Home > Global > Urban Health Bulletin – May 2010

Urban Health Bulletin – May 2010

Below is an annotated bibliography of 12 recently published urban health studies. The entries are listed alphabetically by journal title.

1 Acta Trop. 2010 Apr 24.

An exploratory survey of malaria prevalence and people’s knowledge, attitudes and practices of mosquito larval source management for malaria control in western Kenya.

Imbahale SS, Fillinger U, Githeko A, Mukabana WR, Takken W. Laboratory of Entomology, Wageningen University and Research Centre, P.O. Box 8031, 6700 EH Wageningen, The Netherlands; Kenya Medical Research Institute, Centre for Global Health Research, P.O. Box 1578, 40100, Kisumu, Kenya.

A large proportion of mosquito larval habitats in urban and rural communities in sub-Saharan Africa are man-made. Therefore, community-based larval source management (LSM) could make a significant contribution to malaria control in an integrated vector management approach. Here we implemented an exploratory study to assess malaria prevalence and people’s knowledge, attitudes and practices on malaria transmission, its control and the importance of man-made aquatic habitats for the development of disease vectors in one peri-urban lowland and two rural highland communities in western Kenya. We implemented monthly cross-sectional malaria surveys and administered a semi-structured questionnaire in 90 households, i.e. 30 households in each locality. Malaria prevalence was moderate (3.2-6.5%) in all sites. Nevertheless, residents perceived malaria as their major health risk. Thirty-two percent (29/90) of all respondents did not know that mosquitoes are responsible for the transmission of malaria. Over two-thirds (69/90) of the respondents said that mosquito breeding site could be found close to their homes but correct knowledge of habitat characteristics was poor. Over one-third (26/67) believed that immature mosquitoes develop in vegetation. Man-made pools, drainage channels and burrow pits were rarely mentioned. After explaining where mosquito larvae develop, 56% (50/90) felt that these sites were important for their livelihood. Peri-urban residents knew more about mosquitoes’ role in malaria transmission, could more frequently describe the larval stages and their breeding habitats, and were more likely to use bed nets even though malaria prevalence was only half of what was found in the rural highland sites (p<0.05). This was independent of their education level or socio-economic status. Hence rural communities are more vulnerable to malaria infection, thus calling for additional methods to complement personal protection measures for vector control. Larval source management was the most frequently mentioned (30%) tool for malaria control but was only practiced by 2 out of 90 respondents. Targeting the larval stages of malaria vectors is an underutilized malaria prevention measure. Sustainable elimination or rendering of such habitats unsuitable for larval development needs horizontally organized, community-based programs that take people’s needs into account. Innovative, community-based training programs need to be developed to increase people’s awareness of man-made vector breeding sites and acceptable control methods need to be designed in collaboration with the communities.

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2 Am J Hum Biol. 2010 May;22(3):285-90.

Sociodemographic determinants of growth among Malian adolescent females.

Leslie TF, Pawloski LR. Department of Geography and Geoinformation Science, George Mason University, 4400 University Dr MS 6C3, Fairfax, VA 22030, USA. tleslie@gmu.edu

In Africa, research concerning the social determinants of poor nutritional status has typically focused on children under 5 years of age and has used defined categorical boundaries based on international reference standards. In this article, stunting and wasting of 1,157 Malian adolescent girls is measured through both categorical and continuous data. The focus on adolescent girls is significant because there is relatively little literature examining this group, and because adolescence marks the time when girls gain greater workload responsibilities, autonomy of food choices, and, as a result of the adolescent growth spurt, require the greatest amount of caloric intake respective to their weight since infancy. To differentiate stunting and wasting causes, a number of socioeconomic, geographic, and demographic factors are explored. The findings suggest that continuous data provides a basis for modeling stunting and wasting superior to utilizing international reference categories. Estimations show that decreasing age, the presence of servants, a greater number of wives in a compound, and residence in a large urban area correlate with improved nutritional status while wealthier families appear to correlate with greater stunting and wasting, and no correlation exists with estimated energy expenditure. Future studies should incorporate continuous data, and the need exists for greater analysis of social determinants of growth indicators among adolescent females. Further, these findings have significant implications in the development of nutrition intervention programs aimed at the vulnerable population in Mali, leading us to conclude that factors beyond socioeconomic indicators such as household structure and location should be more fully examined.

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3 Arch Dis Child. 2010 Apr 6.

Urbanisation and child health in resource poor settings with special reference to under-five mortality in Africa.

Garenne M.

The health of children improved dramatically worldwide during the 20th century, although with major contrasts between developed and developing countries, and urban and rural areas. The quantitative evidence on urban child health from a broad historical and comparative perspective is briefly reviewed here. Before the sanitary revolution, urban mortality tended to be higher than rural mortality. However, after World War I, improvements in water, sanitation, hygiene, nutrition and child care resulted in lower urban child mortality in Europe. Despite a similar mortality decline, urban mortality in developing countries since World War II has been generally lower than rural mortality, probably because of better medical care, higher socio-economic status and better nutrition in urban areas. However, higher urban mortality has recently been seen in the slums of large cities in developing countries as a result of extreme poverty, family disintegration, lack of hygiene, sanitation and medical care, low nutritional status, emerging diseases (HIV/AIDS and tuberculosis) and other health hazards (environmental hazards, accidents, violence). These emerging threats need to be addressed by appropriate policies and programmes.

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4 Environ Res. 2010 May;110(4):355-62.

Prenatal and adolescent blood lead levels in South Africa: child, maternal and household risk factors in the Birth to Twenty cohort.

Naicker N, Norris SA, Mathee A, von Schirnding YE, Richter L. Medical Research Council of South Africa, Environment and Health Research Unit, PO Box 87373, Houghton 2041, Johannesburg, South Africa. nisha.naicker@mrc.ac.za

INTRODUCTION: The risk factors for lead exposure in developing countries have not been fully described. This study looks at child, maternal and household factors associated with increased risk of lead exposure at birth and at 13 years of age in the Birth to Twenty cohort.

METHODS: Mothers were recruited from antenatal clinics in the Johannesburg-Soweto metropolitan area in 1990 (n=3273). Lead levels were analysed in cord blood collected at birth (n=618) and at 13 years (n=1546). Data on selected child, maternal and household factors were collected using a structured questionnaire in the third trimester and at 13 years of age. Statistical analyses were conducted to determine the associated risk factors.

RESULTS: The mean blood lead level at birth was 5.85 microg/dl, and at 13 years of age it was 5.66 microg/dl. The majority of children had blood lead levels above 5 microg/dl (52% at birth and 56% at 13 years). At birth, being a teenage mother and having low educational status were strong predictors for elevated cord blood lead levels. Being a male child, having an elevated cord blood level, and lack of household ownership of a phone were significant risk factors for high blood lead levels at 13 years.

CONCLUSION: Significant associations found in the study point to the low socio-economic status of lead-affected mothers and children. These poor circumstances frequently persist into later childhood, resulting in continued high lead levels. Thus broader measures of poverty alleviation and provision of better education may help decrease the risk of exposure.

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5 Global Health. 2010 May 4;6(1):8.

“For someone who’s rich, it’s not a problem”. Insights from Tanzania on diabetes health-seeking and medical pluralism among Dar es Salaam’s urban poor.

Kolling M, Winkley K, von Deden M.

The prevalence of chronic non-communicable disease, such as type 2 diabetes mellitus (T2DM), is rising worldwide. In Africa, T2DM is primarily affecting those living in urban areas and increasingly affecting the poor. Diabetes management among urban poor is an area of research that has received little attention. Based on ethnographic fieldwork in Dar es Salam, the causes and conditions for diabetes management in Tanzania have been examined. In this paper, we focus on the structural context of diabetes services in Tanzania; the current status of biomedical and ethnomedical health care; and health-seeking among people with T2DM. We demonstrate that although Tanzania is actively developing its diabetes services, many people with diabetes and low socioeconomic status are unable to engage continuously in treatment. There are many challenges to be addressed to support people accessing diabetes health care services and improve diabetes management.

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6 Health Place. 2010 May;16(3):573-80.

Urban advantage or Urban penalty? A case study of female-headed households in a South African city.

Goebel A, Dodson B, Hill T. Queen’s University, Kingston, Ontario, Canada. goebela@queensu.ca

Basic services have improved in many urban areas of South Africa, which should improve health and well-being. However, poverty and ill-health persist and are unequally distributed by race, class and place. This paper explores conditions of the most marginalized group, female-headed households, in a case study of Msunduzi Municipality (formerly Pietermaritzburg). Data from two household surveys conducted in 2006 show important patterns regarding the incidences of and coping strategies around, illnesses and deaths. While some positive environmental health outcomes are apparent, considerable stresses face households in relation to HIV/AIDS related deaths, poverty, and lack of health services. The insights of both urban environmental health and feminist geography assist in explaining the gendered and spatialized patterns of health in post-apartheid urban South Africa.

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7 Health Policy. 2010 Apr;95(1):62-8.

Rural-urban differences in health-seeking for the treatment of childhood malaria in south-east Nigeria.

Okeke TA, Okeibunor JC. Department of Community Medicine, College of Medicine, University of Nigeria, P.O. Box 3295, Enugu Campus, Enugu, Nigeria. thdokeke@yahoo.co.uk

OBJECTIVES: To identify the differences in health-seeking for childhood malaria treatment, between urban and rural communities in Nigeria, with a view to providing information to policy makers that will be used to improve malaria control.

METHODS: Quantitative and qualitative research methods were employed in eliciting information. A pre-tested structured questionnaire was administered to 1200 caretakers of children under 5 years who had malaria 2 weeks prior to the survey period. Focus group discussions were held with mothers and in-depth interviews with health care providers.

RESULTS: Health-seeking for malaria, differed significantly between rural and urban mothers. While majority (64.7%) of urban caretakers patronized private/government health facilities, most (62%) of their rural counterparts resorted to self-treatment with drugs bought over-the-counter, from patent medicine vendors. Hospitals were geographically more accessibility to urban than rural dwellers. Rural mothers only go to hospital when the problem persists or becomes worse, which results in delay in seeking appropriate and timely care.

CONCLUSION: Urban and rural mothers differed in their responses to childhood fevers. Training drug vendors and caretakers are important measures to improve malaria control. Health facilities with good quality services and readily available drugs should be provided.

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8 J Pediatr (Rio J). 2010 May 3;86(3).

Association between malnutrition in children living in slums, maternal nutritional status, and environmental factors.

Silveira KB, Alves JF, Ferreira HS, Sawaya AL, Florêncio TM. Universidade Federal de Alagoas (UFAL), Maceió, AL, Brazil.

OBJECTIVE: To investigate the association of malnutrition in children living in substandard settlements (slums) of Maceió, AL, Brazil, with maternal nutritional status and environmental conditions.

METHODS: Cross-sectional study involving a probability sample of 2,075 mothers (18 to 45 years) and their children (4 months to 6 years), living in the slums of the city of Maceió. First, we conducted a cluster analysis with the purpose of choosing the settlements and the administrative region of the city of Maceió with the lowest human development index (HDI). After this analysis, the 7th Administrative Region was designated for the study, including its 23 substandard settlements. Socioeconomic, demographic, anthropometric, and maternal and child health data were collected by means of household survey. The statistic analysis included the odds ratio of a child to be malnourished, and the univariate regression was used to check which maternal variables were associated with this malnutrition.

RESULTS: Chronic malnutrition (-2 standard deviations/height for age) was found in 8.6% of children and was associated with mother’s age and educational level, type of residence, number of rooms, flooring, water supply, and low birth weight (< 2,500 g) in children aged </= 24 months. We also found association between child malnutrition and maternal height. Such association was not observed regarding body mass index.

CONCLUSIONS: The high prevalence of malnutrition observed in these settlements was related to social and environmental conditions and short maternal height, who had weight deficit or weight excess.

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9 J Prev Interv Community. 2010 Apr;38(2):147-61.

Findings from SHAZ!: a feasibility study of a microcredit and life-skills HIV prevention intervention to reduce risk among adolescent female orphans in Zimbabwe.

Dunbar MS, Maternowska MC, Kang MS, Laver SM, Mudekunye-Mahaka I, Padian NS. Women’s Global Health Imperative, RTI International, San Francisco, California, USA.

This study tested the feasibility of a combined microcredit and life-skills HIV prevention intervention among 50 adolescent female orphans in urban/peri-urban Zimbabwe. Quantitative and qualitative data were collected on intervention delivery, HIV knowledge and behavior, and economic indicators. The study also tested for HIV, HSV-2, and pregnancy. At 6 months, results indicated improvements in knowledge and relationship power. Because of the economic context and lack of adequate support, however, loan repayment and business success was poor. The results suggest that microcredit is not the best livelihood option to reduce risk among adolescent girls in this context.

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10 J Urban Health. 2010 May 7.

Menstrual Pattern, Sexual Behaviors, and Contraceptive Use among Postpartum Women in Nairobi Urban Slums.

Ndugwa RP, Cleland J, Madise NJ, Fotso JC, Zulu EM. London School of Hygiene and Tropical Medicine, London, UK, robert.ndugwa@lshtm.ac.uk.

Postpartum months provide a challenging period for poor women. This study examined patterns of menstrual resumption, sexual behaviors and contraceptive use among urban poor postpartum women. Women were eligible for this study if they had a birth after the period September 2006 and were residents of two Nairobi slums of Korogocho and Viwandani. The two communities are under continuous demographic surveillance. A monthly calendar type questionnaire was administered retrospectively to cover the period since birth to the interview date and data on sexual behavior, menstrual resumption, breastfeeding patterns, and contraception were collected. The results show that sexual resumption occurs earlier than menses and postpartum contraceptive use. Out of all postpartum months where women were exposed to the risk of another pregnancy, about 28% were months where no contraceptive method was used. Menstrual resumption acts as a trigger for initiating contraceptive use with a peak of contraceptive initiation occurring shortly after the first month when menses are reported. There was no variation in contraceptive method choice between women who initiate use before and after menstrual resumption. Overall, poor postpartum women in marginalized areas such as slums experience an appreciable risk of unintended pregnancy. Postnatal visits and other subsequent health system contacts provide opportunities for reaching postpartum women with a need for family planning services.

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11PLoS Negl Trop Dis. 2010 Mar 16;4(3):e631.

Informal urban settlements and cholera risk in Dar es Salaam, Tanzania.

Penrose K, de Castro MC, Werema J, Ryan ET. Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, United States of America. kpenrose@post.harvard.edu

BACKGROUND: As a result of poor economic opportunities and an increasing shortage of affordable housing, much of the spatial growth in many of the world’s fastest-growing cities is a result of the expansion of informal settlements where residents live without security of tenure and with limited access to basic infrastructure. Although inadequate water and sanitation facilities, crowding and other poor living conditions can have a significant impact on the spread of infectious diseases, analyses relating these diseases to ongoing global urbanization, especially at the neighborhood and household level in informal settlements, have been infrequent. To begin to address this deficiency, we analyzed urban environmental data and the burden of cholera in Dar es Salaam, Tanzania.

METHODOLOGY/PRINCIPAL FINDINGS: Cholera incidence was examined in relation to the percentage of a ward’s residents who were informal, the percentage of a ward’s informal residents without an improved water source, the percentage of a ward’s informal residents without improved sanitation, distance to the nearest cholera treatment facility, population density, median asset index score in informal areas, and presence or absence of major roads. We found that cholera incidence was most closely associated with informal housing, population density, and the income level of informal residents. Using data available in this study, our model would suggest nearly a one percent increase in cholera incidence for every percentage point increase in informal residents, approximately a two percent increase in cholera incidence for every increase in population density of 1000 people per km(2) in Dar es Salaam in 2006, and close to a fifty percent decrease in cholera incidence in wards where informal residents had minimally improved income levels, as measured by ownership of a radio or CD player on average, in comparison to wards where informal residents did not own any items about which they were asked. In this study, the range of access to improved sanitation and improved water sources was quite narrow at the ward level, limiting our ability to discern relationships between these variables and cholera incidence. Analysis at the individual household level for these variables would be of interest.

CONCLUSIONS/SIGNIFICANCE: Our results suggest that ongoing global urbanization coupled with urban poverty will be associated with increased risks for certain infectious diseases, such as cholera, underscoring the need for improved infrastructure and planning as the world’s urban population continues to expand.

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12 Trans R Soc Trop Med Hyg. 2010 Apr 23.

Cohort trial reveals community impact of insecticide-treated nets on malariometric indices in urban Ghana.

Klinkenberg E, Onwona-Agyeman KA, McCall PJ, Wilson MD, Bates I, Verhoeff FH, Barnish G, Donnelly MJ. Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK; International Water Management Institute, PMB CT 112, Cantonments, Accra, Ghana.

The efficacy of insecticide-treated nets (ITNs) in prevention of malaria and anaemia has been shown in rural settings, but their impact in urban settings is unknown.  We carried out an ITN intervention in two communities in urban Accra, Ghana, where local malaria transmission is known to occur. There was evidence for a mass or community effect, despite ITN use by fewer than 35% of households. Children living within 300 m of a household with an ITN had higher haemoglobin concentrations (0.5g/dl higher, P=0.011) and less anaemia (odds ratio 2.21, 95% CI 1.08-4.52, P=0.031 at month 6), than children living more than 300 m away from a household with an ITN, although malaria parasitaemias were similar. With urban populations growing rapidly across Africa, this study shows that ITNs will be an effective tool to assist African countries to achieve their Millennium Development Goals in urban settings.

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