Adolescent Fertility Is Lower than Expected in Rural Areas: Results from 10 African HDSS

The adolescent birth rate (ABR) is an important indicator of maternal health, adolescent sexual health, and gender equity; it remains high in sub-Saharan Africa. While Demographic and Health Surveys (DHS) are the main source of ABR estimates, Health and Demographic Surveillance Systems (HDSS) also produce ABRs. Studies are lacking, however, to assess the ease of access and accuracy of HDSS ABR measures. In this paper, we use birth and exposure data from 10 HDSS in six African countries to compute local ABRs and compare these rates to DHS regional rates where the HDSS sites are located, standardizing by education and place of residence. In rural HDSS sites, the ABR measure is on average 44 percent lower than the DHS measure, after controlling for education and place of residence. Strong temporary migration of childless young women out of rural areas and different capacities in capturing temporarily absent women in the DHS and HDSS could explain this discrepancy. Further comparisons based on more strictly similar populations and measures seem warranted.

Who Helps Single Mothers in Nairobi? The Role of Kin Support

Single mothers often turn to their extended kin for financial assistance and to help with child care. Such support may be especially important in areas of high poverty and poor environmental conditions. Using novel kinship data, this paper assesses the extent of support given by over 3,000 relatives to 462 single mothers living in a slum area of Nairobi, Kenya. Contrary to stereotypes about families in sub-Saharan Africa, the active kin network of single mothers is relatively small and nearly a fifth of mothers do not receive any financial or child care assistance. Different types of kin offer different kinds of support according to culturally proscribed roles. However, support also depends heavily on kin's employment status, geographic proximity, and age. These findings offer a nuanced picture of how single women living in slum areas draw upon their kin network to cope with their daily demands as mothers.

Moving beyond the household: Innovations in data collection on kinship

Across settings, it has been shown that the co-residential household is an insufficient measure of family structure and support. However, it continues to be the primary means of population data collection. To address this problem, we developed a new instrument, the Kinship Support Tree (KST), to collect kinship structure and support data on co-residential and non-residential kin and tested it on a sample of 462 single mothers and their children in a slum community in Nairobi, Kenya. This instrument is unique in four important ways: (1) it is not limited to the co-residential household; (2) it distinguishes potential from functional kin; (3) it incorporates multiple geospatial measures; and (4) it collects data on kin relationships specifically for children. In this paper, we describe the KST instrument, assess the data collected in comparison to data from household rosters, and consider the challenges and feasibility of administration of the KST.

Influence of parental factors on adolescents' transition to first sexual intercourse in Nairobi, Kenya: a longitudinal study

Background

Several studies have demonstrated a link between young people’s sexual behavior and levels of parental monitoring, parent-child communication, and parental discipline in Western countries. However, little is known about this association in African settings, especially among young people living in high poverty settings such as urban slums. The objective of the study was to assess the influence of parental factors (monitoring, communication, and discipline) on the transition to first sexual intercourse among unmarried adolescents living in urban slums in Kenya.

Methods

Longitudinal data collected from young people living in two slums in Nairobi, Kenya were used. The sample was restricted to unmarried adolescents aged 12–19 years at Wave 1 (weighted n = 1927). Parental factors at Wave 1 were used to predict adolescents’ transition to first sexual intercourse by Wave 2. Relevant covariates including the adolescents’ age, sex, residence, school enrollment, religiosity, delinquency, and peer models for risk behavior were controlled for. Multivariate logistic regression models were used to assess the associations of interest. All analyses were conducted using Stata version 13.

Results

Approximately 6 % of our sample transitioned to first sexual intercourse within the one-year study period; there was no sex difference in the transition rate. In the multivariate analyses, male adolescents who reported communication with their mothers were less likely to transition to first sexual intercourse compared to those who did not (p < 0.05). This association persisted even after controlling for relevant covariates (OR: ≤0.33; p < 0.05). However, parental monitoring, discipline, and communication with their fathers did not predict transition to first sexual intercourse for male adolescents. For female adolescents, parental monitoring, discipline, and communication with fathers predicted transition to first sexual intercourse; however, only communication with fathers remained statistically significant after controlling for relevant covariates (OR: 0.30; 95 % C.I.: 0.13–0.68).

Conclusion

This study provides evidence that cross-gender communication with parents is associated with a delay in the onset of sexual intercourse among slum-dwelling adolescents. Targeted adolescent sexual and reproductive health programmatic interventions that include parents may have significant impacts on delaying sexual debut, and possibly reducing sexual risk behaviors, among young people in high-risk settings such as slums.

Patterns of fertility preferences and contraceptive behaviour over time: change and continuities among the urban poor in Nairobi, Kenya

The main objective of this paper is to investigate the association between fertility preferences and contraceptive use among 15-49-year-old women living in Korogocho and Viwandani, informal settlements in Nairobi, Kenya. We draw on longitudinal data collected under the Maternal and Child Health project conducted between 2006 and 2010 in the two settlements. There is substantial regularity and stability but also unusual instability in reported fertility preferences over time among women living in these settings. Younger women, aged 15-24 years, are likely to change their preferences over time, passing from limiting to wanting additional children. But women aged 35-49 are likely to change their preferences from desiring more children to limiting their childbearing. The desire to limit childbearing is strongly associated with the use of modern and long-acting contraceptive methods. Findings have major implications for the success of family planning programmes in informal settlements where access to and knowledge about contraception may be limited.

Understanding inequities in child vaccination rates among the urban poor: evidence from Nairobi and Ouagadougou health and demographic surveillance systems

Studies on informal settlements in sub-Saharan Africa have questioned the health benefits of urban residence, but this should not suggest that informal settlements (within cities and across cities and/or countries) are homogeneous. They vary in terms of poverty, pollution, overcrowding, criminality, and social exclusion. Moreover, while some informal settlements completely lack public services, others have access to health facilities, sewers, running water, and electricity. There are few comparative studies that have looked at informal settlements across countries accounting for these contextual nuances. In this paper, we comparatively examine the differences in child vaccination rates between Nairobi and Ouagadougou's informal settlements. We further investigate whether the identified differences are related to the differences in demographic and socioeconomic composition between the two settings. We use data from the Ouagadougou and Nairobi Urban Health and Demographic Surveillance Systems (HDSSs), which are the only two urban-based HDSSs in Africa. The results show that children in the slums of Nairobi are less vaccinated than children in the informal settlements in Ouagadougou. The difference in child vaccination rates between Nairobi and Ouagadougou informal settlements are not related to the differences in their demographic and socioeconomic composition but to the inequalities in access to immunization services.

Cause-specific mortality in Africa and Asia: evidence from INDEPTH health and demographic surveillance system sites

BACKGROUND

Because most deaths in Africa and Asia are not well documented, estimates of mortality are often made using scanty data. The INDEPTH Network works to alleviate this problem by collating detailed individual data from defined Health and Demographic Surveillance sites. By registering all deaths over time and carrying out verbal autopsies to determine cause of death across many such sites, using standardised methods, the Network seeks to generate population-based mortality statistics that are not otherwise available.

OBJECTIVE

To build a large standardised mortality database from African and Asian sites, detailing the relevant methods, and use it to describe cause-specific mortality patterns.

DESIGN

Individual demographic and verbal autopsy (VA) data from 22 INDEPTH sites were collated into a standardised database. The INDEPTH 2013 population was used for standardisation. The WHO 2012 VA standard and the InterVA-4 model were used for assigning cause of death.

RESULTS

A total of 111,910 deaths occurring over 12,204,043 person-years (accumulated between 1992 and 2012) were registered across the 22 sites, and for 98,429 of these deaths (88.0%) verbal autopsies were successfully completed. There was considerable variation in all-cause mortality between sites, with most of the differences being accounted for by variations in infectious causes as a proportion of all deaths.

CONCLUSIONS

This dataset documents individual deaths across Africa and Asia in a standardised way, and on an unprecedented scale. While INDEPTH sites are not constructed to constitute a representative sample, and VA may not be the ideal method of determining cause of death, nevertheless these findings represent detailed mortality patterns for parts of the world that are severely under-served in terms of measuring mortality. Further papers explore details of mortality patterns among children and specifically for NCDs, external causes, pregnancy-related mortality, malaria, and HIV/AIDS. Comparisons will also be made where possible with other findings on mortality in the same regions. Findings presented here and in accompanying papers support the need for continued work towards much wider implementation of universal civil registration of deaths by cause on a worldwide basis.

Cause-specific childhood mortality in Africa and Asia: evidence from INDEPTH health and demographic surveillance system sites

Background

Childhood mortality, particularly in the first 5 years of life, is a major global concern and the target of Millennium Development Goal 4. Although the majority of childhood deaths occur in Africa and Asia, these are also the regions where such deaths are least likely to be registered. The INDEPTH Network works to alleviate this problem by collating detailed individual data from defined Health and Demographic Surveillance sites. By registering deaths and carrying out verbal autopsies to determine cause of death across many such sites, using standardised methods, the Network seeks to generate population-based mortality statistics that are not otherwise available.

Objective

To present a description of cause-specific mortality rates and fractions over the first 15 years of life as documented by INDEPTH Network sites in sub-Saharan Africa and south-east Asia.

Design

All childhood deaths at INDEPTH sites are routinely registered and followed up with verbal autopsy (VA) interviews. For this study, VA archives were transformed into the WHO 2012 VA standard format and processed using the InterVA-4 model to assign cause of death. Routine surveillance data also provided person-time denominators for mortality rates. Cause-specific mortality rates and cause-specific mortality fractions are presented according to WHO 2012 VA cause groups for neonatal, infant, 1–4 year and 5–14 year age groups.

Results

A total of 28,751 childhood deaths were documented during 4,387,824 person-years over 18 sites. Infant mortality ranged from 11 to 78 per 1,000 live births, with under-5 mortality from 15 to 152 per 1,000 live births. Sites in Vietnam and Kenya accounted for the lowest and highest mortality rates reported.

Conclusions

Many children continue to die from relatively preventable causes, particularly in areas with high rates of malaria and HIV/AIDS. Neonatal mortality persists at relatively high, and perhaps sometimes under-documented, rates. External causes of death are a significant childhood problem in some settings.

Pregnancy-related mortality in Africa and Asia: evidence from INDEPTH Health and Demographic Surveillance System sites

Background

Women continue to die in unacceptably large numbers around the world as a result of pregnancy, particularly in sub-Saharan Africa and Asia. Part of the problem is a lack of accurate, population-based information characterising the issues and informing solutions. Population surveillance sites, such as those operated within the INDEPTH Network, have the potential to contribute to bridging the information gaps.

Objective

To describe patterns of pregnancy-related mortality at INDEPTH Network Health and Demographic Surveillance System sites in sub-Saharan Africa and southeast Asia in terms of maternal mortality ratio (MMR) and cause-specific mortality rates.

Design

Data on individual deaths among women of reproductive age (WRA) (15–49) resident in INDEPTH sites were collated into a standardised database using the INDEPTH 2013 population standard, the WHO 2012 verbal autopsy (VA) standard, and the InterVA model for assigning cause of death.

Results

These analyses are based on reports from 14 INDEPTH sites, covering 14,198 deaths among WRA over 2,595,605 person-years observed. MMRs varied between 128 and 461 per 100,000 live births, while maternal mortality rates ranged from 0.11 to 0.74 per 1,000 person-years. Detailed rates per cause are tabulated, including analyses of direct maternal, indirect maternal, and incidental pregnancy-related deaths across the 14 sites.

Conclusions

As expected, these findings confirmed unacceptably high continuing levels of maternal mortality. However, they also demonstrate the effectiveness of INDEPTH sites and of the VA methods applied to arrive at measurements of maternal mortality that are essential for planning effective solutions and monitoring programmatic impacts.

Adverse life events and delinquent behavior among Kenyan adolescents: a cross-sectional study on the protective role of parental monitoring, religiosity, and self-esteem

BACKGROUND

Past research provides strong evidence that adverse life events heighten the risk of delinquent behavior among adolescents. Urban informal (slum) settlements in sub-Saharan Africa are marked by extreme adversity. However, the prevalence and consequences of adverse life events as well as protective factors that can mitigate the effects of exposure to these events in slum settlements is largely understudied. We examine two research questions. First, are adverse life events experienced at the individual and household level associated with a higher likelihood of delinquent behavior among adolescents living in two slums in Nairobi, Kenya? Second, are parental monitoring, religiosity, and self-esteem protective against delinquency in a context of high adversity?

METHODS

We used cross-sectional data from 3,064 males and females aged 12-19 years who participated in the Transitions to Adulthood Study. We examined the extent to which a composite index of adverse life events was associated with delinquent behavior (measured using a composite index derived from nine items). We also examined the direct and moderating effects of three protective factors: parental monitoring, religiosity, and self-esteem.

RESULTS

Fifty-four percent of adolescents reported at least one adverse life event, while 18% reported three or more adverse events. For both males and females, adversity was positively and significantly associated with delinquency in bivariate and multivariate models. Negative associations were observed between the protective factors and delinquency. Significant adverse events × protective factor interaction terms were observed for parental monitoring (females and males), religiosity (males), and self-esteem (females).

CONCLUSIONS

Similar to research in high income countries, adverse life events are associated with an increased likelihood of delinquent behavior among adolescents living in urban slums in Kenya, a low-income country. However, parental monitoring, religiosity, and self-esteem may moderate the effect of adversity on delinquent behavior and pinpoint possible avenues to develop interventions to reduce delinquency in resource-poor settings in low and middle income countries.

Unintended pregnancies among young women living in urban slums: evidence from a prospective study in Nairobi city, Kenya

BACKGROUND

Despite the significant proportion of young people residing in slum communities, little attention has been paid to the sexual and reproductive health (SRH) challenges they face during their transition to adulthood within this harsh environment. Little is known about the extent to which living in extreme environments, like slums, impact SRH outcomes, especially during this key developmental period. This paper aims to fill this research gap by examining the levels of and factors associated with unintended pregnancies among young women aged 15-22 in two informal settlements in Nairobi, Kenya.

METHODS

We use data from two waves of a 3-year prospective survey that collected information from adolescents living in the two slums in 2007-2010. In total, 849 young women aged 15-22 were considered for analysis. We employed Cox and logistic regression models to investigate factors associated with timing of pregnancy experience and unintended pregnancy among adolescents who were sexually active by Wave 1 or Wave 2.

FINDINGS

About two thirds of sexually experienced young women (69%) have ever been pregnant by Wave 2. For 41% of adolescents, the pregnancies were unintended, with 26% being mistimed and 15% unwanted. Multivariate analysis shows a significant association between a set of factors including age at first sex, schooling status, living arrangements and timing of pregnancy experience. In addition, marital status, schooling status, age at first sex and living arrangements are the only factors that are significantly associated with unintended pregnancy among the young women.

CONCLUSIONS

Overall, this study underscores the importance of looking at reproductive outcomes of early sexual initiation, the serious health risks early fertility entail, especially among out-of school girls, and sexual activity in general among young women living in slum settlements. This provides greater impetus for addressing reproductive behaviors among young women living in resource-poor settings such as slums.

The INDEPTH standard population for low- and middle-income countries, 2013

Crude rates such as the crude death rate are functions of both the age-specific rates and the age composition of a population. However, differences in the age structure between two populations or two time periods can result in specious differences in the corresponding crude rates making direct comparisons between populations or across time inappropriate. Therefore, when comparing crude rates between populations, it is desirable to eliminate or minimize the influence of age composition. This task is accomplished by using a standard age structure yielding an age-standardized rate. This paper proposes an updated International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) standard for use in low- and middle-income countries (LMICs) based on newly available data from the health and demographic surveillance system site members of the INDEPTH network located throughout Africa and southern Asia. The updated INDEPTH standard should better reflect the age structure of LMICs and result in more accurate health indicators and demographic rates. We demonstrate use of the new INDEPTH standard along with several existing ‘world’ standards and show how resulting age-standardized crude deaths rates differ when using the various standard age compositions.

Predictors of sexual debut among young adolescents in Nairobi's informal settlements

CONTEXT

There is a need to better understand the various social, psychosocial and behavioral factors associated with sexual activity among young adolescents in various settings in Sub-Saharan Africa.

METHODS

Data were drawn from Wave 1 (2007-2008) and Wave 2 (2009) of the Transition to Adulthood study, which collected information about key markers of the transition to adulthood and social, demographic and psychosocial characteristics of male and female youth living in two informal settlements in Nairobi, Kenya. Logistic regression analyses were used to examine variables associated with experience of sexual debut by Wave 2 among youth who were aged 12-16 and sexually inexperienced at Wave 1.

RESULTS

Of the 1,754 youth in the sample, 92 experienced sexual debut between survey waves. For both males and females, sexual debut was positively associated with having permanently dropped out of school (odds ratios, 6.9 and 21.8, respectively), having never attended school (8.6 and 39.4) and having experienced severe family dysfunction (2.8 and 5.7). Lack of parental supervision was a predictor of sexual debut among males only (10.1), whereas low aspiration was a predictor among females only (10.4). Surprisingly, young women, as well as men, who did not have high self-esteem were less likely than those who did to initiate first sex between waves (0.4 and 0.3).

CONCLUSIONS

Study findings underscore the importance of school attendance, family dysfunction, parental supervision and self-esteem in driving sexual behavior in this age-group. Further studies are warranted to elucidate how these factors can be addressed in prevention programs for young adolescents.

Health and demographic surveillance systems: contributing to an understanding of the dynamics in migration and health

BACKGROUND

Migration is difficult to measure because it is highly repeatable. Health and Demographic Surveillance Systems (HDSSs) provide a unique opportunity to study migration as multiple episodes of migration are captured over time. A conceptual framework is needed to show the public health implications of migration.

OBJECTIVE/DESIGN

Research conducted in seven HDSS centres [International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) Network], published in a peer-reviewed volume in 2009, is summarised focussing on the age-sex profile of migrants, the relation between migration and livelihoods, and the impact of migration on health. This illustrates the conceptual structure of the implications of migration. The next phase is described, the Multi-centre Analysis of the Dynamics In Migration And Health (MADIMAH) project, consisting of workshops focussed on preparing data and conducting the analyses for comparative studies amongst HDSS centres in Africa and Asia. The focus here is on the (standardisation of) determinants of migration and the impact of migration on adult mortality.

RESULTS

The findings in the volume showed a relatively regular age structure for migration among all HDSS centres. Furthermore, migration generally contributes to improved living conditions at the place of origin. However, there are potential negative consequences of migration on health. It was concluded that there is a need to compare results from multiple centres using uniform covariate definitions as well as longitudinal analysis techniques. This was the starting point for the on-going MADIMAH initiative, which has increased capacity at the participating HDSS centres to produce the required datasets and conduct the analyses.

CONCLUSIONS

HDSS centres brought together within INDEPTH Network have already provided strong evidence of the potential negative consequences of migration on health, which contrast with the beneficial impacts of migration on livelihoods. Future comparative evidence using standardised tools will help design policies for mitigating the negative effects, and enhancing the positive effects, of migration on health.

Adolescent home-leaving and the transition to adulthood: A psychosocial and behavioural study in the slums of Nairobi

Home-leaving is considered an important marker of the transition to adulthood and is usually framed as an individual decision. We move beyond this limited assumption to examine a broader conceptualization that might better illuminate home-leaving among youth in impoverished circumstances. We adopt the Problem Behavior Theory-framework to investigate the association of home-leaving with behavioral and psychosocial variables and with other transitions. We use data on adolescents aged 14–22 years from a three-wave study conducted between 2007 and 2010. We used variable- and person-centered cross-sectional analyses, as well as predictive analysis of home-leaving by subsequent waves. Parental controls protection predicted home-leaving by subsequent waves. Overall, protective factors moderated the association of problem behavior involvement with leaving home in Nairobi’s slums.

Growing up at the 'margins': Concerns, aspirations, and expectations of young people living in Nairobi's slums

We explore the concerns, challenges, aspirations, and expectations of sub-Saharan African youth, and investigate how these youth cope with neighborhood constraints to aspiration achievement. We draw on cross-sectional survey data from 4033 12-22 year olds (50.3% males) from two Kenyan urban slums and subsequent in-depth interviews conducted with a subset of 75 youth when they were 13-24 years old (45.3% male). We observe that despite the challenges characteristic of urban slums, some youth maintain high aspirations and try to achieve them through education, delinquency, residential mobility, and religion. We note that others adjust their aspirations to account for limited opportunities. Overall, our findings highlight positive youth agency and underscore the need to improve the quality of life in urban slums.

The health and wellbeing of young people in sub-Saharan Africa: an under-researched area?

A third of sub-Saharan Africa’s (SSA) population comprises persons aged 10–24 years. These youth are growing up in a context marked by pervasive poverty, limited educational opportunities, high HIV/AIDS prevalence, widespread conflict, and weak social controls. Published research on the broad issues that affect youth health and wellbeing in SSA is limited and centers heavily on sexual and reproductive health. In this commentary, we provide a broad overview of sub-Saharan African youth, highlight research gaps with respect to youth health and wellbeing, and describe potential avenues to develop the region’s research capacity on youth health and wellbeing.

"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 pro-social 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.

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

Background

Although HIV counseling and testing (HCT) is widely considered an integral component of HIV prevention and treatment strategies, few studies have examined HCT behavior among youth in sub-Saharan Africa-a group at substantial risk for HIV infection. In this paper we examine: the correlates of HIV testing, including whether associations differ based on the context under which a person gets tested; and the motivations for getting (or not getting) an HIV test.

Methods

Drawing on data collected in 2007 from 4028 (51% male) youth (12-22 years) living in Korogocho and Viwandani slum settlements in Nairobi (Kenya), we explored the correlates of and motivations for HIV testing using the Health Belief Model (HBM) as a theoretical framework. Multinomial and binary logistic regression analyses were employed to examine correlates of HIV testing. Bivariate analyses were employed to assess reasons for or against testing.

Results

Nineteen percent of males and 35% of females had been tested. Among tested youth, 74% of males and 43% of females had requested for their most recent HIV test while 7% of males and 32% of females reported that they were required to take their most recent HIV test (i.e., the test was mandatory). About 60% of females who had ever had sex received an HIV test because they were pregnant. We found modest support for the HBM in explaining variation in testing behavior. In particular, we found that perceived risk for HIV infection may drive HIV testing among youth. For example, about half of youth who had ever had sex but had never been tested reported that they had not been tested because they were not at risk.

Conclusions

Targeted interventions to help young people correctly assess their level of risk and to increase awareness of the potential value of HIV testing may help enhance uptake of testing services. Given the relative success of Prevention of Mother-to-Child Transmission (PMTCT) services in increasing HIV testing rates among females, routine provider-initiated testing and counseling among all clients visiting medical facilities may provide an important avenue to increase HIV status awareness among the general population and especially among males.

Do migrant children face greater health hazards in slum settlements? Evidence from Nairobi, Kenya

Between 60% and 70% of Nairobi City's population live in congested informal settlements, commonly referred to as slums, without proper access to sanitation, clean water, health care and other social services. Children in such areas are exposed to disproportionately high health hazards. This paper examines the impact of mother and child migration on the survival of more than 10,000 children in two of Nairobi's informal settlements--Korogocho and Viwandani--between July 2003 and June 2007, using a two-stage semi-parametric proportional hazards (Cox) model that controls for attrition and various factors that affect child survival. Results show that the slum-born have higher mortality than non-slum-born, an indication that delivery in the slums has long-term health consequences for children. Children born in the slums to women who were pregnant at the time of migration have the highest risk of dying. Given the high degree of circular migration, factors predisposing children born in the slums to recent migrant mothers to higher mortality should be better understood and addressed.

Timing and sequencing of events marking the transition to adulthood in two informal settlements in Nairobi, Kenya

Young people living in poor urban informal settlements face unique challenges as they transition to adulthood. This exploratory paper uses retrospective information from the baseline survey of a 3-year prospective study to examine the timing and sequencing of four key markers (first sex, marriage, birth, and independent housing) of the transition to adulthood among 3,944 adolescents in two informal settlements in Nairobi city, Kenya. Event history analysis techniques are employed to examine the timing of the events. Results indicate that there is no significant gender difference with regard to first sexual debut among adolescents. For many boys and girls, the first sexual experience occurs outside of marriage or other union. For males, the sequencing of entry begins with entry into first sex, followed by independent housing. Conversely, for females, the sequencing begins with first sex and then parenthood. Apart from sexual debut, the patterns of entry into union and parenthood do not differ much from what was observed for Nairobi as a whole. The space constraints that typify the two slums may have influenced the pattern of leaving home observed. We discuss these and other findings in light of their implications for young people's health and well-being in resource-poor settings in urban areas.

Overview of migration, poverty and health dynamics in Nairobi City's slum settlements

The Urbanization, Poverty, and Health Dynamics research program was designed to generate and provide the evidence base that would help governments, development partners, and other stakeholders understand how the urban slum context affects health outcomes in order to stimulate policy and action for uplifting the wellbeing of slum residents. The program was nested into the Nairobi Urban Health and Demographic Surveillance System, a uniquely rich longitudinal research platform, set up in Korogocho and Viwandani slum settlements in Nairobi city, Kenya. Findings provide rich insights on the context in which slum dwellers live and how poverty and migration status interacts with health issues over the life course. Contrary to popular opinions and beliefs that see slums as homogenous residential entities, the findings paint a picture of a highly dynamic and heterogeneous setting. While slum populations are highly mobile, about half of the population comprises relatively well doing long-term dwellers who have lived in slum settlements for over 10 years. The poor health outcomes that slum residents exhibit at all stages of the life course are rooted in three key characteristics of slum settlements: poor environmental conditions and infrastructure; limited access to services due to lack of income to pay for treatment and preventive services; and reliance on poor quality and mostly informal and unregulated health services that are not well suited to meeting the unique realities and health needs of slum dwellers. Consequently, policies and programs aimed at improving the wellbeing of slum dwellers should address comprehensively the underlying structural, economic, behavioral, and service-oriented barriers to good health and productive lives among slum residents.

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.

Monitoring of health and demographic outcomes in poor urban settlements: evidence from the Nairobi Urban Health and Demographic Surveillance System

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

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

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

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

BACKGROUND

Consumption of alcohol is associated with acute and chronic adverse health outcomes. There is a paucity of studies that explore the determinants of alcohol use among adolescents in sub-Saharan Africa and, in particular, that examine the effects of adverse childhood experiences on alcohol use.

METHODS

The paper draws on nationally-representative data from 9,819 adolescents aged 12-19 years from Burkina Faso, Ghana, Malawi, and Uganda. Logistic regression models were employed to identify correlates of self-reported past-year drunkenness. Exposure to four adverse childhood experiences comprised the primary independent variables: living in a food-insecure household, living with a problem drinker, having been physically abused, and having been coerced into having sex. We controlled for age, religiosity, current schooling status, the household head's sex, living arrangements, place of residence, marital status, and country of survey. All analyses were conducted separately for males and females.

RESULTS

At the bivariate level, all independent variables (except for coerced sex among males) were associated with the outcome variable. Overall, 9% of adolescents reported that they had been drunk in the 12 months preceding the survey. In general, respondents who had experienced an adverse event during childhood were more likely to report drunkenness. In the multivariate analysis, only two adverse childhood events emerged as significant predictors of self-reported past-year drunkenness among males: living in a household with a problem drinker before age 10, and being physically abused before age 10. For females, exposure to family-alcoholism, experience of physical abuse, and coerced sex increased the likelihood of reporting drunkenness in the last 12 months. The association between adverse events and reported drunkenness was more pronounced for females. For both males and females there was a graded relationship between the number of adverse events experienced and the proportion reporting drunkenness.

CONCLUSIONS

We find an association between experience of adverse childhood events and drunkenness among adolescents in four sub-Saharan African countries. The complex impacts of adverse childhood experiences on young people's development and behavior may have an important bearing on the effectiveness of interventions geared at reducing alcohol dependence among the youth.

Inconsistencies in self-reporting of sexual activity among young people in Nairobi, Kenya

PURPOSE

Accurate and reliable data on the prevalence of adolescents' sexual behavior are paramount for effective sexual and reproductive health intervention. Adolescents' sexual behavior has been widely studied. However, scholars have raised concerns about the accuracy and reliability of self-reported sexual behavior by adolescents. Previous research shows high levels of adolescent sexual activity in urban informal settlements; yet, the accuracy of self-reported sexual experience in these settings is understudied.

METHODS

The objective of this article is to assess consistency of self-reported sexual activity among 2324 adolescents living in slum and nonslum settlements in Nairobi, Kenya. We examine two forms of inconsistencies, namely, what we term "reborn virgins" and inconsistent timing of sexual debut, during two rounds of survey. Factors influencing inconsistent reporting are explored through logistic regression.

RESULTS

A total of 469 (20%) adolescents gave inconsistent information on whether they have ever had sex (n = 190) or timing of first intercourse (n = 279). Males, slum residents, and adolescents attending school were more likely to give inconsistent sexual information. Among inconsistent reporters, slum residents, adolescents reporting substance use, and those with secondary (vs. primary) education were more likely to reclaim virginity status than to misreport the timing of first sex. However, older adolescents were less likely to reclaim virginity status.

CONCLUSIONS

We found significant differences between adolescents who provide consistent reports and those who misreport sexual behavior data. We argue that researchers should account for biases stemming from misreporting of sensitive information among young people and, in particular, should be cognizant of how reporting quality may vary across demographic groups.