Nairobi Urban Health And Demographic Surveillance System Research Articles

Trends and risk factors for non-communicable diseases mortality in Nairobi slums (2008–2017)

IntroductionTracking progress in reaching global targets for reducing premature mortality from non-communicable diseases (NCDs) requires accurately collected population based longitudinal data. However, most African countries lack such data because of weak or non-existent civil registration systems. We used data from the Nairobi Urban Health and Demographic Surveillance System (NUDSS) to estimate NCD mortality trends over time and to explore the determinants of NCD mortality. MethodsDeaths identified in the NUHDSS were followed up with a verbal autopsy to determine the signs and symptoms preceding the death. Causes of death were then assigned using InSilicoVA algorithm. We calculated the rates of NCD mortality in the whole NUHDSS population between 2008 and 2017, looking at how these changed over time. We then merged NCD survey data collected in 2008, which contains information on potential determinants of NCD mortality in a sub-sample of the NUHDSS population, with follow up information from the full NUHDSS including whether any of the participants died of an NCD or non-NCD cause. Poisson regression models were used to identify independent risk factors (broadly categorized as socio-demographic, behavioural and physiological) for NCD mortality, as well as non-NCD mortality. ResultsIn the total NUHDSS population of adults age 18 and over, 23% were assigned an NCD as the most likely cause of death. There was evidence that NCD mortality decreased over the study period, with rates of NCD mortality dropping from 1.32 per 1000 person years in 2008–10 (95% CI: 1.13–1.54) to 0.93 per 1000 person years in 2014–17 (95% CI: 0.80–1.08). Of 5115 individuals who participated in the NCD survey in 2008, 421 died during the follow-up period of which 43% were attributed to NCDs. Increasing age, lower education levels, ever smoking and having high blood pressure were identified as independent determinants of NCD mortality in multivariate analyses. ConclusionWe found that NCDs account for one-quarter of mortality in Nairobi slums, although we document a reduction in the rate of NCD mortality over time. This may be attributed to increased surveillance and introduction of population-wide NCD interventions and health system improvements from research activities in the slums. To achieve further decline there is a need to strengthen health systems to respond to NCD care and prevention along with addressing social factors such as education.

Trends and determinants of health facility childbirth service utilization among mothers in urban slums of Nairobi, Kenya

High maternal mortality remains a challenge for the attainment of the third Sustainable Development Goal in Sub-Saharan Africa. In Kenya, maternal mortality ratio remains high at 362 deaths per 100,000 live births. Utilization of health facility childbirth services ensures safe birth and is vital for the reduction of maternal mortality. However, this can be greatly affected by socioeconomic and geographical inequalities. In this study, we assess the trends and determinants of health facility childbirth service utilization among women giving birth in the urban slums of Nairobi, Kenya. Data were obtained from the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) comprising 19,469 births observed between 2003 and [19]. A logistic regression model, with parameter estimation using a generalized estimating equations (GEE) approach, was used to assess factors associated with health facility childbirth. About 81% of the births occurred at health facilities while 19% were occurring at home or outside a health facility. The results further indicated that, education, parity, and relationship to head of households were associated with health facility childbirth. Increasing awareness of the mothers about the benefits of health facility childbirth service utilization and the risks of home childbirth should be given extra attention by health practitioners during antenatal care visits.

Assessment of cardiovascular risk in a slum population in Kenya: use of World Health Organisation/International Society of Hypertension (WHO/ISH) risk prediction charts - secondary analyses of a household survey

ObjectivesAlthough cardiovascular disease (CVD) is of growing importance in low- and middle-income countries (LMICs), there are conflicting views regarding CVD as a major public health problem for the urban poor,...

Poverty Dynamics in Nairobi’s Slums: Testing for True State Dependence and Heterogeneity Effects

We investigate the factors underlying poverty transitions in Nairobi’s slums focusing on whether differences in characteristics make some individuals more prone to enter poverty and persist in, or whether past experience of poverty matters on future poverty situations. Answers to these issues are crucial for designing effective and successful poverty alleviation policies in informal residential settlements in Africa. The paper uses an endogenous switching model, which accounts for initial conditions, non-random attrition, and unobserved heterogeneity. The estimations are based on a two-wave sample of a panel dataset from the Nairobi Urban Health and Demographic Surveillance System (NUHDSS), the first urban-based Health and Demographic Surveillance Systems (HDSS) in Africa. Estimation results indicate that true state dependence (TSD) constitutes the major factor driving poverty persistence. There is little heterogeneity effects; only 10 percent of poverty persistence is likely due to heterogeneity. Moreover, even when household and individual observed characteristics differ notably, the TSD size remains very large. This implies that active anti-poverty programs aimed at breaking the cycle of poverty constitute the most appropriate policies for taking people out of poverty and preventing them to fall back in. Indeed, this does not exclude policies focusing on individual heterogeneities. Active policies for improving individual’s education, personal skills and capacities, or living environment would also allow preventing people entering poverty or persisting in.

Understanding HIV risks among adolescent girls and young women in informal settlements of Nairobi, Kenya: Lessons for DREAMS.

IntroductionHigh incidence of HIV infection among adolescent girls and young women (AGYW) has been attributed to the numerous and often layered vulnerabilities that they encounter including violence against women, unfavourable power relations that are worsened by age-disparate sexual relations, and limited access to sexual and reproductive health information and services. For AGYW living in urban informal settlements (slums), these vulnerabilities are compounded by pervasive poverty, fragmented social networks, and limited access to social services including health and education. In this paper, we assess sexual risk behaviours and their correlates among AGYW in two slum settlements in Nairobi, Kenya, prior to the implementation of interventions under the Determined Resilient Empowered AIDS-free Mentored and Safe (DREAMS) Partnership.MethodsWe drew on secondary data from the Transition to Adulthood study, the most recent representative study on adolescent sexual behaviour in the two settlements. The study was nested within the Nairobi Urban Health and Demographic Surveillance System (NUHDSS). Data were collected in 2009 from 1,390 AGYW aged 12–23 years. We estimated the proportions of AGYW reporting ever tested for HIV, condom use, multiple sexual partners and age-disparate sex by socio-demographic characteristics. “High risk” sexual behaviour was defined as a composite of these four variables and age at first sex. Multivariable regression analyses were performed to identify factors associated with risk behaviours.ResultsFifty-one percent of AGYW reported that they had ever tested for HIV and received results of their last test, with the proportion rising steeply by age (from 15% to 84% among those <15 years and 20–23 years, respectively). Of 578 AGYW who were sexually active in the 12 months preceding the survey, 26% reported using a condom at last sex, 4% had more than one sexual partner, and 26% had sex with men who were at least 5 years older or younger. All girls aged below 15 years who had sex (n = 9) had not used condoms at last sex. The likelihood of engaging in “high risk” sexual risk behaviour was higher among older AGYW (19–23 years), those in marital unions, of Luo ethnicity, out of school, living alone or with a friend (versus parents), living with spouse (versus parents), and those whose friends engaged in risky/anti-social behaviours. In contrast, Muslim faith, co-residence with both parents, and belonging to an organised social group were associated with lower odds of risky sexual behaviours.ConclusionOur study findings suggest that multifaceted approaches addressing the educational and social mediators of AGYW’s vulnerability and that also reach the people with whom AGYW live and interact, are needed to reduce the rapid onset of sexual risk during the adolescent years. There is a particular need to reach the youngest adolescent girls in poor urban settings, among whom condom use and awareness of HIV status is rare.

Understanding nutrition transition among internal rural-to-urban migrant women in Nairobi, Kenya

Evidence suggests that urbanisation in Kenya is fueling nutrition transition culminating in increased obesity rates among the urban poor, especially women. Mechanisms underlying this transition are poorly understood. I therefore examined nutrition transition among rural-to-urban migrant women to better understand obesity in Kenya. I employed a sequential explanatory mixed methods design. In the quantitative phase I used individual and household secondary-data from the 2014 Kenyan Demographic and Health Survey (n=6,171) and the 2008/2009 Nairobi Urban Health and Demographic Surveillance System (NUHDSS) (n=5,422) to identify characteristics associated with nutrition transition and obesity risk among migrant women. The NUHDSS analysis informed the interview guide and sampling in qualitative research in three Nairobi slum neighbourhoods, with 6 key informant interviews, 7 focus groups, 28 in-depth interviews and 3 PhotoVoice groups. A mixed-methods results synthesis led to the formulation of several key meta-inferences. First, both quantitative studies showed no clear differences between rural-to-urban migrant women’s and urban non-migrants’ diets. The qualitative findings concurred with this as migrant women, despite having mixed attitudes, perceived their diets to be similar to those of local residents. While they appreciated accessibility and diversity of cheap, sweet and animal-sourced food, they had more trust in home-cooked food. Second, economic circumstances were salient on nutrition transition. Household wealth and self-employment were positively associated with having obesity. Wealthier migrant women, and those who sold obesogenic foods, consumed these in larger portions either at home or pre-prepared due to economic insecurity, time scarcity, family responsibilities and/or convenience. Lastly, repeated exposure to obesogenic food and social pressure to conform to community nutrition patterns drove nutrition transition irrespective of individual deprivation. These findings indicate the need for a local systems approach which considers the complex interplay between economic and time insecurity, and socio-cultural norms to address nutrition transition and obesity in slum neighbourhoods.

Trends in Causes of Adult Deaths among the Urban Poor: Evidence from Nairobi Urban Health and Demographic Surveillance System, 2003-2012.

What kills people around the world and how it varies from place to place and over time is critical in mapping the global burden of disease and therefore, a relevant public health question, especially in developing countries. While more than two thirds of deaths worldwide are in developing countries, little is known about the causes of death in these nations. In many instances, vital registration systems are nonexistent or at best rudimentary, and even when deaths are registered, data on the cause of death in particular local contexts, which is an important step toward improving context-specific public health, are lacking. In this paper, we examine the trends in the causes of death among the urban poor in two informal settlements in Nairobi by applying the InterVA-4 software to verbal autopsy data. We examine cause of death data from 2646 verbal autopsies of deaths that occurred in the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) between 1 January 2003 and 31 December 2012 among residents aged 15 years and above. The data is entered into the InterVA-4 computer program, which assigns cause of death using probabilistic modeling. The results are presented as annualized trends from 2003 to 2012 and disaggregated by gender and age. Over the 10-year period, the three major causes of death are tuberculosis (TB), injuries, and HIV/AIDS, accounting for 26.9, 20.9, and 17.3% of all deaths, respectively. In 2003, HIV/AIDS was the highest cause of death followed by TB and then injuries. However, by 2012, TB and injuries had overtaken HIV/AIDS as the major causes of death. When this is examined by gender, HIV/AIDS was consistently higher for women than men across all the years generally by a ratio of 2 to 1. In terms of TB, it was more evenly distributed across the years for both males and females. We find that there is significant gender variation in deaths linked to injuries, with male deaths being higher than female deaths by a ratio of about 4 to 1. We also find a fifteen percentage point increase in the incidences of male deaths due to injuries between 2003 and 2012. For women, the corresponding deaths due to injuries remain fairly stable throughout the period. We find cardiovascular diseases as a significant cause of death over the period, with overall mortality increasing steadily from 1.6% in 2003 to 8.1% in 2012, and peaking at 13.7% in 2005 and at 12.0% in 2009. These deaths were consistently higher among women. We identified substantial variations in causes of death by age, with TB, HIV/AIDS, and CVD deaths lowest among younger residents and increasing with age, while injury-related deaths are highest among the youngest adults 15-19 and steadily declined with age. Also, deaths related to neoplasms and respiratory tract infections (RTIs) were prominent among older adults 50 years and above, especially since 2005. Emerging at this stage is evidence that HIV/AIDS, TB, injuries, and cardiovascular disease are linked to approximately 73% of all adult deaths among the urban poor in Nairobi slums of Korogocho and Viwandani in the last 10 years. While mortality related to HIV/AIDS is generally declining, we see an increasing proportion of deaths due to TB, injuries, and cardiovascular diseases. In sum, substantial epidemiological transition is ongoing in this local context, with deaths linked to communicable diseases declining from 66% in 2003 to 53% in 2012, while deaths due to noncommunicable causes experienced a four-fold increase from 5% in 2003 to 21.3% in 2012, together with another two-fold increase in deaths due to external causes (injuries) from 11% in 2003 to 22% in 2012. It is important to also underscore the gender dimensions of the epidemiological transition clearly visible in the mix. Finally, the elevated levels of disadvantage of slum dwellers in our analysis relative to other population subgroups in Kenya continue to demonstrate appreciable deterioration of key urban health and social indicators, highlighting the need for a deliberate strategic focus on the health needs of the urban poor in policy and program efforts toward achieving international goals and national health and development targets.

Health & Demographic Surveillance System Profile: The Nairobi Urban Health and Demographic Surveillance System (NUHDSS).

The Nairobi Urban Health and Demographic Surveillance System (NUHDSS) was the first urban-based longitudinal health and demographic surveillance platform in sub-Saharan Africa (SSA). The NUHDSS was established in 2002 to provide a platform to investigate the long-term social, economic and health consequences of urban residence, and to serve as a primary research tool for intervention and impact evaluation studies focusing on the needs of the urban poor in SSA. Since its inception, the NUHDSS has successfully followed every year a population of about 65,000 individuals in 24,000 households in two slum communities--Korogocho and Viwandani--in Nairobi, Kenya. Data collected include key demographic and health information (births, deaths including verbal autopsy, in- and out-migration, immunization) and other information that characterizes living conditions in the slums (livelihood opportunities, household amenities and possessions, type of housing etc.). In addition to the routine data, it has provided a robust platform for nesting several studies examining the challenges of rapid urbanization in SSA and associated health and poverty dynamics. NUHDSS data are shared through internal and external collaborations, in accordance with the Centre's guidelines for publications, data sharing.

Vulnerability to Food Insecurity in Urban Slums: Experiences from Nairobi, Kenya

Food and nutrition security is critical for economic development due to the role of nutrition in healthy growth and human capital development. Slum residents, already grossly affected by chronic poverty, are highly vulnerable to different forms of shocks, including those arising from political instability. This study describes the food security situation among slum residents in Nairobi, with specific focus on vulnerability associated with the 2007/2008 postelection crisis in Kenya. The study from which the data is drawn was nested within the Nairobi Urban Health and Demographic Surveillance System (NUHDSS), which follows about 70,000 individuals from close to 30,000 households in two slums in Nairobi, Kenya. The study triangulates data from qualitative and quantitative sources. It uses qualitative data from 10 focus group discussions with community members and 12 key-informant interviews with community opinion leaders conducted in November 2010, and quantitative data involving about 3,000 households randomly sampled from the NUHDSS database in three rounds of data collection between March 2011 and January 2012. Food security was defined using the Household Food Insecurity Access Scale (HFIAS) criteria. The study found high prevalence of food insecurity; 85 % of the households were food insecure, with 50 % being severely food insecure. Factors associated with food security include level of income, source of livelihood, household size, dependence ratio; illness, perceived insecurity and slum of residence. The qualitative narratives highlighted household vulnerability to food insecurity as commonplace but critical during times of crisis. Respondents indicated that residents in the slums generally eat for bare survival, with little concern for quality. The narratives described heightened vulnerability during the 2007/2008 postelection violence in Kenya in the perception of slum residents. Prices of staple foods like maize flour doubled and simultaneously household purchasing power was eroded due to worsened unemployment situation. The use of negative coping strategies to address food insecurity such as reducing the number of meals, reducing food variety and quality, scavenging, and eating street foods was prevalent. In conclusion, this study describes the deeply intertwined nature of chronic poverty and acute crisis, and the subsequent high levels of food insecurity in urban slum settings. Households are extremely vulnerable to food insecurity; the situation worsening during periods of crisis in the perception of slum residents, engendering frequent use of negative coping strategies. Effective response to addressing vulnerability to household food insecurity among the urban poor should focus on both the underlying vulnerabilities of households due to chronic poverty and added impacts of acute crises.

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

BackgroundWe describe trends in childhood mortality in Kenya, paying attention to the urban–rural and intra-urban differentials. MethodsWe 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). ResultsBetween 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. ConclusionsThe 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.

Inter-generational study of educational achievement in the poor urban areas in Sub-Saharan Africa: evidence from the Nairobi informal settlements

Using data from the Nairobi Urban Health and Demographic Surveillance System (NUHDSS), this paper compares the educational achievement of children of slum residents to that of their parents. Using ordered probit models, the study finds that the second-generation children of slum-dwellers fare better than their parents. Although father and mother’s educational attainment have positive effects on the probability of higher educational achievement, the coefficients were not statistically significant. Differences across ethnic groups were also found in the study. Although relatively small, Kamba (10%), Embu/Mberu (4%) and Kisii (6%) have the highest likelihood ratio coefficients, suggesting that these groups have higher probability of achieving higher educational level relative to other groups. Finally, in spite of the encouraging news about progress made at the primary school level, more needs to be done at the secondary and higher school levels for the children of the slum residents to reach their full potential.

Effect of mother’s education on child’s nutritional status in the slums of Nairobi

BackgroundMalnutrition continues to be a critical public health problem in sub-Saharan Africa. For example, in East Africa, 48 % of children under-five are stunted while 36 % are underweight. Poor health and poor nutrition are now more a characteristic of children living in the urban areas than of children in the rural areas. This is because the protective mechanism offered by the urban advantage in the past; that is, the health benefits that historically accrued to residents of cities as compared to residents in rural settings is being eroded due to increasing proportion of urban residents living in slum settings. This study sought to determine effect of mother’s education on child nutritional status of children living in slum settings.MethodsData are from a maternal and child health project nested within the Nairobi Urban Health and Demographic Surveillance System (NUHDSS). The study involves 5156 children aged 0–42 months. Data on nutritional status used were collected between October 2009 and January 2010. We used binomial and multiple logistic regression to estimate the effect of education in the univariable and multivariable models respectively.ResultsResults show that close to 40 % of children in the study are stunted. Maternal education is a strong predictor of child stunting with some minimal attenuation of the association by other factors at maternal, household and community level. Other factors including at child level: child birth weight and gender; maternal level: marital status, parity, pregnancy intentions, and health seeking behaviour; and household level: social economic status are also independently significantly associated with stunting.ConclusionOverall, mothers’ education persists as a strong predictor of child’s nutritional status in urban slum settings, even after controlling for other factors. Given that stunting is a strong predictor of human capital, emphasis on girl-child education may contribute to breaking the poverty cycle in urban poor settings.

Increase in facility-based deliveries associated with a maternal health voucher programme in informal settlements in Nairobi, Kenya.

Objective To measure whether there was an association between the introduction of an output-based voucher programme and the odds of a facility-based delivery in two Nairobi informal settlements.Data sources Nairobi Urban Health and Demographic Surveillance System (NUHDSS) and two cross-sectional household surveys in Korogocho and Viwandani informal settlements in 2004–05 and 2006–08.Methods Odds of facility-based delivery were estimated before and after introduction of an output-based voucher. Supporting NUHDSS data were used to determine whether any trend in maternal health care was coincident with immunizations, a non-voucher outpatient service. As part of NUHDSS, households in Korogocho and Viwandani reported place of delivery and the presence of a skilled birth attendant (2003–10) and vaccination coverage (2003–09). A detailed maternal and child health (MCH) tool was added to NUHDSS (September 2006–10). Prospective enrolment in NUHDSS-MCH was conditional on having a newborn after September 2006. In addition to recording mother’s place of delivery, NUHDSS-MCH recorded the use of the voucher.Findings There were significantly greater odds of a facility-based delivery among respondents during the voucher programme compared with similar respondents prior to voucher launch. Testing whether unrelated outpatient care also increased, a falsification exercise found no significant increase in immunizations for children 12–23 months of age in the same period. Although the proportion completing any antenatal care (ANC) visit remained above 95% of all reported pregnancies and there was a significant increase in facility-based deliveries, the proportion of women completing 4+ ANC visits was significantly lower during the voucher programme.Conclusions A positive association was observed between vouchers and facility-based deliveries in Nairobi. Although there is a need for higher quality evidence and validation in future studies, this statistically significant and policy relevant finding suggests that increases in facility-based deliveries can be achieved through output-based finance models that target subsidies to underserved populations.

The determinants of female circumcision among adolescents from communities that practice female circumcision in two Nairobi informal settlements

Using data from the Nairobi Urban Health and Demographic Surveillance System (NUHDSS), this paper seeks to understand the characteristics of adolescent girls who are circumcised in Kenya. The paper discusses the determinants of female circumcision in two Nairobi informal settlements. It is based on detailed information collected from young persons aged 12–24 targeting major transition events such as first sex, childbirth, marriage, and circumcision. Out of 4058 adolescents and young people interviewed 2010 were adolescent girls and young women. Out of the total number of interviewees, the 527 girls and young women on whom this paper is based are from ethnic communities that practice circumcision. We used the life-table technique to estimate the median age at circumcision and logistic regression to analyse the relationship between female circumcision and adolescent sexuality, controlling for other characteristics. The type of stay within the demographic surveillance area (DSA), religion, ethnicity, residential location and mother’s education were associated with being circumcised. Current school attendance was not associated with being circumcised but if one had never attended school then they were more likely to be circumcised. For policy making, it is imperative to explore the nature of social networks within which circumcision decisions are taken and enforced.

Monitoring of Health and Demographic Outcomes in Poor Urban Settlements: Evidence from the Nairobi Urban Health and Demographic Surveillance System

The Nairobi Urban Health and Demographic Surveillance System (NUHDSS) was set up in Korogocho and Viwandani slum settlements to provide a platform for investigating linkages between urban poverty, health, and demographic and other socioeconomic outcomes, and to facilitate the evaluation of interventions to improve the wellbeing of the urban poor. Data from the NUHDSS confirm the high level of population mobility in slum settlements, and also demonstrate that slum settlements are long-term homes for many people. Research and intervention programs should take account of the duality of slum residency. Consistent with the trends observed countrywide, the data show substantial improvements in measures of child mortality, while there has been limited decline in fertility in slum settlements. The NUHDSS experience has shown that it is feasible to set up and implement long-term health and demographic surveillance system in urban slum settlements and to generate vital data for guiding policy and actions aimed at improving the wellbeing of the urban poor.

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.

The health and well-being of older people in Nairobi's slums

Background: Globally, it is estimated that people aged 60 and over constitute more than 11% of the population, with the corresponding proportion in developing countries being 8%. Rapid urbanisation in sub-Saharan Africa (SSA), fuelled in part by rural–urban migration and a devastating HIV/AIDS epidemic, has altered the status of older people in many SSA societies. Few studies have, however, looked at the health of older people in SSA. This study aims to describe the health and well-being of older people in two Nairobi slums.Methods: Data were collected from residents of the areas covered by the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) aged 50 years and over by 1 October 2006. Health status was assessed using the short SAGE (Study on Global AGEing and Adult Health) form. Mean WHO Quality of Life (WHOQoL) and a composite health score were computed and binary variables generated using the median as the cut-off. Logistic regression was used to determine factors associated with poor quality of life (QoL) and poor health status.Results: Out of 2,696 older people resident in the NUHDSS surveillance area during the study period, data were collected on 2,072. The majority of respondents were male, aged 50–60 years. The mean WHOQoL score was 71.3 (SD 6.7) and mean composite health score was 70.6 (SD 13.9). Males had significantly better QoL and health status than females and older respondents had worse outcomes than younger ones. Sex, age, education level and marital status were significantly associated with QoL, while slum of residence was significantly associated with health status.Conclusion: The study adds to the literature on health and well-being of older people in SSA, especially those in urban informal settlements. Further studies are needed to validate the methods used for assessing health status and to provide comparisons from other settings. Health and Demographic Surveillance Systems have the potential to conduct such studies and to evaluate health and well-being over time.Access the supplementary material to this article: INDEPTH WHO-SAGE questionnaire (including variants of vignettes), a data dictionary and a password-protected dataset (see Supplementary files under Reading Tools online). To obtain a password for the dataset, please send a request with ‘SAGE data’ as its subject, detailing how you propose to use the data, to global.health@epiph.umu.se

Verbal autopsy interpretation: a comparative analysis of the InterVA model versus physician review in determining causes of death in the Nairobi DSS

BackgroundDeveloping countries generally lack complete vital registration systems that can produce cause of death information for health planning in their populations. As an alternative, verbal autopsy (VA) - the process of interviewing family members or caregivers on the circumstances leading to death - is often used by Demographic Surveillance Systems to generate cause of death data. Physician review (PR) is the most common method of interpreting VA, but this method is a time- and resource-intensive process and is liable to produce inconsistent results. The aim of this paper is to explore how a computer-based probabilistic model, InterVA, performs in comparison with PR in interpreting VA data in the Nairobi Urban Health and Demographic Surveillance System (NUHDSS).MethodsBetween August 2002 and December 2008, a total of 1,823 VA interviews were reviewed by physicians in the NUHDSS. Data on these interviews were entered into the InterVA model for interpretation. Cause-specific mortality fractions were then derived from the cause of death data generated by the physicians and by the model. We then estimated the level of agreement between both methods using Kappa statistics.ResultsThe level of agreement between individual causes of death assigned by both methods was only 35% (κ = 0.27, 95% CI: 0.25 - 0.30). However, the patterns of mortality as determined by both methods showed a high burden of infectious diseases, including HIV/AIDS, tuberculosis, and pneumonia, in the study population. These mortality patterns are consistent with existing knowledge on the burden of disease in underdeveloped communities in Africa.ConclusionsThe InterVA model showed promising results as a community-level tool for generating cause of death data from VAs. We recommend further refinement to the model, its adaptation to suit local contexts, and its continued validation with more extensive data from different settings.

Maternal mortality in the informal settlements of Nairobi city: what do we know?

BackgroundCurrent estimates of maternal mortality ratios in Kenya are at least as high as 560 deaths per 100,000 live births. Given the pervasive poverty and lack of quality health services in slum areas, the maternal mortality situation in this setting can only be expected to be worse. With a functioning health care system, most maternal deaths are avoidable if complications are identified early. A major challenge to effective monitoring of maternal mortality in developing countries is the lack of reliable data since vital registration systems are either non-existent or under-utilized. In this paper, we estimated the burden and identified causes of maternal mortality in two slums of Nairobi City, Kenya.MethodsWe used data from verbal autopsy interviews conducted on nearly all female deaths aged 15–49 years between January 2003 and December 2005 in two slum communities covered by the Nairobi Urban Health and Demographic Surveillance System (NUHDSS). In describing the distribution of maternal deaths by cause, we examined maternal and late maternal deaths according to the ICD-10 classification. Additionally we used data from a survey of health care facilities that serve residents living in the surveillance areas for 2004–2005 to examine causes of maternal death.ResultsThe maternal mortality ratio for the two Nairobi slums, for the period January 2003 to December 2005, was 706 maternal deaths per 100,000 live births. The major causes of maternal death were: abortion complications, hemorrhage, sepsis, eclampsia, and ruptured uterus. Only 21% of the 29 maternal deaths delivered or aborted with assistance of a health professional. The verbal autopsy tool seems to capture more abortion related deaths compared to health care facility records. Additionally, there were 22 late maternal deaths (maternal deaths between 42 days and one year of pregnancy termination) most of which were due to HIV/AIDS and anemia.ConclusionMaternal mortality ratio is high in the slum population of Nairobi City. The Demographic Surveillance System and verbal autopsy tool may provide the much needed data on maternal mortality and its causes in developing countries. There is urgent need to address the burden of unwanted pregnancies and unsafe abortions among the urban poor. There is also need to strengthen access to HIV services alongside maternal health services since HIV/AIDS is becoming a major indirect cause of maternal deaths.

The burden of disease profile of residents of Nairobi's slums: Results from a Demographic Surveillance System

BackgroundWith increasing urbanization in sub-Saharan Africa and poor economic performance, the growth of slums is unavoidable. About 71% of urban residents in Kenya live in slums. Slums are characteristically unplanned, underserved by social services, and their residents are largely underemployed and poor. Recent research shows that the urban poor fare worse than their rural counterparts on most health indicators, yet much about the health of the urban poor remains unknown. This study aims to quantify the burden of mortality of the residents in two Nairobi slums, using a Burden of Disease approach and data generated from a Demographic Surveillance System.MethodsData from the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) collected between January 2003 and December 2005 were analysed. Core demographic events in the NUHDSS including deaths are updated three times a year; cause of death is ascertained by verbal autopsy and cause of death is assigned according to the ICD 10 classification. Years of Life Lost due to premature mortality (YLL) were calculated by multiplying deaths in each subcategory of sex, age group and cause of death, by the Global Burden of Disease standard life expectancy at that age.ResultsThe overall mortality burden per capita was 205 YLL/1,000 person years. Children under the age of five years had more than four times the mortality burden of the rest of the population, mostly due to pneumonia and diarrhoeal diseases. Among the population aged five years and above, HIV/AIDS and tuberculosis accounted for about 50% of the mortality burden.ConclusionSlum residents in Nairobi have a high mortality burden from preventable and treatable conditions. It is necessary to focus on these vulnerable populations since their health outcomes are comparable to or even worse than the health outcomes of rural dwellers who are often the focus of most interventions.