Tajikistan - Multiple Indicator Cluster Survey - 2005

Publication date: 2005

Tajikistan Multiple Indicator Cluster Survey 2005 Tajikistan Monitoring the situation of children and women Multiple Indicator Cluster Survey 2005 Tajikistan 2005 M ultiple Indicator C luster S urvey M IC S State Committee on Statistics of the Republic of the Tajikistan United Nations Children’s Fund Department for International Development United States Agency for International Development United Nations Population Fund United Nations Development Programme MICS UNFPA Proofreading Karen (Kay) Kirby Dorji Design and cover photo Mikhail Romanyuk Contributors to the report: MICS Global Team State Committee on Statistics of the Republic of Tajikistan Ivana Bjelic Naoko Hosaka Oleg Benes Farhod Khamidov The Tajikistan Multiple Indicator Cluster Survey (MICS) was led by the State Committee on Statistics of the Republic of Tajikistan, with participation of Government institutions includ- ing the Ministry of Health, the Ministry of Education, the Ministry of Labour and Social Pro- tection, and the Youth Committee under the Government of Tajikistan. Financial and techni- cal support was provided by the United Nations Children’s Fund (UNICEF), Department for International Development in the United Kingdom (DFID), the United Nations Development Programme (UNDP), the United Nations Population Fund (UNFPA) and the United States Agency for International Development (USAID). Additional technical and logistical support was provided by the World Health Organisation (WHO), L’Agence d’Aide à la Coopération Technique et au Dévelopement (ACTED) and the Aga Khan Foundation. The survey has been conducted as part of the third round of MICS surveys (MICS3) carried out in more than 50 countries in 2005-2006, following the first two rounds in 1995 and 2000. Survey tools are based on models and standards developed by the Global MICS Project, designed to collect information on the situation of children and women in countries around the world. Additional information on the Global MICS Project may be obtained from www. childinfo.org. Suggested citation: State Committee on Statistics of the Republic of Tajikistan. 2007. Tajikistan Multiple Indica- tor Cluster Survey 2005, Final Report. Dushanbe, Tajikistan: State Committee on Statistics of the Republic of Tajikistan. Tajikistan Monitoring the situation of children and women Multiple Indicator Cluster Survey 2005 Multiple Indicator Cluster Survey, Tajikistan, 20052 Acknowledgements The 2005 Multiple Indicator Cluster Survey (MICS) provides an excellent picture of the status of children and women in Tajikistan. The MICS was developed in 1995 in response to the World Summit for Children, in order to measure progress toward an internationally agreed-upon set of mid-decade goals. Tajikistan conducted its first MICS in 2000. The current round of MICS aims to ascertain where Tajikistan stands in achieving the selected goals of A World Fit for Children, the Millennium Development Goals (MDGs) and other major international commitments. In contrast to the MICS 2000, the MICS 2005 also provides new data on areas such as child discipline, maternal mortality, marriage/union status of women, domestic violence, tuberculosis, Vitamin A access and nutritional status of children. The MICS 2005 required months of planning and involved more than 160 people, four weeks of train- ings, six weeks of fieldwork and four weeks of data entry. It could not have happened without the hard work and dedication of those who participated in this project, including statistical experts, trainers, field coordinators, editors, mappers, listers, supervisors, interviewers, drivers, monitors, data entry clerks and data processors. We are grateful to them all. Special thanks must be given to: Bakhtiya Mukhammadieva, First Deputy Director of the State Committee on Statistics (SCS). As technical director of the project, she supported the MICS team by providing valuable advice on both overall and technical issues, as well as showing great coordination skills. Thanks also go to Kislitsyna Elena, Head of the Demography Department of SCS, for her analytical skills and insights, as well as to Kholmatov Ikhtier, former Head of the Programming Department of SCS, for his technical support in programming and data processing. Thanks as well to the supervisors of field groups in the various regions: Asoev A., Ashurov G., Boymatov K., Stodolya O., Khaitov C., Boboev R., Vorisov A., Shokirov Sh., Shoibragimov A., Zangirbekov D., Kholdorbekov A., Gumaeva R. and Mamadkarimova Kh. For the MICS 2005 a Coordinating Committee was established that included the active participation of many Government institutions and international organizations. The Ministry of Health, Ministry of Education, SCS, Ministry of Labour and Social Protection and Youth Committee provided thoughtful comments and advice at every stage of implementation. The MICS 2005 would not have been accomplished without financial support and understanding from the Department for International Development in the United Kingdom (DFID), United Nations Chil- dren’s Fund (UNICEF), United Nations Development Programme (UNDP), United Nations Popula- tion Fund (UNFPA), United States Agency for International Development (USAID) and World Bank. These donors also were part of the coordinating committee. Other committee members, including the World Health Organization (WHO), contributed to the successful implementation of the MICS 2005 in diverse ways. The Ministry of Health and SCS staff participated in monitoring of MICS field work in various districts. UNFPA made presentations on contraception and participated in monitoring of field- work in Sogd. Action Against Hunger provided anthropometric demonstrations for interviewers and anthropometric fieldwork equipment. L’Agence d’Aide à la Coopération Technique et au Dévelope- ment (ACTED) carried out presentations on bed nets, and the Aga Khan Foundation provided logisti- cal support for fieldwork in GBAO. 3 Constant support and guidance also were received from staff from UNICEF Headquarters and UNI- CEF Geneva Regional Office, as well as UNICEF Tajikistan. The latter include Yukie Mokuo, UNI- CEF Tajikistan Country Office Representative, who coordinated various partners and always guided the team in the right direction; Niloufar Pourzand, former Programme Coordinator; Naoko Hosaka, Monitoring & Evaluation Officer; Farhod Khamidov, Monitoring & Evaluation Officer; and Nukra Sinavbarova, MICS3 Assistant. Invaluable guidance was given by Oleg Benes, the consultant who designed the sample, supervised trainings, provided advice on fieldwork, created tabulation plans and drafted the preliminary report. Lastly, I would like to thank Ms. Ivana Bjelic for great commitment and flexibility in adapting all the changes emerging throughout the writing this report, as well as professionalism in completing all the tasks to the highest standard and in a timely manner. Chairman of the State Committee on Statistics Shabozov M.Sh. Academician of Academy of Sciences of the Republic of Tajikistan Multiple Indicator Cluster Survey, Tajikistan, 20054 summAry tAble of findings Multiple Indicator Cluster Surveys (MICS) and Millennium Development Goals (MDG) Indicators, Tajikistan, 2005 Topic mics Indicator Number mdg Indicator Number Indicator Value CHILD MORTALITY Child mortality 1 13 Under-5 mortality rate 79 per 1,000 live births 2 14 Infant mortality rate 65 per 1,000 live births NUTRITION Nutritional status 6 4 Underweight prevalence 17.4 per cent 7 Stunting prevalence 27.0 per cent 8 Wasting prevalence 7.2 per cent Breastfeeding 45 Timely initiation of breastfeeding 60.9 per cent 15 Exclusive breastfeeding rate 25.4 per cent 16 Continued breastfeeding rate per cent per cent at 12-15 months 74.9 at 20-23 months 34.2 17 Timely complementary feeding rate 15.3 per cent 18 Frequency of complementary feeding 7.4 per cent 19 Adequately fed infants 15.9 per cent Salt iodization 41 Iodized salt consumption 46.4 per cent Vitamin A 42 Vitamin A supplementation (under-5) 46.6 per cent 43 Vitamin A supplementation (postpartum mothers) 41.3 per cent Low birth weight 9 Low birth weight infants 9.7 per cent 10 Infants weighed at birth 65.9 per cent CHILD HEALTH Immunization 25 Tuberculosis immunization coverage 94.5 per cent 26 Polio immunization coverage 78.9 per cent 27 DPT immunization coverage 81.6 per cent 28 15 Measles immunization coverage 91.1 per cent 31 Fully immunized children 70.6 per cent 29 Hepatitis B immunization coverage 68.9 per cent 5 Topic mics Indicator Number mdg Indicator Number Indicator Value Care of illness 33 Use of oral rehydration therapy (ORT) 58.4 per cent 34 Home management of diarrhoea 6.5 per cent 35 Received ORT or increased fluids, and continued feeding 22.1 per cent 23 Care seeking for suspected pneumonia 63.9 per cent 22 Antibiotic treatment of suspected pneumonia 40.6 per cent Solid fuel use 24 29 Solid fuels 35.0 per cent Malaria 36 Household availability of insecticide-treated nets (ITNs) 2.0 per cent 37 22 Under-5s sleeping under insecticide-treated nets 1.3 per cent 38 Under-5s sleeping under mosquito nets 1.7 per cent 39 22 Antimalarial treatment (under-5s) 1.2 per cent Source and cost of supplies 96 Source of supplies (from public sources) Oral rehydration salts 51.8 per cent 97 Cost of supplies (median costs) Oral rehydration salts public sources 2.3 somoni private sources 1.0 somoni ENVIRONMENT Water and sanitation 11 30 Use of improved drinking water sources 69.5 per cent 13 Water treatment 80.4 per cent 12 31 Use of improved sanitation facilities 93.7 per cent 14 Disposal of child’s faeces 28.9 per cent REPRODUCTIVE HEALTH Contraception and unmet need 21 19c Contraceptive prevalence 37.9 per cent 98 Unmet need for family planning 23.7 per cent 99 Demand satisfied for family planning 61.5 per cent Multiple Indicator Cluster Survey, Tajikistan, 20056 Topic mics Indicator Number mdg Indicator Number Indicator Value Maternal and newborn health 20 Antenatal care 77.1 per cent 44 Content of antenatal care 79.1 per cent Blood test taken 68.0 per cent Blood pressure measured 71.8 per cent Urine specimen taken 65.9 per cent Weight measured 61.7 per cent Blood group determined 65.1 per cent Gynaecological exam passed 66.5 per cent Pregnancy term assessed 70.6 per cent Ultrasound exam passed 57.5 per cent Iron tablets received / bought 47.9 per cent 4 17 Skilled attendant at delivery 83.4 per cent 5 Institutional deliveries 61.7 per cent Maternal mortality 3 16 Maternal mortality ratio 97 per 100,000 live births CHILD DEVELOPMENT Child development 46 Support for learning 59.7 per cent 47 Father’s support for learning 20.9 per cent 48 Support for learning: children’s books 17.0 per cent 49 Support for learning: non-children’s books 45.8 per cent 50 Support for learning: materials for play 15.5 per cent 51 Non-adult care 12.6 per cent EDUCATION Education 52 Preschool attendance 10.2 per cent 53 School readiness 25.3 per cent 54 Net intake rate in primary education 64.8 per cent 55 6 Net primary school attendance rate 88.7 per cent 56 Net secondary school attendance rate 82.3 per cent 57 7 Children reaching grade five 99.3 per cent 58 Transition rate to secondary school 98.8 per cent 59 7b Primary completion rate 85.2 per cent 61 9 Gender parity index primary school secondary school 0.99 0.83 ratio ratio Literacy 60 8 Adult literacy rate 95.0 per cent CHILD PROTECTION Birth registration 62 Birth registration 88.3 per cent 7 Topic mics Indicator Number mdg Indicator Number Indicator Value Child labour 71 Child labour 10.0 per cent 72 Labourer students 89.0 per cent 73 Student labourers 11.8 per cent Child discipline 74 Child discipline Any psychological/ physical punishment 74.4 per cent Early marriage 67 Marriage before age 15 Marriage before age 18 0.8 14.7 per cent per cent 68 Young women aged 15-19 currently married/in union 6.4 per cent 69 Spousal age difference Women aged 15-19 Women aged 20-24 5.3 5.2 per cent per cent Domestic violence 100 Attitudes towards domestic violence 74.4 per cent HIV/AIDS HIV/AIDS knowledge and attitudes 82 19b Comprehensive knowledge about HIV prevention among young people 2.3 per cent 89 Knowledge of mother- to-child transmission of HIV 26.9 per cent 86 Attitude towards people with HIV/AIDS 4.6 per cent 87 Women who know where to be tested for HIV 12.7 per cent 88 Women who have been tested for HIV 4.0 per cent 90 Counselling coverage for the prevention of mother-to-child transmission of HIV 23.8 per cent 91 Testing coverage for the prevention of mother-to-child transmission of HIV 9.8 per cent ORPHANED CHILDREN Orphaned children 78 Children’s living arrangements 1.8 per cent 75 Prevalence of orphans 5.4 per cent KNOWLEDGE OF TUBERCULOSIS TRANSMISSION Knowledge of tuberculosis transmission * Lack of knowledge about tuberculosis transmission 4.1 per cent * Lack of knowledge about symptoms of tuberculosis 8.1 per cent * Country specific indicator Multiple Indicator Cluster Survey, Tajikistan, 20058 tAble of contents Acknowledgements . 3 Summary Table of Findings . 5 List of Abbreviations . 14 Executive Summary . 15 I. Introduction . 22 Background. 22 Survey Objectives . 23 II. Sample and Survey Methodology . 24 Sample Design . 24 Questionnaires . 24 Training and Fieldwork . 25 Data Processing . 26 III. Sample Coverage and the Characteristics of Households and Respondents . 27 Sample Coverage . 27 Characteristics of Households . 27 Characteristics of Respondents . 29 IV. Child Mortality . 32 V. Nutrition. 35 Nutritional Status . 35 Breastfeeding . 37 Salt Iodization . 40 Vitamin A Supplements . 42 Low Birth Weight . 43 VI. Child Health . 45 Immunization . 45 Oral Rehydration Treatment . 47 Care Seeking and Antibiotic Treatment of Pneumonia . 49 Solid Fuel Use . 49 Malaria . 50 Source and Costs of Supplies . 52 VII. Environment . 53 Water and Sanitation . 53 Household Durable Goods and Agicultural Assets . 56 VIII. Reproductive Health . 57 Contraception . 57 Unmet Need . 58 Antenatal Care . 59 Assistance at Delivery . 60 Maternal Mortality . 61 9 IX. Child Development . 62 X. Education . 64 Preschool Attendance and School Readiness . 64 Primary and Secondary School Participation . 64 Adult Literacy . 66 XI. Child Protection . 67 Birth Registration . 67 Child Labour . 67 Child Discipline . 68 Early Marriage . 69 Domestic Violence . 70 Women’s Participation in Decision Making in the Home . 71 XII. HIV/AIDS . 72 Knowledge of HIV Transmission . 72 XIII. Orphans . 75 XIV. Knowledge of Tuberculosis . 76 List of References . 77 tAbles . 78 Appendix A. Sample Design . 178 Appendix B. List of Personnel Involved in the Survey . 181 Appendix C. Estimates of Sampling Errors . 182 Appendix D. Data Quality Tables . 200 Appendix E. MICS Indicators: Numerators and Denominators . 211 Appendix F. Questionnaires . 218 Multiple Indicator Cluster Survey, Tajikistan, 200510 list of tAbles Table HH.1: Results of household and individual interviews. .78 Table HH.2: Household age distribution by sex. . 78 Table HH.3: Household composition. . 79 Table HH.4: Women’s background characteristics. . 80 Table HH.5: Children’s background characteristics. .81 Table CM.1: Child mortality. . 82 Table NU.1w: Child malnourishment (Working table). .83 Table NU.1: Child malnourishment. . 84 Table NU.1.A: Child acute malnutrition. . 86 Table NU.2: Initial breastfeeding. . 88 Table NU.3: Breastfeeding. . 89 Table NU.4: Adequately fed infants. . 90 Table NU.5: Iodized salt consumption. . 91 Table NU.5.A: Knowledge and consumption patterns of iodised salt, Tajikistan, 2005 .92 Table NU.5.B: Acquisition and consumption patterns of iodised salt. .93 Table NU.6: Children’s Vitamin A supplementation. 100 Table NU.7: Postpartum mothers’ Vitamin A supplementation .101 Table NU.8: Low birth weight infants . 102 Table CH.1: Vaccinations in first year of life . 104 Table CH.1c: Vaccinations in first year of life (continued) .104 Table CH.2: Vaccinations by background characteristics .105 Table CH.2c: Vaccinations by background characteristics (continued) .106 Table CH.3: Oral rehydration treatment . 108 Table CH.4: Home management of diarrhoea. 109 Table CH.5: Care seeking for suspected pneumonia .110 Table CH.6: Knowledge of the two danger signs of pneumonia .111 Table CH.7: Solid fuel use . 112 Table CH.8: Solid fuel use by type of stove or fire . 114 Table CH.9: Availability of insecticide treated nets. 115 Table CH.10: Children sleeping under bednets . 117 Table CH.11: Treatment of children with anti-malarial drugs .118 Table CH.12: Source and cost of supplies for oral rehydration salts .120 Table EN.1: Use of improved water sources. . 121 Table EN.2: Household water treatment . 122 Table EN.3: Time to source of water . 124 Table EN.4: Person collecting water . 126 Table EN.5: Use of sanitary means of excreta disposal .126 Table EN.6: Disposal of child’s faeces . 127 Table EN.7: Use of improved water sources and improved sanitation .129 Table EN.8.A: Household durable goods . 131 Table EN8.B: Household durable goods . 132 Table EN8.C: Household agricultural assets . 135 Table RH.1: Use of contraception . 137 Table RH.1.A: Knowledge of contraceptive methods .139 Table RH.2: Unmet need for contraception . 141 Table RH.3: Antenatal care provider . 142 Table RH.4.w: Antenatal care content . 144 Table RH.5: Assistance during delivery . 145 Table RH.5.A: Pregnancy outcome by background characteristics .147 Table RH.6: Maternal mortality ratio . 148 Table CD.1: Family support for learning . 148 Table CD.2: Learning materials . 150 Table CD.3: Children left alone or with other children .153 11 Table ED.2: Primary school entry . 154 Table ED.3: Primary school net attendance ratio . 157 Table ED.4: Secondary school net attendance ratio . 158 Table ED.4W: Secondary school-age children attending primary school .159 Table ED.5: Children reaching grade 5 . 160 Table ED.6: Primary school completion and transition to secondary education .161 Table ED.7: Education gender parity . 162 Table ED.8: Adult literacy . 163 Table CP.1: Birth registration . 164 Table CP.2: Child labour . 165 Table CP.3: Labourer students and student labourers .166 Table CP.4: Child discipline . 167 Table CP.5: Early marriage . 168 Table CP.6: Spousal age difference . 169 Table CP.7: Attitudes toward domestic violence . 171 Table CP7.A.1: Women’s participation in decision making by background characteristics .172 Table CP7.B: Women’s participation in decision making by background characteristics .173 Table CP7.C: Women’s participation in decision making by background characteristics .175 Table CP7.D: Women’s participation in decision making by background characteristics .177 Table CP.7.E: Women’s participation in decision making by background characteristics .178 Table HA.1: Knowledge of preventing HIV transmission .179 Table HA.2: Identifying misconceptions about HIV/AIDS .181 Table HA.3: Comprehensive knowledge of HIV/AIDS transmission .183 Table HA.4: Knowledge of mother-to-child HIV transmission .184 Table HA.5: Attitudes toward people living with HIV/AIDS .185 Table HA.6: Knowledge of a facility for HIV testing . 187 Table HA.7: HIV testing and counseling coverage during antenatal care .189 Table ORPH.1: Children’s living arrangments and orphanhood .191 Table TB.1: Knowledge of tuberculosis and mode of transmission .192 Table TB.2: Knowledge of symptoms of tuberculosis .194 Table TB.3: Symptoms of tuberculosis that would convince respondents to seek medical assistance .196 Table TB.4: Knowledge that tuberculosis can be cured, and the stigma attached to the disease .198 Table TB.5: Perception of the initial treatment of tuberculosis .199 Table TB.6: The place for seeking help in case the respondent or her child has tuberculosis .200 Table SE.1: Indicators selected for sampling error calculations .209 Table SE.2: Sampling errors: Total sample . 211 Table SE.3: Sampling errors: Urban areas . 213 Table SE.4: Sampling errors: Rural areas . 215 Table SE.5: Sampling errors: Dushanbe . 217 Table SE.6: Sampling errors: Khatlon . Table SE.7: Sampling errors: Sogd . Table SE.8: Sampling errors: DRD . Table SE.9: Sampling errors: GBAO. Table DQ.1: Age distribution of household population . Table DQ.2: Age distribution of eligible and interviewed women . Table DQ.3: Age distribution of eligible and interviewed under-5s . Table DQ.4: Age distribution of under-5 children . Table DQ.5: Heaping on ages and periods . Table DQ.6: Completeness of reporting . Table DQ.7: Presence of mother in the household and the person interviewed for the under-5 questionnaire. . Table DQ.8: School attendance by single age . Table DQ.9: Sex ratio at birth among children ever born and living . Table DQ.10: Distribution of women by time since last birth . Multiple Indicator Cluster Survey, Tajikistan, 200512 tAble of figures Figure HH.1. Age and Sex Distribution of Household Population, Tajikistan, 2005 .28 Figure CM.1. Under-5 Mortality Rates by Background Characteristics, Tajikistan, 2005 .33 Figure CM.2. Trend in Infant Mortality Rates, Tajikistan, 2005 .33 Figure CM.2.a. Trends in child mortality according MICS, 2000-2005 .34 Figure NU.1. Percentage of children under-5 who are undernourished, Tajikistan, 2005 .36 Figure NU.2. Percentage of mothers who started breastfeeding within one hour and within one day of birth, Tajikistan, 2005 .38 Figure NU.3. Infant feeding patterns by age: Percent distribution of children aged under 3 years by feeding pattern by age group, Tajikistan, 2005 .39 Figure NU.4. Percentage of households consuming adequately iodized salt, Tajikistan, 2005 .41 Figure NU.4.a. Progress use of iodized salt, Tajikistan, 2000-2005 .41 Figure NU.5. Percentage of Infants Weighing Less Than 2500 Grams at Birth, Tajikistan, 2005 .44 Figure CH.1. Percentage of children aged 18-29 months who received the recommended vaccinations by 12 months (18 months in case of measles), Tajikistan, 2005 .46 Figure CH.2. Percentage of children aged 0-59 months with diarrhoea who received oral rehydration treatment, Tajikistan, 2005 .48 Figure CH.3. Percentage of children aged 0-59 with diarrhoea who received ORT or increased fluids, AND continued feeding, Tajikistan, 2005 .48 Figure EN.1. Percentage distribution of household members by source of drinking water, Tajikistan, 2005 .54 Figure RH.1. Percentage of women aged 15-49 years married or in union who are using (or whose partner is using) a contraceptive method, Tajikistan, 2000 - 2005 .58 Figure HA.1. Percent of women who have comprehensive knowledge of HIV/AIDS transmission, Tajikistan, 2005 .73 Figure 1. Scatterplot of weight (Y-axis) by height (X-axis) (unweighted), Tajikistan 2005 .208 Figure 2. Scatterplot of weights of children by age in months (unweighted), Tajikistan 2005 .208 Figure 3. Scatterplot of heights of children by age in months (unweighted), Tajikistan 2005 .209 Figure 4. Number of male household (Y-axis) by single ages (Y-axis) (unweighted), Tajikistan 2005 .209 Figure 5. Number of female household (Y-axis) by single ages (Y-axis) (unweighted), Tajikistan 2005 .210 Figure 6. Population piramid, Tajikistan 2005 .210 13 list of AbbreviAtions ACTED L’Agence d’Aide à la Coopération Technique et au Dévelopement AIDS Acquired Immune Deficiency Syndrome BCG Bacillis-Cereus-Geuerin (Tuberculosis) CDC United States Centres for Disease Control CIS Commonwealth of Independent States CSPro Census and Survey Processing System DFID Department for International Development, United Kingdom DRD Direct Rule District DPT Diphteria Pertussis Tetanus EPI Expanded Programme on Immunization GAM Global Acute Malnutrition GAVI Global Alliance for Vaccines and Immunization GBAO Gorno Badakhshan GPI Gender Parity Index HIV Human Immunodeficiency Virus IDD Iodine Deficiency Disorders ITN Insecticide Treated Net IUD Intrauterine Device LAM Lactational Amenorrhoea Method LSMS Living Standard Measurement Survey MDGs Millennium Development Goals MICS Multiple Indicator Cluster Survey MoH Ministry of Health MUAC Mid-Upper Arm Circumference NAR Net Attendance Rate ORS Oral Rehydration Salts ORT Oral Rehydration Treatment ppm Parts Per Million RHF Recommended Home Fluids SCS State Committee on Statistics of the Republic of Tajikistan SP Sulfadoxine-Pyrimethamine SPSS Statistical Package for Social Sciences STI Sexually Transmitted Infection TB Tuberculosis UNAIDS United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund USAID United States Agency for International Development WFFC World Fit For Children WHO World Health Organization 14 Multiple Indicator Cluster Survey, Tajikistan, 2005 Executive Summary 15 executive summAry The Tajikistan Multiple Indicator Cluster Survey 2005 is a nationally representative sample of house- holds, women and children. Results pertain to September–October 2005, when fieldwork was con- ducted. Child Mortality The infant mortality rate in Tajikistan is estimated at 65 per 1,000 live births, while the probability • of dying before age of 5 is around 79 per 1,000 live births. Boys and girls face significant differences in the probability of dying, with boys far more dis-• advantaged. The infant mortality rate among boys is 75, and among girls, 54; similarly, under-5 mortality rate among boys is 92, as compared to 66 among girls. Nutritional Status 1 in 6 children (17 per cent) under age 5 are moderately or severely underweight, with 4 per cent • classified as severely underweight. About 1 in 4 (27 per cent) are stunted, or too short for their age, while 7 per cent are wasted, or too thin for their height. Children in Khatlon and GBAO are more likely to be underweight and stunted, while the lowest • figures are found in Dushanbe. For each measure (underweight, wasting stunting), figures for children from the poorest house-• holds significantly exceed the national average. A child’s nutritional status is strongly correlated the with mother’s education. Children whose • mothers attended higher education are least likely to be undernourished. Around 4 per cent of children are overweight.• The prevalence of Global Acute Malnutrition among children aged 12–59 months is 11 per cent. • Children in Khatlon and the poorest households are more likely to be exposed to GAM (about 14 per cent). Breastfeeding Only 61 per cent of women start breastfeeding their baby within one hour of birth. A significantly • higher percentage (87 per cent) begin breastfeeding within one day of birth. Although it is recommended that all children under age 4 months are exclusively breastfed, in • Tajikistan the breastfeeding rate among children at this age is slightly above 1 in 3 (36 per cent) The share of children aged under 6 months who are exclusively breastfed is even lower, at about 1 • in 4. Exclusive breastfeeding is highest among children in Sogd and GBAO, at 45 and 51 per cent respectively. At age 6-9 months, 15 per cent of children are receiving breastmilk and solid or semi-solid foods. • By age 12-15 months, three-quarters of children are still being breastfed, while about one-third re-• main breastfed at age 20-23 months. Boys, children in GBAO and those in the poorest households are most likely to continue breastfeeding. Only 7 per cent of children aged 6-11 months are being adequately fed. Among all infants aged • 0-11 months, adequate feeding rises to a still-low 16 per cent, mainly because of the higher per- centage of breastfed children. Multiple Indicator Cluster Survey, Tajikistan, 200516 Salt Iodization Fewer than half (46 per cent) of overall households in Tajikistan use adequately iodized salt (15 • ppm or more); wide variations are found by region, ranging from 26 per cent in DRD and 27 per cent in Khatlon to 76 per cent in Sogd. Use of iodized salt is almost twice as high in the richest households (62 per cent) compared to the • poorest (33 per cent). Vitamin A Within the six months before the MICS, 47 per cent of children aged 6-59 months received a high-• dose Vitamin A supplement. Another 5 per cent had received a supplement earlier. In addition, 1 of 10 children had received a Vitamin A supplement at some time, but their mother/caretaker was unable to specify when. Nearly one-third never received a Vitamin A supplement. Girls, children living in DRD and GBAO, and children whose mother has a secondary special • education are somewhat more likely to receive Vitamin A supplementation. About 4 in 10 mothers with a birth in the two years before the MICS received a Vitamin A supple-• ment within eight weeks of the birth. Low Birth Weight Overall, 66 per cent of infants were weighed at birth; about 10 per cent of infants are estimated to • weigh less than 2500 grams. Children in rural areas and the poorest households are most likely to be low birth weight. Immunization About 83 per cent of children aged 18 to 29 months had health cards, either at home or at health • facilities. Only 9 per cent had a vaccination card at home. Nearly all (95 per cent) children aged 18-29 months received a BCG vaccination by age 12 • months. All three doses of DPT and polio were given to 82 per cent and 79 per cent respectively. A total of 91 per cent of children of the same age group received a measles vaccine by age 18 months. Fewer than 3 in 4 children (71 per cent) had all eight recommended vaccinations (BCG, three • doses of DPT, three doses of polio and measles), according to the National Immunization Pro- gramme. The percentage of children vaccinated at any time before the MICS survey was 77 per cent, indicating slight delays in vaccinations. About 85 per cent of children aged 18-29 months received the first dose of hepatitis B vaccine by • age 12 months. The prevalence of subsequent doses of hepatitis B vaccine drops to 77 per cent for the second dose and 69 per cent for the third dose. Significant regional differences in immunization coverage exist: the highest percentage of children • who are fully immunized is in Sogd, at 87 per cent, while the lowest is in GBAO and DRD, at 69 and 70 per cent respectively. Urban children (82 per cent) are more likely to be fully immunized than rural children (76 per cent). Oral Rehydration Treatment Overall, 13 per cent of under-5 children had diarrhoea in the two weeks preceding the survey, • corresponding to 3.4 episodes per child annually. Diarrhoea prevalence was highest in DRD, at 15 per cent, and lowest in Dushanbe, at 10 per cent. Fewer than 3 in 5 (58 per cent) of children with diarrhoea received one or more recommended • home treatments, while 42 per cent received no treatment. Executive Summary 17 Home management of diarrhoea is very low, at only 6 per cent, with significant regional differ-• ences (3 per cent in Khatlon, 19 per cent in Dushanbe) and urban-rural differences (9 and 6 per cent respectively). 22 per cent of children with diarrhoea received ORT or increased fluids and continued feeding, • with similar variations by background characteristics as for home management of diarrhoea. Care Seeking and Antibiotic Treatment of Pneumonia 2 per cent of children aged 0-59 months were reported to have had symptoms of pneumonia dur-• ing the two weeks preceding the survey. Of these, nearly 2 in 3 (64 per cent) were taken to an appropriate provider. About 41 per cent of under-5 children with suspected pneumonia had received an antibiotic during • the two weeks before the survey. Only 3 per cent of women know the two danger signs of pneumonia – fast and difficult breathing • – identified by 14 per cent and 13 per cent of mothers respectively as warranting taking a child to a health care provider. By far the most commonly identified symptom for seeking health care for a child was fever (88 per cent). Solid Fuel Use Overall, more than one-third (35 per cent) of households in Tajikistan use solid fuels for cooking. • Such use is significantly lower in urban areas (8 per cent), Dushanbe (1 per cent) and among the richest households (2 per cent). More than half (53 per cent) of households that use solid fuels for cooking have an open stove or • fire with a chimney. About 44 per cent use an open stove or fire with no chimney or hood, while the proportion of closed stoves with chimney is below 1 per cent. Malaria Only 5 per cent of households in Tajikistan have at least one mosquito net. The availability of • insecticide treated net is even lower, at 2 per cent. The proportion of households with at least one bed net is highest in Khatlon (8 per cent) and Sogd (6 per cent), while in other regions the result is below 1 per cent. Only 2 per cent of children under the age 5 slept under any mosquito net the night before the sur-• vey, and 1 per cent slept under an insecticide treated net. About 7 per cent of under-5 children were ill with fever in the two weeks before the survey. Fever • prevalence declined with age and peaked at 12-23 months (10 per cent). Only 2 per cent of chil- dren with fever in the previous two weeks were treated with an appropriate anti-malarial drug. Sources and Cost of Supplies For more than half of children with diarrhoea (52 per cent), ORS was obtained from public sourc-• es; of these, 78 per cent were free. The median price of ORS not obtained for free was 2.3 somoni. A total of 12 per cent of ORS were obtained from private sources, of which only 9 per cent were free. For others, the median cost was 1 somoni. Multiple Indicator Cluster Survey, Tajikistan, 200518 Water and Sanitation Overall, 7 in 10 people in Tajikistan (70 per cent) use an improved source of drinking water, but • the variation between urban and rural areas is wide (93 and 61 per cent respectively). The situa- tion in GBAO and Khatlon is considerably worse than in other regions, at only 51 and 55 per cent respectively. Only 48 per cent of poorest population, compared to 95 per cent of the richest, has access to an improved water source. 80 per cent of the population use an appropriate water treatment method, most commonly boiling • to make water safer for dinking. For one-quarter of all households, it takes less than 15 minutes to get to a water source and bring • water, while 16 per cent of household need to spend more than 30 minutes for this purpose. Ex- cluding those households with water on the premises, the average time to the source of drinking water is 26 minutes. In most households, women usually collect the water. Nearly the entire population (94 per cent) live in households using improved sanitation facilities. • The proportion stands at 97 per cent in urban areas, 92 per cent in rural areas. Residents of GBAO are less likely than others to use improved facilities. The most common type of sanitation is pit latrine with slab (79 per cent), while only 13 per cent of the population has sanitation connected to a sewage system. Contraception Current use of contraception was reported by 38 per cent of women currently married or in union. • Modern contraceptive methods are more used than traditional, at 33 compared to 5 per cent. By far the most popular method is IUD, used by 1 in 4 married women; the next most popular is lac- tational amenorrhoea method (LAM), at 3 per cent. Contraceptive prevalence is highest in Sogd, at 46 per cent, and lowest in DRD, at only 29 per • cent. Fewer than 1 in 10 (9 per cent) of married or in-union women aged 15-19 use a method to prevent • pregnancy, compared to 1 in 4 20- to 24-year-olds and half of women aged 35 to 39. Unmet Need Nearly 1 in 4 women (24 per cent) have an unmet need for contraception, which mainly manifests • as unmet need for limiting (15 per cent). Unmet need for spacing (9 per cent) is mainly found among women aged 15 to 24. Antenatal Care Nearly 4 in 5 pregnant women (79 per cent) received antenatal care one or more times during • pregnancy. Antenatal care coverage is lower among older, less educated and poor women. More than 3 in 4 pregnant women (77 per cent) received antenatal care from skilled personnel. • Medical doctors provided antenatal care to 68 per cent of women, while nurses/midwives looked • after 9 per cent. Assistance at Delivery More than 4 in 5 births in the year before the MICS survey (83 per cent) were delivered by skilled • personnel. Less educated, poorer and older women are behind the national average, with propor- tions ranging from 53 to 70 per cent. About 62 per cent of births in the two years before the survey were delivered in health facilities. • A lower share of institutional deliveries is recorded in Khatlon and GBAO, at 42 and 45 per cent respectively. Executive Summary 19 Maternal Mortality The estimated maternal mortality level in Tajikistan stands at 97 per 100,000 live births.• Child Development For almost two-thirds (60 per cent) of under-5 children, an adult engaged in four or more activities • that promote learning and school readiness during the three days preceding the survey; the aver- age number of activities was 3.7. Fathers’ involvement with one or more activities was signifi- cantly lower, at only 21 per cent. Children from DRD, rural areas and poor households, as well as children whose parents are less • educated, are less likely to be involved in learning-promotion activities. About 46 per cent of children aged 0-59 months live in households where at least three non-chil-• dren’s books are present. However, only 17 per cent live in households that have children’s books. 13 per cent of children were left with inadequate care during the week before the survey. Inad-• equate care is more prevalent among children in Khatlon and Sogd, those from poor households and children whose mothers had secondary special education. Preschool Attendance and School Readiness Only 10 per cent of children aged 36-59 months attend preschool, with attendance highest in • Dushanbe (33 per cent) and lowest in DRD (4 per cent). Higher wealth status is positively corre- lated with children attending preschool. One-quarter of 7-year-olds attending the first grade of primary school were enrolled in preschool • the previous year. Attendance was almost four times higher in urban than rural areas. Primary and Secondary School Participation Among children of primary school entry age (7 years), two-thirds (65 per cent) are attending the • first grade of primary school. Children from urban areas, Dushanbe and the richest households most often start primary education on time. Most children of primary school age are attending school (89 per cent of children aged 7 to 10 • years). About 82 per cent of children aged 11-17 are attending secondary school or higher. Geographical • variations show that a higher proportion of boys and children from GBAO, Dushanbe and urban areas attend. Nearly all children starting grade one will eventually reach grade five (99 per cent).• The Gender Parity Index (GPI) for primary school is 0.99, indicating virtually no difference in • girls’ and boys’ attendance. However, the indicator drops to 0.83 for secondary education. Girls’ disadvantage is slightly less pronounced in Sogd and GBAO, as well as among urban and • richer children. Adult Literacy The literacy rate among young women (15-24 years) is 95 per cent, although younger women • (aged 15-19) are less literate than women aged 20-24. Unsurprisingly, the literacy level is much lower among women with none or primary education, at 12 and 32 per cent respectively. Women in the richest households are the most literate. Multiple Indicator Cluster Survey, Tajikistan, 200520 Birth Registration The births of a large majority of children under-5 (88 per cent) have been registered. A surpris-• ing finding is that birth registration is higher among rural than urban children, at 90 compared to 85 per cent. The indicator rises from 82 per cent among children aged 0-11 months to 92 per cent among children aged 48-59 months, which indicates delayed registration. Cost appears to be the main reason for non-registration (42 per cent). • Child Labour 10 per cent of children aged 5-14 years are involved in child labour, mainly unpaid and domestic • work. The proportion is highest in GBAO, at nearly one-quarter of children. The poorest children, children whose mothers have no education and those aged 12-14 years are most exploited regard- ing child labour. Out of the 75 per cent of children aged 5-14 years attending preschool or school, 12 per cent are • involved in child labour. On the other hand, out of the 10 per cent of the children classified as child labourers, the vast majority also attend school (89 per cent). Child Discipline Nearly 3 in 4 children in Tajikistan aged 2-14 years (74 per cent) have been subjected to at least • one form of psychological or physical punishment by their mothers/caretakers or other household members. A total of 16 per cent of children were subjected to severe physical punishment and 55 per cent to minor physical punishment, while 70 per cent were disciplined through psychological punishment. Every fifth child in Tajikistan has been disciplined through non-violent methods, while 7 per cent • have never been punished nor disciplined. Early Marriage Less than 1 per cent of women aged 15-49 in Tajikistan are married before age 15, but almost 15 • per cent of all women aged 20 to 49 married before age 18. The highest rate of marriage before age 18 is among women aged 25-29 years (23 per cent). This practice also is more prevalent among poor and Tajik women, among whom about 1 in 6 women married before age 18. A total of 6 per cent of women aged 15-19 are married or in union. About 5 per cent of married/in-union women aged 15-19 are married to a partner 10 or more years • older; the percentage is the same among women aged 20-24 years. This indicator is strongly cor- related with the woman’s educational level. Domestic Violence 3 out of 4 married/in-union women in Tajikistan feel that their husband/partner has a right to hit or • beat them for at least one of a variety of scenarios. A vast majority (86 per cent) believe that their partner has a right to hit or beat them if they argue with him. More acceptance is found among rural, less educated and poorer women. Surprisingly, acceptance is highest among young married women; 85 per cent of women aged 15-• 29 said their partner is justified in hitting them, although the proportion falls to 69 per cent among women aged 45-49. Only 1 in 3 married/in-union woman participates in decision making regarding household pur-• chases, her health and her social life. On the other hand, 39 per cent of women make none of these decisions. A woman’s right to participate is strongly correlated with her education level and household wealth. Executive Summary 21 HIV/AIDS 42 per cent of women in Tajikistan had heard of AIDS. Significantly, however, the percentage who • know all three main ways of preventing HIV transmission is very low, at 11 per cent. Only 6 per cent of women reject the two most common misconceptions regarding HIV (that it • cannot be transmitted by sharing food or being bitten by a mosquito) and know that a healthy- looking person can be infected. This percentage is somewhat higher among more educated and Russian-speaking women. An alarming finding is that only 4 per cent of women have comprehensive knowledge about HIV • transmission (identifying 2 prevention methods and 3 misconceptions). Among women aged 15- 24, the proportion with comprehensive knowledge is even lower, at 2 per cent. Overall, 37 per cent of women know that HIV can be transmitted from mother to child. Only 10 • per cent know all three ways of mother-to-child transmission, however, while 4 per cent know no specific way. An overwhelming 95 per cent of women in Tajikistan who have heard of AIDS agree with at least • one discriminatory statement. The most common discriminatory attitude is refusal to buy fresh vegetables from a person with HIV/AIDS. Only 13 per cent of women know where to be tested, while 4 per cent have actually been tested. • Of these, a large proportion have been told the result (87 per cent). Although 77 per cent of women who gave birth in two years preceding the survey received ante-• natal care, less than one-quarter of women were informed about HIV prevention. Only 11 per cent of women were tested for HIV during antenatal care visit. Orphans 88 per cent of children younger than age 17 live with both parents. About 2 per cent of children • of this age do not live with a biological parent, while one or both parents of 5 per cent of children have died. Knowledge of Tuberculosis Transmission 1 in 2 women aged 15-49 has heard of tuberculosis; of these, about two-thirds (67 per cent) know • it can be cured. A high percentage of women (88 per cent) would take care of a family member who had TB and • completed hospital treatment. Even so, one-third of women would like to keep it a secret if a fam- ily member contracted tuberculosis. A large majority of women (88 per cent) think TB should be treated in a hospital.• Multiple Indicator Cluster Survey, Tajikistan, 200522 i. introduction Background This report is based on the Tajikistan Multiple Indicator Cluster Survey, conducted in 2005 by the State Committee on Statistics of the Republic of Tajikistan (SCS), supported by its regional-level offices as well as the Ministry of Health, Ministry of Education, Ministry of Labour and Social Protec- tion, and the Youth Committee. The survey provides valuable information on the situation of children and women in Tajikistan and was based, in large part, on the need to monitor progress toward goals and targets emanating from recent international agreements: the Millennium Declaration, adopted by all 191 United Nations Member States in September 2000, and the Plan of Action of the World Fit For Children, adopted by 189 Member States at the United Nations Special Session on Children in May 2002. Both of these commitments are built upon promises made by the international community at the 1990 World Summit for Children. In signing these international agreements, governments committed themselves to improving conditions for their children and to monitoring progress toward that end. UNICEF was assigned a supporting role in this task (see box below). A Commitment to Action: National and International Reporting Responsibilities The governments that signed the Millennium Declaration and the World Fit for Children Declaration and Plan of Action also committed themselves to monitoring progress toward the goals and objectives they contained: “We will monitor regularly at the national level and, where appropriate, at the regional level and as- sess progress toward the goals and targets of the present Plan of Action at the national, regional and global levels. Accordingly, we will strengthen our national statistical capacity to collect, analyze and disaggregate data, including by sex, age and other relevant factors that may lead to disparities, and support a wide range of child-focused research. We will enhance international cooperation to support statistical capacity building efforts and build community capacity for monitoring, assessment and planning.” (A World Fit for Children, para. 60) “…We will conduct periodic reviews at the national and sub-national levels of progress in order to ad- dress obstacles more effectively and accelerate actions.…” (A World Fit for Children, para. 61) The Plan of Action (para. 61) also calls for the specific involvement of UNICEF in the preparation of periodic progress reports: “… As the world’s lead agency for children, the United Nations Children’s Fund is requested to contin- ue to prepare and disseminate, in close collaboration with governments, relevant funds, programmes and the specialized agencies of the United Nations System, and all other relevant actors, as appropriate, information on the progress made in the implementation of the Declaration and the Plan of Action.” Similarly, the Millennium Declaration (para. 31) calls for periodic reporting on progress: “…We request the General Assembly to review on a regular basis the progress made in implementing the provisions of this Declaration, and ask the Secretary-General to issue periodic reports for consideration by the General Assembly and as a basis for further action.” I. Introduction 23 In recent years, the Government of Tajikistan has increased its political commitment and capacity in undertaking social reforms in line with realization of the Millennium Development Goals (MDGs) and the rights of children and women. In 2005 the Government made major progress toward the MDGs by completing an MDG Needs Assessment and draft National Development Strategy. However, much still remains to be done, especially in the areas of access to quality health, education and child protection services. Indeed, Tajikistan continues to be in great need of additional international support in order to meet the MDG targets, as well as to fulfil its commitment to the realization of children’s and women’s rights. Completion of the 2005 MICS will complement this strategically related work by providing up- dated baseline data for future planning and implementation by all stakeholders and duty bearers. It is expected that MICS 2005 findings will further enhance evidence-based policy planning and analysis of the Government, thus contributing to more systematic policy development and implementation toward the MDGs and a World Fit for Children (WFFC). This final report presents the results of the indicators and topics covered in the survey. Survey Objectives The MICS 2005 has as its primary objectives: To provide up-to-date information for assessing the situation of children and women in Tajikistan 9 To furnish data needed for monitoring progress toward goals established in the Millennium Dec- 9 laration and WFFC as well as other internationally agreed-upon goals, using this as a basis for future action To contribute to the improvement of data and monitoring systems in Tajikistan and to strengthen 9 technical expertise in the design, implementation and analysis of such systems Multiple Indicator Cluster Survey, Tajikistan, 200524 II. SAMPLE AND SURVEy METHODOLOGy Sample Design The sample for the Tajikistan MICS was designed to provide estimates on a large number of indica- tors on the situation of children and women at the national level, for urban and rural areas, and for five regions: Dushanbe (the capital), Direct Rule Districts (DRD), Sogd, Khatlon and Gorno Badakhshan (GBAO). Regions were identified as the main sampling domains, and the sample was selected in two stages. Across all regions, 290 census enumeration areas were selected with probability proportional to size. Because the sample frame (Tajikistan population census of 2000) was not up to date, household lists in each enumeration area were updated before the selection of households. After a household list- ing and mapping was carried out in each enumeration area, a systematic sample of 6,968 households was drawn. All enumeration areas were successfully visited during the fieldwork. Because the distribu- tion of clusters between sampling domains was not proportional to the census distribution of popula- tion, and consequently neither was the final household distribution, the sample is not self-weighting. For reporting national-level results, sample weights are used. A more detailed description of the sample design can be found in Appendix A. Questionnaires Three sets of questionnaires were used in the survey: 1) a household questionnaire to collect informa- tion on all de jure household members, the household and the dwelling; 2) a women’s questionnaire administered in each household to all women aged 15-49; and 3) an under-5 questionnaire, adminis- tered to mothers or caretakers of all children under 5 in the household. The Household Questionnaire included: Household listing• Education• Water and sanitation• Household characteristics• Insecticide treated net (ITN)• Child labour• Child discipline• Maternal mortality• Salt iodization• The Questionnaire for Individual Women included: Child mortality• Maternal and newborn health• Marriage and union• Contraception• II. Sample and Survey Methodology 25 Attitudes toward domestic violence• HIV knowledge• Tuberculosis• The Questionnaire for Children Under 5 normally was administered to mothers of under-5 children;1 when the mother was not listed in the household roster, a primary caretaker for the child was identified and interviewed. The questionnaire included: Birth registration and early learning• Child development• Vitamin A• Breastfeeding• Care of Illness• Malaria• Immunization• Anthropometry• The questionnaires are based on the MICS3 model questionnaire.2 To select the most important topics to be covered by the survey, parents were consulted in Dushanbe. Following these consultations, mod- el MICS3 questionnaires were adjusted to reflect the country-specific situation. The Tajikistan MICS questionnaires encompassed a number of important additions to obtain data that are missing, and valuable for learning about the country’s population in general and women’s and children’s health in particular. For example, the salt iodization module was expanded with a number of questions concern- ing salt acquisition and consumption patterns. The Questionnaire for Individual Women incorporated additional questions on pregnancy outcomes, antenatal health services, knowledge of contraceptives and participation of women in household decision making, as well as a module on tuberculosis. From the MICS3 model English version, the questionnaires were translated into Tajik and Russian. After adaptation, they were pre-tested during July 2005 in both urban and rural areas in districts close to Dushanbe. Based on these results, modifications were made to the wording and translation of the questionnaires. The final questionnaires used in the survey were approved by the Coordinating Com- mittee; copies are provided in Appendix F. In addition to administration of questionnaires, fieldwork teams tested salt used for cooking in the households for iodine content, and measured the weights and heights of under-5 children. Details of these measurements are provided in respective sections of the report. Training and Fieldwork Training for the fieldwork was conducted over nine days in August 2005; this included lectures on interviewing techniques and the contents of the questionnaires, as well as mock interviews between trainees for practice in asking questions. Training also included practicing anthropometry measure- ments and iodine tests. Resource people from UNFPA, Action Against Hunger, ACTED and UNICEF made presentations on family planning, anthropometry, insecticide treated nets, maternal and child 1 The terms “children under 5,” “children aged 0-4 years” and “children aged 0-59 months” are used interchangeably in this report. 2 The model MICS3 questionnaire can be found at www.childinfo.org, or in UNICEF, 2006. Multiple Indicator Cluster Survey, Tajikistan, 200526 health, HIV/AIDS and salt iodization. In addition to in-class training, participants further practiced their interviewing skills during a two-day fieldwork exercise. A final session was held to address any lasting concerns or issues to be faced in the field. Participants selected as field supervisors and editors were given an additional day of training on how to supervise fieldwork and edit questionnaires. These participants also practiced interviewing in urban and rural areas in a district close to Dushanbe. Data were collected by 14 teams, each comprised of three female interviewers, one driver, one female editor/measurer and one supervisor. Senior staff from SCS and two national fieldwork coordinators supervised the fieldwork activities. Fieldwork began in early September and was concluded in mid- October. Data Processing Twelve data entry operators entered data into 12 microcomputers using CSPro software. To ensure quality control, all questionnaires were double-entered and faced internal consistency checks. Proce- dures and standard programmes developed under the Global MICS3 Project and adapted to the Tajiki- stan questionnaire were used throughout. Data processing began simultaneously with data collection in September 2005 and was completed by the end of October 2005. Data were then analyzed using the Statistical Package for Social Sciences (SPSS) software programme, Version 14, and the model syntax and tabulation plans developed by UNICEF for this survey. III. The Characteristics of Households and Respondents 27 III. SAMPLE COVERAGE AND THE CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Sample Coverage Of the 6,968 households selected for the sample, 6,961 were found to be occupied. Of these, 6,684 were successfully interviewed, for a household response rate of 96 per cent. In the interviewed house- holds, 10,626 women (aged 15-49) were identified. Of these, 10,243 were successfully interviewed, also yielding a response rate of 96 per cent. In addition, 4,370 children under age 5 were listed. Ques- tionnaires were completed for 4,273 of these children, corresponding to a response rate of 98 per cent. Overall response rates of 93 and 94 per cent are calculated for the women’s and under-5s’ interviews respectively (Table HH.1). Household response rates are slightly higher in rural than in urban areas, 97 compared to 94 per cent. Response rates in Dushanbe are a little lower than in others regions, perhaps because of the busy lifestyle of respondents in the capital. The lowest women’s response rate is noted in GBAO, at 88 per cent, which was somewhat surprising given that the region is known for its hospitality. Differences be- tween the number of sampled and occupied households are almost nonexistent because of the updated household listings. Characteristics of Households The age and sex distribution of the survey population is provided in Table HH.2. The distribution also is used to produce the population pyramid in Figure HH.1. In the 6,684 households successfully inter- viewed in the survey, 41,695 household members were listed. Of these, 20,919 were males and 20,776 were females. These figures also indicate that the survey estimated the average household size at 6.2 persons. The age and sex distribution of the surveyed population accords with the 2000 census data. The pro- portion of population in the 5-19 age group is highest and decreases with each subsequent five-year interval. Tajikistan’s population is relatively young, in that the median age is 20 years (meaning that half the population is younger than 20). The population aging index3 according to the survey results is 0.1, the same as in the census data. The single-year age distribution (Table DQ.1 and Figure DQ.1 in Appendix D) shows a constant decline in population size in each year after age 20. A slight decrease in 3 Proportion of population from the age of 60 and above and population aged 0-19. Multiple Indicator Cluster Survey, Tajikistan, 200528 the share of the population aged 0-4 exists compared to the previous 15 years. The male-female ratio shows small variations in each observed age band. The overall dependency ratio4 is 73 per cent. Survey results indicate that the 0-14 age group makes up about 38 per cent of total population, while the population aged 65 years and older comprises 4 per cent. The economically active population (aged 15-64) thus make up 58 per cent of Tajikistan’s total population. As the basic check of the quality of age reporting, the percentage of missing data is shown in Table DQ.6 in Appendix D. The age of almost all the survey population was collected. For all interviewed women the year of birth was collected, and fewer than 0.5 per cent of women did not report the exact month and year of birth. By contrast, the complete date of birth (both month and year) was collected for almost every child under 5. Figure HH.1. Age and Sex Distribution of Household Population, Tajikistan, 2005 8 6 4 2 0 2 4 6 8 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80+ Per cent Males Females Table HH.3 provides basic background information on the households. Within households, the sex of household head, region, urban/rural status and number of household members are shown in the table. These background characteristics also are used in subsequent tables in the report; the figures in the table likewise are intended to show the numbers of observations by major categories of analysis. The totals of weighted and unweighted numbers of households are equal, since sample weights were normalized (see Appendix A). Table HH.3 also shows the proportions of households where at least one child under 18, one child under 5, and one eligible woman aged 15-49 were found. 4 Age dependency ratio is the ratio of persons in the “dependent” ages (under 15 years and over 64 years) to those in the “economically productive” ages (15-64 years). III. The Characteristics of Households and Respondents 29 Since approximately equal allocation of the total sample size among the five regions was targeted, weighted and unweighted numbers of households in each region differ significantly. This way, re- sults were gained for all observed regions; later, by using sample weights, the model was adjusted to the census data. About 67 per cent of households live in rural areas, while the rest are urban. Regional distribution of households is in accordance with the census data. Sogd and Khatlon are regions with the largest number of households, about two-thirds of the total. Some 11 per cent of households are in the capital, while the lowest number, 3 per cent, are from GBAO. In most households the household head is male. Household distribution by size shows that almost two-thirds of households have between four and seven members. One-member households in Tajikistan are very rare; only 3 per cent of households fit this category. At least one woman aged 15 to 49 lives in 93 per cent of households, and in 46 per cent lives at least one child under 5. In 9 out of 10 households lives at least one child under age 18. Characteristics of Respondents Tables HH.4 and HH.5 provide information on the background characteristics of female respondents aged 15-49 and of children under age 5. In both tables, the total numbers of weighted and unweighted observations are equal, since sample weights have been normalized (standardized). In addition to pro- viding useful information on background characteristics of women and children, the tables also show the numbers of observations in each category. These categories are used in subsequent tabulations. Like the description of a household’s background characteristics, the numbers of weighted and un- weighted women and children under 5 across regions are different because of the equal sample alloca- tion to the five regions. By using sample weights, the model was adjusted to the census data. Table HH.4 provides background characteristics of female respondents aged 15-49. The table includes information on the distribution of women according to region, urban-rural areas, age, marital status, motherhood status, education5 and wealth index quintiles6. Most women aged 15 to 49 live in Khatlon and Sogd, 34 and 32 per cent respectively. A total of 23 per cent live in the DRD region, 9 per cent in Dushanbe and only 3 per cent in GBAO. Urban– rural pat- terns follows the distribution of households: 72 per cent of women live in rural areas and 28 per cent in urban settlements. These data were expected, being in accordance with the census data. 5 Throughout this report, “education” as a background variable, unless otherwise stated, refers to the educational level attended by the respondent. In addition, in the case of secondary education (incomplete/complete) it refers to the finished educational level. 6 Principal component analysis was performed by using information on the ownership of household goods and amenities (assets) to as- sign weights to each household asset, and to obtain wealth scores for each household. Assets used in these calculations were: number of rooms for sleeping per member; floor, roof and wall material of dwelling; type of water sources and sanitation; type of fuel for cooking; electricity, radio, television, mobile, phone, refrigerator, electric water heater, table, chair, mirror, washing machine, vacuum cleaner, video player, cupboard, suite of furniture, watch, bike, motorcycle/scooter, animal-drawn cart, car/truck, computer and trac- tor/combine. Each household was then weighted by the number of household members, and the household population was divided into five groups of equal size, from the poorest quintile to the richest quintile, based on the wealth scores of households. The wealth index is assumed to indicate the underlying long-term wealth through information on household assets and is intended to produce the ranking of households according to wealth, from poorest to the richest. However, the wealth index does not provide information on absolute poverty, current income or expenditure levels, and wealth scores are applicable only to the particular data set on which they are based. Further information on the construction of the wealth index can be found in Rutstein and Johnson, 2004, and Filmer and Pritchett, 2001. Multiple Indicator Cluster Survey, Tajikistan, 200530 The largest proportion of women are aged 15 to 19 (24 per cent); in each subsequent age category the proportion of women progressively decreases. The share of women aged 40-44 and 45-49 is signifi- cantly lower, at 11 and 8 per cent respectively. Nearly two-thirds of all women in this sample are currently married or in a union, while 34 per cent have never been married. Distribution by motherhood status is similar: 61 per cent of women have given birth, compared to 39 per cent who have never given birth. More than half of women completed secondary school and 31 per cent attended secondary school but never completed it, while the propor- tion of women with higher education is low, at only 6 per cent. Additional analysis, presented in the ta- ble below, indicates a strong correlation between women’s educational level and the household wealth status. Only 1 per cent of women in the poorest households attended higher education, compared to nearly 20 per cent among women in the richest households. Similarly, women who live in urban areas tend to be more educated, with a share in higher education six times that in rural areas. Table 1. Women’s educational level according to household wealth and area of residence Women’s education Wealth index quintiles Area Poorest Second Middle Fourth Richest Urban Rural None 3,1 2,0 1,4 0,9 0,6 1,4 1,6 Primary 3,7 3,6 2,5 2,3 1,2 2,3 2,7 Incomplete secondary 34,8 35,6 32,9 29,7 21,5 25,0 32,9 Complete secondary 56,0 53,8 55,2 52,0 44,1 44,6 55,0 Secondary special 1,4 3,9 6,2 9,4 12,6 11,4 5,1 Higher education 1,0 1,1 1,8 5,8 19,9 15,2 2,6 Total 100,0 100,0 100,0 100,0 100,0 100,0 100,0 NOTE: Figures for non-standard curriculum, missing and don’t know are not shown because of the low number of cases. Education levels are categorized into the following groups: none; non-standard curriculum; primary (grades 1-4); incomplete secondary (completed grade 9 or less); complete secondary (completed grade 9 or 10 – upper secondary); secondary special (specialized, vocational or technical schools with 2- to 3-year programmes); and higher. Because of the low number of cases, non-standard curriculum, miss- ing and don’t know are not presented separately in many analysis tables. In wealth index quintiles, the share of women increases from 18 per cent of those in the poorest house- holds to 21 per cent in the richest. The largest group of women live in households where the mother tongue of household head is Tajik; nearly one-quarter are in households where the household head’s mother tongue is Uzbek, while other language groups comprise less than 2 per cent. Background characteristics of children under 5 are presented in Table HH.5, including distribution of children according to several attributes: sex; region and area of residence; age; mother’s or caretaker’s education; and wealth. The share of male and female children in the under-5 sample is about the same. The largest number of children live in Khatlon (40 per cent) and in rural areas (74 per cent). III. The Characteristics of Households and Respondents 31 The smallest groups in the sample are children aged 0-5 and 6-11 months, at 9 and 10 per cent respectively. The proportion of older children is significantly higher and well-balanced, at about 20 per cent in each subsequent age group. Distribution of children under 5 according to mothers’ education level follows the education pattern from the women’s sample. The share of mothers who attended secondary school is highest: 57 per cent of mothers have completed secondary school, while 28 per cent had not. Only 5 per cent of children aged 0-59 months have mothers who attended higher education. The education level of the caretaker was considered in those cases where mothers did not live in the households. For children, the distribution regarding the mother tongue of household head is about the same as in the household and women’s samples; most children live in a household where the mother tongue is Tajik (72 per cent). Multiple Indicator Cluster Survey, Tajikistan, 200532 IV. CHILD MORTALITy An overarching objective of the MDGs and WFFC is to reduce infant and under-5 mortality. Specifi- cally, the MDGs call for the reduction in under-5 mortality by two-thirds between 1990 and 2015. Monitoring progress toward this objective is important but difficult. Attempts using direct questions, such as “Did anyone in this household die last year?,” give inaccurate results. Using direct measures of child mortality from birth histories is time-consuming, more expensive and requires greater atten- tion to training and supervision of interviewers. Alternatively, indirect methods developed to measure child mortality produce robust estimates comparable with those obtained from other sources. Indirect methods also minimize the pitfalls of memory lapses, inexact or misinterpreted definitions, and poor interviewing techniques. The infant mortality rate is the probability of dying before the first birthday. The under-5 mortality rate is the probability of dying before the fifth birthday. In the MICS surveys, infant and under-5 mortal- ity rates are calculated using an indirect estimation technique known as the Brass method (the United Nations, 1983; 1990a; 1990b). Data used in the estimation are the mean number of children ever born to women aged 15 to 49 (divided into five-year age groups), and the proportion of these children who are dead. The technique converts these data into probabilities of dying by taking into account both the mortality risks to which children are exposed and their length of exposure to the risk of dying, assuming a particular model age pattern of mortality. Based on previous information on mortality in Tajikistan, the East model life table was selected as most appropriate. Table CM.1 provides estimates of child mortality by various background characteristics, while Table CM.2 provides basic data used to calculate mortality rates for the national total. The infant mortality rate is estimated at 65 per 1,000 live births, while the under-5 mortality rate (U5MR) is around 79 per 1,000 live birhts. These estimates have been calculated by averaging out mortality estimates obtained from women aged 20-24 and 25-29, and refer to mid-2003. For both indicators, boys have a far greater probability of dying than girls. The infant mortality rate among boys stands at 75; among girls, 54. Similarly, under-5 mortality among boys is 92, compared to 66 among girls. Regional distribution shows that infant and under-5 mortality rates are lowest in Dushanbe, while figures for Khatlon are significantly higher than the national average. Large differences in mortality rates also are found in terms of mothers’ education level and house- hold wealth. With each increment in mothers’ education, the probability of dying among children progressively decreases. Rates are 6 to 7 times higher among children of mothers with no or only primary education than among those with mothers who attended higher education. In particular, the probabilities of dying among children in the richest 40 per cent of households are about one-third lower than the national average. Differentials in under-5 mortality rates by background characteris- tics are shown in Figure CM.1. IV. Child Mortality 33 Figure CM.1. Under-5 Mortality Rates by Background Characteristics, Tajikistan, 2005 107 70 58 103 79 92 84 87 90 131 102 89 85 28 100 74 89 0 20 40 60 80 100 120 140 Sex M ale Female Regions Dushanbe Khatlon Sogd RRS GBAO Area Urban Rural M other's Education None/Primary Uncomplete Secondary Complete Secondary Secondary special Higher education Wealth Quintiles Poorest 60 % Richest 40 % Tajikistan Per 1000 live births Figure CM.2 shows the review of the infant mortality data on the basis of the 1999 Living Standard Measurment Survey (LSMS), Ministry of Health and the 2000 and 2005 MICS. Figure CM.2. Trend in Infant Mortality Rates, Tajikistan, 2005 40 48 47 41 31 31 31 23 19 16 28 17 14 14 79 89 65 0 10 20 30 40 50 60 70 80 90 100 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Year Pe r 1, 00 0 MoH estimates (HFA) LSMS 1999 MICS2000 MICS 2005 Multiple Indicator Cluster Survey, Tajikistan, 200534 Trends in child mortality show some improvement, with infant and under-5 mortality rates declining from 89 and 126 (MICS 2000) to 65 and 79 per 1,000 live births respectively (Figure CM.2.a). Figure CM.2.a. Trends in child mortality according MICS, 2000-2005 89 126 65 79 0 20 40 60 80 100 120 140 IMR UFMR Pe r 1, 00 0 liv e bi rt hs MICS 2000 MICS 2005 Nonetheless, these rates remain very high and differ significantly from figures reported by the Minis- try of Health. The MICS estimate for infant mortality is much higher than official data, which stood at 27.9 per 1,000 live births in 2001, 17.2 in 2002 and 13.5 in both 2003 and 2004. This variance may be due partly to different methodological approaches; the Ministry of Health uses definitions of infant mortality rates established during the Soviet regime, which do not consider as live births newborns less than 999 grams in weight, those born before 28 weeks of pregnancy and those who do not mani- fest vital signs other than breath. The variance also may arise from the low birth registration rate, particularly for the first six months of a child’s life. (Aleshina & Redmond: 2003). At the same time, the MICS 2005 infant mortality estimates are in line with findings from the 1999 LSMS, which stood at 79 per 1,000 live births (95 per cent confidence, interval 65-92). Research in 2004 into the main causes of infant death in Tajikistan7 suggests infant mortality rates in four regions varied from 58 (Sogd, DRD) to 103 (Dushanbe, Khatlon) during 1998-2002. The UNICEF report ‘State of the World’s Children 2006’ estimates Tajikistan’s infant mortality rate to have been 91 in 2004. Adjusting for potential biases in national data, WHO also estimated the under-5 mortality rate in Ta- jikistan to be around 86 per 1,000 live births in 2001 and 63 per 1,000 live births in 2002. Further examination of these apparent declines and differences, as well as their determinants, should be taken up in a separate, more detailed analysis. 7 Using an adaptation of the standard verbal autopsy protocols of the WHO V. Nutrition 35 v. nutrition Nutritional Status Children’s nutritional status is a reflection of their overall health. When children have access to an adequate food supply, they are not exposed to repeated diseases and are well cared for; then they reach their growth potential and are considered well-nourished. Malnutrition is associated with more than half of all child deaths worldwide. Undernourished children are more likely to die from common childhood ailments, and those who survive have recurring sick- nesses and faltering growth. Three-quarters of the children who die from causes related to malnutri- tion were only mildly or moderately malnourished – showing no outward sign of their vulnerability. The MDG target is to reduce by half the proportion of people suffering from hunger between 1990 and 2015, while the WFFC goal is to reduce malnutrition among under-5 children by at least one-third between 2000 and 2010, with special attention to children under 2 years. A reduction in the prevalence of malnutrition will assist in the goal to reduce child mortality. In a well-nourished population, there exists a reference distribution of height and weight for children under 5. Undernourishment in a population can be gauged by comparing children to the reference population. In this report, the reference population used is the WHO/CDC/NCHS reference, recom- mended by UNICEF and WHO for use. Each of the three nutritional status indicators can be expressed in standard deviation units (z-scores) from the median of the reference population. Weight-for-age is a measure of both acute and chronic malnutrition. Children whose weight-for-age is more than two standard deviations below the median are considered moderately or severely under- weight, while those whose weight-for-age is more than three standard deviations below the median are classified as severely underweight. Height-for-age is a measure of linear growth. Children whose height-for-age is more than two stan- dard deviations below the median are considered short for their age and are classified as moderately or severely stunted. Those whose height-for-age is more than three standard deviations below the median are classified as severely stunted. Stunting reflects chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness. Finally, children whose weight-for-height is more than two standard deviations below the median of the reference population are classified as moderately or severely wasted, while those who fall more than three standard deviations below the median are severely wasted. Wasting is usually the result of a recent nutritional deficiency. The indicator may exhibit significant seasonal shifts associated with changes in the availability of food or disease prevalence. On the other hand, children whose weight-for-height is two or more standard deviations above the median are considered as moderately or severely obese. Obesity is mostly a result of poor nutritional Multiple Indicator Cluster Survey, Tajikistan, 200536 practices (low intake of proteins, fruit and vegetables; high intake of saturated fats and sugar) and is a risk factor for some chronic diseases, like cardiovascular diseases and diabetes. In addition to these standard MICS indicators, two more nutritional status indicators are assessed, the mid-upper arm circumference (MUAC) and the presence of oedema. These indicators were introduced with the aim to assess the presence of the Global Acute Malnutrition among children aged 12 to 59 months (determined by weight-for-height below more than two standard deviations from the median, MUAC below 12.5 cm or oedema). In Tajikistan, weights and heights of all children under 5 were measured using anthropometric equip- ment recommended by UNICEF. In addition, in order to measure Global Acute Malnutrition, MUAC measurements were taken. In assessing child nutritional status the following determinants were used: height (in centimetres), weight (in kilos), age (in months), mid-upper arm circumference (in centime- tres), and sex. Table NU.1 shows percentages of children classified into each malnutrition category, based on an- thropometric measurements during fieldwork. In additionally, the table includes the percentage of overweight children. Children who were not weighed and measured, whose measurements are outside the plausible range and whose birth dates are not known are excluded; thus, about 5 per cent of inter- viewed children are not included in the analysis. In total, about 17 per cent of children under 5 in Tajikistan are moderately or severely underweight and 4 per cent are classified as severely underweight. More than 1 in 4 children (27 per cent) are stunted, or too short for their age, and 7 per cent are wasted, or too thin for their height. Around 4 per cent of children in Tajikistan are overweight. Figure NU.1. Percentage of children under-5 who are undernourished, Tajikistan, 2005 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 0 6 12 18 24 30 36 42 48 54 60 Age (in Months) Pe r ce nt Underweight Stunted Wasted V. Nutrition 37 Children in Khatlon and GBAO are more likely to be underweight and stunted than other children, while the lowest figures are found in Dushanbe. A similar pattern is found for wasting prevalence. No significant differences between boys and girls appear in underweight and wasting figures, whereas boys seem somewhat more likely to be stunted than girls. The age pattern shows that a higher percent- age of children aged 12-23 months are undernourished according to all three nutritional status indica- tors, compared to younger and older children (Figure NU.1). This pattern is expected and is related to the age at which many children cease to be breastfed and are exposed to contamination in water, food and the environment. Results indicate that the child’s nutritional status is strongly correlated with the household material status and mother’s education. By each measure -- underweight, wasting and stunting -- figures for children from the poorest households significantly exceed the national average. In addition, children whose mothers have higher education are the least likely to be undernourished. About 11 per cent of children in Tajikistan aged 12 to 59 months are exposed to Global Acute Malnu- trition, or GAM (Table NU.1.a). The highest percentage is found among children who live in Khatlon (14 per cent). Children aged 12-23 months are most likely to be exposed to GAM, which decreases as the child gets older. The prevalence of GAM is higher among children from the poorest households (13 per cent) compared to children from the richest households (10 per cent). Breastfeeding Breastfeeding for the first few years of life protects children from infection, provides an ideal source of nutrients and is economical and safe. However, many mothers stop breastfeeding too soon, and they are often pressured to switch to infant formula. This can contribute to the faltering of growth and micronutrient malnutrition; in addition, it is unsafe if clean water is not readily available. WHO/UNICEF have the following feeding recommendations: Exclusive breastfeeding for the first 6 months 9 Continued breastfeeding for 2 years or more 9 Safe, appropriate and adequate complementary food beginning at 6 months 9 Frequency of complementary feeding: 2 times per day for 6- to 8-month-olds; 3 times per day for 9 9- to 11-month-olds It also is recommended that breastfeeding be initiated within 1 hour of birth. Indicators of recommended child feeding practices are: Exclusive breastfeeding rate (< 6 months and < 4 months)• Timely complementary feeding rate (6-9 months) • Continued breastfeeding rate (12-15 and 20-23 months)• Timely initiation of breastfeeding (within 1 hour of birth)• Frequency of complementary feeding (6-11 months)• Adequately fed infants (0-11 months)• The early onset of breastfeeding is a very important factor for lactation management and building the emotional connection between mother and baby. Table NU.2 shows the proportion of women who Multiple Indicator Cluster Survey, Tajikistan, 200538 started breastfeeding their infants within 1 hour of birth and women who started breastfeeding within 1 day of birth (which includes those who started within 1 hour). In Tajikistan, 61 per cent of women who had given birth in the 2 years preceding the survey reported breastfeeding within 1 hour of birth; some 87 per cent of women started breastfeeding within 1 day of birth. This share of breastfeeding within 1 day of birth is similar across regions and urban–rural settlements. On the other hand, breastfeeding within 1 hour of birth shows some regional differences; fewer than 1 in 2 women from Khatlon started breastfeeding within 1 hour of birth, compared to more than 3 in 4 (77 per cent) in Sogd and GBAO. Figure NU.2. Percentage of mothers who started breastfeeding within one hour and within one day of birth, Tajikistan, 2005 87 86 88 88 87 85 88 87 62 47 77 65 77 59 61 61 0 10 20 30 40 50 60 70 80 90 100 Du sh an be Kh at lon So gd DR D GB AO Ur ba n Ru ra l Ta jik ist an Pe r ce nt Within one day Within one hour In Table NU.3, breastfeeding status is based on the reports of mothers/caretakers who were aware of food and fluids their children consumed in the 24 hours before the interview. Exclusively breastfed refers to infants who received only breastmilk (and vitamins, mineral supplements or medicine). The table shows exclusive breastfeeding of infants during the first 6 months (separately for 0-3 months and 0-5 months), as well as complementary feeding of children 6-9 months and continued breastfeeding of children at 12-15 and 20-23 months. About 1 in 4 children less than 6 months old in Tajikistan are exclusively breastfed, a level consider- ably lower than recommended. Boys are more frequently exclusively breastfed than girls. The highest rate of exclusively breastfed children is in Sogd (45 per cent) and GBAO (51 per cent). At age 6-9 months, 15 per cent of children receive breastmilk and solid or semi-solid food. By age 12- 15 months, 3 in 4 children are still breastfed and by age 20-23 months, 1 in 3 remain breastfed. Boys, children from GBAO and those in the poorest households are more likely to continue being breastfed. Figure NU.3 shows the detailed pattern of breastfeeding by the child’s age in months. Even at the ear- liest age, most children receive liquids or foods other than breastmilk. Fewer than half of children aged 0-1 months are exclusively breastfed, and this share of exclusive breastfeeding decreases progressively V. Nutrition 39 thereafter; it falls below 3 per cent by the end of the seventh month. About 13 per cent of children receive breastmilk after age 2 years. Figure NU.3. Infant feeding patterns by age: Percent distribution of children aged under 3 years by feeding pattern by age group, Tajikistan, 2005 0 10 20 30 40 50 60 70 80 90 100 0- 1 2- 3 4- 5 6- 7 8- 9 10 -1 1 12 -1 3 14 -1 5 16 -1 7 18 -1 9 20 -2 1 22 -2 3 24 -2 5 26 -2 7 28 -2 9 30 -3 1 32 -3 3 34 -3 5 Age (in Months) Pe r c en t Weaned (not breastfed) Breastfed and complementary foods Breastfed and other milk/ formula Breastfed and non-milk liquids Breastfed and plain water only Exclusively breastfed The adequacy of feeding of children under 12 months is provided in Table NU.4. Different crite- ria of adequate feeding are used depending on the age of the child. For infants aged 0-5 months, exclusive breastfeeding is considered adequate feeding. Infants aged 6-8 months are considered adequately fed if they receive breastmilk and complementary food at least twice a day, while infants aged 9-11 months are considered adequately fed if they receive breastmilk and complementary food at least three times a day. Only 5 per cent of children aged 6-8 months – a critically low percentage -- received breastmilk and complementary food according to the recommended schedule. A somewhat higher percentage is found among children from Sogd (17 per cent) and those whose mothers attended secondary special schools (39 per cent). The recommendation is more practiced in urban than in rural areas, at 9 compared to 4 per cent. The percentage also is slightly higher among children aged 9-11 months, showing a similar pattern by background variables as described above. As a result of these feeding patterns, only 7 per cent of children aged 6-11 months in Tajikistan are adequately fed. Adequate feeding among all infants (aged 0-11 months) rises to 16 per cent, mainly owing to the higher percentage of breastfed children in the younger age group. Boys are better fed than girls. Infants in Sogd and GBAO are better fed than those from Khatlon and DRD, while urban children are likelier to be adequately fed than rural children. Infants in the richest households also are more often adequately fed. On the other hand, children in households in the 4th wealth quintile are least adequately fed. Mother’s education and appropriate child nutrition are strong- ly correlated: The more educated the mother, the better the child’s chance of being adequately fed. The percentage of children under 12 months who are adequately fed rises from 17 per cent among children Multiple Indicator Cluster Survey, Tajikistan, 200540 whose mother has incomplete secondary education up to 24 per cent for those with mothers who have a higher education. Salt Iodization Iodine Deficiency Disorder (IDD) is the world’s leading cause of preventable mental retardation and impaired psychomotor development in young children. In its extreme form, iodine deficiency causes cretinism. It also increases the risks of stillbirth and miscarriage in pregnant women. Iodine deficiency is most commonly and visibly associated with goitre. IDD takes its greatest toll in impaired mental growth and development, contributing in turn to poor school performance, reduced intellectual ability and impaired work performance. The international goal has been to achieve sustainable elimination of iodine deficiency by 2005. The indicator is the percentage of households consuming adequately iodized salt (>15 parts per million). Joint efforts of the Government and donor community to address IDD were formulated in the National Programme for Elimination of IDD, developed in 1997. The programme stipulates that all salt must be iodized to 45 parts per million (ppm). Law № 344 On Salt Iodization, adopted in 2002, regulates the production, distribution and consumption of iodized salt in the country. Development of the national standard for iodized salt and the mobilization of the salt producer community, as well as other concert- ed actions at the national level, aim to achieve change in iodine intake. The MICS survey is the main tool for progress monitoring. The reported incidence of endemic goitre, as a main marker of IDD, increased in Tajikistan from 1.14 per 1,000 in 1997 to 2.15 in 2002. Examinations carried out revealed a high percentage of the popula- tion affected by goitres: for different regions, 45 to 82 per cent among children and 60 per cent among women of reproductive age (MoH, 2003). During the MICS, in nearly all households salt used for cooking was tested for iodine content through detection of the presence of potassium iodide (Figure NU.4). In fewer than 1 in 2 households (46 per cent), salt was found to contain 15 parts per million (ppm) or more of iodine. Significantly, while 46 per cent of households are actually using iodized salt, 61 per cent think that they are using it. Use of iodized salt was lowest in DRD and Khatlon, at 26 and 27 per cent respectively. The highest usage of iodized salt is in Sogd (76 per cent). About 60 per cent of urban households were found to be using adequately iodized salt, compared to only 40 per cent in rural areas. Use of iodized salt is strongly cor- related with household wealth; the percentage rises from 33 per cent in the poorest households up to 62 per cent in the richest. V. Nutrition 41 Figure NU.4. Percentage of households consuming adequately iodized salt, Tajikistan, 2005 55 27 76 26 44 59 40 33 38 42 50 62 46 0 10 20 30 40 50 60 70 80 Regions Pe r c en t D us ha nb e Kh at lo n So gd G BA O D RD U rb an Ru ra l Po or es t Se co nd M id dl e Fo ur th Ri ch es t Ta jik is ta n Nevertheless, analysis of the trends in salt iodization shows that strong progress has been made since 2000 (Figure NU.4.a). The use of adequately iodized salt rose from only 20 per cent at that time (MICS 2000) to 46 per cent in 2005 -- more than 2 times higher Figure NU.4.a. Progress use of iodized salt, Tajikistan, 2000-2005 32 16 20 59 40 46 0 10 20 30 40 50 60 70 80 Urban Rural Tajikistan Pe r ce nt 2000 2005 Knowledge and consumption patterns of iodized salt are presented in Tables NU.5.A and NU.5.B. A high percentage of households in Tajikistan (91 per cent) contain at least one person familiar with iodized salt; such knowledge is higher in Dushanbe, urban areas, those living in the richest households, and households where the education of the household head is secondary special or higher. Results show that knowledge about iodized salt and its consumption are correlated; while Multiple Indicator Cluster Survey, Tajikistan, 200542 95 per cent of households where iodized salt is used know about it, this declines to 86 per cent among households not using it. While the vast majority (85 per cent) use iodized salt to prevent goitre, a significant 14 per cent of the population do not know any reasons why iodized salt should be used. Almost all households in Tajikistan buy salt sold in industrial bags (48 per cent) or in bulk/by kilo (46 per cent). Vitamin A Supplements Vitamin A is essential for eye health and proper functioning of the immune system. It is found in food such as: milk, liver, eggs, red and orange fruits, red palm oil and green leafy vegetables. However, the amount of Vitamin A readily available to the body from these sources varies widely. In developing areas of the world, where Vitamin A is largely consumed in the form of fruits and vegetables, daily per-capita intake is often insufficient to meet dietary requirements. Inadequate intakes are further compromised by increased requirements for the vitamin as children grow or during periods of illness, as well as increased losses during common childhood infections. As a result, Vitamin A deficiency is quite prevalent in the developing world, and particularly in countries with the highest burden of under-5 deaths. The 1990 World Summit for Children set the goal of virtual elimination of Vitamin A deficiency and its consequences, including blindness, by 2000. This goal also was endorsed at the Policy Conference on Ending Hidden Hunger in 1991, the 1992 International Conference on Nutrition, and the United Nations General Assembly’s Special Session on Children in 2002. The critical role of Vitamin A for a child’s health and immune function also makes control of deficiency the primary component of child survival efforts, and therefore critical to achievement of the fourth MDG: a two-thirds reduction in under-5 mortality by 2015. For countries with Vitamin A deficiency problems, current international recommendations call for high-dose Vitamin A supplementation every four to six months, targeted at all children aged 6 to 59 months who live in affected areas. Providing young children with two high-dose Vitamin A capsules a year is a safe, cost-effective, efficient strategy for eliminating Vitamin A deficiency and improving child survival. Giving Vitamin A to new mothers who breastfeed helps protect their children during the first months of life and helps replenish the mother’s stores of Vitamin A, which are depleted during pregnancy and lactation. For countries with Vitamin A supplementation programmes, the definition of the indicator is the per cent of children aged 6-59 months receiving at least one high-dose Vitamin A supplement in the last six months. Based on UNICEF/WHO guidelines, the Tajikistan Ministry of Health recommends that children aged 6-11 months be given one high-dose Vitamin A capsule, with children aged 12-59 months receiving a Vitamin A capsule every six months. In some parts of the country, Vitamin A capsules are linked to immunization services and are given when a child has contact with these services after age 6 months. It also is recommended that mothers take a Vitamin A supplement within eight weeks of giving birth. In the six months before the MICS, 47 per cent of children aged 6-59 months received a high dose of Vitamin A supplement (Table NU.6). About 5 per cent had not received the supplement in the last V. Nutrition 43 six months but had received one earlier. One out of 10 children had received a Vitamin A supplement sometime, but their mother/caretaker was unable to specify when. Nearly one-third of children aged 6-59 months had never received a Vitamin A supplement. Few differences by sex, age, urban/rural and region exist in receiving Vitamin A supplementation. However, a correlation between the mother’s level of education and the likelihood of supplementa- tion is noticed. The percentage of those receiving a supplement in the last six months increases from 35 per cent among children whose mothers have primary education to 55 per cent with mothers who attended secondary special schools. Differences according to household wealth also are shown, with a higher supplementation of Vitamin A among children in households of the 4th wealth quintile (56 per cent), while the lowest percentage of children is among children in the poorest households (39 per cent). About 41 per cent of mothers with a birth in the two years before the MICS received a Vitamin A supplement within eight weeks of birth (Table NU.7). This percentage is highest in GBAO and Sogd, at 65 and 54 per cent respectively, and lowest in the Khatlon (31 per cent). Low Birth Weight Weight at birth is a good indicator not only of a mother’s health and nutritional status but also of the newborn’s chances for survival, growth, long-term health and psychosocial development. Low birth weight (less than 2,500 grams) carries a range of grave health risks for children. Babies who were undernourished in the womb face a greatly increased risk of dying during their early months and years. Those who survive have impaired immune function and increased risk for diseases; they are likely to remain undernourished, with reduced muscle strength, throughout their lives, and suffer a higher incidence of diabetes and heart disease in later life. Children born underweight also tend to have a lower IQ and cognitive disabilities, affecting their performance in school and their job op- portunities as adults. In the developing world, low birth weight stems primarily from the mother’s poor health and nutrition. Three factors have the greatest impact: the mother’s poor nutritional status before conception, short stature (due mostly to undernutrition and infections during her childhood) and poor nutrition during the pregnancy. Inadequate weight gain during the pregnancy is particularly important because it ac- counts for a large proportion of foetal growth retardation. Moreover, diseases such as diarrhoea and malaria, which are common in many developing countries, can significantly impair foetal growth if the mother becomes infected during the pregnancy. In the industrialized world, cigarette smoking during pregnancy is the leading cause of low birth weight. In developed and developing countries alike, teenagers who give birth when their own bodies have yet to finish growing run the risk of bearing underweight babies. A major challenge in measuring the incidence of low birth weight is the fact that more than half of infants in the developing world are not weighed. In the past, most estimates of low birth weight for developing countries were based on data compiled from health facilities. However, these estimates are biased for most developing countries because the majority of newborns are not delivered in facilities, and those who are represent only a selected sample of all births. Multiple Indicator Cluster Survey, Tajikistan, 200544 Because many infants are not weighed at birth and those who are weighed may be a biased sample of all births, reported birth weights usually cannot be used to estimate the prevalence of low birth weight among all children. Therefore, the percentage of births below 2500 grams is estimated according to two items in the questionnaire: the mother’s assessment of the child’s size at birth (i.e., very small, smaller than average, average, larger than average, very large), and the mother’s recall of the child’s weight or the weight as recorded on the health card if the child was weighed at birth.8 Overall, 66 per cent of births in Tajikistan were weighed at birth and about 10 per cent of infants were estimated to weigh less than 2500 grams (Table NU.8). Large variations exist by region, for both the percentage of infants weighed at birth and infants with low birth weight (Figure NU.5). While the highest percentage of infants weighed at birth is in Sogd (92 per cent) and Dushanbe (83 per cent), these regions also have the lowest proportion of infants weighing less than 2500 grams. Children in rural areas and the poorest households are more likely to weigh less than 2500 grams at birth. The indicator improves with the level of mother’s education. Figure NU.5. Percentage of Infants Weighing Less Than 2500 Grams at Birth, Tajikistan, 2005 9 16 12 5 9 8 10 10 0 2 4 6 8 10 12 14 16 18 D us ha nb e Kh at lo n So gd D RD G BA O U rb an Ru ra l Ta jik is ta n Pe r ce nt 8 For a detailed description of the methodology, see Boerma, Weinstein, Rutstein and Sommerfelt, 1996. VI. Child Health 45 VI. CHILD HEALTH Immunization MDG4 is to reduce child mortality by two-thirds between 1990 and 2015, and immunization plays a key part in this goal. Immunization has saved the lives of millions of children in the three decades since the launch of the Expanded Programme on Immunization (EPI) in 1974. Worldwide, 27 million children are still overlooked by routine immunization; as a result, vaccine-preventable diseases cause more than 2 million deaths every year. A WFFC goal is to ensure full immunization of children less than 1 year old at 90 per cent nationally, with at least 80 per cent coverage in every district or equiva- lent administrative unit. According to UNICEF and WHO guidelines, by age 12 months a child should receive a BCG vacci- nation to protect against tuberculosis, three doses of DPT to protect against diphtheria, pertussis, and tetanus, three doses of polio vaccine, and measles vaccination. The vaccination schedule followed by the National Immunization Programme of Tajikistan slightly differs, with an additional three doses of vaccine against Hepatitis B by age12 months and measles vaccine soon after age 12 months. Information on immunization coverage was provided for all children under age 5. In Tajikistan as well as many other countries from the Commonwealth of Independent States (CIS), the practice of keeping an immunization card with a child’s parent or guardian has started recently, with sup- port from the Global Alliance for Vaccines and Immunization (GAVI); a child’s health card is still mainly kept in local health facilities. Information thus was collected from both these sources as well as from the mother. Mothers were asked to provide vaccination cards for children under age 5. If the card was available, interviewers copied vaccination information onto the MICS3 questionnaire, then asked the mother if the child had received BCG, polio, DPT, hepatitis B and measles vaccines, as well as how many doses. Information about the local health facility where the child’s immunization record was kept also was collected, and interviewers or supervisors visited the facility to obtain further information about vac- cinations received. Overall, 83 per cent of children aged 18 to 29 months had health cards, either at home or health facili- ties (Table CH.2). Additional analysis not presented in the table shows that only 9 per cent of children had a vaccination card at home. The percentage of children aged 18 to 29 months who received BCG, DPT, polio and measles vaccinations is shown in Table CH.1; the denominator for the table is com- prised of children aged 18-29 months, so that only children who are old enough to be fully vaccinated are counted. The numerator includes all children vaccinated at any time before the survey, according to the vaccination card or the mother’s report. In the bottom row, only those vaccinated for BCG, DPT and polio before their first birthday are included. For measles vaccine, in the bottom row, the numera- tor includes only those children vaccinated before age 18 months. For children without vaccination Multiple Indicator Cluster Survey, Tajikistan, 200546 cards, the proportion of vaccinations given before the first birthday (18 months in the case of measles) is assumed to be the same as for children with vaccination cards. About 95 per cent of children aged 18-29 months received a BCG vaccination by age 12 months, while the first dose of DPT was given to 91 per cent of children. The percentage declines for subsequent doses of DPT: 86 per cent for the second dose, 82 per cent for the third dose (Figure CH.1). Similarly, 92 per cent of children received polio 1 by age 12 months declining to 79 per cent by the third dose. To achieve lower dropout rates and timely immunization coverage of more than 90 per cent, it is neces- sary to ensure continuity of immunization services at the health delivery level. Coverage for measles vaccine by 18 months is similar to that for other vaccines, at 91 per cent. The percentage of children who had all eight recommended vaccinations (three doses of DPT, three doses of polio excluding polio 0, BCG, and measles) by the specified age is much lower, at 71 per cent. Changing the nominator and including all children vaccinated at any time before the survey still reveals that 77 per cent of children aged 18 to 29 months received all the recom- mended vaccinations. This indicates slight delays in vaccinations, where some children receive vaccines after the defined time. Figure CH.1. Percentage of children aged 18-29 months who received the recommended vaccinations by 12 months (18 months in case of measles), Tajikistan, 2005 95 91 86 82 92 87 79 91 71 0 10 20 30 40 50 60 70 80 90 100 BC G D PT 1 D PT 2 D PT 3 Po lio 1 Po lio 2 Po lio 3 M ea sl es A ll* Pe r ce nt * All = BCG, three doses of DPT, three doses of polio (excluding polio0) and measles In Tajikistan, as noted above, vaccine against hepatitis B also is recommended as part of the immu- nization schedule. According to the National Immunization Programme, a child should receive three doses of hepatitis B vaccine by age 12 months. Coverage with hepatitis B vaccine is analyzed sepa- rately, taking into consideration its recent introduction (covering all districts only since 2003). Results on hepatitis B vaccination are presented in Table CH.1c. About 85 per cent of children aged 18-29 months received the first dose of hepatitis B vaccine by age 12 months. As in the case of polio and DPT coverage, the prevalence of subsequent doses of hepatitis B vaccine drops to 77 per cent for the second dose and 69 per cent for the third dose. VI. Child Health 47 Tables CH.2 and CH.2c show rates of vaccination coverage among children 18-29 months by back- ground characteristics. The figures comprise children receiving vaccinations at any time up to the survey and are based on information from both vaccination cards and mothers’/caretakers’ reports. Regional distribution shows that the lowest share of fully immunized children is in GBAO and DRD (69 and 70 per cent resepectively); the highest percentage is in Sogd, at 87 per cent. Urban children (82 per cent) are more likely to be fully immunized than rural children (76 per cent). The more educated the mother, the better is the chance that the child will be fully vaccinated: Children with all vaccinations rises from 77 per cent for those whose mothers have incomplete secondary school up to 83 per cent for those whose mothers attended higher education. A similar pattern is found regarding household wealth. No significant differences exist between overall immunization coverage of boys and girls, although boys are more likely to receive all three doses of hepatitis B vaccine than girls, at 85 compared to 81 per cent. Children from Sogd and urban settlements also are more likely to receive all three doses of hepatitis B. Oral Rehydration Treatment Diarrhoea is the second leading cause of death among children under-5 worldwide. Most diarrhoea-related deaths in children are due to dehydration from loss of large quantities of water and electrolytes from the body in liquid stools. Management of diarrhoea – either through oral rehydration salts (ORS) or a recom- mended home fluid (RHF) -- can prevent many of these deaths. Preventing dehydration and malnutrition by increasing fluid intake and continuing to feed the child also are important strategies for managing diarrhoea. The goals are to: 1) reduce by one-half death due to diarrhoea among children under-5 by 2010 com- pared to 2000 (WFFC); and 2) reduce by two-thirds the mortality rate among children under-5 by 2015 compared to 1990 (MDGs). In addition, WFFC calls for a reduction in the incidence of diarrhoea by 25 per cent. The indicators are: Prevalence of diarrhoea• Oral rehydration therapy (ORT)• Home management of diarrhoea• ORT or increased fluids • AND continued feeding In the MICS questionnaire, mothers or caretakers were asked to report whether their child had had diarrhoea in the two weeks before the survey. If so, the mother was asked a series of questions about what the child had to drink and eat during the episode and whether this was, more or less, what the child usually ate and drank. Overall, 13 per cent of under-5 children had diarrhoea in the two weeks preceding the survey (Table CH.3. Diarrhoea prevalence was highest in DRD, at 15 per cent, and lowest in Dushanbe (10 per cent). The peak of diarrhoea prevalence occurs in the weaning period, among children aged 6-23 months; diarrhoea also is higher among children in the poorest households, at 18 per cent. Table CH.3 also shows the percentage of children receiving various types of recommended liquids during the episode of diarrhoea. Because mothers were able to name more than one type of liquid, the percentages do not necessarily total 100. About 48 per cent of children received fluids from ORS pack- ets, and 25 per cent received recommended homemade fluids. A total of 58 per cent of children with diarrhoea received one or more recommended home treatments (i.e., were treated with ORS or RHF), while 42 per cent received no treatment. Multiple Indicator Cluster Survey, Tajikistan, 200548 Regional variations regarding ORT use are shown in the Figure CH.2 and Table CH.3; in all, ORT use is similar across regions and areas, with the only significant difference in DRD, which is much lower. Figure CH.2. Percentage of children aged 0-59 months with diarrhoea who received oral rehydration treatment, Tajikistan, 2005 66 60 65 46 69 58 0 10 20 30 40 50 60 70 80 D us ha nb e Kh at lo n So gd D RD G BA O Ta jik is ta n Pe r ce nt Fewre than 1 in 4 (22 per cent) of under-5 children with diarrhoea in the 2 weeks before the survey drank more than usual, while 72 per cent drank the same or less (Table CH.4). A total of 36 per cent continued feeding, but 62 per cent ate much less or almost nothing. Given these figures, only 6 per cent of children received increased fluids and continued feeding. Combining the information in Table CH.4 with that in Table CH.3, it is observed that only 22 per cent of children either received ORT or increased fluid intake AND continued feeding, as recommended. Significant differences exist in the home management of diarrhoea, by background characteristics. In Khatlon, only 3 per cent of children with diarrhoea received increased fluids and continued feed- ing, while the figure was 19 per cent in Dushanbe. Urban-rural differences also were notable. Similar regional and urban-rural differences are shown for children with diarrhoea who received ORT or increased fluids and continued feeding (Figure CH.3). Figure CH.3. Percentage of children aged 0-59 with diarrhoea who received ORT or increased fluids, AND continued feeding, Tajikistan, 2005 38 19 22 2425 28 20 22 0 10 20 30 40 Regions D us ha nb e Kh at lo n So gd D RD G BA O Area U rb an Ru ra l Ta jik is ta n VI. Child Health 49 Care Seeking and Antibiotic Treatment of Pneumonia Pneumonia is the leading cause of death in children, and the use of antibiotics in under-5s with sus- pected pneumonia is a key intervention. A WFFC goal is to reduce by one-third the deaths due to acute respiratory infections. Children with suspected pneumonia are those who had an illness with a cough accompanied by rapid or difficult breathing and whose symptoms were NOT due to a problem in the chest and a blocked nose. The indicators are: Prevalence of suspected pneumonia• Care seeking for suspected pneumonia• Antibiotic treatment for suspected pneumonia• Knowledge of the danger signs of pneumonia• According to the reports of the Ministry of Health and SCS data, respiratory diseases account for 30 to 40 per cent of infant mortality in Tajikistan. Table CH.5 presents the prevalence of suspected pneumonia and, if care was sought outside the home, the site of care. Two per cent of children aged 0-59 months were reported to have had symptoms of pneumonia during the two weeks before the survey. Of these, nearly 2 in 3 (64 per cent) were taken to an appropriate provider. A total of 41 per cent of under-5 children with suspected pneumonia had received an antibiotic during the two weeks before the survey9. Issues related to knowledge of danger signs of pneumonia are presented in Table CH.6. Clearly, moth- ers’ knowledge of the danger signs is an important determinant of care-seeking behaviour. However, only 3 per cent of women in Tajikistan know the two danger signs of pneumonia – fast and difficult breathing. This percentage is even lower among mothers from GBAO (0.1 per cent), while mothers in Katlon are slightly more knowledgeable (5 per cent). The most commonly identified symptom for taking a child to a health facility, noted by 88 per cent of mothers, was fever. In contrast, only 14 per cent of mothers identified fast breathing and 13 per cent identified difficult breathing as symptoms for taking children immediately for health care. Solid Fuel Use More than 3 billion people around the world rely on solid fuels (biomass and coal) for their basic en- ergy needs, including cooking and heating. Cooking and heating with solid fuels leads to high levels of indoor smoke, a complex mix of health-damaging pollutants. The main problems with the use of solid fuels are products of incomplete combustion, including carbon monoxide, polyaromatic hydrocarbons, SO2 and other toxic elements. Use of solid fuels increases the risks of acute respiratory illness, pneu- monia, chronic obstructive lung disease, cancer and possibly tuberculosis, as well as low birth weight, cataracts and asthma. The main indicator is the proportion of the population using solid fuels as the primary source of domestic energy for cooking. 9 Findings about the use of antibiotics for the treatment of suspected pneumonia, by background characteristics, are not shown in a sepa- rate table because the number of observed cases is too small. Multiple Indicator Cluster Survey, Tajikistan, 200550 Overall, more than a third (35 per cent) of all households in Tajikistan use solid fuels, particularly wood, for cooking. Use of solid fuels is very low in urban areas (8 per cent) but high in rural areas (48 per cent). Differences with respect to household wealth and the education level of household head also are marked. While more than two-thirds of the poorest households use solid fuels for cooking, this plummets to only 2 per cent in the richest households. Differences according to the mother tongue of household head also are very large; while only 0.1 per cent of households where the mother tongue is Russian use solid fuels, this rises to 29 per cent for households where the mother tongue is Tajik, and soars to 54 and 74 per cent among Uzbek- and Kirgiz-mother tongue households respectively. Cooking with electricity is highest in Dushanbe, used by 72 per cent of interviewed households, and lowest in Sogd, at 14 per cent overall, where natural gas is most common (34 per cent). Regarding household wealth, 51 per cent of the richest households, as opposed to 24 per cent of the poorest, cook with electricity; 33 per cent of the richest, compared to 1 per cent of the poorest, cook with natural gas. The use of solid fuel alone is a poor proxy for indoor air pollution, since the concentration of the pol- lutants is different when the same fuel is burnt in different stoves or fires. The use of closed stoves with chimneys minimizes indoor pollution, while an open stove or fire with no chimney or hood offers no protection from solid fuels’ harmful effects. The type of stove used with solid fuel is depicted in Table CH.8. About 53 per cent of households that use solid fuels for cooking have an open stove or fire with a chimney, but another high percentage of households (44 per cent) use an open stove or fire with no chimney or hood. The proportion of closed stoves with a chimney is below 1 per cent. Malaria Malaria is the leading cause of death of children under-5 in endemic areas. It also contributes to anae- mia in children and is a common cause of school absenteeism. Preventive measures, especially the use of mosquito nets treated with insecticide (ITNs), can dramatically reduce malaria mortality rates among children. In areas where malaria is common, international recommendations suggest treating any fever in children as if it were malaria and immediately giving the child a full course of recom- mended anti-malarial tablets. Children with severe malaria symptoms, such as fever or convulsions, should be taken to a health facility. In addition, children recovering from malaria should be given extra liquids and food, while younger children should continue breastfeeding. Malaria re-emerged in Tajikistan in 1992 as a result of the socioeconomic deterioration linked to armed conflict; mass population movement across zones of intensive transmission (particularly Af- ghanistan, where malaria is endemic); and disruption of public health care services as well as vector control activities. Marked changes in agricultural practices, particularly the increased cultivation of rice, have led to an increase in vector breeding grounds. These activities also have led to the formation of standing-water reservoirs and establishment of endemic transmission of the disease, particularly in southern Tajikistan. The number of malaria cases reported in the country peaked in 1997, with nearly 30,000 cases. Despite a 92 per cent reduction since this time, Tajikistan’s malaria situation remains serious. The resump- tion of P. falciparum cases, and the expansion of the territory in which this type of malaria is spread, is a matter of particular concern. During the last five years more than three-quarters of reported cases VI. Child Health 51 occurred in Khatlon, with 14 per cent in DRD and only 2 to 4 per cent in remaining regions (source: MoH Malaria Centre). Indeed, the residents of the Khatlon region, an area bordering Afghanistan that is home to 2.2 million people, bear the highest burden of malaria in the whole of the WHO European Region. A 2001 survey in Khatlon indicated that more than 10 per cent of the population were asymptomatic parasite carriers of P. vivax and P. falciparum. Within Khatlon, the number of malaria cases was estimated to be as high as 150,000 to 250,000. The total number of cases in the country, both symptomatic and asymptomatic, was estimated at 300,000 to 400,000. Based on information provided by the MoH Malaria Centre, selected endemic districts of the Khatlon and Sogd have been supplied with almost 115,000 bednets over the last eight years, with support from ACTED and Merlin. The MICS questionnaire incorporates questions on the availability and use of bed nets, both at house- hold level and among children under-5, as well as anti-malarial treatment and intermittent preventive therapy for malaria. In Tajikistan, survey results indicate that only 5 per cent of households have at least one mosquito net, and only 2 per cent have an insecticide treated net (Table CH.9). The propor- tion of households with at least one bed net is highest in Khatlon (8 per cent) and Sogd (6 per cent), while in other regions the result is below 1 per cent. Results also indicate that only 2 per cent of children under age 5 slept under a mosquito net the night before the survey, and 1 per cent slept under an insecticide treated net (Table CH.10). ITN use among children under-5 is recorded only in households from Khatlon (3 per cent). Boys are slightly more likely than girls to sleep under a net (mosquito net or insecticide treated net). All mothers and caretakers of children under-5 were questioned on the prevalence and treatment of fever. About 7 per cent of under-5 children had been ill with fever in the two weeks before the survey (Table CH.11). Fever prevalence peaked at 12-23 months (10 per cent). Fever is less common among children in the richest households. Some regional differences were noted, ranging from 5 per cent in Dushanbe and Sogd to 11 per cent in Khatlon. No significant variation was found by gender, urban/ rural area or level of mother’s education. Mothers were asked to report all medicines given to a child to treat the fever, including both medicines given at home and medicines given/prescribed at a health facility. Only 2 per cent of children with fe- ver were treated with an appropriate anti-malarial drug; 1 per cent received anti-malarial drugs within 24 hours of the onset of symptoms.10 No significant variation of appropriate anti-malaria treatment of children with fever was found by region, urban/rural area, mother’s education or household wealth Little difference was noticed between boys and girls receiving appropriate anti-malarial drugs. 10 Appropriate anti-malarial drugs include chloroquine, sulfadoxine-pyrimethamine (SP), artimisine combination drugs and so forth. In Tajikistan, no children with fever were given chloroquine, quinine or Armodiaquine, and less than 1 per cent were given SP/Fansidar and artimisine combination therapy. A large percentage of children were given other types of medicines that are not antimalarials, including antipyretics such as paracetomal (73 per cent), aspirin (16 per cent), ibuprofen (0.1 per cent) or other (11 per cent). Multiple Indicator Cluster Survey, Tajikistan, 200552 Source and Costs of Supplies In Tajikistan, questions were included to collect information on the sources and costs of four types of supplies: insecticide treated nets, antimalarials, antibiotics and oral rehydration salts. Such information is very important for programme managers in that it provides a population-based assessment of the reach of programmes and the extent to which particular target groups are covered. Such information also is useful for monitoring the provision of free or subsidized supplies and for assessing costs of sup- plies, since prices can be a barrier to use. In this report, only the findings regarding sources and cost of oral rehydration salts are shown in Table CH.12. The results on sources and costs of insecticide treated nets, antimalarials and antibiotics are not presented because they were obtained in only a small number of cases. The table provides information on the sources and median cost of supplies. For more than half of children with suspected pneumonia, ORS was obtained from public sources (52 per cent); 78 per cent of this was free. The median price of ORS not obtained for free was 2.3 somoni. On the other hand, of the 12 per cent obtained from private sources, only 9 per cent was free; the median cost was 1 somoni. VII. Environment 53 vii. environment Water and Sanitation Safe drinking water is essential for good health. Unsafe drinking water can be a significant carrier of diseases such as trachoma, cholera, typhoid and schistosomiasis. Drinking water also can be tainted with chemical, physical and radiological contaminants, with harmful effects on human health. Access to drinking water may be particularly important for women and children, especially in rural areas, who bear the primary responsibility for carrying water, often for long distances. The MDG goal is to reduce by half, between 1990 and 2015, the proportion of people without sustain- able access to safe drinking water and basic sanitation. The WFFC goal calls for the reduction in the proportion of households without access to hygienic sanitation facilities and affordable and safe drink- ing water by at least one-third. The list of indicators used in the MICS are: Water Use of improved drinking water sources• Use of adequate water treatment method• Time needed to reach the source of drinking water• Person collecting drinking water• Sanitation Use of improved sanitation facilities• Sanitary disposal of child’s faeces• Distribution of the population by source of drinking water is shown in Table EN.1 and Figure EN.1. The population using improved sources of drinking water are those using piped water into dwelling, piped water into yard or plot, public tap/standpipe, tube well/borehole, protected well, protected spring or rainwater collection. Bottled water is considered an improved water source only if the household uses it for other purposes, such as hand washing and cooking. Overall, 70 per cent of the population uses an improved source of drinking water – 93 per cent in urban areas and 61 per cent in rural areas. The situation in GBAO and Khatlon is considerably worse than elsewhere: only 51 and 55 per cent of the population in these regions respectively get their drink- ing water from an improved source. Significant variations also exist in access to an improved water source in terms of household wealth; only 48 per cent of the poorest population, compared to 95 per cent of the richest, has such access. Multiple Indicator Cluster Survey, Tajikistan, 200554 Figure EN.1. Percentage distribution of household members by source of drinking water, Tajikistan, 2005 Piped into dwelling Tubewell/borehole Piped into yard or plot Public tap/standpipe Tanker-truck or cart with small tank/drum Surface water Other unimproved 25 1 3 8 4 23 13 22 2 Unprotected well or spring Protected well or spring The source of drinking water for the population varies strongly by region (Table EN.1). In Dushanbe, 93 per cent use drinking water piped into the dwelling or yard/plot. This finding is lower than the data obtained from the National Report for 2005 conducted by the Dushanbe Sanitary Epidemiologi- cal Station, which showed that 99 per cent of the population used piped water. However, it is worth mentioning that supplied pipe water, particularly in Dushanbe, comes from surface sources without being exposed to routine cleaning procedures. In DRD, 39 per cent use piped water. In contrast, only about 27 and 28 per cent of those in Sogd and Khatlon respectively, and around 15 per cent of those in GBAO, have piped water. In Sogd, the most common source of drinking water is tap/standpipe, while in Khatlon and GBAO about 2 in 5 use surface water, an unimproved source. Comparing these results with those from the MICS 2000, however, it is found that improvement has been significant: The share of population using an improved source of drinking water has increased from only 57 per cent to 70 per cent. Use of in-house water treatment is presented in Table EN.2. Households were asked of ways they may be treating water at home to make it safer to drink; boiling, adding bleach or chlorine, using a water filter, and using solar disinfection were considered proper treatment. In Tajikistan 80 per cent of the population use an appropriate water treatment method. The most common method is boiling, employed by 79 per cent of households. Almost no difference is found in appropriate water treatment between households with access to improved and unimproved sources of water. Use of appropriate wa- ter treatment method also is similar across regions, with the exception of GBAO, where a significantly lower percentage (8 per cent) treats water to make it safer. At the same time, household wealth and education level of household head greatly influence water treatment. The population from wealthier households, and those with a highly educated head of household, are more likely to apply appropriate water treatment methods. The amount of time it takes to obtain water is presented in Table EN.3, while the person who usually collects the water is given in Table EN.4. Note that these results refer to one round-trip from home to VII. Environment 55 the drinking water source and back again. Information on the number of trips made in one day was not collected. Table EN.3 shows that for 45 per cent of households, the drinking water source is on the premises. For one-quarter of all households, it takes less than 15 minutes to get to the water source and bring water, while 13 per cent of households spend from 15 minutes to a half-hour for this purpose. Sixteen per cent of households need to spend more than 30 minutes to go to the water source and bring water. Excluding those households with water on the premises, the average time to the source of drinking water is 26 minutes. The time spent in rural areas in collecting water is slightly higher than in urban areas. Regional distribution shows that the highest average time spent in collecting water is in Khatlon (35 minutes). An interesting finding is that no differences exist by education level of household head or household wealth in average time spent in collecting water. Table EN.4 shows that for most households, an adult female usually collects water when the source is not on the premises. Adult men collect water in only 10 per cent of cases, while for the rest, female or male children younger than age 15 do such chores (11 per cent). Inadequate disposal of human excreta and personal hygiene is associated with a range of diseases, including diarrhoeal diseases and polio. Improved sanitation facilities for excreta disposal include: flush or pour-flush to a piped sewer system, septic tank or latrine; ventilated improved pit latrine; and pit latrine with slab. Ninety-four per cent of the population live in households using improved sanitation facilities (Table EN.5); this proportion is 97 per cent in urban areas, 92 per cent in rural areas. Residents of GBAO are less likely to use improved facilities than other regions. A deeper analysis is provided by breaking down the sanitary means according to type. The most common type of sanitation facility in Tajikistan is a pit latrine with slab, in 79 per cent of households. Only 13 per cent of the population has access to a sanitation facility connected to a sewage system. The table indicates that use of improved sanitation facilities is strongly correlated with wealth and differs markedly between urban and rural areas. In rural areas, the population mostly uses pit latrines with slabs, while the most common urban facility is flush toilets with connection to the sewage system. Safe disposal of a child’s faeces is disposing of the stool by the child using a toilet or by rinsing the stool into a toilet or latrine. Disposal of faeces of children aged 0-2 years is presented in Table EN.6. In almost one-third of households with children aged 0 to 2 years, the child’s faeces is safely disposed of. In 9 per cent of households children use a toilet, while in 20 per cent of cases, faeces were put into the toilet of a latrine. Findings show that the most frequently used method of disposal of child faeces in Tajikistan is rinsing it into a drain or ditch (37 per cent of households). Regional distribution shows that the highest proportion of mothers and caretakers disposing of faeces safely is in Dushanbe, at 74 per cent. This practice is far less common in Khatlon, Sogd and DRD, at about 20-28 per cent. Urban-rural differences also are significant; 51 per cent of urban households dispose of child faeces safely, compared to only 20 per cent of rural households. An overview of the percentage of household members using improved sources of drinking water and sanitary means of excreta disposal is presented in Table EN.7. Overall, 69 per cent of the population Multiple Indicator Cluster Survey, Tajikistan, 200556 in Tajikistan has access to improved water sources and sanitation. Residents of Dushanbe, urban areas and the richest households are most likely to have both improved water sources and sanitation facili- ties, ranging from 90 to 95 per cent. Household Durable Goods and Agicultural Assets Ownership of household goods and assets is a direct indicator of household living standards. The percentage of households with different household items is presented in Tables EN.8.A-EN.8.C. Almost all households in Tajikistan have electricity (99 per cent), although this is somewhat lower in GBAO, at 90 per cent. A slightly lower percentage of households own TV (89 per cent), while possession of other household goods is drastically lower. Only one-third own a refrigerator, and only 1 in 5 own a fixed telephone. An electric water heater is present in 18 per cent of households, a washing machine in only 13 per cent. Urban-rural and regional differences are noticeable; many more urban households possess more ex- pensive items like refrigerators, washing machines or televisions. About 68 per cent of households in Tajikistan own agricultural land; the share with land is high in every region except Dushanbe, the capital. Ownership of agricultural land correlates with house- hold wealth; the overwhelming majority of the poorest households (91 per cent) have land, while only 1 in 5 of the richest own it. On average, a household in Tajikistan possesses 0.4 hectares of agricultural land. Nearly every second household in Tajikistan owns cows and/or bulls. Every third household owns chickens, while the ownership of other animals is less than 1 in 6. Similar to agricultural land owner- ship, most households that own animals are in GBAO or rural areas. The richest households own farm animals in much smaller percentages than the average. VIII. Reproductive Health 57 VIII. REPRODUCTIVE HEALTH Contraception Appropriate family planning is important for the health of women and children for several reasons: 1) preventing pregnancies that are too early or too late; 2) extending the period between births; and 3) limiting the number of children. A WFFC goal is to provide access to all couples with information and services for preventing pregnancies that are too early, too closely spaced, too late or too many. Current use of contraception was reported by 38 per cent of women married or in union (Table RH.1). Women in Tajikistan are more likely to use modern contraceptive methods (33 per cent) than tradition- al methods. By far the most popular contraceptive method is the IUD, used by 1 in 4 married women. The next most popular is the lactation amenorrhoea method (LAM), at 3 per cent. Around 2 per cent of women reported use of injections or pills; use of condom and withdrawal was reported by 1 per cent. Less than 1 per cent reported the use of some other method for preventing pregnancy. Contraceptive prevalence is highest in Sogd, at 46 per cent; elsewhere, it ranges from 35 per cent in Khatlon to 38 per cent in Dushanbe and 39 per cent in GBAO. The lowest use of contraception is reported in DRD, at 29 per cent. Urban-rural differences also are notable; 42 per cent of urban married women, compared to 36 per cent in rural areas, reported using contraception. Adolescents are far less likely to use contraception than older women. Only 9 per cent of women aged 15-19 use a method to prevent pregnancy, compared to 25 per cent of 20- to 24-year-olds and 50 per cent of women aged 35 to 49. Use of contraception also varies significantly by the number of living children, from less than 1 per cent, among those with no children, to 48 per cent among women with three living children. Women’s education level likewise is strongly associated with contraceptive prevalence. The percent- age of women using any method of contraception rises from 14 per cent among those with no educa- tion to 25 per cent among women with primary education, and much further, to 51 per cent, among women with higher education. In addition to differences in prevalence, the method mix varies by edu- cation. As the educational level increases, the proportion using modern methods, particularly condoms, increases. A similar pattern is noticed concerning wealth, with women from the richest households using modern contraceptive methods more than average. Comparing results with the MICS 2000 data (Figure RH.1) shows that the indicator is improving. Contraceptive prevalence in Tajikistan has increased by 4 percentage points since that date. Usage of modern method had increased in the last five years, even as traditional methods have slightly declined. Multiple Indicator Cluster Survey, Tajikistan, 200558 Figure RH.1. Percentage of women aged 15-49 years married or in union who are using (or whose partner is using) a contraceptive method, Tajikistan, 2000 - 2005 27% 7% 34%33% 5% 38% Any modern method Any traditional method Current use of contraception MICS 2000 MICS 2005 Results for women’s knowledge of contraceptive methods are presented in table RH.1.A. Most married/in- union women in Tajikistan know about the IUD (87 per cent). Pills as a contraceptive method are familiar to 49 per cent of women; every third women knows about injection; and 19 per cent of women know about condoms, while knowledge of other contraceptive methods is very low, at less than 5 per cent. About 1 in 10 married or in-union women knows no method for preventing pregnancy. The share is highest among young women aged 15-19, at 1 in 3. As with usage, knowledge about contraception and women’s education are highly correlated, rising with additional education. Women in the richest households and households where the mother tongue of household head is Russian also have better knowledge in this regard. Unmet Need Unmet need11 for contraception refers to fecund women who are not using any method of contracep- tion, but who wish to postpone the next birth or who wish to stop childbearing altogether. Unmet need is identified in the MICS by using a set of questions eliciting current behaviours and preferences pertaining to contraceptive use, fecundity and fertility preferences. Women in unmet need for spacing includes women who are currently married (or in union), fecund (are currently pregnant or think that they are physically able to become pregnant), currently not using contraception, and want to space their births. Pregnant women are considered to want to space their births when they do not want the child at the time they get pregnant. Women who are not pregnant are classified in this category if they want to have a (another) child, but want to have the child at least two years later, or after marriage. Women in unmet need for limiting are those women who are currently married (or in union), fecund (cur- rently pregnant or think that they are physically able to become pregnant), currently not using contracep- tion, and want to limit their births. The latter group includes women who are pregnant but did not want 11 Unmet need measurement in the MICS is somewhat different from that used in other household surveys, such as the national Demo- graphic and Health Surveys (DHS). In the DHS, more detailed information is collected on additional variables, such as postpartum amenorrhoea, and sexual activity. Results from the two types of surveys are not strictly comparable. VIII. Reproductive Health 59 the pregnancy at all, and women who are not pregnant but do not want to have a (another) child. Total unmet need for contraception is simply the sum of unmet need for spacing and unmet need for limiting. Using information on contraception and unmet need, the percentage of demand for contraception satis- fied also is estimated from the MICS data. Percentage of demand for contraception satisfied is defined as the proportion of women currently married or in union currently using contraception, compared to total demand for contraception. This total demand includes women who currently have an unmet need (for spacing or limiting), plus those currently using contraception. Table RH.2 shows the results of the survey on contraception, unmet need and the demand for contraception satisfied. Nearly 1 in 4 (24 per cent) of married women or women in union have an unmet need for contracep- tion. Because there exists a close link to contraception use, the findings according to background characteristics are very similar to those of contraceptive prevalence. Needs for contraception are not satisfied among a large proportion of women from the poorest households. Looking at regional distribution, unmet need for contraception is lowest in Sogd and highest in DRD. The unmet need for contraception mainly manifests as unmet need for limiting (15 per cent), with the exception of women aged 15 to 24, whose needs are mainly for spacing. Antenatal Care The antenatal period presents important opportunities for reaching pregnant women with a number of interventions that may be vital to their health and well-being and that of their infants. Better under- standing of foetal growth and development and its relationship to the mother’s health has resulted in increased attention to the potential of antenatal care as an intervention to improve both maternal and newborn health, for example, if the antenatal period is used to inform women and families about dan- ger signs and symptoms and about the risks of labour and delivery. It may provide the route for ensur- ing that pregnant women do deliver with the assistance of a skilled health care provider. The antenatal period also provides an opportunity to supply information on birth spacing, recognised as an important factor in improving infant survival. Tetanus immunization during pregnancy can be lifesaving for both mother and infant. The preven- tion and treatment of malaria among pregnant women, management of anaemia during pregnancy and treatment of STIs can significantly improve foetal outcomes and improve maternal health. Adverse outcomes such as low birth weight can be reduced through a combination of interventions to improve women’s nutritional status and prevent infections (e.g., malaria and STIs) during pregnancy. More re- cently, the potential of the antenatal period as an entry point for HIV prevention and care, in particular for the prevention of HIV transmission from mother to child, has led to renewed interest in access to and use of antenatal services. WHO recommends a minimum of four antenatal visits based on a review of the effectiveness of dif- ferent models of antenatal care. WHO guidelines are specific on the content on antenatal care visits, which include: Blood pressure measurement• Urine testing for bacteraemia and proteinuria• Blood testing for detecting syphilis and severe anaemia• Weight/height measurement (optional)• Multiple Indicator Cluster Survey, Tajikistan, 200560 Coverage of antenatal care (by a doctor, nurse or midwife) is relatively high in Tajikistan, with 77 per cent of women receiving antenatal care at least once during the pregnancy. The lowest level of antena- tal care is found in Khatlon, at 66 per cent, while the highest is in Sogd (92 per cent). Antenatal care coverage is some 10 percentage points higher in urban areas compared to rural areas. Lower antenatal care coverage is noticed among the oldest and less educated women, as well as women from the poor- est households. In addition, women in households where the mother tongue of household head is Tajik are less likely to receive antenatal care. The type of personnel providing antenatal care to women aged 15-49 who gave birth in the two pre- ceding years is presented in Table RH.3. In 68 per cent of cases a medical doctor provided care, while nurses/midwives provided 9 per cent. The types of services pregnant women receive are shown in Table RH.4. Regarding the content of antenatal care received, 66 per cent of women in Tajikistan have their urine taken, and 68 per cent a blood sample, while 72 per cent have blood pressure measured. However, a high percentage (38 per cent) of women are not weighed. A blood group and gynaecological exam are provided to about two- thirds of women; ultrasound is performed for 57 per cent of women, mostly in Dushanbe. Lastly, the pregnancy term is assessed for 71 per cent of women. These interventions are more frequently reported by more educated and wealthier women. Less than one-half of pregnant women bought or received the iron pills as part of their antenatal care. The median number of days of taking iron pills during pregnancy is 10. Assistance at Delivery Three-quarters of all maternal deaths occur during delivery and the immediate postpartum period. The single most critical intervention for safe motherhood is to ensure a competent health worker with mid- wifery skills to be present at every birth. In addition, transport should be available to a referral facility for obstetric care in case of emergency. A WFFC goal is to ensure that women have ready and afford- able access to skilled attendance at delivery. The indicators are the proportion of births with a skilled attendant and proportion of institutional deliveries. The skilled attendant at delivery indicator also is used to track progress toward the MDG of reducing the maternal mortality ratio by three- quarters between 1990 and 2015. The MICS included a number of questions to assess the proportion of births attended by a skilled at- tendant. A skilled attendant includes a doctor, nurse, midwife or auxiliary midwife. Skilled personnel (Table RH.5) delivered about 83 per cent of births in the two years before the MICS survey, highest in Sogd and Dushanbe, at 95 and 87 per cent, and lowest in Khatlon, at 75 per cent. Skilled attendance during delivery is higher in urban areas (89 per cent) than in rural areas (81 per cent). Examining trends in assistance at delivery, important progress has been made sinced the MICS 2000, when delivery by skilled personnel stood at only 71 per cent; nonetheless, room exists for fur- ther improvement. The more educated and wealthier a woman is, the more likely she is to have a delivery with the assis- tance of a skilled attendant. Differences are found regarding women’s age. While 87 per cent of women aged 20-24 are delivered by skilled personnel, this decreases to 78 per cent for women aged 35-39. VIII. Reproductive Health 61 In GBAO, Khatlon and DRD, doctors assisted in only about 3 in 5 births and nurses assisted 1 in 5. Tra- ditional birth attendants delivered about 9 per cent of births in these areas. In the other regions, between 75 and 86 per cent are delivered by a doctor, while 8 to 12 per cent have a midwife in attendance. A total of 62 per cent of births in the previous two years were delivered in health facilities. A far lower share of institutional deliveries is recorded in Khatlon and GBAO, at 42 and 46 per cent respectively. Similar to the pattern of many other indicators, less educated and poorer women are less likely to have their children delivered in a health facility, at 42 per cent. The Tajikistan MICS 2005 included additional questions regarding women’s reproductive health and pregnancy outcomes. Results of this analysis are presented in Table RH.5.A. Live birth was the outcome of 85 per cent of all pregnancies, while 8 per cent ended with induced abortion and 6 per cent were miscarriages. About 1 per cent ended with a stillborn child. Maternal Mortality The complications of pregnancy and childbirth are the leading cause of death and disability among women of reproductive age in developing countries. It is estimated worldwide that around 529,000 women die each year from maternal causes. Moreover, for every woman who dies, about 20 more suffer injuries, infection and disabilities in pregnancy or childbirth. This means that at least 10 million women a year incur this type of damage. The most common fatal complication is the postpartum haemorrhage. Sepsis, complications of un- safe abortion, prolonged or obstructed labour and the hypertensive disorders of pregnancy, especially eclampsia, claim further lives. These complications, which can occur at any time during pregnancy and childbirth without warning, require prompt access to quality obstetric services equipped to provide lifesaving drugs, antibiotics and transfusions, and to perform the Caesarean sections and other surgical interventions that prevent deaths from obstructed labour, eclampsia and intractable haemorrhage. One of the MDG targets is to reduce the maternal mortality ratio by three-quarters between 1990 and 2015. Maternal mortality is defined as the death of a woman from pregnancy-related causes, when pregnant or within 42 days of termination of pregnancy. The maternal mortality ratio is the number of mater- nal deaths per 100,000 live births. In the MICS, the maternal mortality ratio is estimated by using the indirect sisterhood method, which produces estimates centred on about 12 years before the survey was carried out. To collect the information needed for the use of this estimation method, adult household members aged 15-49 were questioned regarding the survival of their sisters and the timing of death relative to pregnancy, childbirth and the postpartum period for these deceased sisters. The information collected was then converted to lifetime risks of maternal death and maternal mortality ratios.12 The Tajikistan MICS results for maternal mortality are shown in Table RH.6. Results are presented only for the national total, because maternal mortality ratios generally have very large sampling errors. Estimated maternal mortality in Tajikistan is 97 per 100,000 live births (alternatively, about 1 death per 1,000 births). 12 For more information on the indirect sisterhood method, see WHO and UNICEF, 1997. Multiple Indicator Cluster Survey, Tajikistan, 200562 IX. CHILD DEVELOPMENT It is well recognized that a period of rapid brain development occurs in the first 3-4 years of life, and that the quality of home care is the major determinant of the child’s development during this period. In this context adult activities with children, presence of books at home for the child, and conditions of care are important indicators of quality of home care. A WFFC goal is that “children should be physi- cally healthy, mentally alert, emotionally secure, socially competent and ready to learn.” Information on a number of activities that support early learning was collected in the survey. These included the involvement of adults with children in the following activities: reading books or looking at picture books; telling stories; singing songs; taking children outside the home, compound or yard; playing with children; and spending time with children naming, counting, or drawing things. For almost two-thirds (60 per cent) of under-5 children, an adult was engaged in four or more activities that promote learning and school readiness during the three days preceding the survey (Table CD.1). The average number of activities that adults engaged with children was 3.7. However, the table also indicates that the father’s involvement in such activities was somewhat limited, at only 21 per cent. Larger proportions of adults are engaged in learning and school readiness activities with children in urban areas (56 per cent) than in rural areas (39 per cent). Strong differences by region and socioeco- nomic status also are observed: adult engagement in activities with children was greatest in GBAO (77 per cent) and lowest in DRD (56 per cent); the proportion was 73 per cent for children in the richest households, as opposed to 44 per cent in the poorest. Fathers’ involvement showed a similar pattern in terms of adults’ engagement in such activities. Mothers and fathers with higher education engage more in such activities with children than those with lower education. Exposure to books in his or her early years not only offers the child greater understanding of the nature of print, but may also give the child opportunities to see others read, such as older siblings doing schoolwork. The presence of books is important for later school performance and IQ scores. In Tajikistan, 46 per cent of children live in households where at least three non-children’s books are present (Table CD.2). However, only 17 per cent of children aged 0-59 months are in households with three or more children’s books. The median numbers of non-children’s books and children’s books in households are both extremely low (1 and none). While no gender differences are observed, urban children appear to have better access to both types of books. A total of 55 per cent of under-5 children in urban areas live in households with more than three non-children’s books, compared to 43 per cent in rural households. The proportion of under-5 children who have three or more children’s books is 27 per cent in urban areas, more than twice as high as the 13 per cent in rural areas. The presence of both non-children’s and children’s books is positively correlated with the older a child is. Table CD.2 also shows that 16 per cent of children aged 0-59 months have three or more playthings in their homes, while 11 per cent have none (Table CD.2). Playthings in the MICS included house- hold objects, homemade toys, toys from a store, and objects and materials found outside the home. It IX. Child Development 63 is interesting to note that 73 per cent of children play with toys from a store; however, other types of toys are below 30 per cent. The proportion of children who have three or more playthings is 14 per cent among boys and 17 per cent among girls. No urban-rural differences are observed in this respect, and only small differences in terms of socioeconomic status. On the other hand, regional differences are quite large: for instance, in Dushanbe only 8 per cent of children have three or more playthings, compared to 26 per cent of children in DRD and 36 per cent in GBAO. One background variable that appears to have a strong correlation with the number of playthings for children is the age of the child. Leaving children alone or in the presence of other young children is known to increase the risk of ac- cidents. In the MICS, two questions were asked to find out whether children aged 0-59 months were left alone during the week preceding the interview, and whether children were left in the care of other children younger than age 10. Table CD.3 shows that 12 per cent of children aged 0-59 months were left in the care of other chil- dren, while 3 per cent were left alone during the week preceding the interview. Combining these two care indicators, it is calculated that 13 per cent of children – or more than 1 in 8 -- were left with inadequate care during the week preceding the survey. No differences were observed by the sex of the child or between urban and rural areas. Children who live in Khatlon and Sogd are more often left with inadequate care, while this proportion is lowest among children from Dushanbe (4 per cent). On the other hand, inadequate care was more prevalent among children whose mothers have secondary special education (17 per cent), as opposed to those whose mothers have higher education (8 per cent). Children aged 24-59 months were left with inadequate care more often (16 per cent) than those aged 0-23 months (7 per cent). With the increase of household wealth, the chances that a child would be left alone with inadequate care decreases slightly. Multiple Indicator Cluster Survey, Tajikistan, 200564 x. educAtion Preschool Attendance and School Readiness Attendance to preschool education in an organised learning or child education programme is important to make children ready for school. One WFFC goal is to promote early childhood education. Only 10 per cent of children in Tajikistan aged 36-59 months attend preschool (Table ED.1). Urban- rural and regional differences are significant – the figure is as high as 25 per cent in urban areas, com- pared to 5 per cent in rural areas. Attendance is most prevalent in Dushanbe (33 per cent) and lowest in DRD (4 per cent). No gender difference exists, but differences by socioeconomic status are significant; 29 per cent of children in the richest households attend preschool, while the figure drops to 1 per cent in the poorest households. The proportion of children attending preschool at ages 36-47 months and 48-59 months are almost identical (10 per cent). Table ED.1 also shows the proportion of children in the first grade of primary school who attended preschool the previous year, an important indicator of school readiness. Overall, 25 per cent of 7-year-olds who attend the first grade of primary school also attended preschool the previous year. The proportion among boys is slightly higher (27 per cent) than girls (24 per cent), while almost two-thirds of urban children (59 per cent) attended preschool the previous year compared to 16 per cent among rural children. Regional differences also are very significant; first graders in Dushanbe attended preschool far more often (75 per cent) than their counterparts in Khatlon (7 per cent). Socioeconomic status of the household appears to positively correlate with school readiness. The indicator is only 11 per cent among children from the poorest households, but increases to 58 per cent among the richest households. Primary and Secondary School Participation Universal access to basic education and the achievement of primary education of children worldwide is one of the most important goals of the MDGs and WFFC. Education is a vital prerequisite for com- bating poverty, empowering women, protecting children from hazardous and exploitative labour and sexual exploitation, promoting human rights and democracy, protecting the environment, and influenc- ing population growth. The indicators for primary and secondary school attendance include: Net intake rate in primary education• Net primary school attendance rate• Net secondary school attendance rate• Net primary school attendance rate of children of secondary school age• Female-to-male education ratio (or gender parity index - GPI)• X. Education 65 The indicators of school progression include: Survival rate to grade five• Transition rate to secondary school• Net primary completion rate• Of children who are of primary school entry age (age 7) in Tajikistan, 65 per cent attend the first grade of primary school (ED.2). Girls are slightly more likely to start primary education on time than boys, 66 compared to 63 per cent. Regional and urban-rural differences are significant. In Dushanbe and Khatlon, for instance, the indicator reaches 84-85 per cent, while it is only 42 per cent in DRD. Chil- dren’s participation in primary schools is timelier in urban areas (67per cent) than in rural areas (64 per cent). A positive correlation with mother’s education and socioeconomic status is observed: for 7-year- olds whose mothers have higher education, 88 per cent attended the first grade. In the richest house- holds, the proportion stands at around 73 per cent, while it is 64 per cent in the poorest households. Table ED.3 shows the percentage of children of primary school age attending primary or secondary school. Most children of primary school age attend school (89 per cent of children aged 7 to 10 years), But this means that more than 1 in 10 children (11 per cent) are out of school. Variations by back- ground characteristics are similar to the primary intake findings described above. Differences between primary education entry age and primary school attendance rate indicate certain children start their education later than expected. The secondary school net attendance ratio is presented in Table ED.4. Most dramatic is the fact that nearly 1 in 5 children of secondary school age does not attend secondary school, having either left school or still studying in primary school (see below). This finding is very similar to the official figure for the school year 2004/2005, which indicated that the net secondary school enrolment was 80 per cent. Geographical variations are significant; children from the GBAO region and Dushanbe are more likely to attend secondary school (93 and 84 per cent) than children from other regions. In addition, urban children more often attend than rural children, as do boys compared with girls (89 compared to 74 per cent). Mother’s educational level and household wealth significantly influence secondary school attendance. The primary school net attendance ratio of children of secondary school age is presented in Table ED.4W. Only 3 per cent of children of secondary school age attend primary school; the remaining 15 per cent do not attend school at all. The percentage of children entering the first grade who eventually reach grade 5 is presented in Table ED.5. Nearly all children who started grade one will eventually reach grade five (99 per cent). This number includes children who repeat grades. The net primary school completion rate and transition rate to secondary education are presented in Table ED.6. At the time of the survey, 85 per cent of children of primary completion age (10 years) were attending the last grade of primary education. A significantly lower percentage of children in the poorest households and the second wealth quintile attended (around 80 per cent). This value should be distinguished from the gross primary completion ratio, which includes children of any age attending the last grade of primary school. Most children who successfully completed the last grade of primary school were found to be attending the first grade of secondary school (99 per cent). Multiple Indicator Cluster Survey, Tajikistan, 200566 The ratio of girls to boys attending primary and secondary education is provided in Table ED.7. These ratios are better known as the Gender Parity Index (GPI). Ratios included here are obtained from net attendance ratios rather than gross attendance ratios, the latter of which erroneously describe the GPI because in most cases the majority of over-aged children are boys. The table shows that gender parity for primary school is close to 1.00, indicating no difference in girls’ and boys’ attendance. However, the indicator drops to 0.83 for secondary education, suggesting that for every 10 boys there are 8 girls attending secondary school. The disadvantage of girls is slightly less pronounced in Sogd and GBAO, as well as among children in the richest households and urban areas. Girls’ disadvantage in school at- tendence is noticed among all language groups except Russian. Adult Literacy One of the WFFC goals is to assure adult literacy. Adult literacy also is an MDG indicator, relating to both men and women. In the MICS, since only a women’s questionnaire was administered, the results are based only on females aged 15-24. Literacy was assessed on the ability of women to read a short simple statement in Tajik or Russian or on school attendance (women who attended any level of sec- ondary school were assumed to be literate). The per cent of literacy is presented in Table ED.8. The literacy rate among young women in Tajikistan is 95 per cent. As expected, the literacy level is low among women with none or primary education, at 12 and 32 per cent respectively. Younger women aged 15-19 are slightly less literate than women aged 20-24, at 94 compared to 96 per cent. Looking at regional differences, findings show that young women from Khatlon and DRD are less literate than women in other regions. Women in the richest households are the most literate; 98 per cent of women aged 15-24 in the richest households are literate, compared to 90 per cent in the poorest households. XI. Child Protection 67 XI. CHILD PROTECTION Birth Registration The Convention on the Rights of the Child states that every child has the right to a name and a na- tionality and the right to protection from being deprived of his or her identity. Birth registration is a fundamental means of securing these rights for children. WFFC states a goal to develop systems to ensure the registration of every child at or shortly after birth, and to fulfil his or her right to acquire a name and a nationality, in accordance with national laws and relevant international instruments. The indicator is the percentage of children under-5 whose birth is registered. The births of 88 per cent of children under-5 in Tajikistan have been registered (Table CP.1), with the prevalence somewhat more likely for children in Sogd, Khatlon and GBAO. A surprising finding is that birth registration is higher among rural than urban children, 90 compared to 85 per cent. The older the child is, the better is the chance that the birth will be registered: the indicator rises from 82 per cent among children aged 0-11 months to 92 per cent among children aged 48-59 months, which indicates delayed registration. Birth registration is highly correlated with mother’s educational status. The per- centage of registered births is highest among children whose mothers have secondary special or higher education (92 per cent). Among those whose births are not registered, cost appears to be the main reason (42 per cent). Lack of time, missing of other documentation and distance from the place of birth also are mentioned, but because of the low number of observed cases, these results should be considered with caution. Child Labour Article 32 of the Convention on the Rights of the Child states: “States Parties recognise the right of the child to be protected from economic exploitation and from performing any work that is likely to be hazardous or to interfere with the child’s education, or to be harmful to the child’s health or physi- cal, mental, spiritual, moral or social development.” WFFC mentions nine strategies to combat child labour, and the MDGs call for the protection of children against exploitation. In the MICS question- naire, a number of questions addressed the issue of child labour, that is, children aged 5-14 involved in labour activities. A child is considered to be involved in child labour activities if during the week preceding the survey: Ages 5-11: he/she had at least one hour of economic work or 28 hours of domestic work per week • Ages 12-14: he/she had at least 14 hours of economic work or 28 hours of domestic work per • week. This definition allows differentiation between child labour and child work to identify the type of work that should be eliminated. As such, the estimate provided here is a minimum of the prevalence of child labour, since some children may be involved in hazardous labour activities for a number of hours that Multiple Indicator Cluster Survey, Tajikistan, 200568 could be less than the numbers specified above. Table CP.2 presents the results of child labour by the type of work. Percentages do not add up to total child labour because children may be involved in more than one type of work. Ten per cent of children in Tajikistan aged 5 to 14 years are involved in child labour, mainly unpaid and domestic work. Regional distribution indicates that the proportion of children involved in child labour is highest in GBAO, encompassing nearly one-quarter of children aged 5 to 14. The pattern is the same as that at the national level, in that they are mainly involved in unpaid and domestic work. On the other hand, children from Dushanbe are the least involved in child labour (2 per cent), mainly working for the family busi- ness. Urban children are less likely to be involved in labour (8 per cent) than rural children (11 per cent). The poorest children, children whose mothers have no education, and those aged 12-14 are the most exploited groups with regard to child labour. A total of 14 per cent of children from the poorest house- holds and 16 per cent of children whose mothers have never attended school are involved. Table CP.3 presents the percentage of children classified as student labourers or as labourer students. Student labourers are children who attended school and were involved in child labour activities at the time of the survey. More specifically, out of 75 per cent of the children aged 5-14 attending preschool or school, 12 per cent also were involved in child labour. The proportion of student labourers is the highest among children from GBAO, rural areas and the poorest households. On the other hand, out of children classified as child labourers, the vast majority also attended school (89 per cent). This is slightly lower among children in households where the mother tongue of house- hold head is Tajik. Child Discipline As stated in the WFFC declaration, “children must be protected against any acts of violence …,” while the Millennium Declaration calls for the protection of children against abuse, exploitation and violence. In the Tajikistan MICS survey, mothers/caretakers of children aged 2-14 were asked a series of questions about the discipline methods they used when their children misbehaved. For the child dis- cipline module, one child aged 2-14 per household was selected randomly during fieldwork. The two indicators used to describe aspects of child discipline are: 1) the number of children aged 2-14 who experience psychological aggression as punishment or minor physical punishment or severe physical punishment; and 2) the number of parents/caretakers of children aged 2-14 who believe that in order to raise their children properly, they need to physically punish them. In Tajikistan, nearly 3 in 4 children aged 2-14 (74 per cent) received at least one form of psychological or physical punishment from their mothers/caretakers or other household members. More importantly, about 1 in 7 children (16 per cent) were subjected to severe physical punishment and more than 1 in 2 (55 per cent) to minor physical punishment. On the other hand, only 15 per cent of mothers/caretak- ers believed that children should be physically punished, a sharp contrast to the actual prevalence of physical discipline. XI. Child Protection 69 Every fifth child in Tajikistan has been disciplined through non-violent methods, while fewer than 1 in 10 (7 per cent) have never been punished or disciplined. Boys were subjected more to both minor and severe physical discipline (58 and 18 per cent) than girls (51 and 14 per cent). Violent disciplines are more practiced in Khatlon, DRD and Dushanbe. Use of violent child discipline methods decreases as wealth rises. Some 18 per cent of caretakers from the poorest households use severe physical punishment, decreasing to 15 per cent among caretakers in the richest households. Early Marriage Marriage before age 18 is a reality for many young girls. According to UNICEF’s worldwide esti- mates, more than 60 million women aged 20-24 were married/in union before age 18. Factors that influence child marriage rates include the state of a country’s civil registration system, which provides proof of age for children; existence of an adequate legislative framework with an accompanying en- forcement mechanism to address cases of child marriage; and existence of customary or religious laws that condone the practice. In many parts of the world, parents encourage their daughters to marry while they are still children, hoping that the marriage will benefit them both financially and socially and relieve the financial burden of the family. In fact, child marriage is a violation of human rights, compromising the development of girls and often resulting in early pregnancy and social isolation, with little education and poor voca- tional training, reinforcing the gendered nature of poverty. The right to ‘free and full’ consent to a mar- riage is recognised in the Universal Declaration of Human Rights -- with the recognition that consent cannot be ‘free and full’ when one party involved is not sufficiently mature to make an informed deci- sion about a life partner. The Convention on the Elimination of all Forms of Discrimination Against Women mentions the right to protection from child marriage in Article 16, which states: “The betrothal and the marriage of a child shall have no legal effect, and all necessary action, including legislation, shall be taken to specify a minimum age for marriage.” While marriage is not considered directly in the Convention on the Rights of the Child, child marriage is linked to other rights -- such as the right to express views freely, the right for protection from all forms of abuse, and the right to be protected from harmful traditional practices -- and is frequently addressed by the Committee on the Rights of the Child. Other international agreements related to child marriage are the Convention on Consent to Mar- riage, Minimum Age for Marriage and Registration of Marriages. Young married girls are a unique, though often invisible, group. Required to perform heavy amounts of domestic work, under pressure to demonstrate fertility, and responsible for raising children while still children themselves, married girls and child mothers face constrained decision making and re- duced life choices. Boys also are affected by child marriage; still, the issue affects girls in far larger numbers and with more intensity. Cohabitation, when a couple lives together as if married, raises the same concerns regarding human rights as marriage. When a girl lives with a man and takes on the role of caregiver to him, the assumption is often that she has become an adult woman, even if she has not yet reached age 18. Additional concerns due to the informality of the relationship (for example, inheri- tance, citizenship and social recognition) might make girls in informal unions even more vulnerable in different ways than those in formally recognised marriages. Multiple Indicator Cluster Survey, Tajikistan, 200570 Research suggests that many factors interact to place a child at risk of marriage. Poverty, protection of girls, family honour and the provision of stability during unstable social periods are considered signifi- cant factors in determining a girl’s risk of marrying while still a child. Women who get married young- er are more likely to believe that it is sometimes acceptable for a husband to beat his wife, and they are more likely to experience domestic violence themselves. The age gap between partners is thought to contribute to these abusive power dynamics and to increase the risk of untimely widowhood. Closely related to the issue of child marriage is the age at which girls become sexually active. Women who are married before age 18 tend to have more children than those who marry later in life. Pregnancy-related deaths are known to be the leading cause of mortality for both married and unmarried girls aged 15-19, particularly among the youngest of this cohort. Evidence suggests that girls who marry young are more likely to marry older men, which puts them at increased risk of HIV infection. Parents seek to marry off their girls to protect their honour, and men often seek younger women to avoid choosing a wife who might already be infected. The demand for these young wives for reproduction, and the power imbalance resulting from the age gap, lead to very low condom use among such couples. Two indicators are the percentage of women married before age 15 and the percentage married before age 18. The percentage of women married at various ages is provided in Table CP.5. Less than 1 per cent of women in Tajikistan aged 15-49 reported marriage before age 15. A slightly higher proportion of marriage before age 15 is recorded among women aged 25-29 years (2 per cent). Marriage at an early age is more common among women with primary and incomplete sec- ondary school. However, almost 15 per cent – more than 1 in 7 -- of all women aged 20-49 married before age 18. This practice is less prominent in GBAO, where only 8 per cent of women marry before age 18. A strong correlation between education level of women and early marriage is evident. While 28 per cent of women aged 20-49 who attended primary school married before age 18, only 5 per cent of women who attended higher school married at such an early age. A similar pattern as in the case of marriage before age 15 is noticed when the age of women is analysed; the highest prevalence of marriage before age 18 is among women aged 25-29 (23 per cent). This practice also is more prevalent among the poorest and Tajik women, where about 1 in 6 are married before age 18. Table CP.5 also shows that 6 per cent of women aged 15-19 are currently married or in union. Table CP.6 presents the results of the age difference between husbands and wives, an important indica- tor as well. Among married women aged 15-19, 5 per cent are married to a partner 10 or more years older. The percentage is the same among married women aged 20-24. Domestic Violence Women aged 15-49 who are currently married or in union were questioned to assess their attitudes about whether husbands are justified to hit or beat their wives/partners for a variety of scenarios. These questions were asked to indicate cultural beliefs that tend to be associated with the prevalence of vio- lence against women by their husbands/partners. The main assumption here is that women who agree with statements indicating that husbands/partners are justified in beating their wives/partners tend to be abused themselves. Responses can be found in Table CP.7. XI. Child Protection 71 About 3 in 4 married/in-union women in Tajikistan feel that their husband/partner has a right to hit or beat them, mostly in cases when they argue with their husband (68 per cent); if they demonstrate their autonomy, e.g., go out without telling their husband (62 per cent); and if they neglect the children (61 per cent). Around one-half of women believe that their partner has a right to hit or beat them if they refuse to have sex with him or if they burn the food. Regional distribution indicates that domestic violence is less acceptable in Dushanbe, where fewer than 1 in 2 women feels that their partner’s violence is justified. At the same time, an overwhelming 83 per cent of women from Khatlon believe domestic violence is justified. Acceptance is higher among rural women, the less educated and the poorest. A surprising finding is that acceptance is highest among young married women; 85 per cent of women aged 15-29 believe that their partner is justified in hitting them. This declines to 69 per cent among women aged 45-49. Women’s Participation in Decision Making in the Home The MICS Survey in Tajikistan includes additional analysis regarding women’s acceptance of domes- tic violence and their attitudes and behaviour in marriage. The following questions were addressed to married/in-union women in order to evaluate women’s participation in decision making: “Who usually makes decisions about women’s health care, about major household purchases, about making purchas- es for daily household needs, and about visits to women’s family relatives?” One-third of married/in-union women participate in each of the described decisions (Table CP.7.A). On the other hand, an equal number (34 per cent) make no decisions regarding household purchases, their own health and their social life. Women from Dushanbe and urban areas participate more in the decisions described above. In addition, the older the woman is, the more involved she is in making decisions; only 18 per cent of women aged 15-19 participate in decision making, while the proportion stands more than two times higher among women aged 45-49. A woman’s right to participate likewise is strongly correlated with her education level and the household wealth. Tables CP.7.B – CP.7.E present results about people in the household who have a final say regarding women’s health care, household purchases and visits to women’s family relatives. Only 13 per cent of women make their own decisions about their own health care. In 36 per cent of cases, the chief deci- sion maker is the husband, while 39 per cent of women make decisions together with their husbands. A similar pattern is found in other decision-making situations; 14 per cent of women make their own decisions about daily purchases, falling to only 6 per cent when large purchases are involved. Only 8 per cent decide on their own about visits to other family members. Multiple Indicator Cluster Survey, Tajikistan, 200572 XII. HIV/AIDS Knowledge of HIV Transmission One of the most important prerequisites for reducing the rate of HIV infection is accurate knowledge of how HIV is transmitted and strategies for preventing transmission. Correct information is the first step toward raising awareness and giving young people the tools to protect themselves from infection. Misconceptions about HIV are common and can confuse young people and hinder prevention efforts. Different regions are likely to have variations in misconceptions, although some appear to be universal (for example, that sharing food or being bitten by a mosquito can transmit HIV). The UN General As- sembly Special Session on HIV/AIDS (UNGASS) called on governments to improve the knowledge and skills of young people to protect themselves from HIV. The indicators to measure this goal as well as the MDG of reducing HIV infections by half include improving the level of knowledge about HIV and its prevention, and changing behaviour to prevent further spread of the disease. The HIV module was administered to women aged 15-49. One indicator for both the MDGs and UNGASS is the percentage of young women who have com- prehensive, correct knowledge of HIV prevention and transmission. Women were asked whether they knew of the three main ways of HIV transmission – having only one faithful uninfected partner, using a condom every time, and abstaining from sex. The results are presented in Table HA.1. In Tajikistan, 42 per cent of interviewed women have heard of AIDS. However, the percentage of women who know all three main ways of preventing HIV transmission stands at only 11 per cent. One-quarter of women know of having one faithful uninfected sex partner; 21 per cent know of using a condom every time; and 19 per cent know of abstaining from sex as main ways of preventing trans- mission. While 32 per cent of women know at least one way, more than 2 in 3 women (68 per cent) do not know any of the three ways. Correct knowledge of HIV prevention is more frequent among urban women, women who are wealthier, those who have secondary special or higher education. On the other hand, women who have only primary education or belong to the poorest households are less aware of AIDS, and their correct knowledge about HIV transmission is below average. An alarming fact is that young women are rarely familiar with HIV prevention. Only 23 per cent of women aged 15-19 have even heard of AIDS, while an extremely low 5 per cent is aware of all three ways of transmission. Table HA.2 presents the percentage of women who can correctly identify misconceptions concerning HIV. The indicator is based on the two most common and relevant misconceptions in Tajikistan: that HIV can be transmitted by sharing food, or by being bitten by a mosquito. The table also provides information on whether women know that HIV cannot be transmitted by supernatural means, and that HIV can be transmitted by sharing needles. Of the interviewed women, only 6 per cent reject the two most common misconceptions and know that a healthy-looking person can be infected. Fewer than 1 in 5 (18 per cent) of women know that HIV cannot be transmitted by sharing food, and about 1 in 5 XII. HIV/AIDS 73 (21 per cent) know that HIV cannot be transmitted by mosquito bites, while 1 in 6 (17 per cent) know that a healthy-looking person can be infected. Misconceptions are higher among poorer and less educated women. Looking at regional variations, it appears that the most informed are women from GBAO and Dushanbe. Table HA.3 summarises information from Tables HA.1 and HA.2 and presents the percentage of women who know two ways of preventing HIV transmission and reject three common misconceptions. Comprehensive knowledge of HIV prevention methods and transmission is still quite low, although differences exist by area of residence, age group, education and wealth. Overall, only 4 per cent of women were found to have comprehensive knowledge, which was slightly higher in urban areas (8 per cent) than rural areas (2 per cent). A higher level of knowledge is registered among women from GBAO and Dushanbe, but it still stands at below 15 per cent. Only 2 per cent of women aged 15-24 have comprehensive knowledge about HIV transmission. As expected, the percentage of women with comprehensive knowledge increases with education level (Figure HA.1). Figure HA.1. Percent of women who have comprehensive knowledge of HIV/AIDS transmission, Tajikistan, 2005 0 4 9 16 40 48 17 0 1 2 5 17 30 6 0 1 1 3 12 22 4 0 10 20 30 40 50 60 None/Non- standard/ Missing/DK Primary Incomplete Secondary Complete Secondary Secondary special Higher education Tajikistan Pe r ce nt Knows 2 ways to prevent HIV Identify 3 misconceptions Comprehensive knowledge Knowledge of mother-to-child transmission of HIV also is an important first step for women to seek HIV testing when they are pregnant to avoid infecting the baby. Women should know that HIV can be transmitted during pregnancy, delivery and breastfeeding. The level of knowledge among women aged 15-49 concerning mother-to-child transmission is presented in Table HA.4. Overall, 37 per cent of women know that HIV can be transmitted from mother to child. The percentage of women who know all three ways of mother-to-child transmission is 27 per cent, while 4 per cent of women did not know any specific way. The pattern of mother-to-child HIV transmission knowledge among background variables is similar to that for comprehensive knowledge. Indicators on attitudes toward people living with HIV measure stigma and discrimination in the community. Stigma and discrimination are low if respondents report an accepting attitude on the fol- Multiple Indicator Cluster Survey, Tajikistan, 200574 lowing four questions: 1)if they would care for family member sick with AIDS; 2) if they would buy fresh vegetables from a vendor who was HIV-positive; 3) if they think that a female teacher who is HIV-positive should be allowed to teach in school; and 4) if they would not want to keep the HIV status of a family member a secret. Table HA.5 presents the attitudes of women toward people who live with HIV/AIDS. In Tajikistan, 95 per cent of women who have heard of AIDS agree with at least one discriminatory statement. The most common discriminatory attitude is an unwillingness to buy fresh vegetables from a person with HIV/AIDS. An overwhelming 88 per cent of women who have heard of AIDS would not buy fresh vegetables from an infected person. Almost one-third of women who have heard about AIDS would not take care of a family member infected with HIV. Women with none or primary education have more discriminatory attitudes in this case, with up to half of these women agreeing. Another important indicator is the knowledge of where to be tested for HIV and the use of such ser- vices. Questions related to knowledge of a facility for HIV testing and whether respondents have ever been tested is presented in Table HA.6. Only 13 per cent of women know where to be tested, while a very low 4 per cent have actually been tested. Of these, however, a large proportion have been told the result (87 per cent). With an increase of women’s education and wealth, knowledge of a place for HIV testing likewise increases. Among women who gave birth within the two years preceding the survey, the percentage of those who received counselling and HIV testing during antenatal care is presented in Table HA.7. While 77 per cent of these women received antenatal care, less than one-quarter of them were informed about HIV prevention. Only 11 per cent were tested for HIV during antenatal care visits, of which 10 per cent received results. Dushanbe is the only region where more than a quarter of women report receiving information about HIV prevention; in addition, 21 per cent of women in Dushanbe have been tested and received results during antenatal care visits. On the other hand, women from DRD are less likely to receive both antenatal care and HIV testing. XIII. Orphans 75 XIII. ORPHANS More children worldwide are becoming orphaned. Children who are orphans may be at increased risk of neglect or exploitation if the parents are not available to assist them. Monitoring the variations in different outcomes for orphans and comparing them to their peers gives us a measure of how well communities and governments respond to their needs. To monitor these variations, a measurable definition of orphans needed to be created. The UNAIDS Monitoring and Evaluation Reference Group developed a proxy definition of children who have been affected by adult morbidity and mortality. This definition classifies children as orphans if they have experienced the death of either parent. The frequency of children who live with neither parent, mother only and father only is presented in Table OTPH.1. In Tajikistan, 89 per cent of children aged 0-17 live with both parents. A total of 2 per cent of children of this age do not live with a biological parent, while one or both parents of 5 per cent of children have died. Multiple Indicator Cluster Survey, Tajikistan, 200576 xiv. knowledge of tuberculosis The Tajikistan MICS3 includes an additional module about knowledge of tuberculosis and ways of transmission. The tuberculosis module was administered to women aged 15-49, who were asked whether they had heard about tuberculosis and the ways it is spread. Results are presented in Tables TB.1 – TB.6. About 1 in 2 women aged 15-49 years had heard of tuberculosis. Women in DRD and rural areas, and those in the poorest households and who are less educated, have less knowledge about the disease. Of women who have heard of tuberculosis, most knew at least one symptom (92 per cent). A total of 51 per cent identified coughing as a known symptom; 37 per cent identified coughing with sputum; 31 per cent noted weight loss; and 29 per cent referred to coughing for more than 3 weeks. Other symp- toms are mentioned by fewer than 16 per cent of women. The most commonly identified symptom for seeking medical help in this regard is cough, with nearly half (49 per cent) of women who have heard of tuberculosis saying they would immediately seek help. Two in 3 women (67 per cent) who have heard of tuberculosis know that it can be cured. Six per cent have a family member who has had TB, and 12 per cent know someone who has had it. A high pro- portion of women (88 per cent) would take care of a family member who had TB and had completed hospital treatment. Nonetheless, discrimination against people who have TB remains widespread; one- third of women would keep it a secret if a family member contracted tuberculosis. The vast majority of women (88 per cent) think TB should be treated in hospitals, which were men- tioned as the main facility for seeking care. List of References 77 list of references Boerma, J. T., Weinstein, K. I., Rutstein, S.O., and Sommerfelt, A. E. , 1996. Data on Birth Weight in Developing Countries: Can Surveys Help? Bulletin of the World Health Organization, 74(2), 209-16. Blanc, A. and Wardlaw, T. 2005. Monitoring Low Birth Weight: An Evaluation of International Estimates and an Updated Estimation Procedure. Bulletin of the World Health Organization, 83 (3), 178-185. Filmer, D. and Pritchett, L., 2001. Estimating Wealth Effects Without Expenditure Data – or Tears: An Application to Educational Enrolments in States of India. Demography 38(1): 115-132. Rutstein, S.O. and Johnson, K., 2004. The DHS Wealth Index. DHS Comparative Reports No. 6. Calverton, Maryland: ORC Macro. UNICEF, 2006. Monitoring the Situation of Children and Women. Multiple Indicator Cluster Survey Manual, New York. United Nations, 1983. Manual X: Indirect Techniques for Demographic Estimation (United Nations Publication, Sales No. E.83.XIII.2). United Nations, 1990a. QFIVE, United Nations Program for Child Mortality Estimation. New York, UN Pop Division United Nations, 1990b. Step-by-Step Guide to the Estimation of Child Mortality. New York, United Nations. WHO and UNICEF, 1997. The Sisterhood Method for Estimating Maternal Mortality: Guidance Notes for Potential Users, Geneva. http://www.childinfo.org Multiple Indicator Cluster Survey, Tajikistan, 200578 tAbles Table HH.1: Results of household and individual interviews. Number of households, women, and children under 5 by results of the household, women’s and under-5s’ interviews, and household, women’s and under-5s’ response rates, Tajikistan, 2005 Area Region Total Urban Rural Dushanbe Khatlon Sogd drd gbAo NUMBER OF HOUSEHOLDS Sampled 2839 4129 1711 1320 1345 1296 1296 6968 Occupied 2836 4125 1710 1319 1342 1296 1294 6961 Interviewed 2677 4007 1594 1285 1297 1269 1239 6684 Response rate 94.4 97.1 93.2 97.4 96.6 97.9 95.7 96.0 NUMBER OF WOMEN Eligible 3750 6876 2074 2297 2087 2200 1968 10626 Interviewed 3593 6650 2031 2244 1999 2165 1804 10243 Response rate 95.8 96.7 97.9 97.7 95.8 98.4 91.7 96.4 Overall response rate 90.4 93.9 91.3 95.2 92.6 96.4 87.8 92.6 NUMBER OF CHILDREN UNDER 5 Eligible 1477 2893 828 1174 815 924 629 4370 Mother/caretaker interviewed 1437 2836 814 1154 794 910 601 4273 Response rate 97.3 98.0 98.3 98.3 97.4 98.5 95.5 97.8 Overall response rate 91.8 95.2 91.6 95.8 94.2 96.4 91.5 93.9 Tables 79 Table HH.2: Household age distribution by sex. Per cent distribution of the household population by five-year age groups and dependency age groups, and number of children aged 0-17 years, by sex, Tajikistan, 2005 Males Females Total Number Per cent Number Per cent Number Per cent AGE 0-4 2383 11.4 2318 11.2 4701 11.3 5-9 2832 13.5 2567 12.4 5398 12.9 10-14 2965 14.2 2680 12.9 5646 13.5 15-19 2701 12.9 2584 12.4 5285 12.7 20-24 1914 9.1 2100 10.1 4014 9.6 25-29 1426 6.8 1513 7.3 2939 7.0 30-34 1261 6.0 1330 6.4 2590 6.2 35-39 1144 5.5 1261 6.1 2405 5.8 40-44 1098 5.3 1196 5.8 2294 5.5 45-49 910 4.3 838 4.0 1748 4.2 50-54 663 3.2 787 3.8 1451 3.5 55-59 405 1.9 400 1.9 805 1.9 60-64 318 1.5 302 1.5 620 1.5 65-69 307 1.5 319 1.5 627 1.5 70+ 589 2.8 579 2.8 1167 2.8 Missing/DK 3 (*) 2 (*) 5 (*) DEPENDENCY AGE GROUPS < 15 8180 39.1 7565 36.4 15745 37.8 15-64 11840 56.6 12311 59.3 24151 57.9 65 + 896 4.3 898 4.3 1794 4.3 Missing/DK 3 (*) 2 (*) 5 (*) AGE Children aged 0-17 9972 47.7 9115 43.9 19086 45.8 Adults 18+/Missing/ DK 10947 52.3 11661 56.1 22609 54.2 TOTAL 20919 100.0 20776 100.0 41695 100.0 Note: (*) – Replaces figures that are based on fewer than 25 unweighted cases. Multiple Indicator Cluster Survey, Tajikistan, 200580 Table HH.3: Household composition. Per cent distribution of households by selected characteristics, Tajikistan, 2005 Number of households Weighted per cent Weighted Unweighted SEX OF HOUSEHOlD HEAD Male 81.7 5460 5432 Female 18.3 1224 1252 REGION Dushanbe 11.2 749 1594 Khatlon 31.3 2092 1285 Sogd 32.9 2201 1297 DRD 21.5 1440 1269 GBAO 3.0 202 1239 AREA Urban 32.9 2198 2677 Rural 67.1 4486 4007 NUMBER OF HOUSEHOLD MEMBERS 1 3.2 217 252 2-3 10.5 699 796 4-5 27.9 1866 1955 6-7 31.5 2104 2070 8-9 16.0 1070 967 10+ 10.9 728 644 Total 100.0 6684 6684 At least one child aged < 18 years 88.6 6684 6684 At least one child aged < 5 years 46.5 6684 6684 At least one woman aged 15-49 years 93.0 6684 6684 Note: (*) – Replaces figures that are based on fewer than 25 unweighted cases. Tables 81 Table HH.4: Women’s background characteristics. Per cent distribution of women aged 15-49 years by background characteristics, Tajikistan, 2005 Number of women Weighted per cent Weighted Unweighted REGION Dushanbe 8.5 876 2031 Khatlon 34.0 3480 2244 Sogd 31.7 3246 1999 DRD 22.9 2344 2165 GBAO 2.9 297 1804 AREA Urban 28.2 2891 3593 Rural 71.8 7352 6650 AGE 15-19 23.9 2445 2432 20-24 19.3 1981 1942 25-29 13.9 1428 1448 30-34 12.4 1270 1268 35-39 11.6 1192 1188 40-44 11.1 1137 1126 45-49 7.7 790 839 MARITAL/UNION STATUS Currently married/in union 61.0 6245 6007 Formerly married/in union 5.3 538 564 Never married/in union 33.8 3460 3672 MOTHERHOOD STATUS Ever gave birth 60.8 6224 6058 Never gave birth 39.2 4019 4185 WOMAN’S EDUCATION LEVEL None 1.6 159 133 Primary 2.6 267 222 Incomplete secondary 30.7 3145 2966 Complete secondary 52.1 5334 5220 Secondary special 6.9 704 774 Higher education 6.2 631 927 Non-standard/Missing/DK (*) 2 1 WEAlTH INDEX qUINTIlES Poorest 18.5 1893 1416 Second 19.3 1981 1694 Middle 20.4 2085 1980 Fourth 20.8 2126 2417 Richest 21.1 2158 2736 TOTAL 100.0 10243 10243 Note: (*) – Replaces figures that are based on fewer than 25 unweighted cases. Multiple Indicator Cluster Survey, Tajikistan, 200582 Table HH.5: Children’s background characteristics. Per cent distribution of children under 5 years of age by background characteristics, Tajikistan, 2005 Number of under-5 children Weighted per cent Weighted Unweighted SEX Male 50.7 2168 2160 Female 49.3 2105 2113 REGION Dushanbe 7.9 336 814 Khatlon 40.1 1714 1154 Sogd 28.2 1205 794 DRD 21.7 928 910 GBAO 2.1 90 601 AREA Urban 26.4 1129 1437 Rural 73.6 3144 2836 AGE < 6 months 9.2 393 388 6-11 months 10.5 447 442 12-23 months 19.6 836 833 24-35 months 20.6 878 890 36-47 months 20.2 865 856 48-59 months 20.0 853 864 MOTHER’S EDUCATION None (1.0) 43 37 Primary 2.2 95 81 Incomplete secondary 27.5 1177 1099 Complete secondary 56.9 2429 2405 Secondary special 7.1 303 334 Higher education 5.2 222 315 Non-standard/Missing/DK (*) 3 2 WEAlTH INDEX qUINTIlES Poorest 22.4 959 745 Second 19.0 813 720 Middle 18.8 803 760 Fourth 20.0 854 985 Richest 19.8 844 1063 TOTAL 100.0 4273 4273 Note: () - Figures that are based at 25 to 49 unweighted cases. (*) – Replaces figures that are based on fewer than 25 unweighted cases. Tables 83 Table CM.1: Child mortality. Infant and under-5 mortality rates by background and demographic characteristics [BASED ON EAST], Tajikistan, 2005 Infant

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