title: Quantitative urban classification for malaria epidemiology in sub-Saharan Africa.
abstract: BACKGROUND
  Although sub-Saharan Africa (SSA) is rapidly urbanizing, the terms used to classify urban ecotypes are poorly defined in the context of malaria epidemiology. Lack of clear definitions may cause misclassification error, which likely decreases the accuracy of continent-wide estimates of malaria burden, limits the generalizability of urban malaria studies, and makes identification of high-risk areas for targeted interventions within cities more difficult. Accordingly, clustering techniques were applied to a set of urbanization- and malaria-related variables in Kisumu, Kenya, to produce a quantitative classification of the urban environment for malaria research.
  
  
  METHODS
  Seven variables with a known or expected relationship with malaria in the context of urbanization were identified and measured at the census enumeration area (EA) level, using three sources: a) the results of a citywide knowledge, attitudes and practices (KAP) survey; b) a high-resolution multispectral satellite image; and c) national census data. Principal components analysis (PCA) was used to identify three factors explaining higher proportions of the combined variance than the original variables. A k-means clustering algorithm was applied to the EA-level factor scores to assign EAs to one of three categories: "urban," "peri-urban," or "semi-rural." The results were compared with classifications derived from two other approaches: a) administrative designation of urban/rural by the census or b) population density thresholds.
  
  
  RESULTS
  Urban zones resulting from the clustering algorithm were more geographically coherent than those delineated by population density. Clustering distributed population more evenly among zones than either of the other methods and more accurately predicted variation in other variables related to urbanization, but not used for classification.
  
  
  CONCLUSIONS
  Effective urban malaria epidemiology and control would benefit from quantitative methods to identify and characterize urban areas. Cluster analysis techniques were used to classify Kisumu, Kenya, into levels of urbanization in a repeatable and unbiased manner, an approach that should permit more relevant comparisons among and within urban areas. To the extent that these divisions predict meaningful intra-urban differences in malaria epidemiology, they should inform targeted urban malaria interventions in cities across SSA.
authors.affiliation: Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA. jsiri@umich.edu
authors.forename: Jose G
authors.initials: JG
authors.lastname: Siri
authors.forename: Kim A
authors.initials: KA
authors.lastname: Lindblade
authors.forename: Daniel H
authors.initials: DH
authors.lastname: Rosen
authors.forename: Bernard
authors.initials: B
authors.lastname: Onyango
authors.forename: John
authors.initials: J
authors.lastname: Vulule
authors.forename: Laurence
authors.initials: L
authors.lastname: Slutsker
authors.forename: Mark L
authors.initials: ML
authors.lastname: Wilson
mesh_terms: D006801:Humans; D007630:Kenya / Q000453:epidemiology; D008288:Malaria / Q000453:epidemiology*; D014504:Urban Health; D014505:Urban Population / Q000706:statistics & numerical data*