Investigating foods and beverages sold and advertised in deprived urban neighbourhoods in Ghana and Kenya: a cross-sectional study

Objectives The aim of this study was to characterise the local foods and beverages sold and advertised in three deprived urban African neighbourhoods. Design Cross-sectional observational study. We undertook an audit of all food outlets (outlet type and food sold) and food advertisements. Descriptive statistics were used to summarise exposures. Latent class analysis was used to explore the interactions between food advertisements, food outlet types and food type availability. Setting Three deprived neighbourhoods in African cities: Jamestown in Accra, Ho Dome in Ho (both Ghana) and Makadara in Nairobi (Kenya). Main outcome measure Types of foods and beverages sold and/or advertised. Results Jamestown (80.5%) and Makadara (70.9%) were dominated by informal vendors. There was a wide diversity of foods, with high availability of healthy (eg, staples, vegetables) and unhealthy foods (eg, processed/fried foods, sugar-sweetened beverages). Almost half of all advertisements were for sugar-sweetened beverages (48.3%), with higher exposure to alcohol adverts compared with other items as well (28.5%). We identified five latent classes which demonstrated the clustering of healthier foods in informal outlets, and unhealthy foods in formal outlets. Conclusion Our study presents one of the most detailed geospatial exploration of the urban food environment in Africa. The high exposure of sugar-sweetened beverages and alcohol both available and advertised represent changing urban food environments. The concentration of unhealthy foods and beverages in formal outlets and advertisements of unhealthy products may offer important policy opportunities for regulation and action

How does poverty affect children's nutritional status in Nairobi slums? A qualitative study of the root causes of undernutrition

Children in slums are at high risk of undernutrition, which has long-term negative consequences on their physical growth and cognitive development. Severe undernutrition can lead to the child's death. The present paper aimed to understand the causes of undernutrition in children as perceived by various groups of community members in Nairobi slums, Kenya. Analysis of ten focus group discussions and ten individual interviews with key informants. The main topic discussed was the root causes of child undernutrition in the slums. The focus group discussions and key informant interviews were recorded and transcribed verbatim. The transcripts were coded in NVivo by extracting concepts and using a constant comparison of data across the different categories of respondents to draw out themes to enable a thematic analysis. Two slum communities in Nairobi, Kenya. Women of childbearing age, community health workers, elders, leaders and other knowledgeable people in the two slum communities (n 90). Participants demonstrated an understanding of undernutrition in children. Findings inform target criteria at community and household level that can be used to identify children at risk of undernutrition. To tackle the immediate and underlying causes of undernutrition, interventions recommended should aim to: (i) improve maternal health and nutrition; (ii) promote optimal infant and young children feeding practices; (iii) support mothers in their working role; (iv) increase access to family planning; (v) improve water, sanitation and hygiene (WASH); (vi) address alcohol problems at all levels; and (vii) address street food issues with infant feeding counselling

Social value of a nutritional counselling and support program for breastfeeding in urban poor settings, Nairobi

Background: In Kenya, poor maternal nutrition, suboptimal infant and young child feeding practices and high levels of malnutrition have been shown among the urban poor. An intervention aimed at promoting optimal maternal infant and young child nutrition (MIYCN) practices in urban poor settings in Nairobi, Kenya was implemented. The intervention involved home-based counselling of pregnant and breastfeeding women and mothers of young children by community health volunteers (CHVs) on optimal MIYCN practices. This study assesses the social impact of the intervention using a Social Return on Investment (SROI) approach. Methods: Data collection was based on SROI methods and used a mixed methods approach (focus group discussions, key informant interviews, in-depth interviews, quantitative stakeholder surveys, and revealed preference approach for outcomes using value games). Results: The SROI analysis revealed that the MIYCN intervention was assessed to be highly effective and created social value, particularly for mothers and their children. Positive changes that participants experienced included mothers being more confident in child care and children and mothers being healthier. Overall, the intervention had a negative social impact on daycare centers and on health care providers, by putting too much pressure on them to provide care without providing extra support. The study calculated that, after accounting for discounting factors, the input ($USD 419,716) generated$USD 8 million of social value at the end of the project. The net present value created by the project was estimated at $USD 29.5 million.$USD 1 invested in the project was estimated to bring USD$71 (sensitivity analysis: USD$ 34-136) of social value for the stakeholders. Conclusion: The MIYCN intervention showed an important social impact in which mothers and children benefited the most. The intervention resulted in better perceived health of mothers and children and increased confidence of mothers to provide care for their children, while it resulted in negative impacts for day care center owners and health care providers

Factors influencing dietary behaviours in urban food environments in Africa: a systematic mapping review

Objective: To identify factors influencing dietary behaviours in urban food environments in Africa and identify areas for future research.Design: We systematically reviewed published/grey literature (Protocol CRD4201706893). Findings were compiled into a map using a socio-ecological model on four environmental levels: individual, social, physical and macro.Setting: Urban food environments in Africa.Participants: Studies involving adolescents and adults (11-70 years, male/female).Results: Thirty-nine studies were included (6 adolescent; 15 adolescent/adult combined; 18 adult). Quantitative methods were most common (28 quantitative; 9 qualitative; 2 mixed methods). Studies were from 15 African countries. Seventy-seven factors influencing dietary behaviours were identified, with two-thirds at the individual level (45/77). Factors in the social (11/77), physical (12/77) and macro (9/77) environments were investigated less. Individual level factors that specifically emerged for adolescents included self-esteem, body satisfaction, dieting, spoken language, school attendance, gender, body composition, pubertal development, BMI and fat mass. Studies involving adolescents investigated social environment level factors more, e.g. sharing food with friends. The physical food environment was more commonly explored in adults e.g. convenience/availability of food. Macro-level factors associated with dietary behaviours were: food/drink advertising, religion and food prices. Factors associated with dietary behaviour were broadly similar for men and women.Conclusions: The dominance of studies exploring individual-level factors suggests a need for research to explore how social, physical and macro-level environments drive dietary behaviours of adolescents and adults in urban Africa. More studies are needed for adolescents and men, and studies widening the geographical scope to encompass all African countries.</div

Factors affecting actualization of the WHO breastfeeding recommendations in urban poor settings in Kenya

Poor breastfeeding practices are widely documented in Kenya, where only a third of children are exclusively breastfed for 6 months and only 2% in urban poor settings.This study aimed to better understand the factors that contribute to poor breastfeeding practices in two urban slums in Nairobi, Kenya. In-depth interviews (IDIs), focus group discussions (FGDs) and key informant interviews (KIIs) were conducted with women of childbear- ing age, community health workers, village elders and community leaders and other knowledgeable people in the community. A total of 19 IDIs, 10 FGDs and 11 KIIs were conducted, and were recorded and transcribed verbatim. Data were coded in NVIVO and analysed thematically. We found that there was general awareness regarding optimal breastfeeding practices, but the knowledge was not translated into practice, leading to suboptimal breastfeeding practices. A number of social and structural barriers to optimal breastfeeding were identified: (1) poverty, livelihood and living arrangements; (2) early and single motherhood; (3) poor social and professional support; (4) poor knowledge, myths and misconceptions; (5) HIV; and (6) unintended pregnancies. The most salient of the factors emerged as livelihoods, whereby women have to resume work shortly after delivery and work for long hours, leaving them unable to breastfeed optimally. Women in urban poor settings face an extremely complex situation with regard to breastfeeding due to multiple challenges and risk behaviours often dictated to them by their circumstances. Macro-level policies and interventions that consider the ecological setting are needed

Sociocultural factors influencing breastfeeding practices in two slums in Nairobi, Kenya

Background: Despite numerous interventions promoting optimal breastfeeding practices in Kenya, pockets of suboptimal breastfeeding practices are documented in Kenya’s urban slums. This paper describes cultural and social beliefs and practices that influence breastfeeding in two urban slums in Nairobi, Kenya. Methods: Qualitative data were collected in Korogocho and Viwandani slums through 10 focus group discussions and 19 in-depth interviews with pregnant, breastfeeding women and community health volunteers and 11 key-informant interviews with community leaders. Interviews were audiotaped, transcribed verbatim, coded in NVIVO and analyzed thematically. Results: Social and cultural beliefs and practices that result to suboptimal breastfeeding practices were highlighted including; considering colostrum as ‘dirty’ or ‘curdled milk’, a curse ‘bad omen’ associated with breastfeeding while engaging in extra marital affairs, a fear of the ‘evil eye’ (malevolent glare which is believed to be a curse associated with witchcraft) when breastfeeding in public and breastfeeding being associated with sagging breasts. Positive social and cultural beliefs were also identified including the association of breast milk with intellectual development and good child health. The beliefs and practices were learnt mainly from spouses, close relatives and peers. Conclusion: Interventions promoting behavior change with regards to breastfeeding should focus on dispelling the beliefs and practices that result to suboptimal breastfeeding practices and to build on the positive ones, while involving spouses and other family members as they are important sources of information on breastfeeding

Effectiveness of home-based nutritional counselling and support on exclusive breastfeeding in urban poor settings in Nairobi: a cluster randomized controlled trial

Background: Exclusive breastfeeding (EBF) improves infant health and survival. We tested the effectiveness of a homebased intervention using Community Health Workers (CHWs) on EBF for six months in urban poor settings in Kenya. Methods: We conducted a cluster-randomized controlled trial in Korogocho and Viwandani slums in Nairobi. We recruited pregnant women and followed them until the infant’s first birthday. Fourteen community clusters were randomized to intervention or control arm. The intervention arm received home-based nutritional counselling during scheduled visits by CHWs trained to provide specific maternal infant and young child nutrition (MIYCN) messages and standard care. The control arm was visited by CHWs who were not trained in MIYCN and they provided standard care (which included aspects of ante-natal and post-natal care, family planning, water, sanitation and hygiene, delivery with skilled attendance, immunization and community nutrition). CHWs in both groups distributed similar information materials on MIYCN. Differences in EBF by intervention status were tested using chi square and logistic regression, employing intention-to-treat analysis. Results: A total of 1110 mother-child pairs were involved, about half in each arm. At baseline, demographic and socioeconomic factors were similar between the two arms. The rates of EBF for 6 months increased from 2% pre-intervention to 55.2% (95% CI 50.4–59.9) in the intervention group and 54.6% (95% CI 50.0–59.1) in the control group. The adjusted odds of EBF (after adjusting for baseline characteristics) were slightly higher in the intervention arm compared to the control arm but not significantly different: for 0–2 months (OR 1.27, 95% CI 0.55 to 2.96; p = 0.550); 0–4 months (OR 1.15; 95% CI 0.54 to 2.42; p = 0.696), and 0–6 months (OR 1.11, 95% CI 0.61 to 2.02; p = 0.718). Conclusions: EBF for six months significantly increased in both arms indicating potential effectiveness of using CHWs to provide home-based counselling to mothers. The lack of any difference in EBF rates in the two groups suggests potential contamination of the control arm by information reserved for the intervention arm. Nevertheless, this study indicates a great potential for use of CHWs when they are incentivized and monitored as an effective model of promotion of EBF, particularly in urban poor settings. Given the equivalence of the results in both arms, the study suggests that the basic nutritional training given to CHWs in the basic primary health care training, and/or provision of information materials may be adequate in improving EBF rates in communities. However, further investigations on this may be needed. One contribution of these findings to implementation science is the difficulty in finding an appropriate counterfactual for community-based educational interventions. Trial registration: ISRCTN ISRCTN83692672. Registered 11 November 2012. Retrospectively registered

Feasibility and effectiveness of the baby friendly community initiative in rural Kenya: study protocol for a randomized controlled trial

Background: Interventions promoting optimal infant and young child nutrition could prevent a fifth of under-5 deaths in countries with high mortality. Poor infant and young child feeding practices are widely documented in Kenya, with potential detrimental effects on child growth, health and survival. Effective strategies to improve these practices are needed. This study aims to pilot implementation of the Baby Friendly Community Initiative (BFCI), a global initiative aimed at promoting optimal infant and young child feeding practices, to determine its feasibility and effectiveness with regards to infant feeding practices, nutrition and health outcomes in a rural setting in Kenya. Methods: The study, employing a cluster-randomized trial design, will be conducted in rural Kenya. A total of 12 clusters, constituting community units within the government's Community Health Strategy, will be randomized, with half allocated to the intervention and the other half to the control arm. A total of 812 pregnant women and their respective children will be recruited into the study. The mother-child pairs will be followed up until the child is 6 months old. Recruitment will last approximately 1 year from January 2015, and the study will run for 3 years, from 2014 to 2016. The intervention will involve regular counseling and support of mothers by trained community health workers and health professionals on maternal, infant and young child nutrition. Regular assessment of knowledge, attitudes and practices on maternal, infant and young child nutrition will be done, coupled with assessment of nutritional status of the mother-child pairs and morbidity for the children. Statistical methods will include analysis of covariance, multinomial logistic regression and multilevel modeling. The study is funded by the NIH and USAID through the Program for Enhanced Research (PEER) Health. Discussion: Findings from the study outlined in this protocol will inform potential feasibility and effectiveness of a community-based intervention aimed at promoting optimal breastfeeding and other infant feeding practices. The intervention, if proved feasible and effective, will inform policy and practice in Kenya and similar settings, particularly regarding implementation of the baby friendly community initiative. Trial registration:ISRCTN03467700 ; Date of Registration: 24 September 201

Balancing paid work and child care in a slum of Nairobi, Kenya: The case for centre-based child care

As a growing number of women across sub-Saharan Africa engage in paid work, they face the challenge of finding suitable child care arrangements. Drawing on survey data from over 1,200 mothers and in-depth interviews with 31 of these women, we find that mothers living in a slum of Nairobi, Kenya, employ three main strategies to balance their work and child care responsibilities: (1) combine work and child care, (2) rely on kin and neighbours, or (3) use centre-based care. Mothers reported numerous disadvantages to either bringing their children to work or depending on others for child care assistance. In contrast, mothers highlighted several perceived benefits of centre-based child care for themselves and their children, while noting that costs were often prohibitive. These findings suggest that providing affordable centre-based child care could be a key strategy to improving the lives and welfare of women and children living in African slums

The challenges of breastfeeeding in poor urban areas in sub-Saharan Africa

CITATION: Kimani-Murage, E. W. et al. 2020. The challenges of breastfeeeding in poor urban areas in sub-Saharan Africa, in Macnab, A., Daar, A. & Pauw, C. 2020. Health in transition : translating developmental origins of health and disease science to improve future health in Africa. Stellenbosch: SUN PReSS, doi:10.18820/9781928357759/07.Optimal breastfeeding has the potential to prevent more than 800 000 deaths in children younger than five years; 500 000 neonatal deaths; and 20 000 deaths in women every year. Despite these benefits, evidence from Sub-Saharan Africa shows that breastfeeding practices remain sub-optimal with only 25 per cent of children exclusively breastfed for the first six months, while six per cent of infants in these countries are never breastfed. For example, although the proportion of children who were exclusively breastfed in Kenya improved from 32 per cent in 2008 to 61 per cent in 2014, pockets of suboptimal breastfeeding practices are documented in urban slums. Exclusive breastfeeding in some of the urban slums in Kenya is as low as two per cent, with the age of introducing complementary foods being onemonth post-delivery, while about a third of children are not breastfed within one hour of delivery as recommended by the World Health Organization (WHO). Urban slums are faced by unique social and structural factors that hinder optimal breastfeeding including poverty and non-conducive livelihood opportunities, poor living conditions, food insecurity, poor professional and social support to breastfeeding mothers and knowledge deficit coupled with negative cultural beliefs and misconceptions about breastfeeding. This situation calls for macrolevel policies and interventions that consider the ecological setting. Promising interventions may include global initiatives such as the Baby-Friendly Hospital Initiative, the Baby-Friendly Community Initiative, Human Milk Banking and the Baby-Friendly Workplace Initiative. However, innovations in their implementation need to take consideration for the contextual complexities. This chapter explores breastfeeding practices, associated challenges and interventions that could promote breastfeeding in urban slums.Publisher's versio