Rwanda - Demographic and Health Survey - 2012

Publication date: 2012

Demographic and Health Survey 2010 Rwanda Republic of Rwanda Rwanda Demographic and Health Survey 2010 Final Report National Institute of Statistics of Rwanda Ministry of Finance and Economic Planning Kigali, Rwanda Ministry of Health Kigali, Rwanda MEASURE DHS ICF International Calverton, Maryland, USA February 2012 Investing in our future The Global Fund To Fight AIDS, Tuberculosis and Malaria The 2010 Rwanda Demographic and Health Survey (2010 RDHS) was implemented by the National Institute of Statistics of Rwanda (NISR) in collaboration with the Ministry of Health (MOH), and the field work was conducted from September 26, 2010, to March 10, 2011. The funding for the RDHS was provided by the United States Agency for International Development (USAID), the United Nations Children’s Fund (UNICEF), the Centers for Disease Control and Prevention/Global AIDS Program (CDC/GAP), the Global Fund to Fight AIDS, Tuberculosis and Malaria, the United Nations Population Fund (UNFPA), World Vision, and the Government of Rwanda. ICF International provided technical assistance to the project through the MEASURE DHS project, a USAID-funded project providing support and technical assistance in the implementation of population and health surveys in countries worldwide. Additional information about the 2010 RDHS may be obtained from the NISR, P.O. Box 6139, Kigali, Rwanda; Telephone: (250) 571 035; E-mail: info@statistics.gov.rw; Internet: http://www.statistics.gov.rw. Information about the MEASURE DHS project may be obtained from ICF Macro, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, USA; Telephone: 301-572-0200; Fax: 301-572-0999; E-mail: info@measuredhs.com; Internet: http://www.measuredhs.com. Recommended citation: National Institute of Statistics of Rwanda (NISR) [Rwanda], Ministry of Health (MOH) [Rwanda], and ICF International. 2012. Rwanda Demographic and Health Survey 2010. Calverton, Maryland, USA: NISR, MOH, and ICF International. Contents • iii CONTENTS TABLES AND FIGURES . ix FOREWORD . xvii ACKNOWLEDGMENTS . xix SUMMARY OF FINDINGS . xxi MAP OF RWANDA . xxvi CHAPTER 1 INTRODUCTION 1.1 Country Profile . 1 1.1.1 Geography . 1 1.1.2 Economy . 2 1.1.3 Population . 3 1.1.4 Population Policy . 3 1.1.5 Public Health Policy . 4 1.2 Objectives and Methodology of the Survey . 4 1.2.1 Objectives of the Survey . 5 1.2.2 Questionnaires . 5 1.2.3 Sample Design . 7 1.2.4 Sample Coverage . 7 1.2.5 Hemoglobin, Malaria, and HIV Testing . 8 1.2.6 Training and Fieldwork Data Collection . 9 1.2.7 Data Processing . 9 CHAPTER 2 HOUSEHOLD CHARACTERISTICS 2.1 Household Population By Age and Sex . 11 2.2 Household Composition . 12 2.3 Educational Attainment . 13 2.4 School Attendance . 15 2.5 Household Conditions . 18 2.5.1 Household Drinking Water . 18 2.5.2 Household Sanitation Facilities . 20 2.5.3 Households with Hand Washing Places . 20 2.5.4 Household Characteristics . 21 2.5.5 Household Possession of Durable Goods . 23 2.5.6 Household Wealth Quintile . 24 2.6 Birth Registration with Civil Authorities . 25 2.7 Children’s Living Arrangements and Orphanhood . 26 2.8 School Attendance by Survivorship of Parents . 27 2.9 Child Labor . 28 2.10 Health Insurance Coverage . 31 2.11 Utilization of Health Services and Out-of-Pocket Expenditure for Health Care . 33 iv • Contents CHAPTER 3 RESPONDENT CHARACTERISTICS 3.1 Background Characteristics of Respondents . 37 3.2 Educational Attainment . 38 3.3 Literacy . 40 3.4 Exposure to Mass Media. 42 3.5 Employment . 44 3.6 Use of Tobacco . 50 CHAPTER 4 PROXIMATE DETERMINANTS OF FERTILITY 4.1 Marital Status . 53 4.2 Polygamy . 54 4.3 Age at First Union . 55 4.4 Age at First Sexual Intercourse . 57 4.5 Recent Sexual Activity . 59 CHAPTER 5 FERTILITY 5.1 Fertility Levels and Differentials . 63 5.2 Fertility Trends . 66 5.4 Children Ever Born and Living . 69 5.5 Birth Intervals . 69 5.6 Exposure to the Risk of Pregnancy . 71 5.7 Menopause . 73 5.8 Age at First Birth . 73 5.9 Teenage Fertility . 74 CHAPTER 6 FERTILITY PREFERENCES 6.1 Desire for Children . 77 6.2 Ideal Number of Children . 80 6.3 Fertility Planning Status . 82 CHAPTER 7 FAMILY PLANNING 7.1 Knowledge of Contraceptive Methods . 85 7.2 Current Use of Contraceptive Methods . 87 7.2.1 Current Use of Contraception by Age . 87 7.2.2 Current Use of Contraception by Background Characteristics . 89 7.3 Timing of Sterilization . 90 7.4 Source of Supply . 90 7.5 Informed Choice . 91 7.6 Contraceptive Discontinuation . 92 7.7 Knowledge of Fertile Period . 93 7.8 Need and Demand for Family Planning Services . 94 7.8.1 Need and Demand for Family Planning among Currently Married Women . 94 7.8.2 Need and Demand for Family Planning among All Women and Women Who Are Not Currently Married . 95 7.9 Future Use of Contraception . 97 7.10 Exposure to Family Planning Messages . 97 7.11 Contact of Nonusers with Family Planning Providers . 98 Contents • v CHAPTER 8 INFANT AND CHILD MORTALITY 8.1 Assessment of Data Quality . 101 8.2 Levels and Trends in Childhood Mortality . 102 8.3 Socioeconomic Differentials in Childhood Mortality . 103 8.4 Demographic Differentials in Mortality . 105 8.5 High-Risk Fertility Behavior . 106 CHAPTER 9 MATERNAL HEALTH 9.1 Antenatal Care . 109 9.1.1 Components of Antenatal Care . 112 9.1.2 Tetanus Vaccinations . 114 9.2 Delivery Care . 115 9.2.1 Place of Delivery . 115 9.2.2 Assistance during Delivery . 116 9.3 Postnatal Care . 118 9.3.1 Maternal Postnatal Care . 118 9.3.2 Newborn Postnatal Care . 120 9.4 Problems in Accessing Health Care . 122 CHAPTER 10 CHILD HEALTH 10.1 Child’s Size at Birth . 125 10.2 Vaccination of Children . 126 10.3 Trends in Vaccination Coverage . 128 10.4 Childhood Illnesses . 129 10.4.1 Acute Respiratory Infections . 129 10.4.2 Fever . 130 10.5 Diarrheal Disease . 132 10.5.1 Prevalence of Diarrhea . 132 10.5.2 Treatment of Diarrhea . 133 10.5.3 Feeding Practices during Diarrhea . 135 10.6 Knowledge of ORS Packets . 137 10.7 Stool Disposal . 137 CHAPTER 11 NUTRITION OF CHILDREN AND ADULTS 11.1 Nutritional Status of Children . 139 11.1.1 Measurement of Nutritional Status among Young Children . 139 11.1.2 Measures of Child Nutritional Status . 141 11.1.3 Trends in Children’s Nutritional Status . 143 11.2 Initiation of Breastfeeding . 144 11.3 Breastfeeding Status by Age . 146 11.4 Duration of Breastfeeding . 147 11.5 Types of Complementary Foods . 149 vi • Contents 11.6 Infant and Young Child Feeding (IYCF) Practices . 151 11.7 Prevalence of Anemia in Children . 154 11.8 Micronutrient Intake among Children . 156 11.9 Use of Iodized Salt . 158 11.10 Nutritional Status of Women . 158 11.11 Prevalence of Anemia in Women . 160 11.12 Micronutrient Intake among Mothers . 162 11.13 Nutritional Status of Men . 163 CHAPTER 12 MALARIA 12.1 Introduction . 165 12.2 Mosquito Nets . 165 12.2.1 Ownership of Mosquito Nets . 166 12.2.2 Use of Mosquito Nets by Persons in the Household . 167 12.2.3 Use of Mosquito Nets by Children Under 5 . 167 12.2.4 Use of Mosquito Nets by Pregnant Women . 168 12.3 Prevalence and Prompt Treatment of Fever . 169 12.4 Prevalence of Anemia and Malaria in Children and Women . 172 CHAPTER 13 HIV- AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR 13.1 Knowledge of HIV and AIDS and of Transmission and Prevention Methods . 177 13.1.1 Awareness of AIDS . 177 13.1.2 HIV Prevention Methods . 178 13.1.3 Knowledge about Transmission . 179 13.1.4 Knowledge of Prevention of Mother-to-Child Transmission of HIV . 182 13.2 Stigma Associated with AIDS and Attitudes Related to HIV and AIDS . 183 13.3 Attitudes towards Negotiating Safer Sex . 185 13.4 Attitudes towards Condom Education for Youth . 187 13.5 Multiple and Concurrent Partnerships, and Paying for Sex . 188 13.5.1 Multiple Sexual Partnerships . 188 13.5.2 Concurrent Sexual Partners . 190 13.5.3 Payment for Sex . 192 13.6 Testing for HIV . 193 13.7 Reports of Recent Sexually Transmitted Infections . 197 13.8 Needle and Syringe Injection . 199 13.9 HIV- and AIDS-Related Knowledge and Behavior among Youth . 200 13.9.1 Knowledge about HIV and AIDS and Source for Condoms . 201 13.9.2 Age at First Sex and Condom Use at First Sexual Intercourse . 202 13.9.3 Recent Sexual Activity . 202 13.9.4 Multiple Sexual Partnerships . 203 13.9.5 HIV Testing . 204 13.10 Male Circumcision . 205 CHAPTER 14 HIV PREVALENCE 14.1 Coverage Rates for HIV Testing . 209 14.2 HIV Prevalence . 211 Contents • vii 14.2.1 HIV Prevalence by Age and Sex . 211 14.2.2 Trends in HIV Prevalence: 2005 RDHS and 2010 RDHS . 212 14.2.3 HIV Prevalence by Socioeconomic Characteristics . 213 14.2.4 HIV Prevalence by Demographic Characteristics . 214 14.2.5 HIV Prevalence by Sexual Risk Behavior . 215 14.3 HIV Prevalence among Youth . 216 14.3.1 HIV Prevalence by Condom Use at Last Sex in Past 12 Months among Youth . 218 14.4 HIV Prevalence by Other Characteristics . 218 14.4.1 HIV Prevalence and STIs . 218 14.4.2 HIV Prevalence by Male Circumcision . 219 14.4.3 Prior HIV Testing by Current HIV Status. 221 14.5 HIV Prevalence among Cohabiting Couples . 221 CHAPTER 15 WOMEN’S STATUS AND DEMOGRAPHIC AND HEALTH OUTCOMES 15.1 Women’s and Men’s Employment . 223 15.1.1 Employment Status . 223 15.2 Women’s Control over Their Own Earnings and Relative Magnitude of Women’s Earnings . 224 15.3 Women’s Participation in Decision-making . 227 15.4 Attitudes towards Wife Beating . 229 15.5 Women’s Empowerment Indicators . 231 15.6 Current Use of Contraception by Women’s Empowerment Status . 232 15.7 Ideal Family Size and Unmet Need by Women’s Status . 232 15.8 Women’s Status and Reproductive Health Care . 233 CHAPTER 16 ADULT AND MATERNAL MORTALITY 16.1 Data Quality Issues . 235 16.2 Adult Mortality . 236 16.3 Maternal Mortality . 237 CHAPTER 17 DOMESTIC VIOLENCE 17.1 Measurement of Violence . 239 17.1.1 The Use of Valid Measures of Violence . 239 17.1.2 Ethical Considerations . 240 17.1.3 Special Training for Implementing the Domestic Violence Module . 241 17.2 Sub-Sample for the Violence Module . 242 17.3 Experience of Physical Violence and Perpetrators of Physical Violence . 242 17.4 Experience of Sexual Violence and Perpetrators of Sexual Violence . 243 17.5 Experience of Different Types of Violence . 246 17.6 Types of Spousal Violence . 246 17.7 Violence by Spousal Characteristics and Women’s Empowerment Indicators . 249 17.8 Frequency of Spousal Violence by Husbands . 250 17.9 Help-seeking to Stop Violence . 251 REFERENCES . 253 viii • Contents APPENDIX A SAMPLE IMPLEMENTATION A.1 Introduction . 255 A.2 Sampling Frame . 255 A.3 Structure of the Sample and the Sampling Procedure . 257 A.4 Selection of Probability and Sampling Weight . 260 APPENDIX B SAMPLING ERRORS . 269 APPENDIX C DATA QUALITY TABLES . 281 APPENDIX D DISTRICT TABLES . 293 APPENDIX E SURVEY PERSONNEL. . 405 APPENDIX F QUESTIONNAIRES . 411 Tables and Figures • ix TABLES AND FIGURES CHAPTER 1 INTRODUCTION Table 1.1 Results of the household and individual interviews . 7 CHAPTER 2 HOUSEHOLD CHARACTERISTICS Table 2.1 Household population by age, sex, and residence . 12 Table 2.2 Household composition . 13 Table 2.3.1 Educational attainment of the female household population . 14 Table 2.3.2 Educational attainment of the male household population . 15 Table 2.4 School attendance ratios . 16 Table 2.5 Household drinking water . 19 Table 2.6 Household sanitation facilities . 20 Table 2.7 Hand washing . 21 Table 2.8 Household characteristics . 22 Table 2.9 Household possessions . 24 Table 2.10 Wealth quintiles . 25 Table 2.11 Birth registration of children under age 5 . 26 Table 2.12 Children’s living arrangements and orphanhood . 27 Table 2.13 School attendance by survivorship of parents . 28 Table 2.14 Child labor . 30 Table 2.15 Health insurance . 31 Table 2.16 Health insurance . 32 Table 2.17 Annual outpatient visits and inpatient admissions for de facto population . 33 Table 2.18 Annual per capita expenditure (in US $) on outpatient visits and inpatient admissions for de facto population . 34 Figure 2.1 Population Pyramid . 12 Figure 2.2 Age-Specific Attendance Rates of the De Facto Population Age 5-24 . 18 CHAPTER 3 RESPONDENT CHARACTERISTICS Table 3.1 Background characteristics of respondents . 37 Table 3.2.1 Educational attainment: Women . 39 Table 3.2.2 Educational attainment: Men . 39 Table 3.3.1 Literacy: Women . 41 Table 3.3.2 Literacy: Men . 41 Table 3.4.1 Exposure to mass media: Women . 42 Table 3.4.2 Exposure to mass media: Men . 43 Table 3.5.1 Employment status: Women . 44 Table 3.5.2 Employment status: Men . 46 Table 3.6.1 Occupation: Women. 48 Table 3.6.2 Occupation: Men . 48 Table 3.7 Type of employment: Women . 50 Table 3.8.1 Use of tobacco: Women . 51 Table 3.8.2 Use of tobacco: Men . 51 x • Tables and Figures CHAPTER 4 PROXIMATE DETERMINANTS OF FERTILITY Table 4.1 Current marital status . 53 Table 4.2.1 Number of women’s co-wives . 54 Table 4.2.2 Number of men’s wives . 55 Table 4.3 Age at first marriage . 56 Table 4.4 Median age at first marriage by background characteristics . 57 Table 4.5 Age at first sexual intercourse . 58 Table 4.6 Median age at first intercourse by background characteristics . 59 Table 4.7.1 Recent sexual activity: Women . 60 Table 4.7.2 Recent sexual activity: Men . 61 CHAPTER 5 FERTILITY Table 5.1 Current fertility . 64 Table 5.2 Fertility by background characteristics . 65 Table 5.3.1 Trends in age-specific fertility rates . 67 Table 5.3.2 Trends in fertility . 68 Table 5.4 Children ever born and living . 69 Table 5.5 Birth intervals . 70 Table 5.6 Postpartum amenorrhea, abstinence, and insusceptibility . 71 Table 5.7 Median duration of amenorrhea, postpartum abstinence, and postpartum insusceptibility . 72 Table 5.8 Menopause . 73 Table 5.9 Age at first birth . 74 Table 5.10 Median age at first birth . 75 Table 5.11 Teenage pregnancy and motherhood . 76 Figure 5.1 Age-Specific Fertility Rates for Five-Year Periods Preceding the Survey . 67 Figure 5.2 Trends in Age-Specific and Total Fertility Rates, Various Sources . 68 CHAPTER 6 FERTILITY PREFERENCES Table 6.1 Fertility preferences by number of living children . 78 Table 6.2.1 Desire to limit childbearing: Women . 79 Table 6.2.2 Desire to limit childbearing: Men . 80 Table 6.3 Ideal number of children . 81 Table 6.4 Mean ideal number of children . 82 Table 6.5 Fertility planning status . 83 Table 6.6 Wanted fertility rates . 84 CHAPTER 7 FAMILY PLANNING Table 7.1 Knowledge of contraceptive methods . 86 Table 7.2 Knowledge of contraceptive methods by background characteristics . 88 Table 7.3 Current use of contraception by age . 88 Table 7.4 Current use of contraception by background characteristics . 90 Table 7.5 Timing of sterilization . 90 Table 7.6 Source of modern contraception methods . 91 Table 7.7 Informed choice . 92 Table 7.8 Reasons for discontinuation . 93 Table 7.9 Knowledge of fertile period . 94 Table 7.10.1 Need and demand for family planning among currently married women . 95 Table 7.10.2 Need and demand for family planning among all women and women who are not currently married . 96 Table 7.11 Future use of contraception . 97 Table 7.12 Exposure to family planning messages . 98 Table 7.13 Contact of nonusers with family planning providers . 99 Tables and Figures • xi CHAPTER 8 INFANT AND CHILD MORTALITY Table 8.1 Early childhood mortality rates . 102 Table 8.2 Early childhood mortality rates by socioeconomic characteristics . 104 Table 8.3 Early childhood mortality rates by demographic characteristics . 105 Table 8.4 High-risk fertility behavior . 107 Figure 8.1 Trend in Childhood Mortality Rates . 103 Figure 8.2 Under-5 Mortality Rates by Socioeconomic Characteristics . 104 Figure 8.3 Infant Mortality Rates by Demographic Characteristics . 106 CHAPTER 9 MATERNAL HEALTH Table 9.1 Antenatal care . 110 Table 9.2 Number of antenatal care visits and timing of first visit . 112 Table 9.3 Components of antenatal care . 113 Table 9.4 Tetanus toxoid injections . 114 Table 9.5 Place of delivery . 115 Table 9.6 Assistance during delivery . 117 Table 9.7 Timing of first postnatal checkup . 118 Table 9.8 Type of provider of first postnatal checkup . 119 Table 9.9 Timing of newborn’s first postnatal checkup . 120 Table 9.10 Type of provider of newborn’s first postnatal checkup . 121 Table 9.11 Problems in accessing health care . 123 Figure 9.1 Trends in Antenatal Care and Delivery, Rwanda 2005, 2007-08, and 2010 . 111 Figure 9.2 Children Whose Delivery Was Assisted by Trained Personnel . 117 CHAPTER 10 CHILD HEALTH Table 10.1 Child's weight and size at birth. 126 Table 10.2 Vaccinations by source of information . 127 Table 10.3 Vaccinations by background characteristics . 128 Table 10.4 Vaccinations in first year of life . 128 Table 10.5 Prevalence and treatment of symptoms of ARI . 129 Table 10.6 Prevalence and treatment of fever . 131 Table 10.7 Prevalence of diarrhea . 133 Table 10.8 Diarrhea treatment . 134 Table 10.9 Feeding practices during diarrhea . 136 Table 10.10 Knowledge of ORS packets or pre-packaged liquids . 137 Table 10.11 Disposal of children's stools . 138 CHAPTER 11 NUTRITION OF CHILDREN AND ADULTS Table 11.1 Nutritional status of children . 142 Table 11.2 Initial breastfeeding . 145 Table 11.3 Breastfeeding status by age . 146 Table 11.4 Median duration of breastfeeding . 148 Table 11.5 Foods and liquids consumed by children in the day or night preceding the interview . 150 Table 11.6 Infant and young child feeding (IYCF) practices . 153 Table 11.7 Prevalence of anemia in children . 154 Table 11.8 Micronutrient intake among children . 157 Table 11.9 Presence of iodized salt in household . 158 Table 11.10 Nutritional status of women . 159 Table 11.11 Prevalence of anemia in women . 161 Table 11.12 Micronutrient intake among mothers . 163 Table 11.13 Nutritional status of men . 164 xii • Tables and Figures Figure 11.1 Nutritional Status of Children by Age . 143 Figure 11.2 Trends in Nutritional Status of Children under 5 Years . 144 Figure 11.3 Infant Feeding Practices by Age . 147 Figure 11.4 IYCF Indicators on Breastfeeding Status . 149 CHAPTER 12 MALARIA Table 12.1 Household possession of mosquito nets . 166 Table 12.2 Use of mosquito nets by persons in the household . 167 Table 12.3 Use of mosquito nets by children . 168 Table 12.4 Use of mosquito nets by pregnant women . 169 Table 12.5 Prevalence, diagnosis, and prompt treatment of children with fever . 170 Table 12.6.1 Type of antimalarial drugs taken by children who took antimalarial drugs . 171 Table 12.6.2 Type and timing of antimalarial drugs taken by children with fever . 171 Table 12.7 Hemoglobin <8.0 g/dl in children . 173 Table 12.8 Malaria among children . 174 Table 12.9 Malaria among women . 175 CHAPTER 13 HIV- AND AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR Table 13.1 Knowledge of AIDS . 177 Table 13.2 Knowledge of HIV prevention methods. 179 Table 13.3.1 Comprehensive knowledge about AIDS: Women . 180 Table 13.3.2 Comprehensive knowledge about AIDS: Men . 181 Table 13.4 Knowledge of prevention of mother to child transmission of HIV . 182 Table 13.5.1 Accepting attitudes toward those living with HIV and AIDS: Women . 184 Table 13.5.2 Accepting attitudes toward those living with HIV and AIDS: Men . 185 Table 13.6 Attitudes toward negotiating safer sexual relations with husband . 186 Table 13.7 Adult support of youth education about condom use to prevent AIDS . 187 Table 13.8.1 Multiple sexual partners: Women . 189 Table 13.8.2 Multiple sexual partners: Men . 190 Table 13.9.1 Point prevalence and cumulative prevalence of concurrent sexual partners . 191 Table 13.9.2 Payment for sexual intercourse and condom use at last paid sexual intercourse . 193 Table 13.10.1 Coverage of prior HIV testing: Women . 194 Table 13.10.2 Coverage of prior HIV testing: Men . 195 Table 13.11.1 Pregnant women counseled and tested for HIV . 196 Table 13.11.2 HIV testing for prenuptial purposes and as a couple . 197 Table 13.12 Self-reported prevalence of sexually-transmitted infections (STIs) and STI symptoms . 198 Table 13.13 Prevalence of medical injections . 200 Table 13.14 Comprehensive knowledge about AIDS and of a source of condoms among youth . 201 Table 13.15 Age at first sexual intercourse among youth . 202 Table 13.16 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth . 203 Table 13.17 Multiple sexual partners in the past 12 months among young people . 204 Table 13.18 Recent HIV tests among youth . 205 Table 13.19 Practice of circumcision . 206 Table 13.20 Place of circumcision . 207 Table 13.21 Age at circumcision . 208 Figure 13.1 Women and Men Seeking Treatment for STIs . 199 CHAPTER 14 HIV PREVALENCE Table 14.1 Coverage of HIV testing by residence and province . 209 Table 14.2 Coverage of HIV testing by selected background characteristics . 210 Table 14.3 HIV prevalence by age . 211 Tables and Figures • xiii Table 14.4 Trends in HIV prevalence by age . 212 Table 14.5 HIV prevalence by socioeconomic characteristics . 213 Table 14.6 HIV prevalence by demographic characteristics . 215 Table 14.7 HIV prevalence by sexual behavior . 216 Table 14.8 HIV prevalence among young people, by background characteristics . 217 Table 14.9 HIV prevalence among young people by condom use at last sex . 218 Table 14.10 HIV prevalence by sexually transmitted infections . 219 Table 14.11 HIV prevalence by male circumcision . 220 Table 14.12 Prior HIV testing by current HIV status . 221 Table 14.13 HIV prevalence among couples . 222 Figure 14.1 HIV Prevalence by Sex and Age . 212 CHAPTER 15 WOMEN’S STATUS AND DEMOGRAPHIC AND HEALTH OUTCOMES Table 15.1 Employment and cash earnings of currently married women and men . 224 Table 15.2.1 Control over women’s cash earnings and relative magnitude of women’s cash earnings . 225 Table 15.2.2 Control over men’s cash earnings . 226 Table 15.3 Women’s control over their own earnings and over those of their husband . 227 Table 15.4 Participation in decision-making . 228 Table 15.5 Women’s participation in decision-making by background characteristics . 228 Table 15.6.1 Attitude toward wife beating: Women . 229 Table 15.6.2 Attitude toward wife beating: Men . 230 Table 15.7 Indicators of women’s empowerment . 231 Table 15.8 Current use of contraception by women’s empowerment. 232 Table 15.9 Women’s empowerment and ideal number of children and unmet need for family planning . 233 Table 15.10 Reproductive health care by women’s empowerment . 234 CHAPTER 16 ADULT AND MATERNAL MORTALITY Table 16.1 Data on siblings . 235 Table 16.2 Sibship size and sex ratio of siblings . 236 Table 16.3 Adult mortality rates . 237 Table 16.4 Direct estimates of maternal mortality . 238 Figure 16.1 Trend in Maternal Mortality Ratios for the Periods of 1995-2000 (2000 RDHS), 2000-2005 (2005 RDHS), and 2005-2010 (2010 RDHS) . 238 CHAPTER 17 DOMESTIC VIOLENCE Table 17.1 Experience of physical violence . 241 Table 17.2 Persons committing physical violence . 243 Table 17.3 Experience of sexual violence . 244 Table 17.4 Age at first experience of sexual violence . 245 Table 17.5 Person committing sexual violence at first experience of sexual violence . 245 Table 17.6 Experience of different forms of violence . 246 Table 17.7 Forms of spousal violence . 246 Table 17.8 Spousal violence by background characteristics . 248 Table 17.9 Spousal violence by husband's characteristics and empowerment indicators . 249 Table 17.10 Frequency of spousal violence among those who report violence . 250 Table 17.11 Help seeking to stop violence . 251 Table 17.12 Sources from where help was sought . 252 xiv • Tables and Figures APPENDIX A SAMPLE IMPLEMENTATION Table A.1 Distribution of village and population by province and by district within province . 256 Table A.2 Average village size and population distribution by district. 257 Table A.3 Sample allocation of clusters, households and expected number of women’s interviews by district . 258 Table A.4 Sample allocation of clusters, households and expected number of men’s interviews by district . 259 Table A.5 Expected number of eligible individuals for HIV testing and expected number of completed HIV tests by sex and by district . 260 Table A.6 Sample implementation: Women . 262 Table A.7 Sample implementation: Men . 263 Table A.8 Coverage of HIV testing by social and demographic characteristics: Women . 264 Table A.9 Coverage of HIV testing by social and demographic characteristics: Men . 265 Table A.10 Coverage of HIV testing by sexual behavior characteristics: Women . 266 Table A.11 Coverage of HIV testing by sexual behavior characteristics: Men . 267 APPENDIX B SAMPLING ERRORS Table B.1. List of selected variables for sampling errors, Rwanda DHS 2010 . 271 Table B.2 Sampling errors: Total sample, Rwanda DHS 2010 . 272 Table B.3 Sampling errors: Urban sample, Rwanda DHS 2010 . 273 Table B.4 Sampling errors: Rural sample, Rwanda DHS 2010 . 274 Table B.5 Sampling errors: City of Kigali sample, Rwanda DHS 2010 . 275 Table B.6 Sampling errors: South sample, Rwanda DHS 2010 . 276 Table B.7 Sampling errors: West sample, Rwanda DHS 2010 . 277 Table B.8 Sampling errors: North sample, Rwanda DHS 2010 . 278 Table B.9 Sampling errors: East sample, Rwanda DHS 2010 . 279 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 . 284 Table C.5 Reporting of age at death in days . 285 Table C.6 Reporting of age at death in months . 286 Table C.7 Nutritional status of children . 287 Table C.8 Prevalence of anemia in children in 2005 . 288 Table C.9 Prevalence of anemia in women in 2005 . 289 Table C.10 Prevalence of anemia in children in 2007-08 . 290 Table C.11 Prevalence of anemia in women in 2007-08 . 291 APPENDIX D DISTRICT TABLES Table D.1 Hand washing . 293 Table D.2. Birth registration of children under age five . 294 Table D.3 Children's living arrangements and orphanhood . 295 Table D.4.1 Educational attainment of the household population: Female . 296 Table D.4.2 Educational attainment of the household population: Men . 297 Table D.5 School attendance ratios . 298 Table D.6 Child labor . 299 Table D.7 Annual outpatient visits and inpatient admissions for de facto population . 300 Table D.8 Annual per capita expenditure (in US $) on outpatient visits and inpatient admissions for de facto population . 301 Table D.9 Health insurance . 302 Tables and Figures • xv Table D.10 Health insurance . 303 Table D.11.1 Educational attainment: Women . 304 Table D.11.2 Educational attainment: Men . 305 Table D.12.1 Literacy: Women . 306 Table D.12.2 Literacy: Men . 307 Table D.13.1 Exposure to mass media: Women . 308 Table D.13.2 Exposure to mass media: Men . 309 Table D.14.1 Employment status: Women . 310 Table D.14.2 Employment status: Men . 311 Table D.15.1 Occupation: Women. 312 Table D.15.2 Occupation: Men . 313 Table D.16.1 Use of tobacco: Women . 314 Table D.16.2 Use of tobacco: Men . 315 Table D.17 Current marital status . 316 Table D.18 Number of women's co-wives . 317 Table D.19 Number of men's wives . 318 Table D.20 Median age at first marriage . 319 Table D.21 Median age at first intercourse . 320 Table D.22.1 Recent sexual activity: Women . 321 Table D.22.2 Recent sexual activity: Men . 322 Table D.23 Fertility by district . 323 Table D.24 Birth intervals . 324 Table D.25 Median duration of amenorrhea, postpartum abstinence, and postpartum insusceptibility . 325 Table D.26 Median age at first birth . 326 Table D.27 Teenage pregnancy and motherhood . 327 Table D.28.1 Desire to limit childbearing: Women . 328 Table D.28.2 Desire to limit childbearing: Men . 329 Table D.29 Mean ideal number of children . 330 Table D.30 Wanted fertility rates . 331 Table D.31 Knowledge of contraceptive methods . 332 Table D.32 Current use of contraception . 333 Table D.33 Need and demand for family planning among currently married women . 334 Table D.34 Exposure to family planning messages . 335 Table D.35 Contact of nonusers with family planning providers . 336 Table D.36 Youth who could get a male condom . 337 Table D.37 Early childhood mortality rates . 338 Table D.38 Antenatal care . 339 Table D.39 Components of antenatal care . 340 Table D.40 Tetanus toxoid injections . 341 Table D.41 Place of delivery . 342 Table D.42 Assistance during delivery . 343 Table D.43 Timing of first postnatal checkup . 344 Table D.44 Type of provider of first postnatal checkup . 345 Table D.45 Timing of first postnatal checkup for the newborn . 346 Table D.46 Type of provider of first postnatal checkup for the newborn . 347 Table D.47 Problems in accessing health care . 348 Table D.48 Child's weight and size at birth. 349 Table D.49 Vaccinations . 350 Table D.50 Prevalence of symptoms of ARI, of fever, and of diarrhea . 351 Table D.51 Knowledge of ORS packets or pre-packaged liquids . 352 Table D.52 Disposal of children's stools . 353 Table D.53 Nutritional status of children . 354 Table D.54 Initial breastfeeding . 355 Table D.55 Median duration of breastfeeding . 356 Table D.56 Infant and young child feeding (IYCF) practices . 357 xvi • Tables and Figures Table D.57 Prevalence of anemia in children . 358 Table D.58 Micronutrient intake among children . 359 Table D.59 Presence of iodized salt in household . 360 Table D.60 Nutritional status of women . 361 Table D.61 Nutritional status of men . 362 Table D.62 Prevalence of anemia in women . 363 Table D.63 Micronutrient intake among mothers . 364 Table D.64 Household possession of mosquito nets . 365 Table D.65 Use of mosquito nets by persons in the household . 366 Table D.66 Use of mosquito nets by children . 367 Table D.67 Malaria among children . 368 Table D.68 Malaria among women . 369 Table D.69 Knowledge of AIDS . 370 Table D.70 Knowledge of HIV prevention methods. 371 Table D.71.1 Comprehensive knowledge about AIDS: Women . 372 Table D.71.2 Comprehensive knowledge about AIDS: Men . 373 Table D.72 Knowledge of prevention of mother to child transmission of HIV . 374 Table D.73 Information given about AIDS during antenatal visits . 375 Table D.74.1 Accepting attitudes toward those living with HIV/AIDS: Women . 376 Table D.74.2 Accepting attitudes toward those living with HIV/AIDS: Men . 377 Table D.75 Attitudes toward negotiating safer sexual relations with husband . 378 Table D.76 Adult support of education about condom use to prevent AIDS . 379 Table D.77.1 Multiple sexual partners: Women . 380 Table D.77.2 Multiple sexual partners: Men . 381 Table D.78 Point prevalence and cumulative prevalence of concurrent sexual partners . 382 Table D.79 Payment for sexual intercourse and condom use at last paid sexual intercourse . 383 Table D.80.1 Coverage of prior HIV testing: Women . 384 Table D.80.2 Coverage of prior HIV testing: Men . 385 Table D.81 Pregnant women counseled and tested for HIV . 386 Table D.82 HIV testing for prenuptial purposes . 387 Table D.83 HIV testing as a couple . 388 Table D.84 Male circumcision . 389 Table D.85 Self-reported prevalence of sexually-transmitted infections (STIs) and STI symptoms . 390 Table D.86 Prevalence of medical injections . 391 Table D.87 Comprehensive knowledge about AIDS and of a source of condoms among youth . 392 Table D.88 Age at first sexual intercourse among youth . 393 Table D.89 Premarital sexual intercourse and condom use during premarital sexual intercourse among youth . 394 Table D.90.1 Multiple sexual partners in the past 12 months among young people: Women . 395 Table D.90.2 Multiple sexual partners in the past 12 months among young people: Men . 396 Table D.91 HIV prevalence . 397 Table D.92 HIV prevalence among young people . 398 Table D.93 HIV prevalence among couples . 399 Table D.94 Control over women's cash earnings and relative magnitude of women's cash earnings . 400 Table D.95 Control over men's cash earnings . 401 Table D.96 Women's participation in decision making by background characteristics . 402 Table D.97.1 Attitude toward wife beating: Women . 403 Table D.97.2 Attitude toward wife beating: Men . 404 Foreword • xvii FOREWORD The government of Rwanda conducted the 2010 Rwanda Demographic and Health Survey (RDHS) to gather up-to-date information for monitoring progress on healthcare programs and policies in Rwanda, including the Economic Development and Poverty Reduction Strategy (EDPRS), the Millennium Development Goals (MDGs), and Vision 2020. The 2010 RDHS is a follow-up to the 1992, 2000, 2005, and 2007-08 RDHS surveys. Each survey provides data on background characteristics of the respondents, demographic and health indicators, household health expenditures, and domestic violence. The target groups in these surveys were women age 15-49 and men age 15-59 who were randomly selected from households across the country. Information about children age 5 and under also was collected, including the weight and height of the children. The 2010 RDHS was implemented by the National Institute of Statistics of Rwanda (NISR) in partnership with the Ministry of Health (MOH). The Rwanda Biomedical Centre, through its Institute of HIV/AIDS, Disease Prevention and Control (RBC-IHDPC), and in particular the HIV, malaria, and National Reference Laboratory (NRL) divisions, collaborated on several aspects of the survey, especially the biomarkers. ICF International provided technical assistance in implementation of the survey. Funding for the 2010 RDHS was provided by the government of Rwanda, the United States Agency for International Development (USAID), the Centers for Disease Control and Prevention (CDC), the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), World Vision, and the Global Fund (through the malaria division of RBC-IHDPC), Results of the 2010 RDHS indicate key changes have occurred in the demographic and health indicators. The survey shows a decrease in maternal and infant mortality rates compared with the surveys of 2005 and 2007-08, an increase in prenatal care visits and utilization of delivery services, an increase in utilization of modern contraceptives, and higher immunization coverage for children age 12-23 months. The total fertility rate has steadily declined. Despite these improvements, the nutritional status of children and mothers remains a big challenge as it has decreased slightly. This report is therefore an important tool that addresses health concerns and informs policy makers and other stakeholders of priority areas for intervention. It provides only a snapshot, however, and it is our sincere hope that researchers will deepen our understanding of the topics covered in the survey by undertaking further analysis of the RDHS datasets. Last but not least, we urge all stakeholders, both individuals and organizations, to play an active role in using this valuable information to contribute to a better quality of life for the Rwandan population. Dr. Agnes BINAGWAHO Minister of Health Acknowledgments • xix ACKNOWLEDGMENTS This report has been prepared with the participation of a large number of individuals and organizations. We would like to express our gratitude to all of them. First, we sincerely acknowledge the men and women who generously agreed to respond to all questions they were asked. The response rate was high, both for men (98.7 percent) and women (99.1 percent). We also present our sincere thanks to the Ministry of Local Government and to the local government authorities for their assistance and contributions to the smooth implementation of the survey. We would like to express our sincere appreciation to the Ministry of Health for close collaboration with the National Institute of Statistics of Rwanda (NISR) during preparation and implementation of the survey. The orientation and directives given by the steering committee members are appreciated. We also express our gratitude to many international organizations for their vital financial assistance. Contributions from the United States Agency for International Development (USAID), United Nations Children’s Fund (UNICEF), Centers for Disease Control and Prevention/Global AIDS Program (CDC/GAP) (through the Rwanda Biomedical Center/Institute of HIV/AIDS Disease Prevention and Control (RBC/IHDPC)/Malaria division), Global Fund, United Nations Population Fund (UNFPA), and World Vision were of immense importance to the effective accomplishment of the survey. We express our profound gratitude to the team from ICF International, and in particular to Dr. Rathavuth Hong and his colleagues. Their technical assistance contributed to the success of the survey. We thank the technical staff from the Ministry of Health (MOH), RBC-IHDPC, and NISR, for their unfailing participation in all activities of the survey, which were coordinated by RUTERANA Baudouin and his assistants, MUKANYONGA Apolline and MUCHOCHORI Kanobana. We congratulate the supervisors, cartographers, team leaders, field editors, enumerators, and office editors for their valuable efforts, and also the drivers who were able to overcome the fatigue and other challenges inherent in this type of operation. We also thank the data processing team led by TWAGIRAMUKIZA Augustin for its contribution to the completion of the survey. We appreciate the valuable support provided by administrative and financial departments of the NISR. Their interventions allowed this RDHS to be carried out smoothly and under good conditions. Summary of Findings • xxi SUMMARY OF FINDINGS The 2010 Rwanda Demographic and Health Survey (RDHS) is designed to provide data for monitoring the population and health situation in Rwanda. The 2010 RDHS is the fifth Demographic and Health Survey to be conducted in Rwanda. The objective of the survey is to provide up-to-date information on fertility, family planning, childhood mortality, nutrition, maternal and child health, domestic violence, malaria, maternal mortality, awareness and behavior regarding HIV/AIDS, HIV prevalence, malaria prevalence, and anemia prevalence. A nationally representative sample of 13,671 women, age 15–49 from 12,540 surveyed households, and 6,329 men, age 15–59 from half of these households, were interviewed. This represents a response rate of 99 percent for women and 99 percent for men. The sample provides estimates at the national and provincial levels. Household composition: The survey results show that Rwandan households consist of an average of 4.4 people. Forty-five percent of the household members are children under age 15. Housing conditions: Housing conditions vary greatly based on residence. Nearly half (45 percent) of urban households have electricity compared with only 4 percent of rural households. Almost all (90 percent) households in urban areas have access to an improved water source; this compares with 71 percent of households in rural areas. Overall, 58 percent of households use an improved, unshared toilet facility. One in four households has a non-improved toilet facility. Ownership of goods: Currently, 63 percent of Rwandan households own a radio, and 40 percent have a mobile phone. Nearly one-third of urban households have a television compared with 2 percent of rural households. Fifteen percent of households own a bicycle, but only 1 percent of households own a car or truck. Rural households are most likely to own agricultural land (82 percent). Education of survey respondents: Sixteen percent of Rwandan women and 10 percent of Rwandan men have had no formal education; 16 percent of women and 21 percent of men have gone to secondary school or beyond. Urban residents and those living in the City of Kigali have the highest level of education. Overall, 77 percent of women and 82 percent of men are literate. FERTILITY AND ITS DETERMINANTS Total Fertility Rate: Fertility in Rwanda has declined over the past two decades. Currently, women in Rwanda have an average of 4.6 children, down from 6.1 in 2005. Fertility varies by residence. Women in urban areas have 3.4 children on average, compared with 4.8 children per woman in rural areas. Fertility also varies with mother’s education and economic status. Women who have no education have nearly twice as many children as women with secondary or higher education (5.4 versus 3.0 children per woman). Fertility increases as the wealth of the respondent’s household decreases. The poorest women, on average, have two children more than women who live in the wealthiest households (5.4 versus 3.4 children per woman). Teenage fertility: According to the 2010 RDHS, 6 percent of young women age 15–19 have already begun childbearing: 5 percent are mothers, and an additional 1 percent of them are pregnant with their first child. Young motherhood is slightly more common in rural areas than in urban areas. Young women with no education are more than six times as likely to have started childbearing by age 19 compared with those who have secondary and higher education (25 percent versus 4 percent). Age at first birth: The median age at first birth for all women age 25–49 is 22.4. Women living in urban areas have their first birth slightly later than women living in rural areas. Age at first birth increases with education and wealth. xxii • Summary of Findings Age at first marriage: Seventeen percent of women in Rwanda are married by age 18, compared with just 3 percent of men. The median age at first marriage is 21.4 for women age 25–49; men age 25–59 marry later, at a median age of 24.9. Age at marriage greatly increases with education; women with more than secondary education get married three and a half years later than those with no education (median age of 23.6 years versus 20.1 years for women age 25–49). Age at first sexual intercourse: Twenty-one percent of women and 16 percent of men age 25–49 were sexually active by age 18. Three percent of women and men have had sex by age 15. Women start sexual activity about a year earlier than men (median age of 20.7 years for women age 25–49 and 21.6 years for men age 25–59). Desired family size: Rwandan women and men want about three children, on average. Women’s ideal family size is similar regardless of residence, province, or wealth. Women with secondary education and higher desire fewer children than women with no education (2.9 percent versus 3.8 percent). FAMILY PLANNING Knowledge of family planning: Knowledge of family planning methods in Rwanda is universal; all women and men age 15–49 know at least one modern method of family planning. The most commonly known methods are injectables, male condoms, and the pill. Current use of family planning: More than four in ten married women (45 percent) currently use a modern method of family planning. Another 6 percent are using a traditional method. Injectables (26 percent), the pill (7 percent), and implants (6 percent) are the most commonly used methods. Similarly, sexually- active unmarried women are equally as likely to use family planning—four in ten (40 percent) are using a modern method, with 18 percent using injectables and 12 percent using male condoms. Use of modern family planning varies little by residence. However, use does vary by province. Modern contraceptive use ranges from a low of 36 percent among married women in West province to a high of 57 percent in North province. Modern contraceptive use increases with education and wealth. Over half (52 percent) of married women with secondary education and higher use modern methods compared with 37 percent of women with no education. NEED FOR FAMILY PLANNING Desire to delay or stop childbearing: Fifty-two percent of currently married Rwandan women want no more children. Another 36 percent want to wait at least two years before their next birth. These women are potential users of family planning. Unmet need for family planning: Unmet need for family planning is defined as the percentage of married women who want to space their next birth or stop childbearing entirely but who are not currently using contraception. The 2010 RDHS reveals that 19 percent of married women have an unmet need for family planning—10 percent of women have a need for spacing births and 9 percent have a need for limiting births. Unmet need is highest among the poorest women and those with no education. West and East provinces have the highest unmet need for family planning: 25 percent and 20 percent, respectively. MATERNAL HEALTH Antenatal care: Almost all (98 percent) Rwandan women receive some antenatal care (ANC) from a skilled provider, most commonly from a nurse or medical assistant (94 percent). Thirty-eight percent of women had an antenatal care visit by the time of their fourth month of pregnancy, as recommended. Thirty- five percent received the recommended four or more ANC visits. Seventy-three percent of women took iron supplements during pregnancy; 39 percent took intestinal parasite drugs. Seven in ten women were informed of signs of pregnancy complications during an ANC visit. Seventy-nine percent of women’s most recent births were protected against neonatal tetanus. Delivery and postnatal care: Over two-thirds (69 percent) of Rwandan births occur in health facilities, primarily in public sector facilities. Home births are twice as common in rural areas (31 percent) as in urban areas (16 percent). Summary of Findings • xxiii Sixty-nine percent of births are assisted by a skilled provider (doctor, clinical officer, nurse, or midwife). Another 16 percent are assisted by untrained relatives or friends and another 10 percent are unassisted. Postnatal care helps prevent complications after childbirth. Only 18 percent of women received a postnatal checkup within two days of delivery. The majority of women (80 percent) did not have a postnatal checkup. CHILD HEALTH Vaccination coverage: Ninety percent of Rwandan children age 12–23 months have received all recommended vaccines—one dose each of BCG and measles, and three doses each of pentavalent (DPT- HepB-Hib) and polio. Less than 1 percent of children did not receive any of the recommended vaccines. Vaccination coverage is slightly higher in urban areas than in rural areas (93 percent versus 90 percent). There is some variation in vaccination coverage by province, ranging from only 81 percent in West province to 96 percent in City of Kigali province. Coverage increases with a mother’s education; 97 percent of children whose mothers have secondary education and higher were fully vaccinated compared with 87 percent of children whose mothers have no education. Vaccination coverage has continued to increase gradually in the past five years. Childhood illnesses: In the two weeks before the survey, four percent of children under 5 were ill with cough and rapid breathing, symptoms of an acute respiratory infection (ARI). Of these children, 50 percent were taken to a health facility or provider. During the two weeks before the survey, 13 percent of Rwandan children under age 5 had diarrhea. The rate was highest among children 12–23 months (25 percent) and 6–11 months (22 percent). Thirty-seven percent of children with diarrhea were taken to a health provider. Children with diarrhea should drink more fluids, particularly through oral rehydration salts (ORS). Nearly one in two children with diarrhea was treated with ORS or increased fluids. However, one in four children received no treatment (from a medical professional or at home) at all. NUTRITION STATUS Breastfeeding and complementary feeding: Breastfeeding is very common in Rwanda, with 99 percent of children having been breastfed at some point in time. The World Health Organization (WHO) recommends that children receive nothing but breast milk (exclusive breastfeeding) for the first six months of life. Over eight in ten children under 6 months in Rwanda are being exclusively breastfed. Infants should not be given water, juices, other milks, or complementary foods until age 6 months, yet 11 percent of Rwandan infants under 6 months receive complementary foods. On average, children breastfeed until age 29 months and are exclusively breastfed for 5.3 months. Complementary foods should be introduced when a child is 6 months old to reduce the risk of malnutrition. In Rwanda, 61 percent of children age 6–8 months begin eating complementary foods. Anemia: About four in ten children are classified as having anemia, most of whom have mild anemia. Anemia has decreased from 52 percent of children in the 2005 RDHS to 38 percent of children in 2010. Seventeen percent of women are anemic, most of whom are mildly anemic. Anemia is higher among pregnant women (20 percent) than among nonpregnant women (17 percent). Mild anemia is the most common form of anemia among both groups of women. Children’s nutritional status: According to the survey, 44 percent of children under age 5 are stunted or too short for their age. This indicates chronic malnutrition. Stunting is most common among children age 18–23 months (55 percent). Stunting is least common among children of more educated mothers and those from wealthier families. Wasting (too thin for height), which is a sign of acute malnutrition, is far less common (only 3 percent). Eleven percent of Rwandan children are underweight or too thin for their age. Women’s nutritional status: Few Rwandan women are too thin (7 percent), and 16 percent of women are overweight or obese. Overweight and obesity is higher in urban areas than in rural areas (25 percent compared with 15 percent) and increases with age, education, and wealth. Women in the City of Kigali are most likely to be overweight or obese (30 percent). xxiv • Summary of Findings Vitamin A and iron supplementation: In the 24 hours before the survey, 73 percent of children age 6–23 months ate food, fruits, and vegetables rich in vitamin A. Ninety-three percent of children age 6–59 months received a vitamin A supplement in the six months prior to the survey. Over half (52 percent) of women received a vitamin A supplement postpartum. Vitamin A supplementation has increased since 2005, when 84 percent of children age 6–59 months received a vitamin A supplement in the six months prior to the survey and 34 percent of pregnant women received a vitamin A supplement postpartum. Only 1 percent of women took iron tablets or syrup for at least 90 days during their last pregnancy to prevent anemia and other complications. MALARIA Malaria prevalence: There has been remarkable progress in the decline of malaria prevalence in Rwanda, which has decreased by half since 2007–08; from 2.6 percent to 1.4 percent among children age 6–59 months and from 1.4 percent to 0.7 percent among women age 15–49. Household ownership of mosquito nets: In Rwanda, 82 percent of households have at least one long lasting, insecticide-treated mosquito net (LLIN). LLIN ownership is highest in East province (90 percent) and lowest in North province (70 percent). LLIN ownership in Rwanda has increased by nearly 50 percent in the past few years. Use of mosquito nets by children and women: Overall, 70 percent of children under 5 and 72 percent of pregnant women slept under an LLIN the night before the survey. This LLIN use shows about a 25 percent increase from use reported in the 2007–08 RDHS. INFANT AND CHILD MORTALITY Childhood mortality levels are decreasing in Rwanda. Currently, infant mortality is 50 deaths per 1,000 live births for the five-year period before the survey compared with 73 deaths for the five-to-nine- year period before the survey. Under 5 mortality levels have also decreased from 133 deaths per 1,000 live births to 76. Mortality rates differ slightly by province. The under 5 mortality rate for the ten-year period before the survey ranges from 79 deaths per 1,000 live births in the City of Kigali to 125 deaths in the East province. Under-5 mortality differs dramatically by a mother’s level of education. Children born to a mother who has a secondary education or higher are markedly less likely to die before their fifth birthday than children whose mothers have received no education (63 and 125 deaths per 1,000 live births, respectively). MATERNAL MORTALITY The maternal mortality ratio (MMR) remains high in Rwanda. According to the 2010 RDHS, the MMR is 476 deaths per 100,000 live births. The 95 percent confidence interval for the 2010 maternal mortality ratio ranges from 393 to 581 deaths per 100,000 live births. This rate has declined considerably in the past 10 years, from 1,071 deaths per 100,000 live births in the 2000 RDHS and 750 deaths per 100,000 live births in the 2005 RDHS. DOMESTIC VIOLENCE Two in five women (41 percent) reported that they have suffered from physical violence at least once since they were 15 years old. One in five women (22 percent) had suffered from sexual violence sometime in the past. Most often, it is the husband or partner who is responsible for the violence, whether physical or sexual. STI AND HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIORS Knowledge: Seventy-nine percent of women and 74 percent of men age 15–49 know that the risk of HIV infection can be reduced by using condoms and limiting sex to one faithful, uninfected partner. This knowledge varies by province, from 68 percent of women in the West province to 89 percent of women in the City of Kigali. Eighty-nine percent of women and 84 percent of men know that HIV can be transmitted by breastfeeding and that the risk of mother-to-child transmission can be reduced by taking drugs during pregnancy. Multiple and concurrent sexual partners: Less than 1 percent of women and 4 percent of men age Summary of Findings • xxv 15–49 report that they had sex with two or more partners in the past 12 months. Over one in four of these women and men report using a condom at last sexual intercourse. Among the women who had two or more partners in the past 12 months, almost two-thirds (63 percent) had overlapping (concurrent) sexual partnerships. Concurrent sexual partnerships may increase the risk of HIV transmission because they allow the virus to pass quickly through multiple individuals. Nearly 8 in 10 men who had two or more partners in the past 12 months had concurrent sexual partnerships. HIV testing: HIV testing is increasing rapidly in Rwanda. Currently, 76 percent of women and 69 percent of men have ever been tested and received their test results. Among young women and men age 15–24, 59 percent of women and 49 percent of men have ever been tested and received the results. Nearly 9 in 10 women (88 percent) who were pregnant in the two years before the survey received HIV counseling, were offered and accepted an HIV test, and received their test results. HIV testing during antenatal care is slightly more common in urban areas (93 percent) than in rural areas (88 percent). HIV PREVALENCE HIV prevalence: The 2010 RDHS included HIV testing of over 6,900 women age 15–49 and over 6,300 men age 15–59. Ninety-nine percent of women and 98 percent of men agreed to be tested for HIV. There has been essentially no change in Rwanda’s HIV prevalence since 2005. According to the 2010 RDHS, HIV prevalence is 3.0 percent for women and men age 15–49, compared with 3.0 percent in the 2005 RDHS. In Rwanda, HIV prevalence is 3.7 percent for women and 2.2 percent for men. HIV prevalence is three times as high in urban areas (7.1 percent) as in rural areas (2.3 percent). HIV estimates vary by age, with HIV prevalence highest among women age 35–39 and men age 40–44. HIV prevalence is highest in the City of Kigali where 7.3 percent of adults age 15–49 are HIV-positive. HIV prevalence is fairly uniform throughout the rest of Rwanda and ranges from 2.1 percent to 2.5 percent. HIV prevalence is particularly high among widows and those who are divorced or separated; 16.6 percent of widows are HIV-positive. CHILD LABOR Nearly 9 of 10 children (88 percent) age 5–14 in households worked in a week prior to the survey, either for their own household or for somebody else. Nearly 8 percent of children worked for someone who was not a member of the household: 2 percent for paid work and 5 percent for unpaid work. Eighty-three percent of children age 5–14 fetched water or collected fire wood for household use, 10 percent performed other family work, and 63 percent helped with household chores for 28 or more hours in a week. HEALTH INSURANCE On average, 78 percent of households have health insurance, an increase from 68 percent in 2007–08. Nearly all insured households (98 percent) are with Mutual Health Insurance. Other insurors are La Rwandaise d’Assurance Maladie (RAMA), Military Medical Insurance (MMI), and private insurance, which are commonly reported by households in urban areas, in the city of Kigali, and in the highest wealth quintile. At the individual level, 67 percent of women and 71 percent of men are insured. The majority of those insured individuals are covered by Mutual Health Insurance. xxvi • Map of Rwanda Introduction • 1 INTRODUCTION 1 1.1 COUNTRY PROFILE 1.1.1 Geography he country of Rwanda is situated in central Africa, immediately south of the equator between latitude 1°4' and 2°51' S and longitude 28°63' and 30°54' E. It has a surface area of 26,338 square kilometers and is bordered by Uganda to the north, Tanzania to the east, the Democratic Republic of the Congo to the west, and Burundi to the south. Landlocked, Rwanda lies 1,200 kilometers from the Indian Ocean and 2,000 kilometers from the Atlantic Ocean. Rwanda forms part of the highlands of eastern and central Africa, with mountainous relief and an average elevation of 1,700 meters. However, there are three distinct geographical regions. Western and north-central Rwanda is made up of the mountains and foothills of the Congo-Nile Divide, the Virunga volcano range, and the northern highlands. This region is characterized by rugged mountains intercut by steep valleys, with elevations generally exceeding 2,000 meters. The Divide itself rises to 3,000 meters at its highest point but is dwarfed by the volcano range, where the highest peak, Mount Karisimbi, reaches 4,507 meters. The Congo-Nile Divide slopes westward to Lake Kivu, which lies 1,460 meters above sea level in the Rift Valley trough. In Rwanda’s center, mountainous terrain gives way to the rolling hills that give the country its nickname, “Land of a Thousand Hills.” Here the average elevation varies between 1,500-2,000 meters. The area is also referred to as the central plateau. Further east lies a vast region known as the “eastern plateaus,” where the hills level gradually into flat lowlands interspersed with a few hills and lake-filled valleys. The elevation of this region generally is below 1,500 meters. Because of its elevation, Rwanda enjoys a temperate, sub-equatorial climate with average yearly temperatures around 18.5°C. The average annual rainfall is 1,250 millimeters, which occurs over two rainy seasons of differing lengths that alternate with one long and one short dry season. The climate varies somewhat from region to region, depending on the altitude. The volcano range and northern highlands are generally cooler and wetter, with an average temperature of 16°C and an average rainfall above 1,300 millimeters. The maximum rainfall is 1,600 millimeters above the Divide and the volcanic range. The hilly central region receives an average of 1,000 to 1,300 millimeters of rain per year, while rainfall on the eastern plateau, where the climate is relatively warmer and drier, generally falls below 1,000 millimeters and can be as low as 800 millimeters. Although Rwanda enjoys more or less constant temperatures, the climate is known to vary from year to year, with extreme variations in rainfall sometimes resulting in flooding or, more often, drought. These extremes have a profound impact on agricultural production. Rwanda has a dense network of rivers and streams, which drain into the Congo River on the western slope of the Congo-Nile Divide, and into the Nile River in the rest of the country via the Akagera River, which receives all the streams of this watershed. Water resources also include several lakes surrounded by wetlands. Deforestation caused mainly by land clearing for agricultural expansion has resulted in mostly anthropic vegetation with only a few small areas of natural forestland (representing 7 percent of the country) remaining on the Congo-Nile Divide and the slopes of the volcanic range. T 2 • Introduction Rwanda is divided into 4 geographically-based provinces—North, South, East, and West—and the City of Kigali, with the provinces being further subdivided into 30 districts, 416 sectors, 2,148 cells, and 14,837 villages (Imidugudu). 1.1.2 Economy In Rwanda, regular efforts have been made to develop the service sector and to stimulate investment in the industrial sector. These efforts are now bearing positive results, as the service sector has contributed more than the agricultural sector to the economy in recent years. Although the agricultural sector appears to have been overtaken by the service sector, it still employs many Rwandans. According to the 2002 General Population and Housing Census (RGPH) more than 8 of 10 people are employed in agriculture, including 81 percent of men and 93 percent of women (NISR, 2005). However, the agricultural sector faces major problems, including production dominated by small farming operations of less than one hectare, rudimentary techniques, and a low rate of investment. Agrarian reforms are being gradually introduced to address these problems; in particular, population resettlement and labor quality improvements focus on specialized training, mainly for women. Efforts are also under way to regionalize crops and to fully expand the use of farming techniques (MAAR, 2004). In 2010, the tertiary sector accounted for the largest share of Rwanda’s gross domestic product (GDP) at 47 percent, followed by the primary sector at 32 percent, the secondary sector at 15 percent, and the reminder at 6 percent were from Financial Intermediation Services Indirectly Measured (FISIM) and taxes. Nevertheless, agricultural production rose by 5 percent from 2009, to 2010. This rise is due to the increase in production of food crops (5 percent) and export crops (14 percent), which recovered from a decrease of 15 percent in 2009. In 2010, industry value added grew by 8 percent, while mining exports registered a decrease for the second consecutive year—11 percent in 2010, compared with 18 percent in 2009. Manufacturing increased by 9 percent; electricity, gas, and water increased by 15 percent; and construction grew by 9 percent. At the same time, services value added increased by 10 percent in 2010 as a result of 9 percent growth in transport, storage, and communication; 8 percent growth in wholesale and retail trade; and 24 percent growth in finance and insurance, after a recovery from a decrease of 4 percent in 2009. In 2010, the private final consumption expenditure was 83 percent of GDP, and the government final consumption expenditure was 15.8 percent of GDP. The level of investment (gross capital formation) was estimated at 21 percent of GDP, reflecting high levels of construction activity and imports of capital equipment. The imports were provisionally estimated to have increased by 12 percent at constant prices. These figures imply an increase of 8 percent in private final consumption expenditure compared to that in 2009. Exports grew by 20 percent after a decrease of 25 percent in 2009. The per capita GDP at constant 2001 prices was FRW 326,160 in 2010, compared with FRW 314,080 in 2009. Data from the 2005 Rwanda Demographic and Health Survey (RDHS) showed that 86 percent of women were working in agriculture, compared with 62 percent of men. In addition, 14 percent of men and 4 percent of women worked as unskilled labor. Results from the 2007-08 Rwanda Interim Demographic and Health Survey (RIDHS) showed that in urban areas, 59 percent of the households fell in the highest wealth quintile, compared with only 12 percent of households in rural areas. By comparison, in urban areas only 9 percent of households fell in the lowest (poorest) wealth quintile, compared with 18 percent in rural areas. Finally, because of the failure of most development strategies that had been based on structural adjustment programs focused on growth measured in terms of per capita GDP, the overwhelming majority of development partners are recognizing the need to incorporate social factors into development strategies. Therefore, new initiatives Introduction • 3 are geared toward pro-poor economic growth and poverty reduction to revive the economies of developing nations (MFEP, 2007). Rwanda has adopted this new orientation. 1.1.3 Population According to a 2009 population projection, the country would grow to 10,412,820 inhabitants in 2010. The population of Rwanda increased steadily and rapidly, from 4,831,527 to 7,157,551 in 1991 and to 8,128,553 inhabitants in 2002. The increase was, essentially, due to rapid population growth. The 2002 RGPH census estimated the natural growth rate at 2.6 percent and the fertility rate at 5.9. The rate of increase declined significantly, to 1.2 percent, between 1991 and 2002. The decline, which resulted from the deaths of more than one million people in the Genocide of the Tutsis, compares with a 3.1 percent decline between 1978 and 1991. Population density is high across the country and has increased steadily to 395 inhabitants per square kilometer in 2010, as compared with 321 in 2002, 283 in 1991, and 191 in 1978. The population is essentially young, with 42.3 percent of all Rwandans under the age of 15. In sex-disaggregated terms, the 2009 population projections show women to be in the majority (51.7 percent), while men make up 48.3 percent of the population. The illiteracy rate in Rwanda declined between 2000 and 2005. Between the two RDHS surveys, the rate decreased from 34 percent to 30 percent of women, and from 24 percent to 23 percent of men. This means that 70 percent of women know how to read and write and are considered literate compared with 77percent of men. The educational level of Rwandans is also low. Twenty-three percent of women and 17 percent of men have had no education, while nearly 67 percent of women and 70 percent of men have only a primary school education. About 11 percent of men and 9 percent of women have reached the secondary school level, while those with education beyond the secondary level make up only 1 percent of the population. Under Article 33 of Rwanda’s current constitution (adopted in 2003), “Freedom of thought, opinion, conscience, religion, worship, and the public manifestation thereof is guaranteed by the State in accordance with conditions determined by law.” Although numerous religions are practiced in Rwanda, Christianity is by far the dominant faith, practiced in some form by 93 percent of the resident population, the majority of whom are Catholic. In the 1991 census, 90 percent of the resident population identified themselves as Christian. Their number has increased at the expense of those who profess no religion, who have declined from 6.8 percent in 1991 to 3.6 percent in 2002. The number of Muslim adherents has risen slightly, from 1.2 percent of the population in the 1991 census to 1.8 percent in 2002. Nearly all Rwandans speak the same language, Kinyarwanda, which is the country’s official first language, followed by English and French. Kiswahili, the third most common foreign language, is generally spoken in urban areas and in the provinces bordering othercountries where this language is widely spoken, such as the Democratic Republic of the Congo and Tanzania. 1.1.4 Population Policy Out of concern for improving the country’s quality of life, the Rwandan government has developed strategies to ensure an acceptable balance between demographic growth and available resources, particularly since the 1980s. A family planning initiative developed in 1982 provided for training, improved access to family planning services and, in particular, the promotion of family planning through trained communicators known as Abakangurambaga (“Awakeners of the People”). A subsequent policy was adopted in 1990 aimed at curbing demographic growth and reducing fertility through family planning. To create an environment favorable to behavioral change that would result in lower fertility rates, other elements were included in the plan, such as 4 • Introduction increased production, public health improvements, land use planning, training of communicators, the promotion of education and school attendance, and the employment and advancement of women. Following the 1994 genocide, population problems were seen in a new light, with emphasis on both quality of life and population growth. A new national population policy was developed and issued to all development partners in 2003. This policy emphasizes quality of life by providing objectives and strategies to affect both demographic (fertility, mortality) and socioeconomic factors. The policy advocates slow population growth, managed sustainability of natural resources, food safety, access to primary and secondary education for all children (with a focus on technical and vocational instruction as well as information technology), good governance, equal opportunity, and participation in development by both men and women. 1.1.5 Public Health Policy Since the 1980s, the Government of Rwanda has implemented primary health care as the key strategy for improving the health of the population. In February 1995, the Ministry of Health began making reforms in the health sector in accord with the Lusaka declaration; these reforms were later adopted by the Government of National Unity in March 1996. The new policy was based upon three main strategies: (1) the decentralization of the health system using the health district as the basic operational unit; (2) the development of the primary health care system through its eight core components; and (3) the reinforcement of community participation in the management and financing of services. The Ministry of Health has laid down seven major policy objectives for the health sector: (1) to improve the availability of human resources; (2) to improve the availability of quality drugs, vaccines, and consumables; (3) to expand geographical accessibility to health services; (4) to improve financial accessibility to health services; (5) to improve the quality of services in the control of disease; (6) to strengthen national referral hospitals and research and treatment institutions; and (7) to strengthen institutional capacity. Characteristics of Rwandan health care services include decentralization, continuous provision, flexibility, and efficiency. The health system consists of three levels of provision: central, intermediary, and peripheral. The central level includes the central directorates and programs of the Ministry of Health and the national referral hospitals. It elaborates policies and strategies, ensures monitoring and evaluation, and regulates the health sector. It organizes and coordinates the intermediary (at the provincial level) and peripheral (at the health district level) levels of the health system and provides them with administrative, technical, and logistical support. 1.2 OBJECTIVES AND METHODOLOGY OF THE SURVEY The 2010 Rwanda Demographic and Health Survey (RDHS) is the fifth of its kind, following surveys conducted in 1992, 2000, 2005, and the 2007-08 Rwanda Interim DHS (RIDHS). The 2010 RDHS was carried out by the National Institute of Statistics of Rwanda (NISR) and the Ministry of Health (MoH). ICF International provided technical assistance to the project through the MEASURE Demographic and Health Surveys program (MEASURE DHS). The survey was funded by the Government of Rwanda, the United States Agency for International Development (USAID), the United Nations Children’s Fund (UNICEF), the Centers for Disease Control and Prevention/Global AIDS Program (CDC/GAP), the Global Fund to Fight AIDS, Tuberculosis and Malaria, the United Nations Population Fund (UNFPA), and World Vision. The survey was conducted on a representative sample of women age 15-49 and men age 15-59. Introduction • 5 1.2.1 Objectives of the Survey The main objectives of the 2010 RDHS were to: • Collect data at the national level to facilitate calculation of essential demographic rates, especially rates for fertility and infant and child mortality, and to analyze the direct and indirect factors that determine levels and trends in fertility and child mortality • Measure the levels of knowledge of contraceptive practices among women • Collect data on family health, including immunization practices; prevalence and treatment of diarrhea, acute upper respiratory infections, fever and/or convulsions among children under age 5; antenatal visits; and assistance at delivery • Collect data on the prevention and treatment of malaria, in particular the possession and use of bed nets among children under 5 and among women and pregnant women • Collect data on nutritional practices of children, including breastfeeding • Collect data on the knowledge and attitudes of men and women concerning sexually transmitted infections (STIs) and acquired immune deficiency syndrome (AIDS) and evaluate recent behavioral changes with regard to condom use • Collect data for the estimation of adult mortality and maternal mortality at the national level • Take anthropometric measurements in half of surveyed households in order to evaluate the nutritional status of children, men, and women • Conduct confidential testing for malaria parasitemia using Rapid Diagnostic Testing in half of the surveyed households and anonymous blood smear testing at the National Reference Laboratory • Collect dried blood spots (from finger pricks) for anonymous HIV testing at the National Reference Laboratory in half of surveyed households • Measure hemoglobin level (by finger prick) for anemia of surveyed respondents in half of surveyed households. 1.2.2 Questionnaires Three questionnaires were used for the 2010 RDHS: the Household Questionnaire, the Woman’s Questionnaire, and the Man’s Questionnaire. They are based on questionnaires developed by the worldwide Demographic and Health Surveys (DHS) program and on questionnaires used during the 2005 RDHS and 2007-08 RIDHS surveys. To reflect relevant issues in population and health in Rwanda, the questionnaires were adapted during a series of technical meetings with various stakeholders from government ministries and agencies, non- governmental organizations, and international donors. The questionnaires were translated from English and French into Kinyarwanda. The Household Questionnaire was used to list all the usual members and visitors in the selected households as well as to identify women and men eligible for individual interviews. Basic information was collected on the characteristics of each person listed, including age, sex, education, and relationship to the head of household. For children under 18, survival status of the parents was determined. The Household Questionnaire also collected information on the following: 6 • Introduction • Dwelling characteristics • Utilization of health services and health expenditures for recent illness and injury • Possession of iodized salt • Possession and utilization of mosquito nets • Height and weight of women and children • Hemoglobin measurement of women and children • Blood collection from women and children for rapid test and laboratory testing of malaria • Blood collection from women and men for laboratory testing for HIV The Woman’s Questionnaire was used to collect information from all women age 15-49 and was organized by the following sections: • Respondent background characteristics • Reproduction, including a complete birth and death history of respondents’ children and information on abortion • Contraception • Pregnancy and postnatal care • Child’s immunization, health, and nutrition • Marriage and sexual activity • Fertility preferences • Husband’s background and woman’s work • HIV/AIDS and other sexually transmitted infections • Other health issues • Adult mortality • Relationship in the household The Man’s Questionnaire was administered to all men age 15-59 living in every other household in the RDHS sample. 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 or nutrition. An instruction manual was also developed to support standardized data collection. All data collection instruments were pretested in June-July 2010. The observations and experiences gathered from the pretest were used to improve the instruments for the main survey data collection. Introduction • 7 1.2.3 Sample Design The sample for the 2010 RDHS was designed to provide population and health indicator estimates for the country as a whole and for urban and rural areas in particular. Survey estimates are also reported for the provinces (South, West, North, and East) and for the City of Kigali. The results presented in this report show key indicators that correspond to these provinces and the City of Kigali. A representative sample of 12,792 households was selected for the 2010 RDHS. The sample was selected in two stages. In the first stage, 492 villages (also known as clusters or enumeration areas) were selected with probability proportional to the village size. The village size is the number of households residing in the village. Then, a complete mapping and listing of all households existing in the selected villages was conducted. The resulting lists of households served as the sampling frame for the second stage of sample selection. Households were systematically selected from those lists for participation in the survey. All women age 15-49 who were either permanent residents of the household or visitors present in the household on the night before the survey were eligible to be interviewed. In addition, in a subsample of half of all households selected for the survey, all men age 15-59 were eligible to be interviewed if they were either permanent residents or visitors present in the household on the night before the survey. 1.2.4 Sample Coverage All of the 492 clusters selected for the sample were surveyed for the 2010 RDHS. A total of 12,792 households were selected, of which 12,570 households were identified and occupied at the time of the survey. Among these households, 12,540 completed the Household Questionnaire, yielding a response rate of nearly 100 percent (Table 1.1). In the 12,540 households surveyed, 13,790 women age 15-49 were identified as being eligible for the individual interview; interviews were completed with 13,671 of these women, yielding a response rate of 99.1 percent. Male interviews were conducted in every second household. A total of 6,414 men age 15-59 were identified in the subsample of households. Of these 6,414 men, 6,329 completed the individual interviews, yielding a response rate of 98.7 percent. The response rates were slightly higher in rural areas for men, while for women they were almost the same in rural and urban areas. Table 1.1 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Rwanda 2010 Result Residence Total Urban Rural Household interviews Households selected 2,054 10,738 12,792 Households occupied 2,014 10,556 12,570 Households interviewed 2,009 10,531 12,540 Household response rate1 99.8 99.8 99.8 Interviews with women age 15-49 Number of eligible women 2,386 11,404 13,790 Number of eligible women interviewed 2,367 11,304 13,671 Eligible women response rate2 99.2 99.1 99.1 Interviews with men age 15-59 Number of eligible men 1,178 5,236 6,414 Number of eligible men interviewed 1,156 5,173 6,329 Eligible men response rate2 98.1 98.8 98.7 1 Households interviewed/households occupied 2 Respondents interviewed/eligible respondents 8 • Introduction 1.2.5 Hemoglobin, Malaria and HIV Testing In a subsample of one-half of all households selected for the Man’s Questionnaire, blood specimens were collected from women age 15-49 and children age 6-59 months for measurement of hemoglobin in the field. The specimens were tested for malaria in the field using the Rapid Diagnostic Test (RDT) and tested for malaria in the lab using the microscopic method. Additionally, in the same one-half of all households, blood specimens for HIV testing were collected from all women age 15-49 and men age 15-59 who consented to the test. The protocol for the blood specimen collection and testing for HIV was reviewed and approved by the Rwanda National Ethics Committee, the Institutional Review Board of ICF International, and the Centers for Disease Control and Prevention (CDC) in Atlanta. Hemoglobin testing The 2010 RDHS included anemia testing of children age 6 to 59 months and women age 15-49 in the same one-half of households that were selected for interviews of men. A consent statement was read to the eligible respondent or to the parent or responsible adult for children and young women age 15-17. This statement explained the purpose of the test, informed respondents that the results would be made available as soon as the test was completed, and requested permission for the test to be carried out. Anemia levels were determined by measuring the level of hemoglobin in the blood (a decreased concentration of hemoglobin characterizes anemia). The concentration of hemoglobin in the blood was measured in the field using the HemoCue system. A special-purpose photometer is used to determine hemoglobin levels. A capillary blood sample is taken from the palm side of the end of a finger, punctured with a sterile, non-reusable, self- retractable lancet. The blood drop is collected in a HemoCue microcuvette, which serves as a measuring tool, and placed in the HemoCue photometer to determine the level of hemoglobin in the blood. A pamphlet was given to each respondent, explaining symptoms of anemia, prevention methods, and the individual results of the hemoglobin measurement of the respondent and any children for whom the respondent gave permission to be measured. Each person whose hemoglobin level was lower than the recommended cutoff point (testing severely anemic) was advised to visit a health facility for follow-up with a health professional. Malaria testing Malaria diagnostic tests, including a rapid diagnostic test (RDT) and a test using thick and thin blood smears, were given to eligible women and children in the 2010 RDHS. For the RDT for malaria, a drop of blood was obtained by a prick at the end of the finger, usually at the same time as anemia testing. First Response test kits were used according to manufacturer recommendations. The results of the malaria RDT were recorded in the Household Questionnaire, which allows linking with the characteristics of the respondents. Results from the RDTs were used to diagnose malaria and guide treatment of parasitemic children during the survey. The parent or guardian of children with a positive RDT was provided with written results, and children were given Coartem® for treatment, according to the current malaria treatment guidelines. Women with a positive RDT were referred to the nearest health center for treatment. Thin and thick blood smears were also collected from participants who agreed to malaria testing. Blood slides were stained with Giemsa stain prepared by the laboratory in advance of the fieldwork. Parasite densities were calculated by counting the number of asexual stage parasites/200 white blood cells (WBCs), assuming 6,000 WBCs/dl of blood. Blood smears were considered negative if no parasites were found after counting 200 fields. An informed consent form was read to the eligible person or parent/responsible adult of the child or teenager age 15-18 . This consent form asks, first of all, for the authorization of the person before undertaking the test and then explains the objectives of the test, informing the individual taking the test or those responsible for children that the results would be communicated immediately after the test. For each eligible woman and child, a Introduction • 9 slide with thick and thin blood smears was prepared, transmitted, and stored for microscopic examination of malaria parasites at the NRL. HIV testing Women and men who were interviewed in the subsample of households selected for the men’s survey of the 2010 RDHS were asked to voluntarily provide blood for HIV testing. The HIV test is anonymous; that is, the results of the test were not linked to survey data until the individual respondent’s identifying information was destroyed by NISR. Therefore, the respondents’ HIV test results can never be linked to identifying data. For women and men willing to be tested, drops of blood were drawn and dried on filter paper. Only an identification number (barcode) drawn at random was assigned to each specimen. Since no information containing personal identification accompanied the samples, it was not possible to inform the respondents of the result of their test. Analysis of the samples for HIV was carried out at the NRL. Information and educational brochures about HIV/AIDS prevention and the existing Voluntary Counseling and Testing (VCT) and Prevention of Mother-To-Child Transmission (PMTCT) sites were distributed to all households selected for the survey, whether these households were selected for testing or not. These brochures were prepared by TRAC-Plus and the Commission Nationale de Lutte contre le Sida (CNLS) or National AIDS Control Commission in close collaboration with NISR and were adapted to the population surveyed. 1.2.6 Training and Fieldwork Data Collection Thirty-eight women and men were trained from June 14-July 2, 2010, in the administration of the RDHS survey instruments, anthropometric measurement, hemoglobin testing, malaria testing, and blood drawing for HIV testing. Seven days of fieldwork were followed by one day of interviewer debriefing and examination. Pre-test fieldwork was conducted in 230 households in two rural and two urban villages outside of City of Kigali. The majority of pretest participants attended the main training and served as field editors and team leaders for the main survey. NISR recruited and trained 117 participants, and at the end of the training it retained 105 to work as field personnel. The main training was conducted from August 16-September 14, 2010. The training consisted of instruction regarding interviewing techniques and field procedures, a detailed review of items on the questionnaires followed by tests, instruction and practice in weighing and measuring children, and mock interviews and role plays among participants in the classroom. Each of the fifteen data collection teams included a team leader, a field editor, three female interviewers, one male interviewer, and one biomarker staff member. The main fieldwork was launched immediately upon the conclusion of field staff training. Each of the 15 teams was assigned to 2 of the 30 districts. Fieldwork supervision was conducted by NISR, NRL, and ICF International through regular visits to teams to review their work and monitor data quality. The UNICEF team also regularly visited the teams in the field. Additional contact between the central office and the teams was maintained through cell phones. Fieldwork was conducted from September 26, 2010, to March 10, 2011. Questionnaires and blood samples were regularly delivered to NISR headquarters. 1.2.7 Data Processing Data entry began on November 1, 2010, almost one month after the survey was launched in the field. Data were entered by a team of 15 data processing personnel recruited and trained for this task. They were assisted during these operations by 4 data verification and codification officers and 2 receptionists. Completed questionnaires were periodically brought in from the field to the National Institute of Statistics headquarters, where assigned agents checked them and coded the open-ended questions. Next, the questionnaires were sent to the data entry facility and the blood samples (DBS and malaria slides) were sent to the NRL to be screened for HIV. Data were entered using 10 • Introduction CSPro, a program developed jointly by the United States Census Bureau, the ORC Macro MEASURE DHS+ program, and Serpro S.A. Processing the data concurrently with data collection allowed for regular monitoring of teams’ performance and data quality. Field check tables were regularly generated during data processing to check various data quality parameters. As a result, feedback was given on a regular basis, encouraging teams to continue their high quality work and to correct areas in need of improvement. Feedback was individually tailored to each team. Data entry, which included 100 percent double entry to minimize keying error and data editing, was completed on April 21, 2011. Data cleaning and finalization was completed on May 27, 2011. Household Characteristics • 11 HOUSEHOLD CHARACTERISTICS 2 household is a person or a group of persons, related or unrelated, who live together and share common cooking and eating arrangements. This chapter summarizes demographic and socioeconomic characteristics of the people who live in the households of Rwanda, which were sampled during the 2010 RDHS. Characteristics of the housing structure were also provided by responses to the survey. The Household Questionnaire collected the basic demographic and socioeconomic information (e.g., age, sex, educational attainment, and current school attendance) for all usual residents and visitors who slept in the household the night preceding the interview. This method of data collection allowed for analysis of the results for either the de jure population (usual residents) or the de facto population (persons in the household at the time of the survey). The Household Questionnaire also collected information on housing facilities, including dwelling characteristics, source of water supply, sanitation facilities, and household assets. The information in this chapter is intended to facilitate interpretation of key demographic, socioeconomic, and health indices presented later in the report. It will also assist in the assessment of the representativeness of the survey sample. 2.1 HOUSEHOLD POPULATION BY AGE AND SEX Table 2.1 shows the distribution by age and sex of the household population surveyed, according to urban- rural residence. The household survey involved 55,292 respondents, of which 47,868, or 87 percent, live in rural areas and 7,424, or 13 percent, live in urban areas. Table 2.1 shows the distribution by age and sex of the household population, which is further depicted by the age pyramid in Figure 2.1. The age pyramid is wide at the base, narrowing rapidly as it reaches the upper age limits, an indication of a population with high fertility and even higher mortality. Although the base of the pyramid (age 0-4 years) remains large, the figure shows a decline in fertility as well as an decrease in mortality between age group 0-4 and age group 5-9. In addition, there is a notable gender imbalance: there are 89 males for every 100 females in the total population. Further analysis reveals structural elements peculiar to the Rwandan population. First, the number of men drops off significantly in age groups 10-14, 15-19, 20-24, 30-34, and 35-39. The same trend occurs among females in age groups 10-14, 15-19, and 30-34. The fall in the population at age 10-14 might relate to high child mortality in previous years. And the drop in the age 15-19 group can be directly attributed to the low birth rate during 1994 and the adjacent years, while the fall observed at age group 30-39 might be the effect of Tutsi genocide in 1994. The overrepresentation of women overall is noted in both urban and rural areas. In rural areas, males predominate among those age 0 to 19. From age 20-24 on, however, the situation begins to reverse, and the gap narrows. In urban areas, males age 0 to 14 and 25 to 34 outnumber females, but beginning at age group 35-39, the proportion of females exceeds that of males. A 12 • Household Characteristics Table 2.1 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and residence, Rwanda 2010 Age Urban Rural Total Male Female Total Male Female Total Male Female Total <5 15.2 13.2 14.2 17.9 15.3 16.5 17.5 15.0 16.2 5-9 13.1 12.7 12.9 17.1 14.6 15.8 16.6 14.3 15.4 10-14 11.5 10.8 11.1 14.1 12.7 13.3 13.7 12.4 13.0 15-19 11.3 11.8 11.6 10.9 9.9 10.4 10.9 10.1 10.5 20-24 11.2 12.1 11.7 8.3 8.7 8.5 8.7 9.2 9.0 25-29 12.3 10.5 11.4 7.3 8.3 7.8 8.0 8.5 8.3 30-34 7.9 7.1 7.5 5.3 6.1 5.7 5.6 6.2 6.0 35-39 4.6 5.7 5.2 3.9 4.9 4.4 4.0 5.0 4.5 40-44 3.8 3.7 3.7 3.2 4.0 3.7 3.3 4.0 3.7 45-49 3.1 3.4 3.2 3.0 3.9 3.5 3.0 3.8 3.4 50-54 2.2 2.9 2.6 3.0 3.5 3.3 2.9 3.4 3.2 55-59 1.4 2.2 1.8 2.1 2.6 2.3 2.0 2.5 2.3 60-64 0.8 1.2 1.0 1.3 1.7 1.5 1.2 1.7 1.5 65-69 0.5 0.7 0.6 0.8 1.3 1.1 0.8 1.2 1.0 70-74 0.5 0.8 0.7 0.8 1.1 1.0 0.7 1.1 0.9 75-79 0.2 0.6 0.4 0.4 0.7 0.5 0.4 0.7 0.5 80 + 0.4 0.5 0.4 0.6 0.9 0.7 0.6 0.8 0.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 3,628 3,796 7,424 22,400 25,468 47,868 26,029 29,264 55,292 Figure 2.1 Population Pyramid Rwanda 2010 80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 <5 A ge g ro u p 0246810 0 2 4 6 8 10 Percent MaleFemale 2.2 HOUSEHOLD COMPOSITION Table 2.2 shows that the mean size of a Rwandan household is 4.4 persons. It has decreased slightly compared with the mean household size of 4.6 found in the 2005 RDHS. This mean size varies somewhat by residence: 4.5 in rural areas compares with 4.2 in urban areas. In addition, Table 2.2 shows that 67 percent of Rwandan households are headed by men. Female-headed households represent 33 percent of households, 34 percent in rural areas and nearly the same percentage in urban areas (31 percent). The percentage of female-headed Household Characteristics • 13 households increased significantly between 1992 and 2000, from 21 percent to 36 percent, but dropped slightly again in 2005 (to 34 percent) and in 2010 (to 33 percent). Approximately half of all households contain three to five people, 26 percent hold six to eight people, and 4 percent have nine or more people. One-person households make up only 7 percent of the population. Table 2.2 shows also that 30 percent of households at the national level are lived in by foster and/or orphaned children. The data show that 22 percent of households are lived in by foster children, 16 percent are lived in by single orphans, and 3 percent are lived in by double orphans. No significant variation exists between rural and urban areas. Table 2.2 Household composition Percent distribution of households by sex of head of household and by household size; mean size of household, and percentage of households with orphans and foster children under 18 years of age, according to residence, Rwanda 2010 Characteristic Residence Total Urban Rural Household headship Male 69.5 66.3 66.7 Female 30.5 33.7 33.3 Total 100.0 100.0 100.0 Number of usual members 0 0.0 0.0 0.0 1 10.4 6.1 6.7 2 14.6 11.5 11.9 3 17.4 18.3 18.2 4 17.6 18.4 18.3 5 13.3 16.3 15.8 6 11.0 12.5 12.3 7 7.9 8.5 8.4 8 3.6 5.0 4.8 9+ 4.3 3.5 3.6 Total 100.0 100.0 100.0 Mean size of households 4.2 4.5 4.4 Percentage of households with orphans and foster children under 18 years of age Foster children1 22.1 21.8 21.9 Double orphans 3.8 3.2 3.3 Single orphans2 16.1 15.7 15.8 Foster and/or orphan children 29.5 30.3 30.2 Number of households 1,759 10,781 12,540 Note: Table is based on de jure household members, i.e., usual residents. 1 Foster children are those under age 18 years of age 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. 2.3 EDUCATIONAL ATTAINMENT Tables 2.3.1 and 2.3.2 show the percent distribution of the female and male household populations according to highest level of education attained, by age, residence, province, and household wealth quintile. Educational attainment is important; it contributes to improved living conditions not only for the individual household but for society as a whole. Reproductive behavior, the use of contraception, health habits, school attendance of household members, and habits relating to hygiene and nutrition are all influenced by educational attainment. The data in these two tables show that 22 percent of women and 16 percent of men have never attended school. A comparison of these proportions to those of the previous survey shows slight improvement: at the time of 14 • Household Characteristics the previous survey, 29 percent of women and 22 percent of men had no education at all. The percentage of men and women who have completed primary school is nearly identical (9 percent for women and 10 percent for men,). As educational attainment increases, the percentage of both women and men in these categories decreases: only 2 percent of women and men have completed secondary level education; about 1 percent of women and 2 percent of men have attended any education beyond the secondary level. The percentage of men and women who have completed primary school has increased, from 7 percent to 9 percent for women and from 8 percent to 10 percent for men. However, when compared with previous generations, the figures show significant gains. The proportion of women with no education at all has dropped from 79 percent for women age 65 and over to 2 percent for girls between the ages of 10 and 14. The percentage for males in these age groups has dropped from 43 percent to 2 percent. In addition, the gap in educational attainment between the sexes seems to be narrowing in the younger age groups. The percentage of women who have completed primary school is the same or close to that of men for all ages up to age 34: 14 percent of women between the ages of 15 and 19, compared with 12 percent of men said they had completed primary school. This narrowing of the gap in educational attainment between the sexes is also seen at the secondary level: between the ages of 20 and 24, 5 percent of women and 6 percent of men and have completed secondary school. This contrasts with the common situation of previous generations, when the proportion of women between the ages of 55 and 59 who had completed primary school was 5 percent, while that of men was 17 percent. Table 2.3.1 Educational attainment of the female household population Percent distribution of the de facto female household populations age 6 and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Rwanda 2010 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Age 6-9 28.4 71.4 0.1 0.1 0.0 0.0 0.0 100.0 3,328 0.0 10-14 1.8 94.2 2.6 1.4 0.0 0.0 0.0 100.0 3,637 2.3 15-19 3.3 59.2 13.5 23.3 0.6 0.1 0.0 100.0 2,966 4.4 20-24 9.5 55.6 13.0 14.5 5.4 1.8 0.1 100.0 2,687 3.9 25-29 14.4 57.8 16.9 4.4 3.8 2.5 0.1 100.0 2,502 3.4 30-34 16.5 50.1 21.6 5.9 3.3 2.4 0.1 100.0 1,827 4.2 35-39 20.9 55.8 8.9 9.2 2.8 2.2 0.2 100.0 1,458 4.2 40-44 32.7 46.1 9.1 9.2 1.4 1.2 0.3 100.0 1,168 3.0 45-49 39.9 41.2 11.6 5.4 1.0 0.7 0.2 100.0 1,111 1.4 50-54 49.6 33.4 12.6 3.1 0.6 0.3 0.5 100.0 996 0.0 55-59 61.4 29.7 4.5 2.7 0.5 0.4 0.9 100.0 737 0.0 60-64 63.3 28.4 5.5 1.7 0.6 0.0 0.4 100.0 485 0.0 65+ 79.4 18.0 1.0 0.8 0.0 0.0 0.7 100.0 1,104 0.0 Residence Urban 12.3 51.3 10.0 16.0 5.6 4.6 0.2 100.0 3,178 4.0 Rural 23.5 59.9 9.2 5.8 1.1 0.3 0.2 100.0 20,834 2.1 Province Kigali City 10.6 47.5 10.3 17.7 7.6 6.2 0.1 100.0 2,281 4.5 South 20.9 61.3 9.5 6.7 1.0 0.2 0.3 100.0 5,841 2.3 West 25.5 59.4 8.0 5.5 0.9 0.6 0.2 100.0 5,979 1.9 North 23.6 58.0 11.1 6.0 1.1 0.2 0.1 100.0 4,239 2.1 East 23.0 60.6 8.6 6.1 1.3 0.3 0.1 100.0 5,672 2.0 Wealth quintile Lowest 32.2 60.1 5.3 2.0 0.0 0.0 0.4 100.0 4,876 1.0 Second 27.2 61.1 8.1 3.5 0.1 0.0 0.0 100.0 4,884 1.5 Middle 22.5 62.1 10.1 4.9 0.3 0.0 0.1 100.0 4,756 2.2 Fourth 17.8 61.4 12.1 7.8 0.8 0.0 0.1 100.0 4,775 2.8 Highest 10.0 49.0 10.9 18.1 7.2 4.5 0.2 100.0 4,719 4.4 Total 22.0 58.8 9.3 7.2 1.7 0.9 0.2 100.0 24,012 2.3 1 Completed 6th grade at the primary level 2 Completed 6th grade at the secondary level By residence, the data show significant gaps in educational attainment. In rural areas, 24 percent of women and 17 percent of men have no education at all, compared with 9 percent of men and 12 percent of women in urban areas. Household Characteristics • 15 There are also variations among provinces. The City of Kigali has the lowest percentage of residents with no education (11 percent of women and 7 percent of men). Conversely, the West province has the highest percentage of women and men with no education (26 percent and 17 percent, respectively). As the level of educational attainment increases, the gaps between the provinces widen: in the City of Kigali, 8 percent of women have completed secondary school compared with 1 percent in other provinces; among men, 7 percent have completed secondary school, compared with 1 to 2 percent in other provinces. Results by wealth quintile show that the proportions of both women and men with no education decrease as the household standard of living increases. Conversely, educational level increases with household wealth. In households in the highest wealth quintile, there is practically no gap in educational attainment between women and men up to the secondary level. Table 2.3.2 Educational attainment of the male household population Percent distribution of the de facto male household populations, age 6 and over, by highest level of schooling attended or completed and median years completed, according to background characteristics, Rwanda 2010 Background characteristic No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Don’t know/ missing Total Number Median years completed Age 6-9 31.1 68.6 0.1 0.1 0.0 0.0 0.1 100.0 3,456 0.0 10-14 2.3 94.0 2.2 1.5 0.0 0.0 0.0 100.0 3,572 2.1 15-19 3.4 62.1 11.6 22.4 0.3 0.2 0.1 100.0 2,850 4.2 20-24 7.2 54.2 12.4 17.8 5.8 2.6 0.1 100.0 2,271 4.3 25-29 11.9 53.8 18.7 6.5 4.8 4.2 0.0 100.0 2,085 3.9 30-34 12.0 48.4 21.5 10.0 3.8 4.2 0.2 100.0 1,468 4.8 35-39 18.8 52.1 10.3 11.2 4.1 3.5 0.1 100.0 1,032 4.5 40-44 19.2 50.6 10.3 13.6 2.3 3.8 0.1 100.0 861 4.7 45-49 30.5 43.8 13.4 8.5 2.2 1.5 0.1 100.0 786 2.5 50-54 28.8 44.0 18.2 4.4 2.4 1.3 0.9 100.0 759 2.5 55-59 29.5 45.9 16.5 5.1 1.7 1.3 0.0 100.0 519 2.4 60-64 37.1 40.5 14.0 5.0 1.8 0.6 0.9 100.0 318 2.0 65+ 43.4 47.1 5.9 2.2 0.6 0.6 0.2 100.0 632 0.7 Residence Urban 9.0 52.2 11.5 15.7 5.4 6.1 0.1 100.0 2,988 4.2 Rural 16.7 64.2 9.4 7.4 1.4 0.8 0.1 100.0 17,622 2.3 Province Kigali City 6.6 49.7 12.1 17.8 6.8 7.0 0.0 100.0 2,197 4.7 South 17.0 64.9 9.0 6.9 1.3 0.5 0.4 100.0 4,977 2.2 West 17.3 64.5 7.6 7.6 1.7 1.3 0.1 100.0 4,889 2.3 North 15.4 62.0 11.9 8.2 1.2 1.1 0.1 100.0 3,469 2.6 East 16.4 64.1 10.0 7.4 1.3 0.7 0.0 100.0 5,078 2.3 Wealth quintile Lowest 25.0 66.1 5.3 3.0 0.1 0.1 0.4 100.0 3,640 1.2 Second 20.0 67.6 7.4 4.6 0.3 0.1 0.1 100.0 3,883 1.8 Middle 15.9 67.0 10.5 5.9 0.5 0.2 0.1 100.0 4,150 2.3 Fourth 12.3 63.1 12.5 10.1 1.6 0.4 0.0 100.0 4,317 3.0 Highest 7.0 50.8 12.0 17.3 6.6 6.1 0.2 100.0 4,621 4.5 Total 15.5 62.5 9.7 8.6 2.0 1.5 0.1 100.0 20,610 2.6 1 Completed 6th grade at the primary level 2 Completed 6th grade at the secondary level 2.4 SCHOOL ATTENDANCE The level of school attendance of children is the primary indicator of a population’s access to education and, indirectly, its socioeconomic development. The 2010 RDHS asked questions concerning school attendance of all respondents between age 5 and age 24. Table 2.4 shows net attendance ratios (NARs) and gross attendance ratios (GARs) by sex and level of schooling, according to background characteristics. Net school attendance ratios (NARs) measure school attendance in children who have reached the official school age. At the primary school level, the NAR is the percentage of the primary-school-age population (age 7-12 in Rwanda) that actually attend primary school. Table 2.4 shows that the primary level NAR is 87 percent for 16 • Household Characteristics Rwanda, which means that almost 9 in 10 children between the ages of 7 and 12 attend primary school. The ratio is higher for urban areas than for rural areas (92 percent compared with 87 percent). In the provinces, the ratio ranges from a high of 92 percent in the City of Kigali to a low of 85 percent in West province. Household wealth also affects the NAR, which is 80 percent at the lowest wealth quintile compared with 94 percent at the highest one. The NAR is also higher for female children (88 percent) than for male children (86 percent), regardless of urban/rural residence, and household wealth quintile. At the secondary level, where children are age 13-18, the NAR is much lower (15 percent), which means that only 15 percent of the official secondary-school-age population actually attends school. There is practically no gap between the sexes (16 percent for women compared with 15 percent for men). However, the NAR is much higher in urban areas than in rural areas (27 percent compared with 13 percent), which may explain the major gap between the City of Kigali, with a NAR of 27 percent, and the other provinces, whose NARs are between 12 percent (East) and 15 percent (North, West, South provinces). Table 2.4 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population by sex and level of schooling; and the Gender Parity Index (GPI), according to background characteristics, Rwanda 2010 Background characteristic Net attendance ratio1 Gross attendance ratio2 Male Female Total Gender Parity Index3 Male Female Total Gender Parity Index3 PRIMARY SCHOOL Residence Urban 90.3 93.6 91.9 1.04 138.1 140.1 139.1 1.01 Rural 85.7 87.7 86.7 1.02 141.1 146.4 143.7 1.04 Province Kigali City 91.4 92.8 92.1 1.01 133.7 138.2 135.7 1.03 South 85.0 88.9 86.8 1.05 141.8 151.0 146.3 1.06 West 84.8 85.5 85.2 1.01 138.0 141.7 139.9 1.03 North 90.6 91.5 91.1 1.01 144.5 148.6 146.6 1.03 East 84.3 87.4 85.8 1.04 142.3 144.6 143.4 1.02 Wealth quintile Lowest 78.0 81.3 79.7 1.04 126.6 134.4 130.5 1.06 Second 84.5 86.9 85.7 1.03 141.0 144.5 142.8 1.02 Middle 87.3 88.5 87.9 1.01 143.3 153.2 148.0 1.07 Fourth 88.5 91.3 90.0 1.03 147.9 150.6 149.3 1.02 Highest 93.4 94.6 94.0 1.01 145.1 145.9 145.5 1.01 Total 86.3 88.4 87.3 1.02 140.7 145.6 143.2 1.03 SECONDARY SCHOOL Residence Urban 23.7 29.0 26.5 1.23 47.8 48.8 48.3 1.02 Rural 13.3 13.6 13.4 1.02 24.7 22.0 23.3 0.89 Province Kigali City 25.4 28.1 26.9 1.10 55.0 53.1 53.9 0.96 South 13.1 15.8 14.5 1.20 24.1 24.4 24.3 1.02 West 15.2 14.4 14.8 0.95 27.0 22.3 24.5 0.82 North 14.6 14.9 14.8 1.02 28.1 23.8 25.9 0.85 East 12.1 12.2 12.2 1.01 23.1 20.7 21.9 0.90 Wealth quintile Lowest 7.3 5.8 6.5 0.80 13.0 8.8 10.8 0.68 Second 10.0 8.8 9.3 0.88 17.6 14.0 15.8 0.80 Middle 11.7 11.3 11.5 0.97 22.1 18.0 20.0 0.81 Fourth 15.7 18.0 16.8 1.15 32.0 28.4 30.2 0.89 Highest 25.6 32.2 28.9 1.26 47.8 55.0 51.4 1.15 Total 14.6 15.6 15.1 1.07 27.6 25.5 26.5 0.93 1 The NAR for primary school is the percentage of the primary-school-age (7-12 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school age (13-18 years) population that is attending secondary 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. The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary-school-age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent. 3 The Gender Parity Index for primary school is the ratio of the primary school NAR(GAR) for females to the NAR(GAR) for males. The Gender Parity Index for secondary school is the ratio of the secondary school NAR(GAR) for females to the NAR(GAR) for males. Table 2.4 also shows gross school attendance ratios (GARs). Unlike a NAR, a GAR measures school attendance in young people regardless of age. The GAR for primary school is the total number of students of any Household Characteristics • 17 age attending primary school, expressed as a percentage of the official primary-school-age population, which is 7 to 12 years in Rwanda. Unless there are significant numbers of over-age and under-age students at a given level of schooling, the GAR is always higher than the NAR and can, in some cases, exceed 100 percent. In Rwanda, the GAR is 143 percent, which means that a significant proportion of children who do not fall into the official primary- school-age category are attending school at the primary level. These are likely to be children over age 12 or under age 7 who are attending primary school; in fact, a program exists to reintegrate children who drop out of primary school for any reason. In addition, the GAR is higher for girls than for boys (146 percent for girls compared with 141 percent for boys). Moreover, there is practically no difference by residence. At the secondary level, the GAR is low. Slightly more than one-quarter (27) percent of all children of official secondary school age actually attend school. The GAR is low either because official secondary-school-age children are still in primary school or because they have dropped out of secondary school or have never attended at all. The ratio is nearly the same for girls (26) and boys (28). However, it is higher in urban areas than in rural areas (48 percent compared with 23 percent). Similarly, there is a pronounced difference by province: at 54 percent, the GAR for the City of Kigali stands out from the other provinces, while the GAR varies from a maximum of 22 percent in the East province to 26 percent in the North province. The GAR increases with wealth; 11 percent of the potential student population from the lowest quintile actually attends secondary school while this proportion is 51 percent for students in the highest quintile. The table also includes a third school attendance indicator: the gender parity index (GPI), which is the ratio of the GAR for females to the GAR for males. The narrower the gap between the sexes, the closer the index is to 1. The GPI for primary school is just above 1, and this situation doesn’t change with residence, province, or wealth quintile. This indicates an absence of disparity between the sexes. The GPI for secondary school is below one (0.93); this indicates that girls are educationally disadvantaged at this level. The inequality is more pronounced in rural areas, which have a GPI of only 0.89 compared with 1.02 in urban areas. South province, has the highest GPI (1.02) while in other provinces it varies from 0.96 (City of Kigali) to 0.85 (North province). The GPI changes with the wealth quintile, rising from 0.68 percent at the lowest quintile to 1.15 at the highest quintile. 18 • Household Characteristics Figure 2.2 Age-Specific Attendance Rates of the De Facto Population Age 5-24 RDHS 2010 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age 0 20 40 60 80 100 Percent Female Male Note: Figure shows percentage of the de facto household population age 5-24 attending school Figure 2.2 shows that the rate of school attendance, which is low at age 5, begins to increase at age 6, and reaches a high level between age 10 and age 13. This period corresponds to the primary school years for children in classes four, five, and six in the normal primary cycle and to the first year of the secondary school. After age 13, the age at the beginning of the secondary cycle, the curve declines steadily, reaching its lowest point at age 24. It should also be noted that the proportion of women who attend is higher than the proportion of men who attend between age 5 and age 11 while the situation balances at ages 12-14 before reversing itself up to age 24. The only exception to this pattern is at age 15 paradoxically, where we observe an imbalance in favor of female students. 2.5 HOUSEHOLD CONDITIONS The household survey gathered information on certain household characteristics: access to electricity, source of drinking water, type of toilet facilities, and type of roofing and flooring materials. Information was also sought concerning ownership of various modern durable goods, including a radio, television, mobile phone, refrigerator, bicycle, motorcycle/scooter, and car/truck. Household characteristics and ownership of durable goods were used to evaluate the socioeconomic conditions of the household. 2.5.1 Household Drinking Water With respect to drinking water, Table 2.5 shows, at the national level, that 74 percent of households have access to an improved source of drinking water. The most common source of drinking water used by the households is protected spring water, which accounts for 38 percent of usage, followed by public tap/standpipe (26 percent). Only 5 percent of the households have running water in their dwelling or courtyard. Overall, 25 percent of households use unimproved sources of water, which is considered unhealthy. For example, 14 percent of the households use an unprotected spring as a water source, which increases the household members’ risk of contracting diarrhea and other waterborne diseases. Household Characteristics • 19 With respect to residence, it appears that the urban households are more likely than rural households to use improved drinking water (90 percent versus 71 percent). In contrast, 28 percent of the households in rural areas use unsafe drinking water compared with 7 percent of those in urban areas. In fact, 16 percent of these households collect their water from an unprotected spring, 10 percent collect it from surface water, and 2 percent retrieve it from an unprotected dug well. Regarding the time spent in roundtrip travel to obtain drinking water, Table 2.5 shows that slightly more than half of the households (53 percent) spend 30 minutes or longer to get to the water source, and only two in five (42 percent) spend fewer than 30 minutes. Only 5 percent of the households have water on their premises. In rural areas, 57 percent of the households take 30 minutes or longer to get to the source of water compared with 29 percent in urban areas. The proportions of households who spend fewer than 30 minutes to get to a source of water vary slightly between rural areas (41 percent) and urban areas (45 percent). With respect to the treatment of water prior to drinking, 49 percent of the households use an appropriate treatment method prior to drinking, while the other 51 percent of the households do not treat their water prior to drinking. Table 2.5 Household drinking water Percent distribution of households and de jure population by source, time to collect, and treatment of drinking water, according to residence, Rwanda 2010 Characteristic Households Population Urban Rural Total Urban Rural Total Source of drinking water Improved source 89.6 71.2 73.8 89.1 71.2 73.6 Piped water into dwelling/yard/plot 23.7 1.4 4.5 26.7 1.6 5.0 Public tap/standpipe 40.9 23.4 25.8 38.1 23.6 25.5 Tubewell/borehole 1.6 2.4 2.3 1.5 2.3 2.2 Protected dug well 2.1 2.5 2.5 2.1 2.4 2.4 Protected spring 20.3 41.0 38.1 20.0 40.8 38.0 Rainwater 0.2 0.4 0.4 0.0 0.4 0.4 Bottled water 0.8 0.0 0.1 0.7 0.0 0.1 Nonimproved source 7.0 27.9 25.0 7.4 27.9 25.2 Unprotected dug well 0.5 2.2 1.9 0.6 2.1 1.9 Unprotected spring 5.4 15.7 14.2 5.6 15.9 14.5 Tanker truck/cart with drum 0.0 0.0 0.0 0.0 0.0 0.0 Surface water 1.1 10.0 8.8 1.2 10.0 8.8 Other 3.4 0.9 1.2 3.4 0.8 1.2 Missing 0.0 0.1 0.0 0.0 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Percentage using any improved source of drinking water 89.6 71.2 73.8 89.1 71.2 73.6 Time to obtain drinking water (round trip) Water on premises 25.7 2.1 5.4 28.9 2.2 5.8 Less than 30 minutes 45.4 40.9 41.5 42.7 40.0 40.4 30 minutes or longer 28.7 56.7 52.8 28.1 57.6 53.6 Don’t know/missing 0.3 0.3 0.3 0.2 0.2 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment prior to drinking1 Boiled 58.5 38.4 41.2 61.8 39.1 42.2 Bleach/chlorine added 10.3 13.7 13.2 11.2 14.6 14.2 Strained through cloth 1.5 0.5 0.6 1.6 0.5 0.6 Ceramic, sand or other filter 0.8 0.2 0.3 1.2 0.2 0.3 Solar disinfection 0.0 0.0 0.0 0.0 0.0 0.0 Other 1.4 1.3 1.4 1.1 1.3 1.3 No treatment 34.7 53.1 50.5 31.2 51.9 49.1 Percentage using an appropriate treatment method2 64.4 46.1 48.7 68.1 47.3 50.1 Number 1,759 10,781 12,540 7,444 48,142 55,585 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. 20 • Household Characteristics The most common method to treat water prior to drinking is boiling (41 percent), followed by adding bleach/chlorine (13 percent). Households in rural areas are more likely to drink untreated water (53 percent) than those in urban areas (35 percent). 2.5.2 Household Sanitation Facilities With respect to type of toilet facilities, Table 2.6 shows 55 percent of households have access to an improved/not shared pit latrine with slab (57 percent in rural areas compared with 42 percent in urban areas). Less than 1 percent of households have flush/pour flush to piped sewer system. Data show also that 2 percent of households use a ventilated improved pit (VIP) latrine. However, 16 percent of households use an improved pit latrine with slab but share the latrine with other households (37 percent in urban areas compared with 13 percent in rural areas). One in four households (26 percent) uses an unimproved facility, with the majority (23 percent) using a pit latrine without a slab/open pit. Twenty-five percent of rural households and 11 percent of urban households use this type of facility. It should be noted that, about 1 percent of households in Rwanda have no sanitation facility at all (1 percent in urban areas and 2 percent in rural areas). The number of households with no facility has decreased from 5 percent since 2005. The pit latrine with or without a slab is the most common sanitation facility in Rwanda. Table 2.6 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Rwanda 2010 Type of toilet/latrine facility Households Population Urban Rural Total Urban Rural Total Improved, not shared facility Flush/pour flush to piped sewer system 3.1 0.1 0.6 3.6 0.2 0.6 Flush/pour flush to septic tank 0.3 0.0 0.1 0.3 0.0 0.1 Flush/pour flush to pit latrine 1.7 0.1 0.4 2.1 0.2 0.4 Ventilated improved pit (VIP) latrine 1.8 1.4 1.5 2.3 1.5 1.6 Pit latrine with slab 42.2 56.8 54.8 47.9 60.5 58.8 Composting toilet 0.1 0.4 0.4 0.1 0.4 0.3 Shared facility1 Flush/pour flush to piped sewer system 0.1 0.0 0.0 0.1 0.0 0.0 Flush/pour flush to septic tank 0.0 0.0 0.0 0.0 0.0 0.0 Flush/pour flush to pit latrine 0.0 0.0 0.0 0.0 0.0 0.0 Ventilated improved pit (VIP) latrine 1.2 0.3 0.4 1.0 0.2 0.3 Pit latrine with slab 36.7 12.8 16.1 30.5 10.3 13.0 Composting toilet 0.1 0.1 0.1 0.1 0.1 0.1 Nonimproved facility Flush/pour flush not to sewer/septic tank/pit latrine 0.3 0.4 0.4 0.4 0.4 0.4 Pit latrine without slab/open pit 10.7 25.1 23.0 10.1 24.4 22.5 Bucket 0.0 0.0 0.0 0.0 0.0 0.0 No facility/bush/field 0.9 1.5 1.4 0.8 1.2 1.1 Other 0.5 0.8 0.8 0.5 0.6 0.6 Missing 0.2 0.0 0.1 0.2 0.0 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,759 10,781 12,540 7,444 48,142 55,585 1 Shared facility of an otherwise improved type. 2.5.3 Households with Hand Washing Places Washing hands with water and soap before eating, while preparing food, and after leaving the toilet is a simple and inexpensive good practice that protects against many diseases. During the survey, the interviewers asked and observed each household to see if there were a place used for hand washing and if water and soap or some other cleansing agent was available. Table 2.7 shows that only 10 percent of the households have a place for hand washing. Among those households, one in five (21 percent) has water and soap for hand washing. Nearly one in four of them (23 percent) has water only, and in 3 percent of the households there is soap but no water. In urban areas, 13 percent of the households have a place for hand washing compared with 10 percent of the households in rural areas. In urban areas, 47 percent of households have soap and water available at a hand washing place, but only 15 percent of the rural Household Characteristics • 21 households have it available. A higher percentage of households in rural areas have no water, no soap, and no other cleansing agent available than do those in urban areas (58 percent compared with 26 percent). Among the provinces, 17 percent of the households in East province and 11 percent of the households in South province have a place for hand washing; however, in West province, only 4 percent of the households have such a place. Among households where a place for hand washing was observed, a high proportion of households in Kigali City (69 percent) have soap and water compared with only 9 percent of households in South province. A large proportion of the households in the other provinces have no water, soap, or other cleansing agent at a place for hand washing (68 percent in the South, 57 percent in the East, and 53 percent in North province) compared with the Kigali City (7 percent). The proportion of households with a place for hand washing increases with the level of wealth index; it rises from 8 percent among households in the lowest and second quintiles to 16 percent among those in the highest quintile. More than three quarters of households in the lowest wealth quintile (77 percent) have no water, soap, or other cleansing agent available at a place for hand washing. This same finding was observed in only 26 percent of the households in the highest quintile. Table 2.7 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, Rwanda 2010 Background characteristics Among households where place for hand washing was observed Percentage of households where place for washing hands was observed Number of households Soap and water1 Water only Soap but no water3 Cleansing agent other than soap only2 No water, no soap, no other cleansing agent Missing Total Number of households with place for hand washing observed Residence Urban 12.7 1,759 47.3 22.0 4.2 0.5 25.7 0.4 100.0 224 Rural 10.0 10,781 14.9 23.5 2.8 0.1 58.0 0.7 100.0 1,083 Province Kigali City 9.7 1,284 69.0 20.2 3.0 0.0 7.0 0.7 100.0 125 South 10.6 3,136 9.1 18.2 4.9 0.0 67.5 0.3 100.0 334 West 4.2 2,967 20.6 35.7 2.3 0.0 39.9 1.6 100.0 126 North 9.3 2,120 18.6 22.6 4.6 1.0 53.2 0.0 100.0 197 East 17.3 3,033 16.8 24.4 1.4 0.0 56.5 0.9 100.0 525 Wealth quintile Lowest 7.9 2,838 5.0 13.4 2.7 0.5 77.1 1.3 100.0 224 Second 7.7 2,600 6.0 17.9 3.9 0.0 71.4 0.7 100.0 200 Middle 9.9 2,448 10.2 28.3 3.3 0.0 56.8 1.4 100.0 242 Fourth 11.9 2,287 14.7 30.6 3.3 0.3 51.0 0.0 100.0 271 Highest 15.6 2,367 48.6 23.4 2.2 0.0 25.5 0.2 100.0 370 Total 10.4 12,540 20.5 23.2 3.0 0.2 52.5 0.7 100.0 1,307 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 2.5.4 Household Characteristics The survey collected household information on access to electricity, type of flooring materials, number of sleeping rooms, places for cooking, types of cooking fuel, and presence of tobacco smoking inside the house. These characteristics and others are used to evaluate the socioeconomic and living conditions of the household. Table 2.8 shows that only 1 in 10 households in Rwanda has access to electricity. The situation has improved since 2005 when only 5 percent, or 1 in 20 households, had access to electricity. The results show large disparities between urban and rural areas. In rural areas, only 4 percent of households have electricity; which compares with 45 percent of households in urban areas. The type of material used for flooring is extremely important. Some materials propagate disease-causing germs and parasites. The large majority (81 percent) of floors in Rwandan houses are earth or sand. This proportion is higher in rural areas (87 percent) than in urban areas (43 percent). Sixteen percent of households have cement floors. However, this type of flooring is more commonly observed in urban than in rural areas (53 percent compared 22 • Household Characteristics with 11 percent). In 2005, 86 percent of the surveyed households’ floors were earth/sand and 13 percent were cement. Table 2.8 shows that 43 percent of households have two rooms for sleeping (44 percent in urban areas compared with 36 percent in rural areas). It should be noted that in about 1 in 4 households (26 percent) all household members sleep together in a single room. This proportion is more or less the same in both rural areas and urban areas (26 percent compared with 29 percent). More than half (52 percent) of the households cook their meals in a separate building. There is no significant difference between rural and urban areas (52 percent and 51 percent respectively). Nevertheless, 27 percent of the households cook in the same house that is used for sleeping (29 percent of rural households and 14 percent of urban households). Table 2.8 shows that, 77 percent of households use wood as cooking fuel. More rural households than urban households use wood as cooking fuel (83 percent compared with 36 percent). The second most common cooking fuel is straw/shrubs/grass, which is used by 12 percent. One in 10 households in Rwanda uses charcoal for cooking, including 50 percent of those in urban areas but only 3 percent in rural areas. Most of the households use a solid fuel such as coal/lignite, charcoal, wood, straw, shrubs, grass, agricultural crops, or animal dung for cooking (98 percent). There is no significant difference between rural and urban areas. Twenty-two percent of the households report that someone has smoked inside the house; in 20 percent of all households, this happens on a daily basis (21 percent in rural areas compared with 16 percent in urban areas). Table 2.8 Household characteristics Percent distribution of households by housing characteristics and percentage using solid fuel for cooking; and percentage distribution by frequency of smoking in the home, according to residence, Rwanda 2010 Housing characteristic Residence Urban Rural Total Electricity Yes 44.5 4.0 9.7 No 55.5 95.9 90.3 Missing 0.0 0.0 0.0 Total 100.0 100.0 100.0 Flooring material Earth, sand 42.5 87.3 81.0 Dung 0.5 0.8 0.8 Wood/planks 0.0 0.0 0.0 Ceramic tiles 2.9 0.1 0.5 Cement 52.8 10.5 16.4 Other 1.2 1.3 1.3 Missing 0.0 0.0 0.0 Total 100.0 100.0 100.0 Rooms used for sleeping One 29.2 25.8 26.2 Two 36.4 43.7 42.7 Three or more 34.1 30.0 30.6 Missing 0.3 0.5 0.4 Total 100.0 100.0 100.0 Place for cooking In the house 14.0 28.9 26.8 In a separate building 50.7 52.2 52.0 Outdoors 32.0 18.0 20.0 Other 0.2 0.0 0.1 Missing 3.1 0.9 1.2 Total 100.0 100.0 100.0 Continued… Household Characteristics • 23 Table 2.8—Continued Housing characteristic Residence Urban Rural Total Cooking fuel Electricity 0.1 0.0 0.0 LPG/natural gas/biogas 0.2 0.0 0.1 Kerosene 0.5 0.0 0.1 Charcoal 50.1 3.0 9.6 Wood 36.4 83.3 76.7 Straw/shrubs/grass 9.1 12.4 12.0 Agricultural crop 0.0 0.2 0.2 Animal dung 0.0 0.0 0.0 Other 0.4 0.1 0.2 No food cooked in household 3.1 0.9 1.2 Missing 0.0 0.0 0.0 Total 100.0 100.0 100.0 Percentage using solid fuel for cooking1 95.6 98.9 98.4 Frequency of smoking in the home Daily 16.1 20.7 20.0 Weekly 1.4 2.0 1.9 Monthly 0.3 0.3 0.3 Less than monthly 0.2 0.1 0.1 Never 82.1 76.9 77.6 Missing 0.0 0.0 0.0 Total 100.0 100.0 100.0 Number 1,759 10,781 12,540 LPG = Liquid petroleum gas 1 Includes coal/lignite, charcoal, wood/straw/shrubs/grass, agricultural crops, and animal dung 2.5.5 Household Possession of Durable Goods To evaluate households’ socioeconomic level, the survey gathered information on the possession of various household durable goods, the means of transportation used by household members, and ownership of agricultural land and livestock/farm animals. Table 2.9 shows that, overall, the most frequently owned household good is the radio (63 percent), which is more often reported by households in urban areas than in rural areas (76 percent compared with 60 percent). The proportion of households owning radios has increased significantly since 2005, when only 46 percent of households owned a radio. The second household effect is the mobile telephone (40 percent), which is found more often in urban households than in rural households (72 percent compared to 35 percent). Also the proportion of households owning a mobile telephone has significantly increased since 2005 when it was only 5 percent. In addition, in urban areas, 28 percent of households own a television, and 7 percent own a refrigerator; in rural areas, these goods are more or less nonexistent. Bicycles are used as a means of transportation in 16 percent of households in rural areas and in 11 percent of households in urban areas. Overall, 82 percent of households own agricultural land. The proportion varies significantly by urban-rural residence: 87 percent of rural households own agricultural land compared with 49 percent of urban households. Fifty-seven percent of households possess farm animals (61 percent of households in rural areas compared with 38 percent of those in urban areas). 24 • Household Characteristics Table 2.9 Household possessions Percentage of households possessing various household effects, means of transportation, agricultural land and livestock/farm animals by residence, Rwanda 2010 Possession Residence Urban Rural Total Household effects Radio 75.9 60.4 62.6 Television 27.6 1.6 5.3 Mobile telephone 71.8 35.1 40.3 Non-mobile telephone 1.4 0.1 0.3 Refrigerator 7.0 0.3 1.2 Means of transport Bicycle 11.0 15.9 15.2 Animal drawn cart 0.1 0.0 0.0 Motorcycle/scooter 2.6 0.9 1.1 Car/truck 4.8 0.2 0.8 Boat with a motor 0.0 0.0 0.0 Ownership of agricultural land 48.6 86.8 81.5 Ownership of farm animals1 37.7 60.6 57.4 Number 1,759 10,781 12,540 1 Cattle, cows, bulls, horses, donkeys, goats, sheep, or chickens 2.5.6 Household Wealth Quintile Table 2.10 shows the percent distribution of the de jure population by wealth quintile and Gini coefficient. The wealth index was developed on the basis of de jure population goods data, using principal components analysis. The information on household goods comes from responses to questions about ownership of certain durable goods (television, radio, car, mobile telephone, etc.) and questions about certain housing characteristics (access to electricity, source of drinking water, type of toilet facilities, type of flooring material, number of rooms used for sleeping, and type of cooking fuel. The index was developed using the following steps: • Each durable goods or housing characteristic was assigned a weight (score or coefficient) generated by principal components analysis. • The resulting scores for durable goods are standardized according to a normal distribution that assumes a mean of 0 and a standard deviation of 1 (Gwatkin et al., 2000). • Each household is assigned a score for each durable good, and these scores are added together to obtain a total for each household. • The households are classified in increasing order of total score and divided into 5 equal categories, or quintiles. This yields a scale from 1 (the poorest quintile) to 5 (the richest quintile). • The score for each household is assigned to the individuals in that household. The individuals are thus distributed among the categories. The results show that in urban areas, 68 percent of the de jure population falls into the richest quintile, while in rural areas only 13 percent falls into this quintile. The proportion of rich households is highest in Kigali City (80 percent). Conversely, in urban areas, only 15 percent of households fall into the poorest quintile. In fact, the preceding tables showing ownership of durable goods, housing characteristics, and source of drinking water have already established that the population of Rwanda is generally poor. Table 2.6 confirms the previous results and explains the relative lack of variation among provinces. Household Characteristics • 25 Table 2.10 Wealth quintiles Percent distribution of the de jure population by wealth quintiles, and the Gini Coefficient, according to residence and province, Rwanda 2010 Residence/Province Wealth quintile Lowest Second Middle Fourth Highest Total Number of population Gini coefficient Residence Urban 15.0 2.7 3.7 11.0 67.6 100.0 7,444 18.8 Rural 20.8 22.7 22.5 21.4 12.6 100.0 48,142 5.2 Province Kigali City 2.2 2.1 5.9 9.6 80.2 100.0 5,459 12.7 South 32.5 21.9 18.3 15.3 12.1 100.0 13,534 8.1 West 23.2 25.5 21.6 17.1 12.7 100.0 13,624 6.0 North 18.5 23.2 25.0 21.6 11.7 100.0 9,413 4.1 East 12.6 17.6 22.4 30.7 16.8 100.0 13,555 5.6 Total 20.0 20.0 20.0 20.0 20.0 100.0 55,585 12.4 2.6 BIRTH REGISTRATION WITH CIVIL AUTHORITIES Registering a child with civil authorities establishes the child’s legal family ties and his or her right to a name and nationality prior to the age of majority. It confers on the child the right to be recognized by his or her parents and the right to state protection if his or her rights are abused by parents. It gives the child access to social assistance through the parents, including health insurance, and establishes family lineage. Registration is therefore an essential formality. Registration of a child with civil authorities, if performed correctly, also provides a reliable source of socio- demographic statistics. For this reason, the survey asked all children in each household whether the children had been registered with the civil authorities. Table 2.11 shows that 63 percent of the children have been registered with the civil authorities and 37 percent have not been registered. The percentage registered has dropped significantly since the 2005 survey when 82 percent were registered. Of those children who were registered with the civil authorities at the time of the survey, only 7 percent possess birth certificates. Those children who are age 2-4 are registered more often than those who are younger than age 2 (71 percent compared with 49 percent, respectively). Gender has little to do with whether or not the children are registered with the civil authorities. Also, level of household wealth does not seem to influence the prevalence of birth registration. Children in the fourth and middle wealth quintiles showed the highest levels of registration (67 percent and 65 percent respectively). There is some discrepancy by urban/rural residence because the rural areas show a higher percentage of birth registrations (64 percent compared with 60 percent in urban areas). Results by province show that households in the North and South provinces are the most likely to have declared their children with the civil authorities (79 percent and 66 percent, respectively). 26 • Household Characteristics Table 2.11 Birth registration of children under age 5 Percentage of de jure children under age 5 whose births are registered with the civil authorities, according to background characteristics, Rwanda 2010 Background characteristic Children whose births are registered Percentage who had birth certificate Percentage who did not have birth certificate Percentage registered Number of children Age <2 6.2 43.1 49.3 3,210 2-4 6.8 64.2 71.0 5,760 Sex Male 6.8 56.8 63.6 4,578 Female 6.4 56.5 62.9 4,393 Residence Urban 8.2 52.2 60.4 1,052 Rural 6.4 57.2 63.6 7,918 Province Kigali City 5.5 52.9 58.5 826 South 8.0 57.5 65.5 2,185 West 8.4 52.6 60.9 2,239 North 7.7 71.4 79.2 1,386 East 3.3 52.2 55.6 2,335 Wealth quintile Lowest 5.6 52.8 58.4 2,086 Second 5.2 57.2 62.3 1,924 Middle 6.6 58.8 65.4 1,800 Fourth 6.8 60.3 67.1 1,668 Highest 9.5 54.7 64.2 1,492 Total 6.6 56.6 63.2 8,971 2.7 CHILDREN’S LIVING ARRANGEMENTS AND ORPHANHOOD Because the family is the primary safety net for children, any strategy aimed at protecting children must place a high priority on strengthening the family’s capacities to care for children. It is therefore essential to identify orphaned children and find out whether those who have one or both parents alive are living with either or both surviving parents. Table 2.12 presents these two types of information for children under age 18, according to background characteristics. The data show that 61 percent of Rwandan children under the age of 18 live with both their parents. This proportion declines steadily with age, from a high of 76 percent under age 2 and 70 percent at age 2 to age 4 years, to a low of 40 percent at age 15 to 17. The results show practically no difference, according to the child’s sex. The proportion of children living with their parents is higher in rural areas (62 percent) than in urban areas (57 percent). The lowest proportion of children living with both parents is in the South province (56 percent); the highest proportion is in the North province (64 percent). Twenty-three percent of children under age 18 live with their mother only, whether their father is alive (16 percent) or deceased (7 percent) and 2 percent live with their father only. Thirteen percent (13 percent) do not live with either parent. Overall, 13 percent of children under age 18 have lost one or both parents: 2 percent have lost both parents, 9 percent have lost their father, and 3 percent have lost their mother. Because a parent’s risk of dying increases with time, the proportion of children who have lost their father and/or mother increases significantly with the age of the child, from 1 percent at age less than 2 years, to 3 percent at age 2 to 4 years, and to 9 percent at age 5 to 9 years. This proportion jumps very high level among children age 10 to 14 (21 percent) and 15 to 17 (35 percent), largely due to the effects of the 1994 genocide. Household Characteristics • 27 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, Rwanda 2010 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 Percent- age not living with a biological parent Percent- age 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 information on father/ mother Age 0-4 72.3 19.0 1.9 0.8 0.2 4.4 0.2 0.2 0.1 0.9 100.0 4.9 2.6 8,971 <2 75.8 21.5 1.2 0.2 0.1 0.6 0.0 0.0 0.0 0.5 100.0 0.7 1.4 3,210 2-4 70.4 17.6 2.2 1.2 0.3 6.6 0.3 0.2 0.2 1.1 100.0 7.3 3.3 5,760 5-9 64.2 15.4 5.1 1.6 0.9 8.9 1.0 1.1 0.9 0.9 100.0 11.9 9.1 8,549 10-14 53.7 13.6 11.6 1.6 1.9 9.1 1.7 2.9 2.7 1.2 100.0 16.4 20.9 7,244 15-17 40.2 10.6 18.3 1.4 2.2 10.2 3.1 5.6 6.1 2.4 100.0 25.0 35.4 3,670 Sex Male 61.4 15.4 7.2 1.5 1.1 7.2 1.3 1.7 1.9 1.2 100.0 12.1 13.4 14,311 Female 60.6 15.5 7.6 1.1 1.1 8.3 1.0 2.0 1.7 1.2 100.0 13.0 13.5 14,121 Residence Urban 57.0 15.8 8.0 2.1 1.0 7.7 1.7 2.9 2.2 1.7 100.0 14.5 16.0 3,336 Rural 61.5 15.4 7.4 1.2 1.1 7.7 1.1 1.7 1.7 1.1 100.0 12.3 13.1 25,097 Province Kigali City 58.6 16.6 6.1 2.0 1.5 6.9 1.7 2.9 2.1 1.7 100.0 13.5 14.5 2,336 South 56.1 18.8 7.6 1.3 1.0 8.7 1.2 1.8 1.9 1.6 100.0 13.6 13.7 6,957 West 63.1 14.2 8.2 1.0 1.1 6.9 1.1 1.7 2.0 0.7 100.0 11.7 14.1 7,223 North 64.4 13.3 6.7 0.8 0.8 8.4 1.4 1.4 1.6 1.1 100.0 12.9 12.2 4,856 East 62.2 14.6 7.4 1.9 1.2 7.5 0.9 1.9 1.5 1.0 100.0 11.8 12.9 7,061 Wealth quintile Lowest 51.3 21.9 11.1 1.5 1.1 7.8 1.2 1.1 1.4 1.5 100.0 11.6 16.0 5,995 Second 58.4 17.5 8.7 0.9 1.2 7.5 1.1 1.5 2.1 1.1 100.0 12.2 14.6 5,913 Middle 66.0 12.8 6.8 1.2 1.1 7.2 1.1 1.4 1.3 1.1 100.0 11.0 11.8 5,635 Fourth 69.5 11.0 5.5 1.0 0.9 6.7 1.1 1.8 1.7 0.8 100.0 11.3 11.1 5,704 Highest 60.5 13.4 4.7 2.1 1.1 9.5 1.5 3.4 2.5 1.3 100.0 16.9 13.3 5,185 Total <15 64.1 16.2 5.8 1.3 0.9 7.4 0.9 1.3 1.1 1.0 100.0 10.7 10.2 24,763 Total <18 61.0 15.5 7.4 1.3 1.1 7.7 1.2 1.8 1.8 1.2 100.0 12.5 13.4 28,433 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. 2.8 SCHOOL ATTENDANCE BY SURVIVORSHIP OF PARENTS Access to education is considered an “essential service” and is included among the key components of national responses to guarantee orphans access to services on an equal basis with other children. To assess whether orphans are educationally disadvantaged in relation to other children, an indicator was devised to compare school attendance among orphans and non-orphans. The results are presented in Table 2.13 for children age 10 to 14, the age group in which school attendance is generally assumed for all children. The data show a clear relationship between parent survivorship and school attendance of children age 10 to 14. Although 96 percent of children whose parents are both alive and who are living with one of their parents attend school, only 88 percent of children who have lost both parents attend school. The ratio of school attendance for orphaned and non-orphaned children is less than 1 (0.91), indicating an educational disadvantage for orphans. By sex, results on parent survivorship and school attendance of children age 10 to 14 show that female children with deceased parents are disadvantaged compared with their male counterparts (84 percent compared with 91 percent), which explains the low ratio for females (0.87 compared with 0.95 for males). By residence, surprisingly, the ratio of school attendance by survivorship shows a disadvantage for urban area children (0.80) compared with their rural counterparts (0.93). This is reflected also by province results, with the City of Kigali showing the lowest school attendance ratio for vulnerable children (0.79) compared with the other provinces. The vulnerable children in the lowest-wealth-quintile household are surprisingly advantaged, with a ratio of 1.04 compared with those in upper wealth quintiles with, for example, a ratio of 0.87 for the highest wealth quintile. 28 • Household Characteristics Table 2.13 School attendance by survivorship of parents For de jure children age 10-14, the percentage attending school, by parental survival, and the ratio of the percentage attending school, by parental survival, according to background characteristics, Rwanda 2010 Background characteristic Percentage attending school by survivorship of parents Both parents deceased Number Both parents alive and living with at least one parent Number Ratio1 Sex Male 91.2 101 96.2 2,502 0.95 Female 83.8 92 96.0 2,491 0.87 Residence Urban * 21 97.3 544 0.80 Rural 88.8 172 96.0 4,449 0.93 Province City of Kigali * 16 96.8 374 0.79 South 83.8 51 96.5 1,210 0.87 West (95.5) 51 96.2 1,257 0.99 North (96.3) 31 96.7 942 1.00 East (81.0) 44 95.0 1,209 0.85 Wealth quintile Lowest (96.9) 34 92.9 922 1.04 Second 81.6 55 95.7 935 0.85 Middle (95.5) 29 96.2 1,038 0.99 Fourth (84.8) 31 97.0 1,124 0.87 Highest (85.1) 44 98.3 974 0.87 Total 87.7 193 96.1 4,993 0.91 Note: Table is based only on children who usually live in the household. Figures in parentheses are based on 25-49 unweighted cases. An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Ratio of the percentage with both parents deceased to the percentage with both parents alive and living with a parent 2.9 CHILD LABOR The government of Rwanda has actively tackled the problem of child labor. Article 32 of the UN Convention on the Rights of the Child recognizes the right of children to be protected from economic exploitation and from performing any work that is hazardous, interferes with their education, or is harmful to their health or physical, mental, spiritual, moral, or social development. To assess how much children are working in Rwanda, the 2010 RDHS included a set of questions on participation by each child age 5-14 years in household work. The types of work asked about included work for persons other than members of the household, work in a household business, and work doing household chores. The number of hours worked in the seven days preceding the survey was recorded for all children engaged in any type of work. For work that was done for any person who was not a member of the household, a question was also asked to determine whether the child was paid or not paid for the work. Table 2.14 presents the percentage of de jure children age 5-14 years, who were engaged in different activities in the seven days preceding the interview, by background characteristics. A child worker is defined by UNICEF as any child, age 5-11, who, in the seven days preceding the survey, (1) worked for someone who was not a member of the household, with or without pay, (2) did household chores for 28 or more hours, or (3) engaged in any family business. A child worker is also any child, age 12-14, who, in the seven days preceding the survey (1) worked for someone who was not a member of the household, with or without pay, for 14 or more hours, (2) did household chores for 28 or more hours, or (3) engaged in any other family work for 14 or more hours. Table 2.14 shows that 88 percent of children age 5-14 in households worked in a week prior to the survey, either for their own household or for somebody else. Nearly 8 percent of children age 5-14 worked for someone who was not member of the household; among them 2 percent are engaged in paid work, 5 percent are engaged in unpaid Household Characteristics • 29 work. The results also show that 83 percent of children age 5-14 are engaged in fetching water or collecting fire wood for household use, 10 percent perform any other family work, and 63 percent are helping with household chores for 28 or more hours in a week. The work participation rate for children who are working for someone who is not member of their household is the same for boys and girls (8 percent for both). The age-specific work participation rate shows an increasing trend in work participation with age, from 6 percent among children age 5-9 years to 11 percent among boys age 10-14 years. The work participation rate is slightly higher in rural areas compared with urban areas (8 percent and 6 percent respectively), while by province it is highest in the South province (14 percent) and the lowest in Kigali City (2 percent). According to wealth quintile, children in the lowest quintile have the highest work participation rate at 12 percent, which compares with the highest wealth quintile at 4 percent. Children who are orphans experience the highest work participation rate at 10 percent, which compares with 8 percent of those who are not orphans. 30 • H ou se ho ld C ha ra ct er is tic s Ta bl e 2. 14 C hi ld la bo r P er ce nt ag e of c hi ld re n 5- 14 y ea rs o ld w ho w or ke d in th e w ee k pr io r t o th e su rv ey fo r s om eo ne w ho w as n ot a m em be r o f t hi s ho us eh ol d, w ho fe tc he d w at er o r c ol le ct ed fi re w oo d fo r h ou se ho ld u se , w ho d id a ny o th er fa m ily w or k, o r h el pe d w ith h ou se ho ld c ho re s su ch a s sh op pi ng , c le an in g, w as hi ng c lo th es , c oo ki ng , o r c ar in g fo r c hi ld re n or s ic k pe op le , a cc or di ng to th e nu m be r o f h ou rs , b y se le ct ed b ac kg ro un d ch ar ac te ris tic , R w an da 2 01 0 W or ke d fo r s om eo ne w ho is n ot m em be r o f t he h ou se ho ld Fe tc he d w at er o r c ol le ct ed fi re w oo d fo r ho us eh ol d us e D id a ny o th er fa m ily w or k H el p w ith h ou se ho ld c ho re s To ta l P ai d, le ss th an 4 ho ur s pe r d ay P ai d 4+ ho ur s pe r d ay U np ai d le ss th an 4 ho ur s pe r d ay U np ai d 4+ h ou rs pe r d ay W or ke d, ho ur s m is si ng To ta l Le ss th an 4 ho ur s pe r d ay 4+ h ou rs pe r d ay W or ke d, ho ur s m is si ng To ta l Le ss th an 4 ho ur s pe r d ay 4+ h ou rs pe r d ay W or ke d, ho ur s m is si ng To ta l Le ss th an 4 ho ur s pe r d ay 4+ h ou rs pe r d ay W or ke d, ho ur s m is si ng To ta l Le ss th an 4 ho ur s pe r d ay 4+ h ou rs pe r d ay W or ke d, ho ur s m is si ng To ta l N o. o f ch ild re n A ge 5- 9 0. 7 0. 0 4. 2 0. 1 0. 8 5. 8 72 .5 2. 4 0. 1 75 .0 3. 0 0. 1 0. 0 3. 2 44 .4 3. 3 0. 1 47 .7 65 .2 14 .7 0. 1 80 .0 8, 65 3 10 -1 4 2. 7 0. 5 6. 1 0. 2 0. 9 10 .5 81 .8 9. 7 0. 1 91 .7 15 .2 2. 1 0. 0 17 .3 73 .2 8. 0 0. 1 81 .2 55 .7 40 .4 0. 5 96 .6 7, 37 5 Se x M al e 1. 9 0. 3 5. 0 0. 1 0. 9 8. 1 76 .3 5. 7 0. 1 82 .1 8. 1 0. 9 0. 0 9. 0 51 .9 4. 2 0. 0 56 .2 61 .8 24 .3 0. 3 86 .4 8, 03 5 Fe m al e 1. 3 0. 2 5. 2 0. 2 0. 8 7. 8 77 .3 5. 8 0. 1 83 .2 9. 2 1. 2 0. 0 10 .4 63 .4 6. 7 0. 1 70 .2 59 .8 28 .9 0. 3 88 .9 7, 99 3 R es id en ce U rb an 1. 6 0. 0 3. 4 0. 2 0. 6 5. 9 59 .0 3. 7 0. 0 62 .8 6. 0 0. 4 0. 1 6. 4 54 .7 3. 8 0. 2 58 .7 58 .6 17 .6 0. 1 76 .4 1, 81 5 R ur al 1. 6 0. 3 5. 3 0. 2 0. 9 8. 2 79 .0 6. 0 0. 1 85 .2 9. 0 1. 1 0. 0 10 .1 58 .0 5. 6 0. 0 63 .7 61 .1 27 .7 0. 3 89 .1 14 ,2 13 Pr ov in ce K i g al i C ity 0. 6 0. 1 1. 0 0. 0 0. 0 1. 7 51 .5 2. 6 0. 1 54 .1 2. 0 0. 3 0. 1 2. 4 52 .7 3. 6 0. 0 56 .2 57 .8 12 .9 0. 1 70 .8 1, 21 6 S ou th 2. 5 0. 2 9. 3 0. 3 2. 1 14 .4 85 .5 5. 4 0. 0 90 .9 10 .2 0. 6 0. 0 10 .9 59 .7 5. 2 0. 0 64 .9 68 .0 25 .1 0. 3 93 .3 3, 96 7 W es t 1. 6 0. 2 4. 1 0. 2 0. 4 6. 6 78 .8 6. 0 0. 2 85 .0 11 .0 1. 2 0. 0 12 .1 57 .9 3. 8 0. 0 61 .7 60 .0 27 .8 0. 3 88 .2 4, 06 4 N or th 1. 4 0. 5 5. 4 0. 1 0. 3 7. 7 76 .1 7. 4 0. 2 83 .8 8. 9 1. 1 0. 0 10 .1 57 .1 8. 6 0. 2 65 .9 56 .3 32 .1 0. 6 88 .9 2, 87 1 E as t 1. 2 0. 1 3. 0 0. 1 0. 7 5. 0 74 .1 5. 7 0. 1 80 .0 6. 4 1. 4 0. 1 7. 9 57 .2 5. 7 0. 0 62 .9 58 .5 27 .0 0. 1 85 .6 3, 91 0 W ea lth q ui nt ile Lo w es t 3. 1 0. 4 7. 2 0. 3 1. 2 12 .3 80 .9 7. 1 0. 0 88 .0 9. 3 1. 0 0. 0 10 .3 58 .7 6. 4 0. 0 65 .1 59 .4 30 .9 0. 4 90 .6 3, 31 4 S ec on d 1. 9 0. 4 6. 2 0. 2 0. 9 9. 5 79 .9 6. 9 0. 3 87 .1 9. 9 0. 9 0. 0 10 .8 58 .9 6. 3 0. 0 65 .2 60 .7 29 .0 0. 3 90 .0 3, 32 8 M id dl e 1. 2 0. 1 4. 7 0. 2 0. 8 7. 0 81 .6 5. 7 0. 1 87 .4 9. 6 1. 4 0. 0 11 .0 59 .2 4. 8 0. 1 64 .0 63 .7 27 .3 0. 2 91 .1 3, 14 9 Fo ur th 1. 2 0. 2 4. 3 0. 1 0. 5 6. 3 79 .0 6. 0 0. 0 85 .0 8. 6 1. 2 0. 1 10 .0 57 .1 5. 5 0. 1 62 .7 60 .7 27 .5 0. 1 88 .4 3, 31 8 H ig he st 0. 4 0. 0 2. 9 0. 0 0. 7 4. 1 60 .7 3. 0 0. 1 63 .8 5. 4 0. 6 0. 0 6. 0 53 .9 4. 1 0. 2 58 .1 59 .5 17 .0 0. 3 76 .8 2, 92 0 O rp ha ns Ye s 3. 1 0. 4 5. 7 0. 3 0. 9 10 .4 80 .2 7. 9 0. 3 88 .4 11 .5 1. 7 0. 0 13 .2 64 .1 6. 7 0. 0 70 .8 58 .2 34 .0 0. 5 92 .6 2, 33 5 N o 1. 3 0. 2 5. 0 0. 1 0. 8 7. 5 76 .2 5. 4 0. 1 81 .7 8. 1 0. 9 0. 0 9. 1 56 .6 5. 2 0. 1 61 .8 61 .3 25 .3 0. 2 86 .8 13 ,5 45 M is si ng 0. 6 0. 8 5. 2 0. 0 1. 4 8. 0 77 .7 5. 8 0. 0 83 .5 9. 0 0. 0 0. 0 9. 0 53 .4 8. 4 0. 0 61 .8 56 .2 30 .4 0. 0 86 .6 14 8 To ta l 1. 6 0. 2 5. 1 0. 2 0. 8 8. 0 76 .8 5. 8 0. 1 82 .7 8. 6 1. 0 0. 0 9. 7 57 .6 5. 4 0. 1 63 .1 60 .8 26 .6 0. 3 87 .6 16 ,0 28 30 • Household Characteristics Household Characteristics • 31 2.10 HEALTH INSURANCE COVERAGE Information on health insurance coverage of household members was collected during the survey. The household coverage is shown in Table 2.15 by type of health insurance, urban-rural residence, province, and household wealth quintile. Overall, 78 percent of Rwandan households have health insurance. This proportion is higher than that in the RIDHS 2007-08 (68 percent). There is almost no variation by residence (78 percent in both urban and rural areas). There is significant difference by province, with proportions varying from the low of 71 percent in the East province to the high of 86 percent in the North province. Households in the higher wealth quintiles are generally better insured than those in the lower wealth quintiles. Concerning the type of health insurance used by households, nearly all households with a least one member insured are insured by Mutual Health Insurance (98 percent). Other types of insurances reported by households are La Rwandaise d’Assurance Maladie (RAMA), Military Medical Insurance (MMI), and private insurance. These insurances are commonly reported by households in urban areas, in the city of Kigali, and in the highest wealth quintile. Table 2.15 Health insurance Percentage of households in which at least one member is covered by health insurance, and percentage of households with specific types of health insurance, according to residence and province, Rwanda 2010 Background characteristics Percentage of households with at least one member covered by health insurance Number of households Type of insurance Mutual RAMA MMI Private Number of households with at least one member covered by health insurance Residence Urban 78.4 1,759 93.9 9.7 1.9 2.5 1,379 Rural 77.7 10,781 98.3 2.7 0.3 0.1 8,377 Province Kigali City 71.7 1,284 91.8 13.0 2.5 4.0 921 South 77.2 3,136 98.4 2.2 0.2 0.0 2,420 West 82.7 2,967 98.7 3.0 0.4 0.0 2,454 North 85.6 2,120 98.3 2.5 0.5 0.1 1,815 East 70.8 3,033 97.7 3.0 0.5 0.1 2,146 Wealth quintile Lowest 67.8 2,838 99.4 0.1 0.0 0.0 1,924 Second 76.1 2,600 99.6 0.0 0.1 0.0 1,978 Middle 79.8 2,448 98.6 0.6 0.1 0.0 1,954 Fourth 84.5 2,287 98.5 1.9 0.6 0.0 1,932 Highest 83.1 2,367 92.2 15.5 2.0 2.1 1,968 Total 77.8 12,540 97.7 3.7 0.6 0.4 9,756 Individual health insurance coverage is presented in Table 2.16 by type of health insurance, according to selected background characteristics. Overall, 71 percent of women and 66 percent of men are insured. Young women age 15-19 (64 percent) and young men age 15-19 (62 percent) are less likely to be insured than the older women and men (70 percent or higher and 67 percent or higher, respectively). According to marital status, currently married women and men are better insured than those in other categories. Women and men in the North province have higher coverage than those in the other provinces. However, there is no variation by urban-rural residence for women or men. The proportion of coverage among women increases as the level of education increases; from 66 percent among those who have no education to 80 percent for secondary education or higher. Among men, these figures are 59 percent and 75 percent respectively. Women and men in the higher wealth quintiles are generally better insured than those in the lower wealth quintiles. Concerning the type of health insurance used by households, nearly all insured household members are insured by Mutual Health Insurance (95 percent for women and 96 percent for men). Other types of insurances are RAMA, MMI, and private insurance. These insurances are commonly reported by women and men who are currently married, live in urban areas, reside in the city of Kigali, have secondary education and higher, and are in the highest wealth quintile. 32 • Household Characteristics Table 2.16 Health insurance Percentage of respondents covered by health insurance, and percent distribution of respondents with specific types of health insurance, according to selected background characteristics, Rwanda 2010 Background characteristic Percentage of respondents covered by health insurance Number of respondents Type of insurance Mutual RAMA MMI Private Don’t know/missing Total Number of respondents covered by health insurance WOMEN Age 15-19 64.4 2,945 97.2 1.3 0.1 0.3 1.1 100.0 1,897 20-24 73.1 2,683 96.8 1.8 0.3 0.3 0.8 100.0 1,961 25-29 75.3 2,494 95.1 3.1 0.6 0.4 0.8 100.0 1,877 30-34 75.0 1,822 92.7 5.7 0.5 0.5 0.6 100.0 1,366 35-39 73.2 1,447 91.7 5.2 1.4 0.5 1.2 100.0 1,058 40-44 70.2 1,168 95.2 3.2 0.1 0.8 0.6 100.0 820 45-49 70.2 1,112 96.3 2.1 0.1 0.5 1.0 100.0 781 Marital status Never married 68.1 5,285 96.3 2.2 0.1 0.3 1.1 100.0 3,597 Married 80.3 4,799 92.7 4.9 1.0 0.7 0.7 100.0 3,854 Living together 65.6 2,098 98.3 1.0 0.0 0.1 0.5 100.0 1,377 Divorced/separated 58.7 746 97.5 1.2 0.0 0.1 1.1 100.0 438 Widowed 66.5 743 97.3 1.4 0.0 0.2 1.1 100.0 494 Residence Urban 71.4 2,057 86.7 8.3 1.2 2.4 1.5 100.0 1,469 Rural 71.4 11,614 96.8 2.1 0.3 0.1 0.8 100.0 8,291 Province Kigali City 65.6 1,596 83.3 9.5 1.4 3.7 2.1 100.0 1,047 South 70.1 3,212 96.9 1.9 0.2 0.0 1.1 100.0 2,251 West 76.1 3,305 96.6 2.5 0.2 0.0 0.7 100.0 2,515 North 80.5 2,278 96.9 1.9 0.5 0.1 0.6 100.0 1,834 East 64.4 3,280 96.5 2.5 0.5 0.0 0.5 100.0 2,113 Education No education 66.2 2,119 98.9 0.2 0.1 0.0 0.8 100.0 1,402 Primary 70.5 9,337 98.6 0.5 0.2 0.1 0.7 100.0 6,583 Secondary and higher 80.1 2,216 80.1 14.6 1.5 2.1 1.6 100.0 1,776 Wealth quintile Lowest 59.8 2,622 99.4 0.1 0.0 0.0 0.6 100.0 1,568 Second 68.8 2,661 99.4 0.0 0.1 0.0 0.5 100.0 1,829 Middle 73.4 2,736 98.7 0.3 0.1 0.0 0.9 100.0 2,008 Fourth 77.6 2,677 97.8 1.0 0.4 0.0 0.8 100.0 2,076 Highest 76.6 2,976 83.8 11.6 1.4 1.8 1.4 100.0 2,279 Total 15-49 71.4 13,671 95.3 3.0 0.4 0.4 0.9 100.0 9,761 MEN Age 15-19 62.1 1,449 98.9 0.2 0.1 0.2 0.4 100.0 899 20-24 61.7 1,159 97.0 1.8 0.0 0.2 1.0 100.0 715 25-29 70.2 1,038 95.6 2.8 0.4 0.4 0.9 100.0 729 30-34 73.5 710 94.3 4.5 0.2 0.7 0.2 100.0 522 35-39 67.3 490 91.4 5.9 0.8 0.9 1.1 100.0 330 40-44 70.3 430 91.8 5.0 1.6 0.6 1.1 100.0 302 45-49 67.0 412 95.5 2.4 0.2 0.6 1.3 100.0 276 Marital status Never married 62.3 2,873 96.6 2.0 0.2 0.2 0.9 100.0 1,790 Married 76.2 1,938 94.1 4.0 0.5 0.6 0.7 100.0 1,478 Living together 60.7 761 97.7 0.9 0.3 0.5 0.6 100.0 462 Divorced/separated 35.2 92 97.7 2.3 0.0 0.0 0.0 100.0 32 Widowed 46.0 22 100.0 0.0 0.0 0.0 0.0 100.0 10 Residence Urban 66.1 939 88.8 6.4 1.1 1.5 2.2 100.0 621 Rural 66.4 4,748 97.2 1.9 0.2 0.2 0.5 100.0 3,152 Province Kigali City 58.4 739 85.2 8.4 1.6 2.5 2.2 100.0 432 South 64.4 1,308 97.7 1.5 0.2 0.0 0.6 100.0 842 West 73.9 1,307 96.8 1.9 0.2 0.3 0.8 100.0 966 North 77.7 899 97.5 2.1 0.2 0.2 0.2 100.0 698 East 58.2 1,435 96.8 2.3 0.1 0.1 0.7 100.0 836 Continued… Household Characteristics • 33 Table 2.16─Continued Background characteristic Percentage of respondents covered by health insurance Number of respondents Type of insurance Mutual RAMA MMI Private Don’t know/missing Total Number of respondents covered by health insurance Education No education 58.8 583 99.8 0.2 0.0 0.0 0.0 100.0 343 Primary 65.0 3,916 99.1 0.2 0.2 0.0 0.6 100.0 2,544 Secondary and higher 74.6 1,189 84.9 10.8 1.0 1.8 1.5 100.0 887 Wealth quintile Lowest 54.4 854 99.8 0.0 0.0 0.0 0.2 100.0 464 Second 64.2 986 99.2 0.0 0.0 0.0 0.8 100.0 633 Middle 65.8 1,139 99.3 0.4 0.0 0.0 0.3 100.0 749 Fourth 72.8 1,235 97.4 1.7 0.2 0.0 0.7 100.0 899 Highest 69.7 1,474 87.9 8.0 1.1 1.6 1.4 100.0 1,028 Total 15-49 66.3 5,687 95.8 2.7 0.3 0.4 0.8 100.0 3,773 50-59 69.7 642 96.0 2.9 0.1 0.3 0.7 100.0 447 Total 15-59 66.7 6,329 95.8 2.7 0.3 0.4 0.8 100.0 4,220 2.11 UTILIZATION OF HEALTH SERVICES AND OUT-OF-POCKET EXPENDITURE FOR HEALTH CARE The 2010 RDHS collected data on the utilization of health services by household members. Information on outpatient visits by each household member to a health care facility, provider, pharmacy, or traditional healer four weeks preceding the interview and information on inpatient admissions 6 months preceding the interview was collected. The survey also collected all out-of-pocket expenditures for visits and admissions during those reference periods. Utilization of health services was assessed in the Household Questionnaire. The questions were asked of all households in the sample. The analysis was carried out to estimate the number of annual outpatient visits (per capita) and inpatient admissions (per 1,000 population), with separate data for women and men. Table 2.17 Annual outpatient visits and inpatient admissions for de facto population Average number of annual outpatient visits and inpatient admissions to health facilities for women and men by background characteristics, Rwanda 2010 Background characteristic Women Men Outpatient visits (per capita) Inpatient admissions (per 1,000 population) De facto population Outpatient visits (per capita) Inpatient admissions (per 1,000 population) De facto population Age <5 2.7 68 4,390 2.9 88 4,561 5-14 0.9 17 7,827 0.9 23 7,885 15-49 1.8 159 13,719 1.1 43 11,353 50-64 2.5 90 2,218 1.7 59 1,595 65+ 2.7 118 1,104 2.6 92 632 Don’t know/missing 0.0 0 5 5.3 0 2 Residence Urban 2.2 95 3,796 1.7 38 3,628 Rural 1.8 102 25,468 1.4 48 22,400 Province Kigali City 2.2 108 2,743 1.9 33 2,713 South 2.1 91 7,127 1.9 43 6,273 West 1.7 131 7,276 1.3 58 6,246 North 1.7 81 5,069 1.2 55 4,305 East 1.6 90 7,049 1.2 40 6,491 Total 1.8 101 29,264 1.5 47 26,029 34 • Household Characteristics Table 2.17 shows that in Rwanda the number of annual outpatient visits in 2010 is 1.8 visits per capita for women and 1.5 visits per capita for men. The number of visits is higher among children under 5 (2.7 visits for girls and 2.9 visits for boys) and among the elderly age 65 and older (2.7 visits for women and 2.6 visits for men). In both populations, the number of visits is higher in urban areas than in rural areas and higher in the city of Kigali and in South province than in other provinces. On average, the annual number of inpatient admissions is 101 admissions (per 1,000 population) for women and 47 admissions (per 1,000 population) for men. For men, the number of annual admissions is higher among young children and the elderly. Among women, the number of annual admission peaks among three age groups: young children (under age 5), women of reproductive age (age 15-49), and the elderly (age 65 and older). For both women and men, the number of inpatient admissions is higher in rural areas than in urban areas. Table 2.18 indicates that the total annual out-of-pocket expenditure for the female population is US$4.14 per capita; that includes US$3.36 in outpatient expenditure and US$0.79 in inpatient expenditure. For the male population, the total annual out-of-pocket expenditure is US$4.37 per capita; that includes US$3.79 in outpatient expenditure and US$0.58 in inpatient expenditure. The total expenditure has a U-shape in relation to age. In the female population, the annual expense is US$3.46 among children under age 5, drops to US$1.40 among girls age 5- 14, then shapely increases to US$4.82 among those age 15-49, and reaches the highest level of US$10.01 among those age 65 or older. A similar pattern is observed among men, except the highest level for men is US$12.74 among those age 50-64. Table 2.18 Annual per capita expenditure (in US $) on outpatient visits and inpatient admissions for de facto population Average annual per capita expenditure for outpatient visits and inpatient admissions for women and men by background characteristics, Rwanda 2010 Background characteristic Women Men Per capita expenditure for outpatient Per capita expenditure for inpatient Total per capita expenditure De facto population Per capita expenditure for outpatient Per capita expenditure for inpatient Total per capita expenditure De facto population Age <5 3.05 0.41 3.46 4,390 5.32 0.38 5.70 4,561 5-14 1.23 0.17 1.40 7,827 1.54 0.28 1.82 7,885 15-49 3.82 1.00 4.82 13,719 3.61 0.67 4.28 11,353 50-64 6.14 1.96 8.10 2,218 10.70 2.04 12.74 1,595 65+ 8.29 1.72 10.01 1,104 6.47 0.49 6.96 632 Don’t know/missing 0.00 0.00 0.00 5 2.68 0.00 2.68 2 Residence Urban 10.90 2.74 13.64 3,796 8.19 0.68 8.87 3,628 Rural 2.23 0.50 2.73 25,468 3.07 0.56 3.64 22,400 Province Kigali City 12.27 3.75 16.03 2,743 13.56 0.73 14.29 2,713 South 2.19 0.44 2.62 7,127 2.55 0.67 3.22 6,273 West 2.35 0.59 2.93 7,276 2.52 0.54 3.06 6,246 North 1.57 0.36 1.92 5,069 1.53 0.28 1.82 4,305 East 3.39 0.51 3.91 7,049 3.61 0.66 4.27 6,491 Education No education 2.98 0.46 3.44 10,433 3.75 0.33 4.08 8,523 Primary 2.87 0.61 3.48 16,426 3.23 0.58 3.81 14,949 Secondary and higher 8.45 3.51 11.96 2,344 7.24 1.46 8.70 2,493 Missing 3.50 0.00 3.50 60 3.37 0.06 3.43 63 Wealth quintile Lowest 2.07 0.38 2.45 6,119 1.60 0.45 2.05 4,861 Second 2.01 0.46 2.47 5,984 2.42 0.31 2.72 5,081 Middle 1.61 0.43 2.04 5,806 2.34 0.42 2.76 5,212 Fourth 1.95 0.58 2.53 5,776 3.05 0.26 3.32 5,311 Highest 9.48 2.18 11.66 5,578 9.00 1.39 10.39 5,563 Total 3.36 0.79 4.14 29,264 3.79 0.58 4.37 26,029 The total out-of- pocket expenditure is higher in urban areas than in rural areas (US$13.64 versus US$2.73 for women and US$8.87 versus US$3.64 for men. The expenditure is significantly higher in the city of Kigali (US$16.03 for women and US$14.29 for men) than in other provinces (US$3.91 or less for women and US$4.27 or Household Characteristics • 35 less for men). On average, people with secondary education and higher spend more for health care than people with primary education or lower. Similarly, out-of-pocket spending of people in the highest wealth quintile (US$11.66 for women and US$10.39 for men) is significantly higher than for those in others quintiles (US$2.53 or less for women and US$3.32 or less for men). Respondent Characteristics • 37 RESPONDENT CHARACTERISTICS 3 his chapter provides a sociodemographic profile of women age 15-49 and men age 15-59 who responded to the survey questions. The information that the women and men provided is important for understanding the behavior of the population with respect to contraception, sexually transmitted infections (STIs), HIV/AIDS, and fertility preferences. Like the Household Questionnaire, the individual questionnaire gathered information concerning respondents’ age, place of residence, marital status, and educational attainment. This chapter also presents level of literacy, exposure to mass media, employment and occupation, and tobacco use of the men and women interviewed. These characteristics are used to interpret findings elsewhere in the report. 3.1 BACKGROUND CHARACTERISTICS OF RESPONDENTS Given the importance of age in analyzing demographic characteristics, special attention was paid to making sure this statistic was accurately recorded in the survey. Prior to recording any information, the interviewer asked respondents to gather all official documents with information about themselves and other members of the household. If no official documents were available, the interviewer confirmed the age provided by the respondent through reference to major life events (age at the time of marriage, age of first child, etc.) or well-known national or regional events. Table 3.1 shows no major disparities in the distribution of women and men age 15-49 grouped by five-year age increments. Proportions in each age group decline with increasing age. For women, the percentages range from 22 percent for the age group 15-19 to 8 percent for the age group 45-49. For men, the percentages range from 26 percent for age group 15-19 to 7 percent for age group 45-49. Table 3.1 Background characteristics of respondents Percent distribution of women and men age 15-49 by selected background characteristics, Rwanda 2010 Background characteristic Women Men Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted number Age 15-19 21.5 2,945 2,963 25.5 1,449 1,436 20-24 19.6 2,683 2,692 20.4 1,159 1,159 25-29 18.2 2,494 2,495 18.3 1,038 1,046 30-34 13.3 1,822 1,822 12.5 710 726 35-39 10.6 1,447 1,442 8.6 490 488 40-44 8.5 1,168 1,155 7.6 430 434 45-49 8.1 1,112 1,102 7.2 412 406 Religion Catholic 42.7 5,842 5,854 47.7 2,710 2,727 Protestant 41.2 5,627 5,586 35.9 2,044 2,031 Adventist 13.0 1,781 1,792 11.9 680 682 Muslim 1.3 179 197 1.9 106 111 Traditional 0.0 0 0 0.0 1 1 Other 0.9 129 131 0.9 50 50 No religion 0.7 92 91 1.7 96 93 Missing 0.2 21 20 0.0 0 0 Marital status Never married 38.7 5,285 5,362 50.5 2,873 2,900 Married 35.1 4,799 4,757 34.1 1,938 1,930 Living together 15.3 2,098 2,077 13.4 761 751 Divorced/separated 5.5 746 746 1.6 92 93 Widowed 5.4 743 729 0.4 22 21 Residence Urban 15.0 2,057 2,367 16.5 939 1,082 Rural 85.0 11,614 11,304 83.5 4,748 4,613 Continued… T 38 • Respondent Characteristics Table 3.1─Continued Background characteristic Women Men Weighted percent Weighted number Unweighted number Weighted percent Weighted number Unweighted number Province City of Kigali 11.7 1,596 1,890 13.0 739 876 South 23.5 3,212 3,340 23.0 1,308 1,373 West 24.2 3,305 3,138 23.0 1,307 1,243 North 16.7 2,278 2,199 15.8 899 859 East 24.0 3,280 3,104 25.2 1,435 1,344 Education No education 15.5 2,119 2,061 10.3 583 580 Primary 68.3 9,337 9,277 68.8 3,916 3,884 Secondary 14.7 2,008 2,090 18.7 1,064 1,089 More than secondary 1.5 207 243 2.2 125 142 Wealth quintile Lowest 19.2 2,622 2,569 15.0 854 850 Second 19.5 2,661 2,603 17.3 986 968 Middle 20.0 2,736 2,663 20.0 1,139 1,102 Fourth 19.6 2,677 2,621 21.7 1,235 1,203 Highest 21.8 2,976 3,215 25.9 1,474 1,572 Total 15-49 100.0 13,671 13,671 100.0 5,687 5,695 50-59 na na na na 642 634 Total 15-59 na na na na 6,329 6,329 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. na = Not applicable All men and women in the sample were asked their marital status. For the 2010 RDHS, all men and women were considered married if they were in union with a partner, whether the union was formal (legally married) or informal (living together). According to this definition, Table 3.1 shows that nearly 2 in 5 women (39 percent) had never been married at the time of the survey, while half of the women were married (35 percent were legally married and 15 percent were living together with a man). In addition, 6 percent of women were divorced or separated and 5 percent were widowed at the time of the survey. About half of the men age 15-49 (51 percent) were single, 47 percent were married (34 percent were legally married, and 13 percent were living with a woman). Slightly under 2 percent were separated or divorced, and less than 1 percent were widowed. The distribution of respondents by residence shows that the majority of the Rwandan population is living in rural areas (85 percent of women and 84 percent of men). Similarly, distribution of respondents by province shows no significant disparities between men and women. The City of Kigali, with 12 percent of women and 13 percent of men, has the lowest proportion of respondents; next is North province with 17 percent of women and 16 percent of men. The tabulation of respondents by religion indicates a majority of Catholic adherents (43 percent of women and 48 percent of men), with Protestant religions coming in second in popularity (41 percent of women and 36 percent of men). The Adventist faith is the next most common religion (13 percent of women and 12 percent of men), followed by the Muslim faith (1 percent of women and 2 percent of men). Table 3.1 also shows the distribution of men and women according to household wealth quintile. The development of this index is explained in Chapter 2. Table 3.1 provides educational attainment data for the respondents. The proportion of women with no education is significantly higher than that of men (16 percent of women, 10 percent of men). Inversely, the proportion of women with secondary education is lower than that of men (15 percent of women, 19 percent of men). The gap between men and women is not very wide at the primary and tertiary levels, however. 3.2 EDUCATIONAL ATTAINMENT Tables 3.2.1 and 3.2.2 show the distributions of female and male respondents by highest level of education attained. The proportion of men who received completed primary education or received some primary education is equal to that of women: 68 percent each. At the secondary level, the proportions are 15 percent for women and Respondent Characteristics • 39 18 percent for men. It is noteworthy that proportions for both men and women drop significantly from primary to secondary and from secondary to postsecondary levels. Table 3.2.1 Educational attainment: Women Percent distribution of women age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Rwanda 2010 Background characteristic Highest level of schooling Total Median years completed Number of women No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 6.1 57.5 13.1 19.6 2.9 0.9 100.0 4.2 5,628 ,,.15-19 2.9 59.0 13.4 24.1 0.6 0.0 100.0 4.4 2,945 …20-24 9.5 55.9 12.9 14.6 5.4 1.8 100.0 3.9 2,683 25-29 14.0 58.5 16.8 4.6 3.6 2.5 100.0 3.4 2,494 30-34 16.4 50.9 21.0 6.1 3.1 2.4 100.0 4.2 1,822 35-39 21.1 56.0 8.9 9.0 2.8 2.2 100.0 4.0 1,447 40-44 32.7 46.8 8.4 9.7 1.4 1.0 100.0 2.9 1,168 45-49 39.8 41.5 11.6 5.4 1.0 0.7 100.0 1.4 1,112 Residence Urban 6.7 42.8 13.0 22.9 8.0 6.6 100.0 5.4 2,057 Rural 17.1 56.5 14.0 10.0 1.8 0.6 100.0 3.6 11,614 Province City of Kigali 6.2 39.3 12.5 23.5 10.2 8.3 100.0 5.7 1,596 South 13.4 58.6 14.3 11.7 1.6 0.4 100.0 3.8 3,212 West 19.9 55.4 12.6 9.5 1.5 1.1 100.0 3.4 3,305 North 16.3 53.9 17.3 10.2 1.8 0.4 100.0 3.8 2,278 East 17.1 57.2 12.9 10.2 2.1 0.5 100.0 3.4 3,280 Wealth quintile Lowest 26.1 61.5 8.5 3.7 0.1 0.0 100.0 2.3 2,622 Second 20.4 60.4 13.2 6.0 0.1 0.0 100.0 3.0 2,661 Middle 16.2 59.9 15.1 8.3 0.5 0.0 100.0 3.6 2,736 Fourth 11.2 56.2 17.6 13.4 1.5 0.1 100.0 4.3 2,677 Highest 5.0 36.2 14.7 26.5 10.7 6.9 100.0 5.8 2,976 Total 15.5 54.4 13.9 11.9 2.8 1.5 100.0 3.8 13,671 1 Completed 6th grade at the primary level 2 Completed 6th grade at the secondary level Table 3.2.2 Educational attainment: Men Percent distribution of men age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Rwanda 2010 Background characteristic Highest level of schooling Total Median years completed Number of men No education Some primary Completed primary1 Some secondary Completed secondary2 More than secondary Age 15-24 3.8 59.3 11.3 22.0 2.6 1.1 100.0 4.3 2,607 …15-19 2.5 62.1 11.1 24.2 0.2 0.0 100.0 4.3 1,449 …20-24 5.3 55.9 11.5 19.3 5.6 2.4 100.0 4.2 1,159 25-29 11.6 55.4 17.5 6.7 4.9 3.9 100.0 3.6 1,038 30-34 10.7 52.4 18.3 11.3 3.6 3.8 100.0 4.6 710 35-39 17.5 53.6 9.9 12.1 4.0 2.9 100.0 4.5 490 40-44 18.8 51.8 10.2 12.9 3.4 2.8 100.0 4.8 430 45-49 29.5 43.2 15.0 9.4 2.0 0.9 100.0 2.7 412 Residence Urban 5.6 43.4 12.7 23.0 8.2 7.0 100.0 5.3 939 Rural 11.2 57.9 13.5 13.9 2.3 1.2 100.0 3.9 4,748 Province City of Kigali 3.9 38.3 14.3 26.2 9.8 7.6 100.0 5.8 739 South 11.2 61.0 12.6 12.1 2.3 0.8 100.0 3.7 1,308 West 11.8 58.9 9.7 14.5 2.8 2.3 100.0 3.9 1,307 North 9.7 51.9 17.8 16.3 2.6 1.7 100.0 4.3 899 East 11.6 58.5 14.1 13.2 1.8 0.9 100.0 3.8 1,435 Wealth quintile Lowest 18.5 67.1 8.3 5.8 0.2 0.0 100.0 2.5 854 Second 15.0 62.4 12.1 9.7 0.5 0.3 100.0 3.2 986 Middle 10.7 62.0 13.8 12.0 0.8 0.6 100.0 3.7 1,139 Fourth 6.8 55.3 17.0 17.4 2.5 0.9 100.0 4.5 1,235 Highest 4.8 39.3 13.7 25.7 9.5 7.1 100.0 5.7 1,474 Total 15-49 10.3 55.5 13.3 15.4 3.3 2.2 100.0 4.1 5,687 50-59 27.2 46.6 16.9 6.3 1.9 1.3 100.0 2.4 642 Total 15-59 12.0 54.6 13.7 14.5 3.1 2.1 100.0 4.0 6,329 1 Completed 6th grade at the primary level 2 Completed 6th grade at the secondary level 40 • Respondent Characteristics The data by age show that the proportions of men and women with no education have decreased significantly in the younger generation. For men, the proportion with no education is 30 percent in the 45-49 age group but only 4 percent in the 15-24 age group. For women, the proportions for these age groups are 40 percent and 6 percent, respectively. The gap between men and women in the previous generations has narrowed significantly: Among women and men age 45 to 49 years, the gap is about 10 percent; for those age 15-19 years, the gap is about 2 percent. Similarly, in the 15-24 age group, the proportion of girls who have attended or completed primary school is exactly equal to that of boys (71 percent for girls and boys). In addition, 25 percent of young women age 15-19 have attended or completed secondary school compared with 24 percent of young men. The educational attainment of respondents varies by residence. The proportion of men and women with no education is higher in rural areas (17 percent for women, 11 percent for men) than in urban areas (7 percent for women, 6 percent for men). Urban areas also have the highest proportions of men and women at every level of education except primary. Results by province show a wide gap between the City of Kigali and the rest of the country. In the City of Kigali, 6 percent of women and 4 percent of men have no education; in the other provinces the proportions vary from 13 percent (South) to 20 percent (West) for women and from 10 percent (North) to 12 percent (West and East) for men. The data in this table show a positive relationship between educational attainment and household wealth: the proportions of men and women with no education decrease as household wealth increases. 3.3 LITERACY For this survey, literacy was established by asking respondents who reported not having attended school or having attended only primary school to read a sentence that was presented to them. Respondents were then classified into one of the following three levels: cannot read at all, can read part of a sentence, and can read a whole sentence. The test was given only to men and women who had less than a secondary education; those with secondary or postsecondary educations (16 percent of women and 21 percent of men) were considered literate and not in need of testing. Tables 3.3.1 and 3.3.2 show that the proportion of men and women who cannot read at all has decreased from previous generations, especially among women. For women, this proportion drops from 46 percent in the 45- 49 age group to 10 percent in the 15-19 age group. For men, the proportions for these age groups are 28 percent and 18 percent, respectively. The data show also that a higher proportion of women than men cannot read (23 percent of women; 18 percent of men). Conversely, 77 percent of women and 82 percent of men are considered literate; that is, they have attended secondary school or, if they have attended only primary school, they are able to read all or part of a sentence. The level of illiteracy varies appreciably by residence. Illiteracy is higher in rural areas than in urban areas (11 percent in urban areas versus 25 percent in rural areas, for women, and 11 percent in urban areas versus 19 percent in rural areas, for men). The results by province show a gap between the City of Kigali and the rest of the country: in Kigali, 91 percent of women and 92 percent of men are literate. In other provinces, the proportion varies from 73 percent (West) to 78 percent (South) for women and from 79 percent (East) to 84 percent (North) for men. In addition, results by wealth quintile show that the level of illiteracy decreases considerably from the poorest to the richest quintile, dropping for women from 38 percent in the lowest quintile to 8 percent in the highest quintile and for men from 33 percent in the lowest quintile to 9 percent in the highest quintile. Respondent Characteristics • 41 Table 3.3.1 Literacy: Women Percent distribution of women age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Rwanda 2010 Background characteristic Secondary school or higher No schooling or primary school Total Percentage literate1 Number of women Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Age 15-24 23.3 54.2 7.4 14.9 0.0 0.0 0.1 100.0 85.0 5,628 …15-19 24.7 58.3 6.5 10.4 0.0 0.0 0.1 100.0 89.5 2,945 …20-24 21.8 49.8 8.5 19.8 0.0 0.1 0.0 100.0 80.1 2,683 25-29 10.8 56.3 9.8 23.0 0.0 0.1 0.0 100.0 76.9 2,494 30-34 11.6 57.7 8.7 21.6 0.0 0.2 0.2 100.0 78.1 1,822 35-39 14.0 50.8 9.1 25.7 0.0 0.1 0.2 100.0 73.9 1,447 40-44 12.2 43.2 8.6 35.3 0.0 0.7 0.1 100.0 63.9 1,168 45-49 7.2 35.4 9.5 46.2 0.1 1.4 0.2 100.0 52.1 1,112 Residence Urban 37.5 45.3 5.9 11.0 0.0 0.2 0.1 100.0 88.8 2,057 Rural 12.4 53.5 9.0 24.8 0.0 0.3 0.1 100.0 74.8 11,614 Province City of Kigali 42.0 42.8 5.5 9.3 0.0 0.3 0.0 100.0 90.4 1,596 South 13.7 56.4 8.2 21.2 0.0 0.4 0.1 100.0 78.3 3,212 West 12.1 50.9 9.7 27.1 0.0 0.1 0.1 100.0 72.7 3,305 North 12.5 54.3 8.9 23.9 0.0 0.2 0.2 100.0 75.7 2,278 East 12.8 52.6 8.8 25.4 0.0 0.4 0.0 100.0 74.2 3,280 Wealth quintile Lowest 3.8 45.9 11.7 38.1 0.0 0.3 0.1 100.0 61.4 2,622 Second 6.1 53.4 10.4 29.9 0.0 0.1 0.1 100.0 69.9 2,661 Middle 8.8 57.7 9.1 23.8 0.0 0.4 0.1 100.0 75.7 2,736 Fourth 15.0 61.6 6.9 16.2 0.0 0.2 0.1 100.0 83.5 2,677 Highest 44.1 43.3 4.8 7.5 0.0 0.2 0.0 100.0 92.2 2,976 Total 16.2 52.2 8.5 22.7 0.0 0.3 0.1 100.0 76.9 13,671 1 Refers to women who attended secondary school or higher and women who can read a whole sentence or part of a sentence Table 3.3.2 Literacy: Men Percent distribution of men age 15-49 by level of schooling attended and level of literacy, and percentage literate, according to background characteristics, Rwanda 2010 Background characteristic Secondary school or higher No schooling or primary school Total Percentage literate1 Number of men Can read a whole sentence Can read part of a sentence Cannot read at all No card with required language Blind/ visually impaired Missing Age 15-24 25.6 50.8 8.8 14.5 0.0 0.0 0.2 100.0 85.3 2,607 …15-19 21.7 52.7 8.8 13.9 0.0 0.0 0.3 100.0 85.9 1,449 …20-24 27.3 48.5 8.9 15.4 0.0 0.0 0.0 100.0 84.6 1,159 25-29 15.5 54.4 8.0 21.8 0.0 0.1 0.2 100.0 78.0 1,038 30-34 18.7 56.0 7.9 17.1 0.2 0.0 0.1 100.0 82.6 710 35-39 19.1 53.5 6.9 20.5 0.0 0.0 0.0 100.0 79.5 490 40-44 19.1 56.1 7.7 17.1 0.0 0.0 0.0 100.0 82.9 430 45-49 12.3 51.2 7.7 27.6 0.0 1.2 0.0 100.0 71.2 412 Residence Urban 38.3 44.3 6.3 11.0 0.0 0.0 0.2 100.0 88.9 939 Rural 17.5 54.5 8.6 19.2 0.0 0.1 0.1 100.0 80.6 4,748 Province City of Kigali 43.6 44.1 4.3 7.8 0.0 0.0 0.2 100.0 92.0 739 South 15.2 52.2 12.0 20.3 0.0 0.2 0.1 100.0 79.4 1,308 West 19.6 54.5 6.9 18.7 0.0 0.2 0.0 100.0 81.1 1,307 North 20.6 56.2 7.2 16.0 0.0 0.0 0.1 100.0 83.9 899 East 15.8 54.1 8.7 21.0 0.1 0.1 0.2 100.0 78.6 1,435 Wealth quintile Lowest 6.1 50.6 10.5 32.6 0.0 0.3 0.0 100.0 67.1 854 Second 10.5 53.8 10.8 24.7 0.0 0.2 0.1 100.0 75.0 986 Middle 13.5 60.0 8.2 18.3 0.0 0.0 0.0 100.0 81.7 1,139 Fourth 20.8 58.4 8.5 11.9 0.1 0.1 0.3 100.0 87.7 1,235 Highest 42.3 43.2 5.0 9.2 0.0 0.0 0.2 100.0 90.6 1,474 Total 15-49 20.9 52.8 8.2 17.8 0.0 0.1 0.1 100.0 81.9 5,687 50-59 9.4 48.8 8.7 31.1 0.0 1.7 0.3 100.0 66.9 642 Total 15-59 19.7 52.4 8.3 19.2 0.0 0.3 0.1 100.0 80.4 6,329 1 Refers to men who attended secondary school or higher and men who can read a whole sentence or part of a sentence 42 • Respondent Characteristics 3.4 EXPOSURE TO MASS MEDIA Data on the exposure of men and women to mass media are especially important to the development of education programs and the dissemination of all types of information, particularly information about health and family planning. Tables 3.4.1 and 3.4.2 present data on the exposure of men and women to mass media (print or broadcast). It should be stated at the outset that it is not necessary for a household to own a radio or television or to buy a newspaper to have access to these media because many people listen to the radio or watch television at the homes of friends and neighbors. Table 3.4.1 Exposure to mass media: Women Percentage of women age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Rwanda 2010 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week Accesses all three media at least once a week Accesses none of the three media at least once a week Number of women Age 15-19 4.4 11.9 70.6 1.1 27.1 2,945 20-24 3.7 11.8 70.8 1.5 27.7 2,683 25-29 3.1 9.1 67.6 1.4 31.1 2,494 30-34 3.3 8.9 66.0 1.4 32.8 1,822 35-39 3.0 8.5 64.8 1.5 34.2 1,447 40-44 2.6 5.3 66.3 0.8 33.0 1,168 45-49 2.7 4.5 66.4 0.9 33.2 1,112 Residence Urban 7.8 41.0 80.0 5.5 15.5 2,057 Rural 2.7 3.8 66.1 0.5 33.1 11,614 Province City of Kigali 9.0 50.8 82.6 7.0 11.7 1,596 South 2.3 3.2 66.3 0.4 33.1 3,212 West 2.3 4.8 55.1 0.5 43.9 3,305 North 3.5 4.0 75.9 0.8 23.5 2,278 East 3.1 3.7 70.8 0.5 28.3 3,280 Education No education 0.0 2.0 52.0 0.0 47.8 2,119 Primary 2.0 6.0 67.6 0.4 31.2 9,337 Secondary and higher 12.7 30.8 85.9 6.3 10.9 2,216 Wealth quintile Lowest 1.3 1.2 36.4 0.1 62.6 2,622 Second 1.6 1.2 57.4 0.2 42.0 2,661 Middle 2.3 1.8 73.3 0.2 26.0 2,736 Fourth 2.9 2.8 82.8 0.3 16.7 2,677 Highest 8.5 37.0 87.9 5.1 8.4 2,976 Total 3.4 9.4 68.2 1.3 30.5 13,671 Table 3.4.1 shows that, at the national level, 31 percent of women and approximately 12 percent of men are not exposed to any media. However, improvement has occurred since the 2005 RDHS, which reported that 44 percent of women and 19 percent of men were not exposed to any media. Radio is the most common form of media exposure: 68 percent of women and 87 percent of men report listening to the radio at least once a week. Men watch television more frequently than women: Almost one in ten women (9 percent) and one quarter of men (24 percent) watch television at least once a week. Only 3 percent of women, compared with 8 percent of men, report reading a newspaper at least once a week, however. The proportions of men and women who are exposed to all three media are very low: only 1 percent of women and 5 percent of men. The data by age show that the younger women receive relatively more exposure to mass media than older women. In fact, the proportions of women who are not exposed to any media vary from 27 percent for women age 15-19 to 33 percent for women age 45-49. For men, the age differences are narrow and uneven. Respondent Characteristics • 43 Table 3.4.2 Exposure to mass media: Men Percentage of men age 15-49 who are exposed to specific media on a weekly basis, by background characteristics, Rwanda 2010 Background characteristic Reads a newspaper at least once a week Watches television at least once a week Listens to the radio at least once a week Accesses all three media at least once a week Accesses none of the three media at least once a week Number of men Age 15-19 6.9 25.7 86.5 3.1 12.5 1,449 20-24 8.3 30.3 90.5 4.8 8.2 1,159 25-29 7.6 28.0 86.0 4.9 12.7 1,038 30-34 7.3 24.0 87.6 5.1 11.0 710 35-39 8.1 18.5 84.2 5.8 14.1 490 40-44 10.4 19.9 88.6 6.6 11.2 430 45-49 7.7 15.2 86.5 5.4 12.8 412 Residence Urban 16.8 58.7 93.7 14.6 4.8 939 Rural 6.0 18.4 86.1 2.7 12.9 4,748 Province City of Kigali 19.5 67.1 95.2 17.3 2.8 739 South 5.0 15.2 85.5 1.5 13.8 1,308 West 5.2 24.8 83.2 3.5 14.5 1,307 North 9.8 16.9 89.4 3.9 9.9 899 East 5.4 17.6 87.3 2.6 12.2 1,435 Education No education 0.3 9.6 76.5 0.0 23.0 583 Primary 4.0 21.2 86.6 1.6 12.2 3,916 Secondary and higher 24.0 45.1 95.0 17.1 3.8 1,189 Wealth quintile Lowest 2.2 11.1 67.1 0.8 30.5 854 Second 3.1 13.4 81.9 1.1 17.3 986 Middle 5.3 17.5 88.3 1.8 10.5 1,139 Fourth 6.8 19.1 94.3 2.4 5.2 1,235 Highest 16.9 51.8 96.1 13.4 2.7 1,474 Total 15-49 7.8 25.0 87.3 4.7 11.5 5,687 50-59 4.7 13.1 84.9 2.9 14.5 642 Total 15-59 7.5 23.8 87.1 4.5 11.8 6,329 Results by residence reveal significant differentials: in urban areas, 16 percent of women are not exposed to any media compared with 33 percent in rural areas. The differential is also wide for men: the proportion of men not exposed to any media varies from 5 percent in urban areas to 13 percent in rural areas. Results by province show significant differences between the City of Kigali and other provinces: the percentage of women who are not exposed to any media is estimated to be 12 percent in the City of Kigali, while in other provinces this proportion varies from 44 percent (West) to 24 percent (North). For men, the proportion is 3 percent in the City of Kigali, while in other provinces it varies from 15 percent (West) to 10 percent (North). Educational attainment has a significant impact on the level of media exposure. For both men and women, those who have secondary education and higher are the most likely to be exposed to all three media: 6 percent of women who have secondary education and higher compared with less than 1 percent of women who have primary education and none of those who have no education. Similarly, 17 percent of men who have secondary education and higher are exposed to all three media compared with 2 percent of men who have primary education and none of those who have no education. The results show that 48 percent of women with no education are not exposed to any media compared with 11 percent of women with secondary education or higher. For men, 23 percent of those with no education are unexposed to any media, compared with only 4 percent of those with secondary or higher education. As in the case of educational attainment, there is a positive relationship between household wealth and media exposure. Men and women in the richest households have the highest levels of exposure to all three media: 5 percent of women and 13 percent of men, compared with less than 1 percent of women and men in the poorest households. 44 • Respondent Characteristics 3.5 EMPLOYMENT The 2010 RDHS asked both men and women whether they were employed at the time of the survey. Respondents who reported having held a job, paid or unpaid, in any sector during the 12 months preceding the survey were considered employed. Table 3.5.1 shows that, at the national level, 11 percent of women were not working at the time of the survey even if they reported working in the preceding 12 months. More than three in five women (73 percent) were employed at the time of the survey. The percentage of women working at the time of the survey increases steadily with age, rising from 52 percent at age 15-19 to 80-83 percent at age 30 and older. Women who were separated, divorced, or widowed (81 percent) and married women (80 percent) were more likely than women never married to be working at the time of the survey. The number of children also affects a woman’s level of employment. As the number of children increases, the proportion of women who work also increases, from 60 percent among women with no children, to 78 percent among women with one or two children, to 82 percent among women with three children or more. Data by residence show that rural areas had the highest proportion of women working at the time of the survey (74 percent compared with 65 percent in urban areas). North province followed by the City of Kigali had the lowest percentages of women working (60 percent and 61 percent, respectively). In other provinces, the proportion of employed women ranged from 72 percent in West province, to 79 percent in East province, to a maximum of 81 percent in South province. Results by educational attainment show that women with no education (80 percent) are proportionally more likely to be employed than women who have primary education (75 percent) and women who have secondary education and higher (55 percent). Finally, women in households in the two poorest wealth quintiles are more likely to be employed (76 percent and 77 percent) than women in the richest households (63 percent). The results for men show that 91 percent of men had some form of employment at the time of the survey. As with women, the percentage of men working at the time of the survey increases with age, from 73 percent for those age 15-19 to 91 percent or more for those age 20 to 49. With respect to marital status, the results show that currently married men are proportionally more likely to be working (99 percent) than separated, divorced, or widowed men (97 percent) and those who have never been married (81 percent respectively). With respect to residence, rural areas had the highest proportion of men working at the time of the survey: 91 percent, compared with 85 percent in rural areas. Table 3.5.1 Employment status: Women Percent distribution of women age 15-49 by employment status, according to background characteristics, Rwanda 2010 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of women Currently employed1 Not currently employed Age 15-19 52.2 11.7 36.2 100.0 2,945 20-24 70.8 13.0 16.2 100.0 2,683 25-29 78.3 11.7 10.0 100.0 2,494 30-34 80.0 10.8 9.2 100.0 1,822 35-39 83.1 9.1 7.8 100.0 1,447 40-44 80.4 10.3 9.3 100.0 1,168 45-49 82.9 9.0 8.2 100.0 1,112 Marital status Never married 60.6 12.1 27.3 100.0 5,285 Married or living together 79.8 10.5 9.7 100.0 6,897 Divorced/separated/widowed 81.0 11.2 7.8 100.0 1,489 Continued… Respondent Characteristics • 45 Table 3.5.1─Continued Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of women Currently employed1 Not currently employed Number of living children 0 60.0 12.2 27.8 100.0 5,207 1-2 77.7 11.7 10.5 100.0 3,552 3-4 82.0 10.1 7.9 100.0 2,704 5+ 81.7 9.6 8.6 100.0 2,209 Residence Urban 64.6 12.6 22.8 100.0 2,057 Rural 73.9 11.0 15.1 100.0 11,614 Province City of Kigali 61.3 17.6 21.1 100.0 1,596 South 80.6 7.3 12.1 100.0 3,212 West 72.1 5.6 22.3 100.0 3,305 North 60.1 27.1 12.8 100.0 2,278 East 79.0 6.5 14.4 100.0 3,280 Education No education 79.6 10.0 10.4 100.0 2,119 Primary 75.0 10.8 14.2 100.0 9,337 Secondary and higher 55.1 14.1 30.9 100.0 2,216 Wealth quintile Lowest 76.3 10.0 13.7 100.0 2,622 Second 77.0 10.0 13.0 100.0 2,661 Middle 75.1 10.9 14.0 100.0 2,736 Fourth 72.6 11.0 16.4 100.0 2,677 Highest 62.7 13.8 23.5 100.0 2,976 Total 72.5 11.2 16.3 100.0 13,671 1 "Currently employed" is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. 46 • Respondent Characteristics Table 3.5.2 Employment status: Men Percent distribution of men age 15-49 by employment status, according to background characteristics, Rwanda 2010 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Total Number of men Currently employed1 Not currently employed Age 15-19 72.5 2.9 24.6 100.0 1,449 20-24 90.7 2.9 6.4 100.0 1,159 25-29 97.4 1.3 1.3 100.0 1,038 30-34 97.9 1.4 0.6 100.0 710 35-39 98.5 1.1 0.4 100.0 490 40-44 98.1 1.4 0.5 100.0 430 45-49 98.4 0.6 1.0 100.0 412 Marital status Never married 81.3 3.2 15.5 100.0 2,873 Married or living together 98.9 0.8 0.3 100.0 2,699 Divorced/separated/widowed 97.3 0.0 2.7 100.0 115 Number of living children 0 82.2 2.9 14.9 100.0 2,987 1-2 98.0 1.5 0.5 100.0 1,177 3-4 99.0 0.6 0.4 100.0 841 5+ 99.2 0.5 0.3 100.0 683 Residence Urban 85.3 7.5 7.2 100.0 939 Rural 90.9 0.9 8.2 100.0 4,748 Province Kigali City 85.1 9.4 5.5 100.0 739 South 92.0 2.0 6.0 100.0 1,308 West 93.8 1.0 5.3 100.0 1,307 North 90.1 0.2 9.6 100.0 899 East 87.1 0.2 12.7 100.0 1,435 Education No education 98.5 1.0 0.5 100.0 583 Primary 92.0 1.0 6.9 100.0 3,916 Secondary and higher 79.1 5.6 15.3 100.0 1,189 Wealth quintile Lowest 93.3 1.2 5.5 100.0 854 Second 91.9 0.6 7.5 100.0 986 Middle 91.6 0.4 8.0 100.0 1,139 Fourth 90.0 0.9 9.1 100.0 1,235 Highest 85.5 5.5 9.0 100.0 1,474 Total 15-49 90.0 2.0 8.0 100.0 5,687 50-59 96.5 0.6 3.0 100.0 642 Total 15-59 90.6 1.8 7.5 100.0 6,329 1 "Currently employed" is defined as having done work in the past seven days. Includes persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. With respect to educational attainment, the results show men with no education (99 percent) being proportionally more likely to be employed than men with primary education (92 percent) and men with secondary education and higher (79 percent). By province, the data show that the City of Kigali had the lowest proportion of the population that was working at the time of the survey (85 percent); the highest proportion was located in West province (94 percent). Finally, similar to findings for women, the proportion of men working was lower in the richest households than in the poorest households (86 percent compared with 93 percent). Also, the proportion of men who were working at the time of the survey exceeded the proportion of women who were working at any level of background characteristics. Compared with the previous survey, the proportion of women and men who worked at the time of the survey has increased from 64 percent to 73 percent among women and from 52 percent to 91 percent among men. Similarly, we see that during the 2005 RDHS, women were more likely than men to work at the time of the survey (64 percent of women compared with 52 percent of men in 2005), while today the situation is reversed in favor of men (73 percent of women compared with 91 percent of men). Respondent Characteristics • 47 Table 3.6.1 shows women’s occupations. The majority of women who were employed at the time of the survey, or who had worked during the 12 months preceding it, were employed in agriculture (77 percent compared with 86 percent in 2005). Among those working in other occupations (23 percent), 8 percent performed unskilled manual labor, 7 percent worked in sales and services, 3 percent worked in domestic services, and 2 percent performed skilled manual labor. Only 2 percent reported working in a technical, professional, or managerial occupation. Results by age show that the older women are more likely to work in agriculture than the younger ones (89 percent at age group 45-49, 59 percent

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