Tajikistan Demographic and Health Survey 2012

Publication date: 2013

Tajikistan Demographic and Health Survey 2012 Tajikistan 2012 D em ographic and H ealth Survey TAJIKISTAN DEMOGRAPHIC AND HEALTH SURVEY 2012 Statistical Agency under the President of the Republic of Tajikistan Dushanbe, Tajikistan Ministry of Health Dushanbe, Tajikistan MEASURE DHS ICF International Calverton, Maryland, USA November 2013 Statistical Agency under the President of the Republic of Tajikistan Ministry of Health of the Republic of Tajikistan Cover motif: Ceiling fragment at Rohat’s teahouse, Dushanbe Courtesy photo ©2013 Benoit Mathivet This report summarizes the findings of 2012 Tajikistan Demographic and Health Surveys (TjDHS) conducted by the Statistical Agency under the President of the Republic of Tajikistan in collaboration with the Ministry of Health. Support for the 2012 TjDHS was provided by the United States Agency for International Development (USAID) as part of the MEASURE DHS project. Additional funding and support for the 2012 TjDHS was received from the United Nations Population Fund (UNFPA). The TjDHS is part of the worldwide Demographic and Health Surveys program, which is designed to collect data on fertility, family planning, and maternal and child health. The opinions expressed in this report are those of the authors and do not necessarily reflect the views of USAID, the government of Tajikistan, or donor organizations. Additional information about the 2012 TjDHS may be obtained from the Statistical Agency under the President of the Republic of Tajikistan: 17 Bokhtar Street, Dushanbe, Tajikistan; Telephone 992-372-23- 02-45, Fax: 992-372-21-43-75, E-mail: stat@tojikiston.com. Information about the MEASURE DHS project may be obtained from ICF International, 11785 Beltsville Drive, Suite 300, Calverton, MD 20705, USA; Telephone: 301-572-0200, Fax: 301-572-0999, E-mail: info@measuredhs.com, Internet: http://www.measuredhs.com. Suggested citation: Statistical Agency under the President of the Republic of Tajikistan (SA), Ministry of Health [Tajikistan], and ICF International. 2013. Tajikistan Demographic and Health Survey 2012. Dushanbe, Tajikistan, and Calverton, Maryland, USA: SA, MOH, and ICF International. Contents • iii CONTENTS LIST OF TABLES AND FIGURES . ix ACKNOWLEDGEMENTS . xv MDG TABLE . xvii MAP OF COUNTRY . xviii 1 INTRODUCTION 1.1 Geography and Population . 1 1.2 History of Tajik Culture . 2 1.3 Economy . 3 1.4 Health Care System . 3 1.4.1 Facilities and Human Resources . 3 1.4.2 Health Care Reforms . 4 1.4.3 Primary and Secondary Health Care . 5 1.4.4 Maternal and Child Health Care . 5 1.4.5 Family Planning Services . 6 1.4.6 Tuberculosis DOTS Program . 7 1.4.7 HIV/AIDS Program . 7 1.5 Systems for Collecting Demographic and Health Data . 8 1.6 Objectives and Organization of the Survey . 9 1.6.1 Sample Design and Implementation . 9 1.6.2 Questionnaires . 9 1.6.3 Training of Field Staff . 10 1.6.4 Fieldwork and Data Processing. 10 1.7 Response Rates . 11 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION 2.1 Housing Characteristics . 14 2.1.1 Drinking Water . 14 2.1.2 Sanitation Facilities . 16 2.1.3 Other Dwelling Characteristics . 17 2.2 Household Possessions . 19 2.3 Household Wealth . 20 2.4 Hand Washing . 21 2.5 Household Population by Age and Sex . 22 2.6 Household Composition . 23 2.7 Birth Registration . 24 2.8 Children’s Living Arrangements . 25 2.9 Education of Household Members . 27 2.9.1 Educational Attainment . 27 2.9.2 School Attendance . 29 2.9.3 Early Childhood Education . 31 3 BACKGROUND CHARACTERISTICS OF RESPONDENTS 3.1 Background Characteristics of Respondents . 33 3.2 Educational Attainment by Background Characteristics . 34 3.3 Media Exposure . 35 3.4 Employment . 36 iv • Contents 3.4.1 Employment Status . 37 3.4.2 Occupation . 38 3.4.3 Type of Employment . 39 3.5 Tuberculosis . 40 3.5.1 Knowledge and Attitudes about Tuberculosis . 40 3.5.2 Knowledge of Tuberculosis Symptoms . 42 3.5.3 Misconceptions about How Tuberculosis is Spread . 44 3.5.4 Knowledge about How to Prevent Tuberculosis . 44 3.6 Hypertension . 46 3.7 Smoking . 48 4 MARRIAGE AND SEXUAL ACTIVITY 4.1 Current Marital Status . 49 4.2 Age at First Marriage . 50 4.3 Age at First Intercourse . 51 4.4 Recent Sexual Activity . 52 5 FERTILITY 5.1 Current Fertility . 55 5.2 Fertility Differentials . 58 5.3 Fertility Trends . 60 5.4 Children Ever Born and Living . 60 5.5 Birth Intervals . 61 5.6 Postpartum Amenorrhea, Abstinence, and Insusceptibility . 63 5.7 Menopause . 65 5.8 Age at First Birth . 65 5.9 Teenage Pregnancy and Motherhood . 66 6 FERTILITY PREFERENCES 6.1 Desire for More Children . 69 6.2 Desire to Limit Childbearing . 71 6.3 Ideal Family Size . 72 6.4 Fertility Planning . 73 6.5 Wanted Fertility Rates . 74 7 FAMILY PLANNING 7.1 Knowledge of Contraceptive Methods . 77 7.2 Current Use of Contraception . 78 7.3 Current Contraceptive Use by Background Characteristics . 80 7.4 Trends in Current Contraceptive Use . 82 7.5 Source of Modern Contraceptive Methods . 83 7.6 Informed Choice . 84 7.7 Contraceptive Discontinuation . 85 7.8 Knowledge of the Fertile Period . 87 7.9 Unmet Need for Family Planning . 88 7.10 Future Use of Family Planning . 90 7.11 Exposure to Family Planning Messages . 91 7.12 Family Planning Discussion with Health Providers . 92 8 ABORTION 8.1 Collection of Abortion Data . 93 8.2 Pregnancies Ending in Induced Abortion . 93 8.3 Lifetime Experience with Induced Abortion . 94 8.4 Rates of Induced Abortion . 96 8.4.1 Abortion Level . 96 8.4.2 Abortion Differentials . 97 8.4.3 Abortion Trends . 98 8.5 Use of Contraception before Abortion . 98 Contents • v 9 INFANT AND CHILD MORTALITY 9.1 Source and Assessment of Mortality Data . 101 9.1.1 Source of the Data . 101 9.1.2 Data Quality . 102 9.2 Levels and Trends in Childhood Mortality . 103 9.3 Socioeconomic Differentials in Childhood Mortality . 104 9.4 Demographic Differentials in Childhood Mortality . 105 9.5 Perinatal Mortality . 106 9.6 High-risk Fertility Behavior . 108 9.7 Registration of Child Deaths . 109 10 MATERNAL HEALTH 10.1 Antenatal Care . 112 10.1.1 Antenatal Care Coverage . 112 10.1.2 Number of Antenatal Visits . 114 10.1.3 Components of Antenatal Care . 114 10.2 Delivery Care . 116 10.2.1 Place of Delivery. 116 10.2.2 Assistance during Delivery . 118 10.2.3 Cesarean Section . 120 10.3 Postnatal Care for Mothers and Children . 120 10.3.1 Postnatal Checkup for Mother . 120 10.3.2 Postnatal Checkup for the Newborn . 123 10.4 Breast Cancer Awareness and Testing . 124 10.5 Awareness of Cervical Cancer . 126 10.6 Visits to Family Doctor . 127 10.7 Problems in Accessing Health Care . 129 11 CHILD HEALTH 11.1 Child’s Size at Birth . 131 11.2 Vaccination of Children . 133 11.2.1 Vaccination Coverage . 133 11.2.2 Differentials in Vaccination Coverage . 135 11.2.3 Trends in Vaccination Coverage . 136 11.3 Childhood Illness and Treatment . 136 11.3.1 Acute Respiratory Infections (ARI) . 136 11.3.2 Fever . 138 11.3.3 Diarrhea . 139 11.3.4 Knowledge of ORS . 143 11.4 Stool Disposal . 144 12 NUTRITION OF CHILDREN AND WOMEN 12.1 Nutritional Status of Children . 147 12.1.1 Measurement of Nutritional Status among Young Children . 148 12.1.2 Levels of Child Malnutrition . 149 12.1.3 Trends in Children’s Nutritional Status . 151 12.2 Breastfeeding and Complementary Feeding . 153 12.2.1 Initiation of Breastfeeding . 153 12.3 Breastfeeding Status by Age . 155 12.4 Duration of Breastfeeding . 157 12.5 Types of Complementary Foods . 158 12.6 Infant and Young Child Feeding Practices . 160 12.7 Micronutrient Intake among Children . 162 12.7.1 Consumption of Micronutrient-rich Foods . 164 12.7.2 Micronutrient Supplementation . 164 12.7.3 Deworming . 165 vi • Contents 12.8 Household Iodized Salt Consumption . 165 12.9 Nutritional Status of Women . 166 12.10 Micronutrient Intake among Mothers . 168 13 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR 13.1 Knowledge of HIV/AIDS and Transmission and Prevention Methods . 172 13.1.1 Knowledge of AIDS . 172 13.1.2 Knowledge of HIV Prevention Methods . 173 13.1.3 Comprehensive Knowledge about AIDS . 174 13.2 Knowledge of Prevention of Mother-to-Child Transmission of HIV . 176 13.3 Attitudes towards People Living with HIV . 177 13.4 Attitudes toward Negotiating Safe Sexual Relations with Husbands . 179 13.5 Attitudes towards Condom Education for Youth . 180 13.6 Multiple Sexual Partners . 181 13.7 Coverage of HIV Counseling and Testing . 182 13.8 Self-reported Prevalence of Sexually Transmitted Infections (STIs) and STI Symptoms . 184 13.9 Prevalence of Medical Injections. 186 13.10 HIV/AIDS Knowledge and Sexual Behavior Among Youth . 187 13.10.1 HIV/AIDS-Related Knowledge among Young Adults . 188 13.10.2 Age at First Sexual Intercourse among Young Adults . 189 13.10.3 Cross-Generational Sexual Partners . 190 13.10.4 Voluntary HIV Counseling and Testing among Young Adults . 190 14 DOMESTIC VIOLENCE 14.1 Measurement of Violence . 193 14.1.1 Use of Valid Measures of Violence . 193 14.1.2 Ethical Considerations in Measuring Violence . 195 14.2 Experience of Physical Violence . 195 14.3 Experience of Sexual Violence . 197 14.4 Experience of Different Forms of Violence . 199 14.5 Violence during Pregnancy . 200 14.6 Marital Control by Husband . 200 14.7 Forms of Spousal Violence . 202 14.8 Differentials in Spousal Violence . 204 14.9 Recent Experience of Spousal Violence . 207 14.10 Onset of Spousal Violence . 209 14.11 Physical Consequences of Spousal Violence . 209 14.12 Violence by Women against Their Spouse . 210 14.13 Help-seeking Behavior by Women Who Experience Violence . 212 15 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES 15.1 Employment and Form of Earnings . 216 15.2 Women’s Control over Their Own Earnings . 216 15.3 Women’s Control over their Husband’s Earnings . 218 15.4 Ownership of Assets . 219 15.5 Women’s Empowerment . 221 15.6 Attitudes toward Wife Beating . 223 15.7 Indicators of Women’s Empowerment . 225 15.8 Current Use of Contraception by Women’s Empowerment . 226 15.9 Ideal Family Size and Unmet Need by Women’s Empowerment . 227 15.10 Reproductive Health Care by Women’s Empowerment . 228 15.11 Infant and Child Mortality and Women’s Empowerment . 229 REFERENCES . 231 Contents • vii APPENDIX A A.1 Introduction . 237 A.2 Sample Frame . 237 A.3 Sampling Procedures and Sample Allocation . 238 A.4 Sample Probabilities and sampling weights . 238 A.5 Survey Results . 239 APPENDIX B . 241 APPENDIX C . 253 APPENDIX D . 259 APPENDIX E . 263 Tables and Figures • ix TABLES AND FIGURES 1 INTRODUCTION Table 1.1 Basic demographic indicators . 2 Table 1.2 Results of the household and individual interviews . 11 2 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION Table 2.1 Household drinking water . 14 Table 2.2 Household sanitation facilities . 16 Table 2.3 Household characteristics . 17 Table 2.4 Household possessions . 19 Table 2.5 Wealth quintiles . 21 Table 2.6 Hand washing . 22 Table 2.7 Household population by age, sex, and residence . 22 Table 2.8 Household composition . 24 Table 2.9 Birth registration of children under age 5 . 25 Table 2.10 Children's living arrangements and orphanhood . 26 Table 2.11.1 Educational attainment of the female household population . 28 Table 2.11.2 Educational attainment of the male household population . 28 Table 2.12 School attendance ratios . 29 Table 2.13 Early childhood education . 32 Figure 2.1 Trends in use of improved drinking water sources, Tajikistan 2000, 2005, and 2012 . 15 Figure 2.2 Population pyramid . 23 Figure 2.3 Age-specific attendance rates of the de facto population 7 to 24 years . 31 3 BACKGROUND CHARACTERISTICS OF RESPONDENTS Table 3.1 Background characteristics of respondents . 34 Table 3.2 Educational attainment . 35 Table 3.3 Exposure to mass media . 36 Table 3.4 Employment status . 37 Table 3.5 Occupation . 39 Table 3.6 Type of employment . 40 Table 3.7 Knowledge and attitude concerning tuberculosis . 41 Table 3.8 Knowledge of symptoms of tuberculosis . 43 Table 3.9 Misconceptions about tuberculosis transmission . 44 Table 3.10 Women's report on how to prevent spreading of tuberculosis . 45 Table 3.11 Knowledge and treatment of high blood pressure . 47 Figure 3.1 Women's employment status in the past 12 months. 38 Figure 3.2 Women ever told they had hypertension by Body Mass Index . 48 4 MARRIAGE AND SEXUAL ACTIVITY Table 4.1 Current marital status . 49 Table 4.2 Age at first marriage . 50 Table 4.3 Median age at first marriage by background characteristics . 51 Table 4.4 Age at first sexual intercourse . 51 Table 4.5 Median age at first sexual intercourse by background characteristics . 52 Table 4.6 Recent sexual activity: Women . 53 x • Tables and Figures 5 FERTILITY Table 5.1 Current fertility . 56 Table 5.2 Fertility by background characteristics . 59 Table 5.3 Trends in age-specific fertility rates . 60 Table 5.4 Children ever born and living . 61 Table 5.5 Birth intervals . 62 Table 5.6 Postpartum amenorrhea, abstinence and insusceptibility . 63 Table 5.7 Median duration of amenorrhea, postpartum abstinence, and postpartum insusceptibility . 64 Table 5.8 Menopause . 65 Table 5.9 Age at first birth . 65 Table 5.10 Median age at first birth . 66 Table 5.11 Teenage pregnancy and motherhood . 67 Figure 5.1 Age-specific fertility rates by urban-rural residence . 57 Figure 5.2 Comparison of TFR in Tajikistan with other countries in the region . 58 Figure 5.3 Fertility differentials . 58 6 FERTILITY PREFERENCES Table 6.1 Fertility preferences by number of living children . 70 Table 6.2 Desire to limit childbearing . 71 Table 6.3 Ideal number of children by number of living children . 72 Table 6.4 Mean ideal number of children, by background characteristics . 73 Table 6.5 Fertility planning status . 74 Table 6.6 Wanted fertility rates . 75 Figure 6.1 Fertility preferences among currently married women age 15-49 . 70 7 FAMILY PLANNING Table 7.1 Knowledge of contraceptive methods . 78 Table 7.2 Current use of contraception by age . 79 Table 7.3 Current use of contraception by background characteristics . 81 Table 7.4 Trends in current use of contraception . 82 Table 7.5 Source of modern contraception methods . 84 Table 7.6 Informed choice . 85 Table 7.7 Twelve-month contraceptive discontinuation rates . 86 Table 7.8 Reasons for discontinuation . 87 Table 7.9 Need and demand for family planning among currently married women . 90 Table 7.10 Future use of contraception . 91 Table 7.11 Exposure to family planning messages . 91 Table 7.12 Contact of nonusers with family planning providers . 92 Figure 7.1 Current contraceptive use among currently married women age 15-49 . 80 Figure 7.2 Trends in current contraceptive use among currently married women, Tajikistan 2000, 2005, and 2012 . 83 Figure 7.3 Perceived fertile period among all women age 15-49 . 88 8 ABORTION Table 8.1 Pregnancy outcome by background characteristics . 94 Table 8.2 Lifetime experience with induced abortion . 95 Table 8.3 Induced abortion rates . 96 Table 8.4 Induced abortion rates by background characteristics . 97 Table 8.5 Trends in age-specific abortion rates . 98 Table 8.6 Use of contraception before pregnancy . 99 Figure 8.1 Age-specific fertility rates and induced abortion rates. 97 Tables and Figures • xi 9 INFANT AND CHILD MORTALITY Table 9.1 Early childhood mortality rates . 103 Table 9.2 Early childhood mortality rates by socioeconomic characteristics . 105 Table 9.3 Early childhood mortality rates by demographic characteristics . 106 Table 9.4 Perinatal mortality . 107 Table 9.5 High-risk fertility behavior . 108 Figure 9.1 Trends in Infant and Child Mortality, Tajikistan 1998-2012 . 104 Figure 9.2 Registration of deaths of children born in the five years prior to the 2012 Tajikistan DHS . 109 10 MATERNAL HEALTH Table 10.1 Antenatal care . 112 Table 10.2 Number of antenatal care visits and timing of first visit . 114 Table 10.3 Components of antenatal care . 115 Table 10.4 Place of delivery . 116 Table 10.5 Assistance during delivery . 119 Table 10.6 Timing of first postnatal checkup for the mother . 121 Table 10.7 Type of provider of first postnatal checkup for the mother . 122 Table 10.8 Timing of first postnatal checkup for the newborn . 123 Table 10.9 Type of provider of first postnatal checkup for the newborn . 124 Table 10.10 Knowledge about breast cancer and symptoms of breast cancer . 125 Table 10.11 Breast examinations . 126 Table 10.12 Knowledge about cervical cancer and Pap smear testing . 127 Table 10.13 Family doctor . 128 Table 10.14 Problems in accessing health care . 130 Figure 10.1 Differentials in coverage of antenatal care from a skilled provider, Tajikistan, 2012 . 113 Figure 10.2 Differentials in percentage of births delivered in health facilities, Tajikistan, 2012 . 117 Figure 10.3 Duration of mother's stay in health facility after giving birth . 118 11 CHILD HEALTH Table 11.1 Child's size and weight at birth . 132 Table 11.2 Vaccinations by source of information . 134 Table 11.3 Vaccinations by background characteristics . 135 Table 11.4 Prevalence and treatment of symptoms of ARI . 137 Table 11.5 Prevalence and treatment of fever . 138 Table 11.6 Prevalence of diarrhea . 139 Table 11.7 Diarrhea treatment . 141 Table 11.8 Feeding practices during diarrhea . 142 Table 11.9 Knowledge of ORS packets . 143 Table 11.10 Disposal of children's stools . 144 Figure 11.1 Percentage of children age 18-29 months with specific vaccinations, Tajikistan 2012 . 134 Figure 11.2 Differentials in vaccination coverage, Tajikistan 2012 . 136 12 NUTRITION OF CHILDREN AND WOMEN Table 12.1 Nutritional status of children . 149 Table 12.2 Initial breastfeeding . 154 Table 12.3 Breastfeeding status by age . 155 Table 12.4 Median duration of breastfeeding . 158 Table 12.5 Foods and liquids consumed by children in the day or night preceding the interview . 159 xii • Tables and Figures Table 12.6 Infant and young child feeding (IYCF) practices . 161 Table 12.7 Micronutrient intake among children . 163 Table 12.8 Presence of iodized salt in household . 166 Table 12.9 Nutritional status of women . 167 Table 12.10 Micronutrient intake among mothers . 169 Figure 12.1 Nutritional status of children by age . 150 Figure 12.2 Trends in nutritional status of children under age 5, Tajikistan 2012 . 152 Figure 12.3 Infant feeding practices by age, Tajikistan 2012 . 156 Figure 12.4 Infant and young child feeding indicators on breastfeeding status, Tajikistan 2012 . 157 Figure 12.5 IYCF indicators on minimum acceptable diet, Tajikistan 2012 . 162 13 HIV/AIDS-RELATED KNOWLEDGE, ATTITUDES, AND BEHAVIOR Table 13.1 Knowledge of AIDS . 172 Table 13.2 Knowledge of HIV prevention methods . 173 Table 13.3 Comprehensive knowledge about AIDS . 175 Table 13.4 Knowledge of prevention of mother-to-child transmission of HIV . 177 Table 13.5 Accepting attitudes toward those living with HIV/AIDS . 178 Table 13.6 Attitudes toward negotiating safer sexual relations with husband . 179 Table 13.7 Adult support of education about condom use to prevent AIDS . 180 Table 13.8 Multiple sexual partners . 181 Table 13.9 Coverage of prior HIV testing . 182 Table 13.10 Pregnant women counseled and tested for HIV . 184 Table 13.11 Self-reported prevalence of sexually-transmitted infections (STIs) and STIs symptoms . 185 Table 13.12 Prevalence of medical injections . 187 Table 13.13 Comprehensive knowledge about AIDS and of a source of condoms among young women . 188 Table 13.14 Age at first sexual intercourse among young women . 189 Table 13.15 Age-mixing in sexual relationships among women age 15-19 . 190 Table 13.16 Recent HIV tests among young women . 191 Figure 13.1 Knowledge about AIDS and HIV prevention methods among women age 15-49, Tajikistan 2012 . 174 Figure 13.2 Knowledge about AIDS transmission, Tajikistan 2012 . 176 Figure 13.3 Treatment seeking for STI symptoms among women age 15-49, Tajikistan 2012 . 186 14 DOMESTIC VIOLENCE Table 14.1 Experience of physical violence . 196 Table 14.2 Persons committing physical violence . 197 Table 14.3 Experience of sexual violence. 198 Table 14.4 Persons committing sexual violence . 199 Table 14.5 Experience of different forms of violence . 199 Table 14.6 Experience of violence during pregnancy . 200 Table 14.7 Marital control exercised by husbands . 201 Table 14.8 Forms of spousal violence . 203 Table 14.9 Spousal violence by background characteristics . 205 Table 14.10 Spousal violence by husband's characteristics and empowerment indicators . 206 Table 14.11 Physical or sexual violence in the past 12 months by any husband/ partner . 208 Table 14.12 Experience of spousal violence by duration of marriage . 209 Table 14.13 Injuries to women due to spousal violence . 209 Table 14.14 Violence by women against their spouse . 210 Table 14.15 Women's violence against their husband by husband's characteristics and empowerment indicators . 211 Tables and Figures • xiii Table 14.16 Help seeking to stop violence . 212 Table 14.17 Sources for help to stop the violence . 213 Figure 14.1 Percentage of ever-married women age 15-49 who have experienced specific types of violence from current or most recent husband, ever and in the last 12 months, Tajikistan 2012 . 203 15 WOMEN’S EMPOWERMENT AND DEMOGRAPHIC AND HEALTH OUTCOMES Table 15.1 Employment and cash earnings of currently married women . 216 Table 15.2.1 Control over women's cash earnings and relative magnitude of women's cash earnings . 217 Table 15.2.2 Control over men's cash earnings . 218 Table 15.3 Women's control over their earnings and over those of their husbands . 219 Table 15.4 Ownership of assets . 220 Table 15.5 Participation in decision making . 221 Table 15.6 Women's participation in decision making by background characteristics . 222 Table 15.7 Attitude toward wife beating . 224 Table 15.8 Indicators of women's empowerment . 226 Table 15.9 Current use of contraception by women's empowerment . 226 Table 15.10 Ideal number of children and unmet need for family planning, by women's empowerment . 227 Table 15.11 Reproductive health care by women's empowerment . 228 Table 15.12 Early childhood mortality rates by women's status . 229 Figure 15.1 Number of decisions in which currently married women participate, Tajikistan 2012 . 223 APPENDIX A Table A.1 Households . 237 Table A.2 Sample allocation of clusters and households . 238 Table A.3 Sample implementation: Women . 240 APPENDIX B Table B.1 List of selected variables for sampling errors, Tajikistan DHS 2012 . 243 Table B.2 Sampling errors: National sample, Tajikistan 2012 . 244 Table B.3 Sampling errors: Urban sample, Tajikistan 2012 . 245 Table B.4 Sampling errors: Rural sample, Tajikistan 2012 . 246 Table B.5 Sampling errors: Dushanbe sample, Tajikistan 2012 . 247 Table B.6 Sampling errors: GBAO sample, Tajikistan 2012 . 248 Table B.7 Sampling errors: Sughd sample, Tajikistan 2012 . 249 Table B.8 Sampling errors: DRS sample, Tajikistan 2012 . 250 Table B.9 Sampling errors: Khatlon sample, Tajikistan 2012 . 251 APPENDIX C Table C.1 Household age distribution . 253 Table C.2 Age distribution of eligible and interviewed women . 254 Table C.3 Completeness of reporting . 254 Table C.4 Births by calendar years . 254 Table C.5 Reporting of age at death in days . 255 Table C.6 Reporting of age at death in months . 255 Table C.7 Nutritional status of children based on the NCHS/CDC/WHO International Reference Population . 256 Acknowledgments • xv ACKNOWLEDGMENTS he Statistical Agency under the President of the Republic of Tajikistan is pleased to present the results of the 2012 Tajikistan Demographic and Health Survey (TjDHS). This survey was sponsored by the United States Agency for International Development (USAID). Additional funding was provided by the United Nations Population Fund (UNFPA) in Tajikistan. The 2012 TjDHS is the first DHS survey to be undertaken in the country. The Statistical Agency wishes to express its appreciation to the Ministry of Health of the Republic of Tajikistan, ICF International, and the TjDHS Steering Committee for their technical assistance and timely support in implementation of this work. The Statistical Agency, in particular, expresses appreciation to the following MEASURE DHS project staff and consultants for their technical support during all stages of survey design and implementation: Dr. Gulnara Semenov, regional coordinator for Europe and Eurasia and the 2012 TjDHS country manager; Alfredo Aliaga, senior sampling specialist; Shawna Kelly, data processing specialist; and Dr. Saida Ismayilova, consultant survey specialist. We also wish to acknowledge the employees of the statistical system of the Republic of Tajikistan for their active participation in and contribution to this work. Over 200 staff members from the Statistical Agency under the President of the Republic of Tajikistan, working in regional, city, and rayon branches of the agency as well as in the State Leading Information Centre, participated in the survey. We hereby extend our gratitude to the government of Tajikistan and to the representatives of local authorities for their support and assistance during the survey process. Above all, we appreciate the co-operation of all the survey respondents who have made the 2012 TjDHS a success. This report was prepared as a joint effort of the Statistical Agency under the President of the Republic of Tajikistan and ICF International staff. Mrs. Bakhtya Muhammadieva Director, Statistical Agency under the President of the Republic of Tajikistan, and National Coordinator, 2012 TjDHS T Millennium Development Goal Indicators • xvii MILLENNIUM DEVELOPMENT GOAL INDICATORS Millennium Development Goal Indicators Tajikistan, 2012 Indicator Sex Total Male Female 1. Eradicate extreme poverty and hunger 1.8 Prevalence of underweight children under 5 years of age 12.3 11.9 12.1 2. Achieve universal primary education 2.1 Net attendance ratio in primary education1 94.0 93.5 93.8 3. Promote gender equality and empower women 3.1 Ratio of girls to boys in primary, secondary and tertiary education 3.1a Ratio of girls to boys in primary education2 na na 1.0 3.1b Ratio of girls to boys in secondary education2 na na 1.0 3.1c Ratio of girls to boys in tertiary education2 na na 0.3 4. Reduce child mortality 4.1 Under five mortality rate3 51 46 43 4.2 Infant mortality rate3 41 36 34 4.3 Percentage of 1 year old children immunized against measles4 95.0 95.5 95.2 5. Improve maternal health 5.2 Percentage of births attended by skilled health personnel5 na na 87.4 5.3 Contraceptive prevalence rate6 na 27.9 na 5.4 Adolescent birth rate7 na 53.6 na 5.5 Antenatal care coverage 5.5a At least one visit8 na 78.8 na 5.5b Four or more visits9 na 52.5 na 5.6 Unmet need for family planning10 na 22.9 na 6. Combat HIV/AIDS, malaria and other diseases 6.3 Percentage of the population age 15-24 years with comprehensive correct knowledge of HIV/AIDS11 na 8.7 na 6.4 Ratio of school attendance of orphans to school attendance of non-orphans age 10-14 years 0.96 0.65 0.81 Urban Rural Total 7. Ensure environmental sustainability 7.8 Percentage of population using an improved water source12 94.1 70.6 76.2 7.9 Percentage of population using an improved sanitation facility13 92.9 94.6 94.2 na = Not applicable 1 This is a proxy for MDG indicator 2.1, Net enrollment ratio. The ratio is based on reported attendance, not enrollment, in primary education among primary school age children (7-10 year-olds). The rate also includes children of primary school age enrolled in secondary education and therefore is different from the Net Attendance Ratio (NAR) for primary school presented in this report in Table 2.12. 2 Based on reported net attendance, not gross enrollment, among 7-10 year-olds for primary, 11-17 year-olds for secondary and 18-22 year-olds for tertiary education. 3 Expressed in terms of deaths per 1,000 live births. Mortality by sex refers to a 10-year reference period preceding the survey. Mortality rates for males and females combined refer to the 5-year period preceding the survey. 4 In Tajikistan, measles vaccinations are given at the age of 12 months (unlike the standard 9 months in many countries). The values presented in the MDG table are for children age 18-29 months who have been vaccinated against measles or MR at any time before the survey. 5 Among births in the five years preceding the survey. 6 Percentage of currently married women age 15-49 using any method of contraception. 7 Equivalent to the age-specific fertility rate for women age 15-19 for the 3-year period preceding the survey, expressed in terms of births per 1,000 women age 15-19. 8 With a skilled provider. 9 With any healthcare provider. 10 Numbers in this table correspond to the revised definition of unmet need described in Bradley et al., 2012. 11 Comprehensive knowledge means knowing that consistent use of a condom during sexual intercourse and having just one uninfected faithful partner can reduce the chance of getting the AIDS virus, knowing that a healthy-looking person can have the AIDS virus, and rejecting the two most common local misconceptions about transmission or prevention of the AIDS virus. 12 Percentage of de jure population whose main source of drinking water is a household connection (piped), public tap or standpipe, tubewell or borehole, protected dug well, protected spring, rainwater collection, or bottled water. 13 Percentage of de jure population whose household has a flush toilet, ventilated improved pit latrine, pit latrine with a slab, or composting toilet and does not share this facility with other households. xviii • Map of Tajikistan Introduction • 1 INTRODUCTION 1 1.1 GEOGRAPHY AND POPULATION he republic of Tajikistan is a small, landlocked country located in the southeastern region of Central Asia. The territory of Tajikistan covers 142,600 square kilometers and is bordered by Uzbekistan and Kyrgyzstan to the west and north, China to the east, and Afghanistan to the south. The country’s border is about 3,000 kilometers long. The capital city of Tajikistan is Dushanbe. Nearly all of Tajikistan is mountainous, with 93 percent of the country covered by the massive mountain systems of Central Asia—the Trans-Alay range in the North and the Pamir Mountains in the Southeast. Somoni Peak, formerly Communism Peak, is the tallest mountain in Tajikistan and in the former Soviet Union (7,495 meters). Tajikistan’s climate is mainly continental, with mild winters and hot summers, but it varies with the altitude. The climate is arid in the subtropical, southwestern lowlands, which have the highest temperatures, and it changes from semi-arid to polar in the Pamir Mountains in the southeast (Curtis, 1997). Tajikistan’s wealth is in its hydropower resources. Among the countries of the former Soviet Union, Tajikistan is second only to Russia in its water resources and has a greater hydroelectric power capacity than any other country in Central Asia. Tajikistan's glaciers and rivers provide an estimated four percent of the world's hydropower resources. The main rivers are the Syr-Darya, Amu-Darya, and Zarafshan. The majority of Tajikistan's hydroelectric energy is produced by hydroelectric stations, including the Varzob, Kayrakkum, Sarband, Nurek, Baipasi, and Sangtuda. The country’s flora and fauna are wonderfully rich and diverse, and include rare species such as the snow leopard, the Macro Polo sheep, the bar-headed migrating goose, the Bukhara red deer, the desert antelope, and the Siberian ibex. The country is rich in mineral resources; there are many deposits of rare and precious metals such as zinc, lead, bismuth, molybdenum, tungsten, gold, silver, aluminum, antimony, mercury, and fluorspar, as well as coal, gas, oil, and other natural resources. Tajikistan is a sovereign, democratic, secular, and unitary state. It is also a presidential democracy. The president is elected by the citizens of Tajikistan on the basis of a universal, equal, and direct vote for a seven-year term. The last election was held on November 6, 2007; the president of Tajikistan is the head of state and head of the executive branch of government. Tajikistan consists of the two administrative regions (oblasts) of Khatlon and Sughd, the Gorno- Badakhshan Autonomous Oblast (GBAO), the Districts of Republican Subordination (DRS), and Dushanbe City. Each region is further broken down into administrative areas called rayons. There are 58 rayons and 74 towns and urban settlements in Tajikistan. With a population of 8 million in 2013, Tajikistan is the seventh most populous country of the former Soviet Union, following in order, Russia, Ukraine, Uzbekistan, Kazakhstan, Belarus, and Azerbaijan. Approximately 73 percent of the population resides in rural areas. The country is characterized by a high rate of population growth, mainly due to the high (although declining) birth rate (28 per 1,000 population in 2012 as opposed to 39 per 1,000 in 1991) and relatively low death rate (4.3 per 1,000 population in 2012) (SA, 2013b). The size of the resident population enumerated in the 2010 census increased by 24 percent or 1.5 million persons compared with the 2000 census (Table 1.1). As a result of T 2 • Introduction high fertility and population growth rates, Tajikistan has a young population: 35 percent of the population is under age 15, and the percentage over age 65 is relatively small at 3 percent (SA, 2013b). Life expectancy in Tajikistan steadily declined after the collapse of the Soviet Union, especially among men during the civil war (1991-1997). In 1993, life expectancy was 68.0 years for women and 56.4 years for men, a difference of nearly 12 years. By 2012, however, life expectancy had increased to 74.6 years for women and 71.1 years for men, a difference between the sexes of only three and a half years. Tajikistan has a double burden of disease, with the majority of deaths being due to cardiovascular diseases (50 percent of all causes), and with malignant neoplasms (cancers) and respiratory, digestive, infectious, and parasitic diseases also being prevalent. A rapid increase in multidrug-resistant tuberculosis and injection drug use is of particular concern. The population density of Tajikistan is 56 persons per square kilometer. However, the population is unevenly distributed among the regions. The population is mainly concentrated in the cultivated lands and in the industrialized urban areas. The capital of Tajikistan, Dushanbe, with a population of more than 764,000, is the largest city in Tajikistan. Tajikistan is a multinational country. According to the 2010 Population Census, people of more than 100 nationalities live in Tajikistan. The majority are Tajik, constituting more than 85 percent of the population. Other major ethnic groups are the Uzbek, Kyrgyz, Russian, and Turkmen. The official state language is Tajik. Russian is widely spoken as the language of “inter-ethnic” communication. Any nationality or ethnic group living in Tajikistan has the right to freely use its own language. The Tajik language belongs to the Persian group of languages. 1.2 HISTORY OF TAJIK CULTURE Tajikistan is one of the world’s most ancient civilizations. Around the 6-4 centuries B.C., much of what is today Tajikistan was part of the Achaemenid Empire, founded by the Persians. The Bactrians and the Sogdians, ancient inhabitants of Central Asia and ancestors of modern Tajik, were involved in agriculture, trade, and craftsmanship. The formation of the Tajik nation was completed under the Samanids. In the eighteenth century, the territory of what is today modern Tajikistan was home for the Kulab, Gissar, Karategin, Darvaz, Vahan, and Shugnan principalities. Throughout its history, the territory inhabited by the Tajiks was under control of many different states and khanates. In the second half of the nineteenth century, the Russian Empire annexed multiple territories in the Central Asia principalities and established the Governorate-General of Turkestan, which included territories in the northern parts of modern Tajikistan and Pamir, while the central and southern parts, the so-called Eastern Bukhara, came under control of the Bukhara Khanate, also subordinate to Russian Empire. The October 1917 Russian Revolution ended the tsarist autocracy, and the Soviets took power in Russia and Central Asia. In 1918, the newly proclaimed Turkestan Autonomous Soviet Socialist Republic (ASSR) became a part of the Russian Federation. In 1924, after the dissolution of the Turkestan ASSR, the Tajikistan Autonomous Soviet Socialist Republic was created as a part of Uzbekistan. In 1929, the Soviet government granted Tajikistan the status of Soviet Socialist Republic, thereby incorporating the republic into the Soviet Union. With the collapse of the Soviet Union in 1991, Tajikistan became a sovereign republic and joined the United Nations. A civil war began almost immediately, resulting in a serious loss of human lives and enormous damage to Tajikistan’s economy. Table 1.1 Basic demographic indicators Demographic indicators from selected sources, Tajikistan Indicators Tajikistan Census 2000 Tajikistan Census 2010 Population (millions) 6.1 7.6 Intercensal growth rate (percent) 20.3 23.5 Density (population/km2) 43 53 Percent urban 26.5 26.5 Life expectancy (years) 68.2 72.5 Male 66.1 70.8 Female 70.3 74.4 Source: SA, 2012a. Demographic year book of the Republic of Tajikistan Introduction • 3 1.3 ECONOMY The economy deteriorated rapidly from 1992 to1996. By 1996 the GDP was about one-third of the level of the early 1990s (World Bank, 2005). Under such dire circumstances, the government of Tajikistan initiated the development, adoption, and then implementation of a comprehensive program of economic reforms, leading to gradual economic recovery. By World Bank estimates, economic growth averaged 8 percent during the 2000-2008 period, fell to 3.4 percent in 2009 during the world economic crisis, and rose again to 6.5 - 7.4 percent in 2010 and 2011. A similar rate of economic growth (7.5 percent) in 2012 was attributed to higher growth in retail trade, services, and agriculture. In spite of the gradual economic growth in recent years, the country’s economy still relies on foreign investment, targeted grants, and support from Tajik citizens working abroad. In search of working opportunities and higher income, approximately 10 percent of the Tajik population is working abroad, mostly in Russia (SA, 2012b). According to the World Bank estimates, remittances from relatives working abroad in 2012 were equivalent to 47 percent of the GDP (World Bank, 2013). The main economic activities in Tajikistan are aluminum and cotton production. Both resources are highly vulnerable to world market fluctuation. Efforts to diversify agricultural production resulted in strong growth in the agricultural sector in 2009 and in 2012. Tajikistan is rich in minerals and other natural resources, including large deposits of coal, and has substantial hydropwer potential. There are many hydroelectic plants in Tajikistan that produce electricity, and the largest among them, the Nurek hydroelectric facility, is the tallest dam in the world. The government of Tajikistan is planning to build a new Roghun dam that will significantly increase electricity output, if implemented. Over the past decade, the government of Tajikistan has embarked on various economic and poverty-reduction programs with the aim of improving the living conditions of its citizenry. As a result of this poverty reduction strategy, the poverty rate declined from 72 percent in 2003 to 47 percent in 2009. Decline was more rapid in urban areas than in rural ones. In spite of these marked improvements, in 2012 almost 40 percent of the Tajikistani population still lived below the poverty level (World Bank, 2013). The National Development Strategy for the current period (by 2015) and the third Poverty Reduction Strategy for the preceding period (2010-2012) have identified priorities and general areas of state policy that aim at sustainable economic growth, better access to social services, and less poverty (IMF, 2012). In March 2013, Tajikistan joined the World Trade Organization (WTO). 1.4 HEALTH CARE SYSTEM The government of Tajikistan is committed to improving access and equity of access to essential health care services. The priority problem areas are maternal and child health, reproductive health, noncommunicable diseases, malaria, tuberculosis, HIV/AIDS, and other sexually transmitted infections (STIs). The government of Tajikistan has established a regulatory framework for the health sector that includes 9 laws, 18 government decrees, and about 40 orders of the Ministry of Health. The National Health Council of Tajikistan was established by government decree to coordinate efforts to improve population health. The Ministry of Health is responsible for “the development, implementation, monitoring, evaluation, and coordination of a unified state policy in the health sector, and for controlling the quality, safety and effectiveness of health services, pharmaceuticals, and medical equipment” (Khodjamurodov and Rechel, 2010). 1.4.1 Facilities and Human Resources A nationwide network of more than 3,748 health care facilities existed in Tajikistan in 2012 (SA, 2013a). The health care system in Tajikistan is almost all state-owned and administered; however, health financing is decentralized. The allocation of money to the health budget of Tajikistan is handled centrally by the Ministry of Finance, which distributes funds to the finance departments of oblast authorities. The oblasts determine how their own health budgets are spent, and the Ministry of Health controls only the 4 • Introduction functioning of health facilities. The republican hospitals, the State Medical University, and public health services operate under the control of the Ministry of Health, while regional and district facilities are managed by local authorities. External funds, mainly in the form of grants from international donors and bilateral agencies, are important sources of revenue to the health sector (Khodjamurodov and Rechel, 2010). In 2010, there were 163 facilities in the parastatal (parallel) health sector that were not directly subordinate to the Ministry of Health. They are under the control of the institutions that provide health care for their employees, such as the Ministries of Defense, Internal Affairs, Justice, Light Industry, and Transport and Communication (Khodjamurodov and Rechel, 2010). From an operational and a financial perspective, the parastatals are each governed by their own set of rules and regulations, have separate budgets funded directly by their ministries or companies, and exercise more autonomy in daily operations. The Ministry of Health has a coordinating share of the decision-making in parastatal organizations, at least in regards to health care protocols and standards of care. There is a small, slow-growing private sector in Tajikistan. Pharmacies and dental services are mostly privately owned. Since 2007, a number of private diagnostic centers have opened in cities to compete with the state run outpatient facilities, and about 14 private hospitals were operating in the country in 2010; however, due to the low purchasing power of the population, the share of services provided by the private sector is still low (Khodjamurodov and Rechel, 2010). According to the legislation of the Republic of Tajikistan, emergency and ambulance care, pediatric services for children under age 1, vaccinations, the initial health examination, and consultation are free of charge. A package of guaranteed health services has been implemented on a pilot basis since 2008, and a fee-for-services program was introduced by the government in 2009. In 2012, there were 16,268 physicians and 38,635 midlevel health professionals working in Tajikistan, or 20.4 physicians and 48.4 midlevel health professionals per 10,000 population (SA, 2013a). The distribution of medical staff is uneven between urban and rural areas, with the highest proportion of physicians residing in urban areas and Dushanbe (Khodjamurodov and Rechel, 2010). In Tajikistan, almost all health professionals are government employees and are paid on a salary basis. Every year the government increases wages, but the average salary is still low, which is the cause of informal payments made by patients, although there is no reliable data on this practice. In 2012, the average monthly salary for employees working in medical and social services was US$94 compared with the workforce average of US$116.60 (SA, 2013b). Over the past 20 years, the number of health professionals in Tajikistan has declined from 242 physicians, 618 nurses, and 122 midwives per 100,000 population in 1991 to 190 physicians, 447 nurses, and 60 midwives per 100,000 population in 2011 (WHO EURO, 2013). It is estimated that between 1990 and 1999, about 10,000 physicians and 39,000 midlevel health professionals left the state health care system (World Bank, 2005). 1.4.2 Health Care Reforms Tajikistan inherited a planned Soviet health system, characterized by a pronounced centralization, disproportionally high levels of funding of inpatient care facilities, and an excessive number of hospital beds and medical staff. Economic problems and financial cuts during the transition led to a serious deterioration of the health care system, including maternal and child health care. Since 1991, Tajikistan has undertaken systemic reforms of its health sector. The 1991-1998 reform priorities focused on the development of national policies, health care financing, resource allocation, and improvement of maternal and child health care services, including family planning. Introduction • 5 The 1998-2005 reform priorities included establishment of a national network of emergency medical care centers; reorganization and restructuring of outpatient and inpatient health facilities; and establishment and further development of family medicine. In 2002, the new concept of health sector reform was approved by the government. In 2005, the government approved the strategy of health care financing in Tajikistan for the period 2005–2015. In addition, in 2008 the concept of reform of medical and pharmaceutical education was approved by the government. Over the past 20 years, Tajikistan has introduced fundamental changes to the provision of maternal and child care services. Many important documents and guidelines, including the national plan on safe pregnancy, have been developed and implemented, and these have radically changed approaches to the assessment of quality care. The Ministry of Health developed and implemented the evidence-based approach of care during pregnancy, labor, and delivery, and of essential neonatal care, in accordance with the international standards of care. 1.4.3 Primary and Secondary Health Care Primary (ambulatory) health care in Tajikistan is provided through health houses and rural health centers in rural areas and through rayon and urban health centers in urban areas. In 2011, there were 1,689 health houses and 1,404 health centers (SA, 2012c). The main focus of rural health houses, staffed by nurses and midwives, is to provide basic first aid, home visits, basic antenatal care services, immunizations, and medical referrals. The rural health centers, staffed by physicians and midlevel health professionals, provide the next level of primary care, including basic blood and urine diagnostics, basic treatment, and surgeries. Rural health centers are subordinate to central rayon hospitals. The main focus of rayon and urban health centers is to provide preventive, diagnostic, and rehabilitative services. On the secondary level, health services are provided by rural hospitals, central rayon and city hospitals, oblast hospitals, and specialized hospitals. National level and specialized hospitals (cardiology, pediatrics, obstetrics and gynecology, tuberculosis, and others) provide advanced levels of diagnostics and medical care; they are also home for clinical research and teaching institutions. Some hospitals offer day care. Emergency care is provided through emergency hospitals and ambulance services (Khodjamurodov and Rechel, 2010). Outreach services, though not always sustained, are available for remote areas, especially for immunization and emergency care. 1.4.4 Maternal and Child Health Care The problems of maternal and child health are among the priority areas identified by the government of Tajikistan, which has ratified a number of international documents, including the Convention on the Elimination of All Forms of Discrimination against Women and the Convention on the Rights of the Child. Legal aspects of protection of the population’s health, including that of the mother and child, are reflected in the principal documents of the Republic: the constitution of Tajikistan, the law on health protection, and the law on reproductive health and reproductive rights, among others. The government pays special attention to gender issues, with a focus on improving the status and role of women in society. Tajikistan is also committed to achievement of the Millennium Development Goals, where three of eight goals relate to the health of women and children. In 2008, the government of Tajikistan approved a “National strategy for health care of children and adolescents until 2015.” 6 • Introduction In rural areas, antenatal care is provided by midwives at rural health houses or by doctors and midwives at rural health centres. In urban areas, antenatal care is provided by family physicians at rayon and urban health centers; however, the initial examination during the first visit is usually conducted with an obstetrician-gynecologist. One family doctor provides care for approximately 1,500 people in a catchment area. Obstetrician-gynecologists serve family doctors as consultants, and they provide care for pregnant women with obstetric complications. The ratio of family doctors to obstetrician-gynecologists is 1:4. Antenatal care starts early in pregnancy (usually during the first trimester) and continues on a regular basis throughout the pregnancy; a standard recommendation is that all pregnant women should have at least four routine antenatal visits during pregnancy; follow-up visits may be required for certain conditions, problems, or complications. According to special decree of the Ministry of Health, since 2008, inpatient health services in Tajikistan are provided at three levels. At the first level, care for women with normal (physiological) deliveries at full term and care for newborn children whose birth weight is 2.5 kilograms or more is provided by midwives. Delivery hospitals/gynecological wards at the secondary-level facilities provide skilled obstetric and neonatal care, including care for abnormal (pathological) deliveries, deliveries by cesarean section, and care for newborn children whose birth weight is less than 2.5 kilograms, as well as diagnostic, treatment, and rehabilitation services for women with gynecologic pathologies. Tertiary health services, including perinatal centers, are planned to carry out all types of high-tech diagnostic, treatment, and rehabilitative care for women and children. Currently, tertiary-level health facilities do not meet all of the requirements of the Ministry of Health. The organization of tertiary-level health facilities at the national level will be implemented in full starting in 2013. In spite of a sufficient number of delivery facilities, about 10 percent of births take place at home without the assistance of a skilled health provider. The main reasons for this are difficulties in accessing a health facility (roads, means of transportation), low social status of women, and in some cases, out-of- pocket payments for delivery in hospitals, a lack of trust in medical personnel, or absence of a specialist in remote settlements. Child health care is provided immediately following delivery while a woman and her newborn are in the delivery hospital. After discharge from the delivery hospital, child care services are mainly provided by primary health care facilities, including family doctors and nurses who provide counseling on child care and nutrition to the mother. Family doctors ensure that the child is vaccinated according to a schedule. They also can refer children for pediatric care and for hospitalization, as necessary. Currently, mandatory childhood vaccinations in Tajikistan include vaccination against hepatitis B, poliomyelitis, tuberculosis, diphtheria, pertussis, tetanus, haemophilus influenzae type b, measles and rubella. The child vaccination schedule in Tajikistan requires that Bacillus Calmette-Guérin (BCG), hepatitis B, and oral polio vaccines be given at birth. A high rate of home births jeopardizes the health of newborns because vaccinations may be delayed. 1.4.5 Family Planning Services The Ministry of Health is responsible for providing family planning services throughout the country. The main goals of family planning policy are to ensure low-risk pregnancy and safe motherhood and to reduce complications caused by closely-spaced pregnancies and pathological conditions among women of reproductive age. Currently, five groups of women at high risk for maternal and perinatal morbidity and mortality have been selected for provision of family planning services upon request. Introduction • 7 The Ministry of Health considers family planning to be an important component of reproductive health care. In 2004, the Strategic Plan for Reproductive Health in 2005-2014 was adopted by government resolution. The Ministry of Health manages a broad spectrum of activities, including extensive family planning education of the population, training of health providers, and supply of contraceptives throughout the country. The private sector is also involved in marketing contraceptives. Regional, district, and city centers on reproductive health work at the primary health care level under the management of the National Centre on Reproductive Health (NCRH). Obstetrician-gynecologists working at the NCRH serve family doctors as consultants; family doctors provide counseling on the selection and use of contraceptive methods to the general population. Induced abortion is legal in Tajikistan. These procedures are typically performed by an obstetrician-gynecologist, either at outpatient clinics by the vacuum aspiration technique during the first five weeks of pregnancy or in state and private health clinics by dilation and curettage during the first 12 weeks of pregnancy. In some cases, induced abortion can be performed after 12 weeks and up to 22 weeks if certain medical or social conditions exist and upon permission from a medical-control commission of the outpatient and inpatient care levels of facilities. These cases require careful supervision of qualified medical personnel in a hospital setting. 1.4.6 Tuberculosis DOTS Program The 2006 law on protection of the population from tuberculosis established the basis for a state- regulated policy on combatting tuberculosis, for defining organizational and legislative regulations of activities aimed to protect the population from tuberculosis, and for regulation of the rights, responsibilities, and social guarantees of population with tuberculosis. To improve the epidemiological situation, the government adopted the National Tuberculosis Control Program of 2011-2015, based on the directly observed treatment, short-course (DOTS) approach. The DOTS approach covers all rayons of the country. Tuberculosis services are available at primary health facilities, at republican, city, and central rayon hospitals, and at tuberculosis hospitals. 1.4.7 HIV/AIDS Program Prevention of HIV/AIDS is high on the political agenda of the government of Tajikistan. It declared its commitment to addressing the HIV/AIDS crisis as outlined in the Declaration of Commitment on HIV/AIDS at the UN General Assembly Special Session on HIV/AIDS (United Nations, 2001). Tajikistan was among the first countries to develop a National Development Strategy by 2015. Issues for combatting the HIV/AIDS epidemic were reflected in the Millennium Development Goals to halt and reverse the spread of HIV/AIDS. In 2008, on the government’s initiative, Dushanbe hosted the third Inter- Parliamentary Conference in Central Asia and Azerbaijan on HIV/AIDS. The government of Tajikistan, with the objective of ensuring effective management and a unified response to the HIV and AIDS epidemic, adopted a multi-sectoral approach. This addressed the developmental challenges of the epidemic and integrated HIV/AIDS issues in the 2010-2012 Poverty Reduction Strategy. Included in the 2010-2020 Health Sector Strategy as high priority issues were prevention, treatment, care, and support activities as well as targeting of the general population, vulnerable groups, and groups at high risk. The HIV and AIDS response in Tajikistan is guided by the National Strategic Framework of 2010-2015 (GOT, 2012). The National Coordination Committee (NCC) to combat HIV/AIDS, Tuberculosis, and Malaria is a single coordinating body for HIV/AIDS activities. It is chaired by the deputy prime minister of Tajikistan. NCC works on a multisectoral approach with 22 organizations, which include representatives from key ministries, international organizations, and local non-governmental organizations as well as individuals living with HIV/AIDS and a religious leader of all Muslims in Tajikistan (GOT, 2012). 8 • Introduction In Tajikistan, HIV prevalence is still low, with only 0.3 percent of the population age 15-49 estimated to be HIV-positive in 2011 (UNAIDS, 2013). The HIV epidemic in Tajikistan is currently concentrated among injection drug users. In 2011, the needle and syringe exchange program was started in 21 drop-in health facilities (trust posts) supported by UNDP grants; this program is also scheduled for implementation in prisons on a pilot basis. In June 2010, the opioid substitution therapy program started on a pilot basis, and 296 patients were covered by the program by the end of 2011 (GOT, 2012). Although the majority of new HIV infections in Tajikistan are contracted through injection drug use, heterosexual transmission is growing quickly, especially among women. Women and men have equal access to HIV/AIDS services as guaranteed by the national law on gender equality. Staff of 26 crisis centers for vulnerable women received information about preventing violence and discrimination against women with HIV/AIDS, and they learned how to provide social and psychological support to HIV-infected women and children (GOT, 2012). All aspects of civil society, including religious institutions, are involved in combatting the HIV/AIDS epidemic in Tajikistan. The Islamic Institute of Tajikistan published the book HIV/AIDS from the Perspective of Islam. Forty-eight religious leaders have been trained at a national seminar, and over 250 religious leaders have been trained about HIV/AIDS issues countrywide (GOT, 2012). There are 35 HIV/AIDS prevention and treatment centers in Tajikistan: 1 republican, 4 regional, and 30 urban and rural centers. The main tasks of these centers are HIV testing and counseling services, treatment and care of HIV-infected persons, technical support of health facilities on HIV/AIDS- related issues, HIV surveillance, HIV prevention among specific population groups, education of the general population on HIV/AIDS prevention, prevention of transmission from mother to child, and implementation, monitoring, and evaluation of the national program on combatting HIV/AIDS. 1.5 SYSTEMS FOR COLLECTING DEMOGRAPHIC AND HEALTH DATA The Statistical Agency is the government agency responsible for collection, processing, analysis, aggregation, dissemination, accumulation, storage, and maintenance of official statistical information. It conducts censuses. Births, deaths, marriages, and divorces are registered in the departments of civil registry (so-called ZAGS) of the Ministry of Justice and in local administrations (jamoats) of rural settlements, where the records are made and certificates of birth, death, marriage, and divorce are issued. Second copies of these records are forwarded on a monthly basis through the rayon and oblast statistical offices to the Statistical Agency for aggregation and processing. The last two censuses in Tajikistan were conducted in 2000 and 2010. Collection of health data is primarily the responsibility of the Statistical and Information Center of the Ministry of Health. Health information is generated by staff at the facilities delivering service. It is then sent to the Statistical and Information Center through the rayon and oblast health statistic departments, then forwarded on to the Ministry of Health and the Statistical Agency under the President of the Republic of Tajikistan. The Statistical and Information Center of the MOH compiles and analyzes these data and issues annual reports entitled Population Health and Health Services in the Republic of Tajikistan. The annual report covers many aspects of health area registration statistics related to morbidity by type of disease; mortality by cause of death; infant deaths, including perinatal and early neonatal deaths; maternal mortality; data on maternal and child health services; the number of health facilities, medical personnel, hospital beds, and length of the average hospital stay; and family medicine, emergency medicine, and funding of health care services. These data are tabulated at the national and oblast levels. These data, at the national level, are also available at the World Health Organization’s European Health-for-All database (HFA-DB). Introduction • 9 1.6 OBJECTIVES AND ORGANIZATION OF THE SURVEY The 2012 TjDHS is a nationally representative sample survey designed to provide information on population and health issues in Tajikistan. The 2012 survey, the first of its kind in the country, was conducted by the Statistical Agency and the Ministry of Health (MOH) from July 2012 through September 2012. Support for the 2012 TjDHS was provided by the United States Agency for International Development (USAID) as part of the MEASURE DHS project. MEASURE DHS is a USAID-funded program through which ICF International provides funding and technical assistance in the implementation of population and health surveys in countries worldwide. The United Nations Population Fund (UNFPA)/Tajikistan provided additional funds for the survey. The purpose of the 2012 TjDHS was to collect national and regional data on fertility and contraceptive use, maternal and child health, childhood mortality, domestic violence against women, and knowledge and behavior regarding tuberculosis, HIV infection, and other sexually-transmitted infections. The survey obtained detailed information on these issues from women of reproductive age. Data are presented by region (oblast) when sample size permits. The 2012 TjDHS results are intended to provide the information needed to evaluate existing social programs and to design new strategies for improving health and health services for women and children in Tajikistan. The 2012 TjDHS also contributes to the growing international database on demographic and health-related indicators. 1.6.1 Sample Design and Implementation The 2012 TjDHS sample was designed to permit detailed analysis, including the estimation of rates of fertility, infant/child mortality, and abortion at the national level and for total urban and rural areas separately. Many indicators can also be estimated at the regional (oblast) level. In addition, in the Khatlon region, the sample is sufficient to provide separate estimates of the nutritional status of children for the 12 districts included in the Feed the Future Initiative (FTF) pilot areas. A representative probability sample of 6,674 households was selected for the 2012 TjDHS sample. The sample was selected in two stages. In the first stage, 356 clusters were selected from a list of enumeration areas that were part of a master sample designed from the 2010 Population Census. In the second stage, a complete listing of households was made for each selected cluster. Households were then systematically selected for participation in the survey. All women age 15-49 who were either permanent residents of the households in the 2012 TjDHS sample or visitors present in the household on the night before the survey were eligible to be interviewed. Interviews were completed with 9,656 women. Appendix A provides additional information on the sample design of the 2012 TjDHS. 1.6.2 Questionnaires Two questionnaires were used in the TjDHS: a Household Questionnaire and a Woman’s Questionnaire. The Household Questionnaire and the Woman’s Questionnaire were based on model survey instruments developed in the MEASURE DHS program. The DHS model questionnaires were adapted for use in Tajikistan by experts from the Statistical Agency (SA) and the Ministry of Health (MOH). Suggestions were also sought from USAID; a number of the UN agencies, including the United Nations Development Program (UNDP), UNFPA, and UNICEF; and other international and nongovernmental organizations (NGOs). The questionnaires were developed in English and translated into Russian and Tajik. The Household Questionnaire and the Woman’s Questionnaire were pretested in March 2012. 10 • Introduction The Household Questionnaire was used to list all usual members of and visitors to the selected households and to collect information on the socioeconomic status of the households. The first part of the Household Questionnaire collected, for each household member or visitor, information on their age, sex, educational attainment, and relationship to the head of household. This information provided basic demographic data for Tajikistan households. It also was used to identify the women who were eligible for the individual interview (i.e., women age 15-49). The first section of the Household Questionnaire also obtained information on other characteristics of household members, including information on each child’s birth registration. Other questions addressed housing characteristics (e.g., the flooring material, the source of water, and the type of toilet facilities), ownership of consumer goods, and other aspects of the socioeconomic status of the household. Results of testing of household salt for the presence of iodine and results of taking height and weight measurements of children under age 5 and of women age 15-49 also were recorded in the Household Questionnaire. The Woman’s Questionnaire obtained information from women age 15-49 on the following topics: • Background characteristics • Pregnancy history • Antenatal, delivery, and postnatal care • Knowledge, attitudes, and use of contraception • Reproductive health • Childhood mortality • Health care utilization • Vaccinations of children under age 5 • Episodes of diarrhea and respiratory illness of children under age 5 • Breastfeeding and weaning practices • Marriage and recent sexual activity • Fertility preferences • Knowledge of and attitudes toward AIDS and other sexually transmitted diseases • Knowledge of and attitudes toward tuberculosis • Woman’s work and husband’s background characteristics • Other women’s health issues • Domestic violence 1.6.3 Training of Field Staff The main survey training, which was conducted by the SA, MOH, and ICF International staff, was held during a three-week period in June and was attended by 100 people (78 females and 22 males), including supervisors, field editors, interviewers, and quality control personnel. The training included lectures, demonstrations, practice interviews, and examinations. All field staff received training in anthropometric measurement and participated in two days of field practice. 1.6.4 Fieldwork and Data Processing Fourteen teams collected the survey data; each team consisted of four female interviewers, a field editor, and a team supervisor. Fieldwork began in early July 2012 and concluded in late September 2012. Senior TjDHS technical staff visited teams regularly to review the work and monitor data quality. MEASURE DHS also assisted with field supervision. In addition, UNFPA/Tajikistan representatives visited teams to monitor data collection and to observe the height and weight measurements of women and children under age 5. Introduction • 11 The processing of the TjDHS results began shortly after fieldwork commenced. Completed questionnaires were returned regularly from the field to SA headquarters in Dushanbe, where they were entered and edited by data processing personnel specially trained for this task. The data processing personnel included a supervisor, a questionnaire administrator (who ensured that the expected number of questionnaires from all clusters was received), several office editors, 11 data entry operators, and a secondary editor. The concurrent processing of the data was an advantage because the senior DHS technical staff were able to advise field teams of problems detected during the data entry. In particular, tables were generated to check various data quality parameters, and the results were used to provide specific feedback to the teams to improve performance. The data entry and editing phase of the survey was completed in November 2012. 1.7 RESPONSE RATES Table 1.2 shows response rates for the 2012 TjDHS. A total of 6,674 households were selected in the sample, of which 6,512 were occupied at the time of the fieldwork. The main reason for the difference is that some of the dwelling units that were occupied during the household listing operation were either vacant or the household was away for an extended period at the time of interviewing. The number of occupied households successfully interviewed was 6,432, yielding a household response rate of 99 percent. The household response rate in urban areas (98 percent) was slightly lower than in rural areas (99 percent). In these households, a total of 9,794 eligible women were identified; interviews were completed with 9,656 of these women, yielding a response rate of 99 percent. Response rates are slightly higher in urban areas (99 percent) than in rural areas (98 percent). Table 1.2 Results of the household and individual interviews Number of households, number of interviews, and response rates, according to residence (unweighted), Tajikistan 2012 Result Residence Total Urban Rural Household interviews Households selected 2,835 3,839 6,674 Households occupied 2,732 3,780 6,512 Households interviewed 2,675 3,757 6,432 Household response rate1 97.9 99.4 98.8 Interviews with women age 15-49 Number of eligible women 3,443 6,351 9,794 Number of eligible women interviewed 3,408 6,248 9,656 Eligible women response rate2 99.0 98.4 98.6 1 Households interviewed/households occupied. 2 Respondents interviewed/eligible respondents. Housing Characteristics and Household Population • 13 HOUSING CHARACTERISTICS AND HOUSEHOLD POPULATION 2 his chapter presents information on housing facilities (sources of water supply, sanitation facilities, and dwelling characteristics), household possessions, and household arrangements (headship and size). The data on the dwelling and household characteristics and assets is used to produce the wealth index, an indicator of the household’s economic status. The chapter also provides information on general characteristics of the population such as age-sex structure and education. The description of the household environment and survey population in the chapter is useful for understanding the many social and demographic phenomena presented later in the report. In reviewing this chapter, it is helpful to understand the definitions of a household and of the de jure and de facto populations used in the 2012 TjDHS. A household consists of a person or group of persons, related or unrelated, who live together in the same dwelling unit, acknowledge one adult male or female as the head of household, share the same living arrangements, and are considered as one unit. For each household, information was obtained on usual household members as well as visitors present in the household on the night before the survey. The de jure population includes all usual household residents whether or not they were present at the time of the TjDHS interview. The de facto population includes household members and visitors who were present in the household on the night before survey. The difference between the de jure and de facto populations is small, and most results are presented for the de facto population unless otherwise noted. T Key Findings • The average Tajik household has 6.3 members. • Nearly all households (97 percent) use improved sanitation facilities. • Access among the population to improved drinking water sources increased from 57 percent in 2000 to 76 percent in 2012. • Among households where the hand washing place was observed, around eight in ten households have soap and water available at the place household members use for hand washing. • Three in ten households, mainly in rural areas, reside in dwellings with earth or sand floors. • Forty-one percent of rural households use solid fuels for cooking compared with 3 percent of urban households. • Possession of cell phones has increased rapidly, from 11 percent of households in 2005 to 93 percent in 2012. Computer ownership also has expanded, from 1 percent in 2005 to 12 percent in 2012. • The median completed years of schooling is 8.6 years among females and 9.3 years among males. • Attendance among the school-age population is widespread but not universal; 87 percent of the primary school-age population and 83 percent of the secondary school-age population are attending school. • There is almost no gender gap in primary school attendance, but males are slightly more likely to attend secondary school than females. • Most young children are not involved in any early childhood education program; only 6 percent of children age 3-6 attend pre-school education. 14 • Housing Characteristics and Household Population 2.1 HOUSING CHARACTERISTICS The 2012 TjDHS collected data on a range of housing characteristics that affect the health of household residents and also reflect the household’s socioeconomic status. Housing characteristics include sources of drinking water, type of sanitation facilities, dwelling materials (roof, walls, and floor), access to electricity, and cooking arrangements. These results are presented for households and for the de jure household population by urban-rural residence. 2.1.1 Drinking Water The source of drinking water is an indicator of whether it is suitable for drinking. Table 2.1 uses the categorization of improved and non-improved sources proposed by the WHO/UNICEF Joint Monitoring Program for Water Supply and Sanitation (UNICEF and WHO, 2012) in presenting the 2012 TjDHS drinking water information. The table also shows the time spent in obtaining drinking water and the practices that Tajik households employ in treating the water they use for drinking. Table 2.1 Household drinking water Percent distribution of households and de jure population by source of drinking water, time to obtain drinking water, and treatment of drinking water, according to residence, Tajikistan 2012 Characteristic Households Population Urban Rural Total Urban Rural Total Source of drinking water Improved source 94.6 70.7 78.1 94.1 70.6 76.2 Piped water into dwelling/yard/plot 78.2 22.1 39.3 76.5 22.9 35.7 Public tap/standpipe 12.9 29.8 24.6 13.4 28.9 25.2 Tube well/borehole 1.4 10.6 7.7 1.7 10.8 8.6 Protected dug well 1.4 4.4 3.5 1.5 4.1 3.5 Protected spring 0.4 3.6 2.6 0.5 3.6 2.8 Rain water 0.4 0.3 0.3 0.5 0.3 0.3 Bottled water 0.0 0.0 0.0 0.0 0.0 0.0 Non-improved source 3.7 28.2 20.7 4.1 28.4 22.5 Unprotected dug well 0.2 0.6 0.5 0.3 0.7 0.6 Unprotected spring 0.8 2.3 1.9 0.6 2.3 1.9 Tanker truck/cart with small tank 0.8 6.1 4.5 0.9 6.0 4.8 Surface water 1.9 19.2 13.9 2.4 19.4 15.3 Other source 1.5 0.9 1.1 1.6 0.9 1.1 Missing 0.1 0.2 0.2 0.1 0.1 0.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Time to obtain drinking water (round trip) Water on premises 81.5 39.8 52.6 80.7 41.0 50.5 Less than 30 minutes 15.1 44.7 35.6 14.7 43.3 36.5 30 minutes or longer 2.7 14.0 10.5 3.8 14.2 11.7 Don't know/missing 0.7 1.5 1.2 0.8 1.4 1.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Water treatment prior to drinking1 Boiled 87.7 83.3 84.6 87.4 83.3 84.3 Bleach/chlorine added 0.3 0.3 0.3 0.4 0.2 0.3 Strained through cloth 0.1 0.4 0.3 0.1 0.4 0.3 Ceramic, sand or other filter 0.6 0.1 0.3 0.5 0.1 0.2 Solar disinfection 0.3 0.5 0.4 0.3 0.5 0.5 Other 24.5 26.1 25.6 22.5 25.3 24.6 No treatment 11.1 15.2 14.0 11.4 15.2 14.3 Percentage using an appropriate treatment method2 87.9 83.5 84.8 87.6 83.5 84.5 Number 1,976 4,456 6,432 9,715 30,753 40,468 1 Respondents may report multiple treatment methods, so the sum of treatment may exceed 100 percent. 2 Appropriate water treatment methods include boiling, bleaching, straining, filtering, and solar disinfecting. More than three-quarters of households in Tajikistan obtain drinking water from an improved source. Most of these households either have piped water available in the dwelling, yard, or plot (39 percent) or get water from a public tap or standpipe (25 percent). The most common non-improved Housing Characteristics and Household Population • 15 water source is surface water (14 percent), i.e., water from rivers, dams, lakes, ponds, or similar sources. Around nine in ten households obtain drinking water from a source on premises (53 percent) or spend less than 30 minutes obtaining water (36 percent). Eighty-five percent of households use an appropriate water treatment method, with almost all boiling the water used for drinking. Urban households are much more likely than rural households to have access to an improved drinking water source (95 percent versus 71 percent), and they are twice as likely as rural households to have the drinking water source on the premises (82 percent versus 40 percent). On the other hand, the proportion using an appropriate water treatment method is only slightly higher among urban households (88 percent) than rural households (83 percent). Figure 2.1 compares the results of the 2012 TjDHS with the findings from the Multiple Indicator Cluster Survey conducted in 2000 (UNICEF, 2000) and 2005 (SCS, 2007). Access among the population to improved drinking water sources increased in Tajikistan from 57 percent in 2000 to 76 percent in 2012. The increase was largely concentrated in rural areas. The percentage of the rural population obtaining drinking water from an improved source rose from 47 percent in 2000 to 71 percent in 2012, while in urban areas where access to an improved source was already widespread in 2000, the percentage increased from 93 percent to 94 percent. Figure 2.1 Trends in use of improved drinking water sources, Tajikistan 2000, 2005, and 2012 93 47 57 93 61 70 94 71 76 Urban Rural Total 2000 MICS 2005 MICS 2012 TjDHS Percent 16 • Housing Characteristics and Household Population 2.1.2 Sanitation Facilities The availability of hygienic sanitation facilities is important in reducing the risk of transmitting diarrhea and other diseases within a household. According to the standards set by the WHO/UNICEF Joint Monitoring Program for Water Supply and Sanitation, the hygienic status of sanitation facilities is determined on the basis of type of facility used and whether or not it is a shared facility (UNICEF and WHO, 2012). A household’s toilet/latrine facility is classified as hygienic if it is used only by household members (i.e., not shared) and if the type of facility effectively separates human waste from human contact. The types of facilities that are most likely to accomplish this are flush or pour flush toilets emptying into a piped sewer system/septic tank/pit latrine; ventilated, improved pit (VIP) latrines; pit latrines with a slab; and composting toilets. Table 2.2 shows that the vast majority of the TjDHS households and household population use improved sanitation facilities (97 percent each), which is an increase over the 94 percent of the household population reported in the 2005 MICS (SCS, 2007). Most households using an improved facility do not share the facility; only 3 percent of Tajik households use an improved facility that is shared with other households. Table 2.2 Household sanitation facilities Percent distribution of households and de jure population by type of toilet/latrine facilities, according to residence, Tajikistan 2012 Type of toilet/latrine facility Households Population Urban Rural Total Urban Rural Total Improved, not shared facility 91.8 94.1 93.4 92.9 94.6 94.2 Flush/pour flush to piped sewer system 52.0 0.1 16.0 45.2 0.1 10.9 Flush/pour flush to septic tank 0.3 0.0 0.1 0.3 0.0 0.1 Flush/pour flush to pit latrine 1.0 0.3 0.5 1.0 0.4 0.5 Ventilated improved pit (VIP) latrine 11.3 23.8 20.0 12.4 23.0 20.4 Pit latrine with slab 27.2 69.8 56.7 34.0 71.1 62.2 Composting toilet 0.0 0.1 0.1 0.0 0.1 0.1 Shared facility1 6.4 1.7 3.2 5.2 1.5 2.4 Flush/pour flush to piped sewer system 3.2 0.0 1.0 2.3 0.0 0.5 Flush/pour flush to septic tank 0.0 0.0 0.0 0.0 0.0 0.0 Flush/pour flush to pit latrine 0.5 0.0 0.2 0.3 0.0 0.1 Ventilated improved pit (VIP) latrine 0.9 0.6 0.7 0.9 0.4 0.5 Pit latrine with slab 1.8 1.2 1.4 1.8 1.1 1.2 Non-improved facility 1.4 4.0 3.2 1.6 3.8 3.3 Flush/pour flush not to sewer/septic tank/pit latrine 0.7 0.2 0.3 0.9 0.1 0.3 Pit latrine without slab/open pit 0.6 3.5 2.7 0.7 3.4 2.8 No facility/bush/field 0.1 0.4 0.3 0.1 0.3 0.2 Other 0.1 0.0 0.0 0.0 0.0 0.0 Missing 0.2 0.1 0.2 0.3 0.1 0.2 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 1,976 4,456 6,432 9,715 30,753 40,468 1 Facilities that would be considered improved if they were not shared by two or more households. Pit latrines with slab (58 percent) are the most common type of toilet, followed by VIP latrines (21 percent). One in six households uses a toilet connected to a piped sewer system. More than half of urban households have flush toilets, while they are virtually nonexistent in rural areas. Housing Characteristics and Household Population • 17 2.1.3 Other Dwelling Characteristics Table 2.3 shows the distribution of households and the de jure population by other dwelling characteristics that reflect the socioeconomic status and also may directly affect the health of household members. Table 2.3 Household characteristics Percent distribution of households by housing characteristics, percentage using solid fuel for cooking, and percent distribution by frequency of smoking in the home, according to residence, Tajikistan 2012 Housing characteristic Residence Total Urban Rural Electricity Yes 99.8 98.8 99.1 No 0.2 1.2 0.9 Total 100.0 100.0 100.0 Flooring material Earth/sand 5.3 39.8 29.2 Wood/planks 31.6 18.6 22.6 Parquet or polished wood 43.3 22.0 28.5 Vinyl or linoleum 9.9 3.6 5.5 Ceramic tiles 0.4 0.4 0.4 Cement 8.8 14.8 13.0 Carpet 0.5 0.2 0.3 Other 0.0 0.4 0.3 Missing 0.0 0.2 0.2 Total 100.0 100.0 100.0 Roof material No roof 0.1 1.2 0.8 Thatch 0.9 5.8 4.3 Sod 0.1 0.0 0.1 Wood planks 0.2 0.1 0.2 Cardboard 0.0 0.1 0.1 Metal 4.6 3.0 3.5 Wood 0.1 0.0 0.1 Calamine/cement fiber 4.0 0.0 1.2 Ceramic tiles 0.3 0.0 0.1 Cement/concrete blocks 15.9 0.2 5.0 Roofing shingles/shifer 62.2 88.5 80.4 Taule (tarred rough paper) 11.3 0.6 3.9 Other 0.2 0.3 0.3 Missing 0.2 0.1 0.1 Total 100.0 100.0 100.0 Wall material No walls 0.1 0.2 0.2 Cane/trunks 0.1 0.3 0.2 Dirt 4.6 13.2 10.5 Stone with mud 3.2 5.3 4.7 Uncovered adobe 6.8 28.0 21.5 Plywood 0.3 0.1 0.2 Reused wood 0.1 0.0 0.0 Cement 33.3 5.6 14.1 Stone with lime/cement 5.2 8.8 7.7 Bricks 32.8 9.0 16.3 Cement blocks 8.5 2.3 4.2 Covered adobe 4.8 27.2 20.3 Wood planks/shingles 0.0 0.0 0.0 Other 0.0 0.0 0.0 Missing 0.2 0.1 0.1 Total 100.0 100.0 100.0 Rooms used for sleeping One 22.8 11.9 15.2 Two 42.4 39.4 40.3 Three or more 34.0 47.9 43.6 Missing 0.8 0.8 0.8 Total 100.0 100.0 100.0 Continued… 18 • Housing Characteristics and Household Population Table 2.3—Continued Percent distribution of households by housing characteristics, percentage using solid fuel for cooking, and percent distribution by frequency of smoking in the home, according to residence, Tajikistan 2012 Housing characteristic Residence Total Urban Rural Place for cooking In the house 51.5 14.2 25.7 In a separate building 47.0 81.0 70.6 Outdoors 1.1 4.7 3.6 No food cooked in household 0.2 0.1 0.1 Other 0.1 0.0 0.1 Total 100.0 100.0 100.0 Cooking fuel Electricity 75.1 42.3 52.3 LPG/natural gas/biogas 21.3 16.8 18.2 Kerosene 0.0 0.0 0.0 Charcoal 0.0 0.1 0.0 Wood 2.6 29.2 21.0 Straw/shrubs/grass 0.1 1.2 0.9 Agricultural crop 0.1 2.8 2.0 Animal dung 0.6 7.4 5.3 Other 0.0 0.2 0.1 No food cooked in household 0.2 0.1 0.1 Total 100.0 100.0 100.0 Percentage using solid fuel for cooking1 3.4 40.7 29.2 Frequency of smoking in the home Daily 10.4 5.5 7.0 Weekly 3.5 2.8 3.0 Monthly 0.7 0.3 0.4 Less than monthly 1.4 1.1 1.2 Never 83.8 90.2 88.2 Missing 0.2 0.2 0.2 Total 100.0 100.0 100.0 Number 1,976 4,456 6,432 LPG = Liquid petroleum gas 1 Includes charcoal, wood, straw/shrubs/grass, agricultural crops, and animal dung. Almost all Tajik households (99 percent) have electricity. With regard to the construction of the dwelling, while most dwellings have some type of flooring, 29 percent of households reside in dwellings with earth or sand floors. Earth/sand floors are much more common in rural than in urban areas (40 percent versus 5 percent). Shingles are the most widely used roofing material, found in around nine in ten rural and six in ten urban dwellings. Cement (33 percent) and bricks (33 percent) are the most common wall materials in urban dwellings, while rural dwellings are most often built with covered or uncovered adobe (27 percent and 28 percent, respectively). More than eight in ten Tajik households have at least two rooms in the dwelling used for sleeping, and 44 percent have three or more rooms. Urban households are almost twice as likely as rural households to have only one room for sleeping (23 percent versus 12 percent). Indoor air pollution from the use of solid (biomass) fuels is related to increased morbidity and mortality (WHO, 2006a). Table 2.3 shows that, while the majority of Tajik households use electricity (52 percent) or LPG/natural gas/biogas (18 percent) for cooking, around three in ten households burn solid fuels (e.g., wood, charcoal, straw, shrubs, grass, agricultural crops or animal dung). Rural households are much more likely than urban households to cook with solid fuels. Among rural households, the practice of cooking in a building separate from the dwelling or outdoors may reduce the exposure to pollutants generated by the burning of solid fuels; more than eight in ten rural households report cooking takes place in a separate building or outside. There is also evidence that the use of solid fuels for cooking is declining in Tajikistan; overall, 35 percent of households reported use of solid fuels for cooking in the 2005 MICS Housing Characteristics and Household Population • 19 (SCS, 2007) compared with 29 percent in the TjDHS. The percentage using solid fuels for cooking declined among urban households from 8 percent in 2005 to 3 percent in 2012 and among rural households from 48 percent to 41 percent. The information on smoking inside the home is included in Table 2.3 to assess the percentage of households in which there is exposure to secondhand smoke. Secondhand smoke (SHS) causes health risks in children and adults who do not smoke. For example, research has shown that children who are exposed to SHS are at increased risk for respiratory and ear infections and poor lung development (US Department of Health and Human Services, 2006) and that pregnant women exposed to SHS have a higher risk of giving birth to a low-birth weight baby (Windham et al., 1999). Overall, around one in nine Tajik households report that smoking occurs in the home, with 7 percent saying smoking takes place in the home on a daily basis and 3 percent saying that it occurs on a weekly basis. Smoking in the home is more frequent in urban households than rural households (16 percent versus 10 percent). 2.2 HOUSEHOLD POSSESSIONS The availability of durable consumer goods is a useful indicator of household socioeconomic level. Moreover, particular goods have specific benefits. Having access to a radio or a television exposes household members to innovative ideas; a refrigerator prolongs the wholesomeness of foods; and a means of transport allows greater access to services located away from the local area. Table 2.4 shows the availability of selected household possessions by residence. Almost all Tajik households (96 percent) own some type of television, primarily a color television, eight in ten have a DVD player, and four in ten own a satellite dish. The vast majority of households (94 percent) have a telephone, with mobile phones much more common than fixed phones. A comparison of the TjDHS and 2005 MICS (SCS, 2007) results documents both a very rapid expansion of mobile phone ownership from 11 percent of households in 2005 to 93 percent in 2012 and a decline in fixed phone ownership from 20 percent in 2005 to 11 percent in 2012. Although the change was not as rapid as the increase in cell phone ownership, computer ownership has also expanded, from 1 percent of households at the time of the 2005 MICS (SCS, 2007) to 12 percent in 2012. Four percent of TjDHS households reported that they could access the Internet in the home. There is considerable variability in the percentages of households possessing other household effects, with households least Table 2.4 Household possessions Percentage of households possessing various household effects, means of transportation, agricultural land, livestock/farm animals, watch, or bank account by residence, Tajikistan 2012 Possession Residence Total Urban Rural Household effects Radio 19.3 25.6 23.7 Any television 97.9 95.8 96.4 Black and white television 6.0 11.7 9.9 Color television 95.7 90.3 91.9 DVD 86.4 77.8 80.5 Dish/satellite antenna 53.6 37.2 42.3 Computer 25.0 6.9 12.4 Internet connection 8.3 1.3 3.5 Any phone 96.6 92.9 94.1 Mobile telephone 95.2 92.5 93.3 Non-mobile telephone 28.9 3.6 11.4 Camera 12.8 5.4 7.7 Video camera 7.3 2.2 3.8 Carpet 97.4 95.7 96.2 Table 52.3 31.8 38.1 Chair 43.0 14.0 22.9 Sofa 58.1 32.0 40.0 Bed 38.3 47.6 44.8 Buffet 58.1 34.7 41.9 Refrigerator 77.3 35.0 48.0 Freezer 6.1 2.1 3.3 Fan 54.0 39.8 44.2 Air conditioner 26.7 5.2 11.8 Washing machine 39.6 10.9 19.7 Vacuum cleaner 48.1 13.1 23.8 Sewing machine 49.7 63.3 59.1 In-door heater (burzhuika) 36.4 87.0 71.4 Mini-generator (dvizhok) 8.8 16.4 14.1 Wood/fuel stock 36.9 93.3 76.0 Means of transport Bicycle 18.6 29.8 26.3 Animal drawn cart 1.0 6.1 4.6 Motorcycle/scooter 0.6 1.6 1.3 Car/truck 28.0 33.0 31.4 Ownership of agricultural land 27.0 92.9 72.7 Ownership of farm animals1 13.4 72.0 54.0 Watch 43.5 33.1 36.3 Bank account 2.9 1.9 2.2 Number 1,976 4,456 6,432 1 Livestock, herds, other farm animals, beehives, or poultry 20 • Housing Characteristics and Household Population likely to have a freezer (3 percent) and most likely to have a stock of wood or other fuel (76 percent) and an indoor heater (71 percent). Urban households are more likely to have most but not all of the household effects in Table 2.4. One of the most notable differences is in the percentage owning a refrigerator; 77 percent of urban households have a refrigerator compared with 35 percent of rural households. On the other hand, rural households are more likely than urban households to have a stock of wood or other fuel and to own an indoor heater. Table 2.4 also presents information on household ownership of a means of transport. Twenty-six percent of Tajik households report they own a bicycle, and 31 percent have a car or truck. Household ownership of cars/trucks has almost doubled since the 2005 MICS survey (SCS, 2007) when 17 percent of households reported owning a car or truck. Rural households are more likely to have a car/truck than urban households (33 percent versus 28 percent) and also to own a bicycle (30 percent versus 19 percent). The majority of Tajik households own agricultural land1 (73 percent), and a large proportion also owns farm animals (54 percent). As expected, rural households are much more likely than urban households to own agricultural land (93 percent versus 27 percent) or farm animals (72 percent versus 13 percent). Few Tajik households have a bank account. Three percent of urban households and 2 percent of rural households report they have an account. 2.3 HOUSEHOLD WEALTH The TjDHS survey did not include direct questions on household consumption or income. However, the detailed data on dwelling and household characteristics and household assets obtained in the survey have been used to construct the wealth index presented in Table 2.5. The wealth index has been shown to be consistent with other expenditure and income measures and to provide a useful measure in assessing inequalities in the use of health and other services and in health outcomes (Rutstein and Johnson, 2004). The process of constructing the wealth index, which takes into account urban-rural differences in the household characteristics, involved three steps. In the first step, a subset of indicators common to both urban and rural areas was used to create wealth scores for households in both areas. To create the scores, categorical variables were transformed into separate dichotomous (0-1) indicators. These variables and other continuous measures were then analyzed using principal components analysis to produce a common factor score for each household. In a second step, separate factor scores were produced for households in urban areas and rural areas using area-specific indicators (Rutstein, 2008). The third step combined the separate area-specific factor scores to produce a nationally applicable combined wealth index by adjusting the area-specific score through regression on the common factor scores. The resulting combined wealth index has a mean of zero and a standard deviation of one. Once the index was computed, national-level wealth quintiles were formed by assigning the household score to each de jure household member, ranking each person in the population by their score, and then dividing the ranking into five equal categories, each including approximately 20 percent of the population. 1 According to the Land Code of the Republic of Tajikistan, land in the Republic of Tajikistan is exclusively owned by the State (GOT, 2008). However, upon appropriate State registration, use of a land plot can be given for perpetual use to natural persons and legal entities of the Republic of Tajikistan (Articles 11-15). Land suitable for agricultural needs can be allocated to natural persons and legal entities for agricultural production (Articles 65-71). Housing Characteristics and Household Population • 21 Table 2.5 shows the distribution of the population across the five wealth quintiles according to urban-rural residence and region. These distributions indicate the degree to which wealth is evenly (or unevenly) distributed by geographic areas. The distribution of households by quintiles is not exactly 20 percent due to the fact that members of the households, not the households themselves, are divided into the quintiles. Table 2.5 Wealth quintiles Percent distribution of the de jure population by wealth quintiles and the Gini Coefficient, according to residence and region, Tajikistan 2012 Residence/region Wealth quintile Total Number of persons Gini coefficient Lowest Second Middle Fourth Highest Residence Urban 2.4 5.0 10.9 20.7 61.1 100.0 9,715 0.27 Rural 25.6 24.8 22.9 19.8 6.9 100.0 30,753 0.19 Region Dushanbe 0.6 0.7 3.4 15.2 80.1 100.0 3,526 0.24 GBAO 33.0 21.4 19.0 15.9 10.7 100.0 894 0.28 Sughd 17.1 13.3 19.7 29.3 20.5 100.0 11,790 0.29 DRS 11.2 18.6 29.7 24.3 16.3 100.0 9,966 0.28 Khatlon 32.5 31.3 17.7 10.8 7.7 100.0 14,291 0.30 Total 20.0 20.0 20.0 20.0 19.9 100.0 40,468 0.33 The results in Table 2.5 show that wealth is not evenly distributed by residence or region. For example, more than 60 percent of the urban population is in the highest quintile. In contrast, 50 percent of the rural population is found in the two lowest quintiles. Similar disparities are observed across the regions. For example, 80 percent of Dushanbe’s population is in the highest wealth quintile, while almost two- thirds of Khatlon’s population and more than half of the population in the GBAO region are in the two lowest quintiles. Table 2.5 also presents the Gini coefficient, which indicates the level of concentration of wealth, 0 being an equal distribution and 1 a totally unequal distribution. The Gini coefficient is higher in urban areas (0.27) than rural areas (0.19), indicating a somewhat more inequitable distribution of wealth in the urban population than in the rural population. Regional differences in Gini coefficients are generally not large; the highest coefficient is observed in the Khatlon region (0.30), indicating that this region has the most inequitable wealth distribution. 2.4 HAND WASHING Washing hands with soap and water is the ideal hygienic practice. Research shows the substantial potential that hand washing with water and soap (or a non-soap cleansing agent such as ash or sand) has for reducing the transmission of diarrhea, respiratory infections, and other illnesses (Ensink, 2008; Luby et al., 2005). To obtain information on hand washing, the TjDHS interviewer asked to see the place where household members most often washed their hands and recorded information on the availability of water and soap and/or other cleansing agents at that place. Table 2.6 shows that the place for hand washing was observed in 93 percent of households. The main reason that interviewers were not able to observe the place where household members washed their hands was because the place was not in the dwelling (data not shown). 22 • Housing Characteristics and Household Population Table 2.6 Hand washing Percentage of households in which the place most often used for washing hands was observed, and among households in which the place for hand washing was observed, percent distribution by availability of water, soap, and other cleansing agents, Tajikistan 2012 Background characteristic Percentage of households where place for washing hands was observed Number of households Among households where place for hand washing was observed, percentage with: Number of households with place for hand washing observed Soap and water1 Water and cleansing agent2 other than soap only Water only Soap but no water3 Cleansing agent other than soap only2 No water, no soap, no other cleansing agent Missing Total Residence Urban 97.7 1,976 90.0 0.0 6.1 1.0 0.0 2.7 0.1 100.0 1,931 Rural 90.2 4,456 73.0 0.6 18.2 1.5 0.0 6.5 0.2 100.0 4,019 Region Dushanbe 98.0 756 93.1 0.1 3.6 0.6 0.0 2.6 0.0 100.0 741 GBAO 93.5 160 85.5 1.3 12.7 0.0 0.0 0.5 0.0 100.0 149 Sughd 92.4 2,069 71.7 0.2 18.7 0.6 0.0 8.7 0.2 100.0 1,911 DRS 91.3 1,433 83.9 0.6 10.6 1.4 0.1 3.3 0.1 100.0 1,309 Khatlon 91.4 2,014 75.2 0.6 16.8 2.6 0.0 4.7 0.1 100.0 1,840 Wealth quintile Lowest 85.7 1,207 60.3 0.7 29.6 2.2 0.0 6.8 0.4 100.0 1,034 Second 86.6 1,132 73.3 0.6 18.9 1.8 0.1 5.3 0.0 100.0 980 Middle 92.5 1,158 75.7 0.6 14.9 1.2 0.0 7.6 0.1 100.0 1,071 Fourth 96.4 1,271 81.2 0.4 10.4 1.3 0.0 6.6 0.1 100.0 1,226 Highest 98.6 1,664 92.9 0.0 4.4 0.8 0.0 1.8 0.1 100.0 1,640 Total 92.5 6,432 78.5 0.4 14.3 1.4 0.0 5.3 0.2 100.0 5,951 1 Soap includes soap or detergent in bar, liquid, powder, or paste form. This column includes households with soap and water only as well as those that had soap and water and another cleansing agent. 2 Cleansing agents other than soap include locally available materials such as ash, mud, or sand. 3 Includes households with soap only as well as those with soap and another cleansing agent Among households where the hand washing place was observed, 79 percent had soap and water available. Most other households had water only available. Only 5 percent of households had no water, soap, or other cleaning agent available at the location. Urban households were more likely to have soap and water available at the usual hand washing place than rural households (90 percent versus 73 percent). The likelihood of having soap and water available was highest in Dushanbe (93 percent) and lowest in Sughd (72 percent) and increased with the wealth quintile, from 60 percent of households in the lowest quintile to more than 90 percent in the highest quintile. 2.5 HOUSEHOLD POPULATION BY AGE AND SEX Table 2.7 gives the distribution of the 2012 TjDHS de facto household population by age, according to sex and residence. A total of 37,779 persons were found in the 6,432 households interviewed in the TjDHS. Table 2.7 Household population by age, sex, and residence Percent distribution of the de facto household population by five-year age groups, according to sex and residence, Tajikistan 2012 Age Urban Rural Total Male Female Total Male Female Total Male Female Total <5 13.7 11.9 12.8 16.3 13.9 15.0 15.7 13.4 14.5 5-9 12.6 9.4 10.9 13.2 11.4 12.2 13.0 10.9 11.9 10-14 11.1 10.7 10.9 13.3 11.0 12.1 12.8 10.9 11.8 15-19 11.4 10.5 10.9 10.9 10.8 10.9 11.1 10.7 10.9 20-24 9.1 10.1 9.6 7.7 10.4 9.1 8.0 10.3 9.2 25-29 7.1 7.7 7.4 7.0 8.8 7.9 7.0 8.5 7.8 30-34 6.0 6.7 6.4 5.1 6.2 5.7 5.3 6.3 5.8 35-39 5.2 6.4 5.8 4.4 5.1 4.8 4.6 5.4 5.0 40-44 5.7 6.5 6.1 4.0 4.9 4.5 4.4 5.3 4.9 45-49 4.9 5.5 5.2 4.2 4.3 4.2 4.4 4.6 4.5 50-54 4.5 5.5 5.0 4.4 4.5 4.5 4.5 4.7 4.6 55-59 3.3 3.1 3.2 2.9 3.1 3.0 3.0 3.1 3.1 60-64 2.0 2.1 2.1 2.1 2.2 2.2 2.1 2.2 2.1 65-69 0.9 1.3 1.1 1.3 1.0 1.2 1.2 1.1 1.2 70-74 1.0 1.0 1.0 1.4 1.0 1.1 1.3 1.0 1.1 75-79 0.7 0.8 0.8 1.0 0.7 0.8 0.9 0.7 0.8 80 + 0.8 0.6 0.7 0.9 0.8 0.8 0.8 0.7 0.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 4,394 4,807 9,202 13,285 15,292 28,577 17,679 20,099 37,779 Housing Characteristics and Household Population • 23 The age structure of the household population shows the effects of past demographic trends in Tajikistan, particularly the country’s moderately high fertility. The majority of the household population is under age 25 (58 percent), and 38 percent is less than age 15. The proportion of the population under age 25 is higher in rural areas (59 percent) than in urban areas (55 percent). The population pyramid shown in Figure 2.2 was constructed using the age and sex distribution of the TjDHS household population. The pyramid has a wide base, which is typical of populations that have experienced high fertility in the recent past. Figure 2.2 Population pyramid 2.6 HOUSEHOLD COMPOSITION Table 2.8 looks at aspects of the composition of households that may affect the allocation of resources (financial, emotional, etc.) available to household members. For example, in cases where women are heads of households, financial resources are often limited. Similarly, the size of the household affects the wellbeing of its members. Where the size of the household is large, crowding can lead to health problems. The presence of orphans and foster children may also strain household resources. 8 6 4 2 0 2 4 6 8 <5 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80 + Percentage Age Male Tajikistan DHS 2012 Female 24 • Housing Characteristics and Household Population Table 2.8 shows that the head of most Tajik households is male; the head is female in only 21 percent of households. Female- headed households are more common in urban areas than in rural areas (28 percent versus 18 percent). The average TjDHS household has 6.3 members. One-quarter of the households have 8 or more members, while just 7 percent have 1 to 2 members. Residence is strongly related to household size; on average, rural households have 6.9 members, two more than the average urban household (4.9 members). Information was collected in the TjDHS on the living arrangements and survival status of the parents of children under age 18. This information is used in Table 2.8 to identify the percentage of households that include: (1) children who were fostered, that is, children whose parents were both alive but not living in the household with the child and (2) children who were orphans, that is, children whose father or mother or both parents were dead. Eight percent of Tajik households are caring for foster children and/or orphans. Additional detail on the prevalence of fosterhood and orphanhood among children under age 18 is presented later in this chapter. 2.7 BIRTH REGISTRATION The registration of a child’s birth is a critical step to ensuring that a child may claim full legal rights and protections and services in a society (UNICEF, 2012). Table 2.9 provides information collected in the TjDHS Household Questionnaire on birth registration and possession of a birth certificate for the de jure children under age 5. The registration of births is the inscription of the facts of the birth into an official log kept at the registrar’s office. A birth certificate is typically issued at the time of registration or later as proof of the registration of the birth. Not all children who are registered may have a birth certificate because some certificates may have been lost or were never issued. However, all children with a certificate have been registered. Table 2.8 Household composition Percent distribution of households by sex of head of household and by household size; mean size of household, and percentage of households with orphans and foster children under age 18, according to residence, Tajikistan 2012 Characteristic Residence Total Urban Rural Household headship Male 71.7 81.7 78.6 Female 28.3 18.3 21.4 Total 100.0 100.0 100.0 Number of usual members 0 0.9 0.1 0.3 1 7.0 0.9 2.8 2 8.4 2.7 4.5 3 12.3 4.9 7.2 4 18.5 9.5 12.3 5 17.8 16.0 16.6 6 14.3 18.4 17.2 7 8.5 16.1 13.8 8 4.7 8.8 7.6 9+ 7.5 22.5 17.9 Total 100.0 100.0 100.0 Mean size of households 4.9 6.9 6.3 Percentage of households with orphans and foster children under age 18 Foster children1 3.5 3.9 3.8 Double orphans 0.4 0.3 0.3 Single orphans2 4.0 5.0 4.7 Foster and/or orphan children 7.0 8.3 7.9 Number of households 1,976 4,456 6,432 Note: Table is based on de jure household members, i.e., usual residents. 1 Foster children are those under age 18 living in households with neither their mother nor their father present. 2 Single orphans include children with one dead parent and an unknown survival status of the other parent. Housing Characteristics and Household Population • 25 Table 2.9 Birth registration of children under age 5 Percentage of de jure children under age 5 whose births are registered with civil authorities, according to background characteristics, Tajikistan 2012 Background characteristic Percentage of children whose births are registered Percentage of children whose births are registered and who have Percentage of children who are not registered or who are registered but do not have a birth certificate Number of children Birth certificate No birth certificate Age <2 84.3 73.5 10.8 26.5 2,356 2-4 91.5 87.7 3.7 12.3 3,181 Sex Male 89.0 82.9 6.2 17.1 2,803 Female 87.8 80.4 7.4 19.6 2,734 Residence Urban 87.8 82.7 5.1 17.3 1,193 Rural 88.6 81.4 7.2 18.6 4,343 Region Dushanbe 86.5 80.8 5.7 19.2 441 GBAO 89.2 79.2 10.0 20.8 102 Sughd 92.2 91.6 0.6 8.4 1,490 DRS 86.4 76.9 9.5 23.1 1,428 Khatlon 87.4 78.1 9.3 21.9 2,076 Wealth quintile Lowest 86.1 76.5 9.6 23.5 1,088 Second 86.8 80.8 6.0 19.2 1,182 Middle 88.7 81.2 7.5 18.8 1,163 Fourth 91.2 85.2 5.9 14.8 1,112 Highest 89.6 85.0 4.6 15.0 991 Total 88.4 81.7 6.8 18.3 5,536 The TjDHS results indicate that almost one in five young children in Tajikistan is potentially at risk of being unable to claim full legal rights and services because their birth is not registered or they lack a birth certificate as proof that the birth was registered. Children under age 2 are more than twice as likely as older children not to be registered or to be without a birth certificate (27 percent versus 12 percent). Only 8 percent of children in the Sughd region are not registered or lack a birth certificate. The percentage of children not registered or lacking a birth certificate is much higher in other regions, ranging from 19 percent in Dushanbe to 23 percent in the DRS region. The likelihood that a child’s birth is not registered or a birth certificate is not available decreases as the wealth quintile increases, from 24 percent in the lowest quintile to 15 percent in the fourth and highest quintiles. 2.8 CHILDREN’S LIVING ARRANGEMENTS The 2012 TjDHS included a series of questions on the living arrangements and the survival status of the parents of all children under age 18. These data were used earlier in this chapter to show the percentage of households in Tajikistan that are caring for foster or orphan children. Table 2.10 employs that information to look at the living arrangements among children under age 18 and to assess the extent of fosterhood and orphanhood among children in Tajikistan. The table shows that 88 percent of de jure children under age 18 live with both parents, 9 percent are living with their mother only, 1 percent are living with their father only, and 2 percent are not living with either parent. One percent of children under age 18 are defined as foster children, that is, their parents are both alive but are not living in the same household as the child. Three percent of children under age 18 are orphans, that is, one or both parents are dead. Among orphaned children, most have lost their fathers, less than 1 percent have lost their mothers, and very few children have lost both parents (0.1 percent). Children who are not living with a biological parent include foster children and double orphans (children who have lost both parents); less than 2 percent of Tajik children fall into this category. 26 • H ou si ng C ha ra ct er is tic s an d H ou se ho ld P op ul at io n Ta bl e 2. 10 C hi ld re n' s liv in g ar ra ng em en ts a nd o rp ha nh oo d Pe rc en t d is tri bu tio n of d e ju re c hi ld re n un de r a ge 1 8 by li vi ng a rra ng em en ts a nd s ur vi va l s ta tu s of p ar en ts , t he p er ce nt ag e of c hi ld re n no t l iv in g w ith a b io lo gi ca l p ar en t, an d th e pe rc en ta ge o f c hi ld re n w ith o ne o r bo th p ar en ts d ea d, a cc or di ng to b ac kg ro un d ch ar ac te ris tic s, T aj ik is ta n 20 12 Ba ck gr ou nd ch ar ac te ris tic Li vi ng w ith bo th p ar en ts Li vi ng w ith m ot he r bu t n ot w ith fa th er Li vi ng w ith fa th er bu t n ot w ith m ot he r N ot li vi ng w ith e ith er p ar en t To ta l Pe rc en ta ge no t l iv in g w ith a bi ol og ic al pa re nt Pe rc en ta ge w ith o ne o r bo th p ar en ts de ad 1 N um be r o f ch ild re n Fa th er al iv e Fa th er de ad M ot he r al iv e M ot he r de ad Bo th al iv e O nl y fa th er a liv e O nl y m ot he r a liv e Bo th de ad M is si ng in fo rm at io n on fa th er / m ot he r A ge 0- 4 91 .1 7. 0 0. 7 0. 1 0. 2 0. 6 0. 0 0. 0 0. 1 0. 2 10 0. 0 0. 7 0. 9 5, 53 6 <2 92 .1 6. 6 0. 5 0. 1 0. 2 0. 4 0. 0 0. 0 0. 0 0. 2 10 0. 0 0. 4 0. 6 2, 35 6 2- 4 90 .5 7. 4 0. 8 0. 2 0. 2 0. 7 0. 0 0. 0 0. 2 0. 2 10 0. 0 0. 9 1. 1 3, 18 1 5- 9 89 .6 6. 2 1. 9 0. 4 0. 2 1. 2 0. 1 0. 1 0. 2 0. 1 10 0. 0 1. 5 2. 4 4, 52 8 10 -1 4 86 .8 5. 9 3. 4 0. 7 0. 6 1. 8 0. 1 0. 3 0. 2 0. 3 10 0. 0 2. 4 4. 6 4, 48 7 15 -1 7 82 .2 5. 5 5. 2 1. 1 1. 1 2. 7 0. 3 0. 6 0. 1 1. 1 10 0. 0 3. 7 7. 3 2, 70 0 Se x M al e 88 .1 6. 3 2. 4 0. 6 0. 5 1. 4 0. 1 0. 1 0. 1 0. 3 10 0. 0 1. 8 3. 3 8, 79 4 Fe m al e 88 .3 6. 3 2. 4 0. 4 0. 4 1. 4 0. 1 0. 2 0. 2 0. 4 10 0. 0 1. 8 3. 3 8, 45 7 R es id en ce U rb an 84 .8 8. 6 3. 1 0. 6 0. 2 2. 0 0. 1 0. 2 0. 3 0. 1 10 0. 0 2. 5 3. 9 3, 88 8 R ur al 89 .2 5. 6 2. 2 0. 5 0. 5 1. 2 0. 1 0. 2 0. 1 0. 4 10 0. 0 1. 6 3. 1 13 ,3 63 R eg io n D us ha nb e 84 .5 8. 0 3. 2 0. 6 0. 2 2. 2 0. 1 0. 3 0. 5 0. 2 10 0. 0 3. 2 4. 4 1, 46 8 G BA O 77 .5 9. 6 2. 2 1. 3 0. 1 8. 0 0. 1 0. 6 0. 1 0. 5 10 0. 0 8. 7 3. 1 34 3 Su gh d 87 .9 7. 2 1. 4 0. 6 0. 6 1. 6 0. 0 0. 0 0. 1 0. 5 10 0. 0 1. 8 2. 2 4, 64 6 D R S 89 .9 5. 0 2. 9 0. 5 0. 4 0. 9 0. 2 0. 1 0. 0 0. 3 10 0. 0 1. 1 3. 4 4, 30 3 Kh at lo n 88 .7 6. 0 2. 6 0. 4 0. 5 1. 0 0. 1 0. 3 0. 2 0. 2 10 0. 0 1. 6 3. 7 6, 49 2 W ea lth q ui nt ile Lo w es t 91 .6 4. 2 2. 1 0. 1 0. 5 0. 8 0. 1 0. 2 0. 0 0. 3 10 0. 0 1. 1 3. 0 3, 84 4 Se co nd 88 .7 5. 6 2. 7 0. 5 0. 7 1. 0 0. 0 0. 1 0. 2 0. 5 10 0. 0 1. 3 3. 8 3, 56 2 M id dl e 87 .5 6. 5 2. 1 0. 9 0. 4 1. 5 0. 3 0. 3 0. 2 0. 4 10 0. 0 2. 3 3. 3 3, 36 1 Fo ur th 87 .8 6. 8 2. 3 0. 4 0. 3 2. 0 0. 0 0. 0 0. 2 0. 2 10 0. 0 2. 2 2. 8 3, 22 8 H ig he st 84 .9 8. 8 2. 7 0. 7 0. 3 1. 9 0. 2 0. 2 0. 1 0. 3 10 0. 0 2. 3 3. 5 3, 25 6 To ta l < 15 89 .3 6. 4 1. 9 0. 4 0. 3 1. 1 0. 1 0. 1 0. 1 0. 2 10 0. 0 1. 5 2. 5 14 ,5 52 To ta l < 18 88 .2 6. 3 2. 4 0. 5 0. 5 1. 4 0. 1 0. 2 0. 1 0. 3 10 0. 0 1. 8 3. 3 17 ,2 52 N ot e: T ab le is b as ed o n de ju re m em be rs , i .e ., us ua l r es id en ts . 1 I nc lu de s ch ild re n w ith fa th er d ea d, m ot he r d ea d, b ot h de ad , a nd o ne p ar en t d ea d bu t m is si ng in fo rm at io n on s ur vi va l s ta tu s of th e ot he r p ar en t. 26 • Housing Characteristics and Household Population Housing Characteristics and Household Population • 27 Table 2.10 shows that, as expected, the percentage of orphaned children rises with age, from 1 percent among children age 0-4 to 7 percent among children age 15-17. Similarly, the proportion of children who are not living with a biological parent increases with age, from less than 1 percent among children age 0-4 to 4 percent among children age 15-17. The proportion of children who are not living with a biological parent is 9 percent in GBAO compared with 3 percent or less in the other regions. The difference is mainly due to the much higher level of fostered children in GBAO (8 percent) than in the other regions (2 percent or less). 2.9 EDUCATION OF HOUSEHOLD MEMBERS Many phenomena such as reproductive behavior, use of contraception, health of children, and proper hygienic habits are affected by the education of household members. During the household interview, questions on the highest level of schooling completed were included for all household members and visitors age three and over and on recent school attendance for persons age 3-24 years. This information is used in this section to examine several aspects of the educational experience of the TjDHS household population, including the overall educational attainment of household members, school attendance among the primary- and secondary-school age populations, and participation in early childhood education programs. 2.9.1 Educational Attainment Tables 2.11.1 and 2.11.2 present information on the educational attainment of the de facto female and male household population age six and over, respectively. Within the Tajikistan system, education levels are as follows: primary (Grades 1-4); general basic, also known as stage I of secondary education (Grades 5-92); general secondary, also known as stage II of secondary education (Grades 10-11); professional primary/middle (specialized technical or vocational school programs involving two or three grades each); and higher (university or post-graduate programs). Individuals who attended or completed the general basic level (Grades 5-9) and those who attended but did not complete the general secondary level (Grades 10-11) are combined into the some secondary category. The completed secondary category includes individuals who completed grade 11 and those who completed grade 10 and were awarded a general education school diploma (“attestat” in the older Soviet education system terminology). Overall, most of the female population age six and older has attained at least some secondary education; only one in five never attended school (7 percent) or attended only the primary level (14 percent). One in three women completed secondary school but did not pursue professional or higher education. Ten percent of women attended or completed professional school or have a university or higher education. The median completed years of schooling among females is 8.6 years. Similar to the female population, only one in five males age six and over never attended school or attained only the primary level. On the other hand, males are more likely than females to have post- secondary education; 8 percent of men have attended or completed the professional level, and 15 percent have higher education. The median completed years of schooling among males is 9.3 years. 2 It should be noted that Tajikistan’s educational system has undergone several stages of restructuring over the past several decades. The current system of formal education was introduced in September 1990. In the new system, primary education consists of Grades 1-4, general basic education consists of Grades 5-9 instead of Grades 5-8 as in the previous system, and general secondary (high school) consists of Grades 10-11 instead of Grades 9-10. For purposes of categorizing educational level in the 2012 TjDHS, individuals who in 1989 were age 15 or older and reported attending or completing grade 9 were included in the general secondary education category because they attained grade 9 before the current educational system change took effect. Individuals who reported at the time of interview that they had attended or completed grade 9 and were age 14 or younger in 1989 were included in the general basic education category, in accordance with the new system. 28 • Housing Characteristics and Household Population Table 2.11.1 Educational attainment of the female household population Percent distribution of the de facto female household population age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Tajikistan 2012 Background characteristic No education Some primary Completed primary1 Some secondary2 Completed secondary3 Profes- sional primary Profes- sional middle Higher Don't know/ missing Total Number Median years completed Age 6-9 39.8 58.0 1.3 0.4 0.0 0.0 0.0 0.0 0.5 100.0 1,831 0.4 10-14 1.8 11.5 18.9 67.7 0.0 0.0 0.0 0.0 0.1 100.0 2,190 5.0 15-19 2.1 1.0 2.6 60.0 29.1 1.3 1.5 2.4 0.0 100.0 2,154 8.8 20-24 3.5 3.4 3.4 38.8 36.1 1.6 5.5 7.7 0.0 100.0 2,073 9.5 25-29 3.1 3.1 3.6 42.0 34.0 2.4 3.9 7.8 0.1 100.0 1,709 9.0 30-34 1.6 0.7 1.5 45.1 38.4 2.3 4.7 5.6 0.1 100.0 1,269 9.2 35-39 2.0 0.5 0.5 21.2 58.7 4.5 5.3 7.3 0.0 100.0 1,088 9.8 40-44 1.3 0.9 0.3 11.9 64.4 6.8 4.7 9.8 0.0 100.0 1,064 9.6 45-49 1.2 0.5 0.2 12.3 70.7 3.0 5.5 6.5 0.0 100.0 924 9.5 50-54 1.3 0.9 1.3 19.8 62.1 3.9 3.7 6.9 0.1 100.0 954 9.4 55-59 2.4 1.3 1.7 27.8 50.8 2.6 3.5 9.7 0.1 100.0 624 9.4 60-64 4.6 2.7 2.5 39.1 39.4 1.8 3.0 6.9 0.0 100.0 443 9.1 65+ 14.7 11.9 10.9 40.1 14.3 1.1 2.1 4.7 0.2 100.0 714 6.2 Residence Urban 4.8 7.7 3.8 31.7 31.2 3.2 5.3 12.2 0.1 100.0 4,159 9.2 Rural 7.4 9.9 4.7 37.7 33.5 1.7 2.3 2.7 0.1 100.0 12,879 8.4 Region Dushanbe 4.5 9.2 4.4 33.3 25.1 2.2 4.2 17.0 0.1 100.0 1,503 9.0 GBAO 3.3 6.1 2.7 22.0 40.0 3.0 7.6 15.2 0.0 100.0 401 9.7 Sughd 5.7 7.8 2.9 32.0 38.2 3.2 4.3 5.9 0.0 100.0 5,059 9.2 DRS 7.4 9.9 5.7 43.1 26.7 1.4 2.8 2.9 0.2 100.0 4,033 8.1 Khatlon 8.1 10.6 5.2 36.8 34.2 1.4 1.5 2.0 0.1 100.0 6,042 8.2 Wealth quintile Lowest 9.4 12.2 6.0 39.8 29.7 1.2 0.6 0.8 0.3 100.0 3,488 7.6 Second 7.9 10.6 5.2 39.3 33.0 1.1 1.5 1.3 0.1 100.0 3,359 8.2 Middle 7.0 9.8 4.8 37.9 34.2 1.8 2.1 2.4 0.0 100.0 3,395 8.5 Fourth 5.3 7.2 3.1 34.3 38.7 2.7 4.4 4.4 0.0 100.0 3,390 9.1 Highest 4.2 7.2 3.4 29.8 29.1 3.4 6.6 16.1 0.1 100.0 3,406 9.4 Total 6.8 9.4 4.5 36.2 32.9 2.1 3.0 5.0 0.1 100.0 17,038 8.6 1 Completed Grade four at the primary level 2 Attended or completed the general basic level (Grades 5-9) and attended but did not complete the general secondary level (Grades 10-11) 3 Completed Grade 11 at the secondary level or completed Grade 10 at the secondary level and has a general education school diploma ("attestat" as in older Soviet educational system terminology) Table 2.11.2 Educational attainment of the male household population Percent distribution of the de facto male household population age six and over by highest level of schooling attended or completed and median years completed, according to background characteristics, Tajikistan 2012 Background characteristic No education Some primary Completed primary1 Some secondary2 Completed secondary3 Profes- sional primary Profes- sional middle Higher Don't know/ missing Total Number Median years completed Age 6-9 41.0 58.0 0.7 0.1 0.0 0.0 0.0 0.0 0.2 100.0 1,886 0.4 10-14 0.9 11.6 17.4 70.0 0.0 0.0 0.0 0.0 0.1 100.0 2,258 5.0 15-19 1.0 0.7 0.2 51.9 36.2 1.7 1.7 6.5 0.1 100.0 1,957 9.3 20-24 1.7 0.9 1.1 19.3 39.5 3.4 3.7 30.3 0.0 100.0 1,417 10.6 25-29 1.5 1.2 1.2 19.8 41.6 3.6 3.2 27.8 0.0 100.0 1,241 10.6 30-34 0.9 0.8 1.3 16.5 46.8 3.6 3.8 26.4 0.0 100.0 940 10.5 35-39 0.4 0.2 0.5 9.6 52.8 9.1 6.1 21.4 0.0 100.0 814 10.3 40-44 1.2 0.3 0.0 5.5 52.7 11.5 8.1 20.7 0.0 100.0 777 9.9 45-49 0.4 0.8 0.3 7.0 46.1 15.4 7.2 22.6 0.0 100.0 771 9.9 50-54 0.4 0.6 0.2 7.7 50.4 11.9 7.7 21.2 0.0 100.0 789 9.8 55-59 1.2 0.4 0.4 9.4 41.4 10.0 12.3 24.6 0.2 100.0 531 10.0 60-64 1.4 0.4 1.4 15.7 38.5 6.2 10.4 25.5 0.4 100.0 368 9.8 65+ 6.3 5.1 7.1 29.0 26.5 6.3 3.9 15.6 0.2 100.0 746 9.1 Residence Urban 5.3 9.8 3.1 22.1 25.7 3.8 4.3 25.9 0.0 100.0 3,704 9.8 Rural 6.9 10.2 3.8 27.9 31.7 4.8 3.4 11.2 0.1 100.0 10,791 9.2 Region Dushanbe 5.9 10.2 3.5 20.6 20.3 2.7 3.5 33.3 0.1 100.0 1,391 9.9 GBAO 4.2 7.6 2.5 19.0 29.0 6.8 9.9 21.0 0.1 100.0 344 10.2 Sughd 7.0 9.3 3.3 26.8 31.5 5.0 3.6 13.3 0.1 100.0 4,095 9.3 DRS 6.2 10.2 3.2 31.0 30.1 3.4 3.7 12.1 0.1 100.0 3,377 9.1 Khatlon 6.6 10.7 4.2 25.2 31.9 5.2 3.2 12.8 0.1 100.0 5,289 9.3 Wealth quintile Lowest 7.9 11.7 4.6 31.9 30.9 4.8 2.6 5.6 0.1 100.0 2,928 8.4 Second 6.7 10.5 4.1 27.5 33.4 4.9 3.4 9.4 0.1 100.0 2,880 9.2 Middle 6.9 9.7 3.1 27.7 32.4 5.3 3.4 11.4 0.2 100.0 2,748 9.2 Fourth 5.7 8.5 3.4 25.9 32.4 4.1 4.7 15.1 0.1 100.0 2,855 9.4 Highest 5.4 10.0 2.8 19.6 22.5 3.7 4.1 32.0 0.1 100.0 3,084 10.0 Total 6.5 10.1 3.6 26.4 30.2 4.5 3.6 14.9 0.1 100.0 14,496 9.3 1 Completed Grade four at the primary level. 2 Attended or completed the general basic level (Grades 5-9) and attended but did not complete the general secondary level (Grades 10-11). 3 Completed Grade 11 at the secondary level or completed Grade 10 at the secondary level and has a general education school diploma ("attestat" as in older Soviet educational system terminology). Housing Characteristics and Household Population • 29 Tables 12.11.1 and 12.11.2 also show differentials in educational attainment by age, residence, region, and wealth quintile. The majority of both females and males in every subgroup have at least some secondary education, except children age 6-9, who are, as expected, concentrated at the primary level or have not yet entered school. The median completed years of schooling is higher in urban areas than in rural areas among both females (9.2 years versus 8.4 years) and males (9.8 years versus 9.2 years). On average, educational attainment is highest in the GBAO region and lowest in the DRS region. Among females, there is a difference of 1.6 years in the median years of schooling between GBAO and DRS while the difference among males is 1.1 years. Dushanbe lags behind GBAO in the median completed years of schooling among both males and females; however, the percentage attaining at least some higher education is higher in Dushanbe than in any of the regions, especially among males. Wealth has a strong positive relationship with education. Among females, the median years of schooling varies from 7.6 in the lowest quintile to 9.4 years in the highest quintile, and, among males, the median ranges from 8.4 years in the lowest quintile to 10.0 years in the highest quintile. 2.9.2 School Attendance Table 2.12 provides information on net and gross attendance ratios and the gender parity index by school level, sex, residence, and region, and Figure 2.3 presents age-specific attendance rates. For purposes of calculating these indicators, children were considered to be currently attending if they had attended school at the given level at any time during the current school year. Table 2.12 School attendance ratios Net attendance ratios (NARs) and gross attendance ratios (GARs) for the de facto household population by sex and level of schooling; and the Gender Parity Index (GPI), according to background characteristics, Tajikistan 2012 Background characteristic Net attendance ratio1 Gross attendance ratio2 Male Female Total Gender Parity Index3 Male Female Total Gender Parity Index3 PRIMARY SCHOOL Residence Urban 88.0 88.0 88.0 1.00 100.9 102.4 101.5 1.01 Rural 86.4 87.6 87.0 1.01 103.3 99.1 101.1 0.96 Region Dushanbe 84.4 88.5 86.3 1.05 97.1 100.6 98.7 1.04 GBAO 87.9 82.2 85.1 0.94 100.4 93.1 96.8 0.93 Sughd 86.2 87.7 86.9 1.02 103.7 103.1 103.4 0.99 DRS 87.5 88.6 88.1 1.01 105.4 98.4 101.7 0.93 Khatlon 87.4 87.1 87.3 1.00 102.0 98.5 100.2 0.97 Wealth quintile Lowest 88.6 87.5 88.0 0.99 101.7 99.5 100.5 0.98 Second 86.2 87.7 87.0 1.02 102.8 99.2 101.0 0.97 Middle 83.8 89.5 86.9 1.07 106.0 102.6 104.2 0.97 Fourth 87.9 84.1 86.1 0.96 102.2 95.8 99.2 0.94 Highest 86.8 89.0 87.8 1.03 101.4 101.2 101.3 1.00 Total 86.8 87.6 87.2 1.01 102.7 99.7 101.2 0.97 SECONDARY SCHOOL Residence Urban 87.6 82.2 84.9 0.94 95.0 88.3 91.6 0.93 Rural 88.4 78.3 83.4 0.89 94.9 84.5 89.8 0.89 Region Dushanbe 87.5 77.0 82.0 0.88 99.8 83.2 91.1 0.83 GBAO 93.0 91.1 92.0 0.98 99.5 100.3 99.9 1.01 Sughd 86.4 80.9 83.6 0.94 92.7 86.8 89.7 0.94 DRS 88.3 78.0 83.3 0.88 93.4 83.4 88.6 0.89 Khatlon 89.3 78.7 84.1 0.88 96.0 85.2 90.7 0.89 Wealth quintile Lowest 90.4 76.5 83.7 0.85 94.6 81.3 88.2 0.86 Second 86.7 79.2 83.0 0.91 93.1 83.8 88.6 0.90 Middle 87.5 78.9 83.3 0.90 92.8 87.1 90.0 0.94 Fourth 88.2 79.4 83.8 0.90 96.4 87.2 91.9 0.91 Highest 88.2 82.4 85.1 0.93 98.1 88.1 92.7 0.90 Total 88.3 79.2 83.8 0.90 94.9 85.4 90.2 0.90 1 The NAR for primary school is the percentage of the primary-school age (7-10) population that is attending primary school. The NAR for secondary school is the percentage of the secondary-school age (11-17) population that is attending secondary school. By definition, the NAR cannot exceed 100 percent. 2 The GAR for primary school is the total number of primary school students, expressed as a percentage of the official primary-school-age population. The GAR for secondary school is the total number of secondary school students, expressed as a percentage of the official secondary-school-age population. If there are significant numbers of overage and underage students at a given level of schooling, the GAR can exceed 100 percent. 3 The Gender Parity Index for primary school is the ratio of the primary school NAR(GAR) for females to the primary school NAR(GAR) for males. The Gender Parity Index for secondary school is the ratio of the secondary school NAR(GAR) for females to the NAR(GAR) for males. 30 • Housing Characteristics and Household Population The net attendance ratio (NAR) is an indicator of participation in schooling among those of official school age, that is, children age 7-10 for the primary level and children age 11-17 for the secondary level. A NAR of 100 would indicate that all children in the official age range for the level are attending school at that level. The gross attendance ratio (GAR) is an indicator of participation in schooling among those of any age between 5 and 24 years, expressed as a percentage of the official school age population. The GAR can exceed 100 percent if children who are overage or underage for the given level are attending school at the level.3 The results in Table 2.12 show school attendance among the school-age population is high but not universal. Among children age 7-10 who should be attending the primary level, 87 percent are doing so. A comparison of primary level NAR and GAR indicates that 14 percent of students attending primary school are underage or over-age for the level. Differentials in the NAR and GAR at the primary level are generally minor. The secondary school NAR indicates that 84 percent of children who should be attending the secondary level are doing so. The comparison of the secondary school NAR and GAR shows the proportion of secondary school students who are outside of the official school age is 6 percent. There are only minor differences in the NAR and GAR across subgroups. Table 2.12 also includes the Gender Parity Index (GPI), or the ratio of the female to the male GAR at the primary and secondary levels. The GPI indicates the magnitude of the gender gap in attendance ratios. If there is no gender difference, the GPI will equal 1.0, whereas the wider the disparity in favor of males, the closer the GPI will be to 0. If the gender gap favors females, the GPI will exceed 1.0. Table 2.12 shows that, at the primary level, the NAR GPI is 1.01 and the GAR GPI is 0.97, indicating there is almost no gender gap in primary school attendance. At the secondary level, the NAR and GAR GPIs are identical at 0.90, evidence of a modest but clear gender gap in secondary attendance favoring males. The secondary school NAR and GAR GPIs are lowest in rural areas, in the Dushanbe, DRS, and Khatlon regions, and in the lowest quintile, indicating that males have the greatest advantage over females in school attendance in these subgroups. Figure 2.3 presents information on age-specific school attendance rates for the population age 7-24. Attendance levels are low among children under age 7, and only about half of children age 7, which is the age at which children are expected to enter school, are currently attending school; the low attendance rate may in part reflect the fact that some of the children were not 7 at the start of the school year and, thus, were not eligible to start school. Among children age 8-14, attendance rates exceed 95 percent, with the rates generally slightly higher among boys than girls. Among the population age 15-24, attendance rates decline rapidly, and the gender gap increases with age. For example, among the population age 18, 61 percent of males are attending school compared with 38 percent of girls. 3 Students who are overage for a given level of schooling may have started school overage, may have repeated one or more grades at school, or may have dropped out of school and later returned. Children who are underage for the level may have started school underage or skipped one or more grades. Housing Characteristics and Household Population • 31 Figure 2.3 Age-specific attendance rates of the de facto population 7 to 24 years 2.9.3 Early Childhood Education Participation in pre-school is important in preparing children to attend school. Table 2.13 shows the percentage of children age 3-6 who were reported to be currently attending pre-school. Interviewers were instructed to record a child as attending pre-school if they were enrolled in a nursery school, a kindergarten, or any other type of separate structured session conducted by some educational center on a regular basis. 0 10 20 30 40 50 60 70 80 90 100 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age Male Female Percentage Tajikistan DHS 2012 32 • Housing Characteristics and Household Population Most young children in Tajikistan are not involved in any type of early childhood educational program; only 6 percent of children age 3-6 are attending pre-school. The highest rates of pre-school attendance are observed among children whose mothers have a professional school or higher education (23 percent and 29 percent, respectively) and children in the highest wealth quintile (20 percent). Urban residence is strongly related to pre-school attendance; 17 percent of children in urban areas are attending pre-school compared with 3 percent in rural areas. Pre-school attendance is markedly higher in Dushanbe (17 percent), GBAO (15 percent), and Sughd (12 percent) than in DRS and Khatlon (2 percent each). Table 2.13 Early childhood education Percentage of children 36-83 months attending a pre-school education program, a kindergarten, or any other organized early child education program, Tajikistan 2012 Background Characteristic Percentage of children attending early child educational program Number of children Age (months) 36-59 6.1 1,967 60-71 8.2 781 72-83 5.4 1,068 Sex Male 7.0 1,962 Female 5.6 1,855 Residence Urban 17.2 844 Rural 3.2 2,973 Region Dushanbe 17.3 314 GBAO 14.9 68 Sughd 12.0 1,117 DRS 1.7 1,003 Khatlon 2.0 1,315 Mother's education None/primary 2.0 246 General basic 2.8 1,337 General secondary 4.5 1,721 Professional primary/middle 22.8 257 Higher 29.0 197 Missing 9.7 59 Wealth quintile Lowest 0.1 807 Second 2.2 749 Middle 3.1 772 Fourth 6.8 751 Highest 20.3 738 Total 6.3 3,817 Background Characteristics of Respondents • 33 BACKGROUND CHARACTERISTICS OF RESPONDENTS 3 his chapter first presents distributions of TjDHS respondents by basic demographic and socioeconomic characteristics including age at the time of the survey, marital status, broad education levels, urban/rural residence, region, and the wealth quintile to which they belong. A number of these characteristics are used in tables throughout the report to provide insights into demographic and social phenomena influencing the health situation of women and children in Tajikistan. The chapter also provides information on respondents’ exposure to mass media and their employment status and earnings. In addition, the chapter covers several important health issues, including respondents’ knowledge of tuberculosis, history of hypertension, and use of tobacco. 3.1 BACKGROUND CHARACTERISTICS OF RESPONDENTS Table 3.1 shows the distribution of the 9,656 women age 15-49 interviewed in the 2012 TjDHS by various demographic and socioeconomic characteristics. Two in five of the TjDHS respondents were under 25, and one in five was age 40 or older. More than two-thirds of respondents were married (67 percent) or living together with a partner (0.2 percent); 27 percent were never-married; and 5 percent were divorced, separated, or widowed. Three-quarters of respondents lived in rural areas. More than one in three respondents was from Khalton (36 percent), 30 percent resided in Sughd, and 23 percent were from DRS. Dushanbe was home to 9 percent of the TjDHS respondents, and 2 percent lived in the GBAO region. Six in ten respondents had at least a general secondary education, or higher, and an additional 35 percent had attended or completed the general basic level. Relatively few respondents never went to school or attended only the primary level (6 percent). T Key Findings • The majority of Tajik women are exposed to some form of media at least once per week; television reaches the largest number of women (84 percent). • One in three women is currently working or was employed during the past 12 months; one in four working women is not paid or receives only in-kind payment. • Seven in ten women have heard about tuberculosis. • Three quarters of the women who knew about tuberculosis correctly identified that the disease is spread through the air when a person with tuberculosis coughs or sneezes, and nearly half mentioned the DOT approach as a way to prevent the spread of tuberculosis. • One in eight women age 15-49 have ever been told by a health provider they had high blood pressure; women who were overweight or obese were much more likely to be hypertensive than other women. • The majority of women told they had high blood pressure (82 percent) were taking prescribed medication to control hypertension; however, less than half of the women were taking other actions to lower their blood pressure such as cutting down on salt intake (46 percent), controlling their weight (39 percent), or exercising (28 percent). 34 • Background Characteristics of Respondents Table 3.1 Background characteristics of respondents Percent distribution of women age 15-49 by selected background characteristics, Tajikistan 2012 Background characteristic Women Weighted percent Weighted number Unweighted number Age 15-19 20.8 2,013 2,001 20-24 20.2 1,950 1,900 25-29 16.7 1,609 1,566 30-34 12.3 1,188 1,173 35-39 10.7 1,030 1,084 40-44 10.3 991 1,018 45-49 9.1 875 914 Marital status Never married 27.4 2,648 2,723 Married 67.1 6,483 6,364 Living together 0.2 21 24 Divorced/separated 2.9 275 301 Widowed 2.4 229 244 Residence Urban 25.0 2,413 3,408 Rural 75.0 7,243 6,248 Region Dushanbe 9.1 881 1,733 GBAO 2.3 220 1,069 Sughd 29.7 2,872 2,084 DRS 23.2 2,240 2,334 Khatlon 35.7 3,444 2,436 Education None 2.0 195 155 Primary 3.9 372 330 General basic 34.7 3,349 3,095 General secondary 46.3 4,474 4,373 Professional primary 2.6 252 276 Professional middle 4.1 394 481 Higher 6.4 620 946 Wealth quintile Lowest 19.5 1,878 1,616 Second 19.8 1,913 1,625 Middle 19.7 1,904 1,736 Fourth 20.4 1,971 1,930 Highest 20.6 1,989 2,749 Total 100.0 9,656 9,656 Note: Education categories refer to the highest level of education attended, whether or not that level was completed. Education categories are described in chapter 2, section 2.9.1. 3.2 EDUCATIONAL ATTAINMENT BY BACKGROUND CHARACTERISTICS Education is a key determinant of health care knowledge, attitudes, and behavior. To gain further insight into how educational attainment varies among TjDHS respondents, Table 3.2 presents the distribution of TjDHS respondents by educational level1, according to other demographic and socioeconomic background characteristics used throughout the report. The results show that Tajik women who are of the reproductive ages 15-49 have completed an average of 9.4 years of schooling. Although the gap is not large, educational attainment tends to be somewhat lower among younger women than among older women, with the median years of schooling exceeding the national average among women age 35 and over and falling below the average among women age 15-24. The lower educational attainment among women age 15-24 is mainly due to the fact that some women in the age group are still in school. The somewhat lower median number of years of schooling among women age 25-34 likely reflects the adverse effects of the civil war in the 1990s on Tajikistan’s educational system (Shemyakina, 2011). 1 Education categories are described in chapter 2, section 2.9.1. Background Characteristics of Respondents • 35 Table 3.2 Educational attainment Percent distribution of women age 15-49 by highest level of schooling attended or completed, and median years completed, according to background characteristics, Tajikistan 2012 Background characteristic Highest level of schooling Total Median years completed Number of women No education Some primary Completed primary1 Some secondary2 Completed secondary3 Profes- sional primary Profes- sional middle Higher Age 15-24 2.5 2.2 2.9 51.1 31.4 1.4 3.4 5.0 100.0 8.9 3,963 15-19 1.7 0.9 2.5 62.3 27.4 1.3 1.3 2.4 100.0 8.8 2,013 20-24 3.4 3.4 3.4 39.6 35.5 1.5 5.6 7.7 100.0 9.4 1,950 25-29 2.5 3.2 3.8 42.9 34.0 2.1 3.9 7.7 100.0 9.0 1,609 30-34 1.4 0.9 1.6 46.0 38.3 2.3 4.1 5.6 100.0 9.2 1,188 35-39 1.6 0.7 0.6 21.0 59.0 3.8 5.6 7.6 100.0 9.8 1,030 40-44 0.8 0.8 0.1 11.8 65.5 7.0 4.4 9.6 100.0 9.6 991 45-49 1.4 0.6 0.3 12.6 70.1 3.0 5.3 6.7 100.0 9.5 875 Residence Urban 0.7 1.6 1.1 32.1 39.4 3.6 6.3 15.2 100.0 9.8 2,413 Rural 2.5 1.8 2.5 40.5 43.7 2.3 3.3 3.5 100.0 9.3 7,243 Region Dushanbe 0.9 2.2 1.6 33.9 32.8 2.3 4.9 21.4 100.0 9.7 881 GBAO 0.2 0.3 0.2 16.0 46.5 5.0 10.4 21.4 100.0 10.6 220 Sughd 0.5 0.4 0.6 33.9 47.6 4.1 5.8 7.1 100.0 9.7 2,872 DRS 1.8 2.2 3.2 48.1 35.1 1.9 3.8 3.9 100.0 8.9 2,240 Khatlon 3.9 2.5 3.0 38.4 45.7 1.7 2.2 2.7 100.0 9.2 3,444 Wealth quintile Lowest 4.6 2.4 3.2 43.6 42.2 1.6 1.2 1.2 100.0 9.0 1,878 Second 3.3 1.7 3.1 41.8 44.4 1.5 2.6 1.7 100.0 9.1 1,913 Middle 1.6 2.6 2.4 41.6 43.3 2.4 2.6 3.5 100.0 9.2 1,904 Fourth 0.4 0.9 1.0 35.8 47.7 3.3 5.8 5.3 100.0 9.6 1,971 Highest 0.4 1.2 0.9 29.7 35.7 4.2 8.0 19.9 100.0 10.1 1,989 Total 2.0 1.7 2.1 38.4 42.6 2.6 4.1 6.4 100.0 9.4 9,656 Note: Education categories are described in chapter 2, section 2.9.1. 1 Completed Grade four at the primary level. 2 Attended or completed the general basic level, also known as stage I, of secondary education (Grades 5-9) and attended but did not complete the general secondary level, also known as stage II of secondary education (Grades 10-11). 3 Completed Grade 11 at the secondary level or completed Grade 10 at the secondary level and has a general education school diploma ("attestat" in the old Soviet educational system terminology). Urban women are notably more likely to have attended or completed professional school or higher levels of education than rural women (25 percent versus 9 percent). The median number of years of schooling among women is highest in GBAO (10.6 years), followed by Dushanbe and Sughd (9.7 years each). As expected, education is directly related to the wealth quintile, with the median number of years completed increasing from 9.0 among women in the lowest quintile to 10.1 years among women in the highest quintile. 3.3 MEDIA EXPOSURE The 2012 TjDHS included questions to assess the frequency with which respondents were exposed to print and broadcast media. This information is useful for understanding which women are likely to be reached by media campaigns disseminating family planning, health, and other information. Table 3.3 shows the percentages of women age 15-49 exposed to three specific media (newspaper/magazine, radio, or television) at least once per week. The table also includes information on the percentage of women who are exposed to all three media at least once per week and the percentage not regularly exposed to any of the media. Overall, television reaches the largest number of women; 84 percent of women watch television at least once per week. Three in ten women read a newspaper or magazine, and 26 percent listen to the radio weekly. Only 17 percent of women access all three media at least once per week, while 15 percent are not regularly exposed to any of the three media. 36 • Background Characteristics of Respondents Table 3.3 Exposure to mass media Percentage of women age 15-49 who are exposed to specific media on a weekly basis by background characteristics, Tajikistan 2012 Background characteristic Reads a newspaper/ magazine at least once a week Watches television at least once a week Listens to the radio at least once a week Accesses all three media at least once a week Accesses none of the three media at least once a week Number of women Age 15-19 37.9 86.7 29.3 20.8 11.0 2,013 20-24 26.0 82.5 26.3 15.2 15.8 1,950 25-29 22.9 82.6 23.7 12.3 15.7 1,609 30-34 25.3 82.6 23.0 13.4 15.3 1,188 35-39 34.3 82.8 25.4 17.8 15.5 1,030 40-44 33.0 84.2 26.8 18.7 13.4 991 45-49 32.4 81.4 26.2 18.6 16.9 875 Residence Urban 43.9 89.5 30.4 22.5 8.2 2,413 Rural 25.4 81.5 24.6 14.6 16.7 7,243 Region Dushanbe 43.0 87.3 28.6 21.2 9.3 881 GBAO 50.4 78.4 8.0 4.0 14.4 220 Sughd 39.4 85.8 31.7 22.3 12.8 2,872 DRS 29.6 79.8 32.1 22.7 19.3 2,240 Khatlon 18.0 83.4 17.9 7.5 14.3 3,444 Education None/primary 5.0 69.9 14.5 3.0 28.4 567 General basic 20.7 81.0 22.3 11.8 17.4 3,349 General secondary 30.2 84.8 25.1 16.0 13.2 4,474 Professional primary/middle 56.3 90.8 36.1 28.8 7.1 645 Higher 75.3 93.1 53.0 46.7 3.5 620 Wealth quintile Lowest 15.0 75.6 16.4 7.4 21.6 1,878 Second 17.7 78.5 19.4 9.3 19.6 1,913 Middle 27.9 84.9 26.4 15.9 14.0 1,904 Fourth 38.7 87.1 32.4 22.1 11.3 1,971 Highest 49.7 91.0 34.8 27.5 6.6 1,989 Total 30.1 83.5 26.0 16.6 14.5 9,656 Looking at media exposure rates among subgroups in Table 3.3, the percentage watching television at least once per week exceeds 90 percent among women with a professional or higher education and women in the highest wealth quintile; women with no or only a primary education have the lowest rate of regular exposure to television (70 percent). The percentage listening to the radio regularly is lowest in the GBAO region (8 percent) and highest among women with higher education (53 percent). Only 5 percent of women with no or only a primary education read a newspaper/magazine weekly. In contrast, three-quarters of women with higher education are exposed to newspapers/magazines at least weekly. 3.4 EMPLOYMENT Like education, employment can be a source of empowerment for women, especially if it puts them in control of income. The measurement of women’s employment, however, is difficult. The difficulty arises largely because some of the work that women do, especially work on family farms, 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 TjDHS asked respondents several questions to probe for their employment status and to ensure complete coverage of employment in both the formal or informal sectors. Additional information was obtained from employed women on the type of work they were doing, whether they worked continuously throughout the year, whom they worked for, and whether they received their earnings in cash or in kind. Background Characteristics of Respondents • 37 3.4.1 Employment Status Table 3.4 presents the percent distribution of TjDHS respondents by current employment status, according to background characteristics. Respondents are defined as employed if they were working at the time of the survey or had worked at any time in the 12 months prior to the survey. They were considered to be currently employed if they had done any work in the seven days before the TjDHS interview or if they were regularly employed but had been absent from work during the week before the survey because they were ill, on vacation, or took leave for some other reason. Table 3.4 Employment status Percent distribution of women age 15-49 by employment status, according to background characteristics, Tajikistan 2012 Background characteristic Employed in the 12 months preceding the survey Not employed in the 12 months preceding the survey Missing/ don't know Total Number of women Currently employed1 Not currently employed Age 15-19 18.0 3.9 78.1 0.0 100.0 2,013 20-24 21.3 6.3 72.3 0.1 100.0 1,950 25-29 26.5 5.3 68.1 0.1 100.0 1,609 30-34 29.5 4.0 66.5 0.0 100.0 1,188 35-39 36.2 4.9 58.8 0.0 100.0 1,030 40-44 41.4 5.3 53.2 0.1 100.0 991 45-49 34.6 5.7 59.6 0.1 100.0 875 Marital status Never married 25.8 4.7 69.6 0.0 100.0 2,648 Married or living together 26.6 5.1 68.1 0.1 100.0 6,504 Divorced/separated/widowed 45.1 5.5 49.4 0.0 100.0 504 Number of living children 0 24.3 5.4 70.3 0.1 100.0 3,483 1-2 25.6 4.5 69.9 0.1 100.0 2,588 3-4 30.4 4.6 65.0 0.0 100.0 2,385 5+ 33.9 6.1 59.9 0.1 100.0 1,200 Residence Urban 25.5 3.8 70.7 0.0 100.0 2,413 Rural 28.0 5.5 66.5 0.1 100.0 7,243 Region Dushanbe 24.8 3.2 72.0 0.0 100.0 881 GBAO 20.1 5.6 74.3 0.0 100.0 220 Sughd 28.3 4.2 67.4 0.0 100.0 2,872 DRS 11.5 0.4 88.0 0.2 100.0 2,240 Khatlon 37.9 9.2 52.9 0.0 100.0 3,444 Education None/primary 25.8 7.0 67.1 0.0 100.0 567 General basic 19.9 4.4 75.5 0.1 100.0 3,349 General secondary 27.1 4.8 68.1 0.1 100.0 4,474 Professional primary/middle 46.6 5.7 47.7 0.0 100.0 645 Higher 50.6 7.5 41.9 0.0 100.0 620 Wealth quintile Lowest 35.3 7.5 57.1 0.2 100.0 1,878 Second 31.0 6.6 62.4 0.1 100.0 1,913 Middle 21.4 3.3 75.2 0.0 100.0 1,904 Fourth 21.6 4.4 74.0 0.0 100.0 1,971 Highest 27.7 3.5 68.7 0.0 100.0 1,989 Total 27.3 5.0 67.6 0.1 100.0 9,656 1 "Currently employed" is defined as having done work in the past seven days. Included are persons who did not work in the past seven days but who are regularly employed and were absent from work for leave, illness, vacation, or any other such reason. 38 • Background Characteristics of Respondents The TjDHS results indicate that more than one in four women age 15-49 in Tajikistan is currently employed, and 5 percent are not currently employed but have worked in the past 12 months (Figure 3.1). The current employment rate generally increases with age and with the number of living children. More than four in ten women who are divorced, separated, or widowed are currently working compared with around one-quarter each of never-married and married women. Rural women are slightly more likely than urban women to be currently employed. The current employment rate is highest in Khalton (38 percent) and lowest in the DRS region (12 percent). Women with higher education are almost twice as likely to be currently employed as women with no or only primary education (51 percent versus 26 percent). Women in the lowest wealth quintile have the highest current employment rate (35 percent) and women in the middle quintile have the lowest (21 percent). Figure 3.1 Women's employment status in the past 12 months Tajikistan DHS 2012 3.4.2 Occupation TjDHS respondents who reported that they were currently employed or had worked in the past 12 months were asked about their occupation. Their responses were recorded verbatim and then coded into major occupation groups after the questionnaires were sent to the central office. Table 3.5 shows the distribution of employed women by occupation group, according to background characteristics. The largest group is employed in unskilled manual labor jobs (45 percent), 21 percent work in sales and services, 20 percent are in professional, technical, or managerial positions, and 10 percent work in agriculture. Urban women, women from the GBAO and Dushanbe regions, women with a professional or higher education, and women in the highest wealth quintile are most likely to be employed in professional, technical, or managerial occupations. One-third or more of employed women in urban areas, in Dushanbe, and in the fourth and highest wealth quintiles work in sales and services. More than six in ten employed women in the lowest two wealth quintiles and in the Khalton region and more than seven in ten employed women who have no or only a primary education are working as unskilled manual laborers. As expected, women in rural areas are much more likely to work in agricultural occupations than women in urban areas (12 percent versus 1 percent). Agricultural employment is also much more common among women in Khalton (12 percent) and Sughd (10 percent) than in other regions (2 percent or less). Currently employed 27% Not currently employed, but worked in past 12 months 5% Did not work in past 12 months 68% Background Characteristics of Respondents • 39 Table 3.5 Occupation Percent distribution of women age 15-49 employed in the 12 months preceding the survey by occupation, according to background characteristics, Tajikistan 2012 Background characteristic Profes- sional/ technical/ managerial Clerical Sales and services Skilled manual Unskilled manual Domestic service Agriculture Other Missing Total Number of women Age 15-19 1.9 0.0 26.1 1.6 58.6 0.3 10.5 0.0 1.0 100.0 441 20-24 16.2 1.4 23.2 2.0 48.2 0.0 7.9 0.9 0.2 100.0 538 25-29 20.7 1.2 16.6 1.1 47.4 0.1 11.8 0.6 0.6 100.0 512 30-34 21.4 1.2 22.4 1.5 42.9 0.5 9.2 0.0 0.8 100.0 397 35-39 27.5 1.0 22.2 2.3 38.0 0.4 7.9 0.0 0.7 100.0 424 40-44 27.1 1.2 18.4 3.4 40.0 0.6 8.8 0.0 0.4 100.0 462 45-49 25.0 1.4 20.8 1.3 39.3 0.0 11.2 0.4 0.6 100.0 352 Marital status Never married 10.9 1.0 24.3 1.5 52.2 0.1 8.8 0.5 0.7 100.0 806 Married or living together 22.3 1.0 18.9 1.7 44.7 0.3 10.5 0.2 0.4 100.0 2,066 Divorced/separated/widowed 26.5 2.0 31.8 4.5 28.1 0.4 4.6 0.6 1.5 100.0 255 Number of living children 0 11.8 0.9 23.6 1.6 51.3 0.1 9.6 0.6 0.5 100.0 1,032 1-2 28.1 1.7 21.1 2.8 38.4 0.6 6.2 0.1 1.1 100.0 779 3-4 26.8 1.1 23.9 2.3 37.8 0.1 7.7 0.1 0.3 100.0 835 5+ 11.0 0.5 12.4 0.4 56.4 0.3 18.3 0.3 0.4 100.0 480 Residence Urban 38.8 3.2 36.6 5.6 12.6 0.7 1.1 0.4 1.0 100.0 707 Rural 14.2 0.5 16.9 0.8 54.8 0.1 12.0 0.3 0.4 100.0 2,420 Region Dushanbe 44.6 2.5 33.4 7.2 10.1 0.9 0.0 0.6 0.6 100.0 247 GBAO 66.2 2.4 18.8 1.1 10.9 0.0 0.5 0.0 0.0 100.0 57 Sughd 25.7 1.1 27.1 1.5 32.3 0.5 10.4 0.6 0.8 100.0 936 DRS 34.9 2.5 30.4 2.3 27.4 0.0 1.6 0.0 1.0 100.0 266 Khatlon 8.4 0.6 14.8 1.3 62.2 0.1 12.2 0.1 0.4 100.0 1,622 Education None/primary 2.9 0.9 11.3 0.6 72.0 0.0 11.5 0.8 0.0 100.0 186 General basic 1.8 0.3 23.2 1.8 58.1 0.2 13.5 0.2 0.9 100.0 816 General secondary 4.4 0.7 25.8 2.3 54.5 0.5 11.4 0.0 0.5 100.0 1,426 Professional primary/middle 72.4 1.1 16.6 1.5 6.9 0.0 0.9 0.1 0.4 100.0 337 Higher 80.1 4.6 9.0 1.7 1.6 0.0 0.7 1.6 0.6 100.0 361 Wealth quintile Lowest 4.9 0.0 11.4 0.7 64.4 0.0 18.1 0.2 0.4 100.0 803 Second 8.4 0.1 14.0 0.5 62.7 0.2 13.9 0.0 0.2 100.0 718 Middle 20.1 1.6 17.1 1.3 50.0 0.5 7.6 0.9 1.0 100.0 472 Fourth 25.7 1.7 33.4 2.9 32.0 0.1 3.4 0.0 0.7 100.0 512 Highest 46.8 2.6 35.9 4.6 7.8 0.6 0.2 0.5 0.9 100.0 622 Total 19.7 1.1 21.3 1.9 45.3 0.3 9.6 0.3 0.6 100.0 3,127 3.4.3 Type of Employment Table 3.6 shows the percent distribution of women who worked at any time during the 12 months preceding the survey by the type of earnings women received (cash, in-kind, or both), the type of employer, and the continuity of employment, according to the type of work (agricultural or non- agricultural). Slightly more than half (53 percent) of employed women are paid in cash only, and 20 percent are paid in cash and in-kind. Around one in four women either is not paid (19 percent) or receives only in-kind payments (8 percent). As expected, women who work in nonagricultural jobs are much more likely to be paid in cash for the work they do. Six in ten women working in agriculture are not paid at all for their work. Around half of women (51 percent) are employed by a nonrelative, slightly more than one-third work for a family member, and 12 percent are self-employed. Women who work in agriculture are mainly employed by family members (83 percent), which is likely the reason a large proportion are not paid. Women in nonagricultural jobs are more likely to be employed by a nonfamily member (55 percent) than to work for a relative (32 percent) or to be self-employed (13 percent). 40 • Background Characteristics of Respondents Table 3.6 Type of employment Percent distribution of women age 15-49 employed in the 12 months preceding the survey by type of earnings, type of employer, and continuity of employment, according to type of employment (agricultural or nonagricultural), Tajikistan 2012 Employment characteristic Agricultural work Non- agricultural work Total Type of earnings Cash only 4.7 58.6 53.4 Cash and in-kind 24.0 19.7 20.1 In-kind only 12.7 7.1 7.6 Not paid 58.7 14.5 18.8 Missing 0.0 0.2 0.2 Total 100.0 100.0 100.0 Type of employer Employed by family member 82.9 31.9 36.9 Employed by nonfamily member 16.6 55.0 51.2 Self-employed 0.4 12.9 11.7 Missing 0.0 0.2 0.2 Total 100.0 100.0 100.0 Continuity of employment All year 10.7 47.2 43.6 Seasonal 83.9 43.3 47.1 Occasional 5.0 9.2 8.9 Missing 0.5 0.3 0.3 Total 100.0 100.0 100.0 Number of women employed during the last 12 months 300 2,809 3,127 Note: Total includes women with missing information on type of employment who are not shown separately. Women’s employment in agricultural jobs is more often seasonal than year-round (84 percent versus 11 percent). Women in nonagricultural jobs are much more likely to be employed throughout the year, but even among these women, only 47 percent report that they work year-round. 3.5 TUBERCULOSIS Tuberculosis is a serious health concern in Tajikistan, which is among 27 nations worldwide identified by WHO as high multi-drug resistant tuberculosis (MDR-TB) countries (WHO, 2012a). In 2010, the prevalence of tuberculosis in Tajikistan was estimated at 332 cases per 100,000 population, and the incidence rate was 206 per 100,000, with 17 percent of new cases being MDR-TB (WHO/EURO, 2012). TjDHS respondents were asked a series of questions to assess the level of tuberculosis awareness, attitudes about the disease, and knowledge about modes of transmission, tuberculosis symptoms, and ways to prevent the spread of the disease. The information they provided is useful for designing communications strategies to improve awareness of the disease. 3.5.1 Knowledge and Attitudes about Tuberculosis Table 3.7 shows the percentage of women age 15-49 who had heard about tuberculosis, and, among women who know about tuberculosis, the percentages who are aware that tuberculosis is spread through the air by coughing or sneezing, who believe that tuberculosis can be cured and who would want to keep it a secret if a family member had tuberculosis. Seventy percent of women say they have heard of tuberculosis, showing that awareness of the disease is widespread in Tajikistan but not yet universal. Women in the 15-19 age group, women living in the DRS region, and women with no or only a primary education are least likely to have heard of tuberculosis (54 percent, 58 percent, and 50 percent, respectively). The level of knowledge reaches 90 percent only among women with professional or higher education. Background Characteristics of Respondents • 41 Table 3.7 Knowledge and attitude concerning tuberculosis Percentage of women age 15-49 who have heard of tuberculosis (TB), and among women who have heard of TB, the percentage who report that TB is spread through the air when an infected person coughs or sneezes, the percentage who believe that TB can be cured, and the percentage who would want to keep secret that a family member has TB, by background characteristics, Tajikistan 2012 Background characteristic Percentage of women who have heard of TB Number of women Among women who have heard of TB, percentage who: Number of women who have heard of tuberculosis Report that TB is spread through the air when an infected person coughs or sneezes Believe that TB can be cured Would want a family member's TB kept secret Age 15-19 54.3 2,013 66.7 73.6 24.2 1,092 20-24 65.4 1,950 75.3 79.7 24.4 1,275 25-29 72.0 1,609 77.2 79.0 27.4 1,159 30-34 75.4 1,188 79.1 82.3 25.3 896 35-39 81.8 1,030 81.9 86.9 24.0 842 40-44 82.5 991 81.1 84.1 21.3 817 45-49 81.8 875 80.4 85.4 23.5 716 Residence Urban 77.7 2,413 80.7 82.3 27.0 1,875 Rural 68.0 7,243 75.3 80.4 23.5 4,922 Region Dushanbe 73.6 881 76.7 76.2 29.5 649 GBAO 79.0 220 72.1 95.7 22.9 173 Sughd 78.5 2,872 85.1 82.7 35.7 2,255 DRS 57.5 2,240 75.0 80.9 20.4 1,288 Khatlon 70.6 3,444 70.4 79.6 15.0 2,432 Education None/primary 49.7 567 66.3 71.2 21.6 282 General basic 61.1 3,349 72.6 76.8 22.7 2,046 General secondary 74.2 4,474 76.9 82.0 24.6 3,321 Professional primary/middle 90.3 645 86.2 86.9 25.3 583 Higher 91.1 620 86.7 88.8 30.5 565 Wealth quintile Lowest 68.8 1,878 71.8 80.5 17.4 1,293 Second 66.0 1,913 71.9 79.9 19.4 1,262 Middle 65.4 1,904 76.8 80.3 22.1 1,245 Fourth 73.9 1,971 81.8 82.0 31.8 1,457 Highest 77.4 1,989 80.2 81.8 29.5 1,540 Total 70.4 9,656 76.8 81.0 24.5 6,797 Around three in four of the women who have heard about tuberculosis correctly believe that the disease is spread through the air when an infected individual coughs or sneezes. The percentage of women identifying coughing and sneezing as a way in which the disease may be transmitted is lowest among women age 15-19 (67 percent) and women with no or only a primary education (66 percent) and highest among women with professional (86 percent) or higher (87 percent) education. The majority (81 percent) of women who know about tuberculosis believe that the disease can be cured. Women who never attended school or only attended primary school are least likely to agree that tuberculosis can be cured (71 percent). One in four women would want to keep a family member’s tuberculosis secret, suggesting there is stigma attached to the disease for these women. The percentages wanting to keep a family member’s tuberculosis diagnosis secret are highest among women in Sughd (36 percent), women with higher education (31 percent), and women in the fourth and in the highest wealth quintiles (32 percent and 30 percent, respectively). 42 • Background Characteristics of Respondents 3.5.2 Knowledge of Tuberculosis Symptoms Table 3.8 presents information on the level of awareness of the symptoms of tuberculosis among women who report knowing about the disease. More than eight in ten of the women identified some form of coughing as a symptom that would lead them to think a person has tuberculosis; 62 percent cited coughing alone, 37 percent mentioned coughing with sputum, and 10 percent cited coughing that lasted for several weeks. Weight loss was mentioned by 24 percent as a tuberculosis symptom, 20 percent cited tiredness/fatigue, and 19 percent said fever was a symptom. Fewer women (11 percent or less) mentioned other symptoms including blood in sputum, loss of appetite, night sweating, and pain in the chest. One in ten women who had heard about tuberculosis was not able to name any symptom that would lead women to think a person had the disease. In general, women with a professional or higher education were more likely than other women to identify the various symptoms of tuberculosis shown in Table 3.8. B ac kg ro un d C ha ra ct er is tic s of R es po nd en ts • 4 3 Ta bl e 3. 8. K no w le dg e of s ym pt om s of tu be rc ul os is Am on g w om en w ho h av e he ar d of tu be rc ul os is (T B) , t he p er ce nt ag e id en tif yi ng s pe ci fic s ym pt om s as s ig ns th at w ou ld le ad th em to th in k a pe rs on h as tu be rc ul os is , b y ba ck gr ou nd c ha ra ct er is tic s, T aj ik is ta n 20 12 Ba ck gr ou nd ch ar ac te ris tic N on - sp ec ifi c co ug hi ng C ou gh in g w ith sp ut um C ou gh in g fo r s ev er al w ee ks An y co ug hi ng Fe ve r Bl oo d in sp ut um Lo ss o f ap pe tit e N ig ht sw ea tin g Pa in in ch es t Ti re dn es s/ fa tig ue W ei gh t lo ss Le th ar gy O th er D on 't kn ow N um be r o f w om en w ho h ea rd of T B A ge 15 -1 9 56 .7 32 .2 9. 8 78 .5 13 .1 6. 1 7. 2 5. 4 9. 3 16 .8 20 .7 0. 2 0. 4 17 .3 1, 09 2 20 -2 4 62 .9 35 .1 8. 6 83 .0 16 .9 8. 2 7. 6 6. 7 10 .3 19 .8 22 .5 0. 3 0. 6 12 .4 1, 27 5 25 -2 9 60 .0 36 .2 10 .8 84 .3 18 .2 7. 2 8. 4 5. 3 9. 9 17 .9 20 .5 0. 5 0. 3 10 .7 1, 15 9 30 -3 4 64 .9 38 .6 10 .9 87 .6 21 .0 8. 0 7. 6 5. 8 11 .1 21 .1 26 .9 0. 7 0. 7 7. 4 89 6 35 -3 9 63 .2 40 .6 10 .0 89 .3 25 .2 7. 9 7. 7 8. 3 10 .2 22 .8 27 .1 0. 8 0. 5 6. 2 84 2 40 -4 4 67 .3 40 .5 11 .6 89 .2 21 .2 8. 7 11 .3 7. 0 12 .3 20 .2 29 .3 0. 3 0. 9 6. 4 81 7 45 -4 9 64 .1 41 .7 9. 1 86 .8 20 .3 7. 8 6. 8 7. 8 11 .1 21 .1 24 .6 0. 7 0. 2 9. 0 71 6 R es id en ce U rb an 66 .8 40 .5 8. 1 88 .4 23 .6 7. 8 9. 2 8. 2 9. 7 19 .9 24 .6 0. 4 0. 7 8. 3 1, 87 5 R ur al 60 .7 36 .1 10 .8 83 .7 17 .2 7. 6 7. 6 5. 8 10 .8 19 .6 23 .8 0. 5 0. 4 11 .2 4, 92 2 R eg io n D us ha nb e 75 .7 37 .6 7. 9 86 .8 23 .7 4. 3 9. 8 4. 6 7. 1 18 .7 18 .7 0. 1 1. 0 10 .2 64 9 G BA O 59 .6 19 .0 8. 8 79 .0 23 .7 6. 9 7. 8 13 .9 2. 4 16 .8 14 .6 1. 2 0. 4 9. 7 17 3 Su gh d 63 .6 42 .9 11 .9 88 .8 29 .9 8. 3 7. 9 9. 9 15 .3 28 .2 24 .3 0. 5 1. 2 8. 2 2, 25 5 D R S 63 .0 33 .6 12 .3 81 .4 11 .4 2. 5 8. 6 3. 7 6. 9 15 .0 21 .2 1. 0 0. 1 11 .1 1, 28 8 Kh at lo n 57 .6 35 .3 7. 8 83 .4 11 .2 10 .7 7. 4 4. 7 9. 4 14 .8 27 .4 0. 2 0. 0 12 .1 2, 43 2 Ed uc at io n N on e/ pr im ar y 61 .9 30 .5 4. 9 78 .6 11 .2 8. 2 3. 4 3. 9 10 .5 10 .5 20 .1 0. 6 0. 2 17 .5 28 2 G en er al b as ic 63 .5 33 .4 9. 1 82 .0 15 .7 6. 3 7. 1 4. 9 9. 0 17 .9 21 .7 0. 5 0. 3 12 .7 2, 04 6 G en er al s ec on da ry 60 .4 38 .4 10 .4 85 .4 18 .4 7. 7 7. 7 6. 3 10 .3 20 .0 24 .2 0. 6 0. 3 10 .2 3, 32 1 Pr of es si on al p rim ar y/ m id dl e 66 .1 45 .7 12 .2 90 .9 30 .6 9. 2 12 .2 7. 8 12 .1 22 .5 24 .6 0. 2 2. 2 5. 4 58 3 H ig he r 66 .3 40 .2 11 .9 90 .8 25 .8 10 .1 11 .5 13 .2 15 .3 26 .0 33 .0 0. 1 1. 3 4. 4 56 5 W ea lth q ui nt ile Lo w es t 66 .7 31 .0 10 .6 84 .3 14 .9 6. 6 7. 5 5. 6 8. 3 21 .1 23 .2 0. 9 0. 0 10 .2 1, 29 3 Se co nd 59 .9 34 .3 10 .0 81 .8 14 .8 9. 3 6. 8 5. 3 11 .1 18 .0 25 .7 0. 6 0. 2 12 .6 1, 26 2 M id dl e 58 .6 39 .3 11 .2 84 .1 17 .0 8. 3 8. 0 5. 8 9. 1 17 .8 23 .5 0. 4 0. 3 11 .9 1, 24 5 Fo ur th 59 .2 41 .5 10 .1 86 .3 21 .9 6. 8 8. 1 6. 2 12 .2 23 .7 24 .9 0. 3 0. 8 9. 1 1, 45 7 H ig he st 66 .7 39 .6 8. 8 87 .8 24 .6 7. 4 9. 5 9. 1 11 .4 17 .6 23 .0 0. 2 1. 0 8. 6 1, 54 0 To ta l 62 .4 37 .3 10 .1 85 .0 18 .9 7. 6 8. 1 6. 5 10 .5 19 .7 24 .0 0. 5 0. 5 10 .4 6, 79 7 Background Characteristics of Respondents • 43 44 • Background Characteristics of Respondents 3.5.3 Misconceptions about How Tuberculosis is Spread Women who had heard about tuberculosis were asked to identify ways in which the disease is spread from one person to another; all of the modes of transmission that women mentioned in response to the question were recorded. As shown in Table 3.7, around three-quarters of women who knew about tuberculosis correctly identified that the disease is spread through the air when an individual with the disease coughs or sneezes. Although the majority of women knew the correct mode by which tuberculosis is spread, Table 3.9 shows that substantial minorities of women share misconceptions about other ways the disease may be spread. For example, three in ten women falsely think that the disease may be spread through food, and 26 percent incorrectly believe that it may be spread by sharing utensils with a person with tuberculosis. Fewer women have other misconceptions including believing that tuberculosis may be spread through sexual contact with a person who has tuberculosis (9 percent) or touching a person who has the disease (6 percent). Only 2 percent of women think tuberculosis is spread through mosquito bites. Table 3.9 Misconceptions about tuberculosis transmission Among women who have heard of tuberculosis (TB), the percentage who report various misconceptions about ways tuberculosis is spread, by background characteristics, Tajikistan 2012 Background characteristic Through sharing utensils Through touching a person with TB Through food Through sexual contact Through mosquito bites Other Don't know Number of women who heard of TB Age 15-19 24.8 6.7 28.0 5.9 2.7 0.2 18.0 1,092 20-24 25.2 6.3 25.7 10.0 2.2 0.4 13.6 1,275 25-29 23.4 4.5 28.1 9.4 1.9 0.2 11.9 1,159 30-34 27.0 7.2 29.8 8.1 3.1 0.5 10.1 896 35-39 28.6 6.1 31.1 8.2 1.2 0.6 6.8 842 40-44 28.2 8.5 31.9 10.6 1.9 0.7 8.1 817 45-49 28.1 6.6 31.1 7.1 1.4 0.5 9.5 716 Residence Urban 26.8 6.4 26.5 8.2 2.2 0.6 10.1 1,875 Rural 25.9 6.4 29.9 8.7 2.1 0.4 12.2 4,922 Region Dushanbe 26.8 6.2 19.7 8.5 3.0 0.9 12.9 649 GBAO 13.0 4.5 39.0 9.0 1.1 0.1 12.7 173 Sughd 32.6 8.8 35.2 6.5 1.2 0.4 9.3 2,255 DRS 30.5 3.0 18.9 3.7 0.2 0.1 11.7 1,288 Khatlon 18.6 6.2 30.3 12.9 3.8 0.5 13.3 2,432 Education None/primary 21.1 1.9 36.0 8.7 1.1 0.9 16.3 282 General basic 25.2 5.6 26.0 8.8 1.9 0.3 14.8 2,046 General secondary 25.0 7.1 29.0 8.5 2.4 0.3 11.4 3,321 Professional primary/middle 34.7 6.1 31.0 8.6 2.0 0.6 5.9 583 Higher 29.8 7.8 34.2 7.8 1.6 1.1 5.0 565 Wealth quintile Lowest 25.7 6.3 36.3 8.9 3.0 0.1 12.6 1,293 Second 26.1 9.2 30.7 12.2 2.7 0.0 13.4 1,262 Middle 26.6 5.5 27.0 6.9 1.8 0.9 12.3 1,245 Fourth 27.6 5.9 26.5 8.3 1.4 0.4 9.2 1,457 Highest 24.8 5.6 25.5 6.8 1.7 0.6 11.1 1,540 Total 26.1 6.4 29.0 8.5 2.1 0.4 11.6 6,797 3.5.4 Knowledge about How to Prevent Tuberculosis Women who knew about tuberculosis were asked how they would prevent the spread of the disease if a member of their family became sick with tuberculosis, and all of the actions they mentioned were recorded in the questionnaire. Table 3.10 presents the percentages of women reporting specific actions to prevent the spread of tuberculosis among family members. B ac kg ro un d C ha ra ct er is tic s of R es po nd en ts • 4 5 Background Characteristics of Respondents • 45 Ta bl e 3. 10 W om en 's re po rt on h ow to p re ve nt s pr ea di ng o f t ub er cu lo si s A m on g w om en w ho h av e he ar d of tu be rc ul os is (T B ), th e pe rc en ta ge w ho re po rt va rio us w ay s to p re ve nt s pr ea di ng o f t ub er cu lo si s, a cc or di ng to b ac kg ro un d ch ar ac te ris tic s, T aj ik is ta n 20 12 B ac kg ro un d ch ar ac te ris tic S ic k pe rs on tre at ed ap pr o- pr ia te ly S ic k pe rs on fo llo w s D O TS tre at m en t S ic k pe rs on is ol at ed S ic k pe rs on as ke d to di sp os e of sp ut um sa fe ly S ic k pe rs on av oi ds co ug hi ng or sn ee zi ng in o pe n ai r Fa m ily m em be rs ge t va cc in a- tio n/ bo os te r Fa m ily m em be rs ta ke p re - ve nt at iv e tre at m en t Fa m ily m em be rs se ek do ct or ’s ad vi ce if ha ve fe ve r Fa m ily m em be rs se ek do ct or ’s ad vi ce if ha ve pr ol on ge d co ug h C le an ho us e da ily D on 't sh ar e fo od a nd ut en si ls w ith in fe ct ed pe rs on s Li m it se xu al co nt ac t w ith in fe ct ed pe rs on D o no th in g S m ok e ho us e w ith he rb P ra y O th er D on 't kn ow N um be r o f w om en w ho h ea rd of T B A ge 15 -1 9 46 .2 45 .2 18 .5 3. 2 10 .1 1. 5 2. 9 7. 7 5. 5 12 .2 17 .7 1. 9 0. 3 1. 2 4. 1 0. 0 7. 7 1, 09 2 20 -2 4 47 .6 45 .5 20 .6 5. 2 9. 7 2. 1 2. 9 8. 5 5. 6 10 .4 18 .1 2. 8 0. 4 1. 3 5. 7 0. 1 6. 0 1, 27 5 25 -2 9 49 .0 45 .6 22 .7 2. 8 9. 2 1. 4 3. 4 6. 8 6. 1 7. 4 18 .3 1. 3 0. 4 0. 8 4. 2 0. 0 4. 9 1, 15 9 30 -3 4 51 .6 49 .5 23 .1 4. 9 10 .3 1. 8 3. 3 7. 5 7. 0 10 .5 21 .3 2. 9 0. 1 1. 0 6. 3 0. 0 2. 4 89 6 35 -3 9 53 .6 47 .8 26 .1 4. 3 10 .9 1. 9 5. 2 5. 8 4. 7 10 .4 18 .8 1. 0 0. 2 0. 7 5. 1 0. 1 1. 9 84 2 40 -4 4 52 .9 49 .7 23 .4 4. 8 9. 9 3. 1 5. 1 9. 3 7. 6 10 .8 21 .0 1. 9 0. 1 1. 2 5. 7 0. 2 3. 5 81 7 45 -4 9 51 .7 50 .6 22 .7 5. 0 8. 7 2. 3 3. 7 9. 8 7. 2 11 .6 19 .9 1. 9 0. 2 0. 9 6. 5 0. 0 2. 1 71 6 R es id en ce U rb an 55 .8 47 .0 23 .3 5. 6 11 .4 2. 7 4. 5 7. 5 6. 8 12 .2 17 .1 2. 2 0. 2 1. 2 6. 2 0. 1 3. 3 1, 87 5 R ur al 47 .7 47 .5 21 .8 3. 8 9. 3 1. 7 3. 4 8. 0 5. 9 9. 6 19 .9 1. 9 0. 3 0. 9 4. 9 0. 0 4. 8 4, 92 2 R eg io n D us ha nb e 57 .7 48 .8 20 .4 2. 9 10 .7 3. 7 4. 9 7. 6 6. 4 15 .7 11 .5 1. 3 0. 4 2. 1 9. 9 0. 1 4. 9 64 9 G B A O 47 .2 46 .9 14 .7 9. 3 6. 2 4. 0 1. 6 2. 3 2. 2 2. 3 2. 4 0. 5 0. 2 0. 3 0. 6 0. 0 1. 1 17 3 S ug hd 63 .2 34 .2 40 .5 5. 7 15 .2 1. 7 4. 8 6. 4 7. 5 10 .0 27 .6 1. 9 0. 2 1. 4 10 .3 0. 1 5. 1 2, 25 5 D R S 47 .4 46 .7 10 .6 1. 7 4. 9 1. 4 2. 1 11 .3 5. 8 6. 6 16 .8 0. 9 0. 0 0. 7 0. 4 0. 0 3. 9 1, 28 8 K ha tlo n 37 .2 59 .5 12 .4 4. 3 7. 6 1. 8 3. 3 7. 8 5. 2 11 .9 15 .7 2. 9 0. 5 0. 7 2. 3 0. 1 4. 1 2, 43 2 Ed uc at io n N on e/ pr im ar y 37 .7 50 .3 10 .2 3. 2 9. 0 2. 3 1. 3 8. 1 3. 7 9. 4 15 .2 3. 0 0. 0 0. 2 1. 6 0. 0 6. 7 28 2 G en er al b as ic 46 .5 48 .6 19 .0 2. 8 8. 6 2. 0 2. 4 8. 5 5. 6 9. 2 18 .9 2. 2 0. 4 0. 8 3. 9 0. 0 5. 5 2, 04 6 G en er al s ec on da ry 50 .5 47 .0 22 .5 4. 5 9. 5 1. 6 3. 9 7. 5 6. 6 10 .6 19 .2 1. 9 0. 3 1. 1 6. 3 0. 1 4. 3 3, 32 1 P ro fe ss io na l pr im ar y/ m id dl e 55 .3 46 .1 29 .5 5. 3 11 .4 2. 1 4. 6 7. 4 5. 3 9. 9 20 .4 1. 1 0. 0 1. 2 3. 0 0. 0 2. 5 58 3 H ig he r 60 .1 44 .7 30 .6 7. 4 15 .5 3. 6 7. 1 7. 6 7. 2 13 .8 20 .4 2. 3 0. 3 2. 0 7. 9 0. 0 1. 5 56 5 W ea lth q ui nt ile Lo w es t 41 .9 56 .5 16 .6 2. 9 6. 0 1. 8 2. 3 8. 7 6. 2 8. 0 19 .0 2. 0 0. 5 0. 6 2. 6 0. 0 4. 6 1, 29 3 S ec on d 44 .4 52 .9 17 .8 4. 1 6. 9 1. 9 2. 9 9. 1 5. 6 9. 6 20 .3 2. 8 0. 3 1. 3 2. 7 0. 1 5. 0 1, 26 2 M id dl e 49 .6 45 .9 23 .5 4. 7 10 .1 1. 4 2. 9 8. 8 6. 4 10 .1 19 .6 2. 1 0. 1 0. 7 5. 3 0. 0 5. 1 1, 24 5 Fo ur th 51 .9 42 .8 28 .8 4. 0 12 .1 2. 0 4. 3 6. 8 6. 4 10 .7 19 .9 1. 4 0. 2 1. 0 7. 7 0. 0 3. 8 1, 45 7 H ig he st 59 .7 40 .6 23 .1 5. 4 13 .2 2. 6 5. 5 6. 3 6. 1 12 .8 17 .1 1. 7 0. 2 1. 4 7. 2 0. 2 3. 8 1, 54 0 To ta l 50 .0 47 .3 22 .2 4. 3 9. 8 1. 9 3. 7 7. 8 6. 1 10 .3 19 .1 2. 0 0. 3 1. 0 5. 3 0. 1 4. 4 6, 79 7 46 • Background Characteristics of Respondents The most common preventative action women reported was to seek appropriate treatment for a family member with tuberculosis (50 percent). Around half of women (47 percent) mentioned that a family member with tuberculosis should be observed by a health worker to ensure the treatment regime is being followed. Tajikistan’s tuberculosis treatment regime is built around the directly observed therapy (DOT) approach recommended by WHO in which a health worker observes that a person with TB takes each dose of the medications prescribed to treat the disease (Zaleskis et al., 2009). Other less frequently mentioned actions that women mention to avoid the spread of tuberculosis include isolating the infected person (22 percent), not sharing food and utensils with the infected person (19 percent), cleaning the house daily (10 percent), and having the infected person avoid coughing or sneezing into the open air (10 percent). Only 4 percent of the women reported that they did not know of any way to avoid the spread of tuberculosis, and virtually no women believed there was nothing a family could do to prevent the spread of tuberculosis. 3.6 HYPERTENSION Cardiovascular diseases, including heart attacks and strokes, accounts for 39 percent of all deaths annually in Tajikistan (WHO, 2011). High blood pressure or hypertension is among the major risk factors for cardiovascular disease. In the 2012 TjDHS, respondents were asked several questions to determine their history of hypertension, including whether they had ever been told by a doctor or other health worker that they had high blood pressure and, if so, whether they had been told that on two or more occasions. If they reported being told one or more times that they had high blood pressure, they were asked additional questions about actions they were taking at the time of the survey to lower their blood pressure. Table 3.11 summarizes the results of the questions relating to hypertension. In reviewing the findings, it is important to remember that they apply only to women who were advised by a health care provider that they had high blood pressure. Many Tajik women may suffer from hypertension but do not know it; hypertension is often termed the ‘silent killer’ because of the lack of warning signs or symptoms. Overall, the TjDHS results indicate 12 percent of women age 15-49 report having ever been told by a doctor or other health worker that their blood pressure was high. A diagnosis of hypertension is usually only made after blood pressure readings are found to be high on several occasions. Table 3.11 shows that the majority of women (78 percent) told they had high blood pressure were advised they were hypertensive on two or more occasions. It is encouraging that more than eight in ten of the women told they had high blood pressure were taking medication to control their blood pressure. Women were much less likely to be taking other measures to lower their blood pressure. For example, less than half were cutting back on salt in their diet (46 percent), 39 percent were controlling or losing weight, and 29 percent were exercising. Background Characteristics of Respondents • 47 Table 3.11 Knowledge and treatment of high blood pressure Percentage of women age 15-49 who were ever told by a health professional that they have high blood pressure, and among women who were ever told that they have hypertension, the percentage who were told on two or more different occasions by a health professional that they have hypertension, and the percentages taking specific actions to lower blood pressure, by background characteristics, Tajikistan 2012 Background characteristic Percentage of women ever told by a health professional they had hypertension or high blood pressure Number of women Among women ever told by a health professional they have hypertension percentage: Number of women ever told they had hyper- tension Told on two or more different occasions that they had high blood pressure Taking prescribed medication Controlling or losing weight Cutting down salt in their diet Exercising to control hyper- tension Cutting down on alcohol intake Stopped smoking Age 15-19 2.6 2,013 42.0 72.4 31.3 41.4 21.6 16.0 15.9 52 20-24 6.6 1,950 69.6 66.8 32.4 36.7 22.3 2.4 2.4 130 25-29 9.9 1,609 75.7 76.7 34.7 33.5 22.2 3.3 5.7 159 30-34 12.7 1,188 79.1 82.8 34.7 42.5 23.6 5.3 5.0 150 35-39 18.4 1,030 78.5 80.6 32.9 48.9 28.1 8.6 8.9 189 40-44 23.3 991 82.7 84.5 47.0 53.0 36.1 10.2 8.2 230 45-49 29.1 875 86.8 92.3 47.9 53.8 34.1 8.7 7.9 254 Body Mass Index 1 <18.5 (thin) 6.4 942 72.5 67.0 20.7 34.0 27.0 11.2 11.4 61 18.5 - 24.9 (normal) 8.4 5,788 71.9 76.7 31.1 41.8 23.7 5.4 6.0 483 25.0-29.9 (overweight) 17.7 2,013 82.4 85.9 45.7 52.3 34.7 9.1 8.3 357 >=30.0 (obese) 29.0 895 85.3 88.7 50.2 48.0 30.5 8.1 7.0 260 Residence Urban 15.0 2,413 80.0 81.3 42.7 47.0 30.4 10.8 9.9 361 Rural 11.1 7,243 77.4 82.0 37.8 45.8 27.9 5.9 6.0 804 Region Dushanbe 12.6 881 85.4 77.2 42.4 42.4 28.4 12.4 11.9 111 GBAO 17.6 220 92.1 89.2 52.0 59.8 45.5 55.7 55.7 39 Sughd 9.8 2,872 76.3 71.9 48.7 56.9 23.3 7.6 6.1 281 DRS 10.6 2,240 82.0 91.0 46.1 41.4 31.6 4.7 4.8 237 Khatlon 14.4 3,444 74.8 83.4 29.1 42.1 29.1 3.8 4.2 497 Education None/primary 9.1 567 (70.6) (74.2) (17.7) (30.3) (21.4) (3.9) (4.3) 52 General basic 7.6 3,349 72.9 83.3 37.5 43.1 22.7 5.7 6.6 253 General secondary 14.5 4,474 81.5 82.6 39.3 47.4 28.3 6.7 6.0 648 Professional primary/ middle 19.3 645 77.6 80.3 47.9 49.6 37.3 10.6 11.4 125 Higher 14.2 620 75.2 77.8 44.9 50.3 40.6 15.2 13.4 88 Wealth quintile Lowest 10.5 1,878 80.8 83.7 30.2 39.6 32.0 6.0 6.1 196 Second 11.6 1,913 73.5 82.7 36.0 48.4 31.0 7.7 8.6 223 Middle 11.6 1,904 71.0 77.1 37.4 49.0 23.1 4.4 3.6 220 Fourth 13.4 1,971 84.9 84.2 42.6 44.9 25.9 6.5 5.9 264 Highest 13.2 1,989 79.6 81.0 47.2 48.0 31.7 11.8 11.2 262 Total 12.1 9,656 78.2 81.8 39.3 46.2 28.7 7.4 7.2 1,165 Note: Total includes women with missing information on Body Mass Index who are not shown separately. Figures in parentheses are based on 25-49 unweighted cases. 1 The Body Mass Index (BMI) is expressed as the ratio of weight in kilograms to the square of height in meters (kg/m2). Table 3.11 also presents the variation in the percentage of women told they had high blood pressure and the percentages of these women taking various actions to control hypertension by background characteristics. As expected, the percentage told that they had high blood pressure increases directly with age, from 3 percent of women age 15-19 to 29 percent among women age 45-49. Also as expected, being overweight is strongly related to high blood pressure. As shown in Figure 3.2, the percentage of women ever told they had high blood pressure is much higher among women classified as obese (29 percent) or overweight (18 percent) based on body mass2 than women considered normal-weight (8 percent) or thin (6 percent). The percentage told they had high blood pressure is slightly higher among urban women than rural women, and it ranges from 10 percent in Sughd to 18 percent in the GBAO region. Women with general secondary or higher education are more likely to report having been told they had high blood pressure than less educated women. The percentage told they had high blood pressure generally increases with the wealth quintile, but the differences between quintiles are small. 2 The 2012 TjDHS obtained data on the height and weight of women age 15-49. This information was used to calculate each woman’s Body Mass Index (BMI), a commonly used measure of nutritional status obtained by dividing weight in kilograms by height in meters squared (kg/m2). More information on BMI levels among TjDHS respondents is presented in Chapter 12 of this report. 48 • Background Characteristics of Respondents Figure 3.2 Women ever told they had hypertension by Body Mass Index Although the pattern is not uniform, groups where the percentages of women told they had high blood pressure are highest tend to be the groups most often taking actions intended to lower blood pressure. For example, among women told they had high blood pressure, those who are obese and overweight women are more likely to say they are taking medication, losing weight, cutting down on salt, and exercising than normal-weight or thin women. 3.7 SMOKING Tobacco use is associated with increased risks of respiratory, cardiovascular, and other diseases among adults who smoke, and the effects of second-hand smoke pose increased morbidity and mortality risks among adults and children who do not use tobacco (WHO, 2012b). The 2012 TjDHS included questions designed to assess the prevalence of smoking among the women interviewed in the survey. Smoking is rare among Tajik women, overall. Only 0.3 percent of women age 15-49 interviewed in the TjDHS reported that they currently smoke (data nor shown). While few women themselves smoke, a substantial number of women are regularly exposed to the harmful effects of second-hand smoke. As reported in Chapter 2, one in ten households reports that smoking takes place in the home daily or weekly. Marriage and Sexual Activity • 49 MARRIAGE AND SEXUAL ACTIVITY 4 his chapter addresses age at first marriage. Marriage is a primary indication of the exposure of women to the risk of pregnancy and, therefore, is important for the understanding of fertility. Populations in which age at marriage is young tend to be populations with early childbearing and high fertility. For this reason, there is an interest in trends in age at marriage. The chapter also includes information on two other direct measures of exposure to pregnancy: the age at first sexual intercourse and the frequency of intercourse. 4.1 CURRENT MARITAL STATUS Table 4.1 presents the distribution of all TjDHS respondents by current marital status and age. The term married in the table refers to legal or formal unions while living together refers to informal unions. In subsequent tables, the two categories are combined into the proportion currently in either type of union, and the new category is referred to as currently married. Table 4.1 shows that more than two-thirds of Tajik women age 15-49 (67 percent) are currently married. Reflecting the traditional character of Tajik society, almost all of these women are in formal unions; less than 1 percent report they are living together with a partner. Just over one-quarter of women are currently never-married, while 5 percent are divorced, separated, or widowed. Table 4.1 Current marital status Percent distribution of women age 15-49 by current marital status, according to age, Tajikistan 2012 Age Marital status Total Percentage of respondents currently in union Number of respondents Never married Married Living together Divorced Separated Widowed 15-19 86.7 13.2 0.0 0.1 0.0 0.0 100.0 13.2 2,013 20-24 29.4 67.4 0.3 1.8 0.0 1.1 100.0 67.7 1,950 25-29 12.8 82.6 0.2 3.2 0.1 1.1 100.0 82.8 1,609 30-34 6.8 85.2 0.2 5.2 0.3 2.3 100.0 85.4 1,188 35-39 2.6 89.5 0.1 4.3 0.2 3.2 100.0 89.6 1,030 40-44 1.1 88.2 0.5 4.3 0.2 5.7 100.0 88.7 991 45-49 0.5 87.5 0.5 3.0 0.3 8.3 100.0 88.0 875 Total 27.4 67.1 0.2 2.7 0.1 2.4 100.0 67.4 9,656 T Key Findings • More than two-thirds of Tajik women age 15-49 (67 percent) are currently married, just over one-quarter are never-married, and 5 percent are divorced, separated, or widowed. • Most Tajik women marry at least once during their lifetime, with the proportion never-married decreasing rapidly with age to less than 1 percent among women age 45-49. • Less than one percent of women age 25-49 married for the first time before age 15, and only 15 percent married before age 18. The median age at first marriage is 20.2 years. 50 • Marriage and Sexual Activity The results in Table 4.1 also suggest that most Tajik women marry at least once during their lifetime, with the proportion never-married decreasing rapidly with age. Among women age 30-34, only 7 percent have never married, and the proportion never married declines to 1 percent or less among women age 40 and older. The proportion divorced or separated peaks at 6 percent among women age 30-34, while the proportion widowed increases directly with age to 8 percent among women age 45-49. 4.2 AGE AT FIRST MARRIAGE First marriage is an important social and demographic indicator since, in most societies, it represents the point in life when childbearing first becomes welcome. The information presented in Table 4.2 on the age at which women first marry was obtained by asking all ever-married TjDHS respondents about the month and year in which they married their first partner. Respondents who were not able to provide the date of their first marriage were asked about their age when they first married. Trends in age at marriage in Tajikistan can be examined in Table 4.2 by comparing changes in the proportions married at specific exact ages across age groups. In addition, the median age at marriage is presented to provide a measure of the average age at which women married. The median is defined as the age by which half of the cohort has married. In drawing conclusions concerning trends in the age at first marriage, the data for the oldest age cohorts should be interpreted cautiously since respondents may not recall dates or ages at marriage with accuracy. Table 4.2 Age at first marriage Percentage of women age 15-49 who were first married, by specific exact ages, and median age at first marriage, according to current age, Tajikistan 2012 Current age Percentage first married by exact age: Percentage never married Number of respondents Median age at first marriage 15 18 20 22 25 15-19 0.1 na na na na 86.7 2,013 a 20-24 0.1 11.6 44.3 na na 29.4 1,950 a 25-29 0.4 10.9 34.5 61.2 80.6 12.8 1,609 21.1 30-34 1.1 18.8 45.9 63.4 81.6 6.8 1,188 20.4 35-39 0.3 23.8 60.4 78.3 88.5 2.6 1,030 19.3 40-44 1.0 11.6 52.9 78.4 89.6 1.1 991 19.8 45-49 0.3 12.1 49.5 76.0 91.3 0.5 875 20.0 25-49 0.6 15.2 47.1 70.0 85.5 5.8 5,693 20.2 Note: The age at first marriage is defined as the age at which the respondent began living with her first spouse/partner. na = Not applicable due to censoring. a = Omitted because less than 50 percent of the women began living with their spouse or partner for the first time before reaching the beginning of the age group. Table 4.2 shows that, among women age 25-49, the median age at first marriage was 20.2 years. Less than one percent of women age 25-49 married for the first time before age 15, and only 15 percent married before age 18. The rate at which the women marry clearly accelerates after age 18, with nearly half of women reporting they married for the first time by age 20 and 86 percent by age 25. An examination of the trend in the median age at marriage indicates that women age 25-29 married for the first time more than one year later on average than women age 35 and older. Table 4.3 presents differentials in the median age at first marriage by background characteristics. In general, differences in age at first marriage are not large, with the median age at marriage for most subgroups falling within half a year of the national median (20.2 years). The median age at first marriage is highest among women in the GBAO region (22.6 years) and women with higher education (22.3 years). Marriage and Sexual Activity • 51 Table 4.3 Median age at first marriage by background characteristics Median age at first marriage among women age 25-49, according to background characteristics, Tajikistan 2012 Background characteristic Women age 25-49 Residence Urban 20.5 Rural 20.1 Region Dushanbe 20.5 GBAO 22.6 Sughd 20.1 DRS 20.1 Khalton 20.2 Education None/primary 20.6 General basic 20.2 General secondary 19.8 Professional primary/middle 20.9 Higher 22.3 Wealth quintile Lowest 20.4 Second 20.0 Middle 20.4 Fourth 20.0 Highest 20.3 Total 20.2 Note: The age at first marriage is defined as the age at which the respondent began living with her first spouse/partner. 4.3 AGE AT FIRST INTERCOURSE Age at first marriage has long been used as a proxy for a woman’s first exposure to sexual intercourse and, thus, to the risk of pregnancy. However, a woman may initiate sexual intercourse before (or in a few cases after) she begins living together or is formally married to her first spouse/partner. In the 2012 TjDHS, women were asked about how old they were when they first had intercourse. Table 4.4 shows the ages at which women start having sexual intercourse and the trend in this indicator across age cohorts. Table 4.5 shows the variation in the median age at first intercourse among women 25-49 by background characteristics. Table 4.4 Age at first sexual intercourse Percentage of women age 15-49 who had first sexual intercourse by specific exact ages, percentage who never had sexual intercourse, and median age at first sexual intercourse, according to current age, Tajikistan 2012 Current age Percentage who had first sexual intercourse by exact age: Percentage who never had intercourse Number Median age at first intercourse 15 18 20 22 25 15-19 0.1 na na na na 86.6 2,013 a 20-24 0.1 11.3 43.3 na na 29.4 1,950 a 25-29 0.3 10.1 32.6 59.1 77.1 12.8 1,609 21.3 30-34 1.1 18.9 45.7 62.7 79.6 6.8 1,188 20.5 35-39 0.2 23.1 59.3 76.2 85.3 2.6 1,030 19.4 40-44 1.0 11.2 52.0 77.1 87.8 1.1 991 19.9 45-49 0.2 11.3 48.7 75.0 89.2 0.5 875 20.1 25-49 0.6 14.7 46.0 68.5 82.8 5.8 5,693 20.3 na = Not applicable due to censoring a = Omitted because less than 50 percent of the respondents had sexual intercourse for the first time before reaching the beginning of the age group. 52 • Marriage and Sexual Activity Tajikistan is a traditional society. In such settings, women are unlikely to have many opportunities to engage in sexual intercourse before marriage. Moreover, those women who initiated intercourse before marriage may be very reluctant to admit that in a survey interview. Thus, it is not surprising that the findings with respect to the age at first intercourse in Table 4.4 correspond almost exactly with the results presented for the age at first marriage in Table 4.2. The median age at first intercourse among women age 25-49 is in fact slightly higher than the age at first marriage (20.3 years versus 20.2 years), and the percentages reporting they initiated sexual intercourse by exact ages 18, 20, 22, and 25 years are uniformly slightly lower than the percentages reporting they were first married at those exact ages. Similarly, the median ages at first intercourse for each of the age cohorts in Table 4.4 are higher than the median ages at first marriage reported for those cohorts in Table 4.2. A comparison of the medians in Table 4.5 with similar information on the median age at first marriage in Table 4.3 indicates that the pattern of a slightly later average age at intercourse than first marriage is apparent in almost all socioeconomic groups. The pattern of a slightly later age at first intercourse than first marriage in the TjDHS results may reflect a tendency for some couples in Tajikistan to delay cohabitation and the initiation of sexual intercourse for a period after they formally marry. However, much of the pattern is likely owed to errors in the reporting of the age at first marriage and, particularly, first intercourse. In particular, TjDHS respondents were asked to provide the exact month and year they first married and only to provide the age at which they married if they could not provide the date. In contrast, respondents were asked to provide information only on their age at first intercourse, which may have resulted in a greater number of reporting errors. 4.4 RECENT SEXUAL ACTIVITY In the absence of contraception, the probability of pregnancy is related to the regularity of sexual intercourse. Thus, information on intercourse is important for refinement of the measurement of exposure to pregnancy. Table 4.6 is based on responses to a question on time since last intercourse and, considered together with information on whether the woman has ever had sex, allows an assessment of the overall level of sexual activity among all women age 15-49 in Tajikistan. More than seven in ten women had ever had sexual intercourse, and 45 percent of women were recently sexually active, that is, they had sex during the four weeks before the survey. Nineteen percent of women had sexual intercourse within the year before the survey, but not during the four weeks immediately before the survey, and 9 percent reported they last had intercourse a year or more ago. The percentage recently sexually active increases with age, peaking at 62 percent among women age 40-44. As expected, marital status is related to the recent sexual activity. Between 60 and 70 percent of currently married women report having recently had intercourse, regardless of the length of time they have been married. The proportion recently sexually active is substantially lower among women who have a husband/partner who lives elsewhere (10 percent) compared with 71 percent among currently married women who report that a husband lives with them. Sixty-three percent of women who have a husband/partner who lives elsewhere had sexual intercourse within the year before the survey, but not during the four weeks immediately before the survey, and 27 percent reported they last had intercourse a year or more ago. Overall, 7 percent of currently married women have a husband/partner who lives elsewhere (data not shown). Table 4.5 Median age at first sexual intercourse by background characteristics Median age at first sexual intercourse among women age 25-49, according to background characteristics, Tajikistan 2012 Background characteristic Women age 25-49 Residence Urban 20.6 Rural 20.2 Region Dushanbe 20.6 GBAO 22.9 Sughd 20.2 DRS 20.2 Khalton 20.3 Education None/primary 20.7 General basic 20.3 General secondary 19.9 Professional primary/middle 21.0 Higher 22.4 Wealth quintile Lowest 20.4 Second 20.2 Middle 20.4 Fourth 20.1 Highest 20.3 Total 20.3 Marriage and Sexual Activity • 53 Not unexpectedly, nine in ten of the women who are divorced, separated, or widowed reported that it had been one year or more since they last had intercourse. Sexual activity is nonexistent (or underreported) among never-married women. The proportions recently sexually active do not vary much with other background characteristics in Table 4.6. Table 4.6 Recent sexual activity: Women Percent distribution of women age 15-49 by timing of last sexual intercourse, according to background characteristics, Tajikistan 2012 Background characteristic Timing of last sexual intercourse Never had sexual intercourse Total Number of women Within the past 4 weeks Within 1 year1 One or more years Missing Age 15-19 8.7 4.3 0.3 0.1 86.6 100.0 2,013 20-24 42.1 22.3 6.0 0.3 29.4 100.0 1,950 25-29 55.4 23.3 8.3 0.3 12.8 100.0 1,609 30-34 57.4 23.7 11.8 0.3 6.8 100.0 1,188 35-39 61.2 24.0 12.0 0.2 2.6 100.0 1,030 40-44 61.9 20.2 16.5 0.3 1.1 100.0 991 45-49 57.5 23.4 18.5 0.1 0.5 100.0 875 Marital status Never married 0.0 0.0 0.0 0.1 99.9 100.0 2,648 Married or living together 66.3 27.5 6.0 0.2 0.0 100.0 6,504 Husband/partner lives with her 70.5 24.9 4.4 0.2 0.0 100.0 6,040 Husband/partner lives elsewhere 9.9 62.7 26.8 0.7 0.0 100.0 455 Divorced/separated/widowed 0.9 8.7 90.2 0.1 0.0 100.0 504 Marital duration2 0-4 years 63.6 31.8 4.2 0.4 0.0 100.0 1,873 5-9 years 64.9 28.1 7.0 0.1 0.0 100.0 1,215 10-14 years 70.1 23.7 5.7 0.5 0.0 100.0 808 15-19 years 67.1 27.3 5.6 0.1 0.0 100.0 852 20-24 years 68.0 23.5 8.3 0.3 0.0 100.0 850 25+ years 67.2 26.0 6.8 0.0 0.0 100.0 698 Married more than once 70.2 22.7 6.8 0.3 0.0 100.0 208 Residence Urban 47.2 14.7 10.9 0.4 26.8 100.0 2,413 Rural 43.9 20.4 8.0 0.2 27.6 100.0 7,243 Region Dushanbe 47.6 14.0 10.1 0.4 28.0 100.0 881 GBAO 39.9 13.2 9.8 0.6 36.5 100.0 220 Sughd 43.1 22.6 8.8 0.2 25.3 100.0 2,872 DRS 41.8 23.6 9.2 0.1 25.3 100.0 2,240 Khalton 47.5 14.5 7.9 0.3 29.7 100.0 3,444 Education None/primary 42.1 17.9 8.3 0.7 31.0 100.0 567 General basic 38.1 19.3 6.9 0.0 35.8 100.0 3,349 General secondary 49.2 19.2 9.8 0.2 21.6 100.0 4,474 Professional primary/middle 48.3 20.6 11.1 0.6 19.3 100.0 645 Higher 47.1 14.6 9.0 0.5 28.9 100.0 620 Wealth quintile Lowest 44.6 16.7 7.8 0.1 30.7 100.0 1,878 Second 43.9 19.6 8.0 0.2 28.3 100.0 1,913 Middle 42.8 22.3 8.4 0.1 26.4 100.0 1,904 Fourth 43.8 21.3 9.3 0.3 25.3 100.0 1,971 Highest 48.3 15.0 10.1 0.3 26.4 100.0 1,989 Total 44.7 19.0 8.7 0.2 27.4 100.0 9,656 Note: Table excludes 10 married women with missing information on whether a husband/partner lives with her or elsewhere. 1 Excludes women who had sexual intercourse within the last 4 weeks. 2 Excludes women who are not currently married. Fertility • 55 FERTILITY 5 major objective of the 2012 TjDHS was to examine fertility levels, trends, and differentials in Tajikistan. This chapter describes current and past fertility, birth intervals, age at first birth, and the reproductive behavior of adolescents. The data on birth intervals are important because short intervals are strongly associated with childhood mortality. The age at which childbearing begins can also have a major impact on the health and well-being of both the mother and the child. All women who were interviewed in the 2012 TjDHS were asked to give a complete reproductive history. To encourage complete reporting, each woman was asked about the number of sons and daughters living with her, the number living elsewhere, and the number who had died. In addition to information on live births, all women were then asked questions on all pregnancies that did not result in a live birth to obtain the number of induced abortions, the number of miscarriages, and the number of stillbirths that women had experienced in their lifetime. After obtaining these aggregate data, an event-by-event pregnancy history was collected. Information was collected about all the pregnancies the respondent had in the order in which they occurred, starting with her first pregnancy. For each pregnancy that resulted in a live birth, information was collected on the child’s sex, survival status, and current age (for surviving children) or age at death (for deceased children). For all pregnancies that did not result in a live birth, information was collected on the month and year the pregnancy ended. For births and terminations that occurred during the five years preceding the survey (i.e., in January 2007 or later), the pregnancy duration was recorded in the 5-year calendar of events. Women were also asked questions about current pregnancies. 5.1 CURRENT FERTILITY Several measures of current fertility are derived from the pregnancy history data. Age-specific fertility rates (ASFRs) refer to the average number of live births per 1,000 women in a certain age group.1 They are a valuable measure to assess the current age pattern of childbearing. The total fertility rate (TFR) is defined as the total number of births a woman would have by the end of her childbearing period if she were to pass through those years bearing children at the currently observed ASFRs. The TFR is obtained by summing the ASFRs and multiplying by five. The general fertility rate (GFR) is expressed as the annual number of live births per 1,000 women age 15-44, and the crude birth rate (CBR) is e

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