Kazakhstan - Multiple Indicator Cluster Survey - 2015

Publication date: 2015

KAZAKHSTAN Multiple Indicator Cluster Survey 2015 Final Report December, 2016 Multiple Indicator Cluster Survey (MICS) in the Republic of Kazakhstan 2015 Monitoring the situation of children and women. Directed by N.S. Aidapkelov, Astana 2016, 396 p. Contributor to the report: G.Z. Kukanova Editorial Board: K.K. Orunkhanov G.S. Karaulova Z.N. Sagimbayeva Z.A. Aidarbekova D.R. Beisenova The Kazakhstan Multiple Indicator Cluster Survey (MICS) was carried out in 2015 by the Statistics Committee of the Ministry of National Economy of the Republic of Kazakhstan (herein MNE RK) in collaboration with the Republican State Enterprise “Information and Computing Centre under the Statistics Committee MNE RK” (herein RSE “ICC under the Statistics Committee of the MNE RK”), as part of the global MICS programme. The United Nations Children’s Fund (UNICEF) provided technical and methodological assistance to the survey. The Statistics Committee financed a significant part of the survey activities, as well as made an in-kind contribution in the form of kept salary of staff members of the Statistics Committee and territorial statistical departments during the survey implementation period. Significant financial support was provided by UNICEF and partially by the United Nations Population Fund (UNFPA) in Kazakhstan. The global MICS programme was developed by UNICEF in the 1990s as an international household survey programme to support countries in the collection of internationally comparable data on a wide range of indicators on the situation of children and women. MICS helped countries to capture rapid changes in key indicators as the Millennium Development Goals (MDGs) target year 2015 approached. MICS played a major role in generating information for over 21 MDG indicators that will be further demanded for monitoring of the Sustainable Development Goals (SDGs) as well as for expanding the evidence base for public policies and programmes. The objective of this report is to facilitate the timely dissemination and use of detailed results from the 2015 Kazakhstan MICS by various demographic, social, economic and cultural characteristics. For more information on indicators and the analysis conducted in the Final report please go to mics.unicef.org and data.unicef.org. Suggested citation: The Statistics Committee of the Ministry of National Economy of the Republic of Kazakhstan (Statistics Committee of the MNE RK), the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA). 2015 Kazakhstan Multiple Indicator Cluster Survey, Final Report. Astana, Kazakhstan: The Statistics Committee of the MNE RK, UNICEF and UNFPA, 2016. The reference to this Report is obligatory when copying, quoting or otherwise using information contained in the Report. The Ministry of National Economy of the Republic of Kazakhstan The Statistics Committee The Republic of Kazakhstan, 010000 Astana city, 8, Mangilik El street, The House of Ministries, entrance #4 Fax: +7 (7172) 74 95 46 Information center: +7 (7172) 74 90 10, 74 90 11 e-mail: kazstat.rk@gmail.com Internet resource (web site): http://www.stat.gov.kz The United Nations Children’s Fund (UNICEF) in the Republic of Kazakhstan The Republic of Kazakhstan, 010000 Astana city, Block 1, 10A, Beibitshilik street Phone: +7 (7172) 32 29 69, 32 28 78, 32 17 97 Web site: http://unicef.kz/ e-mail: info@unicef.kz The United Nations Population Fund (UNFPA) in the Republic of Kazakhstan The Republic of Kazakhstan, 050000 Almaty city, 67, Tole Bi street Phone: +7 (7272) 58 59 79 Fax: +7 (7272) 58 59 93 Web site: http://www.unfpa.org/ mailto:kazstat.rk@gmail.com http://www.stat.gov.kz/ http://unicef.kz/ mailto:info@unicef.kz http://www.unfpa.org/ P a g e | iv Summary Table of Survey Implementation and the Survey Population, Kazakhstan, 2015 Survey implementation Sample frame - Updated 2009 The second National Census of the Republic of Kazakhstan July, 2015 Questionnaires Household Questionnaire Questionnaire for Individual Women (15-49 years) Questionnaire for Children Under Five Appendix for Data Collection at Health Facility about Immunization Interviewer training August, 2015 Fieldwork September – November, 2015 Survey sample Households - Sampled - Occupied - Interviewed - Response rate (Percent) 16,791 16,605 16,500 99.4 Children under five - Eligible - Mothers/caretakers interviewed - Response rate (Percent) 5,561 5,510 99.1 Women - Eligible for interviews - Interviewed - Response rate (Percent) 12,910 12,670 98.1 Survey population Average household size 3.4 Percentage of population living in - Urban areas - Rural areas - Akmola - Aktobe - Almaty oblast - Atyrau - West Kazakhstan - Zhambyl - Karaganda - Kostanai - Kyzylorda - Mangistau - South Kazakhstan - Pavlodar - North Kazakhstan - East Kazakhstan - Astana City - Almaty City 53.2 46.8 4.9 6.3 8.2 3.3 4.6 6.4 8.2 5.1 3.3 3.2 17.5 4.0 3.0 7.2 7.1 7.5 Percentage of population under: - Age 5 - Age 18 10.3 30.8 Percentage of women aged 15-49 years with at least one live birth in the last 2 years 17.0 P a g e | v Housing characteristics Household or personal assets Percentage of households with - Electricity - Finished floor - Finished roofing - Finished walls 100.0 66.2 99.4 92.8 Percentage of households that own - A television - A refrigerator - A microwave - A washing machine - A vacuum cleaner - Agricultural land - Farm animals/livestock 99.3 98.2 63.9 88.2 79.2 32.7 25.1 Mean number of persons per room used for sleeping 1.8 Percentage of households where at least a member has or owns a - A mobile telephone or smartphone - A car or truck - A bank account 96.6 50.0 79.0 P a g e | vi Summary Table of Findings1 Multiple Indicator Cluster Surveys (MICS), Kazakhstan, 2015 NUTRITION Nutritional status MICS Indicator Indicator Description Value 2.1a 2.1b MDG 1.8 Underweight prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for age of the WHO standard 2.0 0.3 2.2a 2.2b Stunting prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median height for age of the WHO standard 8.0 2.4 2.3a 2.3b Wasting prevalence (a) Moderate and severe (b) Severe Percentage of children under age 5 who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for height of the WHO standard 3.1 1.1 2.4 Overweight prevalence Percentage of children under age 5 who are above two standard deviations of the median weight for height of the WHO standard 9.3 Breastfeeding and infant feeding 2.5 Children ever breastfed Percentage of women with a live birth in the last 2 years who breastfed their last live-born child at any time 97.1 2.6 Early initiation of breastfeeding Percentage of women with a live birth in the last 2 years who put their last newborn to the breast within one hour of birth 83.3 2.7 Exclusive breastfeeding under 6 months Percentage of infants under 6 months of age who are exclusively breastfed 37.8 2.8 Predominant breastfeeding under 6 months Percentage of infants under 6 months of age who received breast milk as the predominant source of nourishment during the previous day 73.2 2.9 Continued breastfeeding at 1 year Percentage of children aged 12-15 months who received breast milk during the previous day 59.8 2.10 Continued breastfeeding at 2 years Percentage of children aged 20-23 months who received breast milk during the previous day 21.1 2.11 Median duration of breastfeeding The age in months when 50 percent of children aged 0-35 months did not receive breast milk during the previous day 15.6 2.12 Age-appropriate breastfeeding Percentage of children aged 0-23 months appropriately fed during the previous day 46.3 2.13 Introduction of solid, semi-solid or soft foods Percentage of infants aged 6-8 months who received solid, semi-solid or soft foods during the previous day 66.5 2.14 Milk feeding frequency for non-breastfed children Percentage of non-breastfed children aged 6-23 months who received at least 2 milk feedings during the previous day 79.9 2.15 Minimum meal frequency Percentage of children aged 6-23 months who received solid, semi-solid and soft foods (plus milk feeds for non- breastfed children) the minimum number of times or more during the previous day 74.0 2.16 Minimum dietary diversity Percentage of children aged 6–23 months who received foods from 4 or more food groups during the previous day 68.7 1 See Appendix E for a detailed description of MICS indicators. P a g e | vii 2.17a 2.17b Minimum acceptable diet (a) Percentage of breastfed children aged 6–23 months who had at least the minimum dietary diversity and the minimum meal frequency during the previous day (b) Percentage of non-breastfed children aged 6–23 months who received at least 2 milk feedings and had at least the minimum dietary diversity not including milk feeds and the minimum meal frequency during the previous day 42.6 48.3 2.18 Bottle feeding Percentage of children aged 0-23 months who were fed with a bottle during the previous day 51.2 Salt iodization 2.19 Iodized salt consumption Percentage of households with salt testing 15 parts per million or more of iodate 90.7 Low-birthweight 2.20 Low-birthweight infants Percentage of most recent live births in the last 2 years weighing below 2,500 grams at birth 4.5 2.21 Infants weighed at birth Percentage of most recent live births in the last 2 years who were weighed at birth 98.7 CHILD HEALTH Vaccinations MICS Indicator Indicator Description Value 3.1 Tuberculosis immunization coverage Percentage of children aged 12-23 months who received BCG vaccine by their first birthday 98.5 3.2 Polio immunization coverage Percentage of children aged 12-23 months who received the third dose of Polio vaccine (Polio-3) by their first birthday 89.7 3.3 Diphtheria, pertussis and tetanus (DPT) immunization coverage Percentage of children aged 12-23 months who received the third dose of DPT vaccine (DPT-3) by their first birthday 90.4 3.4 MDG 4.3 Measles immunization coverage Percentage of children aged 24-35 months who received measles vaccine by their second birthday 95.1 3.5 Hepatitis B immunization coverage Percentage of children aged 12-23 months who received the third dose of Hepatitis B vaccine (HepB-3) by their first birthday 88.4 3.6 Haemophilus influenzae type B (Hib) immunization coverage Percentage of children aged 12-23 months who received the third dose of Hib vaccine (Hib-3) by their first birthday 89.3 3.8 Full immunization coverage Percentage of children aged 24-35 months who received all vaccinations recommended in the national immunization schedule by their first birthday (for measles – by their second birthday) 84.1 Solid fuel use 3.15 Use of solid fuels for cooking Percentage of household members in households that use solid fuels as the primary source of domestic energy to cook 1.5 WATER AND SANITATION MICS Indicator Indicator Description Value 4.1 MDG 7.8 Use of improved drinking water sources Percentage of household members using improved sources of drinking water 97.3 4.2 Water treatment Percentage of household members in households using unimproved drinking water who use an appropriate treatment method 46.4 P a g e | viii WATER AND SANITATION MICS Indicator Indicator Description Value 4.3 MDG 7.9 Use of improved sanitation Percentage of household members using improved sanitation facilities which are not shared 98.0 4.5 Place for handwashing Percentage of households with a specific place for handwashing where water and soap are present 99.0 4.6 Availability of soap2 Percentage of households with soap 97.9 REPRODUCTIVE HEALTH Contraception and unmet need MICS Indicator Indicator Description Value - Total fertility rate Total fertility rate for women aged 15-49 years 3.0 5.1 MDG 5.4 Adolescent birth rate Age-specific fertility rate for women aged 15-19 years 36 5.2 Early childbearing Percentage of women aged 20-24 years who had at least one live birth before age 18 2.2 5.3 MDG 5.3 Contraceptive prevalence rate Percentage of women aged 15-49 years currently married or in union who are using (or whose partner is using) a (modern or traditional) contraceptive method 55.7 5.4 MDG 5.6 Unmet need Percentage of women aged 15-49 years who are currently married or in union who are fecund and want to space their births or limit the number of children they have and who are not currently using contraception 9.8 5.S13 Lifetime experience with abortion Percentage of women aged 15–49 years who had at least one induced abortion 20.1 5.S2 Total abortion rate Total abortion rate for women aged 15-49 years 0.3 5.S3 General abortion rate General abortion rate for women aged 15-49 years 10 Maternal and newborn health 5.5a 5.5b MDG 5.5 MDG 5.5 Antenatal care coverage Percentage of women aged 15-49 years with a live birth in the last 2 years who were attended during their last pregnancy that led to a live birth (a) at least once by skilled health personnel (b) at least four times by any provider 99.3 95.3 5.6 Content of antenatal care Percentage of women aged 15-49 years with a live birth in the last 2 years who had their blood pressure measured and gave urine and blood samples during the last pregnancy that led to a live birth 99.3 5.7 MDG 5.2 Skilled attendant at delivery Percentage of women aged 15-49 years with a live birth in the last 2 years who were attended by skilled health personnel during their most recent live birth 99.4 5.8 Institutional deliveries Percentage of women aged 15-49 years with a live birth in the last 2 years whose most recent live birth was delivered in a health facility 99.3 5.9 Caesarean section Percentage of women aged 15-49 years whose most recent live birth in the last 2 years was delivered by caesarean section 14.8 2 The indicator name has been changed from the standard “MICS indicator 4.6 – Availability of soap or other cleansing agent” since other cleansing agents such as ash, mud or sand are not applicable for Kazakhstan. 3 The indicator numbering system #.S# denotes a survey-specific indicator calculated by the introduction of a non-standard module or question(s) to this survey that is not part of the global MICS5 Questionnaires or by applying a non-standard calculation method that is not included in the global MICS5 Tabulation Plan. P a g e | ix Post-natal health checks 5.10 Post-partum stay in health facility Percentage of women aged 15-49 years who stayed in the health facility for 12 hours or more after the delivery of their most recent live birth in the last 2 years 99.9 5.11 Post-natal health check for the newborn Percentage of last live births in the last 2 years who received a health check while in facility or at home following delivery, or a post-natal care visit within 2 days after delivery 99.4 5.12 Post-natal health check for the mother Percentage of women aged 15-49 years who received a health check while in facility or at home following delivery, or a post-natal care visit within 2 days after delivery of their most recent live birth in the last 2 years 97.5 CHILD DEVELOPMENT MICS Indicator Indicator Description Value 6.1 Attendance to early childhood education Percentage of children aged 36-59 months who are attending an early childhood education programme 55.3 6.2 Support for learning Percentage of children aged 36-59 months with whom an adult has engaged in four or more activities to promote learning and school readiness in the last 3 days 85.6 6.3 Father’s support for learning Percentage of children aged 36-59 months whose biological father has engaged in four or more activities to promote learning and school readiness in the last 3 days 6.6 6.4 Mother’s support for learning Percentage of children aged 36-59 months whose biological mother has engaged in four or more activities to promote learning and school readiness in the last 3 days 50.7 6.5 Availability of children’s books Percentage of children under age 5 who have three or more children’s books 50.9 6.6 Availability of playthings Percentage of children under age 5 who play with two or more types of playthings 59.5 6.7 Inadequate care Percentage of children under age 5 left alone or in the care of another child younger than 10 years of age for more than one hour at least once in the last week 5.0 6.8 Early child development index Percentage of children aged 36-59 months who are developmentally on track in at least three of the following four domains: literacy-numeracy, physical, social-emotional, and learning 85.5 LITERACY AND EDUCATION MICS Indicator Indicator Description Value 7.1 MDG 2.3 Literacy rate among young women Percentage of young women aged 15-24 years who are able to read a short simple statement about everyday life or who attended secondary or higher education 100.0 7.2 School readiness Percentage of children in first grade of primary school who attended pre-school during the previous school year 90.8 7.3 Net intake rate in primary education Percentage of children of school-entry age who enter the first grade of primary school 99.2 7.4 MDG 2.1 Primary school net attendance ratio (adjusted) Percentage of children of primary school age currently attending primary or secondary school (age 7-10 years) 99.5 7.5 Secondary school net attendance ratio (adjusted) Percentage of children of secondary school age currently attending secondary school or higher (age 11-17 years) 98.9 P a g e | x 7.S1 Lower secondary school4 net attendance ratio (adjusted) Percentage of children of lower secondary school age currently attending lower secondary school (age 11-15 years) 99.4 7.S2 Upper secondary school5 net attendance ratio (adjusted) Percentage of children of upper secondary school age currently attending upper secondary school or higher (age 16-17 years) 95.7 7.6 MDG 2.2 Children reaching last grade of primary Percentage of children entering the first grade of primary school who eventually reach last grade 100.0 7.7 Primary completion rate Number of children attending the last grade of primary school (excluding repeaters) divided by the number of children of primary school completion age (age appropriate to final grade of primary school) 102.1 7.8 Transition rate to lower secondary school6 Number of children attending the last grade of primary school during the previous school year who are in the first grade of lower secondary school during the current school year divided by the number of children attending the last grade of primary school during the previous school year 99.9 7.S3 Lower secondary school completion rate Number of children attending the last grade of lower secondary school (excluding repeaters) divided by the number of children of lower secondary school completion age (age appropriate to final grade of lower secondary school) 110.8 7.S4 Transition rate to upper secondary school Number of children attending the last grade of lower secondary school during the previous school year who are in the first grade of upper secondary school or in the first grade of technical and professional education during the current school year divided by the number of children attending the last grade of lower secondary school during the previous school year 97.9 7.9 MDG 3.1 Gender parity index (primary school) Primary school net attendance ratio (adjusted) for girls divided by primary school net attendance ratio (adjusted) for boys 1.00 7.10 MDG 3.1 Gender parity index (secondary school) Secondary school net attendance ratio (adjusted) for girls divided by secondary school net attendance ratio (adjusted) for boys 1.00 7.S5 Gender parity index (lower secondary school) Lower secondary school net attendance ratio (adjusted) for girls divided by lower secondary school net attendance ratio (adjusted) for boys 1.00 7.S6 Gender parity index (upper secondary school) Upper secondary school net attendance ratio (adjusted) for girls divided by upper secondary school net attendance ratio (adjusted) for boys 1.01 CHILD PROTECTION Birth registration MICS Indicator Indicator Description Value 8.1 Birth registration Percentage of children under age 5 whose births are reported registered 99.7 Child discipline 8.3 Violent discipline Percentage of children aged 1-14 years who experienced psychological aggression or physical punishment during the last one month 52.7 4 Lower secondary school consists of grades 5-9 of secondary school. 5 Upper secondary school consists of grades 10-11 of secondary school. 6 Transition rate to lower secondary school corresponds to transition rate to secondary school as defined in MICS global indicator 7.8. P a g e | xi Early marriage 8.4 Marriage before age 15 Percentage of women aged 15-49 years who were first married or in union before age 15 0.1 8.5 Marriage before age 18 Percentage of women aged 20-49 years who were first married or in union before age 18 7.8 8.6 Young women age 15-19 years currently married or in union Percentage of young women aged 15-19 years who are married or in union 6.0 8.8a 8.8b Spousal age difference Percentage of young women who are married or in union and whose spouse is 10 or more years older, (a) among women aged 15-19 years, (b) among women aged 20-24 years 5.8 4.5 Attitudes towards domestic violence 8.12 Attitudes towards domestic violence Percentage of women aged 15-49 years who state that a husband is justified in hitting or beating his wife in at least one of the following circumstances: (1) she goes out without telling him, (2) she neglects the children, (3) she argues with him, (4) she refuses sex with him, (5) she burns the food 14.2 8.S1 Attitudes towards domestic violence (including additional circumstance) Percentage of women aged 15-49 years who state that a husband is justified in hitting or beating his wife in at least one of the following circumstances: (1) she goes out without telling him, (2) she neglects the children, (3) she argues with him, (4) she refuses sex with him, (5) she burns the food, (6) she neglects housework 15.1 Children’s living arrangements 8.13 Children’s living arrangements Percentage of children aged 0-17 years living with neither biological parent 3.2 8.14 Prevalence of children with one or both parents dead Percentage of children aged 0-17 years with one or both biological parents dead 4.9 HIV/AIDS AND SEXUAL BEHAVIOUR HIV/AIDS knowledge and attitudes MICS Indicator Indicator Description Value - Have heard of AIDS Percentage of women aged 15-49 years who have heard of AIDS 97.9 9.1 MDG 6.3 Knowledge about HIV prevention among young women Percentage of young women aged 15-24 years who correctly identify ways of preventing the sexual transmission of HIV, and who reject major misconceptions about HIV transmission 26.7 9.2 Knowledge of mother- to-child transmission of HIV Percentage of women aged 15-49 years who correctly identify all three means of mother-to-child transmission of HIV 58.0 9.3 Accepting attitudes towards people living with HIV Percentage of women aged 15-49 years expressing accepting attitudes on all four questions toward people living with HIV 2.5 HIV testing 9.4 Women who know where to be tested for HIV Percentage of women aged 15-49 years who state knowledge of a place to be tested for HIV 86.9 9.5 Women who have been tested for HIV and know the results Percentage of women aged 15-49 years who have been tested for HIV in the last 12 months and who know their results 23.3 P a g e | xii 9.6 Sexually active young women who have been tested for HIV and know the results Percentage of young women aged 15-24 years who have had sex in the last 12 months, who have been tested for HIV in the last 12 months and who know their results 39.0 9.7 HIV counselling during antenatal care Percentage of women aged 15-49 years who had a live birth in the last 2 years and received antenatal care during the pregnancy of their most recent birth, reporting that they received counselling on HIV during antenatal care 67.2 9.8 HIV testing during antenatal care Percentage of women aged 15-49 years who had a live birth in the last 2 years and received antenatal care during the pregnancy of their most recent birth, reporting that they were offered and accepted an HIV test during antenatal care and received their results 79.0 Sexual behaviour 9.9 Young women who have never had sex Percentage of never married young women aged 15-24 years who have never had sex 91.3 9.10 Sex before age 15 among young women Percentage of young women aged 15-24 years who had sexual intercourse before age 15 0.2 9.11 Age-mixing among sexual partners Percentage of women aged 15-24 years who had sex in the last 12 months with a partner who was 10 or more years older 5.5 9.12 Multiple sexual partnerships Percentage of women aged 15-49 years who had sexual intercourse with more than one partner in the last 12 months 0.8 9.13 Condom use at last sex among women with multiple sexual partnerships Percentage of women aged 15-49 years who report having had more than one sexual partner in the last 12 months who also reported that a condom was used the last time they had sex 40.6 9.14 Sex with non-regular partners Percentage of sexually active young women aged 15-24 years who had sex with a non-marital, non-cohabitating partner in the last 12 months 16.6 9.15 MDG 6.2 Condom use with non- regular partners Percentage of young women aged 15-24 years reporting the use of a condom during the last sexual intercourse with a non-marital, non-cohabiting sex partner in the last 12 months 63.7 Orphans 9.16 MDG 6.4 Ratio of school attendance of orphans to school attendance of non-orphans Proportion attending school among children age 10-14 years who have lost both parents divided by proportion attending school among children age 10-14 years whose parents are alive and who are living with one or both parents (*) (*) Figures that are based on fewer than 25 unweighted cases. ACCESS TO MASS MEDIA AND ICT Access to mass media MICS Indicator Indicator Description Value 10.1 Exposure to mass media Percentage of women aged 15-49 years who, at least once a week, read a newspaper or magazine, listen to the radio, and watch television 16.1 Use of information/communication technology 10.2 Use of computers Percentage of young women aged 15-24 years who used a computer during the last 12 months 88.2 10.3 Use of internet Percentage of young women aged 15-24 years who used the internet during the last 12 months 94.6 P a g e | xiii SUBJECTIVE WELL-BEING MICS Indicator Indicator Description Value 11.1 Life satisfaction Percentage of young women aged 15-24 years who are very or somewhat satisfied with their life, overall 96.8 11.2 Happiness Percentage of young women aged 15-24 years who are very or somewhat happy 98.5 11.3 Perception of a better life Percentage of young women aged 15-24 years whose life improved during the last one year, and who expect that their life will be better after one year 64.9 TOBACCO AND ALCOHOL USE Tobacco use MICS Indicator Indicator Description Value 12.1 Tobacco use Percentage of women aged 15-49 years who smoked cigarettes, or used smoked or smokeless tobacco products at any time during the last one month 8.4 12.2 Smoking before age 15 Percentage of women aged 15-49 years who smoked for the first time a whole cigarette before age 15 0.9 Alcohol use 12.3 Use of alcohol Percentage of women aged 15-49 years who had at least one alcoholic drink at any time during the last one month 25.1 12.4 Use of alcohol before age 15 Percentage of women aged 15-49 years who had for the first time at least one alcoholic drink before age 15 0.5 P a g e | xiv Table of Contents Summary Table of Survey Implementation and the Survey Population, Kazakhstan, 2015 . iv Summary Table of Findings . vi Table of Contents .xiv List of Tables…. . xvii List of Figures. . xxi List of Abbreviations . xxii Foreword and Acknowledgements . xxiv Foreword and Acknowledgements . xxvi Foreword and Acknowledgements . xxvii Brief overview of the key indicators . xxviii I. Introduction. . 1 Survey Goals and Objectives . 2 II. Sample and Survey Methodology . 3 Sample Design . 3 Questionnaires . 3 Training and Fieldwork . 5 Data Processing . 5 How to Read Tables . 6 III. Sample Coverage and the Characteristics of Households and Respondents . 7 Sample Coverage . 7 Characteristics of Households . 8 Characteristics of Female Respondents Aged 15-49 Years and Children Under-5 . 12 Housing characteristics, asset ownership, and wealth quintiles . 17 IV. Nutrition…. . 26 Low Birth Weight . 26 Nutritional Status . 29 Breastfeeding and Infant and Young Child Feeding . 33 Salt Iodization . 47 P a g e | xv V. Child Health. 50 Vaccinations . 50 Knowledge of the two danger signs of pneumonia . 60 Solid Fuel Use . 63 VI. Water and Sanitation . 68 Use of Improved Water Sources . 68 Access to Improved Sanitation . 80 Handwashing. 89 VII. Reproductive Health . 94 Fertility . 94 Contraception . 100 Unmet Need . 106 Antenatal Care . 109 Assistance at Delivery . 116 Place of Delivery . 120 Post-natal Health Checks . 121 Abortions . 137 VIII. Early Childhood Development . 142 Early Childhood Care and Education . 142 Quality of Care . 144 Early Child Development Index (ECDI) . 152 IX. Literacy and Education . 155 Literacy among Young Women . 155 School Readiness. 156 Primary and Secondary School Attendance . 160 X. Child Protection . 182 Birth Registration . 182 Child Discipline . 184 Early Marriage . 189 Attitudes toward Domestic Violence . 196 Children’s Living Arrangements and Orphanhood. 198 XI. HIV/AIDS and Sexual Behaviour . 201 Knowledge about HIV Transmission and Misconceptions about HIV . 201 Accepting Attitudes toward People Living with HIV . 208 P a g e | xvi Knowledge of a Place for HIV Testing, Counselling and Testing during Antenatal Care . 212 Sexual Behaviour Related to HIV Transmission . 217 HIV Indicators for Young Women . 219 XII. Access to Mass Media and Use of Information/Communication Technology. 226 Access to Mass Media . 226 Use of Information/Communication Technology . 228 XIII. Subjective well-being . 230 XIV. Tobacco and Alcohol Use . 237 Tobacco Use . 237 Alcohol Use . 243 Appendices: Appendix A. Sample Design . 245 Sample Size and Sample Allocation . 245 Sampling Frame and Selection of Clusters . 246 Listing Activities . 247 Selection of Households . 249 Calculation of Sample Weights . 250 Appendix B. List of Personnel Involved in the Survey . 253 Appendix C. Estimates of Sampling Errors . 257 Appendix D. Data Quality Tables . 298 Appendix E. MICS Indicators, Kazakhstan, 2015: Numerators and Denominators. 319 Appendix F. The 2015 Kazakhstan MICS Questionnaires . 331 F1. Household Questionnaire . 332 F2. Questionnaire for Individual Women . 347 F3. Questionnaire for Children Under Five . 381 F4. Appendix for Data Collection at Health Facility about Immunization to the Questionnaire for Children Under Five . 395 P a g e | xvii List of Tables Table HH.1: Results of household, women's and under-5 interviews . 7 Table HH.2: Age distribution of household population by sex . 8 Table HH.3: Household composition . 11 Table HH.4: Women's background characteristics . 13 Table HH.5: Under-5's background characteristics . 16 Table HH.6: Housing characteristics . 18 Table HH.7: Household and personal assets . 21 Table HH.8: Wealth quintiles . 24 Table NU.1: Low birth weight infants . 27 Table NU.2: Nutritional status of children . 31 Table NU.3: Initial breastfeeding . 35 Table NU.4: Breastfeeding . 38 Table NU.5: Duration of breastfeeding . 40 Table NU.6: Age-appropriate breastfeeding . 41 Table NU.7: Introduction of solid, semi-solid, or soft foods . 42 Table NU.8: Infant and young child feeding (IYCF) practices . 44 Table NU.9: Bottle feeding . 46 Table NU.10: Iodized salt consumption . 48 Table CH.1: Vaccinations in the first year of life . 54 Table CH.2: Vaccinations by background characteristics . 57 Table CH.3: Knowledge of the two danger signs of pneumonia . 61 Table CH.4: Solid fuel use . 64 Table CH.5: Solid fuel use by place of cooking . 66 Table WS.1: Use of improved water sources . 69 Table WS.2: Household water treatment . 74 Table WS.3: Time to source of drinking water . 76 Table WS.4: Person collecting water . 78 Table WS.5: Types of sanitation facilities . 81 Table WS.6: Use and sharing of sanitation facilities . 83 Table WS.7: Drinking water and sanitation ladders . 87 Table WS.8: Water and soap at place for handwashing . 90 Table WS.9: Availability of soap . 92 Table RH.1: Fertility rates . 94 Table RH.2: Adolescent birth rate and total fertility rate . 96 Table RH.3: Early childbearing . 96 Table RH.4: Trends in early childbearing . 99 Table RH.4A: Knowledge of specific contraceptive methods . 100 Table RH.4B: Knowledge of contraceptive methods . 101 Table RH.5: Use of contraception . 104 Table RH.6: Unmet need for contraception . 107 Table RH.7: Antenatal care coverage . 109 Table RH.8: Number of antenatal care visits and timing of first visit . 113 Table RH.9: Content of antenatal care. 115 Table RH.10: Assistance at delivery and caesarian section . 118 P a g e | xviii Table RH.11: Place of delivery . 120 Table RH.12: Post-partum stay in health facility. 122 Table RH.13: Post-natal health checks for newborns . 125 Table RH.14: Post-natal care visits for newborns within the first week following discharge from health facilitya . 128 Table RH.15: Post-natal health checks for mothers . 131 Table RH.16: Post-natal care visits for mothers within the first week following discharge from health facility. 134 Table RH.17: Post-natal health checks for mothers and newborns . 135 Table RH.18: Lifetime experience with wasted pregnancies . 138 Table RH.19: Induced abortion rates by area . 139 Table RH.20: Induced abortion rates . 140 Table CD.1: Early childhood education . 143 Table CD.2: Support for learning. 146 Table CD.3: Learning materials . 149 Table CD.4: Inadequate care . 151 Table CD.5: Early child development index . 153 Table ED.1: Literacy . 155 Table ED.2: School readiness . 157 Table ED.2A: Pre-primary education attendance . 158 Table ED.3: Primary school entry . 161 Table ED.3A: Primary school entry . 162 Table ED.4: Primary school attendance and out of school children . 164 Table ED.5: Secondary school attendance and out of school children . 167 Table ED.5A: Lower secondary school attendance and out of school children . 169 Table ED.5B: Upper secondary school attendance and out of school children . 171 Table ED.6: Children reaching last grade of primary school . 173 Table ED.7: Primary school completion and transition to lower secondary school . 176 Table ED.8: Education gender parity . 179 Table CP.1: Birth registration . 183 Table CP.2: Child discipline . 185 Table CP.3: Attitudes toward physical punishment . 188 Table CP.4: Early marriage . 190 Table CP.5: Trends in early marriage . 192 Table CP.6: Spousal age difference . 194 Table CP.7: Attitudes toward domestic violence . 196 Table CP.8: Children's living arrangements and orphanhood . 199 Table HA.1: Knowledge about HIV transmission, misconceptions about HIV, and comprehensive knowledge about HIV transmission. 202 Table HA.2: Knowledge of mother-to-child HIV transmission . 206 Table HA.3: Accepting attitudes toward people living with HIV . 209 Table HA.4: Knowledge of a place for HIV testing . 212 Table HA.5: HIV testing and counselling during antenatal care . 215 Table HA.6: Sex with multiple partners . 218 Table HA.7: Key HIV and AIDS indicators . 220 Table HA.8: Key sexual behaviour indicators . 223 P a g e | xix Table MT.1: Exposure to mass media . 226 Table MT.2: Use of computers and Internet . 229 Table SW.1: Domains of life satisfaction. 232 Table SW.2: Overall life satisfaction and happiness . 234 Table SW.3: Perception of a better life . 236 Table TA.1: Current and ever use of tobacco . 239 Table TA.2: Age at first use of cigarettes and frequency of use . 241 Table TA.3: Use of alcohol. 243 Appendices: Table SD1: Sample Allocation of Clusters and Households by Region/Urban-Rural for the 2015 Kazakhstan MICS . 246 Table SD.2: Number of teams and days for listing implementation by region . 248 Table SD.3: Number of segmented clusters by region . 249 Table SE.1: Indicators selected for sampling error calculations . 258 Table SE.2: Sampling errors: Total sample . 260 Table SE.3: Sampling errors: Urban . 262 Table SE.4: Sampling errors: Rural . 264 Table SE.5: Sampling errors: Akmola . 266 Table SE.6: Sampling errors: Aktobe . 268 Table SE.7: Sampling errors: Almaty oblast . 270 Table SE.8: Sampling errors: Atyrau . 272 Table SE.9: Sampling errors: West Kazakhstan . 274 Table SE.10: Sampling errors: Zhambyl. 276 Table SE.11: Sampling errors: Karaganda . 278 Table SE.12: Sampling errors: Kostanai . 280 Table SE.13: Sampling errors: Kyzylorda . 282 Table SE.14: Sampling errors: Mangistau . 284 Table SE.15: Sampling errors: South Kazakhstan . 286 Table SE.16: Sampling errors: Pavlodar . 288 Table SE.17: Sampling errors: North Kazakhstan . 290 Table SE.18: Sampling errors: East Kazakhstan . 292 Table SE.19: Sampling errors: Astana city . 294 Table SE.20: Sampling errors: Almaty city . 296 Table DQ.1: Age distribution of household population . 298 Table DQ.2: Age distribution of eligible and interviewed women . 299 Table DQ.3: Age distribution of children in household and under-5 questionnaires . 300 Table DQ.4: Birth date reporting: Household population . 300 Table DQ.5: Birth date and age reporting: Women . 301 Table DQ.6: Birth date and age reporting: Under-5s . 301 Table DQ.7: Birth date reporting: Children, adolescents and young people . 302 Table DQ.8: Birth date reporting: First and last births . 303 Table DQ.9: Completeness of reporting . 304 Table DQ.10: Completeness of information for anthropometric indicators: Underweight . 304 Table DQ.11: Completeness of information for anthropometric indicators: Stunting . 307 Table DQ.12: Completeness of information for anthropometric indicators: Wasting . 310 Table DQ.13: Heaping in anthropometric measurements . 312 P a g e | xx Table DQ.14: Observation of birth certificates . 313 Table DQ.15: Observation of vaccination passports/cards at home and in health facility . 315 Table DQ.16: Observation of places for handwashing . 316 Table DQ.17: Respondent to the under-5 questionnaire . 316 Table DQ.18: Selection of children aged 1-14 years for the child discipline module . 317 Table DQ.19: School attendance by single age . 318 P a g e | xxi List of Figures Figure HH.1: Age and sex distribution of household population, Kazakhstan, 2015 . 10 Figure NU.1: Underweight, stunted, wasted and overweight children under age 5 (moderate and severe), Kazakhstan, 2015 . 33 Figure NU.2: Initiation of breastfeeding, Kazakhstan, 2015 . 37 Figure NU.3: Infant feeding patterns by age, Kazakhstan, 2015 . 39 Figure NU.4: Consumption of iodized salt, Kazakhstan, 2015 . 49 Figure CH.1: Vaccination by age 12 months (measles by 24 months), Kazakhstan, 2015 . 56 Figure WS.1: Percent distribution of household members by source of drinking water, Kazakhstan 2015 . 72 Figure WS.2: Percent distribution of household members by use and sharing of sanitation facilities, Kazakhstan 2015 . 85 Figure WS.3: Percentages of household members using improved drinking water sources and improved sanitation, by wealth quintiles, Kazakhstan, 2015 . 86 Figure RH.1: Age-specific fertility rates by area, Kazakhstan, 2015 . 95 Figure RH.2: Differentials in contraceptive use, Kazakhstan, 2015 . 103 Figure RH.3: Person assisting at delivery, Kazakhstan, 2015 . 117 Figure ED.1: Education indicators by sex, Kazakhstan, 2015 . 181 Figure CP.1: Child disciplining methods, children aged 1-14 years, Kazakhstan, 2015 . 187 Figure CP.2: Early marriage among women, Kazakhstan, 2015 . 193 Figure HA.1: Women with comprehensive knowledge of HIV transmission, Kazakhstan, 2015 . 205 Figure HA.2: Accepting attitudes toward people living with HIV/AIDS, Kazakhstan, 2015 . 211 Figure TA.1: Ever and current smokers, Kazakhstan, 2015 . 241 Appendices: Figure DQ.1: Household population by single ages, Kazakhstan,2015 . 299 Figure DQ.2: Weight and height/length measurements by digits reported for the decimal points, Kazakhstan, 2015 . 313 P a g e | xxii List of Abbreviations AIDS Aquired Immune Deficiency Syndrome BCG Bacillus Calmette-Guérin (Tuberculosis) CBR Crude Birth Rate CRC Convention on the Rights of the Child C-section Caesarian Section CSPro Census and Survey Processing System DPT/DTaP Diphtheria, Pertussis and Tetanus DTaP/DPT Diphtheria, Pertussis and Tetanus EAs Enumeration Areas ECDI Early Child Development Index EPI Expanded Programme on Immunization GAR General Abortion Rate GARPR Global AIDS Response Progress Reporting GFR General Fertility Rate GPI Gender Parity Index GVAP Global Vaccine Action Plan HBV/HepB Hepatitis B HepB/HBV Hepatitis B Hib Haemophilus Influenzae Type B HIV Human Immunodeficiency Virus ICT Information and Communication Technologies IDD Iodine Deficiency Disorders IGME Inter-agency Group for Child Mortality Estimation IPV Inactivated Polio Vaccine IS CSR Information System "Civil Status Registration" IUD Intrauterine Device IYCF practices Infant and Young Child Feeding practices JMP Joint Monitoring Programme LAM Lactational Amenorrhea Method LRK Law of the Republic of Kazakhstan MDGs Millennium Development Goals MICS Multiple Indicator Cluster Survey MICS5 The 5th round of the Multiple Indicator Cluster Survey MMR Measles MNE RK Ministry of National Economy of the Republic of Kazakhstan NAR Net Attendance Ratio OPV Oral Polio Vaccine PCV/PNEUMO Pneumococcal Vaccine PNC Post-natal Care PNEUMO/PCV Pneumococcal Vaccine PNHC Post-natal Health Checks Polio (OPV/IPV) Poliomyelitis post-WWII Post–World War II ppm Parts Per Million PPS Probability proportional to size PSUs Primary Sampling Units P a g e | xxiii RSE “ICC under the Statistics Committee of the MNE RK” Republican State Enterprise “Information and Computing Centre under the Statistics Committee of the Ministry of National Economy of the Republic of Kazakhstan” SDGs Sustainable Development Goals SPSS Statistical Package for Social Science STIs Sexually Transmitted Infections TAR Total Abortion Rate TFR Total Fertility Rate UN United Nations UNFPA United Nations Population Fund UNGASS UN General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund WFFC World Fit for Children WHO World Health Organisation P a g e | xxiv Foreword and Acknowledgements Chair of the Statistics Committee The Ministry of National Economy of the Republic of Kazakhstan Mr. Nurbolat Aidapkelov Since gaining of Independence in December 1991, Kazakhstan witnessed significant changes in all areas of the society’ life; in particular, these changes greatly affect the situation of children and women in the country. The state needs relevant and reliable statistical information in order to keep track of those changes and to take necessary steps to adapt to a new situation. From this point of view, the findings of the 2015 Kazakhstan Multiple Indicator Cluster Survey (2015 Kazakhstan MICS) conducted in a framework of the fifth round of the Global MICS present a great interest. I believe that the survey findings will be useful for the Government and civil society institutions in Kazakhstan in planning and monitoring of social programmes that meet the needs of women and children both at the national level and at the level of every region. The successful completion of the 2015 Kazakhstan MICS and publication of the Final Report is a result of joint efforts of experts at different levels, their well-coordinated and professional work. I would like to mention a noble and vital role of the UN agencies in our country. In particular, I would like to express our gratitude to the United Nations Children’s Fund (UNICEF) and the United Nations Population Fund (UNFPA) for their technical and financial support in preparation and implementation of the 2015 Kazakhstan MICS. I would like to thank the staff of the UNICEF Office in Kazakhstan – Mr. Yuri Oksamitniy, UNICEF Representative in Kazakhstan, and Ms. Zhanar Sagimbayeva, UNICEF Child Rights Monitoring Specialist – for their significant technical and financial support in training and capacity building of the staff of the Statistics Committee and for continuous support in preparation and implementation of this survey. I would like to thank Global MICS Coordinator Mr. Attila Hancioglu (USA, New York) and, in his person, the whole UNICEF team that conducted a series of training workshops, developed questionnaires and data entry and data processing programmes, provided overall management as well as advice at all stages of the survey. Special appreciation goes to the MICS Project Coordinator from CEECIS Regional Office Mr. Siraj Mahmudlu (Switzerland, Geneva), who provided the best possible assistance to the Statistics Committee in preparation and actual undertake of the survey in Kazakhstan. I would especially like to note the help of experts from the UNICEF Regional team, in particular, Mr. Sinan Turkyilmaz, Ms. Ana Abdelbasit, Mr. Ikhtier Kholmatov and Ms. Teuta Halimi, as well as Mr. Larisa Praslova – UNICEF National Consultant in the Kyrgyz Republic, as they all facilitated successful implementation of the Survey. In addition, I would like to express our gratitude to national consultants, Ms. Gyulnar Kukanova and Ms. Dilyara Beisenova, for their great contribution to the MICS implementation and writing of the Final Report. My special thanks to the UNFPA staff in Kazakhstan – Mr. Raimbek Sissemaliyev, UNFPA Assistant Representative in Kazakhstan and Ms. Gaziza Moldakulova, National Programme Officer, for co- financing and methodological help in training the staff of the Statistics Committee, and in other activities during the MICS fieldwork. Overall, I believe that our fruitful cooperation with UNICEF and UNFPA will continue in the implementation of other joint projects. P a g e | xxv I would like to thank heads of statistics departments of Almaty and Astana cities and of all oblasts, supervisors, editors and interviewers as well as the management of the “Information and Computing Centre under the Statistics Committee” for their significant contribution to successful completion of the 2015 Kazakhstan MICS. On this occasion, I would like to express my appreciation to representatives of ministries, state agencies and non-governmental sector, which also contributed to the success of this project. Yours faithfully, P a g e | xxvi Foreword and Acknowledgements Representative of the UN Children’s Fund (UNICEF) in Kazakhstan Mr. Yuri Oksamitniy This year is the 25th anniversary of the Independence of the Republic of Kazakhstan and also the 70th anniversary of UNICEF. Therefore, it is my great pleasure to share the Final Report on the results of the Multi Indicator Cluster Survey (MICS), which was conducted in Kazakhstan over the last year by the Statistics Committee of the Ministry of National Economy and with the technical and financial support of UNICEF and the UN Population Fund (UNFPA). MICS continues to be critically important to Kazakhstan for generating reliable, comprehensive and up-to-date information on the well-being of women and children. This is the third time that Kazakhstan has taken part in MICS, demonstrating its continued interest in collecting unique sets of data that enrich national statistics and with data quality to a level, that meets international standards. The Final Report provides disaggregated data on state of women and children in Kazakhstan. The data can be compared with previous MICS conducted in 2005-2006 and in 2010-2011. Comparisons of the current and previous MICS demonstrate notable progress Kazakhstan has made in mother and child health, improvements for families in their living conditions, in access to water and sanitation, literacy and education, increasing use of ICT and significant level of life satisfaction among women. At the same time, MICS reveals emerging challenges in early child development, reproductive and sexual health of women, in women’ perception of domestic violence and in the level of such violence against children, decreasing knowledge about HIV/AIDS among young women. MICS also stands as an important instrument for monitoring the international obligations of the Republic of Kazakhstan, including its progress towards recently adopted Sustainable Development Goals (2030). The successful completion of the MICS is the result of collective efforts of numerous specialists from the Statistics Committee of the Ministry of National Economy and its territorial divisions, as well as of its subsidiary body, the Information and Computing Centre. UNICEF would like to express its sincerest appreciation to Mr. Alikhan Smailov, Assistant to the President of Kazakhstan, for creating favourable conditions for the successful implementation of MICS; to Mr. Nurbolat Aidapkelov, Chair of the Statistics Committee, for his support in the development of the Final Report; to Mrs. Bakhytbek Imanaliyev and Aidyn Ashuyev for their organizational support during the preparation and data collection stages; and to Mr. Kairat Orunkhanov, the deputy Chair of the Statistics Committee. UNICEF would also like to thank, especially, staff of the Statistics Committee who were engaged in realization of the project: Ms. Gulmira Karaulova, Head of the Division for Social and Demographic Statistics, who was responsible for the overall coordination of the project from the side of the government, Ms. Zhuldyz Aidarbekova and Ms. Zhanar Sabirova. Special acknowledgment goes to Ms. Gyulnor Kukanova and Ms. Dilyara Beisenova – the national consultants for the MICS- foe their valuable contributions. I would like to acknowledge the role of Mr. Eldar Kazganbayev, Director of the Information and Computing Centre namely, and his staff – Mr. Nurlybek Rakhmetov, Ms. Assem Gabdullina, Mr. Erbolat Mussabek, Ms. Aigul Kapisheva, Ms. Saule Dauylbayeva and all specialists who took part in entry and analysis of the MICS data for their effective and timely implementation of an ambitious workplan. I believe that this Final Report will be highly useful for Kazakhstan state bodies, non-governmental and international organisations, academia, mass media as well as to the general public and to all those interested in advancement of the well-being of women and children in the Republic of Kazakhstan. With best regards, P a g e | xxvii Foreword and Acknowledgements Assistant Representative of the UN Population Fund (UNFPA) in Kazakhstan Mr. Raimbek Sissemaliyev On behalf of UNFPA Kazakhstan Country Office, I have a great pleasure to present the Final Report on findings of Multiple Indicator Cluster Survey conducted in Kazakhstan in 2015. This Survey was made possible due to the administrative talent of Special Assistant to the President of the Republic of Kazakhstan on Economic Issues, Mr. Alikhan Askhanovich Smailov who during the implementation period of the project headed the Committee on Statistics of the Ministry of National Economy of the Republic of Kazakhstan. The successful completion of the MICS is a collective effort of many experts of the Committee on Statistics of Kazakhstan under the leadership of Mr. Nurbolat Sergaliyevitch Aidapkelov, due to his energetic conduct we owe the pleasure of presenting this Report to you today. It is important to acknowledge the significant contribution of the United Nations Children's Fund (UNICEF) in the Republic of Kazakhstan, namely Mr. Yury Viktorovich Oksamitnyi, the UNICEF Representative and Ms. Zhanar Nurgaliyevna Sagimbayeva, the Monitoring and Evaluation Officer. The funding and methodological support of this Survey were organized by invaluable inputs of the colleagues' efforts. The independent data on the status of the population's reproductive health, the level of awareness of young people about HIV and gender-based violence presented in the Report are important for strategic decision-making in the field of social policy, including health and education. The data obtained through MICS will be useful not only in the work of the public authorities, but also for non-governmental organizations, international institutions, teachers and students, as well as for the general public. Sincerely, P a g e | xxviii Brief overview of the key indicators Conducted in 2015 Kazakhstan Multiple Indicator Cluster Survey (2015 Kazakhstan MICS) is a representative sample survey at the national and sub-national levels. The target sample size was 16,800 households. Sample coverage Of the 16,791 households in the sample, 16,605 households were inhabited. Of these, 16,500 households were successfully interviewed: the proportion of interviewed households amounted to 99.4 percent. 12,910 women aged 15-49 years were identified in the interviewed households, of which 12,670 women were successfully interviewed: the proportion of female respondents in interviewed households was 98.1 percent. The list of household members in the household Questionnaire identified 5,561 children under 5. Questionnaires were completed for 5,510 children, which corresponds to 99.1 percent response rate for the interviewed households. The household response rates in urban and rural areas were more than 99 percent, and by regions – more than 98 percent. Low Birth Weight In Kazakhstan, in total, 97.8 percent of newborns were weighed at birth; approximately 4.5 percent of newborns weighed less than 2,500 grams at birth. Nutritional Status of Children In Kazakhstan, about 2 percent of children under 5 years are underweight for their age, and 8.0 percent of children are stunted. 3.1 percent of children are wasted for their height. In addition, 9.3 percent of children are overweight. Breastfeeding and Feeding of Infants and Young Children The survey interviewed women with children born within two years prior to the date of the survey about how they fed their child during the first few days of life. In Kazakhstan, only 83.3 percent of newborn babies are breastfed within the first hour after birth; and 92.8 percent of newborns are breastfed within one day of birth. Approximately 38 percent of children under the age of six months are exclusively breastfed, and over 70 percent of children are predominantly breastfed, indicating the prevalence of the practice of giving P a g e | xxix non-milk liquids to infants in addition to breastmilk. Almost 60 percent of children aged 12-15 months, and 21.1 percent of children aged 20-23 months are still breastfed. Median duration of any breastfeeding is 15.6 months; exclusive breastfeeding – 1.8 months and predominant breastfeeding – 4.9 months. Almost every second child (49.2 percent) aged 6-23 months is appropriately breastfed for their age. 66.5 percent of children aged 6-8 months received solid, semi-solid and soft foods at least once during the previous day, while the main proportion (63.9 percent) comprised infants who are breastfed at the time of the survey. The percentage of children receiving a minimum dietary diversity, or foods from at least 4 groups of products out of 7 food groups, was 68.7 percent being the highest among the oldest age group of 18- 23 months (86.1 percent) and the lowest among the youngest children aged 6-8 months (22.6 percent). Less than half of children 6-23 months of age were receiving the minimum acceptable diet (45.1 percent). More than half of children aged 0-23 months are fed with a bottle with a nipple (51.2 percent). Salt Iodization In the survey, salt used for cooking was tested for iodine content in almost every household (98.0 percent). It was revealed that more than 90 percent of households consumed salt that contained iodine in the recommended amount of 15 ppm or more (91.0 percent); 3.7 percent of households used salt with low iodine content (less than 15 ppm), while in 5.0 percent of households salt was not iodized (0 ppm). Survey findings show that salt was not available in only 0.6 percent of households. In urban areas, 94.0 percent of households were consuming adequately iodized salt (≥15 ppm) while for rural areas the figure was 85.6 percent. In 10.4 percent of the poorest households salt was not iodized. Vaccination Data on vaccination coverage was collected for all children under 3 years old. By the age of 12 months, 98.5 percent of children aged 12-23 months received a dose of BCG; the first dose of Polio, DPT and HepB vaccines were administered respectively to 95.6, 95.6 and 97.6 percent of children, and Hib – 94.7 percent of children. The proportion of vaccinated children reduced with each subsequent dose for each type of vaccines: to 93.5 and 94.2 percent respectively for the second dose of Polio and DPT; to 94.7 and 93.5 percent respectively for the HepB and Hib vaccines; the percentage of vaccinated children declines for the third dose of Polio, DPT, HepB and Hib to 89.7, 90.4, 88.4 and 89.3 percent respectively. P a g e | xxx Vaccination coverage of children aged 24-35 months against measles (MMR) by 24 months was 95.1 percent. The percentage of children aged 24-35 months who received all the recommended vaccinations by the age of 12 months (measles vaccines – by 24 months) in Kazakhstan was 84.1 percent. 1.1 percent of children aged 24-35 months received none of the recommended vaccinations. Knowledge of the Two Danger Signs of Pneumonia Overall, 36.7 percent of women know at least one of the two danger signs of pneumonia: fast breathing and/or difficult breathing. 27.6 percent of mothers recognise difficult breathing, and 15.5 percent of mothers recognise fast breathing as a symptom that would cause them to take their child immediately to a health facility. Use of Solid Fuels In Kazakhstan, the use of solid fuels for cooking is almost at a minimum (1.5 percent). In the country, – coal or lignite is used by only 0.6 percent of the household population, wood – by 0.5 percent, animal dung – by 0.3 percent of the population. Solid fuels are used almost exclusively by the rural population (3.0 percent), by households where the household head has no education or only primary education (5.9 percent), as well as the population of the poorest quintile (5.6 percent). Use of Improved Water Sources In Kazakhstan the majority, or 97.3 percent, of the population use improved drinking water sources: 99.7 percent in urban and 94.6 percent in rural areas. The main drinking water source is piped water (including public standpipes), which is used by about 80 percent of the population. Out of this percentage, more than half (58.5 percent) of the population use water piped into their dwellings and 14.6 percent use water piped into the yard or plot; 6.4 percent of the population use public standpipes, and a small proportion of the population (0.5 percent) take water from their neighbours. 6.4 percent of the population use bottled water; 5.9 percent use water from tubewells/boreholes; 5.1 percent use water from protected wells and springs. 2.7 percent of the population use unimproved drinking water sources. About 10 percent of the population use water sources which are not located on premises. 8.2 percent of household members spend less than 30 minutes to get to the water source (improved or unimproved) and collect water; for 1.8 percent of household population it takes 30 minutes or more to collect water. For 6.8 percent of the residents using improved drinking water sources it takes less than 30 minutes to collect water, and for 1.4 percent population it takes 30 minutes or more. In the majority of households, more often collecting of drinking water is performed by an adult man (62.6 percent), and in every third household it is an adult woman (33.2 percent). In 3.5 percent of households, the responsibility for collecting water lies with children under the age of 15 years, with the proportion of girls and boys being 0.9 and 2.7 percent, respectively. P a g e | xxxi In more than 50 percent of households whose household heads have no education or primary education, most often the water collection is performed by adult woman, while in households where the household head has higher education, 22.4 percent of women are engaged in water collection. Overall, 46.4 percent of the household population using unimproved drinking water sources use the appropriate water treatment methods. More than a third of the population use water boiling (37.3 percent); 25.8 percent of the population use filtering utilising different filters, more than 8 percent of the population let the water stand and settle. More than one half of the population using unimproved water sources does not use any water treatment method (53.2 percent). Access to Improved Sanitation Overall, 98.0 percent of Kazakhstan's population live in households using improved sanitation facilities which are not shared with no notable differences by background characteristics. In the country, 48.1 percent of the population use flush or pour flush toilet facilities, and 51.8 percent use pit latrines with slabs or ventilated improved pit latrines. In urban areas, more than 68 percent of the population use facilities that flush to a piped sewer system, while in rural areas 85.5 percent of the population use pit latrines with slabs or ventilated improved pit latrines. Handwashing In Kazakhstan, almost every household (99.0 percent) had both water and soap at the specific place for handwashing. Fertility and Early Childbearing In Kazakhstan, the crude birth rate among women aged 15-49 years is 21 births per 1,000 population, in urban and rural areas this figure is 20 and 23 births per 1,000 population, respectively. The adolescent birth rate among girls aged 15-19 years is 36 births per 1,000 women. The total fertility rate for the one year preceding the Kazakhstan MICS is 3.0 births per woman aged 15-49 years, in rural areas this figure is higher than in urban areas (3.7 and 2.6 births respectively). For women aged 15-49 years there were no cases of births the age of 15 years. 3.9 percent of women of the age 15-49 years have already had a live birth, while 1.4 percent of women in this age group are pregnant with their first child. The percentage of women aged 20-24 years who have had a live birth before age 18 is 2.2 percent. In addition, women in this age group with lower education levels are more likely to have had a live birth compared to those with higher education (15.7 and 0.5 percent respectively). P a g e | xxxii Contraception In Kazakhstan, almost all women aged 15-49 years (98.8 percent) are informed about a contraceptive method, including modern methods. More than half of women aged 15-49 years (55.7 percent), who are currently married/in union reported the use of contraception. The most popular method of contraception is the intrauterine device (IUD), which is used by every third women currently married or in union (31.9 percent). The next most commonly used method/means of contraception is the male condom, the use of which is reported by 12.5 percent of women currently married or in union, while more than 6 percent of the women use the pill. Methods/means of contraception such as an injection, diaphragm/foam/gels, lactational amenorrhea method (LAM), withdrawal or periodic abstinence, and female sterilization, are used by 0.1 – 1.7 percent of women. Adolescents aged 15-19 are much less likely to use methods of contraception than older women (20- 49 years). Unmet Need 5.6 percent of women have an unmet need for contraception for spacing and 4.3 percent of women – for limiting the number of children; therefore, unmet need for contraception of women was 9.8 percent across the country. This indicator is also known as the unmet need for family planning. Antenatal Care In Kazakhstan coverage of antenatal care by skilled health personnel, is very high and amounted to 99.3 percent. Antenatal care for pregnant women was predominantly provided by qualified doctors (92.2 percent), for 6.6 percent of pregnant women – by nurses or midwives, and for 0.5 percent – by feldshers, with these two categories of mid-level medical personnel to be mostly typical for rural areas (10.8 and 1.0 percent respectively). 95.3 percent of pregnant women received antenatal care at least four times. Overall, 90.2 percent of women who had live birth in the past two years, had the first visit to the health care professionals for antenatal care in the first trimester of their last pregnancy, with a median of 2-month pregnancy at the time of the first visit. In the first trimester of pregnancy the first visit to health workers for antenatal care was undertaken by only 82.9 percent of women younger 20 years at time of birth, compared with 91.1 percent of mothers aged 20-34 years at time of birth. Almost all women (99.3 percent) who had a live birth in the two years preceding the survey, received the specified minimum range of services and procedures within antenatal care (blood pressure measured, urine sample taken, and blood sample taken). P a g e | xxxiii Assistance at Delivery In Kazakhstan, 99.4 percent of births were attended by qualified personnel and practically all births took place in public health facilities. More than 90 percent of births in Kazakhstan were delivered with assistance of doctors, and 9.1 percent of births – by nurses and midwives. In general, 14.8 percent of births were conducted by caesarean section. Thus, 9.6 percent pregnant women have consented to the operation before the start of labour, and for 5.3 percent of pregnant women the decision was made during labour. Post-natal Health Checks In Kazakhstan, nearly every woman who gave birth in a health care facility stays there for 12 hours or more after delivery (99.9 percent), with virtually no regional differences. Almost nine out of ten women (88.9 percent) stayed in health facilities for 3 or more days after delivery; of which 44.4 percent stayed in health facilities exactly 3 days after birth and 11.0 percent of women were in health facilities at least 3 days after delivery. Overall, 99.4 percent of newborns receive a health check following birth while in a facility or at home. 97.4 percent of mothers receive a health check following birth while in facility or at home. With regards to PNC visits, these predominantly occur either on the first day following discharge (30.7 percent) or 3-6 days (30.5 percent) following discharge. Approximately every fourth PNC visit for newborns (23.5 percent) was carried out 2 days following discharge, and 10.2 percent after the first week following discharge from a health facility. In Kazakhstan, only 62.2 percent of mothers were covered with postnatal care following discharge from the health facility. 18.3 percent of PNC visits following discharge from the health facility were conducted in less than 3 days following discharge, 17.3 percent – in the 3-6 days following discharge, and 26.4 percent of PNC visits for mothers following discharge from the health facility, were made after the first week following discharge. At the same time, 36.7 percent of mothers had no PNC visits after being discharged from the health care facility. In 97.4 of live births, both the mothers and their newborns receive either a health check following birth or a timely PNC visit, within two days of the most recent birth. For 0.6 percent of cases after childbirth, both the mothers and their newborns neither received health checks or timely visits, and in 1.9 percent of cases – only newborns received this care. Abortions In Kazakhstan, the mean number of induced abortions is 0.4. One in five women (20.1 percent) aged 15-49 had at least one induced abortion during their lifetime. Women at the age of 40-44 years and 45-49 years (34.5 and 38.2 percent, respectively) are more likely to have had at least one induced abortion, compared with young women aged 20-24 years (3.7 percent). 55.1 percent of women had one abortion, 38.8 percent – two or three abortions, and 6.1 percent – four or more abortions. The highest percentage of women who have had 2-3 or 4 and more abortions P a g e | xxxiv is observed among women in the age group of 40-44 years and 45-49 years (46.2 and 45.4 percent, respectively, and 7.0 and 8.4 percent respectively). The total abortion rate is 0.3 per 1 woman aged 15-49 years, while the general abortion rate is 10 abortions per 1,000 women. Early Child Development More than half (55.3 percent) of children aged 36-59 months are attending an organised early childhood education programme. Urban-rural and regional differentials are notable – facilities with such programmes are attended by 62.2 percent of children from urban areas compared to 48.9 percent from rural areas. For more than 85 percent of children aged 36-59 months an adult household member engaged in four (or more) activities that promote learning and school readiness in 3 days preceding the survey. The Early Child Development Index (ECDI) is calculated as the percentage of children who are developmentally on track in at least three of four domains: learning, physical, socio-emotional development, and literacy and numeracy skills. The Early Child Development Index (ECDI) for children aged 36-59 months is 85.5 percent. Analysis of the four domains of child development shows that 98.3 percent of children develop in accordance with the age in the domain of physical development, 97.2 percent – in learning, and 82.1 percent – in social-emotional development. However, the percentage of children aged 36-59 months who are developmentally on track in the literacy-numeracy domain is 3 to 3.5 times (27.7 percent) lower than in the other domains. Literacy among Young Women In Kazakhstan, the literacy of young women aged 15-24 years reaches absolute 100.0 percent. Since the literacy is universal, there are no differences in literacy rates by background characteristic of women. School Readiness In Kazakhstan, in general, 90.8 percent of children who are currently attending the first grade of primary school were attending pre-school the previous year. Socio-economic status of the household seems to play a positive role in preparing children for school: 96.7 percent of children living in the richest households attended pre-school facilities in the previous year, while the corresponding figure among children in the poorest households was only 88.3 percent. The percentage of 5-6-year-old children who attend pre-school was 47.8 percent and primary school – 36.1 percent. The adjusted net attendance ratio in pre-primary education is 84.0 percent. At the same time, the highest proportion of children aged 5 years attend pre-school (68.1 percent), and only P a g e | xxxv 2.6 percent attend primary school; among children aged 6 years, approximately one third of children attend pre-school facilities (28.9 percent) and 67.4 percent attend primary school. Primary and Secondary School Attendance In Kazakhstan, children enroll in Grade 1 at age of six or seven years, and every parent has the right to determine at what age to send their child to school. In Kazakhstan in the 2015-2016 academic year among children of primary school entry age (full 7 years) 99.2 percent of the children attended the first grade of primary school; and of children that started school at age 6 years – 67.4 percent of children attended the first grade. The primary school (adjusted) net attendance ratio for children aged 7-10 years was 99.5 percent. The secondary school (adjusted) net attendance ratio (NAR) for children aged 11-17 years was 98.9 percent. The lower secondary school (adjusted) net attendance ratio (NAR) for children aged 11-15 years was 99.4 percent. The upper secondary school (adjusted) NAR for children aged 16-17 years was 95.7 percent, which is slightly less than lower secondary school (adjusted) NAR. In general, in Kazakhstan, the Gender Parity Index (GPI) for primary, lower secondary education and secondary education is 1.00, indicating no difference in the attendance to these school levels by girls and boys with the exception of the GPI for upper secondary education, which is 1.01. There are no GPI differences by background characteristics. The GPI for upper secondary school (adjusted) NAR indicates that there is a gender gap between upper secondary school attendance of girls and boys in urban areas and also between girls and boys in rural areas (1.03 and 0.98 percent respectively). Birth Registration The survey findings indicate that birth registration in Kazakhstan is almost universal (99.7 percent). Child Discipline In Kazakhstan, 52.7 percent of children aged 1-14 years were subjected to at least one form of psychological or physical punishment by the adult members of the household during the last one month before the survey. 47.2 percent of children were subjected to psychological aggression. The most severe forms of physical punishment (hitting the child on the head, ears or face, or repetitive hits) are not common in the country: 1.0 percent of children were subjected to severe punishment. 55.2 percent of boys and 49.9 percent of girls have been subjected to any violent discipline method. Only 4.7 percent of respondents believe that physical punishment is a necessary part of child-rearing, while in practice, about 26 percent of children were subjected to physical punishment. P a g e | xxxvi Early Marriage In Kazakhstan, the official marriage age for women and men is 18 years, and only in exceptional cases by the decision of the local executive bodies this age can be reduced by a period not exceeding two years for essential reasons: 1) pregnancy; 2) birth of a child. Among women aged 15-49 years, 0.1 percent of girls were married before age 15, and among women aged 20-49 years, 7.8 percent were married before age 18. Among women aged 20-49 years, women living in rural areas are more likely to be married before age 18, compared to women in urban areas (9.5 percent and 6.5, respectively). The proportion of women who were married/in union before age 18 peaked some 20-25 years ago, after which it declined again. In all the age groups of women, it can be stated that marriage before age 18 is more common among women in rural areas than in urban areas. Among currently married/in union women aged 20-24 years, 4.5 percent are married/in union with a man who is older by ten years or more. Among married/in union women aged 15-19 years, the proportion of women whose husband is older by ten years or more, is 5.8 percent. Attitudes toward Domestic Violence According to the 2015 Kazakhstan MICS, 14.2 percent of women believe that a husband/partner may hit or beat his wife/partner in at least one of five situations. Women who justify a husband’s violence, more frequently justify it in instances when: a woman neglects the children (10.8 percent) or goes out without telling her husband (4.1 percent), or argues with him (5.4 percent). Only a small proportion of women justify wife-beating if she refuses to have a sex with her husband (1.5 percent) or if she burns the food (0.7 percent). Children’s Living Arrangements and Orphanhood In Kazakhstan, approximately four out of five children (82.0 percent) aged 0-17 years live in a family with both parents, 13.1 percent – only with their mother, and 1.1 percent – only with their father. 9.2 percent of children live only with their mother, despite the fact that their own father is alive, and 0.8 percent of children live with their father despite the fact that their biological mother is alive. 3.2 percent of children do not live with their biological parents, while 2.6 percent of children have both parents alive. Nearly 5 percent of children have lost one or both parents. Knowledge about HIV Transmission and Misconceptions about HIV In Kazakhstan, nearly every woman aged 15-49, or 97.9 percent, have heard of AIDS. Despite this, the percentage of women who know both main ways of preventing HIV transmission: firstly, having only P a g e | xxxvii one faithful uninfected sex partner, and, secondly, using a condom every time during intercourse – was only 65.4 percent. At the same time, women's awareness about each of the ways is quite high: 82.3 percent of women know that the main way of preventing HIV transmission is to have only one faithful uninfected sex partner and 71.7 percent of women know that using a condom every time during intercourse is one of the most reliable ways to prevent HIV transmission. Overall, less than half (44.0 percent) of women reject the two most common misconceptions about HIV transmission and know that a healthy looking person can be HIV-positive. 71.5 percent of women believe that HIV cannot be transmitted by kissing, and 66.7 percent of women know that HIV cannot be transmitted through mosquito bites; three out of four women (74.1 percent) know that a healthy looking person can be HIV-positive. 88.4 percent of women know that HIV is not transmitted by shaking hands or hugging, about the same percentage (89.1 percent) – that HIV is not transmitted by supernatural means, and 80.0 percent of women know that HIV cannot be transmitted by sharing food. Only one third of women aged 15-49 (33.7 percent) have comprehensive knowledge about HIV prevention and transmission (women who know two ways of HIV prevention: having only one faithful uninfected sex partner and using a condom every time during intercourse; who know that a healthy looking person can be HIV-positive; and who reject the two most common misconceptions in Kazakhstan about HIV transmission). At the same time, in urban areas the figure is slightly higher than in rural areas (38.8 and 27.0 percent, respectively). Young women and girls aged 15-24 years, and, in particular, aged 15-19 years, are more often less informed about all the ways to prevent HIV transmission and about all the misconceptions related to HIV than older women. Accepting Attitudes toward People Living with HIV In Kazakhstan, 90.8 percent of women agree with at least one accepting attitude towards people living with HIV. The most common accepting attitude is the willingness of a woman to care for a family member with AIDS in her own home (82.2 percent). More than a third of women believe that a female teacher who is HIV-positive, but is not sick should be allowed to continue teaching at school (34.9 percent); every fifth woman is willing to buy fresh vegetables from a shopkeeper or vendor who is HIV-positive (20.1 percent) and would not want to keep it a secret if her family member was HIV-positive (20.5 percent). Despite the fact that there are variations in percentages of women expressing accepting attitudes for the individual indicators (from 20 to 82 percent), overall, 2.5 percent of women who have ever heard of AIDS express accepting attitudes on all four indicators. 39.0 percent of women aged 15-49 years think that children living with HIV should be allowed to attend school with children who are HIV-negative, expressing an accepting attitude on this indicator. 76.0 percent of women reported discriminatory attitudes towards people living with HIV on a combination of the following two indicators: 1) would not buy fresh vegetables from a shopkeeper or vendor who is HIV-positive, and 2) think that children living with HIV should not be allowed to attend the school with children who are HIV-negative. P a g e | xxxviii HIV Indicators for Young Women Approximately one in four women aged 15-24 have comprehensive knowledge about HIV (26.7 percent); about half of women know all three ways of mother-to-child HIV transmission (48.0 percent); and more than two-thirds of women in this age group are aware of place (facility) to get tested for HIV (71.4 percent). 2.2 percent of women aged 15-24 years express accepting attitudes towards people living with HIV on all four indicators, which is comparable to the similar rate among 15-49 year old women. 78.4 percent of young women aged 15-24 years reported discriminatory attitudes towards people living with HIV on a combination of the following two indicators, giving negative answers to questions: (1) would buy fresh vegetables from a shopkeeper or vendor who is HIV-positive and 2) think that children living with HIV should be allowed to attend school with children who are HIV-negative). Access to Mass Media Almost half of women aged 15-49 years or 49.0 percent read newspapers or magazines at least once a week, while about one in four women, or 26.5 percent, listen to the radio and 96.0 percent watch television at least once a week. Overall, only 2.3 percent of women do not have regular exposure to any of the three media, while 97.7 percent use at least one type of media, and 16.1 percent – all three media types at least once a week. Newspapers and magazines are read by more than half of women aged 35-49 years (52.7-57 percent), while 39.1 percent of women aged 15-19 years read them at least once a week. Young women aged 18-19 years are more likely to listen to the radio at least once a week than women aged 45-49 years (31.7 and 20.3 percent, respectively). Use of Information/Communication Technology In Kazakhstan, 97.9 percent of women aged 15-24 year have ever used a computer; 88.2 percent used a computer during the last 12 months, and 77.0 percent used it at least once a week during the last one month. Overall, 96.8 percent of women aged 15-24 years have ever used the Internet, while 94.6 percent used the Internet during the 12 months preceding the survey. The proportion of young women who used the Internet more frequently, at least once a week during the last one month, was 89.8 percent. Both computer and Internet use during the last 12 months is slightly more widespread among women aged 15-19 years. P a g e | xxxix Subjective well-being In Kazakhstan, about 97 percent of young women are the most satisfied with family life (97.1 percent), the way they look (97.2 percent), treatment by others (97.1 percent), health (96.6 percent) and friendship (96.7 percent). 92.4 percent of young women are satisfied with living environment. Only 4.6 percent of young women aged 15-19 and 40.5 percent of women aged 20-24 have an income. Satisfaction with income was expressed by 89.0 percent of women in each of these age groups. Overall, 96.4 percent of women aged 15-24 years are very or somewhat satisfied with school (with 49.6 percent of women this age attending school). Of which 97.5 percent of women aged 20-24 years are very or somewhat satisfied with school (with the percentage attending being 21.5 percent). 96.8 percent of women aged 15-24 years are satisfied with their life overall; the figure ranges from 96.0 percent of women living in the poorest households to 97.8 percent among those living in the richest households, showing there are no notable differences in overall life-satisfaction across wealth index quintiles. 98.5 percent of women aged 15-24 years are very or somewhat happy. The percentage of women aged 15-24 years, who believe that life has improved in the last one year and expect that it will get better after one year, is 64.9 percent. Tobacco Use In Kazakhstan, 26.9 percent of women aged 15-49 reported having ever used any tobacco product, with 8.4 percent of women having smoked cigarettes or consumed tobacco or smokeless tobacco products at any time during the last one month prior to the survey. Ever use of any tobacco products by women in urban areas is twice as high as in rural areas (34.7 and 16.9 percent, respectively); the share of urban women having smoked at any time during the last one month prior to survey is more than twice that of women in rural areas (11.4 and 4.7 percent, respectively). 18.3 percent of women who have ever used tobacco products have smoked only cigarettes, while 5.7 percent have used cigarettes and other tobacco products. During the last one month 7.1 percent of women smoked only cigarettes of all tobacco products. The frequency of smoking among women is characterized by the fact that someone limits herself to 1-4- cigarettes a day, and some women smoked 10-20 or more cigarettes in the last 24 hours. 28.2 percent of women smoked in the last 24 hours less than 5 cigarettes, and 29.0 percent – 5.9 cigarettes. Among women aged 15-49 years who smoked cigarettes during the last 24 hours, 10.5 percent smoked 20 cigarettes or more during this time (at least a standard pack of cigarettes), and 32.2 percent of women smoked 10-19 cigarettes in the last 24 hour. P a g e | xl Only 0.9 percent of women smoked their first cigarette before 15 years of age. Alcohol Use In Kazakhstan, at least one in four women aged 15-49 (25.1 percent) had at least one drink of alcohol at any time during the last one month prior to survey. Only 0.5 percent of women in the age group of 15-49 years had at least one drink of alcohol before age of 15, while 33.7 percent of women have never consumed alcohol. Women aged 30 to 49 years are more likely to have had at least one alcoholic drink at any time during the last one month (ranging from 30 to 35 percent), compared with younger women (ranging from 3.1 percent for women aged 15-19 years to 21.7 percent for those aged 25-29 years). P a g e | 1 I. Introduction This report is based on the Kazakhstan Multiple Indicator Cluster Survey (MICS), conducted in 2015 by the Statistics Committee of the Ministry of National Economy of the Republic of Kazakhstan (herein MNE RK). This is the third MICS Survey in Kazakhstan; two previous surveys were conducted in 2005 and 2010, the findings from these surveys were used in development and implementation of state programmes in the areas of mother and child health, as well as country programmes of the United Nation Children’s Fund (UNICEF) in Kazakhstan, highlighting the need to improve the statistical data management system with regard to children. Such surveys are crucially important in terms of assessing the state of children and women in Kazakhstan as they provide unique information for development of the national child-centred policy and for international positioning of Kazakhstan. The survey provides statistically sound and internationally comparable data essential for development of evidence base and programmes, and for monitoring country progress towards national goals and global (international) commitments. Among these global commitments are those emanating from international agreements – the World Fit for Children Declaration and its Plan of Action, the goals of the United Nations General Assembly Special Session on HIV/AIDS, the Education for All Declaration and the Millennium Development Goals (MDGs). In addition, the 2015 Kazakhstan MICS results will contribute to establishing a baseline for monitoring the state of women and children in the context of the Sustainable Development Goals (SDGs). A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration, as well as the World Fit for Children Declaration and its Plan of Action also committed themselves to monitor the progress towards the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and assess progress towards the goals and targets of the present Plan of Action at the national, 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 support a wide range of child- focused research. We will enhance international cooperation to support statistical capacity-building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, paragraph 60) “We will conduct periodic reviews at the national 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 of the World Fit for Children (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 agencies 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: P a g e | 2 “…We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” UNICEF has developed a list of indicators and methods to collect statistically sound and internationally comparable data to increase the capacity of Governments to monitor the situation of children in their countries, to execute the Convention on the Rights of the Child and to implement decisions of the 1990 Global High level Meeting for Children. MICS surveys are an accepted tool for monitoring progress in achieving national goals and global commitments to improve the well-being of children. The Republic of Kazakhstan, as a State party to many international treaties for the protection of mothers and children and human development, attaches great importance to the implementation of its obligations and undertakes specific actions for monitoring of implementation of obligations and statistical capacity building – the main source of information for the development of national strategies for social and economic development. As expected, the results of the MICS survey will contribute to the evidence base of a number of other important initiatives. Survey Goals and Objectives The 2015 Kazakhstan MICS has the following objectives:  To provide up-to-date information for assessing the situation of children and women in the Republic of Kazakhstan;  To collect information that will help to improve national policies in the area of childhood and motherhood protection;  To generate data for the critical assessment of the progress made in various areas, and to put additional efforts in areas that require more attention;  To collect disaggregated data for the identification of disparities, to allow for evidence based policy-making aimed at social inclusion of the most vulnerable;  To validate data from other sources and the results of focused interventions;  To contribute to the generation of baseline data for the post-2015 agenda;  To contribute to the improvement of data and monitoring systems in the Republic of Kazakhstan and to strengthen technical expertise in the design and implementation of such systems as well as in a better analysis of available data. The 2015 Kazakhstan MICS is expected to contribute to the evidence base of several other important initiatives, including the accountability framework proposed by the Commission on Information and Accountability for the Global Strategy for Women's and Children's Health. This Final report presents the results of the indicators and topics covered in the survey. http://www.who.int/woman_child_accountability/en/ http://www.who.int/woman_child_accountability/en/ P a g e | 3 II. Sample and Survey Methodology Sample Design The primary objective of the sample design for the 2015 Kazakhstan MICS was to produce statistically reliable estimates of most indicators, at the national level, for urban and rural areas, and for 16 administrative districts (14 regions and 2 cities) of the country: Akmola, Aktobe, Almaty oblast, Atyrau, West Kazakhstan, Zhambyl, Karaganda, Kostanai, Kyzylorda, Mangistau, South Kazakhstan, Pavlodar, North Kazakhstan and East Kazakhstan regions, as well as two large cities of republican significance – Astana and Almaty. The database and cartographic materials of the 2009 National Population Census (2009 Census) in the Republic of Kazakhstan were used in the process forming the sampling frame. The census enumeration areas (EAs) formed for the Census were used as the primary sampling units (PSUs). The urban and rural areas within each region were identified as the main sampling strata and the sample was selected in two stages. In total, 30 strata were formed – 16 urban including two large cities and 14 rural. At the first sampling stage within each stratum, 840 census enumeration areas were selected systematically with probability proportional to size. At the second sampling stage, upon conducting a household listing within the selected enumeration areas, a random systematic sample of 20 households was drawn in each sample enumeration area, for a total sample size of 16,800 households. Out of 840 clusters, which were liable for verification, cluster #338, located in the Karaganda region, was inaccessible due to the fact that this territory is under a long-term lease to the Russian Federation and thus under its jurisdiction. The sample was stratified by region, urban and rural areas, and is not self-weighted. The sample weights are used for reporting nationally representative results. A more detailed description of the sample design can be found in Appendix A, Sample Design. Questionnaires Three sets of questionnaires were used in the survey: 1) a household questionnaire which was used to collect basic demographic information on all de jure household members (usual residents), the household, and the dwelling; 2) a questionnaire for individual women administered in each household to all women aged 15-49 years; and 3) an under-5 questionnaire, administered to mothers (or primary caretakers) of all children under 5 living in the household that included a form for collecting vaccination records at Health Facilities for children under 3. The questionnaires included the following modules: The Household Questionnaire included the following modules: o List of Household Members o Education o Child Discipline o Household Characteristics P a g e | 4 o Water and Sanitation o Handwashing o Salt Iodization The Questionnaire for Individual Women was administered to all women aged 15-49 years living in the households, and included the following modules: o Woman’s Background o Access to Mass Media and Use of Information/Communication Technology o Fertility7 o Desire for Last Birth o Maternal and Newborn Health o Post-natal Health Checks o Illness Symptoms o Contraception o Unmet Need o Attitudes Toward Domestic Violence o Marriage/Union o Sexual Behaviour o HIV/AIDS o Tobacco and Alcohol Use o Life Satisfaction The Fertility module was included in order to be able to calculate indicators concerning total fertility rate and adolescent birth rate. From the onset, it was decided that childhood mortality indicators will not be calculated on the basis of this survey. Following the 2013 UN Inter-agency Group for Child Mortality Estimation (IGME) mission to Kazakhstan, which assessed that the official registration of births and deaths of children aged 0 to 5 years in the country was in line with international standards, the government made a decision to use infant and child mortality data generated by the official statistics, taking into account the adjustments of the IGME. The Questionnaire for Children Under Five was administered to mothers (or primary caretakers) of children under 5 years of age8 living in the households. Normally, the questionnaire was administered to mothers of under-5 children; in cases when the mother was not listed in the household roster, a primary caretaker for the child was identified and interviewed. The questionnaire included the following modules: o Age o Birth Registration o Early Childhood Development o Breastfeeding and Dietary Intake o Immunization o Anthropometry 7 Additional survey-specific questions about abortion were included in this module (questions СМ12В-СМ12М). 8 The terms “children under 5”, “children aged 0-4 years”, and “children aged 0-59 months” are used interchangeably in this report. P a g e | 5 An additional form was used for all children aged 0-2 years with a completed Questionnaire for Children Under Five, the Appendix For Data Collection At Health Facility About Immunization, to record vaccinations from the registries at health facilities. The questionnaires are based on the MICS5 model questionnaires9. From the MICS5 model English and Russian versions, the questionnaires were customised for 2015 Kazakhstan MICS and translated into the Kazakh language. The questionnaires in the Kazakh and Russian languages were pre-tested in Astana city and in the urban and rural settlements of Karaganda region in May 2015. Based on the results of the pre-test, modifications were made to the wording and translation of the questionnaires. A copy of the 2015 Kazakhstan MICS questionnaires is provided in Appendix F. In addition to the administration of questionnaires, fieldwork teams tested salt used for cooking in the households for iodine content, observed the place for handwashing, and measured the weight and height of children under 5 years of age. Details and findings of these observations and measurements are provided in the respective sections of the report. Training and Fieldwork Training of teams for fieldwork data collection was conducted for 13 days – from 17 to 29 August 2015. Training included lectures and presentations on the rules and interviewing techniques, the contents of the questionnaires, as well as role playing games, pilot interviews and testing the knowledge of participants. Toward the end of the training period, participants spent 2 days in practice interviewing in the clusters of Almaty city and Almaty oblast (urban and rural). 16 teams performed data collection; each comprised of one supervisor, one editor, one measurer and 4 interviewers. Furthermore, each team had one driver. Fieldwork began in early September and concluded in late November 2015. Data Processing Data entry was done using the CSPro software, Version 5.0. The data entry was done on 10 desktop computers by 10 data entry operators and overseen by 2 office editors (questionnaire administrator and data entry editor), as well as by one data entry supervisor. For quality assurance purposes, all questionnaires were entered twice and internal consistency checks were performed. Procedures and standard programmes developed under the global MICS programme and adapted to the 2015 Kazakhstan MICS questionnaires were used throughout. Data processing began in parallel with data collection on 15 September and was completed in December 2015. Data was analysed using the Statistical Package for Social Sciences (SPSS) software, Version 21. Model syntaxes and tabulation plans developed by UNICEF were customized and used for this purpose. 9 The model MICS5 questionnaires can be found at http://mics.unicef.org/tools. http://mics.unicef.org/tools P a g e | 6 How to Read Tables The tables of this report present data collected through this survey in a standard way, intuitively easy to understand. However, the reader should be aware of the following remarks: Values in parentheses ( ) indicate that the percentage or proportion is based on 25–49 unweighted cases and such data should be treated with caution. An asterisk (*) in tables indicates that the percentage or proportion has been suppressed because it is based on fewer than 25 unweighted cases while a dash “–” denotes 0 unweighted cases in that cell or in the denominator. Age groups presented in this report include those persons that had reached the full age indicated by the upper limit for an age group: for example, respondents aged 15–24 years also include persons who had fully reached 15 and 24 years of age. Similarly, the age group of children aged 23–35 months includes those who had fully reached 23 and 35 months. Since the education categories “None” and “Primary” are based on fewer than 25 unweighted cases, these categories are combined into “None/Primary”. In the Report, the terms “primary school”, “lower secondary school” or “upper secondary school” are used to refer to training classes (grades 1-4, 5-9 and 10-11, respectively), and the terms “primary education”, “lower secondary education” or “upper secondary education” are used as the basic characteristics of the education level of household members. In addition, in the tables and throughout the report, mother's education refers to educational attainment of mothers as well as primary caretakers of children under 5, who are the respondents to the under-5 questionnaire if the mother is deceased or is living elsewhere. P a g e | 7 III. Sample Coverage and the Characteristics of Households and Respondents Sample Coverage Of the 16,791 households selected for the sample, 16,605 were found to be occupied. Of these, 16,500 households were successfully interviewed with the household response rate of 99.4 percent. In the interviewed households, 12,910 women (aged 15-49 years) were identified. Of these, 12,670 were successfully interviewed, yielding a response rate of 98.1 percent within interviewed households. There were 5,561 children under age five listed in the household questionnaires. Questionnaires were completed for 5,510 of these children, which corresponds to a response rate of 99.1 percent within interviewed households. Overall response rates of 97.5 and 98.5 are calculated for the individual interviews of women and under-5s, respectively. Household response rates in the urban and rural areas are equally high (over 99 percent), while in all regions, response rates were greater than 98 percent (Table HH.1). Table HH.1: Results of household, women's and under-5 interviews Number of households, women, and children under 5 by interview results, and household, women's and under-5's response rates, Kazakhstan, 2015 Total Area Region u rb a n ru ra l A km o la A kt o b e A lm a ty o b la st A ty ra u W e st K a za kh st a n Z h a m b yl K a ra g a n d a Households Sampled 16791 10750 6041 1281 880 920 880 961 920 1101 Occupied 16605 10625 5980 1260 864 908 868 953 916 1072 Interviewed 16500 10540 5960 1243 856 902 854 950 911 1062 Household response rate 99.4 99.2 99.7 98.7 99.1 99.3 98.4 99.7 99.5 99.1 Women Eligible 12910 7925 4985 853 700 763 773 739 818 716 Interviewed 12670 7810 4860 825 686 756 761 725 806 708 Women's response rate 98.1 98.5 97.5 96.7 98.0 99.1 98.4 98.1 98.5 98.9 Women's overall response rate 97.5 97.8 97.2 95.4 97.1 98.4 96.9 97.8 98.0 98.0 Children under 5 Eligible 5561 3063 2498 313 324 310 406 303 435 274 Mothers/caretakers interviewed 5510 3041 2469 310 321 309 401 302 425 274 Under-5's response rate 99.1 99.3 98.8 99.0 99.1 99.7 98.8 99.7 97.7 100.0 Under-5's overall response rate 98.5 98.5 98.5 97.7 98.2 99.0 97.2 99.4 97.2 99.1 P a g e | 8 Continuation of Table HH.1 Region K o st a n a i K y zy lo rd a M a n g is ta u S o u th K a za kh st a n P a vl o d a r N o rt h K a za kh st a n E a st K a za kh st a n A st a n a c it y A lm a ty c it y Households Sampled 1282 880 880 880 1200 1281 1202 960 1283 Occupied 1275 879 868 873 1200 1268 1184 955 1262 Interviewed 1271 879 862 867 1196 1266 1175 949 1257 Household response rate 99.7 100.0 99.3 99.3 99.7 99.8 99.2 99.4 99.6 Women Eligible 914 903 881 878 767 723 712 831 939 Interviewed 907 884 829 874 760 706 697 821 925 Women's response rate 99.2 97.9 94.1 99.5 99.1 97.6 97.9 98.8 98.5 Women's overall response rate 98.9 97.9 93.4 98.9 98.8 97.5 97.1 98.2 98.1 Children under 5 Eligible 339 496 486 523 255 250 224 317 306 Mothers/caretakers interviewed 339 495 474 520 254 248 221 312 305 Under-5's response rate 100.0 99.8 97.5 99.4 99.6 99.2 98.7 98.4 99.7 Under-5's overall response rate 99.7 99.8 96.9 98.7 99.3 99.0 97.9 97.8 99.3 Response rates to individual questionnaires for women aged 15-49 years and questionnaires about children under 5 were quite high and similar across regions, as well as in urban and rural areas, and were greater than 95 percent (except for the Mangistau region where the proportion of interviewed women was 94.1 percent). Characteristics of Households The weighted age and sex distribution of the survey population is provided in Table HH.2. The distribution is also used to produce the population pyramid in Figure HH.1. In the 16,500 households successfully interviewed in the survey, 56,803 household members were listed. Of these, 27,676 persons or 48.7 percent of the total population were males, and 29,127 persons or 51.3 percent were females. According to official demographic statistics of the Statistics Committee MNE RK, as of 1 January 2015, the proportion of men and women in the total population was 48.3 and 51.7 percent, respectively. This shows that the survey data fully correlates with the national demographic statistics. Table HH.2: Age distribution of household population by sex Percent and frequency distribution of the household population by five-year age groups, dependency age groups (age 0-14 years and 65 years or more), and by child (age 0-17 years) and adult populations (age 18 or more), by sex, Kazakhstan, 2015 Total Males Females Number Percent Number Percent Number Percent Total 56803 100.0 27676 100.0 29127 100.0 Age P a g e | 9 0-4 5877 10.3 2986 10.8 2891 9.9 5-9 5509 9.7 2908 10.5 2601 8.9 10-14 4129 7.3 2191 7.9 1937 6.7 15-19 3075 5.4 1684 6.1 1391 4.8 20-24 3874 6.8 2029 7.3 1845 6.3 25-29 4593 8.1 2344 8.5 2248 7.7 30-34 4166 7.3 2095 7.6 2070 7.1 35-39 3908 6.9 1963 7.1 1945 6.7 40-44 3743 6.6 1809 6.5 1934 6.6 45-49 3415 6.0 1680 6.1 1734 6.0 50-54 3951 7.0 1772 6.4 2178 7.5 55-59 3341 5.9 1546 5.6 1795 6.2 60-64 2602 4.6 1056 3.8 1545 5.3 65-69 1807 3.2 718 2.6 1089 3.7 70-74 868 1.5 322 1.2 546 1.9 75-79 1212 2.1 366 1.3 846 2.9 80-84 399 0.7 126 0.5 273 0.9 85+ 336 0.6 80 0.3 255 0.9 Population age groups 0-14 15515 27.3 8085 29.2 7430 25.5 15-64 36667 64.5 17979 65.0 18688 64.2 65+ 4622 8.1 1612 5.8 3010 10.3 Child and adult populations Children aged 0-17 years 17469 30.8 9155 33.1 8314 28.5 Adults aged 18+ years 39335 69.2 18521 66.9 20814 71.5 There are 950 males (935 – according to official demographic statistics) per 1,000 females. In the age groups of 0-4 years to 35-39 years there is a higher proportion of males compared to females; in the age group of 40-44 years old men there is a slight reduction in the percentage of males in comparison to females. The most noticeable imbalance in the sex ratio with an excess of the female population begins from the age group 60-64 years and above. According to the official data of the current population count, as of January 1, 2015, the structure of the country population by sex and by five- year age interval groups is almost comparable with the survey data. There is no sense to compare survey data with the results of the 2009 Census due to the limitation period (more than six years); whereas a comparison was conducted against the 2010-2011 MICS which was relevant at the time. According to the survey, the proportion of dependents (age groups 0-14 and 65 years and older) was 35.4 percent in total; comprising of 27.3 percent of children aged 0-14 years and 8.1 percent of people aged 65 years and older. Almost two-thirds, or 64.6 percent of the population, are in the so-called “able-bodied age group”. According to official demographic statistics, as of January 1, 2015 the proportion of the population in the age group 0-14 years was 26.6 percent, the proportion of people in the age group 15-64 years was 66.6 percent and the proportion of people aged 65 years and older – 6.8 percent. In general, the data on age and sex structure of the population, based on the findings of the 2015 MICS survey, is comparable to the official statistical data of the country (Table HH.2 and Figure HH.1). Children aged 0-17 years comprise 30.8 percent of the population, compared to the official statistics of 30.4 percent as of January 1, 2015. Children in the age group 0-4 years (10.3 percent) and 5-9 years (9.7 percent) make up the largest proportion in the age group 0-14 year old children, and their proportion in total was 20.0 percent (according to the official statistics – 19.8 percent). P a g e | 10 Figure HH.1: Age and sex d i str ibut ion of household populat ion , Kazakhstan, 2015 The noticeable reduction in the proportion of the population of both sexes in the age groups 10-14 years, 15-19 years and 20-24 years is explained by the fact that due to the collapse of the USSR in Kazakhstan, as in all former Soviet Republics, the deterioration of the social and economic situation took place during the 1990s, which had a negative impact on the development of demographic trends, such as out-of-country migration (negative balance of external migration); increase of mortality, as well as significantly falling birth rates, especially in the period of 1995-1999. Thus, the number of children born, especially girls, had decreased in the period of 1992-2000. The increase of the proportion of the population in the age group 25-29 years caused by echoes of the “baby-boom” in the mid-1980s, when there was a significant increase of birth rates caused by the favourable demographic policy of the country, supported by state incentives for childbirth by providing social support to mothers during antenatal and post-natal periods; and increasing the duration of partially paid maternity leave and other measures. There was also an increase in the proportion of the population aged 50-54 years, due to a high rate of natural population increase in the 1950s-1960s. However, the decrease in the number of males and conversely, the increase in number of females aged 75-79 years was caused by low life expectancy of men and by high mortality of men due to various reasons. Tables HH.3, HH.4 and HH.5 provide basic information about the households, female respondents aged 15-49, and children under-5. Both unweighted and weighted numbers are presented. Such information is essential for the interpretation of findings provided later in the report and for P a g e | 11 background information on the representativeness of the survey sample. The remaining tables in this report are presented only with weighted numbers.10 Table HH.3 provides basic background information on the households, including sex of the household head, region, area, number of household members, education of the household head, and ethnicity11,12 of the household head. These background characteristics are used in subsequent tables in this report; the figures in the table also intend to show the number of observations by major categories of analysis in the report. Table HH.3: Household composition Percent and frequency distribution of households by selected characteristics, Kazakhstan, 2015 Weighted percent Number of households Weighted Unweighted Total 100.0 16500 16500 Sex of household head Male 64.0 10563 10561 Female 36.0 5937 5939 Region Akmola 5.7 944 1243 Aktobe 6.0 983 856 Almaty oblast 7.6 1260 902 Atyrau 2.8 456 854 West Kazakhstan 4.6 764 950 Zhambyl 5.3 880 911 Karaganda 9.8 1614 1062 Kostanai 5.9 978 1271 Kyzylorda 2.4 402 879 Mangistau 2.5 412 862 South Kazakhstan 12.5 2055 867 Pavlodar 5.0 829 1196 North Kazakhstan 3.9 645 1266 East Kazakhstan 9.2 1523 1175 Astana city 7.9 1310 949 Almaty city 8.8 1445 1257 Area Urban 60.4 9967 10540 Rural 39.6 6533 5960 Number of household members 1 15.5 2562 2665 2 22.5 3713 3857 3 18.9 3116 3117 4 16.8 2775 2779 5 11.3 1858 1808 6 7.8 1291 1182 7 4.0 656 592 8 1.7 280 257 10 See Appendix A: Sample Design, for more details on sample weights. 11 This was determined by asking the question “To what ethnicity does the head of this household belong?” in the Household Questionnaire. 12 "Nationality" and "Ethnicity" are used as interchangeable terms in this report. P a g e | 12 9 0.7 119 128 10+ 0.8 130 115 Education of household head None/Primary 2.0 331 337 Lower secondary 10.1 1659 1694 Upper secondary 27.1 4475 4244 Technical and Professional 33.8 5574 5845 Higher 27.0 4453 4375 Missing/DK 0.0 8 5 Ethnicity of household head Kazakh 55.3 9124 9241 Russian 29.2 4811 5141 Other ethnic groups 15.5 2564 2117 Missing/DK 0.0 1 1 Mean household size 3.4 16500 16500 The weighted and unweighted total number of households is equal, since sample weights were normalized. Table HH.3 also shows the weighted mean household size estimated by the survey. There were 16,500 households interviewed, of which 9,967 households or 60.4 percent of the total number of households are in urban areas and 6,533 households or 39.6 percent of households are in rural areas. More than one third of households (36.0 percent) or every third household was headed by a woman. 55.3 percent of surveyed households are headed by persons of Kazakh ethnicity; about one-third of households are headed by persons of Russian ethnicity, and other ethnicities head 15.5 percent of households. Almost 98 percent of heads of households have an education level not lower than lower secondary education: 27.0 percent of them have higher education, almost 34 percent – technical and professional education; slightly more than 37.0 percent have lower and upper secondary education. According to the survey results, the average household size was 3.4 persons. The largest proportion of households have 2 to 4 members – almost 60.0 percent of all households: 2 members – 22.5 percent, 3 members – 18.9 and 4 members– 16.8 percent. According to the 2009 Census data, in Kazakhstan the average household size was 3.6 members; 3.2 in urban areas and 4.4 members in rural areas. Characteristics of Female Respondents Aged 15-49 Years and Children Under-5 Tables HH.4 and HH.5 provide information on the background characteristics of female respondents 15-49 years of age and of children under age 5. In these two tables, the total numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized). In addition to providing useful information on the background characteristics of women and children under age five, the tables are also intended to show the numbers of observations in each background category. These categories are used in the subsequent tabulations of this report. P a g e | 13 Table HH.4 provides background characteristics of female respondents aged 15-49 years. The table includes information on the distribution of women according to region, area, age, marital/union status, motherhood status, births in last two years, education13, wealth index quintiles14,15, and ethnicity11 of the household head. Table HH.4: Women's background characteristics Percent and frequency distribution of women aged 15-49 years by selected background characteristics, Kazakhstan, 2015 Weighted percent Number of women Weighted Unweighted Total 100.0 12670 12670 Region Akmola 4.9 624 825 Aktobe 6.4 806 686 Almaty oblast 8.2 1042 756 Atyrau 3.2 402 761 West Kazakhstan 4.5 572 725 Zhambyl 6.1 778 806 Karaganda 8.2 1035 708 13 Throughout this report, unless otherwise stated, “education” refers to highest educational level ever attended by the respondents when it is used as a background variable. 14 The wealth index is a composite indicator of wealth. To construct the wealth index, principal components analysis is performed by using information on the ownership of consumer goods, dwelling characteristics, water and sanitation, and other characteristics that are related to the household’s wealth, to generate weights (factor scores) for each of the items used. First, initial factor scores are calculated for the total sample. Then, separate factor scores are calculated for households in urban and rural areas. Finally, the urban and rural factor scores are regressed on the initial factor scores to obtain the combined, final factor scores for the total sample. This is carried out to minimize the urban bias in the wealth index values. Each household in the total sample is then assigned a wealth score based on the assets owned by that household and on the final factor scores obtained as described above. The survey household population is then ranked according to the wealth score of the household they are living in, and is finally divided into 5 equal parts (quintiles) from lowest (poorest) to highest (richest). In the 2015 Kazakhstan MICS, the following assets were used in these calculations: radio, television, non-mobile telephone, refrigerator, microwave, table, sofa, bed, wardrobe, dishwasher, washing machine, air conditioner, vacuum cleaner. In addition, the following assets were used in these calculations: mobile telephone / smartphone, bicycle, motorcycle / scooter, animal-drawn cart, car / truck, tractor, boat with motor, personal computer / laptop, tablet, as well as ownership of housing, land, livestock, herds and other farm animals or poultry, or the existence of a bank account, and electricity. 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. 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 Filmer, D and Pritchett, L. 2001. Estimating wealth effects without expenditure data – or tears: An application to educational enrolments in states of India. Demography 38(1): 115-132; Rutstein, SO and Johnson, K. 2004. The DHS Wealth Index. DHS Comparative Reports No. 6; and Rutstein, SO. 2008. The DHS Wealth Index: Approaches for Rural and Urban Areas. DHS Working Papers No. 60. 15 When describing survey results by wealth quintiles, appropriate terminology is used when referring to individual household members, such as for instance “women in the richest population quintile”, which is used interchangeably with “women in the wealthiest survey population”, “women living in households in the richest population wealth quintile”, and similar. P a g e | 14 Kostanai 5.3 675 907 Kyzylorda 3.2 399 884 Mangistau 3.2 408 829 South Kazakhstan 16.4 2079 874 Pavlodar 4.1 517 760 North Kazakhstan 2.8 351 706 East Kazakhstan 6.9 880 697 Astana city 8.6 1086 821 Almaty city 8.0 1015 925 Area Urban 56.4 7140 7810 Rural 43.6 5530 4860 Age 15-19 10.6 1346 1316 20-24 14.0 1768 1771 25-29 17.1 2161 2165 30-34 15.8 1998 1967 35-39 14.8 1870 1860 40-44 14.7 1862 1885 45-49 13.1 1665 1706 Marital/Union status Currently married/in union 65.9 8351 8297 Widowed 3.2 410 380 Divorced 7.4 937 929 Separated 2.2 282 294 Never married/in union 21.2 2690 2770 Motherhood and recent births Never gave birth 26.0 3296 3392 Ever gave birth 74.0 9374 9278 Gave birth in last two years 17.0 2157 2106 No birth in last two years 57.0 7218 7172 Education None/Primary 0.1 16 16 Lower secondary 6.1 778 778 Upper secondary 24.8 3140 2808 Technical and Professional 31.5 3990 4305 Higher 37.5 4745 4763 Wealth index quintile Poorest 18.0 2276 2178 Second 18.4 2334 2053 Middle 19.4 2464 2572 Fourth 21.4 2708 2884 Richest 22.8 2888 2983 Ethnicity of household head Kazakh 64.3 8149 8467 Russian 19.8 2506 2727 Other ethnic groups 15.9 2014 1475 Missing/DK 0.0 1 1 As shown in Table HH.4, 12,670 women aged 15-49 years were successfully interviewed. Of the total number of interviewed women, 56.4 percent live in urban areas and 43.6 percent live in rural areas. The proportion of young women in the age group 15-24 years was 24.6 percent, of which 10.6 percent were aged 15-19 years. P a g e | 15 During the survey, 65.9 percent of women were married/in union; 3.2 percent of women were widowed; 9.6 percent were divorced or separated and 21.2 percent of women were never married/in union. Of all women age 15-49 years, three quarters (74.0 percent) have ever given birth, of which 17.0 percent in the two years preceding the survey. In general, the educational level of almost all women aged 15-49 years was not lower than lower secondary education: 37.5 percent of women this age have higher education, 31.5 percent have technical and professional education, and almost 31 percent have lower or upper secondary education. 18.0 percent of women age 15-49 years are living in households in the poorest wealth index quintile, while 22.8 percent are living in the richest wealth index quintile. Of the total number of interviewed women, 64.3 percent live in households whose heads are persons of Kazakh ethnicity, 19.8 percent in households whose heads are persons of Russian ethnicity, and 15.9 percent in those whose heads are of other ethnicities. Background characteristics of children under 5 are presented in Table HH.5. These include the distribution of children by several attributes: sex, region and area, age in months, respondent type (mother or caretaker), mother’s (or caretaker’s) education, wealth, and ethnicity of the household head. According to the Table HH.5, the proportion of male and female children under-5 years was similar (50.7 and 49.3 percent, respectively). The percentages of children under 5 years range from 22.6 percent in South Kazakhstan to 2.1 percent in North Kazakhstan. 50.9 percent of children under-5 years reside in rural areas, while 49.1 percent live in urban areas. About one-fifth of children are age 0-11 months (19.4 percent), with similar proportions of children aged 12-23, 24-35, 36-47 and 48-59. The distribution of the age structure of children under 5 years correlates with the data of the official demographic statistics of Kazakhstan as of January 1, 2015: 0-11 months – 21.1 percent; 12-23 months – 20.3 percent, 24-35 months – 19.9 percent, 25-47 months – 19.5 percent, and 48-59 months – 19.2 percent. Generally, the respondents to the questionnaires about children under 5 years were mothers of those children – 97.5 percent and only 2.5 percent were other primary caretakers. Among them, the highest proportion are mothers/caretakers with higher education – 40.8 percent, 28.3 percent have technical and professional education; 30.8 percent have lower or upper secondary education. 36.0 percent of children live in households from the fourth and richest quintiles (17.5 and 18.5 percent, respectively), 20.4 percent live in the poorest households; the remaining 43.6 percent of children live in households of the second and middle wealth quintiles (22.1 and 21.5 percent, respectively). P a g e | 16 Almost 70 percent of children under 5 years of age live in households headed by persons of Kazakh ethnicity, 12.5 percent in households headed by persons of Russian ethnicity and 17.9 – by representatives of other ethnicities. The total numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized). Table HH.5: Under-5's background characteristics Percent and frequency distribution of children under five years of age by selected characteristics, Kazakhstan, 2015 Weighted percent Number of under-5 children Weighted Unweighted Total 100.0 5510 5510 Sex Male 50.7 2796 2833 Female 49.3 2714 2677 Region Akmola 4.1 225 310 Aktobe 6.8 376 321 Almaty oblast 7.5 413 309 Atyrau 3.7 202 401 West Kazakhstan 4.1 227 302 Zhambyl 7.5 414 425 Karaganda 6.9 381 274 Kostanai 4.3 239 339 Kyzylorda 3.9 214 495 Mangistau 4.1 224 474 South Kazakhstan 22.6 1246 520 Pavlodar 3.0 166 254 North Kazakhstan 2.1 117 248 East Kazakhstan 5.0 274 221 Astana city 9.1 501 312 Almaty city 5.3 292 305 Area Urban 49.1 2704 3041 Rural 50.9 2806 2469 Age 0-5 months 9.6 531 508 6-11 months 9.8 540 529 12-23 months 19.4 1071 1103 24-35 months 19.0 1045 1093 36-47 months 21.9 1208 1125 48-59 months 20.2 1114 1152 Respondent to the under-5 questionnaire Mother 97.5 5371 5387 Other primary caretaker 2.5 139 123 Mother’s educationa None/Primary 0.1 6 6 Lower secondary 5.6 311 304 Upper secondary 25.2 1386 1161 Technical and Professional 28.3 1559 1716 Higher 40.8 2248 2323 P a g e | 17 Wealth index quintile Poorest 20.4 1124 1077 Second 22.1 1218 1042 Middle 21.5 1183 1232 Fourth 17.5 966 1088 Richest 18.5 1019 1071 Ethnicity of household head Kazakh 69.7 3838 4091 Russian 12.5 687 777 Other ethnic groups 17.9 985 642 a In this table and throughout the report, mother's education refers to educational attainment of mothers as well as caretakers of children under 5, who are the respondents to the under-5 questionnaire if the mother is deceased or is living elsewhere. Housing characteristics, asset ownership, and wealth quintiles Tables HH.6, HH.7 and HH.8 provide further details on household level characteristics. HH.6 presents characteristics of housing, disaggregated by area and region, distributed by whether the dwelling has electricity, the main materials of the flooring, roof, and exterior walls, as well as the number of rooms used for sleeping. Throughout the country, all households have electricity in both urban (100 percent) and rural areas (99.9 percent), with the rare exception of individual households in rural areas in 6 regions. According to the 2009 Census in Kazakhstan, 96.9 percent of households had electricity. Two thirds of households have a finished floor, while 81.8 percent of such households are located in urban areas and 42.4 percent – in rural areas. 33.2 percent of households have a rudimentary floor, with more than 55 percent of such households in rural areas, and less than 20 percent in urban areas. More than 99 percent of households have finished roofing in both urban and rural areas; significant differences were not observed by regions. 92.8 percent of households in the country have finished exterior walls; the proportion of such households is 95.1 percent in urban areas, compared to 89.3 percent in rural areas. The mean number of persons per room used for sleeping in households is 1.8 percent, without difference between urban and rural areas (1.7 and 1.8 respectively). The data for households of the Atyrau, Kyzylorda, Mangistau, South Kazakhstan regions and Astana city is slightly higher – the mean number of persons per room is about 2 persons. The mean numbers of persons per room used for sleeping in the other regions range from 1.4 persons in East Kazakhstan to 1.8 in West Kazakhstan and the Almaty oblast. P a g e | 18 Table HH.6: Housing characteristics Percent distribution of households by selected housing characteristics, according to area of residence and regions, Kazakhstan, 2015 Total Area Region U rb a n R u ra l A km o la A kt o b e A lm a ty o b la st A ty ra u W e st K a za kh st a n Z h a m b yl K a ra g a n d a K o st a n a i K y zy lo rd a M a n g is ta u S o u th K a za kh st a n P a vl o d a r N o rt h K a za kh st a n E a st K a za kh st a n A st a n a c it y A lm a ty c it y Electricity Yes 100.0 100.0 99.9 99.9 100.0 100.0 100.0 99.7 99.9 100.0 99.9 100.0 100.0 100.0 100.0 99.9 99.9 100.0 100.0 No 0.0 0.0 0.1 0.1 0.0 0.0 0.0 0.3 0.1 0.0 0.1 0.0 0.0 0.0 0.0 0.1 0.1 0.0 0.0 Flooring Rudimentary floor 33.2 18.1 56.4 29.8 23.0 47.6 18.2 44.6 54.8 16.1 27.8 70.0 11.7 63.0 28.4 38.3 45.0 1.5 8.7 Finished floor 66.2 81.8 42.4 69.8 76.2 52.4 81.7 54.7 45.2 83.9 72.2 28.8 88.2 34.0 71.4 60.9 54.5 98.5 91.0 Other 0.6 0.2 1.2 0.4 0.3 0.0 0.1 0.7 0.0 0.0 0.0 1.2 0.0 3.0 0.1 0.8 0.4 0.0 0.2 Missing/DK 0.0 0.0 0.1 0.0 0.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.1 0.0 0.0 0.0 0.1 Roof Rudimentary roofing 0.3 0.1 0.5 0.0 0.1 0.5 0.3 0.0 0.0 0.1 0.0 0.3 0.8 1.2 0.3 0.0 0.2 0.0 0.2 Finished roofing 99.4 99.6 99.1 99.6 98.7 99.5 99.1 99.4 100.0 99.7 99.8 99.1 99.0 98.7 99.7 99.5 99.6 98.9 99.8 Other 0.3 0.3 0.4 0.3 1.1 0.0 0.6 0.6 0.0 0.2 0.2 0.6 0.0 0.1 0.0 0.5 0.2 1.1 0.0 Missing/DK 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.2 0.0 0.0 0.0 0.0 0.0 0.1 Exterior walls Rudimentary walls 1.0 0.4 2.0 0.3 1.0 3.7 2.2 2.1 1.8 0.5 0.0 0.3 0.2 1.0 1.3 0.8 0.8 0.4 0.3 Finished walls 92.8 95.1 89.3 92.6 94.8 83.5 97.7 96.6 97.7 91.6 98.0 38.5 99.6 98.8 98.4 74.2 98.2 93.1 94.7 Other 6.2 4.5 8.7 7.0 4.2 12.8 0.1 1.3 0.5 7.9 2.0 61.1 0.0 0.2 0.2 25.0 1.0 6.5 5.0 Missing/DK 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.2 0.0 0.0 0.0 0.0 0.0 0.0 Rooms used for sleeping 1 30.4 39.0 17.3 37.3 17.7 25.6 28.2 28.6 12.1 45.1 38.4 14.3 20.8 11.4 41.7 38.9 28.4 51.4 36.9 2 43.7 42.5 45.4 44.4 48.5 44.6 43.8 48.6 39.3 42.1 45.2 42.9 40.2 41.4 46.7 46.7 48.0 39.3 40.6 3 or more 25.5 18.1 36.9 17.9 33.1 29.3 27.0 22.1 48.4 12.8 16.2 42.2 38.9 47.0 11.4 14.1 23.5 9.2 21.1 Missing/DK 0.4 0.4 0.4 0.4 0.6 0.5 1.1 0.7 0.2 0.0 0.1 0.6 0.1 0.2 0.2 0.2 0.2 0.1 1.4 P a g e | 19 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 16500 9967 6533 944 983 1260 456 764 880 1614 978 402 412 2055 829 645 1523 1310 1445 Mean number of persons per room used for sleeping 1.77 1.73 1.83 1.66 1.74 1.78 2.00 1.81 1.72 1.72 1.70 2.00 1.98 2.03 1.64 1.55 1.42 2.08 1.64 P a g e | 20 Table HH.7 shows the distribution of households according to ownership of various household assets, and ownership of personal assets by individual household members. This also includes ownership of a dwelling. Almost every household in the country, both in urban and in rural areas, has a television (more than 99 percent), there are slight differences by region (98.3-99.7 percent). Some household assets, such as a table and a wardrobe are present in almost 97-98 percent of households; more than 90 percent of households have sofas and beds; a refrigerator is available in almost every household (98.2 percent), a washing machine in 88.2 percent of households, while the proportion of such households is slightly higher in urban areas 91.3 percent, compared to 83.3 percent in rural areas. Almost 80 percent of households have vacuum cleaners (85.0 percent in urban areas and 70.2 percent in rural areas); more than 60 percent of households have a microwave (74.5 percent in urban areas and 47.8 percent in rural areas). Only 15.9 percent of households have air conditioners and 3.6 percent of households have a dish washing machine. More than 70 percent of households have a landline telephone (77.8 percent in urban areas and 59.1 percent in rural areas). Ownership of a radio is not so popular in households – only 7.3 percent of households have a radio. Throughout the country, one-third (32.7 percent) of households own agricultural land and 25.1 percent of households owns farm animals/livestock or poultry. Ownership of agricultural land or farm animals/livestock is more common among households in rural areas (53.4 percent and 56.5 percent, respectively) compared to those in urban areas (19.1 percent and 4.5 percent, respectively). Among owners of agricultural land, we can see a high proportion of households in the North Kazakhstan region – 69.2 percent, while in Zhambyl, Akmola, Almaty oblast, Kostanai and East Kazakhstan more than half of the households are owners of agricultural land. Approximately 40-45 percent of households in the Akmola, West Kazakhstan, North Kazakhstan and South Kazakhstan regions are the owners of farm animals/livestock. In half of the country’s households, at least one member of a household, has a car or truck; more than 55 percent of households have personal computer or laptop, one-fourth of households (25 percent) have tablets; while in 79.0 percent of households at least one member has a bank account. In Kazakhstan, ownership of a mobile telephone and smartphone is very popular in the country, with more than 95 percent of households owning it (at least by one of household members), and with practically no difference between urban and rural households. In almost 90 percent of cases, household members are the owners of the dwelling, while there are notable differences between ownership of dwellings in urban and rural areas (83.7 and 95.9 percent, respectively). In 9.4 percent of cases, the households rent the dwelling. The lowest percentage of households whose members are owners of the dwelling was noticed in the two large metropolitan cities of the country: 61.6 percent in Astana city and 79.5 percent in Almaty city; accordingly, the proportion of households that rent the dwelling is higher in these cities (34.2 and 18.0 percent, respectively). According to the results of the 2009 Census in Kazakhstan, 91.0 percent of households are the owners of dwelling which shows that the MICS findings correlate with the Census data. P a g e | 21 Table HH.7: Household and personal assets Percentage of households by ownership of selected types of property and personal assets, and percent distribution by ownership of dwelling, according to area of residence and regions, Kazakhstan, 2015 Total Area Region Urban Rural Akmola Aktobe Almaty oblast Atyrau West Kazakhstan Zhambyl Karaganda Percentage of households that own a Radio 7.3 7.4 7.2 7.9 6.5 3.4 15.8 11.9 7.6 1.2 Television 99.3 99.2 99.3 98.5 99.6 99.7 99.6 98.6 99.0 98.8 Non-mobile telephone 70.4 77.8 59.1 82.2 83.0 60.1 84.2 58.6 44.1 79.9 Refrigerator 98.2 99.1 96.9 96.2 99.0 98.8 98.4 97.0 96.4 98.7 Microwave 63.9 74.5 47.8 56.8 62.4 57.0 61.0 48.9 47.5 70.2 Table 98.4 99.1 97.3 99.7 99.3 99.9 94.3 93.6 99.5 99.8 Sofa 92.1 93.3 90.3 98.3 89.7 97.6 73.0 88.7 94.3 97.7 Bed 91.1 90.0 92.8 95.7 81.2 97.0 59.9 95.1 96.2 96.8 Wardrobe 97.9 98.1 97.5 98.6 97.5 98.8 97.4 97.6 98.0 98.0 Dishwasher 3.6 5.2 1.1 0.9 1.1 2.5 2.2 1.3 2.0 3.1 Washing machine 88.2 91.3 83.3 92.7 83.4 86.6 84.7 79.5 85.0 91.3 Air conditioner 15.9 20.7 8.7 1.0 14.6 5.9 75.3 17.1 9.2 9.7 Vacuum cleaner 79.2 85.0 70.2 77.5 80.8 79.8 81.5 76.7 73.2 84.2 Percentage of households that own Agricultural land 32.7 19.1 53.4 54.8 21.5 54.1 5.7 25.5 58.1 35.1 Farm animals/Livestock 25.1 4.5 56.5 38.5 34.3 27.5 18.8 37.3 34.1 14.5 Percentage of households where at least one member owns or has a Mobile telephone or smartphone 96.6 96.5 96.7 94.9 97.7 98.7 99.6 95.6 97.3 93.7 Bicycle 18.9 14.6 25.3 32.4 9.7 11.7 13.1 33.7 20.8 19.4 Motorcycle or scooter 2.9 1.4 5.1 5.5 2.8 1.2 2.2 3.0 2.3 3.1 Animal-drawn cart 2.1 0.2 5.0 2.7 0.9 4.0 0.9 3.4 1.5 0.2 Car or truck 50.0 48.0 53.0 44.7 48.6 52.7 46.8 42.0 49.4 43.1 Tractor 2.9 0.3 6.9 4.5 4.6 2.5 2.6 4.7 2.5 3.4 Boat with a motor 0.3 0.3 0.2 0.0 0.1 0.5 0.2 0.1 0.0 0.0 Personal computer or laptop 55.8 62.6 45.5 56.4 50.1 50.7 65.1 47.6 48.1 63.8 Tablet 25.3 30.4 17.5 23.3 22.5 24.9 28.7 23.5 17.4 33.7 P a g e | 22 Bank account 79.0 84.6 70.4 71.8 89.1 65.9 86.5 62.5 77.4 72.9 Ownership of dwelling Owned by a household member 88.6 83.7 95.9 90.2 92.8 94.5 88.8 91.4 90.0 92.4 Not owned 11.4 16.2 4.0 9.8 6.7 5.5 11.1 8.5 10.0 7.5 Rented 9.4 13.6 3.0 5.9 6.7 5.3 8.2 7.4 7.7 5.3 Other 1.9 2.6 0.9 3.9 0.0 0.2 2.9 1.1 2.3 2.2 Missing/DK 0.1 0.0 0.1 0.0 0.5 0.0 0.1 0.1 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 16500 9967 6533 944 983 1260 456 764 880 1614 Continuation of Table HH.7 Region (continuation) Kostanai Kyzylorda Mangistau South Kazakhstan Pavlodar North Kazakhstan East Kazakhstan Astana city Almaty city Percentage of households that own a Radio 13.6 4.2 6.8 9.3 12.5 0.1 4.9 7.3 9.0 Television 99.2 99.3 99.6 99.7 99.1 98.3 99.0 99.6 99.7 Non-mobile telephone 84.2 57.7 71.8 35.5 84.9 83.7 75.7 72.4 92.0 Refrigerator 98.0 97.0 99.5 97.3 99.0 97.3 98.9 98.6 99.8 Microwave 65.1 48.3 79.8 50.0 74.7 54.2 59.8 87.3 87.5 Table 99.9 85.4 91.7 96.2 99.8 100.0 100.0 100.0 99.9 Sofa 97.2 71.2 72.4 82.8 98.8 98.4 97.6 87.1 98.8 Bed 94.5 72.4 81.3 88.7 98.6 95.0 96.7 85.2 90.9 Wardrobe 99.0 93.9 96.7 95.8 99.3 99.5 98.3 97.0 99.4 Dishwasher 3.9 0.8 3.3 0.9 1.7 2.0 2.0 11.8 11.7 Washing machine 95.3 72.7 89.8 78.4 91.4 95.3 89.3 93.7 95.4 Air conditioner 9.1 26.4 86.9 13.2 14.8 2.6 6.9 18.9 25.9 Vacuum cleaner 85.3 56.7 82.1 61.9 82.0 81.2 81.9 84.2 93.1 Percentage of households that own Agricultural land 54.1 7.5 1.9 20.6 38.1 69.2 51.2 4.0 6.7 Farm animals/Livestock 28.5 34.3 16.8 45.5 15.2 44.0 20.5 0.8 2.6 Percentage of households where at least one member owns or has a P a g e | 23 Mobile telephone or smartphone 94.1 99.0 99.0 99.1 94.0 92.8 93.4 98.8 98.5 Bicycle 32.0 17.4 9.8 17.2 24.1 27.2 16.8 10.3 14.6 Motorcycle or scooter 4.3 4.4 2.2 0.8 2.6 8.2 4.4 0.4 2.8 Animal-drawn cart 1.0 1.9 0.1 4.8 1.6 5.5 3.1 0.1 0.2 Car or truck 48.2 44.2 60.2 60.3 41.0 45.4 44.3 52.8 61.5 Tractor 2.8 1.7 0.8 3.1 3.0 8.1 3.6 0.3 0.1 Boat with a motor 0.8 0.5 0.4 0.0 0.4 0.7 0.9 0.1 0.2 Personal computer or laptop 68.2 47.3 70.5 36.3 60.3 57.6 59.0 60.0 68.2 Tablet 31.1 16.6 35.2 9.7 23.2 19.7 24.3 40.0 33.2 Bank account 76.9 77.3 95.7 86.8 81.3 67.7 68.1 90.7 92.7 Ownership of dwelling Owned by a household member 91.1 95.2 92.0 93.4 92.0 91.5 91.2 61.6 79.5 Not owned 8.9 4.8 8.0 6.6 8.0 8.4 8.7 38.4 20.4 Rented 7.7 4.4 6.6 5.8 7.3 5.0 5.3 34.2 18.0 Other 1.2 0.4 1.3 0.8 0.7 3.5 3.3 4.2 2.4 Missing/DK 0.0 0.0 0.0 0.0 0.0 0.1 0.1 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 978 402 412 2055 829 645 1523 1310 1445 P a g e | 24 Table HH.8 shows how the household populations in urban/rural areas and regions are distributed according to household wealth quintiles. Analysing the table, we can see a differentiation of households by wealth index quintiles across regions, and by urban and rural areas. More than one third (36.8 percent) of households in rural areas belong to the poorest wealth quintile in comparison with 5.2 percent of households in urban areas, and conversely, 36.2 percent of households in urban areas belong to the richest wealth quintile, compared to 1.6 percent of households in rural areas. The highest proportion of households of the poorest wealth quintile lives in the North Kazakhstan region (41.7 percent), and about 30 percent of households in the South Kazakhstan, Kyzylorda and West Kazakhstan regions. The lowest proportion of households of the poorest wealth quintile lives in the Almaty and Astana cities (1.5 and 1.8 percent, respectively), while more than half of households (51.5 percent) in Astana city belong to the richest wealth quintile. Table HH.8: Wealth quintiles Percent distribution of the household population by wealth index quintile, according to area of residence, regions, sex, education and ethnicity of household head, Kazakhstan, 2015 Wealth index quintile Total Number of household members Poorest Second Middle Fourth Richest Total 20.0 20.0 20.0 20.0 20.0 100.0 56803 Sex of household head Male 20.6 21.8 20.2 18.2 19.1 100.0 40279 Female 18.4 15.6 19.5 24.3 22.2 100.0 16525 Area Urban 5.2 7.4 19.1 32.1 36.2 100.0 30222 Rural 36.8 34.3 21.0 6.3 1.6 100.0 26582 Region Akmola 26.5 21.7 28.7 19.4 3.8 100.0 2796 Aktobe 8.0 19.8 29.4 19.4 23.4 100.0 3580 Almaty oblast 23.8 24.8 26.2 20.9 4.3 100.0 4679 Atyrau 5.7 14.9 32.1 25.2 22.2 100.0 1849 West Kazakhstan 30.0 19.8 20.9 19.3 10.0 100.0 2591 Zhambyl 27.7 28.8 22.6 10.9 10.0 100.0 3647 Karaganda 9.4 11.4 18.1 25.5 35.6 100.0 4630 Kostanai 22.2 11.4 14.2 20.2 32.1 100.0 2903 Kyzylorda 31.8 30.6 24.7 8.0 4.8 100.0 1893 Mangistau 8.1 19.6 28.4 10.2 33.7 100.0 1841 South Kazakhstan 32.8 38.9 17.9 7.4 3.1 100.0 9964 Pavlodar 14.4 13.8 8.9 19.1 43.9 100.0 2274 North Kazakhstan 41.7 18.6 11.9 23.9 3.8 100.0 1721 East Kazakhstan 25.5 13.3 19.6 21.0 20.6 100.0 4117 Astana city 1.8 1.8 5.4 39.4 51.5 100.0 4047 Almaty city 1.5 2.7 20.5 38.2 37.1 100.0 4271 Education of household head None/Primary 43.0 23.9 16.2 11.8 5.1 100.0 1135 Lower secondary 33.8 28.1 19.4 11.4 7.3 100.0 5704 Upper secondary 31.5 25.7 21.6 12.1 9.0 100.0 17668 Technical and Professional 15.4 18.4 21.6 22.9 21.6 100.0 18200 P a g e | 25 Higher 3.8 11.1 16.5 30.4 38.1 100.0 14030 Missing/DK (41.4) (42.3) (16.4) (0.0) (0.0) 100.0 66 Ethnicity of household head Kazakh 22.3 20.3 19.6 18.6 19.2 100.0 35426 Russian 12.2 10.4 19.6 29.3 28.5 100.0 11904 Other ethnic groups 21.3 31.0 21.8 13.5 12.4 100.0 9472 Missing/DK (*) (*) (*) (*) (*) 100.0 1 ( ) Figures that are based on 25–49 unweighted cases. (*) Figures that are based on fewer than 25 unweighted cases. The information presented on the distribution of households by wealth index quintiles is an indirect assessment and does not provide information on actual income and expenditures of households, as the MICS questionnaires are not intended to collect information on income and expenditures of households from any sources. P a g e | 26 IV. Nutrition Low Birth Weight Weight at birth is a good 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 development. Low birth weight (defined as 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 days, months and years. The children who survive with low birth weight may face problems with immune system function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, to the end of their lives, such children suffer a higher incidence of diabetes and heart disease in later life. Children born with low birth weight also risk a lower IQ and cognitive abilities, affecting their performance 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 mother's poor nutritional status before conception, short stature (due mostly to undernutrition and infections during her childhood), and poor nutrition during pregnancy. Inadequate weight gain during pregnancy is particularly important since it accounts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected while pregnant. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, children born to teenagers who give birth when their own physical development is not yet completed, run a higher risk of bearing low birth weight babies. As many infants are not weighed at birth and those who are weighed may present a distorted sample of all births, the reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births weighing below 2500 grams is estimated from two items in the questionnaire: the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, 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 birth.16 Overall, in Kazakhstan, 98.7 percent of newborn children were weighed at birth; 4.5 percent of infants are estimated to weigh less than 2,500 grams at birth (Table NU.1). There is slight regional variation in prevalence of low birth weight: from 2.7 percent in the Mangistau region to 7.2 percent in the Pavlodar region. There are no notable variations by other background characteristics. 16 For a detailed description of the methodology, see Boerma, JT et al. 1996. Data on Birth Weight in Developing Countries: Can Surveys Help? Bulletin of the World Health Organization 74(2): 209-16. P a g e | 27 Table NU.1: Low birth weight infants Percentage of last live-born children in the last two years that are estimated to have weighed below 2,500 grams at birth and percentage of live births weighed at birth, Kazakhstan, 2015 Percent distribution of births by mother's assessment of size at birth Total Percentage of live births: Number of last live-born children in the last two years Very small Smaller than average Average Larger than average or very large DK Below 2,500 grams1 Weighed at birth2 Total 2.4 8.4 72.0 16.7 0.6 100.0 4.5 98.7 2157 Mother's age at birth Less than 20 years 6.1 10.6 66.7 16.0 0.7 100.0 7.7 97.7 98 20-34 years 2.2 8.1 73.1 16.1 0.5 100.0 4.3 98.8 1789 35-49 years 2.2 9.1 66.6 21.1 0.9 100.0 4.5 98.1 270 Birth order 1 1.8 11.9 71.8 14.0 0.5 100.0 5.0 98.8 686 2-3 2.8 7.3 73.8 15.6 0.5 100.0 4.6 98.6 1112 4-5 2.8 4.7 67.0 24.7 0.8 100.0 3.8 98.9 296 6+ 0.0 5.6 65.0 27.2 2.2 100.0 2.1 97.8 62 Region Akmola 1.7 8.7 75.3 12.9 1.4 100.0 4.1 99.3 93 Aktobe 5.1 8.7 67.8 18.5 0.0 100.0 6.4 99.3 145 Almaty oblast 1.6 11.0 72.5 14.9 0.0 100.0 4.6 99.5 188 Atyrau 2.9 4.9 63.9 25.9 2.4 100.0 4.0 95.2 85 West Kazakhstan 1.5 10.5 69.6 18.4 0.0 100.0 4.3 100.0 100 Zhambyl 5.0 9.5 66.6 18.3 0.6 100.0 6.6 98.8 165 Karaganda 2.0 6.5 71.7 19.9 0.0 100.0 3.7 99.1 139 Kostanai 0.8 11.7 64.4 23.1 0.0 100.0 4.1 100.0 82 Kyzylorda 3.5 5.8 64.4 24.4 1.8 100.0 4.6 96.5 83 Mangistau 1.0 4.7 74.3 18.7 1.3 100.0 2.7 98.3 101 South Kazakhstan 2.6 6.9 74.9 15.0 0.6 100.0 4.3 98.3 474 Pavlodar 4.3 13.2 65.2 15.2 2.1 100.0 7.2 95.8 67 North Kazakhstan 5.0 3.3 75.3 16.5 0.0 100.0 5.1 100.0 44 East Kazakhstan 1.2 12.4 76.5 8.7 1.2 100.0 4.7 98.8 100 Astana city 0.0 9.2 74.7 16.2 0.0 100.0 3.0 100.0 195 P a g e | 28 Almaty city 2.0 7.3 82.3 8.4 0.0 100.0 4.0 98.4 97 Area Urban 1.3 8.9 72.2 17.1 0.6 100.0 3.8 98.5 1076 Rural 3.5 7.8 71.7 16.3 0.6 100.0 5.2 98.9 1081 Mother’s education None/Primary (*) (*) (*) (*) (*) 100.0 (*) (*) 2 Lower secondary 4.0 14.1 63.1 17.4 1.4 100.0 7.1 98.6 97 Upper secondary 3.8 7.1 75.1 13.7 0.3 100.0 5.2 99.2 518 Technical and Professional 2.7 8.3 69.2 19.1 0.7 100.0 4.7 98.6 660 Higher 1.2 8.5 73.1 16.6 0.6 100.0 3.7 98.5 879 Wealth index quintile Poorest 3.3 9.5 71.9 14.9 0.3 100.0 5.5 99.5 415 Second 5.0 8.6 72.2 13.3 0.9 100.0 6.5 98.2 457 Middle 0.9 8.1 72.2 18.5 0.2 100.0 3.4 98.6 502 Fourth 1.0 8.6 69.6 19.7 1.1 100.0 3.6 98.2 422 Richest 1.7 6.8 74.1 17.0 0.3 100.0 3.6 99.1 360 Ethnicity of household head Kazakh 2.4 8.5 70.7 17.7 0.7 100.0 4.5 98.5 1520 Russian 1.1 7.1 72.8 18.7 0.3 100.0 3.2 98.7 261 Other ethnic groups 3.5 8.6 76.3 11.1 0.5 100.0 5.4 99.3 375 1 MICS indicator 2.20 - Low-birthweight infants 2 MICS indicator 2.21 - Infants weighed at birth (*) Figures that are based on fewer than 25 unweighted cases. P a g e | 29 Nutritional Status Children’s nutritional status is a reflection of their overall health. When children have access to food that is adequate in quantity and balanced in composition, they are not exposed to chronic illness, and if they are well cared for, children reach their growth potential and are considered well-nourished and fully developed. Undernutrition is associated with more than half of all child deaths worldwide. Undernourished children are more likely to die at an early age from common childhood ailments, and for those who survive, it is common to have chronic illness and faltering growth. Three-quarters of the children who die from causes related to malnutrition were only mildly or moderately malnourished – showing no outward sign of their vulnerability. For a population not suffering from nutrition problems, there are reference rates of weight and height for children under age five. Undernourishment in a population can be gauged by comparing children to a reference population. The reference population used in this report is based on the WHO height and weight growth standards17. Each of the three nutritional status indicators – weight-for-age, height-for-age, and weight-for-height – 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 considered 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 growth. 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 because of failure to receive adequate nutrition over a long period and recurrent or chronic illness. Weight-for-height can be used to assess wasting and overweight status. 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 classified as severely wasted. Usually wasting is the result of a recent nutritional deficiency. The indicator of wasting may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. Children whose weight-for-height is more than two standard deviations above the median reference population are classified as moderately or severely overweight. 17 http://www.who.int/childgrowth/standards/technical_report. http://www.who.int/childgrowth/standards/technical_report P a g e | 30 In MICS, weights and heights of all children under 5 years of age were measured using the anthropometric equipment recommended18 by UNICEF. Findings in this section are based on the results of these measurements. Table NU.2 shows percentages of children classified into each of the above described categories, based on the anthropometric measurements that were taken during fieldwork. Additionally, the table includes mean z-scores for all three anthropometric indicators. In the 2015 Kazakhstan MICS, there were no cases of children whose birth date (month and year) was not obtained (Table DQ.6), while children whose measurements are outside a plausible range are excluded from Table NU.2. Children are excluded from one or more anthropometric indicators if one of the parameters – their weights and heights – have not been measured, whichever applicable. For example, if a child has been weighed but his/her height/length has not been measured, this child is included in underweight calculations, but is excluded from the calculations for stunting and wasting. Percentages of children (by age and reasons for exclusion by region) are shown in Appendix D in data quality Tables: DQ.10, DQ.11, and DQ.12. The tables show that due to implausible measurement results and/or missing data on weight and/or height, 3.7 percent of children under 5 years were excluded from calculations of the weight-for-age indicator, 4.2 percent of children – from the height- for-age indicator, and 5.3 percent of children – from the weight-for-height indicator. The measurement results of infants under 6 months were more frequently excluded from the weight- for-age indicator (13.2 percent) and from the height-for-age and weight-for-height (14.3 percent) indicators. The main reason for the lack of anthropometric measurements of infants under 6 months (especially newborns), as well as children aged 6-23 months (under 2 years old) is the parents’ refusal of measurements because of fear the child will get cold; while for newborns, the statement that the weight and height of these children at birth were measured in health facilities before the survey. It may be noted that some regions where the anthropometric measurements were lacking in quite a large proportion of children under 5 years, and children are excluded from the analysis of all three indicators of evaluation of nutritional status. In the Mangistau region, the weight and height/length were not measured for 34.5 percent of infants under 6 months, 22.2 percent – 6-11 months, 10.0 percent – 12-23 months, 7.6 percent – 24-35 months, 5.0 percent – 36-47 months and 6.2 percent – at the age of 48-59 months, respectively. Also, it may be noted that the Almaty oblast, as well as the Almaty and Astana cities, demonstrate a quite high percent of exceptions from analysis of the percentage of children in different age groups (in months) due to lack of measurements of weight and height of children under 5 years or unreliable measurement results (Table DQ.10-DQ.12). In some cases, the measurements were not carried out due to the temporary absence of children under 5 years old in the household or illness at the time of the survey. Although there is no evidence of heaping on age or out-transference of children under-5 that would to some extent affect the representativeness of the anthropometric results (Tables DQ.3 and DQ.6), Table DQ.13 shows that for every fifth measured child, the values of the weight (13.0 percent) and height (11.3 percent) measurements completed with “0” or “5”, indicating potential avoidance of rounding of measurements to these decimal digits. 18 See MICS Supply Procurement Instructions: http://mics.unicef.org/tools. http://mics.unicef.org/tools P a g e | 31 Table NU.2: Nutritional status of children Percentage of children under age 5 by nutritional status according to three anthropometric indices: weight for age, height for age, and weight for height, Kazakhstan, 2015 Weight for age Number of children under age 5 Height for age Number of children under age 5 Weight for height Number of children under age 5 Underweight Mean Z- Score (SD) Stunted Mean Z- Score (SD) Wasted Overweight Mean Z- Score (SD) Percent below Percent below Percent below Percent below - 2 S D 1 - 3 S D 2 - 2 S D 3 - 3 S D 4 - 2 S D 5 - 3 S D 6 + 2 S D 7 Total 2.0 0.3 0.3 5304 8.0 2.4 0.0 5277 3.1 1.1 9.3 0.5 5218 Sex Male 1.9 0.2 0.4 2691 7.7 2.3 0.1 2682 2.9 1.1 8.7 0.5 2645 Female 2.0 0.3 0.3 2613 8.3 2.6 -0.1 2595 3.3 1.0 10.0 0.5 2573 Region Akmola 1.1 0.0 0.4 223 2.9 0.1 -0.1 223 1.4 0.2 4.9 0.6 223 Aktobe 3.1 0.6 0.7 368 6.6 4.1 0.7 370 6.3 2.5 10.3 0.4 366 Almaty oblast 2.8 0.0 0.0 368 8.1 2.3 -0.3 370 4.4 1.2 6.3 0.3 365 Atyrau 3.6 0.8 0.3 198 11.8 4.2 -0.2 193 5.9 3.6 14.7 0.5 195 West Kazakhstan 1.4 0.9 0.3 223 7.4 2.5 -0.1 222 1.5 1.2 8.0 0.5 220 Zhambyl 3.0 0.8 0.0 408 6.9 2.5 -0.2 408 3.2 0.9 6.1 0.2 408 Karaganda 1.5 0.0 0.3 351 5.4 0.0 0.1 351 1.6 0.0 6.4 0.4 351 Kostanai 0.9 0.2 0.3 233 11.4 3.3 0.0 233 4.2 1.1 12.5 0.5 228 Kyzylorda 1.0 0.2 0.2 213 10.0 3.3 -0.3 211 2.1 0.7 8.6 0.4 208 Mangistau 1.8 0.4 0.6 195 4.5 2.0 0.6 191 3.4 1.0 4.9 0.3 186 South Kazakhstan 2.2 0.2 0.2 1231 11.4 2.4 -0.3 1220 2.9 0.9 7.6 0.5 1223 Pavlodar 0.8 0.0 0.3 165 5.5 1.6 0.0 165 5.5 2.4 9.7 0.4 162 North Kazakhstan 0.8 0.4 0.2 115 2.3 0.0 0.0 113 1.6 0.0 5.6 0.3 113 East Kazakhstan 1.9 0.0 0.2 271 7.2 2.2 -0.3 271 1.9 0.9 9.2 0.5 269 Astana city 1.1 0.0 0.9 479 7.1 3.5 0.4 473 1.3 0.3 16.2 0.9 452 Almaty city 1.3 0.0 0.9 264 6.3 2.7 0.8 264 3.5 1.4 21.6 0.7 249 Area P a g e | 32 Urban 1.5 0.2 0.5 2573 7.2 2.3 0.2 2561 3.1 1.3 11.2 0.5 2510 Rural 2.4 0.3 0.2 2731 8.9 2.5 -0.1 2716 3.1 0.8 7.6 0.4 2709 Age 0-5 months 4.9 0.7 0.3 461 5.0 1.9 0.6 456 13.7 4.9 5.8 -0.1 455 6-11 months 1.3 0.1 0.5 516 5.8 1.6 0.3 513 2.8 1.0 12.5 0.5 518 12-17 months 1.5 0.3 0.7 531 6.8 3.2 0.2 524 1.7 0.8 15.1 0.8 529 18-23 months 1.1 0.0 0.4 508 11.0 5.0 0.0 504 3.5 0.9 10.1 0.6 505 24-35 months 1.4 0.2 0.4 1022 11.5 3.0 -0.1 1019 1.8 0.9 10.5 0.6 1012 36-47 months 2.9 0.3 0.3 1186 8.4 2.0 -0.1 1181 1.7 0.2 8.0 0.5 1167 48-59 months 1.2 0.3 0.1 1080 6.0 1.4 -0.2 1081 1.9 0.7 6.5 0.3 1032 Mother’s education None/Primary (*) (*) (*) 6 (*) (*) (*) 6 (*) (*) (*) (*) 6 Lower secondary 4.1 0.5 0.0 306 6.9 2.5 -0.4 299 4.7 3.4 4.0 0.2 301 Upper secondary 2.1 0.1 0.3 1351 9.3 2.8 -0.2 1343 2.9 1.0 8.9 0.5 1331 Technical and Professional 2.4 0.5 0.3 1501 9.2 2.5 0.0 1494 4.0 1.2 9.1 0.4 1483 Higher 1.3 0.2 0.5 2140 6.6 2.2 0.2 2134 2.3 0.7 10.6 0.5 2098 Wealth index quintile Poorest 3.2 0.4 0.1 1108 10.3 2.4 -0.4 1101 3.0 0.7 7.7 0.4 1097 Second 1.7 0.3 0.2 1191 8.1 2.9 -0.1 1184 2.9 0.9 7.0 0.4 1177 Middle 1.7 0.2 0.4 1122 8.3 2.3 0.1 1117 3.8 1.7 8.9 0.4 1108 Fourth 2.0 0.3 0.4 918 6.9 1.9 0.2 914 2.9 1.0 11.6 0.5 904 Richest 1.2 0.2 0.6 965 6.2 2.5 0.4 960 2.9 1.0 12.5 0.6 934 Ethnicity of household head Kazakh 2.1 0.3 0.4 3684 7.7 2.6 0.0 3670 3.0 1.1 10.2 0.5 3628 Russian 1.4 0.1 0.4 654 6.9 2.2 0.2 649 3.9 0.5 9.0 0.4 634 Other ethnic groups 1.6 0.1 0.2 966 9.9 2.0 -0.1 958 2.8 1.1 6.3 0.4 956 1 MICS indicator 2.1a and MDG indicator 1.8 - Underweight prevalence (moderate and severe) 2 MICS indicator 2.1b - Underweight prevalence (severe) 3 MICS indicator 2.2a - Stunting prevalence (moderate and severe) 4 MICS indicator 2.2b - Stunting prevalence (severe) 5 MICS indicator 2.3a - Wasting prevalence (moderate and severe) 6 MICS indicator 2.3b - Wasting prevalence (severe) 7 MICS indicator 2.4 - Overweight prevalence (*) Figures that are based on fewer than 25 unweighted cases. P a g e | 33 In Kazakhstan, 2.0 percent of children under age five are underweight (Table NU.2). However, 8.0 percent of children are stunted and 3.1 percent of children are wasted for their height. In addition, 9.3 percent of children are overweight. In country, stunting of children is more prevalent than underweight. The indicator range by region varies from 2.3 percent in the North Kazakhstan region to 11.8 percent in the Atyrau region. Those children whose mothers have higher education face the least likely to be underweight and stunted, and at the same time, the highest probability to be overweight compared to children of mothers with lower education levels. In urban areas, children are more likely to be overweight than in rural areas. The age pattern shows that the youngest, namely those <6 months of age, have the highest rates of underweight and wasting, however this might in part be due to larger proportion of children exlduded from the analysis due to missing weights (Figure NU.1). The prevalence of overweight is higher among children aged 12-17 months. F igure NU.1: Under weight , s tunted, wast ed and over weight ch i ldren under age 5 (moderat e and sever e) , Kazakhstan, 2015 Breastfeeding and Infant and Young Child Feeding Proper feeding of infants and young children can increase their chances of survival; it can also promote optimal growth and development, especially in the critical period from birth to 2 years of age. Breastfeeding in the first days of life protects children from infection, provides an ideal source of P a g e | 34 nutrients, and breastfeeding as well as being an economical and safe method of the feeding. Still some mothers do not start to breastfeed newborns immediately after birth, do not breastfeed exclusively for the first 6 months, or stop breastfeeding too soon. For various reasons, mothers switch to infant formula, which sometimes lacks in micornutrients and can lead to growth faltering. In addition, such food can be unsafe if hygienic conditions are not followed, or safe drinking water is absent or is not always available in the household. Studies have shown that, continued breastfeeding along with complementary feeding to the child from 6 months with age-appropriate nutritious and safe solid, semi-solid and soft foods, are the key to a better health and proper development of the child, and makes it possible to eliminate or reduce stunting during the first two years of life.19 UNICEF and WHO recommend that infants be breastfed within one hour of birth, breastfed exclusively for the first six months of life and continue to be breastfed up to 2 years of age and beyond.20 Starting at 6 months, breastfeeding can be combined with safe, age-appropriate feeding of solid, semi-solid and soft foods.21 A summary of key guiding principles22, 23 for feeding 6-23 month olds is provided below (Box NU.1) along with proximate measures for these guidelines collected in this survey. Box NU.1 Guiding Principle (age 6-23 months) Proximate measures Table Continue frequent, on-demand breastfeeding for two years and beyond Breastfed in the last 24 hours NU.4 Appropriate frequency and energy density of meals Breastfed children Depending on age, two or three meals/snacks provided in the last 24 hours Non-breastfed children Four meals/snacks and/or milk feeds provided in the last 24 hours NU.6 Appropriate nutrient content and micronutrient in food Four food groups24 eaten in the last 24 hours NU.6 Appropriate amount of food No standard indicator exists na Appropriate consistency of food No standard indicator exists na Use of vitamin-mineral supplements or fortified products for infant and mother No standard indicator exists na Practice good hygiene and proper food handling While it was not possible to develop indicators to fully capture programme guidance, one standard indicator does cover part of the principle: Not feeding with a bottle with a nipple NU.9 Practice responsive feeding, applying the principles of psycho-social care No standard indicator exists na The guiding principles for which proximate measures and indicators exist are: (i) continued breastfeeding; (ii) appropriate frequency of meals (but not energy density); and 19 Bhuta, Z. et al. 2013. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? The Lancet June 6, 2013. 20 WHO. 2003. Implementing the Global Strategy for Infant and Young Child Feeding. Meeting Report Geneva, 3-5 February, 2003. 21 WHO. 2003. Global Strategy for Infant and Young Child Feeding. 22 PAHO. 2003. Guiding principles for complementary feeding of the breastfed child. 23 WHO. 2005. Guiding principles for feeding non-breastfed children 6-24 months of age. 24 Food groups used for assessment of this indicator are 1) Grains, roots and tubers, 2) legumes and nuts, 3) dairy products (milk, yogurt, cheese), 4) flesh foods (meat, fish, poultry and liver/organ meats), 5) eggs, 6) vitamin-A rich fruits and vegetables, and 7) other fruits and vegetables. P a g e | 35 (iii) appropriate nutrient content of food. Feeding frequency is used as proxy measure for energy intake, requiring children to receive a minimum number of meals/snacks (and milk feeds and milk products for non-breastfed children) for their age. Dietary diversity is used to ascertain the adequacy of the nutrient content of the food (not including iron) consumed. For dietary diversity, seven food groups were created for which a child consuming at least four of these is considered to have a nutritious food. In most populations, consumption of at least four food groups means that the child has a high likelihood of consuming at least one animal-source food and at least one fruit or vegetable, in addition to a staple food (grain, root or tuber).25 These three dimensions of child feeding are combined into an assessment of the children who received appropriate feeding, using the indicator of “minimum acceptable diet”. To have a minimum acceptable diet in the previous day, a child must have received: (i) the appropriate number of meals/snacks/milk feeds and milk products; (ii) food items from at least 4 food groups; and (iii) breastmilk or at least 2 milk feeds (for non-breastfed children). Table NU.3: Initial breastfeeding Percentage of last live-born children in the last two years who were ever breastfed, breastfed within one hour of birth, and within one day of birth, and percentage who received a prelacteal feed, Kazakhstan, 2015 Percentage who were ever breastfed1 Percentage who were first breastfed: Percentage who received a prelacteal feed Number of last live- born children in the last two years Within one hour of birth2 Within one day of birth Total 97.1 83.3 92.8 13.7 2157 Region Akmola 96.6 77.7 93.2 11.9 93 Aktobe 97.2 76.0 95.7 8.4 145 Almaty oblast 98.5 76.9 89.3 8.1 188 Atyrau 96.1 70.1 90.3 16.3 85 West Kazakhstan 97.7 78.1 96.4 12.7 100 Zhambyl 97.7 88.6 94.5 6.9 165 Karaganda 98.8 84.8 95.0 22.7 139 Kostanai 96.5 74.8 82.6 39.4 82 Kyzylorda 96.4 83.5 91.5 9.1 83 Mangistau 98.7 87.1 93.5 15.3 101 South Kazakhstan 94.9 87.3 91.4 14.6 474 Pavlodar 95.9 75.1 89.9 21.7 67 North Kazakhstan 98.1 81.5 93.9 17.6 44 East Kazakhstan 95.3 89.6 92.0 11.7 100 Astana city 100.0 88.0 98.7 9.3 195 Almaty city 98.2 91.1 94.1 12.1 97 Area Urban 97.8 83.0 93.1 13.6 1076 Rural 96.4 83.6 92.6 13.9 1081 Months since last birth 25 WHO. 2008. Indicators for assessing infant and young child feeding practices. Part 1: Definitions. P a g e | 36 0-11 months 97.1 83.4 93.0 15.1 1094 12-23 months 97.1 83.2 92.6 12.3 1063 Assistance at delivery Skilled attendant 97.6 83.7 93.3 13.8 2144 Other (*) (*) (*) (*) 1 No one/Missing (*) (*) (*) (*) 12 Place of delivery Home (*) (*) (*) (*) 2 Health facility 97.6 83.8 93.4 13.8 2142 Public 97.6 83.7 93.3 13.7 2133 Private (*) (*) (*) (*) 9 Other/DK/Missing (*) (*) (*) (*) 12 Mother’s education None/Primary (*) (*) (*) (*) 2 Lower secondary 95.3 79.5 88.0 15.4 97 Upper secondary 94.8 83.7 90.0 17.3 518 Technical and Professional 97.6 81.8 92.9 14.2 660 Higher 98.3 84.6 95.0 11.1 879 Wealth index quintile Poorest 97.4 85.7 94.5 14.3 415 Second 94.6 84.6 90.8 14.7 457 Middle 98.7 81.5 93.9 11.2 502 Fourth 97.3 79.6 91.8 13.1 422 Richest 97.5 85.7 93.1 16.0 360 Ethnicity of household head Kazakh 98.1 84.1 94.1 12.2 1520 Russian 95.0 76.7 89.6 15.8 261 Other ethnic groups 94.3 84.8 90.0 18.4 375 1 MICS indicator 2.5 - Children ever breastfed 2 MICS indicator 2.6 - Early initiation of breastfeeding (*) Figures that are based on fewer than 25 unweighted cases. Table NU.3 is based on mothers’ reports of what their last-born child, born in the last two years, was fed in the first few days of life. It indicates the proportion who were ever breastfed, those who were first breastfed within one hour and one day (24 hours) of birth, and those who received a prelacteal feed.26 During recent years in Kazakhstan, the percentage of mothers who understand the critical importance of early breastfeeding and the establishment of a physical and emotional relationship between the baby and the mother increases; nevertheless only 83.3 percent of babies are breastfed for the first time within one hour of birth, and 92.8 percent of infants are breastfed within one day of birth. The findings are presented in Figure NU.2 by region and urban and rural areas. Differences in urban and rural areas are not observed; the indicator range by regions varies from 70.1 percent in Atyrau region to 91.1 percent in Almaty city. More than 90 percent of mothers breastfeed the newborns within one day of birth in almost all regions of the country. 26 Prelacteal feed refers to the provision of any liquid or food, other than breastmilk, to a newborn during the period when breastmilk flow is generally being established (estimated here as the first 3 days of life). P a g e | 37 Figure NU.2: In i t iat ion of breastfeeding, Kazakhstan, 2015 The Infant and Young Child Feeding indicators reported in tables NU.4 through NU.8 are based on the mother’s report of consumption of food and different fluids during the day or night prior to being interviewed. In Table NU.4, breastfeeding status is presented for both Exclusively breastfed and Predominantly breastfed. Referring to infants age less than 6 months, it is considered that they are exclusively breastfed, if the baby is given only vitamins, mineral supplements, and medicine in addition to breastmilk; and are predominantly breastfed, if the child is also given plain water and non-milk liquids. In addition, the table shows continued breastfeeding of children at 12-15 and 20-23 months of age. P a g e | 38 Table NU.4: Breastfeeding Percentage of living children according to breastfeeding status at selected age groups, Kazakhstan, 2015 Children aged 0-5 months Children aged 12-15 months Children aged 20-23 months P e rc e n t e xc lu si ve ly b re a st fe d 1 P e rc e n t p re d o m in a n tl y b re a st fe d 2 N u m b e r o f ch ild re n P e rc e n t b re a st fe d ( C o n ti n u e d b re a st fe e d in g a t 1 y e a r) 3 N u m b e r o f ch ild re n P e rc e n t b re a st fe d ( C o n ti n u e d b re a st fe e d in g a t 2 y e a rs )4 N u m b e r o f ch ild re n Total 37.8 73.2 531 59.8 375 21.1 355 Sex Male 38.9 74.9 264 59.9 173 22.3 191 Female 36.6 71.6 267 59.8 202 19.7 164 Region Akmola (35.8) (69.7) 22 (*) 12 (*) 16 Aktobe (38.6) (62.1) 30 (*) 20 (*) 35 Almaty oblast (22.2) (77.0) 51 (*) 26 (*) 31 Atyrau (45.7) (84.3) 20 (63.9) 13 (26.1) 18 West Kazakhstan (37.4) (90.8) 26 (43.6) 19 (*) 10 Zhambyl (32.1) (65.8) 40 (75.1) 29 (20.3) 32 Karaganda (*) (*) 26 (*) 32 (*) 26 Kostanai (22.3) (61.7) 20 (*) 13 (23.9) 18 Kyzylorda (31.9) (69.7) 21 (49.4) 14 (23.9) 15 Mangistau (9.5) (70.0) 25 (59.9) 18 (31.1) 14 South Kazakhstan 54.1 85.3 120 (59.5) 82 (17.2) 84 Pavlodar (*) (*) 13 (*) 13 (*) 11 North Kazakhstan (*) (*) 7 (45.8) 13 (*) 5 East Kazakhstan (*) (*) 25 (*) 16 (*) 16 Astana city (50.6) (72.3) 56 (60.5) 42 (*) 14 Almaty city (29.6) (51.1) 30 (*) 14 (*) 10 Area Urban 33.7 68.8 271 59.9 186 22.7 156 Rural 42.1 77.9 260 59.8 188 19.9 199 Mother’s education None/Primary (*) (*) 1 - 0 - 0 Lower secondary (44.3) (73.2) 30 (*) 17 (*) 14 Upper secondary 38.7 75.5 125 54.1 88 24.8 100 Technical and Professional 35.2 70.3 170 55.5 119 15.3 117 Higher 38.1 74.2 205 70.3 150 23.5 124 Wealth index quintile Poorest 35.2 77.7 98 52.7 77 30.3 78 Second 35.8 70.3 107 62.1 70 6.4 81 Middle 45.3 73.8 142 61.3 98 17.3 80 Fourth 35.8 74.4 94 56.2 66 30.1 55 Richest 33.2 69.9 90 67.5 64 25.6 61 Ethnicity of household head Kazakh 38.3 73.7 385 62.7 265 21.9 258 Russian 30.8 70.5 54 57.7 48 (25.9) 34 P a g e | 39 Other ethnic groups 39.7 73.1 92 (49.1) 62 (14.9) 62 1 MICS indicator 2.7 - Exclusive breastfeeding under 6 months 2 MICS indicator 2.8 - Predominant breastfeeding under 6 months 3 MICS indicator 2.9 - Continued breastfeeding at 1 year 4 MICS indicator 2.10 - Continued breastfeeding at 2 years ( ) Figures that are based on 25–49 unweighted cases. (*) Figures that are based on fewer than 25 unweighted cases. "–" denotes 0 unweighted case in that cell or in the denominator. Approximately 38 percent of children aged 0-5 months are exclusively breastfed, and more than 70 percent of children are predominantly breastfed, indicating the prevalence of practice of giving non- milk liquids to infants in addition to breastmilk. By age 12-15 months, almost 60 percent of children are breastfed and by age 20-23 months, 21.1 percent of children are breastfed; 22.3 percent of boys and 19.7 percent of girls aged 20-23 months continue to be breastfed. Exclusive breastfeeding and predominant breastfeeding are more common in rural areas (42.1 and 77.9 percent, respectively) than in urban areas (33.7 and 68.8 percent, respectively); while the proportion of children aged 20-23 months who continue to be breastfed in urban and rural areas was 22.7 and 19.9 percent, respectively. Figure NU.3 shows the detailed pattern of breastfeeding by the child’s age in months. Even at the earliest ages, in addition to breast milk, the majority of children are receiving plain water and vitamins, even in the first 4 weeks of life. Moreover, almost 70 percent of infants aged 0-1 months are exclusively breastfed; at 2-3 months, the proportion is more than halved (31.4 percent), and by the age of 4-5 months, it is almost 3 times lower at 23.5 percent. By the age of 2 years, more than 80 percent of children are weaned off the breast. Figure NU.3: Infant feeding patterns by age , Kazakhstan, 2015 P a g e | 40 Table NU.5 shows the median duration of breastfeeding by selected background characteristics. Among children under age 3, the median duration is 15.6 months for any breastfeeding, 1.8 months for exclusive breastfeeding, and 4.9 months for predominant breastfeeding. The duration of any breastfeeding in urban and rural areas is almost the same, and the duration of exclusive breastfeeding and predominant breastfeeding in rural areas is slightly higher than in urban areas (2.1 and 1.5 percent, and 5.0 and 4.8 percent, respectively). The shortest duration of exclusive breastfeeding is observed among children living in Mangistau, Akmola, Zhambyl and Karaganda regions, where the duration of breastfeeding ranges from 0.5 to 0.8 months. In the South Kazakhstan region and Astana city, the median duration of exclusive breastfeeding exceeds 2.5 months, and babies from the North Kazakhstan region are exclusively breastfed for almost 4 months. Table NU.5: Duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children aged 0-35 months, Kazakhstan, 2015 Median duration (in months) of: Number of children aged 0-35 months Any breastfeeding1 Exclusive breastfeeding Predominant breastfeeding Median 15.6 1.8 4.9 3188 Sex Male 15.2 1.8 4.9 1636 Female 16.3 1.8 5.0 1552 Region Akmola 15.8 0.7 3.9 136 Aktobe 14.5 1.9 6.4 230 Almaty oblast 14.8 1.7 5.2 254 Atyrau 14.7 2.3 5.3 129 West Kazakhstan 16.8 2.1 6.7 143 Zhambyl 15.7 0.7 4.6 254 Karaganda 17.5 0.8 4.2 226 Kostanai 13.1 1.1 3.6 134 Kyzylorda 12.9 1.6 4.4 122 Mangistau 17.4 0.5 5.5 138 South Kazakhstan 14.9 2.8 5.0 681 Pavlodar 16.7 2.0 4.6 105 North Kazakhstan 18.6 3.9 5.5 65 East Kazakhstan 17.4 1.9 3.5 155 Astana city 16.2 2.7 7.1 281 Almaty city 18.8 1.3 2.6 136 Area Urban 15.5 1.5 4.8 1574 Rural 15.6 2.1 5.0 1614 Mother’s education None/Primary (*) (*) (*) 1 Lower secondary 11.2 1.6 5.2 168 Upper secondary 14.9 1.9 5.1 770 Technical and Professional 14.3 1.7 4.5 949 Higher 17.1 1.9 5.0 1299 Wealth index quintile P a g e | 41 Poorest 14.1 1.7 5.0 607 Second 15.0 1.9 4.3 706 Middle 16.3 2.3 5.0 732 Fourth 15.9 1.1 5.2 580 Richest 16.8 1.0 5.5 563 Ethnicity of household head Kazakh 16.4 1.9 5.1 2254 Russian 13.4 1.4 4.5 392 Other ethnic groups 13.5 2.0 4.4 541 Mean 16.0 2.6 4.9 3188 1 MICS indicator 2.11 - Duration of breastfeeding (*) Figures that are based on fewer than 25 unweighted cases. The age-appropriateness of breastfeeding of children under age 24 months is provided in Table NU.6. Different criteria of feeding are used depending on the age of the child. The criteria for age- appropriate breastfeeding, for infants aged 0-5 months is if they are exclusively breastfed, while for children aged 6-23 months –breastmilk and solid, semi-solid and soft foods. The feeding pattern shows that almost every second child (49.2 percent) aged 6-23 months is appropriately breastfed. At the same time, age-appropriate breastfeeding among all children aged 0- 23 months is 46.3 percent. The percentage of children who are exclusively breastfed in age group of 0-5 months is higher in rural areas than in urban areas (42.1 and 33.7 percent, respectively). Among children aged 6-23 months, those whose mothers have higher education are more likely to be appropriately fed than those whose mothers have lower levels of education. Table NU.6: Age-appropriate breastfeeding Percentage of children aged 0-23 months who were appropriately breastfed during the previous day, Kazakhstan, 2015 Children aged 0-5 months Children aged 6-23 months Children aged 0-23 months Percent exclusively breastfed1 Number of children Percent currently breastfeeding and receiving solid, semi- solid or soft foods Number of children Percent appropriately breastfed2 Number of children Total 37.8 531 49.2 1611 46.3 2143 Sex Male 38.9 264 51.3 842 48.3 1106 Female 36.6 267 46.9 770 44.2 1037 Region Akmola (35.8) 22 45.9 68 43.5 89 Aktobe (38.6) 30 46.7 127 45.1 157 Almaty oblast (22.2) 51 46.3 130 39.5 180 Atyrau (45.7) 20 50.9 62 49.6 82 West Kazakhstan (37.4) 26 48.3 68 45.3 93 Zhambyl (32.1) 40 48.9 128 44.9 168 Karaganda (*) 26 58.1 104 52.3 130 Kostanai (22.3) 20 41.8 61 37.0 80 Kyzylorda (31.9) 21 37.8 64 36.4 85 Mangistau (9.5) 25 53.9 69 42.2 93 South Kazakhstan 54.1 120 45.3 371 47.5 491 Pavlodar (*) 13 50.4 50 47.7 63 North Kazakhstan (*) 7 49.7 36 53.0 42 P a g e | 42 East Kazakhstan (*) 25 62.5 76 52.3 101 Astana city (50.6) 56 51.5 137 51.2 193 Almaty city (29.6) 30 62.1 64 51.6 94 Area Urban 33.7 271 48.7 770 44.7 1041 Rural 42.1 260 49.6 841 47.9 1101 Mother’s education None/Primary (*) 1 - 0 (*) 1 Lower secondary (44.3) 30 40.2 71 41.4 101 Upper secondary 38.7 125 47.4 402 45.3 527 Technical and Professional 35.2 170 44.7 493 42.2 664 Higher 38.1 205 54.7 645 50.7 850 Wealth index quintile Poorest 35.2 98 51.9 324 48.0 422 Second 35.8 107 42.8 362 41.2 469 Middle 45.3 142 51.7 367 49.9 509 Fourth 35.8 94 50.3 297 46.8 391 Richest 33.2 90 49.8 261 45.6 351 Ethnicity of household head Kazakh 38.3 385 51.6 1135 48.2 1521 Russian 30.8 54 41.1 194 38.8 248 Other ethnic groups 39.7 92 44.9 282 43.6 374 1 MICS indicator 2.7 - Exclusive breastfeeding under 6 months 2 MICS indicator 2.12 - Age-appropriate breastfeeding ( ) Figures that are based on 25–49 unweighted cases. (*) Figures that are based on fewer than 25 unweighted cases. "–" denotes 0 unweighted case in that cell or in the denominator. According to survey findings, it was revealed that from the total number of children aged 6-8 months, 66.5 percent received solid, semi-solid and soft foods at least once during the previous day. This is lower than optimal to foster good linear growth among young children, as food should be introduced starting at 6 months of age. Furthermore, the major proportion (63.9 percent) are infants who were breastfeeding at the time of interview (Table NU.7). The percentage of boys who are breastfed and receive solid, semi-solid or soft foods (at least – once) is higher than the percentage of girls (78.6 and 48.9 percent); and the percentage of children living in rural areas is higher than in urban areas (70.9 and 57.9 percent, respectively). Table NU.7: Introduction of solid, semi-solid, or soft foods Percentage of infants aged 6-8 months who received solid, semi-solid, or soft foods during the previous day, Kazakhstan, 2015 Currently breastfeeding Currently not breastfeeding All Percent receiving solid, semi-solid or soft foods Number of children aged 6- 8 months Percent receiving solid, semi- solid or soft foods Number of children aged 6-8 months Percent receiving solid, semi- solid or soft foods1 Number of children aged 6-8 months Total 63.9 204 (85.8) 27 66.5 231 Sex Male 78.6 103 (*) 14 80.1 117 Female 48.9 101 (*) 13 52.5 114 P a g e | 43 Area Urban 57.9 110 (*) 11 59.4 121 Rural 70.9 94 (*) 16 74.3 110 1 MICS indicator 2.13 - Introduction of solid, semi-solid or soft foods ( ) Figures that are based on 25–49 unweighted cases. (*) Figures that are based on fewer than 25 unweighted cases. Overall, throughout the country, 74.0 percent of children aged 6-23 months received solid, semi-solid and soft foods, at least the minimum number of times per day (Table NU.8). The proportion of boys and girls (72.3 and 75.8 percent, respectively), and the proportion of children living in urban and rural areas (74.8 and 73.2 percent, respectively) of those receiving the minimum meal frequency are almost the same. The proportion of children receiving the minimum dietary diversity, or foods from at least 4 food groups out of 7 food groups, was 68.7 percentbeing the highest among the oldest age group of 18-23 months (86.1 percent) and the lowest among the youngest children aged 6-8 months (22.6 percent). P a g e | 44 Table NU.8: Infant and young child feeding (IYCF) practices Percentage of children aged 6-23 months who received appropriate liquids and solid, semi-solid, or soft foods the minimum number of times or more during the previous day, by breastfeeding status, Kazakhstan, 2015 Currently breastfeeding Currently not breastfeeding All Percent of children who received: Number of children aged 6-23 months Percent of children who received: Number of children aged 6-23 months Percent of children who received: Number of children aged 6-23 months M in im u m d ie ta ry d iv e rs it ya M in im u m m e a l fr e q u e n cy b M in im u m a cc e p ta b le d ie t1 , c M in im u m d ie ta ry d iv e rs it ya M in im u m m e a l fr e q u e n cy b M in im u m a cc e p ta b le d ie t2 , c A t le a st 2 m ilk f e e d s3 M in im u m d ie ta ry d iv e rs it y 4 , a M in im u m m e a l fr e q u e n cy 5 , b M in im u m a cc e p ta b le d ie tc Total 57.8 64.2 42.6 881 85.1 86.7 48.3 79.9 674 68.7 74.0 45.1 1611 Sex Male 61.1 61.6 39.8 462 84.3 86.6 51.3 82.9 345 69.9 72.3 44.7 842 Female 54.1 67.1 45.8 418 85.8 86.8 45.3 76.6 329 67.4 75.8 45.6 770 Age 6-8 months 19.4 55.3 17.9 204 (46.5) (100.0) (28.9) (97.9) 25 22.6 60.1 19.1 231 9-11 months 54.6 54.3 33.8 240 79.0 86.5 51.0 87.0 44 54.1 59.3 36.5 309 12-17 months 77.9 75.7 61.7 297 82.1 87.0 43.8 81.4 241 79.7 80.8 53.7 548 18-23 months 76.2 69.7 53.4 140 90.3 85.7 52.3 76.7 365 86.1 81.3 52.6 523 Region Akmola 45.0 79.5 39.8 34 (88.6) (98.2) (47.0) (69.0) 31 66.5 88.5 43.2 68 Aktobe 40.9 49.1 33.2 68 (80.9) (86.9) (61.7) (92.5) 57 58.1 66.3 46.2 127 Almaty oblast (51.5) (79.1) (45.2) 64 (84.1) (96.5) (60.0) (83.9) 63 67.3 87.7 52.5 130 Atyrau 57.0 65.6 43.1 35 84.7 95.4 49.6 78.0 26 68.5 78.4 45.9 62 West Kazakhstan 51.9 45.4 33.5 38 (83.0) (84.1) (45.4) (90.5) 28 64.2 62.0 38.6 68 Zhambyl 73.0 94.7 71.2 65 83.2 92.6 45.1 69.4 60 77.7 93.7 58.7 128 Karaganda (79.2) (79.0) (65.7) 62 (91.2) (78.6) (60.1) (90.1) 39 84.2 78.8 63.5 104 Kostanai (60.5) (80.8) (54.6) 26 (89.6) (100.0) (53.7) (74.3) 32 77.6 91.4 54.1 61 Kyzylorda 32.3 32.3 15.0 32 65.5 73.1 30.4 93.9 30 48.9 52.0 22.4 64 Mangistau 50.0 45.9 20.1 42 67.8 72.8 38.2 77.6 26 57.1 56.2 27.0 69 South Kazakhstan 58.2 41.3 23.3 195 87.7 81.5 37.9 78.0 151 66.7 58.9 29.7 371 Pavlodar (58.9) (78.6) (56.7) 27 (87.8) (97.0) (57.1) (85.2) 22 72.3 86.9 56.9 50 P a g e | 45 North Kazakhstan (70.2) (94.5) (70.2) 19 (85.7) (97.5) (46.1) (76.4) 16 77.9 95.9 59.1 36 East Kazakhstan (78.3) (85.7) (71.1) 48 (*) (*) (*) (*) 24 84.1 87.3 65.4 76 Astana city 51.9 64.8 41.0 84 (91.0) (73.5) (45.3) (62.5) 49 67.3 68.0 42.6 137 Almaty city 61.6 90.5 61.6 42 (*) (*) (*) (*) 20 68.7 91.4 63.8 64 Area Urban 55.6 69.1 46.1 429 83.8 82.4 48.1 76.5 320 67.9 74.8 47.0 770 Rural 59.8 59.5 39.3 452 86.2 90.6 48.6 82.9 354 69.4 73.2 43.4 841 Mother’s education None/Primary - - - 0 - - - - 0 - - - 0 Lower secondary (62.4) (76.9) (55.0) 32 (76.8) (82.8) (40.0) (56.1) 39 70.5 80.1 46.8 71 Upper secondary 64.5 50.6 35.0 207 87.0 87.8 46.3 80.4 162 69.5 66.9 40.0 402 Technical and Professional 53.1 65.4 40.3 239 83.4 84.6 45.5 84.0 247 68.5 75.2 43.0 493 Higher 56.7 69.4 47.0 403 86.9 88.9 54.3 79.0 227 68.1 76.5 49.6 645 Wealth index quintile Poorest 61.4 55.4 35.2 180 82.6 88.6 41.5 81.7 137 70.4 69.7 37.9 324 Second 54.8 59.9 39.9 180 83.2 89.4 49.7 83.6 161 64.8 73.8 44.5 362 Middle 62.0 66.8 46.7 203 86.0 87.8 53.5 81.2 154 71.4 75.8 49.6 367 Fourth 59.0 75.4 53.3 163 84.9 83.8 46.2 73.4 127 70.2 79.1 50.2 297 Richest 50.1 64.3 38.0 154 90.5 81.8 50.5 77.4 96 66.5 70.9 42.8 261 Ethnicity of household head Kazakh 55.7 65.6 44.1 652 83.7 86.9 46.5 82.4 461 67.3 74.4 45.1 1135 Russian 63.1 70.3 50.7 91 92.3 87.7 56.4 76.8 93 78.0 79.1 53.6 194 Other ethnic groups 64.2 53.4 30.2 138 84.5 85.4 49.0 72.6 120 67.7 68.3 39.0 282 1 MICS indicator 2.17a – Minimum acceptable diet (breastfed) 2 MICS indicator 2.17b – Minimum acceptable diet (non-breastfed) 3 MICS indicator 2.14 – Milk feeding frequency for non-breastfed children 4 MICS indicator 2.16 – Minimum dietary diversity 5 MICS indicator 2.15 – Minimum meal frequency a Minimum dietary diversity is defined as receiving foods from at least 4 of 7 food groups: 1) Grains, roots and tubers, 2) legumes and nuts, 3) dairy products (milk, yogurt, cheese), 4) flesh foods (meat, fish, poultry and liver/organ meats), 5) eggs, 6) vitamin-A rich fruits and vegetables, and 7) other fruits and vegetables. b Minimum meal frequency among currently breastfeeding children is defined as children who also received solid, semi-solid, or soft foods 2 times or more daily for children aged 6-8 months and 3 times or more daily for children aged 9-23 months. For non-breastfeeding children aged 6-23 months it is defined as receiving solid, semi-solid or soft foods, or milk feeds, at least 4 times. c The minimum acceptable diet for breastfed children aged 6-23 months is defined as receiving the minimum dietary diversity and the minimum meal frequency, while it for non-breastfed children further requires at least 2 milk feedings and that the minimum dietary diversity is achieved without counting milk feeds. ( ) Figures that are based on 25–49 unweighted cases. (*) Figures that are based on fewer than 25 unweighted cases. “–“ denotes 0 unweighted case in that cell or in the denominator. P a g e | 46 In the country, the current practice of bottle-feeding is a concern of health workers because of the risk of possible contamination due to unsafe water and lack of hygiene in preparation. Table NU.9 shows that bottle-feeding is quite prevalent in Kazakhstan. More than half of children (51.2 percent) aged 0-23 months are fed using a bottle with a nipple; including 34.1 percent of children aged 0-5 months; by the age of 6-12 months, their proportion is almost doubled (62.6 percent); by the age of 12-23 months the proportion of such children is more than half (53.9 percent). The prevalence of bottle-feeding is the same, in urban and in rural areas. The practice of bottle-feeding is more common in the Mangistau region (65.4 percent), and the least common in the West Kazakhstan region (29.5 percent). Table NU.9: Bottle feeding Percentage of children aged 0-23 months who were fed with a bottle with a nipple during the previous day, Kazakhstan, 2015 Percentage of children aged 0-23 months fed with a bottle with a nipple1 Number of children aged 0-23 months Total 51.2 2143 Sex Male 50.0 1106 Female 52.4 1037 Age 0-5 months 34.1 531 6-11 months 62.6 540 12-23 months 53.9 1071 Region Akmola 52.7 89 Aktobe 53.2 157 Almaty oblast 46.4 180 Atyrau 48.6 82 West Kazakhstan 29.5 93 Zhambyl 52.2 168 Karaganda 53.2 130 Kostanai 55.8 80 Kyzylorda 59.7 85 Mangistau 65.4 93 South Kazakhstan 53.5 491 Pavlodar 47.1 63 North Kazakhstan 37.7 42 East Kazakhstan 41.1 101 Astana city 53.0 193 Almaty city 52.1 94 Area Urban 51.6 1041 Rural 50.7 1101 Mother’s education None/Primary (*) 1 Lower secondary 51.3 101 Upper secondary 50.7 527 Technical and Professional 53.8 664 Higher 49.4 850 Wealth index quintile P a g e | 47 Poorest 48.6 422 Second 56.1 469 Middle 49.7 509 Fourth 52.4 391 Richest 48.4 351 Ethnicity of household head Kazakh 51.4 1521 Russian 54.1 248 Other ethnic groups 48.4 374 1 MICS indicator 2.18 - Bottle feeding (*) Figures that are based on fewer than 25 unweighted cases. Salt Iodization The world’s leading cause of preventable mental retardation and impaired psychomotor development in young children is Iodine Deficiency Disorders (IDD). Iodine is the single micronutrient which is directly involved in hormones synthesis. Iodine is involved in the production of the thyroid hormone – Thyroxine. If insufficient iodine is consumed along with food, the human thyroid produces little thyroxine. This condition is called Hypothyroidism or Iodine Deficiency. In its most extreme form, iodine deficiency causes cretinism. It also increases the risks of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with the problem of thyroid functioning (“goitre”). Iodine is required for healthy brain development of children during intrauterine growth and early childhood. IDD takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability, and impaired work performance. Universal salt iodization is the main strategy for the elimination of iodine deficiency in the population. The existing deficiency can be compensated by the consumption of adequately iodized salt by each household member. In accordance with the global policy recommendations, the Law of the Republic of Kazakhstan “On prevention of iodine deficiency disorders” (№ 489-II LRK) was developed and adopted in 2003 by the Government with direct engagement of the Ministry of Health of the Republic of Kazakhstan, the Kazakh Academy of Nutrition, UNICEF and the country office of the Asian Development Bank. A new norm of iodized salt – 40+15 mcg/kg – has been set at the legislative level. Potassium iodate is used for iodization of salt, allowing iodine to be well preserved in salt, in turn this allowed manufacturers to extend the expiration date of iodized salt to 12 months. The MICS indicator is the percentage of households consuming adequately iodized salt (>15 parts per million). P a g e | 48 Table NU.10: Iodized salt consumption Percent distribution of households by consumption of iodized salt, Kazakhstan, 2015 Percentage of households in which salt was tested Number of households Percent of households with: Total Number of households in which salt was tested or with no salt No salt Salt test result Not iodized 0 PPM >0 and <15 PPM 15+ PPM1 Total 98.0 16500 0.6 5.0 3.7 90.7 100.0 16267 Region Akmola 98.6 944 0.5 5.1 4.0 90.4 100.0 935 Aktobe 98.9 983 1.1 0.1 5.5 93.3 100.0 983 Almaty oblast 93.8 1260 0.3 0.7 3.3 95.7 100.0 1185 Atyrau 99.9 456 0.0 15.0 1.4 83.5 100.0 455 West Kazakhstan 98.0 764 0.3 40.0 8.7 51.0 100.0 751 Zhambyl 97.9 880 1.1 10.7 3.5 84.7 100.0 872 Karaganda 98.0 1614 0.9 0.7 0.4 98.0 100.0 1596 Kostanai 99.0 978 0.0 1.1 5.1 93.8 100.0 969 Kyzylorda 99.6 402 0.4 0.3 0.6 98.7 100.0 402 Mangistau 99.0 412 0.5 2.0 0.8 96.7 100.0 410 South Kazakhstan 98.4 2055 0.4 8.2 10.3 81.2 100.0 2030 Pavlodar 99.8 829 0.0 2.3 2.0 95.7 100.0 828 North Kazakhstan 98.5 645 0.9 3.8 3.1 92.2 100.0 641 East Kazakhstan 98.9 1523 0.7 2.5 1.1 95.7 100.0 1516 Astana city 99.0 1310 0.4 1.0 2.2 96.5 100.0 1302 Almaty city 94.9 1445 1.5 0.4 1.6 96.5 100.0 1392 Area Urban 97.9 9967 0.6 2.6 2.8 94.0 100.0 9822 Rural 98.1 6533 0.5 8.8 5.1 85.6 100.0 6444 Wealth index quintile Poorest 97.7 3035 1.2 10.4 5.8 82.5 100.0 3000 Second 98.5 2646 0.1 7.3 5.3 87.3 100.0 2609 Middle 98.0 3109 0.5 5.5 3.3 90.7 100.0 3060 Fourth 97.7 3979 0.7 2.3 2.3 94.6 100.0 3915 Richest 98.3 3731 0.4 1.4 2.7 95.4 100.0 3682 1 MICS indicator 2.19 - Iodized salt consumption P a g e | 49 During the Survey, almost in every household (98.0 percent), salt used for cooking was tested for iodine content by using salt test kits for identifying the presence of potassium iodate. Table NU.10 shows that salt was not available in only 0.6 percent of households; these households are included in the denominator of the indicator. Nearly 91 percent of households consumed adequately iodized (≥15 ppm) salt; 3.7 percent of households salts contains less than 15 ppm, while in 5.0 percent of households salt was not iodized (0 ppm). Consumpiton of salt with at least 15 ppm of iodine was lowest in the West Kazakhstan region (51.0 percent), where 40 percent of the households consumed salt with no iodine at all. In urban areas, 94.0 percent of households were consuming adequately iodized salt (≥15 ppm) while for rural areas the figure was 85.6 percent. Consumption of adequately iodized salt (≥15 ppm) was higher among richest households when compared to the poorest households (95.4 and 82.5 percent, respectively). In 10.4 percent of the poorest households salt was not iodized. The consumption of iodized salt is presented in Figure NU.4 together with the percentage of salt that contains less than 15 ppm. Figure NU.4: Consumption of iodized sa lt , Kazakhstan, 2015 P a g e | 50 V. Child Health Vaccinations The Millennium Development Goal (MDG) 4 aimed to reduce child mortality by two thirds between 1990 and 2015. Target 3.2 of the third goal of the Sustainable Development Goals (SDG) adopted in 2015 aims to end preventable deaths of newborns and children under 5 years of age by 2030. Immunization plays a key role in the attainment of this goal. In addition, the Global Vaccine Action Plan (GVAP) was endorsed by the 194 Member States of the World Health Assembly in May 2012 to achieve the Decade of Vaccines vision by delivering universal access to immunization. Immunization has saved the lives of millions of children in the four decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. However, there are still millions of children worldwide not reached by routine immunization and as a result, vaccine-preventable diseases cause more than 2 million deaths every year. The WHO Recommended Calendar for Routine Immunizations for Children27 recommends all children to be vaccinated against tuberculosis, diphtheria, pertussis, tetanus, polio, measles, hepatitis B, haemophilus influenzae type b, pneumonia, rotavirus, and rubella. All doses in the primary series are recommended to be completed before the child’s first birthday, although depending on the epidemiological situation in a country, the first doses of measles and rubella containing vaccines may be recommended at 12 months or later. The recommended number and timing of most other doses also vary slightly due to local epidemiology and may include booster doses at older ages. In Kazakhstan, vaccinations are made with the consent of children’s parents or their legal caretakers. Information about all received vaccinations is necessarily recorded in the child’s outpatient medical record or vaccination passport. Subsequently, the outpatient medical record or vaccination passport shall be presented at the child’s enrollment to kindergarten or school. In Kazakhstan all performed preventive vaccinations should be registered by the medical professional and should contain the following information: date of administration, vaccine name, batch number, dose, control number, expiration date, nature of infusion reactions and country of origin. Besides the child’s outpatient medical record or vaccination passport, information about vaccinations may be contained in the following documents: preventive vaccination card (form 063/y), history of the child’s development (form 112/y), child's medical card (form 026/y), and among others. In Kazakhstan, by the Decree of the Government of the Republic of Kazakhstan №119 from 12 February 2013, the amendments and additions were introduced to the Decree “On approving the list of diseases against which the preventive vaccinations are carried out, on the Rules of their immunization and on population groups that are subject to planned vaccinations” №2295 from 30 December 2009. 27 http://www.who.int/immunization/policy/immunization_tables/en/. Table 2 includes recommendations for all children and additional antigens recommended only for children residing in certain regions of the world or living in certain high-risk population groups. http://www.who.int/immunization/policy/immunization_tables/en/ P a g e | 51 Below is the schedule for immunization in the Republic of Kazakhstan, as amended and approved in 2013. Immunization Schedule in the Republic of Kazakhstan, approved in 2013 Age Types of Vaccination BCG HepB (HBV) Polio (OPV/IPV) DPT/DTaP Hib Pneumococcal (PCV) Measles (MMR) 1-4 days28 + + 2 months +(DPT+Hib+HBV+IPV) + 3 months +(DPT+Hib+IPV) 4 months +(DPT+Hib+HBV+IPV) + 12-15 months +(OPV) + + 18 months +(DPT+Hib+IPV) The purified pertussis vaccine combined with other toxoids (DTaP) and inactivated polio vaccine (IPV) was introduced in the immunization schedule since 2013. The immunization schedule in Kazakhstan provides all the above mentioned vaccinations: one dose of the tuberculous vaccine (BCG) and the Hepatitis B vaccines (within 24 hours of birth) at birth, three doses of the diphtheria, pertussis, tetanus (DPT) vaccines, Hepatitis B (HBV), and Haemophilus influenzae type b (Hib) antigens, three doses of the Polio vaccine, one dose of the vaccine containing measles, mumps, and rubella antigens (MMR), three doses of the Pneumococcal vaccine (PNEUMO). The PNEUMO vaccine was implemented in Kazakhstan in stages, starting from 2011, and its introduction took place in different regions of the country at different times until 2015. Due to the fact that the PNEUMO vaccine was not administered universally in the country for 3 years prior to the survey, this vaccination was excluded from the 2015 Kazakhstan MICS Tabulation Plan, though at the time of the survey, data on the PNEUMO vaccine were also recorded from medical documents on the MICS form. Sometimes vaccination is carried out in various combinations as a mixed vaccine: for example, the hepatitis B vaccine (HBV) is administered simultaneously with the polio, diphtheria, pertussis, tetanus (DPT) vaccines and the Haemophilus influenzae type b (Hib) antigens – as a hexavalent vaccine; or vaccination against diphtheria, pertussis, tetanus (DTP) can be carried out in combination with vaccines against Haemophilus influenzae type b (Hib) and polio – as a pentavalent vaccine. In accordance with the national immunization schedule, with amendments approved in 2013, every child should receive appropriate doses of vaccines in the recommended age-appropriate period. Exceptions may include a medical exemption from immunization due to illness of the child, as well as the parents’ refusal of vaccinations for valid reasons. 28 HepB-1 vaccine is administered within 24 hours of birth. P a g e | 52 All vaccinations should be received during the first year of life except for the doses of MMR at 12 and 15 months. Taking into consideration this national immunization schedule, the estimates for full immunization coverage from the 2015 Kazakhstan MICS are based on children aged 12-23 and 24-35 months. Information on vaccination coverage was collected for all children under three years of age. In Kazakhstan, the full medical documentation on vaccination of children is mainly stored at health facilities, with a few exceptions – in households. All mothers or caretakers were asked to provide vaccination passports or cards. Only in 1.5 percent of cases for children aged 12-23 months and 2.3 percent of cases for children aged 24-35 months, were the vaccinations recorded based on information provided by mothers. If the vaccina

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