Kazakhstan: Monitoring the situation of children and women: Multiple Indicator Cluster Survey (2006)

Publication date: 2006

KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 I KAZAKHSTAN Multiple Indicator Cluster Survey 2006 Monitoring the situation of children and women United Nations Children’s Fund Agency of the Republic of Kazakhstan on Statistics United States Agency for International Development United Nations Population Fund United Nations Resident Coordinator International Labour Organization Contributor’s to the Report: Erbolat Mussabek Gyulnar Kukanova Gaziza Moldakulova Kazakhstan Multiple Indicator Cluster Survey (MICS) first conducted in Kazakhstan in 2006 by the Agency of the Republic of Kazakhstan on Statistic in collaboration with the Republican State Enterprise “Data Computing Centre”. Financial, methodological and technical support was provided by the United Nations Children’s Fund (UNICEF) and with financial support of United States Agency for International Development (USAID), United Nations Population Fund (UNFPA), UN Resident Coordinator Fund (UN ResCor) and International Labour Organization (ILO). The survey has been conducted as part of the third round of MICS surveys (MICS3), carried out around the world in more than 50 countries, in 2005-2006, following the first two rounds of MICS surveys that were conducted in 1995 and the year 2000. Survey tools are based on the models and standards developed by the global MICS project, designed to collect information on the situation of children and women in countries around the world. Additional information on the global MICS project may be obtained from www.childinfo.org. Suggested citation: United Nations Children’s Fund (UNICEF), Agency of the Republic of Kazakhstan on Statistic © Agency of the Republic of Kazakhstan on Statistics, 2007 © UNICEF, Kazakhstan 2007 Any information from this publication may be freely reproduced, but proper acknowledgement of the source must be provided. The publication is not for sale Agency of the Republic of Kazakhstan on Statistics 010000, Astana City, Left Bank of Ishim River The House of Ministries, 35th Street, 4th Gate Fax: (7172) 74-94-94 E-Mail: stat@mail.online.kz United Nations Children’s Fund (UNICEF) in the Republic of Kazakhstan 010000, Astana City, 10A, Beibitshilik str., Block 1 Tel: (+7 7172) 32-17-97, 32-29-69 Fax: (+7 7172) 32-18-03 Web: www.unicef.org KAZAKHSTAN Multiple Indicator Cluster Survey 2006 Final Report Astana, 2007 MONITORING THE SITUATION OF CHILDREN AND WOMENii Summary Table of Findings Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Kazakhstan, 2006 Topic MICS Indicator Number MDG Indicator Number Indicator Value CHILD MORTALITY Child mortality 1 13 Under-five mortality rate 36.3 per thousand 2 14 Infant mortality rate 31.8 per thousand NUTRITION Nutritional status 6 4 Underweight prevalence 4.0 percent 7 Stunting prevalence 12.8 percent 8 Wasting prevalence 3.8 percent Breastfeeding 45 Timely initiation of breastfeeding 64.2 percent 15 Exclusive breastfeeding rate 16.8 Percent 16 Continued breastfeeding rate at 12-15 months at 20-23 months 57.1 16.2 percent percent 17 Timely complementary feeding rate 39.1 percent 18 Frequency of complementary feeding 24.0 percent 19 Adequately fed infants 20.7 percent Salt iodization 41 Iodized salt consumption 92.0 percent Low birth weight 9 Low birth weight infants 5.8 percent 10 Infants weighed at birth 99.4 percent CHILD HEALTH Immunization 25 Tuberculosis immunization coverage 97.9 percent 26 Polio immunization coverage 93.9 percent 27 DPT immunization coverage 91.7 percent 28 15 Measles immunization coverage 94.7 percent 31 Fully immunized children 81.0 percent 29 Hepatitis B immunization coverage 92.3 percent KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 iii Care of illness 33 Use of oral rehydration therapy (ORT) 74.0 percent 34 Home management of diarrhoea 21.8 percent 35 Received ORT or increased fluids, and continued feeding 48.0 percent 23 Care seeking for suspected pneumonia 70.5 percent 22 Antibiotic treatment of suspected pneumonia 31.7 percent Solid fuel use 24 29 Solid fuels 19.0 percent ENVIRONMENT Water and Sanitation 11 30 Use of improved drinking water sources 93.7 percent 13 Water treatment 70.8 percent 12 31 Use of improved sanitation facilities 99.2 percent 14 Disposal of child’s faeces 31.4 percent REPRODUCTIVE HEALTH Contraception 21 19c Contraceptive prevalence 50.7 percent Maternal and newborn health 20 Antenatal care 99.9 percent 44 Content of antenatal care Weight measured Blood pressure measured Urine specimen taken Blood test taken 99.5 99.5 99.5 99.5 percent percent percent percent 4 17 Skilled attendant at delivery 99.8 percent 5 Institutional deliveries 99.8 percent Maternal mortality 3 16 Maternal mortality ratio 70 per 100 000 CHILD DEVELOPMENT Child development 46 Support for learning 81.0 percent 47 Father’s support for learning 46.9 percent 48 Support for learning: children’s books 66.4 percent 49 Support for learning: non-children’s books 89.1 percent 50 Support for learning: materials for play 19.8 percent 51 Non-adult care 9.8 percent MONITORING THE SITUATION OF CHILDREN AND WOMENiv EDUCATION Education 52 Pre-school attendance 16.0 percent 53 School readiness 39.5 percent 54 Net intake rate in primary education 92.9 percent 55 6 Net primary school attendance rate 98.0 percent 56 Net secondary school attendance rate 95.3 percent 57 7 Children reaching grade five 99.7 percent 58 Transition rate to secondary school 99.7 percent 59 7b Primary completion rate 88.4 percent 60 8 Adult literacy rate 99.8 percent 61 9 Gender parity index primary school secondary school 0.99 1.00 ratio ratio CHILD PROTECTION Birth registration 62 Birth registration 99.2 percent Child labor 71 Child labor 2.2 percent 72 Laborer students 94.3 percent 73 Student laborers 2.3 percent Child discipline 74 Child discipline Any psychological/physical punishment 52.2 percent Early marriage 67 Marriage before age 15 Marriage before age 18 0.4 8.5 percent percent 68 Young women aged 15-19 currently married/in union 4.9 percent 69 Spousal age difference (>10 years) Women aged 20-24 7.4 percent Domestic violence 100 Attitudes towards domestic violence 10.4 percent KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 v HIV/AIDS HIV/AIDS knowl- edge and attitudes 83 19b Comprehensive knowledge about HIV prevention among young people 22.4 percent 89 Knowledge of mother- to-child trans- mission of HIV 54.5 percent 86 Attitude towards people with HIV/AIDS 3.8 percent 87 Women who know where to be tested for HIV 83.5 percent 88 Women who have been tested for HIV 61.7 percent 90 Counselling coverage for the preven- tion of mother-to-child transmission of HIV 82.4 percent 91 Testing coverage for the prevention of mother-to-child transmission of HIV 78.8 percent TUBERCULOSIS Tuberculosis knowledge Awareness of tuberculosis 99.4 percent Knowledge of TB transmission by air 94.9 percent Knowledge of recovery after tuberculo- sis at proper treatment 79.0 percent Women who were sick or have a family member with TB 5.0 percent Women who communicate with neighbours, colleagues or close friends suffering from TB 7.5 percent INFORMATION SOURCES Sources of main information for households Households receiving information from TV 97.7 percent Households receiving information from newspapers 66.4 percent Households receiving information from friends, relatives, neighbours and col- leagues 54.1 percent MONITORING THE SITUATION OF CHILDREN AND WOMENvi Summary Table of Findings . . . . . . . . . . . . . . . . . . . . .ii List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .x List of Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Foreword and Acknowledgments . . . . . . . . . . . . xii Executive Summary . . . . . . . . . . . . . . . . . . . . . 1 I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 7 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Survey objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 II. Sample and Survey Methodology . . . .10 Sample design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Training and fieldwork . . . . . . . . . . . . . . . . . . . . 14 Data Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 III. Sample Coverage and the Characteristics of Households and Respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Sample Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Characteristics of Households . . . . . . . . . . . . 17 Characteristics of Respondents . . . . . . . . . . . 19 Sources of information for the family . . . . 20 IV. Child mortality . . . . . . . . . . . . . . . . . . . . . .21 V. Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Nutritional Status . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Salt iodization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Low Birth Weight . . . . . . . . . . . . . . . . . . . . . . . . . . 30 VI. Child Health . . . . . . . . . . . . . . . . . . . . . . . . .32 Immunization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Oral Rehydration Treatment . . . . . . . . . . . . . . 35 Care Seeking and Antibiotic Treatment of Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Solid Fuel Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 VII. Environment . . . . . . . . . . . . . . . . . . . . . . .39 Water and Sanitation . . . . . . . . . . . . . . . . . . . . . . 40 VIII. Reproductive Health . . . . . . . . . . . . . .43 Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Reproductive Behavior . . . . . . . . . . . . . . . . . . . . 44 Antenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Assistance at Delivery . . . . . . . . . . . . . . . . . . . . . . 46 Maternal Mortality . . . . . . . . . . . . . . . . . . . . . . . . . 47 IX. Child Development . . . . . . . . . . . . . . . . .48 X. Education . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 Pre-School Attendance and School Readiness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Primary and Secondary School Participation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Adult Literacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 XI. Child Protection . . . . . . . . . . . . . . . . . . . . .55 Birth Registration . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Child Labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Child Discipline . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Early Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Domestic Violence . . . . . . . . . . . . . . . . . . . . . . . . 60 XII. HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . .61 Knowledge of HIV Transmission . . . . . . . . . . 61 XIII. Tuberculosis . . . . . . . . . . . . . . . . . . . . . .64 Knowledge of Tuberculosis . . . . . . . . . . . . . . . . 64 List of References . . . . . . . . . . . . . . . . . . . . . . .66 Appendix A. Sample design . . . . . . . . . . . . . . . . .154 Appendix B. List of Personnel Involved in the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .158 Appendix C. Estimates of Sampling Errors . .162 Appendix D. Data Quality Tables . . . . . . . . . . .183 Appendix E. MICS indicators: Numerators and Denominators . . . . . . . . . . . . . . . . . . . . . . . . . . .190 Appendix F. Questionnaires . . . . . . . . . . . . . . . .194 Table of Contents KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 vii List of Tables Table HH.1: Results of household and individual interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Table HH.2: Household age distribution by sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Table HH.3: Household composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Table HH.4: Women’s background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Table HH.5: Children’s background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Table НН. 6: Resources of the main information for households . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Table CM.1: Early child mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Table CM.2: Children ever born and proportion dead . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Table NU.1: Child malnourishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Table NU.2: Initial breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Table NU.3: Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Table NU.4: Adequately fed infants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Table NU.5: Iodized salt consumption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Table NU.8: Low birth weight infants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Table CH.1: Vaccinations in first year of life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Table CH.1C: Vaccinations in first year of life (continued) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Table CH.2: Vaccinations by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Table CH.2C: Vaccinations by background characteristics (continued) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Table CH.4: Oral rehydration treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Table CH.5: Home management of diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Table CH.6: Care seeking for suspected pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Table CH.7: Antibiotic treatment of pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Table CH.7A: Knowledge of the two danger signs of pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Table CH.8: Solid fuel use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Table CH.9: Solid fuel use by type of stove or fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Table EN.1: Use of improved water sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Table EN.2: Household water treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Table EN.3: Time to source of water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Table EN.4: Person collecting water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Table EN.5: Use of sanitary means of excreta disposal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Table EN.5W: Number of households using improved sanitation facilities (worksheet) . . . . . . . . . . . . . .100 Table EN.6: Disposal of child’s faeces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .102 Table EN.7: Use of improved water sources and improved sanitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103 MONITORING THE SITUATION OF CHILDREN AND WOMENviii Table RH.1: Use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104 Table RH.2A: Reproductive behavior of women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106 Table RH.2B: Factors limiting birth rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .108 Table RH.2C: Factors stimulating birth rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .110 Table RH.3: Antenatal care provider. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .112 Table RH.4: Antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .114 Table RH.5: Assistance during delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .116 Table RH.6: Maternal mortality ratio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .118 Table CD.1: Family support for learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .119 Table CD.2: Learning materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121 Table CD.3: Children left alone or with other children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .123 Table ED.1: Early childhood education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .124 Table ED.2: Primary school entry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .125 Table ED.3: Primary school net attendance ratio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .126 Table ED.4: Secondary school net attendance ratio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .127 Table ED.4W: Secondary school age children attending primary school . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .128 Table ED.5: Children reaching grade 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .129 Table ED.6: Primary school completion and transition to secondary education . . . . . . . . . . . . . . . . . . . .130 Table ED.7: Education gender parity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .131 Table ED.8: Adult literacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .132 Table CP.1: Birth registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133 Table CP.2: Child labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .134 Table CP.3: Laborer students and student laborers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .135 Table CP.4: Child discipline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .136 Table CP.5: Early marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137 Table CP.6: Spousal age difference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138 Table CP.9: Attitudes toward domestic violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139 Table HA.1: Knowledge of preventing HIV transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .140 Table HA.2: Identifying misconceptions about HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .141 Table HA.3: Comprehensive knowledge of HIV/AIDS transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .142 Table HA.4: Knowledge of mother-to-child HIV transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .143 Table HA.5: Attitudes toward people living with HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .144 Table HA.6: Knowledge of a facility for HIV testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145 Table HA.7: HIV testing and counseling coverage during antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . .146 Table TB.1: Knowledge about tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .147 KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 ix Table TB.2: Symptoms of suspected tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .149 Table TB.3: TB symptoms, which require seeing a doctor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151 Table TB.4: Attitudes towards people with TB. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .153 Table SD.1. Allocation of sample clusters (primary sampling units) to Sampling Domains . . . . . . . . .155 Table SE.1. Indicators selected for sampling error calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .163 Table SE.2. Sampling errors: total sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .164 Table SE.3. Sampling errors: urban areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .165 Table SE.4. Sampling errors: rural areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .166 Table SE.5. Sampling errors: Akmola Oblast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .167 Table SE.6. Sampling errors: Aktobe Oblast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .168 Table SE.7. Sampling errors: Almaty Oblast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .169 Table SE.8. Sampling errors: Atyrau Oblast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .170 Table SE.9. Sampling errors: West Kazakhstan Oblast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .171 Table SE.10. Sampling errors: Zhambyl Oblast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .172 Table SE.11. Sampling errors: Karagandy Oblast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .173 Table SE.12. Sampling errors: Kostanai Oblast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .174 Table SE.13. Sampling errors: Kyzylorda Oblast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .175 Table SE.14. Sampling errors: Mangistau Oblast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .176 Table SE.15. Sampling errors: South Kazakhstan Oblast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .177 Table SE.16. Sampling errors: Pavlodar Oblast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .178 Table SE.17. Sampling errors: North Kazakhstan Oblast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .179 Table SE.18. Sampling errors: East Kazakhstan Oblast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .180 Table SE.19. Sampling errors: Astana City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .181 Table SE.20. Sample errors: Almaty City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .182 Table DQ.1. Age distribution of household members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .183 Table DQ.2. Age distribution of eligible and interviewed women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .184 Table DQ.3. Age distribution of eligible and interviewed under-5s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .184 Table DQ.4. Age distribution of under 5 children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .185 Table DQ.5. Heaping on ages and periods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .186 Table DQ.6. Completeness of reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187 Table DQ.7. Presence of mother in the household and the person interviewed for the under-5 questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .188 Table DQ.8. School attendance by single age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .188 Table DQ.9. Sex ratio at birth among children ever born and living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189 Table DQ.10. Distribution of women by time since last birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .189 MONITORING THE SITUATION OF CHILDREN AND WOMENx List of Figures Figure HH.2. Age and sex distribution of household population, %, Kazakhstan, 2006 . . . . . . . . 18 Figure CM.1. Infant Mortality by Sources, Kazakhstan, 2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Figure CM.1А. Under Five Mortality Rate, Kazakhstan, 2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Figure CM.1В. Under Five Mortality Tendency, Kazakhstan, 2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Figure NU.1. Percentage of children under 5 who are undernourished, Kazakhstan, 2006 . . . . 26 Figure NU.2. Percentage of mothers who started breastfeeding within one hour and within one day of birth, Kazakhstan, 2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Figure NU.3. Infant feeding patterns by age: Percent distribution of children aged under 3 years by feeding pattern by age group, Kazakhstan, 2006 . . . . . . . . . . . . . . . . . . . . . . . . . .29 Figure NU.5. Percentage of households consuming adequately iodized salt, Kazakhstan, 2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Figure NU.8. Percentage of Infants Weighing Less Than 2500 Grams at Birth, Kazakhstan, 2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Figure CH.1. Percentage of children aged 15-26 months who received the recommended vaccinations by 12 months, Kazakhstan, 2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Figure CH.5. Percentage of children aged 0-59 with diarrhoea who received ORT or increased fluids, AND continued feeding, Kazakhstan, 2006, % . . . . . . . . . . . . . . . . 36 Figure EN.1. Percentage distribution of population by source of drinking water, Kazakhstan, 2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Figure HA.1. Percent of women who have comprehensive knowledge of HIV/AIDS transmission, Kazakhstan, 2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 xi ADB Asian Development Bank AIDS Acquired Immune Deficiency Syndrome BCG Bacillis-Cereus-Geuerin (Tuberculosis) DHS Demography and Health Survey DPT Diphtheria Pertussis Tetanus vaccine EPI Expanded Programme on Immunization GCR Gender Correlation Rate GPI Gender Parity Index HIV Human Immunodeficiency Virus HMRS Home-made Rehydration Solution IDD Iodine Deficiency Disorders ILO International Labour Organization IQ Intelligence Quotient IMR Infant Mortality Rate IUD Intrauterine Device MDG Millennium Development Goals MICS Multiple Indicator Cluster Survey MMR Mumps, Measles, Rubella MoH Ministry of Health NAR Net Attendance Rate ORT Oral Rehydration Therapy ORS Oral Rehydration Salt PLWHA People Living with HIV/AIDS PPS Packed Powder Solution ppm Parts Per Million PSU Primary Sampling Units ResCor UN Resident Coordinator Fund RSE DCC AS Republican State Enterprise, Data Computing Centre of the Agency RK on Statistics AS RK Agency of the Republic of Kazakhstan on Statistic SPSS Statistical Package for Social Sciences STI Sexually Transmitted Infections UNAIDS United Nations Programme on HIV/AIDS UNDAF United Nations Development Assistance Framework UNDP United Nations Development Programme UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund U5MR Under-Five Mortality Rate WFFC World Fit for Children WHO World Health Organization List of Abbreviations MONITORING THE SITUATION OF CHILDREN AND WOMENxii Foreword and Acknowledgments The Kazakhstan Multiple Indicator Cluster Survey (MICS) was first conducted in 2006 with the pur- pose of obtaining information to assess progress towards the situation of children and women in Kazakhstan required for monitoring the Millennium Development Goals (MDGs) and objectives of the World Fit for Children document (WFFC) and other documents agreed at international level. Because of significant discrepancies in social and economic development of the regions of the coun- try, the Kazakhstan MICS was conducted at sub-national level as well, which makes it unique. I hope the survey findings will be useful for the Government and civil society institutes in planning and de- veloping social programs that meet the requirements of the real situations and needs of women and children both at national level and at the level of each region and oblast. The success of MICS and publication of the current Report is the work of many experts at different levels. We would like to mention the following international organizations working in Kazakhstan: United Nations Children’s Fund (UNICEF) for methodological, technical and financial support as well as the US Agency for International Development (USAID), the United Nations Population Fund (UNFPA), the UN Resident Coordinator’s Fund (ResCor) and the UN International Labor Organization (ILO) for their significant financial support. I also express thanks to the staff of the UNICEF Office in Kazakhstan in the person of Mr. Alexander Zouev, UNICEF Representative in Kazakhstan and Mr. Raimbek Sissemaliev, Head of Almaty Zone Office, UNICEF Project Coordinator, Kazakhstan, for technical, methodical and financial sup- port during training of staff from the Agency RK on Statistics and permanent support in preparation and implementation of the current survey; great thanks to Ms. Gaziza Moldakulova, MICS Project Coordinator, UNFPA Kazakhstan, for coordination of UN agencies involved in the MICS Project as well as for collaboration in preparation of financial reports and the current MICS report. I express thanks to UNICEF staff members, who conducted training workshops, developed question- naires and programs for data entry and calculation of indicators, accomplished general manage- ment as well as provided consultations during preparation, implementation and processing the out- comes of current global survey, in particular: MICS-3 Project Coordinator from UNICEF Regional Office Mr. George Sakvarelidze (Geneva, Switzerland) for his maximal assistance to the staff of the Agency in preparation and carrying out this survey in Kazakhstan. We express special gratitude to Mr. Anthony Turner, International Consultant on Sampling (USA) for his expert assistance in Kazakhstan MICS sampling and Mr. Muktar Minbayev, Project Coordinator on Monitoring and Evaluation, UNICEF, Kyrgyzstan, who provided invaluable assist- ance during sampling. Moreover, I would like to highlight local authorities of all levels who provided support during the im- plementation of the project, who provided valuable assistant to MICS field teams during the survey and data collection. In addition, I would like to express high appreciation to members of Coordination Committee on MICS preparation and implementation in Kazakhstan, ministries and agencies of the Republic, the non-governmental sector and international institutions concerned with MICS findings, which ex- pressed their comments and proposals to the current report. Chair Anar Meshimbayeva Agency of the Republic of Kazakhstan KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 xiii 1 Project participants occupied these positions the years MICS was prepared and implemented (2005-2007). Foreword and Acknowledgments I have great pleasure in presenting the Final Report on findings of Multiple Indicator Cluster Survey first held in Kazakhstan in 2006. This is a unique survey based on methodology developed and used by UNICEF in many countries in the world but has an essential feature, since it was conducted not only at the national scale. Unlike in many other countries focusing mainly on the national level, MICS in Kazakhstan was conducted at the sub-national level, which allowed obtaining more complete and reliable picture on social status of children, women and families in the entire country as well as in every region. The survey was based, in large part, on the need to monitor progress towards goals and targets emanat- ing from recent international agreements – the Millennium Declaration, adopted by all United Nations Member States in September 2000, and the Plan of Action of a “World Fit For Children”, adopted by 189 Member States at the United Nations Special Session on Children in May 2002. The success of MICS is the work of many experts from the Agency RK on Statistic and its territorial divi- sions as well as structural subdivision of RSE Data Computing Center. In this regard I sincerely appreciate the assistance of Mr. Kali Abdiyev, the Chair of the Agency RK on Statistics, who launched this Project, made all the necessary arrangements and established an environ- ment for successful Project implementation, Mr. Bakhyt Sultanov and Ms. Anar Meshimbayeva, who provided support to the MICS as Chairs of the Agency RK on Statistics, and express particular ap- preciation and gratitude to Mr. Yuri Shokamanov, Deputy Chair for their ongoing support in further MICS implementation.1 I would like to specially thank Mr. Yerbolat Mussabek, Deputy Director of Social and Demography Statistics Department of the Agency RK on Statistics, National MICS Coordinator, for coordination of all structures involved in the Project as well as planning of MICS preparation and implementation, formation of field teams for data collection, development of training techniques and arrangement of training workshops and Ms. Gulnar Kukanova, Head of the Population Statistics Division of the Social and Demography Statistics Department of the Agency RK on Statistics for training of field teams staff at regional training workshops and assistance in development and adaptation of MICS tools, and also Ms. Zinagul Dzhumanbayeva, Director of the Republican State Enterprise «Data Computing Centre» of the Agency RK on Statistics (RSE DCC AS) and her team for leading arrangements and work- ing with the financial reports of the executive partner of the Project; Ms. Aigul Kapisheva, Head of the Department on Databases Processing (RSE DCC AS) for adaptation of MICS software to the condi- tions of Kazakhstan and its accommodation; Ms. Saule Dauylbayeva, Head of Population Register Dataware Division (RSE DCC AS) and her team for the high quality entering of primary data and for- mation of the MICS database. In addition to the main activities of the Agency RK on Statistics within the current survey, the staff of the Kazakh Academy of Nutrition, our long standing and reliable partner, conducted study on food con- sumption frequency, prevalence of IDD and IDA among women and prevalence of Vitamin A Deficiency among children under 5. Findings of this study will be presented in second volume of the MICS Report due in the beginning 2008. Having this opportunity I would like to thank personally Professor Toregeldy Sharmanov, the President of the Kazakh Academy of Nutrition, and his staff, particularly Professor Shamil Tajibayev for successful completion of this work. I highly appreciate the assistance of the Heads of Oblast/City Departments on Statistics of the Republic of Kazakhstan for provision of human resources – state servants – for fieldwork and their invalu- able contribution to arranging the survey as well as work of the staff of the Regional Departments on Statistics, involved in fieldwork on data collection in the severe winter conditions in 2006. I would like to specially acknowledge the work of field team supervisors for due level of fieldwork arrangement and implementation, development of optimal routes for the teams; interviewers for high-quality and MONITORING THE SITUATION OF CHILDREN AND WOMENxiv timely fieldwork on data collection in compliance with MICS requirements, editors – for quality ques- tionnaires editing, anthropometric measurements and timely delivery of questionnaires to the central office, drivers for timely and safe delivery of teams to remote settlements as per tight schedule. I have to emphasize that implementation of the MICS project became possible in Kazakhstan not only due to financial and overall support of UNICEF but also due to substantial contribution of our reliable UN family partners into the process, primarily United Nations Population Fund (UNFPA) and also UN Resident Coordinator Fund, International Labor Organization (ILO), and certainly our main donor partner the United States Agency for International Development (USAID). Implementation of MICS allowed to train many relevant professionals and technical staff in the coun- try. I believe that state agencies would continue use their capacity and the methodology in other similar surveys concerning social and economical issues of the country as well as to measure their progress. The report contains a lot of interesting information about the status of women and children in Kazakhstan and will be of use for state bodies, non-governmental organizations, international insti- tutes, professors and students as well as the general public. UNICEF Representative in the Republic of Kazakhstan Alexandre Zouev KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 1 EXECUTIVE SUMMARY MONITORING THE SITUATION OF CHILDREN AND WOMEN2 Characteristics of households In 14,564 surveyed households resided 51,261 people. Of them 48.2 percent were males and 51.8 percent females. The average household size was 3.5 people. The major number of households con- sisted of 2-3 people (41 percent) and 4-5 people (32.4 percent). The proportion of households with at least one child under 18 was 56.7 percent; in 21.8 percent of households lived children under 5, the proportion of households with at least one woman aged 15-49 was 70.6 percent. The proportion of children under 15 years made 24.1 percent, persons aged 15-64 – 67.2 percent, people over 65 – 8.7 percent and the number of children aged 0-17 years made 30.3 percent of the total number of surveyed household members. In total, the number of reproductive age women (15-49 years) made 54.9 percent. At the time of the sur- vey, 57.4 percent of interviewed women were married or in union, 14.1 percent – divorced/separated/ widowers and 28.6 percent – never married. According to maternal status – 66.8 percent women had given birth. 13.4 percent of reproductive age women have primary or incomplete secondary education, 33.6 percent have completed secondary education, 27.1 percent have specialized secondary and 25.9 percent – higher education. As for wealth levels the poorest and poor quintiles are represented approxi- mately by the same indicator 18.5-18.7 percent, middle – 19.4 percent, rich – 20 percent and richest 23.4 percent, where reproductive age women resided. Among interviewed women 59.1 percent were Kazakhs, and 30.8 percent Russians. The number of children under 5 was 7.8 percent. 51 percent of children lived in urban areas and 49 percent – in rural areas. Age of children: under 6 months – 8.7 percent, 6-11 months – 10.5 percent, 12-23 months – 21.9 percent, 24-35 months –21.5 percent, 36-47 months – 19.4 percent and 48-59 months – 18 percent. Sources of Information for Family Almost all residents (over 97 percent) of Kazakhstan obtain information for the family, mainly from TV. The second source of information for 66 percent of the population is newspapers. The third prevalent source of information for Kazakhstan citizens are friends, siblings, neighbors and col- leagues. The next source of information reported by over one quarter (25.4 percent) of population was radio. Over 18 percent of Kazakhstan people get information from magazines. Outdoor adver- tisement and posters (9.4 percent), as well as the Internet (4.7 percent) are not very popular among respondents. The popularity of some information sources mainly depends on education level and wealth of population as well as regions and area of residence, and of course, access to some sources, for instance, the Internet. Infant and child mortality The infant mortality rate (IMR) is estimated at 31.8 per thousand life births, while the probability of dying before the age 5 is around 36.3 per thousand live births. Boys’ mortality significantly exceeds girls’ and makes 36.6 and 26.6 per thousand respectively for IMR, and 41.7 and 30.3 per thousand livebirths respectively for under 5 mortality. Nutrition Status In Kazakhstan 4 percent of children under 5 are moderately underweight (weight for age) and 0.8 percent are classified as severely underweight, at that, 3.8 percent of children are wasted (weight for height) and 1 percent severely wasted. At the same time, 12.8 percent of children in the country are stunted for their age and the height of 4 percent is too short for their age. KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 3 Breastfeeding 64.2 percent started breastfeeding within one hour of birth; the urban-rural difference was 4.4 per- cent – urban women 66.3 percent and 61.9 of rural women. 87.8 percent started breastfeeding with- in one day of birth (which includes those who started within one hour), the percentage of such women in urban and rural settlements is almost the same (87.7 and 88 percent respectively). 16.8 percent of children aged less than six months are exclusively breastfed, a level considerably lower than recommended. At aged 6-9 months, 39.1 percent of children are receiving breast milk and solid or semi-solid foods. By age 12-15 months, 57.1 percent of children are still being breastfed and by age 20-23 months, 16.2 percent are still breastfed. Girls were more likely to be exclusively breastfed than boys were, while boys had higher levels than girls for timely complementary feeding. Salt Iodization In 98.8 percent of households, salt used for cooking was tested for iodine content by using salt test kits and testing for the presence of potassium iodate. In 92 percent of households, salt was found to contain 15 ppm or more of iodine. The above data proves that Kazakhstan is ready for certification as a country that has achieved universal salt iodization. Low Birth Weight Overall, 99.4 percent of babies were weighed at birth and approximately 5.8 percent of infants are estimated to weigh less than 2,500 grams at birth. Immunization 97.9 percent of children in Kazakhstan aged 15-26 months received a BCG vaccination and the first dose of DPT by the age of 12 months. The percentage declines for subsequent doses of DPT to 96.7 percent for the second dose, and 91.7 percent for the third dose. Similarly, 99 percent of children received Polio 1 (OPV) by age 12 months and this declines to 93.9 percent by the third dose. The coverage for measles vaccine by 15 months is a bit lower than for the other vaccines at 94.7 percent. This is primarily because, although 99.4 percent of children received the vaccine, only 94.7 percent received it by their first birthday. Despite the fact that by the age of 12 months coverage with some vaccines exceeds 94 percent, the percentage of children who had all the recommended vaccina- tions by their first birthday (by 15 months for measles) is low at only 81 percent. Solid Fuels Overall, 19 percent of all households in Kazakhstan are using solid fuels for cooking. Use of solid fu- els is very high in rural areas, where 40.8 percent of households are using solid fuels and very low in urban areas – 6.8 percent. The highest percent of households using solid fuels for cooking was found in South Kazakhstan (40.7 percent) and Kyzylorda (39.8 percent) Oblasts. The total percentage of solid fuels is too high due to high use of coal for cooking. Use of improved sources of drinking water and water treatment Overall, 93.7 percent of the population in Kazakhstan is using an improved source of drinking wa- ter – 98.1 percent in urban areas and 87.7 percent in rural areas. The situation with drinking water received from improved sources is worse in North Kazakhstan Oblast (81.7 percent), Kostanai (83.2 percent), South Kazakhstan (85.7 percent) and Atyrau (89.3 percent) Oblasts. In Atyrau and South Kazakhstan Oblasts 8.1 and 6.8 percent of population respectively use surface water. MONITORING THE SITUATION OF CHILDREN AND WOMEN4 70.8 percent of the population uses any way to treat drinking water obtained from all sources. The main method of water treatment used almost by 70 percent of the population is boiling; 24.7 per- cent of the population let the water to settle before consuming it. The urban population more often uses water treatment methods than the rural one. Use of improved sanitation Almost all the population of Kazakhstan (99.2 percent) are living in households with improved sani- tation facilities. In urban areas modern lavatory pans are more popular – over 60 percent of house- holds use them – as well as pit latrines with slab (35.5 percent). In rural areas about 95 percent of households use latrines with slab. The proportion of children aged 0-2 years whose last faeces was safely disposed of was 31.4 percent, at that, this indicator in urban area made 54.3 percent against 8.7 percent of rural area. Contraception Current use of contraception was reported by 50.7 percent of women currently married or in union. The most popular method is IUD (intrauterine device) which is used by one in three married women (36.2 percent of married women) in Kazakhstan. The next most popular but of limited occurrence method is pills, which accounts for 6.6 percent. 4.8 percent of women reported use of the condom. Reproductive Behavior Over one-third (37.7 percent) of women wanted to have 2 children, almost one in three (28.7 per- cent) women – three children and 17.0 percent – four children. Less than 9 percent (8.7 percent) of women in the survey wanted to have 5 to 9 children and only 0.5 percent of women – 10 or more. Factors limiting the birth of another child reported by women were low salary (25 percent) and health status (19.7 percent). The factors encouraging the birth of another baby reported by women were ma- ternity leave with sufficient pay (21.4 percent) and reduced age of retirement (19.8 percent). Antenatal Care Coverage of antenatal care (by a doctor, nurse, or midwife) is relatively high in Kazakhstan with 99.9 percent of women receiving antenatal care at least once during the pregnancy. All interviewed women had blood testing, blood pressure measurement; urine testing and were weighted (by 99.5 percent). Assistance at Delivery Almost all births in Kazakhstan (99.8 percent) were delivered by skilled personnel in health facilities. 80.9 percent of births were delivered by doctors, 18.2 percent – by nurses/obstetricians. Maternal Mortality In MICS, the maternal mortality ratio in Kazakhstan over the past 10-14 years was 70 cases per 100,000 of life births. School Readiness and Pre-School Attendance At the time of the survey, only 16 percent of children aged 36-59 months were attending pre-school institutions. Overall, 39.5 percent of children attending the first grade of primary school were at- tending pre-school the previous year. The proportion of males and females was almost the same, while 46.4 percent of children in urban areas had attended pre-school the previous year compared KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 5 to 33 percent among children living in rural areas. Urban-rural differentials are very significant as well as mother’s educational level. Socioeconomic status appears to have a significant impact on school readiness. Primary and Secondary School Participation Of children who are of primary school entry age (age 7) in Kazakhstan, 92.9 percent are attending the first grade of primary school. By gender indicator boys (95.1 percent) prevail over girls (90.4 per- cent). Gender Parity Index for primary school is 0.99, indicating no difference in the attendance of girls and boys to primary school. This indicator is kept for secondary education (1.00). Birth Registration The birth of 99.2 percent of sampled children aged under 5 in Kazakhstan was registered. There are no significant variations in birth registration across sex, age, or education categories. Child Labor In Kazakhstan, 2.2 percent of children aged 5-14 years are involved in child labor of different types, such as work in a household, family business or outside of the household. Child Discipline In Kazakhstan, 52.2 percent of children aged 2-14 years were subjected to at least one form of psy- chological or physical punishment by their mothers/caretakers or other household members. Less than one percent of children were subjected to severe physical punishment; in urban area percent- age of such children is twice as much as in rural. Only 7.4 percent of mothers/caretakers believed that children should be physically punished, when in practice over 20 percent indicated the opposite. Early Marriage In Kazakhstan 57.4 percent of women aged 15-49 years sampled for MICS, are married/in union. It is necessary to note that around 5 percent of young women aged 15-19 years are married. Only 0.4 percents of women aged 15-49 were married or lived with man before they turned 15 years of age and 8.5 percents of women aged 20-49 years got married before they turned 18 years of age. Domestic Violence 10.4 percent of women aged 15-49 years said that a partner might beat his wife for the following reasons: • Goes out for long without telling her husband; • Neglects her children; • Contradicts her husband; • Refuses sex with him; • Burns food. The highest percentage of women (7.1 percent) recognized that partner can beat his wife if she neglects their children or does not care for them; at the same time, the percentage of women cur- rently and previously married was 8.3 and 7.7 percents respectively against 4.6 percent of women MONITORING THE SITUATION OF CHILDREN AND WOMEN6 never married/in union. Least percentage of women (1.5 percent) accepts this situation in case if wife refuses sex with her partner. Distribution of causes justifying, according to interviewed women, domestic violence from the partner and the number of women who accept such situation is almost the same in urban and rural areas. Knowledge of HIV transmission In Kazakhstan, almost all interviewed women (98.7 percent) have heard of AIDS. However, the per- centage of women who know all three main ways of preventing HIV transmission is only 30 per- cent. Almost 66 percent of women know of having one faithful uninfected sex partner, 62.9 percent know of using a condom every time, and 42.7 percent know of abstaining from sex as the main ways of preventing HIV transmission. While 80 percent of women know at least one way, a high propor- tion of women (20 percent) do not know any of the three ways. Misconceptions about HIV/AIDS Of the interviewed women, 36.3 percent reject the two most common misconceptions and know that a healthy-looking person can be infected. 68.7 percent of women know that HIV cannot be transmitted by sharing food, and 60.6 percent of women know that HIV cannot be transmitted by mosquito bites, while 67.5 percent of women know that a healthy-looking person can be infected. 79.8 percent of women know that HIV cannot be transmitted by supernatural means, and 96.2 per- cent of women know that HIV can be transmitted by multiple uses of needles. Attitudes toward people living with HIV 96.2 percent of women in survey agree with at least one discriminatory statement concerning peo- ple with HIV; urban as well as rural population, irrespective of education level, wealth of household, and age were unanimous. 82.7 percent of people would not buy foodstuffs from HIV-positive ven- dor, 65.9 percent of respondents would want to keep HIV status of a family member a secret, 60.1 percent of population of Kazakhstan believes that HIV positive teacher should not be allowed to teach in school. Interviewing revealed that 9.4 percent of population in general would not take care of family member with HIV (AIDS), there were found no significant urban-rural differences. Knowledge of Tuberculosis 99.4 percent of population of the country is aware of tuberculosis, equally in urban and rural areas. 79 percent of women know about tuberculosis patients’ recovery if it is properly treated. 83.2 per- cent of interviewed females reported that TB should be treated in the hospital. Almost all respond- ents regardless of the place of residence, education level and wealth knew about TB transmission by air during coughing. About 42 percent of parents in urban and rural areas responded that they will seek medical care in TB dispensary with suspected TB in children. About 39 percent parents in rural area and 25.5 percents of parents in urban area will seek hospital care. The latter prefer to apply to the clinic (32 percent). Almost 53 percent of interviewed women correctly named ‘coughing for more than three weeks’ as a TB symptom and 58.5 percent of women reported seeking the medical care if this sign appears. Among other symptoms almost 43 percent of women named blood with phlegm, 38 percent – fever and 37 percent – night sweating. Overall in the country over 12 percent of respondents were sick or have family members suffering from TB and communicated with people with TB outside of the family. This shows quite high disease prevalence within the Republic. At the same time the population is well informed on the ways of disease transmission and symptoms. KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 7 I. Introduction MONITORING THE SITUATION OF CHILDREN AND WOMEN8 Background This report is based on the Kazakhstan Multiple Indicator Cluster Survey (hereinafter MICS), first conducted in Kazakhstan in 2006 by the Agency of Kazakhstan on Statistics. The survey provides valu- able information on the situation of children and women in Kazakhstan and was based, in large part, on the need to monitor progress towards goals and targets emanating from recent international agree- ments: the Millennium Declaration, adopted by all 191 United Nations Member States in September 2000, and the Plan of Action of a “World Fit For Children”, adopted by 189 Member States at the United Nations Special Session on Children in May 2002. Both of these commitments build upon promises made by the international community at the 1990 World Summit for Children. By signing these international agreements, govern- ments committed themselves to improving condi- tions for their children and to monitor progress towards that end. UNICEF was assigned a support- ing role in this task (see below). After the President of the Republic of Kazakhstan (RK) signed the Declaration, the Government of RK committed itself to monitor progress towards the Millennium Development Goals (MDGs) to 2015. Assessment of follow-up indicators is essen- tial in view of information provision for further ac- tion and assessment of changes. The long-term strategic development of Kazakhstan associates with the Millennium Development Goals. State and sectoral programs as well as development strategies of the Republic reflect all MDG goals and objectives. The long- term National Strategy ‘Kazakhstan-2030’ and the Mid-Term Development Plan ‘Kazakhstan-2010’ also reflect the strategic development priorities of Kazakhstan focused on reducing gaps between rich and poor people, strengthening human se- curity through a decrease in social vulnerability, improvement of social services quality, environ- mental sanitation, civil society participation in development and strengthening the institutional potential of state bodies. During the last years Kazakhstan made certain progress towards the MDGs achievement. The Republic has developed a number of strategies and state programs for achieving national goals and priorities, such as: • Program on Combating Poverty and Unemployment in the Republic of Kazakhstan for 2000-2002; A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action World Fit for Children also committed themselves to moni- toring progress towards the goals and objec- tives they contained: “We will monitor regularly at the national lev- el and, where appropriate, at the regional lev- el and assess progress towards the goals and targets of the present Plan of Action at the na- tional, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyse and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and sup- port a wide range of child-focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitor- ing, assessment and planning.” (A World Fit for Children, paragraph 60) “…We will conduct periodic reviews at the na- tional and subnational levels of progress in order to address obstacles more effectively and accelerate actions.…” (A World Fit for Children, paragraph 61) The Plan of Action (paragraph 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to continue to prepare and disseminate, in close collaboration with Governments, relevant funds, programmes and the specialized agen- cies of the United Nations system, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (paragraph 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in im- plementing the provisions of this Declaration, and ask the Secretary-General to issue peri- odic reports for consideration by the General Assembly and as a basis for further action.” KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 9 • State Program on Poverty Reduction for 2003- 2005; • State Program on Reforming and Development of Public Health RK for 2005-2010; • State Education Program in Kazakhstan for 2005-2010; • Gender Equality Strategy of the Republic of Kazakhstan for 2005-2015; • Program on Development of Rural Areas for 2004-2010; • Branch Program «Drinking waters» for 2002- 2010; • Program on Counteracting AIDS Epidemics in the Republic of Kazakhstan for 2001-2005. In frames of assistance to the Government of Kazakhstan in achievement of the global goals and national priorities, UN System coordinates and consolidates efforts of individual UN agen- cies at country level through a strategic tool called the United Nations Development Assistance Framework for 2005-2009 (UNDAF). Better access to quality basic social services, in particular, reduction of child mortality, improve- ment of maternal health and reduction of HIV/ AIDS, tuberculosis and other dangerous diseases in Kazakhstan is directly linked to expected UNDAF outcome. UN assistance in achieving these goals focuses on: • Strengthening of legislative base for better public health and education services; • Improvement of public health management; • Improvement and expansion of key health services: MCH, reproductive health and HIV/ AIDS especially to vulnerable groups; • Dissemination and improvement of knowl- edge, behavior skills and practices in the area of MCH, reproductive health, HIV/AIDS and child care to the community and family levels; • Capacity building of education management at the republican and regional level; • Establishment of child and youth-friendly edu- cation environment focused at development of vital skills and HIV/AIDS prevention in pilot regions. Based on the Situation Analysis of Status of Chilren and its own experience UNICEF identified in 2001 five priority areas, where the most impact on chil- dren’s life could be achieved: girl’s education; in- tegrated development in childhood and adolec- sence; immunization «plus»; combating HIV/AIDS; and enforced protection of children against do- mestic violence, exploitation and discrimination. For the first time, the 2006 Kazakhstan Multiple Indicator Cluster Survey (MICS) was conducted in order to analyze and assess progress in the area of mother and child situation in Kazakhstan as well as progress towards Millennium Development Goals. Agency of the Republic of Kazakhstan on Statistics represented the Government RK in the survey conducted under methodological, technical and financial support of UNICEF and financial sup- port of US Agency for International Development (USAID), UN Population Fund (UNFPA), UN Resident Coordinator Fund and International Labor Organization (ILO). Because of significant discrepancies in social and economical development of the regions of the country, Kazakhstan MICS was conducted at sub-national level, which makes it unique; thus, the results of the survey might encourage the Government and civil society institutes to plan and develop social programs that will meet de- mands of real situation and needs of women and children both at national level and at the level of each region. In addition, MICS improves the quality of statisti- cal information and monitoring of situation of children and mothers in Kazakhstan and progress towards Millennium Development Goals as well as strengthens technical and qualification potential of the Agency RK on Statistic staff on such surveys. This final report presents the results of the indica- tors and topics covered in the survey. Survey objectives 2006 Kazakhstan Multiple Indicator Cluster Survey has as its primary objectives: • To provide up-to-date information for assess- ing the situation of children and women in Kazakhstan; • To furnish data needed for monitoring progress toward goals established by the Millennium Development Goals in the Millennium Declaration, the goals of A World Fit For Children (WFFC), and other internationally agreed upon goals, as a basis for future action; • To contribute to the improvement of data and monitoring systems in Kazakhstan and to strengthen technical expertise in the design, implementation, and analysis of such systems. MONITORING THE SITUATION OF CHILDREN AND WOMEN10 II. Sample and Survey Methodology KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 11 Sample design The sample for the Kazakhstan Multiple Indicator Cluster Survey (MICS) was designed to provide es- timates on a large number of indicators on the situation of children and women at the national level, for urban and rural areas, as well as at sub-national level for 16 regions – 14 Oblasts and 2 cities: Akmola Oblast Aktobe Oblast Almaty Oblast Atyrau Oblast West Kazakhstan Oblast Zhambyl Oblast Karaganda Oblast Kostanai Oblast Kyzylorda Oblast Mangistau Oblast South Kazakhstan Oblast Pavlodar Oblast North Kazakhstan Oblast East Kazakhstan Oblast Astana City Almaty City Regions were identified as the main sampling domains and the sample was selected in two stages. The sample was stratified by urban and rural areas (which represent second level territorial and ad- ministrative units). 1999 Population Census enumeration areas were selected as Primary Sampling Units (PSUs). The number of primary sampling units (PSUs) for oblast and main cities depended on the total population at the beginning of 2005. At the first stage, mentioned number of PSUs was randomly selected for each stratum. In general, 625 PSUs were selected within the country. At the second stage, 24 households were systematically se- lected in each sampled primary sampling unit. Thus, the total number of sampled households made 15,000. The sample was stratified by region and is not self-weighting. For reporting national level re- sults, sample weights are used. A more detailed description of the sample design can be found in Appendix A. MONITORING THE SITUATION OF CHILDREN AND WOMEN12 2 Children under-5 and children aged 0–4 years and children aged 0–59 months are used as interchangeable in this report. In addition to the main activities of the Agency RK on Statistics within the current survey, the staff of the Kazakh Academy of Nutrition conducted study on micronutrients. To do so a sub-sample of 5,000 households was made based upon main sample. This study envisaged interviewing of 5,000 women aged 15-49 on food consumption frequency, blood pressure measurement, taking blood samples for haemoglobin, and collection of urine for iodine excretion measurement. Moreover, within the 5,000 households a sub-sample of 1,000 households with children under 5 was identified to measure the contents of Vitamin A in their blood and to collect edible salt for iodine level meas- urement in laboratory. The findings of this study will be presented in the second volume of the MICS report due early 2008. Questionnaires Three sets of questionnaires were used in the survey: 1) a household questionnaire which was used to collect information on all de jure household members, the household, and the dwelling; 2) a women’s questionnaire administered in each household to all women aged 15-49 years; and 3) an under-5 questionnaire2 administered to mothers or caretakers of all children under 5 living in the household. The questionnaires included the following modules: • The Household Questionnaire included the following modules • Household Listing • Education • Water and Sanitation • Household Characteristics • Child Labor • Child Discipline • Maternal Mortality • Consumption of Iodized Salt • The Questionnaire for Individual Woman included the following modules • Child Mortality • Maternal and Newborn Health • Marriage and Union • Contraception • Attitudes Towards Domestic Violence • HIV/AIDS • The Questionnaire for Children Under Five included the following modules • Birth Registration and Early Learning • Child Development • Breastfeeding • Care of Illness KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 13 • Immunization • Anthropometry Moreover, household questionnaires were supplemented with following modules: • UNICEF Module (knowledge about UNICEF, Convention on the Rights of the Child, sources of information for families); • Health Care System Information Module; • Primary Health Care Accessibility Module; • Accessibility of In-patient and Specialized Care Module Individual questionnaire for women was added with specially developed modules on: • Reproductive Behavior • Tuberculosis Also the Mother and Newborn Health Module was supplemented by a number of questions on smok- ing and alcohol consumption by women in general and those pregnant in particular. Out of the 3 questions of UNICEF Module this report only provides findings on sources of informa- tion for family as ones having substantial significance for the public. Unfortunately, it was not possible to process data from the modules on health care system, accessibility of primary health care and in-pa- tient and specialized care within the framework of this exercise. In this regard it was decided to leave the collected data for further research. Due to very low response on ques- tions about tobacco and alcohol consumption the findings are not presented. The questionnaires are based on the MICS3 model questionnaire3; how- ever, some Modules were adapt- ed to Kazakhstan (in particular, Education Module, which was con- siderably changed). English ques- tionnaires were translated into Russian and Kazakh. Questionnaires were pre-tested in Fabrichnyi (Almaty Oblast) and Kordai (Zhambyl Oblast) settlements in November 2005. Based on the results of the pre-test, modifications were made to the wording and translation of the questionnaires. MICS Questionnaires for Kazakhstan are presented in Appendix F. In addition to the administration of questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine content, and measured the weight and height of children age under 5 years. Details and findings of these measurements are provided in the respective sections of the report. 3 The model MICS3 questionnaire can be found at www.childinfo.org, or in UNICEF, 2006. MONITORING THE SITUATION OF CHILDREN AND WOMEN14 received a certificate upon completion of the workshop. Prior to fieldwork, supervisors developed spe- cial routes and schedules for teams moving by clusters. Before fieldwork mass media (newspa- pers, TV and radio) in the fields elucidated MICS targets and terms to population. The data were collected by 16 teams; each com- prised of six female interviewers, two drivers, one editor and one supervisor – head of team. Qualitative composition of fieldworkers was very high; each team comprised of state serv- ants, supervisors were deputy heads of Oblast/ City Statistics Departments, editors – director or deputy director FSE DCC AS RK, interview- ers – senior specialists and heads of depart- ments. Special badge with colored photo, full name, MICS and AS RK logos was prepared for each team member. Fieldwork began in January and concluded in March 2006. Preparatory work and coordination of all struc- tures involved in the Project was agreed with MICS coordinators from the Agency RK on Statistics with close cooperation of UNICEF and UNFPA MICS coordinators. Central office of RSE DCC of the Agency RK on Statistics dispatched all necessary tools and equipment required for MICS fieldwork ahead of time. During the fieldwork, Project Coordinators had Training and fieldwork The list of team members for 16 domains was composed from Oblast/City Statistics Departments staff. Training on data collec- tion techniques in the fields was conducted in November-December 2005. Four regional train- ing workshops 6 days long each were conduct- ed in Petropavlovsk City (21-26 November), Shymkent City (28 November – 3 December), Semipalatinsk City (5-10 December) and Aktobe City (20-25 December) for the staff of regional departments involved in fieldwork. In total, 129 Statistic Division’s staff members were trained. Four teams of eight people from each Oblast par- ticipated in each workshop, in total 32 people. Training included lectures on interviewing tech- niques, contents of the questionnaires and mock interviews between trainees in practice inter- viewing. By the end of the training participants spent two days in practicing interviewing at the venue of training workshops. With the purpose of practical training, teams of interviewers and respondents were established that had mock in- terviews and answered each questionnaire fol- lowed with discussion of completed question- naires, correction of mistakes and amendment of some questions for better comprehension. In addition, training on anthropometric measure- ments of children under 5 and testing of iodine in salt by testers was conducted in small groups. In the frames of the same workshops, special 2- day training workshops were conducted for su- pervisors and editors on monitoring in the fields and editing of questionnaires. Each participant KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 15 a few monitoring visits to the following Oblasts in accordance with schedule for field teams: Akmola, Karaganda, Mangistau, Atyrau, Almaty, Zhambyl, Kyzylorda and South Kazakhstan. Representative from UNICEF Regional Office (Geneva, Switzerland) took part in monitoring in the first two Oblasts. Heads of Oblast, city (rayon and rural) Akimates, health workers as well as statisticians provided efficient assistance to MICS teams in the fields. After completion of fieldwork teams presented reports, photo/video materials, comments and suggestions for MICS to the Central Office of AS RK. Data Processing ing entered data. Data were entered on twelve personal computers by 24 operators in two shifts. Four editors, four controllers (operators) and two supervisors monitored the question- naires quality and data entry. In order to ensure quality control, all questionnaires were double entered and internal consistency checks were performed. Procedures and standard programs developed under the global MICS-3 project and adapted to the Kazakhstan questionnaires were used throughout. Data processing began simul- taneously with data collection in January 2006 and finished at the beginning of April 2006. Data were analysed using the Statistical Package for Social Sciences (SPSS) software program, ver- sion 14, and the model syntax and tabulation plans developed by UNICEF for this purpose. Data were centrally processed in Data Computing Center of the Agency RK on Statistics (DCC AS RK). Editors responsible for checking complete- ness and correctness of completed question- naires as well as controllers responsible for data verification and operators entering data passed special training. Field editors checked complet- ed questionnaires for completeness and quality, composed questionnaires for households with- in clusters and sent them to the Central Office AS RK for data entry and establishment of data- base. Fourteen computers were installed in the ap- propriate premises in DCC AS RK, 12 of these computers had CSPro software for data entry and 2 – CSPro software for controllers verify- MONITORING THE SITUATION OF CHILDREN AND WOMEN16 III. Sample Coverage and the Characteristics of Households and Respondents KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 17 Sample Coverage Of the 15,000 households selected for the sample, 14,984 were found to be occupied. Of these 14,564 were successfully interviewed for a household response rate of 97.2 percent. In the inter- viewed households, 14,719 women (age 15-49) were identified. Of these, 14,570 were successfully interviewed, yielding a response rate of 99.0 percent. In addition, 4,424 children under age five were listed in the household questionnaire. Of these, questionnaires were completed for 4,416, which correspond to a response rate of 99.8 percent. Overall response rates calculated for the interviews of women 15-49 years of age and children under-5 were 96.2 and 97.0 percent respectively (Table HH.1). Household response rates in rural areas were higher than in urban – 99.4 percent and 95.6 percent respectively. The overall household response rate throughout the country was high and varied from 91.6 percent in Almaty City up to 99 percent in Zhambyl Oblast. Characteristics of Households The age and sex distribution of survey population is provided in HH.2. The distribution is also used to produce the population pyramid by sex and age in Figure HH.2. In 14,564 households successfully interviewed in the survey 51,261 household members were listed. Of these 24,724 (48.2 percent) were males and 26,537 (51.8 percent) were females. These data also indicate that the survey esti- mated the average household size at 3.5 people. Population aged 0-14 years made up 12,344 people or 24.1 percent, of these 6,405 were males (25.9 percent of all males), 5,939 were females (22.4 percent of all females). Population aged 15-64 years made 34,428 people or 67.2 percent, of these 16,621 were males (67.2 percent of all males) and 17,807 were females (67.1 percent of all females). People older 65 were 4,488 or 8.7 percent, of these 1,698 were males (6.9 percent of all males) and 2,790 were females (10.5 percent of all females). Children aged 0-17 years were 15,538 or 30.3 percent of total number of survey household mem- bers, of these 8,090 were males (32.7 percent of all males) and 7,448 were females (28.1 percent of all females). According to official statistics , as of 1 January 2006, the distribution of the population of the Republic of Kazakhstan by sex and age was as follows: percentage of males was 48.1 and females – 51,9 per- MONITORING THE SITUATION OF CHILDREN AND WOMEN18 Figure HH.2. Age and sex distribution of household population, %, Kazakhstan, 2006 vey and official statistics of Kazakhstan as of 1 January 2006, deviation makes 0.1 percent to 1.1 percent. Table HH.3 provides basic background infor- mation on the households. Within households, the sex of the household head, region, urban/ rural status, number of household members, and ethnicity4 group of the household head are shown in the table. These background charac- teristics are also used in subsequent tables in this report; the figures in the table are also in- tended to show the numbers of observations by major categories of analysis in the report. The weighted and unweighted numbers of households are equal, since sample weights were normalized (See Appendix A). The ta- ble also shows the proportions of households where at least one child under 18, at least one child under 5, and at least one eligible woman age 15-49 were found. The proportion of house- hold with at least one child under 18 made 56.7 percent, in 21.8 percent of households were children under 5, proportion of households with at least one woman aged 15-49 made 70.6 percent. 13 percent of households had one member, 41 percent had 2-3 members, 32.4 percent had 4- 5 members, 10.5 percent had 6-7 members, 2.4 percent had 8-9 members and 0.8 percent had 10 and more household members. cent. Population aged 0-14 years made 24.2 per- cent, of this age group 25.7 percent were males and 22.8 percent females. Population aged 15- 64 years of age made 68 percent, of this age group 68.5 percent were males and 67.5 percent were females. The age group of people older than 65 made 7.8 percent, of these 5.8 percent were males and 9.7 percent females. Percentage of children aged 0-17 years made 30.3 percent; of these 32.2 percent were males, 28.6 percent were females of total number of males and fe- males respectively. This data proves there is an insignificant diver- gence in distribution of population by sex and age (wide age group) between the current sur- 4 This was determined by asking about native language of household head Males Females KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 19 Tables HH.4 and HH.5 provide information on the background characteristics of female re- spondents 15-49 years of age and of children under age 5. In both tables, the total numbers of weighted and unweighted observations are equal, since sample weights have been normal- ized (standardized). In addition to providing useful information on the background charac- teristics of women and children, the tables are also intended to show the numbers of observa- tions in each background category. These cat- egories are used in the subsequent tabulations of this report. Table HH.4 provides background characteris- tics of female respondents 15-49 years of age. The table includes information on the distri- bution of women according to region, urban- rural areas, age, marital status, motherhood status, education5, wealth index quintiles6, and ethnicity. According to the weighted sample 8,655 peo- ple or 59.5 percent of the total women at the age of 15-49 lived in urban area, and 5,903 people (40.5 percent) lived in rural area (inci- dentally, the unweighted sample provided the urban-rural distribution of women at the age of 15-49 as 7,608 and 6,952 showing the re- spective difference of 1,047 and minus 1,049). At the moment of survey, 8,349 women (57.4 percent) were married or in union, 2,049 wom- en (14.1 percent) divorced/separated/widows and 4,160 women (28.6 percent) were never married. As for motherhood status – 66.8 per- cent of women had given birth. By education 1,948 women or 13.4 percent have primary or incomplete secondary education, 4,893 wom- en or 33.6 percent have secondary education, 3,949 women or 27.1 percent have specialized secondary and 3,768 women or 25.9 percent – higher education. As for wealth level the poor and poorest are rep- resented approximately by the same number 18.5 – 18.7 percent, middle – 19.4 percent, rich – 20 percent and richest 23.4 percent. Ethnicity: 8,609 women (59.1 percent) – Kazakhs, 4,481 women (30.8 percent) – Russians and 1,468 women (10.1 percent) – other nationalities. Some background characteristics of children under 5 are presented in Table HH.5. These include distribution of children by several at- tributes: sex, region and area of residence, age in months, mother’s or caretaker’s education, wealth, and ethnicity. In total, 4,415 children under 5 were surveyed; of these 2,327 or 52.7 percent were males and 2,088 or 47.3 percent were girls. 2,251 children or 51 percent lived in urban area and 2,164 children or 49 percent – in rural area. Age of children: under 6 months – 382 children or 8.7 percent, 6-11 months – 462 children or 10.5 percent, 12-23 months – 969 children or 21.9 percent, 24-35 months – 948 children or 21.5 5 Unless otherwise stated, “education” refers to educational level attended by the respondent throughout this report when it is used as a background variable. 6 Principal components analysis was performed by using information on the ownership of household goods and amenities (assets) to assign weights to each household asset, and obtain wealth scores for each household in the sample (The tools (devises) used in these calculations were as follows: electricity, radio, TV set, mobile phone, stationary (non-mobile) telephone, refrigerator, PC, washing-machine, sewing machine, vacuum cleaner as well as personal belongings of each household member such as watches, bicycle, motorbike, horse cart, vehicle, motor boat). Each household was then weighted by the number of household members, and the household population was divided into five groups of equal size, from the poorest quintile to the richest quintile, based on the wealth scores of households they were living in. The wealth index is assumed to capture the underlying long-term wealth through information on the household assets, and is intended to produce a ranking of households by wealth, from poorest to richest. The wealth index does not provide information on absolute poverty, current income or expenditure levels, and the wealth scores calculated are applicable for only the particular data set they are based on. Further information on the construction of the wealth index can be found in Rutstein and Johnson, 2004, and Filmer and Pritchett, 2001 Characteristics of Respondents MONITORING THE SITUATION OF CHILDREN AND WOMEN20 percent, 36-47 months – 858 children or 19.4 percent and 48-59 months – 796 children or 18 percent. Mothers with children under 5 had the following educational level: primary and incomplete secondary 7 percent or 309 moth- ers, 45.3 percent or 2,000 mothers had second- ary education, 23.3 percent or 1,030 mothers had specialized secondary and 24.4 percent or 1,076 mothers had higher education. Households with children under 5 were distrib- uted by wealth quintiles as the following: poor- est – 26.9 percent, poor – 20.9 percent, mid- dle 19.7 percent, rich – 16 percent and richest – 16.4 percent. tively, while in Aktobe, Mangistau and Atyrau Oblasts – from 82 to 89 percent of population. The next popular source of information report- ed by over one fourth (25.4 percent) of popula- tion was radio, at that, the proportion of urban population is twice as much as rural one. The popularity of radio also varies by region: 62 percent of the population of Almaty City and over 40 percent of the population in Aktobe and Atyrau Oblasts reported radio as one of the source of information for family, while in 8 regions of the Republic proportion of such respondents is below 20 percent. Over 18 per- cent of Kazakhstan’s population gets informa- tion from magazines, with a higher proportion among the urban population. Outdoor adver- tisement and posters (9.4 percent) as well as Internet (4.7 percent) are not very popular among respondents. Internet was mentioned by 7 percent of the urban population and 13.7 percent of respondents with higher education, at that, the largest proportion of respondents live in the cities of Astana (21.9 percent) and Almaty (13.5 percent). Overall, the popular- ity of some sources of information depends mainly on the level of education and wealth of the population as well as regions and place of residence, and, of course, access to some sources, for instance, to Internet. During the survey, household members were asked about the main sources of information for the family. Respondents proposed the fol- lowing sources: newspaper, TV, radio, maga- zines, Internet, outdoor advertisement and posters, siblings, friends, neighbors, colleagues. Almost all the population (over 97 percent) of Kazakhstan was found to be receiving infor- mation for the family, mainly, from TV, with no large difference by the place of residence, level of education, wealth, ethnicity and region. The second source of information for the popula- tion is newspapers (66 percent), with a higher proportion of the urban population; propor- tion of respondents with higher education lev- els prevails over those with lower education levels. Less than half of the population gets in- formation from the newspapers in Kyzylorda (44.1 percent) and South Kazakhstan (49.1 per- cent) Oblasts. The third predominant source of information for over half of Kazakhstan’s population (54.3 percent) are friends, relatives, neighbors and colleagues – equally used by ur- ban and rural population irrespective of edu- cational level, wealth and ethnicity. Popularity of this source varies significantly by region: in Kostanai and North Kazakhstan Oblasts only 38 and 41 percent of population gets information from friends, relatives, and colleagues respec- Sources of information for the family KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 21 IV. Child mortality MONITORING THE SITUATION OF CHILDREN AND WOMEN22 1990b). The data used in the estimation are: the mean number of children ever born for five-year age groups of women from age 15 to 49, and the proportion of these children who are dead, also for five-year age groups of wom- en. The technique converts these data into probabilities of dying by taking into account both the mortality risks to which children are exposed and their length of exposure to the risk of dying, assuming a particular model age pattern of mortality. Based on previous infor- mation on mortality in Kazakhstan the stand- ard East model life table was selected as most appropriate and more accurately reflecting mortality in age groups 20-24, 25-29 and 30- 34 years. Table CM.1 provides estimates of child mortal- ity by various background characteristics, while Table CM.2 provides the basic data used in the calculation of the mortality rates for the na- tional total. IMR and U5MR estimates provided for the national level by sex, place of residence and ethnicity. The infant mortality rate is estimated at 32 per thousand, while the probability of dying under-5 mortality rate (U5MR) is around 36 per thousand livebirths. These estimates have been calculated by averaging mortality esti- mates obtained from women aged 20-24, 25- 29 and 30-34. There is a difference between the probabilities of dying among males and females. Boy’s mortality significantly exceeds One of the overarching goals of the Millennium Development Goals (MDGs) and the World Fit for Children (WFFC) is to reduce in- fant and under-five mortality. Specifically, the MDGs call for the reduction in under-five mor- tality by two-thirds between 1990 and 2015. Monitoring progress towards this goal is an important but difficult objective. Measuring childhood mortality may seem easy, but at- tempts using direct questions, such as “Has an- yone in this household died in the last year?” give inaccurate results. Using direct measures of child mortality from birth histories is time consuming, more expensive, and requires greater attention to training and supervision. Alternatively, indirect methods developed to measure child mortality produce robust esti- mates that are comparable with the ones ob- tained from other sources. Indirect methods minimize the pitfalls of memory lapses, inex- act or misinterpreted definitions, and poor in- terviewing technique. The infant mortality rate is the probability of dying before the first birthday (during the first year of life). The under-five mortality rate (U5MR – under 5 mortality rate) is the prob- ability of dying before the fifth birthday (aged 0-4 years). In MICS surveys, infant and under five mortality rates are calculated based on an indirect estimation technique known as the Brass method (United Nations, 1983; 1990a; Figure CM.1. Infant Mortality by Sources, Kazakhstan, 2006 DHS(1995, 1999), MICS(2006) AS RK Linear (DHS(1995, 1999), MICS(2006)) KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 23 Figure CM.1А. Under Five Mortality Rate, Kazakhstan, 2006 Figure CM.1В. Under Five Mortality Tendency, Kazakhstan, 2006 7 Nutrition Institute MoH-SA RK, Academy of Preventive Medicine, Demography and Health Survey Department, Macro International Inc. Kazakhstan Demography and Health Survey, 1995. Almaty, 1996. 8 Academy of Preventive Medicine, and Macro International Inc., 2000. Kazakhstan Demography and Health Survey, 1999. Almaty, 2000. girl’s and makes 36.6 and 26.6 per thousand respectively. In rural area infant mortality rates are almost 1.5 times higher than in ur- ban areas. Figure CM.1 reflects infant mortality rates by different sources – there are obvious significant differences between official data and data ob- tained from surveys7 conducted in Kazakhstan. According to official statistics, in 1985-1994 infant mortality was on average approximately 27 per 1,000 live births, gradually declining in 1996-2005 reaching over 19 cases per 1,000 of births. Under-5 mortality rates are provided in Figure CM.1A. U5MR is a bit higher in rural than in urban areas and mortality among boys is sig- nificantly higher than among girls. Moreover, U5MR is higher among Kazakh population. Figure CM.1B shows the series of U5MR es- timates of the survey, based on responses of women in different age groups, and referring to various points in time, thus showing the esti- mated trend in U5MR based on DHS-1995 and MICS-2006 as well as country’s official statis- tics8. The MICS estimates indicate a decline in mortality during the last 15 years. Area Urban Rural Sex Boys Girls Ethnicity Kazakhs Russians Kazakhstan Per 1,000 livebirths DHS 1995 AS RK MICS 2006 Linear (DHS 1995) Linear (MICS 2006) Different approaches to life birth definitions and child’s mortality assessment techniques cause discrepancies between different sources. Further qualification of these apparent declines and differences as well as its determinants should be taken up in a more detailed and sep- arate analysis. 30.2 42.6 41.7 30.3 36.2 31.0 36.3 MONITORING THE SITUATION OF CHILDREN AND WOMEN24 V. Nutrition KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 25 Nutritional Status Children’s nutritional status is a reflection of their overall health. When children have access to an adequate food supply, are not exposed to repeated illness, and are well cared for, they reach their growth potential and are considered well nourished. Malnutrition is associated with more than half of all children deaths worldwide. Undernourished children are more likely to die from common childhood ailments, and for those who survive, have recurring sicknesses and faltering growth. Three-quarters of the children who die from causes re- lated to malnutrition were only mildly or moderately malnourished – showing no outward sign of their vulnerability. The Millennium Development target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. The World Fit for Children goal is to re- duce the prevalence of malnutrition among children under five years of age by at least one-third (between 2000 and 2010), with special attention to children under 2 years of age. A reduction in the prevalence of malnutrition will assist in the goal of reducing child mortality. In a well-nourished population, there is a reference distribution of height and weight for children under five. Under-nourishment in a population can be gauged by comparing children to a refer- ence population. The reference population used in this report is the WHO/CDC/NCHS reference, which was recommended for use by UNICEF and the World Health Organization (WHO) at the time the survey was implemented. Each of the three nutritional status indicators can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight-for- age is more than two standard deviations below the median of the reference population are con- sidered moderately or severely underweight while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. Height-for-age is a measure of linear height of children. Children whose height-for-age is more than two standard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Those whose height-for-age is more than three standard deviations below the median are classified as severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. Finally, children whose weight-for-height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator may exhibit lack of foodstuffs in popula- tion or might be related to the high prevalence of illnesses among children from that particular MONITORING THE SITUATION OF CHILDREN AND WOMEN26 children are stunted for their age and 4 percent are too short (Table NU.1). Children in the West Kazakhstan (8.8 percent) and Almaty Oblasts (8.1 percent) are more likely to be underweight for their age than other chil- dren; as for height to age – Aktobe Oblast (23.5 percent), Kyzylorda Oblast (23.3 percent) and Almaty Oblast (22.1 percent). The highest propor- tion of moderately stunted children for their age was found in West Kazakhstan (12.5 percent) and Mangistau Oblasts (9.3 percent). Those children whose mothers have higher levels of education are the least likely to be underweight and stunted compared to children of mothers with primary/ incomplete secondary education. Boys appear more likely to be underweight and stunted. A higher percentage of stunted and under- weight for their age children are found in the age group 12-23 months (Figure NU.1). This pattern may well be expected as it relates to the age at which many children cease to be breast- fed, which coupled with inadequate comple- mentary feeding, lead to high risk of disease development due to exposure to contaminated water, food and other environmental factors. The worst underweight for age was found in age group below 6 months. In addition, 11.3 percent of children are over- weighed; percentage of boys and girls as well as children in urban and rural areas is almost the same. Figure NU.1. Percentage of children under 5 who are undernourished, Kazakhstan, 2006 age group (for example, diarrhoea, HIV/AIDS, etc.). An increase in this indicator by 5 percent requires certain measures as growth of infant mortality could be expected afterwards. In MICS, weights and heights of all children un- der 5 years of age were measured using anthro- pometric equipment recommended by UNICEF (UNICEF, 2006). Findings in this section are based on the results of these measurements. Table NU.1 shows percentages of children clas- sified into each of these categories, based on the anthropometric measurements that were taken during fieldwork. Additionally, the table includes the percentage of children who are overweight, which takes into account those children whose weight for height is above 2 standard deviations from the median of the reference population. In Table NU.1, children who were not weighed and measured (about 2.6 percent of children) and those whose measurements are outside a plausible range are excluded. In addition, a small number of children whose birth dates are not known are excluded. In Kazakhstan 4 percent of children under 5 are moderately underweight (weight for age) and 0.8 percent are classified as severely un- derweight, at that, 3.8 percent of children are wasted (weight for height) and 1 percent – se- vere wasted. At the same time, 12.8 percent of Underweight Stunted Wasted Age (months) % KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 27 Breastfeeding for the first few years of life pro- tects children from infection, provides an ide- al source of nutrients, and is economical and safe. However, many mothers stop breastfeed- ing too soon and there are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnu- trition and is unsafe if clean water is not readily available. The World Fit for Children goal states that children should be exclusively breastfed for 6 months and continue to be breastfed in addition to nutritious, safe and adequate com- plementary feeding for up to 2 years of age and beyond. WHO/UNICEF have the following feeding recommendations: • Exclusive breastfeeding for first six months • Continued breastfeeding for two years or more • Timely introduction of nutritious and safe complementary foods beginning at 6 months • Frequency of complementary feeding should be: 2 times per day for 6-8 month olds; 3 times per day for 9-11 month old children It is also recommended that breastfeeding be ini- tiated within one hour of birth. Quality of child feeding is evaluated by the following indicators: • Exclusive breastfeeding rate (< 6 months & < 4 months) • Timely complementary feeding rate (6-9 months) • Continued breastfeeding rate (12-15 & 20- 23 months) • Timely initiation of breastfeeding (within 1 hour of birth) • Frequency of complementary feeding (6-11 months) • Proportion of adequately fed infants (0-11 months) Table NU.2 provides the proportion of women who started breastfeeding their infants with- in one hour of birth, and women who started Breastfeeding The percentage of women with higher educa- tion who timely started breastfeeding (within 1 hour after birth) almost by 10 percent exceeded the percentage of women with lower education level. The highest proportion of women who started breastfeeding within one hour of birth was in Kyzylorda (95.5 percent) and Karaganda (91.6 percent) Oblasts, the lowest proportion were found in Aktobe Oblast (31.5 percent) and North Kazakhstan (36.6 percent) Oblasts. 87.8 percent started breastfeeding within one day of birth (which includes those who started within one hour), percentage of such women in urban and rural settlements is almost the same – 87.7 and 88 percent respectively (Figures NU.2). In almost all regions of Kazakhstan over 90 percent of wom- en started breastfeeding their infants within one day of birth, with the exception of women from Pavlodar, Akmola and East Kazakhstan Oblasts (68.6, 77.3 and 80.6 percent respectively). In Table NU.3, breastfeeding status is based on the reports of mothers/caretakers of children’s consumption of food and fluids in the 24 hours prior to the interview. Exclusively breastfed re- fers to infants who received only breast milk (and vitamins, mineral supplements, or medi- cine). The table shows exclusive breastfeed- breastfeeding within one day of birth (which in- cludes those who started within one hour). In total 1,719 women who gave birth to a live baby during two years before the survey were interviewed about breastfeeding. Of them 64.2 percent started breastfeeding within one hour of birth, the difference between urban and ru- ral women was 4.4 percent – urban women 66.3 percent and 61.9 of rural women respectively. MONITORING THE SITUATION OF CHILDREN AND WOMEN28 Figure NU.2. Percentage of mothers who started breastfeeding within one hour and within one day of birth, Kazakhstan, 2006 Re gi on s A km ol a A kt ob e A lm at y A ty ra u W es t K az ak hs ta n Zh am by l Ka ra ga nd a Ko st an ai Ky zy lo rd a So ut h Ka za kh st an Pa vl od ar N or th K az ak hs ta n Ea st K az ak hs ta n A lm at y Ci ty U rb an Ru ra l K az ak hs ta n Within one hour Within one day are receiving liquids or foods other than breast milk. By the end of the sixth month, the percent- age of children exclusively breastfed is below 10 percent. Only over 16 percent of children are re- ceiving breast milk after 2 years. The adequacy of infant feeding in children less than 12 months is provided in Table NU.4. Different criteria of adequate feeding are used depending on the age of the child. For infants aged 0-5 months, exclusive breastfeeding is considered as adequate practice. Infants aged 6- 8 months and 9-11 months are considered to be adequately fed if they are receiving breastmilk at least two-three times a day (excluding night feeding) in addition to adequate quality and quantity feeding. 16.8 children aged below 6 month are adequately fed, girls more often than boys. Percentage of exclusively breastfed chil- dren aged 0-5 months in urban and rural areas and by mother’s education is almost the same. 28.8 percent of babies aged 6-8 months receive adequate feeding; boys were slightly more likely to be adequately fed than girls were. The propor- tion of such children in urban and rural areas is 30.3 and 27.1 percent respectively. By age 9-11 months 19.7 percent of children are adequately fed, there is almost no difference between boys and girls. However, the proportion of such chil- dren in rural area is higher than in urban. ing of infants during the first six months of life (separately for 0-3 months and 0-5 months), as well as complementary feeding of children 6-9 months and continued breastfeeding of chil- dren at 12-15 and 20-23 months of age. 16.8 percent of children aged less than six months are exclusively breastfed, which is an extremely low figure. Timely introduction of complemen- tary feeding at age 6-9 months was found in 39.1 percent of children (receive breast milk and solid or semi-solid foods). By age 12-15 months, 57.1 percent of children are still being breastfed and by age 20-23 months, 16.2 percent are still breastfed. Girls were more likely to be exclusively breastfed than boys, while boys had higher levels than girls for timely complementary feeding. In rural area, the percentage of exclusively breast- fed children aged below six months is higher than in urban areas, the same trend is found in children aged 12-15 months and 20-23 months who still receive breast milk. Percentage of chil- dren receiving timely complementary feeding aged 6-9 months is higher than in urban areas and less wealthy households. Figure NU.3 shows the detailed pattern of breast- feeding by the child’s age in months. [This figure is obtained by using data from Table NU.3W]. Even at the earliest ages, the majority of children KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 29 As a result of these feeding patterns, only 24 percent of children aged 6-11 months are be- ing adequately fed: 23.1 percent of urban and 25 percent of rural children, boys were more likely to be adequately fed than girls were. Proportion of children aged 6-11 months in poor house- holds who receive recommended feeding is by 7 percent points higher than in households with middle income. Proportion of children aged 6- Figure NU.3. Infant feeding patterns by age: Percent distribution of children aged under 3 years by feeding pattern by age group, Kazakhstan, 2006 Weaned (not breastfed) Breastfed and comple- mentary foods Breastfed and other milk/ formula Breastfed and non-milk liquids Breastfed and plain water only Exclusively breastfed Age group in months % 11 months who receive adequate feeding is al- most the same in Kazakh and Russian families and varies between 22.1-23.3 percent. There are minor differences by mothers’ education. Only 20.7 percent infants aged 0–11 months were adequately fed, of these 20.3 percent live in ur- ban areas and 21.2 percent in rural areas. There were no significant differences by children’s sex, the mother’s education or ethnicity. It is well known that health and intellectual capital is the most important precondition for the progress of some countries and the world in general. However, preventable deficiency of es- sential foodstuff causes harm for entire genera- tions, and reduces the intelligence quotient (IQ) in a hundred million people. Iodine Deficiency Disorders (IDD) are the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism. It also increases the risks of stillbirth and miscarriage in pregnant women. Iodine de- ficiency is most commonly and visibly associated with goitre. Iodine deficiency takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability, and impaired work performance. The international goal is to achieve sustainable elimination of iodine deficiency by 2005. The indicator is the percentage of house- holds consuming ad- equately iodized salt (>15 parts per million). Following global politi- cal recommendations, the Government of Kazakhstan commit- ted itself to eliminate iodine deficiency in the country through uni- versal salt iodization with potassium iodate during salt production at 40±15 ррм both for home consumption, for the food industry and for animals. Two local salt pro- ducers ‘Araltuz’ (Kyzylorda Oblast) and Salt iodization MONITORING THE SITUATION OF CHILDREN AND WOMEN30 ‘Pavlodarsol’ (Pavlodar Oblast) have the techni- cal capacity to supply the internal market with adequately iodized salt in sufficient quantity. Sanitary-epidemiological services of the Ministry of Healthcare of the Republic of Kazakhstan bear the responsibility for inspection and monitoring of foodstuffs. Success of the Republic of Kazakhstan recent years was based on effective cooperation between the government, salt producers, non- governmental sector and international organiza- tions (UNICEF and ADB). Today, the children of Kazakhstan are better protected against mental retardation due to increased access to iodized salt. Today Kazakhstan joins the elite nations that have achieved comprehensive salt iodization9. In 98.8 percent of households, salt used for cook- ing was tested for iodine content by using salt test ished, with reduced muscle strength, through- out their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born underweight also tend to have a lower IQ and cognitive disabilities, affecting their per- formance in school and their job opportunities as adults. In the developing world, low birth weight stems primarily from the mother’s poor health and nutrition. Three factors have most impact: the Figure NU.5. Percentage of households consuming adequately iodized salt, Kazakhstan, 2006 Weight at birth is an obvious indicator not only of a mother’s health and nutritional status but also the newborn’s chances for survival, growth, long-term health and psychosocial develop- ment. Low birth weight (less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early months and years. Those who survive have impaired immune function and increased risk of disease; they are likely to remain undernour- 9 UNICEF, Kazakhstan. Assessment of Salt Iodization Adequacy and Its Consumption in Kazakhstan, Almaty, 2005. Low Birth Weight kits and testing for the presence of potassium io- date. Table NU.5 shows that in a very small pro- portion of households (0.3 percent), there was no salt available. In 92 percent of households, salt was found to contain 15 ppm or more of iodine. Use of iodized salt was lowest in Pavlodar Obast (only 68.3 percent) and highest in Almaty (99.7 percent) and Mangistau (99.5 percent) Oblasts. The difference between urban and rural house- holds in terms of iodized salt consumption is much less than expected (Figure NU.5). The above data proves that Kazakhstan should be ready for certification as a country that has achieved universal salt iodization. In addi- tion, monitoring of iodized salt quality as well as monitoring of iodine deficiency prevalence among population should be enforced. Re gi on s A km ol a A kt ob e A lm at y A ty ra u W es t K az ak hs ta n Zh am by l Ka ra ga nd a Ko st an ai Ky zy lo rd a M an gi st au So ut h Ka za kh st an Pa vl od ar N or th K az ak hs ta n Ea st K az ak hs ta n A st an a Ci ty A lm at y Ci ty U rb an Ru ra l K az ak hs ta n KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 31 10 For a detailed description of the methodology, see Boerma, Weinstein, Rutstein and Sommerfelt, 1996. U rb an Ru ra l Pr im ar y/ in co m - pl et e se co nd ar y Se co nd ar y Sp ec ia liz ed se co nd ar y H ig he r Po or es t Se co nd M id dl e Fo ur th Ri ch es t K az ak hs ta n Figure NU.8. Percentage of Infants Weighing Less Than 2500 Grams at Birth, Kazakhstan, 2006 mother’s poor nutritional status before concep- tion, short stature (due mostly to undernourish- ment and infections during her childhood), and poor nutrition during the pregnancy. Inadequate weight gain during pregnancy is particularly im- portant since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are com- mon in many developing countries, can signifi- cantly impair foetal growth if the mother be- comes infected while pregnant. In the industrialized world, cigarette smok- ing during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run the risk of bearing underweight babies. Because many infants are not weighed at birth and those who are weighed may be a biased sam- ple of all births, the reported birth weights usu- ally cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births weighing below 2,500 grams is estimated from two items in the ques- tionnaire: the mother’s assessment of the child’s size at birth (i.e., very small, smaller than aver- age, average, larger than average, very large) and the mother’s recall of the child’s weight or the weight as recorded on a health card if the child was weighed at birth10. In Kazakhstan almost all babies were weighed at birth (99.4 percent) and 5.8 percent of infants are estimated to weigh less than 2500 grams at birth (Table NU.8 and Figure NU.8). There was significant variation by region: the highest pro- portion of children with low weight was found in Pavlodar Oblast (19.4 percent), and in 9 Oblasts number of such children was between 4.1 – 4.8 percents. The percentage of low birth weight does not vary much by urban and rural areas, but the percentage of children with low weight was higher if mothers had primary/in- complete secondary education comparing to women with higher levels of education. MONITORING THE SITUATION OF CHILDREN AND WOMEN32 VI. Child Health KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 33 Immunization Millennium Development Goal (MDG) 4 aims to reduce child mortality by two thirds between 1990 and 2015. Immunization plays a key part in this goal. Immunization has saved the lives of millions of children in the three decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. Worldwide there are still 27 million children overlooked by routine immunization and as a result, vaccine-preventable diseases cause more than 2 million deaths every year. A World Fit for Children goal is to ensure full immunization of children under one year of age at 90 percent nationally, with at least 80 percent coverage in every district or equivalent administrative unit. One of the major achievements of Kazakhstan is acquiring of status of Vaccine Independent Country as well as Country Free from Poliomyelitis. Below is Extraction from Schedule for Preventive Vaccination of children under age of 24 months in Kazakhstan. Terms of Vaccination (children under 2 years old) Age Vaccination against: Tuberculosis (BCG) Hepatitis “В” Poliomyelitis (OPV) Pertussis, diphtheria, tetanus (DPT) Measles 1-4 weeks + + + 2 months + + + 3 months + + 4 months + + + 12-15 months + 18 months + Extraction from Annex to the Rules for Vaccination, approved by the Decree of the Government of the Republic of Kazakhstan as of 23 May 2003 N 488 MONITORING THE SITUATION OF CHILDREN AND WOMEN34 of main questionnaire for children under-5 (Immunization Module) – was prepared, which included home address of child in survey, his/ her personalized data and address of health fa- cility indicating number of district. Interviewers copied vaccination data into these forms from vaccination cards available in health facilities. Overall, 95.1 percent of surveyed children in Kazakhstan had immunization cards (Table CH.2). The percentage of children aged 15 to 26 months who received all recommended vacci- nations is shown in Table CH.1. The denomina- tor for the table is comprised of children aged 15-26 months so that only children who are old enough to be fully vaccinated are counted. In the top panel, the numerator includes all chil- dren who were vaccinated at any time before the survey according to the vaccination card or the mother’s report. In the bottom panel, only those who were vaccinated before their first birthday, as recommended, are included (by 15 months for measles). For children without vaccination cards, the proportion of vaccina- tions given before the first birthday is assumed to be the same as for children with vaccination cards. 97.9 percent of children aged 15-26 months re- ceived a BCG vaccination and the first dose of DPT by the age of 12 months. The percentage declines for subsequent doses of DPT to 96.7 percent for the second dose, and 91.7 percent for the third dose (Figure CH.1). Similarly, 99 percent of children received Polio 1 (OPV) and this declines to 93.9 percent by the third dose by age 12 months. The coverage for measles vaccine by 15 months is a bit lower than for the other vaccines at 94.7 percent. This is primarily because, although 99.4 percent of children re- ceived the vaccine, only 94.7 percent received it by their first birthday. Despite the fact that by the age of 12 months coverage with some vaccines exceeds 94 percent, the percentage of children who had all the recommended vacci- nations by their first birthday is low at only 81 percent. In Kazakhstan, Hepatitis B vaccination is also recommended as part of the immunization schedule. The first HepB vaccine is introduced at age of 1-4 days of birth, the second one at age of 2 months and the third one at age of 4 Figure CH.1. Percentage of children aged 15-26 months who received the recommended vaccinations by 12 months, Kazakhstan, 2006 In Kazakhstan since 1 October 2005, children 1 year old and above receive complex vac- cination against measles, mumps and rubella (MMR). The schedule of vaccination against communicable diseases complies with interna- tional standards. According to UNICEF and WHO guidelines, a child should receive a BCG vaccination to pro- tect against tuberculosis, three doses of DPT to protect against diphtheria, pertussis, and teta- nus, three doses of polio vaccine by the age of 12 months, and a measles vaccination by the age of 15 months. Mothers were asked to pro- vide vaccination cards for children (f. 063-у) under the age of five. If the card was available in the household, interviewers copied vaccina- tion information from the cards onto the MICS questionnaire. If the child did not have a card, the mother was asked to recall whether or not the child had received each of the vaccinations and, for DPT and Polio, how many times. In Kazakhstan, health cards of children includ- ing vaccination cards are usually kept in health facilities. Therefore, interviewers visited health facilities to fill in an Immunization Module for each child irrespective of immunization card availability in the household or the mother’s re- port. With this purpose, a special form – copy Total Measles Polio-3 Polio-2 Polio-1 DPT-3 DPT-2 DPT-1 BCG KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 35 months. By the age of 12 month 94.3 percent of children in survey received first dose of HepB vaccine. Percentage of coverage with the sec- ond dose was 94.4 percent and 92.3 percent with the third one (Tables CH.1.C and CH.2.C). Tables CH.2 and CH.2C show vaccination cov- erage rates among children 15-26 months by background characteristics. Data indicate chil- dren receiving the vaccinations at any time up to the date of the survey, and are based on in- formation from both the vaccination cards and mothers’/caretakers’ reports. In Kazakhstan, 96.2 percent of children had all recommended vaccinations by age of 2 years. There are almost no differences by sex; the per- centage of vaccinated children in urban areas is a bit higher than in rural area. Low immuniza- tion coverage was found in Almaty Oblast (82 percent). There was no difference in coverage with BCG vaccination by sex, place of resi- dence, mother’s education, household wealth and almost all children aged 15-26 months were vaccinated with BCG (99.6 percent). By the age of 26 months, 99.4 percent of chil- dren received first dose of DPT. The percentage declines for subsequent doses of DPT to 99.3 percent for the second dose, and 98 percent for the third dose; boys were slightly more likely to be vaccinated with DPT than girls were. By third dose of DPT, percentage of vaccinated children in rural area was by 2 percent points lower than in urban area. Similarly, over 99 percent of children received Polio 1 and this declines to 95.5 percent of vaccinated rural children by the third dose, which is by 2.4 percent points lower than urban children. The coverage for measles vaccine was found to be almost 100 percent in each Oblast of Kazakhstan, except Karaganda (97.7 percent) and Almaty (97.9 percent) Oblasts. 95 percent of children received HepB vaccine by the age of 26 months; at that, percentage of urban children was a bit higher than rural chil- dren (97.1 and 93.0 percent respectively). Low immunization with Hep. B vaccine was found in Almaty Oblast (75.1 percent). The highest percentage of children who re- ceived no vaccination by 26 months was found in Karaganda Oblast (2.3 percent). The per- centage of girls who are not vaccinated is high- er than the boys. The goals are to: 1) reduce by one half death due to diarrhoea among children under five by 2010 compared to 2000 (A World Fit for Children); and 2) reduce by two thirds the mor- tality rate among children under five by 2015 compared to 1990 (Millennium Development Goals). In addition, the World Fit for Children calls for a reduction in the incidence of diar- rhoea by 25 percent. The indicators are: • Prevalence of diarrhoea • Oral rehydration therapy (ORT) Oral Rehydration Treatment Diarrhoea is the second leading cause of death among children under five worldwide. Most diarrhoea-related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from the body in liq- uid stools. Management of diarrhoea – either through oral rehydration salts (ORS) or a rec- ommended home fluid (RHF) – can prevent many of these deaths. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child are also important strategies for managing diarrhoea. MONITORING THE SITUATION OF CHILDREN AND WOMEN36 • Home management of diarrhoea • (ORT or increased fluids) AND continued feeding In the MICS questionnaire, mothers (or care- takers) were asked to report whether their child had had diarrhoea in the two weeks prior to the survey. If so, the mother was asked a se- ries of questions about what the child had to drink and eat during the episode and whether this was more or less than the child usually ate and drank. Overall, only 1.8 percent or 80 of under five children had diarrhoea in the two weeks pre- ceding the survey (Table CH.4). Due to small number of cases, data is distributed by resi- dence and sex of children. Diarrhoea preva- lence was a bit different in rural and urban areas as well as between girls and boys. The peak of diarrhoea among children aged 6-23 months observed during a period when moth- ers stop breastfeeding. Table CH.4 also shows the percentage of chil- dren receiving various types of recommended liquids during the episode of diarrhoea. In Kazakhstan, the most popular medicine for home treatment of diarrhoea is packed pow- der Smekta and Regidron, which should be dissolved with water. In addition, herbal teas and extracts are widely used. Since mothers were able to name more than one type of liq- uid, the percentages do not necessarily add to 100. 73.3 percent of mothers used fluids from ORS packets for diarrhoea treatment in their chil- dren; 16.4 percent used pre-packaged ORS fluids, and 17.9 percent used recommended homemade fluids. Twenty six percent of chil- dren who had diarrhoea received no treat- ment. The rate of ORT use overall in the country was 74 percent. 21.8 percent of children with di- arrhoea received one or more of the recom- mended home treatments. Less than one half (45.3 percent) of under five children with diarrhoea drank more than usual while 53 percent drank the same or less (Table CH.5). About 59 percent ate somewhat less, same or more (continued feeding), but 41 percent ate much less or ate almost none. Given these figures, 48 percent of children received ORT and increased fluids and at the same time continued feeding as recommend- ed. There are significant differences in the home management of diarrhoea by background characteristics: 55.5 percent of rural children received ORT or increased fluids and contin- ued feeding, while urban children – only 42.2 percent, boys a bit less than girls received such diarrhoea treatment (Figure CH.5). Figure CH.5. Percentage of children aged 0-59 with diarrhoea who received ORT or increased fluids, AND continued feeding, Kazakhstan, 2006, % Sex Male Female Residence Urban Rural Kazakhstan KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 37 Pneumonia is the leading cause of death in children and the use of antibiotics for under-5s with suspected pneumonia is a key interven- tion. A World Fit for Children goal is to reduce by one-third deaths due to acute respiratory in- fections. Children with suspected pneumonia are those who had an illness with a cough accompanied by rapid or difficult breathing and whose symp- toms were not due to a problem in the chest and a blocked nose. The indicators are: • Prevalence of suspected pneumonia • Care seeking for suspected pneumonia • Antibiotic treatment for suspected pneu- monia • Knowledge of the danger signs of pneumo- nia Table CH.6 presents the prevalence of suspect- ed pneumonia and, if care was sought outside the home, the site of care. Only 1.5 percent of children 0-59 months were reported to have had symptoms of pneumo- nia (acute respiratory infection) during the two weeks preceding the survey. Due to small number of cases data is distributed by sex and residence only. Approximately 70 percent of ill children were admitted to different health institutions, of them over 40 percent to pub- lic policlinic facilities and 18 percent to public hospitals. Table CH.7 presents the use of antibiotics for the treatment of suspected pneumonia in un- der-5s by sex and residence. In Kazakhstan, 31.7 percent of under-5 children with sus- pected pneumonia had received an antibiotic during the two weeks prior to the survey with urban population more often than the rural one. Issues related to knowledge of danger signs of pneumonia are presented in Table CH.7A. Obviously, mothers’ knowledge of the danger signs is an important determinant of care-seek- ing behaviour. Overall, 31.7 percent of women know of the two danger signs of pneumonia – fast and difficult breathing. The most com- monly identified symptom for taking a child to a health facility is high fever (89.2 percent). 44.7 percent of mothers identified fast breath- ing and 56.2 percent of mothers identified diffi- cult breathing as symptoms for taking children immediately to a health care provider. For over 55.5 percent of mothers danger sign for seek- ing care is if the child becomes weaker, for 45.8 percent of mothers danger signs is blood in stool, for 25.2 percent of mothers – if a child is not able to drink or breastfeed. Only 11.3 per- cent of mothers will seek care if a child drinks poorly. The highest percentage of mothers aware of two danger signs of pneumonia was found in Mangistau (93.4 percent), followed by Pavlodar (71.4 percent) and North Kazakhstan (52.6 percent) Oblasts, the least was in Kyzylorda (8.7 percent) and Almaty (10.6 percent) Oblasts. 36.3 percent of mothers in urban and 26.9 per- cent in rural area are aware of main pneumonia symptoms. Women with higher education are slightly bet- ter aware of two symptoms of pneumonia, their percentage increase depending on wealth of household (from 22 percent – in poorest to 43.4 percent – in richest). Mothers in Russian families are somewhat better informed about two symptoms of pneumonia than in Kazakh families and make 39.5 percent vs. 30.9 per- cent. Care Seeking and Antibiotic Treatment of Pneumonia MONITORING THE SITUATION OF CHILDREN AND WOMEN38 More than 3 billion people around the world rely on solid fuels (biomass and coal) for their basic energy needs, including cooking and heating. Cooking and heating with solid fuels leads to high levels of indoor smoke, a complex mix of health-damaging pollutants. The main problem with the use of solid fuels is the prod- ucts of incomplete combustion, including CO (single-oxide carbon), polyaromatic hydrocar- bons, SO2, (sulphur oxide) and other toxic ele- ments. Use of solid fuels increases the risks of acute respiratory illness, pneumonia, chronic obstructive lung disease, cancer, and possibly tuberculosis, low birth weight, cataracts, and asthma. The primary indicator is the propor- tion of the population using solid fuels as the primary source of domestic energy for cook- ing. Approximately 19 percent of all households in Kazakhstan are using solid fuels for cook- ing. Use of solid fuels is very high in rural ar- eas, where 40.8 percent of households are us- ing solid fuels, but very low in urban areas (6.8 percent). Differentials with respect to house- hold wealth and the educational level of the household head are also significant. The find- ings show that there is no use of solid fuels among households in Almaty and Astana cities and Mangistau Oblast as well as among richest households. The highest percentage of house- holds using solid fuels for cooking was found in South Kazakhstan (40.7 percent) and Kyzylorda (39.8 percent) Oblasts (Table CH.8). The table also clearly shows that the overall percentage is high due to excessive level of coal use for cook- ing purposes (14.7 percent). Solid fuel use alone is a poor proxy for indoor air pollution, since the concentration of the pollutants is different when the same fuel is burnt in different stoves or fires. Use of closed stoves with chimneys minimizes indoor pol- lution, while open stove or fire with no chim- ney or hood means that there is no protection from the harmful effects of solid fuels. The type of stove used to burn solid fuel is depicted in Table CH.9. 83.7 percent of abovementioned households use closed stoves with a chimney – 79.5 per- cent in urban area and – 85 percent in rural. 15.8 percent of households use open stoves with chimney (hook), their percent is higher in urban areas than in rural. The highest percent of closed stove systems was found in poorest (89.7 percent) and poor (81.6 percent) house- holds; only 51.9 percent of rich households use such devices while there is no use among the richest households. Closed stoves with chimney are least spread in Karaganda Oblast (3.4 per- cent) and only one third households of Aktobe Oblast (30.2 percent) use such stoves. Only 0.4 percent of households in the country use open stove (without chimney or hook). These stoves are not widely spread, they could be considered as seasonal devices for cooking in some house- holds. Solid Fuel Use KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 39 VII. Environment MONITORING THE SITUATION OF CHILDREN AND WOMEN40 Water and Sanitation Safe drinking water is a basic necessity for good health. Unsafe drinking water can be a signifi- cant carrier of diseases such as trachoma, chol- era, typhoid, and schistosomiasis. Drinking wa- ter can also be tainted with chemical, physical and radiological contaminants with harmful effects on human health. In addition to its as- sociation with disease, access to drinking water may be particularly important for women and children, especially in rural areas, who bear the primary responsibility for carrying water, often over long distances. The MDG goal is to reduce by half, between 1990 and 2015, the proportion of people without sus- tainable access to safe drinking water and basic sanitation. The World Fit for Children goal calls for a reduction in the proportion of households without access to hygienic sanitation facilities and affordable and safe drinking water by at least one-third. The list of indicators used in MICS are as follows: Water • Use of improved drinking water sources • Use of adequate water treatment method • Time to source of drinking water • Person collecting drinking water Sanitation • Use of improved sanitation facilities • Sanitary disposal of child’s faeces The distribution of the population by source of drinking water is shown in Table EN.1 and Figure EN.1. The population using improved sources of drinking water are those using any of the follow- ing types of supply: piped water (into dwelling, yard or plot), public tap/standpipe, tubewell/ borehole, protected well, protected spring, rain- water collection. Bottled water is considered as an improved water source only if the household is using an improved water source for other pur- poses, such as hand washing and cooking. Overall, 93.7 percent of the population in Kazakhstan is using an improved source of drinking water – 98.1 percent in urban areas and 87.7 percent in rural areas. The situation in North Kazakhstan (81.7 percent), Kostanai (83.2 percent), South Kazakhstan (85.7 per- cent) and Atyrau (89.3 percent) Oblasts is a bit worse. The population of capital city Astana and Almaty gets water only from improved sources. Population with higher education level more of- ten uses improved sources of drinking water. The source of drinking water for the popula- tion varies strongly by region (Table EN.1). In Karaganda, Almaty, Mangistau and East Kazakhstan Oblasts (75.7, 64.9, 64.4 and 62.7 percents respectively) and in Almaty and Astana cities (98.5 and 84.8 percent respectively) use drinking water piped into dwelling, yard or plot. In contrast, only about 27.5 percent of house- holds in North Kazakhstan, 32.3 percent in Akmola and 32.8 percent in West Kazakhstan Oblasts have water piped into dwelling or yard. Almost half (48 percent) of the households in Zhambyl Oblast obtains drinking water from tube-well/borehole, about 35-38 percent of households in Mangystau, West-Kazakhstan and Atyrau Oblasts use water from protected wells, and 33.4 percent of households in Kyzylorda and 38.2 percent – in Akmola Oblasts use public taps/standpipes. Six percent of households use carried water in the North Kazakhstan Oblast. In Atyrau and South Kazakhstan Oblasts 8.1 and 6.8 percent of population respectively use sur- face water sources. Use of in-house water treatment is presented in Table EN.2. Households were asked about ways they may be treating water at home to make it safer to drink – boiling, adding bleach or chlo- rine, using a water filter, and using solar disin- fection were considered as proper treatment of drinking water. The table shows the percentages of household members using appropriate water treatment methods, separately for all house- holds, for households using improved and un- improved drinking water sources. KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 41 In Kazakhstan, 70.8 percent of the population uses an appropriate way to treat drinking wa- ter obtained from all sources, including 70.2 percent of those who appropriately treat drink- ing water obtained from improved sources and 80.7 percent of those who obtains water from unimproved sources use an appropriate wa- ter treatment method. The urban population and population with higher levels of education use treatment methods more often. Wealthier households more often treat drinking water compared to less wealthy households. Overall, 69 percent of population boils water as the main method of water treatment, 24.7 percent of population let the water stay and settle. Other methods of water treatment are not very much popular. 23.7 percent of population use no treat- ment of drinking water, 0.1 percent of popula- tion knows neither method of water treatment. The percentage of households using appropri- ate method of water treatment from improved and unimproved drinking water sources is high in Mangistau (98.5 percent), South Kazakhstan (93.4 percent), Atyrau (93.1 percent) Oblasts and Almaty City (95.9 percent). Low percentage of water treatment was found in households of Zhambyl (24.9 percent), East Kazakhstan (53.2 percent) and Almaty (54.3 percent) Oblasts. Water treatment from unimproved sources for drinking purpose was found very high in Atyrau (100 percent), South Kazakhstan (96 percent) and West Kazakhstan (83.6 percent) Oblasts. Notable is the fact that the urban and the poor households used water treatment more often than those in rural areas and regardless of their education levels. Moreover, Kazakh households resort to water treatment more often than Russian households (84.9 percent and 66.1 per- cent respectively). Water treatment from improved sources for drink- ing purpose was reported by respectively 74 and 65 percent of urban and rural households. Water treatment practice shows direct correlation with education and welfare levels i.e. the higher edu- cation and welfare the higher use of water treat- ment. Almaty city reported the highest utilization of water treatment followed by Mangistau, South Kazakhstan, and Atyrau Oblasts, and the least wa- ter treatment practice was reported by Zhambyl, Almaty and East Kazakhstan Oblasts. The amount of time it takes to obtain water is presented in Table EN.3 and the person who usually collected the water in Table EN.4. Note that these results refer to one roundtrip from home to the drinking water source. Information on the number of trips made in one day was not collected. Figure EN.1. Percentage distribution of population by source of drinking water, Kazakhstan, 2006 Piped into dwelling, yard or plot 56,6% Public tap/stand pipe 15,6% Tube-well/bore-hole 9,2% Protected spring 12,1% Unprotectd spring 1,2% Surface water 1,6% Other unimproved sources 3,7% MONITORING THE SITUATION OF CHILDREN AND WOMEN42 Table EN.3 shows that for 73.4 percent of house- holds, the drinking water source is on the premises. For 20.3 percent of households, it takes less than 30 minutes to get to the water source and bring water, while 4.7 percent of households spend from 30 minutes to one hour and 1.4 percent spend over one hour for this purpose. Excluding those households with water on the premises, the average time to the source of drinking water is 19 minutes. The time spent in rural areas in collect- ing water is slightly higher than in urban areas. The high average time spent in Kostanai and Kyzylorda Oblasts in collecting water is over 25 minutes. Table EN.4 shows that for the majority of house- holds, an adult male is usually the person collect- ing the water, when the source of drinking water is not on the premises. Adult men collect water almost in 65 percent of cases, while for the rest of the households, about 30 percent of adult females and 5.5 percent of female or male children under age 15 collect water. In poor households male children under 15 years more often collect water than in middle income and rich households. Inadequate disposal of human excreta and poor personal hygiene is associated with a range of diseases including diarrhoeal diseases and polio. Improved sanitation facilities for excreta disposal include: flush or pour flush to a piped sewer system, septic tank, or latrine; ventilated improved pit la- trine, pit latrine with slab, and composting toilet. 99.2 percent of the population of Kazakhstan is living in households using improved sanitation facilities (Table EN.5). This percentage is 99.5 in urban areas and 98.9 percent in rural areas. A high proportion of the population almost in all regions of the country uses improved sanitation facilities – 98.3 percent or higher, the lowest is in Aktobe Oblast with 93.6 percent. The table indicates that use of improved sanitation facili- ties is strongly correlated with wealth and is pro- foundly different between urban and rural areas. In rural areas, the population is mostly using pit latrines with slabs, while for urban population, on the contrary, the most common facilities are flush toilets connected to a sewage system or septic tank. Residents of urban areas are much more likely than in rural areas to use modern flush toilets (60 percent of households) and pit latrine with slab (35.5 percent of household); in rural areas about 95 percent of households use pit latrine with slab. By wealth level, 73.3 percent of rich and 99.8 percent of richest households use modern flush toilets, while over 98 percent of poorest and poor households use pit latrines with slab. Use of modern sanitation facilities at large depends on the level of education; popula- tion with lower levels of education uses simpli- fied types of facilities (pit latrines with slab). Residents of Almaty and South Kazakhstan Oblasts are less likely than others to use flush toilets and more pit latrines with slab, which is related mainly to the rural type of dwelling. It could be noted that only 2 percent of im- proved sanitation facilities are used jointly by several households (Table EN.5W). Safe disposal of a child’s faeces is the last stool by the child was disposed of by use of a toilet or rinsed into toilet or latrine. Disposal of faeces of children 0-2 years of age is presented in Table EN.6. Mothers reported only 3.1 percent of children aged 0-2 years visiting toilet, in 28.3 percent of cases faeces were disposed/flushed to the toilet, in 38.2 percent – disposed or flushed to sewer- age, 25.3 percent thrown to garbage, and in 0.5 percent – buried. Percentage of children whose latest faeces were safely disposed made 31.4 per- cent; this indicator in urban area was 54.3 per- cent against 8.7 percent in rural area. Proportion of proper disposal of children’s faeces is higher in rich and richest households (65.7-89.4 percents respectively), while in the less wealthy house- holds this indicator made 5.2 to 15.9 percent. Percentage of children whose faeces were prop- erly disposed is higher if mother has higher level of education – 46.6 percent against 19.2 percent of mothers with primary/incomplete secondary education. There also was significant difference by regions, for instance, very low level of safe fae- ces disposal was found in Almaty (6.1 percent), South Kazakhstan (11.2 percent) Oblasts, as ru- ral population prevails in these regions (as men- tioned above only 8.7 percent of children’s faeces are disposed safely in rural area). High level of safe children’s faeces disposal was found in Astana (77.7 percent) and Almaty (83.3 percent) Cities as well as in Pavlodar Oblast (61.9 percent). As summarized in Table EN.7, 93.7 percent of population of Kazakhstan use improved sources of drinking water. And 99.2 percent use sanitary means of excreta disposal. Overall, 93 percent of population of Kazakhstan use improved sources of drinking water and improved sanitation facil- ities for faeces disposal. KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 43 VIII. Reproductive Health MONITORING THE SITUATION OF CHILDREN AND WOMEN44 Appropriate family planning is important to the health of women and children for: 1) preventing pregnancies that are too early or too late; 2) ex- tending the period between births; and 3) limiting the number of children. A World Fit for Children goal is access by all couples to information and services to prevent pregnancies that are too early, too closely spaced, too late or too frequent. Current use of contraception was reported by 50.7 percent of women currently married or in union (Table RH.1). The most popular method is IUD (intrauterine device) which is used by one in three married women (36.2 percent) in Kazakhstan. The next most popular but of lim- ited occurrence method is pills, which accounts for 6.7 percent. 4.8 percent of women reported use of the condom. Less than one percent use periodic abstinence, withdrawal, female sterili- zation, vaginal methods, or the lactation amen- orrhea method (LAM). Prevalence of contraception is highest in West Kazakhstan, North Kazakhstan, Pavlodar, Kostanai, Akmola and East Kazakhstan Oblasts and Astana City at over 60 percent. The high- est prevalence of pills was found in urban areas where women use them about three times more often than in rural area. In large cities of Astana and Almaty, almost each seventh married wom- an uses contraception pills. Younger women use less contraception than adult women do. Current use of contraception was reported by only 31.7 percent of women aged 15-19 currently married or in union com- paring to 53.7 percent of women aged 25–29 years and 61.5 percent of women aged 30-34. Women’s education level is strongly associated with contraceptive prevalence. The percentage of women using any method of contraception rises from 43 percent among those with pri- mary/incomplete secondary education to 53.3 percent among women with higher education. Education level also corresponds with method of contraception. 48.7 percent of women use modern methods of contraception, while only 2 percent of inter- viewed women used traditional methods. Over 60 percent of women use modern contracep- tion in Astana city and East Kazakhstan Oblast. The percentage of women using contraception is higher among women with two (61.2 percent) and three (51.6 percent) children. Percentage of women without children using contraception was 11.7 percent. Contraception Reproductive behavior is a component of Reproductive Health Program. Family planning as a reserve for the health of woman and com- ponent of Reproductive Health Program is es- sential for birth of wanted children. Based on this thesis WHO Alma-Ata Declaration (1978) considers protection of mother and child health as essential part of primary healthcare needed to ensure health of family. Major provisions related to reproductive health rising from reproductive rights and reproductive behavior were approved by Platform for Action of IV World Conference on Status of Women (Beijing, 1995). Reproductive Behavior Reproductive behavior is the system of human actions and attitudes stipulating birth or refuse birth. The conceive age for woman is considered 15–49 years, called reproductive (fertile) age. This age limitation is conditional; therefore, re- productive period is a part of woman’s life when she is able to give birth. Essential component of Reproductive Health Program is family plannng, which helps to en- sure wanted number of children in the family, safe them and select the best time for birth taking into account age of parents and social- economic conditions, avoid unwanted preg- nancy, plan birth, it reduces maternal and in- KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 45 fant mortality, improves health of mother and child. Over one-third (37.7 percent) women wanted to have 2 children, almost one in three (28.7 percent) women – three children and 17.0 per- cent – four children (Table RH.2A). Less than 9 percent of women in the survey wanted to have 5 to 9 children and only 0.5 percent of women wanted 10 and more children. More ur- ban women prefer having two (44.1 percent) and three (28.4 percent) children. Less than one-third of rural women wanted to have two children (28.5 percent) and approximately the same percentage wanted to have three chil- dren (29.2 percent). Only 13.3 percent of urban women wanted to have four children, while 22.5 percent of rural women wanted to have the same number of children. The largest differ- ence was found among women willing to have 5-9 children: their percentage in rural areas is almost three times greater than the percentage of urban women – 14.0 percent and 5.0 percent respectively. Major number of women regulates the number of children and time for birth of the next baby, i.e. follow certain birth interval. Thus, almost 37.3 percent of interviewed women would pre- fer to have a three-year birth space, 32.6 percent – two years, about 11 percent believe birth space should be 4 – 5 and more years. Least number of women (7.4 percent) wanted to wait for one year before the next birth. Almost half of women in survey (49.3 percent) in Kyzylorda Oblast prefer to have two-year birth space and over half (50.7 percent) women in South Kazakhstan Oblast – three-year. The best birth interval both for urban and rural women is three years (36 percent of urban and 39.3 per- cent of rural women). Reproductive aims of women aged 15 – 49 years differ by Oblasts. Thus, 39.1 percent of women in South Kazakhstan Oblast wish to have four chil- dren and 22.5 percent want to have 5 to 9 chil- dren, while in North Kazakhstan Oblast more women want to have two children (more than half – 50.4 percent), and one-fourth of women (25.3 percent) wanted to have three children (Table RH.2A). Reproductive aims of women slightly differ (by few percent) in Kostanai, Karaganda, East Kazakhstan Oblasts and Astana and Almaty Cities. Percentage of women will- ing to have 5 to 9 children prevails in South Kazakhstan (22.5 percent), Kyzylorda (17.4 per- cent), Zhambyl (14.1 percent) Oblasts and by 10 percents in Atyrau and Mangistau Oblasts. Wealth level is not much associated with per- centage of women willing to have three children and makes around 30 percent in each group sampled by wealth level, while percentage of women planning to have four children declines from 27.2 percent in poorest families to 9.2 per- cent in richer families. The highest percentage of women willing to have 5 to 9 children was found in poorest families – 18.4 percent, the least percentage (2.6 percent) in richer families. As shown in Table RH.2B, women reported on the following factors limiting the number of children: • Low salary – 25 percent. The highest per- centage of women who mentioned this fac- tor was found in South Kazakhstan (48.1 per- cent) and Karaganda (36.8 percent) Oblasts. • Health status – 19.7 percent – almost half of respondents mentioned this factor (46 per- cent) in Almaty Oblast. • Uncertainty about future of children – 14.4 percent; • No job – 9.8 percent. Almost every fifth wom- an (by 21.8 percent) mentioned this factor in Kyzylorda and South Kazakhstan Oblast. The percentage of a restricting factor such as absence of housing and regular work made 6.2 percent and 5.3 percent respectively all over the country. Similarly, the following factors were mentioned as stimuli for birth of another baby (Table RH.2C): • maternity leave with sufficient pay– 21.4 percent; • reducing age of retirement – 19.8 percent. • sufficient family allowance – 16.2 percent; • mortgage and credits – 12.1 percent; About 8 percent of women would give birth to another baby in case of shortened working day for breastfeeding mothers. Maternity leave with sufficient pay and reduction of retirement age are the most popular birth stimulus mentioned by 26 to 38 percent of women. MONITORING THE SITUATION OF CHILDREN AND WOMEN46 The antenatal period presents important op- portunities for reaching pregnant women with a number of interventions that may be vital to their health and well-being and that of their in- fants. Better understanding of foetal growth and development and its relationship to the mother’s health has resulted in increased attention to the potential of antenatal care as an intervention to improve both maternal and newborn health. For example, if the antenatal period is used to inform women and families about the danger signs and symptoms and about the risks of labour and de- livery, it may provide the route for ensuring that pregnant women do, in practice, deliver with the assistance of a skilled health care provider. The antenatal period also provides an opportunity to provide information on birth control, which is recognized as an important factor in improving infant survival. The prevention and treatment of malaria among pregnant women, management anaemia during pregnancy and treatment of STIs can significantly improve foetal outcomes and improve maternal health. Adverse outcomes such as low birth weight can be reduced through a combination of interventions to improve wom- en’s nutritional status and prevent infections (e.g., malaria and STIs) during pregnancy. More recently, the potential of the antenatal period as an entry point for HIV prevention and care, in particular for the prevention of HIV transmission from mother to child, has led to renewed interest in access to and use of antenatal services. WHO recommends a minimum of four antena- tal visits based on a review of the effectiveness of different models of antenatal care. WHO guide- lines are specific on the content of antenatal care visits, which include: • Blood pressure measurement • Urine testing for bacteriuria and proteinuria • Blood testing to detect syphilis and severe anaemia • Weight/height measurement (optional) Coverage of antenatal care (by a doctor, nurse, or midwife) is high in Kazakhstan with 99.9 percent of women receiving antenatal care at least once during the pregnancy (Table RH.3). Antenatal care in all regions of Kazakhstan is 100 percent. Coverage of antenatal care in ur- ban area is 100 percent, while in rural areas this indicator is lower by only 0.3 percent points. The type of personnel providing antenatal care to women aged 15-49 years who gave birth in the two years preceding is also presented in Table RH.3. Mainly doctors provide antenatal care in Kazakhstan (88.9 percent); in 9.1 percent nurses/ midwives, 0.2 percent – auxiliary midwives and 1.7 percent – feldshers provide antenatal care. The types of services pregnant women received are shown in table RH.4. As mentioned above, 99.9 percent of pregnant women in Kazakhstan re- ceived antenatal care. In fact, all women had blood testing, blood pressure measurement; urine test- ing and weight measurement (by 99.5 percent). Antenatal care content varies across the Oblasts. Three quarters of all maternal deaths occur dur- ing delivery and the immediate post-partum period. The single most critical intervention for safe motherhood is to ensure a competent health worker with midwifery skills is present at every birth, and transport is available to a referral facili- ty for obstetric care in case of emergency. A World Fit for Children goal is to ensure that women have ready and affordable access to skilled attendance at delivery. The indicators are the proportion of births with a skilled attendant and proportion of institutional deliveries. The skilled attendant at delivery indicator is also used to track progress toward the Millennium Development target of reducing the maternal mortality ratio by three quarters between 1990 and 2015. The MICS included a number of questions to Antenatal Care Assistance at Delivery KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 47 number of maternal deaths per 100,000 live births. In MICS, the maternal mortality ratio is estimated by using indirect sisterhood method, which allows obtaining maternal mortality es- timates for past 10-14 years before the survey. To collect the information needed for the use of this estimation method in Kazakhstan, adult household members were asked a few questions regarding the survival of their sisters and the timing of death relative to pregnancy, childbirth and the postpartum period for deceased sisters. The information collected is then converted to lifetime risks of maternal death and maternal mortality ratios11. MICS results on maternal mortality are shown in Table RH.6. The results are also presented only for the national total, since maternal mortality ratios generally have very large sampling errors. In total, 38,818 respondents were interviewed, they had 62,823 sisters aged 15 years and older. In survey, in Kazakhstan mortality rate within past 10-14 years was 70 cases per 100,000 of life birth in average. As per official data of the Ministry of Health of the Republic of Kazakhstan, maternal mortality in Kazakhstan was 36.9 in 2004 and 40.5 per 100,000 life births in 2005. In the 1995 and 1999 Demography and Health Surveys (DHS), the level of maternal mortality was 77 and 62.5 per 100,000 life births respec- tively12. Maternal Mortality The complications of pregnancy and child- birth are a leading cause of death and disability among women of reproductive age in devel- oping countries. It is estimated worldwide that around 529,000 women die each year from ma- ternal causes. And for every woman who dies, approximately 20 more suffer injuries, infection and disabilities in pregnancy or childbirth. This means that at least 10 million women a year suf- fer from these type of injuries. The most common fatal complication is post- partum haemorrhage. Sepsis, complications of unsafe abortion, prolonged or obstructed labour and the hypertensive disorders of preg- nancy, especially eclampsia, claim further lives. These complications, which can occur at any time during pregnancy and childbirth without forewarning, require prompt access to quality obstetric services equipped to provide lifesav- ing drugs, antibiotics and transfusions and to perform the caesarean sections and other surgi- cal interventions that prevent deaths from ob- structed labour, eclampsia and haemorrhage. One MDG target is to reduce by three quarters, between 1990 and 2015, the maternal mortality ratio. Maternal mortality is defined as the death of a woman from pregnancy-related causes, when pregnant or within 42 days of termination of pregnancy. The maternal mortality ratio is the 11 For more information on the indirect sisterhood method, see WHO and UNICEF, 1997. 12 Nutrition Institute MoH-SA RK, Academy of Preventive Medicine, Demography and Health Survey Department, Macro International Inc. Kazakhstan Demography and Health Survey, 1995. Almaty, 1996. Academy of Preventive Medicine, and Macro International Inc., 2000. Kazakhstan Demography and Health Survey, 1999. Almaty, 2000 assess the proportion of births attended by a skilled attendant. A skilled attendant includes a doctor, nurse, midwife or auxiliary midwife. In Kazakhstan, almost all births (99.8 percent) were delivered by skilled personnel (Table RH.5). This percentage is 100 percent almost in each Oblast of the country, except in North Kazakhstan Oblast (96.4 percent) and in Astana City (98.8 percent). No significant differences between women delivered with the assistance of skilled attendant was found by education lev- el of woman, wealth and ethnicity. 80.9 percent of deliveries were attended by doctors, while 18.2 percent of deliveries attended nurses/ob- stetricians. MONITORING THE SITUATION OF CHILDREN AND WOMEN48 IX. Child Development KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 49 It is well recognized that a period of rapid brain development occurs in the first 3-4 years of life, and the quality of home care is the major determinant of the child’s development during this period. In this con- text, adult activities with children, presence of books in the home, for the child, and the conditions of care are important indicators of quality of home care. A World Fit for Children goal is that “children should be physically healthy, mentally alert, emotionally secure, so- cially competent and ready to learn.” Information on a number of activities that sup- port early learning was collected in the survey. These included the involvement of adults with children in the following activities: reading books or looking at picture books, telling sto- ries, singing songs, taking children outside the home, compound or yard, playing with chil- dren, and spending time with children nam- ing, counting, or drawing things. For 81 percent of under-five children, an adult engaged in more than four activities that pro- mote learning and school readiness during the 3 days preceding the survey (Table CD.1). The average number of activities that adults engaged with children was 4.9. Father’s and mother’s involvement in such activities are almost the same (81.1 and 80.9 percent re- spectively). Father’s involvement with one or more activities was 46.9 percent. 13.6 percent of total number of children in households had no father. Average number of activities that fa- thers are engaged with their children was 1.2. There are no gender differentials in terms of adult activities with children; however, a larg- er proportion of fathers engaged in activities with male children (47.7 percent) than with female children (46 percent). Larger propor- tions of adults engaged in learning and school readiness activities with children in urban areas (82.9 percent) than in rural areas (79.1 percent). Strong differentials by region and socio-economic status are also observed: adult engagement in activities with children was greatest in South Kazakhstan Oblast (94.3 per- cent) and lowest in Almaty Oblast (60.4 per- cent), while the proportion was 86.9 percent for children living in the richest households, as opposed to almost 80 percent among those living in the poorer households. Father’s in- volvement showed a similar pattern in terms of adults’ engagement in such activities. More educated mothers and fathers engaged more in such activities with children than those with less education. Exposure to books in the early years not only provides the child with greater understanding of the nature of print, but may also give the child opportunities to see others reading, such as older siblings doing school work. Presence of books is important for later school perform- ance and IQ scores. In Kazakhstan, 89.1 percent of children are living in households where at least 3 non-chil- dren’s books are available (Table CD.2). 66.4 percent of children aged 0-59 months have children’s books. Median number of non-chil- dren’s books is twice as many as children’s books (10 and 5 books respectively). While no gender differentials are observed, urban chil- dren appear to have more access to all types of books than those living in rural households. Ninety one percent of under-5 children living in urban areas live in households with more than 3 non-children’s books, while the figure is 87.1 percent in rural households. The pro- portion of under 5 children who have 3 or more children’s books is 76.9 percent in urban areas, compared to 55.5 percent in rural areas. The presence of children’s books is positively correlated with the child’s age: in the homes of 71.2 of children aged 24-59 months there are 3 and more children’s book, while the figure is only 59.6 for children aged 0-23 months. Table CD.2 also shows that 19.8 percent of chil- dren aged 0-59 months had 3 or more playthings to play with in their homes, while 4.5 percent MONITORING THE SITUATION OF CHILDREN AND WOMEN50 had none of the playthings asked to the moth- ers/caretakers (Table CD.2). The playthings in MICS included household objects, homemade toys, toys that came from a store, and objects and materials found outside the home. It is in- teresting to note that 93.5 percent of children play with toys that come from a store; however, the percentages for other types of toys is be- low 7 percent. The proportion of children who have 3 or more playthings to play with is 19.4 percent among male children and 20.2 percent among female children. No urban-rural differ- entials are observed in this respect; some differ- ences are observed in terms of mother’s educa- tion: approximately 20-24 percent of children whose mother’s have primary/incomplete secondary and secondary education have 3 or more playthings, while the proportion is 16.8 and 19.7 percent for children whose mother’s have specialized secondary and higher educa- tion. Differentials are small by socioeconomic status of the households, and regions. The only background variable which appears to have a strong correlation with the number of play- things children have is the age of the child, a somewhat expected result, for instance, only 11.2 percent of children aged 0-23 months and 25.7 percent of children aged 24-59 have 3 and more playthings. Leaving children alone or in the presence of other young children is known to increase the risk of accidents. In MICS, two questions were asked to find out whether children aged 0-59 months had been left alone during the week preceding the interview, and whether children were left in the care of other children under 10 years of age. Table CD.3 shows that 9 percent of children aged 0-59 months were left in the care of oth- er children, while 2.3 percent were left alone during the week preceding the interview. Combining the two care indicators, it is cal- culated that 9.8 percent of children were left with inadequate care during the week preced- ing the survey. No differences were observed by the sex of the child (9.9 and 9.6 percent re- spectively), while there were some difference between urban and rural areas: in urban area 10.4 percent of children were left alone and 9.2 percent in rural area. On the other hand, inadequate care was more prevalent among children whose mothers had primary/ incom- plete secondary education (10 percent) and secondary completed education (11.4 per- cent), as opposed to children whose mothers had higher education (8.3 percent). Children aged 24-59 months were left with inadequate care more (12.7 percent) than those who were aged 0-23 months (5.6 percent). No differenc- es are observed in regard to socioeconomic status and ethnicity of the household (except poorest households – 7.6 percent). In Aktobe (27.3 percent) and Akmola (24.9 percent) Oblasts children were left with in- adequate care more than in other oblasts and this indicator was the lowest in Almaty city (1.9 percent), Almaty (2 percent) and South Kazakhstan (3.7 percent) Oblasts. KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 51 X. Education MONITORING THE SITUATION OF CHILDREN AND WOMEN52 Attendance to pre-school education in an or- ganized learning or child education program is important for the readiness of children to school. One of the World Fit for Children goals is the promotion of early childhood education. Only 16 percent of children aged 36-59 months are attending pre-school institutions (Table ED.1). Urban-rural and regional differentials are significant – the figure is as high as 24.1 per- cent in urban areas, compared to 7 percent in rural areas. Proportion of children attending pre-school facilities at age of 36-47 months and 48-59 months is almost the same (15.4-16.7 percent). Among children aged 36-59 months, attendance to pre-school is more prevalent in Karaganda (33.4 percent) Oblast compared to Almaty (7.1 percent), Kyzylorda (8.2 percent) and South Kazakhstan (8.1 percent) Oblasts. Boys more often than girls attend pre-school institutions (17.8 percent vs. 14.1 percent re- spectively); also differentials by socioeconomic status are significant. 44.8 and 22.5 percent of children living in the richest and rich house- holds respectively attend pre-school facilities, while the figure drops to 8.6 and 2.8 percent in poor and poorest households. Early education of children at large depends on the level of mother’s education. In the survey, proportion of children attending pre-school institutions, whose mothers had specialized secondary or higher education was 20 and 32.5 percent respectively comparing to children of mothers with primary of secondary education (3.2 and 7.5 percent respectively). The table also shows the proportion of children in the first grade of primary school who attend- ed pre-school the previous year (Table ED.1), an important indicator of school readiness. Overall, 39.5 percent of children who currently attend the first grade of primary school were attending pre-school the previous year. This indicator is al- most the same for boys and girls, 46.4 percent of children in urban areas had attended pre-school the previous year compared to 33 percent of in rural areas. Regional differentials are also very significant. Socioeconomic status appears to have a positive correlation with school readi- ness – while the indicator is only 19.2 percent among the poorest households, it increases to 59.2 percent among those children living in the richest households. Pre-School Attendance and School Readiness Universal access to basic education and the achievement of primary education by the world’s children is one of the most important goals of the Millennium Development Goals and A World Fit for Children. Education is a vital prerequisite for combating poverty, empowering women, pro- tecting children from hazardous and exploita- tive labour and sexual exploitation, promoting human rights and democracy, protecting the en- vironment, and influencing population growth. The indicators for primary and secondary school attendance include: • Net intake rate in primary education Primary and Secondary School Participation • Net primary school attendance rate • Net secondary school attendance rate • Net primary school attendance rate of chil- dren of secondary school age • Female to male education ratio (gender par- ity index – GPI) The indicators of school progression in- clude: • Survival rate to grade five • Transition rate to secondary school • Net primary completion rate KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 53 Of children who are of primary school entry age (age 7) in Kazakhstan, 92.9 percent are at- tending the first grade of primary school (Table ED.2). By gender indicator boys (95.1 percent) prevail over girls (90.4 percent); significant dif- ferentials are present by region, but there are no much differences between urban-rural areas. In South Kazakhstan, for instance, all children at- tended primary school, while in East Kazakhstan the value of the indicator reaches only 80.4 per- cent. Children’s participation to primary school is higher in urban areas (93.5 percent) than in rural areas (92.2 percent). A positive correlation with mother’s education and socioeconomic status is observed; for children aged 7 whose mothers have high level of education, 93.9 per- cent were attending the first grade. Table ED.3 provides the percentage of children of primary school age attending primary or second- ary school. The majority of children of primary school age are attending school (98 percent). However, 2 percent of the children are out of school when they are expected to be participating in school. The primary school net attendance ra- tio is almost the same in urban and rural area (98 percent); however, there are small differentials be- tween school attendance by boys and girls (98.5 and 97.5 percent respectively). Some correlation with mother’s education is found – 98.4 percent of children whose mothers have higher level of edu- cation attended primary school, opposed to 94.8 percent of children whose mothers have lower level of education. The primary school net attend- ance increases depending on the age of children – from 93.6 percent at age 7 years to 99.7 percent – at age 8-10 years. The primary school net attend- ance of children from Kazakh families (98.9 per- cent) is higher than children from Russian families (95.4 percent), especially among girls (difference in 5.5 percent). Wealth differentials almost are not present; the indicator varies from 97.6-98.5 percent. There are some differences by regions, for instance, the primary school net attendance is below than in any regions of the Republic only in East Kazakhstan Oblast – 93.6 percent (boys – 97.7, girls – 90.1 percent). The secondary school net attendance ratio is presented in Table ED.4. 95.3 percent of secondary school age children at- tend secondary school. There were no large differ- ences found by sex of children. Attendance ratio is slightly higher among urban children; attend- ance ratio among girls in rural area is higher than among boys. There are significant differences by age of children: 87.4 percent of 11-year-olds and 85.6 percent of 17-year-old children attend sec- ondary school as opposed to 99 percent of chil- dren aged 12-16 years. 90.9 percent of children, whose mothers were missing in the households, attend secondary school. Attendance rate among children, whose mothers have higher level of education, is higher than among those children, whose mothers have primary or incomplete sec- ondary education. The same trend was found by household wealth. The highest attendance rate was found in Mangistau (98.7 percent) and East Kazakhstan (97.9 percent) Oblasts and Astana (97.5 percent) and Almaty (96.2 percent) Cities and lower in Almaty Oblast (93.3 percent). The primary school net attendance ratio of chil- dren of secondary school age is presented in Table ED.4W. 1.6 percent of the children of secondary school age are attending primary school when they should be attending secondary school. The remaining 3.1 percent are not attending school at all; they are children out of school since we already indicated that 95.3 percent of children were attending secondary school. Secondary school age includes children aged 11 years, al- most no children attending primary school were found by other age groups, except 12 years – 0.2 percent of them, by 0.2 percent of boys and girls of secondary school age attend primary school. Percentage of rural boys is higher than urban ones opposed to girls; overall, the percentage of rural children is higher than percentage of ur- ban children (1.7 and 1.4 percent respectively). Percentage of these children is higher at moth- MONITORING THE SITUATION OF CHILDREN AND WOMEN54 ers having primary education and in households with low wealth level. The highest percent of children of secondary school age, who attended primary school at the moment of survey, was found in Pavlodar Oblast (3.1 percent) and the lowest in Atyrau and Mangistau Oblasts, where their percentage made only by 0.3 percent. The percentage of children entering first grade who eventually reach grade 5 is presented in Table ED.5. Of all children starting grade one, almost all of them (99.7 percent) will eventu- ally reach grade five. Notice that this number includes children that repeat grades and that eventually move up to reach grade five. Boys and girls almost with the same probability reach grade five, with slight difference in favor of girls and urban schoolchildren. Almost 100 percent of children, whose mothers have primary and secondary education, reach grade five, while for mothers with specialized secondary and higher education only 98.9—99.7 percent of children reach grade five. Percentage of children entered the first grade and reached grade five in poorest households is slightly lower than in households with higher wealth levels. The lowest indicator was found in Astana City (97.1 percent) and in Almaty Oblast (97.6 percent), in all other re- gions 100 percent of children reach grade five, both boys and girls. The net primary school completion rate and transition rate to secondary education is pre- sented in Table ED.6. At the moment of the sur- vey, 88.4 percent of the children of primary com- pletion age (11 years) were attending the fourth grade of primary education. This value should be distinguished from the gross primary com- pletion ratio, which includes children of any age attending the last grade of primary school. The net primary school completion rate in urban and rural area is almost the same (88 percent) and increasing depending on the level of their mothers’ education from 87 percent for moth- ers with secondary education to 92.8 percent for mothers with higher education. The net pri- mary school completion rate is lower in poorest household (86.6 percent). 99.7 percent of children who successfully com- pleted the last grade of primary school (4th grade), at the moment of survey attended grade 5 of secondary school. Transition rate to second- ary education is 99.7 percent all over Kazakhstan, by 100 percent in 8 regions of the country. There were found no significant differences by child’s sex and residence, mother’s education level, eth- nicity and household wealth level. The ratio of girls to boys attending primary and secondary education is provided in Table ED.7. These ratios are better known as the Gender Parity Index (GPI). Notice that the ratios includ- ed here are obtained from net attendance ratios rather than gross attendance ratios. The last ra- tios provide an erroneous description of the GPI mainly because in most of the cases the majority of over-aged children attending primary educa- tion tend to be boys. The table shows that gen- der parity for secondary school is 1.0, indicating no difference in the attendance of girls and boys to secondary school. This indicator value is kept almost the same for primary education (0.99). There were no significant differentials found at the primary/secondary school attendance level and between boys and girls by residence, moth- er’s education and wealth of household. Adult Literacy One of the World Fit for Children goals is to as- sure adult literacy. Adult literacy is also an MDG indicator, relating to both men and women. In MICS, since only a women’s questionnaire was administered, the results are based only on fe- males age 15-24. Woman’s literacy was assessed on the attendance of any education institutions and made 99.8 percent. In Kazakhstan, literacy is comprehensive, thus, no significant differences by residence, region, level of education, wealth and ethnicity of women were found (Table ED.8). KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 55 XI. Child Protection MONITORING THE SITUATION OF CHILDREN AND WOMEN56 The Convention on the Rights of the Child states that every child has the right to a name and a na- tionality and the right to protection from being deprived of his or her identity. Birth registration is a fundamental means of securing these rights for children. The World Fit for Children states the goal to develop systems to ensure the reg- istration of every child at or shortly after birth, and fulfil his or her right to acquire a name and a nationality, in accordance with national laws and relevant international instruments. The in- dicator is the percentage of children under 5 years of age whose birth is registered. In Kazakhstan, the Law About Marriage and Family regulates order and terms of birth regis- tration. According to the Law, parents or caretak- ers should register the birth within two months. There are no governmental charges for birth registration. Indirect stimulus for birth timely registration is one time birth allowance as well as monthly childcare allowances to mothers/care- takers paid until 1 year of age. Birth of 99.2 per- cent of children aged under 5 in Kazakhstan was registered (Table CP.1). There are no variations in birth registration across sex, age, or educa- tion categories. Children in Kostanai, Zhambyl, Akmola, Almaty and Karaganda Oblasts (98.5- 98.9 percent) are somewhat less likely to have their births registered than other children but this appears to be due primarily to the long jour- ney to the registration office. Birth Registration Article 32 of the Convention on the Rights of the Child states: “States Parties recognize the right of the child to be protected from economic ex- ploitation and from performing any work that is likely to be hazardous or to interfere with the child’s education, or to be harmful to the child’s health or physical, mental, spiritual, moral or so- cial development.” The World Fit for Children mentions nine strategies to combat child labor and the MDGs call for the protection of children Child Labor against exploitation. In the MICS questionnaire, a number of questions addressed the issue of child labor, that is, children 5-14 years of age in- volved in labour activities. A child is considered to be involved in child labor activities at the time of the survey if during the week preceding the survey: • Ages 5-11: at least one hour of economic work or 28 hours of domestic work per week. • Ages 12-14: at least 14 hours of economic work or 28 hours of domestic work per week. This definition allows us to differentiate be- tween child labor and child work to identify the type of work that should be eliminated. As such, the estimate provided here is a minimum of the prevalence of child labor since some children may be involved in hazardous labor activities for a number of hours that could be less than the numbers specified in the criteria explained before. Table CP.2 presents the results of child labor by the type of work. In Kazakhstan 2.2 percent of children aged 5- 14 years are involved in child labor of different type, such as work in household, family busi- ness or outside of household (Table CP.2). 0.5 percent of children in this age group helped to perform domestic work during 4 and more hours per day (28 hours a week). One percent of KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 57 children helped during a week with family busi- ness. One percent of children were involved in unpaid labor outside of the household. In gen- eral, boys were more often involved in labor activity than the girls were (2.4 and 2.1 percent respectively). While boys were more often busy with family business and with unpaid work out- side the household, the girls helped more in do- mestic work. Urban children were more loaded with work than rural children (2.5 and 1.9 per- cent respectively). A higher workload for chil- dren was found in Kyzylorda (7.2 percent) and Pavlodar (5.9 percent) Oblasts, the lowest – in Atyrau (0.2 percent), Karaganda (0.5 percent) and Almaty (0.9 percent) Oblasts. 0.1 percent of children were involved in economic work out- side the household. No significant differences were found by regions, sex of child and educa- tion of mother. Table CP.3 presents the percentage of children classified as student laborers or as laborer stu- dents. Student laborers are categorized as chil- dren attending school that were involved in child labor activities at the moment of the sur- veys. More specifically, of the 90.7 percent of the children 5-14 years of age attending school, 2.3 percent are also involved in child labor activities. On the other hand, out of the 2.2 percent of the children classified as child laborers, almost all of them attend school (94.3 percent). The percent- age of student laborers is lower in urban area than in rural area (90.3 and 99.5 percent respectively). There are differences depending on the level of the mother’s education: 100 percent of working children of mothers with primary/incomplete secondary education attend school compared to 93.8 percent of children whose mothers have higher and specialized secondary education. which implies an interesting contrast with the actual prevalence of physical discipline. The largest number of children age 2-14 years (47.8 percent) in Kazakhstan are exposed to psycho- logical pressure. 30.5 percent of children are subjected only to nonviolent punishment and 22.9 percent of children – to minor physical punishment. In turn, almost every fifth child (17.3 percent) experiences neither discipline methods nor pun- ishment; the percentage of children, who expe- rienced neither form of disciplining, is higher in rural area. Male children were subjected more to both minor and severe physical discipline (25.3 and 1.1 percent) than female children (20.3 and 0.4 percent respectively). Girls are more exposed to non-violent methods of discipline. More children were subjected to severe physical punishment in Kyzylorda Oblast (5.6 percent), where the largest number of mothers/caretakers (14.4 percent) believes that the child should be physically punished. In Almaty City and Almaty Oblast no cases of severe physical punishment of children were found. The number of children who experience non- violent methods, psychological punishment and minor physical punishment as well as se- vere physical punishment is higher in urban area than in rural one. Child Discipline As stated in A World Fit for Children, “children must be protected against any acts of violence…” and the Millennium Declaration calls for the pro- tection of children against abuse, exploitation and violence. In the Kazakhstan MICS survey, mothers/ caretakers of children age 2-14 years were asked a series of questions on the ways parents tend to use to discipline their children when they misbe- have. Note that for the child discipline module, one child aged 2-14 per household was selected randomly during fieldwork. Out of these ques- tions, three indicators used to describe aspects of child discipline are: 1) the number of children 2- 14 years that experience psychological aggression as punishment or minor physical punishment or severe physical punishment; and 2) the number of parents/caretakers of children 2-14 years of age that believe that in order to raise their children properly, they need to physically punish them. In Kazakhstan, over 52 percent of children aged 2-14 years were subjected to at least one form of psychological or physical punishment by their mothers/caretakers or other household mem- bers (Table CP.4). Less than one percent of chil- dren were subjected to severe physical punish- ment; in urban area percentage of such children is almost twice as much as in rural (0.9 and 0.5 percent respectively). On the other hand, 7.4 percent of mothers/caretakers who believed that children should be physically punished, MONITORING THE SITUATION OF CHILDREN AND WOMEN58 It is very interesting to note that differentials with respect to many of the background vari- ables were relatively small. Despite the fact that over 50 percent of elder children (5-9 and 10- 14 years), and those living in urban areas, were subjected to at least one psychological or physi- cal punishment, the differentials in terms of severe physical punishment were high only in rich households – 1 percent. In addition, pun- ishment of children (any) is more prevalent if mothers have primary education (60.7 percent). It is of importance also to indicate that far fewer parents/caretakers believe that in order to raise their children properly, they need to physically punish them (7.4 percent), in practice over 20 percent indicated the opposite. legislation, shall be taken to specify a minimum age for marriage.” While marriage is not consid- ered directly in the Convention on the Rights of the Child, child marriage is linked to other rights – such as the right to express their views freely, the right to protection from all forms of abuse, and the right to be protected from harmful tradi- tional practices – and is frequently addressed by the Committee on the Rights of the Child. Other international agreements related to child mar- riage are the Convention on Consent to Marriage, Minimum Age for Marriage and Registration of Marriages and the African Charter on the Rights and Welfare of the Child and the Protocol to the African Charter on Human and People’s Rights on the Rights of Women in Africa. Child marriage was also identified by the Pan-African Forum against the Sexual Exploitation of Children as a type of commercial sexual exploitation of chil- dren. Young married girls are a unique, though often invisible, group. They are often required to per- form heavy amounts of domestic work, under pressure to demonstrate fertility, and respon- sible for raising children while still children themselves, married girls and child mothers face constrained decision-making and reduced life choices. Boys are also affected by child marriage but the issue impacts on girls in far larger num- bers and with more intensity. Cohabitation – when a couple lives together as if married – raises the same human rights con- cerns as marriage. Where a girl lives with a man Marriage before the age of 18 is a reality for many young girls. According to UNICEF’s world- wide estimates, over 60 million women aged 20-24 were married/in union before the age of 18. Factors that influence child marriage rates include: the state of the country’s civil registra- tion system, which provides proof of age for children; the existence of an adequate legislative framework with an accompanying enforcement mechanism to address cases of child marriage; and the existence of customary or religious laws that condone the practice. In many parts of the world parents encourage the marriage of their daughters while they are still children in the hope that the marriage will benefit them both financially and socially, while also relieving financial burdens on the family. In actual fact, child marriage is a violation of hu- man rights, compromising the development of girls and often resulting in early pregnancy and social isolation, with little education and poor vocational training reinforcing the gendered nature of poverty. The right to ‘free and full’ con- sent to a marriage is recognized in the Universal Declaration of Human Rights – with the recogni- tion that consent cannot be ‘free and full’ when one of the parties involved is not sufficiently mature to make an informed decision about a life partner. The Convention on the Elimination of all Forms of Discrimination against Women (CEDAW) mentions the right to protection from child marriage in article 16, which states: “The betrothal and the marriage of a child shall have no legal effect, and all necessary action, including Early Marriage KAZAKHSTAN MULTIPLE INDICATOR CLUSTER SURVEY (MICS), 2006 59 and takes on the role of caregiver for him, the as- sumption is often that she has become an adult woman, even if she has not yet reached the age of 18. Additional concerns due to the informal- ity of the relationship – for example, inherit- ance, citizenship and social recognition – might make girls in informal unions vulnerable in dif- ferent ways than those who are in formally rec- ognized marriages. Research suggests that many factors interact to place a child at risk of marriage. Poverty, pro- tection of girls, family honor and the provision of stability during unstable social periods are considered as significant factors in determin- ing a girl’s risk of becoming married while still a child. Women who married at younger ages were more likely to believe that it is sometimes acceptable for a husband to beat his wife and were more likely to experience domestic vio- lence themselves. The age gap between partners is thought to contribute to these abusive power dynamics and to increase the risk of untimely widowhood. Closely related to the issue of child marriage is the age at which girls become sexually active. Women who are married before the age of 18 tend to have more children than those who marry later in life. Pregnancy related deaths are known to be a leading cause of mortality for both married and unmarried girls between the ages of 15 and 19, particularly among the youngest of this cohort. Two of the indictors are to estimate the percent- age of women married before 15 years of age and percentage married before 18 years of age. The percentage of women married at various ages is provided in Table CP.5 In Kazakhstan the Law “On Marriage and Family” determines the age of 18 as legal for marriage for both men and women. In exceptional cases the state registrar’s offices have the authority to reg- ister marriage at the earlier age of spouses but not younger than 16. In Kazakhstan 57.4 percent of women at the age of 15-49 years selected in the sample for MICS, are either married or live in union. Noteworthy is the fact that among young women in the age group of 15-19 only 5 percent reported of being married. The proportion of women at the age of 15-49 who had got married or lived in union with men before they turned 15 was 0.4 percent, and 8.5 percent of the 20-49 age group had got married before the age of 18. The results show that early marriages at the age below 15 years are not widely spread in Kazakhstan. In Aktobe, West Kazakhstan and Mangistau Oblasts there were found no such marriages. In the remaining Oblasts, number of marriages below 15 years of age does not exceed 0.5 percent. Only in East Kazakhstan Oblast, the number of such marriages was one percent. This indicator does not differ by urban and rural are- as, making 0.3-0.4 percent. There is small differ- ence by the level of education – this indicator is higher among women with primary education (0.7 percent). More often young women marry at the age below 18 in Zhambyl (12 percent), North Kazakhstan (11.3 percent) and Karaganda (11.1 percent) Oblasts. The least percentage of such marriages was found in Atyrau (4.2 percent) and Mangistau (4.6 percent) Oblasts. Below full 18 years, Russian women, women in rural area and with primary education married more often. A lower percent- age of women from the richest households got married at young age (6 percent). Another component is the spousal age differ- ence with an indicator being the percentage of married/in union women with a difference of 10 or more years of age compared to their current spouse. Table CP.6 presents the results of the age difference between husbands and wives. In Kazakhstan the major proportion of marriages have the age difference between spouses at 0 to 9 years. For instance, the proportion of women MONITORING THE SITUATION OF CHILDREN AND WOMEN60 at the age of 20-24 years with a husband/part- ner’s age of 0-4 years older made 56.5 percent and those of 5-9 years older were 29.7 percent. Only 7.4 percent of young women of this age group married to men of 10 and/or more years older, at the same time, 5.7 percent of women were married to younger men. The percentage of marriages, when husband is by 5-9 years and 10 and more years older than his wife is more prevalent in rural area and among poorest households. Marriages, when husband is by 0-4 years older are more prevalent among women with higher levels of education and in rich households, it is also more often among Russian women than among Kazakh women. this regard, where 47.6 percent of women rec- ognized this fact (of these 28.6 percent believe husband can beat his wife if she argues with him). Negative attitudes to domestic violence (below 5 percent) expressed women of Almaty, Mangistau and South Kazakhstan Oblasts and Astana city. 12.3 percent of women married at the time of the survey and 10.4 percent of previously mar- ried/in union women believe that husband can sometimes beat his wife, 6.5 percent of never married women expressed negative attitudes to beating by partner/husband. Women aged 15- 19 years (6.8 percent) expressed less negative attitude towards domestic violence, in other age groups percentage of women was distributed al- most the same (by 10-12 percent). Interestingly, women with secondary education have more positive attitudes to beating by husband (12.9 percents), than women with primary and higher education (8.4 -9.8 percent). The highest percentage of women (7.1 percent) recognized that partner can beat his wife if she neglects their children and under-cares of them. The percentage for women currently and previ- ously married was 8.3 and 7.7 percents respec- tively while it is 4.6 percent for women never married/in union. Least percentage of women (1.5 percent) accepts this situation in case if wife refuses sex with her partner. Distribution of causes justifying, according to interviewed wom- en, domestic violence from the partner and the number of women who accept such situation is almost the same in urban and rural areas. A number of questions were asked of women age 15-49 years to assess their attitudes towards whether husbands are justified to hit or beat their wives/partners for a variety of reasons. These questions were asked to get an indication of cul- tural beliefs that tend to be associated with the prevalence of violence against women by their husbands/partners. The main assumption here is that women that agree with the statements in- dicating that husbands/partners are justified to beat their wives/partners under the situations described in reality tend to be abused by their own husbands/partners. The responses to these questions can be found in Table CP.9. To study attitudes of women aged 15-49 years towards domestic violence within MICS this group of women were presented with the fol- lowi

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