Nepal DHS Final Report (2011)

Publication date: 2012

Nepal Demographic and Health Survey 2011Dem ographic and H ealth Survey N epal 2011 Nepal Demographic and Health Survey 2011 Population Division Ministry of Health and Population Government of Nepal Kathmandu, Nepal New ERA Kathmandu, Nepal ICF International Calverton, Maryland, U.S.A. March 2012 New ERA Ministry of Health and Population The 2011 Nepal Demographic and Health Survey (2011 NDHS) was implemented by New ERA under the aegis of the Ministry of Health and Population (MOHP). Funding for the survey was provided by USAID. ICF International provided technical assistance for the survey through the MEASURE DHS program, a USAID- funded project providing support and technical assistance in the implementation of population and health surveys in countries worldwide. The opinions expressed herein are those of the authors and do not necessarily reflect the views of the U.S. Agency for International Development. Additional information about the survey may be obtained from the 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. Information about the DHS program may be obtained from MEASURE DHS, ICF International, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, USA; Telephone: 301-572-0200, Fax: 301-572-0999, E-mail: reports@measuredhs.com, Internet: http://www.measuredhs.com. Recommended citation: Ministry of Health and Population (MOHP) [Nepal], New ERA, and ICF International Inc. 2012. Nepal Demographic and Health Survey 2011. Kathmandu, Nepal: Ministry of Health and Population, New ERA, and ICF International, Calverton, Maryland. Contents • iii CONTENTS Tables and Figures . ix Foreword. xv Acknowledgments . xvii Technical Advisory Committee and Technical Working Committee . xix Contributors to the Report . xxi Millennium Development Goal Indicators . xxiii Map of Nepal . xxiv CHAPTER 1 INTRODUCTION . 1 1.1 History, Geography, and Economy . 1 1.1.1 History . 1 1.1.2 Geography . 1 1.1.3 Economy . 3 1.2 Population . 3 1.3 Population and Health Policies and Programs . 4 1.4 Objectives of the Survey . 5 1.5 Organization of the Survey . 6 1.6 Sample Design . 6 1.6.1 Sampling Frame . 7 1.6.2 Domains . 7 1.6.3 Sample Selection . 7 1.7 Questionnaires . 8 1.8 Hemoglobin Testing . 8 1.9 Listing, Pretest, Training, and Fieldwork . 9 1.9.1 Listing . 9 1.9.2 Pretest . 9 1.9.3 Training of Field Staff . 9 1.9.4 Fieldwork . 10 1.10 Data Processing . 10 1.11 Response Rates . 10 CHAPTER 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION . 13 2.1 Household Characteristics . 13 2.1.1 Water and Sanitation . 13 2.1.2 Housing Characteristics . 16 2.1.3 Household Possessions . 18 2.2 Socioeconomic Status Index . 19 2.3 Household Population by Age and Sex . 20 2.4 Migration Status . 22 2.5 Household Composition . 25 2.6 Birth Registration . 25 2.7 Children’s Living Arrangements, Orphanhood, and School Attendance . 26 2.8 Education of Household Population . 28 2.8.1 Educational Attainment of Household Population . 28 2.8.2 School Attendance Ratios . 30 2.8.3 Early Childhood Development Centers . 33 2.9 Possession of Mosquito Nets . 34 2.10 Prevalence and Causes of Food Insecurity and Coping Strategies . 35 iv • Contents CHAPTER 3 CHARACTERISTICS OF RESPONDENTS . 41 3.1 Characteristics of Survey Respondents . 41 3.1.1 Spousal Separation . 43 3.2 Educational Attainment by Background Characteristics . 44 3.3 Literacy . 47 3.4 Access to Mass Media . 49 3.4.1 Access to Specific Radio and Television Programs . 51 3.4.2 Preferred Media Source for Health-Related Programs . 53 3.5 Employment . 54 3.5.1 Employment Status . 54 3.5.2 Occupation . 57 3.5.3 Earnings, Employers, and Continuity of Employment . 60 3.6 Use of Tobacco . 61 CHAPTER 4 MARRIAGE AND SEXUAL ACTIVITY . 65 4.1 Current Marital Status . 65 4.2 Polygyny . 66 4.3 Age at First Marriage . 67 4.4 Median Age at First Marriage . 68 4.5 Age at First Sexual Intercourse . 70 4.6 Median Age at First Sexual Intercourse . 71 4.7 Recent Sexual Activity . 71 CHAPTER 5 FERTILITY . 75 5.1 Current Fertility . 75 5.2 Fertility Differentials . 76 5.3 Fertility Trends . 77 5.4 Children Ever Born and Living . 78 5.5 Birth Intervals . 79 5.6 Postpartum Amenorrhea, Abstinence, and Insusceptibility . 81 5.7 Menopause . 82 5.8 Age at First Birth . 82 5.9 Teenage Pregnancy and Motherhood . 83 CHAPTER 6 FERTILITY PREFERENCES . 85 6.1 Desire for More Children . 85 6.2 Desire to Limit Childbearing by Background Characteristics. 86 6.3 Ideal Family Size . 88 6.4 Fertility Planning . 90 6.5 Wanted Fertility Rates . 90 CHAPTER 7 FAMILY PLANNING . 93 7.1 Knowledge of Contraceptive Methods . 94 7.2 Current Use of Contraception . 94 7.3 Current Use of Contraception by Background Characteristics . 95 7.4 Trends in Current Use of Family Planning . 97 7.5 Timing of Female Sterilization . 98 7.6 Source of Contraception . 99 7.7 Brands of Pills and Condoms Used . 100 7.8 Informed Choice . 101 7.9 Contraceptive Discontinuation Rates . 102 7.10 Reasons for Discontinuation of Contraceptive Use . 102 Contents • v 7.11 Knowledge of Fertile Period . 103 7.12 Need and Demand for Family Planning Services . 103 7.13 Future Use of Contraception . 105 7.14 Exposure to Family Planning Messages . 105 7.15 Contact of Nonusers with Family Planning Providers . 107 7.16 Counseling During Postpartum and Post-abortion . 108 7.17 Men’s Attitudes towards Contraception . 110 CHAPTER 8 INFANT AND CHILD MORTALITY . 111 8.1 Assessment of Data Quality . 112 8.2 Levels and Trends in Infant and Child Mortality . 113 8.3 Socioeconomic Differentials in Childhood Mortality . 114 8.4 Demographic Differentials in Mortality . 115 8.5 Perinatal Mortality . 116 8.6 High-risk Fertility Behavior . 117 CHAPTER 9 MATERNAL HEALTH . 119 9.1 Antenatal Care . 119 9.1.1 Number and Timing of Antenatal Visits . 121 9.2 Components of Antenatal Care . 121 9.3 Tetanus Toxoid Vaccination . 123 9.4 Place of Delivery . 124 9.5 Assistance during Delivery . 126 9.5.1 Care and Support during Delivery . 128 9.5.2 Birth Preparedness . 130 9.6 Postnatal Care . 130 9.6.1 Timing of First Postnatal Checkup for the Mother . 131 9.6.2 Provider of First Postnatal Checkup for Mother . 132 9.7 Newborn Care . 132 9.7.1 Provider of First Postnatal Checkup for the Newborn . 134 9.7.2 Newborn Care Practices. 135 9.8 Abortion . 136 9.8.1 Knowledge that Abortion is Legal in Nepal . 137 9.8.2 Knowledge about Places That Provide Safe Abortions . 138 9.8.3 Pregnancy Outcomes . 139 9.8.4 Reason for the Most Recent Abortion . 140 9.8.5 Type of Abortion Procedure . 141 9.8.6 Place and Provider for Abortion . 142 9.8.7 Complications during and after Abortion and Contraception . 143 9.8.8 Abortion and Post-abortion Cost . 143 9.9 Uterine Prolapse . 143 9.10 Problems in Accessing Health Care . 143 9.10.1 Awareness and Practice of Health Services in the Government Sector . 144 CHAPTER 10 CHILD HEALTH . 147 10.1 Child’s Weight and Size at Birth . 148 10.2 Vaccination Coverage . 149 10.3 Vaccination by Background Characteristics . 150 10.4 Trends in Immunization Coverage . 152 10.5 Acute Respiratory Infection . 152 10.6 Fever . 153 10.7 Diarrhea . 155 vi • Contents 10.8 Diarrhea Treatment . 156 10.9 Feeding Practices during Diarrhea . 158 10.10 Knowledge of ORS Packets . 159 10.11 Disposal of Children’s Stools. 160 CHAPTER 11 NUTRITION OF CHILDREN AND WOMEN . 163 11.1 Nutritional Status of Children . 164 11.1.1 Measurement of Nutritional Status among Young Children . 164 11.1.2 Data Collection . 165 11.1.3 Measures of Child Nutrition Status . 165 11.1.4 Trends in Children’s Nutritional Status . 168 11.2 Breastfeeding and Complementary Feeding . 169 11.2.1 Initiation of Breastfeeding . 169 11.3 Breastfeeding Status by Age . 171 11.4 Duration of Breastfeeding . 173 11.5 Types of Complementary Foods . 174 11.6 Infant and Young Child Feeding (IYCF) Practices . 175 11.7 Prevalence of Anemia in Children . 177 11.8 Micronutrient Intake among Children . 179 11.9 Nutritional Status of Women . 182 11.10 Prevalence of Anemia in Women . 184 11.11 Micronutrient Intake among Mothers . 185 CHAPTER 12 HIV AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR . 189 12.1 Introduction . 189 12.2 HIV and AIDS Knowledge, Transmission, and Prevention Methods . 190 12.2.1 Knowledge of AIDS . 190 12.2.2 Knowledge of HIV Prevention Methods . 191 12.2.3 Comprehensive Knowledge of HIV and AIDS Transmission . 193 12.3 Knowledge of Prevention of Mother-to-Child Transmission of HIV . 196 12.4 Accepting Attitudes toward those Living with HIV and AIDS. 197 12.5 Attitudes toward Negotiating Safer Sex . 199 12.6 Multiple Sexual Partners . 201 12.7 Payment for Sex . 202 12.8 Testing for HIV . 203 12.9 Self-reporting of Sexually Transmitted Infections . 206 12.10 Prevalence of Medical Injections . 207 12.11 HIV and AIDS-related Knowledge and Behavior among Youth . 208 12.11.1 Knowledge about HIV and AIDS and of Sources for Condoms . 209 12.11.2 Age at First Sexual Intercourse among Youth . 210 12.11.3 Premarital Sex . 211 12.11.4 Multiple Sexual Partners among Youth . 212 12.11.5 Age Mixing in Sexual Relationships among Women Age 15-19 . 213 12.11.6 Recent HIV Tests among Youth . 214 CHAPTER 13 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES . 215 13.1 Employment and Form of Earnings . 216 13.2 Women’s Control over Their Own Earnings and Relative Magnitude of Women’s and Their Husbands’ Earnings . 218 13.3 Control over Husbands’ Earnings . 219 13.4 Women’s and Men’s Ownership of Selected Assets . 222 Contents • vii 13.5 Women’s Participation in Decision-making . 224 13.6 Women’s Empowerment Indicators . 227 13.7 Current Use of Contraception by Women’s Status . 229 13.8 Ideal Family Size and Unmet Need by Women’s Status . 230 13.9 Reproductive Health Care and Women’s Empowerment . 231 13.10 Infant and Child Mortality and Women’s Empowerment . 232 CHAPTER 14 DOMESTIC VIOLENCE . 233 14.1 Measurement of Violence . 234 14.1.1 Use of Valid Measures of Violence . 234 14.1.2 Ethical Considerations in the 2011 NDHS . 235 14.1.3 Subsample for the Violence Module . 235 14.2 Experience of Physical Violence . 236 14.3 Perpetrators of Physical Violence . 237 14.4 Experience of Sexual Violence . 237 14.5 Perpetrators of Sexual Violence . 238 14.6 Experience of Different Forms of Violence . 239 14.7 Forced at Sexual Initiation . 239 14.8 Violence during Pregnancy . 239 14.9 Marital Control by Husband. 240 14.10 Forms of Spousal Violence . 241 14.11 Spousal Violence by Background Characteristics . 243 14.12 Violence by Spousal Characteristics and Women’s Empowerment Indicators . 244 14.13 Frequency of Spousal Violence . 245 14.14 Onset of Spousal Violence . 247 14.15 Physical Consequences of Spousal Violence . 247 14.16 Violence by Women against Their Husbands . 248 14.17 Help-seeking Behavior by Women Who Experience Violence . 250 REFERENCES . 253 APPENDIX A SAMPLE DESIGN AND IMPLEMENTATION . 261 APPENDIX B ESTIMATES OF SAMPLING ERRORS . 267 APPENDIX C DATA QUALITY TABLES . 281 APPENDIX D PERSONS INVOLVED IN THE 2011 NEPAL DEMOGRAPHIC AND HEALTH SURVEY . 287 APPENDIX E QUESTIONNAIRES . 291 Tables and Figures • ix TABLES AND FIGURES CHAPTER 1 INTRODUCTION Table 1.1 Basic demographic indicators . 3 Table 1.2 Results of the household and individual interviews . 11 CHAPTER 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION Table 2.1 Household drinking water . 14 Table 2.2 Household sanitation facilities . 15 Table 2.3 Hand washing . 16 Table 2.4 Household characteristics . 17 Table 2.5 Household possessions . 18 Table 2.6 Wealth quintiles . 20 Table 2.7 Household population by age, sex, and residence . 21 Table 2.8 Migration status . 22 Table 2.9.1 Migration status: Men . 23 Table 2.9.2 Migration status: Women . 24 Table 2.10 Household composition . 25 Table 2.11 Birth registration of children under age five . 26 Table 2.12 Children’s living arrangements and orphanhood . 27 Table 2.13.1 Educational attainment of the female household population. 29 Table 2.13.2 Educational attainment of the male household population . 30 Table 2.14.1 School attendance ratios: Primary school . 31 Table 2.14.2 School attendance ratios: Secondary school . 32 Table 2.15 Children enrolled in school-based pre-primary classes and Early Childhood Development centers . 34 Table 2.16 Possession of mosquito nets . 35 Table 2.17 Household food security . 37 Table 2.18 Coping strategies of households with food insecurity . 38 Table 2.19 Causes of household food insecurity . 39 Figure 2.1 Population Pyramid . 21 Figure 2.2 Age-specific Attendance Rates of the de facto Population 5 to 24 Years . 33 CHAPTER 3 CHARACTERISTICS OF RESPONDENTS Table 3.1 Background characteristics of respondents . 42 Table 3.2 Spousal separation. 44 Table 3.3.1 Educational attainment: Women . 45 Table 3.3.2 Educational attainment: Men . 46 Table 3.4.1 Literacy: Women. 47 Table 3.4.2 Literacy: Men . 48 Table 3.5.1 Exposure to mass media: Women . 49 Table 3.5.2 Exposure to mass media: Men . 50 Table 3.6.1 Exposure to specific health programs on radio and television: Women . 51 Table 3.6.2 Exposure to specific health programs on radio and television: Men . 52 Table 3.7.1 Preferred media source for health-related information: Women . 53 Table 3.7.2 Preferred media source for health-related information: Men . 54 Table 3.8.1 Employment status: Women . 55 Table 3.8.2 Employment status: Men . 57 x • Tables and Figures Table 3.9.1 Occupation: Women . 58 Table 3.9.2 Occupation: Men . 59 Table 3.10.1 Type of employment: Women . 60 Table 3.10.2 Type of employment: Men . 61 Table 3.11.1 Use of tobacco: Women . 62 Table 3.11.2 Use of tobacco: Men . 63 Figure 3.1 Women’s Employment Status in the Past 12 Months . 56 CHAPTER 4 MARRIAGE AND SEXUAL ACTIVITY Table 4.1 Current marital status . 65 Table 4.2 Number of co-wives and wives . 67 Table 4.3 Age at first marriage . 68 Table 4.4 Median age at first marriage by background characteristics . 69 Table 4.5 Age at first sexual intercourse . 70 Table 4.6 Median age at first sexual intercourse by background characteristics . 71 Table 4.7.1 Recent sexual activity: Women . 72 Table 4.7.2 Recent sexual activity: Men . 73 Figure 4.1 Trend in Proportion Never Married among Women and Men 15-24 Years . 66 CHAPTER 5 FERTILITY Table 5.1 Current fertility . 76 Table 5.2 Fertility by background characteristics . 77 Table 5.3.1 Trends in age-specific fertility rates . 77 Table 5.3.2 Trends in fertility . 78 Table 5.4 Children ever born and living . 79 Table 5.5 Birth intervals . 80 Table 5.6 Postpartum amenorrhea, abstinence, and insusceptibility . 81 Table 5.7 Median duration of amenorrhea, postpartum abstinence, and postpartum insusceptibility . 82 Table 5.8 Menopause . 82 Table 5.9 Age at first birth . 83 Table 5.10 Median age at first birth . 83 Table 5.11 Teenage pregnancy and motherhood . 84 Figure 5.1 Trends in Fertility . 78 CHAPTER 6 FERTILITY PREFERENCES Table 6.1 Fertility preferences by number of living children . 86 Table 6.2.1 Desire to limit childbearing: Women . 87 Table 6.2.2 Desire to limit childbearing: Men . 87 Table 6.3 Ideal number of children by number of living children . 88 Table 6.4 Mean ideal number of children by background characteristics . 89 Table 6.5 Fertility planning status . 90 Table 6.6 Wanted fertility rates . 91 CHAPTER 7 FAMILY PLANNING Table 7.1 Knowledge of contraceptive methods . 94 Table 7.2 Current use of contraception by age . 95 Table 7.3 Current use of contraception by background characteristics . 96 Table 7.4 Trends in current use of contraceptive methods . 97 Table 7.5 Timing of sterilization . 98 Tables and Figures • xi Table 7.6 Source of modern contraception methods . 99 Table 7.7 Use of social marketing brand pills and condoms . 100 Table 7.8 Informed choice . 101 Table 7.9 Twelve-month contraceptive discontinuation rates . 102 Table 7.10 Reasons for discontinuation . 103 Table 7.11 Knowledge of fertile period . 103 Table 7.12 Need and demand for family planning among currently married women . 104 Table 7.13 Future use of contraception . 105 Table 7.14 Exposure to family planning messages . 106 Table 7.15 Contact of nonusers with family planning providers . 108 Table 7.16 Information on family planning methods and counseling . 109 Table 7.17 Men’s attitudes towards contraceptive use . 110 Figure 7.1 Trends in Contraceptive Use among Currently Married Women . 98 CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates . 113 Table 8.2 Early childhood mortality rates by socioeconomic characteristics . 115 Table 8.3 Early childhood mortality rates by demographic characteristics . 116 Table 8.4 Perinatal mortality . 117 Table 8.5 High-risk fertility behavior . 118 Figure 8.1 Trends in Childhood Mortality, Nepal 1991-2010 . 114 CHAPTER 9 MATERNAL HEALTH Table 9.1 Antenatal care . 120 Table 9.2 Number of antenatal care visits and timing of first visit . 121 Table 9.3 Components of antenatal care . 122 Table 9.4 Tetanus toxoid injections . 124 Table 9.5 Place of delivery . 125 Table 9.6 Reasons for not delivering in a health facility . 126 Table 9.7 Assistance during delivery . 127 Table 9.8 Care and support during delivery . 129 Table 9.9 Birth preparedness. 130 Table 9.10 Timing of first postnatal checkup . 131 Table 9.11 Type of provider of first postnatal checkup for the mother . 132 Table 9.12 Timing of first postnatal checkup for the newborn . 133 Table 9.13 Type of provider of first postnatal checkup for the newborn . 134 Table 9.14 Use of clean home delivery kits and other instruments to cut the umbilical cord . 135 Table 9.15 Newborn care practices . 136 Table 9.16 Knowledge that abortion is legal in Nepal . 138 Table 9.17 Knowledge about places that provide safe abortions . 139 Table 9.18 Pregnancy outcomes by background characteristics . 140 Table 9.19 Main reason for the most recent abortion in the past five years . 141 Table 9.20 Abortion services in the past five years . 142 Table 9.21 Problems in accessing health care . 144 Table 9.22 Awareness and practice of health services in government sector . 145 CHAPTER 10 CHILD HEALTH Table 10.1 Child’s weight and size at birth . 149 Table 10.2 Vaccinations by source of information . 150 Table 10.3 Vaccinations by background characteristics . 151 xii • Tables and Figures Table 10.4 Prevalence of symptoms of ARI . 153 Table 10.5 Prevalence and treatment of fever . 154 Table 10.6 Prevalence of diarrhea . 156 Table 10.7 Diarrhea treatment. 158 Table 10.8 Feeding practices during diarrhea . 159 Table 10.9 Disposal of children’s stools . 161 Figure 10.1 Trends in Vaccination Coverage among Children 12-23 Months, Nepal 1996-2011 . 152 CHAPTER 11 NUTRITION OF CHILDREN AND WOMEN Table 11.1 Nutritional status of children . 166 Table 11.2 Initial breastfeeding . 170 Table 11.3 Breastfeeding status by age . 172 Table 11.4 Median duration of breastfeeding . 174 Table 11.5 Foods and liquids consumed by children in the day or night preceding the interview . 175 Table 11.6 Infant and young child feeding (IYCF) practices . 176 Table 11.7 Prevalence of anemia in children . 178 Table 11.8 Micronutrient intake among children . 180 Table 11.9 Presence of adequately iodized salt in household . 182 Table 11.10 Nutritional status of women . 183 Table 11.11 Prevalence of anemia in women . 185 Table 11.12 Micronutrient intake among mothers . 187 Figure 11.1 Nutritional Status of Children by Age. 167 Figure 11.2 Trends in Nutritional Status of Children under Five Years . 169 Figure 11.3 Infant Feeding Practices by Age . 172 Figure 11.4 IYCF Indicators on Breastfeeding Status . 173 CHAPTER 12 HIV AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR Table 12.1 Knowledge of AIDS . 191 Table 12.2 Knowledge of HIV prevention methods . 192 Table 12.3.1 Comprehensive knowledge about AIDS: Women . 194 Table 12.3.2 Comprehensive knowledge about AIDS: Men . 195 Table 12.4 Knowledge of prevention of mother-to-child transmission of HIV . 196 Table 12.5.1 Accepting attitudes toward those living with HIV/AIDS: Women . 198 Table 12.5.2 Accepting attitudes toward those living with HIV/AIDS: Men . 199 Table 12.6 Attitudes toward negotiating safer sexual relations with husband . 200 Table 12.7 Multiple sexual partners . 201 Table 12.8 Payment for sexual intercourse and condom use at last paid sexual intercourse . 203 Table 12.9.1 Coverage of prior HIV testing: Women . 204 Table 12.9.2 Coverage of prior HIV testing: Men . 205 Table 12.10 Self-reported prevalence of sexually transmitted infections (STIs) and STI symptoms . 206 Table 12.11 Prevalence of medical injections . 208 Table 12.12 Comprehensive knowledge about AIDS and of a source of condoms among youth . 209 Table 12.13 Age at first sexual intercourse among youth . 211 Table 12.14 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth . 212 Table 12.15 Multiple sexual partners in the past 12 months among young men . 213 Table 12.16 Age mixing in sexual relationships among women age 15-19 . 213 Table 12.17 Recent HIV tests among youth . 214 Figure 12.1 Women and Men Seeking Advice or Treatment for STIs . 207 Tables and Figures • xiii CHAPTER 13 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES Table 13.1 Employment and cash earnings of currently married women and men . 216 Table 13.2 Reasons for women not being employed in the past 12 months . 217 Table 13.3.1 Control over women’s cash earnings and relative magnitude of women’s cash earnings: Women . 219 Table 13.3.2 Control over men’s cash earnings . 220 Table 13.4 Woman’s control over their earnings and over those of their husbands . 221 Table 13.5.1 Ownership of assets: Women . 223 Table 13.5.2 Ownership of assets: Men . 224 Table 13.6 Participation in decision-making . 225 Table 13.7.1 Women’s participation in decision-making by background characteristics . 226 Table 13.7.2 Men’s participation in decision-making by background characteristics . 227 Table 13.8 Indicators of women’s empowerment . 229 Table 13.9 Current use of contraception by women’s empowerment . 230 Table 13.10 Women’s empowerment and ideal number of children and unmet need for family planning . 230 Table 13.11 Reproductive health care by women’s empowerment. 231 Table 13.12 Early childhood mortality rates by indicators of women’s empowerment . 232 Figure 13.1 Percent Distribution of Currently Married Women with their Score on Each of the Two Women’s Empowerment Indices . 228 CHAPTER 14 DOMESTIC VIOLENCE Table 14.1 Experience of physical violence . 236 Table 14.2 Persons committing physical violence . 237 Table 14.3 Experience of sexual violence . 238 Table 14.4 Persons committing sexual violence . 238 Table 14.5 Experience of different forms of violence . 239 Table 14.6 Forced sexual initiation . 239 Table 14.7 Violence during pregnancy . 240 Table 14.8 Marital control exercised by husbands . 241 Table 14.9 Forms of spousal violence . 242 Table 14.10 Spousal violence by background characteristics . 244 Table 14.11 Spousal violence by husband’s characteristics and women’s empowerment indicators . 245 Table 14.12 Frequency of spousal violence among those who report violence . 246 Table 14.13 Onset of marital violence . 247 Table 14.14 Injuries to women due to spousal violence . 248 Table 14.15 Violence by women against their spouse . 249 Table 14.16 Help seeking to stop violence . 250 Table 14.17 Sources from where help was sought . 251 Figure 14.1 Specific Forms of Physical and Sexual Violence Committed by Husbands . 243 APPENDIX A SAMPLE DESIGN AND IMPLEMENTATION Table A.1 Enumeration areas . 262 Table A.2 Population . 262 Table A.3 Sample allocation of clusters and households . 263 Table A.4 Sample allocation of expected number of completed interviews . 263 Table A.5 Sample implementation: Women . 264 Table A.6 Sample implementation: Men . 265 xiv • Tables and Figures APPENDIX B ESTIMATES OF SAMPLING ERRORS Table B.1 List of selected variables for sampling errors, Nepal, 2011 . 269 Table B.2 Sampling errors for national sample, Nepal 2011 . 270 Table B.3 Sampling errors for urban sample, Nepal 2011 . 271 Table B.4 Sampling errors for rural sample, Nepal 2011 . 272 Table B.5 Sampling errors for Mountain region, Nepal 2011 . 273 Table B.6 Sampling errors for Hill region, Nepal 2011 . 274 Table B.7 Sampling errors for Terai region, Nepal 2011 . 275 Table B.8 Sampling errors for Eastern region, Nepal 2011 . 276 Table B.9 Sampling errors for Central region, Nepal 2011 . 277 Table B.10 Sampling errors for Western region, Nepal 2011 . 278 Table B.11 Sampling errors for Mid-western region, Nepal 2011. 279 Table B.12 Sampling errors for Far-western region, Nepal 2011 . 280 APPENDIX C DATA QUALITY TABLES Table C.1 Household age distribution . 281 Table C.2.1 Age distribution of eligible and interviewed women . 282 Table C.2.2 Age distribution of eligible and interviewed men . 282 Table C.3 Completeness of reporting . 283 Table C.4 Births by calendar years . 283 Table C.5 Reporting of age at death in days . 284 Table C.6 Reporting of age at death in months . 285 Table C.7 Nutritional status of children based on NCHS/CDC/WHO International Reference Population . 286 Foreword • xv FOREWORD The 2011 Nepal Demographic and Health Survey is the fourth nationally representative comprehensive survey conducted as part of the worldwide Demographic and Health Surveys (DHS) project in the country. The survey was implemented by New ERA under the aegis of the Population Division, Ministry of Health and Population. Technical support for this survey was provided by ICF International with financial support from the United States Agency for International Development (USAID) through its mission in Nepal. The primary objective of the 2011 NDHS is to provide up-to-date and reliable data on different issues related to population and health, which provides guidance in planning, implementing, monitoring, and evaluating health programs in Nepal. The long term objective of the survey is to strengthen the technical capacity of the local institutions to plan, conduct, process and analyze data from complex national population and health surveys. The survey includes topics on fertility levels and determinants, family planning, fertility preferences, childhood mortality, children and women’s nutritional status, the utilization of maternal and child health services, knowledge of HIV/AIDS and STIs, women’s empowerment and for the first time, information on women facing different types of domestic violence. The survey also reports on the anemia status of women age 15-49 and children age 6-59 months. In addition to providing national estimates, the survey report also provides disaggregated data at the level of various domains such as ecological region, development regions and for urban and rural areas. This being the fourth survey of its kind, there is considerable trend information on reproductive and health care over the past 15 years. Moreover, the 2011 NDHS is comparable to similar surveys conducted in other countries and therefore, affords an international comparison. The 2011 NDHS also adds to the vast and growing international database on demographic and health-related variables. The 2011 NDHS collected demographic and health information from a nationally representative sample of 10,826 households, which yielded completed interviews with 12,674 women age 15-49 in all selected households and with 4, 121 men age 15-49 in every second household. This survey is the concerted effort of various individuals and institutions, and it is with great pleasure that I acknowledge the work that has gone into producing 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 also like to acknowledge ICF International for its technical assistance at all stages of the survey. My sincere thanks go to the New ERA study team for their generous effort in carrying out the survey work. I also would like to thank the Population Division of the Ministry of Health and Population for its effort and dedication in the completion of the 2011 NDHS. Praveen Mishra Secretary Ministry of Health and Population Acknowledgments • xvii ACKNOWLEDGMENTS The 2011 Nepal Demographic and Health Survey (NDHS) 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 ICF International. The survey was implemented by New ERA, a local research firm with extensive 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, monitoring the data collection, reviewing the draft tables and providing valuable inputs towards finalizing the report. Our sincere gratitude goes to all the members of Technical Advisory Committee for their time, support and valuable input. We would like to extend or sincere gratitude to Dr. Sudha Sharma, Ex-secretary, Ministry of Health and Population for her guidance and valuable input. Our sincere thanks go to Mr. Surya Prasad Acharya and Mr. Krishna Prasad Lamsal for their support during the different phases of the survey as chiefs of the Population Division, Ministry of Health and Population. We would like to express our heartfelt gratitude to the USAID mission in Nepal. We acknowledge the technical input and support provided by Ms. Anne M. Peniston, Director, Office of Health and Family Planning, Ms. Shanda Steimer, Director, Office of Health and Family Planning, Mr. Han Kang, Deputy Director, Office of Health and Family Planning, and Mr. Deepak Paudel, Senior MNCH Program Management Specialist, Office of Health and Family Planning. Our deep sense of gratitude goes to Dr. Pav Govindasamy, Regional Coordinator for Anglophone Africa and Asia, ICF International for her technical support. We would like to thank Dr. Alfredo Aliaga, Sampling Expert for designing the sample for the survey. Our sincere thanks go to Mr. Albert Themme, Data Processing Specialist for his invaluable input, guidance, and untiring support in making the use of tablet computers materialize in the Nepal DHS for the first time. Similarly, we extend our gratitude to Mr. Alexander Izmukhambetov, Data Processing Specialist and other ICF International staff for their valuable contribution. Special thanks goes to the core staff of New ERA, Ms. Anjushree Pradhan, Project Director; Mr. Yogendra Prasai, Technical Advisor; Mr. Kshitiz Shrestha and Ms. Jyoti Manandhar, Research Officers; Mr. Sachin Shrestha, Senior Research Assistant; Mr. Rajendra Lal Singh Dangol, Senior Data Processing Specialist and Ms. Sarita Vaidya, Data Processing Officer; Mr. Gehendra Man Pradhan and Mr. Babu Raja Dangol, Data Supervisors; Mr. Sanu Raja Shakya and Ms. Geeta Shrestha Amatya, Word Processing Staff, and other staff of New ERA for managing technical, administrative and logistical needs of the survey. Our special thanks go to the field coordinators, the quality control staff, field supervisors and enumerators for their tireless effort in making the fieldwork successful. We are also grateful to Dr. Megha Raj Dhakal, Under-Secretary, Mr. Naresh Khatiwada and Anil Thapa, Demographers, and Ms. Lila K.C., Section Officer, Population Study and Research Section, and other staff at the Ministry of Health and Population for their active support. Similarly, we would like to extend our gratitude to the authors for their valuable contribution to the report. We greatly acknowledge the support we received from various institutions in implementing the survey. We would especially like to thank the local level agencies including the District Health Offices, Health-Posts, Sub-health Posts, District Development Committees and the Village Development Committees for their support throughout the survey period. The FCHVs require special mention here, whose support has been highly appreciated. We extend our deepest gratitude to all the respondents for their time in responding to the survey. Sidhartha Man Tuladhar Padam Raj Bhatta Executive Director Chief, Population Division New ERA Ministry of Health and Population Technical Advisory Committee and Technical Working Committee • xix TECHNICAL ADVISORY COMMITTEE AND TECHNICAL WORKING COMMITTEE 2011 NEPAL DHS TECHNICAL ADVISORY COMMITTEE Secretary (Population), Ministry of Health and Population Chairperson Secretary, Ministry of Health and Population Member Dr. Ram Hari Aryal, Secretary, Ministry of Science and Technology Member Dr. Bal Gopal Baidya, Member, National Population Committee Member Dr. Gajananda Agrawal, Member, National Population Committee Member Dr. Ram Sharan Pathak, Member, National Population Committee Member Dr. Chandrakala Bhadra, Member, National Population Committee Member Dr. Prabha K Hamal, Member, National Population Committee Member Mr. Yogendra Bahadur Gurung, Member, National Population Committee Member Director General, Department of Health Services Member Director General, Central Bureau of Statistics Member Chief, PPICD, Ministry of Health and Population Member Chief, PHA, Monitoring and Evaluation Division, Ministry of Health and Population Member Chief, Curative Service Division, Ministry of Health and Population Member Chief, Administrative Division, Ministry of Health and Population Member Chief, HR and Financial Resource Management Division, Ministry of Health and Population Member Director, Family Health Division, Department of Health Services Member Director, Child Health Division, Department of Health Services Member Director, NCASC, Ministry of Health and Population Member Director, NHIECC, Ministry of Health and Population Member Chairperson, National Health Research Council Member Chief, Social Division, National Planning Commission Member Director General, Family Planning Association Member Representative, USAID Member Representative, UNFPA Member Dr. Pav Govindasamy, ICF International Member Head of Department, Central Department of Population Studies Member Executive Director, New ERA Member Chief, Population Division, Ministry of Health and Population Member-Secretary xx • Technical Advisory Committee and Technical Working Committee 2011 NEPAL DHS TECHNICAL WORKING COMMITTEE Joint Secretary/Chief, Population Division, Ministry of Health and Population Chairperson Dr. Bal Krishna Suvedi, PPICD, Ministry of Health and Population Member Dr. Megha Raj Dhakal, Under Secretary, Population Study and Research Section, MOHP Member Mr. Kabi Raj Khanal, Under Secretary, Ministry of Health and Population Member Dr. Babu Ram Marasini, Public Health Administrator, Ministry of Health and Population Member Mr. Raj Kumar Pokharel, Public Health Administrator, CHD, Department of Health Services Member Mr. Naresh Khatiwada, Statistical Officer/Demographer, Ministry of Health and Population Member Mr. Anil Thapa, Demographer, Ministry of Health and Population Member Mr. Badri Bahadur Khadka, NHIECC Member Chief, Demographic Section, FHD, Department of Health Services Member Mr. Pawan Kumar Ghimire, Chief, HMIS, Department of Health Services Member Mr. Nebin Lal Shrestha, Director, Central Bureau of Statistics Member Mr. Jhabindra Prasad Pandey, Demographer. Family Health Division Member Dr. Laxmi Bilash Acharya, FHI Member Dr. Yagya Bahadur Karki, Demographer Member Dr. Prakash Dev Panta, Family Health International 360 Member Dr. Pushpa Kamal Subedi, Assoc. Professor, Central Department of Population Studies, T.U. Member Mr. Ajit Singh Pradhan, Demographer, Nepal Health Sector Support Program Member Mr. Bharat Ban, Nepal Family Health Program Member Representative, National Center for AIDS and STD Control Member Representative, Nepal Health Research Council Member Representative, New ERA Member Chief, Population Study and Research Section, Population Division Member-Secretary Contributors to the Report • xxi CONTRIBUTORS TO THE REPORT AUTHORS Mr. Padam Raj Bhatta, Population Division, Ministry of Health and Population Mr. Surya Prasad Acharya, Ministry of Health and Population Mr. Upendra Adhikari, Ministry of Women and Social Welfare Dr. Megha Raj Dhakal, Population Division, Ministry of Health and Population Mr. Naresh Khatiwada, Population Division, Ministry of Health and Population Mr. Anil Thapa, Population Division, Ministry of Health and Population Ms. Lila Kumari K.C., Population Division, Ministry of Health and Population Mr. Raj Kumar Pokhrel, Child Health Division, Department of Health Services Mr. Mukti Nath Khanal, Family Health Division, Department of Health Services Mr. Paban Ghimire, Management Division, Department of Health Services Mr. Ramesh Adhikari, District Health Office, Kaski Dr. Purusotam Raj Shedain, Child Health Division, Department of Health Services Mr. Parshu Ram Shrestha, Child Health Division, Department of Health Services Mr. Dilli Raman Adhikari, National Centre for AIDS and STD Control, Department of Health Services Mr. Jhabindra Prasad Pandey, Ministry of Health and Population Mr. Kshitiz Shrestha, New ERA Ms. Jyoti Manandhar, New ERA Dr. Pav Govindasamy, ICF International Ms. Anjushree Pradhan, ICF International RESOURCE PERSONS Mr. Gauri Pradhan, Member, National Human Rights Commission Dr. Sudha Sharma, Ministry of Health and Population Dr. Ram Hari Aryal, Secretary, Ministry of Science and Technology Dr. Bal Krishna Suvedi, Ministry of Health and Population Dr. Chandrakala Bhadra, Member, National Population Committee Dr. Ram Sharan Pathak, Member, National Population Committee Mr. Yogendra Bahadur Gurung, Member, National Population Committee Dr. Y.V. Pradhan, Director General, Department of Health Services Mr. Bed Prasad Bhattarai, Director, National Human Rights Commission Dr. Naresh Pratap K.C., Department of Health Services, Ministry of Health and Population Dr. Shyam Raj Uprety, Child Health Division, Department of Health Services Dr. Ramesh Kharel, National Center for AIDS and STD Control Dr. B.R. Marasini, Ministry of Health and Population Dr. Kedar Baral (PAHS) Dr. R.K. Adhikari, KIST Medical College Dr. Prakash Dev Pant, Family Health International 360 Dr. Suresh Tiwari, Nepal Health Sector Support Program Mr. Ajit Singh Pradhan, Nepal Health Sector Support Program Mr. Ashoke Shrestha, Nepal Family Health Program Dr. Rajendra Bhadra, Nepal Family Health Program Mr. Bharat Ban, Nepal Family Health Program Mr. Dirgha Raj Shrestha, Nepal Family Health Program Mr. Deepak Paudel (USAID) Dr. Amit Bhandari, DFID Ms. Iva Schildbach (GIZ) Mr. Manav Bhattarai, World Bank Mr. Satish Raj Pandey, Family Health International 360 Mr. Shailesh Neupane, Valley Research Group Mr. Shital Bhandari (PAHS) Dr. Sudhir Khanal, UNICEF Mr. Sunil Acharya, Central Department of Population Studies, Tribhuvan University Ms. Pooja Pandey, Helen Keller International Mr. Yogendra Prasai, New ERA Millennium Development Goal Indicators • xxiii MILLENNIUM DEVELOPMENT GOAL INDICATORS Millennium Development Goal Indicators Nepal, 2011 Indicator Sex Total Male Female 1. Eradicate extreme poverty and hunger 1.8 Prevalence of underweight children under five years of age1 29.6 28.0 28.8 2. Achieve universal primary education 2.1 Net enrollment ratio in primary education2 94.6 89.0 91.9 2.3 Literacy rate of 15-24 year olds3 94.6a 82.7 88.6b 3. Promote gender equality and empower women 3.1a Ratio of girls to boys in primary education4 na na 0.9 3.1b Ratio of girls to boys in secondary education4 na na 1.0 3.1c Ratio of girls to boys in tertiary education4 na na 0.8 4. Reduce child mortality 4.1 Under-five mortality rate (per 1,000 live births)5 63 62 54 4.2 Infant mortality rate (per 1,000 live births)5 54 52 46 4.3 Proportion of 1 year-old children immunized against measles6 89.7 86.3 88.0 5. Improve maternal health 5.2 Proportion of births attended by skilled health personnel7 na na 36.0 5.3 Contraceptive prevalence rate8 na 49.7 na 5.4 Adolescent birth rate9 na 81.0 na 5.5a Antenatal care coverage: at least 1 visit by skilled health professional na 58.3 na 5.5b Antenatal care coverage: at least 4 visits by any provider na 50.1 na 5.6 Unmet need for family planning na 27.0 na 6. Combat HIV/AIDS, malaria and other diseases 6.2 Condom use at last high-risk sex: youth 15-24 years10 65.8a na na 6.3 Percentage of population 15-24 years with comprehensive knowledge of AIDS11 33.9a 25.8 29.8b Urban Rural Total 7. Ensure environmental sustainability 7.8 Percentage of population using an improved drinking water source12 93.5 87.8 88.6 7.9 Percentage of population with access to improved sanitation13 58.1 36.7 39.5 na = Not applicable. 1 Proportion of children age 0-59 months who are below -2 standard deviations from the median of the WHO Child Growth Standards in weight-for-age. 2 The rate is based on reported attendance, not enrollment, in primary education among primary school age children (6-10 year- olds). The rate also includes children of primary school age attended in secondary education. This is proxy for MDG indicator 2.1, net enrollment ratio. 3 Refers to respondents who attended secondary school or higher or who could read a whole sentence or part of a sentence. 4 Based on reported net attendance, not gross enrollment, among 6-10 year-olds for primary, 11-15 year-olds for secondary and 16-20 year-olds for tertiary education. 5 Expressed in terms of deaths per 1,000 live births. Mortality by sex refers to a 10-year reference period preceding the survey. Mortality rates for males and females combined refer to the 5-year period preceding the survey. 6 Among children age 12-23 months vaccinated at any time before the survey. 7 Among births in the 5-year period preceding the survey. 8 Percentage of currently married women age 15-49, using any method of contraception. 9 Equivalent to the age-specific fertility rate for women age 15-19 for the 3-year period preceding the survey, expressed in terms of births per 1,000 women age 15-19 10 High-risk sex refers to sexual intercourse with a non-marital, non-cohabiting partner. Expressed as a percentage of men and women age 15-24 who had high-risk sex in the past 12 months. Information for female suppressed as only few women had high-risk sex. 11 Comprehensive knowledge means knowing that consistent use of condom during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about transmission or prevention of the AIDS virus: AIDS can be transmitted by mosquito bites; a person can become infected by sharing food with someone who has AIDS. 12 Percentage of de-jure population whose main source of drinking water are: a household connection (piped), public standpipe, tubewell or borehole, protected well or spring, rainwater collection, or bottled water. 13 Percentage of de-jure population with access to flush toilet, ventilated improved pit latrine, pit latrine with a slab, or composting toilet and does not share this facility with other households. a Restricted to men in sub-sample of households selected for the male interview b The total is calculated as the simple arithmetic mean of the percentages in the columns for males and females xxiv • Map of Nepal Introduction • 1 INTRODUCTION 1 1.1 HISTORY, GEOGRAPHY, AND ECONOMY 1.1.1 History The history of Nepal goes back thousands of years, with early dynasties of Ahirs and Gopalas and Kirant kings ruling the country. It appears that the Kirant people were one of the first to settle in Nepal; they are said to have ruled the country for about 2,500 years. Subsequent dynasties of Licchavi and Thakuri kings ruled the country before the Malla period began in the 12th century. The Malla era is considered to be the golden age of Nepal, and Malla kings were famous for their contribution to art and culture. In 1765 A.D., King Prithvi Narayan Shah—the first Shah king of Nepal—embarked on his mission to unify the country, which had previously been divided into small independent kingdoms. After several battles and sieges, he managed to unify the Kathmandu Valley and surrounding territories three years later in 1768. However, factionalism inside the royal family led to the emergence of the Rana lineage, founded by military leader Jung Bahadur Rana, who assumed power by killing hundreds of military personnel and administrators loyal to Shah rulers in 1846 (Thingo and von der Heide, 1997). Backed by newly emerging pro-democracy movements and political parties, King Tribhuwan Shah ended the century-old system of rule by hereditary Rana premiers and instituted a cabinet system of government in 1951. Reforms in 1990 established a multiparty democracy within the framework of a constitutional monarchy. In early 1996, the Nepal Communist Party (Maoist) launched a movement that 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 places of residence to urban centers and neighboring countries to escape the conflict and to search for employment. Citing dissatisfaction with the government’s lack of progress in addressing the Maoist insurgency, King Gyanendra Bir Bikram Shah dissolved the government, declared a state of emergency, imprisoned party leaders, and assumed power in February 2005. The mass movement of April 2006 in Nepal restored parliament and the democratic process and initiated a peace movement that called for an end to the 10-year-long armed conflict. After nearly three weeks of mass protests organized by the seven-party opposition and the Maoists, the king allowed parliament to reconvene on 8 April 2006. A comprehensive peace agreement was signed between an alliance of the seven major political parties and the Nepal Communist Party (Maoist) on 21 November 2006. An interim constitution was drafted, and the restored parliament dissolved to pave the way for an interim legislature and interim government. The Nepal Communist Party (Maoist) joined the democratic competition, and constituent assembly elections were held in April 2008 to devise a constitution to manage the root causes of the conflicts afflicting the nation. After the dethroning of King Gyanendra Bir Bikram Shah and the obliteration of the monarchy in Nepal, the ruling seven-party alliance announced substantive structural reforms such as the declaration of the country as secular and federal, civilian control of the Nepal Army, nationalization of royal property, and empowerment of the prime minister as head of state (Dahal, 2008). 1.1.2 Geography The total land area of Nepal is 147,181 square kilometers, with India to the east, south, and west and China to the north. It is a land-locked country occupying an area from 26º 22' to 30º 27' north latitude and 80º 4' to 88º 12' east longitude; elevations range from 90 meters to 8,848 meters. Nepal is rectangular in shape and stretches 885 kilometers in length (east to west) and 193 kilometers in width (north to south). According to the 2 • Introduction preliminary results of the 2011 Population Census, the population of Nepal stands at 26.6 million (Central Bureau of Statistics, 2011a). Topographically, Nepal is divided into three distinct ecological zones: 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 43 percent of the total population lives in the hill zone, which covers an area of 61,345 square kilometers and occupies 42 percent of the total land area. The population distribution in the hills varies, with a fairly dense population in the valleys but notably lower population numbers above 2,000 meters (6,562 feet) and very low numbers above 2,500 meters (8,202 feet), where snow occasionally falls in the winter. 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. 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. This region has a subtropical to tropical climate. The outermost range of foothills, the Siwalik or Churia range, crests at 700 to 1,000 meters (2,297 to 3,281 feet) and marks the limit of the Gangetic plains; broad, low valleys called the inner terai lie north of these foothills. The terai consists of dense forest areas, 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, 50 percent of the population lives here (Central Bureau of Statistics, 2011a). 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. The climatic conditions vary substantially by altitude. There are 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, 2006a). For administrative purposes, Nepal is divided into five development regions: Eastern, Central, Western, Mid-western, and Far-western. Similarly, the country is divided into 14 zones and 75 administrative districts. Districts are further divided into smaller units, called village development committees (VDCs) and municipalities. The VDCs are rural areas, whereas municipalities are urban. Currently, there are 3,915 VDCs and 58 municipalities. Each VDC is composed of 9 wards, and the number of wards in each municipality ranges from 9 to 35. Kathmandu is the capital city as well as the principal urban center of Nepal (Central Bureau of Statistics, 2006b). The 2001 census listed 103 diverse ethnic/caste groups, each with its own distinct language and culture (Central Bureau of Statistics, 2003). The major groups are as follows: Chhetri, Brahmins, Magar, Tharu, Tamang, and Newar. The 2001 census 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 Introduction • 3 the population, respectively. According to the 2001 census, the majority of Nepalese are Hindus; there are also substantial numbers of Buddhists, Muslims, and Kirants (Central Bureau of Statistics, 2003). 1.1.3 Economy Nepal has considerable scope for exploiting its resources in areas such as hydropower and tourism, but a lack of political will, weak implementation of state policies, and the government’s failure to maintain law and order have substantially curbed the growth of the economic sector. Although the country has attracted the interest of foreign investors in recent years, lack of security and unnecessary interference by workers and trade unions are continuously diminishing any such prospects. Similarly, the country’s small economy and its technological backwardness, remoteness, and susceptibility to natural disasters also restrict the prospects of foreign trade. The preliminary estimate of per capita gross domestic product (GDP) at current prices stands at Nepalese Rupees 41,851 for 2009-2010. As measured by GDP, the economic growth of the country was 3.4 percent in 2009-2010 against the target of 4.5 percent, due to the slow growth in the nonagricultural sector. Nearly one-fourth of the population lives below the poverty line according to the 2010-2011 Nepal Living Standard Survey (Central Bureau of Statistics, 2011b). According to the Nepal Living Standard Survey 2010- 2011, only 2 percent of the population in Nepal is unemployed. Agriculture is the major occupation, with 76 percent of households involved in agricultural activities. Remittances have become one of the foremost sources of income in Nepal, with nearly 56 percent of households receiving some sort of remittance (Central Bureau of Statistics, 2011c). 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 has been available only since the 1952/1954 census. Table 1.1 provides a summary of the basic demographic indicators for Nepal from the census data for 1971, 1981, 1991, and 2001 and the recent preliminary findings from the 2011 census. According to the preliminary 2011 census findings, the population of the country stands at 26.6 million, with an increase of 3.5 million in the last 10 years. The population has more than doubled in the last 40 years. The population grew at a rapid rate between 1971 and 1981 from 2.1 percent to 2.6 percent but has since slowed to just over 2 percent in 1991 and 1.4 percent in 2011. The population density of Nepal is estimated to be 181 per square kilometer. Table 1.1 Basic demographic indicators Selected demographic indicators for Nepal, 1971-2011 Indicator 1971 census 1981 census 1991 census 2001 census 2011 census (preliminary) Population (millions) 11.6 15.0 18.5 23.2 26.6 Intercensal growth rate (percentage) 2.1 2.6 2.1 2.2 1.4 Density (pop./km2) 79 102 126 157 181 Percent urban 4.0 6.4 9.2 13.9 17.0 Life expectancy (years) Male 42.0 50.9 55.0 60.1 u Female 40.0 48.1 53.5 60.7 u Source: Central Bureau of Statistics, 2003:3, 383; Ministry of Population and Environment and Central Bureau of Statistics, 2003:8; Central Bureau of Statistics, 2011a u = No information The Kathmandu district has the highest population density (4,408) and Manang (3) the lowest. The decennial population growth has been highest in Kathmandu (61 percent) and lowest in Manang (-31 percent) (the overall level in Nepal is 15 percent). Currently, 4.5 million people (17 percent) reside in urban areas. The largest percentage of the population is in the Central development region (36 percent) and the smallest in the Far-western region (10 percent). The sex ratio (number of males per 100 females) is estimated at 94.4 in the current census, as compared to 99.8 in the previous census in 2001. The average household size has decreased from 5.4 in 2001 to 4.7 in 2011 (Central Bureau of Statistics, 2011a). 4 • Introduction 1.3 POPULATION AND HEALTH POLICIES AND PROGRAMS In the Third Development Plan (1965-1970), family planning was a major component of planned development activities, and the Nepal Family Planning and Maternal and Child Health (FP/MCH) Project was subsequently launched under the Ministry of Health (National Planning Council, 1965). Before that, family planning activities were undertaken by the Family Planning Association of Nepal (FPAN), a nongovernmental organization established in 1959 to create awareness about the need for and importance of family planning. While 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 (National Planning Commission, 1970), the Fifth Development Plan (1975-1980) initiated the expansion of family planning services through outreach workers, and serious attempts were made to reduce the birth rate by direct and indirect means. A population policy coordinating board was established in 1975 under the National Planning Commission (NPC) to coordinate the government’s multisectorial activities in population and reproductive health. The board was upgraded in 1978 to become the National Commission on Population (National Planning Commission, 1975). From the Fifth Development Plan (1975-1980) until the end of the Seventh Development Plan (1985- 1990), population issues were addressed from both policy and programmatic points of view. 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 (National Planning Commission, 1985). In 1990, the National Commission on Population was dissolved, and its role was given to the Population Division of the NPC. The Eighth Development Plan (1992-1997) continued with the integrated development approach taken in earlier plans (National Planning Commission, 1992). The Ninth Development Plan (1997-2002) aimed to reduce population growth through social awareness and expansion of education and family planning programs. The long-term objective of the plan was to lower fertility to replacement level in the subsequent 20 years (National Planning Commission, 1997). The primary objectives of population management in the Tenth Development Plan (2002-2007) were to encourage a small family norm, promote the development of an educated and healthy population, and discourage the out-migration of skilled labor (National Planning Commission, 2002). Similarly, the Second Long Term Health Plan (1997- 2017) was formulated to improve the health status of the population; particularly vulnerable groups whose health needs often are not met, including women and children, the poor, and underprivileged and marginalized groups. The plan would address disparities in health status, assuring equitable access to quality health care services with full community participation and gender sensitivity. In 2001, the Nepal Family Health Program (NFHP), funded by the United States Agency for International Development (USAID), was implemented in partnership with the government of Nepal under the leadership of the Ministry of Health and Population (MOHP). The program ran from 2001 to 2006 and focused on reducing fertility and protecting family health through increased use of quality family planning services and selected maternal and child health services. NFHP emphasized household- and community-level services by strengthening health service delivery systems. To maximize the long-term impact, technical assistance and activities were planned and implemented in close collaboration with the MOHP. Similarly, NFHP II (2007- 2012) aims to increase access to health services for all Nepalese, particularly the rural poor, by improving public sector services, community-based family planning services, and maternal, newborn, and child health services in a manner that builds local capacity and engages stakeholders (Johns Hopkins University Center for Communication Programs, 2011; USAID/Nepal, 2010). The Nepal Health Sector Program Implementation Plan (NHSP-IP 2004-2009) was launched by the Ministry of Health and Population to improve the health status of the Nepalese population through increased utilization of essential health services; another goal was to increase the coverage and raise the quality of essential health care services, with a special emphasis on improved access for poor and vulnerable groups through an efficient sector-wide health management system developed with the provision of adequate financial resources (Ministry of Health and Population, 2011a). A further major aim was to achieve the health sector Millennium Development Goals (MDGs) in Nepal through improved health outcomes for the poor and those Introduction • 5 living in remote areas and a consequent reduction in poverty. The program included a number of new actions as part of the Agenda for Reform of the Health Sector. Similarly, NHSP-IP II (2010-2015) represents a continuation and further refinement of earlier policies and plans that were based on the implementation of cost-effective, evidence-based health interventions. A major goal is to sustain and build on a program delivering excellent results. NHSP-IP I did not have a strong focus on gender and social exclusion issues in the initial design. These issues came into greater prominence during the implementation of NHSP-IP II, particularly with the extension of free services. NHSP-IP II is designed to focus from the start on improving the health of poor and marginalized groups. NHSP-IP II also aims to reconsider how best to achieve improved efficiency and accountability in order to sustain government and external development partner (EDP) support and make the best use of limited resources. Furthermore, the plan has set out to meet specific targets with respect to improving key maternal and child health indicators such as maternal mortality ratio (MMR); total fertility rate (TFR); neonatal, infant, and under-five mortality rates; contraceptive prevalence rate; and percentage of underweight children (Ministry of Health and Population, 2010a). The three-year interim development plan (2007/2008-2010/2011), drafted after the historic people’s movement in 2006, accepted the global principle of health as a fundamental right. Among others, the plan set out to meet specific objectives such as increasing the percentage of family planning users, increasing the percentage of women receiving maternity services from health workers, and reducing the TFR, MMR, and infant and child mortality rates. The subsequent three-year interim development plan (2010/2011-2012/2013) has aimed to evaluate achievements against the set targets and continue with the specific objectives set in the earlier plan. Recently, the Population Perspective Plan (PPP) 2010-2031 was formulated based on a multidisciplinary approach in order to integrate population aspects with relevant economic and social sectors. It also provides a thematic focus on three aspects: poverty reduction, gender mainstreaming, and social inclusion. Among other objectives, the plan aims to help prioritize specific sectoral program areas related to population that bear on poverty alleviation and sustainable development. The plan also attempts to address commitments that Nepal had made in endorsing plans of action related to population issues in various international forums, particularly the 1994 International Conference on Population Development and the 2000-2015 MDGs (Ministry of Health and Population, 2010b). Furthermore, the PPP aims to provide guidance in the formulation of population policies that can be implemented with consideration of population as a crucial development variable. The plan also provides a basis for effective institutional arrangements for the coordination, implementation, and monitoring of population programs. 1.4 OBJECTIVES OF THE SURVEY The principal objective of the 2011 Nepal Demographic and Health Survey (NDHS) is to provide current and reliable data on fertility and family planning, child mortality, children’s nutritional status, utilization of maternal and child health services, domestic violence, and knowledge of HIV/AIDS. The 2011 NDHS also provides population-based information on the prevalence of anemia among women age 15-49 and children age 6-59 months. The specific objectives of the survey are to: • collect data at the national level that will allow the calculation of key demographic rates • analyze the direct and indirect factors that determine fertility levels and trends of fertility • measure the level of contraceptive knowledge among women and men by method and use of contraception among women by urban-rural residence and region 6 • Introduction • 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 such as antenatal visits, assistance at delivery, and postnatal care • collect data on infant and child mortality • collect data on child feeding practices, including breastfeeding, and anthropometric measurements 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 of 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 of reproductive age and young children • collect information to assess the situation of domestic violence against women Data from the 2011 NDHS survey allow for comparison of information gathered over a period of time and add to the vast and growing international database on demographic and health-related variables. Information from the survey is essential for informed policy decisions and for planning, monitoring, and evaluation of health programs in general, and reproductive health programs in particular, at both the national and district levels. A long-term objective of the survey is to strengthen the technical capacity of local organizations to plan, conduct, process, and analyze data from complex national population and health surveys. Moreover, the 2011 NDHS is comparable to similar surveys conducted in other developing countries and therefore affords national and international comparisons. 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; subsequently, surveys have been conducted every five years, in 2001, 2006, and now in 2011. Wherever possible, the 2011 NDHS data are compared with data from the earlier DHS surveys in Nepal, which also sampled women age 15-49. Men age 15-49 were also interviewed in the 2011 NDHS to provide comparable data for male respondents over the last 10 years. 1.5 ORGANIZATION OF THE SURVEY The 2011 NDHS is the fourth nationally representative comprehensive survey conducted as part of the worldwide DHS project in the country. It was carried out under the aegis of the Ministry of Health and Population. The survey was implemented by New ERA, a private research firm in Nepal that also conducted the 1996 NFHS and the 2001 and 2006 NDHS. ICF International provided technical assistance through its MEASURE DHS project. The survey was funded by the United States Agency for International Development through its mission in Nepal. A technical advisory committee was formed under the Secretary of the Ministry of Health and Population to be responsible for coordination, oversight, advice, and decision-making on all major aspects of the survey. A technical working committee was also formed under the chairmanship of the chief of the MOHP, Population Division. Both committees included key members from different divisions of the ministry, the National Population Committee, external development partners, and other concerned stakeholders. The committee members provided their technical input throughout the various stages of drafting and finalizing the questionnaires, participated in training and field supervision, and provided feedback in finalizing the report. 1.6 SAMPLE DESIGN The primary focus of the 2011 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 Introduction • 7 addition, the sample was designed to provide estimates of most key variables for the 13 eco-development regions. 1.6.1 Sampling Frame Nepal is divided into 75 districts, which are further divided into smaller VDCs and municipalities. The VDCs and municipalities, in turn, are further divided into wards. The larger wards in the urban areas are divided into subwards. An enumeration area (EA) is defined as a ward in rural areas and a subward in urban areas. Each EA is classified as urban or rural. As the upcoming population census was scheduled for June 2011, the 2011 NDHS used the list of EAs with population and household information developed by the Central Bureau of Statistics for the 2001 Population Census. The long gap between the 2001 census and the fielding of the 2011 NDHS necessitated an updating of the 2001 sampling frame to take into account not only population growth but also mass internal and external migration due to the 10-year political conflict in the country. To obtain an updated list, a partial updating of the 2001 census frame was carried out by conducting a quick count of dwelling units in EAs five times more than the sample required for each of the 13 domains. The results of the quick count survey served as the actual frame for the 2011 NDHS sample design. 1.6.2 Domains The country is broadly divided into three horizontal ecological zones, namely mountain, hill, and terai. Vertically, the country is divided into five development regions. The cross section of these zones and regions results in 15 eco-development regions, which are referred to in the 2011 NDHS as subregions or domains. Due to the small population size in the mountain regions, the Western, Mid-western, and Far-western mountain regions are combined into one domain, yielding a total of 13 domains. In order to provide an adequate sample to calculate most of the key indicators at an acceptable level of precision, each domain had a minimum of about 600 households. Stratification was achieved by separating each of the 13 domains into urban and rural areas. The 2011 NDHS used the same urban-rural stratification as in the 2001 census frame. In total, 25 sampling strata were created. There are no urban areas in the Western, Mid-western, and Far-western mountain regions. The numbers of wards and subwards in each of the 13 domains are not allocated proportional to their population due to the need to provide estimates with acceptable levels of statistical precision for each domain and for urban and rural domains of the country as a whole. The vast majority of the population in Nepal resides in the rural areas. In order to provide national urban estimates, urban areas of the country were oversampled. 1.6.3 Sample Selection Samples were selected independently in each stratum through a two-stage selection process. In the first stage, EAs were selected using a probability-proportional-to-size strategy. In order to achieve the target sample size in each domain, the ratio of urban EAs to rural EAs in each domain was roughly 1 to 2, resulting in 95 urban and 194 rural EAs (a total of 289 EAs). Complete household listing and mapping was carried out in all selected EAs (clusters). In the second stage, 35 households in each urban EA and 40 households in each rural EA were randomly selected. Due to the nonproportional allocation of the sample to the different domains and to oversampling of urban areas in each domain, sampling weights are required for any analysis using the 2011 NDHS data to ensure the actual representativeness of the sample at the national level as well as at the domain levels. Since the 2011 NDHS sample is a two-stage stratified cluster sample, sampling weights were calculated based on sampling probabilities separately for each sampling stage, taking into account nonproportionality in the allocation process for domains and urban-rural strata. 8 • Introduction 1.7 QUESTIONNAIRES Three questionnaires were administered in the 2011 NDHS: the Household Questionnaire, the Woman’s Questionnaire, and the Man’s Questionnaire (Appendix E). These questionnaires were adapted from the standard DHS6 core questionnaires to reflect the population and health issues relevant to Nepal at a series of meetings with various stakeholders from government ministries and agencies, nongovernmental organizations, EDPs, and international donors. The final draft of each questionnaire was discussed at a questionnaire design workshop organized by the MOHP, Population Division on 22 April 2010 in Kathmandu. These questionnaires were then translated from English into the three main local languages—Nepali, Maithali, and Bhojpuri—and back translated into English. Questionnaires were finalized after the pretest, which was held from 30 September to 4 November 2010, with a one-week break in October for the Dasain holiday. The Household Questionnaire was used to list all of the usual members and visitors in the selected households. 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 was used to identify women and men who were eligible for the individual interview and women who were eligible for the interview focusing on domestic violence. The Household Questionnaire also collected information on characteristics of the household’s dwelling unit, such as source of water, type of toilet facilities, materials used for the floor of the house, ownership of various durable goods, ownership of mosquito nets, and household food security. The results of salt testing for iodine content, height and weight measurements, and anemia testing were also recorded in the Household Questionnaire. The Woman’s Questionnaire was used to collect information from women age 15-49. Women were asked questions on the following topics: • background characteristics (education, residential history, media exposure, etc.) • pregnancy history and childhood mortality • knowledge and use of family planning methods • fertility preferences • antenatal, delivery, and postnatal care • breastfeeding and infant feeding practices • vaccinations and childhood illnesses • marriage and sexual activity • work characteristics and husband’s background characteristics • awareness and behavior regarding AIDS and other sexually transmitted infections • domestic violence The Man’s Questionnaire was administered to all men age 15-49 living in every second household in the 2011 NDHS. The Man’s Questionnaire collected much of the same information as the Woman’s Questionnaire but was shorter because it did not contain a detailed reproductive history or questions on maternal and child health, nutrition, or domestic violence. 1.8 HEMOGLOBIN TESTING In the 2011 NDHS, anemia testing was conducted in every second household (i.e., in households where male interviews were conducted). In such households, all women age 15-49 and children age 6-59 months were tested for anemia. The protocol for hemoglobin testing was approved by the Nepal Health Research Council and the ICF Macro Institutional Review Board in Calverton, Maryland, USA. Selected interviewers were trained to conduct this procedure. Respondents (and their parent or guardian in the case of unmarried minors) were asked for their consent to participate in the anemia testing. The interviewers 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 Introduction • 9 carried out. Levels of anemia were classified as severe, moderate, or mild according to criteria developed by the World Health Organization (DeMaeyer et al., 1989). To measure the level of hemoglobin, capillary blood was taken in the field from a finger using sterile, one-time-use lancets that allowed for a relatively painless puncture. The concentration of hemoglobin in the blood was measured using the HemoCue system. 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 the finger was punctured with a sterile, non-reusable, 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 age 6 to 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. Women or children whose results indicated severe anemia were provided with a card referring them to the nearest health facility. 1.9 LISTING, PRETEST, TRAINING, AND FIELDWORK 1.9.1 Listing From the sampling frame, a total of 289 clusters were selected throughout the 13 subregions. A listing operation was conducted from 27 September to 14 December 2010 by 26 teams of two members each, with one member working as a lister and the other as a mapper. Altogether, 52 listers and mappers were recruited from all regions to do the listing of the households. Training was provided using standard DHS manuals and guidelines modified for Nepal that described the listing procedures in detail. Training included classroom demonstrations and field practice, and instructions were given on the use of Global Positioning System (GPS) units to obtain location coordinates for selected clusters. 1.9.2 Pretest Prior to the start of the fieldwork, the questionnaires were pretested in Nepali, Bhojpuri, and Maithali to make sure that the questions were clear and could be understood by the respondents. One of the important components of the pretest was to test the entry program on tablet personal computers (PCs), as 2011 marked the first time the NDHS used tablet PCs to collect data from the field. The data file transfer process using the Internet File Streaming System (IFSS), through which data from the field could be transferred to the main office via the Internet, was also tested. In order to conduct the pretest, 12 interviewers were recruited to interview in the three local languages. Training for the pretest was held at the New ERA office. The pilot survey was conducted (as mentioned) from 30 September to 4 November 2010 in three selected sites. The areas selected for the pretest were Kathmandu (for the Nepali language), the Parsa district (for the Bhojpuri language), and the 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 Questionnaire, Woman’s Questionnaire, and Man’s Questionnaire were further refined in all three languages. Similarly, necessary revisions in the computer program files were made based on the suggestions and feedback obtained in the pretest. 1.9.3 Training of Field Staff A stringent recruitment process was carried out in which candidates had to complete a written examination, a computer aptitude test, and an oral interview to qualify for training. A total of 96 persons were trained to serve as fieldwork supervisors, interviewers, quality control staff, and reserves. The main training took place in Kathmandu from 15 December 2010 to 16 January 2011. Training consisted of two components: training on paper questionnaires and training on the use of tablet PCs. The New ERA research team led the three-week training on paper-based questionnaires and biomarkers, while MEASURE DHS staff led the two-week training on tablet PC use. 10 • Introduction The training included theoretical and practical sessions and presentations, practical demonstrations, practice interviewing in small groups, and several days of field practice. The participants were also trained in measuring women and children’s height and weight and in conducting anemia testing. Special classes on several topics were organized during the training sessions, including Nepal’s health delivery system, family planning, maternal health, abortion, child health, nutrition, women’s empowerment, and domestic violence. These classes were led by experts from the different divisions of the Ministry of Health and Population. During the training sessions, several rounds of mock interviews were also conducted so that the interviewers had ample opportunities to understand the questionnaire and become accustomed with the new technology of conducting interviews with tablet PCs before they started the real fieldwork. 1.9.4 Fieldwork Data collection was carried out by 16 field teams, each consisting of three female interviewers, one male interviewer, and a male supervisor. Teams were initially deployed around Kathmandu on 23 January 2011 to enable intense supervision and technical backstopping. Each team completed one cluster and electronically sent the data to the central office via the Internet. A review session was organized to share the experiences of the teams. The core team provided necessary feedback to the field teams. Field teams traveled to their respective designated clusters on 2 February 2011, and the fieldwork was completed on 14 June 2011. Fieldwork supervision was done by six quality control teams, each consisting of one male and one female member. Additionally, two field coordinators monitored overall data quality. Close contact between the New ERA central office and the teams was maintained through field visits by New ERA senior staff, members of the technical advisory and working committees, staff of the Ministry of Health and Population, and staff of USAID/Nepal. Regular communication was maintained through cell phones. Two review sessions were held to share field issues and refill supplies. The first was held after one month of fieldwork, on 3-5 March 2011, and the second was held on 21 April 2011. These sessions were helpful in updating progress, providing feedback to the teams based on field check tables and field observations, and discussing data inconsistencies and problems faced by the teams. 1.10 DATA PROCESSING The 2011 NDHS used ASUS Eee T101MT tablet PCs with data entry programs developed in CSPro. Code division multiple access (CDMA) wireless technology via Internet File Streaming System (IFSS) was used to transfer data from the field to the central office in Kathmandu. The IFSS package was developed by MEASURE DHS and tested for the first time in Nepal. The data were sent to the central office at New ERA by the teams once they had checked and closed each EA file. This was mostly done before the team left the EA. In the central office, the data were edited by a senior data supervisor who had been specially trained for this task. The concurrent processing of the data was an advantage because field check tables to monitor various data quality parameters could be generated almost instantly and sent to the teams through the field coordinators, the quality control teams, and the core study team members. This allowed the field teams to receive immediate feedback and improve their performance. The data entry and editing phase of the survey was complete by the end of June 2011. 1.11 RESPONSE RATES Table 1.2 shows household and individual response rates for the 2011 NDHS. A total of 11,353 households were selected, out of which 10,888 were found to be occupied during data collection. Interviews were completed for 10,826 of these existing households, yielding a response rate of 99 percent. In the selected households, 12,918 women were identified as eligible for the individual interview. Interviews were completed for 12,674 women, resulting in a response rate of 98 percent. Of the 4,323 eligible men identified in the selected subsample of households, 4,121 were successfully interviewed, yielding a 95 percent response rate. Response rates were higher in rural than urban areas, especially for eligible men. Introduction • 11 Table 1.2 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Nepal 2011 Result Residence Total Urban Rural Household interviews Households selected 3,331 8,022 11,353 Households occupied 3,182 7,706 10,888 Households interviewed 3,148 7,678 10,826 Household response rate1 98.9 99.6 99.4 Interviews with women age 15-49 Number of eligible women 3,822 9,096 12,918 Number of eligible women interviewed 3,701 8,973 12,674 Eligible women response rate2 96.8 98.6 98.1 Interviews with men age 15-49 Number of eligible men 1,451 2,872 4,323 Number of eligible men interviewed 1,351 2,770 4,121 Eligible men response rate2 93.1 96.4 95.3 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents Housing Characteristics and Household Population • 13 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION 2 This chapter provides an overview of demographic and socioeconomic characteristics of the household population, including information on housing facilities and characteristics, household assets, wealth status, education, and food security; these data serve as a basis for understanding the socioeconomic status of households. In addition, information is provided on migration, which plays a vital role in demographic dimensions, especially within the context of Nepal. Finally, the chapter presents information on birth registration, children’s living arrangements and orphanhood, and children’s educational attainment, helping provide an understanding of the general social environment in which children live. In the 2011 NDHS, a household is defined as a person or group of related and unrelated persons who usually live together in the same dwelling unit(s) or in connected premises, who acknowledge one adult member as the head of the household, and who have common cooking and eating arrangements. Information is collected from all usual residents of a selected household (de jure population) as well as persons who had stayed in the selected household the night before the interview (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 CHARACTERISTICS Access to basic utilities, sources of drinking water and water treatment practices, access to sanitation facilities, housing structure and crowdedness of dwelling spaces, 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. Millennium Development Goal 7 (MDG 7), which focuses on environmental sustainability, is measured according to the percentage of the population using solid fuels, the percentage with sustainable access to an improved water source, and the percentage with access to improved sanitation (National Planning Commission [NPC], 2010a). This section provides information from the 2011 NDHS on household drinking water, household sanitation facilities, hand-washing practices, housing characteristics, and possession of basic amenities and utilities. 2.1.1 Water and Sanitation The basic determinants of better health, such as access to safe water, and sanitation, are still in a critical state in Nepal. Poor access to safe drinking water and sanitation facilities and poor hygiene are associated with Key Findings: • The vast majority of households in Nepal (89 percent) have access to an improved source of drinking water. • Thirty-eight percent of households have an improved toilet facility that is not shared with other households. • Seventy-six percent of households have electricity. • Forty percent of households are exposed daily to secondhand smoke. • A large proportion of the Nepalese population (37 percent) is under age 15. • Twenty-eight percent of households are female-headed. • Fifty-seven percent of households have at least one person who has migrated at some time in the past 10 years. • Only one in two households in Nepal (49 percent) is food secure and has access to food year round. 14 • Housing Characteristics and Household Population skin diseases, acute respiratory infection (ARI), and diarrheal diseases, the leading preventable diseases. ARI and diarrheal diseases remain the leading causes of child deaths in Nepal. Among the top 10 causes of morbidity observed in outpatient visits in the country’s health institutions are gastritis, intestinal worm infestations, ARI/lower respiratory tract infections, headaches/migraines, upper respiratory tract infections, impetigo and noninfectious diarrhea, presumed noninfectious diarrhea, and amoebic dysentery (Ministry of Health and Population [MOHP], 2011a). Table 2.1 presents the percent distribution of households and the de jure population, according to urban or rural setting, by source of drinking water, time taken to obtain drinking water, regularity of water source, and water treatment practices adopted by households. Table 2.1 Household drinking water Percent distribution of households and de jure population by source of drinking water, time to obtain drinking water, and treatment of drinking water, according to residence, Nepal 2011 Characteristic Households Population Urban Rural Total Urban Rural Total Source of drinking water Improved source Piped into dwelling/yard/plot 42.6 19.0 22.4 41.0 17.5 20.6 Public tap/standpipe 12.6 26.5 24.5 12.1 25.4 23.6 Tube well or borehole 31.0 40.2 38.9 33.6 43.0 41.7 Protected well 3.3 1.7 1.9 3.7 1.5 1.8 Protected spring 0.1 0.2 0.2 0.1 0.2 0.2 Rain water 0.0 0.0 0.0 0.0 0.1 0.0 Bottled water 3.7 0.4 0.9 2.9 0.3 0.6 Non-improved source Unprotected well 2.2 2.1 2.1 2.5 2.1 2.2 Unprotected spring 0.2 1.1 1.0 0.2 1.1 1.0 Tanker truck/cart with drum 1.8 0.5 0.7 1.5 0.4 0.6 Surface water 2.2 8.1 7.3 2.1 8.5 7.7 Other source 0.2 0.0 0.0 0.2 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using any improved source of drinking water 93.4 88.1 88.9 93.5 87.8 88.6 Time to obtain drinking water (round trip) Water on premises 79.1 53.9 57.5 79.2 55.0 58.2 Less than 30 minutes 16.9 38.4 35.3 17.0 37.3 34.7 30 minutes or longer 3.8 7.6 7.1 3.8 7.6 7.1 Don’t know/missing 0.1 0.0 0.1 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Use of water source (regularity) All year 93.5 94.3 94.2 93.8 94.5 94.4 Part of the year 6.5 5.6 5.8 6.2 5.4 5.5 Total 100.0 100.0 100.0 100.0 99.9 100.0 Water treatment prior to drinking1 Boiled 20.9 6.5 8.6 20.5 5.5 7.5 Bleach/chlorine added 4.0 1.0 1.4 4.0 1.0 1.4 Strained through cloth 1.4 1.4 1.4 1.4 1.3 1.3 Ceramic, sand, or other filter 34.3 6.3 10.3 33.2 5.3 8.9 Solar disinfection 1.4 0.3 0.4 1.2 0.2 0.3 Other 0.3 0.2 0.2 0.4 0.2 0.2 No treatment 54.1 86.9 82.2 55.5 88.6 84.2 Percentage using an appropriate treatment method2 45.8 12.9 17.6 44.3 11.2 15.6 Number 1,546 9,280 10,826 6,338 41,785 48,123 1 Respondents may report multiple treatment methods, so the sum of treatment may exceed 100 percent. 2 Appropriate water treatment methods include boiling, bleaching, straining, filtering, and solar disinfecting. Most households in Nepal (89 percent) obtain drinking water from an improved source, while 11 percent still rely on non-improved sources. There has been some improvement in access to an improved water source since 2006, when 82 percent of the households used an improved source of drinking water (MOHP, New ERA, and Macro International, 2007). Households in urban areas have greater access to an improved source of drinking water than households in rural areas (93 percent versus 88 percent), but the urban-rural gap has narrowed in the last five years. The most common source of drinking water in urban areas is water piped into the Housing Characteristics and Household Population • 15 dwelling/yard/plot, with more than two-fifths of households having access to this source. In contrast, a tube well or borehole is the most common source of drinking water in rural areas, used by two-fifths of households. Fifty- eight percent of households have a source of drinking water within their premises, compared to 46 percent five years ago. Thirty-five percent of households spend less than 30 minutes on gathering water, while about 7 percent of households spend 30 minutes or longer. Accessing drinking water takes longer in rural areas than urban areas, with 8 percent of households taking 30 minutes or more to obtain water. There has been little change in the past five years in the time taken to access drinking water. The vast majority of households are able to access drinking water from their main source all year (94 percent), with little urban-rural difference. The majority of households (82 percent) do not treat drinking water, and rural households are particularly likely not to do so (87 percent, compared to 54 percent of urban households). Forty-six percent of households in urban areas treat drinking water, compared to 13 percent in rural areas. Overall, a ceramic, sand, or other filter is the most common treatment method (10 percent), followed by boiling water prior to drinking (9 percent). Table 2.2 presents information on household sanitation facilities by type of toilet/latrine. Nearly two in five households (38 percent) have an improved (not shared) toilet facility; 19 percent use a facility that would be considered improved if it were not shared with other households. Facilities that are shared are not considered to be as hygienic as those that are not shared. About two in five households use a non-improved toilet facility (43 percent). Thirty-six percent of households still use a bush or open field for defecation, but this is an improvement over 2006, when one in two households had no toilet facility (MOHP, New ERA, and Macro International, 2007). Rural households are more likely than urban households not to have a toilet facility (40 percent versus 9 percent). Table 2.2 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Nepal 2011 Type of toilet/latrine facility Households Population Urban Rural Total Urban Rural Total Improved, not shared facility 52.5 35.8 38.2 58.1 36.7 39.5 Flush/pour flush to piped sewer system 15.9 1.4 3.5 18.0 1.3 3.5 Flush/pour flush to septic tank 32.0 23.7 24.9 35.0 23.9 25.4 Flush/pour flush to pit latrine 2.1 3.3 3.1 2.3 3.4 3.3 Ventilated improved pit (VIP) latrine 0.4 0.6 0.6 0.4 0.6 0.6 Pit latrine with slab 2.1 6.6 6.0 2.4 7.3 6.7 Composting toilet 0.0 0.2 0.2 0.0 0.2 0.2 Shared facility1 36.7 15.9 18.9 29.5 12.6 14.9 Flush/pour flush to piped sewer system 11.4 1.7 3.1 8.4 1.2 2.2 Flush/pour flush to septic tank 22.6 10.0 11.8 18.7 7.7 9.2 Flush/pour flush to pit latrine 1.2 1.3 1.3 1.0 1.1 1.1 Ventilated improved pit (VIP) latrine 0.3 0.3 0.3 0.3 0.3 0.3 Pit latrine with slab 1.2 2.6 2.4 1.1 2.3 2.1 Non-improved facility 10.8 48.3 42.9 12.4 50.6 45.6 Flush/pour flush not to sewer/septic tank/pit latrine 0.4 0.3 0.3 0.4 0.2 0.3 Pit latrine without slab/open pit 1.6 8.0 7.1 1.7 7.7 6.9 No facility/bush/field 8.7 39.9 35.5 10.3 42.7 38.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,546 9,280 10,826 6,338 41,785 48,123 Note: Total includes three households using bucket under non-improved facility not shown separately. 1 Facilities that would be considered improved if they were not shared by two or more households Hand washing, which provides protection against communicable diseases, is promoted by the government of Nepal and included in the framework of the Nepal Health Sector Program II (MOHP, 2010a). Table 2.3 provides information on designated places for hand washing in households and the use of water and cleansing agents for washing hands according to place of residence (urban, rural), ecological region, and wealth quintile. 16 • Housing Characteristics and Household Population Interviewers were instructed to observe the place where household members usually washed their hands. They looked for regularity of water supply and observed whether households had cleansing agents near the place of hand washing. Such observations were made in almost all selected households. About half of households (48 percent) had soap and water at the place where household members washed their hands, 16 percent had water and other cleansing agents (ash, mud, sand, etc.), 17 percent had water only, and 2 percent had soap but no water. Overall, 14 percent of households did not have water or any cleansing agent. In general, these households did not have a fixed designated place for hand washing. Table 2.3 Hand washing Percentage of households in which the place most often used for washing hands was observed, and among households in which the place for hand washing was observed, percent distribution by availability of water, soap, and other cleansing agents, Nepal 2011 Background characteristic Percentage of households where place for washing hands was observed Number of households Among households where place for hand washing was observed, households that had: Number of households with place for hand washing observed Soap and water1 Water and cleansing agent2 other than soap only Water only Soap but no water3 Cleansing agent other than soap only2 No water, no soap, no other cleansing agent Total Residence Urban 99.4 1,546 75.6 6.3 10.8 1.6 0.8 4.8 100.0 1,536 Rural 99.8 9,280 43.2 17.4 18.1 1.6 4.3 15.4 100.0 9,258 Ecological zone Mountain 99.9 761 27.1 19.3 15.2 2.0 6.7 29.6 100.0 760 Hill 99.6 4,563 44.9 15.1 14.9 2.4 5.9 16.8 100.0 4,545 Terai 99.8 5,502 53.1 15.9 19.1 0.9 1.7 9.3 100.0 5,489 Wealth quintile Lowest 99.9 2,029 10.0 21.5 20.1 1.9 10.2 36.3 100.0 2,027 Second 99.8 2,168 23.4 25.8 25.2 1.6 5.8 18.2 100.0 2,163 Middle 99.7 2,068 41.2 22.6 21.6 2.0 2.7 9.9 100.0 2,062 Fourth 99.8 2,185 68.4 9.8 13.5 1.3 1.2 5.9 100.0 2,181 Highest 99.3 2,377 89.4 1.4 6.2 1.4 0.0 1.6 100.0 2,361 Total 99.7 10,826 47.8 15.8 17.0 1.6 3.8 13.9 100.0 10,793 1 Soap includes soap or detergent in bar, liquid, powder, or paste form. This column includes households with soap and water only as well as those that had soap and water and another cleansing agent. 2 Cleansing agents other than soap include locally available materials such as ash, mud, or sand. 3 Includes households with soap only, as well as those with soap and another cleansing agent Seventy-six percent of the households in urban areas had soap and water, compared to 43 percent of rural households. More than half of households (53 percent) in the terai had soap and water, compared to 45 percent of households in the hill zone and 27 percent of households in the mountain zone. Thirty percent of the households in the mountain region did not have water or any cleansing agents for hand washing. Soap and water was very common (89 percent) among households in the highest wealth quintile but much less so in the lowest wealth quintile (10 percent)1. Thirty-six percent of households in the lowest quintile had a designated place for hand washing but did not have water and cleansing agents. 2.1.2 Housing Characteristics Housing characteristics and household assets can be used as a measure of the socioeconomic status of household members. Cooking practices and cooking fuels also impact the health of family members and the environment. For example, use of biomass fuels exposes household members to indoor pollution, which has a direct bearing on their health and surroundings. Table 2.4 presents information on the availability of electricity, type of flooring material, number of rooms for sleeping, type of fuel used for cooking, and place where cooking is done. The table shows that 76 percent of households in Nepal have access to electricity. This is a marked improvement from the 2006 NDHS, which showed that only 51 percent of households had access to electricity. Access to electricity has increased sharply in rural areas in the last five years, with 73 percent of rural households having electricity in 2011 as compared to 43 percent in 2006. This increase can be partially attributed to the rural electrification programs implemented in recent years, including decentralized small hydropower plants, micro-hydropower plants, and 1 Refer to Section 2.2 for details on the wealth index. Housing Characteristics and Household Population • 17 solar energy and biomass sources (ITECO, 2011; Rai, 2010). Urban electricity availability has also been on the rise, with 97 percent of urban households having access to electricity in 2011, compared to 90 percent in 2006. Earth and sand are the most common flooring materials used in Nepalese households (66 percent), and these materials are predominantly used in rural areas (73 percent). The use of cement has increased in the past five years from 11 percent to 22 percent, with increases seen in both urban and rural areas. Urban households remain more likely to use cement (42 percent) than rural households (18 percent). Eight percent of households use carpet as flooring material. The number of rooms used for sleeping provides an indication of the extent of crowding in households. Overcrowding increases the risk of contracting infectious diseases such as acute respiratory infections and skin diseases, which particularly affect children and the elderly population. The proportion of households using one room for sleeping has decreased from 42 percent to 33 percent in the last five years. The presence and extent of indoor pollution are dependent on cooking practices, places used for cooking, and types of fuel used. According to the 2011 NDHS, 71 percent of households cook inside the house, while 20 percent cook in a separate building and 8 percent cook outdoors. The percentage of households that cook within the dwelling unit is higher in urban areas (79 percent) than in rural areas (70 percent). About one in five households in rural areas cooks in a separate building. Coal, lignite, charcoal, and wood are the fuels most commonly used for cooking, reported by 66 percent of households. Use of these fuels is more common in rural areas (73 percent) than in urban areas (28 percent). On the other hand, use of liquid petroleum gas, natural gas, and biogas is much more common in urban (68 percent) than rural (16 percent) areas. Use of gas for cooking has increased significantly in the past five years in both urban and rural households. Use of solid fuel for cooking has declined from 83 percent in 2006 to 75 percent in 2011, primarily due to a decline in rural areas. More than 8 in 10 rural households use solid fuel for cooking, compared with 3 in 10 households in urban areas. A major concern for the government of Nepal is the effect of secondhand smoke (SHS) on the health of children and neonates. The purpose of the Tobacco Related Products (Control and Regulation) Act of 2011 is to control tobacco and tobacco-related product use Table 2.4 Household characteristics Percent distribution of households by housing characteristics, percentage using solid fuel for cooking, and percent distribution by frequency of smoking in the home, according to residence, Nepal 2011 Housing characteristic Residence Total Urban Rural Electricity Yes 97.0 72.9 76.3 No 3.0 27.1 23.7 Total 100.0 100.0 100.0 Flooring material Earth, sand 20.0 73.3 65.7 Dung 0.3 0.5 0.4 Wood/planks 0.6 1.9 1.7 Parquet or polished wood 1.2 0.3 0.4 Vinyl or asphalt strips 5.3 1.1 1.7 Ceramic tiles 0.9 0.2 0.3 Cement 42.0 18.3 21.7 Carpet 29.5 4.4 8.0 Other 0.2 0.1 0.1 Total 100.0 100.0 100.0 Rooms used for sleeping One 36.3 32.8 33.3 Two 32.6 36.2 35.7 Three or more 31.0 30.9 30.9 Missing 0.1 0.2 0.2 Total 100.0 100.0 100.0 Place for cooking In the house 79.0 70.1 71.4 In a separate building 14.5 20.6 19.7 Outdoors 5.7 8.5 8.1 Other 0.1 0.0 0.0 No food cooked in household 0.8 0.7 0.7 Total 100.0 100.0 100.0 Cooking fuel Electricity 0.2 0.1 0.1 LPG, natural gas, biogas 67.6 16.2 23.5 Kerosene 2.0 0.3 0.5 Coal, lignite, charcoal, wood 28.1 72.6 66.2 Agricultural crop, straw, shrubs, grass 0.3 4.7 4.1 Animal dung 1.0 5.4 4.8 No food cooked in household 0.8 0.7 0.7 Total 100.0 100.0 100.0 Percentage using solid fuel for cooking1 29.3 82.7 75.1 Frequency of smoking in the home Daily 26.2 41.9 39.6 Weekly 4.1 5.3 5.1 Monthly 3.0 3.8 3.7 Less than monthly 6.4 7.5 7.4 Never 60.3 41.5 44.2 Total 100.0 100.0 100.0 Number 1,546 9,280 10,826 1 Includes coal/lignite, charcoal, wood/straw/shrubs/grass, agricultural crops, and animal dung LPG = Liquefied petroleum gas 18 • Housing Characteristics and Household Population and distribution (Nepal Law Commission, 2011). Information on smoking was collected in the 2011 NDHS to assess the percentage of households exposed to SHS, which is a risk factor for children and adults who do not smoke. Pregnant women who are exposed to SHS have a higher risk of giving birth to a low birth weight baby (Windham et al., 1999). Also, children who are exposed to SHS are at a higher risk of respiratory and ear infections and poor lung development (U.S. Department of Health and Human Services, 2006). Table 2.4 provides information on household exposure to SHS according to frequency of smoking, used here as a proxy for level of SHS exposure. Forty percent of households are exposed daily to SHS, and rural households (42 percent) are more likely to be exposed than urban households (26 percent). 2.1.3 Household Possessions Possession of durable consumer goods is another useful indicator of household socioeconomic status. The possession and use of household durable goods have multiple effects and implications. For instance, having access to a radio or television exposes household members to updated daily events, information, and educational materials. Similarly, a refrigerator prolongs food storage and keeps food fresh and hygienic. A means of transportation allows greater access to services away from the local area and enhances social and economic activities. The 2011 NDHS collected information on possession of durable commodities, means of transportation, and ownership of agricultural land and farm animals. Table 2.5 shows that radios, televisions, and mobile telephones are very common information and communication devices possessed by most households. Possession of mobile phones has sharply increased from 6 percent in 2006 to 75 percent in 2011. More than 9 in 10 households in urban areas and 7 in 10 households in rural areas possess mobile phones. Half of households have a radio, and a similar proportion have a television. Urban households are slightly more likely to possess a radio (54 percent) than rural households (50 percent). Seventy-six percent of urban households and 42 percent of rural households possess a television. Possession of a radio has decreased from 61 percent to 50 percent in the last five years, while ownership of a television has increased from 28 percent to 47 percent. A refrigerator is available in 11 percent of households, with urban households more than three times as likely (29 percent) as rural households (8 percent) to own one. Ninety-one percent of households in the country possess a bed. Households possessing computers have increased from 2 percent in 2006 to 8 percent in 2011, with a marked increase in urban areas (from 8 percent to 24 percent). Table 2.5 Household possessions Percentage of households possessing various household effects, means of transportation, agricultural land, and livestock/farm animals by residence, Nepal 2011 Possession Residence Total Urban Rural Household effects Radio 53.6 49.8 50.3 Television 76.2 42.0 46.9 Mobile telephone 91.6 71.9 74.7 Non-mobile telephone 25.7 6.8 9.5 Refrigerator 29.3 7.5 10.6 Table 79.8 48.5 53.0 Chair 71.7 42.8 46.9 Bed 97.9 90.2 91.3 Sofa 33.4 10.4 13.7 Cupboard 66.5 38.5 42.5 Computer 23.8 4.9 7.6 Clock 69.0 39.5 43.7 Fan 65.9 33.0 37.7 Dhiki 15.7 38.8 35.5 Means of transport Bicycle/rickshaw 42.1 39.3 39.7 Animal-drawn cart 1.2 3.2 3.0 Motorcycle/scooter 27.8 8.0 10.9 Car/truck/tempo 6.0 1.7 2.3 Ownership of agricultural land 45.1 71.3 67.6 Ownership of farm animals1 29.7 78.4 71.4 Number 1,546 9,280 10,826 1 Buffalo, milk cows, bulls, horses, donkeys, mules, goats, sheep, chickens, ducks, pigs, or yaks Housing Characteristics and Household Population • 19 Bicycles and rickshaws continue to be the most common means of transportation in Nepal; two in five households own a bicycle or rickshaw, with little difference between rural and urban households. Ownership of a motorcycle is much more common in urban areas (28 percent) than in rural areas (8 percent). Nepal is predominantly agricultural, with a large proportion of the population engaged in this sector. NDHS data indicate that 68 percent of households own agricultural land, with rural households more likely to own land (71 percent) than urban households (45 percent). Seventy-one percent of households in the country possess farm animals. Almost 80 percent of rural households own farm animals, as compared with 30 percent of urban households. 2.2 SOCIOECONOMIC STATUS INDEX The wealth index used in this survey is a measure that has been used in many DHS and other country- level surveys to indicate inequalities in household characteristics, in the use of health and other services, and in health outcomes (Rutstein et al., 2000). It serves as an indicator of level of wealth that is consistent with expenditure and income measures (Rutstein, 1999). The index was constructed using household asset data via a principal components analysis. In its current form, which takes better account of urban-rural differences in scores and indicators of wealth, the wealth index is created in three steps. In the first step, a subset of indicators common to urban and rural areas is used to create wealth scores for households in both areas. Categorical variables to be used are transformed into separate dichotomous (0-1) indicators. These indicators and those that are continuous are then examined using a principal components analysis to produce a common factor score for each household. In the second step, separate factor scores are produced for households in urban and rural areas using area-specific indicators. The third step combines the separate area-specific factor scores to produce a nationally applicable combined wealth index by adjusting area-specific scores through a regression on the common factor scores. This three-step procedure permits greater adaptability of the wealth index in both urban and rural areas. The resulting combined wealth index has a mean of zero and a standard deviation of one. Once the index is computed, national-level wealth quintiles (from lowest to highest) are obtained by assigning the household score to each de jure household member, ranking each person in the population by his or her score, and then dividing the ranking into five equal categories, each comprising 20 percent of the population. Table 2.6 presents distributions across the five wealth quintiles by residence, ecological region, development region, and subregion. These distributions indicate the degree to which wealth is evenly (or unevenly) distributed according to geographic area. An overwhelming majority of urban residents (62 percent) are from the richest quintile, while a much lower proportion of rural residents (14 percent) fall in the same category. Rural households are almost equally distributed in the lowest, second, and middle wealth quintiles (around 22 percent each). Among the three ecological zones, the population in the terai (23 percent) is more likely to fall in the highest wealth quintile than the population living in the hill zone (20 percent). Less than 1 percent of the population in the mountain zone (0.5 percent) is in the highest wealth quintile. Within the hill zone, 49 percent of households in the Central hill subregion (which includes the Kathmandu Valley) are in the wealthiest quintile. On the other hand, the Western mountain subregion has the highest proportion of the population in the lowest wealth quintile (60 percent). Among the development regions, the Central, Western, and Eastern regions have large population segments in the highest wealth quintile. Relatively smaller proportions of households in the Mid-western (10 percent) and Far-western (8 percent) regions fall in the highest quintile. 20 • Housing Characteristics and Household Population Table 2.6 Wealth quintiles Percent distribution of the de jure population by wealth quintiles, and Gini coefficient, according to residence and region, Nepal 2011 Residence/region Wealth quintile Total Number of persons Gini coefficient Lowest Second Middle Fourth Highest Residence Urban 3.1 3.3 7.8 23.6 62.3 100.0 6,338 0.12 Rural 22.6 22.5 21.8 19.5 13.6 100.0 41,785 0.22 Ecological zone Mountain 41.4 30.7 19.8 7.7 0.5 100.0 3,358 0.18 Hill 31.9 21.1 14.6 12.5 19.9 100.0 19,501 0.28 Terai 8.0 17.8 24.2 27.4 22.7 100.0 25,264 0.21 Development region Eastern 16.2 18.9 20.3 23.8 20.9 100.0 11,481 0.21 Central 13.7 18.8 20.7 20.7 26.1 100.0 16,011 0.24 Western 14.8 21.4 20.9 22.0 21.0 100.0 9,895 0.22 Mid-western 41.5 20.1 16.3 12.1 10.0 100.0 5,911 0.24 Far-western 34.5 23.7 19.5 14.3 7.9 100.0 4,826 0.20 Subregion Eastern mountain 37.1 28.5 23.4 10.0 1.0 100.0 904 0.17 Central mountain 18.9 41.3 29.3 9.9 0.6 100.0 1,021 0.10 Western mountain 60.1 24.5 10.7 4.7 0.1 100.0 1,433 0.17 Eastern hill 34.4 27.9 19.5 14.0 4.2 100.0 3,703 0.18 Central hill 19.8 13.2 5.0 12.8 49.2 100.0 5,679 0.23 Western hill 23.3 26.2 22.9 14.9 12.7 100.0 5,757 0.24 Mid-western hill 55.8 17.4 10.7 9.2 6.9 100.0 2,648 0.25 Far-western hill 58.6 21.0 13.9 6.0 0.5 100.0 1,714 0.14 Eastern terai 3.6 12.7 20.3 30.9 32.4 100.0 6,874 0.18 Central terai 9.4 19.7 29.3 26.8 14.8 100.0 9,310 0.20 Western terai 2.8 14.8 18.1 31.9 32.4 100.0 4,138 0.20 Mid-western terai 21.1 20.7 23.8 18.3 16.1 100.0 2,519 0.22 Far-western terai 10.1 26.4 26.0 22.0 15.3 100.0 2,422 0.19 Total 20.0 20.0 20.0 20.0 20.0 100.0 48,123 0.24 Table 2.6 also includes information on the Gini coefficient, which indicates the level of concentration of wealth (0 being an equal distribution and 1 a totally unequal distribution). This ratio is expressed as a proportion between 0 and 1. Wealth inequality, as measured by the Gini coefficient, is higher in rural than urban areas. Inequality in wealth is highest in the hill region, the Central and Mid-western development regions, and the Mid-western hill subregion. 2.3 HOUSEHOLD POPULATION BY AGE AND SEX Table 2.7 shows the distribution of the de facto household population by age and sex according to urban and rural residence. The 2011 NDHS enumerated a total of 47,570 persons (25,667 females and 21,903 males). A large proportion of the Nepalese population (37 percent) is under age 15 (Figure 2.1), although this proportion has declined from 41 percent in 2006. Eleven percent of the population is under five years, a decrease since 2006 indicating a declining trend in fertility. Persons age 65 and over account for about 6 percent of the total population, an increase from 4 percent in 2006. There is a smaller proportion of children under five in urban than rural 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. The concentration of the population is high in the 10-14 age group, creating pressure for schooling and adolescent care. Housing Characteristics and Household Population • 21 Table 2.7 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 2011 Age Urban Rural Total Male Female Total Male Female Total Male Female Total <5 8.2 8.0 8.1 13.3 10.4 11.7 12.6 10.1 11.2 5-9 11.8 9.6 10.7 14.2 11.4 12.7 13.8 11.2 12.4 10-14 11.8 10.9 11.3 15.4 12.6 13.9 14.9 12.4 13.6 15-19 11.8 11.5 11.6 9.9 10.7 10.3 10.1 10.8 10.5 20-24 9.6 10.6 10.1 6.1 9.3 7.9 6.6 9.5 8.2 25-29 7.9 10.3 9.1 5.4 8.0 6.8 5.8 8.3 7.1 30-34 7.7 8.5 8.1 4.9 6.6 5.8 5.3 6.8 6.1 35-39 6.8 6.9 6.8 5.2 6.1 5.7 5.4 6.2 5.9 40-44 5.4 5.5 5.5 4.2 5.0 4.7 4.4 5.1 4.8 45-49 4.4 4.1 4.2 4.1 3.8 3.9 4.2 3.8 4.0 50-54 4.2 4.2 4.2 4.2 4.6 4.4 4.2 4.6 4.4 55-59 3.5 2.8 3.1 3.8 3.2 3.5 3.7 3.2 3.4 60-64 2.3 2.3 2.3 3.1 2.8 3.0 3.0 2.8 2.9 65-69 1.6 1.7 1.7 2.4 2.0 2.2 2.3 2.0 2.1 70-74 1.3 1.2 1.3 1.7 1.5 1.6 1.7 1.4 1.5 75-79 0.7 1.0 0.9 1.2 1.0 1.1 1.1 1.0 1.0 80+ 0.9 1.0 1.0 0.8 1.0 0.9 0.9 1.0 0.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 3,028 3,250 6,278 18,875 22,417 41,292 21,903 25,667 47,570 8 6 4 2 0 2 4 6 8 <5 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80 + Percentage Age Figure 2.1 Population Pyramid Male Female The overall sex ratio (the number of males per 100 females) is 85, less than the sex ratio in the 2006 NDHS (89) and the 2011 census (94). It is, however, consistent with the results of the 2010-2011 Nepal Living Standard Survey (NLSS), which indicated that the sex ratio is 86 (Central Bureau of Statistics, 2011c). The sex ratio is lowest in the 20-29 age group, indicating a low proportion of the male population in that group. The sex ratio also differs by residence. Urban areas have a higher sex ratio (93) than rural areas (84). The significantly low proportion of the male population in rural areas could be attributed to greater out-migration, especially movement among those in the working age group to urban areas. 22 • Housing Characteristics and Household Population 2.4 MIGRATION STATUS The 2011 NDHS collected information on migration among individuals who lived in the interviewed households in the past 10 years but have since moved away. Migrants are people who either move from their place of birth to another area or frequently change their residence. Migration may be seasonal, temporary, semipermanent, or permanent depending on the duration of and reasons for migration within a defined geographical area (KC, 2003). Migration brings significant demographic dynamics to a society and carries socioeconomic implications for both the origin and destination. Culture and customs, opportunities for education and employment, and geographic hardships are among the major causes of migration. The 2011 NDHS collected information on former household residents who migrated elsewhere in the 10 years prior to the survey. Information was collected by sex, age, date of migration, cause of migration, and destination. These data provide information on period migration and lifetime migration. Period migration simply indicates the mobility patterns of internal migrants five years before the survey in terms of where they were living then. Lifetime migration, on the other hand, indicates a permanent shift in place of residence since more than five years prior to the survey. Fifty-seven percent of households reported that at least one person had migrated away from the household at some time in the past 10 years. Among households that reported migration of former residents, on average about two persons were likely to have migrated. Table 2.8 provides a brief overview of the background characteristics of the migrant population. Two-thirds migrate at the age of 24 or younger. Twenty- two percent of men migrate at age 20-24, whereas women are most likely to migrate at an earlier age (15-19 years), primarily due to marriage. Overall, 74 percent of males migrate before age 30, while almost 84 percent of females migrate before age 25. Men migrate mostly for work (72 percent), while women primarily migrate due to marriage (54 percent). Another common reason for migrating is educational pursuits, with 17 percent of men and 14 percent of women citing this as a reason. Women also tend to migrate due to family reasons, such as accompanying their spouse or accompanying their children who move to urban areas for education. The vast majority of migrants are from rural areas and from the hill and terai regions. Nearly half of migrants come from the Central and Eastern terai and the Western hill region. Table 2.8 Migration status Percent distribution of men and women who migrated in the 10 years before the survey by selected background characteristics, Nepal 2011 Background characteristic Men Women Total Age at migration <15 16.3 20.2 18.0 15-19 19.5 35.5 26.2 20-24 22.4 28.1 24.8 25-29 15.4 8.4 12.4 30-34 10.4 3.4 7.4 35-39 7.8 1.7 5.2 40-44 4.2 0.8 2.8 45-49 1.9 0.6 1.4 50+ 2.1 1.2 1.8 Total 100.0 100.0 100.0 Reason for migration Work 72.3 9.1 45.6 Study 17.2 14.0 15.8 Marriage 0.3 54.4 23.2 Family reasons 9.4 21.9 14.7 Security 0.1 0.1 0.1 Other 0.7 0.5 0.6 Don’t know 0.1 0.1 0.1 Total 100.0 100.0 100.0 Residence Urban 9.2 10.2 9.6 Rural 90.8 89.8 90.4 Total 100.0 100.0 100.0 Ecological zone Mountain 7.4 7.1 7.3 Hill 42.8 44.9 43.7 Terai 49.8 48.0 49.0 Total 100.0 100.0 100.0 Development region Eastern 25.8 26.2 26.0 Central 29.8 31.0 30.3 Western 24.5 24.9 24.7 Mid-western 9.8 9.5 9.7 Far-western 10.0 8.5 9.4 Total 100.0 100.0 100.0 Subregion Eastern mountain 2.0 2.0 2.0 Central mountain 3.1 3.0 3.1 Western mountain 2.2 2.1 2.2 Eastern hill 8.9 9.5 9.2 Central hill 9.0 11.1 9.9 Western hill 16.4 17.1 16.7 Mid-western hill 5.2 4.4 4.9 Far-western hill 3.3 2.7 3.0 Eastern terai 14.9 14.6 14.8 Central terai 17.6 16.9 17.3 Western terai 8.1 7.8 8.0 Mid-western terai 3.7 3.9 3.7 Far-western terai 5.5 4.8 5.2 Total 100.0 100.0 100.0 Wealth quintile Lowest 18.1 17.0 17.6 Second 22.9 22.5 22.7 Middle 21.3 20.9 21.1 Fourth 20.3 20.4 20.4 Highest 17.3 19.2 18.1 Total 100.0 100.0 100.0 Number of men and women who migrated in the past 10 years 6,829 5,002 11,831 Housing Characteristics and Household Population • 23 Table 2.9.1 shows information for male migrants. An assessment of time since migration shows that the majority of male migrants (85 percent) moved out within the five years prior to the survey, indicating a high proportion of period migration. Fifteen percent of migrants migrated more than five years before the survey. Migration within Nepal is high, with almost half of migrants moving within the country. The most popular out-of-country destination for Nepalese migrants is India, to which 20 percent of all male migrants relocate. One-third of male migrants move to countries other than India, with the most popular destinations being countries in the Middle East and Malaysia. Among men migrating for work, the majority migrated within the last five years, indicating a recent outflux of labor migration. Those migrating for work are most likely to go to countries other than India (44 percent). A quarter of such men migrate to India, while 32 percent move internally within Nepal. Table 2.9.1 Migration status: Men Percentage of male migrants by years since migration and percent distribution of male migrants by destination, according to background characteristics and reason for migration, Nepal 2011 Background characteristic Time since migration Destination Number of male migrants <1 year <5 years1 5+ years Within Nepal India Other countries Total Age at migration <15 30.8 80.1 19.9 81.0 18.0 1.0 100.0 1,115 15-19 31.4 81.9 18.1 60.8 22.6 16.5 100.0 1,330 20-24 36.5 84.6 15.4 37.2 17.6 45.1 100.0 1,527 25-29 40.3 87.3 12.7 32.1 18.4 49.0 100.0 1,049 30-34 38.6 89.4 10.6 24.5 17.6 57.8 100.0 708 35-39 47.9 90.9 9.1 25.9 20.9 53.2 100.0 532 40-44 39.0 86.2 13.8 36.6 18.8 44.4 100.0 289 45-49 50.3 93.9 6.1 37.4 31.2 31.4 100.0 132 50+ 55.8 88.9 11.1 51.9 38.9 8.7 100.0 146 Reason for migration Work 40.1 86.8 13.2 31.8 24.0 44.2 100.0 4,936 Study 27.8 82.8 17.2 86.2 4.7 9.0 100.0 1,172 Family reasons 32.1 78.5 21.5 80.8 16.9 2.2 100.0 642 Other 23.1 67.9 32.1 79.5 7.7 8.9 100.0 78 Residence Urban 35.6 84.6 15.4 45.0 15.1 39.7 100.0 627 Rural 37.2 85.1 14.9 46.4 20.3 33.2 100.0 6,202 Ecological zone Mountain 37.9 82.5 17.5 65.9 13.3 20.4 100.0 504 Hill 32.6 81.6 18.4 50.4 17.3 32.2 100.0 2,926 Terai 40.7 88.5 11.5 39.8 22.9 37.2 100.0 3,399 Development region Eastern 35.5 87.6 12.4 42.3 11.4 46.1 100.0 1,764 Central 38.1 87.1 12.9 52.7 12.5 34.6 100.0 2,033 Western 31.4 80.8 19.2 43.1 18.3 38.6 100.0 1,676 Mid-western 41.7 81.8 18.2 52.0 31.4 16.5 100.0 670 Far-western 46.8 86.7 13.3 39.4 55.4 5.2 100.0 686 Subregion Eastern mountain 31.5 84.2 15.8 53.6 3.1 42.1 100.0 139 Central mountain 36.2 77.2 22.8 72.8 7.3 19.9 100.0 214 Western mountain 46.1 88.5 11.5 67.5 31.2 1.4 100.0 151 Eastern hill 32.7 87.2 12.8 49.2 7.3 43.6 100.0 607 Central hill 35.3 83.3 16.7 59.9 5.5 34.3 100.0 617 Western hill 26.6 77.5 22.5 49.7 14.5 35.8 100.0 1,122 Mid-western hill 40.0 81.0 19.0 47.8 36.3 15.7 100.0 354 Far-western hill 43.4 83.3 16.7 35.7 60.4 3.9 100.0 226 Eastern terai 37.8 88.2 11.8 36.7 15.1 48.2 100.0 1,018 Central terai 39.9 90.7 9.3 45.4 17.0 37.3 100.0 1,202 Western terai 41.1 87.5 12.5 29.8 25.9 44.3 100.0 553 Mid-western terai 46.8 82.5 17.5 53.6 24.8 21.6 100.0 251 Far-western terai 46.6 87.4 12.6 35.5 57.7 6.8 100.0 375 Wealth quintile Lowest 38.8 85.6 14.4 44.3 32.9 22.6 100.0 1,237 Second 40.5 86.5 13.5 49.9 24.0 25.8 100.0 1,565 Middle 38.8 83.3 16.7 45.4 18.2 36.4 100.0 1,453 Fourth 35.2 85.3 14.7 45.7 14.2 40.1 100.0 1,390 Highest 30.6 84.6 15.4 45.2 9.1 45.6 100.0 1,185 Total 37.0 85.1 14.9 46.3 19.8 33.8 100.0 6,829 Note: Total includes six men with missing information on destination not shown separately. 1 Includes those who migrated since less than a year prior to the survey 24 • Housing Characteristics and Household Population A higher proportion of urban than rural migrants go to other countries (40 percent versus 33 percent). Migrants from the terai are most likely to migrate to India and other countries, while those from the mountain (66 percent) and hill (50 percent) zones are more likely to migrate within the country. The majority of male migrants from the Far-western region move to India (55 percent), and very few go to other countries. On the other hand, the largest proportion of male migrants from the Eastern region go to countries other than India (46 percent). Men from the highest wealth quintile are more likely to migrate to other countries (46 percent) than those from the lowest wealth quintile (23 percent). Table 2.9.2 shows the migration status of women. One in four women had migrated within one year, 72 percent within five 5 years, and 28 percent five or more years prior to the survey. Eighty-six percent of women who migrated moved within Nepal. Eight percent migrated to India and very few to other countries. About one- third of women who migrated for work moved to countries other than India. Women were less likely to migrate to other countries for non-work-related reasons. Women in the Far-western terai were more likely to migrate to India, primarily due to cross-border marriage practices. India was the second common destination for women migrants from the lowest wealth quintile, while those in the highest wealth quintile were more likely to migrate to other countries. Table 2.9.2 Migration status: Women Percentage of female migrants by years since migration and percent distribution of female migrants by destination, according to background characteristics and reason for migration, Nepal 2011 Background characteristic Time since migration Destination Total Number of female migrants <1 year <5 years1 5+ years Within Nepal India Other countries Age at migration <15 24.5 71.9 28.1 87.9 10.8 1.1 100.0 1,011 15-19 18.8 66.4 33.6 91.3 6.9 1.8 100.0 1,775 20-24 24.0 73.1 26.9 88.4 6.2 5.5 100.0 1,405 25-29 28.2 76.5 23.5 72.0 11.8 16.2 100.0 418 30-34 36.0 83.6 16.4 70.5 10.8 17.6 100.0 170 35-39 41.1 89.3 10.7 60.8 14.3 24.9 100.0 87 40-44 (30.4) (72.4) (27.6) (56.8) (20.5) (22.8) 100.0 41 45-49 (49.5) (77.4) (22.6) (63.8) (17.9) (18.3) 100.0 31 50+ 40.7 86.6 13.4 84.4 5.3 10.4 100.0 62 Reason for migration Work 35.1 89.8 10.2 56.8 7.7 35.1 100.0 455 Study 35.7 86.3 13.7 88.8 3.6 7.5 100.0 699 Marriage 14.2 61.6 38.4 93.6 6.0 0.4 100.0 2,719 Family reasons 34.2 79.2 20.8 79.3 17.7 3.0 100.0 1,095 Other (47.1) (82.4) (17.6) (85.3) (2.9) (11.8) 100.0 34 Residence Urban 25.9 76.3 23.7 77.2 11.0 11.9 100.0 508 Rural 23.5 71.1 28.9 87.5 8.0 4.4 100.0 4,494 Ecological zone Mountain 31.1 72.5 27.5 91.3 4.4 4.3 100.0 357 Hill 21.5 70.2 29.8 91.2 4.0 4.7 100.0 2,246 Terai 24.7 72.8 27.2 81.2 13.0 5.8 100.0 2,399 Development region Eastern 23.5 71.4 28.6 85.2 8.6 6.1 100.0 1,310 Central 27.4 74.1 25.9 87.2 6.0 6.8 100.0 1,549 Western 17.6 68.0 32.0 88.7 6.1 5.0 100.0 1,247 Mid-western 25.9 70.5 29.5 88.2 10.0 1.8 100.0 473 Far-western 27.1 74.7 25.3 78.7 20.4 1.0 100.0 423 Subregion Eastern mountain 27.2 70.0 30.0 98.4 0.0 1.6 100.0 102 Central mountain 32.5 73.1 26.9 86.9 3.7 9.4 100.0 148 Western mountain 33.0 74.2 25.8 90.4 9.6 0.0 100.0 107 Eastern hill 20.4 71.3 28.7 92.9 2.6 4.2 100.0 476 Central hill 28.6 74.9 25.1 89.0 2.3 8.7 100.0 557 Western hill 15.9 67.4 32.6 92.8 2.7 4.3 100.0 857 Mid-western hill 25.3 69.3 30.7 91.6 8.4 0.0 100.0 222 Far-western hill 25.5 65.8 34.2 83.0 16.8 0.2 100.0 133 Eastern terai 24.9 71.7 28.3 78.3 13.8 8.0 100.0 732 Central terai 25.6 73.8 26.2 86.0 9.0 5.0 100.0 844 Western terai 21.4 69.3 30.7 79.8 13.7 6.6 100.0 390 Mid-western terai 23.9 70.7 29.3 83.9 11.6 4.5 100.0 193 Far-western terai 27.1 79.9 20.1 73.6 24.8 1.6 100.0 241 Wealth quintile Lowest 22.9 70.9 29.1 87.6 10.3 2.1 100.0 851 Second 24.1 71.7 28.3 88.2 8.8 2.7 100.0 1,126 Middle 22.2 69.0 31.0 89.6 6.7 3.7 100.0 1,043 Fourth 26.0 73.7 26.3 87.3 6.5 6.2 100.0 1,022 Highest 23.4 72.6 27.4 78.7 9.8 11.5 100.0 960 Total 23.7 71.6 28.4 86.4 8.3 5.2 100.0 5,002 Note: Total includes five women with missing information on destination not shown separately. Figures in parentheses are based on 25-49 unweighted cases. 1 Includes those who migrated since less than a year prior to the survey. Housing Characteristics and Household Population • 25 2.5 HOUSEHOLD COMPOSITION Information on household composition is critical for understanding family size, household headship, and orphanhood and for implementing meaningful population-based policies and programs. Household composition is also a deter- minant of better health status and well-being. Table 2.10 presents information on household composition. The majority (72 percent) of households are headed by men, although the proportion of female-headed households has risen from 23 percent in 2006 to 28 percent in 2011, with the rise more marked in rural than urban areas. This could be attributed in part to the size- able out-migration of the male population from rural areas. The average household size is 4.4 persons, as compared with 4.9 in 2006; household sizes are larger in rural (4.5) than urban (4.1) areas. This decrease in overall household size is consistent with findings from the 2011 census (Central Bureau of Statistics, 2011a). The 2011 NDHS also collected informa- tion on the presence in households of foster children and orphans. Foster children are children under age 18 living in households with neither their mother nor their father present; orphans are children with one (single orphans) or both parents (double orphans) dead. Foster children and orphans are of concern because they may be at increased risk of neglect or exploitation with their mothers or fathers not present to assist them. There is little difference in the distribution of orphans by rural and urban areas. Eleven percent of households have foster children, and more urban than rural households have foster children (14 percent and 11 percent, respectively). Single orphans are present in 6 percent of households, whereas double orphans are present in less than 1 percent of households. 2.6 BIRTH REGISTRATION Although Nepal has a legal and administrative structure stipulating official registration of births according to standard procedures, few births are registered officially. The practice of formally registering births is not widely adhered to in the country, even though the registration system was implemented 30 years ago and enforced with the Birth, Death and Other Personal Events (Registration) Act of 1976 (Nepal Law Commission, 2006). Table 2.11 presents the percentage of the de jure population under five years whose births are registered with the civil authorities, according to background characteristics. Birth registration information was solicited for children age 0-4. More than two in five (42 percent) children have their births registered. Thirty-eight percent of children under age five have a birth certificate. Although the Three-Year Development Plan (2010- 2013) aims at registering the births of 90 percent of children under age five by 2013, this target is far from being met. The reason is a weak birth registration system coupled with the difficulties encountered in registering births with lack of staff in local registration offices (NPC, 2011). Table 2.10 Household composition Percent distribution of households by sex of head of household and by household size, mean size of household, and percentage of households with orphans and foster children under age 18 years, according to residence, Nepal 2011 Characteristic Residence Total Urban Rural Household headship Male 76.2 71.0 71.8 Female 23.8 29.0 28.2 Total 100.0 100.0 100.0 Number of usual members 0 0.1 0.0 0.0 1 7.0 4.5 4.9 2 13.2 13.6 13.6 3 20.9 16.6 17.2 4 24.1 20.3 20.8 5 14.4 16.9 16.5 6 9.6 12.6 12.2 7 5.0 7.1 6.8 8 2.5 3.9 3.7 9+ 3.2 4.5 4.3 Total 100.0 100.0 100.0 Mean size of households 4.1 4.5 4.4 Percentage of households with orphans and foster children under age 18 Foster children1 13.7 10.8 11.2 Double orphans 0.4 0.4 0.4 Single orphans2 4.7 5.6 5.5 Foster and/or orphan children 16.4 14.3 14.6 Number of households 1,546 9,280 10,826 Note: Table is based on de jure household members (i.e., usual residents). 1 Foster children are those under age 18 living in households with neither their mother nor their father present. 2 Includes children with one dead parent and an unknown survival status of the other parent 26 • Housing Characteristics and Household Population Table 2.11 Birth registration of children under age five Percentage of de jure children under five years of age whose births are registered with the civil authorities, according to background characteristics, Nepal 2011 Background characteristic Children whose births are registered Number of children Percentage who had a birth certificate Percentage who did not have a birth certificate Percentage registered Age <2 26.2 2.4 28.6 2,023 2-4 45.0 5.8 50.8 3,247 Sex Male 38.8 5.2 44.0 2,716 Female 36.7 3.7 40.4 2,554 Residence Urban 38.1 6.1 44.2 498 Rural 37.7 4.3 42.1 4,772 Ecological zone Mountain 40.9 5.0 45.9 412 Hill 32.3 4.8 37.1 2,083 Terai 41.4 4.2 45.6 2,775 Development region Eastern 44.5 6.1 50.7 1,238 Central 34.3 3.7 38.0 1,663 Western 35.1 4.4 39.5 992 Mid-western 41.4 3.8 45.2 783 Far-western 33.1 4.3 37.3 593 Subregion Eastern mountain 29.3 3.9 33.2 97 Central mountain 33.4 6.2 39.6 98 Western mountain 49.4 5.0 54.4 217 Eastern hill 37.6 5.7 43.4 405 Central hill 31.7 5.0 36.7 471 Western hill 33.3 4.2 37.5 592 Mid-western hill 27.2 3.6 30.7 372 Far-western hill 29.9 5.9 35.8 243 Eastern terai 50.4 6.6 57.0 736 Central terai 35.5 3.0 38.5 1,095 Western terai 37.7 4.7 42.4 400 Mid-western terai 45.4 4.3 49.8 295 Far-western terai 42.4 1.5 43.9 249 Wealth quintile Lowest 31.2 4.5 35.6 1,360 Second 37.8 4.2 41.9 1,163 Middle 39.4 3.7 43.1 1,111 Fourth 38.3 5.2 43.5 883 Highest 46.7 5.4 52.1 753 Total 37.8 4.5 42.3 5,269 Although the vital registration system of the government requires that a newborn be registered within 35 days of birth with the respective municipality or village development committee, Table 2.11 indicates that children under 2 are much less likely to be registered than children age 2-4 (29 percent and 51 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. Table 2.11 shows that birth registration is higher among male (44 percent) than female (40 percent) children, higher in urban (44 percent) than rural (42 percent) areas, and higher in the mountain and terai (46 percent each) than in the hill zone (37 percent). The Eastern development region has a higher proportion of children with their births registered (51 percent) than the Far-western region (37 percent). Among the subregions, 57 percent of children from the Eastern terai and 54 percent from the Western mountain subregion are registered. Less than half of the children in the other subregions are registered. Children from the highest wealth quintile are more likely to have their births registered (52 percent) than children in the lowest quintile (36 percent). However, the lowest wealth quintile has seen an improvement since 2006, when only 22 percent of children from that quintile were registered. 2.7 CHILDREN’S LIVING ARRANGEMENTS, ORPHANHOOD, AND SCHOOL ATTENDANCE The 2011 NDHS collected information on living arrangements of children and orphanhood. Living arrangements should be monitored together with the proportion of foster and orphan children because of their Housing Characteristics and Household Population • 27 significant effects on the comprehensive development of children. Table 2.12 shows the percent distribution of children under age 18 by living arrangements and survivorship of parents. The proportion of children in Nepal who are orphans and/or foster children is high and is a reflection of the political turmoil in the country over the past decade and the prevailing poverty in various parts of the country. About 61 percent of children less than age 15 and 60 percent of children less than age 18 live with both of their parents. Similarly, 4 percent of children less than age 15 and 6 percent of those less than age 18 are living away from their parents, even if both are alive. In the case of 4 percent of children less than age 15 and 5 percent of children less than age 18, one or both parents are dead. Table 2.12 Children’s living arrangements and orphanhood Percent distribution of de jure children under age 18 by living arrangements and survival status of parents, the percentage of children not living with a biological parent, and the percentage of children with one or both parents dead, according to background characteristics, Nepal 2011 Background characteristic Living with both parents Living with mother but not with father Living with father but not with mother Not living with either parent Total Percentage not living with a biological parent Percentage with one or both parents dead1 Number of children Father alive Father dead Mother alive Mother dead Both alive Only father alive Only mother alive Both dead Missing informa- tion on father/ mother Age 0-4 62.6 34.3 0.7 0.3 0.2 1.6 0.1 0.1 0.0 0.1 100.0 1.8 1.2 5,269 <2 65.2 34.0 0.5 0.0 0.0 0.1 0.2 0.0 0.0 0.0 100.0 0.3 0.7 2,023 2-4 60.9 34.4 0.9 0.4 0.3 2.5 0.1 0.1 0.0 0.1 100.0 2.8 1.5 3,247 5-9 59.4 30.8 1.8 1.6 0.6 4.7 0.5 0.4 0.2 0.1 100.0 5.7 3.4 5,930 10-14 60.5 23.6 3.9 2.0 1.7 6.5 0.8 0.6 0.4 0.1 100.0 8.3 7.3 6,488 15-17 58.0 15.9 5.0 1.4 1.4 15.5 0.8 1.4 0.5 0.1 100.0 18.2 9.1 3,152 Sex Male 60.5 28.1 2.8 1.4 1.0 5.1 0.5 0.4 0.2 0.1 100.0 6.2 4.9 10,539 Female 60.1 26.3 2.6 1.4 0.9 7.2 0.6 0.6 0.3 0.1 100.0 8.6 5.0 10,300 Residence Urban 64.2 18.9 2.3 1.3 0.9 10.2 0.7 0.9 0.3 0.3 100.0 12.1 5.1 2,308 Rural 59.8 28.2 2.7 1.4 1.0 5.6 0.5 0.5 0.2 0.1 100.0 6.8 4.9 18,531 Ecological zone Mountain 65.7 22.1 2.9 1.3 1.0 5.4 0.6 0.5 0.4 0.0 100.0 6.9 5.5 1,565 Hill 59.7 27.9 2.9 1.1 1.0 6.1 0.5 0.5 0.3 0.1 100.0 7.3 5.1 8,337 Terai 60.0 27.3 2.4 1.6 0.9 6.2 0.6 0.6 0.2 0.1 100.0 7.6 4.7 10,938 Development region Eastern 58.9 26.4 2.5 1.7 1.2 7.9 0.5 0.7 0.2 0.0 100.0 9.3 5.1 4,900 Central 64.8 23.9 1.8 1.4 1.0 5.7 0.7 0.4 0.2 0.1 100.0 7.0 4.1 6,704 Western 54.2 34.6 2.9 1.4 0.5 5.2 0.4 0.5 0.3 0.1 100.0 6.4 4.6 4,121 Mid-western 63.7 23.5 3.8 1.1 1.2 5.5 0.5 0.6 0.2 0.0 100.0 6.7 6.2 2,822 Far-western 57.3 29.8 3.7 0.9 0.9 6.0 0.5 0.4 0.5 0.0 100.0 7.4 6.0 2,292 Subregion Eastern mountain 65.3 22.4 1.4 2.3 0.6 6.4 1.0 0.4 0.2 0.0 100.0 8.0 3.6 412 Central mountain 57.9 29.6 2.1 1.4 0.6 7.4 0.4 0.2 0.3 0.0 100.0 8.4 3.6 425 Western mountain 70.5 17.6 4.2 0.7 1.6 3.6 0.6 0.7 0.6 0.0 100.0 5.5 7.6 727 Eastern hill 62.4 23.3 3.1 1.6 1.1 7.2 0.6 0.5 0.1 0.1 100.0 8.5 5.4 1,625 Central hill 69.2 17.8 1.1 1.2 1.3 8.1 0.4 0.5 0.3 0.1 100.0 9.3 3.6 2,120 Western hill 52.0 37.0 3.5 0.8 0.5 4.9 0.4 0.4 0.3 0.1 100.0 6.1 5.2 2,391 Mid-western hill 57.0 31.0 3.0 1.1 1.1 5.5 0.6 0.5 0.1 0.1 100.0 6.7 5.3 1,336 Far-western hill 56.8 31.7 5.2 0.4 1.1 3.4 0.5 0.3 0.6 0.1 100.0 4.7 7.7 865 Eastern terai 55.9 28.7 2.4 1.6 1.4 8.5 0.4 0.9 0.2 0.0 100.0 9.9 5.2 2,863 Central terai 63.3 26.4 2.1 1.5 0.9 4.3 0.9 0.4 0.1 0.2 100.0 5.7 4.4 4,160 Western terai 57.1 31.3 2.1 2.2 0.5 5.7 0.4 0.6 0.2 0.0 100.0 6.8 3.8 1,730 Mid-western terai 66.4 19.4 4.6 1.4 0.9 6.0 0.4 0.6 0.3 0.0 100.0 7.2 6.8 1,109 Far-western terai 56.4 29.1 2.4 1.3 0.7 8.9 0.5 0.3 0.3 0.0 100.0 10.0 4.2 1,076 Wealth quintile Lowest 64.7 24.7 3.4 0.8 1.5 3.6 0.6 0.4 0.3 0.0 100.0 4.8 6.2 5,034 Second 60.0 28.9 3.2 1.1 1.1 4.6 0.3 0.5 0.2 0.0 100.0 5.6 5.4 4,429 Middle 59.0 29.5 2.7 1.0 0.8 5.4 0.9 0.3 0.2 0.1 100.0 6.8 5.0 4,149 Fourth 54.9 30.8 1.8 2.6 0.7 7.8 0.3 0.8 0.1 0.1 100.0 9.1 3.7 3,819 Highest 62.0 21.8 1.7 1.4 0.5 10.8 0.6 0.7 0.4 0.2 100.0 12.5 3.9 3,408 Total <15 60.7 29.2 2.2 1.4 0.9 4.4 0.5 0.4 0.2 0.1 100.0 5.5 4.2 17,687 Total <18 60.3 27.2 2.7 1.4 1.0 6.1 0.5 0.5 0.2 0.1 100.0 7.4 4.9 20,839 Note: Table is based on de jure members, i.e., usual residents. 1 Includes children with father dead, mother dead, both dead and one parent dead but missing information on survival status of the other parent. A high proportion of children age 15-17 (18 percent) are not living with either parent, even when both parents are alive. This may be due to children moving to a relative’s house to pursue further education or for purposes of seeking work. Table 2.12 shows that 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 is observed in the Eastern development region (9 percent), while the lowest proportion is found in the Western development region (6 percent). 28 • Housing Characteristics and Household Population 2.8 EDUCATION OF HOUSEHOLD POPULATION Studies have shown that education is one of the major socioeconomic factors that influence a person’s behavior and attitude. 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 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 MDG targets, Nepal is committed to ensuring that by 2015 all children, and in particular girls, children in difficult situations, and children from ethnic minority groups, have access to a complete, free, compulsory, and good-quality primary education (UNICEF, 2006). 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). In addition, private parties have invested in opening up non-graded-level schools (e.g., nursery, lower kindergarten, and upper kindergarten), known as pre-primary schools. To gauge the spread of such schools in Nepal, the 2011 NDHS included questions on pre-primary school attendance. Secondary-level schooling includes lower secondary and upper secondary schools, where students can receive an education up to grade 10. More recently, the government has encouraged existing high schools to add two additional years of school (10+2) by affiliating with the Higher Secondary Education Council (on the recommendation of the District Health Education Office and the Department of Education). The goal of the Three Year Plan (2010-2013) of the government of Nepal is to provide free, essential, and quality basic-level education (grade 1 to 8) and expand equitable and participative access to quality education to the secondary level (grade 9 to 12) (NPC, 2010a). 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. The interim constitution of Nepal (2007) explicitly stipulated free education up to the secondary level in the public sector and provisioned for reservation and other promotional arrangements for children and women. 2.8.1 Educational Attainment of Household Population Tables 2.13.1 and 2.13.2 show the percent distribution of the de facto female and male household population age 6 and above by level of education and background characteristics. Table 2.13.1 shows that 41 percent of women have never been to school, 23 percent have an incomplete primary education, 6 percent have completed primary school but not continued on to the next level of schooling, 25 percent have some secondary education or have completed secondary school and have not continued on, and about 5 percent have more than a secondary school education. While 7 percent of girls age 10-14 had no education, 12 percent of girls age 6-9 had no education indicating that school enrollment is quite late among girls. A relatively low proportion of girls in the 6-9 age group have attended some primary education (88 percent), particularly with respect to the MDG target of 100 percent by 2015. The proportion of women with no education increases with age, indicating that older women are less likely to be educated than younger women. Women in rural areas are far behind their urban counterparts with 44 percent having no education and median years of schooling is less than one, compared to urban women with 27 percent having no education and a median years of schooling completed of nearly five years. Forty-eight percent of women in the mountain zone have no education compared with 43 percent in the terai and 39 percent in the hill. Women in the Housing Characteristics and Household Population • 29 Table 2.13.1 Educational attainment of the female household population Percent distribution of the de facto female household population age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Nepal 2011 Background characteristic No education1 Some primary2 Completed primary3 Some secondary Completed secondary4 More than secondary Total Number Median years completed Age 6-9 11.7 87.6 0.7 0.0 0.0 0.0 100.0 2,311 0.1 10-14 6.6 47.6 17.4 28.4 0.0 0.0 100.0 3,181 3.7 15-19 12.5 9.4 6.6 49.9 16.5 5.0 100.0 2,775 7.2 20-24 23.1 11.7 7.9 23.3 16.6 17.4 100.0 2,431 6.5 25-29 35.9 15.1 6.9 21.7 10.4 10.0 100.0 2,126 3.8 30-34 44.8 12.8 7.1 20.0 8.8 6.4 100.0 1,744 1.9 35-39 60.9 10.9 4.4 14.2 4.4 5.3 100.0 1,597 0.0 40-44 70.4 11.4 3.3 8.2 3.6 3.0 100.0 1,309 0.0 45-49 78.2 9.3 2.7 5.3 2.3 2.2 100.0 979 0.0 50-54 84.6 6.5 2.5 3.8 1.3 1.3 100.0 1,178 0.0 55-59 90.0 4.1 0.9 3.5 0.7 0.8 100.0 811 0.0 60-64 95.4 1.7 0.4 1.4 0.6 0.5 100.0 711 0.0 65+ 96.8 1.7 0.2 1.0 0.1 0.2 100.0 1,376 0.0 Residence Urban 26.5 19.9 5.5 22.2 11.9 13.9 100.0 2,947 4.6 Rural 43.7 23.5 6.3 17.8 5.4 3.3 100.0 19,582 0.4 Ecological zone Mountain 47.8 25.5 5.7 15.8 3.7 1.5 100.0 1,539 0.0 Hill 38.5 22.5 7.0 19.7 6.2 6.0 100.0 9,143 1.8 Terai 42.8 23.0 5.6 17.7 6.6 4.1 100.0 11,847 0.5 Development region Eastern 35.1 25.7 5.7 21.1 8.2 4.1 100.0 5,441 2.1 Central 46.3 20.9 5.3 15.4 5.5 6.6 100.0 7,430 0.0 Western 37.9 20.9 8.2 22.0 6.7 4.3 100.0 4,752 2.2 Mid-western 43.2 25.9 6.1 17.0 4.9 2.9 100.0 2,633 0.5 Far-western 46.0 24.5 6.3 15.9 4.4 2.8 100.0 2,274 0.0 Subregion Eastern mountain 36.0 27.9 6.0 22.5 5.5 2.1 100.0 424 1.7 Central mountain 49.4 23.0 5.9 16.5 3.6 1.5 100.0 506 0.0 Western mountain 54.6 25.9 5.3 10.5 2.5 1.1 100.0 609 0.0 Eastern hill 37.4 25.0 7.4 21.7 5.9 2.4 100.0 1,759 1.8 Central hill 33.7 20.8 5.8 18.4 7.9 13.4 100.0 2,619 3.0 Western hill 39.4 20.9 8.1 21.8 6.3 3.4 100.0 2,806 2.1 Mid-western hill 41.7 24.8 6.9 17.9 4.8 3.9 100.0 1,172 0.7 Far-western hill 49.2 25.2 6.8 14.7 2.3 1.6 100.0 787 0.0 Eastern terai 33.7 25.8 4.8 20.6 9.8 5.3 100.0 3,257 2.3 Central terai 53.6 20.7 4.9 13.5 4.2 3.1 100.0 4,305 0.0 Western terai 35.6 20.8 8.4 22.2 7.3 5.5 100.0 1,945 2.5 Mid-western terai 41.7 26.8 5.4 18.0 5.5 2.6 100.0 1,159 1.1 Far-western terai 41.6 24.0 6.3 17.9 6.3 3.9 100.0 1,180 0.6 Wealth quintile Lowest 54.7 29.1 5.7 9.4 0.7 0.3 100.0 4,316 0.0 Second 51.7 23.8 6.4 15.2 2.4 0.4 100.0 4,488 0.0 Middle 45.9 22.7 5.7 19.3 4.7 1.6 100.0 4,486 0.0 Fourth 35.3 21.9 6.6 22.3 9.4 4.3 100.0 4,606 2.6 Highest 20.8 17.8 6.4 25.1 13.4 16.4 100.0 4,633 6.1 Total 41.4 23.0 6.2 18.4 6.2 4.7 100.0 22,529 1.0 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 at the secondary level Central and Far western regions have relatively lower levels of education than women in the other regions. Women in the Western mountain subregion are most likely to have no education (55 percent) while women in the Central hill and Eastern terai regions are least likely (34 percent). Overall the median number of years completed in Nepal is only one year among women. Wealth exerts a positive influence on educational attainment. Women from the highest wealth quintile are more likely to be educated than others. Seventy-nine percent of women from the highest wealth quintile have attended school, and half have completed at least six years of schooling; only 45 percent of women in the lowest wealth quintile have some educational attainment. Table 2.13.2 shows the educational attainment of the male household population. Eighty percent of males have attained some level of education. Thirty-nine percent have attained a primary education only, and 33 percent have some secondary education or have completed secondary schooling but did not continue on. Only 9 percent of males have attained more than a secondary-level education. The median number of years of schooling completed is almost 4. Ninety-four percent of males in the highest wealth quintile have attained any level of education, with a median of 8.1 years of schooling, as compared with only 68 percent of males in the lowest wealth quintile, with a median of 1.3 years. 30 • Housing Characteristics and Household Population Table 2.13.2 Educational attainment of the male household population Percent distribution of the de facto male household population age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Nepal 2011 Background characteristic No education1 Some primary2 Completed primary3 Some secondary Completed secondary4 More than secondary Don’t know/ missing Total Number Median years completed Age 6-9 6.1 93.0 0.6 0.1 0.0 0.2 0.0 100.0 2,470 0.1 10-14 2.2 50.6 17.5 29.6 0.0 0.0 0.0 100.0 3,269 3.8 15-19 3.6 9.9 5.8 54.9 20.8 5.0 0.1 100.0 2,217 7.8 20-24 5.4 10.1 6.5 27.2 20.8 29.8 0.1 100.0 1,449 9.0 25-29 12.4 15.3 8.2 30.2 15.1 18.7 0.2 100.0 1,266 7.2 30-34 17.6 14.6 6.9 28.6 14.4 17.7 0.2 100.0 1,167 7.1 35-39 17.3 16.9 7.1 26.8 14.9 17.0 0.0 100.0 1,187 6.7 40-44 26.3 18.1 8.0 24.3 9.8 13.3 0.2 100.0 957 4.7 45-49 32.5 20.6 6.8 17.6 11.1 11.1 0.3 100.0 916 3.4 50-54 40.4 20.7 8.2 16.0 6.4 8.2 0.0 100.0 915 2.0 55-59 47.9 19.7 6.8 15.0 5.3 5.2 0.1 100.0 820 0.3 60-64 59.2 16.3 5.8 9.2 4.4 5.0 0.2 100.0 654 0.0 65+ 76.5 8.5 2.4 6.5 3.6 2.2 0.4 100.0 1,303 0.0 Residence Urban 10.1 24.0 6.1 24.1 14.9 20.5 0.3 100.0 2,726 6.9 Rural 21.2 32.5 7.9 23.7 8.0 6.6 0.1 100.0 15,865 3.5 Ecological zone Mountain 22.7 34.2 8.2 24.2 6.2 4.5 0.1 100.0 1,255 3.0 Hill 17.3 30.6 8.2 24.5 9.0 10.3 0.1 100.0 7,477 4.3 Terai 20.9 31.4 7.1 23.2 9.3 7.9 0.1 100.0 9,859 3.6 Development region Eastern 16.9 31.7 7.6 25.6 10.7 7.4 0.1 100.0 4,451 4.2 Central 22.8 29.3 7.0 20.6 8.9 11.2 0.2 100.0 6,338 3.6 Western 17.1 31.5 8.1 26.4 8.8 8.0 0.2 100.0 3,781 4.2 Mid-western 22.0 32.8 7.9 23.5 7.7 6.1 0.0 100.0 2,224 3.3 Far-western 17.2 34.4 8.5 25.6 7.4 6.9 0.0 100.0 1,796 3.8 Subregion Eastern mountain 18.8 36.6 7.4 26.5 6.8 3.9 0.0 100.0 342 3.4 Central mountain 30.2 32.5 8.2 20.5 6.1 2.4 0.0 100.0 382 2.2 Western mountain 19.7 33.8 8.7 25.3 5.9 6.5 0.1 100.0 531 3.4 Eastern hill 20.0 33.5 8.8 25.9 7.7 4.1 0.1 100.0 1,386 3.5 Central hill 14.5 25.6 7.3 21.9 11.1 19.2 0.3 100.0 2,400 5.5 Western hill 18.3 30.1 8.5 26.5 8.8 7.8 0.0 100.0 2,131 4.2 Mid-western hill 20.1 35.5 8.2 21.8 8.1 6.3 0.0 100.0 943 3.3 Far-western hill 14.5 36.9 9.2 28.7 6.4 4.4 0.0 100.0 617 3.9 Eastern terai 15.1 30.2 7.0 25.3 12.7 9.6 0.1 100.0 2,723 4.7 Central terai 27.6 31.5 6.7 19.7 7.6 6.7 0.1 100.0 3,556 2.5 Western terai 15.7 33.3 7.6 26.2 8.8 8.2 0.3 100.0 1,650 4.1 Mid-western terai 24.3 30.3 7.2 24.4 7.8 6.1 0.0 100.0 999 3.4 Far-western terai 18.5 32.6 8.2 23.7 8.5 8.3 0.1 100.0 930 3.8 Wealth quintile Lowest 32.3 40.8 7.8 16.2 1.9 1.0 0.0 100.0 3,365 1.3 Second 28.0 36.5 9.5 20.6 3.5 1.8 0.1 100.0 3,570 2.2 Middle 21.3 32.4 8.1 26.5 7.9 3.8 0.1 100.0 3,693 3.5 Fourth 13.9 27.3 8.0 28.9 13.1 8.6 0.1 100.0 3,891 5.1 Highest 5.7 21.4 5.1 25.4 16.8 25.3 0.3 100.0 4,071 8.1 Total 19.6 31.3 7.6 23.8 9.0 8.6 0.1 100.0 18,591 3.9 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 at the secondary level Survey results show that about one in five men and about two in five women have never attended school. Additionally, twice as many females as males (12 percent versus 6 percent) age 6-9 have never been to school (in 2006, the corresponding proportions were 16 percent and 10 percent). The percentage of men and women with no education has declined since 2006, with improvements observed across all education categories. This decline is the result of various interventions by the government to enhance the overall quality of education and improve school enrollment (NPC, 2010a). 2.8.2 School Attendance Ratios The net attendance ratio (NAR) indicates participation in primary schooling for the population age 6-10 and secondary schooling for the population age 11-15. 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. An NAR of 100 percent would indicate that all of 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. Housing Characteristics and Household Population • 31 Tables 2.14.1 and 2.14.2 provide data on net attendance ratios and gross attendance ratios by sex and level of schooling. There has been a rise in the NAR at the primary level from 87 percent in 2006 to 89 percent in 2011, while at the secondary level it has increased from 47 percent to 59 percent over the same period. The rural primary school NAR has increased from 86 percent in 2006 to 89 percent in 2011, with a rise from 91 percent to 94 percent in urban areas over the same period. Among the subregions, the Central terai has the lowest NAR and GAR at the primary as well as at the secondary level. Table 2.14.1 School attendance ratios: Primary school Net attendance ratios (NARs) and gross attendance ratios (GARs) for the de facto household population at the primary level by sex and level of schooling, and the Gender Parity Index (GPI), according to background characteristics, Nepal 2011 Background characteristic Net attendance ratio1 Gross attendance ratio2 Male Female Total Gender Parity Index3 Male Female Total Gender Parity Index3 Residence Urban 94.8 92.7 93.8 0.98 131.4 123.9 127.8 0.94 Rural 91.9 85.4 88.7 0.93 141.3 130.7 136.1 0.93 Ecological zone Mountain 93.5 93.0 93.2 0.99 135.3 132.7 134.0 0.98 Hill 92.1 89.2 90.7 0.97 135.8 133.2 134.5 0.98 Terai 92.1 83.0 87.7 0.90 143.9 127.0 135.8 0.88 Development region Eastern 94.0 89.1 91.6 0.95 142.0 129.9 135.9 0.91 Central 89.8 78.4 84.1 0.87 138.1 114.7 126.4 0.83 Western 91.5 90.1 90.9 0.98 140.7 142.9 141.7 1.02 Mid-western 93.4 91.1 92.3 0.98 141.3 138.6 140.0 0.98 Far-western 95.0 92.2 93.7 0.97 139.6 145.1 142.3 1.04 Subregion Eastern mountain 94.8 93.1 94.0 0.98 139.9 131.9 135.9 0.94 Central mountain 89.6 94.1 92.0 1.05 127.4 131.4 129.5 1.03 Western mountain 94.8 92.1 93.5 0.97 136.7 134.0 135.4 0.98 Eastern hill 92.6 88.6 90.5 0.96 136.7 127.3 131.7 0.93 Central hill 94.1 88.4 91.2 0.94 135.4 120.7 128.0 0.89 Western hill 89.1 91.2 90.1 1.02 132.3 145.6 138.6 1.10 Mid-western hill 92.7 87.3 90.2 0.94 139.3 138.4 138.9 0.99 Far-western hill 93.2 90.7 92.0 0.97 138.8 140.8 139.7 1.01 Eastern terai 94.6 88.8 91.8 0.94 145.1 131.2 138.4 0.90 Central terai 87.6 71.3 79.5 0.81 140.4 109.6 125.2 0.78 Western terai 94.3 88.4 91.8 0.94 150.5 139.1 145.7 0.92 Mid-western terai 94.2 94.4 94.3 1.00 148.5 143.5 145.9 0.97 Far-western terai 96.1 93.7 94.9 0.98 138.7 148.3 143.3 1.07 Wealth quintile Lowest 86.1 81.8 83.9 0.95 136.6 127.1 131.7 0.93 Second 90.9 81.8 86.5 0.90 139.4 130.3 135.0 0.93 Middle 93.3 88.2 91.0 0.95 144.7 139.0 142.1 0.96 Fourth 95.9 89.3 92.6 0.93 148.4 129.4 139.0 0.87 Highest 97.5 94.3 96.0 0.97 132.7 125.1 129.1 0.94 Total 92.2 86.3 89.3 0.94 140.1 129.9 135.1 0.93 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 100.0. 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. Over the past five years, the rise in the NAR and GAR at the secondary level for females has been noticeable, with the NAR increasing from 43 percent in 2006 to 58 percent in 2011 and the GAR increasing from 67 percent in 2006 to 87 percent in 2011. In addition to extensive educational programs, these increases can be credited to government interventions providing specific scholarship initiatives for girls, members of the Dalit ethnic group, children with various disabilities, children of martyrs, and other groups of needy children. The 2006 Scholarship Regulation provisioned for the inclusion in programs of the poor, women, and conflict- affected and disabled populations (Department of Education, 2006). “Welcome to school” programs and the “School Tiffin program” have been maintained over the past five years. 32 • Housing Characteristics and Household Population Table 2.14.2 School attendance ratios: Secondary school Net attendance ratios (NARs) and gross attendance ratios (GARs) for the de facto household population at the secondary level by sex and level of schooling, and the Gender Parity Index (GPI), according to background characteristics, Nepal 2011 Background characteristic Net attendance ratio1 Gross attendance ratio2 Male Female Total Gender Parity Index3 Male Female Total Gender Parity Index3 Residence Urban 70.5 70.9 70.7 1.00 95.7 99.8 97.6 1.04 Rural 57.7 56.2 56.9 0.97 84.3 85.4 84.8 1.01 Ecological zone Mountain 67.3 60.9 64.1 0.91 104.8 94.4 99.5 0.90 Hill 65.9 66.0 66.0 1.00 92.1 97.7 94.9 1.06 Terai 52.9 50.8 51.8 0.96 78.0 77.4 77.7 0.99 Development region Eastern 60.8 60.1 60.5 0.99 87.0 92.6 89.8 1.06 Central 54.4 51.7 53.1 0.95 75.0 76.3 75.6 1.02 Western 62.3 64.4 63.4 1.03 89.5 93.6 91.5 1.05 Mid-western 59.3 60.5 59.9 1.02 94.2 90.6 92.4 0.96 Far-western 63.5 54.5 59.1 0.86 96.6 89.7 93.2 0.93 Subregion Eastern mountain 57.1 63.3 60.3 1.11 97.1 101.9 99.6 1.05 Central mountain 71.2 71.2 71.2 1.00 103.7 109.4 106.8 1.05 Western mountain 70.6 50.9 61.4 0.72 109.6 76.9 94.3 0.70 Eastern hill 64.4 68.3 66.3 1.06 93.9 117.7 105.4 1.25 Central hill 68.8 66.9 67.9 0.97 84.7 92.0 88.2 1.09 Western hill 67.0 67.6 67.3 1.01 95.6 97.4 96.6 1.02 Mid-western hill 58.7 64.2 61.7 1.09 90.7 90.4 90.5 1.00 Far-western hill 66.8 57.8 62.2 0.87 100.3 88.5 94.4 0.88 Eastern terai 59.2 55.1 57.2 0.93 81.7 77.4 79.6 0.95 Central terai 43.8 41.4 42.6 0.94 65.9 64.0 64.9 0.97 Western terai 56.2 59.7 57.9 1.06 81.5 88.1 84.7 1.08 Mid-western terai 56.0 56.9 56.5 1.02 88.5 90.9 89.6 1.03 Far-western terai 59.3 54.6 57.0 0.92 94.5 98.6 96.5 1.04 Wealth quintile Lowest 46.0 41.4 43.6 0.90 70.7 62.8 66.5 0.89 Second 52.3 47.5 49.8 0.91 82.4 78.6 80.4 0.95 Middle 59.3 58.5 58.9 0.99 88.3 91.1 89.7 1.03 Fourth 64.5 68.9 66.5 1.07 90.0 105.6 97.1 1.17 Highest 75.5 78.8 77.1 1.04 97.8 103.7 100.8 1.06 Total 59.2 57.8 58.5 0.98 85.6 86.9 86.3 1.02 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 100.0. 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 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 gender differences in the schooling system. A GPI less than one indicates that a smaller proportion of females than males attend school. The indexes for NAR and GAR at the primary and secondary levels are 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 remained unchanged at the primary level but has narrowed over the past few years at the secondary level. Figure 2.2 shows that females have a lower level of school attendance than males. Attendance is high up to age 8 for both males and females and then drops off gradually after age 14. Housing Characteristics and Household Population • 33 0 10 20 30 40 50 60 70 80 90 100 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Percentage Age Figure 2.2 Age-specific Attendance Rates of the de facto Population 5 to 24 Years Male Female 2.8.3 Early Childhood Development Centers In order to promote pre-primary education for children under five, the government has introduced Early Childhood Development (ECD) centers under Nepal’s Preliminary Child Education regulations. Data collected nationally show that a total of 26,773 ECD centers and school-based pre-primary classes had been established up to the 2010 school year (NPC, 2010a). These school-based centers are mostly managed by the government, while other community-based ECD centers are mostly supported by nongovernmental organizations (NGOs). The 2011 NDHS collected information on the percentage of children age 3-4 enrolled in these centers. Table 2.15 shows that nearly one-third of children age 3-4 are enrolled in school-based pre-primary classes or in ECD centers. School-based pre-primary classes are relatively more widespread; 23 percent of all children age 3-4 are enrolled in these classes, with only 7 percent of children enrolled in ECD centers. Overall, enrollment in pre-primary classes, including ECD centers, has increased from 23 percent in 2006 to 30 percent in 2011. No significant differences in enrollment by gender were observed. Young children in urban areas are more likely to be enrolled in school-based pre-primary classes (43 percent) than are young children in rural areas (21 percent), while the proportion of children enrolled in ECD centers is slightly higher in rural than in urban areas (7 percent versus 5 percent). But it is interesting that enrollment of children from urban areas in school-based pre-primary classes has declined from 50 percent to 43 percent between 2006 and 2011, while enrollment of children in rural areas has increased from 13 percent to 21 percent during the same period. Children in the hill zone are more likely to be enrolled in pre-primary classes or ECD centers (32 percent) than those in the other ecological zones, with most children from the Western region (45 percent) and Western terai (46 percent) enrolled in early education. Children in the highest wealth quintile (61 percent) are significantly more likely to have access to early education than those in other households, especially those in the lowest quintile, where only 14 percent are enrolled in early education. 34 • Housing Characteristics and Household Population Table 2.15 Children enrolled in school-based pre-primary classes and Early Childhood Development centers Percentage of de facto children age 3-4 enrolled in school-based pre-primary classes and Early Childhood Development centers according to background characteristics, Nepal 2011 Background characteristic Percentage of children age 3-4 Number of children School-based pre-primary Early Childhood Development centers Total Sex Male 23.7 5.6 29.3 1,134 Female 23.0 8.0 31.0 1,048 Residence Urban 42.5 4.6 47.1 211 Rural 21.3 7.0 28.3 1,971 Ecological zone Mountain 12.0 17.0 29.0 169 Hill 22.5 9.4 31.9 860 Terai 25.7 3.3 29.0 1,153 Development region Eastern 24.1 4.0 28.1 527 Central 19.7 7.4 27.2 687 Western 37.1 7.8 44.9 393 Mid-western 15.3 8.0 23.3 322 Far-western 20.8 7.5 28.3 253 Subregion Eastern mountain 18.7 13.7 32.5 39 Central mountain 20.0 23.7 43.7 44 Western mountain 4.8 15.0 19.8 86 Eastern hill 14.3 6.1 20.3 183 Central hill 32.2 12.6 44.8 190 Western hill 35.6 8.7 44.3 228 Mid-western hill 8.4 9.0 17.3 157 Far-western hill 12.0 11.1 23.1 102 Eastern terai 30.6 1.5 32.1 305 Central terai 14.5 3.6 18.1 452 Western terai 39.1 6.5 45.6 165 Mid-western terai 27.8 1.7 29.5 118 Far-western terai 35.3 4.0 39.3 112 Wealth quintile Lowest 5.3 9.1 14.3 575 Second 15.3 6.2 21.5 489 Middle 20.6 7.6 28.2 436 Fourth 37.8 4.3 42.1 364 Highest 55.7 5.2 60.9 317 Total 23.4 6.8 30.1 2,182 2.9 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 World Health Organization initiated the Global Malaria Control Strategy 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 targeted for focused initiatives under the Roll Back Malaria strategy. Currently, malaria control activities are in place in 65 of the country’s 75 districts (MOHP, 2011a). In addition to preparing for a malaria pre-elimination strategy, the MOHP has initiated visceral leishmaniasis (kala-azar) elimination programs. An important strategy in the control of malaria and kala-azar is prevention through indoor residual spraying and use of long-lasting insecticide-treated bednets (LLINs). This strategy has been implemented through the promotion of personal protection measures, including the use of simple mosquito nets or LLINs. The MOHP has been distributing nets through various channels in affected areas, and it set a target of 80 percent of people in high-risk areas sleeping under LLINs by 2011 (MOHP, 2011a). The 2011 NDHS collected information on the possession and number of mosquito nets in households. Table 2.16 shows that about 68 percent of households have mosquito nets (78 percent in urban areas and 66 percent in rural areas). Households in the terai (90 percent) are much more likely to possess mosquito nets than households in the hill (49 percent) and mountain (20 percent) zones. This is primarily because the terai is a high- Housing Characteristics and Household Population • 35 risk area for malaria transmission. Households in the Eastern region are more likely to possess nets than other households in the other regions. More than 90 percent of households in the Eastern terai, Western terai, and Far- western terai have mosquito nets. Among households with nets, 24 percent own one net, 55 percent own two or three nets, and 22 percent own at least four nets. Households in the fourth and highest wealth quintiles are more likely to possess mosquito nets (88 percent and 85 percent, respectively) than households in the other wealth quintiles. Households in the lowest wealth quintile are least likely to have nets (26 percent). Table 2.16 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 2011 Background characteristic Percentage of households with nets Number of households Number of nets in household Number of households with nets 1 2-3 4+ Total Residence Urban 77.9 1,546 23.5 55.7 20.8 100.0 1,205 Rural 66.1 9,280 23.7 54.6 21.7 100.0 6,137 Ecological zone Mountain 20.4 761 30.0 50.2 19.8 100.0 156 Hill 48.7 4,563 26.5 54.3 19.2 100.0 2,220 Terai 90.3 5,502 22.2 55.2 22.6 100.0 4,966 Development region Eastern 76.2 2,685 19.7 56.0 24.3 100.0 2,045 Central 69.7 3,627 27.6 55.3 17.1 100.0 2,529 Western 68.8 2,304 19.6 53.4 27.0 100.0 1,586 Mid-western 51.2 1,241 29.6 51.8 18.6 100.0 635 Far-western 56.3 969 25.2 55.7 19.1 100.0 546 Subregion Eastern mountain 30.0 206 24.1 50.4 25.5 100.0 62 Central mountain 25.6 266 30.1 51.0 19.0 100.0 68 Western mountain 8.9 289 44.0 48.0 8.0 100.0 26 Eastern hill 49.7 847 23.8 54.5 21.7 100.0 421 Central hill 52.2 1,386 29.1 55.4 15.5 100.0 724 Western hill 54.9 1,415 23.8 53.5 22.7 100.0 777 Mid-western hill 37.4 577 33.0 50.7 16.3 100.0 216 Far-western hill 24.3 339 25.8 60.6 13.6 100.0 82 Eastern terai 95.7 1,632 18.4 56.7 24.9 100.0 1,563 Central terai 88.0 1,975 26.9 55.4 17.7 100.0 1,737 Western terai 90.9 889 15.6 53.3 31.1 100.0 808 Mid-western terai 79.3 519 27.3 52.5 20.2 100.0 411 Far-western terai 91.7 487 24.6 55.0 20.4 100.0 446 Wealth quintile Lowest 26.1 2,029 45.3 49.9 4.9 100.0 530 Second 58.0 2,168 37.9 54.5 7.5 100.0 1,258 Middle 78.6 2,068 24.2 57.7 18.0 100.0 1,625 Fourth 87.9 2,185 15.8 56.7 27.6 100.0 1,921 Highest 84.5 2,377 16.1 52.2 31.7 100.0 2,008 Total 67.8 10,826 23.7 54.8 21.5 100.0 7,341 2.10 PREVALENCE AND CAUSES OF FOOD INSECURITY AND COPING STRATEGIES Food security refers to the availability of food and one’s access to it. A household is considered food- secure when its occupants do not live in hunger or fear of starvation (Hunt, 2009). In 1996, the World Food Summit defined food security as “the situation when all people at all times have access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life” (Food and Agriculture Organization of the United Nations, 2002). Common to most definitions of food security are the elements of availability, access (physical and economic), utilization, and stability or sustainability. Food insecurity is rooted in poverty and leads to poor health, low productivity, low income, food shortage, and hunger (Khanal and Dahal, 2010). The interim constitution (2006-2007) of Nepal recognized food security as a fundamental human right for all citizens, and this is reflected in the Three Year Interim Plan (2010-2013). With respect to MDG 1, Nepal aims to reduce the proportion of the population living below a minimum level of dietary energy consumption to 25 percent by 2015 (NPC, 2010a). In the absence of representative information on levels of household food insecurity, the 2011 NDHS provided a good opportunity to collect baseline data on food insecurity in Nepal. 36 • Housing Characteristics and Household Population The series of questions on food insecurity included in the 2011 NDHS was adopted from the Household Food Insecurity Access Scale indicators developed in USAID’s Food and Nutrition Technical Assistance (FANTA) project. However, the questions were modified to be specific to Nepal, with seven of the nine generic questions included and the reference period for assessment extended to 12 months from one month to allow for seasonal variations. The food insecurity scale designed from this methodology provides information on a household’s “access” to food, one of the three components of food insecurity—Availability, Access and Utilization. Although the questions on food insecurity included in the Household Questionnaire were administered to the household head, they reflect food insecurity for the household as a unit. The questions, arranged in order of degree of severity and frequency of occurrence, capture the household’s perception of food vulnerability or stress and behavioral responses to food insecurity. Based on responses to these questions, four food insecurity categories were created: 1. Food secure households: These households do not experience any food insecurity (access) conditions and rarely worry about such conditions. 2. Mildly food insecure households: These households worry about not having enough food sometimes or often, and/or are unable to eat preferred foods, and/or eat a more monotonous diet than desired and/or some foods considered undesirable but do so only rarely. They do not cut back on quantity or experience any of the three most severe conditions (running out of food, going to bed hungry, or going a whole day and night without eating). 3. Moderately food insecure households: These households sacrifice quality more frequently, by eating a monotonous diet or undesirable foods sometimes or often, and/or have rarely or sometimes started to cut back on quantity by reducing the size of meals or number of meals. However, they do not experience any of the three most severe conditions. 4. Severely food insecure households: These households have cut back on meal size or number of meals often and/or have experienced any of the three most severe conditions (running out of food, going to bed hungry, or going a whole day and night without eating), even if only rarely. In other words, any household that has experienced one of these three conditions even once in the last 12 months is considered severely food insecure (Coates et al., 2007). Table 2.17 shows that 49 percent of households in Nepal are food secure and have access to food year round. Twelve percent of households are mildly food insecure, 23 percent are moderately food insecure, and 16 percent are severely food insecure. Urban households are more food secure (67 percent) than rural households (46 percent). The proportion of food secure households is higher in the terai (52 percent), which includes the country’s most fertile land areas, than in the hill (47 percent) and mountain (41 percent) zones. Households in the Eastern development region are most likely to be food secure (56 percent), while households in the Mid- western region tend to be least food secure (32 percent). The latter finding is consistent with the government’s recent declaration of the hill districts of the Mid-western region (namely, Humla, Mugu, Kalikot, Rukum, Surkhet, and Jajarkot) as severely food insecure areas (The Himalayan, 2010). The 2011 NDHS indicates that 27 percent of the households in this region are severely food insecure and that 29 percent are moderately food insecure. Overall, two in three households in this region are food insecure at some level. Housing Characteristics and Household Population • 37 Table 2.17 Household food security Percent distribution of households by level of food insecurity, according to background characteristics, Nepal 2011 Background characteristic Food secure Mildly food insecure Moderately food insecure Severely food insecure Total Number of households Residence Urban 67.3 10.1 14.1 8.5 100.0 1,546 Rural 46.2 12.2 24.9 16.7 100.0 9,280 Ecological zone Mountain 40.5 18.2 26.1 15.1 100.0 761 Hill 47.2 12.3 28.7 11.8 100.0 4,563 Terai 52.1 10.7 18.6 18.6 100.0 5,502 Development region Eastern 55.9 11.1 19.0 13.9 100.0 2,685 Central 52.8 11.4 20.1 15.6 100.0 3,627 Western 51.4 11.3 27.1 10.1 100.0 2,304 Mid-western 31.9 12.5 28.5 27.1 100.0 1,241 Far-western 34.2 16.0 32.1 17.7 100.0 969 Subregion Eastern mountain 56.8 15.4 17.4 10.3 100.0 206 Central mountain 44.3 15.1 33.3 7.3 100.0 266 Western mountain 25.4 23.1 25.8 25.8 100.0 289 Eastern hill 49.6 14.4 25.3 10.7 100.0 847 Central hill 58.4 11.7 21.0 8.9 100.0 1,386 Western hill 46.6 11.6 34.5 7.2 100.0 1,415 Mid-western hill 28.9 11.4 30.8 29.0 100.0 577 Far-western hill 29.3 13.7 40.2 16.8 100.0 339 Eastern terai 59.1 8.9 16.0 16.0 100.0 1,632 Central terai 50.1 10.7 17.8 21.4 100.0 1,975 Western terai 59.1 10.9 15.3 14.7 100.0 889 Mid-western terai 39.8 13.5 26.1 20.6 100.0 519 Far-western terai 37.4 12.7 29.0 20.9 100.0 487 Wealth quintile Lowest 18.1 11.8 38.9 31.2 100.0 2,029 Second 32.6 13.6 29.2 24.7 100.0 2,168 Middle 46.3 14.0 25.4 14.2 100.0 2,068 Fourth 62.0 12.4 18.2 7.4 100.0 2,185 Highest 81.9 8.0 7.8 2.3 100.0 2,377 Total 49.2 11.9 23.4 15.5 100.0 10,826 Not surprisingly, households in the highest wealth quintile are much more likely to be food secure (82 percent) than households in the lowest wealth quintile (18 percent). A large proportion of households in the lowest wealth quintile fall in the moderately food insecure category (39 percent), and 31 percent fall in the severely food insecure category. Among households that suffered from food insecurity, further questions were posed on coping strategies and causes. Table 2.18 provides information on strategies adopted by households to cope with food insecurity. Seven of 10 households with food insecurity took a loan to meet their food needs. Other coping strategies included consuming seeds that were meant for the next planting season (19 percent), selling livestock (31 percent), selling other household assets (9 percent), and working in short-term labor positions (4 percent). Households in rural areas were more likely to take loans (71 percent) than urban households (63 percent). Households in the highest wealth quintile are least likely to take loans (54 percent), and households in the lowest wealth quintile are most likely to do so (76 percent). Households that are severely food insecure are more likely to take a loan (82 percent) than households that are moderately (67 percent) or mildly (61 percent) food insecure. 38 • Housing Characteristics and Household Population Table 2.18 Coping strategies of households with food insecurity Among households with food insecurity, the percentage using various coping strategies according to background characteristics, Nepal 2011 Background characteristic Took loan Consumed seed Sold livestock Sold other household assets Worked as labor Number of food insecure households Residence Urban 63.0 5.9 12.8 8.4 1.9 506 Rural 70.8 20.3 33.0 8.7 4.2 4,990 Ecological zone Mountain 73.1 28.1 40.7 8.0 10.8 453 Hill 72.4 23.1 37.3 7.2 4.0 2,409 Terai 67.5 13.7 23.9 10.2 2.7 2,634 Development region Eastern 72.3 13.0 41.3 10.5 1.6 1,184 Central 65.6 14.2 25.6 7.8 1.5 1,711 Western 66.3 13.6 25.9 4.7 6.1 1,119 Mid-western 72.0 36.7 35.5 13.9 11.0 845 Far-western 82.2 29.0 31.1 7.9 1.8 638 Subregion Eastern mountain 81.6 27.4 56.5 5.4 0.2 89 Central mountain 61.0 17.7 36.6 4.9 10.8 148 Western mountain 77.9 35.5 37.1 11.2 15.2 216 Eastern hill 74.9 17.6 55.6 8.1 0.0 427 Central hill 61.3 17.5 29.4 6.0 0.6 577 Western hill 66.8 14.0 29.8 4.3 5.5 755 Mid-western hill 87.7 49.0 47.7 14.2 12.1 410 Far-western hill 86.5 30.4 30.0 5.7 0.8 239 Eastern terai 69.4 8.1 30.1 12.7 2.9 668 Central terai 68.8 11.8 21.7 9.3 0.6 986 Western terai 65.3 12.8 17.8 5.5 7.3 364 Mid-western terai 51.7 18.6 22.8 12.9 3.3 312 Far-western terai 77.6 28.4 26.2 10.5 3.1 305 Wealth quintile Lowest 76.1 31.5 40.3 9.0 5.7 1,662 Second 73.3 17.3 32.4 8.3 4.3 1,462 Middle 70.2 13.6 29.4 10.0 3.9 1,110 Fourth 60.6 11.5 26.1 9.7 1.7 830 Highest 54.3 4.8 6.1 3.7 0.8 431 Degree of food insecurity Mildly food insecure 60.9 8.4 25.1 3.4 2.2 1,286 Moderately food insecure 67.1 17.4 32.6 7.0 3.6 2,531 Severely food insecure 81.8 29.6 33.7 15.4 5.9 1,679 Total 70.1 19.0 31.2 8.7 4.0 5,496 The 2011 NDHS also collected information on the causes of food insecurity. Table 2.19 describes the unexpected causes (drought, flood, landslide, crop failure) and temporary causes (financial problems) that were reported. Twenty-seven percent of households reported an unexpected natural disaster as a cause of their food insecurity, with 25 percent reporting a drought or crop failure. Two percent reported a flood or landslide as the major cause of their food insecurity. Financial problems were reported by 96 percent of the households facing food insecurity. Droughts and crop failures are more common in rural areas, the mountain zone, the Mid- western region, the Western mountain subregion, and households in the lowest wealth quintile. The relationship between household food insecurity and the nutritional status of children is analyzed in Chapter 11. Housing Characteristics and Household Population • 39 Table 2.19 Causes of household food insecurity Among households with food insecurity, the percentage that experienced food insecurity due to various causes, according to background characteristics, Nepal 2011 Background characteristic Drought/ crop failure Flood/ landslide Financial problems Other causes Number of food insecure households Residence Urban 6.3 0.3 96.1 6.0 506 Rural 27.1 2.0 95.6 6.6 4,990 Ecological zone Mountain 56.4 5.1 95.1 11.8 453 Hill 31.7 2.0 95.4 8.7 2,409 Terai 13.9 1.2 96.0 3.7 2,634 Development region Eastern 29.1 1.3 95.3 7.3 1,184 Central 20.0 1.8 95.9 5.7 1,711 Western 10.5 0.5 98.7 6.9 1,119 Mid-western 45.8 2.5 91.5 8.8 845 Far-western 30.2 4.3 96.2 3.8 638 Subregion Eastern mountain 43.1 2.0 94.1 14.3 89 Central mountain 49.3 5.1 94.8 13.7 148 Western mountain 66.7 6.4 95.7 9.5 216 Eastern hill 52.4 1.1 93.9 9.8 427 Central hill 24.2 3.3 95.7 8.0 577 Western hill 10.3 0.8 99.0 8.4 755 Mid-western hill 60.4 2.2 89.3 13.2 410 Far-western hill 31.3 3.7 96.8 2.0 239 Eastern terai 12.4 1.4 96.4 4.8 668 Central terai 13.2 0.5 96.2 3.2 986 Western terai 11.0 0.0 98.0 3.8 364 Mid-western terai 16.8 0.0 93.9 0.8 312 Far-western terai 19.9 5.5 94.5 5.6 305 Wealth quintile Lowest 42.0 3.1 95.0 9.1 1,662 Second 22.8 1.4 97.2 5.5 1,462 Middle 20.1 1.8 95.5 5.0 1,110 Fourth 12.3 0.8 95.0 5.5 830 Highest 6.6 0.5 94.8 6.4 431 Degree of food insecurity Mildly food insecure 23.0 1.0 93.5 5.3 1,286 Moderately food insecure 25.4 1.9 95.9 6.4 2,531 Severely food insecure 26.6 2.4 97.0 7.8 1,679 Total 25.2 1.9 95.7 6.6 5,496 Characteristics of Respondents • 41 CHARACTERISTICS OF RESPONDENTS 3 The purpose of this chapter is to create a demographic and socioeconomic profile of individual female and male respondents. This information helps in the interpretation of findings presented later in the report and provides an indication of the representativeness of the survey. The chapter begins by describing basic background characteristics, including age, marital status, religion, ethnicity, and wealth status. It then provides more detailed information on education, media exposure, employment, and tobacco use. In 2011, for the second time, the NDHS gathered information from all women and men irrespective of their marital status; earlier surveys had sampled only ever-married women and men. The discussion in this report is therefore with reference to all women and men. However, when comparing information with past surveys, the data have been rerun for ever-married women and men wherever possible to enable comparability between surveys. Throughout this report, numbers in the tables reflect weighted numbers. 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 basic characteristics of the 12,674 women and 4,121 men age 15-49 interviewed in the 2011 NDHS is presented in Table 3.1. Relatively high proportions of both female and male respondents are in the younger age groups, with more than half of the respondents (56 percent of women and 54 percent of men) under age 30. In general, the proportion of women and men in each group declines as age increases, reflecting the comparatively young age structure of the population in Nepal as a result of past high fertility levels. The vast majority of women and men are Hindu (84 percent), 9 percent are Buddhist, and 4 percent of women and 3 percent of men are Muslim. Two percent of women and men are Kirat, and another 2 percent are Christian. 1 Parentheses are used if mortality rates are based on 250 to 499 children exposed to the risk of mortality in any of the component rates; mortality rates are suppressed if they are based on fewer than 250 children exposed to the risk of mortality in any of the component rates. Key Findings: • Forty percent of women and 14 percent of men age 15-49 have no education. However, the percentage of women and men with at least some secondary education or higher has increased by 48 percent and 26 percent, respectively, in the last five years. • Thirty-two percent of married women report that their husbands live away from home. • Thirty-three percent of women and 20 percent of men are not exposed to any media source. • Sixty percent of women were employed in the 12 months preceding the survey, with the majority (75 percent) employed in the agricultural sector. • The majority (61 percent) of working women are not paid for their work. In contrast, most men (76 percent) earn cash or cash and in-kind payments. 42 • Characteristics of Respondents Hill Janajatis are the dominant ethnic group, with 25 percent of women and 24 percent of men belonging to this group. Nearly one-fifth (19 percent) of both women and men are hill Chhetris. Fourteen percent of women and 15 percent of men are hill Brahmins, 10 percent of women and 12 percent of men are terai Janajati, 10 percent of women and 9 percent of men are hill Dalit, and 8 percent of women and 9 percent of men are other terai caste. The rest of the ethnic groups represent less than 5 percent of the population. More than one-fifth of women (21 percent) and more than one-third of men (35 percent) have never been married. The majority of women (76 percent) and men (64 percent) are currently married, with a very small percentage divorced or separated. The majority of respondents reside in rural areas, with only 14 percent of women and 17 percent of men residing in urban areas. More than half (54 percent) of the respondents live in the terai, two-fifths (40 percent) live in the hill zone, and 6 percent live in the mountain zone. Table 3.1 Background characteristics of respondents Percent distribution of women and men age 15-49 by selected background characteristics, Nepal 2011 Background characteristic Women Men Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted number Age 15-19 21.7 2,753 2,790 23.7 978 1,009 20-24 18.1 2,297 2,281 16.6 685 693 25-29 16.6 2,101 2,129 14.1 581 567 30-34 13.7 1,734 1,697 12.1 499 492 35-39 12.3 1,557 1,561 13.1 542 533 40-44 10.1 1,285 1,266 10.6 438 458 45-49 7.5 947 950 9.7 399 369 Religion Hindu 84.2 10,672 10,829 84.2 3,472 3,486 Buddhist 8.8 1,112 1,058 8.6 354 352 Muslim 3.7 470 331 3.1 128 107 Kirat 1.5 195 215 2.1 86 92 Christian 1.7 220 236 1.9 77 80 Other 0.0 5 5 0.1 5 4 Ethnicity Hill Brahmin 14.2 1,805 1,798 14.5 597 618 Hill Chhetri 19.2 2,436 3,199 18.9 780 1,000 Terai Brahmin/Chhetri 1.2 156 169 1.3 54 55 Other Terai caste 7.9 1,003 730 9.0 372 303 Hill Dalit 9.6 1,214 1,402 8.6 352 381 Terai Dalit 4.4 559 306 3.9 163 96 Newar 4.3 541 532 4.8 196 180 Hill Janajati 24.9 3,154 2,986 23.5 968 906 Terai Janajati 10.4 1,313 1,198 12.1 497 463 Muslim 3.7 468 327 3.1 127 106 Other 0.2 25 27 0.3 14 13 Marital status Never married 21.4 2,708 2,837 34.8 1,433 1,444 Married1 75.8 9,608 9,460 63.7 2,626 2,628 Divorced/separated 0.8 100 109 0.9 39 32 Widowed 2.0 258 268 0.5 23 17 Residence Urban 14.4 1,819 3,701 17.4 717 1,351 Rural 85.6 10,855 8,973 82.6 3,404 2,770 Ecological zone Mountain 6.4 805 2,033 5.9 245 618 Hill 40.2 5,090 4,974 40.2 1,658 1,582 Terai 53.5 6,779 5,667 53.8 2,218 1,921 Development region Eastern 24.1 3,057 3,019 24.2 996 978 Central 33.4 4,236 3,009 35.1 1,448 1,002 Western 21.0 2,660 2,304 19.4 798 706 Mid-western 11.7 1,478 2,275 12.0 493 781 Far-western 9.8 1,242 2,067 9.3 385 654 Subregion Eastern mountain 1.8 229 737 1.6 66 223 Central mountain 2.0 258 669 1.7 69 177 Western mountain 2.5 319 627 2.7 110 218 Eastern hill 7.5 956 1,043 7.1 293 331 Central hill 12.3 1,563 1,132 15.0 616 423 Western hill 11.9 1,513 1,101 10.7 440 337 Mid-western hill 5.1 649 887 4.6 189 259 Far-western hill 3.2 409 811 2.9 120 232 Eastern terai 14.8 1,873 1,239 15.5 638 424 Central terai 19.1 2,415 1,208 18.5 763 402 Western terai 9.1 1,147 1,203 8.7 358 369 Mid-western terai 5.3 668 1,071 5.9 242 399 Far-western terai 5.3 676 946 5.3 217 327 Continued… Characteristics of Respondents • 43 Table 3.1—Continued Background characteristic Women Men Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted number Education No education 39.8 5,045 4,876 13.8 567 498 Primary 17.4 2,209 2,149 19.7 814 815 Some secondary 24.4 3,088 3,172 34.9 1,437 1,431 SLC and above 18.4 2,331 2,476 31.6 1,303 1,377 Wealth quintile Lowest 16.7 2,120 2,446 14.8 610 711 Second 18.9 2,393 2,296 16.9 695 688 Middle 20.5 2,600 2,336 20.1 830 727 Fourth 21.5 2,722 2,516 22.3 920 861 Highest 22.4 2,839 3,080 25.9 1,066 1,134 Total 15-49 100.0 12,674 12,674 100.0 4,121 4,121 Note: Education categories refer to the highest level of education attended. SLC = School Leaving Certificate 1 Includes one woman and two men who are living together. The distribution of respondents by development region shows that about one-third is from the Central region, nearly one-fourth from the Eastern region, and about one-fifth from the Western region. Twelve percent of the respondents live in the Mid-western region, and 10 percent of women and 9 percent of men are from the Far-western region. The subregional distribution shows the highest concentration of women and men in the Central terai (19 percent), followed by the Eastern terai (15 percent of women and 16 percent of men), Central hill (12 percent of women and 15 percent of men), and Western hill (12 percent of women and 11 percent of men) subregions. The proportion of women and men is less than 10 percent in each of the remaining subregions. Education is one of the most influential factors affecting an individual’s knowledge, attitudes, and behaviors in various facets of life. Educational attainment in Nepal is very low among women, who are much more disadvantaged than men. Forty percent of women do not have any formal education, as compared with 14 percent of men. Seventeen percent of women and 20 percent of men have a primary-level education. Nearly one-fourth (24 percent) of women and more than one-third (35 percent) of men have some secondary education, and nearly one-fifth (18 percent) of women and one-third (32 percent) of men have completed their School Leaving Certificate (SLC) or gone on to higher levels of education. 3.1.1 Spousal Separation The proportion of women whose spouses have been living away from home for a considerable period of time may have reproductive, demographic, and health implications. The 2011 NDHS collected detailed information on husbands living away from home. Table 3.2 presents the percent distribution of currently married women age 15-49 whose husbands live away from home, according to selected background characteristics. Thirty-two percent of women reported that their husbands live away from home, 52 percent reported a spousal separation of less than seven months’ duration, and 35 percent reported a separation lasting one or more years. Women under age 34 are more likely to have husbands living away from home than older women. More rural women than urban women reported that their husbands live away from home (34 percent and 22 percent, respectively). Spousal separation is most prevalent in the Western development region (40 percent). About one in two women in the Eastern region reported that their husband has been away for more than 12 months. This is especially true for women in the Eastern mountain region (57 percent). Women with no education are least likely to be separated from their husband for any length of time. Women with a primary education (37 percent) or some secondary education (36 percent) more often reported that their husbands live away from home. Women in the highest wealth quintile are least likely to report spousal separation. 44 • Characteristics of Respondents Table 3.2 Spousal separation Percentage of currently married women age 15-49 whose husbands live away from home, and among those whose husbands live away, percent distribution by duration away from home, according to background characteristics, Nepal 2011 Background characteristic Husband is away Number of women Duration away from home Number of women <7 months 7-11 months 12+ months Don’t know Total Age 15-19 37.3 792 63.7 18.3 17.8 0.2 100.0 295 20-24 42.7 1,761 54.2 15.3 30.5 0.0 100.0 752 25-29 38.3 1,914 50.2 11.9 37.7 0.2 100.0 732 30-34 32.6 1,659 50.6 12.3 37.1 0.0 100.0 540 35-39 29.1 1,461 45.8 10.2 44.0 0.0 100.0 425 40-44 20.0 1,190 44.3 10.0 45.7 0.0 100.0 238 45-49 11.4 832 57.5 4.9 37.6 0.0 100.0 95 Number of living children 0 35.8 1,075 64.4 12.2 23.1 0.2 100.0 385 1-2 37.2 4,442 49.3 13.5 37.1 0.1 100.0 1,652 3-4 28.3 3,091 49.3 13.0 37.7 0.0 100.0 874 5+ 16.6 999 58.7 6.2 35.1 0.0 100.0 166 Residence Urban 21.8 1,261 50.8 10.5 38.4 0.3 100.0 275 Rural 33.6 8,346 51.8 13.0 35.1 0.1 100.0 2,802 Ecological zone Mountain 27.2 630 59.4 9.8 30.8 0.0 100.0 172 Hill 32.2 3,784 53.1 11.9 34.9 0.2 100.0 1,217 Terai 32.5 5,193 50.0 13.8 36.2 0.0 100.0 1,689 Development region Eastern 32.5 2,293 37.5 12.1 50.3 0.0 100.0 745 Central 26.9 3,210 53.4 11.4 35.0 0.2 100.0 865 Western 39.7 2,031 50.2 14.7 34.9 0.1 100.0 807 Mid-western 29.7 1,149 68.4 11.5 20.1 0.0 100.0 341 Far-western 34.6 925 66.0 14.6 19.4 0.0 100.0 320 Subregion Eastern mountain 30.3 169 31.3 11.5 57.2 0.0 100.0 51 Central mountain 33.7 190 70.8 5.2 24.0 0.0 100.0 64 Western mountain 20.8 271 72.1 13.5 14.4 0.0 100.0 56 Eastern hill 30.9 702 38.1 13.2 48.7 0.0 100.0 217 Central hill 19.1 1,103 50.9 5.6 42.7 0.8 100.0 211 Western hill 41.8 1,164 52.9 13.6 33.3 0.1 100.0 487 Mid-western hill 36.6 510 66.7 12.7 20.6 0.0 100.0 187 Far-western hill 38.1 305 63.3 11.8 24.9 0.0 100.0 116 Eastern terai 33.5 1,421 38.0 11.7 50.3 0.0 100.0 477 Central terai 30.8 1,918 52.5 14.1 33.4 0.0 100.0 590 Western terai 36.9 867 46.1 16.4 37.4 0.1 100.0 320 Mid-western terai 27.8 499 70.0 10.2 19.8 0.0 100.0 139 Far-western terai 33.4 488 66.6 16.6 16.9 0.0 100.0 163 Education No education 28.3 4,580 51.1 13.0 36.0 0.0 100.0 1,297 Primary 37.2 1,844 51.2 11.2 37.6 0.0 100.0 686 Some secondary 36.0 1,833 48.1 14.7 37.2 0.0 100.0 661 SLC and above 32.1 1,350 59.9 11.9 27.7 0.6 100.0 433 Wealth quintile Lowest 31.0 1,664 52.7 13.8 33.5 0.0 100.0 516 Second 35.8 1,846 58.8 12.4 28.9 0.0 100.0 660 Middle 35.0 2,022 52.1 13.4 34.5 0.0 100.0 707 Fourth 34.4 2,052 46.4 12.9 40.8 0.0 100.0 706 Highest 24.1 2,023 48.3 11.3 39.9 0.5 100.0 488 Total 15-49 32.0 9,608 51.7 12.8 35.4 0.1 100.0 3,077 SLC = School Leaving Certificate 3.2 EDUCATIONAL ATTAINMENT BY BACKGROUND CHARACTERISTICS Tables 3.3.1 and 3.3.2 show the distribution of respondents by educational attainment, according to background characteristics. Table 3.3.1 shows that two-fifths (40 percent) of women age 15-49 have never been to school, 12 percent have only some primary education, 6 percent have completed primary school, 24 percent have only some secondary education, 11 percent have completed secondary school, and 8 percent have a secondary education or higher. Older women and those who reside in rural areas are most likely to have no education. The urban-rural difference in level of education is pronounced for those who have completed secondary school or have more than a secondary education. For example, women in urban areas are more than twice as likely as those in rural areas to have a secondary education or more than a secondary education (38 percent and 15 percent, respectively). Characteristics of Respondents • 45 Table 3.3.1 Educational attainment: Women Percent dist

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