Mongolia - Multiple Indicator Cluster Survey - 2016

Publication date: 2016

Mongolia: Khuvsgul Province Multiple Indicator Cluster Survey CHILD DEVELOPMENT SURVEY - 2016 K H U V S G U L P R O V IN C E 2017 Mongolia: Khuvsgul Province Multiple Indicator Cluster Survey Child Development Survey-2016 C hild D evelopm ent Survey-2016 Mongolia: Khuvsgul province Child Development Survey-2016 Multiple Indicator Cluster Survey Final Report 2017 Edited by: D.Oyunchimeg Director, Population and Social Statistics Department, National Statistical Office, Mongolia Prepared by: T.Altantsetseg Senior officer, Population and Social Statistics Department, NSO Note: This report is also available in Mongolian. The statements and opinions expressed here are only those of the authors and do not necessarily reflect those of the institutions involved. ©UNICEF Mongolia/2016/ Mungunkhishig Batbaatar, Burentogtokh soum, Khuvsgul province NATIONAL STATISTICAL OFFICE OF MONGOLIA Government Building III Sukhbaatar District, Baga Toiruu Ulaanbaatar, Mongolia Website: http://www.nso.mn E-mail: international@nso.mn Telephone: (976-11)-326414 Fax: (976-11)-324518 The “Child Development Survey” (Multiple Indicator Cluster Survey) was carried out in Khuvsgul province, Mongolia 2016 by National Statistical Office, as part of the global MICS programme. Financial and technical support was provided by the United Nations Children’s Fund (UNICEF). 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 surveys measure key indicators that allow countries to generate data for use in policies and programmes, and to monitor progress towards the Millennium Development Goals (MDGs) and other internationally agreed upon commitments. Suggested citation: NSO and UNICEF. 2017. Child and Development Survey Multiple Indicator Sample Survey, Final Report. Ulaanbaatar, Mongolia: NSO and UNICEF Prepared for prepress: Munkhtur Erdenebat Paper size: 60х90/8 Press sheet: 61,5 Printed by "Soyombo Printing" LLC iii Child Development Survey-2016 (Mongolia: Khuvsgul province) SUMMARY TABLE OF SURVEY IMPLEMENTATION AND THE SURVEY POPULATION, CHILD DEVELOPMENT SURVEY, 2016 Survey implementation Sample frame - Updated Administrative records of the household and population December 2015 Questionnaires Household Women (age 15-49) Men (age 15-49) Children under five Water quality test Interviewer training 2016 оны 10 дугаар сар Fieldwork Oct-Dec 2016 Survey sample Households - Sampled - Occupied - Interviewed - Response rate (Per cent) Women - Eligible for interviews - Interviewed - Response rate (Per cent) 2, 650 2, 641 2, 626 99.4 2, 115 2, 039 96.4 Children under five - Eligible - Mothers/caretakers interviewed - Response rate (Per cent) Men - Eligible for interviews - Interviewed - Response rate (Per cent) 1, 134 1, 129 99.6 1, 007 943 93.6 Survey population Average household size Percentage of population living in - Urban areas - Rural areas - Central - Tourism - Agriculture - Ider - Tes-Ekh - Murun 24.0 76.0 19.8 19.3 12.5 12.8 11.8 24.0 Percentage of population under: - Age 5 - Age 18 13.2 39.6 Percentage of women age 15-49 years with at least one live birth in the last 2 years 19.5 Housing characteristics Household or personal assets Percentage of households with - Electricity - Finished floor - Finished roofing - Finished walls 63.3 16.3 99.8 97.8 Percentage of households that own - A television - A refrigerator - Agricultural land - Farm animals/livestock 85.5 44.9 2.0 65.2 Mean number of persons per room used for sleeping 2.96 Percentage of households where at least a member has or owns a - Mobile phone - Car or truck 92.7 40.0 iv Child Development Survey-2016 (Mongolia: Khuvsgul province) SUMMARY TABLE OF FINDINGS1 Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Child Development Survey, Khuvsgul, 2016 CHILD MORTALITY Early childhood mortality MICS Indicator Indicator Description Valuea 1.1 Neonatal mortality rate Probability of dying within the first month of life 14 1.2 MDG 4.2 Infant mortality rate Probability of dying between birth and the first birthday 23 1.3 Post-neonatal mortality rate Difference between infant and neonatal mortality rates 9 1.4 Child mortality rate Probability of dying between the first and the fifth birthdays 1 1.2 MDG 4.1 Under-five mortality rate Probability of dying between birth and the fifth birthday 24 a Indicator values are per 1,000 live births and refer to the 5-year period preceding the survey. NUTRITION Nutritional status MICS Indicator Indicator Description Value 2.1a 2.1b МХЗ 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 1.9 0.8 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 19.0 7.6 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 1.6 0.6 2.4 Overweight prevalence Percentage of children under age 5 who are above two stan- dard deviations of the median weight for height of the WHO standard 22.1 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 99.2 2.6 Early initiation of breast- feeding 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 76.4 2.7 Exclusive breastfeeding under 6 months Percentage of infants under 6 months of age who are exclu- sively breastfed 67.4 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 72.4 2.9 Continued breastfeeding at 1 year Percentage of children age 12-15 months who received breast milk during the previous day 81.7 2.10 Continued breastfeeding at 2 years Percentage of children age 20-23 months who received breast milk during the previous day 60.0 2.11 Median duration of breast- feeding The age in months when 50 percent of children age 0-35 months did not receive breast milk during the previous day 24.3 2.12 Age-appropriate breast- feeding Percentage of children age 0-23 months appropriately fed during the previous day 67.4 2.13 Introduction of solid, semi-solid or soft foods Percentage of infants age 6-8 months who received solid, semi-solid or soft foods during the previous day 74.4 2.14 Milk feeding frequency for non-breastfed children Percentage of non-breastfed children age 6-23 months who received at least 2 milk feedings during the previous day 76.1 1 See Appendix E for a detailed description of MICS indicators v Child Development Survey-2016 (Mongolia: Khuvsgul province) 2.15 Minimum meal frequency Percentage of children age 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 87.2 2.16 Minimum dietary diversity Percentage of children age 6–23 months who received foods from 4 or more food groups during the previous day 39.0 2.17a 2.17b Minimum acceptable diet (a) Percentage of breastfed children age 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 age 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 33.3 32.8 2.18 Bottle feeding Percentage of children age 0-23 months who were fed with a bottle during the previous day 19.5 2.S1 Vitamin A supplementation Percentage of children age 6-23 months who received either first or second dose of Vitamin A in the last 6 months 80.4 Salt iodization 2.19 Iodized salt consumption Percentage of households with salt testing 15 parts per million or more of iodide 36.4 Low-birthweight 2.20 Low-birthweight infants Percentage of most recent live births in the last 2 years weigh- ing below 2,500 grams at birth 5.5 2.21 Infants weighed at birth Percentage of most recent live births in the last 2 years who were weighed at birth 99.8 CHILD HEALTH Vaccinations MICS Indicator Indicator Description Value 3.1 Tuberculosis immunization coverage Percentage of children age 12-23 months who received BCG vaccine by their first birthday 89.3 3.2 Polio immunization coverage Percentage of children age 12-23 months who received the third dose of OPV vaccine (OPV3) by their first birthday 85.7 3.3 Diphtheria, pertussis and tetanus (DPT) immunization coverage Percentage of children age 12-23 months who received the third dose of DPT vaccine (DPT3) by their first birthday 85.9 3.4 MDG 4.3 Measles immunization coverage Percentage of children age 12-23 months who received mea- sles vaccine by their first birthday 83.3 3.5 Hepatitis B immunization coverage Percentage of children age 12-23 months who received the third dose of Hepatitis B vaccine (HepB3) by their first birth- day 85.9 3.6 Haemophilus influenzae type B (Hib) immunization coverage Percentage of children age 12-23 months who received the third dose of Hib vaccine (Hib3) by their first birthday 85.9 3.8 Full immunization coverage Percentage of children age 12-23 months who received all vaccinations recommended in the national immunization schedule by their first birthday 79.4 Diarrhoea - Children with diarrhoea Percentage of children under age 5 with diarrhoea in the last 2 weeks 6.9 3.10 Care-seeking for diarrhoea Percentage of children under age 5 with diarrhoea in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 37.4 3.11 Diarrhoea treatment with oral rehydration salts (ORS) and zinc Percentage of children under age 5 with diarrhoea in the last 2 weeks who received ORS and zinc 0.7 vi Child Development Survey-2016 (Mongolia: Khuvsgul province) CHILD HEALTH Vaccinations MICS Indicator Indicator Description Value 3.12 Diarrhoea treatment with oral rehydration therapy (ORT) and continued feeding Percentage of children under age 5 with diarrhoea in the last 2 weeks who received ORT (ORS packet, pre-package ORS fluid, recommended homemade fluid or increased fluids) and continued feeding during the episode of diarrhoea 88.2 Acute Respiratory Infection (ARI) symptoms - Children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks 5.4 3.13 Care-seeking for children with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks for whom advice or treatment was sought from a health facility or provider 77.0 3.14 Antibiotic treatment for chil- dren with ARI symptoms Percentage of children under age 5 with ARI symptoms in the last 2 weeks who received antibiotics 62.7 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 98.3 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 60.6 4.2 Water treatment Percentage of household members in households using unimproved drinking water who use an appropriate treatment method 90.6 4.3 MDG 7.9 Use of improved sanitation Percentage of household members using improved sanitation facilities which are not shared 56.6 4.S2 Use of improved sanitation (based on country specific definition) Percentage of household members using improved sanitation based on country specific definition of improved sanitation facilities 1.9 4.4 Safe disposal of child’s faeces Percentage of children age 0-2 years whose last stools were disposed of safely 70.2 4.5 Place for handwashing Percentage of households with a specific place for hand washing where water and soap or other cleansing agent are present 75.0 4.6 Availability of soap or other cleansing agent Percentage of households with soap or other cleansing agent 94.6 REPRODUCTIVE HEALTH Contraception and unmet need MICS Indicator Indicator Description Value 5.S1 Total fertility rate Total fertility rate for women age 15-49 years 3.8 5.1 MDG 5.4 Adolescent birth rate Age-specific fertility rate for women age 15-19 years 69.3 5.S2 General fertility rate General fertility rate for women age 15-49 years 114.5 5.S3 Crude birth rate Crude fertility rate for women age 15-49 years 24.9 5.2 Early childbearing Percentage of women age 20-24 years who had at least one live birth before age 18 3.1 5.3 MDG 5.3 Contraceptive prevalence rate Percentage of women age 15-49 years currently married or in union who are using (or whose partner is using) a (modern or traditional) contraceptive method 56.5 vii Child Development Survey-2016 (Mongolia: Khuvsgul province) REPRODUCTIVE HEALTH Contraception and unmet need MICS Indicator Indicator Description Value 5.4 MDG 5.6 Unmet need Percentage of women age 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 21.0 Maternal and newborn health 5.5a 5.5b MDG 5.5 MDG 5.5 Antenatal care coverage Percentage of women age 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 99.7 91.0 5.S4 5.S5 Antenatal care coverage (Based on the country spe- cific definition) Percentage of women age 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 six times by any provider 99.3 67.1 5.6 Content of antenatal care Percentage of women age 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.S6 Early antenatal care cover- age (based on the country specific definition) Percentage of women age 15-49 years with a live birth in the last 2 years who had first antenatal care visit in the first trimester of pregnancy 76.9 5.S7 Median months pregnant at first ANC visit The length of time in months when 50 percent of women who had first antenatal care visit in the first trimester of pregnancy , by months 1.8 5.S8 Content of antenatal care (based on country specific definition) Percentage of women age 15-49 years with a live birth in the last 2 years who had their blood pressure and weight mea- sured, gave urine and blood samples, had STIs and syphilis test, examined ultrasound and chest X-ray during the last pregnancy that led to a live birth 40.9 5.7 MDG 5.2 Skilled attendant at delivery Percentage of women age 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 99.9 5.8 Skilled attendant at delivery (based on country specific definition) Percentage of women age 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 99.6 5.S9 Institutional deliveries Percentage of women age 15-49 years with a live birth in the last 2 years whose most recent live birth was delivered in a health facility 99.4 5.9 Caesarean section Percentage of women age 15-49 years whose most recent live birth in the last 2 years was delivered by caesarean section 20.4 Post-natal health checks 5.10 Post-partum stay in health facility Percentage of women age 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 99.4 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 96.9 5.12 Post-natal health check for the mother Percentage of women age 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 95.4 viii Child Development Survey-2016 (Mongolia: Khuvsgul province) CHILD DEVELOPMENT MICS Indicator Indicator Description Value 6.1 Attendance to early childhood education Percentage of children age 36-59 months who are attending an early childhood education programme 63.0 6.2 Support for learning Percentage of children age 36-59 months with whom an adult has engage in four or more activities to promote learning and school readiness in the last 3 days 48.5 6.3 Father’s support for learning Percentage of children age 36-59 months whose biological father has engage in four or more activities to promote learning and school readiness in the last 3 days 5.6 6.4 Mother’s support for learning Percentage of children age 36-59 months whose biological mother has engage in four or more activities to promote learning and school readiness in the last 3 days 17.0 6.5 Availability of children’s books Percentage of children under age 5 who have three or more children’s books 17.8 6.6 Availability of playthings Percentage of children under age 5 who play with two or more types of playthings 63.2 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 17.5 6.8 Early child development index Percentage of children age 36-59 months who are developmentally on track in at least three of the following four domains: literacy-numeracy, physical, social-emotional, and learning 74.7 6.S1 Early child development index (based on country specific definition) Percentage of children age 36-59 months who are developmentally on track in at least three of the following four domains: literacy-numeracy, physical, social-emotional, and learning (based on country specific definition) 75.2 LITERACY AND EDUCATION MICS Indicator Indicator Description Value 7.1 MDG 2.3 Literacy rate among young people Percentage of young people age 15-24 years who are able to read a short simple statement about everyday life or who attended secondary or higher education (a) women (b) men 95.2 88.7 7.2 School readiness Percentage of children in first grade of primary school who attended pre-school during the previous school year 87.3 7.3 Net intake rate in primary education Percentage of children of school-entry age who enter the first grade of primary school 94.0 7.4 MDG 2.1 Primary school net attendance ratio (adjusted) Percentage of children of primary school age currently attend- ing primary or secondary school 97.8 7.5 Secondary school net attendance ratio (adjusted) Percentage of children of secondary school age currently attending secondary school or higher 93.7 7.S1 Basic education net attendance ratio (adjusted) Percentage of children of primary, lower secondary school age currently attending primary, lower secondary school or higher 97.5 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 96.1 7.7 Primary completion rate Number of children attending the last grade of primary school (excluding repeaters) divided by number of children of prima- ry school completion age (age appropriate to final grade of primary school) 104.1 7.8 Transition rate to secondary school Number of children attending the last grade of primary school during the previous school year who are in the first grade of secondary school during the current school year divided by number of children attending the last grade of primary school during the previous school year 99.0 ix Child Development Survey-2016 (Mongolia: Khuvsgul province) LITERACY AND EDUCATION MICS Indicator Indicator Description Value 7.9 MDG 3.1 Gender parity index (primary school) Primary school net attendance ratio (adjusted) for girls divid- ed by primary school net attendance ratio (adjusted) for boys 1.01 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 1.04 7.S2 Gender parity index (Basic education) Primary, lower secondary school net attendance ratio (adjust- ed) for girls divided by primary, lower secondary school net attendance ratio (adjusted) for boys 1.02 CHILD PROTECTION MICS Indicator Indicator Description Value Birth registration 8.1 Birth registration Percentage of children under age 5 whose births are reported registered 98.9 Child labour 8.2 Child labour Percentage of children age 5-17 years who are involved in child labour 23.2 8.S2 Child jockeys Percentage of children age 4-15 years who participated in horse racing since November of 2015 6.4 Child discipline 8.3 Violent discipline Percentage of children age 1-14 years who experienced psy- chological aggression or physical punishment during the last one month 44.0 Early marriage 8.4 Marriage before age 15 Percentage of people age 15-49 years who were first married or in union before age 15 (a) Women (b) Men 0.6 0.2 8.5 Marriage before age 18 Percentage of people age 20-49 years who were first married or in union before age 18 (a) Women (b) Men 7.0 1.4 8.6 Young people age 15-19 years currently married or in union Percentage of young people age 15-19 years who are married or in union (a) Women (b) Men 5.0 0.0 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 age 15-19 years, (b) among women age 20-24 years (*) 3.7 Attitudes towards domestic violence 8.12 Attitudes towards domestic violence Percentage of people age 15-49 years who state that a hus- band 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 (a) Women (b) Men 17.1 8.6 8.S1 Attitudes toward physical punishment Percentage of respondents who believe that physical punish- ment is needed to bring up, raise, or educate a child properly 13.4 Children’s living arrangements 8.13 Children’s living arrange- ments Percentage of children age 0-17 years living with neither bio- logical parent 7.8 8.14 Prevalence of children with one or both parents dead Percentage of children age 0-17 years with one or both biolog- ical parents dead 5.8 x Child Development Survey-2016 (Mongolia: Khuvsgul province) CHILD PROTECTION MICS Indicator Indicator Description Value 8.15 Children with at least one parent living abroad Percentage of children 0-17 years with at least one biological parent living abroad 0.2 (*) Figures that are based on less than 25 unweighted cases. HIV/AIDS AND SEXUAL BEHAVIOUR HIV/AIDS knowledge and attitudes MICS Indicator Indicator Description Value - Have heard of AIDS Percentage of people age 15-49 years who have heard of AIDS (a) Women (b) Men 78.7 78.4 9.1 MDG 6.3 Knowledge about HIV prevention among young people Percentage of young people age 15-24 years who correctly identify ways of preventing the sexual transmission of HIV, and who reject major misconceptions about HIV transmission (a) Women (b) Men 24.3 12.8 9.2 Knowledge of mother-to- child transmission of HIV Percentage of people age 15-49 years who correctly identify all three means of mother-to-child transmission of HIV (a) Women (b) Men 24.3 20.0 9.3 Accepting attitudes towards people living with HIV Percentage of people age 15-49 years expressing accepting attitudes on all four questions toward people living with HIV (a) Women (b) Men 1.9 2.3 HIV testing 9.4 People who know where to be tested for HIV Percentage of people age 15-49 years who state knowledge of a place to be tested for HIV (a) Women (b) Men 60.2 39.8 9.5 People who have been tested for HIV and know the results Percentage of people age 15-49 years who have been tested for HIV in the last 12 months and who know their results (a) Women (b) Men 14.4 4.7 9.6 Sexually active young people who have been tested for HIV and know the results Percentage of young people age 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 (a) Women (b) Men 14.4 4.7 9.7 HIV counselling during antenatal care Percentage of women age 15-49 years who had a live birth in the last 2 years and received antenatal care during the preg- nancy of their most recent birth, reporting that they received counselling on HIV during antenatal care 19.0 9.8 HIV testing during antenatal care Percentage of women age 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 39.3 Sexual behaviour 9.9 Young people who have never had sex Percentage of never married young people age 15-24 years who have never had sex (a) Women (b) Men 75.2 49.5 xi Child Development Survey-2016 (Mongolia: Khuvsgul province) 9.10 Sex before age 15 among young people Percentage of young people age 15-24 years who had sexual intercourse before age 15 (a) Women (b) Men 1.1 4.5 9.11 Age-mixing among sexual partners Percentage of women age 15-24 years who had sex in the last 12 months with a partner who was 10 or more years older 2.1 9.12 Multiple sexual partner- ships Percentage of people age 15-49 years who had sexual inter- course with more than one partner in the last 12 months (a) Women (b) Men 0.5 6.5 9.13 Condom use at last sex among people with multi- ple sexual partnerships Percentage of people age 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 (a) Women (b) Men (*) 30.2 9.14 Sex with non-regular partners Percentage of sexually active young people age 15-24 years who had sex with a non-marital, non-cohabitating partner in the last 12 months (a) Women (b) Men 13.7 36.4 9.15 MDG 6.2 Condom use with non-regu- lar partners Percentage of young people age 15-24 years reporting the use of a condom during the last sexual intercourse with a non-mar- ital, non-cohabiting sex partner in the last 12 months (a) Women (b) Men 44.7 82.5 (*) Figures that are based on less 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 people age 15-49 years who, at least once a week, read a newspaper or magazine, listen to the radio, and watch television (a) Women (b) Men 3.2 6.3 Мэдээлэл, харилцааны технологийн хэрэглээ 10.2 Use of computers Percentage of young people age 15-24 years who used a com- puter during the last 12 months (a) Women (b) Men 56.9 47.9 10.3 Use of internet Percentage of young people age 15-24 years who used the internet during the last 12 months (a) Women (b) Men 66.3 61.2 SUBJECTIVE WELL-BEING MICS Indicator Indicator Description Value 11.1 Life satisfaction Percentage of young people age 15-24 years who are very or somewhat satisfied with their life, overall (a) Women (b) Men 89.5 92.8 11.2 Happiness Percentage of young people age 15-24 years who are very or somewhat happy (a) Women (b) Men 87.0 88.3 xii Child Development Survey-2016 (Mongolia: Khuvsgul province) SUBJECTIVE WELL-BEING MICS Indicator Indicator Description Value 11.3 Perception of a better life Percentage of young people age 15-24 years whose life im- proved during the last one year, and who expect that their life will be better after one year (a) Women (b) Men 53.6 31.4 TOBACCO AND ALCOHOL USE Tobacco use MICS Indicator Indicator Description Value 12.1 Tobacco use Percentage of people age 15-49 years who smoked cigarettes, or used smoked or smokeless tobacco products at any time during the last one month (a) Women (b) Men 2.3 54.2 12.2 Smoking before age 15 Percentage of people age 15-49 years who smoked a whole cigarette before age 15 (a) Women (b) Men 0.2 16.7 Alcohol use 12.3 Use of alcohol Percentage of people age 15-49 years who had at least one alcoholic drink at any time during the last one month (a) Women (b) Men 16.7 35.0 12.4 Use of alcohol before age 15 Percentage of people age 15-49 years who had at least one alcoholic drink before age 15 (a) Women (b) Men 0.3 1.4 xiii Child Development Survey-2016 (Mongolia: Khuvsgul province) TABLE OF CONTENT Summary Table of Survey Implementation and Survey Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii Summary Table of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv Table of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx List of Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxii Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii I. Introduction Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Survey Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 II. Sample and Survey Methodology Sample Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Training and Fieldwork . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Data Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 III. Sample Coverage and the Characteristics of Households and Respondents Sample Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Characteristics of Households . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Characteristics of Female and Male Respondents 15-49 Years of Age and Children Under-5 . . . . . . . 17 Housing Characteristics, Asset Ownership, and Wealth Quintiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 IV. Child Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 V. Nutrition Low Birth Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Nutritional Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Breastfeeding and Infant and Young Child Feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Salt Iodization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Vitamin A Supplementation and enriched food consumption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 VI. Child Health Vaccinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Care of Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Diarrhoea and its treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Acute Respiratory Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Solid fuel use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 VII. Water and Sanitation Use of Improved Water Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Use of Improved Sanitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Handwashing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Drinking water quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 VIII. Reproductive Health Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 xiv Child Development Survey-2016 (Mongolia: Khuvsgul province) Unmet Need . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Antenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Assistance at Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Place of Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Post-natal Health Checks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 IX. Child Development Early Childhood Care and Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Quality of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Developmental Status of Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 X. Literacy and Education Literacy among Young Women and Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 School Readiness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Primary and lower secondary education enrolment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 XI. Child Protection Birth Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 Child Labour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Child Discipline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Early Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 Attitudes toward Domestic Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 Children’s Living Arrangements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 Child jockeys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 XII. HIV/AIDS and Sexual Behaviour Knowledge about HIV Transmission and Misconceptions about HIV . . . . . . . . . . . . . . . . . . . . . . . . . . 194 Accepting Attitudes toward People Living with HIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202 Knowledge of a Place for HIV Testing, Counselling and Testing during Antenatal Care . . . . . . . . . . . 205 Sexual Behaviour Related to HIV Transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210 HIV Indicators for Young Women and Young Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213 XIII. Access to Mass Media and Use of Information/Communication Technology Access to Mass Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220 Use of Information/Communication Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224 XIV. Subjective Well-being . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 XV. Tobacco and Alcohol Use Tobacco Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240 Alcohol Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247 XVI. Child Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 Appendices: Appendix A. Sample Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261 Appendix B. List of Personnel Involved in the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267 Appendix C. Estimates of Sampling Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269 Appendix D. Data Quality Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311 Appendix E. MICS5 Indicators: Numerators and Denominators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331 Appendix F. Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345 xv Child Development Survey-2016 (Mongolia: Khuvsgul province) LIST OF TABLES Table HH.1: Results of household, women's, men's and under-5 interviews . . . . . . . . . . . . . . . . . . . 12 Table HH.2: Age distribution of household population by sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Table HH.3: Household composition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Table HH.4: Women's background characteristics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Table HH.4M: Men's background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Table HH.5: Under-5's background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Table HH.6: Housing characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Table HH.7: Household and personal assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Table HH.8: Wealth quintiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Table CM.1: Children ever born, children surviving and proportion dead . . . . . . . . . . . . . . . . . . . . . . 28 Table CM.2: Infant and under-5 mortality rates by background characteristics . . . . . . . . . . . . . . . . . 30 Table CM.3: Early childhood mortality rates by demographic characteristics . . . . . . . . . . . . . . . . . . . 31 Table NU.1: Low birth weight infants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Table NU.2: Nutritional status of children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Table NU.3: Initial breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Table NU.4: Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Table NU.5: Duration of breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Table NU.6: Age-appropriate breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Table NU.7: Introduction of solid, semi-solid8 or soft foods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Table NU.8: Infant and young child feeding (IYCF) practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Table NU.9: Bottle feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Table NU.10: Iodized salt consumption. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Table NU.12: Micronutreint intake among children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Table CH.1: Vaccinations in the first years of life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Table CH.2: Vaccinations by background characteristics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Table CH.4: Reported disease episodes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Table CH.5: Care-seeking during diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Table CH.6: Feeding practices during diarrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Table CH.7: Oral rehydration solutions, recommended homemade fluids, and zinc . . . . . . . . . . . . . 73 Table CH.8: Oral rehydration therapy with continued feeding and other treatments . . . . . . . . . . . . 74 Table CH.10: Care-seeking for and antibiotic treatment of symptoms of acute respiratory infection (ARI). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Table CH.11: Knowledge of the two danger signs of pneumonia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Table CH.12: Solid fuel use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Table CH.13: Solid fuel use by place of cooking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Table WS.1: Use of improved water sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Table WS.2: Household water treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 xvi Child Development Survey-2016 (Mongolia: Khuvsgul province) Table WS.3: Time to source of drinking water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Table WS.4: Person collecting water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Table WS.5: Types of sanitation facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Table WS.6: Use and sharing of sanitation facilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Table WS.7: Drinking water and sanitation ladders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Table WS.7A: Drinking water and sanitation ladders - Country specific . . . . . . . . . . . . . . . . . . . . . . . . . 96 Table WS.8: Disposal of child's faeces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Table WS.9: Water and soap at place for handwashing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Table WS.10: Availability of soap or other cleansing agent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Table WQ.1: Drinking water quality at source at source and household (E. coli) . . . . . . . . . . . . . . . . 103 Table WQ.2: Drinking water quality at source at source and household (Total Coligorms). . . . . . . . 104 Table RH.1: Fertility rates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Table RH.3: Early childbearing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Table RH.4: Trends in early childbearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Table RH.5: Use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Table RH.6: Unmet need for contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Table RH.7: Antenatal care coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Table RH.8: Number of antenatal care visits and timing of first visit . . . . . . . . . . . . . . . . . . . . . . . . . 117 Table RH.9: Content of antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Table RH.10: Assistance during delivery and caesarian section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Table RH.11: Place of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Table RH.12: Post-partum stay in health facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Table RH.13: Post-natal health checks for newborns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Table RH.14: Post-natal care visits for newborns within one week of birth . . . . . . . . . . . . . . . . . . . . 128 Table RH.15: Post-natal health checks for mothers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Table RH.16: Post-natal care visits for mothers within one week of birth. . . . . . . . . . . . . . . . . . . . . . 130 Table RH.17: Post-natal health checks for mothers and newborns . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Table CD.1: Early childhood education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Table CD.2: Support for learning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Table CD.3: Learning materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Table CD.4: Inadequate care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 Table CD.5: Early child development index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Table CD.5A: Early child development index – Country specific . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Table ED.1: Literacy (young women) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Table ED.1M: Literacy (young men) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Table ED.2: School readiness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Table ED.3: Primary school entry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Table ED.4: Primary school attendance and out of school children. . . . . . . . . . . . . . . . . . . . . . . . . . 154 Table ED.5: Secondary school attendance and out of school children . . . . . . . . . . . . . . . . . . . . . . . 156 xvii Child Development Survey-2016 (Mongolia: Khuvsgul province) Table ED.5A: Basic education attendance and out of school children . . . . . . . . . . . . . . . . . . . . . . . . . 157 Table ED.6: Children reaching last grade of primary school . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Table ED.7: Primary school completion and transition to secondary school . . . . . . . . . . . . . . . . . . 160 Table ED.8: Education gender parity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Table CP.1: Birth registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Table CP.2: Children's involvement in economic activities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Table CP.3: Children's involvement in household chores . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Table CP.4: Child labour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 Table CP.5: Child discipline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 Table CP.6: Attitudes toward physical punishment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Table CP.7: Early marriage (women) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 Table CP.7M: Early marriage (men) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Table CP.8: Trends in early marriage (women) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180 Table CP.8M: Trends in early marriage (men) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Table CP.9: Spousal age difference. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 Table CP.13: Attitudes toward domestic violence (women). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 Table CP.13M: Attitudes toward domestic violence (men) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 Table CP.14: Children's living arrangements and orphanhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 Table CP.15: Children with parents living abroad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 Table CP.16: Child jockeys by number of their participation horse races . . . . . . . . . . . . . . . . . . . . . . 189 Table CP.17: Child jockeys by types of horse races . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 Table CP.18: Age at which child jockeys attended horse racing first . . . . . . . . . . . . . . . . . . . . . . . . . . 190 Table CP.19: Use of protective clothing during horse races . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 Table CP.20: Child injuries during the horse races . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 Table CP.21: Social protection for child jockeys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 Table HA.1: Knowledge about HIV transmission, misconceptions about HIV, and comprehensive knowledge about HIV transmission (women). . . . . . . . . . . . . . . . . . . . 197 Table HA.1M: Knowledge about HIV transmission, misconceptions about HIV, and comprehensive knowledge about HIV transmission (men) . . . . . . . . . . . . . . . . . . . . . . 198 Table HA.2: Knowledge of mother-to-child HIV transmission (women) . . . . . . . . . . . . . . . . . . . . . . 200 Table HA.2M: Knowledge of mother-to-child HIV transmission (men) . . . . . . . . . . . . . . . . . . . . . . . . . 201 Table HA.3: Accepting attitudes toward people living with HIV (women) . . . . . . . . . . . . . . . . . . . . . 203 Table HA.3M: Accepting attitudes toward people living with HIV (men) . . . . . . . . . . . . . . . . . . . . . . . 204 Table HA.4: Knowledge of a place for HIV testing (women) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206 Table HA.4M: Knowledge of a place for HIV testing (men). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207 Table HA.5: HIV counselling and testing during antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209 Table HA.6: Sex with multiple partners (women) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211 Table HA.6M: Sex with multiple partners (men) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212 Table HA.7: Key HIV and AIDS indicators (young women). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 Table HA.7M: Key HIV and AIDS indicators (young men) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 Table HA.8: Key sexual behaviour indicators (young women) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216 xviii Child Development Survey-2016 (Mongolia: Khuvsgul province) Table HA.8M: Key sexual behaviour indicators (young men) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 Table MT.1: Exposure to mass media (women) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 Table MT.1M: Exposure to mass media (men). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 Table MT.2: Use of computers and internet (women). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226 Table MT.2M: Use of computers and internet (men) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227 Table SW.1: Domains of life satisfaction (women) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 Table SW.1M: Domains of life satisfaction (men) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232 Table SW.2: Overall life satisfaction and happiness (women) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234 Table SW.2M: Overall life satisfaction and happiness (men) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235 Table SW.3: Perception of a better life (women) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 Table SW.3M: Perception of a better life (men). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 Table TA.1: Current and ever use of tobacco (women) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 Table TA.1M: Current and ever use of tobacco (men) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 Table TA.2: Age at first use of cigarettes and frequency of use (women) . . . . . . . . . . . . . . . . . . . . . 245 Table TA.2M: Age at first use of cigarettes and frequency of use (men) . . . . . . . . . . . . . . . . . . . . . . . 246 Table TA.3: Use of alcohol (women). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248 Table TA.3M: Use of alcohol (men) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249 Table CF.1: Child functioning for children age 2-4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253 Table CF.2: Child functioning for children age 5-17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255 Table CF.3: Use of assistive devices for children age 2-17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257 Table CF.4: Child functioning for children age 2-17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259 Appendices: Table SD.1: Sample sizes of the survey by relative margin of error and key indicator . . . . . . . . . . . 263 Table SD.2: Sample sizes, relative margin of errors and standard errors by region . . . . . . . . . . . . . 263 Table SD.3: Allocation of Sample Clusters (Primary Sampling Units) to Sampling Strata. . . . . . . . . 264 Table SE.1: Indicators selected for sampling error calculations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271 Table SE.2: Sampling errors: Total sample. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275 Table SE.3: Sampling errors: Urban . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279 Table SE.4: Sampling errors: Rural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283 Table SE.5: Sampling errors: Central . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287 Table SE.6: Sampling errors: Tourism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291 Table SE.7: Sampling errors: Agriculture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295 Table SE.8: Sampling errors: Ider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299 Table SE.9: Sampling errors: Tes-Ekh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303 Table SE.10: Sampling errors: Murun. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307 xix Child Development Survey-2016 (Mongolia: Khuvsgul province) Table DQ.1: Age distribution of household population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312 Table DQ.2: Age distribution of eligible and interviewed women . . . . . . . . . . . . . . . . . . . . . . . . . . . 313 Table DQ.3: Age distribution of eligible and interviewed men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314 Table DQ.4: Age distribution of children in household and under-5 questionnaires . . . . . . . . . . . . 314 Table DQ.5: Birth date reporting: Household population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315 Table DQ.6: Birth date and age reporting: Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315 Table DQ.7: Birth date and age reporting: Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316 Table DQ.8: Birth date and age reporting: Under-5s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316 Table DQ.9: Birth date reporting: Children, adolescents and young people . . . . . . . . . . . . . . . . . . . 317 Table DQ.10: Birth date reporting: First and last births . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318 Table DQ.11: Completeness of reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319 Table DQ.12: Completeness of information for anthropometric indicators: Underweight . . . . . . . . 320 Table DQ.13: Completeness of information for anthropometric indicators: Stunting . . . . . . . . . . . . 320 Table DQ.14: Completeness of information for anthropometric indicators: Wasting. . . . . . . . . . . . . 321 Table DQ.15: Heaping in anthropometric measurements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321 Table DQ.16: Observation of birth certificates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322 Table DQ.17: Observation of vaccination cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323 Table DQ.20: Respondent to the under-5 questionnaire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324 Table DQ.21: Selection of children age 1-17 years for the child labour and child discipline modules. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324 Table DQ.22: School attendance by single age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325 Table DQ.23: Sex ratio at birth among children ever born and living . . . . . . . . . . . . . . . . . . . . . . . . . . 326 Table DQ.24: Births by periods preceding the survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327 Table DQ.25: Reporting of age at death in days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328 Table DQ.26: Reporting of age at death in months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329 xx Child Development Survey-2016 (Mongolia: Khuvsgul province) LIST OF FIGURES Figure SM.1: Data processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Figure HH.1: Age and sex distribution of household population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Figure СМ.1: Early childhood mortality rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Figure CM.2: Under-5 mortality rates for the five year period preceding the survey by area and regions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Figure CM.3: Trend in under-5 mortality rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Figure NU.1: Percentage of children under age 5 who are underweight, stunted and wasted . . . . . . 41 Figure NU.2: Initiation of breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Figure NU.4: Percentage of households consuming adequately iodized salt . . . . . . . . . . . . . . . . . . . . 58 Figure CH.1: Vaccinations by age 12 months. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Figure WS.1: Percent distribution of household members by source of drinking water . . . . . . . . . . . 85 Figure ED.1: Education indicators by sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 Figure HA.1: Women and men with comprehensive knowledge of HIV transmission . . . . . . . . . . . . 195 Figure HA.2: Accepting attitudes toward people living with HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . 202 Figure MT.1: Use of access to mass media among young people . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220 Figure MT.2: Use of computers and the internet among young women. . . . . . . . . . . . . . . . . . . . . . . 224 Figure MT.2M: Use of computers and the internet among young men . . . . . . . . . . . . . . . . . . . . . . . . . 224 Figure TA.1: Ever and current smokers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241 Appendix: Figure DQ.1: Number of household population by single ages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313 Figure DQ.2: Weight and height/length measurements by digits reported for the decimal points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322 xxi Child Development Survey-2016 (Mongolia: Khuvsgul province) LIST OF ABBREVIATIONS AIDS Acquired Immune Deficiency Syndrome BCG Bacillus Calmette-Guérin (Tuberculosis) CSPro Census and Survey Processing System DPT Diphtheria Pertussis Tetanus EPI Expanded Programme on Immunization FGM/C Female genital mutilation/cutting GPI Gender Parity Index HIV Human Immunodeficiency Virus IDD Iodine Deficiency Disorders ITN Insecticide Treated Net IUD Intrauterine Device LAM Lactational Amenorrhea Method MDG Millennium Development Goals MICS Multiple Indicator Cluster Survey MICS5 Fifth global round of Multiple Indicator Clusters Surveys programme MoH Ministry of Health NAR Net Attendance Rate ORT Oral rehydration treatment ppm Parts Per Million SDG Sustainable Development Goals SPSS Statistical Package for Social Sciences UNAIDS United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund WFFC World Fit for Children WHO World Health Organization xxii Child Development Survey-2016 (Mongolia: Khuvsgul province) ACKNOWLEDGEMENTS The National Statistical Office has successfully conducted the “Child Development Survey-2016” (Multiple Indicator Cluster Survey) with technical and financial support from the UNICEF. The survey collected data to reveal the present state of children and women in Khuvsgul province, including information related to fulfilment of their rights, health, education, development, protection, livelihood, as well as men’s and women’s knowledge and attitudes towards HIV, AIDS and sexual behaviours. The survey aimed to enrich and refresh the research statistics, and to provide data to measure progress towards achieving the goals of the National Programme of Action for the Development and Protection of Children implemented by the Government of Mongolia, as well as the goals of the "World Fit for Children" and the Millennium Development Goals, Sustainable Development Goals Declaration of the UN General Assembly Special Session on HIV/AIDS and I believe that the results of the “Child Development Survey 2016” will be a source of valuable information for policy-makers and will make a contribution to provision of researchers and users with a wide range of information on children, women and men. Last but not least, special thanks go to all staff members of the survey including supervisors and interviewers of the NSO and Khuvsgul provinces statistical units and the survey staffs who played a key role to ensure the high quality of the CDS through a unified management, methodology and instructions for the survey activities, UNICEF and its Representative in Khuvsgul province, for the provision of technical and methodological recommendations and collaboration for successful conducting of the survey at the international professional standards for the second time in a rural area, specifically in Khuvsgul province, which ranks highest with its number of households and population. A.ARIUNZAYA Chairwoman National Statistical Office of Mongolia xxiii Child Development Survey-2016 (Mongolia: Khuvsgul province) EXECUTIVE SUMMARY The Multiple Indicator Cluster Survey 2016 carried out in Khuvsgul province is a sample survey that represents all households, women and men age 15-49 years, children under age of 5, and children age 5-17 years. The Multiple Indicator Cluster Survey 2016 was carried out with financial and technical support from the United Nations Children's Fund (UNICEF). The survey results refer to the period of survey conduct in October-December 2016, when the data collection fieldwork was implemented. The main results of the survey are summarized below. Child mortality • In Khuvsgul province, the infant mortality rate is 18 per 1,000 live births while the un- der-five mortality rate is 21 per 1,000 live births. In urban areas, the rates of child mortality are higher than in rural areas. While the infant mortality rate in urban areas is 20 per 1,000 live births, it is 17 in rural areas. As for the under-five mortality rate, it is 26 in urban areas and 20 in rural areas. Low birth weight • 99.8 percent of children age 0-23 months were weighed at birth and 5.5 percent of them are estimated to weigh less than 2,500 grams at birth. Child nutrition • Among children under 5 in Khuvsgul province, the underweight prevalence is 1.9 percent, the stunting prevalence is 19.0 percent and the wasting prevalence is 1.6 percent, the over- weight prevalence is 22.1 percent. Breastfeeding • Although it is recommended that all children under age of 6 months to be exclusively breast- fed, only 67.4 percent of those children were exclusively breastfed during the day and night preceding the survey. • The survey results evidence that 8 of every 10 women with a live birth in the two years pre- ceding the survey, put the newborn infant to the breast within 1 hour of birth. • 81.7 percent of children age 12-15 months and 60.0 percent of children age 20-23 months are still being breastfed. • 26.1 percent of children age 6-23 months received minimum acceptable diet during the day and night preceding the survey. Immunization • 89.3 percent of children age 12-23 months received a Tuberculosis vaccination by the age of 12 months. Immunization coverage for Polio at birth is 89.9 percent and the percentage declines for subsequent doses of Polio to 89.6 percent for the first dose, 87.6 percent for the second dose and 85.7 percent for the third dose. Immunization coverage for the first dose of DPT or Penta is 87.9 percent for the first dose, while it drops to 87.8 percent for the second dose and 85.9 percent for the third dose. • 89.7 percent of children age 12-23 months received the dose of Hepatitis B vaccination at birth by the age of 12 months. Immunization coverage for the first dose of Measles, Mumps and Rubella by the age of 12 months is lower than for the other vaccinations. The percent- xxiv Child Development Survey-2016 (Mongolia: Khuvsgul province) age of children who had all the recommended vaccinations by their first birthday is 79.4 percent. Oral rehydration treatment • Approximately, 6.9 percent of children under age of 5 had diarrhoea during the 14 days preceding the survey. • 88.2 percent of children with diarrhoea either received oral rehydration treatment and, at the same time, feeding was continued. • During the diarrhoea episode, 50.6 percent of children drank more than usual while 46.2 percent drank the usual amount or lesser. 79.1 percent of children ate somewhat less, same or more, but 19.2 percent ate much less or almost none. Care seeking and antibiotic treatment of suspected pneumonia • 5.4 percent of children under 5 were reported to have had symptoms of pneumonia during the 14 days preceding the survey. Of these children, 77.0 percent were taken to an appropriate provider. 62.7 percent of children with suspected symptoms of pneumonia had received an antibiotic treatment. • 14.5 percent of mothers know about the two danger signs of pneumonia – fast and difficult breathing. The most commonly identified symptom for taking a child to a health facility is developing fever (80.2 percent). 11.3 percent of mothers identified fast breathing and 5.7 percent identified difficult breathing as symptoms for taking child immediately to a health care provider. Solid fuel use • 98.3 percent of all households in Khuvsgul province use solid fuels for cooking. Four of every five households cook their meal indoors within a part of their dwelling. Water and sanitation • 44.2 percent of the total population in Khuvsgul province has access to an improved source of drinking water. In rural areas (42.2 percent), the use of improved drinking water sources is less than in urban areas (50.8 percent). • 56.6 percent of the total population has access to an improved sanitation facility. There is a rural-urban disparity in the access to improved sanitation: the percentage in urban areas stands at 69.4 percent, while it is 52.8 percent for the rural population. Use of contraception • The current use of contraception was reported at 56.5 percent. The most commonly used method in Khuvsgul province is the IUD which is used by one in every four women (35.8 percent) currently married or in union. The next most common method is the pill (6.4 percent) and the injectable (4.3 percent). • Results of the survey indicate that 21.0 percent of the total women currently married or in union have unmet need for contraception. xxv Child Development Survey-2016 (Mongolia: Khuvsgul province) Antenatal care • The coverage of antenatal care by skilled personnel (a doctor, obstetrician, midwife, or feld- sher) is relatively high with almost all (99.7 percent) of women receiving antenatal care at least once and 91.0 percent at least four times during the pregnancy. Assistance at delivery • 99.9 percent of births for women age 15-49 years, occurred in the two years preceding the CDS survey, were delivered by skilled personnel. 69.7 percent of the total births were delivered with assistance by an obstetrician, 16.5 percent by a midwife, and 11.8 percent by a family or soum doctor. • The percentage of births delivered by an obstetrician is 89.6 among urban women, while the percentage stands at 64.5 for rural women. In Khuvsgul province, 99.6 percent of births in the two years preceding the survey to women age 15-49, were delivered in hospital and 20.4 percent by Caesarean section. Post-natal care • Seven in every 10 women who gave birth within the 2 years preceding the survey stayed 1-2 days in the facility after delivery (67.2 percent). • As far as special checks after birth, by timing is concerned, majority of infants (45.4 percent) received checks by medical personnel within the first week and 3 in every 10 babies within 3-6 days while 16.4 percent did not receive checks at all. However, only 58.4 percent of women received health checks during home visits. This shows that care by health personnel is weakened after release from hospital. Child Development • For 48.5 percent of children age 3-4, an adult household member provided support and engage in more than four activities that promote learning and cognitive development during the three days preceding the survey. The average number of activities that adults engage with children is 3.4. • Fathers’ participation in providing support to children’s development and learning is relatively low, with only 5.6 percent of fathers engage in more than four activity with their children, and 22.6 percent of children age 3-4 were living in a household without their fathers. • Only 17.8 percent of children age 0-59 months are living in households where at least three children's books are present and the percentage of children with 10 or more children's books declines to 2.2 percent. The proportion of children with three or more children's books in urban areas is 26.7 percent, while this rate stands at 15.1 percent for rural areas, which evidences substantially lower opportunities for children in rural areas to have access to books as compared to their urban peers. xxvi Child Development Survey-2016 (Mongolia: Khuvsgul province) Early childhood development index • Early childhood development index is calculated for children age 3-4 years old in Khuvsgul province as 74.7 percent. (ECDI among id somewhat close girls 75.4 percent and boys 74.1 percent). • By ECDI domains, the percentages of children who are developmentally on track in the physical and learning domain is highest (96.4 percent and 94.7 percent, respectively), the percentages of children who are developmentally on track in the social-emotional domain is 77.3, and it is 5.2 percent for the literacy-numeracy domain. Pre-school attendance and school readiness • In Khuvsgul province, 63.0 percent of children age 36-59 months are attending pre-school, while 4.7 percent of children are attending alternative form of education. The attendance in pre-school is 55.4 percent for rural children while it is 84.0 percent for urban children. • The attendance to pre-school education is 86.1 percent among children from the richest households while the rate is four times as less, or only 21.5 percent, among children from the poorest households. • 87.3 percent of children, who were attending the first grade of primary school during the timing of the survey, had attended kindergarten or alternative programme in the preceding academic year. Primary and basic education enrolment/attendance • The primary education enrolment rate is 97.8 percent, with no significant gender differential observed. • 93.7 percent of children of secondary education age 11-14 years are attending applicable level secondary education. • 96.1 percent of all children starting in grade one, continue their education to eventually reach fifth grade, and this indicator is estimated to be at 100 percent among children from the richest and well-off households and at 80.7 percent among children from second quintile households. Birth registration • In Khuvsgul province, the births of 98.9 percent of children under-5 have been registered. There is no significant difference in the child registration by areas, or household wealth. Child labour • 23.2 percent of all children age 5-17 are involved in child labour, and the majority of them (22.0 percent) are enrolled in schools. 16.7 percent of all children are involved in the worst form of labour. • Boys (27.0 percent) and all children in age bracket 12-14 years (27.4 percent) are more in- volved in child labour. By region, one in every 2 children in Agriculture region (50.0 percent) are involved in child labour while in Murun 3.4 percent it is. The percentage of rural children (28.8 percent) age 5-17 who involved in child labour is 8.5 times higher compared to urban children (3.4 percent). xxvii Child Development Survey-2016 (Mongolia: Khuvsgul province) Child discipline • In the one month preceding the survey parents/ caretakers of 42.4 percent of children age 1-14 resorted to non-violent methods of discipline while 44.0 percent were subjected to at least one form of psychological or physical punishment by their mothers/ caretakers or other household members. • 13.4 percent of parents/ caretakers with children age 1-14 believe that children should be physically punished. Although the majority of parents/ caretakers do not believe in necessity of physical punishment for child discipline, yet one out of 3 children (29.4 percent) covered by the survey were punished physically. Early marriage • The percentage of early marriage or the percentage of women married before age 15 is 0.6 while 0.2 percent among men. The percentage of women married before age 18 is 7.0 and 1.4 for men. • In Khuvsgul province, 3.7 percent of the women married at the age of 20-24, have a husband who is 10 or more years older, 22.0 percent of the women have a husband who is 5-9 years older. Attitude towards domestic violence • For the age range of 15-49 in Khuvsgul province, 8.6 percent of men and 17.1 percent of women feel that a husband/ partner has a right to hit or beat his wife/ partner for a particular reason. • Women who approve a husband's violence, in most cases agree and justify violence in instances when the woman neglects the children (13.5 percent), or if she spends significant amount of money without permission from him (7.9 percent). Among men, these two reasons are also the highest ones (5.0 percent and 4.1 percent, respectively). Knowledge, attitudes, and practice about HIV/AIDS • At the Khuvsgul province, 78.7 percent of women age 15-49 and 78.4 percent of men have heard of AIDS. However, the percentage of women and men who knew of the two main ways of HIV prevention – having only one faithful uninfected partner and using a condom every time is comparably low or 62.8 percent and 59.6 percent, respectively. • Women age 15-49 have better knowledge (23.4 percent) than men (12.1 percent) in terms of rejecting the two most common misconceptions: HIV can be transmitted by mosquito bites and sharing foods with person with AIDS and knowing a healthy looking person can have the AIDS virus. • 20.5 percent of women age 15-49 and 9.8 percent of men age 15-49 were found to have comprehensive knowledge. Comprehensive knowledge about HIV/AIDS is 24.3 percent among young women age 15-24 and 12.8 percent among men age 15-24. • 65.4 percent of women age 15-49 know that HIV can be transmitted from mother to child while 60.3 percent of men have this knowledge, which is comparably lower than women. • Very low portion of respondents or 1.9 percent of women age 15-49 and 2.3 percent of men age 15-49 express accepting attitudes on all four questions (would care for family member sick with AIDS; would buy fresh vegetables from a vendor who is HIV positive; thinks that a female teacher who is HIV positive should be allowed to teach in school; and would not want to keep HIV status of a family member a secret). xxviii Child Development Survey-2016 (Mongolia: Khuvsgul province) • The percentage of women age 15-49 who know of a facility for HIV testing is 60.2 percent while it is 39.8 percent for men age 15-49. The percentage who have been tested in the 12 months preceding the survey and told the results is 14.4 percent among women 4.7 percent among men. Sexual behaviour • As for women and men age 15-24, 0.4 percent of women and 8.6 percent of men had sex with more than one partner in the 12 months preceding the survey. 44.7 percent of young women and 82.5 percent of men who had sex with more than one partner used a condom at last sex. • 4.5 percent of men age 15-24 and 1.1 percent of women age 15-24 had sex before age 15 and in the 12 months preceding the survey 2.1 percent of women of this age group had sex with 10 or more years older men. Access to the mass media and Information/ communication technology • 96.6 percent (89.6 percent) of men (women) read newspaper, listen to FM, radio and watch television at least once on a weekly basis, whereas 3.4 percent (10.4 percent) do not have regular exposure to any of the media. • 73.2 percent (78.1 percent) of men (women) age 15-24 ever used a computer, 47.9 percent (56.9 percent) used a computer during the last year, and 31.1 percent (35.9 percent) used at least once a week during the last month. 72.8 percent (76.5 percent) of men (women) age 15-24 ever used the internet, while 61.2 percent (66.3 percent) surfed the internet during the last year. The proportion of young men (women) who used the internet more frequently, at least once a week during the last month, was slighter, at 41.3 percent (48.6 percent). Subjective well-being • Young women age 15-24 are the most satisfied with their family life (93.0 percent), with their school (90.6 percent) and with their friendships (86.9 percent). The results for young men; they are the most satisfied with their family life (94.0 percent), with their way they look (92.7 percent), and with their school (90.3 percent). • 92.8 percent of men age 15-24 and 89.5 percent of women age 15-24 responded that they were satisfied with their lives. • The proportion of men age 15-24 who are very or somewhat happy (88.3 percent) is similar to that of young women (87.0 percent). • 36.6 percent of men and 55.3 percent of women age 15-24 perceive that their lives improved during the one year preceding the survey. However, 78.2 percent of young men and 88.7 percent of young women think that their lives will get better after one year. Use of tobacco and alcohol • Of the total respondents, age 15-49, 89.2 percent of men and 27.1 percent of women reported to have ever used a tobacco product. For the same age category, 54.2 percent of men and 2.3 percent of women smoked cigarettes, or used smoke or smokeless tobacco products during the one month preceding the survey. • In Khuvsgul province, 35.0 percent of men and 16.7 percent of women age 15-49 years had at least one drink of alcohol during the one month preceding the survey. xxix Child Development Survey-2016 (Mongolia: Khuvsgul province) • Among women, 24.5 percent have never tried alcohol, while 0.3 percent first drank alcohol before age 15. Among men, these figures stand at 14.5 percent and 1.4 percent, respectively. Children at increased risk of disability and child injury • 8.4 percent of children age 2-17 years are reported as with functional difficulties. 4.9 percent of urban children are found to be with functional difficulties, while this rate is comparatively increases to 9.6 percent for children living in rural areas. xxx Child Development Survey-2016 (Mongolia: Khuvsgul province) 1 Child Development Survey-2016 (Mongolia: Khuvsgul province) Chapter I INTRODUCTION 2 Child Development Survey-2016 (Mongolia: Khuvsgul province) Background This report is based on the Child Development Survey (Multiple Indicator Cluster Survey (MICS)), conducted in Khuvsgul province in 2016 by the National Statistics Office of Mongolia (NSO) with the technical support of the United Nations Children's Fund (UNICEF) province. The Survey provides valuable information on the status of children and women in Khuvsgul province and gives statistically sound and internationally comparable data essential for developing evidence-based policies and programmes, and for monitoring progress towards local government’s goals and commitments. Besides of local government's commitments, the report will give profound base to monitor goals and objectives set in the Millennium Development Goals (MDGs), Sustainable Development Goals (SDGs) the goals of the United Nations General Assembly Special Session on HIV/AIDS, the World Declarion on Education for All. In signing these international agreements, governments committed themselves to improving conditions for their children and to monitoring progress towards that end. UNICEF was assigned a supporting role in this task (see table below). Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring 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: “…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.” This final report presents the results of the indicators and topics covered in the survey. Survey Objectives The 2016 CDS in Khuvsgul province has as its primary objectives: • To provide up-to-date information for assessing the situation of children and women in Khuvsgul province; 3 I. INTRODUCTION • 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 furnish data needed to monitor progress towards the Millennium Development Goals and other internationally agreed upon goals, as a basis for future action at the provincial level; • To generate data for the assessment of the progress towards of the objectives set out in the UNICEF Country Program for Mongolia, 2012-2016; • To contribute to the generation of baseline data for the post-2016 agenda; • To validate data from other sources and the results of focused interventions. 4 Child Development Survey-2016 (Mongolia: Khuvsgul province) 5 II. SAMPLE AND SURVEY METHODOLOGY Chapter II SAMPLE AND SURVEY METHODOLOGY 6 Child Development Survey-2016 (Mongolia: Khuvsgul province) Sample Design The sample for the Khuvsgul province CDS was designed to provide estimates for a large number of indicators on the situation of children and women at provincial level , for urban and rural areas, for six regions namely Central, Touristic, Agricultural, Ider, Tes-Ekh and Murun. The regions were identified as the main sampling domains and the sample was selected in two stages. At the first stage the primary sampling units (PSUs) were the baghs in soums in Khuvsgul province. A total of 2650 households were selected and selection probabilities and corresponding weights vary by PSUs and by the second stage stratum of households with and without children under 5 years of age. Within each sampling stratum, the sample was selected in two stages. The PSUs within each stratum were selected systematically with probability proportional to size (PPS). After a household listing was carried out in each sample PSU, a systematic sample of households was selected separately for households with and without children, for a total of 25 sample households per PSU. The 2015 official statistics of the household registration was used as a sampling frame. The sample was stratified by region and is not self-weighting. For reporting all survey results, sample weights are used. As it was mentioned before the lowest administrative units (bagh within soum in the province) were defined as primary sampling units. The survey covered 23 soums and 106 sample baghs; the listing of households was updated during September-October 2016. During the data collection fieldwork in October-December 2016, we had encountered problems due to seasonal movement of families; transportation means to reach remote families were broken due to heavy snow falls and severe cold. In spite of this, we managed to collect survey data in all of the 106 selected PSUs. For reporting survey results, sample weights are used. A more detailed description of the sample design can be found in Appendix A, Sample Design. Questionnaires Questionnaire contents and indicators for the survey were identified based on the survey objectives and covering the main indicators of the MICS5 model questionnaire1 recommended by UNICEF. Moreover, the principle of international comparability and with previous surveys was considered. Five 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 age 15-49 years; 3) a questionnaire for individual men administered in every second household to all men age 15-49 years; 4) an under-5 questionnaire, administered to mothers (or caretakers) for all children under 5 living in the household; and 5) a questionnaire for evaluating water quality administered in every third household2. Questionnaire Form for Vaccination Records at Health Facility, which is part of an under 5 questionnaire were used to collect vaccination records for children in cases where their health records/ vaccinations cards were kept at the health facility. This was included as part of the under-five questionnaire. 1 The model MICS5 questionnaires can be found at http://mics.unicef.org/tools 2 This questionnaire is not MICS5 standard questionnaire. The questionnaire developed by UNICEF and became part of the MICS6 standard set. The questionnaire can be found at www.childinfo.org/mics6_questionnaire.html. 7 II. SAMPLE AND SURVEY METHODOLOGY In addition to the administration of the questionnaires, fieldwork teams tested the salt used for cooking in the households for iodine content, observed the place for hand washing and measured the weights and heights of children age under 5 years. Details and findings of these measurements and observations are provided in the respective sections of the report. The household questionnaires included the following modules: • Household information panel; • List of Household Members; • Education; • Child Functioning (age 5-17)3; • Child Labour; • Child Discipline; • Child Jockeys4; • Household Characteristics; • Water and Sanitation; • Hand Washing; • Salt Iodization. The Questionnaire for Women age 15-49 was administered to all women of this age living in the households by separate interviewing and included the following modules: • Woman’s Background; • Access to Mass Media and Use of Information Communication Technology; • Fertility / Birth history; • Desire for Last Birth; • Maternal and Newborn Health; • Post-natal Health Checks; • Illness Symptoms; • Contraception; • Unmet Need; • Attitudes toward Domestic Violence; • Marriage/ Union; • Sexual Behaviour; • HIV/AIDS; • Tobacco and Alcohol Use; • Life Satisfaction. The Questionnaire for Child under 5 was administered to mothers or caretakers of all children under 55 years of age 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: • Age; • Birth Registration; • Early Childhood Development; 3 This module is not MICS5 standard questionnaire. The module developed by UNICEF and became part of the MICS6 standard set. The questionnaire can be found at www.childinfo.org/mics6_questionnaire.html. 4 This module is Country Specific and designed to collect information in Child jockeys 5 The terms “children under 5”, “children age 0-4 years”, and “children age 0-59 months” are used interchangeably in this report. 8 Child Development Survey-2016 (Mongolia: Khuvsgul province) • Breastfeeding and Dietary Intake; • Immunization; • Care of Illness; • Child Functioning (age 2-4)6; • Anthropometry. The Questionnaire for Individual Men was administered to all men age 15-49 years living in every two households by separate interviewing, and included the following modules: • Man’s Background; • Access to Mass Media and Use of Information and Communication Technology; • Fertility; • Attitudes toward Domestic Violence; • Marriage/Union; • Contraception; • Sexual Behaviour; • HIV/AIDS; • Tobacco and Alcohol Use; • Life Satisfaction. Every third household was administered question on drinking-water quality, questioning water source of the household and testing residential water quality, and included the following modules: • Testing of residential water quality; • water quality testing results. The questionnaires were pre-tested in July 2016 in 3 baghs of Kherlen and Tsenkhermandal soums of Khentii province and 2 khesegs of 8th khoroo of Bayangol District, Ulaanbaatar. The pretesting was not carried out with the tablet PCs. Based on the results of the pre-test, modifications were made to the wording of the questionnaires. A copy of the CDS questionnaires is provided in Appendix F. Training and data collection Training for 45 fieldwork personnel was conducted for fifteen days on 10-20 October 2016 by combined forms of lectures and practice sessions. The training included lectures on interviewing techniques and the contents of the questionnaires. Moreover it has concentrated on teaching paper and tablet questionnaires and mock interviews between trainees to gain practice in asking questions. The paper questionnaires testing was carried out in 7th bagh of Murun soum of Khuvsgul province for two days and testing of tablets in 6th bagh for another two days. As module on water quality was included in MICS for the first time, Mr Andrew Shantz consultant of UNICEF has supported training on water quality testing. Finally, all 45 participants were taken tests and the interviewers, editors and supervisors were selected based on their performance in the test. 6 This module is not MICS5 standard questionnaire. The module developed by UNICEF and became part of the MICS6 standard set. The questionnaire can be found at www.childinfo.org/mics6_questionnaire.html. 9 II. SAMPLE AND SURVEY METHODOLOGY The data were collected by five teams; each team was comprised of a supervisor, 5 interviewers (2 men assigned as main measurers) and 2 drivers. The data collection fieldwork was carried out during October 21 to December 10, 2016. Monitoring, assessment and timely clarification of the data entered on the central network during the data collection helped improve the quality of data. In addition, field monitoring visits were done by NSO and UNICEF staff who have been involved in the training process during the data collection processes who observed some interviews and held discussions with the teams to address the issues and inaccuracies and ways for improvement. These contributed to overall quality of the data. Data processing The MICS utilized tablet PCs for data collection. This environmental friendly solution offered many advantages including, sending the data collected from the field immediately to the central office at a click of a button, time saving from data entry (in the case of paper surveys), cost in the long term and ensuring information collected are of high quality. Figure SM.1 shows the data collection and transferring process used in the survey. Figure SM.1: Data processing The data collected by the interviewers from the respondents aggregated at the team supervisors and after required clarification and editing, the data was sent to the central network of the NSO. The data received at the central office were monitored and checked. Where additional clarifications were needed on a particular data, the team supervisors were made to contact the particular household. Followed by entering the survey data to online database using Census and Survey Processing System 5.03 (CSPro 5.03) public domain software. These followed procedures and standard programs developed under the global MICS programme and adapted to the SISS Mongolia 2013 questionnaire were used throughout. 10 Child Development Survey-2016 (Mongolia: Khuvsgul province) Customization of the generic CDS syntaxes developed for MICS5 for the analysis of the data was done. Data were analyzed using the Statistical Package for Social Sciences Version 21.0 (SPSS) software program and model syntax and tabulation plans were developed by global MICS/UNICEF team. 11 III. SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Chapter III SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS 12 Child Development Survey-2016 (Mongolia: Khuvsgul province) Sample coverage Of the 2650 households selected for the sample 2641 households were available. Of these 2626 households were successfully interviewed yielding a response rate of 99.4 percent (Table HH1). A total of 2115 women age 15-49 years were listed within the interviewed households, of which 2039 were successfully interviewed, indicating a response rate of 96.4 percent. The survey also sampled men age 15-49, but required only a subsample of every second household. 1007 men age 15-49 years were listed in the household questionnaires. Questionnaires were completed for 943 eligible men, which corresponds to a response rate of 93.6 percent within eligible interviewed households. In addition, 1134 children under 5 were listed in the household questionnaires. Questionnaires were completed for 1129 of these children, which corresponds to a response rate of 99.6 percent within interviewed households. Overall response rates in Khuvsgul province stands at 93.1 percent of men age 15-49 years, 95.9 percent for women and 99.0 percent calculated for mothers/ caregivers of children under 5. Table HH.1: Results of household, women’s, men’s and under-5 interviews Number of sample households, women, men, and children under 5 by result status, and corresponding response rates, Khuvsgul, 2016 Total Area Region Urban Rural Cen- tral Tourist Agricul- tural Ider Tes-Ekh Murun Households Sampled 2650 575 2075 400 400 425 425 425 575 Occupied 2641 568 2073 399 400 424 425 425 568 Interviewed 2626 562 2064 398 400 423 419 424 562 Response rate 99.4 98.9 99.6 99.7 100.0 99.8 98.6 99.8 98.9 Women Eligible 2115 462 1653 298 326 323 347 359 462 Interviewed 2039 441 1598 292 321 306 334 345 441 Response rate 96.4 95.5 96.7 98.0 98.5 94.7 96.3 96.1 95.5 Overall response rate 95.9 94.4 96.3 97.7 98.5 94.5 94.9 95.9 94.4 Men Eligible 1007 201 806 165 142 162 163 174 201 Interviewed 943 185 758 158 134 156 154 156 185 Response rate 93.6 92.0 94.0 95.8 94.4 96.3 94.5 89.7 92.0 Overall response rate 93.1 91.1 93.6 95.5 94.4 96.1 93.1 89.4 91.1 Under 5 children Eligible 1134 240 894 156 184 181 184 189 240 Interviewed 1129 239 890 156 184 180 183 187 239 Response rate 99.6 99.6 99.6 100.0 100.0 99.4 99.5 98.9 99.6 Overall response rate 99.0 98.5 99.1 99.7 100.0 99.2 98.1 98.7 98.5 The above-mentioned response rates were similar for urban and rural areas, but varied across locations of residence. However, the response rate for men age 15-49 years is relatively lower than the response rates for other groups, because of the dynamic mobility of men, particularly of young men. 13 III. SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Characteristics of households Table HH.2 provides the weighted age and sex distribution of survey population. The distribution is also used to produce the population pyramid in Figure HH.1. In the survey, 8784 persons form 2626 households were successfully interviewed. Of these 4279 were males, and 4505 were females. The population pyramid indicates a drop of proportion of 15-29 age population in households, especially of those adults of age 20-24 in both sexes. The possible reason might be that the proportion of the population lives for schooling or working in urban areas and were not considered as household members. Table HH.2: Household age distribution by sex Percent and frequency distribution of the household population by five-year age groups, dependency age groups, and by child (age 0-17 years) and adult populations (age 18 or more), by sex, Khuvsgul, 2016 Total Male Female Number Percent Number Percent Number Percent Total 8784 100.0 4279 100.0 4505 100.0 Age groups 0-4 1155 13.2 582 13.6 573 12.7 5-9 1083 12.3 562 13.1 521 11.6 10-14 802 9.1 405 9.5 397 8.8 15-19 550 6.3 287 6.7 264 5.9 20-24 411 4.7 221 5.2 190 4.2 25-29 651 7.4 289 6.8 362 8.0 30-34 678 7.7 333 7.8 345 7.6 35-39 638 7.3 305 7.1 333 7.4 40-44 635 7.2 321 7.5 314 7.0 45-49 581 6.6 294 6.9 287 6.4 50-54 500 5.7 225 5.2 275 6.1 55-59 454 5.2 206 4.8 248 5.5 60-64 249 2.8 99 2.3 151 3.3 65-69 162 1.8 52 1.2 110 2.4 70-74 90 1.0 40 0.9 50 1.1 75-79 70 0.8 38 0.9 31 0.7 80-84 46 0.5 9 0.2 37 0.8 85+ 29 0.3 11 0.3 18 0.4 Dependency age groups 0-14 3040 34.6 1549 36.2 1491 33.1 15-64 5348 60.9 2580 60.3 2768 61.4 65+ 397 4.5 150 3.5 247 5.5 Child and adult population Children (age 0-17) 3482 39.6 1772 41.4 1710 38.0 Adult (age 18 and above) 5302 60.4 2507 58.6 2795 62.0 14 Child Development Survey-2016 (Mongolia: Khuvsgul province) Figure HH.1: Age and sex distribution of household population, Khuvsgul, 2016 85+ 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 8 86 64 42 20 Percent Males Females Table HH.2 provide basic information on the household age and sex structure. Among all interviewed the percentage of children, the population in the working age, and old-age groups (0–14, 15–64 and 65 years and over) in the population were 34.6, 60.9 and 4.5 percent, respectively. In CDS 2012, these figures were very consistent over the time - 31.6, 64.6 and 3.7 percent, for 0-14, 15-64 and 65+ year olds respectively. The children of age 0-4 years constitute 13.2 percent showing an increase from 11.9 percent in CDS 2012, indicating the growth in the fertility rates during last few years. The surveyed population indicates a sex ratio of 95 males per 100 female, indicating an increase from 91.8 percent of CDS 2012. The dependency ratio was 64.3 percent, an increase from 54.7 percent in CDS 2012. Similarly, the proportion of children aged 0-17 has slightly increased as 37.9 percent in CDS 2012 and 39.6 percent in this survey. The total number of the children aged 0-17 is 3482 in 2626 households interviewed in this survey. Tables HH.3, HH.4 and HH.5 provide basic information on the households, female respondents age 15-49, male respondents 15-49, and children under-5. Both unweighted and weighted numbers are presented. Such information is essential for the interpretation of findings presented later in the report and provides background information on the representativeness of the survey sample. The remaining tables in this report present only weighted numbers. See Appendix A for details on weighting. Table HH.3 provides basic background information on the households, including the sex of the household head, region, area, number of household members, education of household head, and ethnicity of the household head. These background characteristics are used in subsequent tables in this report; the figures in the table are also intended to show the numbers of observations by major categories of analysis in the report. Table HH.3 provides basic background information on the households. Within households, the sex of the household head, location, number of household members and education, religion and 15 III. SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS ethnicity of the household head are shown in the table. These background characteristics are used in subsequent tables in this report. Table HH.3 shows that 23.0 percent of households are female headed. Eight out of ten households have household head with education level primary or higher (83.9 percent). From the total 2626 interviewed households 629 or 24.0 percent live in soum centers, with the remaining 1997 or 76.0 percent living in rural areas. Of the total households interviewed, 43.7 percent have 3-4 members, households with size of 1-2 members account for 33.0 percent, and those with more than 5 members – 23.3 percent. The mean household size is 3.3 persons. 68.9 percent of all household heads are of Khalkh ethnicity, 17.3 percent Darkhad and 10.0 percent belong to Khotgoid ethnic group. 16 Child Development Survey-2016 (Mongolia: Khuvsgul province) Table HH.3: Household composition Percent and frequency distribution of households by selected characteristics, Khuvsgul, 2016 Weighted percent Number of households Weighted Unweighted Total 100.0 2626 2626 Sex of household head Male 77.0 2023 2043 Female 23.0 603 583 Location Central 19.8 520 398 Touristic 19.3 506 400 Agricultural 12.5 327 423 Ider 12.8 335 419 Tes-Ekh 11.8 309 424 Murun 24.0 629 562 Area Urban 24.0 629 562 Rural 76.0 1997 2064 Number of household members 1 13.4 352 330 2 19.6 514 494 3 22.0 578 580 4 21.7 569 602 5 14.3 376 378 6 6.6 173 173 7 1.6 43 46 8 0.7 17 17 9 0.1 3 6 10+ - - - Education of household head None 16.1 422 440 Primary 24.3 638 614 Basic (lower secondary) 23.6 620 606 Upper secondary 16.2 427 435 Vocational 7.3 191 206 College, university 12.4 326 321 Missing/DK 0.1 1 4 Household wealth index quintile Poorest 20.0 526 525 Second 18.8 493 525 Middle 19.6 515 526 Fourth 22.0 577 525 Richest 19.7 516 525 Ethnicity of household head Khalkh 68.9 1809 1896 Darkhad 17.3 455 326 Khotgoid 10.0 263 288 Others 3.1 81 105 Missing/DK 0.7 17 11 Mean household size 3.3 2626 2626 17 III. SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Characteristics of female and male respondents 15-49 years of age and children under 5 Tables HH.4, HH.4M and HH.5 provide information on the background characteristics of female and male respondents 15-49 years of age and of children under age 5. In all three 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, men, and children under age five, the tables are also intended to show the numbers of observations in each background category. Table HH.4 presents background characteristics of women age 15-49 years. The data are disaggregated by location, age group, marital status, motherhood status, births in last two years, education1, household wealth index quintiles2, and ethnicity of household head. The table indicates that the highest percentage of women 24.5 percent reside in Murun. The Agricultural location accounted for the lowest percentage of 11.6 percent. 75.5 percent of the all women live in rural areas with the remaining living in urban areas. As mentioned before percentage of female population age 20-24 accounts for the lowest share accounting 9.1 percent. By marital status, the percentage of women who are currently married or in union was 72.2 percent, 21.7 percent have never been married or been in union, 2.3 percent are divorced, 2.4 percent are widowed and remaining 0.9 percent are separated. 19.5 percent of the total women had given a birth to a child in the two years preceding the survey. In terms of education, 9.1 percent of women have no education, 10.4 percent attained primary education, 27.1 percent have basic education, 24.3 percent have upper secondary education, 7.3 percent have vocational education, and 21.7 percent have college, university education. 1 Throughout this report, unless otherwise stated, “education” refers to the highest educational level ever attended by the respondent when it is used as a background variable. 2 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 2016 MICS (CSD), the following assets were used in these calculations: dwelling type, flooring material, roof material, walls material, number of rooms used for sleeping, household and personal assets /radio, television, non-mobile telephone, refrigerator, a renewable energy generator, computer, internet connection, washing machine, vacuum cleaner, library, microwave, iron, motorcycle, animal drawn cart, car or truck, tractor, agricultural land, farm animals/livestock, watch, mobile telephone, bicycle, video or photo camera, ownership of dwelling/, and water and sanitation facilities. 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 18 Child Development Survey-2016 (Mongolia: Khuvsgul province) Table HH.4: Women’s background characteristics Percent and frequency distribution of women age 15-49 years by selected background characteristics, Khuvsgul, 2016 Weighted percent Number of women Weighted Unweighted Total 100.0 2039 2039 Location Central 19.0 387 292 Touristic 19.2 392 321 Agricultural 11.6 237 306 Ider 13.1 266 334 Tes-Ekh 12.7 258 345 Murun 24.5 499 441 Area Urban 24.5 499 441 Rural 75.5 1540 1598 Age group 15-19 12.5 254 247 20-24 9.1 185 198 25-29 17.3 352 346 30-34 16.6 338 324 35-39 16.0 327 324 40-44 15.0 306 296 45-49 13.6 278 304 Marital status Currently married/in union 72.7 1483 1473 Widowed 2.4 49 51 Divorced 2.3 47 52 Separated 0.9 18 21 Never married/in union 21.7 442 442 Motherhood and recent births Never gave birth 17.8 363 363 Ever gave birth 82.2 1676 1676 Gave birth in last two 19.5 397 400 No birth in last two years 62.1 1267 1265 Education None 9.1 185 187 Primary 10.4 212 206 Basic (lower secondary) 27.1 553 553 Upper secondary 24.3 496 508 Vocational 7.3 149 159 College/University 21.7 443 425 Missing/DK 0.0 - 1 Wealth index quintile Poorest 20.3 414 403 Second 18.2 371 391 Middle 18.6 380 405 Fourth 21.3 433 413 Richest 21.6 441 427 Ethnicity of household head Khalkh 68.8 1402 1475 Darkhad 16.7 340 252 Khotogoid 10.5 214 231 Others 2.9 59 69 Missing/DK 1.2 24 12 19 III. SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Table HH.4M: Men’s background characteristics Percent and frequency distribution of men age 15-49 years by selected background characteristics, Khuvsgul, 2016 Weighted percent Number of men Weighted Unweighted Total 100.0 943 943 Location Central 21.6 203 158 Touristic 18.9 178 134 Agricultural 13.7 129 156 Ider 12.1 114 154 Tes-Ekh 13.0 123 156 Murun 20.7 196 185 Area Urban 20.7 196 185 Rural 79.3 747 758 Age group 15-19 13.5 127 136 20-24 9.6 91 101 25-29 14.0 132 137 30-34 17.3 163 153 35-39 15.9 150 140 40-44 15.4 145 132 45-49 14.4 136 144 Marital status Currently married/in union 70.3 663 627 Widowed 0.2 2 2 Divorced 1.2 12 17 Separated 0.6 6 7 Never married/in union 27.7 261 290 Fatherhood status Has at least one living child 70.0 660 627 Has no living children 29.8 281 313 Missing/DK 0.2 2 3 Education None 16.7 157 157 Primary 18.3 173 161 Basic (lower secondary) 27.9 263 269 Upper secondary 20.5 194 196 Vocational 7.1 67 59 College/University 9.3 88 99 Missing/DK 0.1 1 2 Wealth index quintile Poorest 22.4 211 224 Second 21.1 199 191 Middle 17.7 167 178 Fourth 19.2 181 159 Richest 19.6 185 191 Ethnicity of household head Khalkh 69.2 652 684 Darkhad 16.2 152 110 Khotogoid 11.4 107 118 Others 2.6 24 28 Missing/DK 0.7 7 3 20 Child Development Survey-2016 (Mongolia: Khuvsgul province) Similarly, Table HH.4M provides background characteristics of male respondents 15-49 years of age. The table shows information on the distribution of men according to region, area, age, marital status, fatherhood status, education, wealth index quintiles, and ethnicity of the household head. By urban and rural areas, 79.3 percent of the all women live in rural areas with the remaining living in rural areas of the country. 70.3 percent of all men surveyed are married or in union, 27.7 percent are never married or been in union, and the remaining 2.0 percent are either divorced, separated or widowed. Males have lower level of education compared to females: 16.7 percent have no education, 18.3 percent have primary education, 27.9 percent with basic education, 20.5 percent have upper secondary education, 7.1 percent have vocational education, and 9.3 percent with college, university education. 21 III. SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Table HH.5: Under-5’s background characteristics Percent and frequency distribution of children under five years of age by selected characteristics, Khuvsgul, 2016 Weighted percent Number of under-5 children Weighted Unweighted Total 100.0 1129 1129 Sex Male 50.4 569 567 Female 49.6 560 562 Region Central 18.1 205 156 Touristic 22.0 248 184 Agricultural 11.7 132 180 Ider 12.8 144 183 Tes-Ekh 12.1 137 187 Murun 23.3 263 239 Area Urban 23.3 263 239 Rural 76.7 866 890 Age group 0-5 months 8.9 100 106 6-11 months 11.0 124 105 12-23 months 17.3 195 208 24-35 months 21.7 245 249 36-47 months 20.9 235 237 48-59 months 20.3 229 224 Respondent to the under-5 questionnaire Mother 93.0 1050 1044 Other primary caretaker 7.0 79 85 Mother’s educationa None 11.6 131 141 Primary 9.1 103 121 Basic (lower secondary) 15.5 175 185 Upper secondary 26.1 294 287 Vocational 7.7 87 87 College/University 30.1 340 307 Missing/DK 0.0 - 1 Wealth index quintile Poorest 18.6 210 233 Second 15.9 179 208 Middle 23.1 261 244 Fourth 20.2 228 208 Richest 22.2 250 236 Ethnicity of household head Khalkh 66.5 751 804 Darkhad 18.9 213 141 Khotogoid 10.5 119 130 Others 3.7 42 49 Missing/DK 0.3 4 5 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. 22 Child Development Survey-2016 (Mongolia: Khuvsgul province) 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 to the under 5 questionnaire, mother’s/caretaker’s education, household's wealth, and ethnicity of head of household. From the total of 1129 children under 5 covered by the survey, male proportion is 50.4 percent and female proportion is 49.6 percent. By education of their mothers/ caretakers, 11.6 percent have no education, 9.1 percent have primary education, 15.5 percent have basic education, 26.1 percent with upper secondary education, 7.7 percent have vocational education, and 30.1 percent have college, university education. 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. Among all households 2.7 percent of households in the urban areas and 47.4 percent of the total rural population do not have access to electricity. In terms of regional disparities, the agricultural region (44.1%) and Ider region (45.7%) have the lowest percentage of households with electricity. Murun region has the highest percentage with electricity with 97.3 percent of households. The overall percentage of the households whose dwelling had rudimentary floor3 was 43.5 percent, households with finished floor4 account for 16.3 percent and households with natural/ no flooring stand at 40.1 percent. 20.7 percent of households in urban areas and 46.2 percent of households in rural areas have natural /no flooring. The highest rate of the dwelling with natural/ no flooring was in Ider region at 62.9 percent, while it was lowest in Murun region at 20.7 percent. As regards the material of the dwelling roof, 99.8 percent of the all households were living in the houses with finished roof5. 3 Material of rudimentary floor included wood and wood planks. 4 Material of finished floor included Parquet or polished wood, Concrete, vinyl/ asphalt strips, Ceramic tiles and Cement. 5 If ger, material of finished roof included roof double layered in winter time, if other house, material of finished roof included Metal/ Tin, Wood, Concrete/ Cement fibre, Ceramictiles, Cement, Roofing shingles and Tar paper. 23 III. SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Table HH.6: Housing characteristics Percent distribution of households by selected housing characteristics, according to area of residence and regions, Khusvgul, 2016 Total Area Region Urban Rural Central Touristic Agricul- tural Ider Tes-Ekh Murun Electricity Yes 63.3 97.3 52.6 47.9 66.9 44.1 45.7 53.4 97.3 No 36.7 2.7 47.4 52.1 33.1 55.9 54.3 46.6 2.7 Flooring Natural floor/No flooring 40.1 20.7 46.2 56.8 27.4 29.7 62.9 58.3 20.7 Rudimentary floor 43.5 48.8 41.8 30.2 68.4 56.6 22.5 23.2 48.8 Finished floor 16.3 30.3 11.9 12.8 4.2 13.7 14.6 18.0 30.3 Other 0.2 0.2 0.2 0.2 0.1 0.0 0.0 0.5 0.2 Roof Finished roofing 99.8 100.0 99.8 99.4 100.0 100.0 100.0 99.6 100.0 Other 0.2 0.0 0.2 0.6 0.0 0.0 0.0 0.4 0.0 Exterior walls Rudimentary walls 1.7 3.9 1.0 1.4 0.1 0.6 0.4 3.1 3.9 Finished walls 97.8 95.4 98.5 97.9 99.9 99.4 99.4 95.5 95.4 Other 0.5 0.7 0.5 0.7 0.0 0.0 0.2 1.5 0.7 Rooms used for sleeping 1 88.7 74.7 93.1 94.2 93.4 92.8 92.3 92.2 74.7 2 10.1 20.8 6.7 5.6 6.5 7.2 7.7 7.1 20.8 3 or more 1.2 4.6 0.2 0.1 0.1 0.0 0.0 0.7 4.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 2626 629 1997 520 506 327 335 309 629 Mean number of persons per room used for sleeping 2.96 2.59 3.14 3.25 3.11 3.22 2.99 3.02 2.59 In the interviewed households, 97.8 percent live in houses with finished walls6, while 1.7 percent live in households with rudimentary walls7, wooden or timber walls. 88.7 percent of survey respondents had one-room used for sleeping, 10.1 percent had two, while only 1.2 percent had 3 or more rooms. In Table HH.7, households and individual household members assets are distributed by urban and rural areas and regions. This also includes ownership of dwelling. The higher use of electrical appliances by the households in urban areas in comparison with the households in rural areas is related to the access to electricity as shown in Table HH.6. Whereas the households in the rural areas use radio, solar energy panels and wind power turbines, animal cart and tractors in their everyday life and agricultural activities more than those in urban areas. 6 If ger, material of finished walls included walls double layered in winter time, if other house, material of finished walls included Cement, Stone with lime/ cement, Cement blocks, Covered adobe, Wood planks, shingles, logs, Decorative bricks and Construc- tion bricks. 7 If ger, material of rudimentary walls included walls single layered in winter time, if other house, material of rudimentary walls included Stone with mud, Uncovered adobe, Plywood and Reused wood. 24 Child Development Survey-2016 (Mongolia: Khuvsgul province) According to the survey, 2.0 percent of household own agricultural land, 1.7 percent in urban and 2.1 in rural areas. The highest number of households who own agricultural area account for those in Agricultural region and standing at 6.8 percent. Of total respondents 65.2 percent have domestic and pet animals, of which 22.1 percent reside in urban areas and 78.8 percent reside in rural areas. Table HH.7: Household and personal assets Percentage of households by ownership of selected household and personal assets, and percent distribution by ownership of dwelling, according to area of residence and regions, Khuvsgul, 2016 Total Area Region Urban Rural Cen- tral Touristic Agricul- tural Ider Tes- Ekh Murun Percentage of households that own a Radio 5.9 7.0 5.5 7.1 4.9 8.2 3.4 3.5 7.0 Television 85.5 94.9 82.5 78.9 85.7 85.3 81.6 81.5 94.9 Stationary phone 19.2 2.7 24.3 20.0 17.0 32.2 32.3 26.8 2.7 Refrigerator 44.9 79.0 34.2 27.1 35.6 39.4 34.1 38.5 79.0 Renewable energy generator 38.0 3.7 48.8 51.0 35.7 58.8 51.0 53.5 3.7 Computer 14.9 25.6 11.5 12.4 14.8 10.1 7.0 11.2 25.6 Internet connection 5.4 13.3 2.9 1.4 1.5 6.1 3.0 4.0 13.3 Washing machine 52.7 78.4 44.6 41.4 57.0 40.7 34.8 44.7 78.4 Vacuum cleaner 17.6 36.1 11.7 9.4 10.6 13.3 11.7 15.7 36.1 Library 11.8 18.4 9.7 10.5 6.8 13.0 9.2 10.0 18.4 Microwave 8.1 12.9 6.6 4.4 10.3 6.7 7.0 4.1 12.9 Iron 56.9 81.3 49.2 39.9 62.9 52.0 44.4 44.7 81.3 Motorcycle 45.0 12.0 55.3 59.0 54.4 52.2 54.8 54.7 12.0 Animal drawn cart 7.8 0.5 10.2 11.5 12.1 14.2 7.0 3.9 0.5 Car or truck 36.0 40.5 34.7 32.2 36.8 40.8 27.9 36.1 40.5 Tractor 4.0 0.7 5.0 2.1 3.0 18.8 1.6 2.1 0.7 Percentage of households that own Agricultural land 2.0 1.7 2.1 2.8 0.3 6.8 1.1 0.2 1.7 Farm animals/Livestock 65.2 22.1 78.8 77.2 76.1 75.7 86.8 80.1 22.1 Percentage of households where at least one member owns or has a Watch 28.2 40.6 24.4 24.7 26.4 28.1 21.4 19.7 40.6 Mobile phone 92.7 97.5 91.2 90.9 93.2 91.6 88.2 91.2 97.5 Bicycle 2.1 4.6 1.3 1.1 0.7 2.9 0.4 1.8 4.6 Video or photo camera 6.3 10.3 5.0 5.4 1.9 7.6 4.5 7.2 10.3 Bank account 43.0 39.3 44.1 45.2 43.1 53.8 34.3 44.5 39.3 Ownership of dwelling Owned by a household member 92.5 88.9 93.7 91.2 93.2 92.7 96.9 96.3 88.9 Not owned 7.5 11.1 6.3 8.8 6.8 7.3 3.1 3.7 11.1 Rented 1.2 2.0 0.9 1.6 1.1 0.5 0.1 0.6 2.0 Other 6.3 9.1 5.4 7.3 5.7 6.9 3.0 3.2 9.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of households 2626 629 1997 520 506 327 335 309 629 On ownership of dwelling, 88.9 percent of the households in urban areas and 93.7 percent in rural areas own their dwellings, whereas the rest of the households either rent or live in someone else’s dwelling without paying rent. 25 III. SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS In order to construct the wealth index, principal components analysis was performed by using information on the ownership of consumer goods, dwelling characteristics, access to water and sanitation, and other household characteristics that are related to the household’s wealth to generate weights (factor scores) for each of the items used. Each household is assigned a wealth score based on the assets owned by that household8. The survey household population is then ranked from lowest to the highest according to the wealth score of the household they are living in, and is divided into 5 equal parts (quintiles). Table HH.8 shows how the household populations in areas and regions are distributed according to household wealth quintiles. There was a significant difference in the distribution of households by wealth index quintiles between the urban and rural areas. It can be seen from the table that 1.3 percent of the household populations in urban areas were in the lowest wealth quintile, while this quintile was for 25.1 percent for the population living in the rural area. 41.9 percent of the households in urban area were in the richest quintile, and in rural area 14.0 percent. Table HH.8: Wealth quintiles Percent distribution of the household population by wealth index quintiles, according to area of residence and regions, Khuvsgul, 2016 Wealth index quintiles Total Number of householdsPoorest Second Middle Fourth Richest Total 19.6 18.1 20.1 21.7 20.5 100.0 8784 Area Urban 1.3 7.7 22.7 26.4 41.9 100.0 2047 Rural 25.1 21.3 19.3 20.3 14.0 100.0 6737 Region Central 30.1 25.3 13.4 20.3 10.9 100.0 1734 Tourism 14.6 16.3 24.4 30.3 14.4 100.0 1744 Agricultural 14.5 21.2 27.7 20.9 15.7 100.0 1073 Ider 35.5 22.5 14.8 11.4 15.7 100.0 1100 Tes-Ekh 34.1 21.9 16.5 12.6 15.0 100.0 1086 Murun 1.3 7.7 22.7 26.4 41.9 100.0 2047 By regions, 72.9 percent of the household populations in Ider, 72.5 percent in Tes-Ekh and 68.8 percent in Central regions are in the middle, second or poorest wealth index. However, 68.3 percent of the household populations in Murun are the fourth or richest wealth index quintile. 8 See the following sources for more details on how to construct the wealth index. 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, S.O. and Johnson, K., 2004. The DHS Wealth Index. DHS Comparative Reports No. 6. Calverton, Maryland: ORC Macro Rutstein, S.O., 2008. The DHS Wealth Index: Approaches for Rural and Urban Areas. DHS Working Papers No. 60. Calverton, Maryland: Macro International Inc. 26 Child Development Survey-2016 (Mongolia: Khuvsgul province) 27 IV. CHILD MORTALITY Chapter IV CHILD MORTALITY 28 Child Development Survey-2016 (Mongolia: Khuvsgul province) One of the overarching goals of the Sustainable Development Goals (SDGs) is the reduction of infant and under-five mortality Monitoring progress towards this goal is an important, but difficult objective. Mortality rates presented in this chapter are calculated from information collected in the birth histories of the Women’s Questionnaires. All interviewed women were asked whether they had ever given birth, and if yes, they were asked to report the number of sons and daughters who live with them, the number who live elsewhere, and the number who have died. In addition, they were asked to provide a detailed birth history of live births of children in chronological order starting with the firstborn. Women were asked whether births were single or multiple, the sex of the children, the date of birth (month and year), and survival status. Further, for children still alive, they were asked the current age of the child and, if not alive, the age at death. Childhood mortality rates are expressed by conventional age categories and are defined as follows: • Neonatal mortality (NN): probability of dying within the first month of life; • Post-neonatal mortality (PNN): difference between infant and neonatal mortality rates; • Infant mortality (1q0): probability of dying between birth and the first birthday; • Child mortality (4q1): probability of dying between the first and the fifth birthdays; • Under-five mortality (5q0): the probability of dying between birth and the fifth birthday. Rates are expressed as deaths per 1,000 live births, except in the case of child mortality, which is expressed as deaths per 1,000 children surviving to age one, and post-neonatal mortality, which is the difference between infant and neonatal mortality rates. Table CM.1: Early childhood mortality rates Neonatal, post-neonatal, Infant, child and under-five mortality rates for five year periods preceding the survey, Khuvsgul, 2016 Neonatal mortality rate1 Post-neonatal mortality rate2, a Infant mortality rate3 Child mortality rate4 Under-five mortality rate5 Years preceding the survey 0-4 14 9 23 1 24 5-9 14 10 24 3 27 10-14 31 15 45 7 52 1 MICS indicator 1.1 - Neonatal mortality rate 2 MICS indicator 1.3 - Post-neonatal mortality rate 3 MICS indicator 1.2; MDG indicator 4.2 - Infant mortality rate 4 MICS indicator 1.4 - Child mortality rate 5 MICS indicator 1.5; MDG indicator 4.1 - Under-five mortality rate a Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates 29 IV. CHILD MORTALITY Figure CM.1: Early childhood mortality rates, Khuvsgul, 2016 14 14 15 10 9 24 45 23 3 1 7 27 24 24 33 2 35 11 22 41 41 19 52 31 Years preceding the survey Neonatal mortality rate Note: Indicator values are per 1,000 live births Post-neonatal mortality rate Infant mortality rate Child mortality rate Under-five mortality rate Table CM.1 and Figure CM.1 present neonatal, post-neonatal, infant, child, and under-five mortality rates for the three most recent five-year periods before the survey. Neonatal mortality in the most recent 5-year period is estimated at 14 per 1,000 live births, while the post-neonatal mortality rate is estimated at 9 per 1,000 live births. The infant mortality rate in the five years preceding the survey is 23 per 1,000 live births and under five mortality is 24 deaths per 1,000 live births for the same period. The table and figure also show a declining trend at the Khuvsgul province level, during the last 15 years, with under-five mortality at 52 per 1,000 during the 10-14 year period preceding the survey, 27 per 1,000 during the 5-9 year period preceding the survey and 24 per 1,000 live births during the most recent 5-year period, roughly referring to the years of 2012-2016. A similar pattern is observed in all other indicators. 30 Child Development Survey-2016 (Mongolia: Khuvsgul province) Table CM.2: Early childhood mortality rates by socioeconomic characteristics Neonatal, post-neonatal, Infant, child and under-five mortality rates for the five year period preceding the survey, by socioeco- nomic characteristics, Khuvsgul, 2016 Neonatal mortality rate1 Post- neonatal mortality rate2, a Infant mortality rate3 Child mortality rate4 Under-five mortality rate5 Total 14 9 23 1 24 Region Central (*) 15 33 0 33 Tourism (*) 2 2 0 2 Agriculture (*) (24) (33) (2) 35 Ider (*) (6) 11 0 11 Tes-Ekh (*) (0) 22 0 22 Murun (26) 11 37 4 41 Area Urban (26) 11 37 4 41 Rural 10 9 19 0 19 Mother's education None (*) (9) 28 0 28 Primary (*) (36) (55) 0 55 Basic (lower secondary) (*) 11 15 0 15 Upper secondary (5) 8 13 1 14 Vocational (*) (*) (0) (*) (0) College, university (26) 2 28 4 31 Wealth index quintile Poorest (*) 3 16 0 16 Second (*) 11 14 0 14 Middle (*) 21 24 0 24 Fourth (*) 11 21 4 25 Richest (*) 0 39 2 41 Ethnicity of household head Khalkh 16 10 26 1 27 Darkhad (*) 3 4 1 6 Khotgoid (*) (4) (30) (0) 30 Other (*) (*) (*) (*) (55) 1 MICS indicator 1.1 - Neonatal mortality rate 2 MICS indicator 1.3 - Post-neonatal mortality rate 3 MICS indicator 1.2; MDG indicator 4.2 - Infant mortality rate 4 MICS indicator 1.4 - Child mortality rate 5 MICS indicator 1.5; MDG indicator 4.1 - Under-five mortality rate a Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates ( ) Figures that are based on 250-499 unweighted exposed persons. (*) Figures that are based on less than 250 unweighted exposed persons. 31 IV. CHILD MORTALITY Table CM.3: Early childhood mortality rates by demographic characteristics Neonatal, post-neonatal, Infant, child and under-five mortality rates for the five year period preceding the survey, by demographic characteristics, Khuvsgul, 2016 Neonatal mortality rate1 Post- neonatal mortality rate2, a Infant mortality rate3 Child mortality rate4 Under-five mortality rate5 Total 14 9 23 1 24 Sex of child Male 9 4 13 0 13 Female 19 15 33 3 36 Mother's age at birth Less than 20 (*) (*) (*) (*) (13) 20-34 10 10 20 2 21 35-49 (*) (9) 42 0 42 Birth order 1 (14) 1 15 3 18 2-3 4 11 15 1 15 4-6 (*) 18 60 0 60 7+ (*) (*) (*) (*) (*) Previous birth intervalb < 2 years (*) (24) 46 0 46 2 years (*) (7) 8 0 8 3 years (*) (21) (4) (0) 33 4+ years (15) 8 24 1 24 1 MICS indicator 1.1 - Neonatal mortality rate 2 MICS indicator 1.3 - Post-neonatal mortality rate 3 MICS indicator 1.2; MDG indicator 4.2 - Infant mortality rate 4 MICS indicator 1.4 - Child mortality rate 5 MICS indicator 1.5; MDG indicator 4.1 - Under-five mortality rate a Post-neonatal mortality rates are computed as the difference between the infant and neonatal mortality rates b Excludes first order births ( ) Figures that are based on 250-499 unweighted exposed persons. (*) Figures that are based on less than 250 unweighted exposed persons. Tables CM.2 and CM.3 provide estimates of child mortality for the 5 year period preceding the survey by socioeconomic and demographic characteristics. By region, infant and under- five mortality rates are the lowest in Tuirism region (2 per 1000 births and 2 per 1000 births, respectively), while this indicators are the highest in Murun (37 per and 41 per 1000 births, respectively), compared to other regions. There are also differences in mortality in terms of educational levels, wealth, and ethnicity. Children born to mothers with higher educational level have less chance of dying before the fifth birthday compared to children born to mothers with little or no education. However, children born to poorest and second wealth quintile of housoholds have less chance of dying before the fifth birthday compared to children born to richest wealth quintile of households. Under-five mortality rate is highest (30 per 1,000 live births) in households headed by Khotgoid (Table CM.2). As seen in Table СМ.3, probability of dying among females is approximately 2.8 times higher than males. Neonatal mortality rate is 19 per 1000 live births and infant mortality is 33 while under-5 mortality is 36 among girls while for the same indicators, the probability of dying are 9, 13 and 32 Child Development Survey-2016 (Mongolia: Khuvsgul province) 13, respectively among boys. Table СМ.3 also shows a relationship between the birth order of the child and the probability of dying before his/her first birthday. Children born in the 4-6th birth order have higher probability of dying before their first birthday compared to children who are first in the birth order. Similarly, children born to older women, 35-49 year olds, have less chances of surviving to their first birthday compared to those born to younger women, 20-34 year olds. The child mortality, by area still remains high in urban area. Specifically, infant mortality is 37 per 1000 live births, and under-5 mortality is 41 per 1000 live births for the urban area which are approximately two times higher than those in rural area. Figure CM.2: Under-5 mortality rates for the five year period preceding the survey by area and regions, Khuvsgul, 2016 14 14 15 10 9 24 45 23 3 1 7 27 24 24 33 2 35 11 22 41 41 19 52 31 Survey name Under-5 Mortality Rates per 1,000 Births Region Central Tourism Agriculture Ider Tes-Ekh Murun Area Urban Rural 33 IV. CHILD MORTALITY Figure CM.3 compares the findings of CDS 2016 on under-5 mortality rates with those from other data sources such as the Ministry of Health and the previous Child Development Surveys (2012). CDS 2016 findings are obtained from Table CM.1. The previous Child Development Surveys (2012) used indirect estimation method of the Brass and Coale method1 in their estimation of infant and under 5 mortality rates. The CDS 2016 estimates indicate a decline in child mortality during the last 15 years in Khuvsgul, which corresponds to decline in the mortality trend depicted by the vital statistics (administrative) data of the Ministry of Health. The administrative data reveal that under-five mortality was 29 per 1000 live births in 2005 which remained at 39 in 2010 and dropped to 32 in 2016.2 In 2016 child mortality rate is increased by data of the Ministry of Health, which reason is measles disease. Further qualification of these apparent declines and differences as well as, its determinants should be taken up in a more detailed and separate analysis. Figure CM.3: Trend in under-5 mortality rates, Khuvsgul, 2016 Per 1,000 live birth CDS5 2012 indirect methodCDS5 2016 direct method Ministry of Health 1 UN, 1983. Manual X: Indirect method and techniques for demographic estimation (UN’s publication, commercial № E.83.XIII,2). UN, 1990а.Q-five, UN program for child mortality. New York, Demographic Division, UN 1990b. Estimation manual of child mor- tality. New York, UN. 2 NSO, 2005, 2010, 2016.Statistical Yearbook.Mongolia. 34 Child Development Survey-2016 (Mongolia: Khuvsgul province) 35 V. NUTRITION Chapter V NUTRITION 36 Child Development Survey-2016 (Mongolia: Khuvsgul province) 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. Those who survive may have impaired immune function and increased risk of disease; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and 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 disabilities, 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 the most impact: the mother's poor nutritional status before conception, short stature (due mostly to under nutrition 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. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run a higher risk of bearing low birth weight babies. One of the major challenges in measuring the incidence of low birth weight is that more than half of infants in the developing world are not weighed at birth. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of newborns are not delivered in facilities, and those who are represent only a selected sample of all births. In Mongolia, majority of newborns are delivered in health facilities and measuring of birth weight is a common practice. Because many infants are not weighed at birth and those who are weighed may be biased 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 birth1. In Khuvsgul province, 99.8 percent of all children who were born in the 2 years preceding the survey were weighed at birth and 5.5 percent of infants weighed less than 2500 grams at birth (Table NU.1). The percentage of children weighed at birth and the percentage of low birth weight do not vary by regions, rural and urban areas, mother’s age at birth, birth interval and household wealth index quintiles (Table NU.1). 1 For a detailed description of the methodology, see Boerma, J. T., Weinstein, K. I., Rutstein, S.O., and Sommerfelt, A. E. , 1996. Data on Birth Weight in Developing Countries: Can Surveys Help? Bulletin of the World Health Organization, 74(2), 209-16 37 V. NUTRITION However, the percentage of low birth weight varies a bit by birth order. Thus, underweighted babies are prevalent among the first births standing at 7.5 percent compared to those who are the second and consequent order births. By region, Murun (7.3 percent) has the highest of low birth weight newborns. Low birth weight was the highest in middle wealth quintile households (7.5 percent). 38 Child Development Survey-2016 (Mongolia: Khuvsgul province) 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, Khuvsgul, 2016 Percent distribution of births by mother's assessment of size at birth To ta l Percentage of live births: N um be r of la st li ve - bo rn c hi ld re n in t he la st t w o ye ar s Ve ry s m al l Sm al le r th an av er ag e A ve ra ge La rg er t ha n av er ag e or ve ry la rg e D K Be lo w 2 ,5 00 gr am s1 W ei gh ed a t bi rt h2 Total 1.4 8.1 71.7 18.7 0.1 100.0 5.5 99.8 397 Mother's age at birth Less than 20 years (*) (*) (*) (*) (*) 100.0 (*) (*) 24 20-34 years 0.5 7.1 72.8 19.4 0.2 100.0 4.8 99.9 307 35-49 years 6.1 4.9 70.4 18.6 0.0 100.0 5.7 99.4 65 Birth order 1 0.8 13.2 66.3 19.1 0.6 100.0 7.5 99.7 93 2-3 2.1 5.8 72.5 19.6 0.0 100.0 4.8 100.0 226 4-5 0.0 7.9 76.7 15.3 0.0 100.0 5.1 99.5 76 6+ (*) (*) (*) (*) (*) 100.0 (*) (*) 3 Region Central 0.0 6.3 77.3 16.3 0.0 100.0 4.4 100.0 76 Tourism 0.0 7.5 71.0 21.5 0.0 100.0 4.8 100.0 91 Agriculture 9.6 6.4 58.5 25.5 0.0 100.0 7.3 100.0 43 Ider 0.0 2.2 87.7 9.0 1.1 100.0 2.8 100.0 52 Tes-Ekh 0.0 12.2 66.5 21.2 0.0 100.0 6.8 99.4 52 Murun 1.7 12.1 67.3 18.9 0.0 100.0 7.3 99.5 83 Area Urban 1.7 12.1 67.3 18.9 0.0 100.0 7.3 99.5 83 Rural 1.3 7.0 72.8 18.7 0.2 100.0 5.0 99.9 314 Mother’s education None (0.0) (3.7) (70.2) (24.5) (1.6) 100.0 (3.1) (99.2) 37 Primary (0.8) (15.9) (77.1) (6.3) (0.0) 100.0 (8.9) (100.0) 40 Basic (lower secondary) 0.0 3.5 73.7 22.8 0.0 100.0 3.0 100.0 55 Upper secondary 1.5 9.5 68.0 21.0 0.0 100.0 6.1 100.0 94 Vocational (0.0) (3.5) (69.6) (26.9) (0.0) 100.0 (3.0) (98.4) 26 College, university 2.6 8.6 72.4 16.3 0.0 100.0 6.2 100.0 146 Wealth index quintile Poorest 0.0 10.8 66.6 21.9 0.7 100.0 6.2 99.6 86 Second 0.9 6.2 71.4 21.6 0.0 100.0 4.5 100.0 62 Middle 0.0 13.5 75.8 10.8 0.0 100.0 7.5 99.5 89 Fourth 5.7 1.6 73.0 19.7 0.0 100.0 4.1 100.0 63 Richest 1.4 6.0 71.7 20.9 0.0 100.0 4.6 100.0 97 Ethnicity of household head Khalkh 2.1 6.8 72.4 18.5 0.2 100.0 5.2 99.8 266 Darkhad 0.0 9.0 70.0 21.0 0.0 100.0 5.4 100.0 75 Khotgoid (0.0) (12.8) (68.2) (19.0) (0.0) 100.0 (7.1) (99.2) 40 Other (*) (*) (*) (*) (*) 100.0 (*) (*) 16 1 MICS indicator 2.20 - Low-birthweight infants 2 MICS indicator 2.21 - Infants weighed at birth ( ) Figures that are based on 25-49 unweighted cases. (*) Figures that are based on less than 25 unweighted cases. 39 V. NUTRITION Nutritional Status Children’s nutritional status is a reflection of their overall health. When children have access to an adequate food supply, they are not exposed to repeated illness, and are well cared for, they reach their growth potential and are considered well nourished. Under nutrition is associated with more than half of all child deaths worldwide. Undernourished children are more likely to die from common childhood ailments, and for those who survive, have recurring sicknesses and faltering growth. Three-quarters of children who die from causes related to malnutrition were only mildly or moderately malnourished – showing no outward sign of their vulnerability. The Millennium Development Goal target is to reduce by half the proportion of people who suffer from hunger between 1990 and 2015. A reduction in the prevalence of malnutrition will also assist in the goal to reduce child mortality. In a well-nourished population, there is a reference distribution of height and weight for children under age five. Under-nourishment 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 growth standards2. 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 as a result 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. Wasting is usually 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/obese. In MICS, weights and heights of all children under 5 years of age were measured using the anthropometric equipment recommended3 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 2 http://www.who.int/childgrowth/standards/technical_report 3 See MICS Supply Procurement Instructions: http://www.childinfo.org/mics5_planning.html 40 Child Development Survey-2016 (Mongolia: Khuvsgul province) table includes mean z-scores for all three anthropometric indicators. There were no children whose full birth date (day, month and year) was not obtained (Table DQ.8 in included as Appendix D) and children whose measurements are outside a plausible range are excluded from Table NU.2. Children are excluded from one or more of the anthropometric indicators when their weights and heights have not been measured. For example, if a child has been weighed but his/ her height has not been measured, the child is included in underweight calculations, but not in the calculations for stunting and wasting. The percentages of children by age and reasons for exclusion (height and weight measurements are outside of plausible range or to be excluded from the result when their weights and heights have not been measured) are shown in the data quality tables DQ.12; 13 and 14 in appendix D. The tables show that due to implausible measurements and/or missing weight and/or height, 0.7 percent of children have been excluded from the weight-for age indicator (Table DQ.12); 0.9 percent from the height-for-age indicator (Table DQ.13); 1.3 percent for the weight-for-height indicator (Table DQ.14). Table DQ.15 shows final results of weight and height measurement in figures. In this survey there was some digit preference for the final digit 0 for the height/length measure in the report (Appendix D, Table DQ.15). Of the total children under-5 in Khuvsgul province, 2 percent are underweight, including 0.8 percent who are severely underweight. Moreover, 19.0 percent of the children are stunted or too short for their age, including 7.6 percent who are severely stunted. 1.6 percent are wasted or too thin for their height (Table NU.2). Children in urban area (25.5 percent) are more stunted than children in rural area (17.0 percent) by 8.5 percentage points. Among regions, children in Agricultural (7.7 percent) and Ider (7.9 percent) regions have the lowest rates of stunding. Nutritional status of children under-5 differs by education of their mothers/caretakers. Those children whose mothers/caretakers have no education (22.9 percent) have higher risks of being underweight or stunted compared to the children of mothers/caretakers with educational background. However, it is quite interesting to observe that if exclude children, whose mothers/ caretakers have no education or primary education, the percentage of stunted children increases as mother/caretakers education gets higher. For instance, the proportion of stunted children among children whose mothers/caretakers have primary education is 14.7 percent while it is 20.2 percent among children with college or university educated mothers/caretakers. The age pattern shows that a higher percentage of children age 18-23 months are stunted (23.3 percent) compared to children age 0-11 months (Figure NU.1). This pattern is expected and is related to the age at which many children cease to be breastfed and are exposed to contamination in water, food, and environment. Wasting and underweight prevalence are relatively low among the total children under-5 and there are no notable discrepancies observed in its distribution by background characteristics (Table NU.1). 41 V. NUTRITION Figure NU.1: Percentage of children under age 5 who are underweight, stunted, wasted and overweight, Khuvsgul, 2016 Age by months pe rc en t Overweight Wasted Underweight Stunted The overweight prevalence is 21.9 percent, especially this figure around 24 months of children has more overweight. 42 Child D evelopm ent Survey-2016 (M ongolia: Khuvsgul province) 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, Khuvsgul, 2016 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 above - 2 SD1 - 3 SD2 - 2 SD3 - 3 SD4 - 2 SD5 - 3 SD6 + 2 SD7 Total 1.9 0.8 0.2 1121 19.0 7.6 -1.0 1119 1.6 0.6 22.1 1.1 1115 Sex Male 2.1 1.0 0.2 567 21.7 9.6 -1.1 566 1.8 0.3 26.8 1.2 564 Female 1.8 0.6 0.2 554 16.2 5.6 -0.9 553 1.4 1.0 17.2 1.0 551 Region Central 4.8 2.9 0.1 205 17.9 9.1 -1.0 205 3.3 0.0 14.4 0.9 203 Tourism 1.0 0.0 0.2 248 25.9 13.8 -1.2 248 2.6 1.7 34.7 1.2 248 Agriculture 3.2 2.4 0.1 132 7.7 5.1 -0.8 130 0.3 0.0 15.5 0.8 130 Ider 0.4 0.1 0.5 144 7.9 2.4 -0.6 144 0.0 0.0 17.2 1.1 142 Tes-Ekh 0.1 0.0 0.2 135 18.3 1.3 -0.9 134 0.8 0.0 11.3 0.9 134 Murun 1.9 0.0 0.3 258 25.5 7.9 -1.0 258 1.4 1.1 27.5 1.3 257 Area Urban 1.9 0.0 0.3 258 25.5 7.9 -1.0 258 1.4 1.1 27.5 1.3 257 Rural 2.0 1.1 0.2 863 17.0 7.5 -1.0 861 1.7 0.5 20.4 1.0 858 Age 0-5 months 5.2 3.1 0.0 100 9.5 4.6 -0.1 100 12.9 7.0 8.1 0.1 100 6-11 months 0.6 0.3 0.6 121 14.8 1.3 -0.3 121 0.0 0.0 24.8 1.1 121 12-17 months 0.0 0.0 0.4 83 15.5 6.1 -0.8 83 1.1 0.0 21.9 1.0 82 18-23 months 1.0 0.0 0.3 107 23.3 14.3 -1.3 106 0.0 0.0 31.6 1.3 106 24-35 months 0.8 0.0 0.4 245 17.3 6.2 -1.0 243 0.4 0.0 21.6 1.3 240 36-47 months 1.6 1.2 0.1 235 16.7 8.8 -1.1 235 1.2 0.0 19.8 1.1 235 48-59 months 4.0 1.3 -0.1 229 28.7 10.0 -1.4 229 0.1 0.0 25.2 1.2 229 Mother’s education* None 6.2 2.2 0.2 131 22.9 13.7 -1.2 131 0.2 0.0 21.4 1.2 129 Primary 0.7 0.4 0.1 103 14.7 5.1 -1.1 103 1.9 0.0 16.7 1.0 103 Basic (lower secondary) 1.2 0.8 0.1 172 17.8 2.9 -1.1 171 0.8 0.0 20.9 1.0 171 Upper secondary 1.6 0.5 0.3 293 17.4 7.6 -0.9 293 1.2 1.2 24.2 1.1 293 Vocational 3.4 0.0 0.1 84 20.6 7.8 -1.1 84 1.7 0.8 26.4 1.1 84 College, university 1.0 0.9 0.3 338 20.2 8.4 -0.8 336 2.8 0.9 21.6 1.0 335 Wealth index quintile Poorest 0.9 0.1 0.2 210 17.9 6.0 -1.0 208 1.7 0.0 20.6 1.1 208 Second 1.3 0.0 0.1 179 13.0 5.7 -1.1 179 0.2 0.0 23.3 1.1 179 Middle 2.0 0.7 0.2 254 18.3 6.9 -1.0 254 2.1 1.5 19.6 1.0 252 Fourth 4.2 2.7 0.1 228 30.1 12.4 -1.2 228 2.5 0.2 25.9 1.2 226 Richest 1.2 0.4 0.3 250 14.7 6.6 -0.6 250 1.2 1.1 21.3 1.0 249 Ethnicity of household head** Khalkh 2.0 0.6 0.3 745 15.7 6.0 -0.9 743 1.2 0.4 19.6 1.1 740 Darkhad 0.9 0.0 0.2 212 26.9 14.3 -1.2 213 3.9 1.7 36.1 1.2 212 Khotgoid 2.4 2.4 0.0 118 27.9 6.4 -1.2 117 0.7 0.0 13.5 0.9 117 Other (5.3) (4.0) (0.1) (42.0) (14.2) (6.1) -(1.1) (42.0) (0.0) (0.0) (17.3) (1.1) 42 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 * One unweighted cases with missing "Mother's education" are not shown respectively. ** Five unweighted cases with missing "Ethnicity of household head" are not shown respectively. ( ) Figures that are based on 25-49 unweighted cases. 43 V. NUTRITION 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 window from birth to 2 years of age. Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients, and is economical and safe. However, many mothers don’t start to breastfeed early enough, do not breastfeed exclusively for the recommended 6 months or stop breastfeeding too soon. There are often pressures to switch to infant formula, which can contribute to growth faltering and micronutrient malnutrition and can be unsafe if hygienic conditions, including safe drinking water are not readily available. Studies have shown that, in addition to continued breastfeeding, consumption of appropriate, adequate and safe solid, semi-solid and soft food from the age of 6 months onwards leads to better health and growth outcomes, with potential to reduce stunting during the first two years of life.4 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.5 Starting at 6 months, breastfeeding should be combined with safe, age-appropriate feeding of solid, semi-solid and soft food.6 A summary of key guiding principles7, 8 for feeding 6-23 month olds is provided in the table below along with proximate measures for these guidelines collected in this survey. The guiding principles for which proximate measures and indicators exist are: 1. continued breastfeeding; 2. appropriate frequency of meals (but not energy density); and 3. appropriate nutrient content of food. Feeding frequency is used as proxy for energy intake, requiring children to receive a minimum number of meals/snacks (and milk feeds 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 better quality diet. In most popula¬tions, 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).9 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: 1. the appropriate number of meals/snacks/milk feeds; 2. food items from at least 4 food groups; and 3. breast milk or at least 2 milk feeds (for non-breastfed children). 4 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. 5 WHO. 2003. Implementing the Global Strategy for Infant and Young Child Feeding. Meeting Report Geneva, 3-5 February, 2003. 6 WHO. 2003. Global Strategy for Infant and Young Child Feeding. 7 PAHO. 2003. Guiding principles for complementary feeding of the breastfed child. 8 WHO. 2005. Guiding principles for feeding non-breastfed children 6-24 months of age. 9 WHO. 2008. Indicators for assessing infant and young child feeding practices. Part 1: Definitions. 44 Child Development Survey-2016 (Mongolia: Khuvsgul province) 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 of food Four food groups10 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 forti- fied 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 Table NU.310is 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 of birth, and those who received a prelacteal feed.11 Although a very important step in management of lactation and establishment of a physical and emotional relationship between the baby and the mother, only 76.4 percent of babies are breastfed for the first time within one hour of birth, while 97.6 percent started breastfeeding within one day of birth. Table NU.3 shows that the percentages of children that are breastfed for the first time within one hour of birth and within one day of birth does not differ by location. However, the percentage of children that are breastfed for the first time within one hour is the lowest in Tes-Ekh at 65.4 percent compared to other regions where the figure ranges from 74.9 to 82.8 percent. In all regions, more than 95 percent of children initiated breastfeeding within one day of birth. 10 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 food (meat, fish, poultry and liver/organ meats), 5) eggs, 6) vitamin-A rich fruits and vegetables, and 7) other fruits and vegetables. 11 Prelacteal feed refers to the provision 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). 45 V. NUTRITION Figure NU.2: Initiation of breastfeeding, Khuvsgul, 2016 Ce nt ra l To ur ism Ag ric ult ur e Within one day of birth Within one hour of birth Ide r Te s-E kh M ur un Ur ba n Ru ra l To tal The rate of early initiation of breastfeeding increases as from a lower to a higher wealth quintile. The percentage of children that are breastfed for the first time within one hour is 73.7 percent among households with Khalkh heads (Table NU.3). The percentages of children age 0-23 months that are breastfed for the first time within one day of birth does not differ by household wealth quintile. Table NU.3 shows that the percentage of children who received pre-lacteal feed is 12.8 percent. Furthermore, Table NU.3 shows that the practice of feeding the children age 0-23 months with pre-lacteal food is considerably low in Tourism region and among households in the third quintile. 46 Child Development Survey-2016 (Mongolia: Khuvsgul province) 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, Khuvsgul, 2016 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 99.2 76.4 97.6 12.8 397 Region Central 98.5 74.9 95.8 25.2 76 Tourism 100.0 82.8 99.7 2.6 91 Agriculture 98.8 80.2 97.4 13.3 43 Ider 99.5 76.7 99.0 10.4 52 Tes-Ekh 98.4 65.4 98.4 10.5 52 Murun 99.4 75.5 95.7 15.4 83 Area Urban 99.4 75.5 95.7 15.4 83 Rural 99.1 76.6 98.1 12.1 314 Months since last birth 0-11 months 99.8 79.1 99.8 11.5 218 12-23 months 98.5 73.2 95.0 14.4 179 Assistance at delivery Skilled attendant 99.2 76.5 97.6 12.8 397 Traditional birth attendant (*) (*) (*) (*) 1 Place of delivery Home (*) (*) (*) (*) 1 Health facility 99.2 76.4 97.7 12.8 396 Public 99.2 76.9 97.7 12.6 393 Private (*) (*) (*) (*) 3 Mother’s education None (96.9) (67.1) (96.1) (6.9) 37 Primary (100.0) (73.0) (99.2) (12.7) 40 Basic (lower secondary) 100.0 80.4 96.3 11.0 55 Upper secondary 98.3 74.2 98.0 15.7 94 Vocational (100.0) (60.7) (100.0) (10.1) 26 College, university 99.7 82.4 97.4 13.6 146 Wealth index quintile Poorest 100.0 69.0 97.3 13.8 86 Second 98.2 66.6 97.1 12.4 62 Middle 99.1 80.3 99.1 9.1 89 Fourth 98.1 82.0 97.6 14.7 63 Richest 100.0 82.1 96.8 14.3 97 Ethnicity of household head Khalkh 98.8 73.7 96.5 15.8 266 Darkhad 100.0 83.6 99.6 0.0 75 Khotgoid (100.0) (76.2) (100.0) (14.2) 40 Other (*) (*) (*) (*) 16 1 MICS indicator 2.5 - Children ever breastfed 2 MICS indicator 2.6 - Early initiation of breastfeeding ( ) Figures that are based on 25-49 unweighted cases. (*) Figures that are based on less than 25 unweighted cases. 47 V. NUTRITION In Table NU.4, breastfeeding status is presented for both exclusively breastfed and predominantly breastfed; referring to infants age less than 6 months who are breastfed, distinguished by the former only allowing vitamins, mineral supplements, and medicine and the latter allowing also plain water and non-milk liquids. The table also shows continued breastfeeding of children at 12-15 and 20-23 months of age. 67.4 percent of children age less than six months are exclusively breastfed. In addition, by age of 12-15 months, 81.7 percent of children are still being breastfed and by age 20-23 months, 60.0 percent are still breastfed. Please note that the results of breastfeeding indicators should be interpreted with caution as the number of children age 0-5 months, 12-15 months and 20-23 months (denominator of indicators) are small. Table NU.4: Breastfeeding Percentage of living children according to breastfeeding status at selected age groups, Khuvsgul, 2016 Children age 0-5 months Children age 12-15 months Children age 20-23 months Pe rc en t ex cl us iv el y br ea stf ed 1 Pe rc en t pr ed om in an tl y br ea stf ed 2 N um be r of ch ild re n Pe rc en t b re as tf ed (C on ti nu ed br ea stf ee di ng a t 1 ye ar )3 N um be r of ch ild re n Pe rc en t b re as tf ed (C on ti nu ed br ea stf ee di ng a t 2 ye ar s) 4 N um be r of ch ild re n Total 67.4 72.4 100 81.7 52 60.0 71 Sex Male 63.4 69.3 48 (80.0) 21 (43.0) 36 Female 71.1 75.3 53 (82.8) 32 (77.7) 35 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. Table NU.5 shows the median duration of breastfeeding by selected background characteristics. For instance, among children under age 3, the median duration is 24.3 months for any breastfeeding. The median duration for exclusive breastfeeding among children under age 3 is 4.3 months, and median duration for children predominantly breastfed is 4.4 months. The median duration for exclusive breastfeeding among children under age 3, covered by the survey, slightly differ by gender and region. For instance, the median duration for exclusive breastfeeding for girls (4.1 months) is less than for boys (4.5 months). Children in Tes-Ekh exclusively breastfeed for only 0.5 months and have the lowest duration for exclusive breastfeeding compared to other regions. The median duration of exclusive breastfeeding is higher in rural area (3.8 months in urban area and 4.7 months in rural area), but median duration of any breastfeeding is higher in urban areas (26.8 months in urban area and 23.1 months in rural area). 48 Child Development Survey-2016 (Mongolia: Khuvsgul province) Table NU.5: Duration of breastfeeding Median duration of any breastfeeding, exclusive breastfeeding, and predominant breastfeeding among children age 0-35 months, Khuvsgul, 2016 Median duration (in months) of: Number of children age 0-35 months Any breast- feeding1 Exclusive breastfeeding Predominant breastfeeding Median 24.3 4.3 4.4 664 Sex Male 21.1 4.5 4.8 318 Female 24.3 4.1 4.1 346 Region Central 20.3 5.0 5.0 119 Tourism 17.3 4.9 5.6 150 Agriculture 14.1 5.0 5.0 69 Ider 24.8 4.4 4.4 99 Tes-Ekh 26.2 0.5 3.8 87 Murun 26.8 3.8 3.8 140 Area Urban 26.8 3.8 3.8 140 Rural 23.1 4.7 4.9 524 Mother’s education None 26.6 6.1 6.1 74 Primary 15.7 4.0 4.0 74 Basic (lower secondary) 22.7 3.3 3.4 95 Upper secondary 22.1 4.1 4.3 169 Vocational 19.3 2.8 5.0 44 College, university 25.3 4.0 4.3 209 Wealth index quintile Poorest 25.2 5.4 5.4 139 Second 25.0 4.5 4.6 102 Middle 27.1 3.7 3.9 159 Fourth 22.5 3.9 4.7 114 Richest 24.8 4.4 4.4 151 Ethnicity of household head* Khalkh 25.2 4.4 4.4 430 Darkhad 15.9 5.3 9.2 133 Khotgoid 20.3 1.7 3.9 75 Other (19.5) (2.8) (2.8) 24 Mean 23.0 4.3 5.2 664 1 MICS indicator 2.11 - Duration of breastfeeding * Five unweighted cases with missing "Ethnicity of household head" are not shown. ( ) Figures that are based on 25-49 unweighted cases. The adequacy of infant feeding of children under age of 24 months is shown in Table NU.6. Different criteria of appropriate feeding are used depending on the age of the child. For infants age 0-5 months, exclusive breastfeeding is considered as appropriate feeding, while infants age 6-23 months are considered to be appropriately fed if they are receiving breast milk and solid or semi-solid food. 49 V. NUTRITION As for the findings for adequate feeding among young children age 6-23, 67.4 percent of children age 6-23 months are currently breastfeeding and received solid or semi-solid food. Of the total children age 0-23 months, 67.4 percent are appropriately breastfed. The percentage of children under age 2 who are appropriately breastfed differs by gender, urban and rural areas, where appropriately breastfed girls (71.3 percent) is higher than boys (63.3 percent) and that among rural children (65.7 percent) is lower than urban children (74.1 percent). The percentage of children under age 2 who are appropriately breastfed differs slightly by regions. Therefore, appropriately breastfed are lower in Tourism region (53.9 percent) and Agricultural region (58.1 percent) have lower rates of appropriately fed children under 2 compared to other regions. By household wealth quintile, this figure is slightly lower among children who live in fourth wealth quintile households at 55.1 percent compared to children living in other wealth quintile of households. Children living in poorer households have the highest rate of being appropriately fed (85.1 per cent) when compared to those in other wealth quintiles. This figure is the highest among children living in households with Khalkh and stand at 74.9 percent and the lowest among children of households with by Darkhad headed households at 43.2 percent. 50 Child Development Survey-2016 (Mongolia: Khuvsgul province) Table NU.6: Age-appropriate breastfeeding Percentage of children age 0-23 months who were appropriately breastfed during the previous day, Khuvsgul, 2016 Children age 0-5 months Children age 6-23 months Children age 0-23 months Percent exclusively breastfed1 Number of children Percent currently breastfeeding and receiving solid, semi- solid or soft food Number of children Percent ap- propriately breastfed2 Number of children Total 67.4 100 67.4 319 67.4 419 Sex Male 63.4 48 63.3 157 63.4 205 Female 71.1 53 71.4 162 71.3 214 Region Central (*) 26 (70.3) 53 71.2 79 Tourism (*) 15 49.4 87 53.9 102 Agriculture (*) 11 57.5 34 58.1 45 Ider (*) 18 (89.0) 36 80.8 54 Tes-Ekh (*) 13 82.9 41 71.4 54 Murun (*) 17 72.3 68 74.1 84 Area Urban (*) 17 72.3 68 74.1 84 Rural 64.7 84 66.1 251 65.7 335 Mother’s education None (*) 11 (78.0) 27 (79.3) 38 Primary (*) 10 (55.1) 39 (61.4) 49 Basic (lower secondary) (*) 10 67.0 48 66.1 58 Upper secondary (69.9) 24 70.1 75 70.1 99 Vocational (*) 10 (*) 23 (46.1) 33 College, university (62.9) 36 72.2 106 69.9 142 Wealth index quintile Poorest (57.6) 27 61.7 71 60.5 98 Second (*) 12 89.1 47 85.1 58 Middle (*) 21 64.7 82 66.5 104 Fourth (*) 18 (56.1) 44 55.1 62 Richest (*) 23 68.9 75 72.5 97 Ethnicity of household head Khalkh 69.9 71 76.7 198 74.9 269 Darkhad (*) 15 (38.2) 74 43.2 88 Khotgoid (*) 9 (73.1) 37 69.7 45 Other (*) 6 (*) 11 (*) 16 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 less than 25 unweighted cases. 51 V. NUTRITION Of the total children age 6-8 months covered by the survey, 74.4 percent received solid or semi- solid food (MICS Indicator 2.12). Among currently breastfeeding infants, this percentage is 75.6 percent. Please note that the results on complementary feeding indicators should not be interpreted with caution as the number of children age 6-8 months (denominator of indicators) is small. Table NU.7: Introduction of solid, semi-solid, or soft foods Percentage of infants age 6-8 months who received solid, semi-solid, or soft foods during the previous day, Khuvsgul, 2016 Currently breastfeeding Currently not breastfeeding All Percent receiving solid, semi-solid or soft foods Number of children age 6-8 months Percent receiving solid, semi- solid or soft foods Number of children age 6-8 months Percent receiving solid, semi- solid or soft foods1 Number of children age 6-8 months Total 75.6 61 (*) 9 74.4 70 Sex Male (65.2) 40 (*) 1 (65.8) 40 Female (95.0) 22 (*) 8 (86.1) 30 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 less than 25 unweighted cases. Table NU.8 presents the proportion of children age 6-23 months, who received solid or semi-solid food the minimum appropriate number of times or more during the day preceding the survey according to breastfeeding status. Minimum dietary diversity refers to feeding the child from at least four food groups within the 24 hours prior to the survey. The calculation of minimum dietary diversity is different for breastfed and non-breastfed children. For instance, a breastfed child should be fed with complementary food adequate number of times a day, while a non-breastfed child in addition should receive milk products at least twice a day. This is considered as minimum acceptable diet. Overall in Khuvsgul province, only one in every 3 children age 6-23 months (26.1 percent) were receiving minimum acceptable diet (solid, semi-solid or soft food the minimum number of times a day), which shows there is a common practice of inadequate feeding. It is higher among older children (31.1 percent) and Agriculture (54.3 percent) and Tesh-Ekh regions (46.5 pecent). The percentage of children age 6-23 months received minimum meal frequency does not differ by location (31.1 percent in urban and 24.8 percent in rural), but differ by gender (24.5 percent for boys, 27.7 percent for girls). The percentage of children age 6-23 months receiving minimum dietary diversity is 39.0 percent throughout the Khuvsgul province. However, the percentage of children received minimum meal frequency is higher (86.4 percent) compared to other indicators. Table NU.8 shows that there are no notable differences in the proportion of children age 6-23 months receiving minimum acceptable diet by gender, areas and household's wealth index quintiles. 52 Child D evelopm ent Survey-2016 (M ongolia: Khuvsgul province) Table NU.8: Infant and young child feeding (IYCF) practices Percentage of children age 6-23 months who received appropriate liquids and solid, semi-solid, or soft food the minimum number of times or more during the previous day, by breastfeeding status, Khuvsgul, 2016 Currently breastfeeding Currently not breastfeeding All Percent of children who received: N um be r of c hi ld re n ag e 6- 23 m on th s Percent of children who received: N um be r of c hi ld re n ag e 6- 23 m on th s Percent of children who received: N um be r of c hi ld re n ag e 6- 23 m on th s M in im um d ie ta ry di ve rs it ya M in im um m ea l fr eq ue nc yb M in im um ac ce pt ab le d ie t1 , c M in im um d ie ta ry di ve rs it ya M in im um m ea l fr eq ue nc yb M in im um ac ce pt ab le d ie t2 , c A t le as t 2 m ilk fe ed s3 M in im um d ie ta ry di ve rs it y4 , a M in im um m ea l fr eq ue nc y5 , b M in im um ac ce pt ab le d ie tc Total 28.6 84.5 25.5 240 50.0 92.1 27.9 69.2 79 33.9 86.4 26.1 319 Sex Male 27.3 81.5 24.3 114 (53.1) (86.0) (24.9) (65.8) 43 34.4 82.7 24.5 157 Female 29.7 87.2 26.6 126 (46.3) (99.6) (31.7) (73.2) 35 33.4 89.9 27.7 162 Age 6-8 months 12.2 68.5 6.7 61 (*) (*) (*) (*) 9 14.0 72.6 9.1 70 9-11 months (26.3) (88.7) (26.3) 49 (*) (*) (*) (*) 4 (30.4) (89.6) (30.4) 54 12-17 months 30.6 92.8 27.5 66 (*) (*) (*) (*) 18 40.0 94.3 31.1 84 18-23 months 44.2 88.1 41.2 63 (42.8) (86.9) (17.8) (62.6) 48 43.6 87.6 31.1 111 Region Central (17.1) (91.9) (14.3) 39 (*) (*) (*) (*) 14 (26.5) (90.1) (23.0) 53 Tourism (13.5) (71.5) (11.7) 58 (*) (*) (*) (*) 29 21.9 77.5 9.4 87 Agriculture (54.6) (94.7) (52.0) 19 (*) (*) (*) (*) 14 59.4 97.0 54.3 34 Ider (19.0) (86.5) (13.2) 32 (*) (*) (*) (*) 4 (17.1) (87.4) (11.9) 36 Tes-Ekh (49.8) (96.8) (49.8) 34 (*) (*) (*) (*) 7 49.8 95.1 46.5 41 Murun 35.5 80.6 30.6 57 (*) (*) (*) (*) 11 41.4 83.7 31.1 68 Area Urban 35.5 80.6 30.6 57 (*) (*) (*) (*) 11 41.4 83.7 31.1 68 Rural 26.4 85.7 23.9 183 46.5 90.8 27.1 70.4 68 31.8 87.1 24.8 251 Mother’s education None (20.6) (84.5) (19.0) 22 (*) (*) (*) (*) 5 (30.3) (87.3) (15.5) 27 Primary (26.8) (74.0) (17.2) 25 (*) (*) (*) (*) 14 (32.9) (75.7) (19.0) 39 Basic (lower second- ary) (30.4) (80.3) (23.1) 36 (*) (*) (*) (*) 12 30.9 80.6 24.2 48 Upper secondary 34.4 89.6 34.4 59 (*) (*) (*) (*) 16 39.5 91.9 34.6 75 Vocational (*) (*) (*) 15 (*) (*) (*) (*) 8 (*) (*) (*) 23 College, university 28.8 89.7 27.1 83 (*) (*) (*) (*) 23 34.3 91.2 26.9 106 53 V. N U TRITIO N Currently breastfeeding Currently not breastfeeding All Percent of children who received: N um be r of c hi ld re n ag e 6- 23 m on th s Percent of children who received: N um be r of c hi ld re n ag e 6- 23 m on th s Percent of children who received: N um be r of c hi ld re n ag e 6- 23 m on th s M in im um d ie ta ry di ve rs it ya M in im um m ea l fr eq ue nc yb M in im um ac ce pt ab le d ie t1 , c M in im um d ie ta ry di ve rs it ya M in im um m ea l fr eq ue nc yb M in im um ac ce pt ab le d ie t2 , c A t le as t 2 m ilk fe ed s3 M in im um d ie ta ry di ve rs it y4 , a M in im um m ea l fr eq ue nc y5 , b M in im um ac ce pt ab le d ie tc Wealth index quintile Poorest 18.2 81.5 18.2 52 (*) (*) (*) (*) 19 26.5 83.4 24.5 71 Second 21.2 97.4 20.3 42 (*) (*) (*) (*) 5 23.0 97.3 22.2 47 Middle 27.4 88.4 26.5 57 (*) (*) (*) (*) 25 29.8 87.3 20.9 82 Fourth (35.4) (72.6) (35.4) 34 (*) (*) (*) (*) 10 (44.2) (78.8) (31.6) 44 Richest 40.8 80.9 29.2 56 (*) (*) (*) (*) 19 46.1 85.8 32.6 75 Ethnicity of household head Khalkh 32.2 88.5 28.6 160 (60.0) (93.7) (44.1) (79.0) 37 37.4 89.5 31.5 198 Darkhad (9.1) (62.7) (6.6) 43 (*) (*) (*) (*) 30 (19.6) (74.0) (4.4) 74 Khotgoid (41.2) (99.1) (41.2) 27 (*) (*) (*) (*) 10 (48.0) (97.2) (44.3) 37 Other (*) (*) (*) 10 (*) (*) (*) (*) 1 (*) (*) (*) 11 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 food 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 food (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 food 2 times or more daily for children age 6-8 months and 3 times or more daily for children age 9-23 months. For non-breastfeeding children age 6-23 months it is defined as receiving solid, semi-solid or soft food, or milk feeds, at least 4 times. c The minimum acceptable diet for breastfed children age 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 less than 25 unweighted cases. 54 Child Development Survey-2016 (Mongolia: Khuvsgul province) The continued practice of bottle-feeding is a concern because of the possible contamination due to unsafe water and lack of hygiene in preparation. Bottle-feeding among children age 0-23 months is still prevalent. Every 1 in 5 children (19.5 percent) under 2 years old were fed from a bottle with nipple during the day preceding the survey. As shown in Table NU.9, practice of drinking liquids from a bottle with nipple among children age 0-5 months (25.1 percent) is high compared to that among children of other ages. The practice of bottle-feeding among children age 0-23 months does not considerably differ by gender and area. However, children in richest households are likely to practice more bottle feed and (25.0 percent) compared to children from other households (Table NU.9). 55 V. NUTRITION Table NU.9: Bottle feeding Percentage of children age 0-23 months who were fed with a bottle with a nipple during the previous day, Khuvsgul, 2016 Percentage of children age 0-23 months fed with a bottle with a nipple1 Number of children age 0-23 months Total 19.5 419 Sex Male 20.9 205 Female 18.3 214 Age 0-5 months 25.1 100 6-11 months 23.1 124 12-23 months 14.4 195 Region Central 20.3 79 Tourism 18.4 102 Agriculture 30.9 45 Ider 10.0 54 Tes-Ekh 23.6 54 Murun 17.7 84 Area Urban 17.7 84 Rural 20.0 335 Mother’s education None (12.3) 38 Primary (15.6) 49 Basic (lower secondary) 18.0 58 Upper secondary 14.1 99 Vocational (32.6) 33 College, university 24.2 142 Wealth index quintile Poorest 21.3 98 Second 7.2 58 Middle 19.9 104 Fourth 19.2 62 Richest 25.0 97 Ethnicity of household head Khalkh 17.8 269 Darkhad 18.8 88 Khotgoid 28.0 45 Other (*) 16 1 MICS indicator 2.18 - Bottle feeding ( ) Figures that are based on 25-49 unweighted cases. (*) Figures that are based on less than 25 unweighted cases. 56 Child Development Survey-2016 (Mongolia: Khuvsgul province) Salt Iodization Iodine Deficiency Disorders (IDD) is the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its most extreme form, iodine deficiency causes cretinism. It also increases the risks of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. 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. The indicator is the percentage of households consuming adequately iodized salt (>15 parts per million). About 80 percent of Mongolia’s territory is located in a region with the iodine scarcity. In 1992- 1995, an IDD Salt Iodization Research was launched with the assistance of UNICEF primarily to determine the level of national IDD distribution. According to the research12, 29 percent of children age 7-23 years were suffering from goiter in Mongolia. The findings also indicated, IDD distribution has been alarmingly high in some regions of the country. Accordingly, the Government of Mongolia developed and implemented the first National Programme on “Combating IDD”, starting from 1996 to 2001. Since then, the Government approved and implemented the second and the third stages of this program during 2002-2006 and 2007-2010. Under the framework of the National program, the Government of Mongolia implemented various activities such as improving the legal environment for the iodized salt production and support of its consumption; raising public awareness about the iodized salt and its benefits and other actions, directed towards establishing the attitudes and practices of iodized salt consumption. “The National Standards of Iodized Salt (2001)”, the Law of Mongolia on “Prevention of IDD by Salt Iodization” (2003), and the Regulations on “Control of Enriched Products” (2006) were adopted under which legalized the mandatory use of iodized salt. Starting with the launching of “Combating IDD program” in 1996, iodized salt has been introduced into food consumption of the population. Since then, the household consumption of this product has been increasing consistently. According to the National Standards of Mongolia, only potassium iodide is allowed to iodize the salt for cooking. Therefore, in order to determine the presence of iodine in the salt used by the surveyed households, an accelerated method of detecting potassium iodide (KI) in salt was used. In about 95 percent of households, salt used or cooking was tested for iodine content by using salt test kits and testing for the presence of potassium iodide. Table NU.10 shows that in a very small proportion of households (0.5 percent), there was no salt available. In 36.4 percent of households, covered by the survey, salt was found to contain 15 parts per million or more of iodine, which is considered to be at the appropriate level content of iodized salt. The consumption of iodized salt differs significantly by areas. 47.7 percent in urban areas use adequately iodized salt for cooking while this figure is 32.9 percent in rural areas. The usage of adequately iodized salt was the lowest in Ider region (18.1 percent), followed by Central region (27.0 percent) and Tes-Ekh region (28.1 percent). 12 Public Health Institute and UNICEF, 1996. Salt Iodization Research 1995, Final Report. Ulaanbaatar, Mongolia 57 V. NUTRITION Table NU.10: Iodized salt consumption Percent distribution of households by consumption of iodized salt, Khuvsgul, 2016 Percentage of households in which salt was tested N um be r of ho us eh ol ds 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 97.6 2626 0.5 51.9 11.3 36.4 100.0 2574 Region Central 100.0 520 0.0 64.8 8.2 27.0 100.0 520 Tourism 99.6 506 0.4 40.8 19.1 39.7 100.0 506 Agriculture 98.4 327 0.4 30.5 17.9 51.3 100.0 323 Ider 99.9 335 0.0 80.1 1.8 18.1 100.0 335 Tes-Ekh 91.2 309 1.1 68.4 2.4 28.1 100.0 285 Murun 95.3 629 1.0 38.1 13.2 47.7 100.0 606 Area Urban 95.3 629 1.0 38.1 13.2 47.7 100.0 606 Rural 98.3 1997 0.3 56.1 10.7 32.9 100.0 1968 Education of household head* None 98.5 422 0.3 66.2 5.1 28.4 100.0 417 Primary 98.1 638 0.5 58.5 8.4 32.6 100.0 630 Basic (lower sec- ondary) 97.5 620 0.2 52.6 12.7 34.4 100.0 606 Upper secondary 96.6 427 0.6 37.7 13.6 48.1 100.0 414 Vocational 96.0 191 1.4 51.0 12.3 35.3 100.0 186 College, university 97.5 326 0.5 37.7 18.5 43.3 100.0 320 Wealth index quintile Poorest 97.2 526 0.7 69.2 5.3 24.7 100.0 514 Second 99.1 493 0.1 58.3 7.4 34.3 100.0 489 Middle 96.7 515 0.9 46.5 11.0 41.6 100.0 502 Fourth 98.1 577 0.6 49.2 17.0 33.2 100.0 569 Richest 96.7 516 0.0 36.3 14.9 48.8 100.0 499 Ethnicity of household head** Khalkh 97.3 1809 0.3 54.5 10.6 34.5 100.0 1767 Darkhad 99.6 455 0.3 43.6 18.9 37.2 100.0 454 Khotgoid 95.2 263 1.7 56.3 4.2 37.8 100.0 255 Other 98.8 81 0.6 20.5 6.3 72.6 100.0 81 1 MICS indicator 2.19 - Iodized salt consumption * Four unweighted cases with missing "Mother's education" are not shown respectively. ** Eleven unweighted cases with missing "Ethnicity of household head" are not shown respectively. The use of adequately iodized salt has strong association with the household wealth index quintiles, and as household gets wealthier the use of iodized salt increases. For instance, the households in poorest, second and fourth quintiles were found to be using adequately iodized salt at 24.7-34.3 percent, while this figure is 41.6-48.8 percent for the households in middle and richest quintiles (Table NU.10). Figure NU.4 shows that in 47.6 percent of households, covered by the survey, salt was found to contain 15 parts per million or more of iodine, which is considered to be at the appropriate level content of iodized salt. 58 Child Development Survey-2016 (Mongolia: Khuvsgul province) Figure NU.4: Percentage of households consuming adequately iodized salt, Khuvsgul, 2016 Cen tral Tou rism Agr icul ture Ide r Tes -Ekh Mu run Urb an Rur al Poo rest Sec ond Mid dle Fou rth Rich est Tota l Any iodine 15+ PPM of iodine Vitamin A Supplementation and fortified food consumption Vitamin A is essential for eye health and proper functioning of the immune system. It is commonly available in food such as milk, liver, eggs, red and orange fruits, red palm oil and green leafy vegetables. These food can be the direct source of vitamin A for human body. In developing countries, where vitamin A is largely consumed in the form of fruits and vegetables, daily per capita intake is often insufficient to meet dietary requirements. As a result, vitamin A deficiency is quite prevalent in these countries with the highest burden of under-five deaths. The 1990 World Summit for Children set the Nutrition goal (e) of virtual elimination of vitamin A deficiency and its consequences, including blindness, by the year 2000. This goal was also approved at the Policy Conference on Ending Hidden Hunger in 1991, the 1992 International Conference on Nutrition, and the UN General Assembly’s Special Session on Children in 2002. The critical role of vitamin A for child health and immune function also makes control of deficiency a primary component of child survival efforts and therefore critical to the achievement of the fourth Millennium Development Goal: a two-thirds reduction in under-five mortality by the year 2015. For countries with vitamin A deficiency problems, current international recommendations call for high dose vitamin A supplementation every six months, targeted to all children between the age of 6-59 months. Based on UNICEF/ WHO guidelines, the Ministry of Health of Mongolia recommends that children age 6-11 months should be given one high dose Vitamin A capsule and children age 12-59 months should be given a vitamin A capsule every 6 months. The country organizes the programs for supplying high dosage of Vitamin A to young children every May and October each year along with immunization activities. In the six months preceding the CDS Khuvsgul, 80.4 percent of children age 6-23 months received a high dose Vitamin A supplement and the survey findings show urban children receive more than children who live in rural areas by 7.6 percentage points (Table NU.12). 59 V. NUTRITION Within the 6 months preceding the survey, 75.8 percent of children age 6-11 months, and 83.4 percent of children age 12-23 months received a high dose Vitamin A supplements. There can be slight variances observed in the consumption of Vitamin A supplements by children’s household wealth quintiles. Children, who live in the richest (73.3 percent) wealth quintiles consume from 8 to 14 percentage points lower than those who live in other quintiles. The additional indicator in this survey is the consumption of food enriched with vitamin A for children age 6-23 months. Table NU.12 presents the consumption of food rich in the vitamin A for children age 6-23 months. The concept of food “rich with vitamin A” refers to meat, poultry, pork, fowl, guts, fish and eggs, as well as green, yellow and orange color vegetables and fruit such as carrots, pumpkins, yams, broccoli, spinach, watermelons, mangos etc. In Khuvsgul province, 86.6 percent of children age 6-23 months had food rich with vitamin A during the last 24 hours. This indicator does not significantly differ by gender and area. By age groups, 74.5 percent of children age 6-11 months received food with vitamin A during the last 24 hours, while it is 94.4 percent among the children age 12-23 months. Iron deficient anemia is common among infants, so consuming food rich with iron is vital to prevent and treat anemia. The data related to consumption of food enriched with iron were collected through Dietary intake module of Child questionnaire in this survey. For children age 6-23 months, the consumption of food rich with iron was estimated based on having meat, pork, fowl, guts, fish and eggs during the last 24 hours. It can be seen that 82.8 percent of children age 6-23 months received food rich with iron during the last 24 hours. The consumption pattern of children’s food rich with iron is quite similar to that of food rich with vitamin A, by background characteristics. Furthermore, Table NU.12 presents the percentage of children age 6-59 months who live in households where idolized salt is used. This indicator has the same pattern by background characteristics as shown in Table NU.10. 60 Child D evelopm ent Survey-2016 (M ongolia: Khuvsgul province) Table NU.12: Micronutrient intake among children Percent distribution of children age 6-23 months who consumed foods rich in vitamin A and iron in past 24 hours, percent distribution of children age 6-23 months who received high dose vitamin A in past 6 months and percent distribution of children age 6-59 months who living in households with iodized (>15 ppm) salt, Khuvsgul, 2016 Children age 6-23 months Children age 6-23 months living with the mother Children age 6-23 months Children age 6-59 months Percentage of children who consumed foods rich in vitamin A in past 24 hoursa Percentage of children who consumed foods rich in iron in past 24 hoursb Number of children age 6-23 months Percentage of children who consumed foods rich in vitamin A in past 24 hoursa Percentage of children who consumed foods rich in iron in past 24 hoursb Number of children age 6-23 months living with the mother Percentage of children who received Vitamin A during the last 6 months1 Number of children age 6-23 months Percentage of children who living in households with iodized saltc Number of children age 6-59 months Total 86.6 82.8 319 85.8 82.5 295 80.4 319 41.4 1013 Sex Male 85.2 80.9 157 84.0 79.3 143 76.7 157 38.6 516 Female 88.1 84.7 162 87.5 85.6 152 84.1 162 44.4 497 Region Central (84.4) (78.7) 53 (83.2) (77.1) 49 (75.1) 53 29.8 178 Tourism 73.8 69.6 87 72.7 68.2 82 82.2 87 46.8 233 Agriculture 100.0 100.0 34 (100.0) (100.0)

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