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De Snyder V.N.S.,National Health Research Institute | Friel S.,University College London | Friel S.,Australian National University | Fotso J.C.,Africa Population and Health Research Center | And 4 more authors.
Journal of Urban Health | Year: 2011

The process of urbanization entails social improvements with the consequential better quality-of-life for urban residents. However, in many low-income and some middle-income countries, urbanization conveys inequality and exclusion, creating cities and dwellings characterized by poverty, overcrowded conditions, poor housing, severe pollution, and absence of basic services such as water and sanitation. Slums in large cities often have an absence of schools, transportation, health centers, recreational facilities, and other such amenities. Additionally, the persistence of certain conditions, such as poverty, ethnic heterogeneity, and high population turnover, contributes to a lowered ability of individuals and communities to control crime, vandalism, and violence. The social vulnerability in health is not a "natural" or predefined condition but occurs because of the unequal social context that surrounds the daily life of the disadvantaged, and often, socially excluded groups. Social exclusion of individuals and groups is a major threat to development, whether to the community social cohesion and economic prosperity or to the individual self-realization through lack of recognition and acceptance, powerlessness, economic vulnerability, ill health, diminished life experiences, and limited life prospects. In contrast, social inclusion is seen to be vital to the material, psychosocial, and political aspects of empowerment that underpin social well-being and equitable health. Successful experiences of cooperation and networking between slum-based organizations, grassroots groups, local and international NGOs, and city government are important mechanisms that can be replicated in urban settings of different low- and middle-income countries. With increasing urbanization, it is imperative to design health programs for the urban poor that take full advantage of the social resources and resourcefulness of their own communities. © 2011 The New York Academy of Medicine.

Subbaraman R.,Action and Research PUKAR | Subbaraman R.,Brigham and Womens Hospital | Nolan L.,Princeton University | Shitole T.,Action and Research PUKAR | And 8 more authors.
Social Science and Medicine | Year: 2014

In India, "non-notified" slums are not officially recognized by city governments; they suffer from insecure tenure and poorer access to basic services than "notified" (government-recognized) slums. We conducted a study in a non-notified slum of about 12,000 people in Mumbai to determine the prevalence of individuals at high risk for having a common mental disorder (i.e., depression and anxiety), to ascertain the impact of mental health on the burden of functional impairment, and to assess the influence of the slum environment on mental health. We gathered qualitative data (six focus group discussions and 40 individual interviews in July-November 2011), with purposively sampled participants, and quantitative data (521 structured surveys in February 2012), with respondents selected using community-level random sampling. For the surveys, we administered the General Health Questionnaire-12 (GHQ) to screen for common mental disorders (CMDs), the WHO Disability Assessment Schedule 2.0 (WHO DAS) to screen for functional impairment, and a slum adversity questionnaire, which we used to create a composite Slum Adversity Index (SAI) score. Twenty-three percent of individuals have a GHQ score ≥5, suggesting they are at high risk for having a CMD. Psychological distress is a major contributor to the slum's overall burden of functional impairment. In a multivariable logistic regression model, household income, poverty-related factors, and the SAI score all have strong independent associations with CMD risk. The qualitative findings suggest that non-notified status plays a central role in creating psychological distress-by creating and exacerbating deprivations that serve as sources of stress, by placing slum residents in an inherently antagonistic relationship with the government through the criminalization of basic needs, and by shaping a community identity built on a feeling of social exclusion from the rest of the city. © 2014 The Authors.

Subbaraman R.,Action and Research PUKAR | Subbaraman R.,Brigham and Womens Hospital | Shitole S.,Action and Research PUKAR | Shitole T.,Action and Research PUKAR | And 4 more authors.
BMC Public Health | Year: 2013

Background: Urban slums in developing countries that are not recognized by the government often lack legal access to municipal water supplies. This results in the creation of insecure informal water distribution systems (i.e., community-run or private systems outside of the governments purview) that may increase water-borne disease risk. We evaluate an informal water distribution system in a slum in Mumbai, India using commonly accepted health and social equity indicators. We also identify predictors of bacterial contamination of drinking water using logistic regression analysis. Methods. Data were collected through two studies: the 2008 Baseline Needs Assessment survey of 959 households and the 2011 Seasonal Water Assessment, in which 229 samples were collected for water quality testing over three seasons. Water samples were collected in each season from the following points along the distribution system: motors that directly tap the municipal supply (i.e., point-of-source water), hoses going to slum lanes, and storage and drinking water containers from 21 households. Results: Depending on season, households spend an average of 52 to 206 times more than the standard municipal charge of Indian rupees 2.25 (US dollars 0.04) per 1000 liters for water, and, in some seasons, 95% use less than the WHO-recommended minimum of 50 liters per capita per day. During the monsoon season, 50% of point-of-source water samples were contaminated. Despite a lack of point-of-source water contamination in other seasons, stored drinking water was contaminated in all seasons, with rates as high as 43% for E. coli and 76% for coliform bacteria. In the multivariate logistic regression analysis, monsoon and summer seasons were associated with significantly increased odds of drinking water contamination. Conclusions: Our findings reveal severe deficiencies in water-related health and social equity indicators. All bacterial contamination of drinking water occurred due to post-source contamination during storage in the household, except during the monsoon season, when there was some point-of-source water contamination. This suggests that safe storage and household water treatment interventions may improve water quality in slums. Problems of exorbitant expense, inadequate quantity, and poor point-of-source quality can only be remedied by providing unrecognized slums with equitable access to municipal water supplies. © 2013 Subbaraman et al; licensee BioMed Central Ltd.

Subbaraman R.,Action and Research PUKAR | Subbaraman R.,Harvard University | Nolan L.,Princeton University | Sawant K.,Action and Research PUKAR | And 5 more authors.
PLoS ONE | Year: 2015

Objective A focus on bacterial contamination has limited many studies of water service delivery in slums, with diarrheal illness being the presumed outcome of interest.We conducted a mixed methods study in a slum of 12,000 people in Mumbai, India to measure deficiencies in a broader array of water service delivery indicators and their adverse life impacts on the slums residents. Methods Six focus group discussions and 40 individual qualitative interviews were conducted using purposeful sampling. Quantitative data on water indicators quantity, access, price, reliability, and equity were collected via a structured survey of 521 households selected using population-based random sampling. Results In addition to negatively affecting health, the qualitative findings reveal that water service delivery failures have a constellation of other adverse life impacts on household economy, employment, education, quality of life, social cohesion, and peoples sense of political inclusion. In a multivariate logistic regression analysis, price of water is the factor most strongly associated with use of inadequate water quantity (20 liters per capita per day). Water service delivery failures and their adverse impacts vary based on whether households fetch water or have informal water vendors deliver it to their homes. Conclusions Deficiencies in water service delivery are associated with many non-health-related adverse impacts on slum households. Failure to evaluate non-health outcomes may underestimate the deprivation resulting from inadequate water service delivery. Based on these findings, we outline a multidimensional definition of household "water poverty" that encourages policymakers and researchers to look beyond evaluation of water quality and health. Use of multidimensional water metrics by governments, slum communities, and researchers may help to ensure that water supplies are designed to advance a broad array of health, economic, and social outcomes for the urban poor.

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