Developing a Standardized Questionnaire for Measuring Older Adult's Health and Well-Being in Kenya.

Background and Objectives: Policy and program interventions for older adults 60 years or older in Africa have consistently been undermined by a lack of vital data as they are usually excluded from nationally representative population surveys. The Health and Wellbeing of Older Persons in Kenya (HWOPs-1) study developed a standardized assessment questionnaire that can be used for periodic data generation. This study presents how the questionnaire was developed and examines its internal consistency and psychometric properties of the health module. Research Design and Methods: The development and validation of the HWOPs-1 questionnaire was a 3-step process. Step 1 was a review of 19 panel studies and 2 national level surveys followed by a wide consultation with key experts and stakeholders on aging. The 3rd step was validation of the questionnaire with a cross-section of a representative sample to test its applicability and adaptability in a mix of rural and semi-urban settings. The internal consistency and psychometric properties of the 3 subscales: functionality, disability, and quality of life were assessed using Cronbach's (α) alpha and exploratory factor analysis, respectively. Results: Three subscales of functionality, disability, and quality of life showed high internal consistency with α = 0.94, 0.97, and 0.87, respectively. There were also consistent factor loadings above 0.3 across all the factors. Gender differences across the 3 scales from the results of t test were observed. Finally, weak but statistically significant correlations between the measures of well-being and risk factors for noncommunicable diseases were also observed from the analyses. Discussion and Implications: The indicators assessed have been used in settings outside Africa to measure health and well-being of older adults are adaptable and reliable enabling comparability across space and across studies. The questionnaire provides a framework for examining disease and disability burden and their determinants among older adults in Kenya or similar settings.

Changes and Forms of Sexual Behaviour in old age: A Qualitative Study of Older People in Southeastern Nigeria.

The misconceptions that old age is an asexual phase of human life has been challenged by increasing empirical evidence which shows that sexual activity persists in old age albeit in different forms and frequency. This study examined how a group of older people in southeastern Nigeria express their sexual behaviour. The semi-structured individual interviews with 14 older people (9 male, 5 female) aged 60?89 years were conducted using an exploratory qualitative approach. The data generated were analysed thematically, and two themes were conceptualised including diverse sexual behaviour and mutual understanding. These themes supported a pattern among the participants where there is a drop in the frequency of physical sexual behaviour but their sexual interests were described to be more stable. However, the sexual interest is channelled into more intimate sexual behaviour. Thus, sexual behaviours in later life in this study were not declining but showed diversity and modifications; most have adjusted to incorporate more emotional bonding and caring. More so, what forms of sexual behaviour constitute for these older partners are often linked to the presence of dynamic interplay of influencing factors ingrained on the level of the older partners mutuality in understanding and responding to theencroaching age-related changes in their sexual behaviour. Remarkably, these factors could be controlled, which signposts a potential premise and point of policy and practical intervention to promote healthy sexual behaviour in later life.

Targeting Cash Transfers on the "Poorest of the Poor" in the Slums: How Well Did the Kenya's Older Persons Cash Transfer Programme Perform?

In resource poor environments, identifying those most in need of limited available resources is challenging. Kenya's older persons cash transfer programme (OPCT) targeted at the most poor used a 2-stage targeting process to identify beneficiaries, combining community-based selection with a proxy means-test. This paper investigates whether the process "correctly" identified targeted vulnerable older people in Nairobi's informal settlements and whether receipt of the OPCT resulted in an improvement in perceived financial wellbeing. Regression results show that individuals with greater need were covered under the OPCT. Using propensity score matching, the paper evidences that the OPCT improved subjective financial wellbeing among beneficiaries.

Unravelling the wider benefits of social pensions: Secondary beneficiaries of the older persons cash transfer program in the slums of Nairobi.

A growing number of low and middle income countries have introduced social pension programs for older people. Research has highlighted that the impact of such programs can extend beyond the primary recipient when funds are shared. It less clear the extent to which such redistribution persists in the lowest resource settings. Using data from a survey conducted in 2016, this paper examines how recipients of the Kenyan Older Persons Cash Transfer Program (OPCTP) living in two slum communities in Nairobi reallocate their social pension by examining the characteristics of older people who are more likely to share their cash and identifying secondary beneficiaries. Findings suggest that 40% of beneficiaries re-allocate some or all of the cash received. The majority of secondary beneficiaries are either grandchildren or children of the primary beneficiary. Overall, a higher proportion of the total cash is shared with secondary beneficiaries living in rural Kenya, as compared to those living in the same household. This highlights the role played by older people, even the most vulnerable, in providing support to wider kin networks; reinforcing the argument that investing in social pensions has much broader potential societal impact than the intended aims of reducing recipient household poverty. By enhancing economic opportunities and investments in human capital more broadly, societies that invest in social pension programs may improve the overall living conditions and experiences of ageing in their countries at a critical moment of global population ageing.

Gender differentials and old age survival in the Nairobi slums, Kenya.

This paper examines gender differentials in survival amongst older people (50+ years) in the Nairobi slums and to the best of our knowledge is the first study of its kind in an urban African setting. The results provide evidence contrary to the expected paradox of poorer self-rated health yet better survival amongst older women. Older women in the Nairobi slums have poorer self-rated health and poorer circumstances across other factors, including disability and socio-economic status. Further, older women in the slums do not have better survival. The conventional female advantage in mortality only becomes apparent after accounting for the cumulative influence of individual characteristics, social networks, health and socio-economic status, suggesting the female advantage in unadjusted old-age mortality does not apply to contexts where women experience significant disadvantage across multiple life domains. This highlights the urgent need to redress the support, status and opportunities available for women across the life course in contexts such as the Nairobi slums. In addition, a greater number of factors differentiate mortality risk amongst men than amongst women, suggesting inequality amongst slum dwelling older men and highlighting the need for gender sensitive interventions which account for the particular needs of both genders in old age.

Resilience in the face of post-election violence in Kenya: the mediating role of social networks on wellbeing among older people in the Korogocho informal settlement, Nairobi.

Older people in slum settings are a vulnerable sub-group during crises, yet have received minimal attention in the development discourse. This paper examines the protective role of different types of social networks for older slum dwellers' wellbeing during adversity by investigating the relationship between social networks, the Kenyan 2007/08 post-election violence, and dimensions of wellbeing namely self-rated health, life satisfaction and happiness amongst older people in the Korogocho slum, Nairobi. The analyses are based on conditional change logistic regression models using data from a unique longitudinal survey of the health and wellbeing of older people. The results show that maintaining or increasing formal local networks reduced the detrimental effects of the post-election violence for older people's wellbeing, whilst household environment and informal local and non-local networks did not influence the relationship. Consequently, the paper provides evidence that supporting inclusive community organisations which are accessible to older people can be valuable in promoting the resilience of this population group.

Entry and re-entry into informal care-giving over a 3-year prospective study among older people in Nairobi slums, Kenya.

This paper analyses data from a 3-year prospective study to understand the factors associated with becoming a caregiver to a person with a chronic illness and examines the dynamics among caregivers over time. A total of 1485 participants were drawn from a study conducted in the slums of Nairobi, Kenya. Two waves of data collected in 2006 for the baseline and a follow-up in 2009 were used. Information on the demographic, self-reported health and socioeconomic characteristics such as education, sources of livelihood and employment status was used. Age was a significant factor in becoming a caregiver, but there were no significant differences by gender or marital status. New caregivers and those with more than one care-giving episode had a higher socioeconomic position than non-caregivers. Caregivers also had poorer health compared with non-caregivers, highlighting the association between being a caregiver and negative health outcomes. Additionally, having cared for someone with a HIV-related illness compared with other chronic conditions increased the likelihood of subsequently caring for another person in need of long-term care. This may be due to the heterosexual mode of HIV transmission in sub-Saharan Africa, hence clustering of infection within family or married couples. This finding draws attention to the need to provide timely interventions to caregivers for people with HIV-related illness who are likely to end up providing care to multiple care recipients. Furthermore, there is a need to enhance the indispensable contribution of informal caregivers through incorporating their role within the continuum of care for effective HIV and AIDS management. Overall, informal caregivers to persons with chronic illnesses perform the tasks of care-giving without any formal support from health or social services. Therefore, it is crucial to initiate policies and programmes to ease the burden of care that is borne by informal caregivers.

Transitions in caregiving and health dynamics of caregivers for people with AIDS: a prospective study of caregivers in Nairobi Slums, Kenya.

OBJECTIVE: A cohort of older people living in a low-resource setting in Nairobi is followed to understand the transitions in caregiving status and trajectories in health over a 3-year period. METHODS: Three categories of older people comprising 65 AIDS caregivers, 102 Other caregivers and 1,322 noncaregivers identified at baseline were assessed at end-line based on two self-reported health outcome measures, a functionality score and having a severe health problem. RESULTS: A majority of caregivers were still providing care at the end of the study, and or had taken on new care recipients. Compared with noncaregivers, AIDS caregivers reported poor health, with men more likely to report poor health than women. New caregivers also reported poorer health compared with noncaregivers. DISCUSSION: The results indicate improvement in health over time among male caregivers supporting the adaptation model. We recommend timely programs to support caregivers particularly at the onset of caregiving.

Perception of vulnerability to HIV infection among older people in Nairobi, Kenya: a need for intervention.

It is evident that sexual activity tends to decrease with age. Nonetheless, it is still prevalent enough to be considered a risk factor for the spread of HIV among older people. This paper uses quantitative data for 2053 individuals to examine HIV risk perception and correlates of perceived risk among older people aged 50 years and older living in Nairobi slums. It emerged that a majority of older people did not consider themselves at risk of infection. Of those who felt at risk, a greater proportion sensed only a small chance of contracting HIV. Women cited 'no sexual activity' while men mentioned 'having only one and/or a faithful sexual partner' as the primary reasons for perceiving minimal risk of HIV infection. There were no differences by sex in the basis for perceiving moderate-to-great risk of infection. Religion is a key factor in risk perception with Muslims perceiving higher levels of risk and, conversely, devotees irrespective of faith perceiving lower levels of risk. Older people willing to be tested for HIV had a decreased likelihood of perceived risk compared with those unwilling to be tested. This paper recommends evaluation of older people's perception of risk in order to better inform interventions aimed at minimizing their vulnerability to HIV infection.

Concern about HIV and AIDS among older people in the slums of Nairobi, Kenya.

The article explores the way that social networks and personal experiences affect perceived HIV-related concerns among people aged 50 years or older living in a low resource neighborhood with high HIV prevalence in Nairobi, Kenya. Multiple logistic regression is used to model the association between the reporting of an HIV-related concern and individual-level characteristics, personal experiences, and social interaction. The main concerns regarding HIV reported by older people in the study included caring for orphaned children (65%), caring for people with AIDS (48%), and losing material and social support from adult children (36%). Interestingly, 38% of respondents voiced concerns about HIV infection among older people. Respondents who had been individually affected by HIV and AIDS, who were part of a wide social network, or who participated in community activities were frequently more likely to report a concern. The findings highlight the significance of the role of social interaction and social networks in the diffusion of information and knowledge. These findings have implications for HIV and AIDS policy and programs, highlighting the potential for social networks and community-level interventions to educate and increase awareness about HIV and AIDS among older people. Community leaders can make good peer educators and communication agents for HIV/AIDS campaigns. Additionally, the recognized high level of personal vulnerability to HIV infection among older people suggests the need for targeted sexual behavior change programs among this often neglected group.

Gender differentials on the health consequences of care-giving to people with AIDS-related illness among older informal carers in two slums in Nairobi, Kenya.

Informal caregivers, most often older people, provide valuable care and support for people ill due to AIDS, especially in poor-resource settings with inadequate health care systems and limited access to antiretroviral therapy. The negative health consequences associated with care-giving may vary depending on various factors that act to mediate the extent of the effects on the caregiver. This paper investigates the association between care-giving and poor health among older carers to people living with AIDS, and examines potential within-gender differences in reporting poor health. Data from 1429 men and women aged 50 years or older living in two slum areas of Nairobi are used to compare AIDS-caregivers with other caregivers and non-caregivers based on self-reported health using the World Health Organization disability assessment (WHODAS) score and the presence of a severe health problem. Women AIDS-caregivers reported higher disability scores for mobility and the lowest scores in self-care and life activities domains while men AIDS-caregivers reported higher scores in all domains (except interpersonal interaction) compared with other caregivers and non-caregivers. Multiple regression analysis is used to examine the association of providing care with health outcomes while controlling for other confounders. Consistently across all the health measures, no significant differences were observed between female AIDS-caregivers and female non-caregivers. Male AIDS-caregivers were however significantly more likely to report disability and having a severe health problem compared with male non-caregivers. This finding highlights a gendered variation in outcome and is possibly an indication of the differences in care-giving gender-role expectations and coping strategies. This study highlights the relatively neglected role of older men as caregivers and recommends comprehensive interventions to mitigate the impact of HIV and AIDS on caregivers that embrace men as well as women.

Does socioeconomic inequality in health persist among older people living in resource-poor urban slums?

Using self-reported health that assesses functionality or disability status, this paper investigates whether there are any differences in health status among older people living in a deprived area of Nairobi, Kenya. Data from a cross-sectional survey of 2,037 men and women aged 50 years and older are used to examine the association between socioeconomic position and self-reported health status across 6 health domains. Education, occupation, a wealth index, and main source of livelihood are used to assess the presence of a socioeconomic gradient in health. All the indicators showed the expected negative association with health across some, but not all, of the disability domains. Nonetheless, differences based on occupation, the most commonly used indicators to examine health inequalities, were not statistically significant. Primary level of education was a significant factor for women but not for men; conversely, wealth status was associated with lower disability for both men and women. Older people dependent on their own sources of livelihood were also less likely to report a disability. The results suggest the need for further research to identify an appropriate socioeconomic classification that is sensitive in identifying poverty and deprivation among older people living in slums.

Socioeconomic Differentials Between HIV Caregivers and Noncaregivers: Is There a Selection Effect? A Case of Older People Living in Nairobi City Slums.

This article seeks to investigate the association between caregiving to someone with an HIV-related illness and the socioeconomic status of the caregiver using a population-based survey of 1,587 older people living in Nairobi slums. Findings indicate significant differences in living arrangements, wealth, income, and expenditure between HIV caregivers and noncaregivers. HIV caregivers lived in larger households and were also more likely to live in households with a large number of children younger than the age of 15 years. Whereas a high proportion of HIV caregivers were ranked highly in terms of wealth status, differences in per capita income and expenditure were not significant when household size and other confounders were accounted for. The financial costs associated with caring for someone with a chronic illness and the reliance on family members with financial ability for material support, a common feature of African extended family systems, may account for the relative economic advantage of HIV caregivers.