Trends in childhood mortality in Kenya: the urban advantage has seemingly been wiped out

Background: we describe trends in childhood mortality in Kenya, paying attention to the urban–rural and intra-urban differentials.Methods: we use data from the Kenya Demographic and Health Surveys (KDHS) collected between 1993 and 2008 and the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) collected in two Nairobi slums between 2003 and 2010, to estimate infant mortality rate (IMR), child mortality rate (CMR) and under-five mortality rate (U5MR).Results: between 1993 and 2008, there was a downward trend in IMR, CMR and U5MR in both rural and urban areas. The decline was more rapid and statistically significant in rural areas but not in urban areas, hence the gap in urban–rural differentials narrowed over time. There was also a downward trend in childhood mortality in the slums between 2003 and 2010 from 83 to 57 for IMR, 33 to 24 for CMR, and 113 to 79 for U5MR, although the rates remained higher compared to those for rural and non-slum urban areas in Kenya.Conclusions: the narrowing gap between urban and rural areas may be attributed to the deplorable living conditions in urban slums. To reduce childhood mortality, extra emphasis is needed on the urban slums

Adult mortality and its impact on children in two informal settlements in Nairobi, Kenya

This thesis examines the impact of adult deaths on children in two slums in Nairobi city. Over the last two decades, there has been a marked increase in adult mortality in Sub-Saharan Africa. Data on adult mortality in the region are scanty and this makes assessment of its impact on child well-being hard. The thesis analyses data from a longitudinal demographic surveillance system that monitors births, migration, and deaths and identifies causes of death using verbal autopsy. Other data collected include: household characteristics, schooling and health care utilisation. It investigates: i) levels, trends and causes of adult deaths; ii) the impact of adult deaths on children’s household circumstances, and iii) the impact of adult deaths on children’s health and social outcomes. Measures of adult mortality were estimated using life-table and survival analysis techniques. Regression techniques were used to assess impact of adult death on children’s migration, living arrangements, survival, immunisation and schooling. Life expectancy in the two slum populations was low. Adult mortality was higher in women than men. Ethnicity, gender, wealth status were associated with the risk of adult death. Overall, HIV/AIDS was the leading cause of adult death, followed by injuries and tuberculosis. The risk of death from HIV/AIDS was highest in Korogocho slum and the Luo ethnic group. Child mobility in the slums was high. After death of a mother, the risk of child out-migration increased. Death of a father increased average household size while death of a mother resulted in a reduction in household size. Households that experienced adult deaths were more likely to be headed by an older person. Death of a mother, especially from HIV/AIDS, but not that of a father, increased the risk of child death. The risk was highest in the 6 months before and after maternal death. The effect of adult deaths on children’s education depended on slum of residence. While Viwandani children had better educational outcomes overall, death of a mother in Viwandani resulted into poorer schooling outcomes. Interventions aimed at the leading causes of adult deaths need to be scaled up. The results here confirm that adult deaths negatively impact child well-being in this urban setting. Child survival can benefit from scaling up existing interventions, while mitigation of social impacts may require a mix of family and institution-based support for orphaned and vulnerable children

Are slum dwellers at heightened risk of HIV infection than other urban residents? Evidence from population-based HIV prevalence surveys in Kenya

In 2008, the global urban population surpassed the rural population and by 2050 more than 6 billion will be living in urban centres. A growing body of research has reported on poor health outcomes among the urban poor but not much is known about HIV prevalence among this group. A survey of nearly 3000 men and women was conducted in two Nairobi slums in Kenya between 2006 and 2007, where respondents were tested for HIV status. In addition, data from the 2008/2009 Kenya Demographic and Health Survey were used to compare HIV prevalence between slum residents and those living in other urban and rural areas. The results showed strong intra-urban differences. HIV was 12% among slum residents compared with 5% and 6% among non-slum urban and rural residents, respectively. Generally, men had lower HIV prevalence than women although in the slums the gap was narrower. Among women, sexual experience before the age of 15 compared with after 19 years was associated with 62% higher odds of being HIV positive. There was ethnic variation in patterns of HIV infection although the effect depended on the current place of residence

Experiences of violence among adolescent girls and young women in Nairobi's informal settlements prior to scale-up of the DREAMS Partnership: Prevalence, severity and predictors.

INTRODUCTION: We sought to estimate the prevalence, severity and identify predictors of violence among adolescent girls and young women (AGYW) in informal settlement areas of Nairobi, Kenya, selected for DREAMS (Determined Resilient Empowered AIDS-free, Mentored and Safe) investment. METHODS: Data were collected from 1687 AGYW aged 10-14 years (n = 606) and 15-22 years (n = 1081), randomly selected from a general population census in Korogocho and Viwandani in 2017, as part of an impact evaluation of the "DREAMS" Partnership. For 10-14 year-olds, we measured violence experienced either in the past 6 months or ever using a different set of questions from those used for 15-22 year-olds. Among 15-22 year-olds we measured prevalence of violence, experienced in the past 12 months, using World Health Organization (WHO) definitions for violence typologies. Predictors of violence were identified using multivariable logit models. RESULTS: Among 606 girls aged 10-14 years, about 54% and 7% ever experienced psychological and sexual violence, respectively. About 33%, 16% and 5% experienced psychological, physical and sexual violence in the past 6 months. The 10-14 year old girls who engaged in chores or activities for payment in the past 6 months, or whose family did not have enough food due to lack of money were at a greater risk for violence. Invitation to DREAMS and being a non-Christian were protective. Among 1081 AGYW aged 15-22 years, psychological violence was the most prevalent in the past year (33.1%), followed by physical violence (22.9%), and sexual violence (15.8%). About 7% experienced all three types of violence. Severe physical violence was more prevalent (13.8%) than moderate physical violence (9.2%). Among AGYW aged 15-22 years, being previously married/lived with partner, engaging in employment last month, food insecure were all risk factors for psychological violence. For physical violence, living in Viwandani and being a Muslim were protective; while being previously married or lived with a partner, or sleeping hungry at night during the past 4 weeks were risk factors. The odds of sexual violence were lower among AGYW aged 18-22 years and among Muslims. Engaging in sex and food insecurity increased chances for sexual violence. CONCLUSIONS: Prevalence of recent violence among AGYW is high in this population. This calls for increased effort geared towards addressing drivers of violence as an early entry point of HIV prevention effort in this vulnerable group

The effect of participant nonresponse on HIV prevalence estimates in a population-based survey in two informal settlements in Nairobi city

BACKGROUND: Participant nonresponse in an HIV serosurvey can affect estimates of HIV prevalence. Nonresponse can arise from a participant's refusal to provide a blood sample or the failure to trace a sampled individual. In a serosurvey conducted by the African Population and Health Research Center and Kenya Medical Research Centre in the slums of Nairobi, 43% of sampled individuals did not provide a blood sample. This paper describes selective participation in the serosurvey and estimates bias in HIV prevalence figures. METHODS: The paper uses data derived from an HIV serosurvey nested in an on-going demographic surveillance system. Nonresponse was assessed using logistic regression and multiple imputation methods to impute missing data for HIV status using a set of common variables available for all sampled participants. RESULTS: Age, residence, high mobility, wealth, and ethnicity were independent predictors of a sampled individual not being contacted. Individuals aged 30-34 years, females, individuals from the Kikuyu and Kamba ethnicity, married participants, and residents of Viwandani were all less likely to accept HIV testing when contacted. Although men were less likely to be contacted, those found were more willing to be tested compared to females. The overall observed HIV prevalence was overestimated by 2%. The observed prevalence for male participants was underestimated by about 1% and that for females was overestimated by 3%. These differences were small and did not affect the overall estimate substantially as the observed estimates fell within the confidence limits of the corrected prevalence estimate. CONCLUSIONS: Nonresponse in the HIV serosurvey in the two informal settlements was high, however, the effect on overall prevalence estimate was minimal

Awareness and uptake of layered HIV prevention programming for young women: analysis of population-based surveys in three DREAMS settings in Kenya and South Africa

Background The DREAMS Partnership is an ambitious effort to deliver combinations of biomedical, behavioural and structural interventions to reduce HIV incidence among adolescent girls and young women (AGYW). To inform multi-sectoral programming at scale, across diverse settings in Kenya and South Africa, we identified who the programme is reaching, with which interventions and in what combinations. Methods Randomly-selected cohorts of 606 AGYW aged 10–14 years and 1081 aged 15–22 years in Nairobi and 2184 AGYW aged 13–22 years in uMkhanyakude, KwaZulu-Natal, were enrolled in 2017, after ~ 1 year of DREAMS implementation. In Gem, western Kenya, population-wide cross-sectional survey data were collected during roll-out in 2016 (n = 1365 AGYW 15–22 years). We summarised awareness and invitation to participate in DREAMS, uptake of interventions categorised by the DREAMS core package, and uptake of a subset of ‘primary’ interventions. We stratified by age-group and setting, and compared across AGYW characteristics. Results Awareness of DREAMS was higher among younger women (Nairobi: 89%v78%, aged 15-17v18–22 years; uMkhanyakude: 56%v31%, aged 13-17v18–22; and Gem: 28%v25%, aged 15-17v18–22, respectively). HIV testing was the most accessed intervention in Nairobi and Gem (77% and 85%, respectively), and school-based HIV prevention in uMkhanyakude (60%). Among those invited, participation in social asset building was > 50%; > 60% accessed ≥2 core package categories, but few accessed all primary interventions intended for their age-group. Parenting programmes and community mobilisation, including those intended for male partners, were accessed infrequently. In Nairobi and uMkhanyakude, AGYW were more likely to be invited to participate and accessed more categories if they were: aged < 18 years, in school and experienced socio-economic vulnerabilities. Those who had had sex, or a pregnancy, were less likely to be invited to participate but accessed more categories. Conclusions In representative population-based samples, awareness and uptake of DREAMS were high after 1 year of implementation. Evidence of ‘layering’ (receiving multiple interventions from the DREAMS core package), particularly among more socio-economically vulnerable AGYW, indicate that intervention packages can be implemented at scale, for intended recipients, in real-world contexts. Challenges remain for higher coverage and greater ‘layering’, including among older, out-of-school AGYW, and community-based programmes for families and men

Occurrence of spina bifida in the Makerere University Galloway collection: an osteological anatomical study

Spina bifida is one of the commonest neural tube defects. Though food fortification with folic acid has been reported to reduce spina bifida, the incidence of spina bifida and the benefits of taking folic acid have not been documented in many developing countries including Uganda. This study set out to determine the incidence of spina bifida and related skeletal neural tube defects in the skeletons currently housed in the Galloway skeletal collection at Makererere University College of Health Sciences, Anatomy department with the aim of using the data to extrapolate on the usefulness of food fortification with folic acid. This was a descriptive cross sectional study on 226 skeletons in the Galloway osteological collection examined by an experienced anatomist for features of neural tube defects that ranged from non-fusion of the spinal arches to total absence of vertebral structures. Of the skeletons examined 43/226 (19%) had spina bifida. Of these 38/43 (88%) were male, suggesting a higher incidence of spina bifida in males than in the females. Overall 55.2% of the skeletons were within the age range of 20-55 years. This historical study highlights possible differences in the maternal micro nutrient status in the early months of pregnancy for various African populations as shown by the differences in the prevalence rates of minor spina bifida defects in the Galloway osteological collection. There is need for baseline studies on folic acid levels during pregnancy and the various local dietary sources of folic acid for Africans.Key words: Neural tube defects, osteolog

ASSESSMENT OF COMMON BEAN CULTIVAR DIVERSITY IN SELECTED COMMUNITIES OFCENTRAL UGANDA

Common bean ( Phaseolus vulgaris ) L. diversity has been nurtured by Uganda\u2019s farming communities and in return it has sustained their livelihoods for over 40 decades. Despite the farmers\u2019 invaluable effort in perpetuating this diversity, there is limited overall understanding of its status and dynamics on-farm. This study assessed the amount and status of the cultivar diversity in selected rural and peri-urban communities of central Uganda. Data were purposefully collected from 120 households through household surveys, focus group discussions and direct field observations. Diversity measures, status of the cultivars and morphological distinctiveness were estimated by Simpson\u2019s index of diversity (1-D), four cell analysis and cluster analysis, respectively. A total of 24 cultivars were observed in the whole study, and both communities had equal cultivar richness.There were no significant differences in the number of cultivars maintained by the farmers in the rural and those in the peri-urban communities. Both communities had substantial cultivar evenness (0.81 and 0.82 in rural and peri-urban, respectively), although only 19% of cultivars were grown on relatively larger areas and by many households. Impressively, at least 30% of the households in each community nurtured different sets of cultivars. We thus recommend the need to put in place incentive mechanisms that can encourage a section of the community to continue conserving P. vulgaris diversity on-farm to ensure its continued evolution and adaptation to changing biotic and abiotic factors.La diversit\ue9 du haricot commun ( Phaseolus vulgaris ) L. a \ue9t\ue9 d\ue9velopp\ue9 par des communaut\ue9s de fermiers en Ouganda et, en retour, la culture a durablement contribu\ue9 au bien \ueatre familial pendant plus de quarante ans. Malgr\ue9 des efforts consid\ue9rables des fermiers dans la perp\ue9tuation de cette diversit\ue9, la compr\ue9hension de sa situation et dynamique en champ reste limit\ue9e. Cette \ue9tude a \ue9valu\ue9 le nombre et la situation de la diversit\ue9 des cultivars dans des communaut\ue9s s\ue9lectionn\ue9es en milieux rural et p\ue9ri-urbain de l\u2019Ouganda central. Les donn\ue9es d\u2019\ue9taient collect\ue9es de fa\ue7on raisonn\ue9e dans 120 m\ue9nages \ue0 travers une enqu\ueate de m\ue9nage, les groupes de discussions et des observations directes sur terrain. Des mesures de diversit\ue9, la situation des cultivars et la diff\ue9renciation morphologique \ue9taient estim\ue9es par l\u2019index de diversit\ue9 de Simpson (1-D), quatre analyses de cellules et l\u2019analyse de groupes, respectivement. Un total de 24 cultivars \ue9tait observ\ue9 dans toute l\u2019\ue9tude, et toutes les deux communaut\ue9s avaient une richesse \ue9gale de cultivars. Aucune diff\ue9rence significative n\u2019\ue9tait trouv\ue9e dans le nombre de cultivars maintenu par les fermiers ruraux et p\ue9ri-urbains. Les deux communaut\ue9s avaient un nombre substantiellement invariant de cultivars (0.81 et 0.82 en milieu rural et p\ue9ri-urbain, respectivement), malgr\ue9 que 19% seulement des cultivars \ue9taient cultiv\ue9s relativement sur des vastes \ue9tendues et par plusieurs m\ue9nages. De fa\ue7on impressionnante, au moins 30% des m\ue9nages dans chaque communaut\ue9 avaient d\ue9velopp\ue9 diff\ue9rents types de cultivars. Ceci d\ue9montre le besoin de mettre en place des m\ue9canismes d\u2019encouragement des communaut\ue9s afin de continuer la conservation en milieux paysan de la diversit\ue9 du P. vulgaris pour assurer son \ue9volution continue et l\u2019adaptation au changement des facteurs biotiques et abiotiques