Epidemiology of emergency and elective caesarean section and its association with early neonatal mortality in sub-Saharan African countries

INTRODUCTION

Investigating elective and emergency caesarean section (CS) separately is important for a better understanding of birth delivery modes in the sub-Saharan Africa (SSA) region and identifying bottlenecks that prevent favourable childbirth outcomes in SSA. This study aimed at evaluating the prevalences of both CS types, determining their associated socioeconomic factors and their association with early neonatal mortality in SSA.

METHODS

SSA countries Demographic and Health Surveys data that had collected information on the CS' timing were included in our study. A total of 21 countries were included in this study, with a total of 155 172 institutional live births. Prevalences of both CS types were estimated at the countries' level using household sampling weights. Multilevel models were fitted to identify associated socioeconomic factors of both CS types and their associations with early neonatal mortality.

RESULTS

The emergency CS prevalence in SSA countries was estimated at 4.6% (95% CI 4.4-4.7) and was higher than the elective CS prevalence estimated at 3.4% (95% CI 3.3-3.6). Private health facilities' elective CS prevalence was estimated at 10.2% (95% CI 9.3-11.2) which was higher than the emergency CS prevalence estimated at 7.7% (95% CI 7.0-8.5). Conversely, in public health facilities, the emergency CS prevalence was estimated at 4.0% (95% CI 3.8-4.2) was higher than the elective CS prevalence estimated at 2.7% (95% CI 2.6-2.8). The richest women were more likely to have birth delivery by both CS types than normal vaginal delivery. Emergency CS was positively associated with early neonatal mortality (adjusted OR=2.37, 95% CI 1.64-3.41), while no association was found with elective CS.

CONCLUSIONS

Findings suggest shortcomings in pregnancy monitoring, delivery preparation and postnatal care. Beyond antenatal care (ANC) coverage, more attention should be put on quality of ANC, postnatal care, emergency obstetric and newborn care for favourable birth delivery outcomes in SSA.

Women's beliefs about methods and contraceptive discontinuation: Results from a prospective study from Nairobi and Homa Bay counties in Kenya

Background

Rates of contraceptive discontinuation are high in many low and middle countries contributing to unmet need for contraception and other adverse reproductive health outcomes. Few studies have investigated how women's beliefs about methods and strength of fertility preferences affect discontinuation rates. This study examines this question using primary data collected in Nairobi and Homa Bay counties in Kenya.

Methods

We used data from two rounds of a longitudinal study of married women ages 15–39 years (2,812 and 2,424 women from Nairobi and Homa Bay respectively at round 1). Information on fertility preferences, past and current contraceptive behavior, and method-related beliefs about six modern contraceptive methods were collected, along with a monthly calendar of contraceptive use between the two interviews. The analysis focused on discontinuation of the two most commonly used methods in both sites, injectables and implants. We carry out competing risk survival analysis to identify which method related beliefs predict discontinuation among women using at the first round.

Results

The percentages of episodes discontinued in the 12 months between the two rounds was 36%, with a higher rate of discontinuation in Homa Bay (43%) than in the Nairobi slums (32%) and higher for injectables than implants. Method related concerns and side effects were the major self-reported reasons for discontinuation in both sites. The competing risk survival analysis showed that the probability of method related discontinuation of implants and injectables was significantly lower among respondents who believed that the methods do not cause serious health problems (SHR = 0.78, 95% CI: 0.62–0.98), do not interfere with regular menses (SHR = 0.76, 95% CI: 0.61–0.95) and do not cause unpleasant side effects (SHR = 0.72, 95% CI 0.56–0.89). By contrast, there were no net effects of three method related beliefs that are commonly cited as obstacles to contraceptive use in African societies: safety for long-term use, ability to have children after stopping the method, and the approval of the husband.

Conclusion

This study is unique in its examination of the effect of method-specific beliefs on subsequent discontinuation for a method-related reason, using a longitudinal design. The single most important result is that concerns about serious health problems, which are largely unjustified and only moderately associated with beliefs about side effects, are a significant influence on discontinuation. The negative results for other beliefs show that the determinants of discontinuation differ from the determinants of method adoption and method choice.

Childhood vaccination timeliness following maternal migration to an informal urban settlement in Kenya

INTRODUCTION

Timely receipt of recommended vaccines is a proven strategy to reduce preventable under-five deaths. Kenya has experienced impressive declines in child mortality from 111 to 43 deaths per 1000 live births between 1980 and 2019. However, considerable inequities in timely vaccination remain, which unnecessarily increases risk for serious illness and death. Maternal migration is a potentially important driver of timeliness inequities, as the social and financial stressors of moving to a new community may require a woman to delay her child's immunizations. This analysis examined how maternal migration to informal urban settlements in Nairobi, Kenya influenced childhood vaccination timeliness.

METHODS

Data came from the Nairobi Urban Health and Demographic Surveillance System, 2002-2018. Migration exposures were migrant status (migrant, non-migrant), migrant origin (rural, urban), and migrant type (first-time, circular [previously resided in settlement]). Age at vaccine receipt (vaccination timeliness) was calculated for all basic vaccinations. Accelerated failure time models were used to investigate relationships between migration exposures and vaccination timeliness. Confounding was addressed using propensity score weighting.

RESULTS

Over one-third of the children of both migrants and non-migrants received at least one dose late or not at all. Unweighted models showed the children of migrants had shorter time to OPV1 and DPT1 vaccine receipt compared to the children of non-migrants. After accounting for confounding only differences in timeliness for DPT1 remained, with the children of migrants receiving DPT1 significantly earlier than the children of non-migrants. Timeliness was comparable among migrants with rural and urban origins and among first-time and circular migrants.

CONCLUSION

Although a substantial proportion of children in Nairobi's informal urban settlements do not receive timely vaccination, this analysis found limited evidence that maternal migration and migration characteristics were associated with delays for most doses. Future research should seek to elucidate potential drivers of low vaccination timeliness in Kenya.

Prevalence of uncontrolled hypertension in people with comorbidities in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

The burden of uncontrolled hypertension in sub-Saharan Africa (SSA) is high and hypertension is known to coexist with other chronic diseases such as kidney disease, diabetes among others. This is the first systematic review and meta-analysis to determine the burden of uncontrolled hypertension among patients with comorbidities in SSA.

METHODS

A comprehensive search was conducted on MEDLINE, Excerpta Medica Database (Embase) and Web of Science to identify all relevant articles published between 1 January 2000 and 17 June 2021. We included studies that reported on the prevalence of uncontrolled hypertension among people in SSA who report taking antihypertensive treatment and have another chronic condition. A random-effects meta-analysis was performed to obtain the pooled estimate of the prevalence of uncontrolled hypertension among patients with comorbid conditions while on treatment across studies in SSA.

RESULTS

In all, 20 articles were included for meta-analyses. Eleven articles were among diabetic patients, five articles were among patients with HIV, two were among patients with stroke while chronic kidney disease and atrial fibrillation had one article each. The pooled prevalence of uncontrolled hypertension among patients with comorbidities was 78.6% (95% CI 71.1% to 85.3%); I² 95.9%, varying from 73.1% in patients with stroke to 100.0% in patients with atrial fibrillation. Subgroup analysis showed differences in uncontrolled hypertension prevalence by various study-level characteristics CONCLUSION: This study suggests a high burden of uncontrolled hypertension in people with comorbidities in SSA. Strategies to improve the control of hypertension among people with comorbidities are needed.

PROSPERO REGISTRATION NUMBER

CRD42019108218.

Inequalities in early marriage, childbearing and sexual debut among adolescents in sub-Saharan Africa

Background

Adolescent sexual and reproductive health (ASRH) is a major public health concern in sub-Saharan Africa (SSA). However, inequalities in ASRH have received less attention than many other public health priority areas, in part due to limited data. In this study, we examine inequalities in key ASRH indicators.

Methods

We analyzed national household surveys from 37 countries in SSA, conducted during 1990–2018, to examine trends and inequalities in adolescent behaviors related to early marriage, childbearing and sexual debut among adolescents using data from respondents 15–24 years. Survival analyses were conducted on each survey to obtain estimates for the ASRH indicators. Multilevel linear regression modelling was used to obtain estimates for 2000 and 2015 in four subregions of SSA for all indicators, disaggregated by sex, age, household wealth, urban–rural residence and educational status (primary or less versus secondary or higher education).

Results

In 2015, 28% of adolescent girls in SSA were married before age 18, declined at an average annual rate of 1.5% during 2000–2015, while 47% of girls gave birth before age 20, declining at 0.6% per year. Child marriage was rare for boys (2.5%). About 54% and 43% of girls and boys, respectively, had their sexual debut before 18. The declines were greater for the indicators of early adolescence (10–14 years). Large differences in marriage and childbearing were observed between adolescent girls from rural versus urban areas and the poorest versus richest households, with much greater inequalities observed in West and Central Africa where the prevalence was highest. The urban–rural and wealth-related inequalities remained stagnant or widened during 2000–2015, as the decline was relatively slower among rural and the poorest compared to urban and the richest girls. The prevalence of the ASRH indicators did not decline or increase in either education categories.

Conclusion

Early marriage, childbearing and sexual debut declined in SSA but the 2015 levels were still high, especially in Central and West Africa, and inequalities persisted or became larger. In particular, rural, less educated and poorest adolescent girls continued to face higher ASRH risks and vulnerabilities. Greater attention to disparities in ASRH is needed for better targeting of interventions and monitoring of progress.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01125-8.

Wealth-related inequalities in demand for family planning satisfied among married and unmarried adolescent girls and young women in sub-Saharan Africa

Background

The use of modern contraception has increased in much of sub-Saharan Africa (SSA). However, the extent to which changes have occurred across the wealth spectrum among adolescents is not well known. We examine poor-rich gaps in demand for family planning satisfied by modern methods (DFPSm) among sexually active adolescent girls and young women (AGYW) using data from national household surveys.

Methods

We used recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys to describe levels of wealth-related inequalities in DFPSm among sexually active AGYW using an asset index as an indicator of wealth. Further, we used data from countries with more than one survey conducted from 2000 to assess DFPSm trends. We fitted linear models to estimate annual average rate of change (AARC) by country. We fitted random effects regression models to estimate regional AARC in DFPSm. All analysis were stratified by marital status.

Results

Overall, there was significant wealth-related disparities in DFPSm in West Africa only (17.8 percentage points (pp)) among married AGYW. The disparities were significant in 5 out of 10 countries in Eastern, 2 out of 6 in Central, and 7 out of 12 in West among married AGYW and in 2 out of 6 in Central and 2 out of 9 in West Africa among unmarried AGYW. Overall, DFPSm among married AGYW increased over time in both poorest (AARC = 1.6%, p < 0.001) and richest (AARC = 1.4%, p < 0.001) households and among unmarried AGYW from poorest households (AARC = 0.8%, p = 0.045). DPFSm increased over time among married and unmarried AGYW from poorest households in Eastern (AARC = 2.4%, p < 0.001) and Southern sub-regions (AARC = 2.1%, p = 0.030) respectively. Rwanda and Liberia had the largest increases in DPFSm among married AGYW from poorest (AARC = 5.2%, p < 0.001) and richest (AARC = 5.3%, p < 0.001) households respectively. There were decreasing DFPSm trends among both married (AARC = − 1.7%, p < 0.001) and unmarried (AARC = − 4.7%, p < 0.001) AGYW from poorest households in Mozambique.

Conclusion

Despite rapid improvements in DFPSm among married AGYW from the poorest households in many SSA countries there have been only modest reductions in wealth-related inequalities. Significant inequalities remain, especially among married AGYW. DFPSm stalled in most sub-regions among unmarried AGYW.

New Vaccine Introduction and Childhood Vaccination Timeliness in Two Urban, Informal Settlements in Nairobi, Kenya

New vaccine introduction accompanied by social mobilization activities could contribute to improved routine immunization timeliness. This study assesses the impact of Kenya's introduction of pneumococcal conjugate vaccine (PCV) on the timeliness of routine childhood vaccination in two informal, urban settlements in Nairobi. Data collected from 2007 to 2015 as part of a demographic surveillance system were used to estimate annual vaccination delays of ≥ 4 weeks among children aged 12-23 months in the period before and after the introduction of PCV in Kenya. Binomial segmented regression models using generalized estimating equations examined the association between vaccine introduction and timeliness of routine immunization. Over half of all children vaccinated in the two urban areas received one or more doses ≥ 4 weeks after the recommended age. The timeliness of routine immunization showed slight improvements or nonsignificant changes during the years following PCV introduction compared with the preceding years (adjusted prevalence ratio [aPR]: 0.67, 95% CI: 0.45-0.99 for Bacille Calmette-Guerin receipt; aPR: 0.59, 95% CI: 0.41-0.83 for third dose Pentavalent receipt; aPR: 1.19, 95% CI: 0.99-1.42 for measles). However, as of 2015, delayed vaccination remained prevalent in children, particularly among the poorest residing in the settlements. Many sub-Saharan African countries have introduced new life-saving vaccines into their routine childhood immunization schedule. Additional evidence regarding the positive or neutral influence of new vaccine introduction on the performance of delivery systems provides further justification to sustain the inclusion of these more costly vaccines in the immunization schedule.

The influence of maternal migration on child vaccination in Kenya: An inverse probability of treatment-weighted analysis

OBJECTIVES

Kenya has substantially improved child mortality between 1990 and 2019, with under-5 mortality decreasing from 104 to 43 deaths per 1000 live births. However, only two-thirds of Kenyan children receive all recommended vaccines by 1 year, making it essential to identify undervaccinated subpopulations. Internal migrants are a potentially vulnerable group at risk of decreased access to healthcare. This analysis explored how maternal migration within Kenya influences childhood vaccination.

METHODS

Data were from the 2014 Kenya Demographic and Health Survey, a nationally representative cross-sectional survey. Logistic regressions assessed relationships between maternal migration and full and up-to-date child vaccination using inverse probability of treatment weighting. Two exposure variables were examined: migration status and stream (e.g. rural-urban). Multiple imputation was used to impute up-to-date status for children without vaccination cards to reduce selection bias.

RESULTS

After accounting for selection and confounding biases, all relationships between migration status and migration stream and full and up-to-date vaccination became statistically insignificant.

CONCLUSIONS

Null findings indicate that, in Kenya, characteristics enabling migration, rather than the process of migration itself, drive differential vaccination behavior between migrants and non-migrants. This finding is an important deviation from previous literature, which did not rigorously address important biases.

Vaccine Delay and Its Association With Undervaccination in Children in Sub-Saharan Africa

INTRODUCTION

Improving the timeliness and completion of vaccination is the key to reducing under-5 childhood mortality. This study examines the prevalence of delayed vaccination for doses administered at birth and age 6 weeks, 10 weeks, 14 weeks, and 9 months and its association with undervaccination among infants in Sub-Saharan Africa.

METHODS

Pooling data across 33 Sub-Saharan Africa countries, vaccination timing and series completion were assessed for children aged 12-35 months who were included in the immunization module of the Demographic and Health Surveys conducted between 2010 and 2019. Survey design-adjusted logistic regression modeled the likelihood of not fully completing the basic immunization schedule associated with dose-specific delays in vaccination. Data were obtained and analyzed in May 2020.

RESULTS

Among children with complete date records (n=70,006), the proportion of children vaccinated with delays by ≥1 month was high: 25.9% for Bacille Calmette-Guerin (at birth); 49.1% for the third dose of pentavalent combination vaccine (at 14 weeks); and 63.9% for the first dose of measles vaccines (at 9 months). Late vaccination was more common for children born to mothers with lower levels of educational attainment (p<0.001) and wealth (p<0.001). Controlling for place, time, and sociodemographics, vaccination delays at any dose were significantly associated with not completing the immunization schedule by 12 months (Bacille Calmette-Guerin: AOR=1.93, [95% CI=1.83, 2.02]; pentavalent 3: AOR=1.50 [95% CI=1.35, 1.64]; measles: AOR=3.76 [95% CI=3.37, 4.15]).

CONCLUSIONS

Timely initiation of vaccination could contribute to higher rates of immunization schedule completion, improving the reach and impact of vaccination programs on child health outcomes in Sub-Saharan Africa.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.

Women's Empowerment and Child Vaccination in Kenya: The Modifying Role of Wealth

INTRODUCTION

Although vaccination coverage is high in Kenya relative to other African nations, undervaccinated children remain, making it important to identify characteristics of these children and their caregivers. Potentially relevant but understudied factors are women's empowerment and early marriage. Women who marry older and have more autonomous decision-making authority may be better able to ensure their children receive health services, including immunizations. This analysis examines the relationship between early marriage and multiple dimensions of women's empowerment and child vaccination status in Kenya and explores whether these relationships are modified by wealth.

METHODS

Data were from the 2014 Kenya Demographic and Health Survey. The analysis was completed in 2020 using updated data made available to researchers in 2019. Logistic regressions assessed relationships among early marriage, 3 dimensions of women's empowerment (enabling conditions, intrinsic agency, and instrumental agency), and child vaccination. Analyses were stratified by wealth to explore potential effect modification.

RESULTS

For women in the middle wealth tertile, the odds of having a fully vaccinated child were 3.45 (95% CI=1.51, 7.91) times higher for those with higher versus lower empowerment. Further, among the wealthiest women, those with middle empowerment were 5.99 (95% CI=2.06, 17.40) times more likely to have a fully vaccinated child than women with lower empowerment.

CONCLUSIONS

Results suggest a threshold effect of wealth's role in the relationship between empowerment and vaccination. Enabling conditions may not influence immunization among the poorest women but exert a stronger positive influence on childhood vaccination among wealthier women.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.

Inequities in On-Time Childhood Vaccination: Evidence From Sub-Saharan Africa

INTRODUCTION

Vaccination coverage has improved in the past decade, but inequalities persist: the poorest, least educated, and rural communities are left behind. Programming has focused on increasing coverage and reaching the hardest-to-reach children, but vaccination timeliness is equally important because delays leave children vulnerable to infections. This study examines the levels and inequities of on-time vaccination in the Sub-Saharan African region.

METHODS

The most recent Demographic and Health Surveys or Multiple Indicator Clusters Surveys since 2000 from Sub-Saharan Africa were used to assess on-time vaccination and inequalities by household wealth, maternal education, and place of residence. Inequalities were quantified using slope index of inequality and concentration index.

RESULTS

The analysis included 153,632 children aged 12-36 months from 40 Sub-Saharan Africa countries. Median on-time vaccination coverage was <50% in all the 4 subregions. Differences in on-time vaccination were observed by place of residence in the Southern (20.8 percentage points, 95% CI=0.8, 40.8), West (17.5 percentage points, 95% CI=5.1, 29.9), and Eastern (20.9 percentage points, 95% CI=6.5, 35.2) regions. Wealth-related inequities were observed in the Southern (22.6 percentage points, 95% CI=4.0, 41.2), Western (30.6 percentage points, 95% CI=19.1, 42.1), and Eastern (26.1 percentage points, 95% CI=8.2, 44.0) regions. Significant education-related differences in on-time vaccination were observed in the Western (20.7 percentage points, 95% CI=10.9, 30.5) and Eastern (21.2 percentage points, 95% CI=7.0, 35.4) regions.

CONCLUSIONS

On-time vaccination coverage was low in all subregions and nearly all countries. Inequalities in on-time immunization by household wealth, place of residence, and education existed in most countries. Concrete strategies to improve levels of timeliness are needed.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Global Vaccination Equity, which is sponsored by the Global Institute for Vaccine Equity at the University of Michigan School of Public Health.

Do inequalities exist in the disadvantaged populations? Levels and trends of full and on-time vaccination coverage in two Nairobi urban informal settlements

There has been an improvement in childhood vaccination coverage over the last two decades worldwide. However, inequities exist among different populations. Vaccination programs should focus not only on increasing coverage but as also in timeliness to ensure maximum protection. This study examined the levels, inequities, and trends of full and on-time vaccination coverage in two urban informal settlements in Nairobi. The study used longitudinal data from the Nairobi Urban Health and Demographic Surveillance System from 2003 to 2017 to estimate full and on-time vaccination coverage and assess inequalities by background characteristics. The frailty shared Cox model was used to assess time to full- and on-time- immunization coverage. Out of 32,018 children aged 12 to 59 months, less than half (46.7%) produced a vaccination card during the interview. Full and timely immunization coverage was higher in Viwandani site, among Kikuyu and Kamba ethnic groups, and children from the richest quintile. Timely vaccination was below 50% throughout the survey periods. After accounting for the intragroup correlations, for a given level of frailty, the hazard for being fully immunized was 10% more likely among the wealthiest compared to the poorest children. The hazard for being fully immunized was 16%, 16% to 19% less likely for Luhya, Luo, and others as compared to the Kikuyu ethnicity respectively. In conclusion, the study has shown that coverage has been increasing over the years but inequalities exist in immunization coverage among the most disadvantaged populations. More focused intervention approaches that target the disadvantaged groups are needed.

Complete and on-time routine childhood immunisation: determinants and association with severe morbidity in urban informal settlements, Nairobi, Kenya

Background: Completion of the full series of childhood vaccines on-time is crucial to ensuring greater protection against vaccine-preventable diseases.Aim: To examine determinants of complete and on-time vaccination and evaluate the relationship between vaccination patterns and severe morbidity outcomes.Subjects and methods: Vaccination information from infants in Nairobi Urban Health and Demographic Surveillance System was used to evaluate full and on-time vaccination coverage of routine immunisation. Logistic regression was used to identify determinants of full and on-time vaccination coverage. Cox regression model was used to evaluate the relationship between vaccination status and subsequent severe morbidity. A shared frailty cox model was fitted to account for the heterogeneity in hospitalisation episodes.Results: Maternal age, post-natal care, parity, ethnicity, and residence place were identified as determinants of vaccination completion. Institutional deliveries and residence place were identified as the determinants of on-time vaccination. A significant 58% (confidence interval [CI]: 15-79%) (p = .017) lower mortality was observed among fully immunised children compared with not fully immunised. Lower mortality was observed among on-time immunised children, 64% (CI: 20-84%) compared to those with delays.Conclusions: Improving vaccination timeliness and completion schedule is critical for protection against vaccine preventable diseases and may potentially provide protection beyond these targets.

Comparative performance of pooled cohort equations and Framingham risk scores in cardiovascular disease risk classification in a slum setting in Nairobi Kenya

BACKGROUND

Cardiovascular diseases (CVD) cause 18 million deaths annually. Low- and middle-income countries (LMICs) account for 80% of the CVD burden, and the burden is expected to grow in the region in the coming years. Screening for and identification of individuals at high risk for CVD in primary care settings can be accomplished using available CVD risk scores. However, few of these scores have been validated/recalibrated for use in sub-Saharan Africa (SSA).

METHODS

Pooled cohort equations (PCE) and Framingham risk scores for 10-year CVD risk were applied on 1960 men and women aged 40 years and older from the AWI-Gen (Africa, Wits-INDEPTH Partnership for GENomic studies) study 2015. Low, moderate/intermediate or high CVD risk classifications correspond to <10%, 10-20% and >20% chance of developing CVD in 10 years respectively. Agreement between the risk scores was assessed using kappa and correlation coefficients.

RESULTS

High CVD risk was 10.3% in PCE 2013, 0.4% in PCE 2018, 2.9% in Framingham and 3.6% in Framingham non-laboratory scores. Conversely, low CVD risk was 62.2% in PCE 2013 and 95.6% in PCE 2018, 84.0% and 80.1% in Framingham and Framingham non-laboratory scores, respectively. A moderate agreement existed between the Framingham functions (kappa = 0.64, 95% CI 0.59-0.68, correlation, rs = 0.711). There was no agreement between the PCE 2013 and 2018 functions (kappa = 0.05, 95% CI 0.04-0.06).

CONCLUSIONS

Newer cohort-based data is necessary to validate and recalibrate existing CVD risk scores in order to develop appropriate functions for use in SSA.

Adolescent sexual and reproductive health in sub-Saharan Africa: who is left behind?

Adolescent sexual and reproductive health (ASRH) continues to be a major public health challenge in sub-Saharan Africa where child marriage, adolescent childbearing, HIV transmission and low coverage of modern contraceptives are common in many countries. The evidence is still limited on inequalities in ASRH by gender, education, urban-rural residence and household wealth for many critical areas of sexual initiation, fertility, marriage, HIV, condom use and use of modern contraceptives for family planning. We conducted a review of published literature, a synthesis of national representative Demographic and Health Surveys data for 33 countries in sub-Saharan Africa, and analyses of recent trends of 10 countries with surveys in around 2004, 2010 and 2015. Our analysis demonstrates major inequalities and uneven progress in many key ASRH indicators within sub-Saharan Africa. Gender gaps are large with little evidence of change in gaps in age at sexual debut and first marriage, resulting in adolescent girls remaining particularly vulnerable to poor sexual health outcomes. There are also major and persistent inequalities in ASRH indicators by education, urban-rural residence and economic status of the household which need to be addressed to make progress towards the goal of equity as part of the sustainable development goals and universal health coverage. These persistent inequalities suggest the need for multisectoral approaches, which address the structural issues underlying poor ASRH, such as education, poverty, gender-based violence and lack of economic opportunity.

Uncontrolled hypertension among patients with comorbidities in sub-Saharan Africa: protocol for a systematic review and meta-analysis

BACKGROUND

Uncontrolled hypertension is the most important risk factor and leading cause of cardiovascular diseases. It is predicted that the number of people with hypertension will increase, and a large proportion of this increase will occur in developing countries. The highest prevalence of uncontrolled hypertension is reported in sub-Saharan Africa, and treatment for hypertension is unacceptably low. Hypertension commonly co-exists with comorbidities and this is associated with poorer health outcomes for patients. This review aims to estimate the prevalence of uncontrolled hypertension among patients with comorbidities in sub-Saharan Africa.

METHODS AND ANALYSIS

All published and unpublished studies on the prevalence of uncontrolled hypertension among patients with comorbidities in sub-Saharan Africa will be included. MEDLINE via OVID, Embase, and Web of Science will be searched to identify all relevant articles published from January 2000 to June 2019. Experts in the field will be contacted for unpublished literature, and Open SIGLE will be reviewed for relevant information. No language restriction will be imposed. Two reviewers will select, screen, extract data, and assess the risk of bias while a third reviewer will arbitrate the disagreements. A meta-analysis will be performed on variables that are similar across the included studies. Proportions will be stabilized before estimates are pooled using a random effects model. The presence of publication bias will be assessed using Egger's test and visual inspection of the funnel plots. This systematic and meta-analysis review protocol will be reported in accordance with the PRISMA-P protocol guidelines. Results will be stratified by country, comorbidity, and geographic region.

DISCUSSION

This systematic review and meta-analysis is expected to quantify the magnitude of uncontrolled hypertension among patients with certain comorbid conditions in sub-Saharan Africa to guide policies and interventions. This review is registered in PROSPERO International Prospective Register of Systematic reviews CRD42019108218.

Prevalence and factors associated with health insurance coverage in resource-poor urban settings in Nairobi, Kenya: a cross-sectional study

OBJECTIVE

To determine the prevalence of health insurance and associated factors among households in urban slum settings in Nairobi, Kenya.

DESIGN

The data for this study are from a cross-sectional survey of adults aged 18 years or older from randomly selected households in Viwandani slums (Nairobi, Kenya). Respondents participated in the Lown scholars' study conducted between June and July 2018.

SETTING

The Lown scholars' survey was nested in the Nairobi Urban Health and Demographic Surveillance System in Viwandani slums in Nairobi, Kenya.

PARTICIPANTS

A total of 300 randomly sampled households participated in the survey. The study respondents comprised of either the household head, their spouses or credible adult household members.

PRIMARY OUTCOME MEASURE

The primary outcome of this study was enrolment in a health insurance programme. The households were classified into two groups: those having at least one member covered by health insurance and those without any health insurance cover.

RESULTS

The prevalence of health insurance in the sample was 43%. Being unemployed (adjusted OR (aOR) 0.17; p<0.05; 95% CI 0.06 to 0.47) and seeking care from a public health facility (aOR 0.50; p<0.05; 95% CI 0.28 to 0.89) was significantly associated with lower odds of having a health insurance cover. The odds of having a health insurance cover were significantly lower among respondents who perceived their health status as good (aOR 0.62; p<0.05; 95% CI 1.17 to 5.66) and those who were unsatisfied with the cost of seeking primary care (aOR 0.34; p<0.05; 95% CI 0.17 to 0.69).

CONCLUSIONS

Health insurance coverage in Viwandani slums in Nairobi, Kenya, is low. As universal health coverage becomes the growing focus of Kenya's 'Big Four Agenda' for socioeconomic transformation, integrating enabling and need factors in the design of the national health insurance package may scale-up social health protection.

Patterns of non-communicable disease and injury risk factors in Kenyan adult population: a cluster analysis

BACKGROUND

Non-communicable diseases and unintentional injuries are emerging public health problems in sub-Saharan Africa. These threats have multiple risk factors with complex interactions. Though some studies have explored the magnitude and distribution of those risk factors in many populations in Kenya, an exploration of segmentation of population at a national level by risk profile, which is crucial for a differentiated approach, is currently lacking. The aim of this study was to examine patterns of non-communicable disease and injury risk through the identification of clusters and investigation of correlates of those clusters among Kenyan adult population.

METHODS

We used data from the 2015 STEPs survey of non-communicable disease risk factors conducted among 4484 adults aged between 18 and 69 years in Kenya. A total of 12 risk factors for NCDs and 9 factors for injury were used as clustering variables. A K-medians Cluster Analysis was applied. We used matching as the measure of the similarity/dissimilarity among the clustering variables. While clusters were described using the risk factors, the predictors of the clustering were investigated using multinomial logistic regression.

RESULTS

We have identified five clusters for NCDs and four clusters for injury based on the risk profile of the population. The NCD risk clusters were labelled as cluster hypertensives, harmful users, the hopefuls, the obese, and the fat lovers. The injury risk clusters were labelled as helmet users, jaywalkers, the defiant and the compliant. Among the possible predictors of clustering, age, gender, education and wealth index came out as strong predictors of the cluster variables.

CONCLUSION

This cluster analysis has identified important clusters of adult Kenyan population for non-communicable disease and injury risk profiles. Risk reduction interventions could consider these clusters as potential target in the development and segmentation of a differentiated approach.

Prevalence, awareness, treatment and control of hypertension and their determinants: results from a national survey in Kenya

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.

Prevalence and factors associated with pre-diabetes and diabetes mellitus in Kenya: results from a national survey

BACKGROUND

Diabetes Mellitus is one of the four major non-communicable diseases causing about 4 million deaths in 2017. By 2040, low income countries are projected to experience 92% increase in mortality due to diabetes. Undiagnosed diabetes poses a public health concern with costly public health implications especially in Africa. It is therefore crucial to examine the burden and risk factors for diabetes at national level to inform policy and national programs.

METHODS

Data from the 2015 Kenya national STEPs survey of adults aged 18-69 years were used. Pre-diabetes was defined as impaired fasting blood glucose level (6.1 mmol/l to < 7 mmol/l) while diabetes was defined as impaired fasting blood glucose level ≥ 7 mmol/l. Descriptive statistics were used to determine the prevalence of pre-diabetes and diabetes and logistic regression was used to identify associated factors.

RESULTS

Complete data for 4069 respondents (51% females), with 46% aged 18-29 and 61% in rural areas were analyzed. The age-standardized prevalence for pre-diabetes and diabetes were 3.1% (95% CI: 2.2, 4.0) and 2.4% (1.8, 3.0) respectively. Only 43.7% were aware of their glycemic condition, one in five of those who had diabetes had received treatment, and only 7% of those diagnosed with diabetes had their blood glucose under control. Primary education ((both incomplete (0.21, 95%CI 0.10-0.47) and complete (0.40, 95%CI 0.23-0.71)) were associated with lower odds of pre-diabetes. Older age (60-69 years, AOR; 5.6, 95%CI 2.1-15.1) and raised blood pressure (2.8, 95% CI 1.5-5.0) were associated diabetes while overweight/obesity among women was associated with diabetes.

CONCLUSION

The overall diabetes prevalence in Kenya is consistent with what has been reported in other sub-Saharan African countries. Of concern is the higher prevalence of pre-diabetes and undiagnosed diabetes that can progress to complications in the absence of interventions and the low diabetes awareness and control. This is the first nationally representative study to identify important groups at risk of pre-diabetes and diabetes that can be targeted for screening, health promotion and treatment.

Individual and household level factors associated with presence of multiple non-communicable disease risk factors in Kenyan adults

BACKGROUND

Non-communicable diseases (NCDs), are increasing globally, causing about 60% of disability-adjusted life years and 39.8 million deaths in 2015. Risk factors often cluster and interact multiplicatively in an individual and this is strongly associated with the development and severity of NCDs. We assessed the sociodemographic factors associated with the presence of multiple NCD risk factors among individuals aged 18 years and older in the Kenyan population.

METHODS

We used national representative data from 4066 individuals out of 4500 who participated in the WHO STEPs study in 2015. NCD risk factor counts were derived by summing the risk factors present in an individual and categorising into 1-3, 4-6 and 7+ risk factors in any combination of the 12 assessed NCD risk factors (hypertension, diabetes mellitus, cholesterol, insufficient physical activity, excessive alcohol use, tobacco use and obesity, excess sugar intake, insufficient fruit and vegetables intake, high salt consumption, and use of unhealthy cooking fats and oils). Ordered logistic regression was used to investigate the sociodemographic factors associated with an individual possesing multiple NCD risk factors.

RESULTS

Majority (75.8%) of the individuals in the study possesed 4-6 and 10% had ≥7 NCDs risk factors. Nearly everyone (99.8%) had insufficient fruits and vegetable intakes, 89.5% consumed high salt in their diet and 80.3% did not engage in sufficient physical activity. Apart from NCD risk count which increased with age among both men and women, associations with other socio-demographic factors differed between men and women. A woman of Akamba ethinicity had lower odds (0.43) while Meru women had higher odds (3.58) of higher NCD risk factor count, compared to the Kalenjin women. Among men, being a Kisii or Luo was associated with lower odds (0.48 and 0.25 respectively) of higher NCD risk factor count. Women in a marital union had higher odds (1.58) of a higher NCD risk factor count.

CONCLUSION

Majority of Kenyan adults possess more than four NCD risk factors; a clear indication of an emerging epidemic of NCDs in this population. Effective and multi-sectoral interventions targeting multiple risk factors in individuals are required to mitigate especially the behavioural and modifiable NCD risk factors in Kenya.

Evidence of a Double Burden of Malnutrition in Urban Poor Settings in Nairobi, Kenya

Background

Many low- and middle-income countries are undergoing a nutrition transition associated with rapid social and economic transitions. We explore the coexistence of over and under- nutrition at the neighborhood and household level, in an urban poor setting in Nairobi, Kenya.

Methods

Data were collected in 2010 on a cohort of children aged under five years born between 2006 and 2010. Anthropometric measurements of the children and their mothers were taken. Additionally, dietary intake, physical activity, and anthropometric measurements were collected from a stratified random sample of adults aged 18 years and older through a separate cross-sectional study conducted between 2008 and 2009 in the same setting. Proportions of stunting, underweight, wasting and overweight/obesity were dettermined in children, while proportions of underweight and overweight/obesity were determined in adults.

Results

Of the 3335 children included in the analyses with a total of 6750 visits, 46% (51% boys, 40% girls) were stunted, 11% (13% boys, 9% girls) were underweight, 2.5% (3% boys, 2% girls) were wasted, while 9% of boys and girls were overweight/obese respectively. Among their mothers, 7.5% were underweight while 32% were overweight/obese. A large proportion (43% and 37%%) of overweight and obese mothers respectively had stunted children. Among the 5190 adults included in the analyses, 9% (6% female, 11% male) were underweight, and 22% (35% female, 13% male) were overweight/obese.

Conclusion

The findings confirm an existing double burden of malnutrition in this setting, characterized by a high prevalence of undernutrition particularly stunting early in life, with high levels of overweight/obesity in adulthood, particularly among women. In the context of a rapid increase in urban population, particularly in urban poor settings, this calls for urgent action. Multisectoral action may work best given the complex nature of prevailing circumstances in urban poor settings. Further research is needed to understand the pathways to this coexistence, and to test feasibility and effectiveness of context-specific interventions to curb associated health risks.

Ethnicity and delay in measles vaccination in a nairobi slum

The influence of ethnicity on vaccination uptake in urban slums in Kenya is largely unknown. We examined the disparities in timeliness and coverage of measles vaccination associated with ethnicity in the Korogocho slum of Nairobi. The study used data from the Maternal and Child Health component of the Urbanization, Poverty and Health Dynamics Research Programme undertaken in the Korogocho and Viwandani slums by the African Population and Health Research Center from 2006 to 2010. Vaccination information was collected from children recruited into the study during the first year after birth, and a sub-sample of 2,317 who had been followed throughout the period and had the required information on measles vaccination was included in the analysis. Cox regression analysis was used to determine the association of ethnicity with delayed measles in the slum. We found significant disparities in the coverage and timeliness of measles vaccination between the ethnic groups in Korogocho. The Luhya and minor ethnic groups in the slum were more likely than the Kikuyu to have delayed measles vaccination. Ethnic groups with a high proportion of children with delayed measles vaccination need to be targeted to address cultural barriers to vaccination as part of efforts to improve coverage in urban slums.

Patterns and determinants of breastfeeding and complementary feeding practices in urban informal settlements, Nairobi Kenya

BACKGROUND

The World Health Organisation (WHO) recommends exclusive breastfeeding during the first six months of life for optimal growth, development and health. Breastfeeding should continue up to two years or more and nutritionally adequate, safe, and appropriately-fed complementary foods should be introduced at the age of six months to meet the evolving needs of the growing infant. Little evidence exists on breastfeeding and infant feeding practices in urban slums in sub-Saharan Africa. Our aim was to assess breastfeeding and infant feeding practices in Nairobi slums with reference to WHO recommendations.

METHODS

Data from a longitudinal study conducted in two Nairobi slums are used. The study used information on the first year of life of 4299 children born between September 2006 and January 2010. All women who gave birth during this period were interviewed on breastfeeding and complementary feeding practices at recruitment and this information was updated twice, at four-monthly intervals. Cox proportional hazard analysis was used to determine factors associated with cessation of breastfeeding in infancy and early introduction of complementary foods.

RESULTS

There was universal breastfeeding with almost all children (99%) having ever been breastfed. However, more than a third (37%) were not breastfed in the first hour following delivery, and 40% were given something to drink other than the mothers' breast milk within 3 days after delivery. About 85% of infants were still breastfeeding by the end of the 11th month. Exclusive breastfeeding for the first six months was rare as only about 2% of infants were exclusively breastfed for six months. Factors associated with sub-optimal infant breastfeeding and feeding practices in these settings include child's sex; perceived size at birth; mother's marital status, ethnicity; education level; family planning (pregnancy desirability); health seeking behaviour (place of delivery) and; neighbourhood (slum of residence).

CONCLUSIONS

The study indicates poor adherence to WHO recommendations for breastfeeding and infant feeding practices. Interventions and further research should pay attention to factors such as cultural practices, access to and utilization of health care facilities, child feeding education, and family planning.

Childhood vaccination in informal urban settlements in Nairobi, Kenya: who gets vaccinated?

Background

Recent trends in global vaccination coverage have shown increases with most countries reaching 90% DTP3 coverage in 2008, although pockets of undervaccination continue to persist in parts of sub-Saharan Africa particularly in the urban slums. The objectives of this study were to determine the vaccination status of children aged between 12-23 months living in two slums of Nairobi and to identify the risk factors associated with incomplete vaccination.

Methods

The study was carried out as part of a longitudinal Maternal and Child Health study undertaken in Korogocho and Viwandani slums of Nairobi. These slums host the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) run by the African Population and Health Research Centre (APHRC). All women from the NUHDSS area who gave birth since September 2006 were enrolled in the project and administered a questionnaire which asked about the vaccination history of their children. For the purpose of this study, we used data from 1848 children aged 12-23 months who were expected to have received all the WHO-recommended vaccinations. The vaccination details were collected during the first visit about four months after birth with follow-up visits repeated thereafter at four month intervals. Full vaccination was defined as receiving all the basic childhood vaccinations by the end of 24 months of life, whereas up-to-date (UTD) vaccination referred to receipt of BCG, OPV 1-3, DTP 1-3, and measles vaccinations within the first 12 months of life. All vaccination data were obtained from vaccination cards which were sighted during the household visit as well as by recall from mothers. Multivariate models were used to identify the risk factors associated with incomplete vaccination.

Results

Measles coverage was substantially lower than that for the other vaccines when determined using only vaccination cards or in addition to maternal recall. Up-to-date (UTD) coverage with all vaccinations at 12 months was 41.3% and 51.8% with and without the birth dose of OPV, respectively. Full vaccination coverage (57.5%) was higher than up-to-date coverage (51.8%) at 12 months overall, and in both slum settlements, using data from cards. Multivariate analysis showed that household assets and expenditure, ethnicity, place of delivery, mother's level of education, age and parity were all predictors of full vaccination among children living in the slums.

Conclusions

The findings show the extent to which children resident in slums are underserved with vaccination and indicate that service delivery of immunization services in the urban slums needs to be reassessed to ensure that all children are reached.