Kazakhstan - Demographic and Health Survey - 2000

Publication date: 2000

World Summit for Children Indicators: Kazakhstan 1999 __________________________________________________________________________________________________ Value__________________________________________________________________________________________________ BASIC INDICATORS__________________________________________________________________________________________________ Childhood mortality Infant mortality rate 61.9 per 1,000 Under-five mortality rate 71.4 per 1,000 Maternal mortality Maternal mortality ratio 62.5 per 100,0001 Childhood undernutrition Percent stunted (of children under 5 years) 9.7 Percent wasted (of children under 5 years) 1.8 Percent underweight (of children under 5 years) 4.2 Clean water supply Percent of households within 15 minutes of a safe water supply2 83.6 Sanitary excreta disposal Percent of households with flush toilets 47.2 Basic education Percent of women 15-49 with completed primary education 99.3 Percent of men 15-49 with completed primary education 99.1 Percent of girls 6-12 attending school 81.4 Percent of boys 6-12 attending school 80.3 Percent of women 15-49 who are literate 99.8 Children in especially Percent of children who are orphans (both parents dead) 0.2 difficult situations Percent of children who do not live with their natural mother 6.2 Percent of children who live in single adult households 5.9 __________________________________________________________________________________________________ SUPPORTING INDICATORS__________________________________________________________________________________________________ Women's Health Birth spacing Percent of births within 24 months of a previous birth3 32.3 Safe motherhood Percent of births with medical prenatal care 94.4 Percent of births with prenatal care in first trimester 46.8 Percent of births with medical assistance at delivery 99.0 Percent of births in a medical facility 98.0 Percent of births at high risk 38.7 Family planning Contraceptive prevalence rate (any method, married women) 66.1 Percent of currently married women with an unmet demand for family planning 8.7 Percent of currently married women with an unmet need for family planning to avoid a high-risk birth 6.0 Nutrition Maternal nutrition Percent of mothers with low BMI 7.4 Low birth weight Percent of births at low birth weight (of those reporting numeric weight) 7.3 Breastfeeding Percent of children under 4 months who are exclusively breastfed 46.6 Child Health Measles vaccination Percent of children 12-23 months with measles vaccination 86.5 Fully vaccinated Percent of children 12-23 months fully vaccinated 80.5 Diarrhea control Percent of children with diarrhea in preceding 2 weeks who received oral rehydration therapy 32.0 Acute respiratory infection Percent of children with acute respiratory infection in preceding 2 weeks who were seen by medical personnel 48.0 __________________________________________________________________________________________________ 1 Data from the Agency on Health 2 Piped, well, and bottled water 3 First births are excluded. Kazakhstan Demographic and Health Survey 1999 Academy of Preventive Medicine Almaty, Kazakhstan Macro International Inc. Calverton, Maryland USA November 2000 Academy of Preventive Medicine Macro International Inc. ii * Contents The report summarizes the findings of the 1999 Kazakhstan Demographic and Health Survey (1999 KDHS), which was conducted by the Academy of Preventive Medicine of Kazakhstan. Macro International Inc. provided technical assistance. Funding was provided by the U.S. Agency for International Development (USAID). The KDHS is part of the worldwide Demographic and Health Surveys (DHS) program, which is designed to collect data on fertility, family planning, and maternal and child health. Additional information on the Kazakhstan survey may be obtained from the Academy of Preventive Medicine of Kazakhstan (telephone: 73272-427855 ; fax: 73272-429203; e-mail: nutrit@nursat.kz). Additional information about the DHS program may be obtained by writing to DHS, Macro International Inc., 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, USA (telephone 301-572- 0200; fax 301-572-0999; e-mail: reports@macroint.com). Recommended citation: Academy of Preventive Medicine [Kazakhstan] and Macro International Inc. 1999. Kazakhstan Demographic and Health Survey 1999. Calverton, Maryland: Academy of Preventive Medicine and Macro International Inc. Contents * 3 CONTENTS Page Tables and Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Summary of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Map of Kazakhstan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiv CHAPTER 1 KAZAKHSTAN: BACKGROUND INFORMATION, OBJECTIVES, AND ORGANIZATION OF THE SURVEY . . . . . . . . . . . . . . . . 1 Toregeldy Sharmanov 1.1 Geography and Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 History of Kazakhstan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.3 Economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.4 Health Care System and Epidemiological Profile of Kazakhstan . . . . . . . . . . . . 4 1.5 Family Planning Policies and Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.6 Demographic and Health Data Collection System in Kazakhstan . . . . . . . . . . . . 6 1.7 Objectives and Organization of the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.7.1 Sample Design and Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.7.2 Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 1.7.3 Training and Fieldwork . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.7.4 Data Processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 1.7.5 Response Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS . . . . . . . . . 11 Adyl Katarbayev and Kristi Fair 2.1 Demographic Characteristics of Households . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 2.2 Household Composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 2.3 Educational Level of Household Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 2.3.1 Educational Attainment of Household Members . . . . . . . . . . . . . . . . . . 15 2.3.2 School Attendance Ratios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2.3.3 Grade Repetition and Dropout Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 2.4 Housing Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 2.4.1 Household Durable Goods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 CHAPTER 3 CHARACTERISTICS OF SURVEY RESPONDENTS AND WOMEN’S STATUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Raikhan Sissekenova, Sunita Kishor, and Elnar Kurmangaliyeva 3.1 Characteristics of Survey Respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 3.1.1 Background Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 3.1.2 Educational Level of the Respondents . . . . . . . . . . . . . . . . . . . . . . . . . . 23 3.1.3 Occupation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 3.1.4 Access to Mass Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 4 * Contents Page 3.2 Women’s Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 3.2.1 Employment and Cash Earnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 3.2.2 Decision-making Regarding Use of Cash Earnings . . . . . . . . . . . . . . . . . 33 3.2.3 Household Decision-making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 3.2.4 Women’s Agreement with Reasons for Wife Beating . . . . . . . . . . . . . . . 37 3.2.5 Women’s Agreement with Reasons for Refusing Sexual Relations . . . . . 41 CHAPTER 4 FERTILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Toregeldy Sharmanov and Kia I. Weinstein 4.1 Current Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 4.2 Fertility Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 4.3 Children Ever Born and Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 4.4 Birth Intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 4.5 Age at First Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 4.6 Pregnancy and Motherhood Among Teenage Women . . . . . . . . . . . . . . . . . . . . 53 CHAPTER 5 CONTRACEPTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Holly Seyhan and Akkumis Salkhanova 5.1 Knowledge of Contraceptive Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 5.2 Ever Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 5.3 Current Use of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 5.4 Current Use by Background Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 5.5 Current Use by Women’s Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 5.6 Use of the Pill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 5.7 Number of Children at First Use of Contraception . . . . . . . . . . . . . . . . . . . . . . 67 5.8 Source of Family Planning Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 5.9 Informed Choice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 5.10 Discontinuation within 12 Months of Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 5.11 Intention to Use Family Planning among Nonusers . . . . . . . . . . . . . . . . . . . . . 72 5.12 Reasons for Nonuse of Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 5.13 Contact of Nonusers of Family Planning with Family Planning Providers . . . . . 73 5.14 Exposure to Family Planning Messages in the Electronic Media . . . . . . . . . . . . 74 5.15 Exposure to Family Planning Messages in the Print Media . . . . . . . . . . . . . . . . 76 5.16 Red Apple Social Marketing Logo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 5.17 Attitudes of Couples toward Family Planning . . . . . . . . . . . . . . . . . . . . . . . . . . 78 CHAPTER 6 INDUCED ABORTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Akkumis Salkhanova and Holly Seyhan 6.1 Pregnancy Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 6.2 Lifetime Experience with Induced Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 6.3 Rates of Induced Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 6.4 Time Trends in Induced Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 6.5 Abortion Rates from the Agency on Health . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 6.6 Contraceptive Use before Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 6.7 Service Providers and Procedures Used . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Contents * 5 Page CHAPTER 7 OTHER PROXIMATE DETERMINANTS OF FERTILITY . . . . . . . . . . . . . . . 87 Kia I. Weinstein and Zhanar Ashenova 7.1 Marital Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 7.2 Age at First Marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 7.3 Age at First Sexual Intercourse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 7.4 Recent Sexual Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 7.5 Postpartum Amenorrhea, Abstinence, and Insusceptibility . . . . . . . . . . . . . . . . 95 7.6 Menopause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 CHAPTER 8 FERTILITY PREFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Jeremiah M. Sullivan and Igor Tsoy 8.1 Fertility Preferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 8.2 Need for Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 8.3 Ideal Family Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 8.4 Wanted and Unwanted Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 CHAPTER 9 INFANT AND CHILD MORTALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Jeremiah M. Sullivan, Auken Mashkeev, and Adyl Katarbayev 9.1 Background and Assessment of Data Quality . . . . . . . . . . . . . . . . . . . . . . . . . 111 9.2 Levels and Trends in Early Childhood Mortality . . . . . . . . . . . . . . . . . . . . . . . 112 9.3 Infant Mortality Rates from the Agency on Health . . . . . . . . . . . . . . . . . . . . . 113 9.4 Socioeconomic Differentials in Childhood Mortality . . . . . . . . . . . . . . . . . . . . 114 9.5 Demographic Differentials in Childhood Mortality . . . . . . . . . . . . . . . . . . . . . 116 9.6 High-Risk Fertility Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 CHAPTER 10 MATERNAL AND CHILD HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Toregeldy Sharmanov, Ardak Chuyenbekova, and Adyl Katarbayev 10.1 Usual Source of Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 10.2 Antenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 10.3 Antenatal Care Content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 10.4 Assistance and Medical Care at Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 10.5 Characteristics of Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 10.6 Use of Smoking Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 10.7 Vaccinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 10.8 Acute Respiratory Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 10.9 Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 10.10 Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 CHAPTER 11 NUTRITION OF WOMEN AND CHILDREN . . . . . . . . . . . . . . . . . . . . . . 135 Bedel T. Sarbayev, Zaure Kudaibergenova, Ardak Chuyenbekova, and Dauren Imanbayev 11.1 Breastfeeding and Supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 11.2 Initiation of Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 6 * Contents Page 11.3 Breastfeeding Patterns by Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 11.4 Supplemental Foods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 11.5 Frequency of Food Supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 11.6 Differentials in Food Supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 11.7 Nutritional Status of Children under Age Five . . . . . . . . . . . . . . . . . . . . . . . . 141 11.8 Measures of Nutritional Status in Childhood . . . . . . . . . . . . . . . . . . . . . . . . . 145 11.9 Levels of Child Undernutrition in Kazakhstan . . . . . . . . . . . . . . . . . . . . . . . . . 146 11.10 Women's Anthropometric Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 CHAPTER 12 ANEMIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Almaz T. Sharman, Bedel T. Sarbayev, Daulet Baskhozhayev, and Dauren Imanbayev 12.1 Scope of the Anemia Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 12.2 Design and Methodology of the 1999 KDHS Anemia Study . . . . . . . . . . . . . . 152 12.3 Anemia Prevalence Among Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 12.4 Iron Supplementation During Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 12.5 Anemia Prevalence among Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 12.6 Assessment of Causes of Anemia in Kazakhstan: Population-Based Approach . 159 12.7 Changes in the Prevalence of Anemia Since 1995 . . . . . . . . . . . . . . . . . . . . . . 159 CHAPTER 13 SEXUALLY TRANSMITTED INFECTIONS . . . . . . . . . . . . . . . . . . . . . . . . . 165 Almaz T. Sharman and Elnar Kurmangaliyeva 13.1 HIV/AIDS Situation in Kazakhstan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 13.2 Knowledge of HIV/AIDS and Methods of HIV Prevention . . . . . . . . . . . . . . . . 166 13.3 Social Aspects of HIV/AIDS Prevention and Mitigation . . . . . . . . . . . . . . . . . . 171 13.4 Knowledge of Signs and Symptoms of Other Sexually Transmitted Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 13.5 Sexual Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 13.6 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 CHAPTER 14 TUBERCULOSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 Almaz T. Sharman and Dina Abitayeva 14.1 Tuberculosis: Epidemiology and Treatment Strategy . . . . . . . . . . . . . . . . . . . 185 14.2 Exposure to Tuberculosis and Knowledge of Mode of Transmission . . . . . . . . 186 14.3 Treatment of Tuberculosis and Willingness to Care for a Person with Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 14.4 Knowledge of Symptoms of Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 14.5 Seeking Treatment for Tuberculosis at Health Facility . . . . . . . . . . . . . . . . . . 191 14.6 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Contents * 7 Page APPENDIX A: SAMPLE DESIGN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 A.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 A.2 Sampling Frame . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 A.3 Characteristics of the Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 A.4 Sample Allocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202 A.5 Segmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204 A.6 Sampling Probabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204 A.7 Response Rates by Region and Urban-Rural Residence . . . . . . . . . . . . . . . . . . 205 APPENDIX B: ESTIMATES OF SAMPLING ERRORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209 APPENDIX C: DATA QUALITY TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 APPENDIX D: PERSONS INVOLVED IN THE 1999 KAZAKHSTAN DEMOGRAPHIC AND HEALTH SURVEY . . . . . . . . . . . . . . . . . . . . . . . . 237 APPENDIX E: QUESTIONNAIRES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 vi * Contents Tables and Figures * vii TABLES AND FIGURES Page CHAPTER 1 INTRODUCTION Table 1.1 Results of the household and individual interviews . . . . . . . . . . . . . . . . 10 CHAPTER 2 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS Table 2.1 Household population by age, residence, and sex . . . . . . . . . . . . . . . . . 12 Table 2.2 Population by age according to selected sources . . . . . . . . . . . . . . . . . . 13 Table 2.3 Household composition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Table 2.4 Fosterhood and orphanhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Table 2.5 Educational level of the household population . . . . . . . . . . . . . . . . . . . 16 Table 2.6 School attendance ratios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Table 2.7 Grade repetition and dropout rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Table 2.8 Housing characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Table 2.9 Household durable goods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Figure 2.1 Population pyramid of Kazakhstan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Figure 2.2 Age-specific attendance ratios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Figure 2.3 Housing characteristics by residence . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 CHAPTER 3 FERTILITY Table 3.1 Background characteristics of respondents . . . . . . . . . . . . . . . . . . . . . . 24 Table 3.2 Ethnicity, religion, and residence by region . . . . . . . . . . . . . . . . . . . . . 25 Table 3.3 Level of education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Table 3.4 Occupation: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Table 3.5 Occupation: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Table 3.6 Access to mass media: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Table 3.7 Access to mass media: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Table 3.8 Employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Table 3.9 Decision of use of earnings and contribution of earnings to household expenditures . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Table 3.10 Control over earnings by contribution to household expenditures . . . . . 35 Table 3.11 Household decision-making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Table 3.12 Final say in household decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Table 3.13 Women’s agreement with reasons for wife beating . . . . . . . . . . . . . . . . 40 Table 3.14 Women’s agreement with reasons for refusing sexual relations . . . . . . . 42 Figure 3.1 Women’s participation in decision-making . . . . . . . . . . . . . . . . . . . . . . 39 viii * Tables and Figures Page CHAPTER 4 FERTILITY Table 4.1 Current fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Table 4.2 Fertility by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . 45 Table 4.3 Trends in fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Table 4.4 Trends in age-specific fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Table 4.5 Trends in fertility by marital duration . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Table 4.6 Children ever born and living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Table 4.7 Birth intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Table 4.8 Age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Table 4.9 Median age at first birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Table 4.10 Pregnancy and motherhood among teenage women . . . . . . . . . . . . . . . 53 Figure 4.1 Age-specific fertility rates by ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . 44 Figure 4.2 Total fertility rate by background characteristics . . . . . . . . . . . . . . . . . 46 Figure 4.3 Age-specific fertility rates 1989 Census, 1995 KDHS, and 1999 KDHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Figure 4.4 Percentage of women 15-19 who are mothers by ethnicity, 1995 KDHS and 1999 DHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 CHAPTER 5 CONTRACEPTION Table 5.1 Knowledge of contraceptive methods . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Table 5.2 Ever use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Table 5.3 Current use of contraception: women . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Table 5.4 Current use of contraception: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Table 5.5 Current use of contraception by background characteristics . . . . . . . . . 63 Table 5.6 Current use of contraception by women’s status indicators . . . . . . . . . . 65 Table 5.7 Pill use and possession of pill packet . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Table 5.8 Use of pill brands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Table 5.9 Number of children at first use of contraception . . . . . . . . . . . . . . . . . . 67 Table 5.10 Source of supply for modern contraceptive methods . . . . . . . . . . . . . . . 68 Table 5.11 Informed choice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Table 5.12 Contraceptive discontinuation rates . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Table 5.13 Reasons for discontinuation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Table 5.14 Future use of contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Table 5.15 Reasons for not using contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Table 5.16 Contact of nonusers with family planning providers . . . . . . . . . . . . . . . 74 Table 5.17 Exposure to family planning messages on radio and television . . . . . . . 75 Table 5.18 Exposure to family planning messages in print media . . . . . . . . . . . . . . 76 Table 5.19 Knowledge of the Red Apple social marketing logo . . . . . . . . . . . . . . . . 77 Table 5.20 Spouse’s perception of other spouse’s approval of family planning . . . . 78 Figure 5.1 Current use of family planning by region . . . . . . . . . . . . . . . . . . . . . . . 61 Tables and Figures * ix Page CHAPTER 6 INDUCED ABORTION Table 6.1 Pregnancy outcomes by background characteristics . . . . . . . . . . . . . . . 80 Table 6.2 Lifetime experience with induced abortion . . . . . . . . . . . . . . . . . . . . . . 81 Table 6.3 Induced abortion rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Table 6.4 Time trends in induced abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Table 6.5 Comparison of abortion rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Table 6.6 Use of contraception before pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . 85 Table 6.7 Source of services and type of procedure used for abortion . . . . . . . . . 86 Figure 6.1 Age-specific rates of fertility (ASFR) and induced abortion (ASAR) . . . 83 Figure 6.2 Total induced abortion rate by background characteristics . . . . . . . . . . 83 Figure 6.3 Age-specific abortion rates, 1995 KDHS and 1999 KDHS . . . . . . . . . . . 84 CHAPTER 7 OTHER PROXIMATE DETERMINANTS OF FERTILITY Table 7.1 Current marital status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Table 7.2 Age at first marriage: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Table 7.3 Age at first marriage: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Table 7.4 Median age at first marriage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Table 7.5 Age at first sexual intercourse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Table 7.6 Median age at first intercourse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Table 7.7 Recent sexual activity: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Table 7.8 Recent sexual activity: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Table 7.9 Number of partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Table 7.10 Postpartum amenorrhea, abstinence, and insusceptibility . . . . . . . . . . . 97 Table 7.11 Median duration of postpartum amenorrhea, abstinence, and insusceptibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Table 7.12 Menopause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Figure 7.1 Marital status of respondents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 CHAPTER 8 FERTILITY PREFERENCES Table 8.1 Fertility preferences by number of living children . . . . . . . . . . . . . . . . 100 Table 8.2 Fertility preferences by age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Table 8.3 Desire for more children among monogamous couples . . . . . . . . . . . . 102 Table 8.4 Desire to limit childbearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Table 8.5 Need for family planning services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Table 8.6 Ideal and actual number children . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Table 8.7 Mean ideal number of children by background characteristics . . . . . . 107 Table 8.8 Fertility planning status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Table 8.9 Wanted fertility rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Figure 8.1 Fertility preferences for currently married women 15-49 . . . . . . . . . . 101 Figure 8.2 Desire to limit childbearing among currently married Women and men by number of living children . . . . . . . . . . . . . . . . . . 101 x * Tables and Figures Page CHAPTER 9 INFANT AND CHILD MORTALITY Table 9.1 Infant and child mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Table 9.2 AOH infant mortality rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Table 9.3 Infant and child mortality by background characteristics . . . . . . . . . . 115 Table 9.4 Infant and child mortality by demographic characteristics . . . . . . . . . 116 Table 9.5 High-risk fertility behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Figure 9.1 Trends in infant mortality, Agency on Health and KDHS . . . . . . . . . . 115 CHAPTER 10 MATERNAL AND CHILD HEALTH Table 10.1 Usual source of health care by type of facility . . . . . . . . . . . . . . . . . . . 120 Table 10.2 Antenatal care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Table 10.3 Number of antenatal care visits and stage of pregnancy . . . . . . . . . . . 123 Table 10.4 Antenatal care content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Table 10.5 Place of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Table 10.6 Assistance during delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Table 10.7 Delivery characteristics: caesarean section, birth weight, and size . . . 128 Table 10.8 Use of smoking tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Table 10.9 Vaccinations by background characteristics . . . . . . . . . . . . . . . . . . . . 130 Table 10.10 Prevalence of acute respiratory infection and fever . . . . . . . . . . . . . . . 132 Table 10.11 Prevalence of diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Table 10.12 Treatment of diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Table 10.13 Feeding practices during diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Figure 10.1 Percent distribution of births by antenatal care and delivery characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Figure 10.2 Prevalence of respiratory illness, fever and diarrhea in the last two weeks by age of the child . . . . . . . . . . . . . . . . . . . . . . . 133 CHAPTER 11 NUTRITION OF WOMEN AND CHILDREN Table 11.1 Initial breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Table 11.2 Breastfeeding status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 Table 11.3 Median duration and frequency of breastfeeding . . . . . . . . . . . . . . . . 139 Table 11.4 Foods received by children in preceding 24 hours . . . . . . . . . . . . . . . . 140 Table 11.5 Foods received by children in preceding seven days . . . . . . . . . . . . . . 142 Table 11.6.1 Foods received by children in preceding seven days by background characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 Table 11.6.2 Frequency specific foods were received by children in preceding seven days . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144 Table 11.7 Nutritional status of children by demographic characteristics . . . . . . . 147 Table 11.8 Nutritional status of children by background characteristics . . . . . . . . 148 Table 11.9 Anthropometric indicators of women’s nutritional status . . . . . . . . . . 149 Table 11.10 Nutritional status of women by background characteristics . . . . . . . . 150 Tables and Figures * xi Page Figure 11.1 Prevalence of stunting by age of child and length of birth interval . . . 147 Figure 11.2 Prevalence of stunting by background characteristics . . . . . . . . . . . . . 148 CHAPTER 12 ANEMIA Table 12.1 Anemia among women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 Table 12.2 Anemia among women by nutritional status, reproductive history, and IUD use . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Table 12.3 Iron supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Table 12.4 Anemia among children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158 Table 12.5 Moderate-to-severe anemia among women and children . . . . . . . . . . 161 Figure 12.1 Prevalence of moderate-to-severe anemia among women by nutritional status and reproductive health characteristics . . . . . . . . 156 Figure 12.2 Probability plots of cumulative percent distributions for hemoglobin concentrations in pregnant, lactating, and nonpregnant/nonlactating women, 1999 KDHS . . . . . . . . . . . . . . 156 Figure 12.3 Probability plots of cumulative percent distributions for hemoglobin concentrations in children, nonpregnant/nonlactating women, and men, 1999 KDHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Figure 12.4 Probability plots of cumulative percent distributions for hemoglobin concentrations in nonpregnant/nonlactating women, 1995 KDHS and 1999 KDHS . . . . . . . . . . . . . . . . . . . . . . . . . 162 Figure 12.5 Probability plots of cumulative percent distributions for hemoglobin concentrations in children under three years of age, 1995 KDHS and 1999 KDHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 CHAPTER 13 HIV/AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS Table 13.1 Knowledge of AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Table 13.2.1 Knowledge of ways to avoid AIDS: women . . . . . . . . . . . . . . . . . . . . . 168 Table 13.2.2 Knowledge of ways to avoid AIDS: men . . . . . . . . . . . . . . . . . . . . . . . 169 Table 13.3.1 Knowledge of valid ways to avoid AIDS: women . . . . . . . . . . . . . . . . . 170 Table 13.3.2 Knowledge of valid ways to avoid AIDS: men . . . . . . . . . . . . . . . . . . . 171 Table 13.4 Knowledge of AIDS related issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Table 13.5.1 Social aspects of AIDS prevention and mitigation: women . . . . . . . . . 173 Table 13.5.2 Social aspects of AIDS prevention and mitigation: men . . . . . . . . . . . 174 Table 13.6 Discussion with partner concerning HIV prevention . . . . . . . . . . . . . . 175 Table 13.7.1 Knowledge of signs and symptoms of STIs: women . . . . . . . . . . . . . . 176 Table 13.7.2 Knowledge of signs and symptoms of STIs: men . . . . . . . . . . . . . . . . . 177 Table 13.8.1 Number of sexual partners: married women . . . . . . . . . . . . . . . . . . . . 179 Table 13.8.2 Number of sexual partners: married men . . . . . . . . . . . . . . . . . . . . . . 180 Table 13.9.1 Number of sexual partners: unmarried women . . . . . . . . . . . . . . . . . . 181 Table 13.9.2 Number of sexual partners: unmarried men . . . . . . . . . . . . . . . . . . . . 182 Table 13.10.1 Use of condoms: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 Table 13.10.2 Use of condoms: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 xii * Tables and Figures Page CHAPTER 14 TUBERCULOSIS Table 14.1.1 Knowledge of and exposure to tuberculosis: women . . . . . . . . . . . . . . 186 Table 14.2.1 Knowledge of and exposure to tuberculosis: men . . . . . . . . . . . . . . . . 187 Table 14.2.1 Knowledge of treatment of tuberculosis and willingness to provide home care: women . . . . . . . . . . . . . . . . . . 188 Table 14.2.2 Knowledge of treatment of tuberculosis and willingness to provide home care: women . . . . . . . . . . . . . . . . . . 189 Table 14.3.1 Knowledge of symptoms of tuberculosis: women . . . . . . . . . . . . . . . . 190 Table 14.3.2 Knowledge of symptoms of tuberculosis: men . . . . . . . . . . . . . . . . . . . 191 Table 14.4.1 Tuberculosis symptoms that convince women to seek medical assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 Table 14.4.2 Tuberculosis symptoms that convince men to seek medical assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 Table 14.5.1 Seeking treatment for tuberculosis at health facility: women . . . . . . . 194 Table 14.5.2 Seeking treatment for tuberculosis at health facility: men . . . . . . . . . . 195 APPENDIX A: SAMPLE DESIGN Table A.1 Population distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202 Table A.2 Percent distribution of the population . . . . . . . . . . . . . . . . . . . . . . . . . 202 Table A.3 Proposed allocation of the sample of women . . . . . . . . . . . . . . . . . . . 203 Table A.4 Number of households . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 Table A.5 Proposed number of sample points . . . . . . . . . . . . . . . . . . . . . . . . . . . 204 Table A.6.1 Sample implementation: women . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206 Table A.6.2 Sample implementation: men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207 APPENDIX B: ESTIMATES OF SAMPLING ERRORS Table B.1 List of selected variables for sampling errors, Kazakhstan 1999 . . . . . 212 Table B.2 Sampling errors for women - Total sample: Kazakhstan 1999 . . . . . . . 213 Table B.3 Sampling errors for women - Urban sample: Kazakhstan 1999 . . . . . . 214 Table B.4 Sampling errors for women - Rural sample: Kazakhstan 1999 . . . . . . 215 Table B.5 Sampling errors for women - Almaty City sample: Kazakhstan 1999 . 216 Table B.6 Sampling errors for women - South sample: Kazakhstan 1999 . . . . . . 217 Table B.7 Sampling errors for women - West sample: Kazakhstan 1999 . . . . . . . 218 Table B.8 Sampling errors for women - Central sample: Kazakhstan 1999 . . . . . 219 Table B.9 Sampling errors for women - North sample: Kazakhstan 1999 . . . . . . 220 Table B.10 Sampling errors for women - East sample: Kazakhstan 1999 . . . . . . . 221 Table B.11 Sampling errors for women - Kazakh sample: Kazakhstan 1999 . . . . . 222 Table B.12 Sampling errors for women - Russian sample: Kazakhstan 1999 . . . . . 223 Table B13 Sampling errors for women - Other sample: Kazakhstan 1999 . . . . . . 224 Table B.14 Sampling errors for men - Total sample: Kazakhstan 1999 . . . . . . . . . 225 Table B.15 Sampling errors for men - Urban sample: Kazakhstan 1999 . . . . . . . . 225 Table B.16 Sampling errors for men - Rural sample: Kazakhstan 1999 . . . . . . . . . 226 Table B.17 Sampling errors for men - Almaty City sample: Kazakhstan 1999 . . . . 226 Tables and Figures * xiii Page Table B.18 Sampling errors for men - South sample: Kazakhstan 1999 . . . . . . . . 227 Table B.19 Sampling errors for men - West sample: Kazakhstan 1999 . . . . . . . . . 227 Table B.20 Sampling errors for men - Central sample: Kazakhstan 1999 . . . . . . . 228 Table B.21 Sampling errors for men - North sample: Kazakhstan 1999 . . . . . . . . 228 Table B.22 Sampling errors for men - East sample: Kazakhstan 1999 . . . . . . . . . . 229 Table B.23 Sampling errors for men - Kazakh sample: Kazakhstan 1999 . . . . . . . 229 Table B.24 Sampling errors for men - Russian sample: Kazakhstan 1999 . . . . . . . 230 Table B.25 Sampling errors for men - Other sample: Kazakhstan 1999 . . . . . . . . . 230 APPENDIX C: DATA QUALITY TABLES Table C.1 Household age distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 Table C.2.1 Age distribution of eligible and interviewed women . . . . . . . . . . . . . . 232 Table C.2.2 Age distribution of eligible and interviewed men . . . . . . . . . . . . . . . . 232 Table C.3 Completeness of reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233 Table C.4 Births by calendar years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234 Table C.5 Reporting of age at death in days . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235 Table C.6 Reporting of age at death in months . . . . . . . . . . . . . . . . . . . . . . . . . . 236 xiv * Tables and Figures Foreword * xvii FOREWORD With great pleasure I would like to introduce the main findings of the second Kazakhstan Demographic and Health Survey (1999 KDHS). The survey was implemented by the Academy of Preventive Medicine of Kazakhstan through an agreement with Macro International Inc. under the auspices of the MEASURE DHS+ project supported by the U.S. Agency for International Develop- ment (USAID). In addition to presenting the main findings from the 1999 KDHS on maternal and child health and nutrition, this report highlights the major changes that are taking place in Kazakhstan’s demographic and health situation since the previous KDHS survey, which was conducted in 1995. Also, during the 1999 KDHS, information on knowledge and attitudes toward HIV/AIDS and sexually transmitted infections as well as data on men’s reproductive behavior were collected. It is expected that the findings in this report will raise important programmatic issues for policy-makers in the areas of population, health, and nutrition in Kazakhstan. I would like to take this opportunity to thank the USAID Regional Office for Central Asia for its support of the survey. This report is the result of more than half a year of preparatory work, four months of data collection, data entry and processing, and about nine months of analysis of the results and report writing. I am grateful to Dr. Jeremiah Sullivan of Macro International Inc. who had a large part at the inception of the project and in the finalization of the main survey report. Also, my sincere thanks go to other American colleagues: Dr. Almaz Sharman, Mr. Albert Themme, Mr. Mamadou Thiam, Dr. Kia Weinstein, Ms. Holly Seyhan, Ms. Kristi Fair, Ms. Sunita Kishor, Dr. Sidney Moore, and Ms. Celia Khan for their assistance in overall survey design and implementation, data processing, analysis of the results, report writing, and production. This report is the result of a joint effort by a number of organizations and individuals in Kazakhstan who contributed immensely towards the success of the survey. The list of organizations who participated in the survey includes: Kazakhstan State Medical University, Karaganda State Medical Academy, South Kazakhstan State Medical Academy, International Kazakh-Turkish University, National Research Center for Maternal and Child Health, National Research Center for Pediatrics and Pediatric Surgery, National Institute of Nutrition, National Research Center on Tuberculosis, School of Public Health, National Medical College, and Zhezkazgan Department of Health. I would like to express my appreciation to all the professionals from these organizations who were involved in the survey implementation and coordination. I would like to thank the KDHS senior technical staff: Mr. Bedel Sarbayev, Adyl Katarbayev and Alexander Izmukhambetov and other staff members of the Academy of Preventive Medicine for their devotion and sincere efforts in accomplishing the planned activities on time. I am grateful to all 1999 KDHS staff, whose names are listed in Appendix D, for their great contribution in making this survey a success. Toregeldy Sharmanov, MD, PhD President, Academy of Preventive Medicine Summary of Findings * xix SUMMARY OF FINDINGS The 1999 Kazakhstan Demographic and Health Survey (KDHS) is a nationally repre- sentative survey of 4,800 women age 15-49 and 1,440 men age 15-59. This survey is the second of its kind to be carried out in Kazakhstan. It was implemented by the Acad- emy of Preventive Medicine of Kazakhstan, with funding provided by the U.S. Agency for International Development through the MEA- SURE DHS+ program. Fieldwork for the KDHS was conducted from July to September 1999. The purpose of the survey is to provide cur- rent data on women’s reproductive histories, knowledge and use of methods of contracep- tion, breastfeeding practices and nutrition, vaccination coverage, and episodes of diseases among their children under the age of five. The survey also provides comparable data for analysis of trends in fertility, reproductive health, child health, and nutrition. In the 1999 KDHS, information on knowledge and atti- tudes toward HIV/AIDS and sexually transmit- ted infection, as well as data on men’s repro- ductive behavior were collected. The survey included measurement of hemoglobin levels in the blood to assess the prevalence of anemia, and measurements of height and weight to assess nutritional status. The components of the survey related to the anemia testing and anthropometric assessment were funded by the UNICEF Area Office for Central Asia and Kazakhstan (UNICEF/CARK). FERTILITY DECLINE The 1999 KDHS results demonstrate that fertility in the Republic of Kazakhstan has declined rapidly over the last decade. At current fertility levels, a Kazakhstan woman will give birth to 2.1 children during her reproductive period, a decline of 18 percent from the 1995 KDHS when the Total Fertility Rate (TFR) was 2.5 children per woman, and of 29 percent since the 1989 Census when the TFR was 2.9 children per woman. Fertility has fallen in almost every age group and the decline has been exhibited by both ethnic Kazakh women and ethnic Russian women. The TFR among ethnic Kazakh women dropped from 3.6 to 2.5 over the past decade, a decline of one child per woman. Among ethnic Russians, the TFR fell from 2.2 to 1.4 over the decade, a decline of not quite one child per woman, but resulting in a TFR below replacement level. Like the 1995 survey, the 1999 KDHS results show that the TFR is higher among rural women (2.7 children per woman) than among urban women (1.5 children per woman). The TFR is lowest in Almaty City (1.0 children per woman), intermediate for the Central and North regions (1.6 and 1.7 children per woman, respectively) and highest in the South and West regions (2.9 and 2.3, respectively). Women with a primary or secondary educa- tion give birth to an average of 2.4 children, compared with 1.5 children for women with higher education. Overall, about one-third of births (32 percent) in Kazakhstan were born within 24 months of the previous birth. The median birth interval length is 35 months, up from 32 months in the 1995 KDHS. While the age at which women begin child- bearing has changed little over time, women currently age 20-24 are less likely to have begun childbearing than women who were age 20-24 at the time of the 1995 KDHS. The 1995 KDHS found that 44 percent of women who were 20-24 had not yet had a birth, while 54 percent of 20-24 year-olds surveyed in 1999 had not yet given birth. A large proportion of currently married women in Kazakhstan (55 percent) said that they don’t want to have any more children. Less than one-third of women (30 percent) want to have a child, and 43 percent of these would like to wait two or more years before xx * Summary of Findings having that child. Thus, the vast majority of women want either to delay their next birth or to limit childbearing altogether. These are women who are potentially in need of some method of family planning. The 1999 KDHS also collected information on men’s fertility preferences. Sixty-six percent of men either wanted no more children or their spouse was sterilized or infecund, while about one-third (32 percent) wanted another child. CONTRACEPTION AND ABORTION More than half (53 percent) of currently married women in Kazakhstan use a modern method of contraception, up from 46 percent in 1995. Significant increases in contraceptive use have occurred among the older cohorts. Among women 35 to 39 there has been an increase in the use of modern contraceptive methods from 55 to 63 percent; 47 to 58 percent among women 40 to 44; and 22 to 40 percent among married women age 45 to 49. This indicates that modern methods are being adopted by women in older cohorts in order to limit births. The IUD is by far the most widely used method of modern contraception. Among married women there has been a slight increase in users from 40 percent in 1995 to 42 percent. After the IUD, the condom is the next most widely used modern method. Since 1995 there has been no significant increase in overall condom use, but among married women age 25 to 29 use has increased from 3.4 to 7.3 percent. A significantly larger proportion of this cohort reports use of condoms than other cohorts. Approximately 3 percent of currently married women report that they have been sterilized. As in 1995, 13 percent state that they are using a traditional method. The most significant changes in contraceptive use have occurred among unmarried, sexually active women. Currently 56 percent report using a modern method, as opposed to 39 percent in 1995. Use of the pill has doubled (from 5 to 10 percent) as has use of the IUD (14 to 26 percent). Condom use, however, appears to have remained constant in the last 5 years (approximately 19 percent). Use of traditional methods has decreased. Currently 13 percent of all sexually active unmarried women report using a traditional method, down from 19 percent five years previously. Fifty-five percent of men in Kazakhstan are currently using a method of contraception; almost half (48 percent) of all men surveyed use a modern method. Among men who use a modern method, 54 percent report using the IUD, the most common method among all age groups, and 37 percent reported use of a condom. Condom use is concentrated among younger men (for example, 35 percent of 20 to 24 year olds versus 17 percent of 40 to 44 year olds). The Total Abortion Rate (TAR) in Kazakhstan has declined from 1.8 abortions per woman for the period 1992-1995 to 1.4 abortions per woman for the period 1996-1999 (a decline of almost 25 percent over an interval of four years). The abortion rates have fallen substan- tially in every age group in the broad age range from 20 to 40 where the practice of induced abortion is concentrated. Not all ethnic groups however have exhibited a change in rates. The TAR among Kazakhs appears to have remained stable at 1.1, while the TAR among Russians has declined by 36 percent from 2.7 to 1.7. Like the 1995 survey, the 1999 KDHS showed substantial regional variations in the rate of induced abortion. In the high-fertility South and West regions, the TAR is lowest (1.1 abortions per woman). In the Central and East regions where fertility levels are interme- diate, abortion rates are also intermediate (1.2 and 1.6, respectively), while in the rela- tively low fertility areas of Almaty City and the North region, abortion rates are highest (1.8 and 2.0, respectively). Summary of Findings * xxi MATERNAL AND CHILD HEALTH In Kazakhstan, the levels of antenatal care services and delivery assistance remain high. Ninety-four percent of mothers received ante- natal care from professional health providers. For 76 percent of births in the five years preceding the survey, mothers received ante- natal care from a doctor, 3 percent from a doctor’s assistant, and 15 percent from a nurse or trained midwife. Mothers are more apt to receive care by a doctor for first births (83 percent) than for births of order six or higher (67 percent). Virtually all births in Kazakhstan (98 percent) are delivered at health facilities. The great majority of births occur in a delivery hospital (89 percent) and another 9 percent in a public hospital. Only 2 percent of births are reported as occurring outside the setting of a health facility (i.e., primarily at the respondent's home). Almost all births are delivered under the supervision of persons with medical train- ing: 77 percent by a doctor and 22 percent by a doctor’s assistant and a nurse or trained midwife. In the 1999 KDHS the child vaccination data was collected from the health cards main- tained at the health facilities. The survey data showed high levels of vaccination coverage with about 99 percent of children age 12-23 months having received a BCG vaccination and the first dose of polio and DPT/DP vac- cines. Coverage for the second dose of polio and DPT/DT was 98 and 99 percent, respectively. The third dose of polio and DPT/DT was received by 92 and 98 percent of children, respectively. Eighty-seven percent of children have received measles vaccine. The percent- age of children 12-23 months of age who have received all WHO-recommended vaccinations is 81 percent. CHILDHOOD MORTALITY One of the main objectives of the 1999 KDHS was to document current levels and trends in infant and child mortality. In the KDHS, infant mortality data were collected based on the international definition of a live birth, which, irrespective of the duration of the pregnancy, is an infant that breathes or shows any signs of life (such as the beating of the heart or movement of voluntary muscles) after separation from the mother. An infant death is the death of a live-born infant under one year of age (United Nations, 1992). For the five years immediately preceding the survey (1994-99), the infant mortality esti- mate was 62 per 1,000 births. The estimates of neonatal and postneonatal mortality were 34 and 28 per 1,000 births, respectively. The estimate of child mortality (age 1 to age 5) was much lower; 10 per 1,000. The overall under-five mortality rate for the period was 71 per 1,000. For the fifteen-year period preceding the survey, the estimates of infant mortality indicate a decline from 55 per 1,000 (1984- 89) to 50 per 1,000 (1989-94) and then an increase to 62 per 1,000 (1994-99). The same pattern is evident in the estimates of child mortality where there is a decline from 12 per 1,000 (1984-89) to 7 per 1,000 (1989-94) and then an increase to 10 per 1,000 (1994- 99). While these statistics suggest improving mortality conditions between the mid-1980s and the early 1990s, then deteriorating cond- itions from the early 1990s to the late 1990s, the true extent of mortality change may differ from the estimated rates because of sampling variability. BREASTFEEDING AND NUTRITIONAL STATUS Breastfeeding is nearly universal in Kazakhstan; 95 percent of children born in the five years preceding the survey were breast- fed. Forty-seven percent of children age 0-3 months were exclusively breastfed. This per- centage is significantly higher than in 1995 when only 12 percent of children age 0-3 months were exclusively breastfed. xxii * Summary of Findings Exclusive breastfeeding among children age 4-7 months has also increased from 3 percent in 1995 to 10 percent in 1999. During these months most breastfed children (64 percent) receive supplementary feeding and 10 percent receive plain water. For all of Kazakhstan, the median duration of any breastfeeding is 7.1 months, and the durations of exclusive and full breastfeeding (breastfeeding plus plain water) are 0.7 and 1.9 months, respectively. After the first birthday, almost all nonbreast- feeding children receive high protein foods made of flour. A high proportion of them (more than 70 percent) receive products rich in protein, vitamins and minerals, such as meat, poultry, and some fruits and vegetables. In the 1999 KDHS, all surviving children born since January 1994 and living in every second selected household were eligible for height and weight measurements. (In the cities of Almaty, Zhezkazgan, and Semipalatinsk chil- dren were selected in all households but in every second cluster.) Complete and plausible anthropometric data were collected for a total of 612 children under age five. For all of Kazakhstan, 10 percent of children are moderately or severely stunted, 2 percent are moderately or severely wasted, and 4 percent are moderately or severely under- weight for age. Children age 12-23 months and 36-47 months are less well-nourished than infants by almost all indices of under- nutrition. Stunting is more common among female children than among male (11 versus 9 percent), whereas boys are more likely to be wasted than girls. ANEMIA Anemia remains among the leading public health problems in Kazakhstan. The 1999 KDHS data show that 36 percent of the women in Kazakhstan are classified as having some degree of anemia; 8 percent of women have moderate anemia, and 1 percent have severe anemia. Thirty-six percent of children under the age of five are anemic; 17 percent have moderate anemia, and 1 percent are severely anemic. A comparison of probability plots of cumula- tive percent distributions for hemoglobin concentrations in the blood of children, nonpregnant and nonlactating women, as well as men, showed that hemoglobin distribution curves for women and children are shifted downward compared with those for men. This pattern is characteristic of populations where iron deficiency is the main cause of anemia. This confirms previous suggestions that ane- mia among women and children in Kazakhstan is primarily due to negative iron balance. Supplementation of iron during pregnancy is one of the main components of the UNICEF/CARK Anemia Control and Preven- tion Strategy in Kazakhstan. The government of Kazakhstan supports this program by pro- moting iron supplementation during preg- nancy and the postpartum period. The 1999 KDHS showed that 48 percent of women in Kazakhstan received iron pills during the last pregnancy; they took the iron pills for an average of 22 days. Compared with the results from the 1995 KDHS there has been a decline in the preva- lence of moderate-to-severe anemia among both women and children during the four-year period. The rate of moderate-to-severe anemia has declined from 12 to 9 percent among women and from 39 to 26 percent among children under age three. HIV/AIDS AND OTHER SEXUALLY TRANSMITTED INFECTIONS The current low level of the HIV epidemic in Kazakhstan provides a unique window of opportunity for early targeted interventions to prevent further spread of the infection. How- ever, increases in the cumulative incidence of HIV infection as well as the exponential in- crease in other sexually transmitted infections (STIs), suggest that this window of opportu- nity is rapidly closing. Summary of Findings * xxiii The 1999 KDHS data show that the know- ledge of HIV/AIDS among women and men in Kazakhstan is nearly universal and a large proportion of them know one or more valid ways to protect against HIV/AIDS, such as using condoms, having only one sex partner, or limiting the number of sex partners. There is some stigma regarding HIV/AIDS in Kazakhstan, which is evidenced by the fact that 40 percent of women and 26 percent of men would prefer to keep information about HIV/AIDS private. The percentage of women and men who wouldn’t be willing to care for a relative with AIDS at home, which is an indicator of discriminatory attitudes toward such persons, was 31 and 15 percent, respectively. Despite the high prevalence of STIs other than HIV/AIDS, 18 percent of women and 7 per- cent of men in Kazakhstan reported that they had not heard of such infections. Among those who have heard of STIs, more than 40 percent of women and more than 60 percent of men cited one or more symptoms of STIs such as abdominal pain, genital discharge, and burn- ing pain on urination. Relatively low levels of knowledge of STI symptoms among men and women of younger ages raises concerns be- cause of their potential contribution to future epidemics of HIV/AIDS and other STIs in Kazakhstan. Since the spread of HIV/AIDS and other STIs depends on unprotected sex with people who have multiple partners, the fact that 10 per- cent of married men reported having extra- marital sexual relationships and that 22 per- cent of unmarried men have multiple sex partners raises another concern. The data also show that about 81 percent of women and 42 percent of men did not use a condom during the last sexual intercourse with a noncohabi- tating partner. Such behaviors carry a high risk of transmission of HIV/AIDS and other STIs. TUBERCULOSIS With high levels of morbidity and mortality, tuberculosis (TB) presents a major health problem in Kazakhstan: The 1999 KDHS data showed that more than 9 percent of men and women in Kazakhstan reported that someone in their family had had TB and more than 23 percent reported having frequent exposure to a person with TB. This information confirms the high prevalence of tuberculosis in different regions of Kazakhstan reported by govern- ment statistics. The 1999 KDHS data also show that almost 100 percent of both female and male respon- dents have heard of tuberculosis and more than 71 percent of them can correctly identify the way tuberculosis is transmitted, which is through the air during coughing. Approxi- mately half of the respondents mentioned without prompting the main symptom of tuberculosis, which is coughing for more than three weeks. A significant percentage of the respondents also cited other important symp- toms of tuberculosis such as fever, blood in sputum, and night sweating. However, despite such high levels of knowledge of TB symptoms and the modes of its transmission, only 68 percent of women and 62 percent of men knew that tuberculosis could be completely cured with proper medi- cation. The complete curability of tuberculosis with a properly selected drug treatment regi- men is an important concept of the DOTS (Directly Observed Treatment Short-Course) strategy endorsed by the WHO. Another important concept is the possibility of follow-up home treatment under close obser- vation of a health professional, after the initial phase of intensive drug therapy in the hospi- tal. In the 1999 KDHS, only 13 percent of female respondents and 9 percent of male respondents cited such a sequence of TB treatment. The vast majority of respondents, more than 82 percent, believe that the entire TB treatment should be carried out in the hospital. In addition, more than half of the respondents would seek treatment at a hospi- tal in the event of a case of TB in their family, compared with less than 19 percent who would seek treatment at a TB dispensary and less than 18 percent who would rely on an ambulatory care setting such as a polyclinic or family group practice. Background Information and Organization * 1 1KAZAKHSTAN: BACKGROUND INFORMATION, OBJECTIVES, AND ORGANIZATION OF THE SURVEY Toregeldy Sharmanov 1.1 Geography and Population Kazakhstan lies in the north of the central Asian republics and is bounded by Russia in the north, China in the east, the Kyrgyz Republic and Uzbekistan in the south, and the Caspian Sea and part of Turkmenistan in the west. The territory of Kazakhstan is mostly steppe with hilly plains and plateaus. The national language is Kazakh, which belongs to the Turkic language group. Russian is widely spoken and is an important language of communication. The primary religion of the people of Kazakhstan is Sunni Islam. According to the last census, conducted in 1999, the population of Kazakhstan is 14.9 million people, making Kazakstan the fourth most populous former Soviet republic. Fifty-six percent of the country’s residents live in cities (National Statistical Agency, 1999). With a population density of approximately 6 people per square kilometer, Kazakhstan is one of the most sparsely populated regions in the world. Currently, Kazakhstan is experiencing rapid social change that includes a dramatic reduction in the number of children desired and fertility rates fast approaching Western levels. The country is now nearing the end of a demographic transition, having an annual rate of natural increase of 0.5 percent and a total fertility rate estimated at 2.0 births per woman. People representing more than 100 nationalities live in Kazakhstan, with Kazakhs and Slavs (mostly Russians and Ukrainians) constituting the two largest ethnic groups. According the 1999 census, the ethnic breakdown was as follows: 53.4 percent Kazakh, 30.0 percent Russian, and 16.6 percent Ukrainian, Uzbek, German, Tartar, Byelorussian, Korean, and others. (National Statistical Agency, 1999). Kazakhstan is experiencing a pronounced outflow of citizens, primarily Russians moving to other former Soviet republics. Official figures indicate that 472,273 people left Kazakhstan in 1998; 63.9 percent of them were ethnically non-Kazakh. To some extent, the outflow has been offset by in-migration. Kazakhstan’s government has actively encouraged the return of ethnic Kazakhs from elsewhere in the former Soviet Union, as well as from Mongolia, Turkey, Iran, and other countries. As a result, 40,624 persons identified as ethnic Kazakhs immigrated to Kazakhstan in 1998 (National Statistical Agency, 1999). 1.2 History of Kazakhstan Historically, the Kazakh people pursued a nomadic lifestyle for which the region’s climate and terrain were well suited. The indigenous Kazakhs belonged to several divisions of Turkic tribes, and the movements, conflicts, and alliances of these tribes determined the early history of Kazakhstan. The earliest well-documented state in the region was the Turkic Kaganate, which came into existence in the sixth century A.D. Various Turkic tribes ruled the country until it fell under 200 years of Mongol rule in the thirteenth century. 2 * Background Information and Organization The present-day Kazakhs became a recognizable group in the mid-fifteenth century, when Qasym-Khan ruled the country. The Kazakhs then separated into three hordes: the Great Horde, which controlled Semirech’ye and southern Kazakhstan; the Middle Horde, which occupied north- central Kazakstan; and the Lesser Horde, which occupied western Kazakstan. The hordes were unified in eighteenth century in the Ulu-Tau area by the great leader Abylai Khan. Under his leadership, the country was able to maintain effective diplomatic relations with its powerful neighbors: Russia and China. Despite such diplomacy, Russia conquered Kazakhstan in the late eighteenth century. The Middle Horde fell first, followed by the rest of the country. Soon after the conquest, the Kazakhs began to resist Russian control, and the first mass uprising was led by Khan Kene, who is now considered a Kazakh national hero. In 1917, a group of secular nationalists called the Alash Orda attempted to set up an independent national government. This state lasted less than two years (1918-20) before surrendering to the Bolshevik authorities, who then sought to preserve Communist control under a new political system. In 1920, Kazakhstan became part of the Kyrgyz Autonomous Republic formed by the Soviet authorities, and in 1925 this entity’s name was changed to the Kazakh Autonomous Soviet Socialist Republic. In 1936, Kazakhstan was made a full Soviet republic. After 1930, the Soviet government began forcing the nomadic Kazakhs to settle on collective and state farms, and the Soviets encouraged large numbers of Russians and other Slavs to settle in the region. During this period (known as Stalin’s collectivization), Kazakstan endured repeated famines. At least 1.5 million Kazakhs and 80 percent of the republic’s livestock died. Thousands more Kazakhs tried to escape to China, Afghanistan, Iran, and Turkey; however, most of them starved in the attempt. During the so-called Virgin Land campaign (1956-1964) a significant part of Kazakhstan’s territory was put to the plow for the cultivation of wheat and corn. Also during this period, industrial development was initiated in Kazakhstan and benefited from the country’s abundance of natural resources. Economic development was accelerated by the military industry and the space program, which were promoted by the Soviet government. During this period of intensive industrialization and agricultural development, many non-Kazakhs arrived in the country. By the 1970s Kazakhstan was the only Soviet republic in which the eponymous nationality was a minority in its own territory. One negative consequence of such intensive industrialization and agricultural development was significant industrial and agrochemical pollution. The Soviet government also used Kazakhstan as a testing ground for nuclear weapons, which raised concerns about radioactive pollution in the Semipalatinsk region where the weapons were tested. In 1991, after the collapse of the former Soviet Union, Kazakhstan officially declared itself an independent state. According to the country’s Constitution, Kazakhstan is a parliamentary republic, with the president as the head of state. Former Communist Party leader Nursultan Nazarbayev became Kazakhstan’s first president in 1999. In January 1999, he was sworn into office for another seven years. Background Information and Organization * 3 Thus, two major demographic trends characterize Kazakhstan in the twentieth century: rapid urbanization and a shift in the national ethnic structure. Kazakhstan’s present ethnic spectrum is the result of a migration process initiated and influenced by industrialization and political changes throughout Kazakhstan’s history. Millions of ethnic Slavs (Russians, Ukrainians, Byelorussians) settled in the northern territories of Kazakshtan, whereas the central and southern regions remained populated primarily by ethnic Kazakhs. 1.3 Economy Kazakhstan, the second largest of the former Soviet republics, possesses significant amounts of fuel reserves as well as plentiful supplies of other minerals and metals. It also has considerable agricultural potential: its vast areas of steppe accommodate both livestock and grain production. Kazakhstan’s industrial sector rests on the extraction and processing of these natural resources and on a relatively large machine-building sector specializing in construction equipment, tractors, agricultural machinery, and defense items. The breakup of the USSR and the collapse of demand for Kazakhstan’s traditional heavy industry products have resulted in a sharp contraction of the economy since 1991, with the steepest annual decline occurring in 1994. In response to worsening economic conditions, the government began accelerating reforms with a revised package of structural reform. Economic stabilization and fundamental structural reforms in the trade regime have brought about an improvement in Kazakstan’s external situation. Between 1995 and 1997, the pace of the government’s program of economic reform and privatization quickened, resulting in a substantial shifting of assets into the private sector. The December 1996 signing of the Caspian Pipeline Consortium agreement to build a new pipeline from western Kazakhstan’s Tengiz oil field to the Black Sea increases prospects for substantially larger oil exports in the near future. However, there was a downward turn in Kazakhstan’s economy in 1998 with a 2.5 percent decline in growth of the gross domestic product (GDP) due to slumping oil prices and the Russian financial crisis in August. Another complicating factor was moving the capital to Astana, which has both disrupted government operations and diverted a large portion of the government’s budget into the massive construction necessary to make Astana a functioning capital. Despite these difficulties, most of which can be attributed to the transition period, some evidence indicates that the economy started recovering in 1999. The government continues to commit itself to a free-market economy and has put in place efficient monetary policy and innovative pension reform. Other positive signs are the thriving securities markets and continuous fiscal and banking reform. The government has actively encouraged international trade and foreign investment, leading to higher per capita foreign-investment levels in Kazakhstan than any other former Soviet republic. To become more efficient, the government restructured and consolidated many operations to reduce the number of government ministries and agencies. Because of such policies and Kazakhstan’s vast oil and mineral resources, relatively low external-debt obligations, and well-trained work force, the country’s medium- and long-term economic prospects continue to be good. 4 * Background Information and Organization 1.4 Health Care System and Epidemiological Profile of Kazakhstan Until recently, Kazakhstan’s health care system, which developed as part of the Soviet- planned system, could be defined as a planned public service provided by the state, with all health personnel being state employees. The system was highly centralized and standardized. Services were free to patients, provided in state-owned facilities, and financed mostly by the state budget. Heavy emphasis was placed on training large numbers of doctors and providing large numbers of hospital beds. The system intended to provide comprehensive health coverage and universal access to services with a focus on disease prevention. Health services were provided through a network of primary-health-care institutions, including ambulatories, dispensaries, polyclinics, hospitals (rural, delivery, and other types), and doctor’s assistant/midwife posts (so-called FAPs). For the purpose of management, the country was divided into health-service-delivery areas, each representing between 3,000 and 4,000 people. Specialized services were provided through secondary and tertiary health systems. The Soviet health care system has been successful in providing adequate access to services for most of Kazakhstan’s population, including those who reside in rural and remote areas. However, maintaining such a system required substantial and continuous budgetary support and enormous manpower resources and managerial skills. Although the Soviet health care system met many of its goals, the system itself and the health of the population has deteriorated, largely due to the political and economic turmoil that accompanied the collapse of the former Soviet Union. As a result, Kazakhstan inherited a health care system that was in a chronic state of disarray. Even in the years that preceded the collapse, the former Soviet Union was the only major country where the percentage of the gross domestic product (GDP) going to health care decreased, and it was already in the range of just 3 to 4 percent. This percentage compares with average health-care expenditures of 6 to 10 percent of the GDP in most developed countries. After the collapse of the former Soviet Union, funding to the health sector in Kazakhstan decreased to about 1 or 3 percent of the GDP, and the GDP fell by as much as 50 percent. This situation has resulted in decline in life expectancy, increased morbidity, poor conditions of hospitals and other health facilities, and overall public dissatisfaction with health services (Sharmanov et al., 1996). The failure of the state-run health care system forces people to turn to a growing array of private health services that are available mostly through a cash payment. As a result, the picture now emerging in Kazakhstan is of a dual system: the old state system, facing chronic underfunding, and a second, loosely regulated private system, offering market and competitive solutions. This situation, as well as the guarantee of free basic health care in the 1995 Constitution of Kazakhstan, prompted the country to search for other ways to fund health services. A new institutional structure, the Health Insurance Fund, was established in 1995 to operate the health insurance system. Initially, the fund was successful in increasing the efficiency of the health sector. However, because of mismanagement and corruption, which resulted in inefficiency and growing public criticism, the idea of the national health insurance system collapsed in 1999. While searching for an efficient funding mechanism, the country took major steps in restructuring the primary-health-care system with the intent to redirect resources to the primary- health-care sector. Efforts to restructure the primary-care delivery system in Kazakhstan have focused on creating a network of family group practices. These practices are physically, financially, and administratively independent from higher level facilities. The funding mechanism of this system is based on a capitation system, and the ultimate goal is to increase the managerial autonomy and internal control that primary-care providers have over their resources, so they can better adapt to the needs of their service population (Borowitz et al., 1999). Background Information and Organization * 5 Pilot programs in family group practices and new payment systems demonstrating their cost- effectiveness and high-quality services have been established in the cities of Zhezkazgan and Semipalatinsk. In late 1998, President Nazarbayev endorsed a plan to replicate nationwide the new health-care model, and a large World Bank loan was negotiated to provide support for the program. Despite some criticism among conservative groups of physicians and health administrators, the new system continues to be envisioned as an efficient means of health care management and financing. From an epidemiological point of view, Kazakhstan has features of both developed and developing countries. The major causes of death are similar to those of industrialized countries: cardiovascular disease, cancer, and accidents. The decline in life expectancy is not due to infectious diseases, but rather to increases in cardiovascular mortality, alcohol-related deaths, accidents, and violence. Infectious diseases account for a relatively low percentage of overall mortality, generally less than 20 percent (Sharmanov, 1996, Borowitz et al., 1999). At the same time, there is a rising incidence of tuberculosis, especially its multi-drug- resistant forms. Because of tuberculosis’ consumption of a large proportion of the limited resources available to the health sector and its potentially to spread to other countries, tuberculosis is of great public-health concern in Kazakhstan. Recently, the government of Kazakshtan endorsed the DOTS program, which is a new treatment protocol for tuberculosis that provides effective treatment and prevents drug-resistant forms of the disease from spreading. Among children, acute respiratory infections and childhood diarrheal diseases are the main causes of death. From a burden-of-disease perspective, this area is the most critical because it requires significant investment of resources as well as development of effective intervention programs. 1.5 Family Planning Policies and Programs The main goals of Kazakhstan’s family planning policy are to ensure low-risk pregnancies and safe motherhood, to reduce complications due to inadequately spaced pregnancies, and to reduce the incidence and prevalence of pregnancy complications and extragenital diseases among women of reproductive age. In Kazakhstan, one of the primary methods of birth control is induced abortion. After its initial legalization in 1920, abortion was banned in 1936 as part of a pronatalist policy emphasizing population growth. Since this attempt to increase population growth proved unsuccessful and even harmful because of maternal deaths caused by illegal abortions, the Soviet government again legalized induced abortion for nonmedical reasons in 1955. Abortions were allowed to be performed free of charge in most health facilities, such as outpatient departments of general hospitals and delivery hospitals. Currently, induced abortion is legal in Kazakhstan during the first 12 weeks of pregnancy. In some cases, it can be performed after 12 weeks if certain medical or social indications exist. These cases require supervision of qualified medical personnel in a hospital setting. Abortion can be done free of charge; however, fee-for-services facilities have become available to perform mini- abortions by the vacuum aspiration technique. Despite indications that the number of induced abortions has declined in recent years, the abortion issue remains a public health concern in Kazakhstan because of the prevalence of complications and the overall adverse effects on women’s health. 6 * Background Information and Organization Because of the policy of promoting safe methods of family planning, widespread use of contraception has been observed in Kazakhstan during the past several years. Among the most popular methods is the intrauterine device (IUD). Many women rely on the IUD as a convenient and safe method of contraception. For many years, oral contraceptives were less available in Kazakhstan because of the order “On the Side Effects and Complications of Oral Contraceptives”, published by the Ministry of Health of the former Soviet Union in 1974. This document, in effect, banned the distribution and use of oral contraceptives (United Nations, 1995). After the collapse of the former Soviet Union, the government of Kazakhstan liberalized its policy on family planning. Currently, the government manages a broad spectrum of activities including providing intensive family planning education for the population and supplying contraceptives throughout the country. The private sector is also involved in marketing contraceptives. Women in Kazakhstan now have access to a variety of methods of contraception including oral contraceptives and injectables. Contraceptives are distributed in the public sector by pharmacies and women=s consulting centers, and in the private sector by private pharmacies. Part of the success in reducing the abortion rate has been attributed to social marketing of contraceptives and education programs supported by the U.S. Agency for International Development (USAID) and the United Nations Population Fund (UNFPA). As a result of the government’s policies and international assistance, reliance on abortion is diminishing in Kazakhstan as use of contraceptive methods becomes more widespread. Some evidence suggests that further significant declines in the abortion rate can occur with an increase in contraceptive use (Westoff et al., 1998). 1.6 Demographic and Health Data Collection System in Kazakhstan The demographic and health data collection system in Kazakhstan is based on the registration of events and periodic censuses. The data on births, deaths, marriages, and divorces are registered at the local administrative level of an internal passport control system. These data are then forwarded to the National Statistical Agency through the raion- and oblast-level statistical offices. The committee is responsible for conducting censuses and maintaining this registration system. The last census in Kazakhstan was conducted in 1999, and its results were published in 2000. The National Statistical Agency is also responsible for tabulating and publishing an annual report of demographic data generated by the registration system. Collection of health data is a primary responsibility of the Health Statistics Department of the National Agency on Health. Health information is collected by staff at the facilities delivering services and then sent to the Health Statistics Department through the raion- and oblast-level health information centers. The Health Statistics Department complies and analyzes the data and issues an annual report entitled Health of the Population of the Republic of Kazakhstan and Health Resources. The health data collected and published by the Health Statistics Department consist of the following major categories: 1) morbidity specified by type of disease (infectious and noninfectious); 2) mortality specified by causes of death; 3) infant deaths, including data on antenatal, perinatal, and early neonatal deaths; 4) maternal mortality specified by causes of maternal death; 5) data on maternal and child health, including antenatal care and delivery assistance, contraceptive clients, induced abortion rates, and pediatric services; 6) number of health facilities, medical personnel, hospital beds, and length of average stay in the hospital; and 7) health data specified by type of medical services, including medical care for patients with cancer, tuberculosis, mental disorders, drug abuse, and sexually transmitted diseases. These data are usually tabulated at the national and oblast levels, and for some categories, by the age groups 0-14 and 15 or more years. 1 A detailed description of definitional differences and different estimates of infant mortality is presented in chapter 9 of this report. Background Information and Organization * 7 Despite this collection effort, a data analysis function that provides tools to evaluate and inform policy development is not sufficient. There is significant underreporting of some cases of morbidity and mortality and some of the criteria used to calculate important demographic and health indicators are based on old Soviet definitions, which sometimes do not comply with international standards. An example is the definition of live birth, which is used to calculate infant mortality rates. Kazakhstan still uses the old Soviet definition of live birth. As a result, infant mortality rates, particularly neonatal mortality rates reported by the government, are significantly lower than the actual infant mortality rates.1 Besides the problems of inaccurate data and lack of a data analysis function, the health information collection process and systems are vertical and not integrated to create one set of data providing a picture of the health sector in Kazakhstan. 1.7 Objectives and Organization of the Survey The 1999 Kazakhstan Demographic and Health Survey (1999 KDHS) is the second national- level population and health survey in Kazakhstan. The first Demographic and Health Survey was conducted in 1995. The 1999 KDHS was implemented by the Academy of Preventive Medicine of Kazakhstan and was funded by USAID. Technical assistance for the program was provided by the MEASURE DHS+ project of Macro International Inc. in the U.S. The purpose of the survey is to develop a single integrated set of data for the government of Kazakhstan to use in planning effective policies and programs in the areas of health and nutrition. The survey was designed to provide current data on women’s reproductive histories; knowledge and use of methods of contraception; breastfeeding practices; and the nutrition, vaccination coverage, and episodes of diseases among their children under the age of five. Information on knowledge of and attitudes toward HIV/AIDS and other sexually transmitted infections, as well as data on men’s reproductive behavior, were also collected in the 1999 KDHS. The survey also included the measurement of the hemoglobin level in the blood to assess the prevalence of anemia, and measurements of height and weight to assess nutritional status (funded by UNICEF). Since the 1999 KDHS is the second survey, it provides comparable data for analysis of trends in fertility, reproductive health, and child health and nutrition. The 1999 KDHS also contributes to the growing international database on demographic and health-related variables. 1.7.1 Sample Design and Implementation The sample for the 1999 KDHS successfully interviewed 4,800 women 15-49 years of age and 1,440 men 15-59 years of age. Survey estimates are presented for six geographic regions. The six survey regions were defined as follows: (1) Almaty City (2) South Region: Almatinskaya, Zhambylskaya, Kyzylordinskaya, and South- Kazakhstanskaya oblast (3) West Region: Aktyubinskaya, Atyrauskaya, Mangistauskaya, and West- Kazakhstanskaya oblast 8 * Background Information and Organization (4) North Region: Akmolinskaya, Kostnaiskaya, Pavlodarskaya, and North- Kazakhstanskaya oblast (5) Central Region: Karagandinskaya oblast (6) East Region: East-Kazakhstanskaya oblast The sampling frame for the 1999 KDHS consisted of the lists of health blocks obtained from local health-care departments and the National Committee on Health (for urban areas), and of the lists of villages obtained from the National Statistical Agency. The 1999 KDHS sample is a stratified two-stage sample. Stratification was achieved by dividing each survey region into urban and rural areas. In the first stage of selection, 251 health blocks and villages were selected as primary sampling units (PSUs) with probability proportional to the population count. A complete listing of the households residing in the selected blocks and villages was carried out. The lists of households served as the sampling frame for the systematic selection of 6336 households in the second stage. Women age 15-49 were identified and interviewed in selected households. Every third household was identified as selected for the male survey, and in those households, all men age 15-59 were interviewed. Details concerning the 1999 KDHS sample design are provided in Appendix A and the estimation of sampling errors is included in Appendix B. 1.7.2 Questionnaires Three questionnaires were used for the 1999 KDHS: the Household Questionnaire, the Women’s Questionnaire, and the Men’s Questionnaire. These questionnaires were based on the model survey instruments developed for the MEASURE DHS+ program and were adapted to the data needs of Kazakhstan during consultations with specialists in the areas of reproductive health and child health and nutrition in Kazakhstan. The questionnaires were developed in English and then translated into Russian and Kazakh. A pretest was conducted in April 1999. Based on the pretest experience, the questionnaires were further modified. The Household Questionnaire was used to enumerate all usual members and visitors in a sample household and to collect information relating to the socioeconomic position of the household. In the first part of the Household Questionnaire, information was collected on age, sex, educational attainment, and relationship to the head of household for each person listed as a household member or visitor. A primary objective of the first part of the Household Questionnaire was to identify women and men who were eligible for the individual interview. In the second part of the Household Questionnaire, questions were included on the dwelling unit, such as the number of rooms, the flooring material, the source of water, and the type of toilet facilities, and on the availability of a variety of consumer goods. The Women’s Questionnaire was used to collect information from women age 15-49 on the following major topics: • Background characteristics • Pregnancy history • Outcome of pregnancies, antenatal and postnatal care • Child health and nutrition practices • Child immunization and episodes of diarrhea and respiratory illness • Knowledge and use of contraception Background Information and Organization * 9 • Marriage and fertility preferences • Husband’s background and woman’s work • Knowledge of HIV/AIDS and other sexually transmitted infections • Maternal and child anthropometry • Hemoglobin measurement of women and children. The Men’s Questionnaire was used to collect information from men age 15-59 on the following topics: • Background characteristics • Reproduction • Contraceptive knowledge and use • Marriage • Fertility preferences and attitudes about family planning • Knowledge of HIV/AIDS and other sexually transmitted infections. 1.7.3 Training and Fieldwork The 1999 KDHS questionnaires were pretested in April 1999. Eight interviewers were trained during a one-week period at the Academy of Preventive Medicine of Kazakhstan. The pretest included one week of interviewing in an urban area (Almaty City) and one week in a rural area (Talgar District of Almaty Oblast). A total of 110 women were interviewed. Pretest interviewers were retained to serve as supervisors and field editors for the main survey. Sixty-four persons, mostly physicians, were recruited as field supervisors, editors, health investigators and interviewers for the 1999 KDHS and were trained at the Academy of Preventive Medicine for three and a half weeks in June and July 1999. Male interviewers responsible for the men=s interviews were trained separately. Training consisted of lectures and practice in the classroom, as well as interviewing in the field. The training of health investigators, who were responsible for anthropometric measurements (height and weight) and hemoglobin testing of women and children, was accomplished by two days in the classroom and three days in the field. At the end of the training, the field staff were divided into seven groups according to their assignments to the survey teams. Nine people, including one supervisor, one editor, five female interviewers, one male interviewer, and one male health investigator, were selected for each of the seven survey teams. The 1999 KDHS field staff represented various medical-research and educational institutions in Kazakhstan, including Kazakhstan State Medical University, Karaganda State Medical Academy, South Kazakhstan State Medical Academy, International Kazakh-Turkish University, National Research Center for Maternal and Child Health, National Research Center for Pediatrics and Pediatric Surgery, National Institute of Nutrition, Institute of Tuberculosis, School of Public Health, National Medical College, and Zhezkazgan Department of Health. The Academy of Preventive Medicine recruited five field coordinators who were responsible for facilitating the communication and coordination between the Academy and the interviewing teams. All seven 1999 KDHS interviewing teams began collecting data in Almaty City on July 12, 1999. On July 26, 1999, the teams began fieldwork in the remaining survey regions of Kazakhstan. Data collection was completed on September 25, 1999. 10 * Background Information and Organization Table 1.1 Results of the household and individual interviews Number of households, number of interviews and response rates, Kazakstan 1999 _________________________________________________________ Residence _________________ Result Urban Rural Total ________________________________________________________ WOMEN ________________________________________________________ Household interviews Households sampled Households found Households interviewed Household response rate Individual interviews Number of eligible women Number of eligible women interviewed Eligible woman response rate 4,311 1,990 6,301 4,038 1,922 5,960 3,939 1,905 5,844 97.5 99.1 98.1 2,989 1,917 4,906 2,927 1,873 4,800 97.9 97.7 97.8 _______________________________________________________ MEN________________________________________________________ Household interviews Households sampled Households found Households interviewed Household response rate Individual interviews Number of eligible men Number of eligible men interviewed Eligible man response rate 959 591 1,550 915 572 1,487 899 569 1,468 98.3 99.5 98.7 897 634 1,531 850 590 1,440 94.8 93.1 94.1 1.7.4 Data Processing Questionnaires were returned to the Academy of Preventive Medicine for data processing. The office editing staff checked that questionnaires for all selected households and eligible respondents were returned from the field. The few questions that had not been precoded (e.g., occupation) were coded at this time. Data were then entered and edited on microcomputers using the Integrated System for Survey Analysis (ISSA) package, with the data entry software translated into Russian. Office editing and data entry activities began on July 12, 1999, and were completed on October 15, 1999. 1.7.5 Response Rates Table 1.1 presents informa tion on the coverage of the 1999 KDHS sample including household and individual response rates. A total of 6,301 households were selected in the sample, of which 5,960 were occupied at the time the fieldwork was conducted. The main reason for the difference was that some dwell- ing units that were occupied at the time of the household listing opera- tion were either vacant or the resi- dents were away for an extended period at the time of interviewing. Of the 5,960 occupied households, 5,844 were interviewed, yielding a household response rate of 98 per- cent. In the interviewed house- holds, 4,906 women were eligible for the individual interview (i.e., all women 15-49 years of age who were either usual residents or visitors who had spent the previous night in the household). Interviews were success- fully completed with 4,800 of these women, yielding a response rate of 98 percent. The principal reason for nonresponse was a failure to find an eligible woman at home after re- peated visits to the household. A total of 1,531 eligible men (i.e., all men 15-59 years of age who were either usual residents or visitors who had spent the previous night in the household) were identified in every third household. Interviews were successfully completed with 1,440 of these men, yielding a response rate of 94 percent. Characteristics of Household * 11 CHARACTERISTICS OF HOUSEHOLDS AND RESPONDENTS 2 Adyl Katarbayev and Kristi Fair This chapter provides a descriptive summary of the demographic and socioeconomic characteristics of the household population and the individual respondents in the 1999 Kazakhstan Demographic and Health Survey (KDHS). This information is useful for interpreting the survey findings and serves as an approximate indicator of the representativeness of the survey and of the quality of the data. This chapter is divided into three parts. The first part deals with the characteristics of the household population in terms of age-sex composition, household size and distribution, and educational background. The second part describes the housing environment in which the respondents and their children live. The background characteristics of men age 15 to 59 years and women age 15 to 49 years are discussed in the last part of the chapter. 2.1 Demographic Characteristics of Households The household questionnaire was used in the 1999 KDHS to collect data on the demographic and social characteristics of all the usual residents of the sampled household and visitors who had spent the previous night in the household. A household, as defined in the survey, refers to a person or group of persons usually living and eating together and jointly running the household's economy (de jure population). A visitor is someone who is not a usual resident of the household but slept in the household the night before the interview. The distribution of the 1999 KDHS household population is presented in Table 2.1 and Figure 2.1, by five-year age groups according to urban-rural residence and sex. The total de facto population in the selected households was 20,203 people. In general, the survey results show that females outnumber males in Kazakhstan (53 and 47 percent, respectively). The sex ratio varies by age and residence. It is slightly higher in the rural than in urban areas (95 versus 84 males per 100 females). The ratio is as high as 103 among those below age 15 and as low as 55 among those age 65 and older. About one-third (30 percent) of the population consists of children under 14 years of age, with the proportion of children in rural areas greater than in urban areas (34 and 25 percent, respectively). Starting with age group 40-44, there is a gradual decrease in the proportion of the population in each successive age group. The relatively small size of the male and female populations in age group 55-59 is a reflection of the low birth rates during World War II (i.e., 55 to 60 years prior to the 1999 KDHS). Women 15-49 years of age and men 15-59 years of age, who are the main KDHS respondents, each constitute about one-fourth of the de facto household population (25 and 27 percent, respectively). The results further indicate that 62 percent of the population of Kazakhstan is in the 15-64 age group, and the population age 65 years and older accounts for 7 percent of the total population. A distinct feature of the age distribution of the population is that the proportion of the dependent population—those younger than 15 or older than 65—is higher in rural areas (41 percent) than in urban areas (34 percent). This difference may be attributed to rural-urban migration of the economically active population—those age 15 to 65—especially youth, in search of jobs. 12 * Characteristics of Household Table 2.1 Household population by age, residence, and sex Percent distribution of the de facto household population by age, according to sex and residence, Kazakhstan 1999 ___________________________________________________________________________ Urban Rural Total ____________________ ____________________ ____________________ Age Male Female Total Male Female Total Male Female Total ___________________________________________________________________________ 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+ Total Number 6.7 5.5 6.1 9.4 9.6 9.5 8.2 7.6 7.9 9.8 8.1 8.9 13.3 12.0 12.6 11.7 10.1 10.9 11.7 8.8 10.1 13.1 12.5 12.8 12.5 10.7 11.6 8.1 7.8 7.9 9.7 8.8 9.2 9.0 8.3 8.6 7.4 6.7 7.0 7.1 7.1 7.1 7.2 6.9 7.1 7.1 7.7 7.5 7.7 6.3 7.0 7.5 7.0 7.2 8.0 6.7 7.3 6.8 7.5 7.2 7.3 7.1 7.2 8.5 7.7 8.0 7.5 7.4 7.4 7.9 7.5 7.7 7.5 7.4 7.4 6.2 6.2 6.2 6.8 6.7 6.8 5.6 6.2 5.9 4.6 4.3 4.5 5.1 5.2 5.1 4.7 6.5 5.7 3.3 3.9 3.6 3.9 5.1 4.6 4.2 4.5 4.4 2.7 2.9 2.8 3.4 3.7 3.5 4.6 5.9 5.3 3.6 4.5 4.0 4.0 5.2 4.6 2.7 3.7 3.2 1.8 2.1 1.9 2.2 2.9 2.5 2.6 3.4 3.0 1.8 2.7 2.3 2.1 3.1 2.6 0.6 1.7 1.2 0.7 1.3 1.0 0.7 1.5 1.1 0.3 1.8 1.1 0.5 1.0 0.8 0.4 1.3 0.9 .100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 .4,273 5,069 9,342 5,289 5,572 10,861 9,562 10,641 20,203 Characteristics of Household * 13 Table 2.2 Population by age according to selected sources Percent distribution of the de jure population by age group, according to selected sources, Kazakstan 1989- 1999 _______________________________________________ 1989 1995 1999 1999 Age group Census KDHS Census KDHS _______________________________________________ <15 15-64 65+ Total Median age Dependency ratio 31.8 31.0 28.6 29.9 62.5 62.1 64.7 63.0 5.7 6.9 6.7 7.1 100.0 100.0 100.0 100.0 26.9 26.5 29.9 27.9 60.0 61.0 54.6 58.8 Table 2.3 Household composition Percent distribution of households by sex of head of household, household size, and percentage of households with foster children, according to residence, Kazakhstan 1999 _____________________________________________ Residence ______________ Characteristic Urban Rural Total _____________________________________________ Head of household Male Female Number of members 1 2 3 4 5 6 7 8 9+ Total Mean size Percent with foster children 57.5 78.1 66.6 42.5 21.9 33.4 18.9 5.9 13.1 25.6 14.0 20.5 21.3 14.4 18.2 18.5 22.4 20.2 8.1 17.8 12.4 3.8 11.5 7.2 1.9 6.8 4.1 0.9 4.3 2.4 1.0 2.9 1.8 100.0 100.0 100.0 3.0 4.4 3.6 2.2 4.8 3.3 _____________________________________________ Note: Table is based on de jure members; i.e., usual residents. The percent distribution of the popula- tion by broad age groups according to the 1995 KDHS, the 1999 KDHS, the 1989 Census, and the 1999 Census is presented in Table 2.2. There appears to be a progressive decline since the 1989 Census in the proportion of the population under 15, as well as a concomitant increase in the median age. The growth of the 15-64 age group results in a declining depend- ency ratio, calculated as the ratio of persons in the dependent age groups to persons in the economically active age group. This slight aging of the population is the result of a con- tinuous, albeit slow decline in fertility levels. It is interesting to compare the 1999 KDHS data with that of the 1999 Census. Correspon- dence of the percent distribution of the popu- lation in broad age groups between the 1999 KDHS and the 1999 Census confirms the representativeness of the KDHS sample. 2.2 Household Composition Information on the size and composition of sample households by urban-rural residence is presented on Table 2.3. The head of house- hold (as recognized by other members) and the relationship of each household member to the head was determined in each household. In general, heads of households are male (67 percent). In urban areas the proportion of households headed by men (58 percent) is less than the proportion in rural areas (78 percent). Compared with the 1995 KDHS, the average size of a household reported in the 1999 KDHS has decreased slightly from 3.8 to 3.6 members. The 1999 KDHS results show that rural households (4.4 members) are larger than urban households (3.0 members). A large pro- portion of rural households (52 percent) consist of four to six persons, while the majority of urban households (84 percent) have one to four members. Both the 1995 KDHS data and the 1999 KDHS data show that only 3 percent of house- holds include foster children, i.e., children less 15 years old living with neither biological parent. 14 * Characteristics of Household Table 2.4 Fosterhood and orphanhood Percent distribution of de facto children under age 15 by their living arrangement and survival status of parents, according to child's age, sex, residence, and region, Kazakhstan 1999 __________________________________________________________________________________________________________ Living Living with mother with father Not living with but not father but not mother either parent Living _____________ _____________ _________________________ Missing with Father Mother info. on Number Background both Father Father Mother Mother Both only only Both father/ of characteristic parents alive dead alive dead alive alive alive dead mother Total children __________________________________________________________________________________________________________ Age 0-2 3-5 6-9 10-14 Sex Male Female Residence Urban Rural Region Almaty City South West Central North East Total 88.8 6.7 1.2 0.2 0.0 2.3 0.0 0.1 0.0 0.7 100.0 941 85.2 8.8 1.8 0.6 0.4 2.5 0.0 0.0 0.0 0.7 100.0 1,035 81.4 9.2 3.6 0.4 0.1 2.8 0.3 0.2 0.3 1.7 100.0 1,864 75.7 11.0 6.1 0.6 1.0 2.6 0.6 0.4 0.3 1.8 100.0 2,463 80 3 9.6 4.3 0.6 0.4 2.7 0.3 0.2 0.3 1.4 100.0 3,196 81.5 9.3 3.5 0.4 0.6 2.5 0.3 0.3 0.2 1.4 100.0 3,108 76.6 14.2 4.0 0.2 0.6 1.8 0.3 0.1 0.1 2.2 100.0 2,452 83.6 6.5 3.9 0.6 0.4 3.1 0.4 0.3 0.3 0.9 100.0 3,851 71.2 17.2 5.3 1.0 0.6 1.8 0.4 0.0 0.0 2.7 100.0 224 84.8 7.6 3.1 0.2 0.4 2.8 0.3 0.2 0.1 0.4 100.0 2,781 83.1 5.6 5.6 0.3 0.5 2.6 0.3 0.7 0.3 1.1 100.0 917 76.2 14.2 3.1 0.0 0.8 2.6 0.1 0.4 0.1 2.5 100.0 415 76.6 11.5 4.4 1.3 0.1 1.8 0.6 0.0 0.4 3.2 100.0 1,281 75.9 12.9 4.0 0.3 1.5 3.3 0.1 0.2 0.1 1.6 100.0 685 80.9 9.5 3.9 0.5 0.5 2.6 0.3 0.2 0.2 1.4 100.0 6,303 __________________________________________________________________________________________________________ Note: By convention, foster children are those who are not living with either parent. This includes orphans, i.e., children both of whose parents are dead. Table 2.4 presents information on fosterhood and orphanhood among children under age 15. The 1995 KDHS and 1999 KDHS show a similar distribution of children under age 15 living with both parents (79 and 81 percent, respectively). As children get older, fewer of them live with both parents; 89 percent of children in the under-three age group live with both parents, compared with 76 percent in the 10 years or older age group. There is little difference by residence in the percentage of children living with both parents: 77 percent in urban areas and 84 percent in rural areas. Households with children living with both parents are more common in the West and South Regions (83 and 85 percent, respectively). Thirteen percent of children under 15 are living with only their mother; of these children, 4 percent have lost their fathers and 9 percent have fathers who are still alive. There are variations in this parameter depending on age of child, sex, and residence. For example, households with children living with only their mother are more common in urban areas than in rural areas, and in Almaty City and the Central region compared with other regions. Regarding orphanhood, about 4 percent of children under age 15 have fathers who have died, less than 1 percent have mothers who have died, and an insignificant proportion (0.2 percent) have lost both parents. 1 Youths who are over age for a given level of schooling may have started school over age, may have repeated one or more grades in school, or may have dropped out of school and returned later. Characteristics of Household * 15 2.3 Educational Level of Household Members The high correlation between level of education and positive health and other social indicators makes education an important variable in any study of households. Higher education, especially for women, is usually associated with greater knowledge and use of sound health practices and family planning methods. Kazakhstan’s primary and secondary educational system has three levels: primary (classes 1 through 4, age 7 to 11 years), principal (classes 5 through 9, age 12 to 15 years), secondary (classes 10 and 11, age 16 to 17 years). Most schools in Kazakhstan offer all three levels of primary/secondary education. The primary and principal education levels are compulsory. Students who leave school after the principal level may continue in secondary-special (vocational) education. Students who finish all three levels of primary/secondary school can continue on in higher education at universities or in academic training classes. 2.3.1 Educational Attainment of Household Members Table 2.5 presents information on the highest level of education attained by the population according to sex, age, residence, and region. As the 1995 KDHS data did, the 1999 KDHS data confirm the high educational level of Kazakhstan’s population with about 98 percent of men and 97 percent of women having had at least some education. Educational attainment is slightly higher among women than men in Kazakstan, with 14 percent of female and 12 percent of male household members age 7 and older having had some higher education. There are noticeable attainment differences by residence, with urban residents being more likely than rural residents to have attended secondary-special or higher education. Educational attainment is also significantly higher in Almaty City than in other regions. 2.3.2 School Attendance Ratios Table 2.6 presents net and gross attendance ratios by education level, sex, and residence. The net attendance ratio (NAR) indicates participation in schooling among children of official school age (age 7 to 10 for primary and 11 to17 for secondary). The gross attendance ratio (GAR) indicates participation in schooling among youth age 7-24 and is expressed as a percentage of the school-aged population for that level of schooling. The GAR is nearly always higher than the NAR for the same level because the GAR includes participation by youths who may be older or younger than the official age range for that level.1 A NAR of 100 percent would indicate that all of the children in the official age range for that level are attending at that level. The GAR can exceed 100 percent if there is significant overage or underage participation at that level of schooling. The difference between these ratios indicates the incidence of overage and underage participation. In Kazakhstan, school participation among household members of school age is high. The NAR is virtually the same among female and male youths at both the primary (86 percent each) and secondary levels (87 and 88 percent, respectively). The NAR at both the primary and secondary levels is slightly higher in urban than in rural areas. A comparison of the NAR and GAR among male and female students and urban and rural students indicates that a similar proportion of students (about 13 percent at the primary level, and at 8 percent at the secondary level) is under age or over age across groups within each level. 16 * Characteristics of Household Table 2.5 Educational level of the household population Percent distribution of the de facto household population age seven and over by highest level of education attended, and median number of years of schooling, according to selected background characteristics, Kazakhstan 1999 _____________________________________________________________________________________________________ Level of education Number __________________________________________________ of Median Background No Primary/ Secondary- females/ years of characteristic education secondary special Higher Missing Total males schooling _____________________________________________________________________________________________________ FEMALES_____________________________________________________________________________________________________ Age 7-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ Residence Urban Rural Region Almaty City South West Central North East Total 13.9 86.0 0.1 0.0 0.0 100.0 686 1.1 0.5 99.5 0.0 0.0 0.0 100.0 1,142 5.2 0.4 76.0 13.3 10.2 0.0 100.0 888 9.8 0.4 43.0 35.1 21.6 0.0 100.0 737 10.4 0.1 34.1 47.1 18.5 0.2 100.0 743 10.0 0.1 30.3 45.9 23.7 0.0 100.0 756 10.0 0.1 31.7 45.5 22.7 0.0 100.0 798 9.9 0.5 34.9 46.1 18.3 0.2 100.0 717 9.9 0.8 34.7 41.4 22.7 0.5 100.0 553 9.9 0.5 43.1 35.6 20.4 0.4 100.0 545 10.0 1.4 57.5 24.8 16.2 0.0 100.0 389 9.1 4.4 68.3 18.1 9.2 0.0 100.0 548 6.9 15.1 65.8 9.8 8.4 0.9 100.0 933 4.9 2.9 47.9 29.6 19.4 0.2 100.0 4,641 9.6 3.3 65.0 23.1 8.4 0.2 100.0 4,794 9.1 2.3 37.9 25.2 34.4 0.2 100.0 502 10.3 3.3 61.3 22.0 13.0 0.4 100.0 3,334 9.3 3.8 63.2 22.5 10.5 0.0 100.0 1,311 9.2 1.9 49.9 32.5 15.7 0.0 100.0 776 9.5 2.8 55.0 30.5 11.6 0.2 100.0 2,264 9.1 3.1 51.8 30.6 14.4 0.0 100.0 1,248 9.4 3.1 56.6 26.3 13.9 0.2 100.0 9,435 9.3 ______________________________________________________________________________________________________ MALES______________________________________________________________________________________________________ Age 7-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ Residence Urban Rural Region Almaty City South West Central North East Total 15.4 84.6 0.0 0.0 0.0 100.0 739 1.0 0.4 99.5 0.0 0.0 0.0 100.0 1,194 5.1 0.3 75.5 17.2 7.0 0.0 100.0 857 9.4 0.5 53.9 29.0 16.5 0.0 100.0 690 10.3 0.4 46.4 39.1 14.1 0.0 100.0 712 10.1 0.4 40.2 43.8 15.6 0.0 100.0 703 9.9 0.1 37.3 44.8 17.8 0.0 100.0 760 10.0 0.4 38.6 41.3 19.8 0.0 100.0 649 9.9 0.8 43.7 35.6 19.1 0.9 100.0 486 9.9 0.3 41.4 35.7 22.1 0.5 100.0 378 10.1 0.4 50.6 28.1 20.4 0.5 100.0 321 9.6 1.6 54.9 27.6 15.8 0.0 100.0 384 9.1 5.8 63.2 17.4 12.9 0.7 100.0 520 6.6 1.6 51.3 29.2 17.7 0.1 100.0 3,859 9.7 2.5 67.7 22.3 7.3 0.2 100.0 4,533 9.1 1.1 46.3 21.0 31.6 0.0 100.0 389 10.0 2.0 63.8 22.2 11.8 0.1 100.0 3,042 9.4 1.9 67.2 21.5 9.4 0.0 100.0 1,188 9.3 1.8 52.5 32.2 13.4 0.1 100.0 654 9.5 2.2 57.6 29.8 10.1 0.4 100.0 2,035 9.2 2.9 56.9 28.3 11.9 0.0 100.0 1,083 9.3 2.1 60.2 25.5 12.1 0.1 100.0 8,392 9.4 Characteristics of Household * 17 Table 2.6 School attendance ratios Net attendance ratios (NAR) and gross attendance ratios (GAR) for the de facto household population age 7-24 years, by education level, sex, and residence, Kazakhstan 1999 _________________________________________________________________________ Net attendance ratio1 Gross attendance ratio2 Variable and ______________________ ______________________ category Male Female Total Male Female Total _________________________________________________________________________ PRIMARY SCHOOL_________________________________________________________________________ Urban Rural Total 85.2 84.6 84.9 98.5 99.4 98.9 85.9 86.4 86.1 98.6 98.8 98.7 86.0 86.0 86.0 99.0 99.0 99.0 ________________________________________________________________________ SECONDARY SCHOOL__________________________________________________________________________ Urban Rural Total 88.5 89.5 89.0 97.4 97.6 97.5 85.7 87.8 86.7 93.8 96.9 95.3 87.0 88.0 88.0 95.0 97.0 96.0 ________________________________________________________________________ 1 The NAR for primary school is the percentage of the primary-school-age (7-10 years) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school-age (11-17 years) population that is attending secondary school. By definition the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, regardless of age, expressed as the percentage of the official primary-school-age population. The GAR for secondary school is the total number of secondary school students, regardless of age, expressed as the percentage of the official secondary-school-age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent. Figure 2.2 presents the age-specific attendance ratios (ASAR) for the population age 7-24, by sex. The ASAR indicates participation in schooling at any level, from primary through higher education. The closer the ASAR is to 100 percent, the higher the proportion of people of a given age attending school. In Kazakhstan, the majority of youths of primary to secondary school age (7-17) attend school, and there are no significant differences by gender. The relatively lower age-specific attendance ratio for children age 7 (about 55 percent) reflects that many of these 7-year-olds were only age 6 during the school year covered by the survey, and hence were not eligible to attend school at that time. From age 18 to 24, an increasingly smaller proportion of youths attend school. 2.3.3 Grade Repetition and Dropout Rates Table 2.7 shows repetition and dropout rates by school grade. In Kazakhstan, repetition rates are exceptionally low among both male and female students, and in both urban and rural areas. The dropout rate is also low through both the primary and secondary school grades. At the end of secondary school, however, about 48 percent of students leave school instead of continuing to a higher level. Youths in rural areas are less likely than youths in urban areas to make the transition to higher education: more than 61 percent of rural youths leave school after grade 11, compared with 32 percent of urban youth. 18 * Characteristics of Household 2.4 Housing Characteristics Table 2.8 and Figure 2.3 provide information on selected housing characteristics by residence. This information is helpful in assessing the general socioeconomic conditions of the population. To assess the conditions in which respondents live, they were asked questions about certain characteristics of their households, including electricity, source of drinking water, type of sanitation facilities, time to water sources, handwashing facilities, type of fuel for cooking, quality of the floor, and ownership of a garden or dacha and animals. Overall, 97 percent of the households covered in the 1999 KDHS have electricity. However, in rural areas the percentage of households with electricity has declined from 100 percent in 1995 to 94 in 1999. More than half of the households in the 1999 KDHS sample have piped water (59 percent) and most of these households have water piped into the residence (50 percent). About one-third of households (30 percent) use water from an open well. A significant difference is noted between urban-rural households. In urban areas, 90 percent of households have piped water, compared with only 35 percent of households in rural areas. Open wells are among the main sources of water in rural areas (59 percent). Tanker trucks provide water to 5 percent of rural households. The vast majority or urban and rural households are within 15 minutes of a source of water. One indicator of sanitary conditions is the type of toilet in a household. In Kazakhstan, a majority of households (52 percent) have traditional pit toilets (latrines) and 47 percent have flush toilets. In urban areas, 81 percent of households have a flush toilet, compared with 5 percent in rural areas. Ninety-four percent of rural households have traditional pit toilets. Characteristics of Household * 19 Table 2.7 Grade repetition and dropout rates Repetition and dropout rates for the de facto household population age 6-24 years by school grade, sex, and residence, Kazakhstan 1999 _____________________________________________________________________________________________________ School grade __________________________________________________________________________________ Characteristic 1 2 3 4 5 6 7 8 9 10 11 _____________________________________________________________________________________________________ REPETITION RATE1_____________________________________________________________________________________________________ Sex Male Female Residence Urban Rural Total 0.8 0.2 0.0 0.8 1.6 0.3 0.0 0.0 1.1 0.0 0.0 0.9 0.6 0.4 0.0 0.4 0.0 0.3 0.0 0.0 0.0 0.3 0.0 0.8 0.5 0.2 1.6 0.3 0.0 0.0 0.0 0.0 0.3 1.4 0.2 0.0 0.6 0.6 0.0 0.3 0.0 0.9 0.0 0.0 0.8 0.4 0.2 0.4 1.0 0.1 0.2 0.0 0.6 0.0 0.1 _____________________________________________________________________________________________________ DROPOUT RATE2_____________________________________________________________________________________________________ Sex Male Female Residence Urban Rural Total 0.0 0.0 0.8 1.8 1.9 3.9 3.0 1.1 5.7 3.5 50.7 0.0 0.0 0.0 1.1 3.5 6.8 4.6 0.0 1.3 0.7 46.5 0.0 0.0 0.0 0.8 2.3 4.0 2.7 0.0 3.3 2.3 32.1 0.0 0.0 0.7 1.9 3.0 6.4 4.4 0.9 3.6 1.7 60.6 0.0 0.0 0.4 1.5 2.7 5.4 3.8 0.6 3.5 2.0 48.2 ____________________________________________________________________________________________________ 1 The repetition rate is the percentage of students in a given grade that are repeating that grade. 2 The dropout rate is the percentage of students in a given grade in the previous school year who are not attending school. Regarding the type of flooring material, a large percentage (69 percent) of households have wood planks, which are slightly more common in rural households (89 percent) than urban households (52 percent). Forty-two percent of urban households and 5 percent of rural households have linoleum floors. Handwashing facilities are available in most households: 93 percent or more use soap or another cleaning agent and have a basin for handwashing. More than 64 percent of households in Kazakhstan use biogas and natural gas for cooking: biogas is used predominantly in rural areas (51 percent), and natural gas is mostly used in urban areas (42 percent). Twenty-four percent of urban households use electricity for cooking, whereas electricity is used for cooking in only 2 percent of rural households; 39 percent of rural household use firewood, straw, or tezek (dung) for cooking. In the 1999 KDHS, households were asked if any member owned a dacha or had access to a garden from which he or she obtained fruits and vegetables during the growing season. The data indicate that the majority of urban and rural households (51 and 85 percent, respectively) have access to a dacha or garden. Households were also asked about ownership of animals. Seventy-four percent of rural households own animals, compared with only 13 percent in urban areas. 20 * Characteristics of Household Table 2.8 Housing characteristics Percent distribution of households by housing characteristics, according to residence, Kazakhstan 1999 ____________________________________________________ Residence ______________ Characteristic Urban Rural Total ___________________________________________________ Electricity Yes No Total Source of drinking water Piped into residence Piped into yard/plot Public tap Well in residence Well in yard/plot Public well Open water Tanker truck Bottled water Other Total Time to water source <15 minutes (%) Median time to source (minutes) Sanitation facilities Flush toilet Traditional pit toilet No facility/bush Other Total Handwashing facilities Water/tap in household Soap or other cleaning agent Basin in household Type of fuel Electricity Natural gas Biogas Kerosene Coal/lignite Charcoal Firewood/straw Tezek Other Total Floor material Earth/sand Wood planks Parquet/polished wood Linoleum Cement Carpet Other Missing Total Household owns A dacha or access to garden Animals Number of households 99.4 93.9 97.0 0.6 6.1 3.0 100.0 100.0 100.0 82.4 8.0 49.5 4.3 15.3 9.2 4.1 12.0 7.6 0.1 2.6 1.2 3.6 18.6 10.2 3.9 34.5 17.4 0.0 2.8 1.3 1.3 5.2 3.0 0.2 0.0 0.1 0.2 0.9 0.5 100.0 100.0 100.0 94.8 70.0 83.8 0.0 4.3 0.0 80.8 4.9 47.2 19.1 94.1 52.3 0.1 1.0 0.5 0.0 0.1 0.0 100.0 100.0 100.0 97.9 88.5 93.7 97.0 87.7 92.9 97.0 87.1 92.6 24.2 1.8 14.3 42.0 4.5 25.4 29.8 50.7 39.0 0.1 0.2 0.2 0.4 2.3 1.2 0.1 0.8 0.4 2.2 27.5 13.4 0.6 11.1 5.3 0.5 1.1 0.8 100.0 100.0 100.0 0.3 2.6 1.3 52.2 89.0 68.5 2.7 0.3 1.7 41.9 4.6 25.4 0.3 0.7 0.5 0.2 0.0 0.1 2.3 2.6 2.5 0.1 0.0 0.0 100.0 100.0 100.0 50.6 84.5 65.6 12.9 73.7 39.8 3,257 2,587 5,844 2.4.1 Household Durable Goods Table 2.9 indicates the percentage of households owning specific durable goods by residence. Ownership of a radio or a television is a measure of access to mass media; refrigerator ownership indicates the capacity for hygienic food storage; and ownership of a bicycle, motor- cycle, or private car shows the means of transpor- tation available to the household. The availability of durable consumer goods is a rough measure of household socioeconomic status. The results show that 41 percent of households have a radio, 92 percent have a television, 79 percent have a refrigerator, 39 percent have a telephone, 14 percent have a bicycle, and 27 percent have a car. Only 9 per- cent have a private motorcycle. About 4 percent of households have none of these durable goods. Urban-rural differentials can be seen in the ownership of specific durable goods. In general, these goods are more available in urban households than in rural households. For exam- ple, more than half of urban households have a telephone (55 percent), while the proportion in rural areas is only 20 percent. Ninety-one percent of households in urban areas have a refrigerator, compared with 65 percent in rural areas. A higher proportion of both urban and rural house- holds own a television (95 and 87 percent, re- spectively). Rural households are three times more likely to own a motorcycle than urban households due to the greater need for transpor- tation in rural areas. Ownership of televisions, telephones, refrigerators, and private cars has increased slightly since the 1995 KDHS. Conversely, the number of households having radios, bicycles, and motorcycles has declined. Characteristics of Household * 21 Table 2.9 Household durable goods Percentage of households possessing various durable consumer goods, by residence, Kazakhstan 1999 _____________________________________________ Residence ______________ Durable goods Urban Rural Total _____________________________________________ Radio Television Telephone Refrigerator Bicycle Motorcycle Private car None of the above Number of households 51.6 28.5 41.4 .95.3 87.3 91.8 .54.9 19.6 39.3 .90.5 65.1 79.2 12.7 15.7 14.0 4.8 14.4 9.1 .25.8 27.9 26.7 2.0 7.5 4.4 3,257 2,587 5,844 Characteristics of Survey Respondents * 23 3CHARACTERISTICS OF SURVEY RESPONDENTS AND WOMEN’S STATUS Raikhan Sissekenova, Sunita Kishor, and Elnar Kurmangaliyeva 3.1 Characteristics of Survey Respondents 3.1.1 Background Characteristics Table 3.1 presents the percent distribution of women and men by age, current marital status, residence, region, highest educational level, school attendance, religion, and ethnicity. Women and men were asked two questions to determine their ages: “In what month and year were you born?” and “How old were you at your last birthday?” Interviewers were trained in probing techniques for situations in which respondents did not know their age or date of birth. Results show that about 30 percent of women and 28 percent of men are in the age group 15-24 and 29 percent of women and 24 percent of men are in the age group 25-34. Married women and men comprise large proportions of the total women and men interviewed (63 and 65 percent, respectively), while never-married women and men constitute 25 and 30 percent, respectively. Nine percent of women and 5 percent of men are divorced. The distribution of women by marital status is similar in both the 1995 KDHS and the 1999 KDHS. Table 3.1 also shows that the majority of both male and female respondents are Muslims (about 56 percent). Twenty-seven percent of the female respondents and 34 percent of men said they are Christians. Kazakhs are the dominant ethnic group, with 54 percent of females and 52 percent of males belonging to this group. Russian women and men account for 30 and 32 percent of the population, respectively. Table 3.2 shows the distribution of women and men by ethnicity, religion, and residence according to region. The data indicates that the South and West regions have a higher than average concentration of women and men of Kazakh ethnicity, while Russian men and women make up a majority of the respondents in Almaty City and the North region. Similarly, Muslims tend to be concentrated in the South, West, and East regions, while Christians are concentrated in Almaty City. 3.1.2 Educational Level of the Respondents Information on educational level of the respondents by background characteristics is presented in Table 3.3. Differences in educational attainment among female and male respondents are similar to those among the adult household population, which are discussed in section 2.3.1. Twenty-percent of female respondents have had some higher education, compared with only about 14 percent of male respondents. Among both women and men, respondents of Kazakh and Russian ethnicity are more likely to have had some higher education than are respondents in other ethnic groups. 24 * Characteristics of Survey Respondents Table 3.1 Background characteristics of respondents Percent distribution of women 15-49 and men 15-59 by selected background characteristics, Kazakhstan 1999_______________________________________________________________________________ Number of women Number of men __________________ __________________ Background Weighted Un- Weighted Un- characteristic percent Weighted weighted percent Weighted weighted_______________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 Marital status Never married Married/living together Widowed Divorced/separated Residence Urban Rural Region Almaty City South West Central North East Education Primary/secondary Secondary-special Higher Respondent still in school Yes No Religion Muslim Christian Other Not religious Don't know Missing Ethnicity Kazakh Russian Other Total 16.5 791 778 15.7 226 216 13.9 666 662 12.6 182 174 14.4 692 688 12.2 176 188 14.6 698 693 11.9 172 179 15.6 749 766 15.9 229 218 14.2 681 680 11.4 164 174 10.9 522 533 8.5 122 123 0.0 0 0 7.3 104 105 0.0 0 0 4.5 65 63 25.3 1,215 1,243 30.1 433 422 62.9 3,018 2,950 64.8 933 938 3.0 145 152 0.5 8 10 8.8 422 455 4.6 66 70 55.6 2,668 2,927 54.9 790 850 44.4 2,132 1,873 45.1 650 590 6.1 291 636 6.2 90 168 30.3 1,455 922 29.6 426 281 13.1 628 753 12.7 182 264 9.9 475 875 9.7 139 275 26.2 1,259 655 27.5 396 172 14.4 692 959 14.4 207 280 40.1 1,927 1,829 45.9 661 645 39.7 1,908 1,903 40.3 581 568 20.1 965 1,068 13.8 198 227 15.4 741 759 13.7 197 192 84.0 4,034 4,020 86.2 1,241 1,245 55.9 2,685 2,601 56.9 819 824 26.8 1,288 1,397 34.0 490 448 1.4 66 53 0.5 8 4 14.4 693 688 8.3 119 159 1.4 65 58 0.3 4 5 0.0 2 3 0.0 0 0 53.9 2,587 2,545 51.9 747 761 30.3 1,454 1,595 31.9 460 468 15.8 760 660 16.2 234 211 100.0 4,800 4,800 100.0 1,440 1,440 Characteristics of Survey Respondents * 25 Table 3.2 Ethnicity, religion, and residence by region Percent distribution of women and men by ethnicity, religion and residence, according to region, Kazakhstan 1999 ______________________________________________________________________________________ Region _____________________________________________________ Background Almaty characteristic City South West Central North East Total ______________________________________________________________________________________ WOMEN______________________________________________________________________________________ Ethnicity Kazakh Russian Ukrainian German Korean Tatar Other Religion Muslim Christian Other Not religious Don't know Residence Urban Rural Total Number of women 36.6 74.9 72.7 40.6 33.7 45.8 53.9 47.6 11.0 20.9 45.0 38.9 46.3 30.3 1.9 1.4 2.1 5.0 11.6 1.5 4.6 1.3 0.6 0.5 1.9 6.9 2.9 2.7 2.2 0.9 0.5 1.5 0.0 0.1 0.6 2.5 0.4 1.0 2.3 3.2 1.4 1.7 7.9 10.7 2.3 3.5 5.7 1.7 6.1 41.2 83.2 71.6 40.9 34.6 39.7 55.9 45.3 12.9 20.7 41.6 35.0 29.1 26.8 0.8 0.1 0.8 1.0 3.6 1.1 1.4 11.9 3.4 5.9 15.8 24.0 28.1 14.4 0.8 0.4 1.1 0.7 2.8 1.7 1.4 100.0 37.4 56.8 86.4 48.0 66.8 55.6 0.0 62.6 43.2 13.6 52.0 33.2 44.4 100.0 100.0 100.0 100.0 100.0 100.0 100.0 291 1,455 628 475 1,259 692 4,800 ______________________________________________________________________________________ MEN______________________________________________________________________________________ Ethnicity Kazakh Russian Ukrainian German Byelorussian Other Religion Muslim Christian Other Not religious Don't know Residence Urban Rural Total Number of men 33.3 76.3 73.7 36.4 27.8 47.0 51.9 54.8 9.7 19.7 40.2 47.3 43.5 31.9 1.2 0.5 1.8 7.2 10.1 1.6 4.2 0.6 0.0 1.2 3.3 9.6 2.0 3.4 3.0 1.9 0.9 1.6 0.0 0.0 1.0 7.1 11.7 2.6 11.3 5.1 5.8 7.6 37.5 85.0 75.2 39.8 32.2 50.1 56.9 47.6 4.4 15.2 36.9 67.1 40.1 34.0 0.0 1.0 0.5 0.0 0.7 0.0 0.5 14.9 9.3 8.8 22.8 0.0 9.0 8.3 0.0 0.3 0.3 0.4 0.0 0.8 0.3 100.0 37.3 57.1 86.5 46.6 64.2 54.9 0.0 62.7 42.9 13.5 53.4 35.8 45.1 100.0 100.0 100.0 100.0 100.0 100.0 100.0 90 426 182 139 396 207 1,440 26 * Characteristics of Survey Respondents Table 3.3 Level of education Percent distribution of women and men by the highest level of education attended, according to selected background characteristics, Kazakhstan 1999 ________________________________________________________________________ Highest level of education Number _________________________________ of Background Primary/ Secondary- women/ characteristic secondary special Higher Total men ________________________________________________________________________ WOMEN________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Residence Urban Rural Region Almaty City South West Central North East Ethnicity Kazakh Russian Other Total 76.0 12.9 11.2 100.0 791 41.7 35.1 23.2 100.0 666 31.7 48.8 19.5 100.0 692 28.5 47.9 23.6 100.0 698 29.5 47.1 23.4 100.0 749 34.4 46.9 18.7 100.0 681 33.5 43.4 23.1 100.0 522 32.2 41.5 26.2 100.0 2,668 50.1 37.5 12.4 100.0 2,132 25.5 30.7 43.9 100.0 291 48.9 32.7 18.4 100.0 1,455 49.4 34.6 16.0 100.0 628 29.3 47.1 23.6 100.0 475 36.0 47.0 17.0 100.0 1,259 34.5 44.7 20.8 100.0 692 43.7 35.4 20.9 100.0 2,587 32.5 46.7 20.7 100.0 1,454 42.6 41.1 16.3 100.0 760 40.1 39.7 20.1 100.0 4,800 ________________________________________________________________________ MEN________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 Residence Urban Rural Region Almaty City South West Central North East Ethnicity Kazakh Russian Other Total 75.7 22.3 2.0 100.0 226 50.0 36.8 13.2 100.0 182 36.8 50.6 12.6 100.0 176 35.4 47.4 17.2 100.0 172 29.9 54.5 15.6 100.0 229 35.7 49.5 14.8 100.0 164 47.1 32.7 20.3 100.0 122 46.0 34.7 19.3 100.0 104 62.8 16.7 20.6 100.0 65 38.4 43.1 18.5 100.0 790 55.0 36.9 8.1 100.0 650 35.1 31.0 33.9 100.0 90 53.3 36.0 10.7 100.0 426 51.4 36.8 11.8 100.0 182 38.8 43.5 17.7 100.0 139 44.1 44.2 11.7 100.0 396 38.8 46.8 14.4 100.0 207 51.4 34.2 14.4 100.0 747 35.3 51.0 13.7 100.0 460 49.1 39.0 11.9 100.0 234 45.9 40.3 13.8 100.0 1,440 Characteristics of Survey Respondents * 27 Table 3.4 Occupation: women Percent distribution of employed women by current occupation, according to background characteristics, Kazakhstan 1999 ______________________________________________________________________________________________________ Prof./ Number Background Agri- tech./ Sales, Skilled Unskilled of characteristic culture manag. services manual manual Other Missing Total women ______________________________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Marital status Never married Married/living together Widowed Divorced/separated No. of living children 0 1-2 3-4 5+ Residence Urban Rural Region Almaty City South West Central North East Education Primary/secondary Secondary-special Higher Ethnicity Kazakh Russian Other Total 11.2 26.3 47.5 4.2 6.2 4.7 0.0 100.0 61 3.9 47.9 31.0 6.9 7.3 1.0 2.2 100.0 186 3.4 44.5 30.3 10.8 9.4 0.8 0.8 100.0 308 4.8 52.3 27.3 9.3 5.6 0.1 0.4 100.0 328 2.7 49.2 26.4 7.8 12.2 1.3 0.5 100.0 412 3.2 45.6 23.5 13.4 13.5 0.0 0.9 100.0 363 3.3 57.2 17.5 9.6 11.8 0.4 0.1 100.0 323 3.6 50.5 28.3 9.4 5.4 1.8 1.0 100.0 316 4.0 49.7 25.0 9.1 11.1 0.5 0.5 100.0 1,302 2.7 50.5 21.4 13.1 12.2 0.0 0.0 100.0 89 3.0 41.9 31.3 11.0 10.7 0.7 1.4 100.0 273 4.0 48.5 30.9 7.5 6.5 1.8 0.8 100.0 390 2.6 49.5 26.8 10.6 9.3 0.4 0.8 100.0 1,138 5.1 49.8 21.4 9.0 13.6 0.7 0.5 100.0 375 12.2 35.7 18.6 8.9 24.6 0.0 0.0 100.0 78 1.1 48.1 28.4 12.2 8.4 0.7 1.0 100.0 1,315 8.9 50.1 21.9 4.6 13.7 0.7 0.1 100.0 665 0.6 43.2 38.4 5.7 6.5 1.2 4.5 100.0 154 9.1 53.2 23.5 8.1 6.1 0.0 0.0 100.0 544 3.1 51.0 26.7 7.4 11.1 0.3 0.4 100.0 230 2.5 50.2 20.4 14.1 11.2 0.6 1.0 100.0 204 0.7 46.2 25.1 11.5 15.3 0.7 0.4 100.0 534 2.2 45.8 30.5 9.7 9.1 2.1 0.6 100.0 314 9.3 20.7 33.5 15.0 20.2 1.1 0.2 100.0 512 2.5 45.8 29.0 11.2 10.1 0.8 0.6 100.0 877 0.6 77.6 16.0 2.6 1.7 0.2 1.3 100.0 591 3.9 53.7 25.0 6.3 9.8 0.7 0.5 100.0 945 1.8 46.2 25.2 13.8 11.4 0.5 1.2 100.0 711 7.2 40.2 32.4 10.2 8.5 1.2 0.3 100.0 323 3.7 48.8 26.3 9.6 10.2 0.7 0.7 100.0 1,979 3.1.3 Occupation Table 3.4 shows the occupational profiles of currently employed women by background characteristics. Almost half of all employed women are in professional, technical, or managerial occupations, 26 percent are in sales or service occupations, and 10 percent each are in the skilled manual and unskilled manual occupations. Agricultural occupations account for only 4 percent of women’s employment. The professional, technical, or managerial occupations dominate the occupational profiles of employed women at all ages except age 15-19. Women age 15-19 are more likely to be in sales or service occupations than in a professional, technical, or managerial occupation. The professional, technical, and managerial occupations also account for 40 percent or more of employed women in almost all of the other subgroups of the population. 28 * Characteristics of Survey Respondents The largest variation in the proportion of women in these occupations is found by level of education. Only 21 percent of women who have completed only secondary school are in professional, technical, or managerial occupations compared with 78 percent of women with higher education. Accordingly, women who have only completed secondary school are also more likely than women in the other educational categories to be in the agricultural occupations and each of the other types of occupations. As expected, agricultural occupations are of negligible importance in urban areas; however, even in rural areas they account for only 9 percent of working women. Agricultural occupations, however, account for 9-12 percent of employment among the youngest women, women with five or more children, women with the lowest levels of education, and women living in the South region. Sales and service occupations are more common among working women in Almaty City than in any other region of the country. These occupations are relatively less common among the oldest women, women with five or more children, and women in the highest educational category than among women in other subgroups. Notably, unskilled manual occupations, which account for 10 percent of all employed women, are at least twice as common among women who have five or more children and women who have completed only secondary school. Fifty-nine percent of men age 15-59 are currently employed (Table 3.5). This percentage increases from 10 percent for men age 15-19 to 78 percent for men age 35 to 39 and then declines to 41 percent for men age 55-59. Urban men are more likely than rural men to be currently employed and men in Almaty City and the Central region are more likely to be employed than men in other regions. In the West region, only 47 percent of men age 15-59 are currently employed. Men’s employment increases with education and is higher among Russian men than among Kazakh men or men of other ethnicities. In contrast with employed women, half of whom are in professional, technical, or managerial occupations, about half of employed men are in skilled manual occupations. Agricultural occupations (15 percent) are the next most common occupations among men. Only 13 percent of men are in professional, technical, and managerial occupations. Rural men are most likely to be in agricultural occupations, whereas urban men are most likely to be in skilled manual occupations. The proportion of men in professional, technical, or managerial occupations increases with age from 0 percent for age 15-19 to 7 percent for age 20-24 and 25 percent for age 55-59. Almost half of men with a higher education are in these occupations compared with 4-7 percent of men who have completed only secondary or secondary-special education. By region, agricultural occupations are most common in the South region (30 percent); professional, technical, and managerial occupations are most common in the West region (21 percent); sales and service occupations are most common in Almaty City; skilled manual occupations are most common in the Central region; and unskilled manual occupations are most common in the East region. The occupational profile of Russian men is less diversified than that of Kazakh men and men of other ethnicities. For example, 61 percent of Russian men are in the skilled manual occupations, and 10 percent or less are in each of the remaining occupations. In contrast, 37 percent of Kazakh men are in the skilled manual occupations; 19 percent are in agricultural occupations; 16 percent are in professional, technical, or managerial occupations; and the remaining are distributed about equally between sales and services and unskilled manual occupations. 3.1.4 Access to Mass Media Tables 3.6 and 3.7 show the percentage of female and male respondents exposed to different types of mass media by age, urban-rural residence, region, highest educational level, and ethnicity. It is important to know which subgroups are more or less likely to be reached by the media for purposes of planning programs intended to spread information about health, nutrition, and family planning. Characteristics of Survey Respondents * 29 Table 3.5 Occupation: men Percent distribution of employed men by current occupation, according to background characteristics, Kazakhstan 1999 __________________________________________________________________________________________________________ Not Number Prof./ Un- Number Background Em- em- of Agri- tech./ Sales, Skilled skilled of characteristic ployed ployed Total men culture manag. services manual manual Other Missing Total men __________________________________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 Residence Urban Rural Region Almaty City South West Central North East Education Primary/secondary Secondary-special Higher Ethnicity Kazakh Russian Other Total 10.1 89.9 100.0 226 15.8 0.0 10.2 38.1 22.0 4.5 9.3 100.0 23 53.2 46.8 100.0 182 18.3 7.0 10.0 49.4 13.3 1.0 1.0 100.0 97 70.3 29.7 100.0 176 21.0 8.6 13.8 46.8 8.7 1.1 0.0 100.0 124 72.8 27.2 100.0 172 12.1 13.9 17.5 43.0 12.1 1.3 0.0 100.0 125 77.6 22.4 100.0 229 20.7 12.2 11.7 45.3 9.1 0.0 0.9 100.0 178 73.9 26.1 100.0 164 5.5 18.2 8.6 52.0 12.7 2.6 0.4 100.0 121 72.6 27.4 100.0 122 11.4 15.3 9.4 53.6 8.0 1.6 0.6 100.0 89 64.5 35.5 100.0 104 12.4 20.7 2.7 54.7 9.4 0.0 0.0 100.0 67 41.3 58.7 100.0 65 20.4 25.2 1.9 46.7 5.8 0.0 0.0 100.0 27 65.5 34.5 100.0 790 1.6 15.2 14.4 57.8 8.4 1.8 0.9 100.0 518 51.2 48.8 100.0 650 36.6 10.2 5.6 33.0 14.1 0.2 0.4 100.0 333 78.6 21.4 100.0 90 2.3 14.4 22.0 42.4 12.1 3.8 3.0 100.0 71 53.3 46.7 100.0 426 29.8 11.8 9.5 37.1 11.9 0.0 0.0 100.0 227 46.5 53.5 100.0 182 5.2 20.5 12.6 49.4 8.9 1.7 1.7 100.0 85 78.1 21.9 100.0 139 4.8 12.7 9.5 59.9 9.8 1.9 1.4 100.0 109 58.5 41.5 100.0 396 14.7 12.6 6.3 56.7 8.6 1.1 0.0 100.0 232 61.7 38.3 100.0 207 13.4 12.0 16.0 44.1 13.2 0.7 0.6 100.0 128 45.9 54.1 100.0 661 21.7 4.4 6.5 50.0 16.0 0.8 0.7 100.0 304 68.9 31.1 100.0 581 14.3 7.2 11.2 56.1 8.6 1.7 0.9 100.0 400 73.8 26.2 100.0 198 4.7 48.1 19.6 22.2 5.1 0.3 0.0 100.0 147 50.1 49.9 100.0 747 19.2 15.6 13.3 36.9 13.7 0.8 0.5 100.0 374 71.9 28.1 100.0 460 9.5 10.2 8.0 60.6 9.3 1.7 0.7 100.0 330 62.3 37.7 100.0 234 18.3 14.1 11.5 48.6 5.8 0.7 1.1 100.0 146 59.0 41.0 100.0 1,440 15.3 13.3 10.9 48.1 10.6 1.1 0.7 100.0 850 About 62 percent of women and 51 percent of men read newspapers or magazines at least once a week, 90 percent of women and men watch television weekly, and 28 percent of women and 31 percent of men listen to the radio every day. An approximately equal proportion of female and male respondents (6 and 7 percent, respectively) have no access to mass media. The proportion of people with no access to mass media is higher in rural areas than in urban areas. Female and male respondents in Almaty City are most likely to be exposed to all three types of mass media (48 and 64 percent, respectively ). Education clearly has an impact on exposure to mass media. Female and male respondents with higher their education are more likely to have been exposed to mass media. The higher the educational level, the more often women watch television, read newspapers, and listen to the radio. Russian women are more likely to be exposed to mass media (30 percent) than Kazakh women (16 percent) and women of other ethnic groups (23 percent). 3.2 Women’s Status Information on the situation of women of reproductive age (15-49) is useful for understanding the context of reproduction and health in Kazakhstan, and provides indicators of the status of women and of women’s empowerment. While education and employment can contribute to women’s empowerment, direct measures of women’s empowerment allow an evaluation of women’s perception of their own rights and their degree of control over their own lives. 30 * Characteristics of Survey Respondents Table 3.6 Access to mass media: women Percentage of women who usually read a newspaper once a week, watch television once a week, or listen to radio daily, by selected background characteristics, Kazakhstan 1999 ___________________________________________________________________________ Mass media ____________________________________ No Read Watch Listen to All Number Background mass newspaper television radio three of characteristic media weekly weekly daily media women ___________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Residence Urban Rural Region Almaty City South West Central North East Education Primary/secondary Secondary-special Higher Ethnicity Kazakh Russian Other Total 6.6 58.1 89.7 28.5 19.8 791 6.7 60.4 89.5 30.8 22.3 666 5.7 61.3 90.6 30.2 24.7 692 7.3 61.7 89.4 26.0 18.6 698 6.2 64.8 90.1 25.2 20.2 749 6.5 62.5 90.5 28.0 22.3 681 6.0 65.9 91.1 29.9 23.9 522 2.5 72.8 94.5 37.2 30.1 2,668 11.4 48.4 84.6 17.1 10.9 2,132 1.6 81.4 93.4 57.1 48.0 291 9.0 53.7 86.3 27.0 17.1 1,455 9.9 52.6 85.7 21.1 14.7 628 4.5 70.4 93.4 26.7 22.9 475 5.0 70.5 92.7 28.7 24.8 1,259 3.8 58.2 93.6 25.6 19.2 692 10.1 47.9 85.8 21.2 13.2 1,927 5.4 65.4 91.5 29.8 23.6 1,908 1.1 83.0 95.8 39.4 34.1 965 9.0 54.8 86.8 23.3 16.4 2,587 3.1 72.6 94.3 36.2 29.8 1,454 3.9 65.8 93.3 29.9 23.4 760 6.4 61.9 90.1 28.3 21.6 4,800 3.2.1 Employment and Cash Earnings The 1999 KDHS asked a series of questions to determine women’s employment status over the 12 months preceding the survey. For women who were employed, information was also obtained on the nature of employment including occupation and type of earnings, if any. Like education, employment can be a source of empowerment for women, especially if it puts them in control of income. However, measuring women’s employment is difficult. The difficulty arises largely because some of the work that women do, especially work on family farms, in family businesses, or in the informal sector, is often not perceived by women themselves as employment, and hence not reported as such. To avoid underestimating women’s employment, the 1999 KDHS Characteristics of Survey Respondents * 31 Table 3.7 Access to mass media: men Percentage of men who usually read a newspaper once a week, watch television once a week, or listen to radio daily, by selected background characteristics, Kazakhstan 1999 ___________________________________________________________________________ Mass media ____________________________________ No Read Watch Listen to All Number Background mass newspaper television radio three of characteristic media weekly weekly daily media men ___________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 Residence Urban Rural Region Almaty City South West Central North East Education Primary/secondary Secondary-special Higher Ethnicity Kazakh Russian Other Total 9.8 41.6 87.9 26.0 15.2 226 5.8 49.9 89.2 32.4 25.0 182 7.5 41.8 91.2 26.9 17.8 176 10.1 53.3 87.6 32.5 24.8 172 4.9 55.4 92.9 35.3 21.8 229 6.3 53.4 87.1 27.4 14.7 164 4.8 68.1 90.5 31.6 26.1 122 6.1 62.8 90.3 38.1 24.8 104 6.4 40.6 88.4 27.6 12.5 65 2.7 63.2 94.3 39.6 28.3 790 12.3 37.0 83.7 20.0 10.7 650 1.2 82.1 95.8 76.2 63.7 90 12.0 46.7 82.2 29.6 18.6 426 7.6 28.8 90.0 5.1 2.2 182 6.2 65.2 91.3 38.0 30.8 139 4.4 48.8 93.9 32.4 16.3 396 4.7 63.0 92.0 28.0 22.0 207 10.6 37.1 85.6 25.5 14.4 661 5.1 56.8 91.6 30.9 19.7 581 1.1 83.0 96.7 47.8 42.5 198 10.4 45.0 85.1 22.1 14.3 747 3.9 61.9 93.6 38.4 27.7 460 2.7 51.0 95.8 43.2 25.3 234 7.0 51.4 89.6 30.7 20.4 1,440 asked women several questions to ascertain their employment status. First, women were asked, “Aside from your own housework, are you currently working?” Women who answered “no” to this question were then asked, “As you know, some women take up jobs for which they are paid in cash or in kind. Others sell things, have a small business, or work on the family farm or in the family business. Are you currently doing any of these things or any other work?” Women who answered “no” to this question were asked, “Have you done any work in the last 12 months?” Women are considered currently employed if they answered “yes” to either of the first two questions. Women who answered “yes” to the third question are not currently employed but have worked in the past 12 months. All employed women were asked their occupation, whether they were paid in cash, in kind, or not paid at all, and whether their work was done at home or away from home. 32 * Characteristics of Survey Respondents Table 3.8 Employment Percent distribution of women by employment status and among those currently working, whether or not they earned cash, according to background characteristics, Kazakhstan 1999 __________________________________________________________________________________________________ Employment Currently working _______________________________ ______________ No work Worked Number Did not Number Background last 12 last 12 Currently of Earned earn of characteristic months months working Missing Total women cash cash Total women __________________________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Residence Urban Rural Region Almaty City South West Central North East Education Primary/secondary Secondary-special Higher Ethnicity Kazakh Russian Other Total 90.7 1.5 7.7 0.1 100.0 791 71.8 28.2 100.0 61 66.5 5.5 27.9 0.1 100.0 666 94.9 5.1 100.0 186 48.9 6.7 44.5 0.0 100.0 692 92.9 7.1 100.0 308 46.3 6.7 46.9 0.1 100.0 698 90.9 9.1 100.0 328 38.6 5.7 55.0 0.7 100.0 749 90.2 9.8 100.0 412 40.4 6.2 53.3 0.1 100.0 681 88.6 11.4 100.0 363 33.5 4.6 61.8 0.1 100.0 522 88.3 11.7 100.0 323 44.1 6.4 49.3 0.3 100.0 2,668 93.6 6.4 100.0 1,315 65.0 3.8 31.2 0.0 100.0 2,132 82.9 17.1 100.0 665 37.9 9.1 52.8 0.2 100.0 291 93.8 6.3 100.0 154 58.4 4.2 37.4 0.0 100.0 1,455 86.0 14.0 100.0 544 59.5 4.0 36.6 0.0 100.0 628 93.3 6.7 100.0 230 50.3 6.0 42.9 0.8 100.0 475 94.8 5.2 100.0 204 52.2 5.2 42.4 0.2 100.0 1,259 87.5 12.5 100.0 534 48.1 6.4 45.3 0.3 100.0 692 93.7 6.3 100.0 314 69.0 4.4 26.5 0.1 100.0 1,927 83.0 17.0 100.0 512 47.5 6.2 46.0 0.3 100.0 1,908 90.5 9.5 100.0 877 33.7 4.9 61.2 0.2 100.0 965 95.4 4.6 100.0 591 59.8 3.6 36.5 0.1 100.0 2,587 91.3 8.7 100.0 945 43.5 7.4 48.9 0.2 100.0 1,454 91.0 9.0 100.0 711 50.4 6.8 42.5 0.3 100.0 760 84.0 16.0 100.0 323 53.4 5.2 41.2 0.2 100.0 4,800 90.0 10.0 100.0 1,979 Table 3.8 shows that, in Kazakhstan, almost half (46 percent) of all women age 15-49 were either currently employed or had worked during the 12 months preceding the survey. The majority of the women who had worked at all during the 12 months preceding the survey, were also working at the time of the survey. Only 11 percent of women who had worked during the past 12 months (5 percent of all women) were not currently working. Few women age 15-19 were employed during the past 12 months (9 percent), which is expected because women at these ages are still likely to be enrolled in school. Among women age 20 and older, who are more likely to have completed their studies, age is positively associated with the probability of being employed. One-third of women age 20-24 were employed at some time in the past 12 months compared with two-thirds of women age 45-49. The likelihood of employment increases sharply with education. For example, the proportion of women currently employed increases from 27 percent for women who have completed only secondary school to 46 percent for women with secondary-special education and 61 percent for women with higher education. Women in urban areas are more likely than women in rural areas to be employed, and women’s employment also varies substantially by region. The proportion of women employed at any time in the past 12 months is highest in Almaty City (62 percent) and Characteristics of Survey Respondents * 33 lowest in the South and West regions (41 to 42 percent). Russian women are more likely to be employed than either Kazakh women or women of other ethnic groups. While the large majority of women who were currently working did earn cash for their work, one in ten women did not earn cash. Employed women age 15-19 are most likely to be working without earning cash (28 percent). Among older women, however, the proportion working without earning cash doubles with age, from 5 percent for women age 20-24 to 11-12 percent for women age 40-49. By background characteristics other than age, the proportion of women working, but not earning cash is never greater than about 17 percent for any subgroup of working women and is highest for rural women, women who have completed only secondary school, women in the South and North regions, and women of non-Kazakh and non-Russian ethnicities. 3.2.2 Decision-making Regarding Use of Cash Earnings Employed women who earn cash for their work were asked who the main decisionmaker is regarding use of their earnings. This information allows the assessment of women’s control over their own earnings. Table 3.9 shows how women‘s control over their earnings varies by background characteristics. The majority of women (59 percent) decide the use of their earnings alone, and more than one-third (36 percent) do so jointly with their partner or someone else. Only 5 percent of women have no part in deciding how their earnings are used. The likelihood that women decide the use of their earnings alone increases with women’s age. This likelihood is higher in urban than in rural areas and in the Central region and Almaty City than in other regions. It does not vary greatly by education or ethnicity, but is much higher among unmarried women (83 percent) than among currently married women (47 percent). Notably, women in the West region of the country and currently married women are the only subgroups in which less than half of the women decide the use of their earnings alone. In both of these subgroups, women are about as likely to decide the use of their earnings alone as they are to do so with their husband or partner. To assess the relative importance of women’s earnings in meeting household expenditures, the 1999 KDHS asked employed women who earned cash the following question: “On average, how much of your household’s expenditure do your earnings pay for: almost none, less than half, about half, more than half, or all?” This information not only allows an evaluation of the relative importance of women’s earnings in the household economy, but also has implications for women’s status. It is expected that the greater the share of women’s earnings in meeting household expenditures, the more likely it is that women’s employment empowers them, at least within their own households. The variation by background characteristics in the extent to which women’s earnings pay for their households’ expenditures (for women who are employed and earn cash) is also shown in Table 3.9. From Table 3.9 it is clear that when women work for cash, their earnings are critical to meeting household expenditures in most cases. Specifically, in the case of 65 percent of women who earn cash, the woman’s earnings alone pay for at least half of her household’s expenditures, and in the case of 27 percent of women, the woman’s earnings alone pay for all of her household’s expenditures. This suggests that one-tenth of all households in Kazakhstan are solely dependent on the earnings of women for all their expenditures, and in one-fourth of households at least half the expenditures are paid for by women’s earnings alone. For women who earn cash, the likelihood that their earnings alone pay for all of the household’s expenditures rises by women’s age, from 3 percent for women age 15-19 to 33-34 percent for women age 40-49. This proportion varies from 23 percent in the North region to 39 percent in the West region and is much higher for unmarried women (37 percent) than for currently married women (22 percent). It does not vary much however by urban-rural residence, education level, or ethnic group. With the exception of two subgroups of women (women age 15-19 and 20-25), the earnings of at least 60 percent of women in all other subgroups are used to pay for half or more of the household’s expenditures. 34 * Characteristics of Survey Respondents Ta bl e 3. 9 D ec isi on o f u se o f e ar ni ng s an d co nt rib ut io n of e ar ni ng s to h ou se ho ld e xp en di tu re s Pe rc en t d ist rib ut io n of w om en re ce iv in g ca sh e ar ni ng s b y pe rs on w ho d ec id es h ow e ar ni ng s a re u se d, a nd b y pr op or tio n of h ou se ho ld e xp en di tu re s m et b y ea rn in gs , a cc or di ng to b ac kg ro un d ch ar ac te ris tic s, K az ak hs ta n 19 99 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Pe rs on w ho d ec id es h ow e ar ni ng s ar e us ed Pr op or tio n of h ou se ho ld e xp en di tu re s m et b y ea rn in gs __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ N on e, h er Jo in tly So m e- Jo in tly Le ss M or e in co m e D on ’t N um be r Ba ck gr ou nd Re sp on - w ith on e w ith Al m os t th an Ab ou t th an is al l kn ow of ch ar ac te ris tic de nt Pa rtn er pa rtn er el se so m eo ne M iss in g To ta l no ne ha lf ha lf ha lf Al l sa ve d m iss in g To ta l w om en __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ Ag e 1 5- 19 2 0- 24 2 5- 29 3 0- 34 3 5- 39 4 0- 44 4 5- 49 M ar ita l s ta tu s N ot m ar rie d C ur re nt ly m ar rie d Re si de nc e U rb an R ur al Re gi on A lm at y C ity S ou th W es t C en tra l N or th E as t Ed uc at io n P rim ar y/ se co nd ar y S ec on da ry -s pe ci al H ig he r Et hn ic ity K az ak h R us sia n O th er To ta l 50 .8 0. 0 2 .0 26 .1 21 .0 0. 0 10 0. 0 15 .1 46 .6 28 .7 5 .6 2 .7 1. 2 0. 0 10 0. 0 4 3 58 .0 2. 0 15 .4 12 .6 11 .7 0. 3 10 0. 0 15 .7 31 .0 26 .6 8 .7 15 .9 2. 1 0. 0 10 0. 0 17 6 59 .2 1. 9 30 .6 3 .0 5 .2 0. 0 10 0. 0 5 .0 27 .7 29 .4 13 .4 23 .0 1. 2 0. 3 10 0. 0 28 6 59 .2 2. 3 34 .2 2 .9 1 .5 0. 0 10 0. 0 3 .4 25 .2 25 .0 15 .9 29 .0 1. 1 0. 5 10 0. 0 29 8 55 .1 0. 9 40 .9 0 .5 2 .2 0. 4 10 0. 0 4 .0 29 .7 25 .4 11 .9 28 .6 0. 4 0. 0 10 0. 0 37 2 60 .6 1. 4 35 .5 0 .9 1 .6 0. 0 10 0. 0 3 .3 26 .9 20 .1 16 .1 33 .5 0. 0 0. 0 10 0. 0 32 2 66 .2 1. 1 29 .1 1 .0 2 .7 0. 0 10 0. 0 3 .8 32 .7 20 .0 10 .6 32 .5 0. 3 0. 0 10 0. 0 28 5 83 .4 0. 0 0 .7 5 .5 10 .4 0. 0 10 0. 0 7 .0 24 .7 19 .8 9 .3 37 .2 1. 9 0. 1 10 0. 0 61 0 46 .9 2. 3 48 .0 2 .1 0 .6 0. 2 10 0. 0 4 .5 31 .5 26 .7 14 .8 22 .3 0. 2 0. 1 10 0. 0 1, 17 1 63 .0 1. 5 29 .4 2 .1 3 .8 0. 1 10 0. 0 5 .0 28 .9 24 .3 12 .6 28 .2 1. 0 0. 1 10 0. 0 1, 23 1 51 .4 1. 4 37 .1 5 .8 4 .1 0. 1 10 0. 0 6 .1 29 .7 24 .6 13 .6 25 .6 0. 1 0. 3 10 0. 0 55 1 67 .3 1. 9 22 .2 3 .5 5 .1 0. 0 10 0. 0 7 .0 27 .3 21 .3 14 .0 28 .9 1. 6 0. 0 10 0. 0 14 4 54 .6 2. 8 31 .4 7 .7 3 .5 0. 0 10 0. 0 7 .4 33 .9 24 .0 10 .5 23 .9 0. 0 0. 3 10 0. 0 46 8 45 .8 0. 9 45 .8 3 .9 3 .6 0. 0 10 0. 0 5 .0 29 .3 19 .0 7 .0 38 .8 0. 9 0. 0 10 0. 0 21 4 73 .1 1. 4 20 .8 2 .4 1 .8 0. 6 10 0. 0 4 .3 26 .4 23 .2 11 .0 33 .9 1. 3 0. 0 10 0. 0 19 3 61 .8 0. 9 32 .3 0 .4 4 .6 0. 0 10 0. 0 5 .3 27 .5 27 .2 15 .9 23 .3 0. 9 0. 0 10 0. 0 46 8 60 .4 0. 7 33 .3 0 .7 4 .6 0. 2 10 0. 0 2 .1 26 .8 26 .6 17 .2 26 .2 0. 9 0. 3 10 0. 0 29 4 56 .3 2. 1 32 .3 3 .9 5 .2 0. 1 10 0. 0 6 .4 32 .6 26 .8 8 .2 25 .4 0. 3 0. 3 10 0. 0 42 4 61 .4 0. 7 32 .6 2 .3 2 .9 0. 2 10 0. 0 6 .1 29 .3 21 .6 12 .7 29 .5 0. 7 0. 1 10 0. 0 79 4 58 .9 2. 1 30 .3 4 .2 4 .5 0. 0 10 0. 0 3 .4 26 .4 26 .3 16 .7 26 .0 1. 2 0. 0 10 0. 0 56 3 55 .9 1. 9 33 .3 5 .4 3 .3 0. 1 10 0. 0 6 .2 31 .3 24 .1 11 .6 26 .1 0. 7 0. 0 10 0. 0 86 3 63 .5 0. 9 30 .5 0 .8 4 .2 0. 1 10 0. 0 3 .9 28 .8 24 .8 13 .2 28 .0 1. 2 0. 1 10 0. 0 64 8 60 .9 1. 6 30 .1 2 .3 5 .1 0. 0 10 0. 0 6 .2 23 .0 24 .2 16 .3 29 .9 0. 0 0. 5 10 0. 0 27 1 59 .4 1. 5 31 .8 3 .3 3 .9 0. 1 10 0. 0 5 .3 29 .2 24 .4 12 .9 27 .4 0. 8 0. 1 10 0. 0 1, 78 2 Characteristics of Survey Respondents * 35 Table 3.10 Control over earnings by contribution to household expenditures Percent distribution of women receiving cash earnings by person who decides how earnings are used and marital status, according to how much of household expenditures are met by earnings, Kazakhstan 1999 ______________________________________________________________________________________________________________ Married/living together Not married/not living together _______________________________________________ ___________________________ Jointly with: Contribution ______________ Some- Jointly Some- of earnings to Some- Husband/ one Number some- one Number household’s Self Husband/ one partner else of Self one else of expenditures only partner else only only Missing Total women only else only Total women ______________________________________________________________________________________________________________ Almost none 43.6 51.5 0.0 3.0 1.9 0.0 100.0 52 74.6 11.5 13.9 100.0 43 Less than half 48.1 46.3 1.1 1.6 2.6 0.4 100.0 369 74.2 13.6 12.3 100.0 151 About half 44.0 49.0 0.9 3.6 2.4 0.0 100.0 313 79.3 16.9 3.9 100.0 121 More than half 49.0 45.1 0.0 4.0 1.6 0.3 100.0 173 80.8 14.4 4.9 100.0 57 All 48.3 50.6 0.0 0.3 0.8 0.0 100.0 261 93.1 6.0 0.9 100.0 227 None, her income is all saved 35.3 64.7 0.0 0.0 0.0 0.0 100 2.0 100.0 0.0 0.0 100.0 11 Don't know/missing 0.0 0.0 0.0 0.0 100.0 0.0 100.0 1 100.0 0.0 0.0 100.0 1 Total 46.9 48.0 0.6 2.3 2.1 0.2 100.0 1,171 83.4 11.1 5.5 100.0 610 Table 3.10 shows whether working women’s control over their own earnings varies by the extent to which their earnings help to meet household expenditures. Among currently married women who work for cash, there is almost no variation in the likelihood that a woman alone will decide how her earnings are to be used by the extent to which her earnings pay for household expenditures. Irrespective of the proportion of household expenditures paid for by the woman’s own earnings, only 44-49 percent of women decide how their earnings are to be used alone. Among unmarried women, however, the percentage who decide alone how their earnings are to be used increases from 75 percent for women whose earnings pay for almost none of their household’s expenditures to 93 percent for women whose earnings pay for all of their household’s expenditures. 3.2.3 Household Decision-making Besides information on women’s education, employment status, and earnings control, the 1999 KDHS also obtained information on some additional direct measures of women’s autonomy and empowerment. Questions were asked on women’s participation in household decision-making, on their acceptance of wife beating, and on their opinions about when a wife should be able to refuse sex to her husband. These data provide insight into women’s control over their environment and their attitudes toward traditional gender roles, which are two important aspects of women’s empowerment relevant to understanding women’s demographic and health behaviors. In order to assess women’s decision-making autonomy, women were asked about their participation in five different decisions: on the respondent’s own health care; on making large household purchases; on making household purchases for daily needs; on visits to family, friends, or relatives; and on what food to cook each day. Table 3.11 shows the percent distribution of women according to who in the household usually has the final say on each of these decisions. Women are most likely to make decisions alone on matters related to their own health care (68 percent) and to what food to cook each day (69 percent). They are less likely to make other types of household decisions alone: decisions about daily purchases (56 percent); decisions about visits to family, friends, or relatives (28 percent); and decisions about large household purchases (25 percent). Only 18 percent of women do not participate at all in making decisions about their 36 * Characteristics of Survey Respondents Ta bl e 3. 11 H ou se ho ld d ec isi on -m ak in g Pe rc en t d ist rib ut io n of w om en b y pe rs on w ho m ak es s pe ci fic h ou se ho ld d ec isi on s an d m ar ita l s ta tu s, a cc or di ng to ty pe o f d ec isi on , K az ak hs ta n 19 99 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ M ar rie d/ liv in g to ge th er N ot m ar rie d/ no t l iv in g to ge th er Al l w om en __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ Jo in tly Jo in tly So m e- Jo in tly So m e- Jo in tly So m e- w ith so m e- H us ba nd / on e N um be r so m e- on e N um be r so m e- on e N um be r Ty pe o f Se lf hu sb an d/ on e pa rtn er el se of Se lf on e el se of Se lf on e el se of de ci sio n on ly pa rtn er el se on ly on ly To ta l w om en on ly el se on ly To ta l w om en on ly el se on ly To ta l w om en __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Re sp on de nt 's ow n he al th 72 .9 16 .7 1. 2 6. 9 2. 2 10 0. 0 3, 01 8 59 .3 7. 1 33 .5 10 0. 0 1, 78 2 67 .9 13 .9 18 .2 10 0. 0 4, 80 0 La rg e ho us eh ol d p ur ch as es 20 .9 59 .8 2. 8 9. 6 6. 8 10 0. 0 3, 01 8 31 .3 14 .1 54 .6 10 0. 0 1, 78 2 24 .7 44 .6 30 .6 10 0. 0 4, 80 0 D ai ly h ou se ho ld p ur ch as es 66 .9 21 .1 1. 9 3. 7 6. 4 10 0. 0 3, 01 8 37 .4 10 .9 51 .6 10 0. 0 1, 78 2 56 .0 18 .5 25 .5 10 0. 0 4, 80 0 V isi ts to fa m ily , f rie nd s, o r r el at iv es 17 .8 68 .4 2. 6 5. 8 5. 4 10 0. 0 3, 01 8 44 .4 16 .9 38 .7 10 0. 0 1, 78 2 27 .7 50 .9 21 .4 10 0. 0 4, 80 0 W ha t f oo d to c oo k ea ch d ay 86 .2 6. 4 2. 5 1. 2 3. 7 10 0. 0 3, 01 8 40 .6 14 .4 45 .0 10 0. 0 1, 78 2 69 .2 11 .0 19 .8 10 0. 0 4, 80 0 Characteristics of Survey Respondents * 37 own health care (alone or jointly with someone else), but almost one-third (31 percent) do not participate in decisions about making large household purchases. Unmarried women are much less likely than currently married women to be involved in making each of the different decisions. The proportion of currently married women who do not participate in decision-making ranges from 5 percent for decisions about what food to cook to 16 percent for decisions about making large household purchases, whereas the proportion of unmarried women who do not participate in decision-making ranges from 34 percent for decisions about the woman’s own health care to 55 percent for decisions about making large household purchases. Table 3.12 shows how participation in decision-making varies for all women by background characteristics. The proportion of women who participate in all five decisions increases more or less steadily with age, from 12 percent for women age 15-19 to 86 percent for women age 40-44 and then declines slightly to 82 percent for women age 45-49. More than nine out of ten women age 35 and older participate in each of the specific decisions. Among younger women, however, participation varies greatly by type of decision. Never-married women are the least likely to participate in all decisions, and widowed women are the most likely to do so. Almost one-third of never-married women do not participate in any of these decisions. Women with one or two children are more likely than women with no children or three or more children to participate in all decisions. Furthermore, among women who have children, decision-making power decreases sharply with number of children. Women who have five or more children are four times less likely than women with one or two children to participate in any of the decisions. Urban women are slightly more likely than rural women to participate in decision making; however, the size of the urban-rural differential varies by the type of decision. For example, the percentages of urban and rural women participating in decisions about what food to cook are similar (81 and 80 percent, respectively), but 74 percent of urban women participate in decisions about large purchases compared with 64 percent of rural women. Participation in all decisions varies from 74-75 percent for women in the Central and East regions to only 47 percent for women in the South region. Almost one in five women in the South region does not participate in any decision at all. Although women who have completed only secondary school are less likely than women with more education to participate in all the decisions, women with a higher education are somewhat less likely than women with secondary-special education to do so. Kazakh women are much less likely than Russian women and women of other ethnicities to participate in decision- making. As expected women who work, especially women who work for cash, are more likely to participate in all decisions than women who do not work. Women may have a say in some decisions but not in others. To assess a woman’s overall decision-making autonomy, the total number of decisions she participates in (i.e., she alone has the final say or does so jointly with her husband or someone else) are added together. Figure 3.1 gives the distribution of all women according to the number of decisions in which they participate. In Kazakhstan, the majority of women participate in all five of the decisions, and 9 percent do not participate in any of the decisions. Nine percent also participate in only four decisions. The remainder of the women are distributed about equally among those who participate in only one, only two, and only three decisions. 3.2.4 Women’s Agreement with Reasons for Wife Beating Attitudes that see wife beating as “justified” are indicative of women’s lower status both absolutely and relative to men. To assess women’s acceptance of wife beating, the 1999 KDHS asked all women the following: “Sometimes a husband is annoyed or angered by things which his wife does. In your opinion, is a husband justified in hitting or beating his wife in the following situations. . .” 38 * Characteristics of Survey Respondents Table 3.12 Final say in household decisions Percentage of women who say they alone or jointly have the final say in specific household decisions, according to background characteristics, Kazakhstan 1999 ________________________________________________________________________________________ Alone or jointly has final say in: _________________________________________ Visits to Has final Has final Own Making Making family, Food to say in say in no Number Background health large daily friends, cook specified specified of characteristic care purchases purchases relatives daily decisions decisions women ________________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Marital status Never married Married/ living together Widowed Divorced/separated No. of living children 0 1-2 3-4 5+ Residence Urban Rural Region Almaty City South West Central North East Education Primary/secondary Secondary-special Higher Ethnicity Kazakh Russian Other Employment Not employed Working for cash Working, not for cash Total 40.9 17.0 20.8 35.1 30.7 12.2 42.2 791 73.8 48.1 54.5 64.6 68.3 37.9 11.7 666 90.5 74.2 81.6 86.8 90.3 67.5 1.6 692 91.1 81.1 89.1 87.4 94.2 72.5 1.1 698 93.6 91.4 95.4 95.0 96.9 84.7 0.6 749 95.9 92.1 94.7 95.7 96.0 85.8 0.5 681 94.7 92.4 95.6 93.8 93.7 82.4 0.1 522 52.8 27.2 30.4 46.8 39.4 20.4 32.3 1,215 90.9 83.5 89.9 88.8 95.1 75.3 1.2 3,018 99.0 93.4 94.2 97.4 92.7 89.1 0.4 145 94.6 81.3 84.4 90.7 86.9 76.2 2.1 422 75.2 58.7 62.0 69.5 69.7 49.9 14.7 856 86.3 76.7 80.5 85.2 85.6 69.1 5.3 2,563 79.6 62.8 71.9 73.4 78.7 57.5 10.8 1,092 69.6 60.4 67.0 66.7 69.3 51.0 20.5 290 85.6 73.6 77.1 83.2 80.8 65.6 7.4 2,668 77.1 64.0 71.1 72.8 79.5 57.3 11.3 2,132 88.8 74.1 78.3 86.2 82.2 63.5 3.3 291 68.3 55.8 63.3 64.3 73.6 47.3 17.9 1,455 79.5 70.8 72.7 77.3 79.4 63.2 9.7 628 91.0 79.0 80.9 87.6 85.1 73.5 4.8 475 87.5 73.8 80.6 84.5 83.9 66.5 4.2 1,259 92.7 79.9 82.2 89.7 83.9 74.6 4.7 692 71.5 56.9 62.6 67.0 69.8 49.7 16.7 1,927 88.9 79.7 84.2 87.5 89.4 72.3 3.6 1,908 88.4 73.9 78.8 84.1 82.8 65.9 5.0 965 76.6 63.6 69.7 71.9 77.3 56.0 12.7 2,587 89.6 77.6 80.5 87.8 83.1 70.6 5.0 1,454 84.6 73.2 78.8 83.6 84.5 65.3 4.8 760 74.9 59.8 65.9 70.6 74.6 53.2 13.5 2,821 92.7 83.4 87.3 90.7 88.7 75.2 2.2 1,782 82.3 78.8 80.8 82.5 83.8 66.9 9.6 198 81.8 69.4 74.4 78.6 80.2 61.9 9.1 4,800 The five situations presented to women for their opinion were as follows: she burns the food, she argues with him, she goes out without telling him, she neglects the children, and she refuses to have sex with him. The first five columns in Table 3.13 show how acceptance of wife beating varies for each reason. The sixth column gives the percentage of women who feel that wife beating is justified for at least one of the given reasons. Characteristics of Survey Respondents * 39 Among women age 15-49, agreement with the different reasons justifying wife beating is relatively low, varying from only 4 percent for “she burns the food” to 26 percent for “she neglects the children.” Nevertheless, 30 percent of women age 15-49 agreed with at least one reason for which a husband would be justified in beating his wife. There is little variation by age in the proportion of women agreeing with each of the different reasons; nevertheless, the data do suggest that younger women (age 15-34) are somewhat more likely than older women (age 35-49) to agree with at least one reason justifying wife beating. Currently married women more than women in any other marital status are likely to agree with each of the reasons. The proportion agreeing with at least one reason justifying wife beating ranges from 32 percent for currently married women to 22 percent for women who are divorced or separated. Women who have one or two children are less likely than women with no children or three or more children to agree with any of the reasons justifying wife beating. Furthermore, among women who have children, women’s acceptance of wife beating increases sharply with the number of children from 25 percent for women with one or two children to 44 percent for women with five or more children. Rural women are more than twice as likely as urban women to agree with each of the different reasons for wife beating. The level of agreement with wife beating varies greatly by region. Only 10 percent of women in the Central region agree with at least one reason for wife beating compared with 48 percent in the South region. Women in the South region are also more likely than women in most other subgroups to agree with each of the reasons for wife beating. Agreement falls sharply with education level. Those who have completed only secondary school are more than twice as likely (39 percent) as those who have a higher education (17 percent) to agree with at least one reason. Agreement with each of the reasons for wife beating is highest among Kazakh women and lowest among Russian women. Only 14 percent of Russian women agree with at least one reason for wife beating compared with 40 percent of Kazakh women. As expected, women who work for cash are much less likely to agree with each of the different reasons for wife beating. However, women who work but do so without earning cash are likely to agree with each of the reasons for wife beating than unemployed women or women who work for cash. 40 * Characteristics of Survey Respondents Table 3.13 Women’s agreement with reasons for wife beating Percentage of women who agree with specific reasons for justifying wife beating and percentage who agree with at least one reason or none of the reasons, according to background characteristics, Kazakhstan 1999 ________________________________________________________________________________________ Goes out At least Burns Argues without Neglects Refuses one Background the with telling the sexual selected All characteristic food him him children relations reason reasons Total ________________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Current marital status Never married Married/ living together Widowed Divorced/separated No. of living children 0 1-2 3-4 5+ Residence Urban Rural Region Almaty City South West Central North East Mother's education Primary/Secondary Secondary-special Higher Ethnicity Kazakh Russian Other Employment Not employed Working for cash Working not for cash Number of decisions in which she has final say 0-1 2-3 4-5 Total 3.1 11.4 9.8 28.0 3.7 32.4 1.0 791 4.2 11.1 10.6 26.6 6.7 30.8 1.2 666 5.5 11.1 12.0 25.1 5.1 29.2 2.6 692 6.0 13.2 13.9 31.0 7.3 35.6 2.8 698 2.9 8.9 10.4 23.8 4.7 26.3 1.5 749 4.4 10.9 10.4 22.7 6.8 27.1 1.6 681 4.2 12.8 11.8 25.1 7.9 28.6 2.0 522 3.5 7.9 7.6 23.9 3.6 27.7 1.0 1,215 4.8 13.3 13.5 27.9 7.2 32.3 2.2 3,018 3.7 8.5 7.2 23.7 5.2 25.5 0.8 145 3.1 7.5 7.1 20.5 3.4 22.4 1.6 422 4.7 10.3 10.6 22.8 5.7 28.4 1.9 856 2.9 8.0 8.0 22.6 4.7 25.4 1.2 2,563 6.0 17.5 16.1 34.1 7.2 38.6 2.0 1,092 8.6 19.2 23.2 37.3 11.5 43.9 5.5 290 2.8 7.3 6.8 18.6 4.3 21.5 1.5 2,668 6.2 16.2 16.8 35.5 7.8 40.9 2.2 2,132 2.2 4.6 3.5 13.4 1.6 15.6 0.6 291 7.6 22.3 25.9 40.5 11.7 47.8 4.0 1,455 8.4 14.7 13.6 25.4 8.3 31.4 2.8 628 1.1 2.7 0.4 9.0 1.0 9.9 0.0 475 1.6 4.5 3.0 26.1 2.4 27.9 0.1 1,259 1.5 5.9 4.0 13.7 3.0 15.5 0.9 692 6.4 15.5 15.7 33.7 8.0 38.9 2.5 1,927 3.5 9.9 9.8 24.4 5.5 27.6 1.6 1,908 1.7 5.5 5.1 14.3 2.4 17.4 0.8 965 6.4 16.6 17.0 34.1 8.6 39.6 2.6 2,587 1.2 2.3 2.3 11.8 1.9 13.6 0.4 1,454 3.0 10.2 8.6 26.4 4.4 29.1 1.7 760 4.7 12.7 12.3 29.2 6.3 33.3 1.8 2,821 3.5 8.4 9.0 20.5 4.7 24.3 1.8 1,782 5.8 17.0 15.7 32.2 9.9 35.8 2.0 198 5.1 16.2 15.8 34.3 6.8 38.7 2.1 760 6.4 13.1 13.1 31.0 8.4 37.6 3.0 656 3.7 9.8 9.8 23.3 5.2 26.7 1.5 3,384 4.3 11.3 11.2 26.1 5.9 30.1 1.8 4,800 Characteristics of Survey Respondents * 41 As expected agreement with at least one reason for wife beating falls with the level of women’s participation in household decision-making, from 39 percent for women who participate in no more than one household decision to 27 percent for women who participate in all or almost all (4 to 5) household decisions. The lower level of agreement with wife beating among women who are working for cash and among those who participate in all or most household decisions reinforces the idea that even normative acceptance of wife beating decreases with women’s empowerment. Nevertheless, that a substantial proportion of even the women who earn cash and the women who have a relatively high degree of decision-making autonomy agree with at least one reason for wife beating testifies to the strength of norms that promote the acceptance of wife beating. 3.2.5 Women’s Agreement with Reasons for Refusing Sexual Relations The extent of control women have over when and with whom they have sex has important implications for demographic and health outcomes. The 1999 KDHS included a question on whether the respondent thinks that a wife is justified in refusing to have sex with her husband under four circumstances: she is tired or not in the mood, she has recently given birth, she knows her husband has sex with other women, and she knows her husband has a sexually transmitted disease. These four circumstances for which women’s opinions are sought were chosen because they are effective in combining issues regarding women’s rights and women’s health. Table 3.14 shows the percentage of women who say that women are justified in refusing sex to their husband for specific reasons by background characteristics. The table also shows how women’s opinions on refusing sex to their husband vary with their decision-making autonomy and their attitude toward wife beating, both important aspects of women’s empowerment. Overall, 69 percent of women in Kazakhstan agree that women can refuse sex to their husband for all four reasons. Specifically, 79 percent said that women can refuse to have sex with their husband if they are tired or not in the mood, 92 percent said that they can refuse if they have recently given birth, 83 percent said that they can refuse if the husband has sexual relations with other women, and 91 percent said that they can refuse if the husband has the AIDS virus. The proportion of women agreeing with a woman’s right to refuse sex varies little by age for women age 20-49; however, women age 15-19 are less likely than all older women to agree with each of the reasons for women refusing sex to their husband. Sixteen percent of women age 15-19 do not agree with any of the reasons for refusing sex. Furthermore, 13 percent of never-married women and 7 percent of women with no children (both groups that are likely to be composed of younger women) do not agree with any of the reasons for refusing sex. Among ever-married women, divorced women followed by currently married women are more likely than widowed women to agree with all four reasons. Among women with children, the likelihood that a woman will agree with each of the four reasons decreases with the number of children. Urban women are somewhat more likely than rural women to agree with the different reasons for refusing sex. The variation by region is much greater; 65 percent of women in the South region agree with all four reasons compared with 78 percent of women in the Central region. Variation in agreement with all selected reasons is also as expected by education, employment, women’s participation in household decision-making, and with the level of women’s agreement with wife beating. Women with secondary-special and higher education, women working for cash, women who participate in most household decisions (all 4-5 decisions asked about) and women who disagree with all of the reasons for wife beating are more likely than other women in these subgroups to agree with all four reasons for refusing sex. Indeed, agreement with each of the four reasons varies more by the number of decisions women participate in than by most other background variables. For example, 59 percent of women who have the lowest level of participation in household decisions (0-1 decisions only) agree with all four reasons for refusing sex compared with 72 percent of women who have the highest level of participation in household decisions (4-5 decisions). These results also suggest that the different aspects of women’s empowerment, as measured by the indicators being used here, strongly reinforce each other. 42 * Characteristics of Survey Respondents Table 3.14 Women’s agreement with reasons for refusing sexual relations Percentage of women who agree with specific reasons for justifying a wife refusing to have sexual relations with her husband, according to background characteristics, Kazakhstan 1999 _____________________________________________________________________________________ Reason justifying wife refusing sexual relations with husband _________________________________ Wife knows Wife Wife husband knows tired Wife has sexual her or not gave relations husband All No Number Background in the birth with other has the specified specified of characteristic mood recently women AIDS virus reasons reasons women ______________________________________________________________________________________ Age 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Marital status Never married Married/living together Widowed Divorced/separated No. of living children 0 1-2 3-4 5+ Residence Urban Rural Region Almaty City South West Central North East Education Primary/secondary Secondary-special Higher Ethnicity Kazakh Russian Other Employment Not employed Working for cash Working, not for cash Number of decisions in which women has final say 0-1 2-3 4-5 Number of reasons wife beating justified 0-1 2-3 4-5 Total 67.8 77.2 75.7 81.4 61.4 15.7 791 79.7 91.4 84.3 91.0 70.7 4.3 666 81.6 93.9 85.3 93.5 70.6 2.7 692 82.1 95.5 84.6 93.1 71.2 1.9 698 82.5 95.6 84.9 94.6 72.9 1.3 749 78.4 93.7 83.6 92.1 68.7 3.3 681 80.2 96.0 82.9 94.3 70.0 1.4 522 70.6 80.0 77.6 84.5 63.6 12.9 1,215 81.5 95.1 84.1 93.4 70.8 2.0 3,018 77.4 95.4 82.1 89.8 66.9 3.4 145 82.0 97.2 90.4 94.6 74.8 0.9 422 76.2 88.9 81.0 88.9 67.6 6.9 856 80.6 94.0 84.6 92.5 70.5 3.1 2,563 78.0 89.1 81.9 91.6 69.1 5.4 1,092 72.0 85.9 77.4 84.7 62.5 9.4 290 80.7 92.8 84.4 91.9 71.5 4.0 2,668 76.2 89.8 81.1 90.3 66.3 5.5 2,132 81.4 91.7 82.1 89.6 68.7 4.7 291 74.0 88.3 79.3 89.4 64.8 7.6 1,455 78.2 86.5 81.9 85.4 71.4 8.8 628 83.5 96.1 91.1 94.6 77.6 1.5 475 76.9 94.4 84.3 94.8 66.3 1.2 1,259 87.7 94.3 83.7 91.9 76.1 3.3 692 74.9 87.0 79.4 87.8 65.4 7.5 1,927 81.2 95.3 85.8 93.5 72.2 2.9 1,908 81.1 93.1 84.2 93.3 70.9 2.6 965 76.9 88.6 80.8 89.7 67.8 6.7 2,587 82.1 95.4 85.9 92.9 72.2 2.1 1,454 78.3 94.0 84.3 92.9 68.4 2.8 760 77.1 89.2 81.6 89.8 67.6 6.1 2,821 82.0 95.1 85.5 93.9 73.0 2.3 1,782 71.4 91.4 78.3 86.3 58.8 5.4 198 63.7 74.7 72.3 79.2 58.6 18.5 760 78.4 89.9 84.1 92.4 67.1 3.2 656 82.1 95.6 85.1 93.6 72.0 1.9 3,384 69.2 88.1 75.9 88.6 62.7 7.0 195 74.2 89.3 80.4 90.0 62.1 4.4 1,249 80.9 92.5 84.3 91.8 72.2 4.7 3,356 78.7 91.5 82.9 91.2 69.2 4.7 4,800 Characteristics of Survey Respondents * 43 1 Numerators for age-specific fertility rates are calculated by summing the number of live births that occurred in the 1-36 months preceding the survey (determined from the date of interview and birth date of the child) and classifying them by age (in five-year groups) of the mother at the time of birth (determined from the birth date of the mother). The denominators of the rates are the number of woman-years lived in each of the specified five-year age groups during the 1-36 months preceding the survey. Fertility * 43 FERTILITY 4 Toregeldy Sharmanov and Kia I. Weinstein All women interviewed in the 1999 KDHS were asked to provide their complete pregnancy histories. For the data to accurately describe the fertility status of the population of Kazakhstan, it was important for women to report all their pregnancies. To encourage complete reporting of all such events, women were asked separate questions about pregnancies that had ended in live births, induced abortions, miscarriages, and stillbirths. An accounting of live births was achieved by asking separately about the number of sons and daughters living with the respondent, the number living elsewhere, and the number who had died. An accounting of all pregnancies was double-checked by interviewers probing for intervening pregnancies in all pregnancy intervals of four or more years. Each woman’s pregnancy history was obtained in reverse chronological order, from the most recent pregnancy to the respondent’s first pregnancy. The outcome of each pregnancy was recorded (live birth, abortion, miscarriage, or stillbirth), as was the date the pregnancy ended. For each pregnancy that resulted in a live birth, information was collected on the sex of the child, survival status, and age (of living children) or age at death (of deceased children). This chapter presents the findings pertaining to live births. Because ethnicity is a major determinant of fertility in Kazakhstan, fertility data are shown separately for ethnic Kazakhs and ethnic Russians, as well as the overall rates for all of Kazakhstan. Findings pertaining to pregnancy loss are presented in another chapter. 4.1 Current Fertility Age-specific and total fertility rates presented in Table 4.1 and Figure 4.1 were calculated directly from the information obtained in the pregnancy history. The reported rates refer to the three-year period preceding the survey (mid-1996 to mid-1999). Age-specific fertility rates were calculated by dividing the number of births to women in a five-year age interval by the number of woman-years lived in that age interval.1 The total fertility rate (TFR) is a construct of the age- specific rates computed by summing the age-specific rates and multiplying by five. The TFR is expressed per woman and is calculated to provide a snapshot view of current fertility levels. The TFR is interpreted as the number of children a woman would have in her lifetime if she experienced the currently observed age-specific fertility rates during her childbearing years. Table 4.1 presents two other summary measures of fertility: the general fertility rate (GFR) and the crude birth rate (CBR). The GFR represents the annual number of births in the population per 1,000 women age 15-44. The crude birth rate is the annual number of births in the population per 1,000 population. These measures are calculated from the birth history data for the three-year period preceding the survey and the age and sex distribution of the household population. 44 * Fertility Table 4.1 Current fertility Age-specific and cumulative fertility rates and the crude birth rate for the three years preceding the survey, by residence and ethnicity, Kazakhstan 1999 _____________________________________________________________________ Residence Ethnicity ________________ _________________________ Age Urban Rural Kazakh Russian Other Total _____________________________________________________________________ 15-19 20-24 25-29 30-34 35-39 40-44 45-49 TFR 15-49 TFR 15-44 GFR CBR 36 44 30 41 79 40 109 233 202 121 (126) 167 86 133 129 75 67 106 51 78 88 23 47 64 18 32 39 8 8 24 6 12 12 8 0 9 0 0 0 0 (0) 0 1.52 2.66 2.50 1.38 1.63 2.05 1.52 2.66 2.50 1.38 1.63 2.05 50.00 88.00 84.00 43.00 52.00 67.00 11.90 19.40 - - - 15.40 _____________________________________________________________________ Note: Rates are for the period 1-36 months preceding the survey. Rates for age group 45-49 may be slightly biased due to truncation. Rates in parentheses indicate that one or more of the component age-specific rates is based on fewer than 250 woman-years of exposure. TFR: Total fertility rate, expressed per woman GFR: General fertility rate (births divided by number of women 15-44), expressed per 1,000 women CBR: Crude birth rate, expressed per 1,000 population Fertility * 45 Table 4.2 Fertility by background characteristics Total fertility rate for the three years preceding the survey, percentage currently pregnant and mean number of children ever born to women age 40-49, by selected background characteristics, Kazakhstan 1999 _________________________________________________________ Mean number of children Total Percentage ever born Background fertility currently to women characteristic rate1 pregnant1 age 40-49 _________________________________________________________ Residence Urban Rural Region Almaty City South West Central North East Education Primary/secondary Secondary-special Higher Ethnicity Kazakh Russian Other Total 1.52 2.51 2.40 2.66 3.36 3.71 1.00 1.73 1.94 2.86 4.75 3.81 2.26 2.20 3.22 1.59 2.30 2.25 1.72 2.28 2.62 1.42 1.58 2.57 2.42 3.38 3.62 2.06 2.61 2.77 1.51 2.44 2.11 2.50 2.95 3.71 1.38 2.49 2.12 1.63 3.42 2.67 2.05 2.89 2.92 _________________________________________________________ 1 Women age 15-49 years Fertility among urban women is lower than it is among rural women throughout all the childbearing years, resulting in a TFR among urban women that is one child lower than among rural women. If fertility were to remain constant at current levels, a woman in Kazakhstan would give birth to an average of 2.1 children; urban women would have 1.5, while rural women would have 2.7 children. The peak childbearing years for both urban and rural women are during the early twenties (age 20-24). No respondents age 45-49 reported having a live birth in the three years preceding the survey. Ethnic Kazakhs and ethnic Russians both experience their peak childbearing years during their early twenties. However, ethnic Kazakhs achieve a TFR that is higher (2.5 children per woman) than the overall TFR of 2.1, and ethnic Russians achieve a TFR that is lower (1.4 children per woman) than the overall TFR. The lower TFR of ethnic Russians is a result of lower age-specific rates at every age, with the exception of women age 15-19, among whom ethnic Russians exhibit slightly higher fertility than do ethnic Kazakhs. Table 4.2 and Figure 4.2 present TFRs for the three years preceding the survey by background characteristics. It can be seen that regional variation in fertility is substantial, varying by nearly two children. The TFR is lowest among women in Almaty City (1.0 children per woman) and the East region (1.4); intermediate in the Central region (1.6), North region (1.7), and West region (2.3); and highest in the South region (2.9). 46 * Fertility Women in Kazakhstan exhibit a childbearing pattern

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