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Otieno P, Asiki G, Wekesah F, Wilunda C, Sanya RE, Wami W, Agyemang C. Multimorbidity of cardiometabolic diseases: a cross-sectional study of patterns, clusters and associated risk factors in sub-Saharan Africa. BMJ Open 2023; 13:e064275. [PMID: 36759029 PMCID: PMC9923299 DOI: 10.1136/bmjopen-2022-064275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
OBJECTIVE To determine the patterns of cardiometabolic multimorbidity and associated risk factors in sub-Saharan Africa (SSA). DESIGN We used data from the WHO STEPwise approach to non-communicable disease risk factor surveillance cross-sectional surveys conducted between 2014 and 2017. PARTICIPANTS The participants comprised 39, 658 respondents aged 15-69 years randomly selected from nine SSA countries using a multistage stratified sampling design. PRIMARY OUTCOME MEASURE Using latent class analysis and agglomerative hierarchical clustering algorithms, we analysed the clustering of cardiometabolic diseases (CMDs) including high blood sugar, hypercholesterolaemia, hypertension and cardiovascular diseases (CVDs) such as heart attack, angina and stroke. Clusters of lifestyle risk factors: harmful salt intake, physical inactivity, obesity, tobacco and alcohol use were also computed. Prevalence ratios (PR) from modified Poisson regression were used to assess the association of cardiometabolic multimorbidity with sociodemographic and lifestyle risk factors. RESULTS Two distinct classes of CMDs were identified: relatively healthy group with minimal CMDs (95.2%) and cardiometabolic multimorbidity class comprising participants with high blood sugar, hypercholesterolaemia, hypertension and CVDs (4.8%). The clusters of lifestyle risk factors included alcohol, tobacco and harmful salt consumption (27.0%), and physical inactivity and obesity (5.8%). The cardiometabolic multimorbidity cluster exhibited unique sociodemographic and lifestyle risk profiles. Being female (PR=1.7, 95% CI (1.5 to 2.0), middle-aged (35-54 years) (3.9 (95% CI 3.2 to 4.8)), compared with age 15-34 years, employed (1.2 (95% CI 1.1 to 1.4)), having tertiary education (2.5 (95% CI 2.0 to 3.3)), vs no formal education and clustering of physical inactivity and obesity (2.4 (95% CI 2.0 to 2.8)) were associated with a higher likelihood of cardiometabolic multimorbidity. CONCLUSION Our findings show that cardiometabolic multimorbidity and lifestyle risk factors cluster in distinct patterns with a disproportionate burden among women, middle-aged, persons in high socioeconomic positions, and those with sedentary lifestyles and obesity. These results provide insights for health systems response in SSA to focus on these clusters as potential targets for integrated care.
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Affiliation(s)
- Peter Otieno
- Chronic Diseases Management Unit, African Population and Health Research Center, Nairobi, Kenya
- Department of Public & Occupational Health, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Gershim Asiki
- Chronic Diseases Management Unit, African Population and Health Research Center, Nairobi, Kenya
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Frederick Wekesah
- Chronic Diseases Management Unit, African Population and Health Research Center, Nairobi, Kenya
- Lown Scholars Program, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Calistus Wilunda
- Chronic Diseases Management Unit, African Population and Health Research Center, Nairobi, Kenya
| | - Richard E Sanya
- Chronic Diseases Management Unit, African Population and Health Research Center, Nairobi, Kenya
| | - Welcome Wami
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Charles Agyemang
- Department of Public & Occupational Health, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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Ajeigbe O, Arage G, Besong M, Chacha W, Desai R, Doegah P, Hamoonga TE, Hussein H, Matchado A, Mbotwe-Sibanda S, Mukoma G, Odebode A, Olawole T, Phaswana M, Rotimi O, Silubonde TM, Thabethe N, Thiba A, Thomford NE, Wekesah F, Macnab A. Culturally relevant COVID-19 vaccine acceptance strategies in sub-Saharan Africa. The Lancet Global Health 2022; 10:e1090-e1091. [PMID: 35691328 PMCID: PMC9183213 DOI: 10.1016/s2214-109x(22)00251-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 11/26/2022] Open
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Asiki G, Kadengye D, Calvert C, Wamukoya M, Mohamed SF, Ziraba A, Iddi S, Bangha M, Wekesah F, Chikozho C, Price A, Crampin M, Kyobutungi C. Trends and risk factors for non-communicable diseases mortality in Nairobi slums (2008-2017). Glob Epidemiol 2021; 3:100049. [PMID: 34977550 PMCID: PMC8683743 DOI: 10.1016/j.gloepi.2021.100049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/17/2021] [Accepted: 02/17/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Tracking progress in reaching global targets for reducing premature mortality from non-communicable diseases (NCDs) requires accurately collected population based longitudinal data. However, most African countries lack such data because of weak or non-existent civil registration systems. We used data from the Nairobi Urban Health and Demographic Surveillance System (NUDSS) to estimate NCD mortality trends over time and to explore the determinants of NCD mortality. METHODS Deaths identified in the NUHDSS were followed up with a verbal autopsy to determine the signs and symptoms preceding the death. Causes of death were then assigned using InSilicoVA algorithm. We calculated the rates of NCD mortality in the whole NUHDSS population between 2008 and 2017, looking at how these changed over time. We then merged NCD survey data collected in 2008, which contains information on potential determinants of NCD mortality in a sub-sample of the NUHDSS population, with follow up information from the full NUHDSS including whether any of the participants died of an NCD or non-NCD cause. Poisson regression models were used to identify independent risk factors (broadly categorized as socio-demographic, behavioural and physiological) for NCD mortality, as well as non-NCD mortality. RESULTS In the total NUHDSS population of adults age 18 and over, 23% were assigned an NCD as the most likely cause of death. There was evidence that NCD mortality decreased over the study period, with rates of NCD mortality dropping from 1.32 per 1000 person years in 2008-10 (95% CI: 1.13-1.54) to 0.93 per 1000 person years in 2014-17 (95% CI: 0.80-1.08). Of 5115 individuals who participated in the NCD survey in 2008, 421 died during the follow-up period of which 43% were attributed to NCDs. Increasing age, lower education levels, ever smoking and having high blood pressure were identified as independent determinants of NCD mortality in multivariate analyses. CONCLUSION We found that NCDs account for one-quarter of mortality in Nairobi slums, although we document a reduction in the rate of NCD mortality over time. This may be attributed to increased surveillance and introduction of population-wide NCD interventions and health system improvements from research activities in the slums. To achieve further decline there is a need to strengthen health systems to respond to NCD care and prevention along with addressing social factors such as education.
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Affiliation(s)
- Gershim Asiki
- African Population and Health Research Center, Nairobi, Kenya
- Department of women's and children's health, Karolinska Institutet, Stockholm, Sweden
| | - Damazo Kadengye
- African Population and Health Research Center, Nairobi, Kenya
| | - Clara Calvert
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - Abdhalah Ziraba
- African Population and Health Research Center, Nairobi, Kenya
| | - Samuel Iddi
- African Population and Health Research Center, Nairobi, Kenya
| | - Martin Bangha
- African Population and Health Research Center, Nairobi, Kenya
| | | | | | - Alison Price
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mia Crampin
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Abstract
The vulnerability of lesbian, gay, bisexual and transgender (LGBT) persons in Africa to public health and other risks is heightened by their exclusion from socio-economic opportunities and services. We analysed existing regional-level legal and policy instruments and treaties for the opportunities they offer to tackle the exclusion of LGBT persons in Africa. We identified seven key living legal and policy instruments, formulated and adopted between 1981 and 2018, by the African Union (AU) or its precursor, the Organization of African Unity. These treaties and instruments do not only highlight the region’s challenges related to inclusion, most of them are binding and enforceable, and all enshrine the responsibility of AU member-states to safeguard and ensure the inclusion and protection of citizens, their gender or sexual orientation notwithstanding. The instruments set forth strong and ambitious agendas of inclusion and recognise and affirm the rights of the region’s citizens to sexual and reproductive health (SRH), equality, freedom and opportunities, regardless of their sexual orientation. Their language is generally universalist and their rejection of discrimination, criminalisation, and denial of socio-economic opportunities and services to the region’s sexual minorities is forthright. However, the instruments do not explicitly mention LGBT persons and lack clear and effective mechanisms for answerability among member-states. Accountability and commitment among member-states towards these instruments and policies will improve national legal and policy environments and propel forward the agenda of LGBT inclusion, SRH and wellbeing in the region.
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Affiliation(s)
- Chimaraoke Izugbara
- Director, Global Health, Youth & Development, International Center for Research on Women, Washington, DC, USA . Correspondence :
| | - Seun Bakare
- Programs Manager, Amnesty International Nigeria, Abuja, Nigeria
| | - Meroji Sebany
- Gender and Health Specialist, International Center for Research on Women, Washington, DC, USA
| | - Boniface Ushie
- Associate Research Scientist, African Population & Health Research Center, Nairobi, Kenya
| | - Frederick Wekesah
- Research Officer, African Population & Health Research Center, Nairobi, Kenya
| | - Joan Njagi
- Research Officer, African Population & Health Research Center, Nairobi, Kenya
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Vusirikala A, Wekesah F, Kyobutungi C, Oyebode O. Assessment of cardiovascular risk in a slum population in Kenya: use of World Health Organisation/International Society of Hypertension (WHO/ISH) risk prediction charts - secondary analyses of a household survey. BMJ Open 2019; 9:e029304. [PMID: 31488481 PMCID: PMC6731939 DOI: 10.1136/bmjopen-2019-029304] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 07/09/2019] [Accepted: 07/19/2019] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Although cardiovascular disease (CVD) is of growing importance in low- and middle-income countries (LMICs), there are conflicting views regarding CVD as a major public health problem for the urban poor, including those living in slums. We examine multivariable risk prediction in a slum population and assess the number of cardiovascular related deaths within 10 years of application of the tool. SETTING We use data from the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) population (residents of two slum communities) between May 2008 and April 2009. DESIGN This is a secondary data analysis from a cross-sectional survey. We use the WHO/International Society of Hypertension (WHO/ISH) cardiovascular risk prediction tool to examine 10-year risk of major CVD events in a slum population. CVD deaths in the cohort, reported up until June 2018 and identified through verbal autopsy are also presented. PARTICIPANTS 3063 men and women aged over 40 years with complete data for variables needed for the WHO/ISH risk prediction tool were eligible to take part. RESULTS The majority of study members (2895, 94.5%) were predicted to have 'low' risk (<10%) of a cardiovascular event over the next 10 years and just 51 (1.7%) to have 'high' CVD risk (≥20%). 91 CVD deaths were reported for the cohort up until June 2018. Of individuals classified as low risk, 74 (2.6%) were identified as having died of CVD. Nine (7.7%) individuals classified at 10% to 20% risk and eight (15.9%) classified at >20% were identified as dying of CVD. CONCLUSIONS This study shows that there is a low risk profile of CVD in this slum population in Nairobi, Kenya, in comparison to results from application of multivariable risk prediction tools in other LMIC populations. This has implications for health service planning in these contexts.
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Affiliation(s)
| | - Frederick Wekesah
- African Population and Health Research Center, Nairobi, Kenya
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Wainaina CW, Wanjohi M, Wekesah F, Woolhead G, Kimani-Murage E. Exploring the Experiences of Middle Income Mothers in Practicing Exclusive Breastfeeding in Nairobi, Kenya. Matern Child Health J 2019; 22:608-616. [PMID: 29349653 DOI: 10.1007/s10995-018-2430-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objectives To establish exclusive breastfeeding (EBF) practice, women are encouraged to initiate breastfeeding of their newborns within one hour of delivery and breastfeed exclusively for the first 6 months of the infant's life. Research in Kenya has shown evidence of a reduced rate of EBF with an increase in socio-economic class (SES). This study explores the experiences of middle-income women so as to understand their attitudes and practices of EBF and to contribute toward the Baby Friendly Hospital (BFHI) and Baby Friendly Community Initiatives (BFCI) programs in Kenya. Methods A qualitative study using nine in-depth interviews and two focus group discussions were conducted with middle-income women with a child < 2 years. Thematic content analysis was used to analyze the data. Results The majority of the women interviewed did not achieve EBF and this was attributed to many challenges that they encountered such as; inadequate workplace support including short maternity leave, lack of designated breast feeding facilities flexible hours and breastfeeding breaks. Support structures were highlighted as either inadequate or lacking while the internet was preferred by most of the women for breastfeeding information. Mass media was seen as more credible, though some women indicated that there was lack of depth in the information it provided. Conclusion The study showed that majority of women were unable to EBF for the first 6 months. Women experienced inadequate social, healthcare and workplace support and preferred online sites for information on breastfeeding than the healthcare professionals or mass media. Recommendation There is need to implement policies at the workplace that promote a breastfeeding friendly environment. There is also a need for more research on role of mass media in promotion of optimal breastfeeding practices, especially how to reach this population. There is a need for continued advocacy on social support including spousal, relatives, and other community members at the community level.
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Affiliation(s)
- Caroline W Wainaina
- School of Public Health, Laureate Online Education, University of Liverpool, Liverpool, UK.
- African Population Health Research Center (APHRC), Nairobi, Kenya.
| | - Milka Wanjohi
- African Population Health Research Center (APHRC), Nairobi, Kenya
| | | | - Gillian Woolhead
- School of Public Health, Laureate Online Education, University of Liverpool, Liverpool, UK
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Mohamed SF, Mutua MK, Wamai R, Wekesah F, Haregu T, Juma P, Nyanjau L, Kyobutungi C, Ogola E. Prevalence, awareness, treatment and control of hypertension and their determinants: results from a national survey in Kenya. BMC Public Health 2018; 18:1219. [PMID: 30400858 PMCID: PMC6219055 DOI: 10.1186/s12889-018-6052-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hypertension is the most important risk factor for cardiovascular diseases and the leading cause of death worldwide. Despite growing evidence that the prevalence of hypertension is rising in sub-Saharan Africa, national data on hypertension that can guide programming are missing for many countries. In this study, we estimated the prevalence of hypertension, awareness, treatment, and control. We further examined the factors associated with hypertension and awareness. METHOD We used data from the 2015 Kenya STEPs survey, a national cross-sectional household survey targeting randomly selected people aged 18-69 years. Demographic and behavioral characteristics as well as physical measurements were collected using the World Health Organization's STEPs Survey methodology. Descriptive statistics were used to estimate the prevalence, awareness, treatment and control of hypertension. Multiple logistic regression models were used to identify the determinants of hypertension and awareness. RESULTS The study surveyed 4485 participants. The overall age-standardized prevalence for hypertension was 24.5% (95% confidence interval (CI) 22.6% to 26.6%). Among individuals with hypertension, only 15.6% (95% CI 12.4% to 18.9%) were aware of their elevated blood pressure. Among those aware only 26.9%; (95% CI 17.1% to 36.4%) were on treatment and 51.7%; (95% CI 33.5% to 69.9%) among those on treatment had achieved blood pressure control. Factors associated with hypertension were older age (p < 0.001), higher body mass index (BMI) (p < 0.001) and harmful use of alcohol (p < 0.001). Similarly, factors associated with awareness were older age (p = 0.013) and being male (p < 0.001). CONCLUSION This study provides the first nationally-representative estimates for hypertension in Kenya. Prevalence among adults is high, with unacceptably low levels of awareness, treatment and control. The results also reveal that men are less aware of their hypertension status hence special attention should focus on this group.
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Affiliation(s)
- Shukri F. Mohamed
- Health and Systems for Health Unit, African Population and Health Research Center (APHRC), Nairobi, Kenya
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Martin K. Mutua
- Health and Systems for Health Unit, African Population and Health Research Center (APHRC), Nairobi, Kenya
| | - Richard Wamai
- Department of Cultures, Societies and Global Studies, North Eastern University, Massachusetts, USA
| | - Frederick Wekesah
- Health and Systems for Health Unit, African Population and Health Research Center (APHRC), Nairobi, Kenya
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, Netherlands
| | - Tilahun Haregu
- Health and Systems for Health Unit, African Population and Health Research Center (APHRC), Nairobi, Kenya
| | - Pamela Juma
- Health and Systems for Health Unit, African Population and Health Research Center (APHRC), Nairobi, Kenya
| | - Loise Nyanjau
- Division of Non Communicable Diseases, Ministry of Health, Nairobi, Kenya
| | - Catherine Kyobutungi
- Health and Systems for Health Unit, African Population and Health Research Center (APHRC), Nairobi, Kenya
| | - Elijah Ogola
- Clinical Medicine, University of Nairobi, Nairobi, Kenya
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Abstract
User priorities regarding quality care in contexts of medical pluralism are poorly documented. Drawing on group and individual interviews with women, we interrogate ideas of quality maternity care in the context of Nigeria's medical pluralism. We found complex utilization patterns for conventional, complementary and alternative maternity care services as well as ideas of quality maternity care that stress effective coordination and integration of different typologies of maternity health services; socially sensitive and truthful providers; and socioeconomic, physical and parochial forms of safety. Informal providers were the commonly reported source of maternal health services in the study. Maternal health services in the country were also generally viewed as poor quality, characterized by pervasive abuse, quackery and lack of commitment to the needs and sensitivities of women. Convenience, availability and affordability of maternal health services, as well as sociocultural factors were major influences on women's use of services. Results demonstrate the embeddedness of women's quality of care notions in the vast socioeconomic inequities that typify Nigeria's particular form of poorly regulated medical pluralism, raising need for strategies to strengthen the delivery, coordination and supervision of maternal health services in the country.
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Affiliation(s)
- Chimaraoke O Izugbara
- African Population and Health Research Center, 2nd Floor, APHRC Campus, P.O. Box 10787- 00100, Nairobi, Kenya
| | - Frederick Wekesah
- African Population and Health Research Center, 2nd Floor, APHRC Campus, P.O. Box 10787- 00100, Nairobi, Kenya
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Boateng D, Wekesah F, Browne JL, Agyemang C, Agyei-Baffour P, Aikins ADG, Smit HA, Grobbee DE, Klipstein-Grobusch K. Knowledge and awareness of and perception towards cardiovascular disease risk in sub-Saharan Africa: A systematic review. PLoS One 2017; 12:e0189264. [PMID: 29232703 PMCID: PMC5726714 DOI: 10.1371/journal.pone.0189264] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 11/23/2017] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Cardiovascular diseases (CVDs) are the most common cause of non-communicable disease mortality in sub-Saharan African (SSA) countries. Gaps in knowledge of CVD conditions and their risk factors are important barriers in effective prevention and treatment. Yet, evidence on the awareness and knowledge level of CVD and associated risk factors among populations of SSA is scarce. This review aimed to synthesize available evidence of the level of knowledge of and perceptions towards CVDs and risk factors in the SSA region. METHODS Five databases were searched for publications up to December 2016. Narrative synthesis was conducted for knowledge level of CVDs, knowledge of risk factors and clinical signs, factors influencing knowledge of CVDs and source of health information on CVDs. The review was registered with Prospero (CRD42016049165). RESULTS Of 2212 titles and abstracts screened, 45 full-text papers were retrieved and reviewed and 20 were included: eighteen quantitative and two qualitative studies. Levels of knowledge and awareness for CVD and risk factors were generally low, coupled with poor perception. Most studies reported less than half of their study participants having good knowledge of CVDs and/or risk factors. Proportion of participants who were unable to identify a single risk factor and clinical symptom for CVDs ranged from 1.8% in a study among hospital staff in Nigeria to a high of 73% in a population-based survey in Uganda and 7% among University staff in Nigeria to 75.1% in a general population in Uganda respectively. High educational attainment and place of residence had a significant influence on the levels of knowledge for CVDs among SSA populations. CONCLUSION Low knowledge of CVDs, risk factors and clinical symptoms is strongly associated with the low levels of educational attainment and rural residency in the region. These findings provide useful information for implementers of interventions targeted at the prevention and control of CVDs, and encourages them to incorporate health promotion and awareness campaigns in order to enhance knowledge and awareness of CVDs in the region.
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Affiliation(s)
- Daniel Boateng
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Frederick Wekesah
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- African Population and Health Research Center, Nairobi, Kenya
| | - Joyce L. Browne
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Charles Agyemang
- Department of Public Health, Academic Medical Center, University of Amsterdam, Amsterdam Public Health Institute, Amsterdam, The Netherlands
| | - Peter Agyei-Baffour
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Ama de-Graft Aikins
- Regional Institute for Population Studies, University of Ghana, Legon, Ghana
| | - Henriette A. Smit
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Diederick E. Grobbee
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Division of Epidemiology & Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Wanjohi M, Griffiths P, Wekesah F, Muriuki P, Muhia N, Musoke RN, Fouts HN, Madise NJ, Kimani-Murage EW. Sociocultural factors influencing breastfeeding practices in two slums in Nairobi, Kenya. Int Breastfeed J 2017; 12:5. [PMID: 28096888 PMCID: PMC5225512 DOI: 10.1186/s13006-016-0092-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 12/12/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Despite numerous interventions promoting optimal breastfeeding practices in Kenya, pockets of suboptimal breastfeeding practices are documented in Kenya's urban slums. This paper describes cultural and social beliefs and practices that influence breastfeeding in two urban slums in Nairobi, Kenya. METHODS Qualitative data were collected in Korogocho and Viwandani slums through 10 focus group discussions and 19 in-depth interviews with pregnant, breastfeeding women and community health volunteers and 11 key-informant interviews with community leaders. Interviews were audiotaped, transcribed verbatim, coded in NVIVO and analyzed thematically. RESULTS Social and cultural beliefs and practices that result to suboptimal breastfeeding practices were highlighted including; considering colostrum as 'dirty' or 'curdled milk', a curse 'bad omen' associated with breastfeeding while engaging in extra marital affairs, a fear of the 'evil eye' (malevolent glare which is believed to be a curse associated with witchcraft) when breastfeeding in public and breastfeeding being associated with sagging breasts. Positive social and cultural beliefs were also identified including the association of breast milk with intellectual development and good child health. The beliefs and practices were learnt mainly from spouses, close relatives and peers. CONCLUSION Interventions promoting behavior change with regards to breastfeeding should focus on dispelling the beliefs and practices that result to suboptimal breastfeeding practices and to build on the positive ones, while involving spouses and other family members as they are important sources of information on breastfeeding. TRIAL REGISTRATION ISRCTN83692672: December 2013 (retrospectively registered).
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Affiliation(s)
- Milka Wanjohi
- African Population and Health Research Center (APHRC), Nairobi, Kenya
| | - Paula Griffiths
- Centers for Global Health and Human Development; Loughborough University, Loughborough, UK
- MRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Frederick Wekesah
- African Population and Health Research Center (APHRC), Nairobi, Kenya
| | - Peter Muriuki
- African Population and Health Research Center (APHRC), Nairobi, Kenya
| | - Nelson Muhia
- African Population and Health Research Center (APHRC), Nairobi, Kenya
| | - Rachel N. Musoke
- Departments of Pediatrics, University of Nairobi, Nairobi, Kenya
| | - Hillary N. Fouts
- Department of Child and Family Studies, University of Tennessee, Knoxville, USA
| | - Nyovani J. Madise
- Center for Global Health, Population, Poverty, and Policy University of Southampton, Southampton, UK
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Ye Y, Arnold F, Noor A, Wamukoya M, Amuasi J, Blay S, Mberu B, Ren R, Kyobutungi C, Wekesah F, Gatakaa H, Toda M, Njogu J, Evance I, O'Connell K, Shewchuk T, Thougher S, Mann A, Willey B, Goodman C, Hanson K. The Affordable Medicines Facility-malaria (AMFm): are remote areas benefiting from the intervention? Malar J 2015; 14:398. [PMID: 26452625 PMCID: PMC4600285 DOI: 10.1186/s12936-015-0904-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 09/13/2015] [Indexed: 11/19/2022] Open
Abstract
Background To assess the availability, price and
market share of quality-assured artemisinin-based combination therapy (QAACT) in remote areas (RAs) compared with non-remote areas (nRAs) in Kenya and Ghana at end-line of the Affordable Medicines Facility-malaria (AMFm) intervention. Methods Areas were classified by remoteness using a composite index computed from estimated travel times to three levels of service centres. The index was used to five categories of remoteness, which were then grouped into two categories of remote and non-remote areas. The number of public or private outlets with the potential to sell or distribute anti-malarial medicines, screened in nRAs and RAs, respectively, was 501 and 194 in Ghana and 9980 and 2353 in Kenya. The analysis compares RAs with nRAs in terms of availability, price and market share of QAACT in each country. Results QAACT were similarly available in RAs as nRAs in Ghana and Kenya. In both countries, there was no statistical difference in availability of QAACT with AMFm logo between RAs and nRAs in public health facilities (PHFs), while private-for-profit (PFP) outlets had lower availability in RA than in nRAs (Ghana: 66.0 vs 82.2 %, p < 0.0001; Kenya: 44.9 vs 63.5 %, p = <0.0001. The median price of QAACT with AMFm logo for PFP outlets in RAs (USD1.25 in Ghana and USD0.69 in Kenya) was above the recommended retail price in Ghana (US$0.95) and Kenya (US$0.46), and much higher than in nRAs for both countries. QAACT with AMFm logo represented the majority of QAACT in RAs and nRAs in Kenya and Ghana. In the PFP sector in Ghana, the market share for QAACT with AMFm logo was significantly higher in RAs than in nRAs (75.6 vs 51.4 %, p < 0.0001). In contrast, in similar outlets in Kenya, the market share of QAACT with AMFm logo was significantly lower in RAs than in nRAs (39.4 vs 65.1 %, p < 0.0001). Conclusion The findings indicate the AMFm programme contributed to making QAACT more available in RAs in these two countries. Therefore, the AMFm approach can inform other health interventions aiming at reaching hard-to-reach populations, particularly in the context of universal access to health interventions. However, further examination of the factors accounting for the deep penetration of the AMFm programme into RAs is needed to inform actions to improve the healthcare delivery system, particularly in RAs.
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Affiliation(s)
- Yazoume Ye
- ICF International, 530 Gaither Road, Suite 500, Rockville, MD, 20850, USA.
| | - Fred Arnold
- ICF International, 530 Gaither Road, Suite 500, Rockville, MD, 20850, USA.
| | | | | | - John Amuasi
- Kumasi Centre for Collaborative Research in Tropical Medicine, Kumasi, Ghana.
| | - Samuel Blay
- Komfo Anokye Teaching Hospital, Kumasi, Ghana.
| | - Blessing Mberu
- African Population and Health Research Center, Nairobi, Kenya.
| | - Ruilin Ren
- ICF International, 530 Gaither Road, Suite 500, Rockville, MD, 20850, USA.
| | | | | | - Hellen Gatakaa
- ICF International, 530 Gaither Road, Suite 500, Rockville, MD, 20850, USA.
| | - Mitsuru Toda
- Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan.
| | - Julius Njogu
- The ACTwatch project (Population Services International), Nairobi, Kenya.
| | - Illah Evance
- The ACTwatch project (Population Services International), Nairobi, Kenya.
| | - Kathryn O'Connell
- The ACTwatch project (Population Services International), Nairobi, Kenya.
| | - Tanya Shewchuk
- The ACTwatch project (Population Services International), Nairobi, Kenya.
| | - Sarah Thougher
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | - Andrea Mann
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | - Barbara Willey
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | - Kara Hanson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
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12
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Kimani-Murage EW, Kimiywe J, Kabue M, Wekesah F, Matiri E, Muhia N, Wanjohi M, Muriuki P, Samburu B, Kanyuira JN, Young SL, Griffiths PL, Madise NJ, McGarvey ST. Feasibility and effectiveness of the baby friendly community initiative in rural Kenya: study protocol for a randomized controlled trial. Trials 2015; 16:431. [PMID: 26416177 PMCID: PMC4587817 DOI: 10.1186/s13063-015-0935-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 08/28/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Interventions promoting optimal infant and young child nutrition could prevent a fifth of under-5 deaths in countries with high mortality. Poor infant and young child feeding practices are widely documented in Kenya, with potential detrimental effects on child growth, health and survival. Effective strategies to improve these practices are needed. This study aims to pilot implementation of the Baby Friendly Community Initiative (BFCI), a global initiative aimed at promoting optimal infant and young child feeding practices, to determine its feasibility and effectiveness with regards to infant feeding practices, nutrition and health outcomes in a rural setting in Kenya. METHODS The study, employing a cluster-randomized trial design, will be conducted in rural Kenya. A total of 12 clusters, constituting community units within the government's Community Health Strategy, will be randomized, with half allocated to the intervention and the other half to the control arm. A total of 812 pregnant women and their respective children will be recruited into the study. The mother-child pairs will be followed up until the child is 6 months old. Recruitment will last approximately 1 year from January 2015, and the study will run for 3 years, from 2014 to 2016. The intervention will involve regular counseling and support of mothers by trained community health workers and health professionals on maternal, infant and young child nutrition. Regular assessment of knowledge, attitudes and practices on maternal, infant and young child nutrition will be done, coupled with assessment of nutritional status of the mother-child pairs and morbidity for the children. Statistical methods will include analysis of covariance, multinomial logistic regression and multilevel modeling. The study is funded by the NIH and USAID through the Program for Enhanced Research (PEER) Health. DISCUSSION Findings from the study outlined in this protocol will inform potential feasibility and effectiveness of a community-based intervention aimed at promoting optimal breastfeeding and other infant feeding practices. The intervention, if proved feasible and effective, will inform policy and practice in Kenya and similar settings, particularly regarding implementation of the baby friendly community initiative. TRIAL REGISTRATION ISRCTN03467700 ; Date of Registration: 24 September 2014.
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Affiliation(s)
- Elizabeth W Kimani-Murage
- African Population and Health Research Centre (APHRC), APHRC Campus, Kirawa Road, Off PeponiRoad, P.O. Box 10787, 00100, Nairobi, Kenya.
| | - Judith Kimiywe
- Department of Food, Nutrition and Dietetics, Kenyatta University, School of Applied Human Sciences Complex, Conference Road, Room HE7, P.O. Box 43844, 00100, Nairobi, Kenya.
| | - Mark Kabue
- Jhpiego, Off Riverside Drive, 14 Riverside, Arlington Block-2nd Floor, Nairobi, Kenya.
| | - Frederick Wekesah
- African Population and Health Research Centre (APHRC), APHRC Campus, Kirawa Road, Off PeponiRoad, P.O. Box 10787, 00100, Nairobi, Kenya.
| | - Evelyn Matiri
- PATH, ACS Plaza, 4th floor, Lenana Road, P.O. Box 76634-00508, Nairobi, Kenya.
| | - Nelson Muhia
- African Population and Health Research Centre (APHRC), APHRC Campus, Kirawa Road, Off PeponiRoad, P.O. Box 10787, 00100, Nairobi, Kenya.
| | - Milka Wanjohi
- African Population and Health Research Centre (APHRC), APHRC Campus, Kirawa Road, Off PeponiRoad, P.O. Box 10787, 00100, Nairobi, Kenya.
| | - Peterrock Muriuki
- African Population and Health Research Centre (APHRC), APHRC Campus, Kirawa Road, Off PeponiRoad, P.O. Box 10787, 00100, Nairobi, Kenya.
| | - Betty Samburu
- Human Nutrition and Dietetics Unit, Ministry of Health, P.O. Box 43319-00100, Nairobi, Kenya.
| | - James N Kanyuira
- Action Against Hunger (ACF), 4th Floor, Suite 17, Green House, Ngong Road, P.O. Box 39900-00623, Nairobi, Kenya.
| | - Sera L Young
- Department of Population Medicine and Diagnostics, Program in International Nutrition, Cornell University, Ithaca, NY, USA.
| | - Paula L Griffiths
- Centre for Global Health and Human Development, Loughborough University, Loughborough, UK.
| | - Nyovani J Madise
- Centre for Global Health, Population, Poverty and Policy, ESRC Centre for Population Change, Faculty of Social and Human Science, University of Southampton, Building 58, Room 2001, Southampton, SO17 1BJ, UK.
| | - Stephen T McGarvey
- International Health Institute, Brown University, Providence, RI 02903, USA.
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13
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Abstract
The prevalence of HIV in the adult population in slum areas in Nairobi, Kenya, is higher than for residents in the city as a whole. This disparity suggests that the characteristics of slum areas may adversely influence the HIV-prevention strategies directed at reducing the national prevalence of HIV. The objective of the study was to identify some of the sociodemographic and behavioural correlates of HIV-status awareness among the adult population of two slums in Nairobi. In a household-based survey conducted by the African Population and Health Research Center (APHRC), 4 767 men and women aged between 15 and 54 years were randomly sampled from two slums (Korogocho and Viwandani) in Nairobi and data were collected on the social and health context of HIV and AIDS in these settlements. Bivariate and multivariate logistic regression analyses were conducted to identify factors associated with HIV-status awareness. The proportion of respondents that had ever been tested and knew their HIV status was 53%, with the women having greater awareness of their HIV status (62%) than the men (38%). Awareness of HIV status was significantly associated with age, sex, level of education, marital status and slum of residence. The lower level of HIV-status awareness among the men compared with the women in the slums suggests a poor uptake of HIV-testing services by males. Innovative strategies are needed to ensure greater access and uptake of HIV-testing services by the younger and less-educated residents of these slums if the barriers to HIV-status awareness are to be overcome.
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Affiliation(s)
- Remare Renner Ettarh
- a African Population and Health Research Center (APHRC) , Manga Close, PO Box 10787 , Nairobi , 00100 , Kenya
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14
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Kimani-Murage EW, Wekesah F, Wanjohi M, Kyobutungi C, Ezeh AC, Musoke RN, Norris SA, Madise NJ, Griffiths P. Factors affecting actualisation of the WHO breastfeeding recommendations in urban poor settings in Kenya. Matern Child Nutr 2014; 11:314-32. [PMID: 25521041 PMCID: PMC6860346 DOI: 10.1111/mcn.12161] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Poor breastfeeding practices are widely documented in Kenya, where only a third of children are exclusively breastfed for 6 months and only 2% in urban poor settings. This study aimed to better understand the factors that contribute to poor breastfeeding practices in two urban slums in Nairobi, Kenya. In‐depth interviews (IDIs), focus group discussions (FGDs) and key informant interviews (KIIs) were conducted with women of childbearing age, community health workers, village elders and community leaders and other knowledgeable people in the community. A total of 19 IDIs, 10 FGDs and 11 KIIs were conducted, and were recorded and transcribed verbatim. Data were coded in NVIVO and analysed thematically. We found that there was general awareness regarding optimal breastfeeding practices, but the knowledge was not translated into practice, leading to suboptimal breastfeeding practices. A number of social and structural barriers to optimal breastfeeding were identified: (1) poverty, livelihood and living arrangements; (2) early and single motherhood; (3) poor social and professional support; (4) poor knowledge, myths and misconceptions; (5) HIV; and (6) unintended pregnancies. The most salient of the factors emerged as livelihoods, whereby women have to resume work shortly after delivery and work for long hours, leaving them unable to breastfeed optimally. Women in urban poor settings face an extremely complex situation with regard to breastfeeding due to multiple challenges and risk behaviours often dictated to them by their circumstances. Macro‐level policies and interventions that consider the ecological setting are needed.
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Affiliation(s)
| | - Frederick Wekesah
- African Population and Health Research Center (APHRC), Nairobi, Kenya
| | - Milka Wanjohi
- African Population and Health Research Center (APHRC), Nairobi, Kenya
| | | | - Alex C Ezeh
- African Population and Health Research Center (APHRC), Nairobi, Kenya
| | - Rachel N Musoke
- Department of Paediatrics, University of Nairobi, Nairobi, Kenya
| | - Shane A Norris
- MRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nyovani J Madise
- Centre for Global Health, Population, Poverty, and Policy, University of Southampton, Southampton, UK
| | - Paula Griffiths
- MRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Centre for Global Health and Human Development, Loughborough University, Loughborough, UK
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15
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Kimani-Murage EW, Schofield L, Wekesah F, Mohamed S, Mberu B, Ettarh R, Egondi T, Kyobutungi C, Ezeh A. Vulnerability to food insecurity in urban slums: experiences from Nairobi, Kenya. J Urban Health 2014; 91:1098-113. [PMID: 25172616 PMCID: PMC4242851 DOI: 10.1007/s11524-014-9894-3] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Food and nutrition security is critical for economic development due to the role of nutrition in healthy growth and human capital development. Slum residents, already grossly affected by chronic poverty, are highly vulnerable to different forms of shocks, including those arising from political instability. This study describes the food security situation among slum residents in Nairobi, with specific focus on vulnerability associated with the 2007/2008 postelection crisis in Kenya. The study from which the data is drawn was nested within the Nairobi Urban Health and Demographic Surveillance System (NUHDSS), which follows about 70,000 individuals from close to 30,000 households in two slums in Nairobi, Kenya. The study triangulates data from qualitative and quantitative sources. It uses qualitative data from 10 focus group discussions with community members and 12 key-informant interviews with community opinion leaders conducted in November 2010, and quantitative data involving about 3,000 households randomly sampled from the NUHDSS database in three rounds of data collection between March 2011 and January 2012. Food security was defined using the Household Food Insecurity Access Scale (HFIAS) criteria. The study found high prevalence of food insecurity; 85% of the households were food insecure, with 50% being severely food insecure. Factors associated with food security include level of income, source of livelihood, household size, dependence ratio; illness, perceived insecurity and slum of residence. The qualitative narratives highlighted household vulnerability to food insecurity as commonplace but critical during times of crisis. Respondents indicated that residents in the slums generally eat for bare survival, with little concern for quality. The narratives described heightened vulnerability during the 2007/2008 postelection violence in Kenya in the perception of slum residents. Prices of staple foods like maize flour doubled and simultaneously household purchasing power was eroded due to worsened unemployment situation. The use of negative coping strategies to address food insecurity such as reducing the number of meals, reducing food variety and quality, scavenging, and eating street foods was prevalent. In conclusion, this study describes the deeply intertwined nature of chronic poverty and acute crisis, and the subsequent high levels of food insecurity in urban slum settings. Households are extremely vulnerable to food insecurity; the situation worsening during periods of crisis in the perception of slum residents, engendering frequent use of negative coping strategies. Effective response to addressing vulnerability to household food insecurity among the urban poor should focus on both the underlying vulnerabilities of households due to chronic poverty and added impacts of acute crises.
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Affiliation(s)
- E W Kimani-Murage
- African Population and Health Research Centre, Nairobi, Kenya, P.O. Box 10787, 00100, Nairobi, Kenya,
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16
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Kimani-Murage EW, Kyobutungi C, Ezeh AC, Wekesah F, Wanjohi M, Muriuki P, Musoke RN, Norris SA, Griffiths P, Madise NJ. Effectiveness of personalised, home-based nutritional counselling on infant feeding practices, morbidity and nutritional outcomes among infants in Nairobi slums: study protocol for a cluster randomised controlled trial. Trials 2013; 14:445. [PMID: 24370263 PMCID: PMC3879433 DOI: 10.1186/1745-6215-14-445] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 12/09/2013] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Nutrition in the first 1,000 days of life (during pregnancy and the first two years) is critical for child growth and survival. Poor maternal, infant and young child nutrition (MIYCN) practices are widely documented in Kenya, with potential detrimental effects on child growth and survival. This is particularly a problem in slums, where most urban residents live. For example, exclusive breastfeeding for the first six months is only about two per cent. Innovative strategies to reach slum residents are therefore needed. Strategies like the Baby Friendly Hospital Initiative have proven effective in some settings but their effectiveness in resource-limited settings, including slums where many women do not deliver in hospital, is questionable. We propose to test the effectiveness of a home-based intervention on infant feeding practices, nutrition and health outcomes of infants born in two slums in Nairobi, Kenya. METHODS/DESIGN The study, employing a cluster-randomised study design, will be conducted in two slums in Nairobi: Korogocho and Viwandani where 14 community units (defined by the Government's health care system) will form the unit of randomization. A total of 780 pregnant women and their respective child will be recruited into the study. The mother-child pair will be followed up until the child is one year old. Recruitment will last approximately one year and three months from September 2012 to December 2013. The mothers will receive regular, personalised, home-based counselling by trained Community Health Workers on MIYCN. Regular assessment of knowledge, attitudes and practices on MIYCN will be done, coupled with assessments of nutritional status of the mother-child pairs and diarrhea morbidity for the children. Statistical methods will include analysis of covariance and multinomial logistic regression. Additionally, cost-effectiveness analysis will be done. The study is funded by the Wellcome Trust and will run from March 2012 to February 2015. DISCUSSION Interventions aimed at promoting optimal breastfeeding and complementary feeding practices are considered to have high impact and could prevent a fifth of the under-five deaths in countries with high mortality rates. This study will inform policy and practice in Kenya and similar settings regarding delivery mechanisms for such high-impact interventions, particularly among urban poor populations. TRIAL REGISTRATION ISRCTN83692672.
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Affiliation(s)
| | - Catherine Kyobutungi
- African Population and Health Research Center (APHRC), P.O. 10787, 00100 Nairobi, Kenya
| | - Alex C Ezeh
- African Population and Health Research Center (APHRC), P.O. 10787, 00100 Nairobi, Kenya
| | - Frederick Wekesah
- African Population and Health Research Center (APHRC), P.O. 10787, 00100 Nairobi, Kenya
| | - Milka Wanjohi
- African Population and Health Research Center (APHRC), P.O. 10787, 00100 Nairobi, Kenya
| | - Peterrock Muriuki
- African Population and Health Research Center (APHRC), P.O. 10787, 00100 Nairobi, Kenya
| | - Rachel N Musoke
- Department of Paediatrics, University of Nairobi, Nairobi, Kenya
| | - Shane A Norris
- MRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Paula Griffiths
- MRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Centre for Global Health and Human Development, Loughborough University, Loughborough, UK
| | - Nyovani J Madise
- Centre for Global Health, Population, Poverty, and Policy University of Southampton, Southampton, UK
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