Nepal - Demographic and Health Survey - 2007

Publication date: 2007

Nepal Demographic And Health Survey 2006 Population Division Ministry of Health and Population Government of Nepal Kathmandu, Nepal New ERA Kathmandu, Nepal Macro International Inc. Calverton, Maryland, U.S.A. May 2007 New ERA Ministry of Health and Population The 2006 Nepal Demographic and Health Survey (2006 NDHS) is part of the worldwide MEASURE DHS project, which is funded by the United States Agency for International Development (USAID) under contract GPO-C-00- 03-00002-00. The views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. Additional information about the 2006 NDHS may be obtained from Population Division, Ministry of Health and Population, Government of Nepal, Ramshahpath, Kathmandu, Nepal; Telephone: (977-1) 4262987; New ERA, P.O. Box 722, Kathmandu, Nepal; Telephone: (977-1) 4423176/4413603; Fax: (977-1) 4419562; E-mail: info@newera.wlink.com.np. Additional information about the DHS project may be obtained from Macro International Inc., 11785 Beltsville Drive, Calverton, MD 20705 USA; Telephone: 301-572-0200, Fax: 301-572- 0999, E-mail: reports@orcmacro.com, Internet: http://www.measuredhs.com. Recommended citation: Ministry of Health and Population (MOHP) [Nepal], New ERA, and Macro International Inc. 2007. Nepal Demographic and Health Survey 2006. Kathmandu, Nepal: Ministry of Health and Population, New ERA, and Macro International Inc. Contents | iii CONTENTS TABLES AND FIGURES . ix FOREWORD . xv ACKNOWLEDGMENTS .xvii 2006 NDHS TECHNICAL ADVISORY COMMITTEE .xix CONTRIBUTORS TO THE REPORT .xxi SUMMARY OF FINDINGS .xxiii MILLENNIUM DEVELOPMENT GOALS .xxix MAP OF NEPAL .xxx CHAPTER 1 INTRODUCTION 1.1 History, Geography, and Economy.1 1.2 Population .3 1.3 Population and Reproductive Health Policies and Programs .3 1.4 Objectives of the Survey .5 1.5 Organization of the Survey.6 1.6 Sample Design .6 1.7 Questionnaires.7 1.8 Hemoglobin Testing .8 1.9 Listing, Pretest, Training and Fieldwork .8 1.9.1 Listing .8 1.9.2 Pretest .8 1.9.3 Training .8 1.9.4 Fieldwork.9 1.10 Data Processing.9 1.11 Response Rates .10 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2.1 Household Population by Age and Sex.11 2.2 Household Composition .14 2.3 Household Characteristics .16 2.4 Household Possessions.20 2.5 Socioeconomic Status Index.21 2.6 Possession of Mosquito Nets .22 2.7 Education of Household Population .23 2.7.1 Educational Attainment of Household Population .23 2.7.2 School Attendance Ratios.27 2.8 Birth Registration.32 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS 3.1 Characteristics of Survey Respondents.35 3.2 Educational Attainment and Literacy .37 iv │ Contents 3.3 Access to Mass Media .43 3.3.1 Access to Specific Radio and Television Programs .45 3.4 Employment .48 3.4.1 Employment Status .48 3.4.2 Occupation.51 3.4.3 Earnings, Employers, and Continuity of Employment .54 3.5 Knowledge and Attitudes Concerning Tuberculosis .55 3.6 Use of Tobacco.58 3.7 Hand Washing Practices .61 CHAPTER 4 FERTILITY 4.1 Current Fertility.63 4.2 Fertility Differentials .64 4.3 Fertility Trends .66 4.4 Pregnancy Outcomes .68 4.5 Children Ever Born and Surviving .69 4.6 Birth Intervals.70 4.7 Age at First Birth.72 4.8 Adolescent Pregnancy and Motherhood.73 CHAPTER 5 FAMILY PLANNING 5.1 Knowledge of Contraceptive Methods.75 5.2 Ever Use of Contraception .76 5.3 Current Use of Contraception .78 5.4 Current Use of Contraception by Background Characteristics .79 5.5 Trends in Current Use of Family Planning.81 5.6 Number of Children at First Use of Contraception.82 5.7 Knowledge of Fertile Period .83 5.8 Sterilization .83 5.9 Source of Contraception .86 5.10 Payment of Fees for Modern Contraceptive Methods .87 5.11 Informed Choice.88 5.12 Contraceptive Discontinuation .89 5.13 Future Use of Contraception .89 5.14 Reasons for Nonuse of Contraception .90 5.15 Preferred Method of Contraception for Future Use .90 5.16 Exposure to Family Planning Messages .91 5.17 Contact of Nonusers with Family Planning Providers .93 5.18 Men’s Attitudes toward Contraception .94 5.19 Husband’s Knowledge of Wife’s Use of Contraception.97 5.20 Discussion of Family Planning Between Spouses .97 CHAPTER 6 PROXIMATE DETERMINANTS OF FERTILITY 6.1 Current Marital Status .99 6.2 Polygyny .100 6.3 Age at First Marriage .102 6.4 Age at First Sexual Intercourse.105 Contents | v 6.5 Recent Sexual Activity .106 6.6 Postpartum Amenorrhea, Abstinence, and Insusceptibility.109 6.7 Menopause.112 CHAPTER 7 FERTILITY PREFERENCES 7.1 Desire for More Children .113 7.2 Desire to Limit Childbearing by Background Characteristics .115 7.3 Need for Family Planning Services.116 7.4 Ideal Family Size .118 7.5 Fertility Planning .121 CHAPTER 8 INFANT AND CHILD MORTALITY 8.1 Assessment of Data Quality .124 8.2 Levels and Trends in Infant and Child Mortality.125 8.3 Socioeconomic Differentials in Childhood Mortality.126 8.4 Demographic Differentials in Mortality.127 8.5 Perinatal Mortality.128 8.6 High-risk Fertility Behavior .129 CHAPTER 9 ADULT AND MATERNAL MORTALITY 9.1 Data Quality Issues .131 9.2 Adult Mortality .132 9.3 Maternal Mortality .132 CHAPTER 10 MATERNAL HEALTH 10.1 Antenatal Care .135 10.2 Delivery Care.140 10.3 Postnatal Care.147 10.4 Newborn Care .150 10.5 Problems in Accessing Health Care .154 CHAPTER 11 CHILD HEALTH 11.1 Child’s Weight and Size at Birth .157 11.2 Immunization Coverage .160 11.3 Acute Respiratory Infections .163 11.4 Fever.165 11.5 Prevalence of Diarrhea.167 11.6 Diarrhea Treatment.168 11.7 Feeding Practices During Diarrhea .170 11.8 Knowledge of ORS Packets .171 11.9 Stool Disposal .171 CHAPTER 12 NUTRITION OF CHILDREN AND WOMEN 12.1 Initiation of Breastfeeding.173 vi │ Contents 12.2 Breastfeeding Status by Age.175 12.3 Duration and Frequency of Breastfeeding .177 12.4 Types of Complementary Foods .179 12.5 Foods Consumed by Mothers.182 12.6 Micronutrient Intake .182 12.6.1 Micronutrient Intake among Children .183 12.6.2 Micronutrient Intake among Mothers .185 12.7 Prevalence of Anemia .188 12.7.1 Prevalence of Anemia in Children .188 12.7.2 Prevalence of Anemia in Women.190 12.8 Nutritional Status .192 12.8.1 Nutritional Status of Children .192 12.8.2 Trends in Children’s Nutritional Status .196 12.8.3 Nutritional Status of Women.196 CHAPTER 13 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR 13.1 Knowledge of HIV/AIDS and of Transmission and Prevention Methods .200 13.1.1 Knowledge of AIDS.200 13.1.2 Knowledge of HIV/AIDS Prevention Methods.202 13.1.3 Comprehensive Knowledge of HIV/AIDS Transmission.204 13.2 Attitudes toward People Living with HIV/AIDS .207 13.3 Attitudes toward Negotiating Safer Sex.210 13.4 Higher-risk Sexual Intercourse.210 13.4.1 Multiple Sexual Partners and Higher-risk Sexual Intercourse.211 13.4.2 Paid Sex.213 13.5 Knowledge on HIV Testing.213 13.6 Reports of Recent Sexually Transmitted Infections .215 13.7 HIV/AIDS-related Knowledge and Behavior among Youth .217 13.7.1 Comprehensive Knowledge about HIV/AIDS and Source for Condoms.217 13.7.2 Age at First Sex and Condom Use at First Sexual Intercourse .219 13.7.3 Recent Sexual Activity among Never-married Youth.222 13.7.4 Higher-risk Sexual Intercourse.222 CHAPTER 14 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 14.1 Employment and Form of Earnings .225 14.2 Control Over and Relative Magnitude of Women’s Earnings.226 14.3 Woman’s Participation in Decisionmaking .228 14.4 Attitudes toward Wife Beating.233 14.5 Attitudes toward Refusing Sex with Husband.236 14.6 Current Use of Contraception by Women’s Status.241 14.7 Ideal Family Size and Unmet Need by Women’s Status.242 14.8 Reproductive Health Care by Women’s Status .243 REFERENCES . 245 APPENDIX A CAUSES OF UNDER-FIVE MORTALITY . 249 Contents | vii APPENDIX B SAMPLE IMPLEMENTATION .263 APPENDIX C ESTIMATES OF SAMPLING ERRORS.265 APPENDIX D DATA QUALITY TABLES .281 APPENDIX E PERSONS INVOLVED IN THE 2006 NEPAL DEMOGRAPHIC AND HEALTH SURVEY.289 APPENDIX F QUESTIONNAIRES .293 Tables and Figures | ix TABLES AND FIGURES Page CHAPTER 1 INTRODUCTION Table 1.1 Basic demographic indicators.3 Table 1.2 Results of household and individual interviews.10 CHAPTER 2 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS Table 2.1 Household population by age, sex, and residence.11 Table 2.2.1 Migration status: Men .13 Table 2.2.2 Migration status: Women.14 Table 2.3 Household composition.15 Table 2.4 Children's living arrangements and orphanhood.16 Table 2.5 Household drinking water.17 Table 2.6 Household sanitation facilities.18 Table 2.7 Housing characteristics.19 Table 2.8 Household possessions .20 Table 2.9 Wealth quintiles.21 Table 2.10 Possession of mosquito nets .22 Table 2.11.1 Educational attainment of household population: Male.24 Table 2.11.2 Educational attainment of household population: Female .25 Table 2.12 Children enrolled in school-based pre-primary classes and early childhood development centers.26 Table 2.13.1 School attendance ratios: primary school .28 Table 2.13.2 School attendance ratios: secondary school .29 Table 2.14.1 Grade repetition rates .30 Table 2.14.2 Grade dropout rates.31 Table 2.15 Birth registration .33 Figure 2.1 Population pyramid .12 Figure 2.2 Age-specific attendance rates .32 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS Table 3.1 Background characteristics of respondents .36 Table 3.2.1 Educational attainment: Women.38 Table 3.2.2 Educational attainment: Men .39 Table 3.3.1 Literacy: Women .41 Table 3.3.2 Literacy: Men .42 Table 3.4.1 Exposure to mass media: Women.43 Table 3.4.2 Exposure to mass media: Men .44 Table 3.5.1 Exposure to specific health programs on radio and television: Women.46 Table 3.5.2 Exposure to specific health programs on radio and television: Men .47 Table 3.6.1 Employment status: Women .49 Table 3.6.2 Employment status: Men.50 x | Tables and Figures Table 3.7.1 Occupation: Women. 52 Table 3.7.2 Occupation: Men . 53 Table 3.8.1 Type of employment: Women. 54 Table 3.8.2 Type of employment: Men . 55 Table 3.9.1 Knowledge and attitudes concerning tuberculosis: Women. 56 Table 3.9.2 Knowledge and attitudes concerning tuberculosis: Men . 57 Table 3.10.1 Use of tobacco: Women. 59 Table 3.10.2 Use of tobacco: Men . 60 Table 3.11 Hand washing practices . 62 CHAPTER 4 FERTILITY Table 4.1 Current fertility . 63 Table 4.2 Fertility by background characteristics . 65 Table 4.3 Trends in age-specific fertility rates. 66 Table 4.4 Trends in fertility. 67 Table 4.5 Pregnancy outcome . 68 Table 4.6 Children ever born and living. 69 Table 4.7 Birth intervals. 71 Table 4.8 Age at first birth . 72 Table 4.9 Median age at first birth . 73 Table 4.10 Adolescent pregnancy and motherhood. 74 Figure 4.1 Age-specific fertility rates by urban-rural residence. 64 Figure 4.2 Total fertility rates by background characteristics . 66 Figure 4.3 Trends in total fertility rates 1993-2005. 67 CHAPTER 5 FAMILY PLANNING Table 5.1 Knowledge of contraceptive methods . 76 Table 5.2.1 Ever use of contraception: Women . 77 Table 5.2.2 Ever use of contraception: Men . 78 Table 5.3 Current use of contraception by age . 79 Table 5.4 Current use of contraception by background characteristics . 80 Table 5.5 Trends in current use of modern contraceptive methods. 81 Table 5.6 Number of children at first use of contraception . 82 Table 5.7 Knowledge of fertile period. 83 Table 5.8 Timing of sterilization. 84 Table 5.9 Sterilization regret . 85 Table 5.10 Source of modern methods of contraception . 86 Table 5.11 Payment for modern contraceptive methods. 87 Table 5.12 Informed choice . 88 Table 5.13 First-year contraceptive discontinuation rates . 89 Table 5.14 Future use of contraception . 89 Table 5.15 Reason for not intending to use contraception in the future . 90 Table 5.16 Preferred method of contraception for future use. 90 Table 5.17 Exposure to family planning messages . 92 Table 5.18 Contact of nonusers with family planning providers . 94 Table 5.19 Men's attitudes toward contraceptive use . 95 Table 5.20 Discussion of family planning with spouse. 97 Tables and Figures | xi Figure 5.1 Trends in contraceptive use among currently married women, Nepal 1996-2006 . 82 CHAPTER 6 PROXIMATE DETERMINANTS OF FERTILITY Table 6.1 Current marital status . 99 Table 6.2 Trend in proportion never married. 100 Table 6.3 Number of co-wives and wives . 101 Table 6.4 Age at first marriage . 102 Table 6.5.1 Median age at first marriage: Women . 103 Table 6.5.2 Median age at first marriage: Men. 104 Table 6.6 Age at first sexual intercourse . 105 Table 6.7 Median age at first intercourse for men . 106 Table 6.8.1 Recent sexual activity: Women . 107 Table 6.8.2 Recent sexual activity: Men . 108 Table 6.9 Postpartum amenorrhea, abstinence, and insusceptibility. 110 Table 6.10 Median duration of amenorrhea, postpartum abstinence, and postpartum insusceptibility. 111 Table 6.11 Menopause. 112 CHAPTER 7 FERTILITY PREFERENCES Table 7.1 Fertility preferences by number of living children . 114 Table 7.2 Desire for more children among monogamous couples. 115 Table 7.3 Desire to limit childbearing . 116 Table 7.4 Need and demand for family planning among currently married women . 117 Table 7.5 Ideal number of children . 119 Table 7.6 Mean ideal number of children by background characteristics . 120 Table 7.7 Fertility planning status. 121 Table 7.8 Wanted fertility rates. 122 CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates . 125 Table 8.2 Early childhood mortality rates by socioeconomic characteristics. 126 Table 8.3 Early childhood mortality rates by demographic characteristics. 127 Table 8.4 Perinatal mortality. 129 Table 8.5 High-risk fertility behavior . 130 Figure 8.1 Trends in childhood mortality, Nepal 1990-2005. 126 Figure 8.2 Under-five mortality by selected demographic characteristics. 128 CHAPTER 9 ADULT AND MATERNAL MORTALITY Table 9.1 Adult mortality rates. 132 Table 9.2 Direct estimates of maternal mortality . 133 CHAPTER 10 MATERNAL HEALTH Table 10.1 Antenatal care. 136 xii | Tables and Figures Table 10.2 Number of antenatal care visits and timing of first visit . 137 Table 10.3 Components of antenatal care . 138 Table 10.4 Tetanus toxoid injections . 140 Table 10.5 Place of delivery . 142 Table 10.6 Assistance during delivery . 144 Table 10.7.1 Birth preparedness: Women . 145 Table 10.7.2 Birth preparedness: Men. 146 Table 10.8 Timing of first postnatal checkup. 148 Table 10.9 Provider at first postnatal checkup. 149 Table 10.10 Use of clean home delivery kits and other instruments to cut the umbilical cord. 151 Table 10.11 Newborn care practices . 152 Table 10.12 Abortion and associated complications . 153 Table 10.13 Problems in accessing health care . 155 CHAPTER 11 CHILD HEALTH Table 11.1 Child's weight and size at birth. 159 Table 11.2 Immunization by source of information. 161 Table 11.3 Immunization by background characteristics . 162 Table 11.4 Prevalence and treatment of symptoms of ARI . 164 Table 11.5 Prevalence and treatment of fever. 166 Table 11.6 Prevalence of diarrhea . 167 Table 11.7 Diarrhea treatment . 169 Table 11.8 Feeding practices during diarrhea . 170 Table 11.9 Disposal of children's stools. 172 Figure 11.1 Trends in immunization coverage among children 12-23 months. 163 CHAPTER 12 NUTRITION OF CHILDREN AND WOMEN Table 12.1 Initial breastfeeding. 174 Table 12.2 Breastfeeding status by age . 176 Table 12.3 Median duration and frequency of breastfeeding . 178 Table 12.4 Foods and liquids consumed by children in the day and night preceding the survey. 179 Table 12.5 Infant and young child feeding (IYCF) practices . 181 Table 12.6 Foods consumed by mothers in the day and night preceding the survey . 182 Table 12.7 Micronutrient intake among children . 184 Table 12.8 Micronutrient intake among mothers . 186 Table 12.9 Prevalence of anemia in children . 189 Table 12.10 Prevalence of anemia in women . 191 Table 12.11 Nutritional status of children . 194 Table 12.12 Nutritional status of women . 198 Figure 12.1 Trends in anemia status among children 6-59 months. 190 Figure 12.2 Nutritional status of children under age five . 195 Figure 12.3 Trends in nutritional status of children under five years . 196 Tables and Figures | xiii CHAPTER 13 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR Table 13.1 Knowledge of AIDS.201 Table 13.2 Knowledge of HIV prevention methods.203 Table 13.3.1 Comprehensive knowledge about AIDS: Women . 205 Table 13.3.2 Comprehensive knowledge about AIDS: Men. 206 Table 13.4.1 Accepting attitudes toward those living with HIV/AIDS: Women . 208 Table 13.4.2 Accepting attitudes toward those living with HIV/AIDS: Men . 209 Table 13.5 Attitudes toward negotiating safer sexual relations with husband . 210 Table 13.6 Multiple sexual partners and higher-risk sexual intercourse in the past 12 months . 212 Table 13.7 Payment for sexual intercourse . 213 Table 13.8 Knowledge of source for HIV testing and women ever tested . 214 Table 13.9 Self-reported prevalence of sexually transmitted infections (STIs) and STI symptoms. 216 Table 13.10 Comprehensive knowledge about AIDS and knowledge of a source for condoms among youth . 218 Table 13.11 Age at first sexual intercourse among youth. 220 Table 13.12 Condom use at first sexual intercourse among youth. 221 Table 13.13 Premarital sexual intercourse among male youth. 222 Table 13.14 Higher-risk sexual intercourse among male youth . 223 Figure 13.1 Trend in HIV/AIDS knowledge, Ever-married Women 15-49 and Men 15-59, 1996-2006 . 202 Figure 13.2 Women and men seeking advice or treatment for STIs. 217 Figure 13.3 Abstinence, being faithful, and condom use (ABC) among male youth . 224 CHAPTER 14 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES Table 14.1 Employment and cash earnings of currently married women and men . 226 Table 14.2 Control over women's cash earnings and relative magnitude of women's earnings. 227 Table 14.3.1 Participation in decisionmaking: Women. 228 Table 14.3.2 Participation in decisionmaking: Men . 229 Table 14.4.1 Women's participation in decisionmaking by background characteristics. 230 Table 14.4.2 Men's attitude toward wives' participation in decisionmaking . 232 Table 14.5.1 Attitudes toward wife beating: Women. 234 Table 14.5.2 Attitudes toward wife beating: Men . 235 Table 14.6.1 Attitudes toward refusing sexual intercourse with husband: Women . 237 Table 14.6.2 Attitudes toward refusing sexual intercourse with husband: Men. 238 Table 14.7 Men's attitudes toward a husband's rights when his wife refuses to have sexual intercourse . 240 Table 14.8 Indicators of women's empowerment. 241 Table 14.9 Current use of contraception by women's empowerment. 242 Table 14.10 Women's empowerment according to ideal number of children and unmet need for family planning . 243 Table 14.11 Reproductive health care by women's empowerment . 244 xiv | Tables and Figures Figure 14.1 Number of decisions in which currently married women participate . 231 APPENDIX A CAUSES OF DEATH IN CHILDREN UNDER FIVE YEARS OF AGE IN NEPAL Table A.1 Cause of death among children under five . 253 Table A.2 Cause of death among children under five by sex of child. 255 Table A.3 Cause of death among children under five by mother’s education . 256 Table A.4 Cause of death among children under five by birth order. 256 Table A.5 Cause of death among children under five by urban-rural residence . 257 Table A.6 Cause of death among children under five by ecological zone . 257 Table A.7 Cause of death among children under five by development region . 258 Table A.8 Cause of death among children under five by wealth quintile . 258 Figure A.1 Cause of death hierarchy . 251 Figure A.2 Distribution of the verbal autopsy sample . 253 APPENDIX B SAMPLE IMPLEMENTATION Table B.1 Sample implementation: Women . 263 Table B.2 Sample implementation: Men. 264 APPENDIX C ESTIMATES OF SAMPLING ERRORS Table C.1 List of selected variables for sampling errors . 268 Table C.2 Sampling errors for national sample . 269 Table C.3 Sampling errors for urban sample. 270 Table C.4 Sampling errors for rural sample. 271 Table C.5 Sampling errors for Mountain region . 272 Table C.6 Sampling errors for Hill region. 273 Table C.7 Sampling errors for Terai region . 274 Table C.8 Sampling errors for Eastern region . 275 Table C.9 Sampling errors for Central region. 276 Table C.10 Sampling errors for Western region . 277 Table C.11 Sampling errors for Mid-western region. 278 Table C.12 Sampling errors for Far-western region . 279 APPENDIX D DATA QUALITY TABLES Table D.1 Household age distribution . 281 Table D.2.1 Age distribution of eligible and interviewed women . 282 Table D.2.2 Age distribution of eligible and interviewed men. 282 Table D.3 Completeness of reporting . 283 Table D.4 Births by calendar years . 284 Table D.5 Reporting of age at death in days . 285 Table D.6 Reporting of age at death in months. 286 Table D.7 Data on siblings . 287 Table D.8 Indicators on data quality. 287 Table D.9 Sibship size and sex ratio of siblings . 287 Foreword | xv The 2006 Nepal Demographic and Health Survey (NDHS) is the seventh in a series of demographic surveys conducted in the country and is the third survey conducted as part of the worldwide Demographic and Health Surveys (DHS) program. The survey was conducted under the aegis of the Population Division of the Ministry of Health and Population and implemented by New ERA. Technical support for the survey was provided by Macro International Inc., and financial support was provided by the United States Agency for International Development through its mission in Nepal. The 2006 NDHS supplements and complements the information collected through the censuses, updates the available information on population and health issues, and provides guidance in planning, implementing, monitoring and evaluating Nepal’s health programs. Further, the results of the survey assist in the monitoring of the progress made towards meeting the Millennium Development Goals (MDGs). The 2006 NDHS includes topics related to fertility levels and determinants, family planning, fertility preferences, infant, child, adult and maternal mortality, maternal and child health, nutrition, knowledge of HIV/AIDS and women’s empowerment. The 2006 NDHS for the first time also includes anemia testing among women age 15-49 and children age 6-59 months. As well as providing national estimates, the survey also provides disaggregated data at the level of various domains such as ecological region, development region, as well as for urban and rural areas. This being the third survey of its kind, there is considerable trend information on reproductive and health care over the past 10 years. This survey is the result of concerted effort on the part of various individuals and institutions, and it is with great pleasure that I would like to acknowledge the work put in to produce this useful document. The participation and cooperation that was extended by the members of the Technical Advisory Committee in the different phases of the survey is greatly appreciated. I would like to extend my appreciation to USAID/Nepal for providing financial support for the survey. I would like to extend my sincere thanks to Macro International Inc. for their technical support. The earnest effort put forth by the New ERA study team in the timely completion of the survey is highly appreciated. I also would like to thank the Population Division of the Ministry of Health and Population for its efforts and dedication in the successful completion of the 2006 NDHS. This report serves not only as a valuable reference, but is a call for effective action. Ram Chandra Man Singh Secretary Ministry of Health and Population FOREWORD Acknowledgments | xvii The 2006 Nepal Demographic and Health Survey (NDHS) is the result of earnest effort put forth by different individuals and organizations. The survey was conducted under the aegis of the Population Division, Ministry of Health and Population of the Government of Nepal. The United States Agency for International Development (USAID) provided financial support through its mission in Nepal while technical assistance was provided by Macro International Inc. The survey was implemented by New ERA, a local research firm having wide experience in conducting such surveys in the past. We express our deep sense of appreciation to the technical experts in the different fields of population and health for their valuable input in the various phases of the survey including the finalization of the questionnaires, training of field staff, reviewing the draft tables and providing valuable inputs towards finalizing the report. The input provided by the Technical Advisory Committee is highly appreciated. We would like to extend our appreciation to the USAID mission in Nepal. The technical input provided by Dr. John Quinley, former Health and Child Survival Advisor is highly appreciated. We also acknowledge the support provided by Ms. Anne Peniston, Deputy Health Office Director, Ms. Sharon Arscott-Mills, Team Leader and Senior Technical Advisor HIV/AIDS and Dr. Debendra Karki, HIV-AIDS Senior Programme Management Specialist. Our deep sense of gratitude goes to Dr. Pav Govindasamy, Senior Country Coordinator, Macro International Inc. for her technical support provided throughout the survey. We extend our appreciation to Ms. Jasbir Sangha, Biomarker trainer, Macro International Inc. for providing technical support on anemia testing. We also would wish to thank Dr. Alfredo Aliaga, sampling expert; Mr. Martin Wulfe, Deputy Chief of Data Processing; and Mr. Guillermo Rojas, Chief of Data Processing, for their support. Special thanks goes to the core staff of New ERA, Ms. Anjushree Pradhan, Project Director, Mr. Matrika Chapagain, Deputy Project Director; Mr. Sujan Karki, Research Officer; Mr. Bishnu Das Dangol, Technical Advisor; Mr. Chhitish Chandra Dhakal and Mr. Min Bahadur K.C., Research Assistants; Mr. Rajendra Lal Singh Dangol, Senior Data Processing Specialist and Ms. Sarita Vaidya, Data Processing Staff; Mr. Sanu Raja Shakya and Ms. Geeta Shrestha Amatya, Word Processing Staff; and other field staff, office editors and data entry staff of New ERA for their valuable contributions towards the successful completion of the survey. We are also grateful to Mr. Upendra Adhikary, Under-Secretary, Ministry of Health and Population, for his support. We would like to extend our heartiest appreciation to the survey respondents, who were critical to the successful completion of the survey. The survey was made possible through the support we received from the local level agencies including the District Health Offices, Health-Posts, Sub-health Posts, District Development Committees and the Village Development Committees. The FCHVs require special mention here, whose support has been highly appreciated. Yogendra Prasai Ram Hari Aryal, Ph.D Executive Director Chief, Population Division New ERA Ministry of Health and Population ACKNOWLEDGMENTS 2006 NDHS Technical Advisory Committee | xix Dr. Ram Chandra Man Singh, Secretary, Ministry of Health and Population Dr. Nirakar Man Shrestha, Chief Specialist, Ministry of Health and Population Dr. Ram Hari Aryal, Chief, Population Division, Ministry of Health and Population Dr. Mahendra Bahadur Bista, former Director General, Department of Health Services Dr. Bal Krishna Suvedi, Director, Family Health Division Dr. Piyush Kumar Rajendra, former Director, Family Health Division Dr. Yasho Vardhan Pradhan, Director, Child Health Division Dr. Shyam Sundar Mishra, former Director, National Center for AIDS and STD Control Mr. Krishna Raj Giri, Director, National Health Education Information and Communication Center Dr. Sharad Onta, Member Secretary, Nepal Health Research Council Mr. Tunga Siromani Bastola, Director General, Central Bureau of Statistics Mr. Tirtha Dhakal, Under Secretary, National Planning Commission Dr. John Quinley, former Health and Child Survival Advisor, USAID/Nepal Ms. Sharon Arscott-Mills, Team Leader and Senior Technical Advisor HIV/AIDS, USAID/Nepal Dr. Pav Govindasamy, Senior Country Coordinator, Macro International Mr. Yogendra Prasai, Executive Director, New ERA Technical Sub-Committee Dr. Ram Hari Aryal, Chief, Population Division, Ministry of Health and Population Mr. Upendra Adhikary, Under-secretary, Ministry of Health and Population Mr. Megh Raj Dhakal, Under-secretary, Ministry of Health and Population Mr. Ajit Pradhan, Monitoring and Evaluation Advisor, Support to Safe Motherhood Program Mr. Radha Krishna G.C., Deputy Director, Central Bureau of Statistics Dr. Bhim Acharya, CB-IMCI Chief, Child Health Division, Department of Health Services Ms. Kusum Shakya, Lecturer, Tribhuvan University Dr. Ram Sharan Pathak, Associate Professor, Central Department of Population Studies, Tribhuvan University Ms. Srijana Shrestha, National Center for AIDS and STD Control Dr. Khem Karki, Director, Society for Local Integrated Development-Nepal 2006 NDHS TECHNICAL ADVISORY COMMITTEE Contributors to the Report | xxi Authors: Dr. Ram Hari Aryal, Population Division, Ministry of Health and Population Mr. Upendra Adhikary, Population Division, Ministry of Health and Population Mr. Megh Raj Dhakal, Population Division, Ministry of Health and Population Mr. Radha Krishna G.C., Central Bureau of Statistics Dr. Bal Krishna Suvedi, Family Health Division, Ministry of Health and Population Dr. Sun Lal Thapa, Child Health Division, Ministry of Health and Population Dr. Ram Sharan Pathak, Central Department of Population Studies, Tribhuvan University Dr. Laxmi Bilas Acharya, Family Health International Dr. Prakash Dev Pant, Measure for Intervention, Training, Research and Action (MITRA Samaj) Mr. Bishnu Das Dangol, New ERA Ms. Anjushree Pradhan, New ERA Mr. Sujan Karki, New ERA Dr. Pav Govindasamy, Macro International Inc. Dr. Alfredo Aliaga, Macro International Inc. Dr. Abdullah Baqui, Macro consultant at Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University Resource persons: Dr. Lava Deo Awasthi, Ministry of Education Dr. Yagya Bahadur Karki, The Population, Health and Development Group Mr. Ajit Pradhan, Support to Safe Motherhood Program Mr. Shital Bhandary, Kathmandu University Mr. Tek Bahadur Dangi, Ministry of Health and Population Mr. Ashoke Shrestha, Nepal Family Health Program Mr. Bharat Ban, Nepal Family Health Program Dr. Bhim Acharya, Child Health Division, Ministry of Health and Population Dr. Shyam Raj Upteri, Child Health Division, Ministry of Health and Population Dr. Yasho Vardhan Pradhan, Child Health Division, Ministry of Health and Population Dr. Ramesh Kant Adhikari, Dean, Institute of Medicine, Tribhuvan University Ms. Sharda Pandey, Child Health Division, Ministry of Health and Population Mr. Navin Paudel, United Nation’s Children’s Fund (UNICEF)/Nepal Mr. Macha Raja Maharjan, Micronutrient Initiative/Nepal CONTRIBUTORS TO THE REPORT Summary of Findings | xxiii SUMMARY OF FINDINGS The 2006 Nepal Demographic and Health Survey (NDHS) is a nationally representative survey of 10,793 women age 15-49 and 4,397 men age 15-59. The 2006 NDHS is the third comprehensive survey conducted in Nepal as part of the worldwide Demographic and Health Surveys (DHS) project. The primary purpose of the 2006 NDHS is to furnish policymakers and planners with detailed information on fertility, family planning, infant, child, adult and maternal mortality, maternal and child health, nutrition and knowledge of HIV/AIDS and other sexually transmitted infections. In addition, the 2006 NDHS is the first DHS survey in Nepal to provide population-based prevalence estimates for anemia among women age 15-49 and children age 6-59 months. FERTILITY Survey results indicate that there has been an unprecedented decline in fertility from 4.6 births per woman in 1996 to 3.1 births per woman in 2006, a drop of one and a half births per woman in the past ten years. The decline is more pronounced in the five years between 2001 and 2006 (a one child or 24 percent decline) than between 1996 and 2001, with declines observed in every age group over the past ten years, and larger declines seen in the older than younger age cohorts. Fertility is considerably higher in rural (3.3 births per woman) than in urban areas (2.1 births per woman). There are noticeable differ- entials in fertility among ecological zones and development regions, ranging from a low of 3.0 births per woman in the hills to a high of 4.1 births per woman in the mountains, and from a low of 3.0 births per woman in the Central region to a high of 3.5 births per woman in the Mid- and Far-western regions. Education and wealth have a marked effect on fertility, uneducated mothers having twice as many births as women with SLC and higher education and women in the lowest wealth quintile having two and a half times as many births as women in the highest wealth quintile. Childbearing begins early. Almost one- quarter of Nepalese women have given birth before reaching age 18, and more than half have had a birth by age 20. The median age at first birth is about 20 years for all age cohorts, indicating virtually no change in the age at first birth over the past few decades. Marriage patterns are an important determinant of fertility levels in a population. Data from the 1996 NFHS, the 2001 NDHS and the 2006 NDHS indicate that the proportion never married among women age 15-19 and 20-24 increased by 21 percent each over the past ten years, with the decline more pronounced in the past five years than in the previous five years. A similar pattern of decline in nuptiality is observed among men as well in the past five years, although the decline is much smaller among men than women. Nepalese women generally begin sexual intercourse at the time of their first marriage. This can be seen from the identical medians for age at first marriage and age at first sexual intercourse (17.2 years) among women age 20-49. Men, on the other hand, are sexually active before marriage, although the difference in age at first intercourse and age at first marriage has narrowed over the past five years. The median age at first sexual intercourse for men age 25-49 is 19.6 years, while the median age at first marriage is 20.2 years. In general, Nepalese men marry about three years later than women. The median age at marriage among women age 20-49 increased by nearly a year over the past ten years but this increase was small over the past five years. However, the median age at marriage among men rose by nearly a year in the last five years. Data from the 2006 NDHS show that 4 percent of currently married women are married to men who are in a polygynous union. Older women, urban women, women residing in the Far-western terai, uneducated women, and women in the highest wealth quintile are more likely to be in a polygynous union than other women. Two percent of men report having two or more wives. The median age at first birth is about 20 years across all age cohorts, indicating virtually no change in the age at first birth over the past two decades. More than 70 percent of women in all age cohorts had their first birth by age 22, with the xxiv * Summary of Findings proportion of women having their first birth by age 22 declining with increasing age of the mother. About 90 percent of Nepalese women have their first birth by age 25. One in five adolescent women age 15-19 are already mothers or pregnant with their first child. The proportion of teenage women who have started childbearing increases from 1 percent among women age 15 to 41 percent among women age 19. The interval between births is relatively long in Nepal. Half of all births occur just under three years (33.6 months) after a previous birth. The median birth interval increased by nearly two months in the past five years. The long period of breastfeeding in Nepal (34.3 months) and the corresponding long period of postpartum insus- ceptibility (10.5 months) are factors contributing to the long birth interval. Data from the three NDHS surveys show that the desire to stop childbearing continues to in- crease, from 59 percent among currently married women in 1996 to 66 percent in 2001 and 71 percent in 2006. In addition, the data show a steady decline in the mean ideal number of children among currently married women over the past ten years, from 2.9 children in 1996 to 2.6 children in 2001 and to 2.4 children in 2006. These findings could also explain the declining total fertility rate in Nepal. As in the previous two DHS surveys, the 2006 NDHS gathered complete pregnancy histories from women and hence provides information on pregnancy outcomes. One in ten pregnancies that occurred in the ten years preceding the survey did not end in a live birth, with pregnancy losses highest among women age 35-39 (14 percent) and noticeably higher among urban (13 percent) than rural women (9 percent). This latter difference is attributed primarily to more reporting of induced abortions in urban areas than rural areas. FAMILY PLANNING Nearly all Nepalese women and men know of at least one method of contraception. Injectables, female sterilization, condoms, male sterilization, and the contraceptive pill are known to most (95 percent and higher) currently married women and men, with somewhat lower proportions reporting knowledge of implants and IUDs. A higher proportion of respondents reported knowing a modern method than a traditional method. Nearly one in two currently married women is using a method of contraception, with most women using a modern method (44 percent). The two most popular modern methods are female sterilization (18 percent) and injectables (10 percent). The use of modern contraceptive methods among currently married women increased by 70 percent in the past ten years from 26 percent in 1996 to 44 percent in 2006, with much of this increase attributed to the rise in the use of female sterilization, the pill, condoms and injectables. Overall, there has been a 36 percent increase in the share of temporary methods over permanent methods in the past decade. The government sector remains the major source of contraceptive methods providing methods to nearly four in five female users, with nearly one in three users obtaining their method from government hospitals and another one in five from mobile camps (serving sterilization users alone). Twelve percent of female users obtain their method from sub-health posts. The non- government sector, primarily Family Planning Association of Nepal (FPAN) and Marie Stopes, supplies 6 percent of users, while the private medical sector supplies contraceptives to 14 percent of users, most of whom (10 percent) obtain their supplies from pharmacies. Nearly three-quarters of currently married women who were not using any family planning method at the time of the survey say they intend to use a method in the future. The majority of prospective users prefer injectables and female sterilization. Nearly two-thirds of currently married nonusers cited fertility-related reasons, primarily subfecundity or infecundity, for not intending to use a method of contraception in the future. Twelve percent of women cited opposition to use, especially religious opposition, for not wanting to use a method in the future, while about one in ten were not intending to use because of method-related reasons, primarily fear of side effects. In spite of the marked increase in the use of contraceptives in Nepal, there continues to be considerable scope for increased use of family planning. Twenty-five percent of currently Summary of Findings | xxv married women in Nepal have an unmet need for family planning services, of which 9 percent have a need for spacing and 15 percent have a need for limiting. At the same time, among women currently using a method, 43 percent are using for limiting and 5 percent are using for spacing. Taken together, nearly three in four Nepalese women have a demand for family planning. However, only two-thirds of these women’s demand is currently being met. If all women with unmet need were to use family planning, the contraceptive prevalence rate would increase from 48 percent to 73 percent. Family planning information is largely received through the radio with limited exposure through the television and print media. Sixty- eight percent of women heard about family planning on the radio compared with 40 percent who heard about it from the television, 40 percent who have seen a message on a poster or billboard, 15 percent who read about it in newspapers or magazines and 6 percent who saw a family planning message at a street drama. CHILD HEALTH At current mortality levels, one in every 21 Nepalese children dies before reaching age one, while one in every sixteen does not survive to the fifth birthday. Data from the 2006 NDHS show that infant mortality has declined by 41 percent over the past 15 years from 82 deaths per 1,000 live births to 48. Under-five mortality has gone down by 48 percent from 117 deaths per 1,000 live births to 61. The corresponding declines in neonatal and postneonatal mortality over the 15-year period are 33 percent and 55 percent, respectively. Mortality is consistently lower in urban areas than in rural areas. Wide differentials are also observed by ecological zones (being lowest in the hills and highest in the mountains), and by development regions, with children living in the Eastern region faring much better than children living in the other regions. This is similar to findings from the 1996 NFHS and 2001 NDHS surveys. Eighty-three percent of children age 12-23 months had been fully immunized at the time of the survey. Ninety-three percent have received the BCG vaccination, and 85 percent have been immunized against measles. The coverage for the first dose of DPT is very high (93 percent). However, only 89 percent go on to receive the third dose of DPT. Polio coverage is much higher than DPT coverage because of the success of the national immunization day campaigns during which polio vaccines are administered. Neverthe- less, the dropout between the first and subsequent doses of polio is noticeable—a 6 percent decline between the first and third dose. Seventy-six percent of children age 12-23 months received the first dose of the Hepatitis B vaccine, but coverage dropped to 69 percent for the third dose. Immunization coverage in Nepal has improved over the past ten years. The percentage of children 12-23 months fully immunized at the time of the survey almost doubled from 43 percent in 1996 to 83 percent in 2006, with the increase in coverage higher in the first five years than in the second five years, primarily due to the marked increase in polio vaccine coverage between 1996 and 2001. The percentage who did not receive any of the six basic immunizations also decreased from 20 percent to 3 percent over the same ten-year period. Five percent of children under age five showed symptoms of acute respiratory infection (ARI) in the two weeks before the survey. Forty- three percent of children under five with symptoms of ARI were taken to a health facility or provider. Seventeen percent of children under five were reported to have had fever. One in three children was taken to a health facility or provider for treatment. Twenty percent of children with fever received antibiotics and almost no children received antimalarial drugs. The 2006 NDHS gathered information on the use of mosquito nets. The data show that about three-fifths of households in Nepal have mosquito nets, with households in the terai much more likely to possess mosquito nets than households in the mountains and hills. More than 90 percent of households in the Far-western terai have mosquito nets. One in two households have 2-3 nets. Nationally, 12 percent of children under age five had diarrhea in the two weeks before the survey, while 2 percent had diarrhea with blood during the same period. The proportion of xxvi * Summary of Findings children with diarrhea taken to a health provider for treatment has increased from 14 percent in 1996 to 21 percent in 2001 and 27 percent in 2006. The percentage of children who were treated with oral rehydration salts (ORS) increased from 26 percent in 1996 to 32 percent in 2001, but dropped to 29 percent in 2006. MATERNAL HEALTH Forty-four percent of mothers received antenatal care from skilled birth attendants (SBAs) for their most recent birth in the five years preceding the survey. In addition, 28 percent received antenatal care from trained health workers such as a health assistant or auxiliary health worker, a maternal and child health worker (MCHW), or a village health worker (VHW). Less than 2 percent of women received antenatal care from a traditional birth attendant or a female community health volunteer (FCHV). One in four births received no antenatal care at all. There has been a significant improvement over the past ten years in the proportion of mothers who receive antenatal care from an SBA, increasing from 24 percent in 1996, to 28 percent in 2001 and 44 percent in 2006. About three in ten women make four or more antenatal care visits during their entire pregnancy. The percentage of women who made four or more antenatal visits during their pregnancy tripled during the past ten years. The median duration of pregnancy for the first antenatal visit is 4.6 months, indicating that Nepalese women start antenatal care at a relatively later stage of their pregnancy. Among mothers who received antenatal care more than half (57 percent) reported that they were informed about pregnancy complications during their antenatal care visits. Fifty-nine percent took iron tablets and 20 percent took intestinal parasite drugs while pregnant with their last birth. About three-fourths of pregnant women who sought antenatal care were weighed, and had their blood pressure taken. About three in ten women gave urine and blood samples for testing. Nearly four out of five mothers with a live birth in the five years preceding the survey were protected against neonatal tetanus. However, less than two-thirds of pregnant women received two or more tetanus injections during their last pregnancy. The percentage of mothers who received at least two tetanus toxoid injections for their last birth has increased by 40 percent over the past five years. An overwhelming majority of births in the five years before the survey were delivered at home (81 percent). Thirteen percent of births were delivered in a public facility, 4 percent in a non-government health facility and 1 percent in a private facility. The percentage of births taking place in a health facility has doubled in the past five years. Less than one-fifth of births take place with the assistance of an SBA. Health assistants or health workers assist in the delivery of 4 percent of births, FCHVs assist in 2 percent of births, and traditional birth attendants assist in 19 percent of births. Seven percent of births were delivered without any type of assistance at all. One-third of women received postnatal care for their last birth that occurred in the five years before the survey. One in five women received care within the first 24 hours, and 4 percent of women were seen within 1-2 days of delivery. Nineteen percent of mothers received postnatal care from an SBA. One in five mothers had a pelvic examination during their postnatal checkup. BREASTFEEDING AND NUTRITION Breastfeeding is nearly universal in Nepal, and the median duration of any breastfeeding is long (34.3 months). Exclusive breastfeeding, on the other hand, is relatively short, with a median duration of 2.5 months. Contrary to UNICEF and WHO recommendations, only around one in two children less than age 6 months are exclusively breastfed. The data also show that comple- mentary foods are not introduced in a timely fashion for all children. At 6-9 months, three in four children are receiving complementary foods. The use of a bottle with a nipple is not widespread in Nepal. However, the proportion of children who are bottle-fed rises from 2 percent among children age less than 2 months to 6 percent among children age 8-9 months, after which it declines gradually. Nearly all children age 6-23 months are breastfed or given milk products, about three out of five children are given the recommended number of foods, and more than four out of five children are fed at Summary of Findings | xxvii least as often as recommended by the Infant and Young Child Feeding (IYCF) practices. Micronutrient deficiency is an important cause of childhood morbidity and mortality. Information gathered in the 2006 NDHS shows that 64 percent of last-born children age 6-35 months living with the mother consumed vitamin A-rich foods in the 24 hours preceding the survey and 24 percent consumed foods rich in iron. Eighty-eight percent of children age 6-59 months was given vitamin A supplements in the six months preceding the survey. In addition, 82 percent of children 12-59 months were given deworming medication in the six months before the survey. Nearly one in two Nepalese children age 6- 59 months are classified as anemic, with 26 percent mildly anemic, 22 percent moderately anemic, and less than 1 percent severely anemic. According to the new WHO Child Growth Standards, undernutrition is significant in Nepal, with one in two Nepalese children under five years of age stunted (short for their age), 13 percent wasted (thin for their age), and 39 percent underweight. A comparison of the 2006 NDHS data with data collected in the 2001 NDHS using the new WHO Child Growth Standards for both the surveys shows that there has been a marked decline in the level of stunting in the last five years, a modest decline in the level of children underweight, but a very small increase in the level of wasting over the same period. A similar trend is also seen when using the old NCHS/CDC/WHO reference population to calculate the nutritional status of children under five years. The 2006 NDHS also collected information on the nutritional status of women age 15-49 and measured their anemia status. Survey results show that 24 percent of Nepalese women were malnourished, that is, they fall below the cutoff of 18.5 for the body mass index (BMI), which utilizes both height and weight to measure thinness (kg/m2). Nine percent of women were overweight or obese. Women’s nutritional status has improved only slightly over the years. Thirty-six percent of women age 15-49 are anemic, with 29 percent mildly anemic, 6 percent moderately anemic, and less than 1 percent severely anemic. Overall, 76 percent of mothers with a child below three years living with her consumed vitamin A-rich foods and 30 percent consumed iron-rich foods. Twenty-three percent of mothers with a child born in the five years before the survey received iron tablets postpartum while 29 percent received a vitamin A dose postpartum. Five percent of women reported night blindness during their last pregnancy. Two in five women who gave birth in the five years preceding the survey did not take iron supplementation tablets during their most recent pregnancy, while only 7 percent reported taking these tablets for the recommended 180 days or longer. The proportion of women receiving iron supplements during pregnancy has risen from 23 percent in 2001 to 59 percent in 2006. HIV/AIDS AND STIs Knowledge of AIDS is widespread in Nepal. Seventy-three percent of women age 15-49 and 92 percent of men age 15-49 have heard of AIDS. Women are most aware that the chances of getting the AIDS virus can be reduced by limiting sex to one uninfected partner who has no other partners (65 percent) or by abstaining from sexual intercourse (60 percent). Among men, the most commonly known prevention methods are use of condoms (84 percent) and limiting sex to one uninfected partner (83 percent). Knowledge of condoms and the role they can play in preventing transmission of the AIDS virus is much less common, particularly among women. Only 59 percent of women and 75 percent of men age 15-49 know that a healthy-looking person can have the AIDS virus. Also, many women and men erroneously believe that AIDS can be transmitted by mosquito bites. Larger proportions of respondents are aware that the AIDS virus cannot be transmitted by sharing food with a person who has AIDS or by touching someone with AIDS. The 2006 NDHS results also show that a minority of women (20 percent) and men (36 percent) have comprehensive knowledge of HIV/AIDS transmission, that is, they know that both condom use and limiting sex partners to one uninfected partner are HIV prevention methods; that a healthy-looking person can have HIV; and reject the two most common local misconceptions about HIV/ AIDS—that AIDS can be transmitted through mosquito bites and by sharing food with an infected person. Fifty-six percent of women and xxviii * Summary of Findings 61 percent of men expressed accepting attitudes toward people living with HIV/AIDS. Twenty- eight percent of women and forty-four percent of men age 15-24 have comprehensive knowledge about HIV/AIDS. Information on higher-risk sex (sexual intercourse with a partner who is neither a spouse nor a cohabiting partner) indicates that less than 1 percent of women and 3 percent of men had two or more partners in the 12 months preceding the survey; 6 percent of men had higher-risk sexual intercourse. Among male respondents who engaged in higher-risk sexual intercourse, 71 percent of men reported condom use the last time they had sexual intercourse. Among women age 15-49, about 1 percent reported that they had been tested for HIV at some time. Thirty-five percent of women and 70 percent of men age 15-49 know where to go to get an HIV test. Seven percent of sexually active women and 2 percent of sexually active men reported that they had had an STI and/or STI symptoms in the 12 months prior to the survey. Forty-two percent of women and 61 percent of men age 15-49 reported that they had sought advice or treatment from a health facility or provider. WOMEN’S STATUS Data from the 2006 NDHS show that women in Nepal are generally less educated than men at all levels of education, with a median of less than 1 year of schooling compared with 2.8 years among males. However, this gender gap has narrowed in recent years. Nevertheless, more than one in two women age 15-49 has never been to school, compared with one in five men in the same age group. Although female employment is high in Nepal, with 71 percent employed in the 12 months preceding the survey, the majority (86 percent) are employed in the agricultural sector. This compares with 86 of men age 15-49 currently employed, with just over one in two (52 percent) employed in agriculture. The majority (68 percent) of working women are not paid at all or are paid in kind only. In contrast, most men (70 percent) earn cash or cash and in-kind earnings. The proportion of currently married women who say that they alone decide how their earnings are used decreased from 39 percent in 2001 to 31 percent in 2006. On the other hand, the percentage of currently married women who say that they jointly decide with their husband on how their earnings are used increased from 38 percent to 56 percent over the same period. Thirty-seven percent of currently married women participate in all four important household decisions: own health care, major household purchases, purchases of daily household needs, and visits to her family or relatives; 31 percent do not participate in any of the decisions. Although one in five women report that they alone make decisions on their own health care, one in three says that her husband makes such decisions mainly by himself. Twenty-three percent of women and 22 percent of men age 15-49 believe that a husband is justified in beating his wife for at least one of five specified reasons: if she burns the food. if she argues with him, if she goes out without telling him, if she neglects the children, and if she refuses to have sexual intercourse with her husband. The majority of women (83 percent) and men (79 percent) agree that a wife is justified in refusing to have sexual intercourse with her husband for three specified reasons: if she knows that her husband has a sexually transmitted disease, if she knows that her husband has sexual intercourse with other women, and, if she is tired or not in the mood. Data from the 2006 NDHS indicate that there is a positive relationship between contraceptive use and participation in household decision- making. In addition, the data show that women who believe that wife beating is justified for all of the five specified reasons are least likely to use a method of contraception. However, a similar association is not seen between contraceptive use and a woman’s right to refuse sexual intercourse with her husband. Millennium Development Goal Indicators | xxix Millennium Development Goal Indicators, Nepal 2006 Goal Indicator Value Male Female Total 1. Eradicate extreme poverty and hunger 4. Prevalence of underweight children under five years of age 37.5 39.7 38.6 2. Achieve universal primary education 6. Net enrolment ratio in primary education 88.8 84.2 86.6 8. Literacy rate of 15-24 year-olds 90.9 75.2 79.4 na na 0.98 3. Promote gender equality and empower women 9. Ratio of girls to boys in primary education 9. Ratio of girls to boys in secondary education na na 0.87 10. Ratio of literate women to men, 15-24 years old na na 0.83 11. Share of women in wage employment in the non- agricultural sector na na 92.1 4. Reduce child mortality 13. Under-five mortality rate (per 1,000 live births) 61 14. Infant mortality rate (per 1,000 live births) 48 15. Percentage of 1 year-old children immunized against measles 87.1 82.8 85.0 5. Improve maternal health 16. Maternal mortality ratio (per 100,000 live births) na na 281 17. Percentage of births attended by skilled birth attendant na na 18.7 6. Combat HIV/AIDS, malaria and other diseases 19. Percentage of current users of contraception who are using condoms na 1.09 na 19A. Condom use at last high-risk sex 71.2 na na 19B. Percentage of population aged 15-24 years with comprehensive knowledge of HIV/AIDS 43.6 27.6 na 19C. Contraceptive prevalence rate na 44.2 na Urban Rural Total 7. Ensure environmental sustainability 29. Percentage of population using solid fuels 39.1 92.3 83.3 30. Percentage of population with sustainable access to an improved water source, urban and rural 89.5 80.2 81.8 31. Percentage of population with access to improved sanitation, urban and rural 36.9 19.8 22.7 na = Not applicable NEPAL CHINA INDIA Mountains Hills Terai EASTERN REGION CENTRAL REGION WESTERN REGION MID-WESTERN REGION FAR-WESTERN REGION GORKHA SOLUKHUMBU SANKHUWASABHA TAPLEJUNG RA ME CH HA P RASUWA NUWAKOT DHANKUTA ILAM PA NC HT HA R TE RH AT HU M BHOJPURKHOTANG OKHALDHUNGA DOLAKHA UDAYAPUR SINDHULI MAKAWANPUR KABHREPALANCHOK LALITPUR BHAKTAPUR KATHMANDU Ecological Regions SINDHUPALCHOK Introduction | 1 INTRODUCTION 1 1.1 HISTORY, GEOGRAPHY, AND ECONOMY History The history of Nepal can be traced back thousands of years to the dynasties of Ahirs and Gopalas, Kirants, Licchavis and Thakuris, which ruled the country before the Malla period began in the 12th century. Modern Nepal is an amalgamation of a number of principalities that were independent entities in the past. Before the campaign of national integration launched by King Prithivi Narayan Shah—the first Shah King of Nepal, the Kathmandu Valley was ruled by the Malla Kings, famous for their contribution to art and culture. The Malla era is considered to be the golden age of Nepal. In 1768 A.D., the Shah King defeated the Malla Kings and unified the country that was divided into small independent kingdoms. In 1951, the Nepalese monarch ended the century-old system of rule by hereditary premiers and instituted a cabinet system of government. Reforms in 1990 established a multiparty democracy within the framework of a constitutional monarchy. However, despite the declaration of multiparty democracy, economic progress continued to stagnate. The Maoist movement which began in early 1996 in the countryside capitalized on the growing dissatisfaction among the general population with the lack of reforms expected from a democratically elected government. The constant conflict between the Maoists and the elected government resulted in the displacement of the population. Growing numbers of people began migrating out of their usual place of residence to urban centers and neighboring countries to escape the conflict and to search for employment. As a consequence of the conflict-led migration, both internal and international, large numbers of couples have been compelled to live separately for extended periods of time. Citing dissatisfaction with the government’s lack of progress in addressing the Maoist insurgency, the king, in February 2005, dissolved the government, declared a state of emergency, imprisoned party leaders, and assumed power. The king’s government subsequently released party leaders and officially ended the state of emergency in May 2005, but the monarch retained absolute power until April 2006. After nearly three weeks of mass protests organized by the seven-party opposition and the Maoists, the king allowed parliament to reconvene on 28 April 2006. Geography Nepal is a land-locked country nestled in the foothills of the Himalayas. It occupies an area from 26º 22' to 30º 27' north latitude and 80º 4' to 88º 12' east longitude with elevation ranging from 90 meters to 8,848 meters. The country is sandwiched between the two most populous countries of the world, India to the east, south, and west and China to the north. Nepal is rectangular in shape and stretches 885 kilometers in length (east to west) and 193 kilometers in width (north to south). The total land area of the country is 147,181 square kilometers. According to the 2001 Census, the population of Nepal is just over 23 million (Central Bureau of Statistics, 2006a). Topographically, Nepal is divided into three distinct ecological zones. These are the mountain, hill, and terai (or plains). The mountain zone, which accounts for 35 percent of the total land area, ranges in altitude from 4,877 meters to 8,848 meters above sea level and covers a land area of 51,817 square kilometers. Because of the harsh terrain, transportation and communication facilities in this zone are very limited and only about 7 percent of the total population lives here. In contrast, the hill ecological zone, which ranges in altitude from 610 meters to 4,876 meters above sea level, is densely populated. About 44 percent of the total population lives in the hill zone, which covers an 2 | Introduction area of 61,345 square kilometers and occupies 42 percent of the total area. This zone includes the Kathmandu Valley, the country’s most fertile and urbanized area. Although the terrain is also rugged in this zone, because of the higher concentration of people, transportation and communication facilities are much more developed here than in the mountains. Despite its geographical isolation and limited economic potential, the region always has been the political and cultural center of Nepal. Unlike the mountain and hill, the terai zone in the southern part of the country can be regarded as an extension of the relatively flat Gangetic plains of alluvial soil. The terai consists of dense forest area, national parks, wildlife reserves, and conservation areas. This area, which covers 34,019 square kilometers, is the most fertile part of the country. While it constitutes only 23 percent of the total land area in Nepal, 48 percent of the population lives here. Because of its relatively flat terrain, transportation and communication facilities are more developed in this zone than in the other two zones of the country and this has attracted newly emerging industries (Central Bureau of Statistics, 2006b). In Nepal, climatic conditions vary substantially by altitude. Nepal has five climatic zones, broadly corresponding to altitude. The tropical and subtropical zones lie below 1,200 meters, the temperate zone 1,200 to 2,400 meters, the cold zone 2,400 to 3,600 meters, the subarctic zone 3,600 to 4,400 meters, and the arctic zone above 4,400 meters. In the terai, temperatures can go up to 44º Celsius in the summer and fall to 1º Celsius in the winter. The corresponding temperatures for the hill and mountain areas are 43º Celsius and 29º Celsius, respectively, in the summer, and -1º Celsius and far below 0º Celsius, respectively, in the winter. The annual mean rainfall in the country is around 1,500 millimeters (Central Bureau of Statistics, 2006b). For administrative purposes there are five development regions in Nepal - Eastern, Central, Western, Mid-western and Far-western. Nepal is divided into 14 zones and 75 administrative districts. Districts are further divided into smaller units, called village development committees (VDCs) and municipalities. Currently there are 3915 VDCs and 58 municipalities. Each VDC is composed of nine wards, with the number of wards in each municipality ranging from 9 to 35. Kathmandu is the capital city as well as the principal urban center of Nepal (Central Bureau of Statistics, 2006a). The 2001 Census listed 103 diverse ethnic/caste groups, each with its own distinct language and culture (Central Bureau of Statistics, 2003). The percentage breakdown by size of some of these major groups are as follows: Chhetri (16 percent), Brahmins (13 percent), Magar (7 percent), Tharu (7 percent), Tamang (6 percent), and Newar (5 percent). The 2001 Census has also identified about 92 mother tongues. Most of these languages originated from two major groups: the Indo-Europeans, who constitute about 79 percent of the population, and the Sino-Tibetans, who constitute about 18 percent of the population. Nepali is the official language of the country and is the mother tongue of about half of the population. However, it is used and understood by most people in the country. The other two major languages are Maithili and Bhojpuri, spoken by about 12 percent and 8 percent of the population, respectively. According to the 2001 Census, the majority of Nepalese are Hindus (81 percent), while 11 percent are Buddhist, 4 percent are Muslims and 4 percent are Kirant (Central Bureau of Statistics, 2003). Economy Nepal thus far has not benefited fully from the rapid economic growth of its immediate neighbors China and India, primarily due to internal conflict, political instability, absence of a democratic government, ineffective policies and weak implementation of programs benefiting the country. The continued internal conflict not only stalled the creation of new infrastructure but also destroyed many existing ones. Thus, Nepal remains among the poorest and least developed countries in the world with almost one-third of its population living below the poverty line (Ministry of Finance, 2006). Agriculture is the mainstay of the economy, providing a livelihood for three-fourths of the population and accounting for 38 percent of the Gross Domestic Product (Ministry of Finance, 2006). Industrial activity mainly involves the processing of agricultural produce including jute, Introduction | 3 sugarcane, tobacco, and grain. Nepal has considerable scope for exploiting its potential in hydropower and tourism, areas of recent foreign investment interest. Prospects for foreign trade or investment in other sectors will remain poor, however, because of the small size of the economy, Nepal’s technological backwardness, remoteness, landlocked geographic location, civil strife, and susceptibility to natural disaster. 1.2 POPULATION Population censuses have been carried out in Nepal since 1911 at decennial intervals. However, detailed information about the size and structure of the population was provided only since the 1952/54 census. Table 1.1 provides a summary of the basic demographic indicators for Nepal from the census data for 1971, 1981, 1991 and 2001. Nepal’s population doubled in the last 30 years from around 12 million in 1971 to 23 million in 2001. The population grew at a rapid rate between 1971 and 1981 from 2.1 percent to 2.6 percent, but the population growth rate has slowed since 1981 to just over 2 percent (Central Bureau of Statistics, 2003). The population density has doubled over the three decades from 79 persons per square kilometer in 1971 to 157 persons per square kilometer in 2001. Nepal is predominantly rural. Nevertheless, the proportion of the urban population has increased steadily over the last 30 years from about 4 percent in 1971 to 14 percent in 2001. Life expectancy in Nepal is improving, increasing by about 20 years for males and females between 1971 and 2001. Female life expectancy is slightly higher than male life expectancy (60.7 years versus 60.1 years). Table 1.1 Basic demographic indicators Selected demographic indicators for Nepal, 1971-2001 Indicator 1971 Census 1981 Census 1991 Census 2001 Census Population (millions) 11.6 15.0 18.5 23.2 Intercensal growth rate (percent) 2.1 2.6 2.1 2.2 Density (pop./km2) 79 102 126 157 Percent urban 4.0 6.4 9.2 13.9 Life expectancy (years) Male 42.0 50.9 55.0 60.1 Female 40.0 48.1 53.5 60.7 Source: Central Bureau of Statistics, 2003:3, 383; Ministry of Population and Environment and Central Bureau of Statistics, 2003:8 1.3 POPULATION AND REPRODUCTIVE HEALTH POLICIES AND PROGRAMS Evolution of Population Policy Family planning emerged as one of the major components of Nepal’s planned development activities in 1968 with the implementation of the Third Development Plan (1965-70) and the launching of the Nepal Family Planning and Maternal and Child Health Project (FP/MCH) under the Ministry of Health. Until then, family planning activities were undertaken by the Family Planning Association of Nepal (FPAN), a nongovernmental organization, established in 1959 to create awareness among the people about the need for and importance of family planning. The Fourth Development Plan (1970-1975) targeted the provision of family planning services to 15 percent of married couples by the end of the plan period. From the Fifth Development Plan (1975-80) onwards, family planning services were greatly expanded through outreach workers, and serious attempts were made to reduce the birth rate by direct and indirect means. To coordinate the government’s multisectoral activities in population and reproductive health, a population policy 4 | Introduction coordinating board was established in 1975 under the National Planning Commission (NPC). In 1978, this board was upgraded to become the National Commission on Population (NCP). Subsequent development plans dealt with the population issue from both a policy and programmatic point of view. From the Fifth Development Plan until the end of the Seventh Development Plan (1985-1990) population policies and programs not only emphasized family planning issues in the short run, but also focused on long-term concerns to encourage the small family norm through education and employment programs aimed at raising women’s status and decreasing infant mortality. This included launching population-related programs in reproductive health, agriculture, forestry, urbanization, manpower and employment, education and women’s development, as well as community development programs. In 1990, the NCP was dissolved and its role was given to the Population Division of the National Planning Commission. In 1995, the Ministry of Population and Environment (MOPE) was established as a separate ministry for population-related activities and reflected the government’s commitment to population programs. The ministry was primarily responsible for formulating and implementing population policies, plans, and programs, and for monitoring and evaluating these programs. This ministry, along with the other sectoral ministries, was responsible for implementing programs of action recommended by the International Conference on Population and Development (ICPD) and to achieve the Millennium Development Goals (MDGs). Of the eight MDG goals, three are related to health (child mortality, maternal health, HIV/AIDS and malaria) that have direct relevance to the Nepalese population. Furthermore, three other goals (universal primary education, poverty eradication, and gender equity) are also of immediate concern for human resource development. In 1996, the government established a National Population Committee comprised of ministers from various ministries and chaired by the Prime Minister, to provide strong political leadership and guidance in formulating population policies and coordinating, implementing, monitoring, and evaluating population activities. The Eighth Development Plan (1992-97) continued with the integrated development approach taken in earlier plans. The Ninth Development Plan (1997-2002) was developed as a 20-year, long- term plan. The plan’s major strategies included reduction in population growth through social awareness, expansion of education and family planning programs. The long-term objective of the plan is to lower fertility to replacement level in the next 20 years. The current Tenth Development Plan (2002-2007) builds on the long-term projected targets of the Ninth Development Plan. The primary objectives of population management in the Tenth Development Plan are to encourage a small family norm, promote the development of an educated and healthy population, and discourage the out- migration of skilled labor. In 2005, MOPE was dissolved and its Population Division was merged into the Ministry of Health, which was renamed the Ministry of Health and Population (MOHP). Although the Population Division has merged with the Ministry of Health its mandate has not changed. Family Planning Programs Family planning services in Nepal were initially limited to the Kathmandu Valley. The pioneering work of the FPAN led to the establishment of the semiautonomous Nepal Family Planning and Maternal Child Health Project in November 1968 at the government level. This project was gradually expanded to cover all 75 districts in Nepal. Family planning services have become an integral part of government health services. Currently, temporary modern family planning methods (male condoms, contraceptive pills and injectables) are provided on a regular basis through national, regional, zonal and district hospitals, Introduction | 5 primary health care centers/health centers, health posts and sub-health posts by peripheral health workers and volunteers. Services such as Norplant implants and IUD insertions are available only at a limited number of hospitals, health centers, and selected health posts where trained personnel are available. Depending on the district, sterilization services are provided at static sites (21 districts) through scheduled “seasonal” or mobile outreach services. A number of local nongovernmental organizations (NGOs) and international nongovernmental organizations (INGOs) also currently are involved in the delivery of family planning services at the grass roots level. 1.4 OBJECTIVES OF THE SURVEY The principal objective of the 2006 Nepal Demographic and Health Survey (NDHS) is to provide current and reliable data on fertility and family planning behavior, child mortality, adult and maternal mortality, children’s nutritional status, the utilization of maternal and child health services, and knowledge of HIV/AIDS. For the first time, the 2006 NDHS conducted anemia testing at the household level for the country as a whole to provide information on the prevalence of anemia at the population level. The specific objectives of the survey are to: • collect data at the national level which will allow the calculation of key demographic rates; • analyze the direct and indirect factors which determine the level and trends of fertility; • measure the level of contraceptive knowledge and practice among women and men by method, urban-rural residence and region, • collect high-quality data on family health including immunization coverage among children, prevalence and treatment of diarrhea and other diseases among children under five, and maternity care indicators including antenatal visits, assistance at delivery, and postnatal care; • collect data on infant and child mortality, and maternal and adult mortality; • obtain data on child feeding practices including breastfeeding, and collect anthropometric measures to use in assessing the nutritional status of women and children; • collect data on knowledge and attitudes of women and men about sexually transmitted infections and HIV/AIDS and evaluate patterns of recent behavior regarding condom use; • conduct hemoglobin testing on women age 15-49 and children age 6-59 months in the households selected for the survey to provide information on the prevalence of anemia among women in the reproductive ages and young children. This information is essential for informed policy decisions, planning, monitoring, and evaluation of programs on health in general and reproductive health in particular at both the national and regional levels. A long-term objective of the survey is to strengthen the technical capacity of government organizations to plan, conduct, process, and analyze data from complex national population and health surveys. Moreover, the 2006 NDHS provides national, regional and sub- regional estimates on population and health that are comparable to data collected in similar surveys in other developing countries. The first Demographic and Health Survey (DHS) in Nepal was the 1996 Nepal Family Health Survey (NFHS) conducted as part of the worldwide DHS program, and was followed five years later by the 2001 Nepal Demographic and Health Survey (NDHS). Data from the 2006 NDHS survey, the third such survey, allow for comparison of information gathered over a longer period of time and add to the vast and growing international database on demographic and health variables. Wherever possible, the 2006 NDHS data are compared with data from the two earlier DHS surveys—the 2001 NDHS and the 1996 NFHS—which also sampled women age 15-49. Additionally, 6 | Introduction men age 15-59 were interviewed in the 2001 NDHS and the 2006 NDHS to provide comparable data for men over the last five years. 1.5 ORGANIZATION OF THE SURVEY The 2006 NDHS was carried out under the aegis of the Population Division of the Ministry of Health and Population and was implemented by New ERA, a local research organization, which also conducted the 1996 NFHS and the 2001 NDHS. Macro International Inc. provided technical assistance through its MEASURE DHS project. The survey was funded by the U.S. Agency for International Development (USAID) through its mission in Nepal. A steering committee was formed to be responsible for coordination, oversight, advice and decisionmaking on all major aspects of the survey. The steering committee was composed of representatives from various ministries and key stakeholders including MOHP, NPC, Central Bureau of Statistics (CBS), USAID, and local and international NGOs. A technical advisory committee and technical subcommittee were also formed. 1.6 SAMPLE DESIGN The primary focus of the 2006 NDHS was to provide estimates of key population and health indicators, including fertility and mortality rates, for the country as a whole and for urban and rural areas separately. In addition, the sample was designed to provide estimates of most key indicators for the 13 domains obtained by cross-classifying the three ecological zones (mountain, hill and terai) with the five development regions (East, Central, West, Mid-west, and Far-west).1 The 2006 NDHS used the sampling frame provided by the list of census enumeration areas with population and household information from the 2001 Population Census. Each of the 75 districts in Nepal is subdivided into Village Development Committees (VDCs), and each VDC into wards. The primary sampling unit (PSU) for the 2006 NDHS is a ward, subward, or group of wards in rural areas, and subwards in urban areas. In rural areas, the ward is small enough in size for a complete household listing, but in urban areas the ward is large. It was therefore necessary to subdivide each urban ward into subwards. Information on the subdivision of the urban wards was obtained from the updated Living Standards Measurement Survey. The sampling frame is representative of 96 percent of the noninstitutional population.2 The sample for the survey is based on a two-stage, stratified, nationally representative sample of households. At the first stage of sampling, 260 PSUs (82 in urban areas and 178 in rural areas) were selected using systematic sampling with probability proportional to size. A complete household listing operation was then carried out in all the selected PSUs to provide a sampling frame for the second stage selection of households. At the second stage of sampling, systematic samples of about 30 households per PSU on average in urban areas and about 36 households per PSU on average in rural areas were selected in all the regions, in order to provide statistically reliable estimates of key demographic and health variables. However, since Nepal is predominantly rural, in order to obtain statistically reliable estimates for urban areas, it was necessary to oversample the urban areas. As such, the total sample is weighted and a final weighting procedure was applied to provide estimates for the different domains, and for the urban and rural areas of the country as a whole. The survey was designed to obtain completed interviews of 8,600 women age 15-49. In addition, males age 15-59 in every second household were interviewed. To take nonresponse into account, a total of 9,036 households nationwide were selected. 1 Because of their small size, the mountain areas of the West, Mid-west and Far-west were combined. 2 The sampling frame has 36,010 noninstitutional wards of which 1,840 were excluded because of incomplete information or security concerns. Introduction | 7 1.7 QUESTIONNAIRES Three questionnaires were administered for the 2006 NDHS: the Household Questionnaire, the Women’s Questionnaire, and the Men’s Questionnaire. These questionnaires were adapted to reflect the population and health issues relevant to Nepal at a series of meetings with various stakeholders from government ministries and agencies, NGOs and international donors. The final draft of the questionnaires was discussed at a questionnaire design workshop organized by MOHP in September 2005 in Kathmandu. The survey questionnaires were then translated into the three main local languages—Nepali, Bhojpuri and Maithili and pretested from November 16 to December 13, 2005. The Household Questionnaire was used to list all the usual members and visitors in the selected households and to identify women and men who were eligible for the individual interview. Some basic information was collected on the characteristics of each person listed, including age, sex, education, and relationship to the head of the household. For children under age 18, the survival status of the parents was determined. The Household Questionnaire also collected information on characteristics of the household’s dwelling unit, such as the source of water, type of toilet facilities, materials used for the floor of the house, ownership of various durable goods, and ownership of mosquito nets. Additionally, the Household Questionnaire was used to record height, weight, and hemoglobin measurements of women age 15-49 and children age 6-59 months. The Women’s Questionnaire was used to collect information from all women age 15-49. These women were asked questions on the following topics: • respondent’s characteristics such as education, residential history, media exposure, • pregnancy history, childhood mortality, • knowledge and use of family planning methods, • fertility preferences, • antenatal, delivery, and postnatal care, • breastfeeding and infant feeding practices, • immunization and childhood illnesses, • marriage and sexual activity, • woman’s work and husband’s background characteristics, • awareness and behavior regarding AIDS and other sexually transmitted infections (STIs), and • maternal mortality. The Men’s Questionnaire was administered to all men age 15-59 living in every second household in the 2006 NDHS sample. The Men’s Questionnaire collected much of the same information found in the Women’s Questionnaire, but was shorter because it did not contain a detailed reproductive history or questions on maternal and child health or nutrition. In addition, the Verbal Autopsy Module into the causes of under-five mortality was administered to all women age 15-49 (and anyone else who remembered the circumstances surround- ing the reported death) who reported a death or stillbirth in the five years preceding the survey to children under five years of age. The analysis of this data is discussed in detail in Appendix A. 8 | Introduction 1.8 HEMOGLOBIN TESTING In all households selected for the 2006 NDHS, women age 15-49 and children age 6-59 months were tested for anemia. Anemia testing was only carried out if consent was provided by the respondent and in the case of a minor, by the parent or guardian. The protocol for hemoglobin testing was approved by the Nepal Health Research Council (NHRC), and the Macro Institutional Review Board in Calverton, Maryland, USA. Hemoglobin testing is the primary method of anemia diagnosis. In the 2006 NDHS, testing was done using the HemoCue system. A consent statement was read to the eligible woman and to the parent or responsible adult of young children and women age 15-17. This statement explained the purpose of the test, informed prospective subjects and/or their caretakers that the results would be made available as soon as the test was completed, and requested permission for the test to be carried out. Before the blood was taken, the finger was wiped with an alcohol prep swab and allowed to air-dry. Then the palm side of the end of a finger was punctured with a sterile, nonreusable, self- retractable lancet. A drop of blood was collected with a HemoCue microcuvette and placed in a HemoCue photometer where the results were displayed. For children 6-11 months who were particularly undernourished and bony, a heel puncture was made to draw a drop of blood. The results were recorded in the Household Questionnaire, as well as on a brochure given to each woman, parent, or responsible adult, explaining what the results meant. 1.9 LISTING, PRETEST, TRAINING AND FIELDWORK 1.9.1 Listing After the selection of the 260 clusters throughout the 13 subregions, a listing operation was carried out in the selected clusters starting from September 2005. For this purpose, training was conducted for 53 listers and mappers who had been recruited from all the regions to do the listing of households and delineation of EAs. A manual that described the listing procedure was prepared as a guideline and the training was conducted using classroom demonstrations and field practices. Instructions were given on the use of Global Positioning System (GPS) units to obtain location coordinates for selected clusters. The listing was performed by teams composed of one lister and one mapper. Five core team members were also assigned to perform quality checks and handle all the administrative and financial issues of the listing staff. 1.9.2 Pretest Prior to the start of the fieldwork, the questionnaires were pretested in all the three local languages, Nepali, Bhojpuri and Maithali, to make sure that the questions were clear and could be understood by the respondents. In order to conduct the pilot survey, 14 interviewers were recruited to interview in the three local languages. The pilot survey was conducted from November 16 to December 13, 2005, in three selected sites. The areas selected for the pretest were Kathmandu for the Nepali language, Parsa district for the Bhojpuri language and Dhanusha district for the Maithili language. Both rural and urban households were selected for the pretest in all three districts. Based on the findings of the pretest, the Household, the Women’s and Men’s Questionnaires were further refined in all the three local languages. 1.9.3 Training The training of interviewers, editors, supervisors, quality control staff and reserves was conducted from January 4 to February 3, 2006. The Nepali questionnaires were used during the training, while the Bhojpuri and Maithali versions were simultaneously checked against the Nepali questionnaires to ensure accurate translation. In addition to classroom training, trainees did several Introduction | 9 days of field practice to gain more experience on interviewing in the three local languages and fieldwork logistics. A total of 86 trainees were trained in two classrooms. In each class the training was conducted by two senior staff members of New ERA. The Population Division of MOHP, and staff of the Department of Health Services conducted different sessions on population and health issues. After the training on how to complete the Household, Women’s and Men’s Questionnaires was completed, all trainees were given written and oral tests to gauge their understanding of the DHS questionnaires and interviewing techniques. On the basis of the scores on the exam and overall performance in the classroom, 78 trainees were selected to participate in the main fieldwork. From the group, 6 of the best trainees were selected as quality control staff, 12 of the best male trainees were selected as supervisors and 12 of the best female interviewers were identified as field editors. The remaining 48 trainees were selected to be interviewers. The trainees not selected to participate in the fieldwork were kept as reserves. After completing the interviewers’ training, the field editors and supervisors were trained for an additional three days on how to supervise the fieldwork and edit questionnaires in the field, in order to ensure data quality. The participants also received training on anthropometric measurements and hemoglobin testing. 1.9.4 Fieldwork Data collection began on February 5, 2006 by 12 field teams each consisting of three female interviewers, one male interviewer, a male supervisor and a female field editor. Fieldwork was completed on August 18, 2006. Fieldwork supervision was coordinated by New ERA; 3 quality control teams made up of one male and one female member each monitored data quality. Additionally, close contact between New ERA and the field teams was maintained through field visits by senior staff, members of the steering committee and Macro International Inc. staff. Regular communication was also maintained through cell phones. 1.10 DATA PROCESSING The processing of the 2006 NDHS results began soon after the start of fieldwork. Completed questionnaires were returned periodically from the field to the New ERA data processing center in Kathmandu, where they were entered and edited by 17 data processing personnel who were specially trained for this task. The data processing personnel included a supervisor, a questionnaire administrator, 4 office editors and 11 data entry operators. The concurrent processing of the data was an advantage since field check tables were generated early on to monitor various data quality parameters. As a result, specific and ongoing feedback was given to the field teams to improve performance. The data entry and editing of the questionnaires was completed by September 17, 2006. 10 | Introduction 1.11 RESPONSE RATES Table 1.2 shows household and individual response rates for the 2006 NDHS. A total of 9,036 households were selected, of which 8,742 were found to be occupied during data collection. Of these existing households, 8,707 were successfully interviewed, giving a household response rate of nearly 100 percent. In the selected households, 10,973 women were identified as eligible for the individual interview. Interviews were completed for 10,793 women, yielding a response rate of 98 percent. Of the 4,582 eligible men identified in the selected subsample of households, 4,397 were successfully interviewed, giving a 96 percent response rate. Response rates were higher in rural than urban areas, especially for eligible men. Table 1.2 Results of household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Nepal 2006 Residence Result Urban Rural Total Household interviews Households selected 2,534 6,502 9,036 Households occupied 2,433 6,309 8,742 Households interviewed 2,422 6,285 8,707 Household response rate1 99.5 99.6 99.6 Interviews with women age 15-49 Number of eligible women 3,016 7,957 10,973 Number of eligible women interviewed 2,949 7,844 10,793 Eligible women response rate2 97.8 98.6 98.4 Interviews with men age 15-59 Number of eligible men 1,403 3,179 4,582 Number of eligible men interviewed 1,300 3,097 4,397 Eligible men response rate2 92.7 97.4 96.0 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents Household Population and Housing Characteristics | 11 HOUSEHOLD POPULATION AND HOUSING CHARACTERISTICS 2 This chapter provides basic information on demographic and socioeconomic characteristics of the household population. It also provides information on household facilities and assets, which is important for studying and identifying major indicators like wealth quintile that reflect the status of households as well as the characteristics associated with the population residing in the households. A household in the DHS survey is defined as a person or group of related and unrelated persons who live together in the same dwelling unit(s) or in connected premises, who acknowledge one adult member as head of the household, and who have common arrangements for cooking and eating. The 2006 NDHS collected information from all usual residents of a selected household (the de jure population) and persons who had stayed in the selected household the night before the interview (the de facto population). The difference between these two populations is very small, and all tables in this report refer to the de facto population unless otherwise specified, to maintain comparability with other DHS reports. 2.1 HOUSEHOLD POPULATION BY AGE AND SEX Table 2.1 shows the distribution of the de facto household population by age and sex according to urban and rural residence. The 2006 NDHS enumerated a total of 41,947 persons, with females outnumbering males at 53 percent. Because of relatively high fertility in the past, a large proportion of Nepal’s population (41 percent) is under 15 years of age, with 13 percent under age five. Persons age 65 and over account for just 4 percent of the total population (Figure 2.1). There is a smaller proportion of children under age five in urban areas, suggesting that recent declines in fertility are more evident in urban than rural areas and that the transition to lower fertility began with the urban population. A similar finding was observed in the 1996 NFHS and the 2001 NDHS surveys. Table 2.1 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and residence, Nepal 2006 Urban Rural Total Age Male Female Total Male Female Total Male Female Total <5 11.1 10.6 10.8 14.9 12.2 13.5 14.3 12.0 13.1 5-9 12.1 11.8 11.9 16.2 12.9 14.4 15.5 12.7 14.0 10-14 11.9 10.5 11.2 14.6 13.1 13.8 14.1 12.8 13.4 15-19 12.4 11.6 12.0 9.5 11.1 10.4 10.0 11.2 10.6 20-24 10.9 11.8 11.4 5.9 9.0 7.6 6.7 9.4 8.2 25-29 8.9 9.9 9.4 5.6 7.7 6.7 6.1 8.0 7.1 30-34 6.8 6.7 6.8 5.2 6.2 5.8 5.5 6.3 5.9 35-39 5.5 6.0 5.7 5.0 5.6 5.3 5.0 5.6 5.4 40-44 4.0 5.5 4.7 4.6 4.8 4.7 4.5 4.9 4.7 45-49 4.2 3.7 4.0 4.1 4.3 4.2 4.1 4.2 4.2 50-54 3.4 2.9 3.2 3.7 3.5 3.6 3.6 3.4 3.5 55-59 2.6 3.0 2.8 2.5 2.9 2.7 2.5 2.9 2.7 60-64 2.2 2.4 2.3 3.0 2.5 2.7 2.9 2.5 2.7 65-69 1.5 1.2 1.3 1.9 1.6 1.7 1.8 1.5 1.6 70-74 0.7 1.0 0.9 1.5 1.3 1.4 1.4 1.3 1.3 75-79 0.7 0.8 0.7 1.0 0.7 0.8 1.0 0.7 0.8 80+ 1.1 0.8 0.9 0.8 0.6 0.7 0.8 0.6 0.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 3,198 3,173 6,370 16,503 19,074 35,577 19,700 22,247 41,947 12 | Household Population and Housing Characteristics The overall sex ratio—the number of males per 100 females—is 89, similar to the sex ratio obtained in the 2001 NDHS but lower than that obtained in the 2001 Census (100) and the 1996 NFHS (93).1 The sex ratio differs by residence. Urban areas have a higher sex ratio (101) than rural areas (87). The lower proportion of males in the rural population could be attributed to greater out- migration of men than women from rural areas—in search of jobs—to urban centers within the country, as well as to other countries, including India. The 2006 NDHS collected additional information on usual residents who had traveled away from their household in the 12 months prior to the survey. Thirty-seven percent of households reported that at least one person had traveled away from the household at some time in the past 12 months. Among households that reported migration of usual residents, on average at least two persons were likely to have migrated. Men were nearly three times as likely to have migrated as women (data not shown). Table 2.2.1 shows the migration status among men. Data show that among male migrants, two-thirds have been away for at least 6 months in the past 12 months. Men who have migrated out of rural areas, the hill zone, and the Western development region are more likely to have been away for at least six months, with out-migration for six months or longer most obvious in the Western hill subregion (82 percent). One in two migrants has moved to places within Nepal, more than one in three (37 percent) has moved to India, and about one in seven has moved to other countries (e.g., Malaysia, Qatar and Saudi Arabia). Table 2.2.2 shows the status of female migrants. Among female migrants, about three-fifths have been away for at least 6 months in the past 12 months. Migrants who were 20 years or older, had never been married, had migrated out of rural areas, and the Western development region, and were highly educated (SLC and above) were more likely to have been away for at least six months. The majority (86 percent) of women who migrated moved to places within the country, whereas 12 percent moved to India. It is noteworthy to point out that about 16 percent of female migrants from the terai moved to India. 1 The marked difference in the sex ratio between the 2001 Census and the NDHS surveys could be due to the fact that the sex ratio from the census is based on the de jure population, whereas the sex ratio obtained from the NDHS surveys is based on the de facto household population. Figure 2.1 Population Pyramid 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 0246810 0 2 4 6 8 10 NDHS 2006 Age Male Percentage Female Household Population and Housing Characteristics | 13 Table 2.2.1 Migration status: Men Percent distribution of migrants by months since migration in the past 12 months and percentage of migrants who went to specific countries, according to background characteristics, Nepal 2006 Months since migration Country of migration1 Background characteristic <6 months 6-12 months Total Within Nepal India Other country Number of migrants Age 15-19 41.1 58.7 100.0 58.8 37.2 5.2 671 20-24 32.4 67.6 100.0 50.0 34.8 16.3 799 25-29 30.4 69.6 100.0 46.7 33.4 22.4 557 30-34 28.4 71.6 100.0 41.4 38.5 22.0 413 35-39 31.4 68.6 100.0 45.6 40.8 16.8 252 40-44 32.1 67.9 100.0 43.8 49.6 10.9 174 45-49 31.1 68.9 100.0 49.4 43.4 7.1 107 50+ 35.6 63.6 100.0 61.5 36.2 2.3 181 Marital status Never married 32.1 67.8 100.0 60.7 29.9 10.8 1,091 Married 34.1 65.9 100.0 44.5 41.0 16.4 2,034 Divorced/separated/widowed (37.8) (62.2) (100.0) (42.7) (50.0) (7.4) 29 Residence Urban 38.2 61.8 100.0 48.4 24.3 28.4 305 Rural 32.9 67.0 100.0 50.3 38.6 12.9 2,849 Ecological zone Mountain 41.4 58.6 100.0 65.9 24.6 10.3 212 Hill 28.4 71.4 100.0 56.3 31.1 14.0 1,461 Terai 37.3 62.7 100.0 41.7 45.1 15.4 1,480 Development region Eastern 35.6 64.4 100.0 52.3 21.4 28.2 512 Central 37.2 62.7 100.0 59.3 30.9 11.9 1,102 Western 22.6 77.4 100.0 42.5 40.7 18.8 714 Mid-western 31.4 68.3 100.0 45.1 46.5 9.4 384 Far-western 41.0 59.0 100.0 41.5 57.6 1.9 443 Subregion Eastern mountain 27.2 72.8 100.0 70.5 4.7 26.5 39 Central mountain 37.6 62.4 100.0 79.7 11.7 8.6 67 Western mountain 48.9 51.1 100.0 55.5 39.8 5.4 107 Eastern hill 41.0 59.0 100.0 63.1 18.9 19.7 133 Central hill 34.0 65.7 100.0 79.0 9.7 12.5 459 Western hill 17.8 82.2 100.0 43.1 37.7 21.2 499 Mid-western hill 31.8 67.6 100.0 48.8 45.4 6.1 229 Far-western hill 30.1 69.9 100.0 35.6 66.0 0.9 141 Eastern terai 34.4 65.6 100.0 45.9 24.3 31.7 340 Central terai 39.6 60.4 100.0 41.1 50.1 11.9 576 Western terai 33.1 66.9 100.0 40.4 48.6 13.6 211 Mid-western terai 30.9 69.1 100.0 34.9 51.6 14.9 142 Far-western terai 43.9 56.1 100.0 42.2 57.1 1.0 212 Education No education 47.6 51.8 100.0 32.9 58.9 10.0 454 Primary 33.9 66.1 100.0 42.7 50.0 10.2 815 Some secondary 34.1 65.9 100.0 49.0 35.6 16.6 1,095 SLC and above 23.9 76.1 100.0 69.2 13.9 18.3 789 Total 33.4 66.5 100.0 50.1 37.2 14.4 3,154 Note: Total includes men missing information on migration status not shown separately. Figures in parentheses are based on 25-49 unweighted cases. 1 Total exceeds 100 percent because a small percentage of men have moved to more than one place in the past 12 months. 14 | Household Population and Housing Characteristics Table 2.2.2 Migration status: Women Percent distribution of migrants by months since migration in the past 12 months and percentage of migrants who went to specific countries, according to background characteristics, Nepal 2006 Months since migration Country of migration Background characteristic <6 months 6-12 months Total Within Nepal India Other country Number of migrants Age 15-19 48.3 51.7 100.0 91.5 7.9 0.7 435 20-24 41.9 58.1 100.0 84.0 12.7 3.2 326 25+ 39.8 59.6 100.0 80.9 15.1 4.2 354 Marital status Never married 33.9 66.1 100.0 90.8 5.0 4.3 341 Married 47.9 51.8 100.0 83.3 15.2 1.5 735 Divorced/separated/widowed (51.1) (48.9) (100.0) (92.5) (1.4) (6.1) 39 Residence Urban 47.2 52.1 100.0 78.1 14.1 7.7 109 Rural 43.4 56.5 100.0 86.8 11.3 2.0 1,006 Ecological zone Mountain 44.9 55.1 100.0 90.4 2.5 7.5 102 Hill 44.5 55.5 100.0 87.8 10.3 1.9 604 Terai 42.4 57.1 100.0 82.1 15.7 2.2 409 Development region Eastern 46.5 53.5 100.0 85.0 10.5 4.4 217 Central 41.4 58.2 100.0 88.4 7.5 4.2 398 Western 36.5 63.5 100.0 84.8 14.4 0.8 235 Mid-western 54.2 45.8 100.0 86.8 13.5 0.0 136 Far-western 48.4 51.1 100.0 81.1 18.9 0.0 128 Education No education 51.6 47.7 100.0 79.5 18.3 2.2 293 Primary 45.2 54.8 100.0 85.3 13.1 1.6 200 Some secondary 48.3 51.7 100.0 88.5 9.6 2.0 363 SLC and above 26.8 73.2 100.0 90.1 5.6 4.5 256 Total 43.7 56.1 100.0 85.9 11.6 2.5 1,115 Note: Total includes women missing information on migration not shown separately. Figures in parentheses are based on 25-49 unweighted cases. 2.2 HOUSEHOLD COMPOSITION Table 2.3 presents information on the household composition. The majority (77 percent) of households are headed by men, although the proportion of female-headed households has risen from 16 percent in 2001 to 23 percent in 2006, with the rise more marked in rural than urban areas. This could be attributed in part to the sizeable out-migration of the male population in rural areas. The proportion of female-headed households in rural areas increased by 49 percent (from 16 percent to 24 percent) compared with a 20 percent increase (from 17 percent to 20 percent) in urban areas between 2001 and 2006. Household size is smaller in urban areas than in rural areas (4.4 persons versus 5.0 persons), with single member households substantially higher in urban than in rural areas. It is interesting to note that there are more households with foster children in urban than in rural areas. Household Population and Housing Characteristics | 15 Table 2.3 Household composition Percent distribution of households by sex of head of household and by household size; mean size of household, and percentage of households with orphans and foster children under 18 years of age, according to residence, Nepal 2006 Residence Characteristic Urban Rural Total Household headship Male 79.9 76.0 76.6 Female 20.1 24.0 23.4 Total 100.0 100.0 100.0 Number of usual members 1 7.3 4.6 5.0 2 12.7 10.5 10.9 3 17.1 14.0 14.5 4 22.1 19.4 19.9 5 16.7 17.1 17.1 6 10.4 13.8 13.3 7 5.4 8.2 7.8 8 3.6 4.6 4.4 9+ 4.6 7.7 7.1 Total 100.0 100.0 100.0 Mean size of households 4.4 5.0 4.9 Percentage of households with orphans and foster children under 18 years of age Foster children1 15.8 11.5 12.2 Double orphans 0.3 0.5 0.5 Single orphans 5.6 6.6 6.4 Number of households 1,473 7,234 8,707 Note: Table is based on de jure household members, i.e., usual residents. 1 Foster children are those under age 18 living in households with neither their mother nor their father present. Table 2.4 provides additional information on children’s living arrangements and orphanhood. More than two-thirds (67 percent) of children under age 18 live with both parents, about one-fourth (23 percent) live with only their mother, and 2 percent live with only their father. Seven percent of children do not live with either parent, with 6 percent not living with either parent even though both of their parents are alive. The percentage of children not living with their parents increases with age. Rural children are more likely to live with either parent than urban children. The highest proportion of children not living with either parent occurs in the Mid-western development region (9 percent), while the lowest (5 percent) proportion is found in the Far-western development region. One in twenty children under 18 is an orphan. 16 | Household Population and Housing Characteristics Table 2.4 Children's living arrangements and orphanhood Percent distribution of de jure children under age 18 years of age by living arrangements and survival status of parents, the percentage of children not living with a biological parent, and the percentage of children with one or both parents dead, according to background characteristics, Nepal 2006 Not living with either parent Living with mother but not with father Living with father but not with mother Background characteristic Living with both parents Father alive Father dead Mother alive Mother dead Both alive Only father alive Only mother alive Both dead Missing informa- tion on father/ mother Total Percent- age not living with a bio- logical parent Percent- age with one or both parents dead Number of children Age 0-4 69.0 27.9 0.8 0.3 0.3 1.3 0.2 0.0 0.0 0.0 100.0 1.6 1.4 5,439 <2 71.5 27.7 0.4 0.1 0.0 0.2 0.1 0.0 0.0 0.0 100.0 0.3 0.5 2,046 2-4 67.6 28.0 1.0 0.5 0.5 2.0 0.3 0.1 0.0 0.0 100.0 2.4 1.9 3,393 5-9 67.4 23.2 2.0 0.8 0.9 4.5 0.5 0.4 0.1 0.2 100.0 5.4 3.8 5,890 10-14 67.8 16.7 3.9 1.3 1.7 6.2 0.7 0.8 0.4 0.4 100.0 8.1 7.5 5,699 15-17 61.3 10.4 4.5 1.0 2.7 15.8 1.1 1.2 0.8 1.2 100.0 18.9 10.2 2,778 Sex Male 67.8 20.8 2.8 1.0 1.4 4.7 0.5 0.4 0.3 0.3 100.0 5.8 5.4 9,935 Female 66.5 20.8 2.3 0.7 1.1 6.7 0.7 0.6 0.3 0.4 100.0 8.2 4.9 9,871 Residence Urban 67.5 15.6 2.0 1.2 1.2 10.1 0.9 0.8 0.2 0.5 100.0 12.0 5.1 2,611 Rural 67.1 21.6 2.6 0.8 1.2 5.0 0.5 0.5 0.3 0.4 100.0 6.3 5.1 17,195 Ecological zone Mountain 69.7 19.1 2.4 2.3 1.1 3.7 0.3 0.7 0.3 0.4 100.0 5.0 4.9 1,516 Hill 63.6 22.6 2.9 1.0 1.2 6.8 0.7 0.6 0.3 0.3 100.0 8.4 5.8 8,224 Terai 69.7 19.6 2.3 0.5 1.3 5.1 0.5 0.4 0.2 0.4 100.0 6.2 4.6 10,066 Development region Eastern 69.2 17.4 2.5 0.8 1.4 6.5 0.5 0.8 0.3 0.6 100.0 8.0 5.4 4,259 Central 68.1 19.1 2.8 1.1 1.6 5.7 0.6 0.4 0.3 0.2 100.0 7.1 5.8 6,361 Western 62.9 26.9 2.3 0.3 0.9 5.2 0.5 0.1 0.3 0.4 100.0 6.2 4.3 3,757 Mid-western 65.1 21.2 2.4 0.9 0.9 7.4 0.7 1.0 0.0 0.2 100.0 9.1 5.1 2,520 Far-western 69.1 21.4 2.6 0.8 0.9 3.8 0.4 0.3 0.3 0.5 100.0 4.8 4.4 2,908 Subregion Eastern mountain 66.3 23.3 2.1 1.8 1.5 2.9 0.5 1.2 0.3 0.1 100.0 4.8 5.6 363 Central mountain 68.8 16.7 2.2 4.7 2.3 4.1 0.0 0.2 0.2 0.9 100.0 4.5 4.8 404 Western mountain 71.8 18.3 2.7 1.3 0.3 3.8 0.3 0.8 0.5 0.3 100.0 5.3 4.5 750 Eastern hill 72.1 15.7 2.3 0.4 1.5 6.0 0.4 0.9 0.6 0.2 100.0 7.8 5.6 1,236 Central hill 68.5 15.2 3.5 1.5 1.3 7.9 1.0 0.6 0.3 0.3 100.0 9.8 6.6 2,653 Western hill 56.8 32.6 2.8 0.3 1.0 5.1 0.4 0.1 0.4 0.5 100.0 6.0 4.7 2,262 Mid-western hill 59.8 23.7 2.2 1.4 0.8 9.5 0.9 1.5 0.0 0.3 100.0 11.8 5.4 1,359 Far-western hill 59.0 28.2 3.6 1.2 2.2 4.6 0.5 0.4 0.4 0.0 100.0 5.8 7.0 714 Eastern terai 68.3 17.5 2.6 0.9 1.3 7.2 0.5 0.6 0.2 0.9 100.0 8.5 5.3 2,661 Central terai 67.7 22.5 2.4 0.4 1.8 4.2 0.4 0.3 0.3 0.1 100.0 5.2 5.2 3,305 Western terai 72.2 18.3 1.5 0.4 0.9 5.4 0.7 0.1 0.2 0.3 100.0 6.4 3.4 1,473 Mid-western terai 66.9 22.2 2.5 0.4 1.2 5.6 0.6 0.4 0.0 0.1 100.0 6.7 4.7 876 Far-western terai 74.5 17.5 2.3 0.4 0.5 3.4 0.4 0.2 0.2 0.7 100.0 4.1 3.5 1,752 Total <18 67.1 20.8 2.6 0.8 1.2 5.7 0.6 0.5 0.3 0.4 100.0 7.0 5.1 19,806 Total <15 68.1 22.5 2.3 0.8 1.0 4.1 0.5 0.4 0.2 0.2 100.0 5.1 4.3 17,028 Note: Table is based on de jure household members, i.e., usual residents. 2.3 HOUSEHOLD CHARACTERISTICS Information on access to electricity, source and access to drinking water and water treatment, type of sanitation facility in the household, main material of the floor, sleeping space, place for cooking and type of fuel used for cooking are physical characteristics of a household that are used to assess the general well being and socioeconomic status of household members. Table 2.5 presents information on the distribution of households and the de jure population by source of drinking water, and time taken to fetch drinking water. Eighty-two percent of households obtain drinking water from an improved source. Households in urban areas have higher access to an Household Population and Housing Characteristics | 17 improved source of drinking water than households in rural areas (90 percent compared with 80 percent). The most common source of drinking water in urban areas is piped water, with about two- fifths of households having this source. On the other hand, tube well or borehole is the most common source of drinking water in rural areas. Urban households are more likely to have a source of drinking water within their premises (72 percent) than rural households (41 percent). Nearly one in ten households in rural areas takes half an hour or longer to access their drinking water. Adult women are mostly responsible for fetching drinking water in both urban and rural areas. Table 2.5 Household drinking water Percent distribution of households and de jure population by source, time to collect, and person who usually collects drinking water; and percentage of households and de jure population by treatment of drinking water, according to residence, Nepal 2006 Households Population Characteristic Urban Rural Total Urban Rural Total Source of drinking water Improved source 89.5 80.2 81.8 90.0 81.1 82.5 Piped water into house/yard/plot 39.9 9.5 14.6 37.1 8.9 13.2 Public tap/standpipe 10.6 29.4 26.2 10.9 27.0 24.5 Tube well or borehole 30.6 39.3 37.8 34.0 43.3 41.9 Protected dug well 6.1 0.3 1.3 5.6 0.2 1.0 Protected spring 2.2 1.8 1.9 2.3 1.7 1.8 Rainwater 0.1 0.0 0.0 0.1 0.0 0.0 Nonimproved source 9.8 19.6 17.9 9.7 18.7 17.3 Unprotected dug well 2.5 2.8 2.7 2.5 2.8 2.7 Unprotected spring 0.9 10.1 8.5 0.9 9.3 8.1 Tanker truck 0.1 0.0 0.0 0.2 0.0 0.0 Surface water 6.2 6.7 6.6 6.0 6.6 6.5 Bottled water, improved source for cooking/washing1 0.5 0.0 0.1 0.2 0.0 0.0 Bottled water, nonimproved source for cooking/washing1 0.1 0.0 0.0 0.1 0.0 0.0 Other sources 0.1 0.2 0.2 0.1 0.2 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using any improved source of water 90.0 80.2 81.9 90.2 81.1 82.5 Time to obtain drinking water (round trip) Water on premises 72.1 40.8 46.1 72.1 44.4 48.6 Less than 30 minutes 21.5 49.8 45.0 21.4 46.6 42.8 30 minutes or longer 6.4 9.4 8.9 6.5 9.0 8.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 Person who usually collects drinking water Adult female 15+ 20.3 51.5 46.2 21.0 49.2 44.9 Adult male 15+ 5.7 4.0 4.3 4.6 2.6 2.9 Female child under age 15 1.5 2.9 2.7 2.1 3.1 2.9 Male child under age 15 0.3 0.8 0.8 0.3 0.8 0.7 Water on premises 72.1 40.8 46.1 72.1 44.4 48.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment prior to drinking2 Boiled 22.9 5.8 8.7 21.7 4.7 7.3 Bleach/chlorine added 5.1 0.4 1.2 5.2 0.3 1.1 Strained through cloth 2.9 3.2 3.1 3.2 3.0 3.0 Ceramic, sand, or other filter 25.7 2.4 6.3 24.2 2.1 5.4 Solar disinfection 0.6 0.1 0.2 0.6 0.0 0.1 Other 0.5 0.2 0.3 0.4 0.2 0.2 No treatment 58.3 89.8 84.5 59.8 91.3 86.5 Percentage using an appropriate treatment method3 41.3 10.0 15.3 39.8 8.6 13.3 Number 1,473 7,234 8,707 6,415 35,841 42,256 1 Because the quality of bottled water is not known, households using bottled water for drinking are classified as using an improved or nonimproved source according to their water source for cooking and washing. 2 Respondents may report multiple treatment methods so the sum of treatment may exceed 100 percent. 3 Appropriate water treatment methods include boiling, bleaching, straining, filtering and solar disinfecting. 18 | Household Population and Housing Characteristics The majority of households (85 percent) do not treat drinking water. However, more than two in five households in urban areas treat water prior to drinking. About one-fourth of urban households treat drinking water by using ceramic, sand or other filters, while 23 percent boil the water before drinking. Table 2.6 presents information on household sanitation facilities by type of toilet/latrine. Overall, half of Nepalese households do not have a toilet facility. About 23 percent of households have an improved toilet facility while 27 percent have nonimproved toilet facility. Nearly two in five urban households have improved toilet facilities compared with only one in five rural households. There has been an improvement in household sanitation over the past five years. Data from the 2001 NDHS showed that about 70 percent of households did not have a toilet facility. Table 2.6 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Nepal 2006 Households Population Type of toilet/latrine facility Urban Rural Total Urban Rural Total Improved, not shared facility 36.9 19.8 22.7 42.1 21.3 24.5 Flush to piped sewer system 8.3 0.2 1.6 8.7 0.4 1.7 Flush to septic tank 26.2 12.3 14.7 30.7 13.3 16.0 Flush to pit latrine 0.1 0.7 0.6 0.1 0.7 0.6 Ventilated improved pit (VIP) latrine 0.2 0.9 0.7 0.3 1.0 0.9 Pit latrine with slab 2.1 5.2 4.7 2.3 5.4 4.9 Composting toilet 0.0 0.5 0.4 0.0 0.5 0.4 Nonimproved facility 63.3 80.3 77.4 57.7 78.7 75.5 Any facility shared with other households 42.0 10.6 15.9 34.4 8.0 12.0 Flush not to sewer/septic tank/pit latrine 2.2 0.2 0.6 2.0 0.2 0.5 Pit latrine without slab/open pit 3.6 12.3 10.8 3.9 12.3 11.0 No facility/bush/field 15.3 57.2 50.1 17.4 58.2 52.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,473 7,234 8,707 6,415 35,841 42,256 Table 2.7 presents information on the availability of electricity, type of flooring material, number of rooms for sleeping, type of fuel used for cooking, place where cooking is done and the type of fire/stove used for cooking. The table shows that more than one in two households in Nepal has access to electricity. Access to electricity has doubled in the past five years, with data from the 2001 NDHS showing only 25 percent of households having electricity. A nationwide study conducted in 2003/04 also indicated that 40 percent of the households in the country had access to electricity (Central Bureau of Statistics, 2004). However, access to electricity varies largely between urban areas (90 percent) and rural areas (43 percent). Three in four households use earth, mud, and dung as the main material for flooring material. These materials are more common in rural than in urban areas. The percentage of households using cement as the main flooring material has increased slightly over the years. Two-fifths of households use only one room for sleeping, one-third of households have two rooms, and nearly one-fourth have three or more rooms for sleeping. Household Population and Housing Characteristics | 19 Table 2.7 Housing characteristics Percent distribution of households and de jure population by housing characteristics and percentage using solid fuel for cooking; and among those using solid fuel, percent distribution by type of fire/stove, according to residence, Nepal 2006 Households Population Housing characteristic Urban Rural Total Urban Rural Total Electricity Yes 90.1 43.2 51.2 89.7 42.2 49.5 No 9.9 56.8 48.8 10.3 57.8 50.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 Flooring material Earth/mud 24.8 74.7 66.3 26.8 76.9 69.3 Dung 2.2 8.3 7.2 2.5 8.2 7.3 Wood planks 1.3 4.7 4.1 1.5 4.3 3.8 Palm/bamboo 0.0 0.0 0.0 0.0 0.0 0.0 Parquet/polished wood 0.4 0.1 0.1 0.5 0.1 0.1 Vinyl/asphalt strips 21.3 2.8 6.0 18.4 2.1 4.6 Ceramic tiles 1.1 0.0 0.2 1.3 0.0 0.2 Cement 31.7 7.0 11.2 32.8 6.5 10.5 Carpet 15.1 0.9 3.3 14.9 0.7 2.9 Other 2.0 1.4 1.5 1.4 1.2 1.3 Missing 0.1 0.1 0.1 0.0 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Rooms used for sleeping One 47.8 40.9 42.1 35.9 31.6 32.2 Two 27.5 34.7 33.5 29.3 34.3 33.6 Three or more 24.7 24.4 24.4 34.8 34.1 34.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Place for cooking In the house 75.8 79.5 78.9 72.0 77.7 76.8 In a separate building 17.0 15.9 16.1 20.4 18.0 18.4 Outdoors 6.7 4.3 4.7 7.4 4.2 4.7 Missing 0.5 0.3 0.3 0.2 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Cooking fuel Electricity 0.4 0.0 0.1 0.3 0.0 0.1 LPG, natural gas, Biogas 43.6 6.3 12.6 42.8 5.4 11.1 Kerosene 15.8 1.0 3.5 11.1 0.5 2.1 Coal, lignite, charcoal, wood 35.7 78.7 71.4 40.8 79.2 73.4 Agricultural crops/straw/ shrubs/grass 0.8 4.5 3.9 0.8 4.7 4.1 Dung 2.5 9.1 8.0 3.2 9.9 8.9 No food cooked in household 0.5 0.3 0.3 0.2 0.1 0.1 Other 0.6 0.1 0.2 0.8 0.1 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using solid fuel for cooking1 39.1 92.3 83.3 44.8 93.8 86.4 Number of households/population 1,473 7,234 8,707 6,415 35,841 42,256 Type of fire/stove among households using solid fuel1 Chulo with chimney 4.1 6.4 6.2 4.3 5.9 5.8 Open fire/stove with chimney/hood 0.3 0.2 0.2 0.2 0.2 0.2 Open fire/stove/chulo without chimney or hood 95.6 93.4 93.5 95.5 93.9 94.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of households/ population using solid fuel1 576 6,675 7,251 2,871 33,635 36,505 LPG = Liquid petroleum gas 1 Includes coal/lignite, charcoal, wood/straw/shrubs, agricultural crops and animal dung 20 | Household Population and Housing Characteristics Indoor pollution has important implications for the health of household members. The survey collected information on the type of fuel used for cooking, the place where cooking is done and whether households have a chimney or hood to ventilate cooking fumes. Nearly four in five households cook in the house. About 38 percent of all households do not have a separate kitchen for cooking and possibly are subject to the risk of indoor pollution (data not shown). An overwhelming majority of households (71 percent) use, coal, lignite, charcoal, or wood for cooking. While liquid petroleum gas (LPG), natural gas and biogas are commonly used in urban areas (44 percent), coal, lignite, charcoal, or wood are more common in rural areas (79 percent). Of the total households, 83 percent use solid fuel for cooking, which includes coal/lignite, charcoal, wood/straw/shrubs, agricultural crops and animal dung. These households were asked for the type of fire/stove used for cooking. Only 6 percent of these households have a chulo or open fire/stove with a chimney/hood while the rest do not have any system for ventilating the indoor pollution from cooking fumes. 2.4 HOUSEHOLD POSSESSIONS Table 2.8 shows the percentage of households possessing various durable goods and means of transportation, by residence. Information on the ownership of durable goods and other possessions reflects the socioeconomic status of households. Radio is a very common possession in most households with 70 percent of households in urban areas and 59 percent of households in rural areas possessing it. Slightly more than one-fourth of households have a television, which is considered a luxury item and is found mostly in urban households (63 percent). Overall, 6 percent of households have a telephone and a similar proportion have a mobile telephone. Less than 5 percent of households have a refrigerator. Except for a dhiki (rice grinder), animal-drawn cart, agricultural land, and farm animals, which are more common in rural areas, the rest of the items listed are more common in urban than rural areas. Table 2.8 Household possessions Percentage of households and de jure population possessing various household effects, means of transportation, agricultural land and livestock/farm animals, by residence, Nepal 2006 Households Population Possession Urban Rural Total Urban Rural Total Household effects Radio 69.7 59.2 61.0 70.3 62.8 63.9 Television 62.9 20.8 27.9 67.6 23.4 30.1 Mobile telephone 22.5 2.1 5.5 23.6 2.0 5.3 Non-mobile telephone 27.2 2.1 6.3 31.1 2.0 6.4 Refrigerator 18.8 1.4 4.3 22.0 1.2 4.4 Table 68.1 36.0 41.5 70.9 38.6 43.5 Chair 58.4 31.4 36.0 63.3 34.3 38.7 Bed 95.1 85.6 87.2 95.7 86.7 88.1 Sofa 29.7 5.7 9.7 33.7 6.0 10.2 Cupboard 57.1 27.4 32.4 61.2 29.1 34.0 Computer 7.9 0.7 1.9 10.2 0.7 2.1 Clock 87.8 69.7 72.8 89.4 73.7 76.1 Fan 50.4 13.5 19.7 55.8 13.5 19.9 Dhiki 15.0 46.3 41.0 18.5 50.2 45.4 Means of transport Bicycle 38.9 31.4 32.7 45.9 37.8 39.0 Animal-drawn cart 1.2 5.6 4.8 2.5 9.4 8.4 Motorcycle/scooter 14.1 2.0 4.1 17.2 2.4 4.6 Car/truck/tempo 3.2 0.9 1.3 4.4 1.4 1.9 Ownership of agricultural land 43.6 73.1 68.1 46.4 76.4 71.8 Ownership of farm animals1 34.1 85.6 76.9 41.2 90.1 82.6 Number 1,473 7,234 8,707 6,415 35,841 42,256 1 Buffalo, milk cows, bulls, horses, donkeys, mules, goats, sheep, chickens, ducks, pigs, or yaks Household Population and Housing Characteristics | 21 2.5 SOCIOECONOMIC STATUS INDEX One of the background characteristics used throughout this report is an index of socioeconomic status. The economic index used in this study was developed and tested in a large number of countries in relation to inequalities in household income, use of health services and health outcomes (Rutstein et al., 2000). It is an indicator of the level of wealth that is consistent with expenditure and income measures (Rutstein, 1999). The economic index was constructed using household asset data including ownership of a number of consumer items ranging from a television to a bicycle or car, as well as dwelling characteristics, such as source of drinking water, sanitation facilities and type of material used for flooring. Each asset is assigned a weight (factor score) generated through principal components analysis, and the resulting asset scores were standardized in relation to a normal distribution with a mean of zero and standard deviation of one (Gwatkin et al., 2000). Each household was then assigned a score for each asset and the scores were summed for each household; individuals were ranked according to the score of the household in which they resided. The sample was then divided into quintiles from one (lowest) to five (highest). A single asset index was developed for the whole sample; no separate indices were prepared for the urban and rural population. This classification of population by quintiles is used as a background variable in the following sections to assess the demographic and health outcomes in relation to socioeconomic status. Table 2.9 presents the wealth quintiles by residence and regions. An overwhelming majority of the population residing in urban areas are from the richest quintile. Among the three ecological zones, the population in the hills is more likely to fall in the highest wealth quintile than the population living in the terai and mountain zones. Within the hill zone, nearly one in two households (47 percent) in the Central hills, which includes the Kathmandu Valley, is in the wealthiest quintile. On the other hand, the Western mountain subregion has the highest proportion of the population in the lowest wealth quintile (61 percent). Table 2.9 Wealth quintiles Percent distribution of de jure population by wealth quintiles, according to residence and region, Nepal 2006 Wealth quintile Residence/region Lowest Second Middle Fourth Highest Total Number of population Residence Urban 2.3 5.5 5.1 15.6 71.5 100.0 6,415 Rural 23.2 22.6 22.7 20.8 10.8 100.0 35,841 Ecological zone Mountain 46.6 22.3 16.4 13.4 1.2 100.0 3,166 Hill 28.0 15.6 13.9 17.6 24.9 100.0 17,990 Terai 9.2 23.4 25.8 23.0 18.6 100.0 21,100 Development region Eastern 15.0 19.5 23.2 27.5 14.8 100.0 9,226 Central 15.1 18.1 18.4 18.7 29.7 100.0 14,170 Western 14.7 17.1 20.9 24.8 22.6 100.0 8,110 Mid-western 32.8 25.3 17.3 15.5 9.0 100.0 4,956 Far-western 36.3 25.2 19.7 8.4 10.4 100.0 5,794 Subregion Eastern mountain 37.9 27.8 20.4 13.6 0.2 100.0 748 Central mountain 28.4 19.3 23.0 25.4 3.9 100.0 872 Western mountain 61.1 21.3 10.8 6.6 0.2 100.0 1,546 Eastern hill 35.2 19.7 16.0 21.2 7.9 100.0 2,608 Central hill 15.6 10.5 9.3 17.7 46.9 100.0 6,560 Western hill 20.5 19.0 18.7 20.9 20.8 100.0 4,865 Mid-western hill 50.7 19.1 12.7 11.6 5.8 100.0 2,596 Far-western hill 57.6 13.7 16.9 9.3 2.6 100.0 1,363 Eastern terai 3.1 18.3 26.8 32.0 19.7 100.0 5,870 Central terai 12.9 25.3 26.8 18.8 16.3 100.0 6,738 Western terai 6.2 13.7 23.7 30.7 25.7 100.0 3,174 Mid-western terai 7.4 29.9 23.6 22.3 16.8 100.0 1,768 Far-western terai 15.6 33.7 24.9 9.8 16.0 100.0 3,550 Total 20.0 20.0 20.0 20.0 20.0 100.0 42,256 22 | Household Population and Housing Characteristics 2.6 POSSESSION OF MOSQUITO NETS Since 1954, USAID has promoted malaria control programs through the Insect Borne Disease Control Program. The malaria eradication program, launched in 1958, reverted to a malaria control program in 1978. In 1993, the WHO initiated the Global Malaria Control Strategy (GMCS) to focus on problem areas. Areas with a high incidence of malaria were identified, and 12 priority districts in the forest area, foothills and inner terai were identified for focused initiative under the Roll Back Malaria (RBM) strategy. Currently, malaria control activities are in place in 65 out of the 75 districts in the country (Ministry of Health and Population, 2006). An important strategy in the control of malaria is the promotion of personal protection measures, including the use of simple mosquito nets or insecticide-treated mosquito nets. The 2006 NDHS collected information on the possession and number of mosquito nets in the households. Table 2.10 shows that about three-fifths (61 percent) of households have mosquito nets. Households in the terai (85 percent) are much more likely to possess mosquito nets than households in the mountains (14 percent) and hills (47 percent), as this zone is a high risk area for malaria. More than 90 percent of households in the Far-western terai have mosquito nets. Among households with nets, three in ten own one net, one in two owns two to three nets, and one in five owns at least four nets. Table 2.10 Possession of mosquito nets Percentage of households with mosquito nets, and among households with mosquito nets, the percent distribution by number of nets in the household, according to background characteristics, Nepal 2006 Number of nets in household Background characteristic Percentage of households with nets Number of households 1 2-3 4+ Total Number of households with nets Residence Urban 74.9 1,473 30.0 52.8 17.2 100.0 1,104 Rural 58.5 7,234 29.4 50.2 20.4 100.0 4,234 Ecological zone Mountain 14.4 700 35.8 50.9 13.3 100.0 101 Hill 46.6 4,069 32.8 53.1 14.1 100.0 1,895 Terai 84.9 3,938 27.5 49.4 23.2 100.0 3,342 Region Eastern 66.1 1,911 30.8 49.7 19.6 100.0 1,264 Central 66.0 3,079 33.3 51.1 15.6 100.0 2,031 Western 63.5 1,680 24.5 55.3 20.2 100.0 1,067 Mid-western 46.3 1,043 30.2 55.4 14.5 100.0 483 Far-western 49.6 994 21.0 37.7 41.3 100.0 493 Subregion Eastern mountain 19.7 162 30.7 43.8 25.4 100.0 32 Central mountain 26.6 209 30.7 59.8 9.4 100.0 56 Western mountain 4.0 329 * * * * 13 Eastern hill 36.0 571 35.5 49.6 14.8 100.0 206 Central hill 58.7 1,554 31.4 52.8 15.8 100.0 913 Western hill 54.0 1,089 30.5 56.5 13.0 100.0 588 Mid-western hill 30.2 573 41.6 49.8 8.6 100.0 173 Far-western hill 5.6 282 (70.0) (26.9) (3.1) (100.0) 16 Eastern terai 87.1 1,178 29.8 49.8 20.3 100.0 1,026 Central terai 80.7 1,316 35.1 49.2 15.8 100.0 1,063 Western terai 84.0 570 17.2 53.8 29.0 100.0 479 Mid-western terai 84.9 358 23.3 58.6 18.1 100.0 304 Far-western terai 91.3 515 18.3 38.5 43.3 100.0 470 Wealth quintile Lowest 23.3 1,726 49.5 45.4 5.1 100.0 402 Second 55.8 1,732 42.0 43.4 14.6 100.0 967 Middle 68.2 1,605 29.7 52.0 18.3 100.0 1,094 Fourth 78.6 1,697 21.7 54.2 24.1 100.0 1,333 Highest 79.2 1,947 23.2 52.8 24.0 100.0 1,541 Total 61.3 8,707 29.5 50.7 19.7 100.0 5,338 Note: Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. Household Population and Housing Characteristics | 23 2.7 EDUCATION OF HOUSEHOLD POPULATION Studies have shown that education is one of the major socioeconomic factors that influence a person’s behavior and attitudes. In general, the higher the level of education of a woman, the more knowledgeable she is about the use of health facilities, family planning methods, and the health of her children. Inspired by the collective commitment expressed in the Dakar Framework for Action (DFA) 2000, Nepal has already adopted the “Education for All” (EFA) strategy. To achieve this, a National Plan of Action, (NPA, EFA 2001-2015) has been in place since 2001 (Department of Education, 2004). In order to meet the target of the MDGs, Nepal is committed to ensuring that by 2015, all children, particularly girls, children in difficult situations, and children from ethnic minority groups, have access to complete, free, compulsory, and good quality primary education (UNICEF, 2006a). To cope with the demand for education, the government of Nepal has opened investment in the education sector to private parties. Education is divided into two broad categories, primary and secondary (Department of Education, 2004). Besides these levels, private parties have also invested in opening up non-graded level schools, known as pre-primary schools, such as nursery, lower kindergarten (KG) and upper KG. To gauge the spread of pre-primary schools in Nepal, the 2006 NDHS included some additional questions on pre-primary school attendance. Secondary level schooling includes lower secondary and upper secondary schools where students can get an education up to grade 10. More recently, the government has encouraged existing high schools to add two additional years of school (10+2). In order to promote job-oriented education, skill development schools with a vocational and technical focus have increased over the years in various parts of the country. 2.7.1 Educational Attainment of Household Population Tables 2.11.1 and 2.11.2 show the percent distribution of the male and female household population age six years and above by level of education according to age, residence, ecological zone, development region, subregion, and wealth quintile. Survey results show that about one in four men and about one in two women have never attended school. Additionally, 35 percent of males and 26 percent of females have only some primary education. Eight percent of men and 5 percent of women have completed primary education only, and 22 percent of males and 15 percent of females have attended but not completed secondary education. More than twice as many men as women have completed secondary school or higher (12 percent and 5 percent, respectively). It must be noted that the percentage of men and women with no education has declined since 2001 from 32 percent to 23 percent among men and from 60 percent to 49 percent among women, with the improvement observed across all education categories. The gender gap in educational attainment has also narrowed over the years. For instance, among the age group 6-9 years, 21 percent of males and 34 percent of females had no education in 2001, and this declined to 10 percent and 16 percent, respectively, in 2006. This decline is the result of various interventions by the government to enhance the overall quality of education and improve school enrollment. Initiatives include the “Welcome to School” Program and the introduction of scholarship schemes to encourage enrolment of students, especially girls and those belonging to the Dalit (Untouchables) group (Department of Education, 2004). An investigation of the changes in educational attainment by successive age groups indicates the long-term trend of the country’s educational achievement. Survey results show that there has been a marked improvement in the educational attainment of both men and women over the years. The proportion of the male population with no education is significantly higher (84 percent) among the oldest age group (65 years or more) than among boys age 10-14 years (4 percent). Similarly, 98 percent of the female population age 65 and over has no education compared with 11 percent among girls age 10-14. 24 | Household Population and Housing Characteristics Table 2.11.1 Educational attainment of household population: Male Percent distribution of the de facto male household population age six and over by highest level of schooling attended or completed and median years of schooling completed, according to background characteristics, Nepal 2006 Background characteristic No education1 Some primary2 Completed primary3 Some secondary Completed secondary4 More than secondary Don't know/ missing Total Number Median years of schooling Age 6-9 10.4 89.0 0.6 0.0 0.0 0.0 0.0 100.0 2,458 0.0 10-14 4.0 56.4 16.9 22.6 0.0 0.0 0.1 100.0 2,782 3.4 15-19 4.5 15.2 10.5 54.2 7.9 7.7 0.0 100.0 1,965 6.8 20-24 9.6 14.3 9.9 35.3 10.0 20.8 0.0 100.0 1,323 7.2 25-29 19.5 17.6 9.1 29.5 10.1 14.2 0.1 100.0 1,203 5.9 30-34 21.7 21.0 5.9 29.0 7.5 14.8 0.1 100.0 1,082 5.3 35-39 28.2 21.3 6.5 23.4 10.4 10.2 0.0 100.0 993 4.1 40-44 32.1 22.5 5.4 23.0 8.1 8.8 0.0 100.0 888 3.1 45-49 39.1 22.2 9.4 16.1 5.6 7.5 0.0 100.0 810 1.8 50-54 43.4 23.3 10.4 13.8 4.3 4.6 0.1 100.0 718 1.0 55-59 52.6 21.8 4.6 11.1 5.4 4.3 0.3 100.0 499 0.0 60-64 73.4 9.3 4.6 6.8 3.7 2.2 0.1 100.0 572 0.0 65+ 83.9 6.4 3.1 3.6 2.0 1.0 0.0 100.0 988 0.0 Residence Urban 14.2 26.7 6.7 23.7 9.8 18.9 0.1 100.0 2,761 5.5 Rural 24.9 36.5 8.5 22.0 4.0 4.1 0.0 100.0 13,520 2.3 Ecological zone Mountain 27.5 36.9 9.0 20.7 3.1 2.8 0.0 100.0 1,135 1.8 Hill 19.4 34.2 8.2 23.3 5.5 9.3 0.1 100.0 6,867 3.5 Terai 25.5 35.0 8.1 21.7 4.8 4.9 0.0 100.0 8,278 2.3 Development region Eastern 24.4 33.8 8.5 23.3 4.9 5.1 0.0 100.0 3,621 2.7 Central 25.2 33.0 6.7 19.7 6.0 9.3 0.1 100.0 5,617 2.6 Western 21.2 35.7 9.3 22.9 4.8 6.1 0.0 100.0 3,022 3.1 Mid-western 20.1 40.0 8.7 21.3 4.1 5.8 0.0 100.0 1,811 2.7 Far-western 20.4 35.5 9.7 27.2 3.6 3.5 0.0 100.0 2,209 3.1 Subregion Eastern mountain 28.2 36.4 9.4 19.7 3.1 3.2 0.0 100.0 267 2.1 Central mountain 30.6 39.7 7.1 16.6 2.7 3.3 0.0 100.0 333 1.5 Western mountain 25.3 35.4 10.0 23.7 3.3 2.4 0.0 100.0 535 2.0 Eastern hill 21.3 36.4 7.8 24.5 4.8 5.3 0.0 100.0 1,015 2.9 Central hill 19.0 29.4 7.1 23.2 6.8 14.3 0.2 100.0 2,717 4.2 Western hill 20.0 34.2 9.5 24.2 5.6 6.4 0.0 100.0 1,746 3.4 Mid-western hill 18.6 41.3 8.9 20.6 3.9 6.7 0.0 100.0 903 2.8 Far-western hill 16.7 43.8 10.1 22.2 2.7 4.4 0.0 100.0 486 2.8 Eastern terai 25.4 32.5 8.7 23.1 5.1 5.2 0.1 100.0 2,338 2.7 Central terai 31.1 35.9 6.3 16.3 5.5 4.9 0.0 100.0 2,567 1.1 Western terai 22.5 37.7 8.7 21.5 3.9 5.6 0.1 100.0 1,249 2.7 Mid-western terai 22.2 38.0 9.0 21.5 4.1 5.2 0.0 100.0 697 2.7 Far-western terai 20.1 33.6 9.2 29.2 4.1 3.7 0.1 100.0 1,428 3.4 Wealth quintile Lowest 31.4 43.7 7.9 15.1 1.2 0.7 0.0 100.0 2,910 0.7 Second 31.6 38.0 8.1 18.7 2.7 0.9 0.0 100.0 3,129 1.2 Middle 24.8 38.6 9.5 22.3 2.7 2.1 0.0 100.0 3,283 2.3 Fourth 20.6 31.0 8.8 28.0 5.6 6.0 0.0 100.0 3,359 3.8 Highest 9.6 25.0 6.8 25.8 11.6 21.0 0.2 100.0 3,600 6.7 Total 23.1 34.8 8.2 22.3 5.0 6.6 0.1 100.0 16,281 2.8 1 Includes those who have never attended school and those in Early Childhood Development (ECD) centers 2 Includes those who have completed 0-4 years of school and those in school-based pre-primary classes 3 Completed grade 5 at the primary level 4 Completed grade 10 grade at the secondary level Household Population and Housing Characteristics | 25 Table 2.11.2 Educational attainment of household population: Female Percent distribution of the de facto female household population age six and over by highest level of schooling attended or completed, according to background characteristics, Nepal 2006 Background characteristic No education1 Some primary2 Completed primary3 Some secondary Completed secondary4 More than secondary Don't know/ missing Total Number Age 6-9 16.4 83.4 0.3 0.0 0.0 0.0 0.0 100.0 2,284 10-14 11.3 55.5 15.3 17.7 0.0 0.0 0.1 100.0 2,839 15-19 21.3 15.5 9.4 44.3 5.1 4.4 0.0 100.0 2,489 20-24 37.2 14.8 6.3 26.3 5.8 9.6 0.0 100.0 2,097 25-29 53.5 12.0 5.0 17.3 6.5 5.6 0.0 100.0 1,782 30-34 64.5 12.0 4.2 11.4 5.0 2.9 0.0 100.0 1,397 35-39 76.1 9.3 3.4 7.2 2.6 1.5 0.0 100.0 1,257 40-44 85.0 6.4 1.7 3.4 1.6 1.8 0.0 100.0 1,084 45-49 88.4 6.9 0.8 3.1 0.6 0.2 0.0 100.0 938 50-54 91.8 3.6 0.9 1.9 0.7 1.1 0.0 100.0 767 55-59 93.1 2.8 0.7 2.1 0.2 1.1 0.1 100.0 649 60-64 97.8 0.9 0.2 0.5 0.1 0.6 0.0 100.0 545 65+ 97.9 1.4 0.3 0.1 0.4 0.0 0.0 100.0 903 Residence Urban 32.1 24.1 5.5 21.4 7.2 9.7 0.0 100.0 2,762 Rural 51.7 25.9 5.4 13.7 1.9 1.5 0.0 100.0 16,270 Ecological zone Mountain 56.5 26.2 5.2 9.8 1.2 1.2 0.0 100.0 1,405 Hill 42.9 26.6 6.3 17.0 3.4 3.7 0.1 100.0 8,208 Terai 52.9 24.7 4.7 13.6 2.2 2.0 0.0 100.0 9,419 Development region Eastern 47.2 25.6 5.9 16.0 2.5 2.8 0.0 100.0 4,176 Central 51.8 24.4 4.3 12.2 3.6 3.7 0.1 100.0 6,254 Western 43.1 26.5 6.5 18.8 2.4 2.8 0.0 100.0 3,739 Mid-western 47.3 28.3 5.6 14.8 2.4 1.6 0.0 100.0 2,219 Far-western 53.9 24.8 5.9 13.4 1.1 0.9 0.0 100.0 2,644 Subregion Eastern mountain 43.1 26.8 7.8 17.9 1.6 2.9 0.0 100.0 340 Central mountain 54.1 28.2 4.7 10.6 1.5 1.0 0.0 100.0 399 Western mountain 64.8 24.6 4.1 5.1 0.7 0.6 0.0 100.0 666 Eastern hill 41.8 28.6 7.7 15.7 2.9 3.2 0.0 100.0 1,163 Central hill 43.2 24.4 5.3 15.7 5.0 6.2 0.1 100.0 2,927 Western hill 38.7 26.4 7.0 22.3 2.7 2.8 0.0 100.0 2,308 Mid-western hill 44.3 29.7 5.4 16.8 2.5 1.4 0.0 100.0 1,176 Far-western hill 56.2 27.7 7.9 6.7 0.9 0.6 0.0 100.0 634 Eastern terai 50.0 24.1 4.8 15.9 2.5 2.7 0.0 100.0 2,673 Central terai 60.1 24.0 3.1 8.8 2.5 1.5 0.0 100.0 2,928 Western terai 50.0 26.7 5.4 13.4 1.8 2.6 0.0 100.0 1,394 Mid-western terai 46.4 27.0 6.4 15.0 2.9 2.3 0.0 100.0 808 Far-western terai 50.2 23.9 5.9 17.9 1.2 1.0 0.0 100.0 1,616 Wealth quintile Lowest 57.9 29.5 4.8 7.1 0.3 0.4 0.0 100.0 3,761 Second 56.4 27.6 5.2 9.8 0.7 0.3 0.0 100.0 3,826 Middle 56.4 24.3 5.3 12.3 0.9 0.7 0.0 100.0 3,828 Fourth 45.1 24.2 6.2 19.6 2.8 2.0 0.0 100.0 3,872 Highest 28.1 22.3 5.6 25.1 8.5 10.2 0.1 100.0 3,744 Total 48.8 25.6 5.4 14.8 2.6 2.7 0.0 100.0 19,032 Note: Median years of schooling was not calculated for women because in most categories, less than 50 percent have ever attended school. 1 Includes those who have never attended school and those in Early Childhood Development (ECD) centers 2 Includes those who have completed 0-4 years of school and those in school-based pre-primary classes 3 Completed grade 5 at the primary level 4 Completed grade 10 grade at the secondary level 26 | Household Population and Housing Characteristics Educational attainment varies widely by residence with higher proportions of males and females in rural areas having no education compared with urban areas. For example, one in two rural women has no education compared with one in three urban women. Similarly, more women and men residing in the hills have at least some education, com- pared with those residing in the mountains and terai. The proportion of female and male household members who have never attended school decreases with wealth. For example, one in three men in the lowest wealth quintile has no education compared with one in ten men in the highest wealth quintile. Early Childhood Development Center In order to promote pre- primary education to children below eight years the government has introduced Early Childhood Develop- ment (ECD) centers under the Preliminary Child Education regula- tion. Data collected from all 75 districts show that a total of 7,426 early childhood development centers and school-based pre-primary classes were operational in the school year 2005-2006 (Department of Education, 2006). The school-based centers are mostly managed by the government while the other community-based early childhood development centers are mostly supported by NGOs. The 2006 NDHS collected information on the percentage of children 3-4 years enrolled in these centers. Table 2.12 shows that nearly one-fourth of children age 3-4 years are enrolled in school-based pre-primary classes and in ECD centers. School-based pre-primary classes are relatively more widespread, with 18 percent of all children age 3-4 years enrolled in these classes compared with only 5 percent of children age 3-4 years enrolled in ECD centers. Young children in urban areas are more likely to be enrolled in school-based pre-primary classes (50 percent) than in rural areas (13 percent), while the proportion of children enrolled in ECD centers is slightly higher in rural than in urban areas (5 percent versus 3 percent). Children in the hills are more likely to be enrolled in pre-primary classes or ECD centers (28 percent) compared with those in the other ecological zones, with most children from the Western hills (40 percent) and Central hills Table 2.12 Children enrolled in school-based pre-primary classes and early childhood development centers Percentage of de facto children age 3-4 years enrolled in school-based pre- primary classes and early childhood development centers (ECD), by back- ground characteristics, Nepal 2006 Background characteristic Children 3-4 years enrolled in school- based pre- primary classes Children 3-4 years enrolled in ECD centers Total Number of children Age 3 12.6 4.8 17.4 1,085 4 23.2 5.0 28.2 1,172 Sex Male 19.4 4.9 24.2 1,177 Female 16.8 4.9 21.7 1,080 Residence Urban 49.6 3.3 53.0 293 Rural 13.4 5.1 18.6 1,963 Ecological zone Mountain 9.8 7.9 17.8 184 Hill 22.5 5.7 28.1 928 Terai 16.0 3.8 19.7 1,145 Development region Eastern 10.9 5.9 16.8 495 Central 23.8 1.9 25.7 773 Western 24.2 7.5 31.7 405 Mid-western 18.2 6.1 24.3 280 Far-western 7.2 6.2 13.4 304 Subregion Eastern mountain 5.8 10.0 15.8 44 Central mountain 7.4 1.7 9.1 39 Western mountain 12.5 9.4 22.0 101 Eastern hill 9.8 1.4 11.1 149 Central hill 33.2 4.1 37.3 306 Western hill 28.6 11.0 39.6 237 Mid-western hill 13.4 5.3 18.7 150 Far-western hill 4.9 4.9 9.8 85 Eastern terai 12.2 7.6 19.8 301 Central terai 18.6 0.4 19.0 427 Western terai 18.5 2.7 21.2 163 Mid-western terai 20.4 8.8 29.1 90 Far-western terai 10.9 4.1 14.9 163 Wealth quintile Lowest 6.8 4.7 11.5 547 Second 7.6 3.4 10.9 491 Middle 8.1 5.2 13.3 468 Fourth 21.8 7.8 29.6 394 Highest 59.1 3.7 62.8 357 Total 18.1 4.9 23.0 2,257 Household Population and Housing Characteristics | 27 (37 percent) having access to early education. Children in the richest households are significantly more likely to have access to early education than those in other households. 2.7.2 School Attendance Ratios The net attendance ratio (NAR) indicates participation in primary schooling for the population age 6-10 years and secondary schooling for the population age 11-15 years. The gross attendance ratio (GAR) measures participation at each level of schooling among those of any age from 5 to 24 years. The GAR is almost always higher than the NAR for the same level because the GAR includes participation by those who may be older or younger than the official age range for that level.2 A NAR of 100 percent would indicate that all those in the official age range for that level are attending at that level. The GAR can exceed 100 percent if there is significant overage or underage participation at a given level of schooling. Tables 2.13.1 and 2.13.2 provide data on net attendance ratios (NARs) and gross attendance ratios (GARs) by sex and level of schooling. There has been a rise in the NAR at the primary level from 73 percent in 2001 to 87 percent in 2006, while at the secondary level it has gone up from 31 percent to 47 percent over the same period. The rise in NAR and GAR has been more pronounced in rural areas than in urban areas. For instance, the rural primary school NAR increased from 72 percent in 2001 to 86 percent in 2006 while the rise was from 89 percent to 91 percent in the urban areas over the same period. This could be explained by the fact that primary school NAR and GAR were already high in the urban areas and therefore, the rise is not substantial. Similarly, the rise in NAR and GAR at the secondary level is also more marked in the rural areas. Attendance ratios at the primary and secondary levels are highest in the hills. Among the subregions, the Central terai has the lowest attendance ratio at the primary as well as at the secondary level. Over the past five years, the rise in the NAR and GAR at the primary as well as the secondary levels has been more substantial among females than males. For instance, the NAR at the primary school level for females was 67 percent in 2001, and increased to 84 percent in 2006, while the rise in male NAR during the same period was from 79 percent to 89 percent. This increase in the female attendance ratio has been more obvious in rural areas. Interventions by the government through the provision of specific scholarship schemes for girls (whereby 50 percent of the girls enrolled receive scholarships), for Dalit students, for children with various disabilities, for children of martyrs, and for other groups of needy children, have contributed to this progress. Tables 2.13.1 and 2.13.2 also show the Gender Parity Index (GPI) which represents the ratio of the NAR and GAR for females to the NAR and GAR for males. It is a more precise indicator of the gender differences in the schooling system. A GPI less than one indicates that a smaller proportion of females than males attend school. The index for NAR and GAR at the primary and secondary school is slightly less than one (0.9) indicating that the gender gap is very narrow. It is worth noting here that the gender gap in attendance has narrowed over the years. The 2001 NDHS indicated the GAR at the primary school to be 0.8 and at the secondary school to be 0.7. 2 Students who are overage for a given level of schooling may have started school overage, may have repeated one or more grades in school, or may have dropped out of school and later returned. 28 | Household Population and Housing Characteristics Table 2.13.1 School attendance ratios: Primary school Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population by sex and level of schooling; and the Gender Parity Index (GPI), according to background characteristics, Nepal 2006 Net attendance ratio1 Gross attendance ratio2 Background characteristic Male Female Total Gender Parity Index3 Male Female Total Gender Parity Index3 Residence Urban 92.8 88.1 90.5 0.95 137.4 135.7 136.5 0.99 Rural 88.3 83.6 86.0 0.95 134.1 130.8 132.5 0.98 Ecological zone Mountain 87.7 80.2 83.7 0.91 138.1 123.6 130.4 0.90 Hill 91.4 90.5 90.9 0.99 140.6 139.0 139.8 0.99 Terai 87.1 79.5 83.5 0.91 129.5 126.3 128.0 0.98 Development region Eastern 87.9 83.8 86.0 0.95 128.1 127.3 127.7 0.99 Central 85.1 77.9 81.6 0.92 128.9 125.9 127.5 0.98 Western 91.3 88.8 90.1 0.97 141.6 136.5 139.1 0.96 Mid-western 92.9 91.2 92.1 0.98 146.3 136.9 141.5 0.94 Far-western 91.7 85.8 88.9 0.94 137.0 138.0 137.5 1.01 Subregion Eastern mountain 78.7 80.3 79.5 1.02 130.4 132.4 131.4 1.01 Central mountain 91.7 85.9 88.6 0.94 157.1 140.2 148.2 0.89 Western mountain 90.0 77.1 82.9 0.86 130.8 110.9 120.0 0.85 Eastern hill 88.5 88.5 88.5 1.00 137.5 140.9 139.1 1.03 Central hill 91.5 88.6 90.1 0.97 139.6 143.1 141.3 1.03 Western hill 92.1 92.2 92.1 1.00 138.8 136.5 137.7 0.98 Mid-western hill 89.9 94.0 92.0 1.04 141.3 136.0 138.6 0.96 Far-western hill 96.7 87.6 91.9 0.91 154.3 136.4 145.0 0.88 Eastern terai 88.8 82.1 85.6 0.93 123.6 120.3 122.0 0.97 Central terai 80.0 69.2 74.8 0.86 118.7 111.8 115.4 0.94 Western terai 89.9 83.2 86.8 0.93 145.2 136.9 141.4 0.94 Mid-western terai 96.2 89.2 92.9 0.93 150.0 142.1 146.3 0.95 Far-western terai 91.1 88.7 90.0 0.97 135.9 149.5 142.0 1.10 Wealth quintile Lowest 83.6 78.0 80.6 0.93 135.2 124.5 129.6 0.92 Second 85.0 83.5 84.3 0.98 127.8 130.2 129.0 1.02 Middle 92.0 82.1 87.4 0.89 137.4 126.1 132.1 0.92 Fourth 90.4 87.4 89.0 0.97 137.6 138.0 137.8 1.00 Highest 94.7 94.3 94.5 1.00 135.2 144.0 139.2 1.06 Total 88.8 84.2 86.6 0.95 134.5 131.4 133.0 0.98 1 The NAR for primary school is the percentage of the primary-school age (6-10 years) population that is attending primary school. By definition the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the official primary- school-age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent. 3 The Gender Parity Index for primary school is the ratio of the primary school NAR (GAR) for females to the NAR (GAR) for males. Household Population and Housing Characteristics | 29 Table 2.13.2 School attendance ratios: Secondary school Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population by sex and level of schooling; and the Gender Parity Index (GPI), according to background characteristics, Nepal 2006 Net attendance ratio1 Gross attendance ratio2 Background characteristic Male Female Total Gender Parity Index3 Male Female Total Gender Parity Index3 Residence Urban 57.5 55.5 56.6 0.97 83.4 88.1 85.6 1.06 Rural 49.2 41.4 45.2 0.84 75.2 63.9 69.3 0.85 Ecological zone Mountain 50.7 33.5 42.2 0.66 77.2 49.7 63.5 0.64 Hill 56.3 53.2 54.7 0.95 82.9 79.8 81.3 0.96 Terai 45.4 36.3 40.7 0.80 70.8 58.6 64.5 0.83 Development region Eastern 49.8 44.2 46.9 0.89 82.6 75.0 78.6 0.91 Central 45.2 37.0 41.0 0.82 62.0 54.8 58.3 0.88 Western 55.5 47.7 51.5 0.86 80.8 70.3 75.5 0.87 Mid-western 52.5 53.3 52.9 1.01 78.0 75.3 76.6 0.97 Far-western 54.2 40.1 47.1 0.74 92.3 69.7 80.9 0.76 Subregion Eastern mountain 50.9 44.9 47.8 0.88 74.9 76.9 76.0 1.03 Central mountain 44.5 47.0 45.7 1.06 68.5 63.5 66.1 0.93 Western mountain 55.1 17.5 36.6 0.32 84.6 24.6 55.0 0.29 Eastern hill 46.6 49.7 48.2 1.07 91.4 85.3 88.2 0.93 Central hill 55.5 50.0 52.8 0.90 75.7 78.3 77.0 1.03 Western hill 66.4 59.0 62.6 0.89 93.3 84.3 88.7 0.90 Mid-western hill 54.4 61.2 58.2 1.13 82.6 86.0 84.5 1.04 Far-western hill 45.7 34.5 40.1 0.75 66.8 46.7 56.8 0.70 Eastern terai 51.1 41.6 46.1 0.81 79.6 69.9 74.6 0.88 Central terai 35.0 24.8 29.5 0.71 46.9 34.1 40.1 0.73 Western terai 39.9 31.6 35.7 0.79 63.4 50.4 56.7 0.80 Mid-western terai 53.4 47.0 50.3 0.88 70.0 66.5 68.3 0.95 Far-western terai 54.6 47.3 50.8 0.87 103.0 87.8 95.2 0.85 Wealth quintile Lowest 37.6 25.2 31.2 0.67 53.7 39.0 46.1 0.73 Second 44.7 35.5 39.7 0.79 69.6 52.3 60.2 0.75 Middle 48.8 41.0 45.1 0.84 75.2 68.9 72.2 0.92 Fourth 58.1 53.3 55.7 0.92 91.1 85.3 88.2 0.94 Highest 64.9 65.1 65.0 1.00 95.4 95.2 95.3 1.00 Total 50.4 43.1 46.7 0.86 76.4 66.8 71.5 0.87 1 The NAR for secondary school is the percentage of the secondary-school age (11-15 years) population that is attending secondary school. By definition the NAR cannot exceed 100 percent. 2 The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary-school-age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent. 3 The Gender Parity Index for secondary school is the ratio of the secondary school NAR (GAR) for females to the NAR (GAR) for males. Tables 2.14.1 and 2.14.2 present data on grade repetition and dropout rates for the household population age 5-24 who attended primary school in the previous school year by school grade, according to background characteristics. The repetition rate is the percentage of students in a given grade in the previous school year repeating that grade in the current school year. Likewise, the dropout rate is the percentage of students in a given grade in the previous school year not attending school. School attendance ratios combined with repetition and dropout rates describe the flow of students in the schooling system. 30 | Household Population and Housing Characteristics Table 2.14.1 shows that repetitions rates are higher at lower grades than at higher grades, both for males and females. For example, less than one-tenth of students repeat grade five, whereas about three-tenths repeat grade one. Table 2.14.2 shows that as the school grade rises, the dropout rate generally increases. Less than 1 percent of children drop out of school after attending grade one compared with a dropout rate of 4 percent at grade five. This represents a rise from a dropout rate of 3 percent at grade five as reported in the 2001 NDHS. One of the contributing factors for school dropouts and suspension of education has been the Maoist insurgency that contributed to the displacement of families. Repetition among rural children is higher than among urban children at all grade levels. Children from the terai are less likely to repeat a grade at every level, consistent with the findings of the 2001 NDHS. Tables 2.14.1 and 2.14.2 also indicate that there is an inverse relation- ship between grade repetition and drop- out rates and wealth, with children in lower wealth quintiles more likely to repeat a grade at all levels than other children. Figure 2.2 shows the percentage of the de jure household population age 5-24 years attending school by age and sex. The age-specific attendance rate indicates participation in school at any level from primary to higher levels of education. The minimum official age for school enrolment in Nepal is five years. The percentage of girls and boys attending school at age five has risen over the years with more than two in three children attending school. This is primarily due to the contribution of school-based pre- primary education. Slightly higher proportions of males than females attend school at every age but this difference is significantly higher after age 13. School attendance drops substantially after age 14 for females and after age 16 for males. Table 2.14.1 Grade repetition rates Repetition rates for the de facto household population age 5-24 who attended primary school in the previous school year by school grade, according to background characteristics, Nepal 2006 School grade Background characteristic 1 2 3 4 5 Sex Male 27.9 10.5 9.2 9.3 8.8 Female 28.2 10.7 8.4 11.7 7.7 Residence Urban 16.5 6.0 8.2 6.5 4.8 Rural 29.2 11.2 8.9 11.1 8.8 Ecological zone Mountain 32.5 14.9 11.4 8.4 14.0 Hill 28.7 13.9 10.3 14.4 7.6 Terai 26.8 6.7 7.0 6.4 7.9 Development region Eastern 33.1 8.6 9.2 15.5 7.5 Central 22.0 9.2 7.0 8.6 3.5 Western 23.2 17.2 9.2 8.3 10.5 Mid-western 31.8 10.2 13.0 12.6 7.8 Far-western 32.8 7.4 7.3 8.4 14.2 Subregion Eastern mountain 23.9 18.6 8.6 16.9 20.3 Central mountain 27.7 13.0 1.7 0.4 13.0 Western mountain 38.6 14.1 20.4 10.2 9.2 Eastern hill 29.7 9.4 9.3 26.8 8.4 Central hill 23.2 16.2 9.4 13.7 2.3 Western hill 23.6 18.6 11.4 7.7 11.7 Mid-western hill 34.3 8.2 10.9 14.3 9.3 Far-western hill 44.6 10.9 10.3 15.1 8.9 Eastern terai 36.0 6.4 9.3 6.5 4.8 Central terai 20.3 2.1 5.1 3.1 2.7 Western terai 22.9 14.9 6.0 9.4 8.2 Mid-western terai 28.8 11.4 12.8 10.9 7.3 Far-western terai 26.4 4.8 3.9 4.9 15.6 Wealth quintile Lowest 33.9 19.5 14.6 15.5 13.1 Second 26.4 11.6 9.0 5.7 8.2 Middle 34.3 6.1 9.2 13.7 11.3 Fourth 18.0 10.9 5.3 9.3 6.5 Highest 18.0 3.4 5.9 7.7 2.2 Total 28.0 10.6 8.8 10.4 8.3 Note: The repetition rate is the percentage of students in a given grade in the previous school year who are repeating that grade in the current school year. Household Population and Housing Characteristics | 31 Table 2.14.2 Grade dropout rates Dropout rates for the de facto household population age 5-24 who attended primary school in the previous school year by school grade, according to background characteristics, Nepal 2006 School grade Background characteristic 1 2 3 4 5 Sex Male 0.5 0.5 1.0 2.1 2.6 Female 0.9 0.8 1.1 2.0 5.7 Residence Urban 1.8 0.6 1.5 2.3 2.4 Rural 0.6 0.6 1.0 2.0 4.4 Ecological zone Mountain 1.1 0.3 5.3 0.3 2.5 Hill 0.4 0.8 0.7 2.6 4.9 Terai 0.9 0.5 0.7 1.7 3.6 Development region Eastern 0.4 1.4 1.4 1.7 4.5 Central 1.0 0.2 1.4 3.7 3.7 Western 0.8 0.3 0.3 2.3 5.7 Mid-western 1.0 0.1 2.1 0.0 4.6 Far-western 0.3 1.4 0.0 0.7 2.1 Subregion Eastern mountain 0.0 1.1 5.7 1.2 4.0 Central mountain 3.8 0.0 6.5 0.0 1.6 Western mountain 0.0 0.0 4.2 0.0 2.0 Eastern hill 0.3 2.3 2.7 3.9 7.2 Central hill 0.5 0.5 0.7 4.8 3.6 Western hill 0.0 0.0 0.0 1.5 4.1 Mid-western hill 0.9 0.1 0.7 0.0 7.1 Far-western hill 0.8 2.8 0.0 0.0 4.6 Eastern terai 0.5 0.9 0.0 0.0 3.1 Central terai 1.0 0.0 1.4 2.8 4.5 Western terai 2.3 0.8 0.8 3.6 8.2 Mid-western terai 1.3 0.0 2.0 0.0 1.7 Far-western terai 0.2 1.0 0.0 1.1 1.7 Wealth quintile Lowest 0.8 0.9 1.3 3.1 9.4 Second 0.8 0.7 1.3 2.7 3.0 Middle 0.4 1.0 1.3 2.2 3.6 Fourth 0.8 0.0 0.4 0.7 4.0 Highest 0.7 0.4 0.8 1.8 1.2 Total 0.7 0.6 1.0 2.1 4.1 Note: The dropout rate is the percentage of students in a given grade in the previous school year who are not attending school in the current school year. 32 | Household Population and Housing Characteristics 2.8 BIRTH REGISTRATION Registration of births refers to the inscription of the birth facts in an official log kept at the registrar’s office. Although Nepal has a legal and administrative structure that performs official registration of births according to standard procedures, few births are registered. In other words, the system is not widely practiced in the country although it was implemented 30 years ago. Table 2.15 presents the percentage of the de jure population under five years of age whose births are registered with the civil authorities, according to background characteristics. Birth registration information was solicited for children 0-4 years. More than one in three (35 percent) children have their births registered. The majority of these children have a birth certificate. This finding is consistent with the finding of a nationwide survey conducted in 2000, which revealed that about 34 percent of children less than five years and 22 percent of children less than one year had their births registered (Central Bureau of Statistics, 2001). Although the Tenth Plan aims at registering births of 80 percent of children under age five by 2006, this target is far from being met. This is due to a weak birth registration system coupled with the difficulties encountered in registering births during the Maoist insurgency. Although the vital registration system of the government requires that a child be registered within 35 days of birth at the respective municipality or VDC, Table 2.15 indicates that children less than 2 years are much less likely to be registered than children age 2-4 years (21 percent and 43 percent, respectively). The registration of older children is primarily driven by the practice of asking parents to produce a child’s birth certificate for school admission, although it is not legally required (UNICEF, 2006a). A survey conducted in seven districts in 2003 also indicated similar findings (UNICEF, 2006b). Table 2.15 shows that children in the urban areas, those living in the terai, and those in the Eastern development region are more likely to have their births registered. Except for the Far-western terai subregion (18 percent), more than two in five children in the rest of the terai subregion have their births registered. Children from the highest wealth quintile are more likely to have their births registered (47 percent) compared with those belonging to the lowest quintile (22 percent). Figure 2.2 Age-Specific Attendance Rates 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age 0 20 40 60 80 100 Percent Male Female NDHS 2006 Note: Figure shows percentage of de jure household population age 5-24 years attending school. Household Population and Housing Characteristics | 33 Table 2.15 Birth registration Percentage of de jure children under five years of age whose births are registered with the civil authorities, by background characteristics, Nepal 2006 Percentage of children whose births are registered: Background characteristic Had a birth certificate Did not have a birth certificate Total registered Number of children Age <2 19.9 1.3 21.1 2,046 2-4 40.7 2.6 43.3 3,393 Sex Male 33.6 2.4 36.0 2,772 Female 32.1 1.8 33.9 2,667 Residence Urban 39.8 2.1 41.9 685 Rural 31.9 2.1 34.0 4,754 Ecological zone Mountain 23.0 1.3 24.4 457 Hill 27.5 2.3 29.8 2,239 Terai 38.9 2.1 41.0 2,743 Development region Eastern 40.4 2.5 42.9 1,188 Central 38.3 1.3 39.6 1,791 Western 29.0 3.6 32.6 1,033 Mid-western 31.8 2.3 34.2 670 Far-western 14.4 1.0 15.4 757 Subregion Eastern mountain 27.7 0.0 27.7 110 Central mountain 28.9 2.5 31.4 88 Western mountain 19.1 1.5 20.6 259 Eastern hill 33.2 2.0 35.1 342 Central hill 35.5 1.2 36.8 707 Western hill 21.2 4.2 25.5 611 Mid-western hill 23.2 2.3 25.4 357 Far-western hill 17.6 0.7 18.3 222 Eastern terai 45.6 3.1 48.8 736 Central terai 41.0 1.3 42.4 996 Western terai 39.9 2.7 42.6 415 Mid-western terai 42.1 2.5 44.6 215 Far-western terai 17.0 1.3 18.3 380 Wealth quintile Lowest 19.8 1.8 21.6 1,364 Second 31.3 1.5 32.8 1,152 Middle 36.7 2.6 39.3 1,089 Fourth 38.9 2.4 41.3 993 Highest 44.1 2.6 46.7 841 Total 32.9 2.1 35.0 5,439 Characteristics of Respondents | 35 CHARACTERISTICS OF RESPONDENTS 3 This chapter describes the demographic and socioeconomic profile of respondents inter- viewed in the 2006 NDHS. This information is useful in the interpretation of findings and for understanding the results presented later in the report. The survey collected basic information on respondents’ age, level of education, marital status, religion, ethnicity, and wealth status. In addition, information was also collected on respondents’ exposure to mass media and literacy status, employ- ment status, occupation, and type of earnings. Additional information collected includes knowledge and attitudes concerning tuberculosis, use of tobacco and hand washing practices of women. For the first time, the 2006 NDHS gathered information from all women and men irrespective of their marital status, in contrast to the 1996 NFHS and 2001 NDHS surveys, which sampled only ever-married women and men. The discussion in this report is therefore with reference to all women and men. However, wherever possible when comparing information with past surveys, the data have been rerun for ever-married women and men to enable comparability between surveys. In addition, unlike the 2001 NDHS, tables in this report show detailed information for men age 15-49 in order to be comparable with characteristics associated with women in the same age group. However, to enable comparisons for men between the 2001 and 2006 surveys, information is also provided for men age 15-59. Throughout this report, numbers in the tables reflect weighted numbers. In most cases, percentages based on 25 to 49 unweighted cases are shown in parentheses and percentages based on fewer than 25 unweighted cases are suppressed and replaced with an asterisk, to caution readers when interpreting data that a percentage based on fewer than 50 cases may not be statistically reliable.1 3.1 CHARACTERISTICS OF SURVEY RESPONDENTS A description of the background characteristics of the 10,793 women age 15-49 and 4,397 men age 15-59 interviewed in the 2006 NDHS is shown in Table 3.1. More than half of the respondents (58 percent of women and 54 percent men) are under age 30. In general, the proportion of women and men in each age group declines as age increases, reflecting the comparatively young age structure of the population in Nepal as a result of past high fertility levels. More than two-thirds of the respondents (77 percent of women and 67 percent of men) are married. The proportion not currently married varies by gender. One in five women has never married compared with one in three men. On the other hand, women are more likely to be divorced, separated, or widowed (4 percent) than men (1 percent). The place of residence is another characteristic that determines access to services and exposure to information pertaining to reproductive health and other aspects of life. The majority of respondents reside in rural areas, with only 16 percent of women and 19 percent of men residing in urban areas. More than half of the respondents live in the terai, two in five live in the hills, and 7 percent of women and 6 percent of men live in the mountains. 1 For mortality rates, parentheses are used if based on 250 to 499 children exposed to the risk of mortality in any of the component rates, and suppressed if based on fewer than 250 children exposed to the risk of mortality in any of the component rates. 36 | Characteristics of Respondents Table 3.1 Background characteristics of respondents Percent distribution of women and men age 15-49 by selected background characteristics, Nepal 2006 Women Men Background characteristic Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted number Age 15-19 22.6 2,437 2,437 24.4 941 939 20-24 18.5 1,995 2,042 16.4 632 635 25-29 16.4 1,773 1,770 13.6 524 542 30-34 12.4 1,336 1,331 13.0 499 493 35-39 11.3 1,220 1,249 11.5 444 412 40-44 10.4 1,121 1,097 10.8 414 412 45-49 8.4 912 867 10.3 399 409 Marital status Never married 19.9 2,149 2,153 31.3 1,207 1,208 Married 76.5 8,257 8,244 67.4 2,598 2,586 Divorced/separated 1.3 144 141 0.9 34 31 Widowed 2.3 243 255 0.4 14 17 Residence Urban 15.6 1,687 2,949 19.0 730 1,149 Rural 84.4 9,106 7,844 81.0 3,123 2,693 Ecological zone Mountain 7.0 753 1,480 6.2 241 503 Hill 42.6 4,598 4,229 42.6 1,641 1,462 Terai 50.4 5,443 5,084 51.2 1,972 1,877 Development region Eastern 22.2 2,392 2,529 22.0 849 896 Central 32.9 3,553 2,739 35.5 1,367 1,010 Western 19.2 2,070 2,105 18.6 716 782 Mid-western 11.6 1,250 1,691 10.8 416 577 Far-western 14.2 1,528 1,729 13.1 506 577 Subregion Eastern mountain 1.7 189 541 1.5 59 178 Central mountain 1.9 202 448 1.9 73 146 Western mountain 3.4 362 491 2.8 109 179 Eastern hill 5.8 627 729 5.6 215 256 Central hill 15.9 1,713 1,070 18.7 722 418 Western hill 11.7 1,267 1,078 10.0 387 345 Mid-western hill 6.0 650 733 5.4 210 234 Far-western hill 3.2 341 619 2.8 107 209 Eastern terai 14.6 1,576 1,259 14.9 576 462 Central terai 15.2 1,638 1,221 14.8 571 446 Western terai 7.3 783 971 8.3 320 410 Mid-western terai 4.2 457 738 4.0 155 253 Far-western terai 9.2 989 895 9.1 350 306 Education No education 53.1 5,728 5,677 18.4 710 669 Primary 17.6 1,901 1,908 28.1 1,083 1,084 Some secondary 20.6 2,225 2,207 33.2 1,281 1,289 SLC and above 8.7 938 1,001 20.2 779 800 Wealth quintile Lowest 18.2 1,961 2,207 16.1 621 697 Second 19.3 2,079 2,005 18.1 696 700 Middle 20.5 2,214 1,974 18.5 714 632 Fourth 20.6 2,226 2,267 22.3 861 854 Highest 21.4 2,313 2,340 24.9 961 959 Religion Hindu 85.1 9,187 9,348 84.9 3,272 3,304 Buddhist 8.6 932 821 8.5 329 284 Muslim 3.6 389 330 3.3 127 118 Kirant 1.6 178 188 2.4 91 99 Christian 0.9 98 101 0.9 33 35 Other 0.1 6 4 0.0 2 2 Ethnicity Brahmin 12.8 1,377 1,542 12.2 471 538 Chettri 18.5 1,998 2,364 16.9 653 794 Newar 4.2 453 491 4.4 169 161 Gurung 3.0 319 271 2.7 103 84 Magar 6.6 716 721 5.5 212 216 Tamang/Sherpa 6.2 667 614 5.3 205 177 Rai/Limbu 4.6 495 535 4.3 164 178 Muslim/Churaute 3.9 425 369 3.6 137 128 Tharu/Rajbanshi 12.2 1,321 1,044 13.9 535 430 Yadav/Ahir 2.5 267 258 3.1 120 121 Occupational caste 11.6 1,251 1,353 11.6 446 497 Other hill origin 4.4 478 362 5.4 207 142 Other terai origin 9.5 1,025 869 11.2 433 376 Total 15-49 100.0 10,793 10,793 100.0 3,854 3,842 Men 50-59 na na na 12.4 543 555 Total men 15-59 na na na 100.0 4,397 4,397 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. Total includes 1 woman missing information on religion not shown separately. na = Not applicable Characteristics of Respondents | 37 The distribution of respondents by development region shows that about one-third are from the Central region, one-fifth are from the Eastern and Western regions, and about one in ten are from the Mid-western and Far-western regions. The subregional distribution shows the highest concentra- tion of women and men in the Central hill (16 percent and 19 percent, respectively), followed by the Central terai and Eastern terai (15 percent each for both women and men), and Western hill subregions (12 percent and 10 percent, respectively). In each of the remaining subregions, the proportion of women and men is less than 10 percent. Education is one of the most influential factors affecting an individual’s attitude, knowledge and behavior in various facets of life. Not surprisingly, educational attainment in Nepal is very low among women, who are much more disadvantaged than men. More than half (53 percent) of women compared with less than one in five (18 percent) men do not have any formal education. Eighteen percent of women and 28 percent of men have only reached primary school, 21 percent of women and 33 percent of men have only attended secondary school, and 9 percent of women and 20 percent of men have completed their School Leaving Certificate (SLC) or gone on to higher levels of education. The distribution of respondents by religious affiliation shows that 85 percent of the respondents are Hindu, 9 percent are Buddhist, and about 4 percent of women and 3 percent of men are Muslim. With respect to ethnic classification, one in five respondents are Chettris, while 12 to 14 percent of women and men belong to the Tharu/Rajbansi, Brahmin or occupational caste groups. While there are more than 100 ethnic and caste groups in Nepal (Central Bureau of Statistics, 2003), most are small in number and, therefore, are not shown separately. They are grouped under the category “Other hill origin” and “Other terai origin.” 3.2 EDUCATIONAL ATTAINMENT AND LITERACY Tables 3.2.1 and 3.2.2 show the distribution of respondents by educational attainment, accord- ing to background characteristics. More than one in two (53 percent) women age 15-49 have never been to school, 12 percent have only some primary education, 5 percent have completed primary, 21 percent have only some secondary education, and less than 10 percent have completed secondary or higher level of education. Women who are older and reside in rural areas are more likely to have no education. The urban-rural difference in the level of education is pronounced at the secondary or higher levels. For example, four times as many women in urban areas as in rural areas have completed secondary or higher level of education (24 percent and 6 percent, respectively). Respondents from the hills are most likely to have formal education and are more highly educated than respondents from the terai and mountains. Regarding regional differentials in educational attainment, women in the Far- western region have the highest proportion with no education (62 percent), while the lowest proportion live in the Western region, where 42 percent of women have never received formal education. Among subregions, nearly three in four (73 percent) women living in the Western mountain subregion have no education, compared with more than three in ten (34 percent) women living in the Western hill. Educational attainment is directly related to the economic status of respondents. An analysis of education by wealth quintile indicates that women in the highest wealth quintile are most likely to complete secondary or higher level of education. For example, 27 percent of women in the highest wealth quintile have completed secondary or higher level of education, compared with just 1 percent of women in the lowest wealth quintile. A similar pattern in educational attainment is found among men (Table 3.2.2). However, men are more educated than women in all categories. One in five men has never been in formal schooling, one in five has only some primary education, one in thirteen has completed primary, one in three has only some secondary education, and one in five men has completed secondary or higher education. Only 6 percent of men in the highest quintile have never attended school, compared with 30 percent of men in the lowest quintile. Surprisingly, a higher proportion of men in the Central region have never attended formal education compared with men from other regions. 38 | Characteristics of Respondents Table 3.2.1 Educational attainment: Women Percent distribution of women age 15-49 by highest level of schooling attended or completed, according to background characteristics, Nepal 2006 Highest level of schooling Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Total Number of women Age 15-24 27.8 15.6 8.2 36.2 6.1 6.1 100.0 4,431 15-19 21.0 15.5 9.8 44.2 5.6 3.9 100.0 2,437 20-24 36.1 15.7 6.2 26.5 6.6 8.8 100.0 1,995 25-29 54.8 12.1 5.5 16.4 6.0 5.2 100.0 1,773 30-34 61.5 13.5 4.3 13.0 4.8 2.9 100.0 1,336 35-39 76.0 9.7 2.8 7.2 2.9 1.3 100.0 1,220 40-44 85.6 5.7 1.5 3.6 1.8 1.7 100.0 1,121 45-49 89.7 6.0 0.8 2.9 0.4 0.4 100.0 912 Residence Urban 30.5 11.9 5.5 27.8 11.5 12.9 100.0 1,687 Rural 57.3 12.3 5.3 19.3 3.4 2.4 100.0 9,106 Ecological zone Mountain 61.9 13.0 6.1 14.6 2.0 2.4 100.0 753 Hill 44.3 14.7 6.4 23.0 5.9 5.6 100.0 4,598 Terai 59.2 10.1 4.3 19.4 3.9 3.0 100.0 5,443 Development region Eastern 49.7 13.0 4.6 23.7 4.9 4.1 100.0 2,392 Central 55.8 12.8 4.0 16.3 5.9 5.2 100.0 3,553 Western 42.4 14.0 7.7 26.8 4.4 4.8 100.0 2,070 Mid-western 58.4 11.5 5.1 18.1 4.1 2.8 100.0 1,250 Far-western 62.3 8.2 6.7 19.4 2.0 1.4 100.0 1,528 Subregion Eastern mountain 40.1 17.1 8.1 26.5 2.8 5.5 100.0 189 Central mountain 63.3 14.0 4.5 13.8 2.5 1.8 100.0 202 Western mountain 72.6 10.2 6.0 8.8 1.4 1.1 100.0 362 Eastern hill 42.0 16.7 6.0 24.4 5.5 5.5 100.0 627 Central hill 43.2 15.4 5.2 19.9 8.1 8.2 100.0 1,713 Western hill 34.1 15.3 8.7 31.7 5.2 4.9 100.0 1,267 Mid-western hill 56.9 12.4 4.0 19.9 4.3 2.6 100.0 650 Far-western hill 68.6 9.8 9.4 9.4 1.5 1.3 100.0 341 Eastern terai 53.9 11.0 3.6 23.1 4.9 3.4 100.0 1,576 Central terai 68.0 10.0 2.7 12.8 4.1 2.5 100.0 1,638 Western terai 55.5 11.8 5.7 19.4 3.1 4.6 100.0 783 Mid-western terai 53.5 11.3 6.5 19.8 4.9 4.0 100.0 457 Far-western terai 58.9 7.0 6.0 24.4 2.2 1.5 100.0 989 Wealth quintile Lowest 70.4 12.0 5.3 11.0 0.6 0.7 100.0 1,961 Second 65.2 13.5 5.4 14.2 1.3 0.4 100.0 2,079 Middle 63.3 11.8 5.5 16.8 1.6 1.1 100.0 2,214 Fourth 45.4 13.1 5.9 27.3 5.1 3.3 100.0 2,226 Highest 25.2 11.2 4.6 31.7 13.4 13.9 100.0 2,313 Total 53.1 12.3 5.3 20.6 4.6 4.1 100.0 10,793 Note: Median years of schooling was not calculated for women because in most categories less than 50 percent have ever attended school. 1 Completed grade 5 at the primary level 2 Completed grade 10 at the secondary level Characteristics of Respondents | 39 Table 3.2.2 Educational attainment: Men Percent distribution of men age 15-49 by highest level of schooling attended or completed, and median years of schooling completed, according to background characteristics, Nepal 2006 Highest level of schooling Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Total Number of men Median years of schooling Age 15-24 6.3 14.8 9.5 47.6 8.9 12.9 100.0 1,573 7.0 15-19 4.5 14.2 10.2 54.5 8.0 8.6 100.0 941 6.9 20-24 9.0 15.7 8.4 37.3 10.2 19.4 100.0 632 7.1 25-29 17.5 19.8 8.1 31.6 6.5 16.4 100.0 524 5.9 30-34 20.1 26.3 6.9 25.7 7.1 13.9 100.0 499 4.5 35-39 30.4 21.9 6.1 21.7 8.8 11.1 100.0 444 3.6 40-44 33.8 25.5 5.5 17.9 8.8 8.6 100.0 414 2.1 45-49 36.1 26.1 8.2 16.9 5.7 7.0 100.0 399 1.8 Residence Urban 10.6 15.0 5.0 28.8 11.8 28.8 100.0 730 8.2 Rural 20.3 21.3 8.7 34.3 7.1 8.4 100.0 3,123 5.0 Ecological zone Mountain 22.3 22.5 8.6 34.5 6.0 6.3 100.0 241 4.6 Hill 12.2 19.6 7.1 36.1 8.6 16.4 100.0 1,641 6.6 Terai 23.1 20.2 8.7 30.8 7.7 9.5 100.0 1,972 4.8 Development region Eastern 19.1 20.3 9.4 33.8 7.9 9.6 100.0 849 5.2 Central 21.5 20.3 5.9 26.5 9.5 16.3 100.0 1,367 5.4 Western 12.9 19.7 8.5 38.8 7.9 12.2 100.0 716 6.3 Mid-western 16.1 23.7 7.9 32.9 7.8 11.5 100.0 416 5.4 Far-western 18.6 17.0 10.7 43.1 4.3 6.4 100.0 506 5.5 Subregion Eastern mountain 13.1 29.8 10.2 32.2 6.8 7.8 100.0 59 4.7 Central mountain 29.0 22.1 9.4 29.4 2.9 7.3 100.0 73 3.8 Western mountain 22.7 18.8 7.2 39.1 7.5 4.8 100.0 109 5.2 Eastern hill 14.3 18.8 9.3 42.3 5.7 9.6 100.0 215 6.2 Central hill 13.5 19.9 5.0 30.1 10.0 21.6 100.0 722 6.9 Western hill 8.9 16.5 8.7 43.0 9.5 13.3 100.0 387 7.1 Mid-western hill 13.2 24.8 6.0 33.5 7.3 15.2 100.0 210 6.0 Far-western hill 9.8 20.6 13.5 43.7 3.8 8.6 100.0 107 5.8 Eastern terai 21.5 19.8 9.3 30.7 8.9 9.8 100.0 576 4.9 Central terai 30.8 20.5 6.8 21.6 9.7 10.6 100.0 571 3.8 Western terai 17.7 22.8 7.6 34.7 6.2 11.0 100.0 320 5.3 Mid-western terai 18.1 23.7 11.6 31.7 7.1 7.9 100.0 155 4.7 Far-western terai 20.4 16.4 10.6 41.8 4.4 6.4 100.0 350 5.4 Wealth quintile Lowest 30.3 29.6 8.4 28.4 2.3 1.0 100.0 621 2.6 Second 25.5 25.3 9.1 33.1 4.7 2.2 100.0 696 3.9 Middle 22.2 22.3 14.3 31.6 5.0 4.7 100.0 714 4.4 Fourth 14.7 17.1 7.0 40.9 8.7 11.7 100.0 861 6.6 Highest 6.2 11.3 3.3 30.9 15.6 32.8 100.0 961 8.9 Total 15-49 18.4 20.1 8.0 33.2 8.0 12.2 100.0 3,854 5.6 Men 50-59 43.2 25.7 7.8 14.1 4.7 4.5 100.0 543 1.0 Total 15-59 21.5 20.8 8.0 30.9 7.6 11.3 100.0 4,397 5.0 1 Completed grade at 5 the primary level 2 Completed grade 10 at the secondary level 40 | Characteristics of Respondents The median grade of schooling among those who have attended formal school is six years for men. The median for women is not shown because more than 50 percent of women in most of the categories have no education and, therefore, the overall median for women is less than one year. Literacy is widely acknowledged as benefiting the individual and the society and is associated with a number of positive outcomes for health, nutrition, and the overall well-being of both men and women. In the 2006 NDHS, literacy was determined by the respondents’ ability to read all or part of a sentence. During data collection, interviewers carried a set of cards on which simple sentences were printed in five of the major languages for testing a respondent’s reading ability. Only those who had never been to school and those who had not completed primary level were asked to read the cards in the language they were most likely able to read. Those who had attended secondary school or higher education were assumed to be literate. Table 3.3.1 indicates that more than half of women in Nepal (55 percent) are literate. The literacy status varies by place of residence. Three-fourths of women residing in urban areas are literate compared with only half of their rural counterparts. The level of literacy by age shows a consistent decrease with increasing age. This suggests that the younger generations have had more opportunity for learning than the older generations. Four in five women age 15-19 are literate compared with only about one in five women age 45-49. A higher proportion of women (63 percent) living in the hills are literate, compared with those living in the mountain and terai zones (46 percent and 48 percent, respectively). Regional and subregional differences in literacy are notable, with literacy being highest among women in the Western region (65 percent) and lowest in the Far-western region (48 percent). The percentage of literate women is highest in the Western hill subregion (71 percent) and lowest in Central terai, Far-western hill, and Western mountain subregions (35 percent each). There is also a significant difference in literacy levels by women’s wealth status, ranging from a low of 37 percent among women in the lowest wealth quintile to a high of 81 percent among women in the highest wealth quintile. This reaffirms the positive association between economic status and literacy. Men are more likely to be literate than women (Table 3.3.2). Four-fifths of Nepalese men age 15-59 are literate. The gap in urban-rural literacy among men is smaller than that among women, suggesting that men in rural areas are better able to access learning than women. Men in the Western and Mid-western development regions are more likely to be literate than those in other development regions. Nearly all men (96 percent) in the highest wealth quintile are literate. There has been a notable increase in educational attainment and literacy over the last five years among both ever-married men and women. For example, ever-married women attending secondary school or higher education increased by 55 percent, from 13 percent in 2001 to 21 percent in 2006. At the same time, the percentage of ever-married women who are literate increased by 32 percent, from 35 percent in 2001 to 47 percent in 2006. Literacy among ever-married men rose from 70 percent to 73 percent during the same time period. Characteristics of Respondents | 41 Table 3.3.1 Literacy: Women Percent distribution of women age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Nepal 2006 No schooling or primary school Background characteristic Secondary school or higher Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Total Percent- age literate1 Number Age 15-19 53.6 20.1 5.9 20.3 0.0 0.0 0.0 100.0 79.7 2,437 20-24 42.0 19.3 8.5 30.2 0.0 0.0 0.0 100.0 69.8 1,995 25-29 27.6 17.6 9.2 45.6 0.0 0.0 0.0 100.0 54.4 1,773 30-34 20.7 16.2 12.4 50.4 0.3 0.0 0.0 100.0 49.3 1,336 35-39 11.4 14.7 12.1 61.4 0.3 0.0 0.0 100.0 38.3 1,220 40-44 7.2 9.8 9.3 73.6 0.0 0.1 0.0 100.0 26.2 1,121 45-49 3.6 7.8 6.9 81.3 0.0 0.1 0.2 100.0 18.4 912 Residence Urban 52.1 16.6 7.1 24.2 0.0 0.0 0.0 100.0 75.8 1,687 Rural 25.1 16.3 9.2 49.3 0.1 0.0 0.0 100.0 50.6 9,106 Ecological zone Mountain 19.0 15.4 12.1 53.6 0.0 0.0 0.0 100.0 46.4 753 Hill 34.5 20.2 8.6 36.4 0.2 0.0 0.0 100.0 63.4 4,598 Terai 26.3 13.2 8.6 51.8 0.0 0.0 0.0 100.0 48.2 5,443 Development region Eastern 32.7 16.4 6.7 44.1 0.0 0.1 0.0 100.0 55.9 2,392 Central 27.4 14.7 8.3 49.3 0.2 0.0 0.0 100.0 50.5 3,553 Western 35.9 20.1 8.5 35.3 0.0 0.0 0.1 100.0 64.6 2,070 Mid-western 25.0 15.9 13.7 45.3 0.0 0.1 0.0 100.0 54.7 1,250 Far-western 22.9 15.1 10.1 51.9 0.0 0.0 0.0 100.0 48.1 1,528 Subregion Eastern mountain 34.7 25.8 6.5 33.0 0.0 0.0 0.0 100.0 67.0 189 Central mountain 18.2 16.7 12.7 52.4 0.0 0.0 0.0 100.0 47.6 202 Western mountain 11.3 9.2 14.6 64.9 0.0 0.0 0.0 100.0 35.1 362 Eastern hill 35.4 23.7 8.0 32.9 0.0 0.0 0.0 100.0 67.1 627 Central hill 36.2 20.9 8.7 33.7 0.5 0.0 0.0 100.0 65.9 1,713 Western hill 41.8 21.9 7.3 28.9 0.0 0.0 0.1 100.0 71.0 1,267 Mid-western hill 26.7 14.6 11.8 46.8 0.0 0.0 0.0 100.0 53.2 650 Far-western hill 12.2 14.1 8.7 65.0 0.0 0.1 0.0 100.0 34.9 341 Eastern terai 31.4 12.4 6.2 49.8 0.0 0.1 0.0 100.0 50.1 1,576 Central terai 19.4 8.0 7.3 65.3 0.0 0.0 0.0 100.0 34.7 1,638 Western terai 27.0 17.2 10.8 45.0 0.0 0.0 0.0 100.0 55.0 783 Mid-western terai 28.6 20.4 12.9 37.9 0.0 0.2 0.0 100.0 61.9 457 Far-western terai 28.1 16.6 11.0 44.3 0.0 0.0 0.0 100.0 55.7 989 Wealth quintile Lowest 12.4 14.8 9.5 63.2 0.0 0.0 0.1 100.0 36.7 1,961 Second 15.9 17.2 9.5 57.4 0.0 0.0 0.0 100.0 42.6 2,079 Middle 19.5 16.3 10.1 54.0 0.0 0.1 0.0 100.0 45.9 2,214 Fourth 35.6 17.9 8.5 38.0 0.0 0.0 0.0 100.0 62.0 2,226 Highest 59.0 15.3 7.0 18.3 0.3 0.0 0.0 100.0 81.4 2,313 Total 29.3 16.3 8.9 45.4 0.1 0.0 0.0 100.0 54.5 10,793 1 Refers to women who attended secondary school or higher and who can read a whole sentence or part of a sentence 42 | Characteristics of Respondents Table 3.3.2 Literacy: Men Percent distribution of men age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Nepal 2006 No schooling or primary school Background characteristic Secondary school or higher Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Total Percent- age literate1 Number Age 15-19 71.2 16.8 4.0 7.9 0.1 0.0 100.0 91.9 941 20-24 66.9 17.3 5.3 10.5 0.0 0.0 100.0 89.5 632 25-29 54.6 21.8 5.0 18.7 0.0 0.0 100.0 81.3 524 30-34 46.7 22.9 10.7 19.7 0.0 0.0 100.0 80.3 499 35-39 41.6 22.8 7.0 28.6 0.0 0.0 100.0 71.4 444 40-44 35.3 20.2 13.6 30.5 0.0 0.4 100.0 69.1 414 45-49 29.6 25.9 9.9 34.3 0.0 0.3 100.0 65.4 399 Residence Urban 69.4 15.9 4.8 9.7 0.0 0.1 100.0 90.1 730 Rural 49.7 21.4 7.8 21.0 0.0 0.1 100.0 78.9 3,123 Ecological zone Mountain 46.7 23.5 7.6 22.1 0.0 0.0 100.0 77.9 241 Hill 61.0 21.5 6.0 11.3 0.1 0.0 100.0 88.6 1,641 Terai 48.0 19.0 8.1 24.8 0.0 0.1 100.0 75.1 1,972 Development region Eastern 51.3 21.2 6.6 20.4 0.2 0.3 100.0 79.1 849 Central 52.2 19.0 6.5 22.3 0.0 0.0 100.0 77.7 1,367 Western 58.9 22.7 5.5 13.0 0.0 0.0 100.0 87.0 716 Mid-western 52.3 23.4 11.6 12.7 0.0 0.0 100.0 87.3 416 Far-western 53.7 16.6 9.1 20.6 0.0 0.0 100.0 79.4 506 Subregion Eastern mountain 46.9 30.1 9.3 13.7 0.0 0.0 100.0 86.3 59 Central mountain 39.6 31.2 6.0 23.2 0.0 0.0 100.0 76.8 73 Western mountain 51.4 14.9 7.8 25.9 0.0 0.0 100.0 74.1 109 Eastern hill 57.6 21.6 3.9 16.3 0.6 0.0 100.0 83.1 215 Central hill 61.7 20.0 6.7 11.6 0.0 0.0 100.0 88.4 722 Western hill 65.8 22.4 2.4 9.4 0.0 0.0 100.0 90.6 387 Mid-western hill 56.0 22.2 13.8 8.0 0.0 0.0 100.0 92.0 210 Far-western hill 56.1 27.4 3.5 13.0 0.0 0.0 100.0 87.0 107 Eastern terai 49.4 20.2 7.3 22.6 0.0 0.5 100.0 76.9 576 Central terai 41.9 16.2 6.1 35.7 0.0 0.0 100.0 64.3 571 Western terai 51.9 22.1 9.0 17.0 0.0 0.0 100.0 83.0 320 Mid-western terai 46.7 28.4 10.4 14.5 0.0 0.0 100.0 85.5 155 Far-western terai 52.5 14.4 10.8 22.2 0.0 0.0 100.0 77.8 350 Wealth quintile Lowest 31.7 24.1 11.7 32.5 0.0 0.0 100.0 67.5 621 Second 40.1 23.6 8.1 28.3 0.0 0.0 100.0 71.7 696 Middle 41.3 26.3 9.9 22.4 0.2 0.0 100.0 77.4 714 Fourth 61.3 18.7 5.0 14.9 0.0 0.1 100.0 85.0 861 Highest 79.2 12.6 3.7 4.3 0.0 0.2 100.0 95.6 961 Total 15-49 53.5 20.3 7.2 18.9 0.0 0.1 100.0 81.0 3,854 Men 50-59 23.3 28.3 10.9 37.3 0.0 0.2 100.0 62.5 543 Total 15-59 49.7 21.3 7.7 21.2 0.0 0.1 100.0 78.7 4,397 1 Refers to men who attended secondary school or higher and who can read a whole sentence or part of a sentence Characteristics of Respondents | 43 3.3 ACCESS TO MASS MEDIA Access to information through the media is essential to increasing people’s knowledge and awareness of what is taking place around them, which may eventually affect their perceptions and behavior. In the 2006 NDHS, exposure to media was assessed by asking respondents if they listened to a radio, watched television, or read newspapers or magazines at least once a week. This information is useful for program managers and planners in determining which media may be more effective for disseminating health information to targeted audiences. The detailed results are presented in Tables 3.4.1 and 3.4.2 by background characteristics. Table 3.4.1 Exposure to mass media: Women Percentage of women age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Nepal 2006 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week All three media at least once a week No media at least once a week Number Age 15-19 15.3 44.8 72.3 11.7 20.0 2,437 20-24 15.3 44.9 65.6 12.2 24.7 1,995 25-29 10.4 38.9 57.5 8.1 31.1 1,773 30-34 8.5 35.8 59.9 6.9 30.1 1,336 35-39 5.0 30.3 53.6 3.7 37.3 1,220 40-44 4.5 28.9 47.9 3.1 41.8 1,121 45-49 2.6 29.2 48.8 1.7 41.6 912 Residence Urban 34.6 78.7 66.2 28.2 12.2 1,687 Rural 5.8 30.6 59.4 4.2 33.3 9,106 Ecological zone Mountain 3.1 11.0 52.2 1.7 45.9 753 Hill 13.4 39.4 65.6 10.1 23.9 4,598 Terai 8.7 40.8 57.3 7.1 33.0 5,443 Development region Eastern 11.6 42.5 63.4 9.9 28.3 2,392 Central 14.7 48.4 56.0 11.1 29.8 3,553 Western 8.2 37.9 63.8 6.6 27.3 2,070 Mid-western 5.5 22.9 71.7 4.2 25.2 1,250 Far-western 4.7 20.0 52.6 2.7 40.5 1,528 Subregion Eastern mountain 3.4 10.8 61.3 1.4 38.1 189 Central mountain 7.2 21.3 67.9 4.7 28.5 202 Western mountain 0.6 5.4 38.8 0.2 59.6 362 Eastern hill 11.0 28.8 79.7 8.7 18.7 627 Central hill 23.8 63.1 60.9 17.6 18.9 1,713 Western hill 8.9 32.7 67.1 6.8 24.4 1,267 Mid-western hill 3.3 18.6 72.3 2.9 25.2 650 Far-western hill 1.8 4.2 44.7 0.8 54.0 341 Eastern terai 12.9 51.8 57.1 11.3 31.0 1,576 Central terai 6.2 36.4 49.3 5.1 41.4 1,638 Western terai 7.2 47.0 59.5 6.3 30.9 783 Mid-western terai 10.0 33.0 77.9 7.3 17.8 457 Far-western terai 6.7 29.2 59.4 3.8 30.6 989 Education No education 0.4 22.4 45.6 0.2 46.1 5,728 Primary 3.6 40.8 68.6 2.7 21.3 1,901 Some secondary 21.3 58.7 81.8 16.5 7.6 2,225 SLC and above 58.1 79.8 84.0 46.1 2.3 938 Wealth quintile Lowest 0.8 3.4 46.1 0.2 52.8 1,961 Second 1.6 12.5 52.6 0.9 44.1 2,079 Middle 2.5 25.3 58.4 1.6 35.1 2,214 Fourth 9.7 56.0 70.0 7.4 17.3 2,226 Highest 34.2 85.6 72.6 27.6 5.3 2,313 Total 10.3 38.1 60.5 8.0 30.0 10,793 44 | Characteristics of Respondents Media exposure in Nepal is relatively high with men much more likely than women to be exposed to any of the three specified types of mass media. More than three-fifths of women and four- fifths of men are exposed to at least one type of media, with exposure to the radio being the highest. Two-fifths of women and men watch television at least once a week. Exposure to the print media is relatively lower with only one in ten women and three in ten men reporting that they read a newspaper or magazine at least once a week. Eight percent of women and 22 percent of men are exposed to all three media, and 30 percent of women and 17 percent of men are not exposed to any of the three media. Table 3.4.2 Exposure to mass media: Men Percentage of men age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Nepal 2006 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week All three media at least once a week No media at least once a week Number Age 15-19 35.2 53.7 81.7 24.7 11.6 941 20-24 42.5 53.1 82.8 32.2 12.7 632 25-29 31.7 51.3 78.5 26.2 15.3 524 30-34 34.1 44.2 77.1 22.2 16.4 499 35-39 25.1 33.8 73.0 14.7 21.8 444 40-44 18.7 29.4 73.0 12.2 22.4 414 45-49 21.8 31.7 70.1 14.3 23.8 399 Residence Urban 63.6 79.0 82.6 50.0 5.9 730 Rural 23.9 36.9 76.6 15.8 19.0 3,123 Ecological zone Mountain 20.7 16.0 86.9 8.1 11.4 241 Hill 42.4 48.4 85.7 28.8 7.9 1,641 Terai 23.7 45.4 70.0 18.5 24.3 1,972 Development region Eastern 31.4 53.6 82.1 23.6 13.3 849 Central 38.5 55.5 77.0 29.0 14.8 1,367 Western 30.0 45.1 84.2 20.7 10.6 716 Mid-western 28.2 22.3 83.8 14.5 13.6 416 Far-western 17.1 19.5 58.1 10.3 37.3 506 Subregion Eastern mountain 25.9 21.5 87.6 13.4 12.4 59 Central mountain 30.0 25.5 86.6 13.0 9.7 73 Western mountain 11.6 6.5 86.7 2.0 11.9 109 Eastern hill 30.6 35.6 93.0 16.1 4.8 215 Central hill 55.9 71.7 82.6 43.3 7.6 722 Western hill 35.9 37.7 84.9 21.4 9.4 387 Mid-western hill 34.0 20.1 87.9 16.2 9.2 210 Far-western hill 14.8 11.1 90.4 7.9 9.0 107 Eastern terai 32.3 63.6 77.5 27.4 16.5 576 Central terai 17.6 38.9 68.8 12.9 24.5 571 Western terai 23.4 54.0 83.5 20.2 11.9 320 Mid-western terai 23.8 30.6 79.0 16.3 18.7 155 Far-western terai 19.4 24.7 43.0 12.3 50.4 350 Education No education 2.5 22.2 56.2 1.9 37.9 710 Primary 11.5 34.2 76.5 7.7 19.1 1,083 Some secondary 36.9 48.4 83.3 24.8 11.2 1,281 SLC and above 76.5 74.4 89.9 56.8 2.2 779 Wealth quintile Lowest 5.1 6.9 70.4 1.9 28.5 621 Second 12.4 19.0 68.7 4.9 27.9 696 Middle 16.0 30.5 72.2 9.3 23.3 714 Fourth 36.4 61.1 85.4 27.1 8.9 861 Highest 69.3 84.1 86.2 53.2 2.2 961 Total 15-49 31.4 44.9 77.7 22.2 16.5 3,854 Men 50-59 15.4 31.1 65.1 11.0 29.1 543 Total 15-59 29.5 43.1 76.2 20.9 18.1 4,397 Characteristics of Respondents | 45 Young women under 25 years of age are more likely to be exposed to the mass media than older women, presumably in part because of their higher level of education. There is also a wide gap in exposure to mass media by place of residence. For example, the proportion of newspaper readers is significantly higher among urban women (35 percent) than among their rural counterparts (6 percent). Not surprisingly, media exposure is highly related to the educational level as well as economic status of the respondent. Exposure to mass media is highest among women with secondary or higher level of education and those who are in the highest wealth quintile. The lower level of exposure to media among poor respondents may be because they are less likely to own a radio or television and, therefore, are less likely to be consistently exposed to these media sources. Women residing in the Central region are more likely to be exposed to most of the three media on a weekly basis than women in the other regions. The proportions of newspapers readers and television viewers are highest among women in the Central hill subregion. Access to mass media among women is lowest in the mountains, the Far-western region and the Western mountain subregion. A similar pattern is seen among men with regards to media exposure by background characteristics. There has been considerable improvement in respondents’ exposure to the electronic media over the last five years. The proportion of ever-married women who watch television at least once a week has increased by 49 percent, from 23 percent in 2001 to 35 percent in 2006, while the proportion among ever-married men rose from 34 percent to 37 percent. On the other hand, there was little change in exposure to the print media. 3.3.1 Access to Specific Radio and Television Programs Dissemination of health information through the electronic media and especially through the radio is not new in Nepal. The National Health Education, Information and Communication Center (NHEICC), USAID, UNICEF, and other organizations have launched several different radio and television programs to raise awareness about life in general and health in particular. Information on the exposure to several specific radio programs was collected in the 2006 NDHS. These are Janaswasthya radio karyakram, Sewa nai dharma ho, Gyan nai shakti ho, Hamro swasthya radio karyakram, Ek apaas ka kura, Sathi sanga manka kura, and Desh pardesh. Information was also collected on respondents’ exposure to two television programs: Jeevan chakra and Teli-swasthya karyakram. Tables 3.5.1 and Table 3.5.2 show the percentage of men and women who have heard or seen such programs. About six in ten men (58 percent) and nearly one out of two women (47 percent) age 15-49 listened to the Sathi sanga manka kura radio program. About 20-30 percent of women and about 30-40 percent of men were exposed to each of the other radio programs. Men were only slightly more likely than women to be exposed to the two programs on the television. Sathi sanga manka kura is the most popular radio program among young listeners, with nearly three-fourths of men and just over two-thirds of women in the age group 15-19 listening to this program. Exposure to specific radio and television programs decreases with age among women. Young men are more likely to view television programs than older men. Urban women are more likely than rural women to access both radio and television programs, whereas men in rural areas are more likely to listen to the specific radio programs in contrast to urban men who are more likely to watch the two television programs. Women in the mountain, Far-western region and Far-western hill subregions are least likely to be exposed to the specific television programs. A similar pattern is observed among men with regards to the specific health programs on television. Not surprisingly, level of education and economic status are directly associated with exposure to the specific health programs. Respondents who are highly educated and come from the wealthiest households are more likely to have heard or seen these programs. 46 | Characteristics of Respondents Table 3.5.1 Exposure to specific health programs on radio and television: Women Percentage of women age 15-49 who have heard or seen specific health programs on the radio and television, by background characteristics, Nepal 2006 Background characteristic Janaswasthya radio karyakram Sewa nai dharma ho Gyan nai shakti ho Hamro swasthya radio karyakram Ek apaas ka kura Sathi sanga manka kura Desh pardesh Jeevan chakra Teli- swasthya karyakram Number Age 15-19 36.1 32.9 26.7 35.4 39.7 66.3 27.1 31.1 18.6 2,437 20-24 33.6 30.2 23.0 32.6 32.2 56.8 22.0 30.7 20.2 1,995 25-29 27.7 24.2 16.3 23.9 25.4 42.6 18.5 23.1 13.5 1,773 30-34 31.2 26.9 18.5 26.7 23.9 42.0 17.3 24.9 14.7 1,336 35-39 23.6 24.6 18.7 24.4 20.0 35.9 16.5 16.9 9.7 1,220 40-44 20.5 20.7 15.2 19.0 15.5 28.1 13.1 15.7 6.7 1,121 45-49 18.3 17.9 14.6 18.8 13.3 26.7 12.1 15.1 7.5 912 Residence Urban 34.7 34.8 22.2 33.5 33.9 55.4 21.4 45.9 32.2 1,687 Rural 28.1 25.2 19.8 26.5 25.8 45.3 19.3 20.4 11.1 9,106 Ecological zone Mountain 31.2 25.1 17.6 26.7 23.8 41.7 18.5 8.4 4.4 753 Hill 34.8 32.6 22.1 36.5 34.2 59.3 26.0 29.1 17.1 4,598 Terai 24.1 22.0 18.9 20.1 21.4 37.1 14.4 22.7 13.5 5,443 Region Eastern 34.6 32.8 23.8 35.2 35.4 56.5 25.3 32.4 17.7 2,392 Central 24.4 23.0 17.6 23.7 20.7 41.0 16.5 28.6 18.4 3,553 Western 29.7 29.0 21.4 30.5 34.2 54.5 22.9 25.9 13.9 2,070 Mid-western 35.9 32.1 24.1 35.1 33.6 58.3 23.7 15.1 9.5 1,250 Far-western 25.3 18.5 15.7 14.4 13.4 25.9 10.1 7.8 4.6 1,528 Subregion Eastern mountain 40.7 37.8 24.3 37.9 34.5 63.2 36.2 4.3 1.4 189 Central mountain 41.1 33.6 26.1 34.3 32.8 58.7 27.6 17.7 12.1 202 Western mountain 20.

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