6The Situation of Older People in Poor Urban Settings: The Case of Nairobi, Kenya

The Study Setting

Nairobi typifies the current urban population boom and its associated health and poverty problems, characteristic of many sub-Saharan African cities. During the colonial era, restrictive settlement policies on migration to the city maintained the growth within certain limits, with a population of 120,000 in 1948 (Muwonge, 1980). With the elimination of the “pass” system, in which migrants were required to obtain a permit to reside in Nairobi, and the relaxation of other migration rules following Kenya’s independence in 1963, Nairobi’s growth entered its second phase; its population reached 350,000 in 1962 and 500,000 in 1971, with an estimated one-third living in unauthorized housing (Muwonge, 1980). The 1999 Kenyan Population Census enumerated the population of Nairobi at 2.3 million (Republic of Kenya, 2001). With economic declines since the 1980s, 60 to 70 percent of the Nairobi population is currently estimated to be living in informal settlements that occupy only 5 percent of the residential land area of the city (Matrix Development Consultants, 1993; UN-Habitat, 2003).

This study covers 2 of the more than 40 informal settlements in Nairobi: Viwandani and Korogocho. Although the two communities are similar in many respects, they also have some key differences. Viwandani, which is located very close to the city’s industrial area, is home to many low-income industrial workers, as reflected in the relatively high proportion of men of working age (15-49). In line with its strategic location near the major source of employment in the city (the industrial area), Viwandani attracts somewhat more educated residents than Korogocho. However, this means that the population is also more transient, with residents on average having lived there only six years, whereas Korogocho residents have spent an average of 11.5 years in the community. Also, while Viwandani has more than 53 percent of the total population of the two settlements, it has less than a quarter of the population age 60 and over.

The two communities also share a number of features characteristic of informal settlements in Nairobi. Most households live in one-room houses that serve multiple purposes, including sleeping, sitting, and cooking and eating. Over 95 percent of the households cook in the same room they use for sleeping. Over 90 percent of the households do not have any organized mechanism for garbage disposal, while fewer than 5 percent have their own toilets. Similar patterns are observed for water supply: over 90 percent of households depend on poor-quality water distributed by vendors or kiosks for which they pay three or more times the tariff charged by the Nairobi City Council to pipe water to middle or upper income households (African Population and Health Research Center, 2002; Matrix Development Consultants, 1993; UNICEF, 2002). The social, economic, and environmental conditions prevailing in informal settlements provide a challenge to the wellbeing of older people living in this setting, given their increased vulnerability due to declining physical and health status and reduced economic productivity. It is against this background that this paper seeks to explore the living conditions of the elderly in the informal settlements in Nairobi.

Data and Methods

The quantitative data are drawn from the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) that the African Population and Health Research Centre set up in 2002. The NUHDSS covers a population of about 60,000 living in about 23,000 households in the two informal settlements. The NUHDSS involves visits to all the households once every four months to continuously update information on pregnancies and pregnancy outcomes, migration, episodes of morbidity, health-seeking behavior, mortality and causes of death, livelihood activities, vaccination coverage, marital status, and school attendance. Data on 791 persons age 60 and older present at the end of the three waves of observation in 2003 are used in this analysis.

Qualitative data are also used to examine the meanings attached to being old by older people themselves and other residents of the communities under study and also to provide a snapshot of older people through the use of case studies. The qualitative research involved focus group discussions and in-depth interviews with older persons, as well as focus group discussions with other members of the two communities. The focus group data were collected to provide an overview of the communities’ attitudes and opinions toward older people and aging. They addressed a number of issues relating to community perceptions and definitions of an older person, roles older people play in the community and how these might vary between men and women, support networks available, and general problems older people encounter in urban informal settlements. The focus group participants were randomly selected and stratified according to age. In the indepth interviews, different categories of older people (those living alone, those living only with children under age 15, those with physical disabilities or chronic conditions, those who recently lost an adult child, etc.) were purposively selected for interview. The interviews focused on obtaining case histories of their lives and experiences, support networks, and reasons why they continue to reside where they do. Although these qualitative data are rich and deserve fuller exploration beyond the scope of this paper, we have made only limited use of them, generally to underscore the results emerging from the quantitative data and to highlight the lives of specific older people in the form of case studies.

Who Are Regarded as Older People in Poor Urban Communities?

Although old age is defined differently by various cultures and societies, age 60 is widely used as the cutoff age to define older people. Chronological age, physical features, and social attributes are widely used as characteristics that define old age. The concept of defining old age by chronological age in sub-Saharan Africa has severely been criticized (Bledsoe and Fatoumatta, 2002; HelpAge International, 2002; Kimuna and Adamchak, 1999; United Nations, 1991). Social definitions that see old age as both a process and a stage have been recommended instead, as this comes much closer to local perceptions and notions regarding old age. The qualitative study explored the meanings attached to being old among the study population. Analysis of the data shows clearly that being an older person is perceived both as a process and a stage that a person enters after attaining a certain age or reproductive and other life experiences.

Most of the discussants define an older person according to their physical characteristics, their marital or childbearing experiences, their dress, or the sort of lifestyle they lead. In 15 of the 24 focus group discussions, physical attributes, such as having grey hair and wrinkles, using a walking stick, or having a stooped back, were mentioned in defining an older person. Reproductive experience, especially having grandchildren, and personal character, especially manner of dressing, were also said to define an older person. The degree of contribution to community-wide programs or the ability to command respect in the community are other common descriptions of older people, often made without much regard to chronological age. These nonphysical notions of who an older person is were mentioned in about two-thirds of the focus group discussions. For some discussants, being an older person is equated with importance in men, the onset of menopause for women, and loss of interest in sex for both sexes. Declining physical strength and health status and increased physical and financial dependence and vulnerability were also mentioned as characterizing older people.

Apart from physical features and reproductive experiences, the roles that older people play in their community, especially in arbitrating disputes and providing guidance and local leadership, are also seen as their defining characteristics. Older people were said to play an important role in the community, for example in settling disputes both at the domestic or family level and at the community level. In about 21 of the 24 focus groups, older people were said to be nonpartisan when settling disputes because of their wealth of experience and knowledge, hence their ability to give valuable advice on various issues. They were also said to play a major role in security matters in the community and to participate and provide leadership in community development initiatives, such as the construction of schools, bridges, and toilets, the provision of water, and ensuring that the community is clean. During calamities or disasters such as fires, older people are said to play a lead role in mobilizing the community. The excerpts below provide examples of the views on older people mentioned above.

You may identify an old person by looking at his age and especially for men you may also see their grey hair. Women normally wear head scarves so you may not see the hair. He may also use a walking stick, have impaired vision and may occasionally need assistance from another person (women ages 15-24, Korogocho).

Res6: It means being unable to do things for themselves. There is no work you can do. Even in employment you cannot work. It is like being a child. It is like sickness.

Res9: An older person is someone who is sickly, has no one to help them. They wake up and stare through the window and pray to God and leave everything to God. I am old and I have nothing. I have nobody to help me. I am sick and I have nobody to give me water or to do anything for me. I am old.

Res6: Like me, the way I was last year is not the same this year. I am now incapacitated. I feel I cannot walk. I have aches in the limbs and the back. I feel my whole body paining now.

Res1: It is when your body is incapacitated. It does not concern money but when you can no longer work or do things for yourself then you are old (women age 60 and older, Korogocho).

Res6: An older person cannot walk and his life is almost over. You will shake while walking. Others have no food and this food we are given by our children while others go without food. That is one of the problems the older people face because you are old and you cannot fend for yourself. When you are sick there is nobody to give you health care. Perhaps you have children but they are poor and they wander around because you never gave them proper upbringing due to your poverty status (men age 60 and older, Viwandani).

Res3: They are involved in the administration of the community. Most of them act as chairmen in the community leadership. They attend to community problems like fire outbreaks, shortage of water and village cleanliness, and so on (men ages 25-49, Viwandani).

Those who use chronological age in defining older people often mentioned ages ranging from 35 to 65 and over as the cutoff. Specific ages were given in 13 of the 24 focus groups. Each age group appears to consider anyone in the age groups above theirs as an old person. Discussants in the age group 15-24 were more likely to report age 35 or 40 as the cutoff age. Those ages 25-49 were more likely to mention age 50 or 55 as the cutoff, while most discussants ages 50-59 gave the cutoff as 65. It is interesting that, except for those age 60 and older who feel incapacitated, people do not regard themselves as older. It is unclear the extent to which the negative images often used in describing older people in the slum communities contribute to this view.

The defining characteristics ascribed to older people as noted above suggest that being an older person is not only a function of having attained a certain age, but also reflects certain physical attributes, reproductive experiences, and roles performed in the community. This gives a different perspective on who is an older person as seen through the eyes of members of these communities. The different meanings attached to being an older person call for caution in conducting studies that look at older people in such settings. The discussion below, however, focuses on persons age 60 and above in line with the international definition of older persons.

Sociodemographic Characteristics of Study Participants

Table 6-1 shows the sociodemographic characteristics of older people resident in the two informal settlements. There is a variation in the sex distribution across and within each slum community. There are generally more men than women in the overall population, and this is also reflected in the population age 60 and over. It may reflect historical migration patterns in many parts of sub-Saharan Africa, which are largely dominated by male migration. As noted earlier, Viwandani tends to attract more men: 58 percent of the total male population in the two communities resides in Viwandani (statistics not shown in table). A slightly larger proportion (57 percent) of the total population of the two slum communities also resides in Viwandani. However, only 23 percent of the population age 60 and over resides here. This can be attributed to the fact that Viwandani attracts a more youthful population, who work in the adjoining industries. The imbalance in the older population between Viwandani and Korogocho is also reflected in the gender distribution. Whereas only 56 percent of the total older population is male, this proportion rises to 74 percent in Viwandani, whereas the proportion in Korogocho is the same as that of older women.

TABLE 6-1

Sociodemographic Characteristics of the Overall Population and Older People Age 60 and Above, Nairobi Demographic Surveillance System, 2003.

Almost one-third of the total population consists of people from the Kikuyu ethnic group, and the proportion rises to more than one half (54 percent) among the population age 60 and older. Across the sexes, more than two-thirds of older women in the two slum communities are Kikuyu compared with only 43 percent of the older men. The overrepresentation of Kikuyu older women in the two slum communities may reflect a combination of factors, including the fact that Nairobi is almost surrounded by Central Province, which is largely dominated by the Kikuyu ethnic group. It may also be the case that older women from other ethnic groups may be more likely to return to their rural origins in old age or less likely to have migrated to Nairobi in the past. With growing poverty, it is also possible that poor women from Kikuyu-dominated districts surrounding Nairobi may decide to move to Nairobi to beg or carry out petty business and there fore more likely to reside in the slums. The large disparity between older men and women from the Kikuyu ethnic group is not reflected in the overall ethnic distribution of the total population in the two slum communities. Kikuyu women account for only 34 percent of the total female population, similar to Kikuyu men, who account for 29 percent of the total male population. Across other ethnic groups, older men are more predominant than women in both slum communities.

Slightly more than half of the older population have no education, and less than 5 percent have attained secondary or higher education. The disparity between the sexes in terms of level of education is very wide: more than two-thirds of the older women have no formal education compared with only 38 percent of the older men. Older men are almost eight times more likely than older women to have secondary or higher education.

Among older women, about one in five is currently married compared with 77 percent of older men. An overwhelming majority of the women (76 percent) are formerly married, the majority of these being widowed, and 5 percent have never been married. For the older men, only 21 percent are formerly married, reflecting the higher propensity of widowed and divorced men to remarry, often to much younger women. Widowed or divorced older women, in contrast, rarely remarry and may end up living alone or with their children or other adult relatives.

Among the currently married, older women are more likely to reside with their spouse than are men, and this is true of residents of Korogocho more often than Viwandani. While almost two-thirds of the currently married older men in Korogocho live with their wives, only 29 percent of those living in Viwandani do so. Also, while more than three-quarters of currently married older women in Korogocho live with their spouses, fewer than 40 percent of their counterparts in Viwandani do so. These patterns of gender and slum location differentials in coresidence also exist in the general population, with 96 to 98 percent of currently married women in the two communities coresiding with their husbands compared with only 71 and 61 percent (not shown) of the currently married men in Viwandani and Korogocho, respectively. One plausible explanation for these gender differentials may be differences in reasons for rural-urban migration between men and women: married men may migrate to the city in search of jobs, leaving their families behind, while the women may migrate to join their husbands in the city.

The sociodemographic profile of older people living in urban informal settlements as described above may have implications for their well-being. For example, older women who are largely uneducated and unmarried may face more severe forms of poverty, isolation, and vulnerability than men, and they may be more likely to be excluded from formal employment in the past and social support systems in the present, such as the country’s contributory pension scheme. We use the case study of an in-depth interview with an 82-year-old woman to highlight the vulnerability women face in the urban informal settlements (Box 6-1).

BOX 6-1

Case Study 1: Female Living Alone, Viwandani. She is 82 years old and has been living alone for the past year after her two adopted children were admitted to a boarding school, which also serves as a rehabilitation center. She ran away from her matrimonial (more...)

Living Arrangements

The living arrangements of older people greatly affect their social, economic, and health status and overall well-being. Older people who live alone may lack the necessary social capital and networks to survive in urban informal settlements. Table 6-2 shows the living arrangements of the study group. Overall, 47 and 38 percent of older men and women, respectively, live alone in one-person dwelling units in the two slum communities. In both Korogocho and Viwandani, 7 and 10 percent of the older women, respectively, live only with children under age 15 compared with about 1 percent of the men in each of the slum communities. This finding supports earlier reports suggesting that older women, who may be more vulnerable economically and socially, are often more likely to shoulder the burden of caring for orphaned grandchildren or relatives (Ntozi and Zirimenya, 1999). Among older people who reported being currently married, older men are about 2.5 times more likely than older women to live with only a spouse or with a spouse and children under age 15. The greater proportion of older men living with a spouse may reflect the higher likelihood of widowed or divorced men remarrying, often to much younger women, compared with widowed or divorced women. Overall, close to one-half of older women live with at least one other adult (other than the spouse) who is age 15 or older compared with only a third of the men.

TABLE 6-2

Living Arrangements of Older People, Nairobi Demographic Surveillance System, 2003 (in percentage).

Across the two slum communities, there are substantial variations in living arrangements. More than half of older people in Viwandani (54 percent) live alone compared with only 40 percent in Korogocho. In Viwandani, 60 percent of older men live alone in one-person dwelling units, compared with only 36 percent of the women in the same community. While 12 percent of the older men in Korogocho live with only a spouse, less than 4 percent of those in Viwandani reported living with only their spouse. Compared with estimates for Nairobi from the 1999 census in which only 16.8 percent of the older people live alone, those in the two informal settlements (43 percent) are 2.5 times more likely to live alone. This suggests that older people in poor urban settings may experience much higher levels of isolation. A recent analysis of Demographic and Health Survey data from several African countries suggests that only 6.5 and 5.1 percent of older people age 65 and above in the urban and rural areas, respectively, live alone (Bongaarts and Zimmer, 2005). Most of the older people are heads of their households. This can be attributed to the fact that a large proportion of them live alone and are hence heads of their single-member households. Older women are more likely to report being a spouse or other relative to the head of households compared with men.

The living arrangement categories highlighted above may not adequately capture the range of vulnerabilities that older people face in urban informal settlements. Even when an older person lives with a spouse or other adults, their situation may not necessarily improve, especially if they have primary responsibility for the upkeep of the household. The experiences of two case studies may help highlight this point clearly (Box 6-2). Although these older persons do not live alone, their situations are as bad as those of many other older people who do live alone.

BOX 6-2

Two Case Studies. Case Study #2: Man with a Disability Living with a Spouse, Korogocho The subject is a 90-year-old man whose leg was crippled by injuries he sustained following a bicycle accident five years ago. Although he lives with his wife, he seems (more...)

Economic Status

Table 6-3 shows the labor force participation of the study population, the type of activity they are engaged in, and reasons for not working for those not engaged in any type of income-generating activity. Although the retirement age in Kenya is 55, more than half and close to two-thirds of older women and men, respectively, living in the two slum communities were engaged in an income-generating activity at the time of the study. Nearly three-quarters of the older women and half of the older men who are currently working are engaged in businesses—mainly petty trading, such as selling vegetables along walkways in the community. More than one in five of both men and women are still working in formal employment, whereas 27 percent of the men and only 7 percent of the women are engaged in informal employment—mainly casual labor. There are few variations in the proportions working or type of work across the two communities: older men in Viwandani (39 percent) are more than twice as likely as older men in Korogocho to be working in formal employment. These are largely employed in the industries around Viwandani slum, often as security guards.

TABLE 6-3

Working Status, Reasons for Not Working, and Other Economic Indicators, Nairobi Demographic Surveillance System, 2003 (in percentage).

For those not working, 63 percent of the women and 55 percent of the men reported they are too old or have retired, while 19 percent of the women and 15 percent of the men reported being sick or too ill to work. A total of 30 percent of households headed by an older woman and 15 percent of those headed by a man receive transfers or remittances; nearly half of the transfers come from children and other relatives for both men and women. Older women (34 percent) are more likely than men (26 percent) to receive support from religious organizations, nongovernmental organizations, or the government, probably because they are more likely to reside with younger children, unlike the men. Only 2 percent of older women and 10 percent of men participate in some form of welfare program, mainly the National Social Security Fund. Since it is a contributory scheme, this disparity may reflect traditional gender inequities in employment, with men being much more likely to be in formal employment and therefore to contribute to the program. Indeed, the difference between the two slum communities also points to this fact. In Viwandani, where about 40 percent of the older men report having formal employment, almost one in four reported receiving social security support compared with only 2 to 4 percent of older men in Korogocho and women in both slum communities who receive social security support.

One of the biggest challenges to the economic well-being of older people in the urban informal settlements is the informality of their economic activities. A majority of the residents work in the informal sector, and even those who have formal employment often lack job security despite working in high-risk jobs. The case in Box 6-3 highlights the complex linkages between economic activity, health status, and aging among the urban poor.

BOX 6-3

Case Study #4: Man with a Disability (Blindness), Viwandani. The subject is a 61-year-old man living with his wife and two school-age children. He moved to Nairobi during the preindependence period and has lived in this particular slum community for close (more...)

Health Status

Table 6-4 shows 30 percent of older women and 18 percent of the men reported being sick during a two-week period preceding a visit to their households between January and April 2003. A look at the main illnesses reported by these older people show few differences by gender and slum location. Overall, musculoskeletal illnesses account for 57 percent of the illnesses reported by the women in both slum communities but for only 35 to 47 percent of the illnesses reported by men. Men are more likely to report respiratory illnesses, with one in four in Viwandani reporting this compared with only 15 percent of the women in Korogocho and Viwandani. Equal proportions of men and women in Korogocho reported gastrointestinal illnesses, reflecting the common environmental conditions affecting health in this particular slum community. In contrast to Korogocho, no woman in Viwandani reported gastrointestinal illness, although 10 percent of the men in the community reported it.

TABLE 6-4

Health Status and Treatment-Seeking Behavior Among Older People, Nairobi Demographic Surveillance System, 2003 (in percentage).

Between 10 and 18 percent of the men and women reported illnesses associated with the central nervous system. Although there are indications that depression and dementia are less common in Africa, there might be gross underreporting given the fact that the occurrence of neurovascular disorders, dementia, and depression increases with age. Again, since the reports are generally obtained from the household respondent, who may not necessarily be the older person, such proxy reports on such illnesses as depression may be poor (Alverado-Esquivel et al., 2004; Heun and Hein, 2005; Prince, Acosta, Chiu, Scazufca, and Varghese, 2003). Although older women are more than 1.5 times as likely as older men to be sick, they are not any more likely to have sought care during an illness episode. In general, treatment seeking is quite low among older people, with less than one-half of the sick receiving treatment.

A major health challenge faced by older people is the increasing prevalence of noncommunicable diseases often requiring constant long-term care. These illnesses have the potential of affecting every aspect of their lives, including their families, as some spend all household resources on medication, often at the expense of other basic needs. The case in Box 6-4, a diabetic octogenarian, highlights the situation of older people in dealing with chronic illnesses.

BOX 6-4

Case Study #5: Man Living Alone, Korogocho. The subject is almost 90 years old and has been living alone for the past 5 years. His three children moved out of Nairobi to different parts of the country, and his wife moved in with their son to help look (more...)

Interaction of Living Arrangements, Health, and Economic Status

Table 6-5 looks at the health and working status of older people in the two slum communities by their living arrangements. In Korogocho where the sample is large enough, older women and men living alone are more likely to report being sick than those who live with a spouse or children (or both) or those living with other adults. While 37 percent of older women living alone reported being sick, only 23 percent of those living with other adults reported an illness. Similar patterns are also observed for men, with those living alone being more than two times as likely to report an illness as those living with at least one other adult.

TABLE 6-5

Health and Economic Status by Living Arrangement, Nairobi Demographic Surveillance System, 2003.

Data on treatment-seeking behavior by living arrangement suggests that older women and men living alone may have less access to treatment when ill compared with those living with at least one other adult. Among older women and those in Korogocho, those who live with at least one other adult (other than the spouse) reported higher levels of seeking treatment during an illness episode compared with those who live alone. The number of cases is too small to explore treatment-seeking behavior in other forms of living arrangements. From the qualitative data, lack of transport fare and absence of health personnel at the health facilities were often cited as major hindrances to seeking health care in hospitals. This may partly explain why older people living alone are less likely to seek care even though they are sicker.

In addition, the table shows that in both slum communities and for both men and women, older people who live alone are more likely to continue working to support themselves than those who live with at least one other adult. This is further evidence that older people who live alone may face greater vulnerability than those who live with other adults. Compared with their female counterparts, older men are more likely to be currently working irrespective of their living arrangement.