by 26 percent who live in dwellings with wood planks. In rural areas, approximately half of households live in dwellings with wood plank flooring, followed by one-quarter who live in dwellings with palm or bamboo flooring1. About two-thirds of rural households (66 percent) sleep together in one room, whereas only 42 percent of urban households do so. In urban areas, 57 percent of households use two or more rooms for sleeping. Firewood is the most common source of fuel for cooking in rural areas, with 85 percent of rural households using firewood for this purpose. There is more variability in urban areas as to what is used for cooking fuel. Twenty-two percent of urban households use firewood, 59 percent use liquid petroleum gas, and 16 percent use charcoal. Sixty-one percent of urban households and 37 percent of rural households report that they do their cooking in the house. Table 2.9 Household characteristics Percent distribution of households by housing characteristics and percentage of households using solid fuel for cooking, according to residence, Cambodia 2014 Households Population Housing characteristic Urban Rural Total Urban Rural Total Electricity Yes 96.9 49.2 56.1 97.3 49.8 57.1 No 3.1 50.8 43.9 2.7 50.2 42.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 Flooring material Earth, sand 3.1 9.2 8.3 2.9 8.7 7.8 Dung 0.1 0.0 0.0 0.1 0.0 0.0 Wood/planks 26.1 51.1 47.5 26.7 52.7 48.7 Palm/bamboo 3.7 23.6 20.7 3.5 22.7 19.8 Parquet or polished wood 0.1 0.1 0.1 0.1 0.1 0.1 Vinyl or asphalt strips 0.0 0.1 0.1 0.0 0.0 0.0 Ceramic tiles 35.6 5.3 9.6 35.3 5.5 10.1 Cement tiles 19.2 2.8 5.2 20.0 2.8 5.5 Cement 12.1 7.7 8.4 11.4 7.2 7.9 Floating house 0.1 0.1 0.1 0.0 0.2 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Rooms used for sleeping One 42.2 65.8 62.4 38.1 63.9 59.9 Two 27.4 23.8 24.3 27.5 24.7 25.2 Three or more 29.8 8.7 11.8 33.8 9.8 13.5 Missing 0.6 1.7 1.5 0.6 1.6 1.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 Cooking fuel Electricity 2.1 0.6 0.8 2.0 0.6 0.8 LPG/natural gas/biogas 58.8 7.7 15.0 59.0 7.2 15.2 Charcoal 16.3 6.5 7.9 16.3 6.5 8.0 Wood 22.1 84.6 75.6 22.3 85.2 75.4 Agricultural crop 0.0 0.3 0.2 0.0 0.3 0.2 Animal dung 0.0 0.1 0.1 0.0 0.1 0.1 No food cooked in household 0.7 0.2 0.3 0.4 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Place for cooking In the house 60.9 37.0 40.4 60.6 36.5 40.3 In a separate building 17.1 25.8 24.6 17.8 26.9 25.5 Outdoors 20.4 34.1 32.1 20.4 33.5 31.5 No food cooked in household 1.4 3.1 2.8 1.1 3.0 2.7 Other 0.1 0.0 0.0 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 2,284 13,541 15,825 13,753 75,030 88,783 LPG = Liquid petroleum gas 1 If there was more than one type of flooring, interviewers recorded the predominant flooring material. Household Population and Housing Characteristics • 23 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 a household’s 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. Sixty-six percent of households in Cambodia own a television, and 87 percent own a mobile telephone. Ownership of mobile telephones is almost universal among urban households (96 percent) and is very common among rural households (86 percent). About two of five households (39 percent) own a generator/battery or a solar panel. Twenty-six percent of urban households own a car, truck, or van, an increase from 22 percent in 2010. About two-thirds of all households (68 percent) own a motorcycle, an increase from 54 percent of households in 2010. The percentage of households owning a boat remains unchanged at about 8 percent. Sixty-nine percent of all households own some land, which is about the same as the 2010 figure of 68 percent. Sixty-six percent of households own at least one farm animal, also about the same as the figure reported in 2010 (67 percent). Table 2.10 Household possessions Percentage of households possessing various household effects, means of transportation, agricultural land, and livestock/farm animals by residence, Cambodia 2014 Households Population Possession Urban Rural Total Urban Rural Total Household effects Radio 50.4 38.2 40.0 52.9 38.4 40.7 Television 91.4 61.4 65.7 93.6 63.9 68.6 Mobile telephone 96.1 85.7 87.2 97.1 88.4 89.8 Non-mobile telephone 12.2 5.5 6.5 13.2 5.8 7.0 Refrigerator 40.4 2.5 8.0 43.5 2.7 9.1 Wardrobe 72.7 38.5 43.4 75.1 39.7 45.3 Sewing machine 17.6 6.7 8.3 19.2 7.1 9.0 CD/DVD player 47.7 27.3 30.2 51.4 30.0 33.4 Generator/battery/solar 7.9 43.9 38.7 9.2 44.9 39.3 Watch 43.7 14.9 19.0 47.7 16.2 21.1 Means of transport Bicycle/cyclo 54.9 65.7 64.2 59.8 68.9 67.5 Animal-drawn cart 1.0 14.2 12.3 1.1 15.4 13.2 Motorcycle/scooter 83.2 65.5 68.0 86.6 69.9 72.5 Car/truck 26.0 12.1 14.1 29.1 13.4 15.8 Boat with a motor 1.3 4.5 4.1 1.7 5.3 4.8 Motorcycle cart 6.7 3.3 3.8 8.5 3.7 4.5 Boat without a motor 1.1 4.7 4.1 1.3 5.3 4.6 Ownership of agricultural land 28.7 75.9 69.1 29.5 77.1 69.6 Ownership of farm animals1 21.9 73.0 65.6 22.9 76.2 67.8 Number 2,284 13,541 15,825 11,469 61,489 72,958 1 Water buffaloes, cows, bulls, horses, donkeys, mules, goats, sheep, pigs, chickens, ducks, or elephants 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 2014 CDHS did not collect data on consumption or income, but the information collected on dwelling and household characteristics, consumer goods, and assets is used as a measure of socioeconomic status. The resulting wealth index is an indicator of relative level of wealth that is used as a proxy for expenditure and income measures. 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. 24 • Household Population and Housing Characteristics 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 owns 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 grouped into each wealth quintile. A single asset index is developed on the basis of data from the entire country sample and used in all of 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, quintile rates for infant mortality refer to 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 poverty rates and gross domestic product per capita in India and against expenditure data from household surveys in Nepal, Pakistan, and Indonesia (Filmer and Pritchett, 1998) as well as Guatemala (Rutstein, 1999). The evidence from those studies suggests that the asset index is highly comparable to conventionally measured consumption expenditures. Table 2.11 shows the distribution of the 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, 84 percent of Phnom Penh’s population falls in the highest wealth quintile. By contrast, Pursat has the lowest representation in the highest wealth quintile, with only 5 percent of its population falling in that quintile. Table 2.11 Wealth quintiles Percent distribution of the de jure population by wealth quintiles, according to residence and province, Cambodia 2014 Wealth quintile Total Number of persons Residence/region Lowest Second Middle Fourth Highest Residence Urban 1.3 1.8 4.1 14.9 78.0 100.0 11,469 Rural 23.5 23.4 23.0 20.9 9.2 100.0 61,489 Province Banteay Meanchey 6.0 12.1 22.6 36.4 22.9 100.0 3,134 Kampong Cham 25.2 21.0 25.3 17.5 11.0 100.0 9,454 Kampong Chhnang 35.5 25.6 17.9 11.2 9.9 100.0 2,574 Kampong Speu 20.4 21.3 25.6 24.4 8.2 100.0 4,665 Kampong Thom 35.9 27.5 15.3 12.7 8.8 100.0 3,632 Kandal 5.3 13.3 27.4 33.7 20.2 100.0 5,674 Kratie 43.0 21.5 14.7 15.0 5.8 100.0 2,160 Phnom Penh 0.3 1.3 3.0 11.0 84.4 100.0 6,814 Prey Veng 22.6 27.6 26.9 15.6 7.3 100.0 4,942 Pursat 34.2 29.6 16.0 15.5 4.7 100.0 2,839 Siem Reap 30.9 25.3 15.8 11.6 16.4 100.0 4,811 Svay Rieng 23.4 30.0 24.7 14.9 6.9 100.0 2,736 Takeo 8.5 21.4 27.2 34.3 8.6 100.0 4,475 Otdar Meanchey 23.5 27.3 19.8 17.2 12.2 100.0 1,203 Battambang/Pailin 9.1 13.6 20.8 29.4 27.1 100.0 5,623 Kampot/Kep 23.2 28.5 23.6 17.2 7.5 100.0 3,220 Preah Sihanouk/Koh Kong 8.0 9.3 11.0 28.3 43.5 100.0 1,622 Preah Vihear/Stung Treng 47.1 27.3 12.9 7.0 5.7 100.0 1,813 Mondul Kiri/Ratanak Kiri 30.8 26.1 11.4 13.5 18.1 100.0 1,567 Total 20.0 20.0 20.0 20.0 20.0 100.0 72,958 2.6 BIRTH REGISTRATION The registration of births is the inscription of the facts of a 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 Household Population and Housing Characteristics • 25 collected in the household interview by asking whether children under age 5 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. Nearly two-thirds of children (64 percent) had a birth certificate, and the births of 73 percent of children under age 5 were registered. These figures are significantly higher than those found in the 2010 CDHS (51 percent and 62 percent, respectively). However, levels of registration varied greatly across the country, as shown in Table 2.12. Table 2.12 Birth registration of children under age 5 Percentage of de jure children under age 5 whose births are registered with the civil authorities, according to background characteristics, Cambodia 2014 Children whose births are registered Number of children Background characteristic Percentage who had a birth certificate Percentage who did not have a birth certificate Percentage registered Age <2 59.4 7.8 67.2 3,125 2-4 66.8 10.5 77.4 4,680 Sex Male 64.8 8.9 73.7 3,940 Female 62.9 10.0 72.9 3,865 Residence Urban 75.5 8.8 84.4 1,066 Rural 62.0 9.5 71.6 6,739 Province Banteay Meanchey 61.7 10.5 72.2 372 Kampong Cham 54.1 15.8 69.9 1,086 Kampong Chhnang 71.5 4.0 75.5 263 Kampong Speu 74.0 4.2 78.1 478 Kampong Thom 59.7 4.0 63.7 364 Kandal 80.1 4.0 84.1 530 Kratie 40.5 4.8 45.3 271 Phnom Penh 84.9 4.5 89.4 607 Prey Veng 73.7 5.5 79.2 592 Pursat 52.0 10.7 62.7 313 Siem Reap 70.5 2.0 72.6 536 Svay Rieng 84.7 2.8 87.5 297 Takeo 60.4 15.3 75.7 408 Otdar Meanchey 73.5 7.9 81.4 140 Battambang/Pailin 32.6 37.8 70.5 613 Kampot/Kep 75.8 1.1 76.9 321 Preah Sihanouk/Koh Kong 72.8 0.8 73.6 170 Preah Vihear/Stung Treng 62.8 3.7 66.5 234 Mondul Kiri/Ratanak Kiri 32.8 7.0 39.7 211 Wealth quintile Lowest 52.5 6.7 59.1 1,878 Second 60.7 8.8 69.6 1,586 Middle 65.6 9.9 75.4 1,554 Fourth 69.1 11.7 80.8 1,347 Highest 75.5 11.1 86.6 1,439 Total 63.9 9.4 73.3 7,805 2.7 CHILDREN’S LIVING ARRANGEMENTS, ORPHANHOOD, AND SCHOOL ATTENDANCE BY SURVIVORSHIP OF PARENTS 2.7.1 Children’s Living Arrangements and Orphanhood Because the family is the primary safety net for children, any strategy aimed at protecting children must place a high priority on strengthening the family’s capacities to care for children. It is therefore essential to identify orphaned children and find out whether those who have one or both parents alive are living with either or both surviving parents. Table 2.13 presents these two types of information for children under age 18, according to background characteristics. 26 • Household Population and Housing Characteristics Table 2.13 Children’s living arrangements and orphanhood Percent distribution of de jure children under age 18 by living arrangements and survival status of parents, the percentage of children not living with a biological parent, and the percentage of children with one or both parents dead, according to background characteristics, Cambodia 2014 Living with both parents Living with mother but not with father Living with father but not with mother Not living with either parent Total Percentage not living with a biological parent Percentage with one or both parents dead1 Number of children Background characteristic Father alive Father dead Mother alive Mother dead Both alive Only father alive Only mother alive Both dead Missing infor- mation on father/ mother Age 0-4 82.8 6.4 0.9 0.6 0.1 8.5 0.1 0.3 0.3 0.0 100.0 9.2 1.7 7,805 <2 85.9 7.2 0.7 0.3 0.0 5.3 0.2 0.2 0.2 0.0 100.0 5.8 1.2 3,125 2-4 80.7 5.9 1.1 0.8 0.1 10.7 0.1 0.4 0.3 0.0 100.0 11.4 2.0 4,680 5-9 78.3 5.3 2.2 1.1 0.6 10.6 0.4 0.7 0.8 0.0 100.0 12.5 4.6 8,377 10-14 76.1 5.5 4.6 1.2 0.9 9.2 0.6 0.9 0.8 0.1 100.0 11.5 7.8 8,069 15-17 72.3 5.8 7.2 1.3 1.9 8.0 0.8 1.1 1.5 0.1 100.0 11.4 12.5 3,963 Sex Male 77.9 5.9 3.4 1.0 0.7 9.3 0.5 0.6 0.7 0.1 100.0 11.0 5.8 14,346 Female 78.2 5.5 3.1 1.1 0.8 9.3 0.4 0.8 0.8 0.0 100.0 11.3 5.9 13,868 Residence Urban 75.1 7.2 2.6 1.5 0.7 10.2 0.7 0.8 0.9 0.2 100.0 12.7 5.6 3,745 Rural 78.5 5.5 3.4 1.0 0.7 9.1 0.4 0.7 0.7 0.0 100.0 10.9 5.9 24,470 Province Banteay Meanchey 67.6 4.5 2.9 0.8 0.4 23.2 0.3 0.1 0.2 0.0 100.0 23.8 3.8 1,251 Kampong Cham 77.7 5.8 3.4 0.9 0.9 9.0 0.2 0.8 1.2 0.1 100.0 11.2 6.6 3,723 Kampong Chhnang 74.4 7.9 5.7 1.2 0.7 9.0 0.3 0.4 0.4 0.0 100.0 10.1 7.4 1,014 Kampong Speu 85.6 5.1 2.1 0.4 0.8 5.5 0.1 0.2 0.2 0.0 100.0 6.0 3.4 1,832 Kampong Thom 78.9 6.4 3.3 0.8 0.9 8.1 0.4 0.3 0.8 0.0 100.0 9.7 5.7 1,514 Kandal 81.3 6.4 3.9 0.3 0.5 6.3 0.2 0.5 0.7 0.0 100.0 7.6 5.7 2,047 Kratie 84.5 3.7 2.2 0.6 0.4 6.0 1.7 0.5 0.4 0.0 100.0 8.6 5.1 885 Phnom Penh 77.3 7.0 2.2 1.3 0.8 8.4 0.9 0.9 0.9 0.3 100.0 11.1 5.6 2,079 Prey Veng 66.9 10.0 3.3 1.4 0.8 16.1 0.3 0.6 0.5 0.0 100.0 17.5 5.5 1,913 Pursat 81.9 3.6 4.0 1.7 0.2 7.1 0.3 0.6 0.6 0.1 100.0 8.6 5.7 1,156 Siem Reap 80.0 5.1 4.3 0.6 1.0 6.6 0.5 0.8 0.9 0.1 100.0 8.8 7.5 2,037 Svay Rieng 78.7 4.6 2.5 1.3 0.4 10.5 0.2 0.7 1.0 0.0 100.0 12.5 4.9 976 Takeo 73.6 6.5 4.2 1.7 0.7 9.5 0.1 2.3 1.3 0.0 100.0 13.2 8.6 1,678 Otdar Meanchey 83.8 2.3 2.5 1.5 0.4 7.1 0.5 0.4 1.5 0.1 100.0 9.4 5.3 515 Battambang/Pailin 74.9 5.1 1.5 2.0 0.9 13.2 0.7 0.9 0.7 0.2 100.0 15.5 4.7 2,243 Kampot/Kep 79.9 3.6 3.2 0.8 0.8 9.9 0.8 0.7 0.4 0.0 100.0 11.7 5.9 1,246 Preah Sihanouk/ Koh Kong 81.5 5.8 1.9 1.9 0.8 7.1 0.1 0.6 0.3 0.0 100.0 8.1 3.7 612 Preah Vihear/Stung Treng 85.6 3.9 6.1 0.5 0.6 2.3 0.3 0.1 0.5 0.0 100.0 3.2 7.6 808 Mondul Kiri/Ratanak Kiri 86.2 4.5 3.4 0.5 0.6 2.8 0.6 0.3 1.1 0.0 100.0 4.8 5.9 685 Wealth quintile Lowest 79.5 5.5 4.5 1.0 0.9 7.0 0.3 0.6 0.8 0.0 100.0 8.7 7.0 6,616 Second 77.7 5.7 3.7 1.1 1.0 8.9 0.5 0.5 0.8 0.0 100.0 10.8 6.5 6,023 Middle 77.4 6.1 2.6 1.2 0.5 10.2 0.4 0.8 0.6 0.1 100.0 12.0 5.0 5,574 Fourth 77.2 5.5 3.0 0.7 0.5 11.1 0.5 0.8 0.7 0.0 100.0 13.1 5.5 5,213 Highest 78.3 5.9 2.0 1.1 0.7 9.7 0.4 0.8 0.8 0.2 100.0 11.8 4.7 4,788 Total <15 79.0 5.7 2.6 1.0 0.5 9.5 0.4 0.6 0.6 0.1 100.0 11.1 4.7 24,252 Total <18 78.1 5.7 3.3 1.0 0.7 9.3 0.4 0.7 0.7 0.1 100.0 11.1 5.8 28,215 Note: Table is based on de jure members, i.e., usual residents. 1 Includes children with father dead, mother dead, both dead, and one parent dead but missing information on survival status of the other parent The data show that 78 percent of Cambodian children under age 18 live with both of their parents. This proportion declines steadily with age, from a high of 86 percent among children under age 2 to a low of 72 percent among children age 15 to 17. There is little variation according to the child’s sex. The proportion of children living with both of their parents is slightly higher in rural areas (79 percent) than in urban areas (75 percent). The lowest proportions of children living with both parents are in Prey Veng (67 percent) and Banteay Meanchey (68 percent). Nine percent of children under age 18 live with their mother only, whether their father is alive (6 percent) or deceased (3 percent), and 2 percent live with their father only. Eleven percent do not live with either parent. Overall, 6 percent of children under age 18 have lost one or both parents: less than 1 percent have lost both parents, 5 percent have lost their father, and 2 percent have lost their mother. Because a parent’s Household Population and Housing Characteristics • 27 risk of dying increases with time, the proportion of children who have lost their father and/or mother increases significantly with age, from 1 percent among children less than age 2 and 2 percent among children age 2 to 4 to 5 percent among children age 5 to 9. It increases further to 8 percent among children age 10 to 14 and 13 percent among children age 15 to 17. 2.7.2 School Attendance by Survivorship of Parents Access to education is considered an “essential service” and is included among the key components of national responses to guarantee orphans access to services on an equal basis with other children. To assess whether orphans are educationally disadvantaged in relation to other children, an indicator was devised to compare school attendance among orphans and non-orphans. The results are presented in Table 2.14 for children age 10 to 14, the age group in which school attendance is generally assumed for all children. The data show a clear relationship between parent survivorship and school attendance of children age 10 to 14. According to the 2014 CDHS, 89 percent of children whose parents are both alive and who are living with one or both of their parents attend school, as compared with only 78 percent of children who have lost both parents. The ratio of school attendance for orphaned and non-orphaned children is less than 1 (0.88), indicating an educational disadvantage for orphans. Table 2.14 School attendance by survivorship of parents For de jure children 10-14 years of age, the percentage attending school by parental survival and the ratio of the percentage attending, by parental survival, according to background characteristics, Cambodia 2014 Percentage attending school by survivorship of parents Background characteristic Both parents deceased Number Both parents alive and living with at least one parent Number Ratio1 Sex Male (65.0) 24 88.4 3,360 0.74 Female (86.0) 39 89.1 3,323 0.97 Residence Urban (89.9) 8 93.4 842 0.96 Rural (76.2) 55 88.1 5,841 0.86 Province Banteay Meanchey * 0 85.4 248 1.17 Kampong Cham * 2 91.0 882 1.10 Kampong Chhnang * 3 93.5 240 1.07 Kampong Speu * 3 86.7 504 1.15 Kampong Thom * 5 84.7 375 0.72 Kandal * 6 83.4 475 0.35 Kratie * 2 89.6 202 1.12 Phnom Penh * 2 94.2 452 1.06 Prey Veng * 5 93.1 414 0.37 Pursat * 2 86.2 298 1.10 Siem Reap * 6 81.5 479 1.23 Svay Rieng * 1 93.2 246 1.07 Takeo * 6 95.2 386 0.82 Otdar Meanchey * 4 86.1 125 0.85 Battambang/Pailin * 8 90.0 489 1.11 Kampot/Kep * 3 90.8 326 0.73 Preah Sihanouk/Koh Kong * 1 92.0 157 0.88 Preah Vihear/Stung Treng * 1 84.3 196 1.19 Mondul Kiri/Ratanak Kiri * 2 80.5 189 1.02 Wealth quintile Lowest * 18 81.0 1,626 0.81 Second * 14 86.7 1,446 0.79 Middle * 10 89.9 1,339 0.83 Fourth * 11 93.9 1,249 1.04 Highest * 10 96.1 1,023 0.99 Total 78.0 63 88.7 6,683 0.88 Note: Table is based only on children who usually live in the household. 1 Ratio of the percentage with both parents deceased to the percentage with both parents alive and living with a parent Utilization of Health Services for Accident, Illness, or Injury • 29 UTILIZATION OF HEALTH SERVICES FOR ACCIDENT, ILLNESS, OR INJURY 3 Key Findings • Two percent of household members were injured or killed in an accident in the years before the survey. • Seven in 10 injuries or deaths are attributed to road accidents. • Thirteen percent of household members had an illness or injury in the month before the survey. Among them 95 percent sought a first treatment, 22 percent a second treatment, and 7 percent a third treatment. n 1998, 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 aim of the new health care plan was to create a network of health centers throughout the country delivering the “Minimum Package of Activities” services. The data collected in the 1998 National Health Survey provided a baseline of health conditions in the country before implementation of the new health coverage plan. The CDHS surveys implemented in 2000, 2005, and 2010 assessed progress every five years under the coverage plan, and the 2014 CDHS provides updated progress on those health conditions. 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 whether 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 among all members of the household who had been ill or injured in the 30 days preceding the interview. 3.1 ACCIDENTAL DEATH OR INJURY All households reported on whether any household member had suffered accidental injury or death in the 12 months preceding 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, if a death was noted, the cause of death. 3.1.1 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, 17 suffered an injury and 1 suffered an accidental death. The percentage of the population injured in the past 12 months increased with age from 0.7 percent among children age 0-9 to a peak of 2.6 percent among adults age 20-39. The percentage experiencing accidental injury decreased thereafter, to 1.7 percent among adults age 40-59 and 1.5 percent among those age 60 and above. Males were more than twice as likely as females to be injured in an accident. Overall, 2.4 percent of males had been injured in an accident in the past 12 months, as compared with 1.1 percent of females. I 30 • Utilization of Health Services for Accident, Illness, or Injury Although there were no differences in accidental injuries by urban-rural residence, there were differences across provinces. The highest percentage of accidental injury was reported in Kratie, with 3.3 percent of the household population experiencing an injury in the preceding 12 months. The lowest rates of accidental injury were in Preah Vihear/Stung Treng (0.2 percent) and Otdar Meanchey (0.8 percent). The percentage of accidental death ranged from 0.0 to 0.2 percent across provinces. Table 3.1 Injury or death in an accident Percentage of the de jure household population injured or killed in an accident in the past 12 months, according to background characteristics, Cambodia 2014 Background characteristic Result of accident Total injured or killed Total number of de jure household members Injured Killed Age 0-9 0.7 0.2 0.9 16,182 10-19 1.6 0.1 1.6 14,576 20-39 2.6 0.0 2.6 22,161 40-59 1.7 0.0 1.7 13,959 60+ 1.5 0.0 1.6 6,079 Sex Male 2.4 0.0 2.5 35,336 Female 1.1 0.1 1.1 37,622 Residence Urban 1.7 0.0 1.7 11,469 Rural 1.7 0.1 1.8 61,489 Province Banteay Meanchey 1.4 0.1 1.5 3,134 Kampong Cham 2.1 0.0 2.1 9,454 Kampong Chhnang 2.9 0.1 3.0 2,574 Kampong Speu 1.4 0.1 1.5 4,665 Kampong Thom 1.4 0.0 1.4 3,632 Kandal 2.1 0.0 2.1 5,674 Kratie 3.3 0.0 3.3 2,160 Phnom Penh 1.7 0.0 1.7 6,814 Prey Veng 1.1 0.1 1.2 4,942 Pursat 1.1 0.1 1.2 2,839 Siem Reap 1.6 0.0 1.7 4,811 Svay Rieng 1.4 0.1 1.5 2,736 Takeo 1.6 0.1 1.7 4,475 Otdar Meanchey 0.8 0.0 0.8 1,203 Battambang/Pailin 2.1 0.1 2.2 5,623 Kampot/Kep 1.7 0.1 1.8 3,220 Preah Sihanouk/Koh Kong 2.3 0.0 2.3 1,622 Preah Vihear/Stung Treng 0.2 0.0 0.3 1,813 Mondul Kiri/Ratanak Kiri 1.6 0.2 1.8 1,567 Total 1.7 0.1 1.8 72,958 3.1.2 Type of Accident Table 3.2 presents data on accidental injury by type of accident, according to the background characteristics of age, sex, residence, and province. Data on accidental deaths are also included, but these data are not available by age and sex. Road accidents accounted for the greatest proportion of accidental injuries and deaths. More than 7 of 10 people who had been injured or killed in the previous 12 months were injured as a result of a road accident. Nine percent of injuries/deaths were the result of a fall, and 5 percent were the result of a snake or animal bite. Two percent of injuries/deaths resulted from violence. One percent of injuries/deaths were the result of burning, while less than 1 percent each were the result of a gunshot, drowning, and poisoning. Nine percent of injuries/deaths were due to other or unknown causes. Utilization of Health Services for Accident, Illness, or Injury • 31 Table 3.2 Injury or death in an accident by type of accident Percentage of the de jure household population injured or killed in an accident in the past 12 months by type of accident, according to age and sex, Cambodia 2014 Type of accident Don’t know/ missing Total Number of persons injured Background characteristic Gunshot Road accident Severe burning Snake/ animal bite Fall from tree/ building Drowning1 Poisoning (chemical) Violence Other INJURED Age 0-9 0.0 48.7 2.0 13.5 22.5 0.0 0.0 1.5 6.6 5.1 100.0 121 10-19 0.0 67.8 2.0 5.1 9.2 0.0 0.0 3.7 12.1 0.0 100.0 230 20-39 0.7 79.4 1.1 3.3 6.1 0.0 0.4 2.7 6.3 0.0 100.0 581 40-59 0.1 73.1 0.9 4.5 11.1 0.0 0.6 1.6 8.2 0.0 100.0 243 60+ 0.0 60.3 0.0 6.4 13.1 0.0 0.0 1.1 17.6 1.4 100.0 92 Sex Male 0.5 74.1 0.2 4.9 8.6 0.0 0.3 3.0 8.2 0.3 100.0 864 Female 0.0 66.8 3.5 5.6 12.0 0.0 0.3 1.3 9.3 1.3 100.0 402 Total 0.3 71.8 1.2 5.1 9.7 0.0 0.3 2.4 8.6 0.6 100.0 1,267 INJURED OR KILLED Residence Urban 1.5 81.8 0.6 2.0 5.5 0.0 0.1 3.1 4.8 0.5 100.0 197 Rural 0.3 69.6 1.3 5.5 10.1 0.9 0.3 2.3 9.2 0.6 100.0 1,109 Province Banteay Meanchey 0.0 62.5 9.5 4.0 14.4 0.0 0.0 0.0 9.6 0.0 100.0 47 Kampong Cham 0.0 67.3 1.8 6.6 14.4 0.0 0.0 0.0 8.0 1.9 100.0 199 Kampong Chhnang 0.0 64.8 0.0 2.7 15.4 1.1 0.0 3.4 12.6 0.0 100.0 78 Kampong Speu 0.0 90.4 0.0 0.0 4.2 0.0 0.0 0.0 5.4 0.0 100.0 69 Kampong Thom 0.4 63.7 2.9 7.0 14.6 2.3 0.0 2.4 4.5 2.2 100.0 53 Kandal 0.0 71.1 1.5 2.2 6.2 0.0 0.0 5.2 13.8 0.0 100.0 120 Kratie 0.0 56.4 0.8 10.7 15.5 0.0 4.4 0.9 11.4 0.0 100.0 72 Phnom Penh 2.3 84.5 0.8 3.5 2.8 0.0 0.0 2.0 4.1 0.0 100.0 115 Prey Veng (5.2) (71.9) (0.0) (3.0) (8.2) (5.5) (0.0) (2.6) (3.5) (0.0) (100.0) 60 Pursat (0.0) (59.9) (0.0) (6.8) (19.1) (8.6) (0.0) (0.5) (5.0) (0.0) (100.0) 34 Siem Reap 0.0 81.1 0.0 0.0 8.2 0.0 0.0 5.9 4.9 0.0 100.0 81 Svay Rieng 0.0 75.8 3.8 0.0 12.7 0.0 0.0 0.0 7.8 0.0 100.0 41 Takeo 0.0 68.9 1.7 5.4 6.7 2.0 0.0 1.8 11.9 1.7 100.0 76 Otdar Meanchey (0.0) (89.0) (0.0) (0.0) (6.6) (0.0) (0.0) (4.4) (0.0) (0.0) (100.0) 10 Battambang/Pailin 0.0 80.4 0.0 2.9 5.5 0.0 0.0 4.1 7.0 0.0 100.0 123 Kampot/Kep 0.0 56.0 0.0 17.2 6.5 0.0 0.5 3.9 13.9 2.1 100.0 57 Preah Sihanouk/Koh Kong 0.0 67.1 0.0 4.0 8.2 0.0 0.0 6.5 14.1 0.0 100.0 38 Preah Vihear/Stung Treng * * * * * * * * * * * 5 Mondul Kiri/Ratanak Kiri 0.0 63.8 0.0 20.5 2.2 2.1 0.0 0.8 10.5 0.0 100.0 28 Total 0.5 71.4 1.2 4.9 9.4 0.8 0.3 2.4 8.5 0.6 100.0 1,306 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1All drowning cases reported were deceased Cause of injury varied by age, but road accidents were the most commonly cited source of injury for people of all ages, especially those age 20-39. After road accidents, animal/snake bites and falls from trees/buildings were the most common causes of injuries among children age 0-9, accounting for 14 percent and 23 percent of injuries, respectively. Gunshots accounted for a higher percentage of injuries among people age 20-39 than for any other age group. Severe burning accounted for a higher percentage among children and young adults less than age 20 than among other age groups. Violence as a cause of injury was most common among people age 10-39. There were significant differences in accidental injuries in the preceding 12 months by sex. While males were more likely than females to be injured in road accidents (74 percent versus 67 percent), females were more likely to be injured from severe burning and falls than males. There were other significant differences in accidental injuries/deaths in the preceding 12 months by urban-rural residence and province. Not surprisingly, road accidents accounted for a higher percentage of injuries/deaths in urban areas (82 percent) than in rural areas (70 percent). Falls accounted for a higher proportion of accidental injuries or deaths in rural areas than in urban areas (10 percent versus 6 percent). The distribution of causes of injuries/deaths by province should be analyzed with caution because sample sizes were small in some provinces. 32 • Utilization of Health Services for Accident, Illness, or Injury 3.2 PREVALENCE AND SEVERITY OF ILLNESS OR INJURY All households were asked whether any members had been sick or injured at any time in the 30 days before the interview. If any members had been 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 serious. Finally, questions were asked as to whether ill or injured household members sought care, where they sought care, how much they spent on transport, and how much they spent on treatment. These questions were repeated to collect information on patterns of health care-seeking behavior. For example, a man might first seek treatment from a Kru Khmer traditional healer but later visit a health clinic if the illness continued. Up to three care-seeking attempts were recorded on the questionnaire for each ill or injured person. Thirteen percent of household members had been ill in the 30 days prior to the interview (Table 3.3). However, this percentage may underrepresent 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 excluded any cases that ended in the death of a household member in the 30 days prior to the interview. Furthermore, the responses were based on the 30- day recall of one respondent in the household. That respondent might not have been aware of all of 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 that were of mild severity were forgotten and not reported. Table 3.3 Prevalence and severity of illness or injury in previous 30 days Percent distribution of the de jure household population ill or injured in the previous 30 days by severity of illness or injury, according to background characteristics, Cambodia 2014 Severity of illness or injury Any illness or injury Number of persons Background characteristics Not ill or injured Slight Moderate Serious Age 0-9 83.1 10.1 5.7 1.2 16.9 16,182 10-19 93.7 3.0 2.6 0.6 6.3 14,576 20-39 90.6 3.9 4.6 0.9 9.4 22,161 40-59 82.7 6.2 9.3 1.8 17.3 13,959 60+ 75.5 7.5 13.4 3.6 24.5 6,079 Sex Male 88.8 5.1 4.8 1.3 11.2 35,336 Female 84.9 6.5 7.3 1.3 15.1 37,622 Residence Urban 84.7 9.1 5.2 0.9 15.3 11,469 Rural 87.1 5.2 6.3 1.4 12.9 61,489 Province Banteay Meanchey 87.8 4.3 6.0 1.8 12.2 3,134 Kampong Cham 86.3 6.2 6.1 1.4 13.7 9,454 Kampong Chhnang 82.0 5.8 10.7 1.5 18.0 2,574 Kampong Speu 85.9 7.2 5.9 0.9 14.1 4,665 Kampong Thom 87.7 5.9 5.3 1.1 12.3 3,632 Kandal 87.3 4.1 7.2 1.3 12.7 5,674 Kratie 82.7 6.6 9.0 1.6 17.3 2,160 Phnom Penh 76.8 15.8 6.8 0.6 23.2 6,814 Prey Veng 92.1 1.8 5.0 1.1 7.9 4,942 Pursat 93.7 2.3 2.8 1.2 6.3 2,839 Siem Reap 90.9 2.9 5.1 1.1 9.1 4,811 Svay Rieng 83.2 7.6 7.6 1.6 16.8 2,736 Takeo 91.3 1.9 4.6 2.2 8.7 4,475 Otdar Meanchey 89.9 4.2 5.2 0.7 10.1 1,203 Battambang/Pailin 86.7 6.6 5.1 1.5 13.3 5,623 Kampot/Kep 86.9 3.0 9.0 1.1 13.1 3,220 Preah Sihanouk/Koh Kong 88.3 5.5 5.0 1.2 11.7 1,622 Preah Vihear/Stung Treng 85.0 5.7 7.1 2.0 15.0 1,813 Mondul Kiri/Ratanak Kiri 91.9 4.8 2.0 1.3 8.1 1,567 Total 86.8 5.8 6.1 1.3 13.2 72,958 Utilization of Health Services for Accident, Illness, or Injury • 33 The majority (90 percent) of all illnesses or injuries were slight or moderate in severity. Only 1.3 percent of household members experienced a serious illness or injury. The highest percentage of illness or injury was found among persons age 60 and older; 25 percent had an illness or injury. Females and urban residents suffered slightly more illnesses and injuries than males and rural residents. The highest percentages of illness or injury were found in Phnom Penh (23 percent), Kampong Chhnang (18 percent), and Kratie and Svay Rieng (17 percent each). 3.3 TREATMENT SOUGHT FOR ILLNESS OR INJURY Table 3.4 presents the percentage of ill or injured household members who sought treatment according to the number of times they did so. The type of treatment recorded included, but was not limited to, care provided 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 medicine was not effective and the parents took the child to a doctor at a private clinic, this was recorded as the third treatment. Table 3.4 Percentage of ill or injured population who sought treatment Percentage of de jure household members ill or injured in the past 30 days who sought a first, second, and third treatment, according to background characteristics, Cambodia 2014 Treatment for illness or injury Number of ill/injured population Background characteristics First treatment Second treatment Third treatment Severity of illness or injury1 Slight 93.2 17.8 5.2 4,249 Moderate 96.3 23.5 7.7 4,442 Serious 98.4 36.1 12.6 956 Age 0-9 97.1 21.8 6.1 2,742 10-19 97.0 18.5 5.2 912 20-39 95.0 24.1 7.2 2,094 40-59 93.6 22.9 8.6 2,416 60+ 93.1 21.4 7.4 1,492 Sex Male 95.6 22.3 6.8 3,973 Female 94.8 22.1 7.3 5,683 Residence Urban 96.1 28.5 11.5 1,755 Rural 94.9 20.8 6.1 7,902 Province Banteay Meanchey 96.1 16.8 4.9 381 Kampong Cham 93.0 17.3 5.8 1,296 Kampong Chhnang 99.2 26.9 5.1 464 Kampong Speu 96.7 7.5 2.0 657 Kampong Thom 96.2 9.5 1.5 448 Kandal 95.6 31.6 11.5 718 Kratie 94.5 9.2 1.1 373 Phnom Penh 96.8 37.9 16.3 1,582 Prey Veng 98.3 40.4 16.2 390 Pursat 91.1 12.3 0.0 180 Siem Reap 96.5 23.8 6.2 440 Svay Rieng 95.7 18.9 3.4 460 Takeo 94.3 28.0 10.9 389 Otdar Meanchey 87.8 16.6 1.0 121 Battambang/Pailin 91.2 15.0 3.2 748 Kampot/Kep 96.5 16.6 3.5 420 Preah Sihanouk/Koh Kong 97.2 17.1 3.8 189 Preah Vihear/Stung Treng 92.2 16.4 1.5 273 Mondul Kiri/Ratanak Kiri 86.1 13.7 3.2 126 Total 95.1 22.2 7.1 9,656 1 Includes 10 cases of don’t know or missing severity of illness or injury 34 • Utilization of Health Services for Accident, Illness, or Injury Ninety-five percent of household members who were ill sought at least one treatment (Table 3.4), a slight increase from the 2010 CDHS. Twenty-two percent of those ill or injured sought at least two treatments, and 7 percent 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 was sought. Persons with serious illnesses or injuries were more likely to seek treatment than those with moderate illnesses or injuries. These latter individuals in turn were more likely to seek treatment than those with slight illnesses or injuries. Ninety-three percent of those with a slight illness, 96 percent of those with a moderate illness, and 98 percent of those with a serious illness or injury sought a first treatment. The corresponding percentages among those who sought a second treatment were 18 percent, 24 percent, and 36 percent. Five percent of those with slight illnesses or injuries were treated three times or more, as compared with 13 percent of those with serious illnesses or injuries. There were small differences in health-seeking behavior by sex and age. Urban residents were twice as likely to seek a third treatment as rural residents (12 percent versus 6 percent). The provinces with the highest percentages of ill or injured persons seeking treatment were Kampong Chhnang (99 percent) and Prey Veng (98 percent), whereas the province with the lowest percentage was Mondul Kiri/Ratanak Kiri (86 percent). 3.4 UTILIZATION OF HEALTH CARE FACILITIES Information on the location of health care providers was collected to determine where persons who were ill or injured went for treatment. Health care providers were distinguished by public sector, private sector, and non-medical sector. Interviewers were provided with descriptions of the different types of hospitals, clinics, pharmacies, and other health venues. If, during data collection, the interviewer had difficulties distinguishing among the various types, the team supervisor or field editor ascertained the correct designation from local sources. Table 3.5 presents data on utilization of health services by type of residence (urban-rural). Small differences in patterns of health care use can be observed, with the private sector in general used most often, followed by the public sector and then the non-medical sector. Within the public sector, health centers were most often visited for treatment of illnesses and injuries in rural areas (13 percent), whereas national hospitals were the most common source for treatment in urban areas (7 percent). Within the private sector, private pharmacies were most often visited for treatment in urban areas (41 percent), and private clinics were the most common source in rural areas (17 percent). Private pharmacies were much more likely to be visited for first treatment in urban areas than in rural areas (41 percent versus 13 percent), whereas trained health workers and nurses were more commonly sought out for first-time treatment in rural areas than in urban areas (29 percent versus 10 percent). Within the non-medical sector, shops or markets were the overwhelming choice as a source of health care. Utilization of Health Services for Accident, Illness, or Injury • 35 Table 3.5 Percentage of ill or injured population who sought treatment Percent distribution of de jure household members who were ill or injured in the past 30 days by place of treatment, according to urban-rural residence, Cambodia 2014 Residence Total Urban Rural 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 3.9 71.5 88.5 5.1 79.2 93.9 4.9 77.8 92.9 Public sector 14.9 4.0 1.3 23.5 4.8 1.4 21.9 4.7 1.4 National hospital (PP) 6.5 2.2 0.9 3.6 1.0 0.5 4.2 1.2 0.5 Provincial hospital (RH) 2.2 0.2 0.1 3.1 0.6 0.1 3.0 0.5 0.1 District hospital (RH) 0.5 0.4 0.0 2.9 0.7 0.3 2.5 0.7 0.2 Health center 5.0 1.1 0.4 12.8 2.2 0.5 11.4 2.0 0.4 Health post 0.0 0.0 0.0 0.2 0.0 0.0 0.2 0.0 0.0 Outreach 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Other public 0.7 0.1 0.0 0.8 0.2 0.1 0.7 0.2 0.1 Private sector 78.1 23.9 9.9 64.7 14.5 4.3 67.1 16.2 5.3 Private hospital 3.3 1.0 0.2 3.6 1.0 0.3 3.6 1.0 0.3 Private clinic 22.6 6.7 2.4 17.2 5.0 1.3 18.2 5.3 1.5 Private pharmacy 40.6 13.4 6.1 12.7 2.2 0.8 17.8 4.2 1.8 Home/office of trained health worker/nurse 5.4 1.6 0.4 14.4 3.7 1.0 12.8 3.3 0.9 Visit of trained health worker/nurse 4.7 0.9 0.6 15.0 2.2 0.8 13.1 2.0 0.8 Other private medical 1.5 0.4 0.2 1.7 0.4 0.1 1.7 0.4 0.1 Non-medical sector 1.0 0.4 0.2 5.3 1.1 0.3 4.5 1.0 0.3 Shop/market 0.7 0.2 0.1 4.3 0.5 0.1 3.6 0.4 0.1 Kru Khmer/magician 0.3 0.1 0.1 0.9 0.6 0.1 0.8 0.5 0.1 Monk/religious leader 0.0 0.0 0.0 0.1 0.0 0.0 0.1 0.0 0.0 Traditional birth attendant 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Outside of country/other 2.1 0.2 0.1 1.5 0.3 0.1 1.6 0.3 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,755 1,755 1,755 7,902 7,902 7,902 9,656 9,656 9,656 Figure 3.1 summarizes the findings detailed in Table 3.5. The private sector is the most popular source for all three types of treatments. After the private sector, people most often choose the public sector for first, second, and third treatments, whereas the non-medical sector is the least popular choice for seeking treatment. Figure 3.1 Percentage of ill or injured household members seeking treatment by order of treatment and sector of health care 0.3 1 5 5 16 67 1 5 22 Third treatment Second treatment First treatment Percentage Public sector Private sector Non-medical sector CDHS 2014 36 • Utilization of Health Services for Accident, Illness, or Injury 3.5 COST FOR HEALTH CARE 3.5.1 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 were reported only for living people who had been recently ill or injured and did not include costs incurred for people who had died in the 30 days preceding the interview. Costs are presented in US dollars in Table 3.6. In the case of all treatments, 9 percent of household members spent $1 or less for transportation and treatment for illness or injury, and 21 percent spent $1 to $4. Ten percent of all household members spent $50-$99 for transportation and treatment for illness or injury, and another 10 percent spent $100 or more. These expenditures varied by type of spending. For transport, 48 percent of household members spent less than $1, 35 percent spent $1 to $4, 8 percent spent $5 to $9, and the rest spent $10 or more. For health care, 6 in 10 household members spent up to $19, 18 percent spent between $20 and $49, 10 percent spent between $50 and $99, and 9 percent spent $100 or more. There were small variations in spending according to order of treatment. Table 3.6 Distribution of cost for health care Percent distribution of de jure household members who were ill or injured in the past 30 days and sought treatment by amount of money spent for transport and health care, according to number of treatments, Cambodia 2014 Treatment for illness or injury Amount spent for transport and health care First treatment Second treatment Third treatment All treatments Transport Health care Total Transport Health care Total Transport Health care Total Transport Health care Total $0-1 50.4 17.3 10.6 46.0 16.4 9.7 51.6 19.2 11.7 48.4 14.9 9.3 $1-4 35.1 20.9 23.7 37.5 22.1 23.9 32.5 26.5 28.7 34.5 19.1 21.1 $5-9 7.5 13.9 15.1 8.4 14.8 15.4 7.6 15.1 16.0 8.1 13.1 13.9 $10-19 4.1 15.8 16.5 4.1 17.7 18.8 3.5 16.5 17.7 4.6 16.0 16.3 $20-49 1.2 15.9 16.6 2.3 15.8 17.7 1.5 13.5 14.8 2.3 17.5 18.5 $50-99 0.4 7.9 8.3 0.5 7.0 7.6 1.1 2.9 3.9 0.7 9.6 10.0 $100+ 0.4 7.7 7.9 0.6 5.6 6.0 1.2 5.1 5.7 0.6 9.2 9.6 Don’t know/ missing 0.8 0.6 1.2 0.6 0.4 0.9 1.0 1.1 1.5 0.8 0.7 1.4 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 Number 9,186 9,186 9,186 2,143 2,143 2,143 684 684 684 9,186 9,186 9,186 3.5.2 Expenditures for Health Care Table 3.7 presents the mean cost of transport and treatment by order of treatment and background characteristics. Mean total costs for first, second, and third treatments are $41.08, $34.27, and $32.19, respectively. Mean cost of transport increases with treatment order, from $2.78 for the first treatment to $3.59 for the second treatment and then $4.94 for the third treatment. The mean cost of transport and health care varies according to type of health sector, severity of illness or injury, age group, sex, residence, and province. Examining total costs by type of health sector shows that the highest mean expenditure is for “outside of country/other” treatment, which may include going to Singapore, Thailand, or Vietnam or seeking specialized services. This is true for both costs of transport and costs of health care. Total cost has continued to increase in the past four years, from a mean of $32.37 in 2010 to $39.36 in 2014. Increases have been observed in both the public and private sectors, in the first and third treatment cycles, and in transport as well as health care costs. Total “outside of country/other” costs have declined from the level reported in the 2010 CDHS, from $324.26 to $234.93. “Outside of country/other” treatment is the most expensive treatment option due to high transport ($33.86) and health care ($201.08) costs. Utilization of Health Services for Accident, Illness, or Injury • 37 Table 3.7 Expenditures for health care Mean expenditures in United States dollars for transport and health care by de jure household members who were ill or injured in the past 30 days and sought treatment by order of treatments, according to background characteristics, Cambodia 2014 Treatment for illness or injury First treatment Second treatment Third treatment All treatments Background characteristic Transport Health care Total Transport Health care Total Transport Health care Total Transport Health care Total Type of health sector Public 4.57 48.76 53.33 6.81 27.22 34.03 8.17 32.20 40.36 5.11 44.39 49.51 Private 1.72 33.00 34.72 2.03 30.16 32.19 2.61 21.27 23.88 1.83 31.78 33.61 Non-medical 0.66 8.54 9.20 2.75 18.71 21.45 0.43 5.56 5.98 1.01 10.12 11.12 Outside of country/ other 28.48 202.49 230.97 43.27 155.88 199.15 83.19 293.65 376.83 33.86 201.08 234.93 Severity of illness or injury Slight 1.22 11.82 13.04 1.23 8.78 10.00 2.51 17.62 20.12 1.28 11.61 12.89 Moderate 2.59 36.97 39.56 2.84 27.13 29.97 2.57 26.32 28.89 2.63 34.50 37.14 Serious 10.22 156.53 166.75 11.16 90.23 101.39 16.27 47.91 64.18 10.96 131.12 142.08 Age 0-9 1.62 10.90 12.52 2.92 11.49 14.41 4.08 5.51 9.59 1.97 10.74 12.71 10-19 1.95 23.69 25.64 3.32 21.87 25.19 1.70 9.37 11.07 2.15 22.78 24.93 20-39 3.28 49.60 52.88 2.72 31.21 33.93 2.60 21.68 24.28 3.14 44.54 47.67 40-59 3.25 47.90 51.15 5.03 45.60 50.63 9.45 45.01 54.46 4.01 47.28 51.28 60+ 4.04 68.52 72.55 3.89 44.77 48.66 2.10 41.84 43.94 3.90 62.73 66.62 Sex Male 2.74 38.20 40.94 3.83 36.14 39.97 3.77 20.93 24.69 2.99 36.89 39.88 Female 2.80 38.38 41.18 3.43 26.86 30.28 5.70 31.36 37.06 3.08 35.90 38.99 Residence Urban 3.39 48.49 51.88 2.41 22.69 25.09 4.74 32.82 37.56 3.30 41.76 45.05 Rural 2.64 36.00 38.64 3.95 33.12 37.08 5.02 24.93 29.95 2.98 34.95 37.94 Province Banteay Meanchey 3.63 53.97 57.59 5.14 48.72 53.86 11.01 46.96 57.97 4.15 52.93 57.08 Kampong Cham 2.71 34.11 36.82 5.70 44.42 50.12 13.98 54.87 68.85 3.71 36.67 40.38 Kampong Chhnang 2.21 32.62 34.83 2.28 38.86 41.14 3.00 44.70 47.70 2.26 34.34 36.60 Kampong Speu 2.28 36.44 38.72 2.39 19.64 22.03 1.23 13.07 14.31 2.27 34.79 37.06 Kampong Thom 1.61 26.16 27.77 7.21 94.18 101.39 3.29 23.88 27.17 2.13 32.19 34.32 Kandal 1.84 46.81 48.64 1.36 12.21 13.57 4.04 18.32 22.36 1.91 36.62 38.53 Kratie 2.88 27.83 30.71 4.08 51.43 55.51 3.87 38.15 42.02 3.00 30.02 33.02 Phnom Penh 2.65 33.59 36.24 1.23 13.21 14.44 2.22 18.24 20.46 2.25 26.82 29.06 Prey Veng 3.54 66.03 69.57 3.10 24.54 27.64 2.53 27.14 29.68 3.32 51.15 54.47 Pursat 3.64 71.72 75.36 5.84 63.55 69.40 na na na 3.90 70.75 74.65 Siem Reap 3.45 37.77 41.21 6.29 40.46 46.75 10.91 43.36 54.27 4.34 38.55 42.89 Svay Rieng 2.32 42.75 45.07 3.10 61.09 64.19 1.44 19.03 20.47 2.42 45.04 47.47 Takeo 3.97 45.15 49.12 3.16 27.19 30.35 3.09 17.77 20.86 3.73 39.24 42.98 Otdar Meanchey 9.70 36.80 46.50 31.14 51.97 83.11 178.65 178.75 357.40 14.74 40.58 55.33 Battambang/Pailin 2.97 37.06 40.03 8.49 51.72 60.21 5.74 33.05 38.79 3.82 38.99 42.82 Kampot/Kep 1.63 34.82 36.45 1.22 13.26 14.48 0.95 8.17 9.13 1.55 30.99 32.54 Preah Sihanouk/Koh Kong 2.84 29.35 32.19 4.70 33.89 38.59 4.58 46.14 50.72 3.17 30.55 33.72 Preah Vihear/Stung Treng 2.32 21.64 23.96 3.73 19.39 23.13 23.59 139.47 163.05 2.82 22.92 25.74 Mondul Kiri/Ratanak Kiri 7.10 49.35 56.45 18.40 166.02 184.42 1.59 8.02 9.60 8.59 65.33 73.92 Total 2.78 38.30 41.08 3.59 30.68 34.27 4.94 27.25 32.19 3.05 36.31 39.36 na = No third treatment was reported In general, health care costs increased significantly by severity of illness or injury. The total mean cost of health care increased from $11.61 for slight illness or injury to $131.12 for serious conditions. This followed the same pattern established in the 2010 CDHS. Overall, average health care costs rise consistently with the patient’s age, from $10.74 for children age 0-9 to $62.73 for people age 60 or older. Health care expenditures by sex show that men and women spent about the same on health care ($36.89 and $35.90, respectively). A comparison with the findings of the 2010 CDHS shows that health care spending seems to have become more equitable. In 2010, men spent more than women on health care ($34.28 versus $26.90). Total health care costs have remained higher in urban areas than in rural areas since the 2010 CDHS. However, the urban-rural difference in health care costs has narrowed considerably due to a decline in costs in urban areas. In urban areas average health care costs decreased from $74.79 in 2010 to 38 • Utilization of Health Services for Accident, Illness, or Injury $41.76 in 2014, and in rural areas costs increased from $23.55 to $34.95 over the same period. The average transport cost per treatment has not changed much over the past four years (from $2.38 to $3.05). The difference in transport costs in urban and rural areas is small ($3.30 versus $2.98). Health care expenditures vary greatly in Cambodia’s provinces. The cost of health care is highest in Pursat ($70.75) and lowest in Preah Vihear/Stung Treng ($22.92). 3.5.3 Sources of Money for Health Care Expenditures Because the health care system in Cambodia is largely fee-based, 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 3.8 shows the different sources of money spent by people seeking treatment for health care. Percentages could sum to greater than 100 because a person could use money from more than one source. Table 3.8 shows the different sources of money spent by persons who sought treatment for health care. The total percent could be greater than 100 because a person could use money from more than one source. Similar to 2010, the two major sources of money spent on health care are wages or income and savings; in 2014, 64 percent of people who sought health care used money from wages/income and 31 percent used savings. Gifts from relatives or friends and sale of assets were mentioned as a source of funding by 14 percent and 8 percent of those who obtained health care, respectively. Twelve percent of those who had health care treatment said they used money from tontine,1 and 4 percent used money from a health equity fund. Each of the other sources of funding was mentioned by 1 percent or less of respondents. There are small differences in the source of money spent on health care by type of health sector. In all sectors, the most common source of funding is wages or income (50 percent to 72 percent), followed by savings (22 percent to 33 percent). Gifts from relatives are the next most common source of funding for health care (13 percent to 17 percent). As severity of illness or injury increases, dependence on loans, sale of assets, gifts, and savings increases; however, spending of wages or income declines as severity of illness or injury increases. Wages/income was the most common source of funding regardless of the total cost of treatments; however, as treatment costs increase, the proportion of people who use funds from loans, sale of assets, gifts from relatives, and savings also increases. Health equity funds were used by 15 percent of those spending $0 to $1. There were no substantial differences in the source of money used for health care costs by the patient’s sex. Urban residents were more likely than rural residents to use wages (86 percent versus 59 percent) but less likely to use savings (13 percent versus 35 percent) for health care. Large differences were found in the sources of money for health care costs by province. Patients in Phnom Penh, Preah Vihear/Stung Treng, and Kandal were most likely to use wages to pay for their health care (92 percent, 89 percent, and 87 percent, respectively) and among the least likely to use their savings (5 percent and 15 percent, respectively). Conversely, Kampong Chhnang and Kampot/Kep are the provinces in which health care users are most likely to use savings for health care spending (86 percent and 76 percent, respectively). Patients in Prey Veng are least likely to use wages for health care spending (9 percent). Patients in Svay Rieng (34 percent) had the highest reliance on sale of assets for health care spending. Patients in Otdar Meanchey were most likely to use a health equity fund to finance their health care spending. Approximately 1 of 3 patients (32 percent) in Prey Veng reported gifts from relatives or friends as a source of funding for health care costs. 1 Tontine is an informal group saving and loan scheme in Cambodia. Utilization of Health Services for Accident, Illness, or Injury • 39 Table 3.8 Source of money (United States dollars) spent by persons who sought treatment for health care Among de jure household members who were ill or injured in the 30 days before the survey and who sought treatment, percentage who reported specific sources of expenditures for transport and health care, according to background characteristics, Cambodia 2014 Source of money for health care Background characteristic Health equity fund Voucher Free exemp- tion NGO National Security Fund Commu- nity based health insur- ance Employ- er Com- mercial health insur- ance Wages/ income Loan/ tontine Sale of assets Gift from relative Savings Other/ missing Number1 Type of health sector Public 13.1 0.3 3.5 0.8 0.1 0.7 0.2 0.3 50.4 11.1 7.3 13.1 30.9 0.0 1,958 Private 1.4 0.1 0.2 0.2 0.0 0.1 0.3 0.0 67.5 12.9 7.7 14.3 31.5 0.1 6,594 Non-medical 2.4 0.3 0.5 0.6 0.0 0.0 0.0 0.0 72.1 11.3 7.2 16.6 33.4 0.3 472 Other 1.1 0.0 1.9 1.4 0.0 0.0 1.0 0.0 62.6 9.6 7.7 16.9 22.4 2.7 161 Severity of illness or injury2 Slight 3.7 0.1 0.8 0.2 0.0 0.1 0.1 0.0 74.6 9.1 4.5 9.6 24.4 0.0 3,961 Moderate 4.1 0.2 1.3 0.4 0.0 0.3 0.4 0.2 57.7 13.1 8.4 16.1 36.3 0.2 4,277 Serious 4.6 0.3 0.4 0.3 0.1 0.1 0.7 0.0 47.5 23.0 16.9 25.6 38.2 0.2 941 Cost of transport and health care $0-1 15.2 0.1 5.0 1.6 0.2 0.2 0.9 0.0 55.9 2.4 1.5 7.8 25.0 0.7 851 $1-4 4.9 0.2 1.1 0.2 0.1 0.4 0.4 0.1 72.7 4.7 3.8 8.9 26.6 0.1 1,934 $5-9 3.4 0.0 0.9 0.5 0.0 0.2 0.0 0.1 68.7 8.6 6.4 9.7 32.1 0.0 1,274 $10-19 2.8 0.1 0.3 0.2 0.0 0.0 0.1 0.1 64.1 12.4 6.7 13.9 33.0 0.1 1,499 $20-49 1.6 0.1 0.4 0.1 0.0 0.2 0.0 0.1 60.9 15.8 9.2 19.1 34.4 0.0 1,702 $50-99 1.2 0.1 0.0 0.0 0.0 0.0 0.2 0.0 60.7 22.8 12.5 20.1 32.4 0.0 917 $100+ 1.5 0.2 0.0 0.1 0.0 0.0 0.2 0.0 56.7 27.9 17.3 23.7 37.1 0.0 883 Sex Male 3.9 0.1 1.0 0.4 0.0 0.3 0.4 0.0 65.0 11.8 7.3 12.9 31.2 0.2 3,799 Female 4.0 0.2 0.9 0.3 0.0 0.1 0.2 0.1 63.3 12.8 7.8 15.2 31.4 0.0 5,387 Residence Urban 3.3 0.0 1.1 0.9 0.0 0.1 0.5 0.1 85.7 6.8 1.6 11.2 13.2 0.0 1,686 Rural 4.1 0.2 1.0 0.2 0.0 0.2 0.2 0.1 59.1 13.7 8.9 14.9 35.4 0.1 7,500 Province Banteay Meanchey 3.1 0.0 0.8 0.3 0.0 0.2 0.0 0.0 57.8 16.1 8.4 31.1 35.0 0.0 366 Kampong Cham 4.0 0.3 0.5 0.2 0.0 0.3 0.5 0.0 62.1 19.9 6.6 12.1 33.8 0.3 1,206 Kampong Chhnang 7.4 0.0 1.4 0.2 0.0 0.0 0.3 0.0 42.2 7.3 13.9 16.0 85.8 0.0 460 Kampong Speu 0.9 0.0 0.2 0.0 0.0 0.0 0.0 0.0 64.5 7.0 11.3 14.7 22.4 0.0 635 Kampong Thom 5.4 0.0 0.3 0.0 0.0 0.7 0.0 0.0 63.2 6.1 6.5 4.8 40.3 0.0 431 Kandal 0.7 0.2 0.4 0.2 0.0 0.0 0.3 0.0 86.6 6.2 1.7 18.6 14.7 0.0 687 Kratie 4.0 0.1 0.7 0.6 0.0 0.0 0.0 0.0 70.8 12.4 5.7 12.6 31.8 0.4 352 Phnom Penh 3.6 0.0 1.7 0.9 0.0 0.1 0.7 0.1 92.1 8.5 1.0 8.6 4.6 0.0 1,532 Prey Veng 2.1 0.0 0.4 0.0 0.0 0.0 0.0 0.0 8.7 20.5 12.2 32.0 64.4 0.0 384 Pursat 9.1 0.0 0.5 0.2 0.9 1.2 0.0 0.4 24.3 12.0 8.0 8.6 59.3 0.0 164 Siem Reap 5.4 0.8 1.1 0.0 0.0 1.4 0.0 0.0 52.6 22.5 5.9 5.3 32.8 0.0 424 Svay Rieng 0.4 0.0 0.5 0.0 0.0 0.0 0.2 0.0 64.1 19.1 34.3 23.9 34.5 0.2 440 Takeo 7.7 1.2 0.8 0.0 0.4 0.0 0.0 1.3 36.1 12.3 19.2 20.5 36.2 0.8 367 Otdar Meanchey 13.3 0.0 1.1 0.2 0.0 0.0 0.0 0.0 61.7 18.9 4.0 5.5 51.5 0.0 106 Battambang/Pailin 6.0 0.1 0.8 0.4 0.0 0.0 0.7 0.0 66.7 15.5 2.0 21.0 13.9 0.0 683 Kampot/Kep 1.9 0.0 2.7 0.5 0.0 0.0 0.0 0.0 36.3 7.6 10.2 8.7 75.6 0.0 406 Preah Sihanouk/ Koh Kong 8.5 0.3 0.6 1.2 0.0 0.0 0.3 0.2 56.2 5.6 1.8 10.3 41.1 0.2 184 Preah Vihear/ Stung Treng 3.6 0.0 3.9 0.0 0.0 0.0 0.0 0.0 89.2 11.3 2.2 4.2 9.9 0.0 251 Mondul Kiri/ Ratanak Kiri 2.7 0.4 0.2 1.7 0.0 0.0 0.0 0.0 74.3 2.8 1.7 3.1 21.8 0.6 109 Total 4.0 0.2 1.0 0.3 0.0 0.2 0.3 0.1 64.0 12.4 7.6 14.2 31.3 0.1 9,186 1 Total includes 127 non-monetary cases (1 in-kind case and 126 cases of don’t know or missing amount of spending) 2 Includes 7 cases for which information on severity of illness is missing Disability • 41 DISABILITY 4 Key Findings • Overall, 10 percent of household members age 5 and older suffer with at least one form of disability. • Twenty-one percent of household members who were ill or injured in the 30 days prior to the interview are disabled. • The most common types of disabilities reported in the survey are difficulties in seeing, walking or climbing stairs, and concentrating. • One in 10 men who are not currently employed are disabled, as compared with only 5 percent among other men. ersons with disabilities are considered vulnerable in Cambodia. The commitment of the Royal Government of Cambodia (RGC) to improving the lives of people with disabilities through recognition of their rights was demonstrated through ratification of the Convention on the Rights of Persons with Disabilities (CRPD) in 2012. The RGC has also enacted a number of disability laws and strategic plans in recent years. The government has developed a National Disability Policy to promote effective service delivery to persons with disabilities, and recently the Disability Rights Initiative Cambodia (DRIC) was jointly developed by the Australian government, the United Nations Development Program (UNDP), the World Health Organization (WHO), and the United Nations Children’s Fund (UNICEF). The main objective of this latter initiative is to improve the quality of life of persons with disabilities in Cambodia. People with disabilities are disadvantaged in workplaces and in other public places. Understanding the prevalence of disabilities in the population and the associated circumstances can improve efforts to remove disabling barriers and provide services that allow people with disabilities to integrate better into society. In the 2014 CDHS, information was collected on each household member age 5 and older about whether he or she had difficulties with seeing, hearing, walking or climbing stairs, remembering or concentrating, performing self-care, or communicating. The survey also collected information as to the severity of these disabilities, that is, whether a disabled person has some difficulty performing the listed activities, a great deal of difficulty, or cannot perform the listed activities at all. 4.1 DISABILITY AMONG THE GENERAL HOUSEHOLD POPULATION Table 4.1 presents the prevalence of disability in Cambodia according to type of disability and level of difficulty. The first column shows the proportion of the population with no disabilities. The next group of columns shows the proportion of the population with some level of difficulty performing various types of functions, while the final set of columns shows those with a great degree of difficulty or no ability to perform the described functions at all. According to the survey, 10 percent of persons age 5 and over have some form of disability. Difficulties in seeing, walking or climbing stairs, and concentrating are the most common types of disabilities reported. Five percent of household members have difficulty seeing, 3 percent have difficulty hearing, 4 percent have difficulty walking or climbing stairs, and 4 percent have difficulties with remembering or concentrating. Only 1 percent of the population has at least some difficulty with self-care and 2 percent with communicating. P 42 • Disability The prevalence of disability increases with age, from 2 percent among children age 5-14 to 44 percent among those age 60 and above. The prevalence of disability is 13 percent among persons age 35- 59. Table 4.1 Disability among the household population Percentage of the de jure household population age 5 and over with specific types of physical disabilities, according to background characteristics, Cambodia 2014 Background characteristic No diffi- culties Some difficulty, a lot of difficulty, or cannot do Any domain A lot of difficulty or cannot do Number Any domain Seeing Hearing Walking Concen- trating Self- care Com- muni- cating Seeing Hearing Walking Concen- trating Self- care Com- muni- cating Age 5-14 98.2 1.8 0.3 0.5 0.3 0.7 0.6 0.5 0.5 0.1 0.1 0.1 0.2 0.2 0.3 16,446 15-34 96.5 3.5 1.0 1.0 0.8 1.6 0.3 0.8 0.9 0.1 0.3 0.2 0.4 0.2 0.5 24,987 35-59 86.8 13.2 6.6 2.7 4.4 5.2 0.7 1.2 2.0 0.4 0.4 0.9 0.5 0.3 0.6 17,640 60+ 55.7 44.2 30.5 17.0 22.3 21.5 6.9 7.9 11.8 5.3 3.2 5.5 3.6 3.0 2.2 6,079 Sex Male 91.5 8.5 4.2 2.5 3.1 3.5 1.0 1.3 1.9 0.5 0.6 0.8 0.6 0.4 0.6 31,395 Female 89.5 10.5 5.9 3.1 4.2 4.9 1.2 1.7 2.3 0.8 0.6 0.9 0.8 0.5 0.6 33,757 Marital status1 Never married 94.9 5.1 1.5 1.5 1.3 2.3 0.9 1.9 2.2 0.3 0.6 0.6 1.0 0.4 1.3 11,787 Married 88.4 11.6 6.4 3.1 4.4 4.9 0.8 1.1 1.9 0.6 0.5 0.8 0.4 0.3 0.3 31,883 Widowed 63.1 36.7 25.0 14.7 19.2 18.4 6.2 7.1 10.5 4.6 2.8 5.3 3.6 2.8 2.2 3,913 Divorced 86.9 13.1 6.2 2.8 3.6 6.3 1.6 2.7 2.9 0.8 0.8 0.7 1.5 0.9 1.4 1,099 Education No education 79.4 20.5 12.0 7.7 9.1 10.4 3.8 5.1 6.4 2.3 2.1 2.4 2.5 1.8 2.4 10,587 Primary 91.3 8.7 4.5 2.4 3.2 3.5 0.7 1.0 1.6 0.5 0.4 0.7 0.4 0.3 0.3 33,787 Secondary 94.5 5.5 2.6 1.1 1.9 2.2 0.4 0.5 0.9 0.2 0.1 0.4 0.3 0.1 0.2 18,393 Higher 97.2 2.8 1.3 0.4 0.4 1.7 0.0 0.2 0.4 0.1 0.1 0.1 0.1 0.0 0.1 2,378 Household size2 1-4 89.1 10.9 6.2 3.2 4.3 4.9 1.2 1.7 2.3 0.8 0.6 0.9 0.8 0.4 0.6 27,500 5+ 91.5 8.5 4.3 2.6 3.2 3.7 1.1 1.4 2.0 0.6 0.6 0.9 0.6 0.5 0.6 37,588 Region Banteay Meanchey 89.8 10.1 6.4 2.0 4.1 2.8 1.2 1.0 1.5 0.4 0.4 0.8 0.3 0.2 0.4 2,763 Kampong Cham 88.2 11.7 6.6 4.0 4.5 4.4 1.1 1.8 2.6 1.0 0.8 0.8 0.9 0.7 0.8 8,368 Kampong Chhnang 94.7 5.3 3.6 1.8 1.9 1.7 1.1 1.1 1.6 0.6 0.4 0.6 0.5 0.5 0.3 2,311 Kampong Speu 94.9 5.1 1.9 2.2 1.5 1.2 0.7 1.4 1.9 0.4 0.7 0.7 0.7 0.5 0.6 4,187 Kampong Thom 92.5 7.5 4.5 2.7 2.9 2.3 1.1 1.0 2.1 0.6 0.8 1.1 0.5 0.6 0.6 3,268 Kandal 88.9 11.1 6.3 4.0 2.6 5.3 1.4 2.1 2.7 0.9 0.9 1.0 0.7 0.6 0.8 5,144 Kratie 92.7 7.2 3.1 2.1 1.7 3.4 0.8 1.9 1.7 0.4 0.4 0.5 0.6 0.3 0.9 1,889 Phnom Penh 91.0 9.0 4.8 2.4 2.3 4.5 0.7 1.1 2.5 0.9 0.4 0.9 0.7 0.2 0.7 6,206 Prey Veng 90.8 9.2 5.2 3.0 3.2 3.9 1.4 1.8 2.0 0.6 0.5 1.0 0.5 0.5 0.7 4,351 Pursat 91.8 8.1 4.6 2.2 4.7 3.5 1.4 1.7 2.5 0.6 0.5 1.2 0.6 0.7 0.7 2,526 Siem Reap 89.6 10.3 5.0 3.6 2.8 5.3 0.8 1.5 1.3 0.3 0.4 0.4 0.5 0.3 0.4 4,275 Svay Rieng 90.4 9.6 5.4 2.9 2.6 3.9 0.4 1.0 1.5 0.3 0.4 0.5 0.7 0.2 0.5 2,440 Takeo 94.0 6.0 2.8 1.9 2.9 3.3 1.6 1.9 1.5 0.6 0.4 0.8 0.7 0.5 0.6 4,067 Otdar Meanchey 93.3 6.6 4.3 1.8 3.2 2.0 1.0 1.0 2.3 0.9 0.7 1.1 1.0 0.5 0.5 1,063 Battambang/Pailin 80.3 19.7 9.7 2.8 12.4 11.0 1.1 1.2 3.4 1.1 0.6 1.7 1.4 0.4 0.6 5,010 Kampot/Kep 93.8 6.2 2.7 2.4 2.9 2.5 2.6 2.6 2.5 0.9 0.8 1.1 0.9 0.9 0.7 2,900 Preah Sihanouk/ Koh Kong 95.6 4.4 1.9 1.3 1.7 1.7 0.9 1.1 0.7 0.2 0.1 0.3 0.2 0.3 0.1 1,452 Preah Vihear/ Stung Treng 85.0 15.0 8.8 5.1 4.0 7.4 0.8 1.2 1.9 0.5 0.5 0.6 0.6 0.2 0.5 1,579 Mondul Kiri/ Ratanak Kiri 97.8 2.1 1.0 0.9 0.6 0.5 0.2 0.4 0.8 0.3 0.2 0.3 0.2 0.1 0.2 1,356 Residence Urban 91.3 8.7 4.8 2.3 3.0 4.0 0.9 1.1 2.2 0.7 0.4 0.9 0.6 0.3 0.6 10,403 Rural 90.3 9.7 5.1 2.9 3.8 4.3 1.1 1.6 2.1 0.7 0.6 0.8 0.7 0.5 0.6 54,750 Ill or injured in the past 30 days Yes 79.3 20.7 11.8 6.3 10.3 10.0 3.1 3.5 5.8 2.2 1.4 2.9 1.6 1.5 1.4 7,852 No 92.0 8.0 4.2 2.3 2.8 3.4 0.8 1.2 1.6 0.5 0.5 0.6 0.6 0.3 0.5 57,301 Total 90.5 9.5 5.1 2.8 3.7 4.2 1.1 1.5 2.1 0.7 0.6 0.9 0.7 0.5 0.6 65,153 Note: Total includes 2 cases for which information on illness or injury in the past 30 days is missing, 21 cases for which information on marital status is missing, and 8 cases for which information on education is missing. 1 Marital status was asked only for household members age 15 or older. 2 Households with only de facto member(s) are excluded. Disability • 43 Females are slightly more likely to suffer from some level of disability than their male counterparts (11 percent versus 9 percent). The prevalence of disability is much higher among household members who are widowed (37 percent) than those who are divorced (13 percent), currently in a union (12 percent), or single (5 percent). There is a notable association between disability and education. Household members who have no education (21 percent) are more than twice as likely to suffer from some level of disability as those with a primary education (9 percent) and seven times as likely as those with more than a secondary education (3 percent). There is little difference according to urban or rural residence. However, the level of disability varies substantially by province, from 2 percent in Mondul Kiri/Ratanak Kiri to 20 percent in Battambang/Pailin. Household members who recently suffered an illness or injury (in the 30 days prior to the interview) are more likely than those who did not (21 percent versus 8 percent) to report a disability. Only 2 percent of the household population suffers from a severe disability (a great degree of difficulty or lack of ability to perform the function at all). This indicates that the majority of disabled people experience a moderate level of disability. Overall, less than 1 percent of the population age 5 and older is severely suffering from each form of disability. The distribution of more severe disabilities by background characteristics follows a pattern similar to that observed among overall disability. 4.2 DISABILITY AMONG ILL OR INJURED HOUSEHOLD MEMBERS Table 4.2 presents information about disability among household members who were ill or injured in the 30 days prior to the survey. It is worth noting that respondents were not asked the order in which these two morbidities occurred. Therefore, the relationship between disability and illness or injury as discussed here is purely an association and does not indicate cause and effect. Table 4.2 Disability among the ill or injured population Among the de jure household population age 5 and over who were ill or injured in the 30 days before the survey, percentage with specific types of physical disabilities, according to background characteristics, Cambodia 2014 Background characteristic No diffi- culties Some difficulty, a lot of difficulty, or cannot do A lot of difficulty or cannot do Number Any domain Seeing Hearing Walking Concen- trating Self- care Com- muni- cating Any domain Seeing Hearing Walking Concen- trating Self- care Com- muni- cating Sought advice or health facility contact Did not seek treatment 64.4 33.2 20.2 8.9 18.3 18.7 3.9 7.4 7.0 3.5 3.7 3.8 3.0 2.5 4.0 418 Public sector 77.5 21.3 12.3 6.6 11.4 11.0 4.7 5.1 7.0 2.4 2.0 3.3 1.4 2.3 1.9 1,590 Private pharmacy 80.4 17.6 9.7 4.5 6.8 9.2 2.8 2.8 5.5 2.1 1.1 2.4 2.0 1.2 1.2 1,384 Other private facilities 78.1 20.0 11.3 6.7 10.3 9.3 2.7 3.0 5.7 2.2 1.1 2.9 1.6 1.2 1.2 3,903 Other/missing 75.7 21.6 13.6 4.9 9.2 8.2 1.0 1.3 3.2 1.1 0.5 2.0 0.5 0.5 0.4 558 Transport cost Free/no cost 77.2 20.6 12.5 6.0 9.9 9.7 2.9 2.9 5.8 2.9 1.1 2.9 1.3 1.5 0.9 2,393 Paid money 78.6 19.7 10.9 6.2 9.8 9.6 3.1 3.5 5.7 1.8 1.3 2.8 1.7 1.3 1.5 4,980 Other/don’t know/ missing 66.9 30.7 17.9 8.9 16.8 16.7 4.1 6.9 6.8 3.1 3.2 4.0 2.9 2.6 3.9 480 Treatment cost Free/no cost 74.6 23.7 13.1 7.0 12.7 12.4 4.7 5.0 5.3 1.9 1.9 2.1 1.2 2.1 1.3 542 Paid money 78.5 19.6 11.2 6.1 9.6 9.3 2.9 3.2 5.8 2.2 1.2 2.8 1.6 1.4 1.3 6,842 Other/don’t know/ missing 65.1 32.4 19.3 8.3 17.7 17.4 4.1 7.0 7.1 3.1 3.3 4.0 2.7 2.4 4.0 468 Health care financing mechanism Health equity fund 72.2 25.2 13.0 6.3 16.8 11.1 3.3 3.3 6.2 1.7 1.9 2.8 1.0 1.3 1.0 315 Other subsidy 74.4 20.9 15.6 2.8 5.4 5.7 1.3 2.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 102 Insurance (77.2) 22.8 20.8 10.4 10.4 9.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 41 Out of pocket 77.8 20.4 11.7 6.3 10.0 10.0 3.1 3.6 5.9 2.3 1.4 2.9 1.7 1.5 1.5 7,381 Total 77.5 20.7 11.8 6.3 10.3 10.0 3.1 3.5 5.8 2.2 1.4 2.9 1.6 1.5 1.4 7,852 Note: Total includes 14 cases for which information on health care financing mechanism is missing. Figures in parentheses are based on 25-49 unweighted cases. 44 • Disability The prevalence of disability among ill or injured household members is about two times higher than that among the general household population (21 percent versus 10 percent). Difficulties in seeing (12 percent), walking or climbing stairs (10 percent), and remembering or concentrating (10 percent) are the most common types of disabilities reported among the ill and injured population. According to source of treatment, level of disability is higher among those who did not seek any treatment for their illness or injury (33 percent) than among those who sought treatment in a public health facility (21 percent), a private facility (20 percent), or a pharmacy (18 percent). The percentage of people with a disability is slightly higher among those who received free treatment for their illness or injury than among those who paid for treatment (24 percent versus 20 percent). However, the difference in prevalence by cost of transport is minimal. The prevalence of disability among ill or injured people by type of health care financing shows that the percentage with a disability is slightly higher among those for whom the cost of treatment for their illness or injury was paid by a health equity fund (25 percent) than among those who received other forms of subsidies (21 percent), those who have insurance (23 percent), and those who paid out of their pocket for the treatment of their illness or injury (20 percent). Six percent of ill and injured household members suffer from more severe disabilities (i.e., they have a great deal of difficulty or cannot perform the function at all). Similar to the general population, this finding indicates that the majority of ill or injured people experience a moderate level of disability. The distribution of more severe disability among the ill or injured population by background characteristics follows somewhat the same pattern observed for overall disability. 4.3 DISABILITY AND EMPLOYMENT Table 4.3 presents information about disability by type of employment. Since information on employment was collected only among interviewed women and men age 15-49, this table provides data on disability and employment among only household members age 15-49 who were eligible for an individual interview and completed the interview. Table 4.3 Disability and employment Percentage of interviewed women and men age 15-49 with a physical disability according to employment status, Cambodia 2014 Employment status No diffi- culties Some difficulty, a lot of difficulty, or cannot do A lot of difficulty or cannot do Number Any domain Seeing Hearing Walking Concen trating Self- care Com- muni- cating Any domain Seeing Hearing Walking Concen trating Self- care Com- muni- cating WOMEN Employed in the 12 months preceding the survey Currently employed1 95.1 4.9 2.3 0.9 1.0 1.8 0.0 0.3 0.3 0.1 0.1 0.1 0.0 0.0 0.1 12,436 Not currently employed 94.4 5.6 2.7 1.0 1.9 2.2 0.0 0.2 0.6 0.1 0.0 0.2 0.3 0.0 0.1 1,542 Not employed in the 12 months preceding the survey 93.8 6.2 2.4 0.8 2.0 2.7 0.4 0.8 1.1 0.3 0.1 0.7 0.2 0.1 0.3 3,599 Total 94.7 5.3 2.3 0.9 1.3 2.0 0.1 0.4 0.5 0.2 0.1 0.2 0.1 0.0 0.1 17,578 MEN Employed in the 12 months preceding the survey Currently employed1 95.2 4.7 1.8 0.9 1.2 1.6 0.3 0.2 0.4 0.2 0.0 0.2 0.1 0.1 0.0 4,547 Not currently employed 89.8 10.2 2.5 4.4 2.3 3.8 0.9 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 271 Not employed in the 12 months preceding the survey 94.8 5.2 1.4 0.2 3.0 1.7 0.3 1.1 2.0 1.0 0.2 0.7 0.3 0.0 0.3 372 Total 94.9 5.0 1.8 1.0 1.4 1.7 0.3 0.3 0.5 0.2 0.0 0.2 0.1 0.1 0.0 5,190 Note: Total includes 1 woman for whom information on employment is missing. 1 “Currently employed” is defined as having done work in the past 7 days. Includes persons who did not work in the past 7 days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. Disability • 45 According to the 2014 CDHS, only 5 percent of interviewed women and men age 15-49 suffer from at least one form of disability. Difficulties in seeing and concentrating (2 percent each) are the most common types of disabilities reported among these women and men. The prevalence of disability among women who are currently employed is 5 percent, slightly lower than among those who are not currently employed and those who were not employed in the 12 months preceding the survey (6 percent each). Men who are not currently employed are twice as likely to be disabled as men who are currently employed and those not employed in the 12 months preceding the survey (10 percent versus 5 percent each). Severe disability is only reported for less than 1 percent among this group. Respondent Characteristics • 47 RESPONDENT CHARACTERISTICS 5 Key Findings • Thirteen percent of women and 6 percent of men age 15-49 have no education; an additional 40 percent and 52 percent have at least some secondary education. • Twenty-one percent of women and 25 percent of men age 15-49 are exposed to at least one source of mass media once a week. • Only 16 percent of Cambodian women and 13 percent of men are covered by health insurance. • Sixty-nine percent of women were employed in the 12 months preceding the survey, with the majority (57 percent of women) employed in the agricultural sector. • Nearly half of working women (44 percent) work in the agricultural sector, and about three in four of these women are self-employed. his chapter provides a demographic and socioeconomic profile of respondents interviewed in the 2014 Cambodia Demographic and Health Survey (CDHS). Such background information is essential to interpret the findings and understand the results presented later in the report. Basic characteristics of respondents 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 health insurance coverage and use of tobacco. 5.1 CHARACTERISTICS OF SURVEY RESPONDENTS Background characteristics of the 17,578 women age 15-49 and the 5,190 men age 15-49 interviewed in the 2014 CDHS are shown in Table 5.1. This table is important because it provides background for interpreting findings presented later in the report. The distribution of the population of women and men by age reflects recent Cambodian history. It is notable that 16-18 percent of women and men fall into each of the age groups between 15-19 and 30-34. Smaller proportions are found in the older age groups. Between 11 and 12 percent of women and men fall into each of the five-year age groups between 35 and 49. This age distribution of respondents is unusual and reflects the effects of the Khmer Rouge regime (1975-1979), during which fertility rates declined and were coupled with higher than normal mortality. 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 age groups between 35 and 49. Approximately 68 percent of women and 66 percent of men are married or living with their partner. The proportion not currently married varies by gender, with 25 percent of women never married compared with 32 percent of men. Women are more than three times as likely as men to be divorced, separated, or widowed (7 percent and 2 percent, respectively). Access to services and exposure to information pertaining to reproductive health and other aspects of life are often determined by one’s area of residence. The majority of respondents reside in rural areas, with only 19 percent of women and 17 percent of men residing in urban areas. About 12 percent of women and 13 percent of men live in Kampong Cham, and 11 percent of each live in the capital city of Phnom Penh. Cambodians are predominantly Buddhist (96 percent of women and 95 percent of men). The other two main religions, Islam and Christianity, are practiced by a very small proportion of respondents (Table 5.1). T 48 • Respondent Characteristics Table 5.1 Background characteristics of respondents Percent distribution of women and men age 15-49 by selected background characteristics, Cambodia 2014 Women Men Background characteristic Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted number Age 15-19 16.5 2,893 3,006 17.8 926 946 20-24 17.2 3,017 3,038 16.1 835 881 25-29 16.1 2,836 2,866 15.7 815 796 30-34 17.3 3,046 2,996 17.5 907 888 35-39 10.5 1,839 1,776 10.7 556 528 40-44 11.6 2,030 1,995 11.5 595 603 45-49 10.9 1,916 1,901 10.7 556 548 Religion Buddhist 96.0 16,882 16,699 95.4 4,949 4,888 Moslem 1.9 335 338 2.6 133 124 Christian 0.9 157 151 0.9 47 48 Other/missing 1.2 204 390 1.2 61 130 Marital status Never married 25.2 4,428 4,651 32.0 1,663 1,746 Married 67.2 11,808 11,574 65.3 3,388 3,306 Living together 0.5 91 94 0.3 17 14 Divorced/separated 3.8 664 697 1.8 95 97 Widowed 3.3 588 562 0.5 26 27 Residence Urban 18.5 3,251 5,667 16.7 869 1,540 Rural 81.5 14,327 11,911 83.3 4,321 3,650 Province Banteay Meanchey 3.9 689 810 3.7 192 223 Kampong Cham 11.5 2,021 853 12.8 663 300 Kampong Chhnang 3.8 662 899 3.5 182 251 Kampong Speu 6.8 1,196 1,022 6.2 323 269 Kampong Thom 4.8 851 905 4.5 232 261 Kandal 7.6 1,330 875 8.0 413 239 Kratie 2.8 488 874 2.8 143 258 Phnom Penh 11.3 1,994 1,400 10.6 550 391 Prey Veng 6.8 1,188 819 6.6 342 244 Pursat 3.6 631 859 3.5 184 261 Siem Reap 6.5 1,137 943 6.5 337 282 Svay Rieng 3.7 654 822 3.5 183 237 Takeo 6.2 1,082 868 6.4 334 252 Otdar Meanchey 1.7 294 823 1.9 99 277 Battambang/Pailin 7.6 1,333 867 7.8 405 249 Kampot/Kep 4.4 770 880 4.6 241 284 Preah Sihanouk/Koh Kong 2.4 422 1,010 2.3 120 288 Preah Vihear/Stung Treng 2.6 462 1,085 2.2 112 274 Mondul Kiri/Ratanak Kiri 2.1 372 964 2.6 134 350 Education No education 12.8 2,250 2,233 6.2 324 327 Primary 47.1 8,281 7,826 41.8 2,167 2,026 Secondary and higher 40.1 7,047 7,519 52.0 2,699 2,837 Wealth quintile Lowest 17.9 3,143 3,050 17.4 901 885 Second 18.9 3,314 3,057 18.4 954 930 Middle 19.2 3,381 2,798 20.0 1,040 867 Fourth 20.6 3,612 3,450 21.7 1,124 1,037 Highest 23.5 4,128 5,223 22.6 1,171 1,471 Total 100.0 17,578 17,578 100.0 5,190 5,190 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. The majority of Cambodians have some formal schooling, and educational levels of women have improved within the past 10 years. The percentage of women with no schooling declined from 28 percent in the 2000 CDHS to 19 percent in the 2005 CDHS, declined further to 16 percent in the 2010 CDHS, and finished at 13 percent in the 2014 CDHS. Moreover, the percentage of women who had at least some secondary education increased from 25 percent in 2005, to 35 percent in 2010, and reached 40 percent in 2014. However, Table 5.1 shows there are still notable differences in educational attainment between women and men. Twice as many women as men have no schooling (13 percent versus 6 percent), and men are more likely than women to have secondary education or higher (52 percent versus 40 percent). Respondent Characteristics • 49 5.2 EDUCATIONAL ATTAINMENT AND LITERACY Tables 5.2.1 and 5.2.2 present a detailed distribution of educational attainment among Cambodian women and men, according to background characteristics. The general pattern evident in Table 5.2.1 indicates a decrease in the proportion of women with no schooling from the oldest to the youngest cohorts. Men, with the exception of those in the 40-44 age group, exhibit the same pattern (Table 5.2.2). The data presented in Tables 5.2.1 and 5.2.2 provide evidence of an increase in educational attainment among the youngest age cohort. For example, 68 percent of women age 15-19 have attended secondary school, as compared with only 58 percent of women age 20-24. A similar trend is seen in young men, with 66 percent of those age 15-19 and 62 percent of those age 20-24 having attended some secondary school. Table 5.2.1 Educational attainment: Women Percent distribution of women age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Cambodia 2014 Highest level of schooling Total Median years completed Number of women Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 4.1 22.6 10.5 50.2 5.4 7.2 100.0 6.9 5,910 15-19 2.8 19.7 9.7 61.8 3.1 2.9 100.0 7.2 2,893 20-24 5.3 25.3 11.3 39.2 7.6 11.3 100.0 6.6 3,017 25-29 11.2 36.2 11.0 29.6 4.5 7.6 100.0 5.2 2,836 30-34 17.8 46.7 6.6 22.2 3.3 3.4 100.0 3.8 3,046 35-39 17.4 53.8 5.8 19.8 2.3 0.9 100.0 3.2 1,839 40-44 17.2 51.0 5.3 22.4 2.3 1.8 100.0 3.3 2,030 45-49 24.9 55.7 2.9 14.0 1.7 0.7 100.0 2.3 1,916 Residence Urban 5.4 23.5 5.7 39.8 8.9 16.6 100.0 7.5 3,251 Rural 14.5 42.6 8.5 29.8 2.6 1.9 100.0 4.3 14,327 Province Banteay Meanchey 12.8 46.3 7.1 27.7 4.0 2.1 100.0 4.2 689 Kampong Cham 14.1 43.1 9.9 28.4 2.7 1.8 100.0 4.0 2,021 Kampong Chhnang 8.7 41.1 8.7 33.6 4.3 3.5 100.0 5.0 662 Kampong Speu 11.0 39.2 11.2 35.4 1.9 1.3 100.0 5.0 1,196 Kampong Thom 14.0 46.9 8.8 23.6 3.7 3.0 100.0 3.7 851 Kandal 5.4 42.0 8.5 38.5 2.1 3.6 100.0 5.2 1,330 Kratie 15.6 50.1 7.7 22.1 2.6 1.9 100.0 3.3 488 Phnom Penh 4.1 23.7 5.3 39.6 7.8 19.5 100.0 7.6 1,994 Prey Veng 19.1 42.7 7.6 27.3 2.2 1.0 100.0 3.9 1,188 Pursat 16.3 41.0 10.5 26.5 4.0 1.7 100.0 4.2 631 Siem Reap 25.4 38.4 6.8 22.0 3.9 3.4 100.0 3.3 1,137 Svay Rieng 6.0 50.7 8.1 30.6 2.1 2.5 100.0 4.2 654 Takeo 11.7 32.6 6.1 40.8 5.3 3.5 100.0 5.6 1,082 Otdar Meanchey 26.4 37.2 7.8 24.9 2.8 0.9 100.0 3.3 294 Battambang/Pailin 10.0 35.1 7.9 36.6 5.1 5.3 100.0 5.6 1,333 Kampot/Kep 8.5 39.9 7.4 37.3 3.9 3.0 100.0 5.2 770 Preah Sihanouk/Koh Kong 9.6 38.8 9.6 32.3 4.0 5.6 100.0 5.2 422 Preah Vihear/Stung Treng 23.7 45.1 7.1 19.7 2.2 2.1 100.0 2.8 462 Mondul Kiri/Ratanak Kiri 34.5 32.9 6.0 23.8 1.4 1.3 100.0 2.3 372 Wealth quintile Lowest 27.9 50.4 7.0 14.0 0.6 0.1 100.0 2.2 3,143 Second 18.1 48.5 8.9 22.9 1.1 0.4 100.0 3.3 3,314 Middle 10.3 46.0 8.0 33.0 1.9 0.8 100.0 4.5 3,381 Fourth 7.1 34.1 9.3 40.2 5.2 4.0 100.0 5.8 3,612 Highest 4.1 21.7 6.9 43.7 8.6 15.1 100.0 7.6 4,128 Total 12.8 39.1 8.0 31.7 3.8 4.6 100.0 4.8 17,578 1 Completed 6th grade at the primary level 2 Completed 12th grade at the secondary level Urban women have higher levels of education than rural women. Almost two-thirds of urban women have attended at least some secondary school, as compared with only about one-third of rural women. Tables 5.2.1 and 5.2.2 show great variation in education across provinces. Mondul Kiri/Ratanak Kiri has an exceptionally low level of educational attainment among women (35 percent of women having no formal education) whereas Siem Reap has the lowest level among men (21 percent of men having no formal education). By contrast, only 4 percent of women and less than 1 percent of men in Phnom Penh have no schooling. Median number of years of education completed is highest in Phnom Penh (7.6 for women and 9.9 for men). 50 • Respondent Characteristics Educational attainment rises dramatically with wealth quintile. Twenty-eight percent of women in the lowest quintile have no formal education, as compared with 4 percent of women in the highest wealth quintile. The percentage of women who have attended some secondary school increases from 15 percent in the lowest wealth quintile to 67 percent in the highest. The pattern of variation in educational attainment by wealth among men is similar to that among women. Table 5.2.2 Educational attainment: Men Percent distribution of men age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Cambodia 2014 Highest level of schooling Total Median years completed Number of men Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 3.3 24.2 8.2 50.9 5.2 8.2 100.0 7.0 1,760 15-19 2.2 23.6 7.9 59.3 2.8 4.2 100.0 7.0 926 20-24 4.5 25.0 8.6 41.5 7.8 12.6 100.0 7.0 835 25-29 3.9 30.4 9.4 36.6 6.4 13.4 100.0 6.5 815 30-34 8.4 38.4 8.4 30.0 7.0 7.8 100.0 5.3 907 35-39 10.3 45.0 6.9 28.0 5.8 4.0 100.0 4.6 556 40-44 8.1 42.6 6.7 29.3 8.3 5.0 100.0 4.9 595 45-49 9.6 39.5 8.2 34.6 4.9 3.3 100.0 5.1 556 Residence Urban 1.0 14.9 5.1 42.2 10.0 26.8 100.0 9.0 869 Rural 7.3 37.4 8.7 37.5 5.3 3.7 100.0 5.5 4,321 Province Banteay Meanchey 7.5 40.0 5.5 38.7 4.2 4.2 100.0 5.3 192 Kampong Cham 5.2 45.5 10.0 30.1 2.5 6.7 100.0 4.9 663 Kampong Chhnang 4.6 41.3 8.9 31.4 7.3 6.5 100.0 5.5 182 Kampong Speu 6.7 24.9 12.4 48.6 5.5 1.9 100.0 6.3 323 Kampong Thom 8.7 42.1 10.6 30.5 3.2 4.9 100.0 4.9 232 Kandal 2.1 39.7 6.8 40.0 6.5 5.0 100.0 5.5 413 Kratie 3.6 45.1 5.2 33.2 8.3 4.5 100.0 5.2 143 Phnom Penh 0.3 11.2 3.7 43.4 10.2 31.2 100.0 9.9 550 Prey Veng 9.2 25.4 9.0 51.6 2.8 2.1 100.0 6.5 342 Pursat 8.0 41.3 12.6 30.6 5.8 1.8 100.0 5.1 184 Siem Reap 20.8 35.5 9.0 20.3 9.8 4.6 100.0 4.2 337 Svay Rieng 1.1 31.6 7.2 48.0 7.8 4.4 100.0 6.7 183 Takeo 4.1 29.9 7.9 45.8 6.9 5.4 100.0 6.9 334 Otdar Meanchey 13.0 38.4 8.7 33.1 6.1 0.8 100.0 4.8 99 Battambang/Pailin 2.3 29.9 9.0 46.3 5.7 6.8 100.0 6.7 405 Kampot/Kep 6.1 33.9 8.0 40.6 8.7 2.7 100.0 6.1 241 Preah Sihanouk/Koh Kong 4.7 29.0 8.1 39.5 8.2 10.5 100.0 6.7 120 Preah Vihear/Stung Treng 11.7 53.1 0.8 26.6 1.5 6.4 100.0 3.7 112 Mondul Kiri/Ratanak Kiri 16.4 36.9 6.3 30.8 3.9 5.7 100.0 4.6 134 Wealth quintile Lowest 15.7 53.4 8.2 20.5 1.5 0.7 100.0 3.3 901 Second 8.9 47.7 10.8 29.6 1.7 1.2 100.0 4.5 954 Middle 5.7 36.9 9.6 41.2 4.5 2.1 100.0 5.6 1,040 Fourth 2.9 26.3 8.3 49.0 8.2 5.4 100.0 6.9 1,124 Highest 0.6 11.1 4.3 46.3 12.5 25.2 100.0 9.2 1,171 Total 6.2 33.6 8.1 38.3 6.1 7.6 100.0 6.0 5,190 1 Completed 6th grade at the primary level 2 Completed 12th grade at the secondary level The 2014 CDHS assessed literacy levels among respondents who had never been to school or who had attended only primary school by asking them to read all or part of a sentence in whatever language they chose. Those with at least some secondary education were assumed to be literate. Literacy results are shown in Tables 5.3.1 and 5.3.2. Table 5.3.1 shows that 76 percent of women are literate, and Table 5.3.2 shows that 84 percent of men are literate. For women, those in the younger age groups are more likely to be literate than those in the older age groups. Literacy increases from 62 percent among women age 45-49 to 90 percent among women age 15-19. For men the negative relationship between literacy and age is less evident. The percentage of men who are literate is highest at age group 15-19 (89 percent). It decreases gradually to 76 percent among those age 35-39; then it reverses its pattern and is 83 percent among men age 40-49. Respondent Characteristics • 51 Table 5.3.1 Literacy: Women Percent distribution of women age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Cambodia 2014 Secondary school or higher No schooling or primary school Total Percentage literate1 Number of women Background characteristic Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Age 15-24 62.8 12.6 12.8 11.7 0.0 0.0 0.0 100.0 88.2 5,910 15-19 67.7 11.8 10.2 10.1 0.0 0.1 0.1 100.0 89.8 2,893 20-24 58.1 13.4 15.2 13.3 0.0 0.0 0.0 100.0 86.7 3,017 25-29 41.6 17.1 20.9 20.2 0.0 0.0 0.1 100.0 79.6 2,836 30-34 28.9 18.7 20.9 31.5 0.0 0.0 0.1 100.0 68.5 3,046 35-39 23.0 16.2 26.2 34.6 0.0 0.0 0.0 100.0 65.4 1,839 40-44 26.5 18.7 24.9 29.8 0.0 0.0 0.1 100.0 70.1 2,030 45-49 16.4 16.6 29.1 37.9 0.0 0.0 0.0 100.0 62.1 1,916 Residence Urban 65.4 14.8 10.3 9.5 0.0 0.0 0.1 100.0 90.5 3,251 Rural 34.3 16.2 22.3 27.1 0.0 0.0 0.1 100.0 72.8 14,327 Province Banteay Meanchey 33.8 12.1 26.6 27.5 0.0 0.0 0.0 100.0 72.5 689 Kampong Cham 32.9 12.0 29.9 25.2 0.0 0.0 0.0 100.0 74.8 2,021 Kampong Chhnang 41.5 14.0 24.9 19.5 0.0 0.0 0.0 100.0 80.5 662 Kampong Speu 38.5 15.0 18.6 27.8 0.0 0.0 0.0 100.0 72.2 1,196 Kampong Thom 30.3 18.7 30.1 20.9 0.0 0.0 0.0 100.0 79.1 851 Kandal 44.2 27.2 8.1 20.3 0.0 0.0 0.2 100.0 79.5 1,330 Kratie 26.6 28.4 15.0 29.8 0.0 0.0 0.3 100.0 69.9 488 Phnom Penh 66.9 17.2 7.2 8.6 0.0 0.0 0.1 100.0 91.3 1,994 Prey Veng 30.6 15.0 22.3 31.7 0.0 0.1 0.3 100.0 67.9 1,188 Pursat 32.2 4.7 35.4 27.7 0.0 0.0 0.0 100.0 72.3 631 Siem Reap 29.3 16.4 21.4 33.0 0.0 0.0 0.0 100.0 67.0 1,137 Svay Rieng 35.2 19.8 19.2 25.7 0.0 0.2 0.0 100.0 74.2 654 Takeo 49.5 12.3 18.1 20.0 0.0 0.0 0.0 100.0 80.0 1,082 Otdar Meanchey 28.6 2.3 27.7 41.2 0.2 0.0 0.0 100.0 58.6 294 Battambang/Pailin 47.0 22.2 14.9 15.9 0.0 0.0 0.0 100.0 84.1 1,333 Kampot/Kep 44.2 12.2 21.2 22.5 0.0 0.0 0.0 100.0 77.5 770 Preah Sihanouk/Koh Kong 42.0 14.6 27.3 16.0 0.0 0.0 0.1 100.0 83.9 422 Preah Vihear/Stung Treng 24.1 15.7 14.6 45.2 0.4 0.0 0.0 100.0 54.4 462 Mondul Kiri/Ratanak Kiri 26.5 2.1 24.5 46.9 0.0 0.0 0.0 100.0 53.1 372 Wealth quintile Lowest 14.7 12.5 27.4 45.3 0.0 0.1 0.0 100.0 54.6 3,143 Second 24.4 17.0 24.4 34.0 0.1 0.0 0.0 100.0 65.8 3,314 Middle 35.7 17.8 23.6 22.8 0.0 0.0 0.1 100.0 77.1 3,381 Fourth 49.5 16.6 17.8 16.0 0.0 0.0 0.1 100.0 83.9 3,612 Highest 67.4 15.5 10.0 7.0 0.0 0.0 0.0 100.0 92.9 4,128 Total 40.1 15.9 20.1 23.9 0.0 0.0 0.1 100.0 76.1 17,578 1 Refers to women who attended secondary school or higher and women who can read a whole sentence or part of a sentence Ninety-one percent of women residing in urban areas are literate, as compared with 73 percent of their rural counterparts. Similarly, urban men show higher rates of literacy than rural men (95 percent and 82 percent, respectively). Differences in literacy across provinces are marked, with the highest literacy rate among women in Phnom Penh (91 percent) and the lowest among women in Mondul Kiri/Ratanak Kiri (53 percent). Among men, literacy is also highest in Phnom Penh (96 percent) and lowest in Preah Vihear/Stung Treng (76 percent). Literacy levels increase along with wealth status among both women and men. For example, literacy levels increase from 55 percent among women in the lowest wealth quintile to 93 percent among women in the highest wealth quintile and from 67 percent among men in the lowest wealth quintile to 98 percent among men in the highest wealth quintile. Women’s overall literacy rate has continued to increase since the 2000 CDHS (67 percent in 2000 versus 69 percent in 2005, 74 percent in 2010, and 76 percent in 2014). The difference in the literacy rates among Cambodian men between 2010 (83 percent) and 2014 (84 percent) is very minimal. 52 • Respondent Characteristics Table 5.3.2 Literacy: Men Percent distribution of men age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Cambodia 2014 Secondary school or higher No schooling or primary school Total Percentage literate1 Number of men Background characteristic Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Age 15-24 64.3 6.1 17.8 11.8 0.1 0.0 0.0 100.0 88.1 1,760 15-19 66.4 6.1 16.4 11.0 0.2 0.0 0.0 100.0 88.8 926 20-24 61.9 6.1 19.3 12.7 0.0 0.0 0.0 100.0 87.3 835 25-29 56.4 11.3 18.9 13.0 0.0 0.4 0.0 100.0 86.6 815 30-34 44.8 13.3 22.5 19.3 0.1 0.0 0.0 100.0 80.6 907 35-39 37.7 16.4 22.3 23.6 0.0 0.0 0.0 100.0 76.4 556 40-44 42.7 13.8 26.2 17.2 0.0 0.0 0.1 100.0 82.6 595 45-49 42.8 15.6 24.7 16.9 0.0 0.0 0.0 100.0 83.1 556 Residence Urban 78.9 6.7 9.1 5.3 0.0 0.0 0.0 100.0 94.7 869 Rural 46.6 12.1 23.4 17.8 0.1 0.1 0.0 100.0 82.0 4,321 Province Banteay Meanchey 47.0 1.1 36.2 15.6 0.0 0.0 0.0 100.0 84.4 192 Kampong Cham 39.3 17.4 24.6 18.2 0.0 0.5 0.0 100.0 81.3 663 Kampong Chhnang 45.2 13.0 25.2 16.1 0.0 0.0 0.5 100.0 83.4 182 Kampong Speu 56.0 5.7 17.8 20.5 0.0 0.0 0.0 100.0 79.5 323 Kampong Thom 38.6 23.4 22.3 15.7 0.0 0.0 0.0 100.0 84.3 232 Kandal 51.5 12.3 14.7 21.5 0.0 0.0 0.0 100.0 78.5 413 Kratie 46.1 13.0 24.6 16.3 0.0 0.0 0.0 100.0 83.7 143 Phnom Penh 84.8 4.5 6.3 4.4 0.0 0.0 0.0 100.0 95.6 550 Prey Veng 56.5 7.8 20.5 15.2 0.0 0.0 0.0 100.0 84.8 342 Pursat 38.2 16.1 30.2 15.5 0.0 0.0 0.0 100.0 84.5 184 Siem Reap 34.7 9.8 36.1 19.0 0.5 0.0 0.0 100.0 80.5 337 Svay Rieng 60.1 11.9 14.6 13.3 0.0 0.0 0.0 100.0 86.7 183 Takeo 58.1 10.5 13.6 17.8 0.0 0.0 0.0 100.0 82.2 334 Otdar Meanchey 40.0 3.1 38.9 17.9 0.0 0.0 0.0 100.0 82.1 99 Battambang/Pailin 58.8 22.5 8.2 10.5 0.0 0.0 0.0 100.0 89.5 405 Kampot/Kep 52.0 0.6 29.2 18.3 0.0 0.0 0.0 100.0 81.7 241 Preah Sihanouk/Koh Kong 58.2 20.6 12.5 8.7 0.0 0.0 0.0 100.0 91.3 120 Preah Vihear/Stung Treng 34.5 5.1 35.9 24.5 0.0 0.0 0.0 100.0 75.5 112 Mondul Kiri/Ratanak Kiri 40.4 0.0 39.8 19.4 0.4 0.0 0.0 100.0 80.2 134 Wealth quintile Lowest 22.8 11.6 33.0 32.6 0.1 0.0 0.0 100.0 67.4 901 Second 32.6 14.0 31.2 22.0 0.2 0.0 0.0 100.0 77.8 954 Middle 47.7 14.2 21.1 17.0 0.0 0.0 0.1 100.0 83.0 1,040 Fourth 62.5 10.8 17.0 9.5 0.0 0.3 0.0 100.0 90.2 1,124 Highest 84.0 6.3 7.1 2.5 0.0 0.0 0.0 100.0 97.5 1,171 Total 52.0 11.2 21.0 15.7 0.0 0.1 0.0 100.0 84.1 5,190 1 Refers to men who attended secondary school or higher and men who can read a whole sentence or part of a sentence 5.3 ACCESS TO MASS MEDIA The 2014 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 5.4.1 shows that 69 percent of women have some weekly exposure to mass media. Watching television is the most common way of accessing the media: 61 percent of women watch television at least once a week. Listening to the radio is also common (32 percent of women listen at least once a week), with newspapers being the least utilized form of media (8 percent read a newspaper at least once a week). There is no strong pattern in access to the three types of media by age. The youngest group of women (age 1

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