History

After nearly a century under French control, Cambodia had gained complete independence from France under the leadership of Prince Norodom Sihanouk on 9 November 1954 with the recognition of the Geneva Conference in May 1954.  However, under his reign, an internal political conflict continued. In March 1970, a promilitary coup led by General Lon Nol overthrew Prince Sihanouk.

On 17 April 1975, the Khmer Rouge ousted the Lon Nol regime and took control of the country. Under the new regime, the country was renamed Democratic Kampuchea. Just a few weeks after taking power, the radical Khmer Rouge forced the whole population of the capital city and provincial towns to leave for the countryside where they were placed in mobile teams and worked as slaves in the fields from 12 to 15 hours a day. Cut off from the outside world, Cambodia then came into a dark era, or year zero society, as all national infrastructures were completely eradicated. Nearly three million Cambodian people died during the Khmer Rouge’s most radical and genocidal regime.

On 7 January 1979, the revolutionary army of the National Front for Solidarity and Liberation of Cambodia defeated the Khmer Rouge regime and then proclaimed the country as the People’s Republic of Kampuchea and later the State of Cambodia in 1989.

The most important event was the free elections on 25 May 1993 with the turnout of 89.6 percent under the close supervision of the United Nations Transitional Authority in Cambodia (UNTAC). Since then, Cambodia was proclaimed as the Kingdom of Cambodia again with a system of constitutional monarchy. Now, Cambodia is stable and on its way to democracy and a brilliant future.

 Economy
 
Since the 1991 Paris Peace Accord, Cambodia’s economy has made remarkable progress after more than two decades of political unrest (Ministry of Planning, 1999). However, Cambodia still remains the poorest and least developed country in Asia, with the gross domestic product per capita estimated at approximately $238 in 2000. The government expenditure on health is $1 per capita.    

Agriculture, mainly rice production, is still the main economic activity for Cambodia. In addition, small-scale subsistence agriculture, such as fisheries, forestry, and livestock, are still the most important sector, which accounted for about 38 percent of the GDP in 2000. Tourism services are also important components of foreign direct investment.  

1.2   Health Status and Policy 

Cambodian health is still among the worst in the Western Pacific Region. The overall health system performance was ranked 174th among other member states of the World Health Organization (WHO, 2000). The average life expectancy at birth is estimated at 54.4 years. For males, life expectancy at birth is 54 years, whereas females can expect to live an average of 58 years. Due to poverty, poor sanitation, and inadequate health services, it is estimated that more than one in ten Cambodian children dies before his or her fifth birthday.  The pattern of morbidity and mortality have remained virtually unchanged for years, and the general populace seems to be greatly affected by the same diseases including diarrhea, acute respiratory infections (ARI), dengue hemorrhagic fever, malaria, malnutrition, and other vaccine-preventable diseases. The maternal mortality rate (MMR) is 437 per 100,000 live births, due mainly to abortion complications, eclampsia, and hemorrhage.

1.3   Objective and Survey Organization 

The Cambodia Demographic and Health Survey 2000 (CDHS) is the first nationally representative survey ever conducted in Cambodia on population and health issues.  The primary objective of the survey is to provide the Ministry of Health, Ministry of Planning (MoP), and other relevant institutions and users with updated and reliable data on infant and child mortality, fertility preferences, family planning behavior, maternal mortality, utilization of maternal and child health services, health expenditures, women’s status, domestic violence, and knowledge and behavior regarding AIDS and other sexually transmitted infections (STIs).  This information contributes to policy decisions, planning, monitoring, and program evaluation for the development of Cambodia, at both national- and local-government levels.

The long-term objectives of the survey are to technically strengthen the capacity both of the Ministry of Health and the National Institute of Statistics (NIS) of MoP for planning, conducting, and analyzing the results of further surveys.  

The CDHS 2000 survey was conducted by the National Institute of Statistics of the Ministry of Planning, and the Ministry of Health. The CDHS executive committee and technical committee were established to oversee all technical aspects of implementation. They consisted of repre­sentatives from the Ministry of Health, the Ministry of Planning, the National Institute of Statistics, the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF), and the U.S. Agency for International Development (USAID).  ORC Macro provided technical assistance including sampling design, survey methodology, interviewer training, and data analysis through the MEASURE DHS+ project. Funding for the survey came from UNFPA, UNICEF, and USAID. 

1.4   Sample Design 

The CDHS survey called for a nationally representative sample of 15,300 women between the ages of 15 and 49.  Survey estimates are produced for 12 individual provinces (Banteay Mean Chey, Kampong Cham, Kampong Chhnang, Kampong Spueu, Kampong Thum, Kandal, Kaoh Kong, Phnom Penh, Prey Veaeng, Pousat, Svay Rieng, and Takaev) and for the following 5 groups of provinces:

·    Bat Dambang and Krong Pailin

·    Kampot, Krong Preah Sihanouk, and Krong Kaeb

·    Kracheh, Preah Vihear, and Stueng Traeng

·    Mondol Kiri and Rotanak Kiri

·    Otdar Mean Chey and Siem Reab.

The master sample developed in 1998 by the National Institute of Statistics served as the sampling frame for the CDHS survey.  The master sample is based on the 1998 Cambodia General Population Census and consists of 600 villages selected with probability proportional to the number of households within the village.  Villages are listed with the total population count and the number of enumeration areas (EAs), households, and segments.  Enumeration areas were created during the cartography conducted in preparation for the 1998 census.  A segment in a village corresponds to a block of about ten households.  Segments were created only for villages retained in the master sample and maps showing their boundaries were also available for all of them.   

The sample for the CDHS survey is a stratified sample selected in three stages.  As for the master sample, stratification was achieved by separating every reporting domain into urban and rural areas.  The sample was selected independently in every stratum.   

The master sample contains a small number of villages for some of the provinces.  For this reason, additional villages were directly selected from the census frame in order to reach the required sample size in these provinces.  In the first stage, 471 villages were selected with probability proportional to the number of households in the village.  Of these 471 villages, 63 were directly selected from the 1998 census frame.  In the second stage, 5 or fewer segments were retained from each of the villages selected from the master sample, while 1 EA was retained from each of the 63 villages directly selected from the 1998 census frame.  Each of these EAs consists of several segments.

A household listing was carried out in all selected segments and EAs, and the resulting lists of households served as the sampling frame for the selection of households in the third stage.  All women 15-49 were interviewed in selected households.    

In addition, a subsample of 50 percent of households was selected for data collection of anthropometry.  Anemia testing was implemented in 25 percent of the sample.  Only the women identified in the households with anemia testing were eligible for the section related to women’s status.  In this subsample of households, only one woman was selected in each household to be interviewed on domestic violence.  

1.5   Questionnaires 

Two types of questionnaires were used in the CDHS 2000 survey: the Household Questionnaire and the Women’s questionnaire. The contents of these questionnaires were based on the international MEASURE DHS+ model. They were modified according to the situation in Cambodia and were designed to provide information needed by health and family planning program managers and policymakers, mainly the Ministry of Health, the Ministry of Planning, and other relevant institutions and organizations. The agencies involved in developing these questionnaires were the National Institute of Public Health/MoH, the National Institute of Statistics/MoP, UNFPA, UNICEF, USAID, WHO, Hellen Keller International, Marie Stopes International, the Ministry of Women’s Affairs, Project Against Domestic Violence, and the Demographic and Health Surveys (DHS) project of ORC Macro. The questionnaires were developed in English and then translated into Khmer.  Back translation of the questionnaires, from Khmer to English, was also conducted. 

The Household Questionnaire enumerated all the usual members and visitors of the selected households and collected information on the socioeconomic status of the households. The first part of the questionnaire collected information on the relationship of the persons to the head of household and items such as residence, sex, age, marital status, and level of education. This information was used to identify women who were eligible for the individual interview. The Household Questionnaire also contained information on the prevalence of accidents, physical impairment, illness, and health expenditures. Information was also collected on the dwelling units, including source of water, type of toilet facilities, fuels used for cooking, materials used for the house’s floor and roof, and ownership of a variety of consumer goods. In addition, during the household survey, anthropometry and anemia testing were carried out to determine nutritional status among children less than five years old and women age 15-49.  

The Women’s Questionnaire collected information from all women age 15-49 on the following topics: 

·     Respondent’s background characteristics

·     Reproduction

·     Contraception (knowledge and use of family planning)

·     Pregnancy, antenatal care, delivery, and postnatal care

·     Infant feeding practices, child immunization, and health

·     Marriage and sexual activity

·     Fertility preference

·     Husband’s background characteristics and women’s work

·     Knowledge of HIV/AIDS and other sexually transmitted infections

·     Maternal mortality and adult mortality

·     Women’s status

·     Domestic violence (household relations module)

1.6   Training and Fieldwork 

Prior to the main survey, the pretest training and fieldwork were conducted in November and December 1999. Twenty-two interviewers (5 health staff from the MoH in Phnom Penh and 17 from provincial health departments) were trained to perform the pretest within three-week periods. The pretest fieldwork was carried out over a one-week period in both rural and urban areas and resulted in 240 completed pretest interviews. In addition, anemia testing and iodine testing for household salt were also included in the pretest. Debriefing sessions were held with the field staff and survey coordinators, and questionnaires were then modified based on the outcome of the pretest.  

The training of the main survey was carried out from January 3 to February 9, 2000. Instruction on interviewing techniques, fieldwork procedures, and a detailed review of questionnaires section by section were thoroughly and clearly explained. In addition, in-class mock interviews among participants, anemia testing, and anthropometry practices were also performed.  The practice of the main survey was conducted, in both rural and urban areas, at several locations. For practice purposes, anemia testing, weighing, and measuring children were carried out by team supervisors and field editors as well as team members at two kindergartens and an orphanage in Phnom Penh. The interviewing practices with real respondents took place in areas outside of the main sample.  Moreover, during the practice period, team supervisors and field editors were additionally instructed in the procedures for contacting local authorities, editing filled-out questionnaires, and controlling data quality.  

The CDHS data were collected by 17 teams, each consisting of a team supervisor, a field editor, and four female interviewers. Each team was in charge of data collection in one province or a group of provinces. Coordination and supervision of the interviewing activities were done by four survey coordinators and four supervisory staff members from the National Institute of Sta­tistics/MoP and the Ministry of Health. Data collection took place over a six-month period, from February to July 2000.  

1.7   Data Processing 

All completed questionnaires were brought to the National Institute of Statistics for data processing. Questionnaires were checked for the selected households and eligible respondents by the office editors. Moreover, the few questions that had not been precoded (e.g., occupation) were coded prior to data entry. Data were then entered and edited using the software package Integrated System for Survey Analysis (ISSA) developed specially for the Demographic and Health Survey program. Data entry and office editing commenced in February and was completed in October 2000. To provide feedback for the field teams, the office editors were instructed to report any problems found during the editing of questionnaires. These reports were reviewed by the senior staff. If serious errors were detected in one or more questionnaires from a cluster, the team’s supervisor working in the cluster was informed and advised of the measures to be taken to prevent these problems in the future.