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Thirty one percent of young Kenyan women ages 15–24 reported sexual harassment and violence (SHV) in 2003, with a majority experiencing sexual debut due to coercion (Central Bureau of Statistics[CBS], 2004). Data were obtained from a sample of 20 girls attending school in Kamu and Lafamu (pseudonyms used for the study sites), 10 girls who had dropped out of school, and 14 teachers using structured interviews. A phenomenological approach was used to describe narratives of girls' experiences with SHV in and out of school. The findings indicated that girls experienced frequent SHV in and out of school despite the Sexual Offences Act enacted by the Kenyan Parliament in 2006 (Government of Kenya[GOK], 2006). Hence, stakeholders need to reengage and implement existing policies on sexual abuse among children and women.

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The objective of this study was to examine the association between education and domestic violence among women being offered an HIV test in urban and rural areas in Kenya. A sample selection of women who experienced physical (n = 4,308), sexual (n = 4,309), and emotional violence (n = 4,312) aged 15 to 49 allowed for the estimation of the association between education and domestic violence with further analysis stratified by urban and rural residence. The main outcome of interest was a three-factor (physical, sexual, and emotional) measure for violence with the main predictor being education. Nearly half of all domestic violence, physical (46%), sexual (45%), and emotional (45%) occurred among women aged 15 to 29. After adjusting for confounding variables, women who resided in urban areas and had a postprimary/vocational/secondary and college/university education were 26% (OR = 0.74, 95% CI: [0.64, 0.86]), p < .001 and 22% (OR = 0.78, 95% CI: [0.66, 0.92]), p < .01 less likely to have experienced physical violence compared to those who had a primary education respectively. This was 17% (OR = 0.83, 95% CI: [0.73, 0.94]), p < .01 and 17% (OR = 0.83, 95% CI: [0.72, 0.96]), p < .05 less likely among women who resided in rural areas. A surprising finding was that women residing in rural areas with less than a primary education were 35% less likely to have experienced sexual violence (OR = 0.65, 95% CI: [0.43, 0.99]), p < .01 compared to those who had a primary education. These findings suggest that physical, sexual, and emotional violence were prevalent in Kenya among married and formerly married women. This study indicates that more research is needed to understand factors for HIV/AIDS among Kenyan women who have specifically tested positive for HIV or identified as AIDS-positive and the implications for women's health.

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In 2010, there was a slight decrease in the number of out-of school adolescents from 75 million in 2009 (UNESCO, 2009) to 71 million in 2010, of which 55% are girls (UNESCO, 2010). In Kenya, only 17% of girls have secondary education (CBS, 2004). This paper analyzes the role of families in girls’ secondary education in two schools within Nairobi province, Kenya. Data were obtained from interviews with adolescent girls attending Kamu and Lafama¹ schools in Nairobi province, the dropouts, and a sample of teachers. Results show girls’ lives and opportunities were socially constructed and this permeated into the families, influencing the way parents treated their daughters. This further provided a fertile ground for sexual harassment that plagued girls within their own families. The Kenyan Government needs to influence women and girls perceptions, through increasing campaigns from the grassroots on the importance of being committed to girls’ education.

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The introduction of universal primary education in sub-Sahara African countries in the 1990s increased enrolment rates and provided opportunities to children who were previously not in school. Research demonstrates that eliminating fees is not the magic bullet that delivers universal access. This study seeks to determine risk factors associated with dropout among primary school children in the low-income areas of Nairobi. Qualitative data is from the Education Research Program, collected between June and July 2008. The study found that: dumpsites in the two slum sites of Korogocho and Viwandani lure children out of school; school levies still charged in schools keep children out of school; and chronic poverty within families lure girls aged 14–16 into transactional sex. In conclusion, the declaration of free primary education is not sufficient to realize improved educational attainment as dropout after initial entry negates the purpose for which it was introduced.

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Research shows that fathers' level of education predicts achievement of both boys and girls, with significantly greater effect for boys. Similarly, mothers' level of education predicts the achievement of girls but not boys. This study tests the mother–child education achievement hypothesis, by examining the effect of mothers' education on the maths test score of children, using data from 71 schools across 6 districts in Kenya. The findings of a multilevel random intercept model, based on a sample of 1907 learners reveal surprisingly negative effect of mothers' education on pupil's achievement, with an interaction effect of mother's and father's education being positive.

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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.

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Several factors have contributed to the social construct of adolescence as a distinct period of life, including the rise in education (and with it age segregation), social media, and urbanisation.1 But adolescence also has a biological basis. Many of the behaviours we associate with the teenage years (eg, risk taking) are evident in other species,2 and we know that brain maturation in human beings is not complete until about age 25 years. As young people enter adolescence they bring with them resources and vulnerabilities, both biological (genetics, epigenetics, natural endowments) and environmental (national and local policies, as well as community, school, workplace, peers, neighbourhood, and family influences). Consequently, an ecological or life-course framework is crucial to understanding adolescent trajectories

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Parental communication and support is associated with improved developmental, health and behavioral outcomes in adolescence. This study explores the quality of mother-daughter communication about sexual maturation, abstinence and unintended pregnancy in Korogocho, an informal settlement in Nairobi, Kenya. We use data from 14 focus group discussions (n = 124) and 25 interviews with girls aged 12-17, mothers of teenage girls, and key informant teachers. Many girls and women believed that mothers are the best source of information and support during puberty but only a minority described good experiences with communication in practice. Girls preferred communication to begin early and be repeated regularly. Mothers often combined themes of sexual maturation, abstinence and avoiding pregnancy in their messages. Communication was facilitated by mothers' availability, warmth and close parent-child relationships. Challenges included communication taboos, embarrassment, ambiguous message content, and parental lack of knowledge and uncertainty. Neighborhood poverty undermined some mothers' time and motivation for communicating.

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Despite legal restriction, induced abortions and resulting complications are common in Nigeria. Misoprostol administration for
incomplete abortion was introduced in 3 Nigerian hospitals. The feasibility of the hospitals, patient and provider acceptability
were assessed using questionnaire and interview guides administered to 205 women and 17 providers respectively. Amongst the
women, 194 (95%) were satisfied and very satisfied with misoprostol, 176 (86%) would choose misoprostol again if another
incomplete abortion occurred and 191 (93%) would recommend it to another woman in a similar situation. Providers were highly
satisfied with misoprostol. The ease of use and ability to redirect surgical resources to more complicated issues were positive
features cited by them. The providers agreed that integration of misoprostol was straightforward and required few resources.
Therefore, misoprostol for incomplete abortion is safe, efficacious and acceptable to providers and patients. In remote areas of
Nigeria with limited post-abortion care (PAC), misoprostol administration is an important potential PAC treatment modality.
Features of misoprostol-low cost, room temperature stability, and ease of introduction-render it an important treatment option,
particularly in low resource and rural settings

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We conducted a needs assessment that describes the landscape of civil society organizations (CSOs) in three informal settlements around Nairobi, Kenya. The numbers of CSOs have rapidly increased in areas underserved by governments including poor urban neighbourhoods but little is known about CSOs capacity to meet the priority health needs of the urban poor. It is also unclear why, despite a proliferation of CSOs, residents still experience unimproved health outcomes. We collected data on core activities, financial management, and governance structures. Of the 952 CSOs assessed, 47 per cent reported HIV/AIDS counselling, prevention, and treatment as their core activity. Most CSOs reported good financial management systems and governance structures but responses were not validated. Representation in district health stakeholder fora was low; most CSOs did not have the capacity to effectively deliver services that would have impact. For CSOs to realize the desired goal to improve the well-being of low-income populations, programmes to build their management capacity are essential.

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Rapid population growth is a threat to wellbeing in the poorest countries, whereas very low fertility increasingly threatens the future welfare of many developed countries. The mapping of global trends in population growth from 2005—10 shows four distinct patterns. Most of the poorest countries, especially in sub-Saharan Africa, are characterised by rapid growth of more than 2% per year. Moderate annual growth of 1—2% is concentrated in large countries, such as India and Indonesia, and across north Africa and western Latin America. Whereas most advanced-economy countries and large middle-income countries, such as China and Brazil, are characterised by low or no growth (0—1% per year), most of eastern Europe, Japan, and a few western European countries are characterised by population decline. Countries with rapid growth face adverse social, economic, and environmental pressures, whereas those with low or negative growth face rapid population ageing, unsustainable burdens on public pensions and health-care systems, and slow economic growth. Countries with rapid growth should consider the implementation of voluntary family planning programmes as their main policy option to reduce the high unmet need for contraception, unwanted pregnancies, and probirth reproductive norms. In countries with low or negative growth, policies to address ageing and very low fertility are still evolving. Further research into the potential effect of demographic policies on other social systems, social groups, and fertility decisions and trends is therefore recommended.

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Summary The majority of studies of the birth spacing-child survival relationship rely on retrospective data, which are vulnerable to errors that might bias results. The relationship is re-assessed using prospective data on 13,502 children born in two Nairobi slums between 2003 and 2009. Nearly 48% were first births. Among the remainder, short preceding intervals are common: 20% of second and higher order births were delivered within 24 months of an elder sibling, including 9% with a very short preceding interval of less than 18 months. After adjustment for potential confounders, the length of the preceding birth interval is a major determinant of infant and early childhood mortality. In infancy, a preceding birth interval of less than 18 months is associated with a two-fold increase in mortality risks (compared with lengthened intervals of 36 months or longer), while an interval of 18-23 months is associated with an increase of 18%. During the early childhood period, children born within 18 months of an elder sibling are more than twice as likely to die as those born after an interval of 36 months or more. Only 592 children experienced the birth of a younger sibling within 20 months; their second-year mortality was about twice as high as that of other children. These results support the findings based on retrospective data.

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This paper uses longitudinal data from two informal settlements of Nairobi, Kenya to examine patterns of child growth and how these are affected by four different dimensions of poverty at the household level namely, expenditures poverty, assets poverty, food poverty, and subjective poverty. The descriptive results show a grim picture, with the prevalence of overall stunting reaching nearly 60% in the age group 15-17 months and remaining almost constant thereafter. There is a strong association between food poverty and stunting among children aged 6-11 months (p<0.01), while assets poverty and subjective poverty have stronger relationships (p<0.01) with undernutrition at older age (24 months or older for assets poverty, and 12 months or older for subjective poverty). The effect of expenditures poverty does not reach statistical significant in any age group. These findings shed light on the degree of vulnerability of urban poor infants and children and on the influences of various aspects of poverty measures.

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Although attitudes to premarital sex may be influenced by several factors, the importance of religion to that discourse cannot be underestimated. By providing standards to judge and guide behaviour, religion provides a social control function such that religious persons are expected to act in ways that conform to certain norms. This study investigated the interconnectedness of several dimensions of religion and premarital sexual attitudes among young people in the informal settlements of Nairobi, Kenya. Using reference group as the theoretical base, it was found that those affiliated with Pentecostal/Evangelical faiths had more conservative attitudes towards premarital sex than those of other Christian faiths. Additionally, while a high level of religiosity was found to associate with more conservative views on premarital sex, the effect was more pronounced among Pentecostal groups. The findings are discussed in relation to programmes on adolescent sexuality.

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It is still a small body of research that directly addresses female sex workers' relationships with their regular commercial male partners. I used ethnographic data from Nairobi, Kenya to interrogate motivations and strategies for recruiting and retaining regular male clients among female sex workers (FSWs). Regular commercial male partners, popularly called customer care, wera or wesh by Nairobi's FSWs, played diverse roles in their lives. Client retention enabled sex workers to manage the risk of reduced marriage prospects, guaranteed them steady work, livelihoods, and incomes, and prevented their victimization and harassment. To retain clients, sex workers obliged them a great deal, pretended they had quit prostitution, and sometimes resorted to magical practices. However, these strategies were also accompanied by risks that reinforced the vulnerability of sex workers. Lack of critical attention to sex workers' practices for managing perceived risks in their particular type of work may hamper current programmatic efforts to make their job safer.

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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.

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Objectives: Existing evidence in sub-Saharan Africa indicates that less than 40% of people living with HIV are aware of their status. HIV
testing and counselling (HTC) is one of the key national strategies for HIV prevention but rural-urban inequalities exist in the uptake of this
service. The aim of this study was to determine the factors associated with the uptake of HIV testing and counselling through the providerinitiated
testing and counselling (PITC) and client-initiated testing and counselling (CITC) pathways in rural and urban areas in Kenya.
Methods: Retrospective cross-sectional data were derived from the 2008-2009 Kenya Demographic and Health Survey. Descriptive statistics
and multinomial logistic regression analysis were used to describe the characteristics of the sample and to identify the determinants of
pathways to HIV testing. Results: Overall, in the rural areas, 66.3% of respondents had never tested for HIV, 17.3% had been tested through
CITC and 16.3% through PITC. In urban areas, 49.6% of respondents had never tested, 30.4% had been tested through CITC and 19.9%
through PITC. In both rural and urban areas, men were significantly more likely to test for HIV through CITC, while women were significantly
associated with PITC. Individuals aged 15 to 19 years, households in the poorest quintile, and rural and urban areas in the North Eastern
Province were less likely to utilize CITC and PITC services. Conclusion: The findings highlight the need to increase testing coverage in rural
areas where a greater proportion of people had never been tested. There is also need to address existing disparities in HIV testing across
different groups and geographic provinces. Targeted efforts aimed at reaching individuals aged 15 to 19 years, the poorest households, and people residing in the North Eastern Province are critical for increasing HIV testing uptake.

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The disparity in under-five year-old mortality rates between rural and urban areas in Kenya (also reported in other in sub-Saharan African countries), is a critical national concern. The objective of this study was to investigate the influence of geographical location and maternal factors on the likelihood of mortality among under-five children in rural and urban areas in Kenya.

METHODS:

Data from the 2008-2009 Kenya Demographic and Health Survey were used to determine mortality among under-five children (n=16,162) in rural and urban areas in the 5 years preceding the survey. Multivariate analysis was used to compare the influence of key risk factors in rural and urban areas.

RESULTS:

Overall, the likelihood of death among under-five children in the rural areas was significantly higher than that in the urban areas (p<0.05). Household poverty was a key predictor for mortality in the rural areas, but the influence of breastfeeding was similar in the two areas. The likelihood of under-five mortality was significantly higher in the rural areas of Coast, Nyanza and Western Provinces than in Central Province.

CONCLUSIONS:

The study shows that the determinants of under-five mortality differ in rural and urban areas in Kenya. Innovative and targeted strategies are required to address rural poverty and province-specific sociocultural factors in order to improve child survival in rural Kenya.

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The government of Kenya is making plans to implement a social health insurance program by transforming the National Hospital Insurance Fund (NHIF) into a universal health coverage program. This paper examines the determinants associated with participation in the NHIF among residents of urban slums in Nairobi city.

Methods

The study used data from the Nairobi Urban Health and Demographic Surveillance System in two slums in Nairobi city, where a total of about 60,000 individuals living in approximately 23,000 households are under surveillance. Descriptive statistics and multivariate logistic regression analysis were used to describe the characteristics of the sample and to identify factors associated with participation in the NHIF program.

Results

Only 10% of the respondents were participating in the NHIF program, while less than 1% (0.8%) had private insurance coverage. The majority of the respondents (89%) did not have any type of insurance coverage. Females were more likely to participate in the NHIF program (OR = 2.4; p < 0.001), while respondents who were formerly in a union (OR = 0.5; p < 0.05) and who were never in a union (OR = 0.6; p < 0.05) were less likely to have public insurance coverage. Respondents working in the formal employment sector (OR = 4.1; p < 0.001) were more likely to be enrolled in the NHIF program compared to those in the informal sector. Membership in microfinance institutions such as savings and credit cooperative organizations (SACCOs) and community-based savings and credit groups were important determinants of access to health insurance.

Conclusions

The proportion of slum residents without any type of insurance is high, which underscores the need for a social health insurance program to ensure equitable access to health care among the poor and vulnerable segments of the population. As the Kenyan government moves toward transforming the NHIF into a universal health program, it is important to harness the unique opportunities offered by both the formal and informal microfinance institutions in improving health care capacity by considering them as viable financing options within a comprehensive national health financing policy framework.

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Migration during the formative adolescent years can affect important life-course transitions, including the initiation of sexual activity. In this study, we use life history calendar data to investigate the relationship between changes in residence and timing of premarital sexual debut among young people in urban Kenya. By age 18, 64 percent of respondents had initiated premarital sex, and 45 percent had moved at least once between the ages of 12 and 18. Results of the event history analysis show that girls and boys who move during early adolescence experience the earliest onset of sexual activity. For adolescent girls, however, other dimensions of migration provide protective effects, with greater numbers of residential changes and residential changes in the last one to three months associated with later sexual initiation. To support young people's ability to navigate the social, economic, and sexual environments that accompany residential change, researchers and policymakers should consider how various dimensions of migration affect sexual activity.

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

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Building on African migration as a household survival strategy; urban–rural linkages as critical for migrants' continued engagement with origin communities; reintegration in case of return; and safety net for supplementing precarious urban incomes; we examine the role of family ties in rural origin linkages among 1,693 older migrants living in Nairobi informal settlements. Despite the grim of slum residence, 80% of older migrants in Nairobi slums maintained contact with their rural origin homes during a full year of observation. Family-related factors, especially members of the nuclear family residing in rural origin, explained 45% of explained linkages. Religion, ethnicity, land ownership at origin, and current health and economic statuses are other key predictors. The patterns and reasons of linkages are consistent with migrants' positive contributions to the upkeep of rural origin households. Our findings are well-anchored in the larger continental literature that has shown the urban migrant as not a ‘disembedded individual’ but instead part of rural origin collectives. Against the weakness of state safety net system, the study sheds crucial light on the enduring importance of sociocultural networks in people's everyday lives, particularly the importance of family ties for older migrants. To the extent that poor health status, being aged 60 years or older, and long duration of residence in the slums, which are predictors of low propensities to maintain contacts with rural origin, are also indicators of diminished social engagement, policy interventions among the urban poor may need to include efforts to enhance rural origin reintegration of the most-aged individuals.

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Internal and international migration increasingly continues to be of global importance for development policies and programmes, but the dearth of data on migration for African countries and the limited focus on the structural conditions that motivate migration from specific localities within the region remain glaring. In this study, we examine the patterns and drivers of migration in Cameroon, focusing on the dynamics of rural–urban migration, migrant circulation, regional economic migrants and refugees, international migration, brain drain and returns from emigration. Consequent upon regional conflicts and instability, we highlight the refugee problem in Cameroon and significant challenges in addressing it. Finally, we underscore the policy and research challenges necessary to harness the potentials of internal and international migration for national development.

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This paper describes the design and methodology used to assess the impact of free primary education (FPE) policy in Nairobi, Kenya. The key outcome of the study was to assess the impact of FPE on schooling outcomes among the urban poor. The study assesses the impact of FPE by examining how two non-comparable groups responded to the introduction of the policy. Retrospective data were collected for 2000–2004, while prospective data has been collected annually since 2005. This household survey has created both cross-sectional and longitudinal data sets. This provided an opportunity to assess factors, other than lack of fees, which associate with school enrolment and retention. The strength of this paper is in demonstrating how survey design can be utilized to assess the impact of a public policy between different population groups. Based on the design and methodology used in this Nairobi case study, the paper provides lessons on how to utilize household surveys to assess policy impacts.

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This paper focuses on the patterns of teaching styles and active teaching across subjects and between low and high performing schools in an attempt to examine what accounts for differences in performance between schools which are within the same locality. It uses data collected in 72 primary schools spread across six districts in Kenya. Video recordings of 213 lessons in maths (72), science (71) and English (70), and interviews with subject teachers in primary schools, were used to generate evidence on patterns of teaching styles and active teaching. Results show that teaching practice across subjects is inclined towards the command and task styles that do not promote critical thinking among learners. The dominant teaching activity was individual seat work in maths lessons; recitation in English lessons; and whole class chorus in science lessons. Overall, active teaching accounted for 62% of the lesson time. The one way ANOVA results show insignificant variation between subjects and school category on active teaching, and therefore this may not be the source of differential performance between low and high performing schools.

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This paper aims to improve the understanding of classroom-based gender differences that may lead to differential opportunities to learn provided to girls and boys in low and high performing primary schools in Kenya. The paper uses an opportunity to learn framework and tests the hypothesis that teaching practices and classroom interactions explain gender gaps in maths achievement in Kenya. The data used is obtained from a cross sectional study involving video recordings of 70 lessons in mathematics, students’ scores in a maths test and interviews with subject teachers in Kenyan primary schools randomly selected from six districts. Results show that gender gaps in maths achievement are more evidenced in the area of measurement. The gaps are more pronounced among low achievers in favour of boys. The most revealing finding is that entry achievement level is the main source of gender gaps in maths learning outcomes, implying that girls start at lower levels than boys and this gap is not closed by school. The policy implication to education is that boys have better chances of transition to secondary school and tertiary levels than girls, and consequently, there are broader gender disparities than can be closed by pro-gender education policies.

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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.

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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.

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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.

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OBJECTIVE:

Children with autism spectrum disorders (ASDs) often have co-occurring conditions, but little is known on the effect of those conditions on their medical care cost. Medical expenditures attributable to ASDs among Medicaid-enrolled children were calculated, and the effects of 3 commonly co-occurring conditions--intellectual disability (ID), attention deficit/hyperactivity disorder (ADHD), and epilepsy-on those expenditures were analyzed.

METHODS:

Using MarketScan Medicaid Multi-State Databases (2003-2005) and the International Classification of Disease, Ninth Revision, children with ASD were identified. Children without ASD formed the comparison group. The 3 co-occurring conditions were identified among both the ASD and the comparison groups. Annual mean, median, and 95th percentile of total expenditures were calculated for children with ASD and the co-occurring conditions and compared with those of children without ASD. Multivariate analyses established the influence of each of those co-occurring conditions on the average expenditures for children with and without ASD.

RESULTS:

In 2005, 47% of children with ASD had at least 1 selected co-occurring condition; attention deficit/hyperactivity disorder was the most common, at 30%. The mean medical expenditures for children with ASD were 6 times higher than those of the comparison group. Children with ASD and ID incurred expenditures 2.7 times higher than did children with ASD and no co-occurring condition.

CONCLUSION:

Medicaid-enrolled children with ASD incurred higher medical costs than did Medicaid-enrolled children without ASD. Among Medicaid-enrolled children with ASD, cost varied substantially based on the presence of another neurodevelopmental disorder. In particular, children with ID had much higher costs than did other children with ASD.

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BACKGROUND:

Health facilities require teams of health workers with complementary skills and responsibilities to efficiently provide quality care. In low-income countries, failure to attract and retain health workers in rural areas reduces population access to health services and undermines facility performance, resulting in poor health outcomes. It is important that governments consider health worker preferences in crafting policies to address attraction and retention in underserved areas.

METHODS:

We investigated preferences for job characteristics among final year medical, nursing, pharmacy, and laboratory students at select universities in Uganda. Participants were administered a cadre-specific discrete choice experiment that elicited preferences for attributes of potential job postings they were likely to pursue after graduation. Job attributes included salary, facility quality, housing, length of commitment, manager support, training tuition, and dual practice opportunities. Mixed logit models were used to estimate stated preferences for these attributes.

RESULTS:

Data were collected from 246 medical students, 132 nursing students, 50 pharmacy students and 57 laboratory students. For all student-groups, choice of job posting was strongly influenced by salary, facility quality and manager support, relative to other attributes. For medical and laboratory students, tuition support for future training was also important, while pharmacy students valued opportunities for dual practice.

CONCLUSIONS:

In Uganda, financial and non-financial incentives may be effective in attracting health workers to underserved areas. Our findings contribute to mounting evidence that salary is not the only important factor health workers consider when deciding where to work. Better quality facilities and supportive managers were important to all students. Similarities in preferences for these factors suggest that team-based, facility-level strategies for attracting health workers may be appropriate. Improving facility quality and training managers to be more supportive of facility staff may be particularly cost-effective, as investments are borne once while benefits accrue to a range of health workers at the facility.

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Adolescence is a life phase in which the opportunities for health are great and future patterns of adult health are established. Health in adolescence is the result of interactions between prenatal and early childhood development and the specific biological and social-role changes that accompany puberty, shaped by social determinants and risk and protective factors that affect the uptake of health-related behaviours. The shape of adolescence is rapidly changing—the age of onset of puberty is decreasing and the age at which mature social roles are achieved is rising. New understandings of the diverse and dynamic effects on adolescent health include insights into the effects of puberty and brain development, together with social media. A focus on adolescence is central to the success of many public health agendas, including the Millennium Development Goals aiming to reduce child and maternal mortality and HIV/AIDS, and the more recent emphases on mental health, injuries, and non-communicable diseases. Greater attention to adolescence is needed within each of these public health domains if global health targets are to be met. Strategies that place the adolescent years centre stage—rather than focusing only on specific health agendas—provide important opportunities to improve health, both in adolescence and later in life.

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In the developed world, information on vital events is routinely collected nationally to inform population and health policies. However, in many low-and middle-income countries, especially those in sub-Saharan Africa (SSA), there is a lack of effective and comprehensive national civil registration and vital statistics system. In the past decades, the number of Health and Demographic Surveillance Systems (HDSSs) has increased throughout SSA. An HDSS monitors births, deaths, causes of death, migration, and other health and socio-economic indicators within a defined population over time. Currently, the International Network for the Continuous Demographic Evaluation of Populations and Their Health (INDEPTH) brings together 38 member research centers which run 44 HDSS sites from 20 countries in Africa, Asia and Oceana. Thirty two of these HDSS sites are in SSA.

Discussion

This paper argues that, in the absence of an adequate national CRVS, HDSSs should be more effectively utilised to generate relevant public health data, and also to create local capacity for longitudinal data collection and management systems in SSA. If HDSSs get strategically located to cover different geographical regions in a country, data from these sites could be used to provide a more complete national picture of the health of the population. They provide useful data that can be extrapolated for national estimates if their regional coverage is well planned. HDSSs are however resource-intensive. Efforts are being put towards getting them linked to local or national policy contexts and to reduce their dependence on external funding. Increasing their number in SSA to cover a critical proportion of the population, especially urban populations, must be carefully planned. Strategic planning is needed at national levels to geographically locate HDSS sites and to support these through national funding mechanisms.

Summary

The paper does not suggest that HDSSs should be seen as a replacement for civil registration systems. Rather, they should serve as a short- to medium-term measure to provide data for health and population planning at regional levels with possible extrapolation to national levels. HDSSs can also provide useful lessons for countries that intend to set up nationally representative sample vital registration systems in the long term.

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Background: Many studies have established a link between weather (primarily temperature) and daily mortality in developed countries. However, little is known about this relationship in urban populations in sub- Saharan Africa.

Objectives: The objective of this study was to describe the relationship between daily weather and mortality in Nairobi, Kenya, and to evaluate this relationship with regard to cause of death, age, and sex.

Methods: We utilized mortality data from the Nairobi Urban Health and Demographic Surveillance System and applied time-series models to study the relationship between daily weather and mortality for a population of approximately 60,000 during the period 2003-2008. We used a distributed lag approach to model the delayed effect of weather on mortality, stratified by cause of death, age, and sex.

Results: Increasing temperatures (above 75th percentile) were significantly associated with mortality in children and non-communicable disease (NCD) deaths. We found all-cause mortality of shorter lag of same day and previous day to increase by 3.0% for a 1 degree decrease from the 25th percentile of 18°C (not statistically significant). Mortality among people aged 50+ and children aged below 5 years appeared most susceptible to cold compared to other age groups. Rainfall, in the lag period of 0-29 days, increased all-cause mortality in general, but was found strongest related to mortality among females. Low temperatures were associated with deaths due to acute infections, whereas rainfall was associated with all-cause pneumonia and NCD deaths.

Conclusions: Increases in mortality were associated with both hot and cold weather as well as rainfall in Nairobi, but the relationship differed with regard to age, sex, and cause of death. Our findings indicate that weather-related mortality is a public health concern for the population in the informal settlements of Nairobi, Kenya, especially if current trends in climate change continue.

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BACKGROUND:

Malaria is one of the greatest causes of mortality worldwide. Use of the most effective treatments for malaria remains inadequate for those in need, and there is concern over the emergence of resistance to these treatments. In 2010, the Global Fund launched the Affordable Medicines Facility-malaria (AMFm), a series of national-scale pilot programmes designed to increase the access and use of quality-assured artemisinin based combination therapies (QAACTs) and reduce that of artemisinin monotherapies for treatment of malaria. AMFm involves manufacturer price negotiations, subsidies on the manufacturer price of each treatment purchased, and supporting interventions such as communications campaigns. We present findings on the effect of AMFm on QAACT price, availability, and market share, 6-15 months after the delivery of subsidised ACTs in Ghana, Kenya, Madagascar, Niger, Nigeria, Uganda, and Tanzania (including Zanzibar).

METHODS:

We did nationally representative baseline and endpoint surveys of public and private sector outlets that stock antimalarial treatments. QAACTs were identified on the basis of the Global Fund's quality assurance policy. Changes in availability, price, and market share were assessed against specified success benchmarks for 1 year of AMFm implementation. Key informant interviews and document reviews recorded contextual factors and the implementation process.

FINDINGS:

In all pilots except Niger and Madagascar, there were large increases in QAACT availability (25·8-51·9 percentage points), and market share (15·9-40·3 percentage points), driven mainly by changes in the private for-profit sector. Large falls in median price for QAACTs per adult equivalent dose were seen in the private for-profit sector in six pilots, ranging from US$1·28 to $4·82. The market share of oral artemisinin monotherapies decreased in Nigeria and Zanzibar, the two pilots where it was more than 5% at baseline.

INTERPRETATION:

Subsidies combined with supporting interventions can be effective in rapidly improving availability, price, and market share of QAACTs, particularly in the private for-profit sector. Decisions about the future of AMFm should also consider the effect on use in vulnerable populations, access to malaria diagnostics, and cost-effectiveness.

FUNDING:

The Global Fund to Fight AIDS, Tuberculosis and Malaria, and the Bill & Melinda Gates Foundation.

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Background: Many studies have established a link between weather (primarily temperature) and daily mortality in developed countries. However, little is known about this relationship in urban populations in sub- Saharan Africa.

Objectives: The objective of this study was to describe the relationship between daily weather and mortality in Nairobi, Kenya, and to evaluate this relationship with regard to cause of death, age, and sex.

Methods: We utilized mortality data from the Nairobi Urban Health and Demographic Surveillance System and applied time-series models to study the relationship between daily weather and mortality for a population of approximately 60,000 during the period 2003-2008. We used a distributed lag approach to model the delayed effect of weather on mortality, stratified by cause of death, age, and sex.

Results: Increasing temperatures (above 75th percentile) were significantly associated with mortality in children and non-communicable disease (NCD) deaths. We found all-cause mortality of shorter lag of same day and previous day to increase by 3.0% for a 1 degree decrease from the 25th percentile of 18°C (not statistically significant). Mortality among people aged 50+ and children aged below 5 years appeared most susceptible to cold compared to other age groups. Rainfall, in the lag period of 0-29 days, increased all-cause mortality in general, but was found strongest related to mortality among females. Low temperatures were associated with deaths due to acute infections, whereas rainfall was associated with all-cause pneumonia and NCD deaths.

Conclusions: Increases in mortality were associated with both hot and cold weather as well as rainfall in Nairobi, but the relationship differed with regard to age, sex, and cause of death. Our findings indicate that weather-related mortality is a public health concern for the population in the informal settlements of Nairobi, Kenya, especially if current trends in climate change continue.

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mHealth is a term used to refer to mobile technologies such as personal digital assistants and mobile phones for healthcare. mHealth initiatives to support care and treatment of patients are emerging globally and this workshop brought together researchers, policy makers, information, communication and technology programmers, academics and civil society representatives for one and a half days synergy meeting in Kenya to review regional evidence based mHealth research for HIV care and treatment, review mHealth technologies for adherence and retention interventions in anti-retroviral therapy (ART) programs and develop a framework for scale up of evidence based mHealth interventions. The workshop was held in May 2011 in Nairobi, Kenya and was funded by the Canadian Global Health Research Initiatives (GHRI) and the US Centre for Disease Control and Prevention (CDC). At the end of the workshop participants came up with a framework to guide mHealth initiatives in the region and a plan to work together in scaling up evidence based mHealth interventions. The participants acknowledged the importance of the meeting in setting the pace for strengthening and coordinating mHealth initiatives and unanimously agreed to hold a follow up meeting after three months.

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Background

Modern declarations on human rights have often proceeded without reference to the cultural content of rights, the existence of rights in African indigenous backgrounds, and the embodiment of certain key rights in the community itself. This paper is an attempt at developing an ‘inventory’ of rights in African cultures as a prelude to the generation both of a holistic theory of rights as well as a research agenda that can recognize the multifaceted nature of rights.

Methods

We use an interpretive ethnographic approach built on three sources of data: 1) our continuing ethnographic work among two distinct ethnic groups in southeastern Nigeria – the Ubang and the Igbo; 2) informal conversational interviews with individuals from a range of African countries; and 3) a review of relevant literature based on African cultures which provides a context for some of the issues we raise.

Results

An examination of selected indigenous rights, entitlements, or privileges among the Ubang and Igbo illustrates indigenous culture as a key, but often neglected, axis of rights, as a critical framework for understanding human relationships with rights, and as a resource for, and challenge to, contemporary programmatic efforts focusing on universalized notions of rights. Understanding or interpreting rights in African settings within the framework defined by contemporary human rights discourse poses steep challenges to making progress in the realization of sexual and reproductive rights.

Conclusions

Despite the potential dangers of privileging group rights over individual rights, when important rights are vested in the community; rights, entitlements, and privileges can also be recognized through community experiences, and realized through engagement with communities. Building on communal conceptualizations of rights in order to realize an even wider range of rights remains a largely unexplored strategy which holds promise for the achievement of sexual and reproductive health rights.

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This paper examines the politics and the underlying discourses of water provisioning and how residents of Korogocho and Viwandani slum settlements in Nairobi city cope with challenges relating to water access. We use qualitative data from 36 focus group discussions conducted in the two slums to unravel discourses regarding water provisioning in the rapidly growing slum settlements in African cities. Results show that the problems concerning water provisioning within Nairobi slums are less about water scarcity and more about unequal distribution and the marginalisation of slum areas in development plans. Poor water management, lack of equity-based policies and programmes, and other slum-specific features such as land-tenure systems and insecurity exacerbate water-supply problems within slum areas. It is hard to see how water supply in these communities can improve without the direct and active involvement of the government in infrastructural development and oversight of the water-supply actors. Innovative public-private partnerships in water provision and the harnessing of existing community efforts to improve the water supply would go a long way towards improving the water supply to the rapidly growing urban poor population in Africa.

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BACKGROUND:

Cancer is a leading cause of deaths among Asian Americans. However, the rates of screening among Asian Americans are low. The use of effective culturally-appropriate interventions needs to be explored.

METHODS:

Electronic databases were searched for articles published between January 1995 and December 2010 for a comprehensive literature review. Interventions to increase breast, cervical and colorectal cancer screening among Asians populations in the US and overseas were included.

RESULTS:

A total of thirty studies were reviewed. These studies differed on study design, target population, theoretical underpinning of intervention approach and outcome measures. Effective interventions employed a variety of strategies including the use of social networks, lay health workers, media education, community-based education, reminder notices, health care provider assistance and health system changes. Fifteen studies utilized behavioral theories in intervention development.

CONCLUSIONS:

This review finds culturally-appropriate community-based interventions and lay health worker strategies can improve cancer screening behaviors among Asian populations. Selections of intervention strategies will depend on the characteristics of the target group and feasibility of implementation. Challenges and recommendations for tailored screening interventions for Asians are discussed.

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Abstract

Sickle cell disease (SCD) is common throughout much of sub-Saharan Africa, affecting up to 3% of births in some parts of the continent. Nevertheless, it remains a low priority for many health ministries. The most common form of SCD is caused by homozygosity for the β-globin S gene mutation (SS disease). It is widely believed that this condition is associated with very high child mortality, but reliable contemporary data are lacking. We have reviewed available African data on mortality associated with SS disease from published and unpublished sources, with an emphasis on two types of studies: cross-sectional population surveys and cohort studies. We have concluded that, although current data are inadequate to support definitive statements, they are consistent with an early-life mortality of 50%-90% among children born in Africa with SS disease. Inclusion of SCD interventions in child survival policies and programs in Africa could benefit from more precise estimates of numbers of deaths among children with SCD. A simple, representative, and affordable approach to estimate SCD child mortality is to test blood specimens already collected through large population surveys targeting conditions such as HIV, malaria, and malnutrition, and covering children of varying ages. Thus, although there is enough evidence to justify investments in screening, prophylaxis, and treatment for African children with SCD, better data are needed to estimate the numbers of child deaths preventable by such interventions and their cost effectiveness.

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This paper uses data from a maternal health study carried out in 2006 in two slums of Nairobi, Kenya, to: describe perceptions of access to and quality of care among women living in informal settlements of Nairobi, Kenya; quantify the effects of women's perceived quality of, and access to, care on the utilization of delivery services; and draw policy implications regarding the delivery of maternal health services to the urban poor. Based on the results of the facility survey, all health facilities were classified as ‘appropriate’ or ‘inappropriate’. The research was based on the premise that despite the poor quality of these maternal health facilities, their responsiveness to the socio-cultural and economic sensitivities of women would result in good perceptions and higher utilization by women.

Our results show a pattern of women's good perceptions in terms of access to, and quality of, health care provided by the privately owned, sub-standard and often unlicensed clinics and maternity homes located within their communities. In the multivariate model, the association between women's perceptions of access to and quality of care, and delivery at these ‘inappropriate’ facilities remained strong, graded and in the expected direction.

Women from the study area are seldom able to reach not-for-profit private providers of maternal health care services like missionary and non-governmental organization (NGO) clinics and hospitals. Against the backdrop of challenges faced by the public sector in health care provision, we recommend that the government should harness the potential of private clinics operating in urban, resource-deprived settings. First, the government should regulate private health facilities operating in urban slum settlements to ensure that the services they offer meet the acceptable minimum standards of obstetric care. Second, ‘good’ facilities should be given technical support and supplied with drugs and equipment.

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The process of urbanization entails social improvements with the consequential better quality-of-life for urban residents. However, in many low-income and some middle-income countries, urbanization conveys inequality and exclusion, creating cities and dwellings characterized by poverty, overcrowded conditions, poor housing, severe pollution, and absence of basic services such as water and sanitation. Slums in large cities often have an absence of schools, transportation, health centers, recreational facilities, and other such amenities. Additionally, the persistence of certain conditions, such as poverty, ethnic heterogeneity, and high population turnover, contributes to a lowered ability of individuals and communities to control crime, vandalism, and violence. The social vulnerability in health is not a "natural" or predefined condition but occurs because of the unequal social context that surrounds the daily life of the disadvantaged, and often, socially excluded groups. Social exclusion of individuals and groups is a major threat to development, whether to the community social cohesion and economic prosperity or to the individual self-realization through lack of recognition and acceptance, powerlessness, economic vulnerability, ill health, diminished life experiences, and limited life prospects. In contrast, social inclusion is seen to be vital to the material, psychosocial, and political aspects of empowerment that underpin social well-being and equitable health. Successful experiences of cooperation and networking between slum-based organizations, grassroots groups, local and international NGOs, and city government are important mechanisms that can be replicated in urban settings of different low- and middle-income countries. With increasing urbanization, it is imperative to design health programs for the urban poor that take full advantage of the social resources and resourcefulness of their own communities.

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