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The Nairobi Urban Health and Demographic Surveillance System (NUHDSS) was the first urban-based longitudinal health and demographic surveillance platform in sub-Saharan Africa (SSA). The NUHDSS was established in 2002 to provide a platform to investigate the long-term social, economic and health consequences of urban residence, and to serve as a primary research tool for intervention and impact evaluation studies focusing on the needs of the urban poor in SSA. Since its inception, the NUHDSS has successfully followed every year a population of about 65,000 individuals in 24,000 households in two slum communities--Korogocho and Viwandani--in Nairobi, Kenya. Data collected include key demographic and health information (births, deaths including verbal autopsy, in- and out-migration, immunization) and other information that characterizes living conditions in the slums (livelihood opportunities, household amenities and possessions, type of housing etc.). In addition to the routine data, it has provided a robust platform for nesting several studies examining the challenges of rapid urbanization in SSA and associated health and poverty dynamics. NUHDSS data are shared through internal and external collaborations, in accordance with the Centre's guidelines for publications, data sharing., (© The Author 2015; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association.)

Background: The government of Kenya is making plans to implement a social health insurance program by transforming the National Hospital Insurance Fund (NHIF) into a universal health coverage program. This paper examines the determinants associated with participation in the NHIF among residents of urban slums in Nairobi city., Methods: The study used data from the Nairobi Urban Health and Demographic Surveillance System in two slums in Nairobi city, where a total of about 60,000 individuals living in approximately 23,000 households are under surveillance. Descriptive statistics and multivariate logistic regression analysis were used to describe the characteristics of the sample and to identify factors associated with participation in the NHIF program., Results: Only 10% of the respondents were participating in the NHIF program, while less than 1% (0.8%) had private insurance coverage. The majority of the respondents (89%) did not have any type of insurance coverage. Females were more likely to participate in the NHIF program (OR = 2.4; p < 0.001), while respondents who were formerly in a union (OR = 0.5; p < 0.05) and who were never in a union (OR = 0.6; p < 0.05) were less likely to have public insurance coverage. Respondents working in the formal employment sector (OR = 4.1; p < 0.001) were more likely to be enrolled in the NHIF program compared to those in the informal sector. Membership in microfinance institutions such as savings and credit cooperative organizations (SACCOs) and community-based savings and credit groups were important determinants of access to health insurance., Conclusions: The proportion of slum residents without any type of insurance is high, which underscores the need for a social health insurance program to ensure equitable access to health care among the poor and vulnerable segments of the population. As the Kenyan government moves toward transforming the NHIF into a universal health program, it is important to harness the unique opportunities offered by both the formal and informal microfinance institutions in improving health care capacity by considering them as viable financing options within a comprehensive national health financing policy framework.

The informal settlements of the Global South are the least prepared for the pandemic of COVID-19 since basic needs such as water, toilets, sewers, drainage, waste collection, and secure and adequate housing are already in short supply or non-existent. Further, space constraints, violence, and overcrowding in slums make physical distancing and self-quarantine impractical, and the rapid spread of an infection highly likely. Residents of informal settlements are also economically vulnerable during any COVID-19 responses. Any responses to COVID-19 that do not recognize these realities will further jeopardize the survival of large segments of the urban population globally. Most top-down strategies to arrest an infectious disease will likely ignore the often-robust social groups and knowledge that already exist in many slums. Here, we offer a set of practice and policy suggestions that aim to (1) dampen the spread of COVID-19 based on the latest available science, (2) improve the likelihood of medical care for the urban poor whether or not they get infected, and (3) provide economic, social, and physical improvements and protections to the urban poor, including migrants, slum communities, and their residents, that can improve their long-term well-being. Immediate measures to protect residents of urban informal settlements, the homeless, those living in precarious settlements, and the entire population from COVID-19 include the following: (1) institute informal settlements/slum emergency planning committees in every urban informal settlement; (2) apply an immediate moratorium on evictions; (3) provide an immediate guarantee of payments to the poor; (4) immediately train and deploy community health workers; (5) immediately meet Sphere Humanitarian standards for water, sanitation, and hygiene; (6) provide immediate food assistance; (7) develop and implement a solid waste collection strategy; and (8) implement immediately a plan for mobility and health care. Lessons have been learned from earlier pandemics such as HIV and epidemics such as Ebola. They can be applied here. At the same time, the opportunity exists for public health, public administration, international aid, NGOs, and community groups to innovate beyond disaster response and move toward long-term plans.

Many African towns and cities face a range of hazards, which can best be described as representing a "spectrum of risk" of events that can cause death, illness or injury, and impoverishment. Yet despite the growing numbers of people living in African urban centres, the extent and relative severity of these different risks is poorly understood. This paper provides a rationale for using a spectrum of methods to address this spectrum of risk, and demonstrates the utility of mixed‐methods approaches in planning for resilience. It describes activities undertaken in a wide‐ranging multi‐country programme of research, which use multiple approaches to gather empirical data on risk, in order to build a stronger evidence base and provide a more solid base for planning and investment. It concludes that methods need to be chosen in regard to social, political economic, biophysical and hydrogeological context, while also recognising the different levels of complexity and institutional capacity in different urban centres. The paper concludes that as well as the importance of taking individual contexts into account, there are underlying methodological principles – based on multidisciplinary expertise and multi‐faceted and collaborative research endeavours – that can inform a range of related approaches to understanding urban risk in sub‐Saharan Africa and break the cycle of risk accumulation. Many African towns and cities face a range of hazards, which can best be described as representing a "spectrum of risk" of events that can cause death, illness or injury, and impoverishment. This paper provides a rationale for using a spectrum of methods to address this spectrum of risk, and demonstrates the utility of mixed‐methods approaches in planning for resilience. [ABSTRACT FROM AUTHOR]

Background: It is generally assumed that urban slum residents have worse health status when compared with other urban populations, but better health status than their rural counterparts. This belief/assumption is often because of their physical proximity and assumed better access to health care services in urban areas. However, a few recent studies have cast doubt on this belief. Whether slum dwellers are better off, similar to, or worse off as compared with rural and other urban populations remain poorly understood as indicators for slum dwellers are generally hidden in urban averages. Objective: The aim of this study was to compare health and health-related indicators among slum, rural, and other urban populations in four countries where specific efforts have been made to generate health indicators specific to slum populations. Design: We conducted a comparative analysis of health indicators among slums, non-slums, and all urban and rural populations as well as national averages in Bangladesh, Kenya, Egypt, and India. We triangulated data from demographic and health surveys, urban health surveys, and special cross-sectional slum surveys in these countries to assess differences in health indicators across the residential domains. We focused the comparisons on child health, maternal health, reproductive health, access to health services, and HIV/AIDS indicators. Within each country, we compared indicators for slums with non-slum, city/urban averages, rural, and national indicators. Between-country differences were also highlighted. Results: In all the countries, except India, slum children had much poorer health outcomes than children in all other residential domains, including those in rural areas. Childhood illnesses and malnutrition were higher among children living in slum communities compared to those living elsewhere. Although treatment seeking was better among slum children as compared with those in rural areas, this did not translate to better mortality outcomes. They bear a disproportionately much higher mortality burden than those living elsewhere. Slum communities had higher coverage of maternal health services than rural communities but it was not possible to compare maternal mortality rates across these residential domains. Compared to rural areas, slum communities had lower fertility and higher contraceptive use rates but these differences were reversed when slums were compared to other urban populations. Slumrural differences in infant mortality were found to be larger in Bangladesh compared to Kenya. Conclusion: Mortality and morbidity indicators were worse in slums than elsewhere. However, indicators of access to care and health service coverage were found to be better in slums than in rural communities. [ABSTRACT FROM AUTHOR]

What kills people around the world and how it varies from place to place and over time is critical in mapping the global burden of disease and therefore, a relevant public health question, especially in developing countries. While more than two thirds of deaths worldwide are in developing countries, little is known about the causes of death in these nations. In many instances, vital registration systems are nonexistent or at best rudimentary, and even when deaths are registered, data on the cause of death in particular local contexts, which is an important step toward improving context-specific public health, are lacking. In this paper, we examine the trends in the causes of death among the urban poor in two informal settlements in Nairobi by applying the InterVA-4 software to verbal autopsy data. We examine cause of death data from 2646 verbal autopsies of deaths that occurred in the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) between 1 January 2003 and 31 December 2012 among residents aged 15 years and above. The data is entered into the InterVA-4 computer program, which assigns cause of death using probabilistic modeling. The results are presented as annualized trends from 2003 to 2012 and disaggregated by gender and age. Over the 10-year period, the three major causes of death are tuberculosis (TB), injuries, and HIV/AIDS, accounting for 26.9, 20.9, and 17.3 % of all deaths, respectively. In 2003, HIV/AIDS was the highest cause of death followed by TB and then injuries. However, by 2012, TB and injuries had overtaken HIV/AIDS as the major causes of death. When this is examined by gender, HIV/AIDS was consistently higher for women than men across all the years generally by a ratio of 2 to 1. In terms of TB, it was more evenly distributed across the years for both males and females. We find that there is significant gender variation in deaths linked to injuries, with male deaths being higher than female deaths by a ratio of about 4 to 1. We also find a fifteen percentage point increase in the incidences of male deaths due to injuries between 2003 and 2012. For women, the corresponding deaths due to injuries remain fairly stable throughout the period. We find cardiovascular diseases as a significant cause of death over the period, with overall mortality increasing steadily from 1.6 % in 2003 to 8.1 % in 2012, and peaking at 13.7 % in 2005 and at 12.0 % in 2009. These deaths were consistently higher among women. We identified substantial variations in causes of death by age, with TB, HIV/AIDS, and CVD deaths lowest among younger residents and increasing with age, while injury-related deaths are highest among the youngest adults 15-19 and steadily declined with age. Also, deaths related to neoplasms and respiratory tract infections (RTIs) were prominent among older adults 50 years and above, especially since 2005. Emerging at this stage is evidence that HIV/AIDS, TB, injuries, and cardiovascular disease are linked to approximately 73 % of all adult deaths among the urban poor in Nairobi slums of Korogocho and Viwandani in the last 10 years. While mortality related to HIV/AIDS is generally declining, we see an increasing proportion of deaths due to TB, injuries, and cardiovascular diseases. In sum, substantial epidemiological transition is ongoing in this local context, with deaths linked to communicable diseases declining from 66 % in 2003 to 53 % in 2012, while deaths due to noncommunicable causes experienced a four-fold increase from 5 % in 2003 to 21.3 % in 2012, together with another two-fold increase in deaths due to external causes (injuries) from 11 % in 2003 to 22 % in 2012. It is important to also underscore the gender dimensions of the epidemiological transition clearly visible in the mix. Finally, the elevated levels of disadvantage of slum dwellers in our analysis relative to other population subgroups in Kenya continue to demonstrate appreciable deterioration of key urban health and social indicators, highlighting the need for a deliberate strategic focus on the health needs of the urban poor in policy and program efforts toward achieving international goals and national health and development targets. [ABSTRACT FROM AUTHOR]

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

Massive slums have become major features of cities in many low-income and middle-income countries. Here, in the first in a Series of two papers, we discuss why slums are unhealthy places with especially high risks of infection and injury. We show that children are especially vulnerable, and that the combination of malnutrition and recurrent diarrhoea leads to stunted growth and longer-term effects on cognitive development. We find that the scientific literature on slum health is underdeveloped in comparison to urban health, and poverty and health. This shortcoming is important because health is affected by factors arising from the shared physical and social environment, which have effects beyond those of poverty alone. In the second paper we will consider what can be done to improve health and make recommendations for the development of slum health as a field of study. [ABSTRACT FROM AUTHOR]