THE INFLUENCE OF VARIED ENERGY SOURCES AND HOUSEHOLD SOCIOECONOMIC CHARACTERISTICS ON THE PREVALENCE OF ACUTE RESPIRATORY INFECTIONS AMONG CHILDREN IN NAKURU TOWN, KENYA

ABSTRACT
Indoor Air Pollution is the result of combustion of biomass fuels, which leads to 3-4 million deaths worldwide and 500,000 deaths in Africa annually. Indoor air pollution is known to cause respiratory illnesses among children under-5. In Nakuru 39.4% of urban dwellers live below the national poverty line of KSH 2,913 per person per month, thus their accessibility to energy sources is limited to charcoal, paraffin, and other biomass. The objective of this study was to assess the influence of energy sources and household socioeconomic characteristics on the prevalence of ARI among children in Nakuru Town, Kenya. The study was conducted on 187 randomly selected households comprising of low-income and middle-income strata in Nakuru Town. Data was collected using structured questionnaires and observation of the physical characteristics of the houses. Descriptive statistics and multiple linear regression analysis tests were used to analyze the data. From the study findings, charcoal was preferred for cooking among low-income households, while gas and charcoal were preferred among middle-income households. Electricity was the most preferable source of lighting energy for both low and middle-income households. The prevalence rates of ARI for middle-income households were 80 in 100 children and 89 in 100 children in low-income households. Among low-income households, cooking was done outside due to discomfort, fire hazards and lack of space, which assisted in reducing exposure to pollutants that cause ARIs. The socioeconomic factors that were significant and affected thepresence of ARI among children in low-income households were carpeting (p=0.003) and hours spent indoors (p=0.026). In middle-income households the socioeconomic factors were insignificant and did not affect the presence on ARI in children. Overall, 78% of low- income households did not meet government ventilation standards thus landlords and homeowners should build a secure roof hatch window for ventilation. It is also recommended that cooking should be done in properly ventilated areas in order to reduce or curb the adverse human health impacts associated with pollutants from biomass fuels.

CHAPTER ONE
INTRODUCTION
Background Information
In sub Saharan Africa, about 70 to 90 per cent of the population depends on biomass fuels as energy sources. Further, it is estimated that more than half a million deaths annually in Africa are associated with indoor air pollution arising from combustion of biomass fuels (UNCTAD, 2012). Acute respiratory infections (ARI) are the leading cause of the global burden of disease and account for more than 6% of worldwide diseases and mortality, primarily in developing countries. Between 1997 and 1999, acute lower respiratory infections (ALRI) caused 3.5–4.0 million deaths worldwide more than that caused by any other infectious disease (Ezzati and Kammen, 2001).According to the World Health Organization (WHO), indoor air pollution (IAP) from the use of solid fuels in households in the developing world is responsible for more than 1.6 million premature deaths each year (Mestl et al., 2007).In Kenya, the National outpatient morbidity rates for respiratory infections among children under 5 were 67% or 4.4 million cases reported. In Nakuru Town, the outpatient morbidity rates for respiratory infections among children under 5 were 41% or 60,000 cases reported (G.o.K., 2011; G.o.K., 2012).

ARI is acute respiratory infection, is a respiratory tract infection that inhibits normal breathing function. It usually begins as a viral infection in the nose, trachea (windpipe), or lungs. Acute respiratory infections can be categorized as upper respiratory infection and lower respiratory infection. Upper respiratory infection occurs in the upper tract of the respiratory system otherwise known as the common cold. The lower respiratory infection affects the lung(s) area primarily causing pneumonia or further lung abscess and acute bronchitis. The early symptoms of acute respiratory infection usually appear in the nose and upper lungs. Other symptoms include: Congestion, either in the nasal sinuses or lungs, runny nose, cough, sore throat, Body aches and fatigue. For lower respiratory infections such as pneumonia the common symptoms likely to be seen are: shortness of breath (struggling to breath), coughing, fever, chills, headaches, loss of appetite, hypothermia, and wheezing (DiMaria and Solano, 2012; WHO, 2012).

Acute respiratory infection prevents the body from getting ample oxygen and can potentially lead to death. Acute respiratory infections are contagious meaning that they can spread from person to person (DiMaria and Solano, 2012; WHO, 2012). Children, older adults, and people with immune system disorders are at a high risk of contracting this disease. For persons and children from low-income homes, immune problems will tend to be persistent due to the lack of proper nutritional contents and good healthcare accessibility. The World Health Organization (WHO) indicates that acute respiratory infections kill an estimated 2.6 million children under-5 yearly worldwide (DiMaria and Solan, 2012).

Indoor air pollution refers to the chemical, biological and physical contamination of indoor air, which may result in adverse health effects. In developing countries, the main source of indoor air pollution is biomass smoke, which contains suspended particulate matter, nitrogen dioxide, sulphur dioxide, carbon monoxide, formaldehyde and polycyclic aromatic hydrocarbons. In industrialized countries, NO2, CO, and formaldehyde are also the main sources of indoor pollution. They originate from compounds such as radon, asbestos, mercury, and human-made mineral fibers. Volatile organic compounds, allergens, tobacco smoke, bacteria and viruses are the other main culprits that contribute to indoor air pollution (United Nations, 1997). According to Moturi (2010), lower respiratory tract infections in children have been linked to indoor air pollution. Other studies have reported an association between exposure to biomass fuel smoke and upper respiratory tract infections.

In developing countries particulate matter has been singled as the prime pollutant responsible for ARI. Other gaseous and particulate products such as nitrogen dioxide and formaldehyde have also been singled out as pulmonary irritants (Ezzati and Kammen, 2001). Given that children are usually at home with the mothers or domestic workers, they are likely to spend majority of their time around cooking areas, increasing their likelihood of exposure to particulate matter and other gaseous and particulate products. The particulate matter concentration (PM10) from where biomass is used could rangefrom 1000ug/m3 to as high 50,000ug/m3 (Duflo et al., 2008). The acceptable limit set by the United States Environmental Protection Agency for particulate matter (PM10) concentration is 150ug/m3 but 50ug/m3 is the acceptable level (WHO, 2014). Alarmingly the exposure to PM10 concentrations faced by the urban poor is 7 to 330 times higher than the accepted US EPA levels. The National Environmental Management Authority (NEMA) of Kenya is in the process of developing a policy on air quality under the Environmental Management and Coordination Act (EMCA).

The common types of lighting and cooking fuels used in Kenyan urban centers are gas, charcoal, firewood and kerosene. Charcoal is the main source of cooking fuel among 43% of the urban poor and 57% of the urban non-poor. As for lighting paraffin is mostly used by both urban poor (76%), while the urban non-poor (48%) may use it as an alternative if there is electricity shortage (G.o.K., 2008). The use of firewood for cooking in a single room, which is not well aerated as observed, is a known documented health risk. Volatilization of particulate matter, chemicals and infectious agents arising from open fires, ravages the respiratory systems of all the household members (Moturi, 2010). In Kenya, the immediate cooking vicinity alone, has reported concentrations of particulate matter (PM10) exceeding 50,000ug/m3 (Duflo et al, 2008), which is alarmingly above the US recommended levels of 150ug/m3 but 50ug/m3.

Socioeconomic factors are known to influence the prevalence of ARI. A study by Rahman (1997) found that the prevalence of ARI among children aged below 5 years in Bangladesh was 58.7% and among the risk factors; malnutrition, illiteracy, poverty, overcrowding, and parental smoking, were found in significant higher proportions in ARI victims compared to those without ARI. These observations underlined the need for research aimed at socioeconomic influences on respiratory infections in developing countries.Indoor air pollution exposure is a function of the complex interplay between household fuel patterns (Smith, 1987), appliances (Ezzati et al., 2000), housing design (Bruce et al., 2002) and human behavior (Barnes, 2005). In addition, risk factors such as nutrition, crowding, family history of infection, poor vaccination history and exposure to environmental tobacco smoke (Kirkwood et al., 1995; Victora et al., 1994) may influence child susceptibility to ARI. Even more challenging is the fact that indoor air pollution unravels against the backdrop of poverty that influence each of these factors.

This study investigated the relationship between incidences of ARI among the under 5 children and the type of energy used as well as household socioeconomic characteristics in Nakuru Town.

The Statement of the problem
In 2012, Rift Valley Province recorded the highest number of under-5 ARI cases in Kenya with 1,134,123 cases, which was 25% of the cases reported nationally. Nakuru being the largest urban center in the Rift Valley province recorded 59,168 under-5 morbidity cases of respiratory illnesses the highest number of under-5 ARI cases in the region. Over the past three decades, Nakuru town has also witnessed a tremendous increase in its population, which has led to an increase in demand for basic services and infrastructure such as housing. Despite the high growth in population, the growth rate of the formal housing sector has been minimal leading to an increase of residents living in informal housing where living conditions are harsh and are inappropriate for household indoor energy use. Studies have been done in rural areas, but not much documentation has been done in urban areas regarding the relationship between household energy use, household socioeconomic characteristics and ARI. Unlike rural areas, urban areas have a variation in socioeconomic characteristics, energy sources, and a diversity of housing structures.With such a high number of ARI cases, it is therefore imperative, to identify whether energy sources, socioeconomic characteristics and the indoor structure of houses influence the prevalence of acute respiratory infections in children under-5 in Nakuru Town.

Broad Objective
To assess the influence of energy sources and household socioeconomic characteristics on the prevalence of Acute Respiratory Infections among children in Nakuru Town.

1.3.1 Specific Objectives
1. To assess the household socioeconomic characteristics of sampled households.

2. To describe the types of energy sources used based on income groups.

3. To assess the prevalence of ARI among children in sampled households.

4. To assess the relationship between energy sources, household socioeconomic characteristics and the prevalence of ARI among children in Nakuru Town.

Research Questions
The following were research questions that guided study:

1. What are the household socioeconomic characteristicsof sampled households?

2. What are the types of energy sources used in sampled households?

3. What are the prevalencerates of ARI among children in sampled households?

4. Is there a relationship between energy sources, socioeconomic characteristics and the prevalence of ARI among children in Nakuru Town?

Justification of the study
It was estimated in 2012 that 4.4 million morbidity cases of ARI were reported for children under-5 in Kenya. Nakuru, the most populous town in the Rift Valley province recorded 59,168 under 5 morbidity cases of respiratory illnesses, while Rift Valley recorded the highest number of under 5 morbidity cases of respiratory illnesses in Kenya with 1,134,123 cases which was 25% of the cases reported nationally (G.o.K., 2011; G.o.K., 2012). Energy expenditure showed that charcoal and paraffin were the most preferred energy sources. With a high number of people living below the poverty line, this would signify that the high under-5 morbidity cases wereas a cause of socioeconomic factors that lead to restricted living conditions and restricted energy use to wood fuel and paraffin. Part of addressing and alleviating the problem of energy use, indoor air pollution and ARI was to ensure that Kenya is moving along the guidelines of the Sustainable Development Goals (SDGs) and Vision 2030 initiatives.

This research was designed to create an insight on the unprecedented environmental health hazards of energy use pollution in households, which have adverse health effects on the respiratory health of children. Data generated from this study would therefore contribute to the realization of Sustainable Development Goals (SDGs) 3, 7, 15 and the social pillar of vision 2030 on healthcare and improved health care services. Exposing the influence of energy sources and household socioeconomic characteristics on ARI in children under 5 will help stakeholders in formulating strategies to ensure healthy lives and promote well-being for all at all ages (SDG 3). Addressing the problem of high biomass usage would serve as a platform for policy development on affordable and clean energy (SDG 7) and ensuring environmental sustainability through sustainable management of forests (SDG 15). Data generated on ARI prevalence rates in children and its relationship to energy sources and household socioeconomic characteristics would serve as a guideline for policy development and the social pillar of vision 2030 for improved health services by reducing the number of ARI cases, raising awareness on environmental friendly fuel sources, and improvement of housing by addressing the issue of urban housing inequality.

Scope
The study focused on children under 5 years old from low-income and middle- income households in Nakuru Town and their caregivers who were interviewed. The caregivers provided information on energy sources (charcoal, paraffin, LPG, wood, etc.) used, and socioeconomic characteristics (education level, income level, and number of household members). Observation of the selected indoor structural characteristics (house type, ventilation chimney, carpeting, floor type roof type, and number of rooms) was carried out. A lot of diseases can be caused by smoke and energy sources, but this research only considered respiratory illnesses that are associated with indoor pollution.

Limitations
1. The study did not rely on the child’s personal physician’s opinion on the health status or the medical records of the child. Instead the mother or caretaker was relied upon to provide information on the child’s health status or medical records.

2. Though outdoor air pollution may also be a cause for ARIs, it was not considered in the study

3. The results of this study cannot be generalized to all households in sampled areas due to differences in household socioeconomic characteristics.

4. There was no assurance that the caregivers information was accurate to the questions asked. The caregivers were asked to list illnesses that their children suffered from in the previous 2 months before the study began. Vernacular translation was used when necessary to communicate with respondents.

Assumptions
1. The mothers or caregivers were aware of their children’s health status and provided accurate information concerning their children’s ARI incidences.

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Item Type: Kenyan Material  |  Attribute: 70 pages  |  Chapters: 1-5
Format: MS Word  |  Price: KSh900  |  Delivery: Within 30Mins.
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