Urban–rural differences in the socioeconomic deprivation–Sexual behavior link in Kenya
Introduction
Sub-Saharan Africa's ongoing urbanization is occurring amid what are arguably the worst economic circumstances of any world region. This is the only region of the world where poverty is increasing, with close to half of Africans living on a dollar a day (World Bank, 2004). Africa is also the only region where income inequality is worsening (Firebaugh, 2004). Economic hardship is acknowledged to compound women's sexual vulnerability (Carael & Allen, 1995; Ulin, 1992), and is associated with early onset of sexual activity, extramarital sex, and multiple sexual partnerships, all of which have serious implications for the spread of HIV/AIDS. Against this backdrop, it is surprising that little attention has been paid to the HIV-related implications of urban poverty.
The influence of community context on onset of sexual intercourse and prevalence of multiple partnerships is well understood in the developed world (Brewster (1994a), Brewster (1994b); Klitsch, 1994). Contributions of community factors such as socioeconomic status, female unemployment, youth idleness, social hazards (drug abuse, gangs, etc.), proportion of sexually active men, and single parentage, to group differences in sexual behavior have been documented. In Africa, the preponderance of demographic and health research remains on rural areas not only because they are home to majority of the population, but also because they have been considered relatively deprived in terms of access to resources and services (HABITAT, 1996). Mounting evidence, however, points to a growing vulnerability of an increasingly marginalized and burgeoning slum population that merits attention apparently because poverty and its attendant lack of access to basic amenities have greater sexual health implications for urban residents (Brockerhoff & Brennan, 1998; HABITAT, 1996; Oberai, 1993; Todaro, 1989; White, 1996). Economic stresses associated with low wages, unemployment, and increasing poverty presumably incline many women to use sex to generate income for basic needs, provoking early initiation of sexual activity and high incidence of multiple sexual partnerships (Carael & Allen, 1995; Ulin, 1992). These conditions also prompt men to exploit women's economic vulnerability by paying very little for sex and subjecting women to domestic violence (Ezeh & Gage, 2000; Oppong, 1995).
A handful of recent studies from Kenya intimates an urban poverty disadvantage insofar as sexual outcomes related to HIV are concerned (Dodoo, Sloan, & Zulu, 2003; Zulu, Dodoo, & Ezeh (2002), Zulu, Dodoo, & Ezeh (2003)). Zulu et al. (2002), in particular, provide empirical evidence that slum residence is unique in its adverse impact on sexual outcomes, presumably because monetary currency is central to existence in cities where difficult economic circumstances coerce women to use sex as a means of survival. Yet, that finding is based on analysis of Nairobi data alone, thereby precluding assessment of whether the impact of deprivation is truly unique to urban settings, or more generally attaches to deprived groups in other contexts. This question is particularly germane, given the call to shift resources from rural areas, where considerable poverty remains and traditional arrangements foster early marriage and sex among networks of physically proximate extended kin (Airhihenbuwa, 1991; Geelhoed, 1991). The current paper examines the relationship between economic circumstances and sexual outcomes—onset of sexual activity and multiple sexual partnerships—across urban and rural space, and asks whether deprivation translates into sexual outcomes differently in rural and urban settings? Such a study is particularly useful in contexts where condom use with regular sexual partners is evidently unpopular.
Section snippets
Background
Growing attention to the urban poor accompanies the substantial population shifts from rural to urban areas. About 90% of global population growth in the first quarter of the 21st century will stem from urban growth in developing countries, with Africa expected to become majority urban within the next two decades (United Nations, 1998). Some African cities, including Nairobi, have grown at rates close to 5% annually over the last three decades (Obudho, 1997; Todaro, 1989), with severe
The current study
We examine the relationship between HIV-related sexual activity outcomes—specifically age at first sex and multiple sexual partnerships—and socioeconomic deprivation in rural and urban Kenyan settings. Because heterosexual contact represents the primary transmission mode, behavior change remains fundamental to stemming HIV spread (Caldwell, 2000; Cleland & Ferry, 1995; Hope, 1995). Not surprisingly, much effort has been expended to understand the predictors of condom use (Cleland & Ferry, 1995;
Data and analysis
Our data come from the Demographic and Health Surveys (DHS) of Kenya. Given the small urban samples found in the DHS (and, by extension, even smaller samples for Nairobi), we follow Zulu, Dodoo, & Ezeh (2002), Zulu, Dodoo, & Ezeh (2003) in pooling the first three waves of the DHS—1989, 1993, and 1998—to obtain reasonable sample sizes for Nairobi and other urban areas. Repeated surveys can be pooled to increase sample size so long as the effect of the study variable is relatively invariant over
Initiation of sexual intercourse
Table 2 presents median ages at sexual debut across the three surveys and the nine area categories based on level of deprivation and urban/rural type (and the associated 95% confidence intervals for the medians). The medians derive from life table survival functions whereby virgins, at the time of the respective surveys, represent censored cases. For both deprivation indexes, these data show a consistent inverse association between level of deprivation and age at first sex in each of the three
Discussion
This paper set out to evaluate whether deprivation is associated with sexual outcomes in city, other-urban, and rural contexts and whether this association also varies across these various settings. Two basic findings consistently emerge. First, poverty is significantly related to risky sexual outcomes, as evidenced in the analysis of age at sexual debut in which, regardless of residential setting, we see a consistent within-residence deprivation gradient whereby the poorest have worse outcomes
Acknowledgments
The authors wish to acknowledge support from the National Institute of Child Health and Human Development (NICHD) and the Office of AIDS Research (OAR) through grant # 1 R01 HD044236-01A1, the Rockefeller Foundation through grant # 2001 AR 095, and the Hewlett Foundation through grant # 2004-9699).
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