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Alcohol, substance and drug use among urban slum adolescents in Nairobi, Kenya
doi:10.1016/S0264-2751(03)00034-9
Cities, Vol. 20, No. 4, p. 231–240, 2003 2003 Elsevier Science Ltd. All rights reserved. Printed in Great Britain 0264-2751/03 $ - see front matter
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Alcohol, substance and drug use among urban slum adolescents in Nairobi, Kenya Frederick Mugisha∗ African Population and Health Research Center (APHRC), Shelter Afrique Center, Longonot Road, Upper Hill, P.O Box, 10787—00100, GPO Nairobi, Kenya
Jacqueline Arinaitwe-Mugisha CARE International in Uganda, Arua, Uganda
Bilhah O.N. Hagembe National Agency for Campaign Against Drug Abuse (NACADA), Nairobi, Kenya
Alcohol, substance and drug use among urban slum adolescents is not only a risky behavior in the era of HIV/AIDS but also a potential security threat to a growing city. Based on the Nairobi Urban Slum Survey, adolescent males are more than 20 times more likely to engage in drugs, and 5 times more likely to consume alcohol than girls. In addition, being out-ofschool increases the risk of alcohol and drug abuse. There is a gender dimension to this; societal expectation, division of labor, and nature of upbringing is different for males and females. While the government policy of free primary education is likely to reduce the alcohol and drug incidence, gender targeted interventions, providing alternatives for both boys and girls, would be equally essential. 2003 Elsevier Science Ltd. All rights reserved. Keywords: Gender, illicit drug use, informal settlements, urban
Introduction
ility of nations, the structure of all societies, and the dignity of millions of people and their families”. Young people are at the center of this declaration as our most valuable asset. Recently, during the launch of “Crime in Nairobi: victimization survey”, the director of the National Agency for Campaign Against Drug Abuse (NACADA) noted that drug abuse is one of the factors behind the increase in crime in Nairobi (UN-Habitat, 2002a). He emphasized the need to tackle drug abuse if crime is to be reduced, and the reduction of drug abuse is therefore of significance to both governments and individuals, and in light of this, various international and government declarations have been made and adopted. A case in point is the Declaration on the Guiding Principles of Drug Demand Reduction adopted by the UN. Under this declaration, member states pledged a sustained political, social, health and educational commitment to investing in illicit drug demand reduction programs that will contribute towards reducing public
This paper examines alcohol, substance and drug use among adolescents in the informal settlements of Nairobi, Kenya. The effect of drug abuse on society was probably best summed up in the political declaration on global drug control adopted at the Twentieth Special Session of the United Nations General Assembly on the World Drug Problem (General Assembly, 2003a). In the introduction, it states “drugs destroy lives and communities, undermine sustainable human development and generate crime. Drugs affect all sectors of society in all countries; in particular, drug abuse affects the freedom and development of young people, the world’s most valuable asset. Drugs are a grave threat to the health and wellbeing of all mankind, the independence of states, democracy, the stab∗ Corresponding author. Tel.: +254-2-2720-400; fax: +254-2-2720380; e-mail: [email protected]
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Alcohol, substance and drug use among urban slum adolescents in Nairobi, Kenya: Frederick Mugisha et al.
health problems, improving individual health and well-being, promoting social and economic integration, reinforcing family systems and making communities safer. In addition they agreed to promote, in a balanced way, interregional and international cooperation in order to control supply and reduce demand for drugs (General Assembly, 2003b). However, for these interventions to be effective, they ought to be tailored to the local conditions in the way they target adolescent boys and girls in urban slums. This paper therefore examines alcohol and drug use among urban slum adolescents in Nairobi, Kenya and the resulting implications for targeting.
Urbanization and drug abuse The urban boom in Africa, unlike that of the western world a century or so ago, has been accompained by marked economic stagnation (Brockerhoff and Brennan, 1998), and many of these new city dwellers are poor migrants from the hinterland who will be forced to live in slums and peri-urban areas in cities. The African dilemma is highlighted by the fact that, although 28% of urban residents live in poverty in less developed countries as a whole, over 41% do in Africa (United Nations Population Fund, 1996). It is therefore not suprising to learn that over two in five of city residents live in cirmustances deemed to be “life and health threatening” (Cairncross et al., 1990). In Nairobi alone, slums or informal settlements accommodate more than 60% of the residents yet occupy only 5% of the residential land (APHRC, 2002; WHO, 1998), and thrive among relatively well organized and economically better off neighborhoods. In addition, these communities have had to bear the brunt of the economic decline with increasing unemployment, low school enrollment and pronounced school dropout rates for adolescents. Their health indicators are also known to be worse than their rural counterparts (APHRC, 2002). This has at least two implications; income inequalities are wide and visible, which creates a sense of hopelessness, and the added poor and unstable economic conditions have challenged many would-be breadwinners. This state of hopelessness creates an atmosphere conducive to seeking refuge in alcohol, addictive substances and drugs. Second, the traditional division of labor in urban areas is unlikely to be protective against alcohol, drug and substance abuse. In the African tradition, there is division of labor between males and females—women take up mainly household chores such as cooking, taking care of children and the sick, and household farming (Arinaitwe-Mugisha, 1999). Men, on the other hand, are supposed to go hunting, till the land, look after animals and carry out construction work (Arinaitwe-Mugisha, 1999). This is largely still practiced in most rural areas of Africa. However, with urbanization, and in particular the mushrooming of informal settlements in urban areas of most African 232
cities, land problems, low school enrollment, and unemployment limit adolescent choices for gainful occupation. If not in school, they cannot afford recreation facilities, and have no access to employment, so that their unlimited free time increases their vulnerability to alcohol and drugs. In her keynote address at the launch of the “Crime in Nairobi: results of a Citywide Victim Survey”, the director of UN-Habitat explained the need to target youth. She noted that, “In order to target the youth and reduce the chances of them being marginalized and involved in activities of criminal nature, we need to develop programs that enhance their entrepreneurial and other skills” (UNHabitat, 2002b). The effect, though, is likely to be more pronounced among the adolescent boys, owing to the fact that some elements of the female division of labor (e.g. the household chores) are still similar to those in rural areas. Third, there is easy access to alcohol, drugs like bhang (marijuana) and cocaine, and substances like glue and petrol. One of the illicit alcohol brews, locally known as chang’aa, is believed to be even more dangerous than drugs and other substances. Press reports suggest that the brew is responsible for many deaths, disabilities and other social problems in the country. It is locally described as ‘kill me quick,’ reflecting its strength, or ‘kumi–kumi,’ which is literally translated as ten–ten (0.1 US dollars), reflecting its cheapness. It is made from sorghum, maize or millet, and is popular in low-income urban and rural areas, where a half-liter bottle of legal beer costs 55 shillings (nearly 0.7 US dollars; Ngungiri, 2000). What is most dangerous with this brew is that it is sometimes mixed with other substances to make it even stronger. For example, in 2000 at least 137 people died, 500 were hospitalized and 20 were blinded in Nairobi after drinking chang’aa laced with methanol (Rowan, 2000). This example reflects the range of issues the National Agency for Campaign Against Drug Abuse will have to deal with. With projections that Nairobi city will add another 5 million people in the next 10 years (Central Bureau of Statistics, 2001), and that the majority of these people will live in slums, the problem of alcohol, drug and substance abuse can only escalate.
Adolescents in the context of the Nairobi slums The African Population and Health Research Center (APHRC, 2002) report highlights a number of issues related to adolescent life. Educational experiences demonstrate considerably lower enrollment rates for adolescents in Nairobi slums compared to other parts of Kenya, including rural areas. Overall, only one in five of the adolescents in the slums aged 12–24 years was attending school, and the primary reason for school dropout was lack of school fees. Their lives and social conditions are not favourable. While almost three-quarters report having both parents, less
Alcohol, substance and drug use among urban slum adolescents in Nairobi, Kenya: Frederick Mugisha et al.
than one in five live with both parents. Sexual activity begins at an earlier age in the slums than the whole of Kenya, yet contraceptive use, including condoms, was generally low. As a consquence, the incidence of unplanned pregnancies is more frequent. In addition, these adolescents live in conditions similar to all the other slums residents; poor housing, lack of sanitation, insecure livelihoods, poor access to water, poor health and in many cases, crime prone neighbourhoods. The context in which the adolescents live puts them at increased risk for a number of things, including drugs and alcohol.
Methods The Nairobi slum survey To examine alcohol and drug use among adolescents, we used data collected from a representative sample of slums in Nairobi (APHRC, 2002), supplemented by a qualitative survey of the slum residents. Based on census enumeration areas used in the 1999 Kenya National Census, a weighted cross-sectional sample was drawn to be representative of households in all slum clusters in Nairobi. A two-stage stratified sample design was used. Sample points or enumeration areas were selected at the first stage of sampling while households were selected from the sampled enumeration areas at the second stage. In each selected dwelling unit, a household questionnaire schedule was completed to identify household members who would be eligible for individual interviews. All female and male household members aged 12–49 years and 12– 24 years respectively were eligible for individual interviews. The survey instruments were modified from the Kenya Demographic and Health Survey to allow direct comparison with similar data from rural and other urban areas of Kenya. An additional adolescent module for 12–24 years to elicit information on health, livelihood and social issues was included. In addition, qualitative data collected by the African Population and Health Research Center in four of Nairobi City’s nineteen slums during January 1999 were used. The data were collected in order to understand the relationship between slum residents’ living conditions and reproductive health outcomes. The four slums where the study was conducted were: Kibera, Majengo, Kahawa North and Embakasi. Because the composition of residents varies considerably across slums by ethnicity, gender, age, marital status and size, the four were selected to reflect these variations and geographic spread. To ensure a comprehensive coverage of these issues across gender and generation, focus group discussions (FGDs) were conducted with men and women categorized into four age groups (13–17, 18–24, 25–49 and 50+ years). Two additional FGDs were conducted in each of the four slums with community leaders and service providers. In total, therefore, 10 FGDs were conducted in each of the four slums (Bauni and Wasao, 2000). The qualitative data were transcribed verbatim and
analyzed using NUDIST, a specialized software package for analyzing qualitative data. Variables Dependent variable: ever used any drug or alcohol The dependent variable is an indicator of whether the adolescent had ever used drugs or other substances. The drugs and substances included pills, bhang (marijuana), miraa, cocaine, petrol, glue, paint or any other unspecified drug or substance. Alcohol consumption was treated differently, to explore whether there are any differences in the determinants of alcohol consumption and drugs. Independent variables: alcohol, substance and drug abuse related variables Explanatory variables included whether the adolescent is male or female, the age, whether still in school, marital status, and the number sleeping rooms used by the household due to the expected influence they have based on the use of alcohol and drugs. Gender is expected to influence alcohol, substance and drug use, partly due to the underlying different social expectations for men and women (Dong et al., 2003; WHO, 1998). The risk of drug use is expected to increase systematically with age (Guo et al., 2002; WHO, 1998). Age was categorized as 12–14 years, 15–19 years and 20–24 years representing, respectively, early adolescence, late adolescence and early adulthood. School attendance limits free time available to adolescents and focuses their minds out of substance abuse (Asiimwe-Okiror et al., 1997). Marital breakdown reflects a level of disruption that may encourage drug use; for example, compared to those who are “married” or “never married”, the “divorced” or “widowed” or “separated” are all expected to be at increased risk for drug use (Amaro et al., 1990; Wiemann et al., 1995). Discussion with slum residents revealed that there is stronger social control on the girls than the boys. Using domestic sleeping arrangements as a proxy, if a household has more than one sleeping room, the boy is more likely to have his own room than the girl. This provides him with freedom to move during the night, thus increasing the likelihood of getting access to alcohol, substances and drugs. Other variables included in the analysis are reflective of the adolescents’ living conditions and perceptions. These include place of residence, household income, parent characteristics, household characteristics, perceived risk of HIV infection, peer influence (denoted by whether friends are involved in drug use) and whether an individual had at least three meals the day preceeding the survey, as an indicator of access to basic needs. Household income was constructed from the quantities of owned assets (bicyles, motocycle, refrigerator, radio, television, sofa set, cooking stove, lamps and flash light) and the corresponding average market prices, and therefore is best treated as potential rather than actual income, since some of the 233
Alcohol, substance and drug use among urban slum adolescents in Nairobi, Kenya: Frederick Mugisha et al.
property could have been bought when the person was still economically active, or not yet paid for.
alcohol or drugs, although generally the onset of drugs was earlier than for alcohol for both groups.
Statistical analysis: the use of drugs, alcohol and other substances Our analysis started by testing the independence of a number of variables in alcohol and drug use using the Pearson’s χ2 (testing the independence hypothesis). Then multivariate analysis, evaluating the marginal effect of such variables on alcohol, substance and drug use, was based on the economic demand model, where the demand is a function of income, gender and other variables. The focus of the analysis is the effect of the variables on alcohol, substance and drug use and not the type of drug used (the price of the drug therefore is unlikely to be an explanation), rather it is the influence of other factors. Since the dependent variable has two possible outcomes (ever used and never used), we used the logit estimation to examine alcohol and drug use among adolescents in the Nairobi Slums.
Effect of gender on alcohol and drug use The results in Tables 1 and 2 show that 18.9% of the boys compared to 1.4% of the girls have ever used drugs and other substances like glue, petrol, or paint. Similarly, 52.6% of adolescent boys have ever used alcohol compared to 35.1% of the adolescent girls. Logistic regression results also show that being a male increases the odds of using drugs by a factor of 20.8 and and alcohol by a factor of 5.5. The differences are not only likely to be due to gender but to socially constructed gender roles. These differences among adolescent boys and girls are rooted in the division of labor and social control, where boys have significantly more freedom and time, thus the increased likelihood of engaging in alcohol and drugs. Girls are expected to do household work including cleaning, taking care of the children and cooking. This is reflected in some of the focus group discussion responses; “and girls of this place, mostly me I see … it is like they have no work. Unless she is given work by her parents … they loiter around so much … most of the time they are usually walking around” (Kibera community leaders). “We just sit and wait for the time for cooking; some of us take a walk to west so as to kill time” (girls 13–17 years). “They make hair, they talk” (Embakasi females 13–17 years). The boys on the other hand, are expected to do chores outside the house. They are to fetch water for the household, which is usually three times a day. Since there are no shambas [small farms or allotments] in which to help their fathers as in the rural areas, no gainful employment or school, they have plenty of
Results In this section, we shall present the results from the quantitative survey data supplemented with the results of the focus group discussions. Descriptive results for the use of drugs and other substances are presented in Table 1 and those of alcohol use in Table 2. Multivariate analysis results are presented in Tables 3 and 4 for alcohol and drugs respectively. Figure 1 shows the predicted probabilities of alcohol and drug use among the slum adolescents by current age for males and females. No significant differences were observed for boys and girls with respect to age at initiation of
Table 1 Key characteristics of drug and substance abusers (excluding alcohol) among the Nairobi urban slum adolescents Boys Age group
12–14 years 15–19 years 20–24 years
Still in school
Girls
Both
224 453 997
3.6 17.7 22.9
316 673 933
0.3 1.5 1.7
540 1126 1930
1.7 8.0 12.6
Yes No
350 1309
5.4 22.4
380 1541
0.5 1.6
730 2850
2.9 11.5
Marital status
Never married Currently married Formerly married
1377 261 36
17.9 21.1 38.9
1088 780 54
1.5 1.0 5.6
2465 1041 90
10.7 6.1 18.9
Friends take drugs Imputed household incomes (Kshs)
Yes No Less than 1000 1000 to 5000 5000 to 10 000 more than 10 000
468 1179 392 620 459 203
53.2 5.4 19.6 19.5 19.6 13.8
178 1627 355 555 579 433
12.9 0.3 3.1 1.4 0.9 0.7
646 2806 747 1175 1038 636
42.1 2.4 11.8 11.0 9.2 4.9
Number of sleeping rooms
One Two More than two
1310 267 86
18.6 16.1 32.6
1377 408 123
1.5 1.0 2.4
2687 675 209
9.8 7.0 14.8
1674
18.9
1922
1.4
3596
9.5
Total
234
Alcohol, substance and drug use among urban slum adolescents in Nairobi, Kenya: Frederick Mugisha et al. Table 2 Key characteristics of alcohol users among the Nairobi urban slum adolescents Boys Age group
12–14 years 15–19 years 20–24 years
Still in school
Girls
Both
224 453 997
6.7 40.2 68.6
316 673 933
4.4 16.8 27.3
540 1126 1930
5.4 26.2 48.6
Yes No
350 1309
16.3 62.6
380 1541
9.5 22.4
730 2850
12.7 40.9
Never married Currently married Formerly married
1377 261 36
47.6 74.3 86.1
1088 780 54
16.8 22.3 46.3
2465 1041 90
34.0 35.3 62.2
Imputed household incomes (Kshs)
Less than 1000 1000 to 5000 5000 to 10 000 more than 10 000
392 620 459 203
58.7 53.2 49.5 46.3
355 555 579 433
21.1 16.7 20.4 22.2
747 1175 1038 636
40.8 36.0 33.2 29.9
Number of sleeping rooms
One Two More than two
1310 267 86
57.0 35.6 40.7
1377 408 123
20.4 15.9 26.8
2687 675 209
38.2 23.7 32.5
1674
52.6
1922
19.9
3596
35.1
Marital status
Total
free time at their disposal. The defining factor then would be how they spend their free time. Here are some responses: “They fetch water. They go fetch water and sell” (Embakasi males 13–17 years). “In the past boys used to play football during their free time but it is no longer the case because there is no space for them to play football” (Embakasi slum males ages 25–49 years). “… But even if you come from this slum and you are free and want to play football, you have to pay the city council. Now what do you use to pay and you are jobless? Now you see during the free time, the youth cannot go to play because they do not have the equipment” (Kahawa North community leaders). There is stronger social control for girls than for boys, which is reflected in many ways, including the sleeping arrangements. If the household uses more than one room for sleeping, there was a perception that girls would sleep in the same room with the parents and the boys would have separate quarters.1 Effect of age on alcohol and drug use The results in Tables 1 and 2 shows that the older the adolescents, the more likely for them to have used drugs and/or alcohol. Age 14 seems to be the threshold, as a jump is observed at this age from 3.6 to 17.7% for boys and for girls from 0.3 to 1.5%. A similar pattern with alcohol use is also observed from 6.7 to 40.2% for boys and from 4.4 to 16.8% for girls. The jump for boys is more pronounced with alcohol (about six times) than for girls (about four times), while it is similar for drugs (about 5 times). After 1 Most of the housing units in the slums are built as single rooms, and one household can occupy more than one room.
controlling for other variables, in Tables 3 and 4, the pattern is maintained with alcohol, while with drugs, the effect of age on male adolsecents is more pronounced. Similar patterns are shown in Figure 1, which shows the predicted probabilities of alcohol and drug use separately for adolescent boys and girls. The figure shows that for both alcohol and drugs, men are more likely than women to use them. In both cases, the use increases with age, seems to level off for drugs at the age of 20 but for alcohol, it is increasing steadily. Effect school attendance on alcohol and drug use Being in school is likely to be a protectiion against alcohol or drug use among adolsecents. From Table 1, the out-of-school boys and girls are four times and three times more likely to use drugs respectively. The pattern is similar with alcohol where out-of-school boys and girls are four and two times more likely to use alcohol respectively. Being out of school, though, seems to affect boys much more than girls, (see Tables 3 and 4). Effect of marital disruption on alcohol and drug use The effect of marriage disruption, shown by those formerly married, is more pronounced among female than male adolescents with respect to drugs (see Table 4). With adolescent boys, those currently married and formely married are at increased risk of taking alcohol compared to those never married (Table 3). So it may not necessarily be due to marital disruption. On the other hand, the girls who are formely married have an increased risk of using alcohol. Therefore, marital 235
Alcohol, substance and drug use among urban slum adolescents in Nairobi, Kenya: Frederick Mugisha et al. Table 3 Coefficients of logistic regression for alcohol use among adolescent males and female in Nairobi informal settlements Variable (base category)
Female adolescentsa
β-statistic Male Household income Age (12–14 years) 15–19 years 20–24 years Still in school Marital status (never married) Currently married Formely married Years of education Household head is male Perceived HIV risk (none) Small HIV risk Moderate to high Friends use drugs Number of household members Age of household head Ever been forced to have sex Perceived good health mother alive Father alive sleeping rooms At least 3 meals previous year Constant
Male adolescentsb
Std. Err.
Odds ratio
0.147
0.069
1.158∗
0.944 1.305 ⫺0.287
0.356 0.366 0.273
⫺0.036 1.029 ⫺0.051 ⫺0.659
β-statistic
Both sexesc
Std. Err.
Odds ratio
0.028
0.069
1.028
2.572∗∗ 3.689∗∗ 0.751
1.219 1.845 ⫺0.757
0.352 0.382 0.220
0.185 0.326 0.026 0.175
0.964 2.799∗∗ 0.950∗ 0.517∗∗
0.540 1.374 0.046 ⫺0.078
0.455 0.831 0.711 ⫺0.076
0.160 0.194 0.191 0.028
1.576∗∗ 2.295∗∗ 2.036∗∗ 0.927∗∗
⫺0.012
0.007
0.988
1.026
0.156
⫺0.304 0.350 ⫺0.126 0.371 ⫺0.002 ⫺2.470
β-statistic
Std. Err.
Odds ratio
1.703 0.089
0.120 0.047
5.493∗∗ 1.093
3.385∗∗ 6.325∗∗ 0.469∗∗
1.181 1.833 ⫺0.566
0.252 0.260 0.170
3.259∗∗ 6.250∗∗ 0.568∗∗
0.176 0.531 0.027 0.213
1.716∗∗ 3.952∗∗ 1.047 0.925
0.042 1.130 0.004 ⫺0.435
0.116 0.269 0.018 0.129
1.043 3.096∗∗ 1.004 0.647∗∗
0.334 0.782 1.225 ⫺0.078
0.142 0.229 0.146 0.036
1.396∗ 2.187∗∗ 3.405∗∗ 0.925∗
0.437 0.758 1.031 ⫺0.066
0.104 0.142 0.112 0.021
1.547∗∗ 2.134∗∗ 2.803∗∗ 0.936∗∗
⫺0.018
0.007
0.982∗∗
⫺0.023
0.005
0.977∗∗
2.791∗∗
0.955
0.335
2.598∗∗
0.938
0.140
2.555∗∗
0.164 0.225 0.155 0.094 0.134
0.738 1.419 0.882 1.450∗∗ 0.998
⫺0.198 ⫺0.123 0.043 0.211 0.086
0.162 0.229 0.156 0.103 0.124
0.820 0.884 1.044 1.235∗ 1.089
⫺0.182 0.129 0.000 0.357 0.020
0.113 0.152 0.108 0.068 0.089
0.833 1.138 1.000 1.430∗∗ 1.020
0.531
0.085∗∗
⫺1.578
0.521
0.206∗∗
⫺2.920
0.361
0.054∗∗
N R2
1746 0.141
1563 0.242
3309 0.257
p ⬍ 0.01 ∗p ⬍ 0.05. Model test: χ2 value = 249.2, p ⬍ 0.01. b Model test: χ2 value = 521.9, p ⬍ 0.01. c Model test: χ2 value = 1,111.0, p ⬍ 0.01. ∗∗ a
disruption is more likely to affect the female adolescents than the male adolescents. Effect of peer influence on alcohol and drug use Peer influence was captured using the question “whether a friend takes drugs or not”. If a friend takes drugs and the adolescent does, then this is a reflection of influence either from the adolescent himself or from the friend. Although there was no way of establishing whether the friend started prior to the respondent adolescent, we still used it as a proxy of peer influence, keeping in mind this limitation. The results in Tables 3 and 4 show that the peer influence is greater for drugs than alcohol. The effect is strongest for females than for males. Effect of other variables on alcohol and drug use The effect of household income is more pronounced among the girls than the boys with the adolescents 236
from the highest income bracket less likely to use drugs. However, the pattern is different when it comes to alcohol, girls from richer households are more likely to use alcohol, while for boys the pattern is similar but tends more to the null. Also the more the rooms a household has, the more likely for both male and female adolescents to use alcohol and drugs. Contrary to expection, this is more pronounced for girls than for boys. Two differences are observed in respect to the determinants of alcohol use on one hand and, substance and drug use on the other. First, when the head of the household is a man, the likelihood of adolescents using alcohol is reduced significantly. Although it is also reduced for substance and drug abuse, the levels are not significant. Secondly, those that have ever been forced to have sex are more likely to have used alcohol and drugs, although the coefficients are not significant for drugs.
Alcohol, substance and drug use among urban slum adolescents in Nairobi, Kenya: Frederick Mugisha et al. Table 4 Coefficients of logistic regression for drug and substance use among adolescent males and female in Nairobi informal settlements Variable (base category)
Male Household income Age (12–14 years) 15–19 years 20–24 years Still in school Marital status (never married) Currently married Formely married education level (years) Household head is male Perceived HIV risk (none) Small HIV risk Moderate to high Friends use drugs Number of household members Age of household head Ever been forced to have sex Perceived good health mother alive Father alive sleeping rooms At least 3 meals previous year (constant)
Female adolescentsa
Male adolescentsb
Both sexesc
β-statistic
Std. Err.
Odds ratio
β-statistic
Std. Err.
Odds ratio
β-statistic
Std. Err.
Odds ratio
⫺0.473
0.257
0.623
⫺0.079
0.094
0.924
3.036 ⫺0.147
0.278 0.087
20.819∗∗ 0.864
0.638 0.553 ⫺0.363
1.248 1.301 1.102
1.893 1.738 0.695
1.396 1.456 ⫺1.036
0.526 0.564 0.337
4.039 4.289 0.355
1.258 1.297 ⫺0.959
0.488 0.513 0.318
3.518∗∗ 3.659∗ 0.383∗∗
⫺0.729 2.086 ⫺0.036 ⫺0.071
0.638 0.920 0.096 0.588
0.483 8.054∗ 0.965 0.932
0.438 0.561 ⫺0.091 ⫺0.351
0.226 0.487 0.035 0.281
1.550 1.753 0.913 0.704
0.326 0.964 ⫺0.074 ⫺0.473
0.207 0.430 0.032 0.239
1.386 2.623∗ 0.929∗ 0.623∗
⫺0.726 ⫺0.137 4.040 ⫺0.079
0.630 0.627 0.631 0.077
0.484 0.872 56.847∗∗ 0.924
⫺0.394 0.625 2.976 ⫺0.072
0.206 0.263 0.176 0.048
0.674 1.867 19.611 0.931
⫺0.432 0.514 3.047 ⫺0.059
0.194 0.237 0.166 0.037
0.649∗ 1.671∗ 21.049∗ 0.943
⫺0.061
0.028
0.941∗
0.005
0.009
1.005
⫺0.001
0.008
0.999
1.474
0.514
4.367∗∗
⫺0.256
0.338
0.774
0.326
0.268
1.386
⫺0.082 0.951 0.265 0.570 ⫺0.276
0.549 0.866 0.578 0.233 0.485
0.921 2.589 1.303 1.769∗ 0.758
0.592 ⫺0.239 0.074 0.390 ⫺0.166
0.215 0.287 0.209 0.120 0.166
1.808 0.788 1.076 1.477 0.847
0.477 ⫺0.149 0.050 0.398 ⫺0.194
0.198 0.266 0.195 0.102 0.155
1.612∗ 0.862 1.051 1.489∗∗ 0.824
⫺4.661
1.905
0.009∗
⫺3.401
0.721
0.033
⫺6.073
0.683
0.002∗∗
N R2
1745 0.434
1563 0.335
3308 0.435
p ⬍ 0.01 ∗p ⬍ 0.05. Model test: χ2 value = 117.2, p ⬍ 0.01. b Model test: χ2 value = 505.3, p ⬍ 0.01. c Model test: χ2 value = 1,111.0, p ⬍ 0.01. ∗∗ a
Discussion Effect of gender Before a detailed discussion of the influence of gender on alcohol use, drug abuse and abuse of other substances, let us first address the issue of the validity of the findings arising from either overreporting or underreporting of use. Studies that have investigated the validity of self-reported drug use have found reasonable levels of congruence between self-reports and other measures—like urinalysis—and this has not varied by sex (Martin and Bryant, 2001). The fact that males are more likely to use alcohol and drugs than the female adolescents can be explained partly by their gender differences, which is distinct from their biological differences. Gender is a social construct of how males and females behave and are expected and conditioned to behave under different circumstances. While our result, that males are more likely to use alcohol and drugs is not new (Guo et al., 2002;
Kecskes et al., 2002; Martin and Bryant, 2001; Peretti-Watel et al., 2002; Zweig et al., 2002; Kim and Fendrich, 2002; Chen et al., 2001; Bretteville-Jensen, 1999), an understanding of the gender dimension in the slum setting provides new insights into why there is differential drug use among adolescents and provides a basis for its handling. “Gender refers to women’s and men’s roles and responsibilities that are socially determined. Gender is related to how we are perceived and expected to think and act as women and men because of the way society is organized, not because of the biological differences” (WHO, 1998). Women are usually associated primarily with household and domestic duties—cooking, cleaning of the household, care for the children and the elderly. On the other hand, men are much more closely associated with the world outside the home—with activities of waged work and the rights and duties of citizenship (Doyal, 1998). Through the ethnographic evidence, boys and girls 237
Alcohol, substance and drug use among urban slum adolescents in Nairobi, Kenya: Frederick Mugisha et al.
Figure 1 Predicted probabilities of using alcohol, drug and other substances among slum adolescents in Nairobi, Kenya
are brought up with clear mandates on what they are expected to do to contribute to the household and the wider society. Boys are conditioned for the outside world, while the girls are conditioned for the domestic world. This division of labor at an early age to be consistent and protective from drug and alcohol abuse needs to be supported throughout the child development. In rural areas for example, males are supposed to help in the shambas, plantations and taking care of animals, which is largely still practiced in traditional societies. In the urban settings like Nairobi’s informal settlements, no systems have been developed to help boys and girls fulfill the constructs that society has placed upon them. There are neither plantations nor shambas to work in, which makes the young boys irrelevant and they get frustrated with their lives, since they cannot contribute accordingly. Going to school would be the best substitute, but as we shall see latter in the discussion, it is the lack of schooling that drives adolescents to drugs and alcohol. The other issue of concern is the nature of upbringing of males and females. Women are taught from childhood how to be submissive while men are taught how to exercise authority. This affects the way they behave when faced with crises. “Women, faced with difficult situations and in charge of the daily survival of children and the elderly, do not lose hope; instead, they fight, find new answers, invent new solutions, group together with other women better to organize their daily struggle in the form of nurseries, alternative day-care centers, new family structures (e.g. sisters, mothers and daughters) and new economic activities such as organizing garbage collection. On 238
the contrary, many men faced with a situation that undermines their authority such as unemployment or an accident in the workplace far too often adopt an escapist attitude, seeking refuge in alcohol, drugs, violence or abandonment” (Bisilliat, 2001). This affects them in times of adversity. Women who were educated to be subservient, tend to fight and resist, even at the cost of great suffering, while men, who were educated to be dominant, do not know how to react in situations which deprive them of their “natural authority” (Bisilliat, 2001). In the urban slums, where the prevalence of unemployment and school dropout are high, and the general living conditions are poor, the likelihood of them turning to drugs is also likely to be high and more especially for boys. Effect of school attendance Going to school would be a best substitute for adolescents in the slums since it would deter them from not going into drugs and alcohol. The rate of school attendance is very low in these communities and dropout is high. The recently elected NARC government of Kibaki has instituted free primary education, which is likely to provide an alternative for the primary school age group and postpone the onset of drug and alcohol use. Effect of age The age pattern most likely reflects the onset of drug use among adolescents. The jump in the age pattern suggests that most of the drug use starts at about age 15, which has implications for policy. Interventions
Alcohol, substance and drug use among urban slum adolescents in Nairobi, Kenya: Frederick Mugisha et al.
aimed at preventing illicit drug among adolescents may be best at an early age and preferably before 14 years. Similar results were obtained in a study among school students in Australia, where life time prevalence of illicit drug use increased with age (Lynskey et al., 1999). The government policy on free primary education is likely to shift the age at onset of drug and alcohol use, although the problem is likely to remain, if lack of jobs is all that awaits them. Effect of marriage disruption The effect of marriage disruption, shown by those formerly married, is more pronounced among female than male adolescents. This is true both for alcohol and drug use. The effect is likely to be due to the gender differences, again due to societal expectations. Women are expected to get married and settle in a family, whether the marriage does not seem to work for them or not. Therefore, when such disruption occurs, as in the case of divorce or separation, the women are more likely to be rejected by society. The effect of friends taking drugs One of the factors that is strongly associated with drug use (but not very much with alcohol) is the influence of peers. If an adolescent has a friend who abuses drugs or other substances, the likelihood of him/her using drugs is increased by a factor of 21.1, keeping other things constant. This in a way also reflects the environment in which these adolescents live. Where the prevalence is as high as 18.9% for adolescent boys, this means that one in every five adolescent boys has abused drugs. Therefore, the effect of peers is likely to run quite rapidly. Policy implications In summary, gender does influence whether adolescence boys and girls use drugs or/and alcohol, which is a reflection of different societal constructs and expectations. While improving livelihoods through mothers would lessen the pressure on adolescent boys, providing livelihood alternatives for both boys and girls would equally be essential. The interventions though are likely to be different to cater for the gender differences. Clearly, the free education policy of the current Kenyan government is likely to improve the situation. However, other policies that target the household and communities to reduce the gender divide in the upbringing of children should be tackled. In this case, adolescent boys are at highest risk of drugs, in other cases however, adolescent girls are at highest risk of HIV infection. Gender sensitive interventions such as developing affordable recreational facilities for the slum residents would likely reduce the use of these drugs.
References Amaro, H, Whitaker, R, Coffman, G and Heeren, T (1990) Acculturation and marijuana and cocaine use: findings from
HHANES 1982–1984. American Journal of Public Health 80(suppl.), 54–60. APHRC (2002) Population and health dynamics in Nairobi’s informal settlements. In African Population and Health Research Center (APHRC), Nairobi, Kenya. Arinaitwe-Mugisha J (1999) The changing traditional roles of men and women, and the coping mechanisms. Gender Alert News 3. Asiimwe-Okiror, G, Opio, A A and Musinguzi, J (1997) Change in sexual behaviour and decline in HIV infection among young pregnant women in urban Uganda. AIDS 11, 1757–1763. Bauni, E K and Wasao, S (2000) Voices from the slums: Preliminary report of a qualitative study on sexual networking and reproductive health outcomes in Nairobi City. African Population and Health Research Center. Bisilliat, J (2001) Introducing the gender pespective in national essential drug programmes. In Department of Essential Drugs and Medicine Policy, World Health Organization. Bretteville-Jensen, A L (1999) Gender, heroin consumption and economic behaviour. Health Economics 8, 379–389. Brockerhoff, M and Brennan, E (1998) The poverty of cities in developing countries. Population and Development Review 24, 75–114. Cairncross, S, Hardoy, J E and Satterthwaite, D (1990) The Urban context. In The poor die young: housing and health in third world cities, (eds) S Cairncross, J E Hardoy and D Satterthwaite., pp 1–24. Earthscan Publications, London. Central Bureau of Statistics (2001) The 1999 population and housing census Vol. 1. Central Bureau of Statistics, Ministry of finance and planning, Nairobi, Kenya. Chen, K T, Chen, C J, Fagot-Campagna, A and Chen, K T (2001) & Narayan KM. Tobacco, betel quid, alcohol, and illicit drug use among- to 35-year- olds in I-Lan, rural Taiwan: prevalence and risk factors. American Journal of Public Health, 91 13, 1130–1134. Dong, H, Kouyate, B, Snow, R, Mugisha, F and Sauerborn, R (2003) “Gender’s effect on willingness-to-pay for communitybased insurance in Burkina Faso”. Health Policy 64(2), 153– 162. Doyal, L (1998) Sex, Gender and Health: a preliminary conceptual framework. In Gender and Health, (eds) V Diwan, A Thorson and A Winkvist., pp 17–27. The Nordic School of Public Health, Goteborg. General Assembly (2003a) “Declaration on the Guiding Principles of drug demand reduction: Resolution II adopted as recommended by the Ad Hoc Committee of the Whole” Text of the draft resolution presented in A/S-20/4, chapter V, section A. A/RES/S-20/3. 8-9-2003. General Assembly (2003b) “Political declaration: Resolution I adopted as recommended by the Ad Hoc Committee of the Whole” Text of the draft resolution presented in A/S-20/4, chapter V, section A. A/RES/S-20/3. 8-9-2003. Guo, J, Hill, K G, Hawkins, J D, Catalano, R F and Abbott, R D (2002) A developmental analysis of sociodemographic, family, and peer effects on adolescent illicit drug initiation. Journal of the American Academy of Child Adolescent Psychiatry 41, 838–845. Kecskes, I, Rihmer, ZKiss, K et al. (2002) Gender differences in panic disorder symptoms and illicit drug use among young people in Hungary. European Psychiatry 17, 29–32. Kim, J Y and Fendrich, M (2002) Gender differences in juvenile arrestees’ drug use, self-reported dependence, and perceived need for treatment. Psychiatrics Services 53, 70–75. Lynskey, M, White, V, Hill, D, Letcher, T and Hall, W (1999) Prevalence of illicit drug use among youth: results from the Australian School Students’ Alcohol and Drugs Survey. The Australian & New Zealand Journal of Public Health 23, 519–524. Martin, S E and Bryant, K (2001) Gender differences in the association of alcohol intoxication and illicit drug abuse among persons arrested for violent and property offenses. Journal of Substance Abuse 13, 563–581. Ngungiri, P (2000) “Killer brew leaves Kenyans dead”. http://www.african.com. Internet Communication.
239
Alcohol, substance and drug use among urban slum adolescents in Nairobi, Kenya: Frederick Mugisha et al. Peretti-Watel, P, Beck, F and Legleye, S (2002) Beyond the Ucurve: the relationship between sport and alcohol, cigarette and cannabis use in adolescents. Addiction 97, 707–716. Rowan, D (2000) Alcohol deaths reflect desperate conditions in Kenya. In World Socialist Web Site. UN-Habitat (2002a) “Crime survey in Nairobi” Launch of UNHabitat Safer Cities Publication: Keynote address by Anna Kajumulo Tibaijuka, Executive Director UN-HABITAT, Norfolk Hotel — 05 December 2002. UN-Habitat (2002b) “Crime in Nairobi”, Results of a Citywide Victim Survey. United Nations Population Fund (1996) The state of the World
240
Population 1996. In population, development and the urban poor, United Nations, New York, Changing places. WHO (1998) Gender and Health: technical paper. In World Health Organization, Geneva, Switzerland. Wiemann, C M, Berenson, A B and Landwehr, B M (1995) Racial and ethnic correlates of tobacco, alcohol and illicit drug use in a pregnant population. Journal of Reproductive Medicine 40, 571–578. Zweig, J M, Phillips, S D and Lindberg, L D (2002) Predicting adolescent profiles of risk: looking beyond demographics. Journal of Adolescent Health 31, 343–353.
Cities, Vol. 20, No. 4, p. 231–240, 2003 2003 Elsevier Science Ltd. All rights reserved. Printed in Great Britain 0264-2751/03 $ - see front matter
www.elsevier.com/locate/cities
Alcohol, substance and drug use among urban slum adolescents in Nairobi, Kenya Frederick Mugisha∗ African Population and Health Research Center (APHRC), Shelter Afrique Center, Longonot Road, Upper Hill, P.O Box, 10787—00100, GPO Nairobi, Kenya
Jacqueline Arinaitwe-Mugisha CARE International in Uganda, Arua, Uganda
Bilhah O.N. Hagembe National Agency for Campaign Against Drug Abuse (NACADA), Nairobi, Kenya
Alcohol, substance and drug use among urban slum adolescents is not only a risky behavior in the era of HIV/AIDS but also a potential security threat to a growing city. Based on the Nairobi Urban Slum Survey, adolescent males are more than 20 times more likely to engage in drugs, and 5 times more likely to consume alcohol than girls. In addition, being out-ofschool increases the risk of alcohol and drug abuse. There is a gender dimension to this; societal expectation, division of labor, and nature of upbringing is different for males and females. While the government policy of free primary education is likely to reduce the alcohol and drug incidence, gender targeted interventions, providing alternatives for both boys and girls, would be equally essential. 2003 Elsevier Science Ltd. All rights reserved. Keywords: Gender, illicit drug use, informal settlements, urban
Introduction
ility of nations, the structure of all societies, and the dignity of millions of people and their families”. Young people are at the center of this declaration as our most valuable asset. Recently, during the launch of “Crime in Nairobi: victimization survey”, the director of the National Agency for Campaign Against Drug Abuse (NACADA) noted that drug abuse is one of the factors behind the increase in crime in Nairobi (UN-Habitat, 2002a). He emphasized the need to tackle drug abuse if crime is to be reduced, and the reduction of drug abuse is therefore of significance to both governments and individuals, and in light of this, various international and government declarations have been made and adopted. A case in point is the Declaration on the Guiding Principles of Drug Demand Reduction adopted by the UN. Under this declaration, member states pledged a sustained political, social, health and educational commitment to investing in illicit drug demand reduction programs that will contribute towards reducing public
This paper examines alcohol, substance and drug use among adolescents in the informal settlements of Nairobi, Kenya. The effect of drug abuse on society was probably best summed up in the political declaration on global drug control adopted at the Twentieth Special Session of the United Nations General Assembly on the World Drug Problem (General Assembly, 2003a). In the introduction, it states “drugs destroy lives and communities, undermine sustainable human development and generate crime. Drugs affect all sectors of society in all countries; in particular, drug abuse affects the freedom and development of young people, the world’s most valuable asset. Drugs are a grave threat to the health and wellbeing of all mankind, the independence of states, democracy, the stab∗ Corresponding author. Tel.: +254-2-2720-400; fax: +254-2-2720380; e-mail: [email protected]
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Alcohol, substance and drug use among urban slum adolescents in Nairobi, Kenya: Frederick Mugisha et al.
health problems, improving individual health and well-being, promoting social and economic integration, reinforcing family systems and making communities safer. In addition they agreed to promote, in a balanced way, interregional and international cooperation in order to control supply and reduce demand for drugs (General Assembly, 2003b). However, for these interventions to be effective, they ought to be tailored to the local conditions in the way they target adolescent boys and girls in urban slums. This paper therefore examines alcohol and drug use among urban slum adolescents in Nairobi, Kenya and the resulting implications for targeting.
Urbanization and drug abuse The urban boom in Africa, unlike that of the western world a century or so ago, has been accompained by marked economic stagnation (Brockerhoff and Brennan, 1998), and many of these new city dwellers are poor migrants from the hinterland who will be forced to live in slums and peri-urban areas in cities. The African dilemma is highlighted by the fact that, although 28% of urban residents live in poverty in less developed countries as a whole, over 41% do in Africa (United Nations Population Fund, 1996). It is therefore not suprising to learn that over two in five of city residents live in cirmustances deemed to be “life and health threatening” (Cairncross et al., 1990). In Nairobi alone, slums or informal settlements accommodate more than 60% of the residents yet occupy only 5% of the residential land (APHRC, 2002; WHO, 1998), and thrive among relatively well organized and economically better off neighborhoods. In addition, these communities have had to bear the brunt of the economic decline with increasing unemployment, low school enrollment and pronounced school dropout rates for adolescents. Their health indicators are also known to be worse than their rural counterparts (APHRC, 2002). This has at least two implications; income inequalities are wide and visible, which creates a sense of hopelessness, and the added poor and unstable economic conditions have challenged many would-be breadwinners. This state of hopelessness creates an atmosphere conducive to seeking refuge in alcohol, addictive substances and drugs. Second, the traditional division of labor in urban areas is unlikely to be protective against alcohol, drug and substance abuse. In the African tradition, there is division of labor between males and females—women take up mainly household chores such as cooking, taking care of children and the sick, and household farming (Arinaitwe-Mugisha, 1999). Men, on the other hand, are supposed to go hunting, till the land, look after animals and carry out construction work (Arinaitwe-Mugisha, 1999). This is largely still practiced in most rural areas of Africa. However, with urbanization, and in particular the mushrooming of informal settlements in urban areas of most African 232
cities, land problems, low school enrollment, and unemployment limit adolescent choices for gainful occupation. If not in school, they cannot afford recreation facilities, and have no access to employment, so that their unlimited free time increases their vulnerability to alcohol and drugs. In her keynote address at the launch of the “Crime in Nairobi: results of a Citywide Victim Survey”, the director of UN-Habitat explained the need to target youth. She noted that, “In order to target the youth and reduce the chances of them being marginalized and involved in activities of criminal nature, we need to develop programs that enhance their entrepreneurial and other skills” (UNHabitat, 2002b). The effect, though, is likely to be more pronounced among the adolescent boys, owing to the fact that some elements of the female division of labor (e.g. the household chores) are still similar to those in rural areas. Third, there is easy access to alcohol, drugs like bhang (marijuana) and cocaine, and substances like glue and petrol. One of the illicit alcohol brews, locally known as chang’aa, is believed to be even more dangerous than drugs and other substances. Press reports suggest that the brew is responsible for many deaths, disabilities and other social problems in the country. It is locally described as ‘kill me quick,’ reflecting its strength, or ‘kumi–kumi,’ which is literally translated as ten–ten (0.1 US dollars), reflecting its cheapness. It is made from sorghum, maize or millet, and is popular in low-income urban and rural areas, where a half-liter bottle of legal beer costs 55 shillings (nearly 0.7 US dollars; Ngungiri, 2000). What is most dangerous with this brew is that it is sometimes mixed with other substances to make it even stronger. For example, in 2000 at least 137 people died, 500 were hospitalized and 20 were blinded in Nairobi after drinking chang’aa laced with methanol (Rowan, 2000). This example reflects the range of issues the National Agency for Campaign Against Drug Abuse will have to deal with. With projections that Nairobi city will add another 5 million people in the next 10 years (Central Bureau of Statistics, 2001), and that the majority of these people will live in slums, the problem of alcohol, drug and substance abuse can only escalate.
Adolescents in the context of the Nairobi slums The African Population and Health Research Center (APHRC, 2002) report highlights a number of issues related to adolescent life. Educational experiences demonstrate considerably lower enrollment rates for adolescents in Nairobi slums compared to other parts of Kenya, including rural areas. Overall, only one in five of the adolescents in the slums aged 12–24 years was attending school, and the primary reason for school dropout was lack of school fees. Their lives and social conditions are not favourable. While almost three-quarters report having both parents, less
Alcohol, substance and drug use among urban slum adolescents in Nairobi, Kenya: Frederick Mugisha et al.
than one in five live with both parents. Sexual activity begins at an earlier age in the slums than the whole of Kenya, yet contraceptive use, including condoms, was generally low. As a consquence, the incidence of unplanned pregnancies is more frequent. In addition, these adolescents live in conditions similar to all the other slums residents; poor housing, lack of sanitation, insecure livelihoods, poor access to water, poor health and in many cases, crime prone neighbourhoods. The context in which the adolescents live puts them at increased risk for a number of things, including drugs and alcohol.
Methods The Nairobi slum survey To examine alcohol and drug use among adolescents, we used data collected from a representative sample of slums in Nairobi (APHRC, 2002), supplemented by a qualitative survey of the slum residents. Based on census enumeration areas used in the 1999 Kenya National Census, a weighted cross-sectional sample was drawn to be representative of households in all slum clusters in Nairobi. A two-stage stratified sample design was used. Sample points or enumeration areas were selected at the first stage of sampling while households were selected from the sampled enumeration areas at the second stage. In each selected dwelling unit, a household questionnaire schedule was completed to identify household members who would be eligible for individual interviews. All female and male household members aged 12–49 years and 12– 24 years respectively were eligible for individual interviews. The survey instruments were modified from the Kenya Demographic and Health Survey to allow direct comparison with similar data from rural and other urban areas of Kenya. An additional adolescent module for 12–24 years to elicit information on health, livelihood and social issues was included. In addition, qualitative data collected by the African Population and Health Research Center in four of Nairobi City’s nineteen slums during January 1999 were used. The data were collected in order to understand the relationship between slum residents’ living conditions and reproductive health outcomes. The four slums where the study was conducted were: Kibera, Majengo, Kahawa North and Embakasi. Because the composition of residents varies considerably across slums by ethnicity, gender, age, marital status and size, the four were selected to reflect these variations and geographic spread. To ensure a comprehensive coverage of these issues across gender and generation, focus group discussions (FGDs) were conducted with men and women categorized into four age groups (13–17, 18–24, 25–49 and 50+ years). Two additional FGDs were conducted in each of the four slums with community leaders and service providers. In total, therefore, 10 FGDs were conducted in each of the four slums (Bauni and Wasao, 2000). The qualitative data were transcribed verbatim and
analyzed using NUDIST, a specialized software package for analyzing qualitative data. Variables Dependent variable: ever used any drug or alcohol The dependent variable is an indicator of whether the adolescent had ever used drugs or other substances. The drugs and substances included pills, bhang (marijuana), miraa, cocaine, petrol, glue, paint or any other unspecified drug or substance. Alcohol consumption was treated differently, to explore whether there are any differences in the determinants of alcohol consumption and drugs. Independent variables: alcohol, substance and drug abuse related variables Explanatory variables included whether the adolescent is male or female, the age, whether still in school, marital status, and the number sleeping rooms used by the household due to the expected influence they have based on the use of alcohol and drugs. Gender is expected to influence alcohol, substance and drug use, partly due to the underlying different social expectations for men and women (Dong et al., 2003; WHO, 1998). The risk of drug use is expected to increase systematically with age (Guo et al., 2002; WHO, 1998). Age was categorized as 12–14 years, 15–19 years and 20–24 years representing, respectively, early adolescence, late adolescence and early adulthood. School attendance limits free time available to adolescents and focuses their minds out of substance abuse (Asiimwe-Okiror et al., 1997). Marital breakdown reflects a level of disruption that may encourage drug use; for example, compared to those who are “married” or “never married”, the “divorced” or “widowed” or “separated” are all expected to be at increased risk for drug use (Amaro et al., 1990; Wiemann et al., 1995). Discussion with slum residents revealed that there is stronger social control on the girls than the boys. Using domestic sleeping arrangements as a proxy, if a household has more than one sleeping room, the boy is more likely to have his own room than the girl. This provides him with freedom to move during the night, thus increasing the likelihood of getting access to alcohol, substances and drugs. Other variables included in the analysis are reflective of the adolescents’ living conditions and perceptions. These include place of residence, household income, parent characteristics, household characteristics, perceived risk of HIV infection, peer influence (denoted by whether friends are involved in drug use) and whether an individual had at least three meals the day preceeding the survey, as an indicator of access to basic needs. Household income was constructed from the quantities of owned assets (bicyles, motocycle, refrigerator, radio, television, sofa set, cooking stove, lamps and flash light) and the corresponding average market prices, and therefore is best treated as potential rather than actual income, since some of the 233
Alcohol, substance and drug use among urban slum adolescents in Nairobi, Kenya: Frederick Mugisha et al.
property could have been bought when the person was still economically active, or not yet paid for.
alcohol or drugs, although generally the onset of drugs was earlier than for alcohol for both groups.
Statistical analysis: the use of drugs, alcohol and other substances Our analysis started by testing the independence of a number of variables in alcohol and drug use using the Pearson’s χ2 (testing the independence hypothesis). Then multivariate analysis, evaluating the marginal effect of such variables on alcohol, substance and drug use, was based on the economic demand model, where the demand is a function of income, gender and other variables. The focus of the analysis is the effect of the variables on alcohol, substance and drug use and not the type of drug used (the price of the drug therefore is unlikely to be an explanation), rather it is the influence of other factors. Since the dependent variable has two possible outcomes (ever used and never used), we used the logit estimation to examine alcohol and drug use among adolescents in the Nairobi Slums.
Effect of gender on alcohol and drug use The results in Tables 1 and 2 show that 18.9% of the boys compared to 1.4% of the girls have ever used drugs and other substances like glue, petrol, or paint. Similarly, 52.6% of adolescent boys have ever used alcohol compared to 35.1% of the adolescent girls. Logistic regression results also show that being a male increases the odds of using drugs by a factor of 20.8 and and alcohol by a factor of 5.5. The differences are not only likely to be due to gender but to socially constructed gender roles. These differences among adolescent boys and girls are rooted in the division of labor and social control, where boys have significantly more freedom and time, thus the increased likelihood of engaging in alcohol and drugs. Girls are expected to do household work including cleaning, taking care of the children and cooking. This is reflected in some of the focus group discussion responses; “and girls of this place, mostly me I see … it is like they have no work. Unless she is given work by her parents … they loiter around so much … most of the time they are usually walking around” (Kibera community leaders). “We just sit and wait for the time for cooking; some of us take a walk to west so as to kill time” (girls 13–17 years). “They make hair, they talk” (Embakasi females 13–17 years). The boys on the other hand, are expected to do chores outside the house. They are to fetch water for the household, which is usually three times a day. Since there are no shambas [small farms or allotments] in which to help their fathers as in the rural areas, no gainful employment or school, they have plenty of
Results In this section, we shall present the results from the quantitative survey data supplemented with the results of the focus group discussions. Descriptive results for the use of drugs and other substances are presented in Table 1 and those of alcohol use in Table 2. Multivariate analysis results are presented in Tables 3 and 4 for alcohol and drugs respectively. Figure 1 shows the predicted probabilities of alcohol and drug use among the slum adolescents by current age for males and females. No significant differences were observed for boys and girls with respect to age at initiation of
Table 1 Key characteristics of drug and substance abusers (excluding alcohol) among the Nairobi urban slum adolescents Boys Age group
12–14 years 15–19 years 20–24 years
Still in school
Girls
Both
224 453 997
3.6 17.7 22.9
316 673 933
0.3 1.5 1.7
540 1126 1930
1.7 8.0 12.6
Yes No
350 1309
5.4 22.4
380 1541
0.5 1.6
730 2850
2.9 11.5
Marital status
Never married Currently married Formerly married
1377 261 36
17.9 21.1 38.9
1088 780 54
1.5 1.0 5.6
2465 1041 90
10.7 6.1 18.9
Friends take drugs Imputed household incomes (Kshs)
Yes No Less than 1000 1000 to 5000 5000 to 10 000 more than 10 000
468 1179 392 620 459 203
53.2 5.4 19.6 19.5 19.6 13.8
178 1627 355 555 579 433
12.9 0.3 3.1 1.4 0.9 0.7
646 2806 747 1175 1038 636
42.1 2.4 11.8 11.0 9.2 4.9
Number of sleeping rooms
One Two More than two
1310 267 86
18.6 16.1 32.6
1377 408 123
1.5 1.0 2.4
2687 675 209
9.8 7.0 14.8
1674
18.9
1922
1.4
3596
9.5
Total
234
Alcohol, substance and drug use among urban slum adolescents in Nairobi, Kenya: Frederick Mugisha et al. Table 2 Key characteristics of alcohol users among the Nairobi urban slum adolescents Boys Age group
12–14 years 15–19 years 20–24 years
Still in school
Girls
Both
224 453 997
6.7 40.2 68.6
316 673 933
4.4 16.8 27.3
540 1126 1930
5.4 26.2 48.6
Yes No
350 1309
16.3 62.6
380 1541
9.5 22.4
730 2850
12.7 40.9
Never married Currently married Formerly married
1377 261 36
47.6 74.3 86.1
1088 780 54
16.8 22.3 46.3
2465 1041 90
34.0 35.3 62.2
Imputed household incomes (Kshs)
Less than 1000 1000 to 5000 5000 to 10 000 more than 10 000
392 620 459 203
58.7 53.2 49.5 46.3
355 555 579 433
21.1 16.7 20.4 22.2
747 1175 1038 636
40.8 36.0 33.2 29.9
Number of sleeping rooms
One Two More than two
1310 267 86
57.0 35.6 40.7
1377 408 123
20.4 15.9 26.8
2687 675 209
38.2 23.7 32.5
1674
52.6
1922
19.9
3596
35.1
Marital status
Total
free time at their disposal. The defining factor then would be how they spend their free time. Here are some responses: “They fetch water. They go fetch water and sell” (Embakasi males 13–17 years). “In the past boys used to play football during their free time but it is no longer the case because there is no space for them to play football” (Embakasi slum males ages 25–49 years). “… But even if you come from this slum and you are free and want to play football, you have to pay the city council. Now what do you use to pay and you are jobless? Now you see during the free time, the youth cannot go to play because they do not have the equipment” (Kahawa North community leaders). There is stronger social control for girls than for boys, which is reflected in many ways, including the sleeping arrangements. If the household uses more than one room for sleeping, there was a perception that girls would sleep in the same room with the parents and the boys would have separate quarters.1 Effect of age on alcohol and drug use The results in Tables 1 and 2 shows that the older the adolescents, the more likely for them to have used drugs and/or alcohol. Age 14 seems to be the threshold, as a jump is observed at this age from 3.6 to 17.7% for boys and for girls from 0.3 to 1.5%. A similar pattern with alcohol use is also observed from 6.7 to 40.2% for boys and from 4.4 to 16.8% for girls. The jump for boys is more pronounced with alcohol (about six times) than for girls (about four times), while it is similar for drugs (about 5 times). After 1 Most of the housing units in the slums are built as single rooms, and one household can occupy more than one room.
controlling for other variables, in Tables 3 and 4, the pattern is maintained with alcohol, while with drugs, the effect of age on male adolsecents is more pronounced. Similar patterns are shown in Figure 1, which shows the predicted probabilities of alcohol and drug use separately for adolescent boys and girls. The figure shows that for both alcohol and drugs, men are more likely than women to use them. In both cases, the use increases with age, seems to level off for drugs at the age of 20 but for alcohol, it is increasing steadily. Effect school attendance on alcohol and drug use Being in school is likely to be a protectiion against alcohol or drug use among adolsecents. From Table 1, the out-of-school boys and girls are four times and three times more likely to use drugs respectively. The pattern is similar with alcohol where out-of-school boys and girls are four and two times more likely to use alcohol respectively. Being out of school, though, seems to affect boys much more than girls, (see Tables 3 and 4). Effect of marital disruption on alcohol and drug use The effect of marriage disruption, shown by those formerly married, is more pronounced among female than male adolescents with respect to drugs (see Table 4). With adolescent boys, those currently married and formely married are at increased risk of taking alcohol compared to those never married (Table 3). So it may not necessarily be due to marital disruption. On the other hand, the girls who are formely married have an increased risk of using alcohol. Therefore, marital 235
Alcohol, substance and drug use among urban slum adolescents in Nairobi, Kenya: Frederick Mugisha et al. Table 3 Coefficients of logistic regression for alcohol use among adolescent males and female in Nairobi informal settlements Variable (base category)
Female adolescentsa
β-statistic Male Household income Age (12–14 years) 15–19 years 20–24 years Still in school Marital status (never married) Currently married Formely married Years of education Household head is male Perceived HIV risk (none) Small HIV risk Moderate to high Friends use drugs Number of household members Age of household head Ever been forced to have sex Perceived good health mother alive Father alive sleeping rooms At least 3 meals previous year Constant
Male adolescentsb
Std. Err.
Odds ratio
0.147
0.069
1.158∗
0.944 1.305 ⫺0.287
0.356 0.366 0.273
⫺0.036 1.029 ⫺0.051 ⫺0.659
β-statistic
Both sexesc
Std. Err.
Odds ratio
0.028
0.069
1.028
2.572∗∗ 3.689∗∗ 0.751
1.219 1.845 ⫺0.757
0.352 0.382 0.220
0.185 0.326 0.026 0.175
0.964 2.799∗∗ 0.950∗ 0.517∗∗
0.540 1.374 0.046 ⫺0.078
0.455 0.831 0.711 ⫺0.076
0.160 0.194 0.191 0.028
1.576∗∗ 2.295∗∗ 2.036∗∗ 0.927∗∗
⫺0.012
0.007
0.988
1.026
0.156
⫺0.304 0.350 ⫺0.126 0.371 ⫺0.002 ⫺2.470
β-statistic
Std. Err.
Odds ratio
1.703 0.089
0.120 0.047
5.493∗∗ 1.093
3.385∗∗ 6.325∗∗ 0.469∗∗
1.181 1.833 ⫺0.566
0.252 0.260 0.170
3.259∗∗ 6.250∗∗ 0.568∗∗
0.176 0.531 0.027 0.213
1.716∗∗ 3.952∗∗ 1.047 0.925
0.042 1.130 0.004 ⫺0.435
0.116 0.269 0.018 0.129
1.043 3.096∗∗ 1.004 0.647∗∗
0.334 0.782 1.225 ⫺0.078
0.142 0.229 0.146 0.036
1.396∗ 2.187∗∗ 3.405∗∗ 0.925∗
0.437 0.758 1.031 ⫺0.066
0.104 0.142 0.112 0.021
1.547∗∗ 2.134∗∗ 2.803∗∗ 0.936∗∗
⫺0.018
0.007
0.982∗∗
⫺0.023
0.005
0.977∗∗
2.791∗∗
0.955
0.335
2.598∗∗
0.938
0.140
2.555∗∗
0.164 0.225 0.155 0.094 0.134
0.738 1.419 0.882 1.450∗∗ 0.998
⫺0.198 ⫺0.123 0.043 0.211 0.086
0.162 0.229 0.156 0.103 0.124
0.820 0.884 1.044 1.235∗ 1.089
⫺0.182 0.129 0.000 0.357 0.020
0.113 0.152 0.108 0.068 0.089
0.833 1.138 1.000 1.430∗∗ 1.020
0.531
0.085∗∗
⫺1.578
0.521
0.206∗∗
⫺2.920
0.361
0.054∗∗
N R2
1746 0.141
1563 0.242
3309 0.257
p ⬍ 0.01 ∗p ⬍ 0.05. Model test: χ2 value = 249.2, p ⬍ 0.01. b Model test: χ2 value = 521.9, p ⬍ 0.01. c Model test: χ2 value = 1,111.0, p ⬍ 0.01. ∗∗ a
disruption is more likely to affect the female adolescents than the male adolescents. Effect of peer influence on alcohol and drug use Peer influence was captured using the question “whether a friend takes drugs or not”. If a friend takes drugs and the adolescent does, then this is a reflection of influence either from the adolescent himself or from the friend. Although there was no way of establishing whether the friend started prior to the respondent adolescent, we still used it as a proxy of peer influence, keeping in mind this limitation. The results in Tables 3 and 4 show that the peer influence is greater for drugs than alcohol. The effect is strongest for females than for males. Effect of other variables on alcohol and drug use The effect of household income is more pronounced among the girls than the boys with the adolescents 236
from the highest income bracket less likely to use drugs. However, the pattern is different when it comes to alcohol, girls from richer households are more likely to use alcohol, while for boys the pattern is similar but tends more to the null. Also the more the rooms a household has, the more likely for both male and female adolescents to use alcohol and drugs. Contrary to expection, this is more pronounced for girls than for boys. Two differences are observed in respect to the determinants of alcohol use on one hand and, substance and drug use on the other. First, when the head of the household is a man, the likelihood of adolescents using alcohol is reduced significantly. Although it is also reduced for substance and drug abuse, the levels are not significant. Secondly, those that have ever been forced to have sex are more likely to have used alcohol and drugs, although the coefficients are not significant for drugs.
Alcohol, substance and drug use among urban slum adolescents in Nairobi, Kenya: Frederick Mugisha et al. Table 4 Coefficients of logistic regression for drug and substance use among adolescent males and female in Nairobi informal settlements Variable (base category)
Male Household income Age (12–14 years) 15–19 years 20–24 years Still in school Marital status (never married) Currently married Formely married education level (years) Household head is male Perceived HIV risk (none) Small HIV risk Moderate to high Friends use drugs Number of household members Age of household head Ever been forced to have sex Perceived good health mother alive Father alive sleeping rooms At least 3 meals previous year (constant)
Female adolescentsa
Male adolescentsb
Both sexesc
β-statistic
Std. Err.
Odds ratio
β-statistic
Std. Err.
Odds ratio
β-statistic
Std. Err.
Odds ratio
⫺0.473
0.257
0.623
⫺0.079
0.094
0.924
3.036 ⫺0.147
0.278 0.087
20.819∗∗ 0.864
0.638 0.553 ⫺0.363
1.248 1.301 1.102
1.893 1.738 0.695
1.396 1.456 ⫺1.036
0.526 0.564 0.337
4.039 4.289 0.355
1.258 1.297 ⫺0.959
0.488 0.513 0.318
3.518∗∗ 3.659∗ 0.383∗∗
⫺0.729 2.086 ⫺0.036 ⫺0.071
0.638 0.920 0.096 0.588
0.483 8.054∗ 0.965 0.932
0.438 0.561 ⫺0.091 ⫺0.351
0.226 0.487 0.035 0.281
1.550 1.753 0.913 0.704
0.326 0.964 ⫺0.074 ⫺0.473
0.207 0.430 0.032 0.239
1.386 2.623∗ 0.929∗ 0.623∗
⫺0.726 ⫺0.137 4.040 ⫺0.079
0.630 0.627 0.631 0.077
0.484 0.872 56.847∗∗ 0.924
⫺0.394 0.625 2.976 ⫺0.072
0.206 0.263 0.176 0.048
0.674 1.867 19.611 0.931
⫺0.432 0.514 3.047 ⫺0.059
0.194 0.237 0.166 0.037
0.649∗ 1.671∗ 21.049∗ 0.943
⫺0.061
0.028
0.941∗
0.005
0.009
1.005
⫺0.001
0.008
0.999
1.474
0.514
4.367∗∗
⫺0.256
0.338
0.774
0.326
0.268
1.386
⫺0.082 0.951 0.265 0.570 ⫺0.276
0.549 0.866 0.578 0.233 0.485
0.921 2.589 1.303 1.769∗ 0.758
0.592 ⫺0.239 0.074 0.390 ⫺0.166
0.215 0.287 0.209 0.120 0.166
1.808 0.788 1.076 1.477 0.847
0.477 ⫺0.149 0.050 0.398 ⫺0.194
0.198 0.266 0.195 0.102 0.155
1.612∗ 0.862 1.051 1.489∗∗ 0.824
⫺4.661
1.905
0.009∗
⫺3.401
0.721
0.033
⫺6.073
0.683
0.002∗∗
N R2
1745 0.434
1563 0.335
3308 0.435
p ⬍ 0.01 ∗p ⬍ 0.05. Model test: χ2 value = 117.2, p ⬍ 0.01. b Model test: χ2 value = 505.3, p ⬍ 0.01. c Model test: χ2 value = 1,111.0, p ⬍ 0.01. ∗∗ a
Discussion Effect of gender Before a detailed discussion of the influence of gender on alcohol use, drug abuse and abuse of other substances, let us first address the issue of the validity of the findings arising from either overreporting or underreporting of use. Studies that have investigated the validity of self-reported drug use have found reasonable levels of congruence between self-reports and other measures—like urinalysis—and this has not varied by sex (Martin and Bryant, 2001). The fact that males are more likely to use alcohol and drugs than the female adolescents can be explained partly by their gender differences, which is distinct from their biological differences. Gender is a social construct of how males and females behave and are expected and conditioned to behave under different circumstances. While our result, that males are more likely to use alcohol and drugs is not new (Guo et al., 2002;
Kecskes et al., 2002; Martin and Bryant, 2001; Peretti-Watel et al., 2002; Zweig et al., 2002; Kim and Fendrich, 2002; Chen et al., 2001; Bretteville-Jensen, 1999), an understanding of the gender dimension in the slum setting provides new insights into why there is differential drug use among adolescents and provides a basis for its handling. “Gender refers to women’s and men’s roles and responsibilities that are socially determined. Gender is related to how we are perceived and expected to think and act as women and men because of the way society is organized, not because of the biological differences” (WHO, 1998). Women are usually associated primarily with household and domestic duties—cooking, cleaning of the household, care for the children and the elderly. On the other hand, men are much more closely associated with the world outside the home—with activities of waged work and the rights and duties of citizenship (Doyal, 1998). Through the ethnographic evidence, boys and girls 237
Alcohol, substance and drug use among urban slum adolescents in Nairobi, Kenya: Frederick Mugisha et al.
Figure 1 Predicted probabilities of using alcohol, drug and other substances among slum adolescents in Nairobi, Kenya
are brought up with clear mandates on what they are expected to do to contribute to the household and the wider society. Boys are conditioned for the outside world, while the girls are conditioned for the domestic world. This division of labor at an early age to be consistent and protective from drug and alcohol abuse needs to be supported throughout the child development. In rural areas for example, males are supposed to help in the shambas, plantations and taking care of animals, which is largely still practiced in traditional societies. In the urban settings like Nairobi’s informal settlements, no systems have been developed to help boys and girls fulfill the constructs that society has placed upon them. There are neither plantations nor shambas to work in, which makes the young boys irrelevant and they get frustrated with their lives, since they cannot contribute accordingly. Going to school would be the best substitute, but as we shall see latter in the discussion, it is the lack of schooling that drives adolescents to drugs and alcohol. The other issue of concern is the nature of upbringing of males and females. Women are taught from childhood how to be submissive while men are taught how to exercise authority. This affects the way they behave when faced with crises. “Women, faced with difficult situations and in charge of the daily survival of children and the elderly, do not lose hope; instead, they fight, find new answers, invent new solutions, group together with other women better to organize their daily struggle in the form of nurseries, alternative day-care centers, new family structures (e.g. sisters, mothers and daughters) and new economic activities such as organizing garbage collection. On 238
the contrary, many men faced with a situation that undermines their authority such as unemployment or an accident in the workplace far too often adopt an escapist attitude, seeking refuge in alcohol, drugs, violence or abandonment” (Bisilliat, 2001). This affects them in times of adversity. Women who were educated to be subservient, tend to fight and resist, even at the cost of great suffering, while men, who were educated to be dominant, do not know how to react in situations which deprive them of their “natural authority” (Bisilliat, 2001). In the urban slums, where the prevalence of unemployment and school dropout are high, and the general living conditions are poor, the likelihood of them turning to drugs is also likely to be high and more especially for boys. Effect of school attendance Going to school would be a best substitute for adolescents in the slums since it would deter them from not going into drugs and alcohol. The rate of school attendance is very low in these communities and dropout is high. The recently elected NARC government of Kibaki has instituted free primary education, which is likely to provide an alternative for the primary school age group and postpone the onset of drug and alcohol use. Effect of age The age pattern most likely reflects the onset of drug use among adolescents. The jump in the age pattern suggests that most of the drug use starts at about age 15, which has implications for policy. Interventions
Alcohol, substance and drug use among urban slum adolescents in Nairobi, Kenya: Frederick Mugisha et al.
aimed at preventing illicit drug among adolescents may be best at an early age and preferably before 14 years. Similar results were obtained in a study among school students in Australia, where life time prevalence of illicit drug use increased with age (Lynskey et al., 1999). The government policy on free primary education is likely to shift the age at onset of drug and alcohol use, although the problem is likely to remain, if lack of jobs is all that awaits them. Effect of marriage disruption The effect of marriage disruption, shown by those formerly married, is more pronounced among female than male adolescents. This is true both for alcohol and drug use. The effect is likely to be due to the gender differences, again due to societal expectations. Women are expected to get married and settle in a family, whether the marriage does not seem to work for them or not. Therefore, when such disruption occurs, as in the case of divorce or separation, the women are more likely to be rejected by society. The effect of friends taking drugs One of the factors that is strongly associated with drug use (but not very much with alcohol) is the influence of peers. If an adolescent has a friend who abuses drugs or other substances, the likelihood of him/her using drugs is increased by a factor of 21.1, keeping other things constant. This in a way also reflects the environment in which these adolescents live. Where the prevalence is as high as 18.9% for adolescent boys, this means that one in every five adolescent boys has abused drugs. Therefore, the effect of peers is likely to run quite rapidly. Policy implications In summary, gender does influence whether adolescence boys and girls use drugs or/and alcohol, which is a reflection of different societal constructs and expectations. While improving livelihoods through mothers would lessen the pressure on adolescent boys, providing livelihood alternatives for both boys and girls would equally be essential. The interventions though are likely to be different to cater for the gender differences. Clearly, the free education policy of the current Kenyan government is likely to improve the situation. However, other policies that target the household and communities to reduce the gender divide in the upbringing of children should be tackled. In this case, adolescent boys are at highest risk of drugs, in other cases however, adolescent girls are at highest risk of HIV infection. Gender sensitive interventions such as developing affordable recreational facilities for the slum residents would likely reduce the use of these drugs.
References Amaro, H, Whitaker, R, Coffman, G and Heeren, T (1990) Acculturation and marijuana and cocaine use: findings from
HHANES 1982–1984. American Journal of Public Health 80(suppl.), 54–60. APHRC (2002) Population and health dynamics in Nairobi’s informal settlements. In African Population and Health Research Center (APHRC), Nairobi, Kenya. Arinaitwe-Mugisha J (1999) The changing traditional roles of men and women, and the coping mechanisms. Gender Alert News 3. Asiimwe-Okiror, G, Opio, A A and Musinguzi, J (1997) Change in sexual behaviour and decline in HIV infection among young pregnant women in urban Uganda. AIDS 11, 1757–1763. Bauni, E K and Wasao, S (2000) Voices from the slums: Preliminary report of a qualitative study on sexual networking and reproductive health outcomes in Nairobi City. African Population and Health Research Center. Bisilliat, J (2001) Introducing the gender pespective in national essential drug programmes. In Department of Essential Drugs and Medicine Policy, World Health Organization. Bretteville-Jensen, A L (1999) Gender, heroin consumption and economic behaviour. Health Economics 8, 379–389. Brockerhoff, M and Brennan, E (1998) The poverty of cities in developing countries. Population and Development Review 24, 75–114. Cairncross, S, Hardoy, J E and Satterthwaite, D (1990) The Urban context. In The poor die young: housing and health in third world cities, (eds) S Cairncross, J E Hardoy and D Satterthwaite., pp 1–24. Earthscan Publications, London. Central Bureau of Statistics (2001) The 1999 population and housing census Vol. 1. Central Bureau of Statistics, Ministry of finance and planning, Nairobi, Kenya. Chen, K T, Chen, C J, Fagot-Campagna, A and Chen, K T (2001) & Narayan KM. Tobacco, betel quid, alcohol, and illicit drug use among- to 35-year- olds in I-Lan, rural Taiwan: prevalence and risk factors. American Journal of Public Health, 91 13, 1130–1134. Dong, H, Kouyate, B, Snow, R, Mugisha, F and Sauerborn, R (2003) “Gender’s effect on willingness-to-pay for communitybased insurance in Burkina Faso”. Health Policy 64(2), 153– 162. Doyal, L (1998) Sex, Gender and Health: a preliminary conceptual framework. In Gender and Health, (eds) V Diwan, A Thorson and A Winkvist., pp 17–27. The Nordic School of Public Health, Goteborg. General Assembly (2003a) “Declaration on the Guiding Principles of drug demand reduction: Resolution II adopted as recommended by the Ad Hoc Committee of the Whole” Text of the draft resolution presented in A/S-20/4, chapter V, section A. A/RES/S-20/3. 8-9-2003. General Assembly (2003b) “Political declaration: Resolution I adopted as recommended by the Ad Hoc Committee of the Whole” Text of the draft resolution presented in A/S-20/4, chapter V, section A. A/RES/S-20/3. 8-9-2003. Guo, J, Hill, K G, Hawkins, J D, Catalano, R F and Abbott, R D (2002) A developmental analysis of sociodemographic, family, and peer effects on adolescent illicit drug initiation. Journal of the American Academy of Child Adolescent Psychiatry 41, 838–845. Kecskes, I, Rihmer, ZKiss, K et al. (2002) Gender differences in panic disorder symptoms and illicit drug use among young people in Hungary. European Psychiatry 17, 29–32. Kim, J Y and Fendrich, M (2002) Gender differences in juvenile arrestees’ drug use, self-reported dependence, and perceived need for treatment. Psychiatrics Services 53, 70–75. Lynskey, M, White, V, Hill, D, Letcher, T and Hall, W (1999) Prevalence of illicit drug use among youth: results from the Australian School Students’ Alcohol and Drugs Survey. The Australian & New Zealand Journal of Public Health 23, 519–524. Martin, S E and Bryant, K (2001) Gender differences in the association of alcohol intoxication and illicit drug abuse among persons arrested for violent and property offenses. Journal of Substance Abuse 13, 563–581. Ngungiri, P (2000) “Killer brew leaves Kenyans dead”. http://www.african.com. Internet Communication.
239
Alcohol, substance and drug use among urban slum adolescents in Nairobi, Kenya: Frederick Mugisha et al. Peretti-Watel, P, Beck, F and Legleye, S (2002) Beyond the Ucurve: the relationship between sport and alcohol, cigarette and cannabis use in adolescents. Addiction 97, 707–716. Rowan, D (2000) Alcohol deaths reflect desperate conditions in Kenya. In World Socialist Web Site. UN-Habitat (2002a) “Crime survey in Nairobi” Launch of UNHabitat Safer Cities Publication: Keynote address by Anna Kajumulo Tibaijuka, Executive Director UN-HABITAT, Norfolk Hotel — 05 December 2002. UN-Habitat (2002b) “Crime in Nairobi”, Results of a Citywide Victim Survey. United Nations Population Fund (1996) The state of the World
240
Population 1996. In population, development and the urban poor, United Nations, New York, Changing places. WHO (1998) Gender and Health: technical paper. In World Health Organization, Geneva, Switzerland. Wiemann, C M, Berenson, A B and Landwehr, B M (1995) Racial and ethnic correlates of tobacco, alcohol and illicit drug use in a pregnant population. Journal of Reproductive Medicine 40, 571–578. Zweig, J M, Phillips, S D and Lindberg, L D (2002) Predicting adolescent profiles of risk: looking beyond demographics. Journal of Adolescent Health 31, 343–353.