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Objective Children in slums are at high risk of undernutrition, which has long-term negative consequences on their physical growth and cognitive development. Severe undernutrition can lead to the child’s death. The present paper aimed to understand the causes of undernutrition in children as perceived by various groups of community members in Nairobi slums, Kenya. Design Analysis of ten focus group discussions and ten individual interviews with key informants. The main topic discussed was the root causes of child undernutrition in the slums. The focus group discussions and key informant interviews were recorded and transcribed verbatim. The transcripts were coded in NVivo by extracting concepts and using a constant comparison of data across the different categories of respondents to draw out themes to enable a thematic analysis. Setting Two slum communities in Nairobi, Kenya. Subjects Women of childbearing age, community health workers, elders, leaders and other knowledgeable people in the two slum communities (n 90). Results Participants demonstrated an understanding of undernutrition in children. Conclusions Findings inform target criteria at community and household level that can be used to identify children at risk of undernutrition. To tackle the immediate and underlying causes of undernutrition, interventions recommended should aim to: (i) improve maternal health and nutrition; (ii) promote optimal infant and young children feeding practices; (iii) support mothers in their working role; (iv) increase access to family planning; (v) improve water, sanitation and hygiene (WASH); (vi) address alcohol problems at all levels; and (vii) address street food issues with infant feeding counselling.
The study was conducted in two slums of Nairobi, Kenya, namely Korogocho and Viwandani, which are included in the Nairobi Urban Health and Demographic Surveillance System( 47 ). The two slums are located about 7 km from each other, occupy a total area of slightly less than 1 km2 and are densely populated (average 57 950 inhabitants/km2). Viwandani, being located in the industrial area, attracts migrant workers especially men with relatively higher levels of education. Korogocho has a more stable population and greater co-residence of spouses but higher unemployment levels( 47 ). The data used here were part of a formative study conducted in April 2012. The formative study aimed to understand infant and young child feeding (IYCF) practices, the community’s perceptions of the root causes of child undernutrition, and the local contexts and norms which contribute towards decision making for IYCF practices. The findings from the formative study on IYCF practices informed the design of an intervention for which details are published elsewhere( 48 ). The intervention involved home-based counselling of pregnant women and mothers of young children on optimal maternal, infant and young child nutrition by community health workers. We have previously identified factors affecting actualisation of the WHO breast-feeding recommendations from this work( 37 ). Here we use the data related to understanding the root causes of undernutrition with the question posed ‘Why do you think children grow undernourished in your community?’ Participants were recruited through purposive sampling depending on category of respondents, taking into account different ethnicity, religious affiliation and village of residence. Interviews were recorded and transcribed verbatim. The present paper draws on the analysis of ten focus group discussions (FGD) and ten individual interviews with key informants (KII). Both the FGD and the KII were conducted with women of childbearing age, community health workers, community elders, community leaders and other knowledgeable people in the two slum communities (Tables 1 and and2).2). Two KII were conducted with each participant profile (health-care provider, religious leader, traditional birth attendant, youth leader, women’s group leader), of which 40 % were men and 50 % were in Korogocho. Three FGD were conducted with young mothers, three with older mothers (≥25 years old), two with community health workers and another three with community elders. Pictures of children depicting different nutritional statuses and of foods were used to stimulate responses from respondents. Questions included perceptions on the nutritional status of the majority of infants living in the local community; knowledge, attitudes and practices with regard to maternal, infant and young child nutrition including initiation of breast-feeding, use of colostrum, exclusive breast-feeding, duration of breast-feeding and complementary feeding; and nutritional status of children growing in urban slums. Additionally, questions focused on the contextual and sociocultural norms that influence IYCF practices. Interviews were conducted by ten experienced field interviewers (seven females and three males) with university training in nutrition, public health, sociology or anthropology. The field interviewers were trained to ensure they understood the concepts and the meanings of the questions and on how to engage the participants to ensure frank and complete responses. Role plays among the interviewers and pilot field interviews were conducted as part of the training sessions to ensure the interviewers grasped the concepts. Some of the researchers accompanied the field team in pilot interviews. Debriefing sessions between the interviewers and researchers were held after the pilot interviews to discuss emerging issues and to ensure consistency of meaning to questions. There was always an interviewer/moderator and a note-taker in each interview to ensure all issues discussed were captured. Interviews were conducted in Swahili, and all were audio-taped and transcribed verbatim. Concurrent transcription and translation was done by two graduates with good experience in anthropology and transcription who had participated in the training of the interviewers and the pilot sessions. Details of participants in the key informant interviews (KII) conducted in two slum communities in Nairobi, Kenya, April 2012 M, male; F, female. Details of participants in the focus group discussions (FGD) conducted in two slum communities in Nairobi, Kenya, April 2012 M, male; F, female. Word transcripts were imported into NVivo 10 software (QSR International Pty Ltd) which helped to identify primary and meta codes and major themes. They were coded by extracting concepts and using a constant comparison of the data across different participant groups to identify similarities and variations and to draw out themes based on the UNICEF conceptual framework( 49 , 50 ). Themes were developed from the literature and from the narratives from the respondents. The researchers familiarised themselves with the data by listening to the audio tapes and reading the transcripts. Coding and interpretation were done by two members of the research team to ensure objectivity and to check for consistency in application of the coding process. Final checks for understanding and consistency of the application of the codes were undertaken with a third member of the research team. Ethics approval was granted by the Kenya Medical Research Institute, a recognised Ethics Review Committee, approved by the Government of Kenya. The investigators respected the fundamental principles regarding research on human subjects. For all data collection activities, informed consent was sought from the eligible participants following full disclosure regarding the study before data collection was done.
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