title: Place of Residence Moderates the Risk of Infant Death in Kenya: Evidence from the Most Recent Census 2009.
abstract: BACKGROUND
  Substantial progress has been made in reducing childhood mortality worldwide from 1990-2015 (Millennium Development Goal, target 4). Achieving target goals on this however remains a challenge in Sub-Saharan Africa. Kenya's infant mortality rates are higher than the global average and are more pronounced in urban areas as compared to rural areas. Only limited knowledge exists about the differences in individual level risk factors for infant death among rural, non-slum urban, and slum areas in Kenya. Therefore, this paper aims at 1) assess individual and socio-ecological risk factors for infant death in Kenya, and at 2) identify whether living in rural, non-slum urban, or slum areas moderated individual or socio-ecological risk factors for infant death in Kenya.
  
  
  METHODS
  We used a cross-sectional study design based on the most recent Kenya Population and Housing Census of 2009 and extracted the records of all females who had their last child born in 12 months preceding the survey (N = 1,120,960). Multivariable regression analyses were used to identify risk factors that accounted for the risk of dying before the age of one at the individual level in Kenya. Place of residence (rural, non-slum urban, slum) was used as an interaction term to account for moderating effects in individual and socio-ecological risk factors.
  
  
  RESULTS
  Individual characteristics of mothers and children (older age, less previously born children that died, better education, girl infants) and household contexts (better structural quality of housing, improved water and sanitation, married household head) were associated with lower risk for infant death in Kenya. Living in non-slum urban areas was associated with significantly lower infant death as compared to living in rural or slum areas, when all predictors were held at their reference levels. Moreover, place of residence was significantly moderating individual level predictors: As compared to rural areas, living in urban areas was a protective factor for mothers who had previous born children who died, and who were better educated. However, living in urban areas also reduced the health promoting effects of better structural quality of housing (i.e. poor or good versus non-durable). Furthermore, durable housing quality in urban areas turned out to be a risk factor for infant death as compared to rural areas. Living in slum areas was also a protective factor for mothers with previous child death, however it also reduced the promoting effects of older ages in mothers.
  
  
  CONCLUSIONS
  While urbanization and slum development continues in Kenya, public health interventions should invest in healthy environments that ideally would include improvements to access to safe water and sanitation, better structural quality of housing, and to access to education, health care, and family planning services, especially in urban slums and rural areas. In non-slum urban areas however, health education programs that target healthy diets and promote physical exercise may be an important adjunct to these structural interventions.
authors.affiliation: Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States of America; Center for Development and Environment (CDE), University of Bern, Bern, Switzerland.
authors.forename: Oliver
authors.initials: O
authors.lastname: Gruebner
authors.affiliation: Institute of Geodesy and Geoinformation, University of Bonn, Bonn, Germany.
authors.forename: Sven
authors.initials: S
authors.lastname: Lautenbach
authors.affiliation: Department of Public Health Medicine, School of Public Health, University of Bielefeld, Bielefeld, Germany.
authors.forename: M M H
authors.initials: MM
authors.lastname: Khan
authors.affiliation: Kenya Bureau of Statistics (KNBS), Nairobi, Kenya.
authors.forename: Samuel
authors.initials: S
authors.lastname: Kipruto
authors.affiliation: Center for Development and Environment (CDE), University of Bern, Bern, Switzerland.
authors.forename: Michael
authors.initials: M
authors.lastname: Epprecht
authors.affiliation: School of Public Health, Boston University, Boston, MA, United States of America.
authors.forename: Sandro
authors.initials: S
authors.lastname: Galea
mesh_terms: D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007630:Kenya / Q000453:epidemiology; D008297:Male; D012307:Risk Factors; D012424:Rural Population; D012959:Socioeconomic Factors; D013398:Sudden Infant Death / Q000453:epidemiology*; D014505:Urban Population