Background
While rapid urbanization is emerging as a major challenge globally, the population of urban poor is expected to grow worldwide. Over 800 million people are thought to live in urban slums at present globally, with an estimation to double in the next 30 years [
1]. In India, the urban population is expected to grow rapidly from a third to half of its total population by 2030, with a simultaneous expansion of its population of urban poor [
2‐
4].
Within this wider context, Bangalore is a rapidly expanding and developing city that is situated in the southern Indian state of Karnataka, and attracts a large number of migrants from surrounding rural areas [
5]. While the Karnataka State Slum Development Board recognizes approximately 600 urban slum areas in Bangalore, informal estimates indicate that there may be up to 1600–2000 slums in the city (
pers comms.). This includes non-notified slums, which are not recognized formally by the government, and lack many vital services, facilities and amenities [
5].
Urban slums are characterised by poverty, housing of poor structural integrity, overcrowding, poor access to water, sanitation and other facilities, and challenging living conditions overall, which impact their inhabitants directly and indirectly [
6,
7]. All these factors work in concert to create a unique set of challenges that compromise the health of slum communities. This is illustrated by the fact that urban slum communities often have poorer health outcomes than those in neighbouring urban areas, and even rural areas. The complexity of this situation is exacerbated by the diversity and fluidity of urban slum settings, and given the interplay between the physical and environmental features of slum systems and local socio-cultural contexts, slum communities tend to be particularly vulnerable to a range of health issues, many of which are largely preventable [
6‐
8]. However, slum-based patients have relatively poor access to care, and only tend to come into contact with formal health care services relatively late into their illnesses, if at all [
6,
7]. Further, there is a scarcity of information available as to the priority health issues that exist, and are likely to emerge, in these settings, making efforts to prevent, screen for, diagnose and treat the health issues of urban slum communities immensely challenging.
Addressing the health challenges of urban slum communities is becoming an increasingly important consideration in global health [
8]. A crucial first step in addressing the needs of these vulnerable communities is to identify, explore, understand and prioritise the major priority health issues they are facing. The present study seeks to identify and prioritise health issues in urban slums in Bangalore, with a wider view of urban slums elsewhere in India, through an exploration of literature and interviews with key stakeholders who work closely with slum communities.
The findings of this study are used to develop a mobile diagnostic and screening toolkit that will help to detect and address the major health challenges in these communities more effectively.
Discussion
This study aimed to identify the priority health issues in urban slums in Bangalore, India. Malnutrition and anaemia were identified as top priorities for women and children. This finding was expected, as these conditions top the list for factors contributing to the disease burden in India overall [
69], particularly in children and women living in areas of poverty [
70,
71]. Diarrhoea was also selected in the child health and infectious disease categories. This finding was also expected, as diarrhoeal diseases are one of the top five leading causes of death in children and in the population overall [
69], in India, with slum dwellers being disproportionately susceptible to these conditions due to the challenging living conditions they endure, including extreme poverty and poor sanitation. It should be noted that diarrhoea, malnutrition and diabetes were also the most frequently mentioned conditions encountered in the interviews and the literature examined during this study.
Nevertheless, the frequency of being reported in the literature is not necessarily a reflection of the prevalence of a particular health issue among the urban slum communities in Bangalore. On the contrary, it might indicate a publication bias or the prominence of that health issue in a region or at a given point in time. In this study, several conditions were identified as priorities in the workshop despite not receiving much attention in either or both of the data sources during the first phase of the study. For instance, dengue fever was selected as a top priority in the infectious diseases category for all four criteria during the prioritisation exercise. Given that it is a seasonal or epidemic health issue, it is possible that seasonality was taken into account when scoring the criteria for this condition. Sepsis was also selected as a priority health condition in the child health category for three criteria, which is in line with the WHO statistical profile of India that lists neonatal sepsis as one of the main causes of mortality in children under the age of five [
69]. Further, although diabetes and hypertension were not mentioned in a large number of the publications examined, they were selected as top priorities in the non-communicable disease category, reported for the majority of patients visiting the community health centre, and listed among the main health complaints during the community consultation session. Indeed, non-communicable diseases, such as diabetes and hypertension are emerging as major public health problems in several developing countries including India and are recognised to exist in slum areas.
This study also demonstrated an equal distribution of health issues across infectious and non-communicable disease categories in both data sources examined in the first phase of the study, which might indicate that both types of health issues are of almost equal importance in urban slums in Bangalore. This is contrary to the common belief that infectious diseases would be more dominant in these areas [
72] due to poor living conditions like lack of clean water, and indicates that the double burden of disease that characterises the health status of people in many low and lower middle income countries is also reflected within urban slum communities.
Women and children were found to be the most studied demographic groups in the literature review, and were also identified by interviewees as the most vulnerable groups in the slums. This is consistent with several national and international reports, which reveal large inequities in the health and mortality rates of women and children in Low and Lower Middle-Income Countries (LMICs).
It would have been beneficial to compare the results of this study with priority health issues in slums in other parts of India, and the world, to understand the similarities and variations of health issues in different settings. However, studies on priority health issues in urban slums are scarce. The vast majority of studies that examine the health status of urban slum dwellers focus on reporting the prevalence of specific health issues or causes of ill health in slums and so do not provide a suitable comparison.
One of the main strengths of this study is that it followed a mixed methods approach, which helped to gain a better understanding of the health issues in urban slums in Bangalore than would be obtained by a single method of data collection. For instance, several health issues identified from the literature were not mentioned in any of the interviews, and would have been missed in the prioritisation activity if only one data source was used. Further, the perceptions of the local slum community expressed during the community consultation session with regard to their health provided additional, and unexpected insights, that would have otherwise been missed. For example, they did not regard diarrhoea as a serious health problem among children below the age of one year, despite the fact that diarrhoea can be life threatening at this age and was identified as a priority health issue for the local urban slum community during the prioritization exercise. Certain health issues can become “normalised” due to their high prevalence and close association with the challenging living conditions in slums, and the fact that there is often little that slum dwellers can do to address them. Therefore, it was important to engage with local communities, and better understand their perceptions of health and priorities in order to develop future interventions based on their needs.
One of the limitations of the study was the sampling strategy utilized for the interviews. Snowball sampling was used to recruit participants as it would have otherwise been difficult to identify interviewees within the local context. This might have introduced some bias into the health issues identified in the interviews as the sample is not necessarily a clear representation of all people working in health-related projects in the slums. However, it is anticipated that using other data sources (e.g. examination of the literature) to identify the health issues in urban slums may have overcome this bias partially. Also, the professional background of the participants might have influenced the health conditions identified, particularly in the case of the technology experts as their area of expertise was different to the remaining participants. However, by comparing their results to the rest of the group, no considerable difference was observed which may be due the fact that many of them were familiar with urban slum settings and health challenges of these settings through other initiatives.
Although there are similarities in the living conditions of urban slums in different regions, and the findings of the present study may be useful to stakeholders working with urban slum communities outside of Bangalore, extrapolation to other slums within India and elsewhere should be done with caution, as all slums have their own unique characteristics, challenges and health issues. Also, the priority health conditions identified were based on criteria relevant to the objective of the wider project to which this study belongs (i.e. to develop a screening and diagnostic toolkit to address priority health conditions in urban slums). This might need to be taken into consideration when interpreting the results of the prioritisation exercise as there might be other criteria that are relevant to the local communities.
The study was of exploratory in nature and aimed to identify and prioritise health conditions occurring in the urban slums of Bangalore. Hence, identifying and addressing factors contributing to the burden of ill health in these communities was beyond the scope of this study. However, it is noteworthy that this study is linked to a large initiative called “Health in Slums” which aims at improving the health and wellbeing of urban slums communities in Bangalore and include other projects that address some of the challenging living conditions faced by these communities.
Following the completion of the present study, a preliminary prototype of the toolkit was developed by the project team. This initial prototype has been field tested and evaluated through a pilot study in one large slum, and it is expected that it will be refined and developed further through future projects.