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Housing is a key social determinant of health with implications for both physical and mental health. The measurement of healthy housing and studies characterizing the same in sub-Saharan Africa (SSA) are uncommon. This study described a methodological approach employed in the assessment and characterization of healthy housing in SSA using the Demographic and Health Survey (DHS) data for 15 countries and explored healthy housing determinants using a multiple survey-weighted logistic regression analysis. For all countries, we demonstrated that the healthy housing index developed using factor analysis reasonably satisfies both reliability and validity tests and can therefore be used to describe the distribution of healthy housing across different groups and in understanding the linkage with individual health outcomes. We infer from the results that unhealthy housing remains quite high in most SSA countries. Having a male head of the household was associated with decreased odds of healthy housing in Burkina Faso (OR = 0.80, CI = 0.68–0.95), Cameroon (OR = 0.65, CI = 0.57, 0.76), Malawi (OR = 0.70, CI = 0.64–0.78), and Senegal (OR = 0.62, CI = 0.51–0.74). Further, increasing household size was associated with reducing odds of healthy housing in Kenya (OR = 0.53, CI = 0.44–0.65), Namibia (OR = 0.34, CI = 0.24–0.48), Nigeria (OR = 0.57, CI = 0.46–0.71), and Uganda (OR = 0.79, CI = 0.67–0.94). Across all countries, household wealth was a strong determinant of healthy housing, with middle and rich households having higher odds of residing in healthy homes compared to poor households. Odds ratios ranged from 3.63 (CI = 2.96–4.44) for households in the middle wealth group in the DRC to 2812.2 (CI = 1634.8–4837.7) in Namibia’s wealthiest households. For other factors, the analysis also showed variation across countries. Our findings provide timely insights for the implementation of housing policies across SSA countries, drawing attention to aspects of housing that would promote occupant health and wellbeing. Beyond the contribution to the measurement of healthy housing in SSA, our paper highlights key policy and program issues that need further interrogation in the search for pathways to addressing the healthy housing deficit across most SSA countries. This has become critical amid the COVID-19 pandemic, where access to healthy housing is pivotal in its control.

We present novel co-created transdisciplinary research that uses arts and humanities methods to explore air pollution in an informal settlement (Mukuru) in Nairobi, Kenya. Air pollution is a well-documented major human health issue, but despite many air pollution reduction interventions designed to improve health, these are frequently ineffective. Often this is because they fail to account for local knowledge, cultural practices and priorities of the intended recipients. Designing solutions therefore requires in-depth exploration of relevant issues with stakeholders. Researchers worked collaboratively with local residents to develop a range of methods to explore understandings of air pollution including interviews, storytelling, participatory mapping and theatre. Together, we uncovered contrasting definitions of air pollution, differing perceptions of who was responsible for enacting solutions, and overall a view that air pollution cannot be seen in isolation from the other issues faced by settlement residents. The methods used also allowed us to communicate about the topic with a wide audience. While we acknowledge that this research approach is more time consuming than traditional approaches, we urge other researchers wishing to address multifactorial problems, such as air pollution to use a mixture of qualitative, participatory and creative methods to engage with a wide range of stakeholders to elicit new and unexpected understandings that may not otherwise emerge.

Among the barriers to proper solid waste management (SWM), and which have received little research attention is the role of conflict and crime in the sector. This paper explores conflict and crime ...

Urbanization in most African countries has overstretched the available sanitation services, leading to unsafe disposal of faecal sludge especially among the urban poor. Recycling of faecal sludge i...

The primary goal of solid waste management to protect the health of the population, particularly low-income groups, has been hindered by lack of local data to pinpoint priorities and identify appro...

Building on available evidence that there are differences of exposure to solid waste among men, women and children, it follows that effective solid waste management (SWM) policies need to recognise such variations, as a prelude to rolling out programmes to address associated socio-economic and health risks. However, this logical scenario does not seem to be the case in many middle- and low-income countries. In this paper, we use analytical review methodology to examine integrated environmental management and sector specific policies in Nairobi and Mombasa, Kenya's two biggest cities, to highlight the extent to which existing policies cover the differential challenges of exposure to solid waste and associated health challenges for women and children. We found that apart from one municipal policy and the Kenya Vision 2030 documents respectively, which underscore the importance of including women and young people in waste management, 16 other policy documents reviewed are generally silent on women and children issues. Beyond the limited focus on women- and children-specific challenges, the general lag in policy implementation and enforcement of regulations will still hinder the emergence of an effective SWM system out of the best policy frameworks . The preceding discussion underscores both policy and implementation gaps, which need to be filled, if policies will potentially engender SWM practices that will be relevant and effective in protecting the health of the most vulnerable in urban Africa.

The study used quality methods to collect the data. The data collection was conducted both in Nairobi and Mombasa (two main commercial cities), using in-depth interviews (IDIs), key informant interviews (KIIs) and focus group discussions (FGDs). A total of 10 FGDs (Each FGD was made up of 8-12 people), 15 IDIs and 15 KIIs were completed with selected respondents in the two cities. The purposive sampling strategy was used to select respondents who would be better positioned to provide rich information on the subject being investigated. The IDIs and FGDs were conducted with community members and solid waste (SW) workers, including scavengers. while KIIs were conducted with policymakers, civil society organisations, international non-governmental organisations, community-based organisations and national institutions responsible for environmental issues in Kenya. All interviews were audio-recorded and transcribed verbatim by professional transcribers, translated into English for interviews conducted in the local language, and validated by an independent transcriber. Thematic analytical approach was employed in the analysis of the data.

The problem of solid waste management presents an issue of increasing importance in many low-income settings, including the progressively urbanised context of Kenya. Kisumu County is one such setting with an estimated 500 t of waste generated per day and with less than half of it regularly collected. The open burning and natural decay of solid waste is an important source of greenhouse gas (GHG) emissions and atmospheric pollutants with adverse health consequences. In this paper, we use system dynamics modelling to investigate the expected impact on GHG and PM2.5 emissions of (i) a waste-to-biogas initiative and (ii) a regulatory ban on the open burning of waste in landfill. We use life tables to estimate the impact on mortality of the reduction in PM2.5 exposure. Our results indicate that combining these two interventions can generate over 1.1 million tonnes of cumulative savings in GHG emissions by 2035, of which the largest contribution (42%) results from the biogas produced replacing unclean fuels in household cooking. Combining the two interventions is expected to reduce PM2.5 emissions from the waste and residential sectors by over 30% compared to our baseline scenario by 2035, resulting in at least around 1150 cumulative life years saved over 2021–2035. The contribution and novelty of this study lies in the quantification of a potential waste-to-biogas scenario and its environmental and health impact in Kisumu for the first time., Graphical abstract Unlabelled Image, Highlights • We present a system dynamics study of solid waste management in Kisumu, Kenya. • Scenarios involve a waste-to-biogas initiative and a ban on open burning in landfill. • Combined scenario generates 1.1m tonnes cumulative GHG savings by 2035. • Largest contribution (42%) is from biogas substituting traditional cooking fuels. • Combined scenario may save 1,150 cumulative life years by 2035, plus ~220 more p.a.

Background: Environmental improvement is a priority for urban sustainability and health and achieving it requires transformative change in cities. An approach to achieving such change is to bring together researchers, decision-makers, and public groups in the creation of research and use of scientific evidence. Methods: This article describes the development of a programme theory for Complex Urban Systems for Sustainability and Health (CUSSH), a four-year Wellcome-funded research collaboration which aims to improve capacity to guide transformational health and environmental changes in cities. Results: Drawing on ideas about complex systems, programme evaluation, and transdisciplinary learning, we describe how the programme is understood to “work” in terms of its anticipated processes and resulting changes. The programme theory describes a chain of outputs that ultimately leads to improvement in city sustainability and health (described in an ‘action model’), and the kinds of changes that we expect CUSSH should lead to in people, processes, policies, practices, and research (described in a ‘change model’). Conclusions: Our paper adds to a growing body of research on the process of developing a comprehensive understanding of a transdisciplinary, multiagency, multi-context programme. The programme theory was developed collaboratively over two years. It involved a participatory process to ensure that a broad range of perspectives were included, to contribute to shared understanding across a multidisciplinary team. Examining our approach allowed an appreciation of the benefits and challenges of developing a programme theory for a complex, transdisciplinary research collaboration. Benefits included the development of teamworking and shared understanding and the use of programme theory in guiding evaluation. Challenges included changing membership within a large group, reaching agreement on what the theory would be ‘about’, and the inherent unpredictability of complex initiatives.

Surging amounts of waste are reported globally and especially in lower-income countries, with negative consequences for health and the environment. Increasing concern has been raised for the limited progress achieved in practice by diverse sets of policies and programmes. Waste management is a wicked problem characterised by multilayered interdependencies, complex social dynamics and webs of stakeholders. Interactions among these generate unpredictable outcomes that can be missed by decision makers through their understanding and framing of their context. This article aims to identify possible sources of persistent problems by focussing on what captures, shapes and limits the attention of stakeholders and decision-makers, drawing on the attention-based view from organisation theory. The theory describes the process through which issues and opportunities are noticed and how these are translated into actions, by focussing on the influencers at the individual, organisational and context scale. Views on issues and opportunities for waste management were collected in a series of fieldwork activities from 60 participants representing seven main types of stakeholders in the typical lower-middle income Kenyan city of Kisumu. Through a thematic analysis guided by the attention-based view, we identified patterns and misalignment of views, especially between government, community-based organisations and residents, which may contribute to persistent waste problems in Kisumu. Some point to detrimental waste handling practices, from separation to collection and treatment, as the main cause of issues. For others, these practices are due to a poor control of such practices and enforcement of the law. This study's major theoretical contribution is extending the application of attention theory to multi-stakeholder problems and to non-formalized organisations, namely residents and to the new field of waste management. This novel lens contributes a greater understanding of waste issues and their management in Africa that is relevant to policy and future research. By revealing the “wickedness” of the waste problem, we point to the need for a holistic and systems-based policy approach to limit further unintended consequences., Graphical abstract Image 1, Highlights • Attention-based view helps understand multi-stakeholder waste management problems. • Our analysis highlighted individual, social and contextual factors driving attention. • Household behaviour and government control are pointed as main source of the issues. • Misaligned scales in issues and moves across stakeholders must be tackled. • We rapport waste management wicked problem to multiple actors and agendas.

This paper provides a summary of the priorities and strategies stipulated by the major solid waste management (SWM) policies in Kenya. It also provides a brief assessment of their implementation in Nairobi and Mombasa, drawing on data from a 2016 community-based study. We found that SWM policies have evolved to specificity in terms of focus, functions and scope. There was a shift from criminalizing solid waste action or inaction to promoting good practices; from generic acts to specific ones; and from centralized mandates to more decentralized responsibilities. However, SWM remains a critical concern and a major challenge in Nairobi and Mombasa as a result of weak institutional structures and capacity, weak enforcement of regulatory frameworks, and the control of the sector by criminal cartels.

Ambient air pollution is a growing global health concern tightly connected to the rapid global urbanization. Health impacts from outdoor air pollution exposure amounts to high burdens of deaths and disease worldwide. However, the lack of systematic collection of air pollution and health data in many low-and middle-income countries remains a challenge for epidemiological studies in the local environment. This study aimed to provide a description of the particulate matter (PM2.5) concentration in the poorest urban residential areas of Nairobi, Kenya.Real-time measurements of (PM2.5) were conducted in two urban informal settlements of Nairobi City, Kenya"s Capital, from February 2013 to October 2013. The measurements were conducted using DustTrak II 8532 hand-held samplers at a height of about 1.5m above ground level with a resolution of 1-min logging. Sampling took place from early morning to evenings according to a fixed route of measurement within areas including fixed geographical checkpoints.The study period average concentration of PM2.5 was 166μg/m(3) in the Korogocho area and 67μg/m(3) in the Viwandani area. The PM2.5 levels in both areas reached bimodal daily peaks in the morning and evening. The average peak value of morning concentration in Korogocho was 214μg/m(3), and 164μg/m(3) in the evening and in Viwandani was 76μg/m(3) and 82μg/m(3) respectively. The daily mid-day average low observed during was 146μg/m(3) in Korogocho and 59μg/m(3) in Viwandani.The results show that residents in both slums are continuously exposed to PM2.5 levels exceeding hazardous levels according to World Health Organization guidelines. The study showed a marked disparity between the two slum areas situated only 7km apart indicating the local situation and sources to be very important for exposure to PM2.5.

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

Air pollution is among the leading global risks for mortality and responsible for increasing risk for chronic diseases. Community perceptions on exposure are critical in determining people's response and acceptance of related policies. Therefore, understanding people' perception is critical in informing the design of appropriate intervention measures. The aim of this paper was to establish levels and associations between perceived pollution and health risk perception among slum residents. A cross-sectional study of 5,317 individuals aged 35+ years was conducted in two slums of Nairobi. Association of perceived score and individual characteristics was assessed using linear regression. Spatial variation in the perceived levels was determined through hot spot analysis using ArcGIS. The average perceived air pollution level was higher among residents in Viwandani compared to those in Korogocho. Perceived air pollution level was positively associated with perceived health risks. The majority of respondents were exposed to air pollution in their place of work with 66% exposed to at least two sources of air pollution. Less than 20% of the respondents in both areas mentioned sources related to indoor pollution. The perceived air pollution level and related health risks in the study community were low among the residents indicating the need for promoting awareness on air pollution sources and related health risks.

Slum dwellers constitute an increasing share of urban populations in sub-Saharan Africa. This paper examines changes in proximate determinants of fertility in slums in Nairobi, Kenya between 2000 and 2012. We used data from the Nairobi Cross-sectional Slum Surveys (NCSS) conducted in in all Nairobi’s informal settlements, among 3,256 women aged 15-49 in 2000 and 4,240 aged 12-49 in 2012. We employed Stover’s revised proximate determinants of fertility framework to assess the relative contribution of contraception, marriage, sterility and postpartum insusceptibility to the fertility levels between 2000 and 2012. There has been a change in the influence of the proximate determinants in Nairobi’s slums. Marriage as measured by recent sexual activity had the largest inhibiting effect in 2000, whereas contraception had the largest effect in 2012. Findings suggest the need to sustain and/or strengthen FP/SRH initiatives that emphasize contraceptive use among women in urban slums in Kenya

Timely and adequate antenatal care (ANC) attendance is important in maternal health. This paper examined the factors associated with ANC utilization in Nairobi slums in 2000 and 2012. Data come from two cross sectional surveys in the slums in Nairobi city. We fitted multinomial and logistic regression models to assess respectively, factors associated with timing of the first ANC visit and the frequency of ANC visits. In both years, parity, mother’s ethnic group and educational attainment were significantly associated with timing of first ANC visit. Frequency of visits was significantly associated with mother’s educational attainment, parity, pregnancy wantedness and place of residence. We conclude that for optimal ANC utilization, there is need to improve women’s educational outcomes and address cultural barriers to utilization

Using the principles of reputational case selection sampling procedure and thematic search of electronic databases and websites, we implemented a regional synthesis of evidence on the health vulnerabilities of migrant and mobile populations in urban areas of East and Southern Africa. The review identified key health challenges relating to various diseases, including the increasing challenge of non-communicable diseases, such diabetes among migrants by 2030. While figures are difficult to obtain, our review suggested high levels of urban migrants, including refugees, internally displaced persons (IDPs) and asylum seekers in urban areas of the region, which for undocumented migrants poses particular logistics challenges in terms of administering targeted interventions, more so in contexts where poor socio-economic situations of countries do not provide them with opportunities to become self-reliant and less dependent on humanitarian assistance. This calls for policies, program interventions and research investments targeting vulnerable migrant and mobile groups in the region

With 2.8 billion biomass users globally, household air pollution remains a public health threat in many low- and middle-income countries. However, little evidence on pollution levels and health effects exists in low-income settings, especially slums. This study assesses the levels and sources of household air pollution in the urban slums of Nairobi. This cross-sectional study was embedded in a prospective cohort of pregnant women living in two slum areasKorogocho and Viwandaniin Nairobi. Data on fuel and stove types and ventilation use come from 1058 households, while air quality data based on the particulate matters (PM2.5) level were collected in a sub-sample of 72 households using the DustTrak II Model 8532 monitor. We measured PM2.5 levels mainly during daytime and using sources of indoor air pollutions. The majority of the households used kerosene (69.7%) as a cooking fuel. In households where air quality was monitored, the mean PM2.5 levels were high and varied widely, especially during the evenings (124.6 mu g/m(3) SD: 372.7 in Korogocho and 82.2 mu g/m(3) SD: 249.9 in Viwandani), and in households using charcoal (126.5 mu g/m(3) SD: 434.7 in Korogocho and 75.7 mu g/m(3) SD: 323.0 in Viwandani). Overall, the mean PM2.5 levels measured within homes at both sites (Korogocho = 108.9 mu g/m(3) SD: 371.2; Viwandani = 59.3 mu g/m(3) SD: 234.1) were high. Residents of the two slums are exposed to high levels of PM2.5 in their homes. We recommend interventions, especially those focusing on clean cookstoves and lighting fuels to mitigate indoor levels of fine particles.

Background: People's perceptions of and attitudes towards pollution are critical for reducing exposure among people and can also influence the response to interventions that are aimed at encouraging behaviour change. This study assessed the perceptions and attitudes of residents in two slums in Nairobi regarding air pollution. Methods: We conducted focus group discussions with residents aged 18 years and above using an emergent design in the formulation of the study guide. A thematic approach was used in data analysis. Results: The discussions revealed that the two communities experience air pollution arising mainly from industries and dump sites. There was an apparent disconnect between knowledge and practice, with individuals engaging in practices that placed them at high risk of exposure to air pollution. Residents appear to have rationalized the situation in which they live in and were resigned to these conditions. Consequently, they expressed lack of agency in addressing prevalent air pollution within their communities. Conclusions: Community-wide education on air pollution and related health effects together with the measures needed to reduce exposure to air pollution are necessary towards reducing air pollution impacts. A similar city-wide study is recommended to enable comparison of perceptions along socio-economic groups and neighbourhoods.

This report is based on secondary analysis of data from the Transition to Adulthood (TTA) project among 12-22 years olds living in two informal settlements Korogocho and Viwandani in Nairobi Kenya. The report highlights the sexual and reproductive health (SRH) challenges faced by adolescents living in these slums as well as the perceptions and strategies that adolescents adopt to deal with each of these challenges. The findings are expected to contribute guidance to the design and implementation of appropriate SRH intervention programs that respond to the unique needs of adolescent boys and girls living in poor urban settings.

Background: Many studies have established a link between weather (primarily temperature) and daily mortality in developed countries. However, little is known about this relationship in urban populations in sub- Saharan Africa.Objectives: The objective of this study was to describe the relationship between daily weather and mortality in Nairobi, Kenya, and to evaluate this relationship with regard to cause of death, age, and sex.Methods: We utilized mortality data from the Nairobi Urban Health and Demographic Surveillance System and applied time-series models to study the relationship between daily weather and mortality for a population of approximately 60,000 during the period 2003-2008. We used a distributed lag approach to model the delayed effect of weather on mortality, stratified by cause of death, age, and sex.Results: Increasing temperatures (above 75th percentile) were significantly associated with mortality in children and non-communicable disease (NCD) deaths. We found all-cause mortality of shorter lag of same day and previous day to increase by 3.0% for a 1 degree decrease from the 25th percentile of 18°C (not statistically significant). Mortality among people aged 50+ and children aged below 5 years appeared most susceptible to cold compared to other age groups. Rainfall, in the lag period of 0-29 days, increased all-cause mortality in general, but was found strongest related to mortality among females. Low temperatures were associated with deaths due to acute infections, whereas rainfall was associated with all-cause pneumonia and NCD deaths.Conclusions: Increases in mortality were associated with both hot and cold weather as well as rainfall in Nairobi, but the relationship differed with regard to age, sex, and cause of death. Our findings indicate that weather-related mortality is a public health concern for the population in the informal settlements of Nairobi, Kenya, especially if current trends in climate change continue.Keywords: time-series; temperature; rainfall; mortality; climate; urban(Published: 23 November 2012)Citation: Glob Health Action 2012, 5: 19065 - http://dx.doi.org/10.3402/gha.v5i0.19065

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

SummaryAlthough desired family size is often different from actual family size, the dynamics of this difference are not well understood. This paper examines the patterns and determinants of the difference between desired and actual number of children (unmet fertility desires) among women aged 15–49 years using pooled data from the 1990, 1999 and 2003 Nigeria Demographic and Health Surveys (NDHSs). The results show that more than two-thirds of the sample have unmet fertility desires (18.1% have more while 52.4% have fewer than desired). It was found that early and late childbearing increased the odds of unmet fertility desires. Also, women with low levels of education, from poor households, rural residents as well as those who had experienced child death were at a higher risk of unmet fertility desires in the multivariate context. The study highlights the policy and programme implications of the findings.

Background Maternal mortality is higher and skilled attendance at delivery is lower in the slums of Nairobi (Kenya) compared to Ouagadougou (Burkina Faso). Lower numbers of public health facilities greater distance to facilities and higher costs of maternal health services in Nairobi could explain these differences. Objective By comparing the use of maternal health care services among women with similar characteristics in the two cities we will produce a more nuanced picture of the contextual factors at play. Design We use birth statistics collected between 2009 and 2011 in all households living in several poor neighborhoods followed by the Nairobi and the Ouagadougou Health and Demographic Surveillances Systems (n=3346 and 4239 births). We compare the socioeconomic characteristics associated with antenatal care (ANC) use and deliveries at health facilities controlling for demographic variables. Results ANC use is greater in Nairobi than in Ouagadougou for every category of women. In Ouagadougou there are few differentials in having at least one ANC visit and in delivering at a health facility; however differences are observed for completing all four ANC visits. In Nairobi less educated poorer non Kikuyu women and women living in the neighborhood farther from public health services have poorer ANC and deliver more often outside of a health facility. Conclusions These results suggest that women are more aware of the importance of ANC utilization in Nairobi compared to Ouagadougou. The presence of numerous for profit health facilities within slums in Nairobi may also help women have all four ANC visits although the services received may be of substandard quality. In Ouagadougou the lack of socioeconomic differentials in having at least one ANC visit and in delivering at a health facility suggests that these practices stem from the application of well enforced maternal health regulations; however these regulations do not cover the entire set of four ANC visits.

Although linked to poverty as conditions reflecting inadequate access to resources to obtain food, issues such as hunger and food insecurity have seldom been recognized as important in urban settings. Overall, little is known about the prevalence and magnitude of hunger and food insecurity in most cities. Yet, in sub-Saharan Africa where the majority of urban dwellers live on less than one dollar a day, it is obvious that a large proportion of the urban population must be satisfied with just one meal a day. This paper suggests using the one- and two-parameter item response theory models to infer a reliable and valid measure of hunger and food insecurity relevant to low-income urban settings, drawing evidence from the Nairobi Urban Health and Demographic Surveillance System. The reliability and accuracy of the items are tested using both the Mokken scale analysis and the Cronbach test. The validity of the inferred household food insecurity measure is assessed by examining how it is associated with households’ economic status. Results show that food insecurity is pervasive amongst slum dwellers in Nairobi. Only one household in five is food-secure, and nearly half of all households are categorized as “food-insecure with both adult and child hunger.” Moreover, in line with what is known about household allocation of resources, evidence indicates that parents often forego food in order to prioritize their children.