"The fertility transition in Kenya : patterns and determinants"

Thèse diffusée initialement dans le cadre d'un projet pilote des Presses de l'Université de Montréal/Centre d'édition numérique UdeM (1997-2008) avec l'autorisation de l'auteur.In spite of considerable research on Kenya’s fertility, questions remain. This dissertation examines three of these issues - the national and sub-national trend patterns in the country’s fertility and related proximate determinants, factors in the transitions to second and third conceptions, and the determinants of contraceptive use. Results, presented below, are based upon data which comprised five sample surveys conducted between 1977 and 2003 among women of reproductive age, as well as a community and health facility survey implemented in 1999. First, an exploratory analysis of trends in fertility and its proximate determinants shows that a pattern of later family formation and of a higher level of fertility control is associated with the more modernized and developed regions (urban areas and rural Central Province). Secondly, using survival analysis, the relative hazards of transition to the second and third conceptions for the 12-year periods during which fertility fell rapidly (1977-1989) and the pace of decline reduced (1991-2003) are compared. Among the findings, although child survival has significant effects during both periods, its influence is more pronounced during the recent period. Thirdly, multivariate analysis of the determinants of contraceptive use shows that motivation for fertility control is significant, while access to family planning services is not. That proximity to family planning services might nevertheless be important is shown by the significance of exposure to family planning messages, many of which are often communicated from the health facilities. This dissertation makes contributions in three areas. One, it confirms the dichotomy in the pattern of fertility change and its proximate determinants in the country, not so much along the usual rural-urban separation, but rather between urban areas and rural Central versus the rest of rural Kenya. Two, it shows that the decreased pace of the fertility transition in Kenya, including constant fertility over 1998-2003, might be associated with the rise in infant and child mortality since the 1990s. Three, it shows the significance of education, motivation for fertility control, and exposure to media messages about family planning in contraceptive use, thereby pointing out where policy and program effort should be directed in order to sustain the fertility transition.Malgré de nombreuses études consacrées à la problématique de la transition de fécondité au Kenya, des questions subsistent. Cette thèse traite de trois d’entre elles : les tendances de la fécondité et ses déterminants proches, les facteurs liés au passage à la deuxième et à la troisième grossesse, et les déterminants de l’utilisation de la contraception. Les données proviennent de cinq enquêtes menées dans ce pays entre 1977 et 2003, auprès de femmes d’âge reproductif, ainsi que d’une étude, conduite en 1999, au niveau communautaire et de centres de santé. Les résultats montrent d’abord une tendance au mariage tardif et à un niveau plus élevé de contrôle de la fécondité dans les régions les plus modernisées et les plus développées (les villes et les zones rurales de la région de la Province Central). Deuxièmement, dans la comparaison des 12 années durant lesquelles la fécondité, mesurée par l’indice de fécondité, s’est réduite (1977- 1989) et celles où le pas de sa baisse a ralenti (1991-2003), on note une augmentation des effets relatifs de la mortalité infantile pendant la deuxième période. Troisièmement, la régression multi variée utilisée pour l’analyse des déterminants proches de l’utilisation de la contraception fait ressortir le rôle important de la motivation pour le contrôle de la fécondité. Bien que l’accès aux services de planification familiale ne constitue pas un facteur significatif en soi, il pourrait jouer néanmoins un rôle dans la mesure où les résultats montrent que l’exposition aux messages de planification familiale (généralement offerts dans les centres de santé) a un effet significatif. La contribution de cette thèse s’articule autour de trois aspects. Premièrement, elle montre une opposition dans les changements de la fécondité et de ses déterminants entre 1977 et 2003, non pas entre les zones urbaines et rurales comme d’habitude, mais plutôt entre zones urbaines et partie rurale de la Province Central d’une part et le reste du Kenya d’autre part. Deuxièmement, le ralentissement de la baisse de la fécondité, y compris le niveau stable observé entre 1998 et 2003, est probablement lié à la hausse, depuis les années quatre-vingt dix, de la mortalité infantile. Troisièmement, cette thèse confirme le rôle significatif de la scolarisation, de la motivation pour le contrôle des naissances, et de l’effet positif des messages sur l’usage des méthodes de planification familiale, montrant ainsi les domaines dans lesquels doivent intervenir les politiques et programmes afin de maintenir la transition de fécondité

Impact of internalized stigma on HIV prevention behaviors among HIV-infected individuals seeking HIV care in Kenya

In general, an initial diagnosis of HIV is likely to be correlated with the onset of HIV stigma. HIV-positive individuals are likely to internalize stigma, may suffer from psychosocial issues, or engage in maladaptive behaviors to cope with the diagnosis. Internalized stigma stems from fear of stigmatization also known as felt stigma. The current study examined the impact of HIV felt stigma on overall health and success of HIV prevention behaviors among 370 participants living with HIV and receiving care at an urban HIV clinic in Kenya. An 18-item instrument was cross culturally adapted to measure felt stigma. Descriptive and logistic regression analyses examined the data. Findings indicate that 25.9% (n=96) of participants who reported experiencing high levels of felt stigma related to other people's attitudes toward their condition, ostracizing, and a disruption of their personal life, were likely to not adhere to prescribed HIV medication and not disclose their HIV serostatus to one other person. Those who also experienced felt stigma related to a disruption of their personal lives while mediated by depression were likely to report poor overall health. Findings support having HIV clinics and interventions develop relevant HIV prevention strategies that focus on the emerging dimensions of felt stigma which can significantly impact disclosure of serostatus, medication adherence, and overall health

National study to review existing policy documents and identification of upcoming priority national health policy issues in East African community partner states : Kenya country report

There is lack of clearly referenced verifiable evidence for selected approaches to health issues in Kenya. The paper provides a review of literature, further identifying policy gaps, and to confirm main actors in the primary healthcare sector. Priority areas requiring research evidence are: Health care financing and access; Human resources/personnel for the Health Sector with equitable distribution of health workers to rural and urban areas; government delinking from direct provision of healthcare to concentrate on policy formulation, stewardship and regulatory functions; Shifting from curative services to preventive services

Community perceptions of a malaria vaccine in the Kintampo districts of Ghana.

BACKGROUND: Malaria remains the leading cause of morbidity and mortality in sub-Saharan Africa despite tools currently available for its control. Making malaria vaccine available for routine use will be a major hallmark, but its acceptance by community members and health professionals within the health system could pose considerable challenge as has been found with the introduction of polio vaccinations in parts of West Africa. Some of these challenges may not be expected since decisions people make are many a time driven by a complex myriad of perceptions. This paper reports knowledge and perceptions of community members in the Kintampo area of Ghana where malaria vaccine trials have been ongoing as part of the drive for the first-ever licensed malaria vaccine in the near future. METHODS: Both qualitative and quantitative methods were used in the data collection processes. Women and men whose children were or were not involved in the malaria vaccine trial were invited to participate in focus group discussions (FGDs). Respondents, made up of heads of religious groupings in the study area, health care providers, traditional healers and traditional birth attendants, were also invited to participate in in-depth interviews (IDIs). A cross-sectional survey was conducted in communities where the malaria vaccine trial (Mal 047RTS,S) was carried out. In total, 12 FGDs, 15 IDIs and 466 household head interviews were conducted. RESULTS: Knowledge about vaccines was widespread among participants. Respondents would like their children to be vaccinated against all childhood illnesses including malaria. Knowledge of the long existing routine vaccines was relatively high among respondents compared to hepatitis B and Haemophilus influenza type B vaccines that were introduced more recently in 2002. There was no clear religious belief or sociocultural practice that will serve as a possible barrier to the acceptance of a malaria vaccine. CONCLUSION: With the assumption that a malaria vaccine will be as efficacious as other EPI vaccines, community members in Central Ghana will accept and prefer malaria vaccine to malaria drugs as a malaria control tool. Beliefs and cultural practices as barriers to the acceptance of malaria vaccine were virtually unknown in the communities surveyed

Community perceptions of malaria and vaccines in the South Coast and Busia regions of Kenya

<p>Abstract</p> <p>Background</p> <p>Malaria is a leading cause of morbidity and mortality in children younger than 5 years in Kenya. Within the context of planning for a vaccine to be used alongside existing malaria control methods, this study explores sociocultural and health communications issues among individuals who are responsible for or influence decisions on childhood vaccination at the community level.</p> <p>Methods</p> <p>This qualitative study was conducted in two malaria-endemic regions of Kenya--South Coast and Busia. Participant selection was purposive and criterion based. A total of 20 focus group discussions, 22 in-depth interviews, and 18 exit interviews were conducted.</p> <p>Results</p> <p>Participants understand that malaria is a serious problem that no single tool can defeat. Communities would welcome a malaria vaccine, although they would have questions and concerns about the intervention. While support for local child immunization programs exists, limited understanding about vaccines and what they do is evident among younger and older people, particularly men. Even as health care providers are frustrated when parents do not have their children vaccinated, some parents have concerns about access to and the quality of vaccination services. Some women, including older mothers and those less economically privileged, see themselves as the focus of health workers' negative comments associated with either their parenting choices or their children's appearance. In general, parents and caregivers weigh several factors--such as personal opportunity costs, resource constraints, and perceived benefits--when deciding whether or not to have their children vaccinated, and the decision often is influenced by a network of people, including community leaders and health workers.</p> <p>Conclusions</p> <p>The study raises issues that should inform a communications strategy and guide policy decisions within Kenya on eventual malaria vaccine introduction. Unlike the current practice, where health education on child welfare and immunization focuses on women, the communications strategy should equally target men and women in ways that are appropriate for each gender. It should involve influential community members and provide needed information and reassurances about immunization. Efforts also should be made to address concerns about the quality of immunization services--including health workers' interpersonal communication skills.</p