Reasons for unmet need for family planning, with attention to the measurement of fertility preferences: protocol for a multi-site cohort study

Background

Unmet need for family planning points to the gap between women’s reproductive desire to avoid pregnancy and contraceptive behaviour. An estimated 222 million women in low- and middle-income countries have unmet need for modern contraception. Despite its prevalence, there has been little rigorous research during the past fifteen years on reasons for this widespread failure to implement childbearing desires in contraceptive practice. There is demographic survey data on women’s self-reported reasons for non-use, but these data provide limited insight on the full set of possible obstacles to use, and one may doubt the meaningfulness of explanations provided by non-users alone. To rectify this evidence gap, this study will gather extensive information on women’s perceptions of contraception (generic and method-specific) and their past contraceptive experience, and it will allow for more complexity in fertility preferences than is standard in demographic surveys.

Methods

A multi-site cohort study will be conducted in urban Kenya, rural Kenya, and rural Bangladesh. In each setting trained fieldworkers will recruit and interview 2600 women, with participants re-interviewed at 12 and 18 months. Data will be collected using a questionnaire whose development was informed by a review of existing literature and instruments from past studies in both developed and developing countries. Dozens of experts in the field were consulted as the instrument was developed. The questionnaire has three main components: a sub-set of Demographic and Health Survey items measuring socio-demographic characteristics, reproductive history, and sexual activity; additional questions on prospective and retrospective fertility preferences designed to capture ambivalence and uncertainty; and two large blocks of items on (i) generic concerns about contraception and (ii) method-specific attributes. The method-specific items encompass eight modern and traditional methods.

Discussion

Policy and programmes intended to reduce unmet need for contraception in developing countries should be informed by clear understanding of the causes of this phenomenon to better reflect the population needs and to more effectively target planning and investments. To this end, this study will field an innovative instrument in Kenya and Bangladesh. The information to be collected will support a rigorous assessment of reasons for unmet need for family planning.

H3Africa AWI-Gen Collaborative Centre: a resource to study the interplay between genomic and environmental risk factors for cardiometabolic diseases in four sub-Saharan African countries

Africa is experiencing a rapid increase in adult obesity and associated cardiometabolic diseases (CMDs). The H3Africa AWI-Gen Collaborative Centre was established to examine genomic and environmental factors that influence body composition, body fat distribution and CMD risk, with the aim to provide insights towards effective treatment and intervention strategies. It provides a research platform of over 10 500 participants, 40–60 years old, from Burkina Faso, Ghana, Kenya and South Africa. Following a process that involved community engagement, training of project staff and participant informed consent, participants were administered detailed questionnaires, anthropometric measurements were taken and biospecimens collected. This generated a wealth of demographic, health history, environmental, behavioural and biomarker data. The H3Africa SNP array will be used for genome-wide association studies. AWI-Gen is building capacity to perform large epidemiological, genomic and epigenomic studies across several African counties and strives to become a valuable resource for research collaborations in Africa.

Measurement of overweight and obesity an urban slum setting in sub-Saharan Africa: a comparison of four anthropometric indices

BACKGROUND

As a result of both genetic and environmental factors, the body composition and topography of African populations are presumed to be different from western populations. Accordingly, globally accepted anthropometric markers may perform differently in African populations. In the era of rapid emergence of cardio-vascular diseases in sub-Saharan Africa, evidence about the performance of these markers in African settings is essential. The aim of this study was to investigate the inter-relationships among the four main anthropometric indices in measuring overweight and obesity in an urban poor African setting.

METHODS

Data from a cardiovascular disease risk factor assessment study in urban slums of Nairobi were analyzed. In the major study, data were collected from 5190 study participants. We considered four anthropometric markers of overweight and obesity: Body Mass Index, Waist Circumference, Waist to Hip Ratio, and Waist to Height Ratio. Pairwise correlations and kappa statistics were used to assess the relationship and agreement among these markers, respectively. Discordances between the indices were also analyzed.

RESULTS

The weighted prevalence of above normal body composition was 21.6 % by body mass index, 28.9 % by waist circumference, 45.5 % by waist to hip ratio, and 38.9 % by waist to height ratio. The overall inter-index correlation was +0.44. Waist to hip ratio generally had lower correlation with the other anthropometric indices. High level of discordance exists between body mass index and waist to hip ratio. Combining the four indices shows that 791 (16.1 %) respondents had above normal body composition in all four indices. Waist circumference better predicted hypertension and hyperglycemia while waist to height ratio better predicted hypercholesterolemia.

CONCLUSIONS

There exists a moderate level of correlation and a remarkable level of discordance among the four anthropometric indices with regard to the ascertainment of abnormal body composition in an urban slum setting in Africa. Waist circumference is a better predictor of cardio-metabolic risk.

Household Air Pollution: Sources and Exposure Levels to Fine Particulate Matter in Nairobi Slums

With 2.8 billion biomass users globally, household air pollution remains a public health threat in many low- and middle-income countries. However, little evidence on pollution levels and health effects exists in low-income settings, especially slums. This study assesses the levels and sources of household air pollution in the urban slums of Nairobi. This cross-sectional study was embedded in a prospective cohort of pregnant women living in two slum areas—Korogocho and Viwandani—in Nairobi. Data on fuel and stove types and ventilation use come from 1058 households, while air quality data based on the particulate matters (PM_2.5) level were collected in a sub-sample of 72 households using the DustTrak™ II Model 8532 monitor. We measured PM_2.5 levels mainly during daytime and using sources of indoor air pollutions. The majority of the households used kerosene (69.7%) as a cooking fuel. In households where air quality was monitored, the mean PM_2.5 levels were high and varied widely, especially during the evenings (124.6 µg/m³ SD: 372.7 in Korogocho and 82.2 µg/m³ SD: 249.9 in Viwandani), and in households using charcoal (126.5 µg/m³ SD: 434.7 in Korogocho and 75.7 µg/m³ SD: 323.0 in Viwandani). Overall, the mean PM_2.5 levels measured within homes at both sites (Korogocho = 108.9 µg/m³ SD: 371.2; Viwandani = 59.3 µg/m³ SD: 234.1) were high. Residents of the two slums are exposed to high levels of PM_2.5 in their homes. We recommend interventions, especially those focusing on clean cookstoves and lighting fuels to mitigate indoor levels of fine particles.

Contraceptive method choice among women in slum and non-slum communities in Nairobi, Kenya

BACKGROUND

Understanding women's contraceptive method choices is key to enhancing family planning services provision and programming. Currently however, very little research has addressed inter and intra-regional disparities in women's contraceptive method choice. Using data from slum and non-slum contexts in Nairobi, Kenya, the current study investigates the prevalence of and factors associated with contraceptive method choice among women.

METHODS

Data were from a cross-sectional quantitative study conducted among a random sample of 1,873 women (aged 15-49 years) in two non-slum and two slum settlement areas in Nairobi, Kenya. The study locations were purposively sampled by virtue of being part of the Nairobi Urban Health and Demographic Surveillance System. Bivariate and multivariate logistic regression were used to explore the association between the outcome variable, contraceptive method choice, and explanatory variables.

RESULTS

The prevalence of contraceptive method choice was relatively similar across slum and non-slum settlements. 34.3 % of women in slum communities and 28.1 % of women in non-slum communities reported using short-term methods. Slightly more women living in the non-slum settlements reported use of long-term methods, 9.2 %, compared to 3.6 % in slum communities. Older women were less likely to use short-term methods than their younger counterparts but more likely to use long-term methods. Currently married women were more likely than never married women to use short-term and long-term methods. Compared to those with no children, women with three or more children were more likely to report using long term methods. Women working outside the home or those in formal employment also used modern methods of contraception more than those in self-employment or unemployed.

CONCLUSION

Use of short-term and long-term methods is generally low among women living in slum and non-slum contexts in Nairobi. Investments in increasing women's access to various contraceptive options are urgently needed to help increase contraceptive prevalence rate. Thus, interventions that focus on more disadvantaged segments of the population will accelerate contraceptive uptake and improve maternal and child health in Kenya.

Can a community health worker administered postnatal checklist increase health-seeking behaviors and knowledge?: evidence from a randomized trial with a private maternity facility in Kiambu County, Kenya

BACKGROUND

Since the 2009 WHO and UNICEF recommendation that women receive home-based postnatal care within the first three days after birth, a growing number of low-income countries have explored integrating postnatal home visit interventions into their maternal and newborn health strategies. This randomized trial evaluates a pilot program in which community health workers (CHWs) visit or call new mothers three days after delivery in peri-urban Kiambu County, Kenya.

METHODS

Participants were individually randomized to one of three groups: 1) early postnatal care three days after delivery provided in-person with a CHW using a simple checklist, 2) care provided by phone with a CHW using the same checklist, or 3) a standard of care group. Surveys were conducted ten days and nine weeks postnatal to measure outcomes related to compliance with referrals, self-reported health problems for mother and baby, care-seeking behaviors, and postnatal knowledge and practices around the recognition of danger signs, feeding, nutrition, infant care and family planning.

RESULTS

The home visit administration of the checklist increased the likelihood that women recognized postnatal problems for themselves and their babies and increased the likelihood that they sought care to address those problems identified for the child. In both the home visit and mobile phone implementation of the checklist, actions taken for postnatal problems happened earlier, particularly for infants. Knowledge was found to be high across all groups, with limited evidence that the checklist impacted knowledge and postnatal practices around the recognition of danger signs, feeding, nutrition, infant care and family planning.

CONCLUSION

We find evidence that CHW-administered postnatal checklists can lead to better recognition of postnatal problems and more timely care-seeking. Furthermore, our results suggest that CHWs can affordably deliver many of the benefits of postnatal checklists.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02104635 ; registered April 2, 2014.

Diverse Empirical Evidence on Epidemiological Transition in Low- and Middle-Income Countries: Population-Based Findings from INDEPTH Network Data

Background

Low- and middle-income countries are often described as being at intermediate stages of epidemiological transition, but there is little population-based data with reliable cause of death assignment to examine the situation in more detail. Non-communicable diseases are widely seen as a coming threat to population health, alongside receding burdens of infection. The INDEPTH Network has collected empirical population data in a number of health and demographic surveillance sites in low- and middle-income countries which permit more detailed examination of mortality trends over time.

Objective

To examine cause-specific mortality trends across all ages at INDEPTH Network sites in Africa and Asia during the period 1992–2012. Emphasis is given to the 15–64 year age group, which is the main focus of concern around the impact of the HIV pandemic and emerging non-communicable disease threats.

Methods

INDEPTH Network public domain data from 12 sites that each reported at least five years of cause-specific mortality data were used. Causes of death were attributed using standardised WHO verbal autopsy methods, and mortality rates were standardised for comparison using the INDEPTH standard population. Annual changes in mortality rates were calculated for each site.

Results

A total of 96,255 deaths were observed during 9,487,418 person years at the 12 sites. Verbal autopsies were completed for 86,039 deaths (89.4%). There were substantial variations in mortality rates between sites and over time. HIV-related mortality played a major part at sites in eastern and southern Africa. Deaths in the age group 15–64 years accounted for 43% of overall mortality. Trends in mortality were generally downwards, in some cases quite rapidly so. The Bangladeshi sites reflected populations at later stages of transition than in Africa, and were largely free of the effects of HIV/AIDS.

Conclusions

To some extent the patterns of epidemiological transition observed followed theoretical expectations, despite the impact of the HIV pandemic having a major effect in some locations. Trends towards lower overall mortality, driven by decreasing infections, were the general pattern. Low- and middle-income country populations appear to be in an era of rapid transition.

Fully immunized child: coverage, timing and sequencing of routine immunization in an urban poor settlement in Nairobi, Kenya

BACKGROUND

More efforts have been put in place to increase full immunization coverage rates in the last decade. Little is known about the levels and consequences of delaying or vaccinating children in different schedules. Vaccine effectiveness depends on the timing of its administration, and it is not optimal if given early, delayed or not given as recommended. Evidence of non-specific effects of vaccines is well documented and could be linked to timing and sequencing of immunization. This paper documents the levels of coverage, timing and sequencing of routine childhood vaccines.

METHODS

The study was conducted between 2007 and 2014 in two informal urban settlements in Nairobi. A total of 3856 children, aged 12-23 months and having a vaccination card seen were included in analysis. Vaccination dates recorded from the cards seen were used to define full immunization coverage, timeliness and sequencing. Proportions, medians and Kaplan-Meier curves were used to assess and describe the levels of full immunization coverage, vaccination delays and sequencing.

RESULTS

The findings indicate that 67 % of the children were fully immunized by 12 months of age. Missing measles and third doses of polio and pentavalent vaccine were the main reason for not being fully immunized. Delays were highest for third doses of polio and pentavalent and measles. About 22 % of fully immunized children had vaccines in an out-of-sequence manner with 18 % not receiving pentavalent together with polio vaccine as recommended.

CONCLUSIONS

Results show higher levels of missed opportunities and low coverage of routine childhood vaccinations given at later ages. New strategies are needed to enable health care providers and parents/guardians to work together to increase the levels of completion of all required vaccinations. In particular, more focus is needed on vaccines given in multiple doses (polio, pentavalent and pneumococcal conjugate vaccines).

Outcomes and costs of implementing a community-based intervention for hypertension in an urban slum in Kenya

Objective

To describe the processes, outcomes and costs of implementing a multi-component, community-based intervention for hypertension among adults aged > 35 years in a large slum in Nairobi, Kenya.

Methods

The intervention in 2012–2013 was based on four components: awareness-raising; improved access to screening; standardized clinical management of hypertension; and long-term retention in care. Using multiple sources of data, including administrative records and surveys, we described the inputs and outputs of each intervention activity and estimated the outcomes of each component and the impact of the intervention. We also estimated the costs associated with implementation, using a top-down costing approach.

Findings

The intervention reached 60% of the target population (4049/6780 people), at a cost of 17 United States dollars (US$) per person screened and provided access to treatment for 68% (660/976) of people referred, at a cost of US$ 123 per person with hypertension who attended the clinic. Of the 660 people who attended the clinic, 27% (178) were retained in care, at a cost of US$ 194 per person retained; and of those patients, 33% (58/178) achieved blood pressure control. The total intervention cost per patient with blood pressure controlled was US$ 3205.

Conclusion

With moderate implementation costs, it was possible to achieve hypertension awareness and treatment levels comparable to those in high-income settings. However, retention in care and blood pressure control were challenges in this slum setting. For patients, the costs and lack of time or forgetfulness were barriers to retention in care.

Interlinkage among cardio-metabolic disease markers in an urban poor setting in Nairobi, Kenya

Introduction

The main cardio-metabolic diseases – mostly cardiovascular diseases such as stroke and ischemic heart disease – share common clinical markers such as raised blood pressure and blood glucose. The pathways of development of many of these conditions are also interlinked. In this regard, a higher level of co-occurrence of the main cardio-metabolic disease markers is expected. Evidence about the patterns of occurrence of cardio-metabolic markers and their interlinkage in the sub-Saharan African setting is inadequate.

Objective

The goal of the study was to describe the interlinkage among common cardio-metabolic disease markers in an African setting.

Design

We used data collected in a cross-sectional study from 5,190 study participants as part of cardiovascular disease risk assessment in the urban slums of Nairobi, Kenya. Five commonly used clinical markers of cardio-metabolic conditions were considered in this analysis. These markers were waist circumference, blood pressure, random blood glucose, total blood cholesterol, and triglyceride levels. Patterns of these markers were described using means, standard deviations, and proportions. The associations between the markers were determined using odds ratios.

Results

The weighted prevalence of central obesity, hypertension, hyperglycemia, hypercholesterolemia, and hypertriglyceridemia were 12.3%, 7.0%, 2.5%, 10.3%, and 17.3%, respectively. Women had a higher prevalence of central obesity and hypercholesterolemia as compared to men. Blood glucose was strongly associated with central obesity, blood pressure, and triglyceride levels, whereas the association between blood glucose and total blood cholesterol was not statistically significant.

Conclusions

This study shows that most of the common cardio-metabolic markers are interlinked, suggesting a higher probability of comorbidity due to cardio-metabolic conditions and thus the need for integrated approaches.

Household food (in)security and nutritional status of urban poor children aged 6 to 23 months in Kenya

BACKGROUND

Millions of people in low and low middle income countries suffer from extreme hunger and malnutrition. Research on the effect of food insecurity on child nutrition is concentrated in high income settings and has produced mixed results. Moreover, the existing evidence on food security and nutrition in children in low and middle income countries is either cross-sectional and/or is based primarily on rural populations. In this paper, we examine the effect of household food security status and its interaction with household wealth status on stunting among children aged between 6 and 23 months in resource-poor urban setting in Kenya.

METHODS

We use longitudinal data collected between 2006 and 2012 from two informal settlements in Nairobi, Kenya. Mothers and their new-borns were recruited into the study at birth and followed prospectively. The analytical sample comprised 6858 children from 6552 households. Household food security was measured as a latent variable derived from a set of questions capturing the main domains of access, availability and affordability. A composite measure of wealth was calculated using asset ownership and amenities. Nutritional status was measured using Height-for-Age (HFA) z-scores. Children whose HFA z-scores were below -2 standard deviation were categorized as stunted. We used Cox regression to analyse the data.

RESULTS

The prevalence of stunting was 49 %. The risk of stunting increased by 12 % among children from food insecure households. When the joint effect of food security and wealth status was assessed, the risk of stunting increased significantly by 19 and 22 % among children from moderately food insecure and severely food insecure households and ranked in the middle poor wealth status. Among the poorest and least poor households, food security was not statistically associated with stunting.

CONCLUSION

Our results shed light on the joint effect of food security and wealth status on stunting. Study findings underscore the need for social protection policies to reduce the high rates of child malnutrition in the urban informal settlements.

Co-occurrence of behavioral risk factors of common non-communicable diseases among urban slum dwellers in Nairobi, Kenya

BACKGROUND

The four common non-communicable diseases (NCDs) account for 80% of NCD-related deaths worldwide. The four NCDs share four common risk factors. As most of the existing evidence on the common NCD risk factors is based on analysis of a single factor at a time, there is a need to investigate the co-occurrence of the common NCD risk factors, particularly in an urban slum setting in sub-Saharan Africa.

OBJECTIVE

To determine the prevalence of co-occurrence of the four common NCDs risk factors among urban slum dwellers in Nairobi, Kenya.

DESIGN

This analysis was based on the data collected as part of a cross-sectional survey to assess linkages among socio-economic status, perceived personal risk, and risk factors for cardiovascular and NCDs in a population of slum dwellers in Nairobi, Kenya, in 2008-2009. A total of 5,190 study subjects were included in the analysis. After selecting relevant variables for common NCD risk factors, we computed the prevalence of all possible combinations of the four common NCD risk factors. The analysis was disaggregated by relevant background variables.

RESULTS

The weighted prevalences of unhealthy diet, insufficient physical activity, harmful use of alcohol, and tobacco use were found to be 57.2, 14.4, 10.1, and 12.4%, respectively. Nearly 72% of the study participants had at least one of the four NCD risk factors. About 52% of the study population had any one of the four NCD risk factors. About one-fifth (19.8%) had co-occurrence of NCD risk factors. Close to one in six individuals (17.6%) had two NCD risk factors, while only 2.2% had three or four NCD risk factors.

CONCLUSIONS

One out of five of people in the urban slum settings of Nairobi had co-occurrence of NCD risk factors. Both comprehensive and differentiated approaches are needed for effective NCD prevention and control in these settings.