Urban–rural differences in the socioeconomic deprivation–Sexual behavior link in Kenya

Abstract

We compare the impact of socioeconomic deprivation on risky sexual outcomes in rural and urban Kenya. Quantitative data are drawn from the Demographic & Health Surveys (DHS) and qualitative data from the Sexual Networking and Associated Reproductive and Social Health Concerns study. Using two separate indicators of deprivation we show that, although poverty is significantly associated with the examined sexual outcomes in all settings, the urban poor are significantly more likely than their rural counterparts to have an early sexual debut and a greater incidence of multiple sexual partnerships. The disadvantage of the urban poor is accentuated for married women; those in Nairobi's slums are at least three times as likely to have multiple sexual partners as their rural counterparts. The implications of these findings are discussed.

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.