Caroline W. Kabiru

Factors associated with sexual activity among high-school students in Nairobi, Kenya

The high level of HIV infection in sub-Saharan Africa has led to an increased interest in understanding the determinants of sexual activity among young people, who are at high risk of sexually transmitted infections. The present study examined sociodemographic, behavioral, and psychosocial factors associated with heterosexual activity among a sample of 3556 male and female high-school students in Nairobi, Kenya. Approximately 50% of the males and 11% of females reported having had sexual intercourse at least once in their lifetime with a significant proportion reporting multiple sexual partnerships. Sexual activity was associated with various factors including religiosity, perceived parental attitudes towards sex, living arrangements, and school characteristics. However, the pattern of association differed for males and females. Results suggest that adolescents may benefit from sex education programs addressing multiple factors that may predispose adolescents to sexual activity, and that take into account gender differences.

Transition into first sex among adolescents in slum and non-slum communities in Nairobi, Kenya

While early sexual experiences are a key marker of the transition from childhood to adulthood, it is widely acknowledged that precocious initiation of sexual activity predisposes adolescents to negative health and psychological outcomes. Extant studies investigating adolescent sexuality in sub-Saharan Africa often rely on cross-sectional data lacking information on the social-psychological under-pinnings of adolescent behaviour. Through the theoretical lens of the protection–risk conceptual framework, this paper draws on two waves of longitudinal data collected from 2,134 adolescents to examine sociodemographic, psychosocial and behavioural predictors of transition to first sex among adolescents living in slum and non-slum settlements in urban Kenya. We employ logistic regression models to examine the effect of antecedent sociodemographic and risk and protective factors measured during the first wave of data collection on transition to first sex by the second wave. We observe that transition to first sex is influenced by age, slum residence, perceived parental monitoring, and peer behaviour. We also find evidence for coupling of risk behaviours. Study findings underscore the need to focus on very young adolescents and those growing up in resource-poor settings, as these young people may be highly vulnerable to negative health outcomes stemming from precocious sexual activity.

HIV/AIDS among youth in urban informal (slum) settlements in Kenya: What are the correlates of and motivations for HIV testing?

BackgroundAlthough HIV counseling and testing (HCT) is widely considered an integral component of HIV prevention and treatment strategies, few studies have examined HCT behavior among youth in sub-Saharan Africa-a group at substantial risk for HIV infection. In this paper we examine: the correlates of HIV testing, including whether associations differ based on the context under which a person gets tested; and the motivations for getting (or not getting) an HIV test.MethodsDrawing on data collected in 2007 from 4028 (51% male) youth (12-22 years) living in Korogocho and Viwandani slum settlements in Nairobi (Kenya), we explored the correlates of and motivations for HIV testing using the Health Belief Model (HBM) as a theoretical framework. Multinomial and binary logistic regression analyses were employed to examine correlates of HIV testing. Bivariate analyses were employed to assess reasons for or against testing.ResultsNineteen percent of males and 35% of females had been tested. Among tested youth, 74% of males and 43% of females had requested for their most recent HIV test while 7% of males and 32% of females reported that they were required to take their most recent HIV test (i.e., the test was mandatory). About 60% of females who had ever had sex received an HIV test because they were pregnant. We found modest support for the HBM in explaining variation in testing behavior. In particular, we found that perceived risk for HIV infection may drive HIV testing among youth. For example, about half of youth who had ever had sex but had never been tested reported that they had not been tested because they were not at risk.ConclusionsTargeted interventions to help young people correctly assess their level of risk and to increase awareness of the potential value of HIV testing may help enhance uptake of testing services. Given the relative success of Prevention of Mother-to-Child Transmission (PMTCT) services in increasing HIV testing rates among females, routine provider-initiated testing and counseling among all clients visiting medical facilities may provide an important avenue to increase HIV status awareness among the general population and especially among males.

Dietary exposure to chlorpyrifos and levels of 3,5,6-trichloro-2-pyridinol in urine

Information on associations between chlorpyrifos residues in food and personal exposure to chlorpyrifos would be valuable for evaluating the relationship between personal exposure and possible health effects. We used food consumption records, chlorpyrifos levels in duplicate plates, and measures of 3,5,6-trichloro-2-pyridinol (TCPy) in urine obtained from human volunteers in the National Human Exposure Assessment Survey in Maryland (NHEXAS-MD) to evaluate a food consumption–chemical residue model for estimating dietary intake of chlorpyrifos. Model inputs were the NHEXAS-MD food consumption records and chlorpyrifos residues in specific foods measured in the U.S. Food and Drug Administration Total Diet Study (TDS) market baskets from 1993 to 1997. The estimated mean and standard deviation of chlorpyrifos concentration (μg/kg) in duplicate plates (n=203) were within 20% and 50%, respectively, of the corresponding parameters of measured chlorpyrifos levels. However, predicted and measured concentrations in the 78 duplicate plates with detectable levels of chlorpyrifos were not significantly associated according to Spearman correlation analysis (r=0.04, p=0.7667) and linear regression (p=0.2726). Measured and estimated chlorpyrifos intakes for observations with non-zero values for each intake measure (n=71) were moderately associated on a rank (Spearmans r=0.24, p=0.0462) and linear basis (regression r2=0.07, p=0.0242). Measured intakes of chlorpyrifos from food and urinary TCPy were significantly correlated in rank order (n=87, Spearmans r=0.30, p=0.0041) and linear (n=87, Pearsons r=0.22, p=0.0409) analyses. Correlation coefficients between estimated intake of chlorpyrifos from food and TCPy were significantly different from zero (n=87; Spearmans r=0.22, p=0.0393; Pearsons r=0.21, p=0.0479). Comparing mean measured chlorpyrifos intake from food (0.46 μg/day) to mean estimated TCPy excretion via urine (6.3 μg/day), dietary intake of chlorpyrifos accounted for approximately 7% of TCPy in this population. These findings suggest the food consumption–chemical residue model can yield reasonably accurate estimates of the population distribution of dietary chlorpyrifos intake, but has little ability to predict dietary exposure for individuals; and that intake of chlorpyrifos from food is a minor contributor to TCPy in urine.

Building capacity for public and population health research in Africa: the consortium for advanced research training in Africa (CARTA) model.

Background: Globally, sub-Saharan Africa bears the greatest burden of disease. Strengthened research capacity to understand the social determinants of health among different African populations is key to addressing the drivers of poor health and developing interventions to improve health outcomes and health systems in the region. Yet, the continent clearly lacks centers of research excellence that can generate a strong evidence base to address the regions socio-economic and health problems. Objective and program overview: We describe the recently launched Consortium for Advanced Research Training in Africa (CARTA), which brings together a network of nine academic and four research institutions from West, East, Central, and Southern Africa, and select northern universities and training institutes. CARTAs program of activities comprises two primary, interrelated, and mutually reinforcing objectives: to strengthen research infrastructure and capacity at African universities; and to support doctoral training through the creation of a collaborative doctoral training program in population and public health. The ultimate goal of CARTA is to build local research capacity to understand the determinants of population health and effectively intervene to improve health outcomes and health systems. Conclusions: CARTAs focus on the local production of networked and high-skilled researchers committed to working in sub-Saharan Africa, and on the concomitant increase in local research and training capacity of African universities and research institutes addresses the inability of existing programs to create a critical mass of well-trained and networked researchers across the continent. The initiatives goal of strengthening human resources and university-wide systems critical to the success and sustainability of research productivity in public and population health will rejuvenate institutional teaching, research, and administrative systems.

Adolescent Problem Behavior in Nairobi's Informal Settlements: Applying Problem Behavior Theory in Sub-Saharan Africa

Adolescent involvement in problem behaviors can compromise health, development, and successful transition to adulthood. The present study explores the appropriateness of a particular theoretical framework, Problem Behavior Theory, to account for variation in problem behavior among adolescents in informal settlements around a large, rapidly urbanizing city in sub-Saharan Africa. Data were collected from samples of never married adolescents of both sexes, aged 12–19, living in two Nairobi slum settlements (N = 1,722). Measures of the theoretical psychosocial protective and risk factor concepts provided a substantial, multi-variate, and explanatory account of adolescent problem behavior variation and demonstrated that protection can also moderate the impact of exposure to risk. Key protective and risk factors constitute targets for policies and programs to enhance the health and well-being of poor urban adolescents in sub-Saharan Africa.

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.

Self-reported drunkenness among adolescents in four sub-Saharan African countries: associations with adverse childhood experiences.

BackgroundConsumption of alcohol is associated with acute and chronic adverse health outcomes. There is a paucity of studies that explore the determinants of alcohol use among adolescents in sub-Saharan Africa and, in particular, that examine the effects of adverse childhood experiences on alcohol use.MethodsThe paper draws on nationally-representative data from 9,819 adolescents aged 12-19 years from Burkina Faso, Ghana, Malawi, and Uganda. Logistic regression models were employed to identify correlates of self-reported past-year drunkenness. Exposure to four adverse childhood experiences comprised the primary independent variables: living in a food-insecure household, living with a problem drinker, having been physically abused, and having been coerced into having sex. We controlled for age, religiosity, current schooling status, the household heads sex, living arrangements, place of residence, marital status, and country of survey. All analyses were conducted separately for males and females.ResultsAt the bivariate level, all independent variables (except for coerced sex among males) were associated with the outcome variable. Overall, 9% of adolescents reported that they had been drunk in the 12 months preceding the survey. In general, respondents who had experienced an adverse event during childhood were more likely to report drunkenness. In the multivariate analysis, only two adverse childhood events emerged as significant predictors of self-reported past-year drunkenness among males: living in a household with a problem drinker before age 10, and being physically abused before age 10. For females, exposure to family-alcoholism, experience of physical abuse, and coerced sex increased the likelihood of reporting drunkenness in the last 12 months. The association between adverse events and reported drunkenness was more pronounced for females. For both males and females there was a graded relationship between the number of adverse events experienced and the proportion reporting drunkenness.ConclusionsWe find an association between experience of adverse childhood events and drunkenness among adolescents in four sub-Saharan African countries. The complex impacts of adverse childhood experiences on young peoples development and behavior may have an important bearing on the effectiveness of interventions geared at reducing alcohol dependence among the youth.

Predictors of Sexual Debut Among Young Adolescents In Nairobi's Informal Settlements

CONTEXT There is a need to better understand the various social, psychosocial and behavioral factors associated with sexual activity among young adolescents in various settings in Sub-Saharan Africa. METHODS Data were drawn from Wave 1 (2007-2008) and Wave 2 (2009) of the Transition to Adulthood study, which collected information about key markers of the transition to adulthood and social, demographic and psychosocial characteristics of male and female youth living in two informal settlements in Nairobi, Kenya. Logistic regression analyses were used to examine variables associated with experience of sexual debut by Wave 2 among youth who were aged 12-16 and sexually inexperienced at Wave 1. RESULTS Of the 1,754 youth in the sample, 92 experienced sexual debut between survey waves. For both males and females, sexual debut was positively associated with having permanently dropped out of school (odds ratios, 6.9 and 21.8, respectively), having never attended school (8.6 and 39.4) and having experienced severe family dysfunction (2.8 and 5.7). Lack of parental supervision was a predictor of sexual debut among males only (10.1), whereas low aspiration was a predictor among females only (10.4). Surprisingly, young women, as well as men, who did not have high self-esteem were less likely than those who did to initiate first sex between waves (0.4 and 0.3). CONCLUSIONS Study findings underscore the importance of school attendance, family dysfunction, parental supervision and self-esteem in driving sexual behavior in this age-group. Further studies are warranted to elucidate how these factors can be addressed in prevention programs for young adolescents.

URBAN POOR KENYAN WOMEN AND HOSPITAL-BASED DELIVERY

The increasing availability of formal obstetric care in Kenya notwithstanding the majority of births in urban areas of the country still occur at home assisted by unskilled traditional birth attendants (TBAs). To add to current knowledge on this topic we probed the views of poor women -- who form the bulk of mothers who deliver at home in urban Kenya -- on the attractions of and deterrents to hospital-based deliveries. In investigating lay views surrounding the hospital as a delivery site our aim was to illuminate the lives and plights of urban poor Kenyan women who even in the 21st century continue to experience difficulties in accessing quality obstetric care. The participants indicated availability of providers and equipment that could make birthing safer as the major appeal of hospital-based deliveries. They generally admitted to the capacity of hospital-based providers to make childbearing safer frequently noting that hospital-based delivery put women under the care of skilled providers and ensured the ready availability of equipment for managing emergencies and difficult deliveries. Informal providers (e.g. TBAs) reportedly lacked these skills and tools. While delivery could occur safely in any birth site the respondents only characterized hospitals as capable of effectively managing life-threatening complications and difficult deliveries. An important issue that dominated the narratives however was that it was unreasonable for women to seek hospital birth unless they anticipated a difficult delivery. So although respondents frequently admitted to the superiority of the hospital as a delivery site they tended to view it primarily as a delivery site for women anticipating or at risk of obstetric emergencies and difficult deliveries. The women considered the management of uncomplicated deliveries to be the traditional turf of TBAs who were depicted as naturally and divinely gifted to assist during deliveries. Respondents frequently viewed TBAs’ innate expertise and skills as more effectual and dependable than the learned practice of hospital-based providers. (Excerpts)