Robert P. Ndugwa

Family planning in sub-Saharan Africa: progress or stagnation?

OBJECTIVE To review progress towards adoption of contraception among married or cohabiting women in western and eastern Africa between 1991 and 2004 by examining subjective need, approval, access and use. METHODS Indicators of attitudes towards and use of contraception were derived from Demographic and Health Surveys, which are nationally representative and yield internationally comparable data. Trends were examined for 24 countries that had conducted at least two surveys between 1986 and 2007. FINDINGS In western Africa, the subjective need for contraception remained unchanged; about 46% of married or cohabiting women reported a desire to stop and/or postpone childbearing for at least two years. The percentage of women who approved of contraception rose from 32 to 39 and the percentage with access to contraceptive methods rose from 8 to 29. The proportion of women who were using a modern method when interviewed increased from 7 to 15% (equivalent to an average annual increase of 0.6 percentage points). In eastern African countries, trends were much more favourable, with contraceptive use showing an average annual increase of 1.4 percentage points (from 16% in 1986 to 33% in 2007). CONCLUSION In western Africa, progress towards adoption of contraception has been dismally slow. Attitudinal resistance remains a barrier and access to contraceptives, though improving, is still shockingly limited. If this situation does not change radically in the short run, the United Nations population projections for this subregion are likely to be exceeded. In eastern Africa, the prospects for a future decline in fertility are much more positive.

Menstrual Pattern, Sexual Behaviors, and Contraceptive Use among Postpartum Women in Nairobi Urban Slums

Postpartum months provide a challenging period for poor women. This study examined patterns of menstrual resumption, sexual behaviors and contraceptive use among urban poor postpartum women. Women were eligible for this study if they had a birth after the period September 2006 and were residents of two Nairobi slums of Korogocho and Viwandani. The two communities are under continuous demographic surveillance. A monthly calendar type questionnaire was administered retrospectively to cover the period since birth to the interview date and data on sexual behavior, menstrual resumption, breastfeeding patterns, and contraception were collected. The results show that sexual resumption occurs earlier than menses and postpartum contraceptive use. Out of all postpartum months where women were exposed to the risk of another pregnancy, about 28% were months where no contraceptive method was used. Menstrual resumption acts as a trigger for initiating contraceptive use with a peak of contraceptive initiation occurring shortly after the first month when menses are reported. There was no variation in contraceptive method choice between women who initiate use before and after menstrual resumption. Overall, poor postpartum women in marginalized areas such as slums experience an appreciable risk of unintended pregnancy. Postnatal visits and other subsequent health system contacts provide opportunities for reaching postpartum women with a need for family planning services.

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.

Child morbidity and care-seeking in Nairobi slum settlements: the role of environmental and socio-economic factors

The aim of this study was to investigate factors that influence morbidity patterns and health-seeking decisions in an urban slum community. Data were collected between May and August 2003 as part of the ongoing Nairobi urban demographic surveillance system and were analysed to identify factors that influence morbidity patterns and health-seeking decisions. The results show that the factors that influenced morbidity were the childs age, ethnicity and type of toilet facility. Predictors for seeking health care were the childs age, type and severity of illness, survival of father and mother, mothers education, mothers work status and wealth class. The conclusions drawn show that economic resources fall short in preventing child illnesses where children live in poor environmental conditions. However, by enhancing access to health care services, socio-economic status is critical for mitigating disease burden among children in slum settlements.

Fever treatment in the absence of malaria transmission in an urban informal settlement in Nairobi, Kenya.

BackgroundIn sub-Saharan Africa, knowledge of malaria transmission across rapidly proliferating urban centres and recommendations for its prevention or management remain poorly defined. This paper presents the results of an investigation into infection prevalence and treatment of recent febrile events among a slum population in Nairobi, Kenya.MethodsIn July 2008, a community-based malaria parasite prevalence survey was conducted in Korogocho slum, which forms part of the Nairobi Urban Health and Demographic Surveillance system. Interviewers visited 1,069 participants at home and collected data on reported fevers experienced over the preceding 14 days and details on the treatment of these episodes. Each participant was tested for malaria parasite presence with Rapid Diagnostic Test (RDT) and microscopy. Descriptive analyses were performed to assess the period prevalence of reported fever episodes and treatment behaviour.ResultsOf the 1,069 participants visited, 983 (92%) consented to be tested. Three were positive for Plasmodium falciparum using RDT; however, all were confirmed negative on microscopy. Microscopic examination of all 953 readable slides showed zero prevalence. Overall, from the 1,004 participants who have data on fever, 170 fever episodes were reported giving a relatively high period prevalence (16.9%, 95% CI:13.9%–20.5%) and higher among children below five years (20.1%, 95%CI:13.8%–27.8%). Of the fever episodes with treatment information 54.3% (95%CI:46.3%–62.2%) were treated as malaria using mainly sulphadoxine-pyrimethamine or amodiaquine, including those managed at a formal health facility. Only four episodes were managed using the nationally recommended first-line treatment, artemether-lumefantrine.ConclusionThe study could not demonstrate any evidence of malaria in Korogocho, a slum in the centre of Nairobi. Fever was a common complaint and often treated as malaria with anti-malarial drugs. Strategies, including testing for malaria parasites to reduce the inappropriate exposure of poor communities to expensive anti-malarial drugs provided by clinical services and drug vendors, should be a priority for district planners.

Decreasing childhood mortality and increasing proportion of malaria deaths in rural Burkina Faso

Background: Malaria is the leading cause of death among children less than five years of age in sub-Saharan Africa (SSA), however, precise estimates on the burden of malaria are lacking. The aim of this study was to describe temporal trends for malaria and all-cause mortality by combining a series of clinical and intervention studies conducted in Burkina Faso. Methods: Data from a demographic surveillance system was used to follow-up children under five years who participated in five observational and intervention studies between June 1999 and December 2004 in rural north-western Burkina Faso. Mortality data was analyzed with cause-specific mortality ascertained using the verbal autopsy method. Person-years (PY) of observations were computed and age-standardized mortality rates (MR) for all-causes and malaria (adjusted for missing causes of death) were calculated. Rate ratios to investigate mortality variations over years were calculated using multivariate Poisson regression. Results: The study followed 6,387 children aged less than five years (mean follow-up: 2.8 years; 16,099 PY). During the study period, 443 deaths were registered with malaria accounting for 49% of all deaths. All-cause and malaria-specific MR were 26.7 (95% CI: 24.2–29.2) and 15.8 (95% CI: 14.217.7) per 1,000 PY. All-cause MR declined over years of follow-up (from 31.2 to 16.3 per 1,000 PY in 1999/2000 to 2004, respectively) but malaria MR remained relatively stable (from 15.8 to 12.1 per 1,000 PY in 1999/2000 to 2004, respectively) resulting in an increasing relative effect of malaria on all-cause mortality. Variations in all-cause and malaria-specific mortality were observed with increasing age and across village town clusters. Conclusion: The findings of this study support the continuously decreasing trend of all-cause mortality in most of SSA, but call for more efforts to comprehensively address malaria with existing control tools such as insecticide-treated bed nets and effective first-line combination therapies.

Making It: Understanding Adolescent Resilience in Two Informal Settlements (Slums) in Nairobi, Kenya

Many adolescents living in contexts characterized by adversity achieve positive outcomes. We adopt a protection–risk conceptual framework to examine resilience (academic achievement, civic participation, and avoidance of risk behaviors) among 1,722 never-married 12–19 year olds living in two Kenyan urban slums. We find stronger associations between explanatory factors and resilience among older (15–19 years) than younger (12–14 years) adolescents. Models for prosocial behavior and models for antisocial behavior emerge as key predictors of resilience. Further accumulation of evidence on risk and protective factors is needed to inform interventions to promote positive outcomes among youth situated in an ecology of adversity.

Successful Adolescence in the Slums of Nairobi, Kenya

Many adolescents living in contexts characterized by adversity achieve positive outcomes. We adopt a protection-risk conceptual framework to examine resilience (academic achievement, civic participation, and avoidance of risk behaviors) among 1,722 never-married 12–19 year olds living in two Kenyan urban slums. We find stronger associations between explanatory factors and resilience among older (15–19 years) than younger (12–14 years) adolescents. Models for prosocial behavior and models for anti-social behavior emerge as key predictors of resilience. Further accumulation of evidence on risk and protective factors is needed to inform interventions to promote positive outcomes among youth situated in an ecology of adversity.

Problem Behavior Theory and Adolescent Problem Behavior 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.