African Population And Health Research Center Research Articles

Trends in African Research and Innovation Using Dimensions Data

In this webinar hosted by Training Centre in Communication (TCC Africa), we are joined by a panel of experts from the African Population and Health Research Centre (APHRC) and Digital Science discussing the latest trends in African research and innovation using Dimensions.

Navigating Secondary School: What Cushioned Adolescents in an Education Intervention in Urban Kenya

This paper explains sustained effects and what worked for students in the Advancing Learning Outcomes and Transformational (ALOT Change III) program. Data comes from qualitative narratives from the baseline survey of the program collected by the African Population and Health Research Center (APHRC) between December 4, 2019, and January 31, 2020, using focus group discussions (FGDs) and dialogues. The analysis followed the Miles and Huberman (1994) framework to make comparisons and contrasts. Results showed that students transferred skills such as self-confidence from primary to secondary schools, enabling the adolescents to speak up and engage. This showed an effective implementation uptake. The implication of the study points to the efficacy of community-based programs in impacting behavior of adolescents beyond primary school.

Beyond free primary education: pathways to academic persistence in Kenyan free education system

ABSTRACT Persistence to complete has emerged as a pressing issue facing free primary education (FPE) in Kenya. Only 58% of the students who enroll in FPE complete and this proportion drops as they advance to higher levels. Failure to complete primary school, let alone the higher levels of education is alarming. Besides funding, this study explores the features that contribute to students’ pathways to persistence. Using data from the African Population and Health Research Center (APHRC), this study found the retention level to be 57%. The logistic analysis showed that parents’ level of education and student's age (i.e. 10–14 years) were over five times more likely to improve student persistent. Family socio-economic status, the level of engagement, positive school experience, parents’ involvement and collaboration with the school, and a high-quality school with supportive learning were also positively associated with academic persistence. The implications for practice and research are discussed below.

From the Minds of Adolescents: What Has Worked for Them in an Education Intervention in the Slums of Nairobi

This paper highlights findings from the, ‘Advancing learning outcomes for transformational change (A LOT-Change), whose goal was to increase efforts towards securing the future of children living in urban informal settlements. The intervention was implemented in Korogocho and Site 2 respectively. This paper looks at the narratives from girls, boys and their parents and seeks to answer the question, “From the minds of adolescents: What has worked for them in an education intervention in the slums of Nairobi. Qualitative data comes from the qualitative component of the endline evaluation study that was collected in July and August 2018, by the African Population and Health Research Center (APHRC). Findings from this study done by APHRC show that: scores in numeracy skills and literacy skills improved, improved self-confidence, which enabled girls to model the way in their schools and communities. Aspirations for school and higher education improved as girls and boys wanted to go beyond primary school. Communication improved across the board girls and boys, together with their parents. Girls and boys gained the confidence to speak up due to the knowledge gained out of the motivational talks within the leadership component. Overall, this paper reinforces the importance of young people having a voice to speak up on programs that affect their lives.

Catherine Kyobutungi: leading African health research capacity

Catherine Kyobutungi leads an organisation with a broad mandate to generate evidence and strengthen research capacity in Africa. As Executive Director of the Nairobi-based African Population and Health Research Center (APHRC) since Oct 1, 2017, she's clear about her mission: “For me the important thing is that we are doing research not for the sake of research, but to generate policy-relevant evidence while building credible profiles to be able to speak and be listened to where it matters. So that people making policy decisions have the best evidence available to them and they think about it and they look for it, and the evidence actually goes into policies.” Ibrahim Abubakar, Director of University College London's Institute for Global Health, UK, welcomes her appointment. “Dr Kyobutungi is an exceptional African scientist, incredibly well placed to take APHRC to its next level of development. Her experience of direct provision of health care as a junior doctor locally combined with world-class research and global recognition in health policy makes her an ideal choice to lead APHRC, an organisation that aims to transform lives through research in Africa”, he says. The African Population and Health Research CenterThe African Population and Health Research Center (APHRC) has a new leader and a new strategic vision. Full-Text PDF

Offline: Africa does not need a Prince Charming

By the end of this century, one in three people on our planet will be living in sub-Saharan Africa (today, the proportion is one in eight). Yet this profound shift in population power carries with it little agreement on what should be done to secure the future health and wellbeing of African peoples. Economists are divided. Olusegun Obasanjo (President of Nigeria, 1999–2007), together with several Africa experts, published his prescription for the continent this month (Making Africa Work: a Handbook, Hurst). Their analysis is rooted in a deeply negative diagnosis. Africa continues to suffer from patronage-ridden political systems, violence, poverty, poor governance, failed states, social chaos, and aid dependency. The only way out is through fundamental change, strengthening the private sector, and learning from other countries. By striking contrast, Morten Jerven (Africa: Why Economists Got It Wrong, Zed, 2015) argues that African nations have not been the persistent failures so many (including Obasanjo) suggest. Jerven sees the period from postcolonial independence (the early 1960s) to the oil-price shocks of the 1970s as one of impressive economic growth that surpassed the rest of the world. The slowdowns or reversals of the 1980s were not due to bad policies enacted by incompetent governments. On the contrary, they can be largely attributed to externally imposed crises, such as one-size-fits-all structural adjustment programmes. It was these neocolonial inflictions that caused poor governance, incentivised corruption, and triggered aid dependency. The pessimism that infects so much allegedly informed opinion about Africa today is mistaken. With such wildly opposite conclusions, is it any wonder that politicians and policy makers might be confused about what they should do to realise the hopes of Africa's citizens? Kenya is an example of a country caught between these two conflicting visions. Pessimists could point to the re-run of a bitterly contested presidential election on Oct 17, which is raising extreme political tensions; a 3-month-old nurses' strike; and economic growth forecasts that are now being revised downwards. Optimists, meanwhile, might point to the construction of a KSh500 million health complex in Kilifi, with state-of-the-art cancer treatment and intensive care facilities; an internationally admired ban on plastic bags; and a growing reputation for devising home-grown solutions to the country's challenges—the African Population and Health Research Centre (APHRC) in Nairobi, led by Alex Ezeh, was rated the premiere African thinktank for domestic health policy in 2016. The APHRC has made a huge contribution to policy capacity-building in Kenya, with 370 completed PhD degrees over the 19 years of Ezeh's leadership. At the launch of The Lancet's Commission on the Future of Health in sub-Saharan Africa at the APHRC in Nairobi this month, Siddharth Chatterjee, UN Resident Coordinator in Kenya, argued that the country could lead the way towards Africa's goal of universal health coverage. The major conclusion of our Commission backed Jerven's more positive analysis of Africa's opportunities. Closing the health gap for Africa within a generation is achievable. Nelson Sewankambo put it this way—“evidence-based optimism, with caution”. Dr Tedros, WHO's Director-General, endorsed the Commission's findings and recommendations. “This report is central to the future of health in Africa”, he wrote. None of us present in Nairobi were complacent about the challenges ahead. Africa is not a single entity, and health predicaments will require historically and culturally contextualised solutions. A report by itself will not change anything. Advocacy, investments in higher education, and regional cooperation will be essential. And evidence must be applied with appropriate accountability to ensure that promises and commitments are fulfilled. Ezeh vacates his position as Executive Director of APHRC on Oct 1, 2017. In another sign that Africa is embracing a very different future, he is to be succeeded by Catherine Kyobutungi. We will be working with Catherine and the Commission to deliver on their recommendations. At the first meeting of the Commission in 2013, lead author Irene Agyepong noted that some see Africa consisting of “sleeping beasts under the influence of a wicked fairy hoping for a Prince Charming”. As she intimated, Africa is not bewitched by an evil spirit. It does not need a Prince Charming. In Ezeh's words, it's time Africans believed more in themselves and the work they do.

Prospects for Fertility Decline in Africa

Prospects for Fertility Decline in Africa

Editorial: The full spectrum of risk in urban centres: changing perceptions, changing priorities

In many urban centres in the global South, there is little or no information on either the scale or the causes of premature death, serious injury, illness or impoverishment. In sub-Saharan Africa, this is the case for most urban centres. Even where there may be some information, it is seldom available for every district in the city. We get some sense of the scale of these issues from household surveys (such as the Demographic and Health Surveys), which show very high infant, child and maternal mortality rates “for urban areas” in many African and Asian nations.(1) But for practical action this kind of information is needed for every ward or district – on what the problems are, where they are and who is most impacted. Civil servants, politicians and civil society groups working at neighbourhood, ward, district and city levels may have some sense, based on their experience, of what the concerns are within their jurisdictions. But without data to present to higher-ups, it can be difficult to get proper action in response. The availability of data is worst of all for informal settlements – despite the fact that they often house more than half of a city’s population. In Nairobi, the African Population and Health Research Center (APHRC) has shown that aggregate figures for infant and under-5 mortality rates for the city hide the much higher rates in informal settlements.(2) But this kind of information is needed everywhere, and there is in general scant documentation of the serious risks faced by the billion or so urban dwellers who live in informal settlements.

Hope and despair 3/3: pluses and minuses for community health assistants in rural Zambia

Hope and despair 3/3: pluses and minuses for community health assistants in rural Zambia

When to Randomize: Lessons From Independent Impact Evaluation of Reading to Learn (RtL) Programme to Improve Literacy and Numeracy in Kenya and Uganda

In East Africa, there is great effort directed toward ensuring that there is learning and value for money invested in universal education policies initiated over the past decade. Kenya and Uganda are two countries that typify this effort. The effort includes the work of research organisations such as Uwezo, which assess learning levels; RTI, which assesses language and early grade reading; and the work of African Population and Health Research Center (APHRC), which looks at schooling patterns of different households. All these studies paint a disappointing picture both for the universal access Education for All policy and the large sums of money that have been devoted to achieve it. The verdict is that too many pupils in schools are not learning and too many poor ones are excluded from universal public access. Uwezo reports that 70% of pupils in Grade 3 cannot do Grade 2 work, and 9% of those completing Primary 8 in Kenya cannot do Grade 2 work. Answers are not easy to find, so borrowing what has worked elsewhere has been attempted. This article presents one effort toward finding what can work to improve learning for pupils in early grades. It is based on the idea of “Reading to Learn” implemented elsewhere and attempted in East Africa by Aga Khan Foundation and independently evaluated by APHRC using randomization methods. Lessons presented highlight the role and complexities of randomization in addressing the educational challenges in East Africa.

Introducing a model of cardiovascular prevention in Nairobi's slums by integrating a public health and private-sector approach: the SCALE-UP study

IntroductionCardiovascular disease (CVD) is a leading cause of death in sub-Saharan Africa (SSA), with annual deaths expected to increase to 2 million by 2030. Currently, most national health systems in SSA are not adequately prepared for this epidemic. This is especially so in slum settlements where access to formal healthcare and resources is limited.ObjectiveTo develop and introduce a model of cardiovascular prevention in the slums of Nairobi by integrating public health and private sector approaches.Study designTwo non-profit organizations that conduct public health research, Amsterdam Institute for Global Health and Development (AIGHD) and African Population and Health Research Center (APHRC), collaborated with private-sector Boston Consulting Group (BCG) to develop a service delivery package for CVD prevention in slum settings. A theoretic model was designed based on the integration of public and private sector approaches with the focus on costs and feasibility.ResultsThe final model includes components that aim to improve community awareness, a home-based screening service, patient and provider incentives to seek and deliver treatment specifically for hypertension, and adherence support. The expected outcomes projected by this model could prove potentially cost effective and affordable (1 USD/person/year). The model is currently being implemented in a Nairobi slum and is closely followed by key stakeholders in Kenya including the Ministry of Health, the World Health Organization (WHO), and leading non-governmental organizations (NGOs).ConclusionThrough the collaboration of public health and private sectors, a theoretically cost-effective model was developed for the prevention of CVD and is currently being implemented in the slums of Nairobi. If results are in line with the theoretical projections and first impressions on the ground, scale-up of the service delivery package could be planned in other poor urban areas in Kenya by relevant policymakers and NGOs.

The effect of free primary education policy on late school entry in urban primary schools in Kenya

Late school entry is driven by several factors, one of the key ones being the cost barrier to schooling. Policies such as free primary education (FPE) that advocate for universal coverage are therefore partly aimed at removing the cost barrier. The Kenyan Government, like many in sub-Saharan Africa (SSA), introduced FPE in 2003 with the aim of universalising access to schooling, which is one of the eight United Nations Millennium Development Goals (MDGs) it signed up to achieve. Based on a case study of four sites in Nairobi, the aim of this paper is to assess whether the FPE policy has affected late enrolment. The data used were collected by the African Population and Health Research Center (APHRC) and comprise a sub-sample of 4,325 first-graders during 2000–2005. The paper applies a probit model to assess the impact of the policy on the basis of marginal effects on the predicted probability of late enrolment. The results show that the FPE policy reduces the probability of late enrolment by 14 per cent. The reduction in probability of late enrolment was greater among children residing in slums (16 per cent) than those in non-slums (9 per cent). The main implication of the findings for policy makers is that cost barriers are a likely cause of over-age enrolment.

PROTOCOL: Community‐Based Rehabilitation for People with Disabilities in Low‐ and Middle‐Income Countries

PROTOCOL: Community‐Based Rehabilitation for People with Disabilities in Low‐ and Middle‐Income Countries

Correlates of HIV-status awareness among adults in Nairobi slum areas

The prevalence of HIV in the adult population in slum areas in Nairobi, Kenya, is higher than for residents in the city as a whole. This disparity suggests that the characteristics of slum areas may adversely influence the HIV-prevention strategies directed at reducing the national prevalence of HIV. The objective of the study was to identify some of the sociodemographic and behavioural correlates of HIV-status awareness among the adult population of two slums in Nairobi. In a household-based survey conducted by the African Population and Health Research Center (APHRC), 4 767 men and women aged between 15 and 54 years were randomly sampled from two slums (Korogocho and Viwandani) in Nairobi and data were collected on the social and health context of HIV and AIDS in these settlements. Bivariate and multivariate logistic regression analyses were conducted to identify factors associated with HIV-status awareness. The proportion of respondents that had ever been tested and knew their HIV status was 53%, with the women having greater awareness of their HIV status (62%) than the men (38%). Awareness of HIV status was significantly associated with age, sex, level of education, marital status and slum of residence. The lower level of HIV-status awareness among the men compared with the women in the slums suggests a poor uptake of HIV-testing services by males. Innovative strategies are needed to ensure greater access and uptake of HIV-testing services by the younger and less-educated residents of these slums if the barriers to HIV-status awareness are to be overcome.

Parental aspirations for their children's educational attainment and the realisation of universal primary education (UPE) in Kenya: Evidence from slum and non-slum residences

There is a sound research base attesting to the importance of parental involvement and to the many potential benefits it can offer for children's education. This study sought to examine differences in parental aspirations (as a mechanism of parental involvement in their children's education) for their children's educational attainment between slum and non-slum residing parents in Kenya. The study used cross-sectional household data for a sample of 4065 parents, collected in 2007 by the African Population and Health Research Centre (APHRC) in Nairobi. A multinomial logistic model was used for the analysis to explore the factors determining parental aspirations. The results indicate the following: (i) that parents who live in the slums have lower aspirations for their children's educational attainment when compared to those who live in non-slum areas; (ii) that parents in the slums have aspirations for higher levels of educational attainment for their children than their own levels of education. We conclude that parents in urban Kenya have a strong belief in the education of their children irrespective of their slum or non-slum residence but aspirations are higher in non-slums than in slums.

Do poverty dynamics explain the shift to an informal private schooling system in the wake of free public primary education in Nairobi slums?

With the introduction of free primary education (FPE) in Kenya in 2003, it was expected that the burden on poor households in financing primary education would be reduced substantially. This in turn would increase enrolment in public schools and lead to universal primary education. However, studies have shown that a considerable proportion of households in urban slums continue to enrol their children in pro-poor fee charging informal schools. The reasons presented in the available literature to explain this phenomenon of why poor slum-residing households bypass free public education are varied and some are simply speculative. In this paper, we hypothesise that poverty dynamics can partly explain households' decisions on the type of school in which to enrol their children. The analysis is based on longitudinal data collected by the African Population and Health Research Centre (APHRC) using urban demographic surveillance in two slums of Nairobi, Kenya. The data covers the period between 2005 and 2009 with a sample of 6965 pupils spread across 3763 households. Logistic regression methods are applied. The findings reveal that moving in and out of poverty can affect the type of schooling decision a household makes, with one quarter of those moving out of poverty shifting schools. The findings demonstrate that there is both willingness and ability to pay by the slum residents that is driving the utilisation of the private schools. The decisions are not random occurrences, but seem systematic and rational – parents want quality and affordability and a good number of those whose economic situation improved do not seem to believe the public schools, even under FPE, offers quality. The policy implication to be drawn from these findings is that the private schools for the poor should not simply be dismissed as 'informal schools' because it seems they have some features which are attracting parents to choose them and leave the state system. Free primary education policy is being 'rejected' by a good number of parents in the slums and this needs further investigation, as 'excess' demand as suggested in some research papers does not seem to be the only explanation.

The effect of active teaching and subject content coverage on students' achievement: evidence from primary schools in Kenya

There is a growing public concern in Kenya over the persistent gap between those schools that are consistently ranked at the top and those ranked at the bottom of the annual Kenya Certificate of Primary Education (KCPE) examination league tables. This has raised the issue of inequality in educational opportunity. Our primary concern in this paper is to understand some of the classroom–school factors that may explain the persistent differences in achievement between the top and bottom schools. We focus on time-on-task (the length of exposure to any particular teaching and learning task) and curriculum content, and ask whether this explains the difference in performance. We test the following hypotheses: differences exist on teachers' time-on-task between low and high performing schools; greater teacher time-on-task has a positive effect on student gain score; and greater content coverage has a positive effect on student achievement. For the student achievement gains, we use item response theory test scores of 1889 Grade 6 pupils from 70 schools in Kenya. Data on time-on-task were generated from 70 maths lessons observed in these schools, while content coverage was developed from students' maths note books for the entire period they were in Grade 6. The study was conducted by a team of researchers at the African Population and Health Research Center (APHRC) with funding from Google.org. Using two level hierarchical modelling, we control for pupil, teacher and school factors. Results show that exposure to content is positively correlated with pupil gain scores (gain score is the difference in score between test at time t1 and test at time t2 of the same pupil taught by the same teacher). Maths teachers in both bottom and top performing schools spend the same proportion of time-on-task. However, we do not find that time-on-task is related to achievement in this sample.

Childhood vaccination in informal urban settlements in Nairobi, Kenya: Who gets vaccinated?

BackgroundRecent trends in global vaccination coverage have shown increases with most countries reaching 90% DTP3 coverage in 2008, although pockets of undervaccination continue to persist in parts of sub-Saharan Africa particularly in the urban slums. The objectives of this study were to determine the vaccination status of children aged between 12-23 months living in two slums of Nairobi and to identify the risk factors associated with incomplete vaccination.MethodsThe study was carried out as part of a longitudinal Maternal and Child Health study undertaken in Korogocho and Viwandani slums of Nairobi. These slums host the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) run by the African Population and Health Research Centre (APHRC). All women from the NUHDSS area who gave birth since September 2006 were enrolled in the project and administered a questionnaire which asked about the vaccination history of their children. For the purpose of this study, we used data from 1848 children aged 12-23 months who were expected to have received all the WHO-recommended vaccinations. The vaccination details were collected during the first visit about four months after birth with follow-up visits repeated thereafter at four month intervals. Full vaccination was defined as receiving all the basic childhood vaccinations by the end of 24 months of life, whereas up-to-date (UTD) vaccination referred to receipt of BCG, OPV 1-3, DTP 1-3, and measles vaccinations within the first 12 months of life. All vaccination data were obtained from vaccination cards which were sighted during the household visit as well as by recall from mothers. Multivariate models were used to identify the risk factors associated with incomplete vaccination.ResultsMeasles coverage was substantially lower than that for the other vaccines when determined using only vaccination cards or in addition to maternal recall. Up-to-date (UTD) coverage with all vaccinations at 12 months was 41.3% and 51.8% with and without the birth dose of OPV, respectively. Full vaccination coverage (57.5%) was higher than up-to-date coverage (51.8%) at 12 months overall, and in both slum settlements, using data from cards. Multivariate analysis showed that household assets and expenditure, ethnicity, place of delivery, mother's level of education, age and parity were all predictors of full vaccination among children living in the slums.ConclusionsThe findings show the extent to which children resident in slums are underserved with vaccination and indicate that service delivery of immunization services in the urban slums needs to be reassessed to ensure that all children are reached.

Free primary education policy and pupil school mobility in urban Kenya

This paper examines pupil school mobility in urban Kenya using African Population and Health Research Centre (APHRC) household survey data which contain information on pupil transfers between schools. The aim is to identify which school characteristics attract the greatest demand for incoming transfers. The analysis reveals that there are frequent transfers in the slums than in the non-slum settlements; that transfer are in favour of private schools; and that quality is the main motivation for the transfers. Quality schools are perceived to have good discipline and better teacher performance. Given these results, should the Kenya government recognise the ‘low cost’ schools found in the slums which serve nearly half of the pupils and devise mechanisms of funding them?