Search Results (296)

Background: Large urban centers in low- and middle-income countries (LMICs) often have persistent pockets of under-immunized children, despite higher overall vaccination coverage than rural areas. Lahore, a megacity in Pakistan, had the lowest rate of fully immunized children in Punjab province as of 2022 (70%), partly due to challenges in its urban slums. In 2023, an innovative intervention was implemented, utilizing Pakistan’s extensive polio eradication workforce to identify and reach children who were missing routine vaccinations. Objective: The objective was to assess changes in routine immunization coverage during a pre–post evaluation period in which polio campaign workers were engaged to support routine immunization among under-immunized urban populations in Lahore. Methods: A special outreach strategy engaged polio vaccination teams to conduct door-to-door visits of children aged 12–23 months, recording each child’s routine immunization status. These data were integrated into the electronic health system and provided to Expanded Programme on Immunization (EPI) staff for targeted follow-up. Two cross-sectional household surveys of caregivers of children aged 12–23 months were conducted: a 2022 baseline survey and a 2023 follow-up survey conducted six months after implementation. Both surveys used two-stage cluster sampling and WHO-standard immunization coverage methods, with vaccination status verified using cards or caregiver recall. Results: A total of 773 children were surveyed at baseline and 780 at endline. Full immunization coverage increased from 69.8% (CI: 64.13–74.98) to 85.1% (CI: 81.01–88.51). Partial immunization declined from 26.9% (CI: 22.37–31.92) to 14.5% (CI: 11.27–18.50), and the proportion of children not vaccinated at all dropped from 3.3% (CI: 1.92–5.60) to 0.3% (CI: 0.11–0.98). Penta-3 coverage improved from 83.2% (CI: 78.65–87.04) to 94.1% (CI: 91.15–96.07), and Measles 1 from 76.9% (CI: 71.80–81.40) % to 92.1% (CI: 88.71–94.56). Immunization card retention increased from 69.9% (CI: 64.15–75.16) to 84% (CI:81.19–86.94). Improvements were observed across all socio-demographic groups, with a higher impact in peri-urban clusters and low socio-economic groups, and all remained statistically significant. Conclusions: Our findings showed improvements in routine immunization coverage in urban Lahore between 2022 and 2023. This period coincided with district-wide implementation of a polio worker outreach strategy as well as the broader post-COVID-19 recovery of immunization services. This study lacked a control group; therefore, the findings indicate a temporal association occurring during the post COVID-19 recovery period, rather than definitive evidence of causal impact. Nonetheless, integrating the workforce of the polio program into routine immunization could be a promising programmatic strategy to close immunization gaps in urban areas. Full article

The role of poverty, specifically the urban poor, in shaping the urban landscape is often solely linked to slums and informal settlements in urban centers. However, contrary to this common perception, this study aims to elucidate how urban poor residents contribute to shaping urban sprawl in developing countries. After identifying patterns of urban sprawl and poverty in the Jakarta Metropolitan Area (JMA) in Indonesia, the study used the Structural Equation Model (SEM) method to analyze survey data from 195 respondents with a per capita income of less than USD 2.15 (IDR 34,000) daily in Tangerang Regency, a western suburb of the JMA. This study shows that urban sprawl and poverty concentration overlap. The urban poor contribute to urban sprawl by purchasing affordable land on the urban periphery, traveling there with their motorized vehicles, and taking advantage of government subsidies. However, rather than gaining more land, they face increased public service costs, a lack of basic facilities, and habitat destruction. Most respondents own their own homes, but almost half of the respondents (41.54%) state that these homes are less than 48 m² in size. It can be concluded that economically vulnerable populations can contribute to urban sprawl when confronted with ineffective planning institutions. Full article

People living in India are experiencing some of the hottest summers on the planet. Conditions are particularly harsh in Indian cities, like Kolkata, where high temperatures are combined with high humidity. Understanding how conditions in Kolkata have evolved could provide an important addition to the growing study of the problems facing megacities in the hot, humid tropics. Yet in Kolkata, this understanding is obscured by different, often incompatible, methods of assessing the intensity of heat stress. This narrative review considers the problems encountered when attempting to develop a clear understanding of past increases or even to quantify current conditions using conventional meteorological or remote sensing data. Rather than trying to arrive at a precise quantification of how much hotter it is now in Kolkata than in the past, we argue for more fine-grained, individual-level understanding of how heat is experienced. An example of this approach is provided by a study that used telemetric devices to continuously monitor the temperature and humidity to which elderly residents of slum areas in Kolkata were exposed during 24h periods as they went about their daily lives. This study indicates that individuals experience a diversity of heat conditions that are inadequately represented by outdoor temperatures. Living in dwellings where indoor temperatures are often hotter than outdoor temperatures, the daily heat stress experienced by this vulnerable group varies between conditions that are stressful but endurable to those that approach the limits of human heat tolerance. Given the likelihood of even hotter environments in the future, urban planners will need access to more comprehensive heat studies, focusing on continual monitoring of heat stress and physiological responses of individuals from different walks of life. Full article

The purpose of this study was to use the Columbia Suicide Severity Rating Scale (C-SSRS) to assess the prevalence and patterns of suicidality among young women living in poverty to guide effective, targeted interventions for vulnerable populations. Data were drawn from ‘The Onward Project On Wellbeing and Adversity’ (TOPOWA) study, a prospective cohort examining mental health in the context of social determinants of young women aged 18 to 24 years in Kampala’s urban slums. A cohort of 300 women, recruited from three study sites, participated in baseline assessments. Suicidality was assessed using the C-SSRS. Demographic and psychosocial factors and their associations with suicidality are presented. Of the 300 women participants, 66.0% had some secondary education and 62.0% had children, with most of them living with their children (81.7%). Suicidal thoughts were reported by 46.0%, and 17.3% had attempted suicide, with poisoning (23.1%) and hanging (21.2%) being the most common methods. The prevalence of suicidality in this population was very high, indicating significant unmet mental health needs. Since not all suicide attempts are associated with preceding thoughts or plans, it is crucial to consider a broader range of risk factors and warning signs. Social support systems and socioeconomic strengthening may be fruitful strategies for the prevention of suicidality in this population. Full article

Low-income individuals are unlikely to save relatively large sums on a regular basis; however, many still fall short of even the modest threshold required for long-term financial security. This study examines the determinants of benchmark-defined undersaving among retail e-payment agents (REAs) operating in the urban slums of Lagos, Nigeria. We use a contingent valuation survey, descriptive analysis, and logistic regression to examine how selected behavioural and demographic factors, alongside a 60-day experimental intervention—the Programmed Microsaving Scheme (PMSS), a hard daily commitment savings device—affect the likelihood of undersaving, defined as saving less than 12% of each REA’s average daily income. While the PMSS appears to have contributed to improvements in post-treatment saving participation and performance among REAs, it did not significantly increase the likelihood of reaching or exceeding the benchmark savings threshold. Consistent with this, average daily income, age, gender, marital status, education, and religion are statistically insignificant predictors of benchmark-defined undersaving. In contrast, self-control, measured using a literature-validated instrument, exhibits a statistically significant negative association with benchmark-defined undersaving, indicating that higher self-control reduces the likelihood of failing to meet the benchmark. Measured risk aversion similarly shows no significant association. Notably, this study introduces a novel 60-day PMSS, co-designed with REAs and neobanks to accommodate daily income savings—a characteristic of the informal sector largely overlooked in the literature on commitment savings devices. From a policy perspective, the findings suggest that while short-horizon commitment devices (such as the 60-day PMSS) and financial literacy are associated with improvements in microsavings among low-income daily earners, achieving benchmark-level saving might require longer-term and more adaptive mechanisms that address income volatility and mitigate other inherent risks. Full article

Urbanicity is a recognized determinant of mental health, yet conventional measures such as population density or the rural–urban divide often fail to capture the complex realities of informal settlements in low- and middle-income countries. This paper conceptualizes neighborhood effects through the lived experiences of young women in Kampala, Uganda, drawing on participatory research from the NIH-funded TOPOWA study. Using community mapping and Photovoice, participants identified neighborhood features that shape wellbeing, including sanitation facilities, drainage systems, alcohol outlets, health centers, schools, boda boda stages (motorcycle taxis), lodges, religious institutions, water sources, markets, and recreational spaces. These methods revealed both stressors—poor waste management, flooding, violence, gendered harassment, crime, and alcohol-related harms—and protective resources, including education, places of worship, health centers, social networks, identity, and sports activities. We argue that urbanicity in slum contexts should be understood as a multidimensional construct encompassing deprivation, fragmentation, exclusion, and resilience. This reconceptualization advances conceptual clarity, strengthens the validity of mental health research in low-resource settings, and informs interventions that simultaneously address structural risks and promote community assets. The case of Kampala demonstrates how participatory evidence can reshape the understanding of neighborhood effects with implications, for global mental health research and practice. Full article

Compulsory education is a foundation for equitable development, yet many children in urban slums remain excluded. In Dhaka, Bangladesh, this exclusion challenges the assumption that cities naturally provide better educational opportunities. This study aimed to identify the social and economic factors influencing access to compulsory education among slum households. A mixed-methods design was applied using multistage sampling. Quantitative data were collected through surveys of 410 households across four large slums in Dhaka, and qualitative insights were drawn from 15 household interviews. Statistical tests, including Chi-square and one-way ANOVA, were used to examine associations between school dropout and socioeconomic variables. The results indicate that both social and economic conditions affect school dropout rates. Social influences include early marriage, child labor, drug use, low parental education, and household responsibilities that reduce time for schooling. Economic barriers include low family income, schooling costs, and dependence on child earnings. These constraints reduce the real opportunities children have to remain in school, which helps explain why exclusion continues despite compulsory education policies. Coordinated policy action is needed, including simplified school admission procedures, expanded mobile documentation services, and conditional stipends to offset incidental schooling costs. Adult literacy initiatives, stronger enforcement of child marriage and child labor laws, and practical training for school staff to work with slum communities are also important. These measures would support more consistent access to compulsory education for children living in Dhaka’s slums. Full article

Housing conditions are increasingly recognized as critical determinants of non-communicable diseases; however, their influence on hypertension (HTN) risk remains underexplored in low- and middle-income countries. In urban India, structural disparities in housing are especially pronounced between slum and non-slum areas, making comparative analysis crucial for understanding context-specific health risks. This study examines the relationship between multidimensional housing conditions and HTN risk among women aged 18–49, drawing on data from 68,422 respondents in the fourth National Family Health Survey. A composite housing index was developed to capture six dimensions: structural quality, housing services access, indoor air quality, crowding, tenure security, and asset ownership. Survey-weighted logistic regressions were used to assess associations between housing conditions and HTN, controlling for key socio-demographic and health-related factors. We found that overall HTN prevalence was lower in slum households (11.6%) than in non-slum households (16.0%). Unexpectedly, slum households reported better structural durability and indoor air quality than non-slum households, suggesting incremental improvements in notified or tenure-secure slums. Better tenure security and asset ownership were found to be protective factors for HTN risk, while better structural quality was associated with higher HTN odds in non-slum areas. Crowding showed contrasting effects: in slums, higher crowding increased HTN risk, whereas in non-slums, lower crowding was associated with higher HTN. These findings highlight the context-dependent nature of housing-health links. Targeted interventions that address both physical infrastructure and broader living conditions can play a vital role in reducing urban hypertension disparities among women in India. Full article

Unintended pregnancies among adolescent and young women in low- and middle-income countries pose major public health challenges, underscoring the need for improved access to modern contraceptives. This study examined prevalence, preferences, and correlates of modern contraceptive use among young women living in urban slums of Kampala, Uganda, to inform targeted interventions. We analyzed baseline data from The Onward Project On Wellbeing and Adversity (TOPOWA), an NIH-funded, multi-component prospective cohort study on mental health among women aged 18–24 years. In 2023, 300 participants were recruited from three sites (Banda, Bwaise, Makindye). Interviewer-administered surveys assessed contraceptive choices, lifestyle, and demographic factors. Modified Poisson regression was used to examine correlates of contraceptive use. Among participants, 66.0% had ever used contraception, 40.0% were current users, and 38.0% reported modern contraceptive use. Multivariable analyses showed that having a consistent partner (PR = 3.28; 95% CI: 1.90–5.67), engaging in sex work (PR = 2.10; 95% CI: 1.46–3.02), older age (PR = 1.08; 95% CI: 1.01–1.16), and having children (PR = 1.72; 95% CI: 1.12–2.66) were associated with higher modern contraceptive use. Findings highlight important gaps in sustained contraceptive use and the need for tailored interventions addressing economic, social, and educational barriers to improve reproductive health in this low-resource setting. Full article

Vocational training can lead to higher employment rates and improved incomes, particularly for young women in low-resource settings like Kampala’s slums. Despite these benefits, further research is needed to understand the full impact and mechanisms of vocational training on youth in low-resource environments. In 2022, a focus group project, part of a larger study, involved 60 women aged 18 to 24, recruited from three Youth Support Centers operated by the Uganda Youth Development Link (UYDEL) in Kampala. Six focus groups (about 10 women in each group) were held to explore urban stress and how vocational training might mitigate social and environmental stressors and improve mental health. Data analysis conducted using NVivo software identified five key themes: economic benefits, skill development, building confidence and self-esteem, improved social and behavioral well-being, and enhanced lifestyle and quality of life. This formative research underscores that vocational training benefits young women, highlighting outcomes such as job acquisition, financial empowerment, and skill development. Additionally, self-esteem and confidence development emphasize the training’s role in fostering mental health and agency and addressing gender inequality. These findings underscore the value of vocational training in enhancing the mental health and overall well-being of young women and suggest areas for future research for how to best optimize and scale these programs in low-resource settings. Full article

For the majority of its existence, Addis Ababa has had predominantly low-quality housing with inadequate water and sanitation services. However, in 2004, the government-led condominium housing development project started changing the availability and quality of these services. Our team has performed a systematic review of articles dealing with this housing development project and related water and wastewater issues. The results of the review show that over 208,000 condominium housing units with modern water and sanitation infrastructure were built between 2005 and 2021. The condominium housing units have a significantly higher per capita water consumption of 60.5 L/d compared to 17 L/d for the city’s old low-quality Kebele houses. The city has had to more than double the pre-2005 water supply and expand its very limited wastewater treatment capacity from a mere 7500 m³/d to more than 185,000 m³/d in response to the new demand. Overall, both the IHDP and private housing development have increased the quality of life for over 30% of Addis Ababa’s residents by providing modern cooking, bathing, and toilet facilities. Despite this, water supply interruptions are persistent and require a sustainable solution. Full article

Background: Caesarean section (CS) is a critical intervention, yet stark inequities in access persist across low- and middle-income countries (LMICs). Over the last decade, governments have introduced policies to eliminate or subsidize user fees; however, the collective impact of these initiatives on utilization, equity, and financial protection has not been fully synthesized. Methods: We conducted a systematic review in line with PRISMA 2020 guidelines. Searches were conducted in PubMed, Dimensions, Google Scholar, Scopus, Web of Science, and government portals for studies published between 1 January 2009 and 30 May 2025. Eligible studies evaluated government-initiated financing reforms, including full user-fee exemptions, partial subsidies, vouchers, insurance schemes, and provider-payment restructuring. Two reviewers independently applied the PICOS criteria, extracted data using a 15-item template, and assessed the study quality. Given heterogeneity, results were synthesized narratively. Results: Thirty-seven studies from 28 LMICs were included. Most (70%) evaluated fee exemptions. Mixed-methods and cross-sectional designs predominated, while only six studies employed interrupted time series designs. Twenty-two evaluations (59%) reported increased CS uptake, ranging from a 1.4-fold rise in Senegal to a threefold increase in Kano State, Nigeria. Similar surges were also observed in non-African contexts such as Iran and Georgia, where reforms included incentives for vaginal delivery or punitive tariffs to curb overuse. Fourteen of 26 fee-exemption studies documented pro-rich or pro-urban drift, while catastrophic expenditure persisted for 12–43% of households, despite the implementation of “free” policies. Median out-of-pocket costs ranged from USD 14 in Burkina Faso to nearly USD 300 in Dakar’s slums. Only one study linked reforms to a reduction in neonatal mortality (a 30% decrease in Mali/Benin), while none demonstrated an impact on maternal mortality. Qualitative evidence highlighted hidden costs, delayed reimbursements, and weak accountability. At the same time, China and Bangladesh demonstrated how demographic reforms or voucher schemes could inadvertently lead to CS overuse or expose gaps in service readiness. Conclusions: Government-led financing reforms consistently increased CS volumes but fell short of ensuring equity, financial protection, or sustained quality. Effective initiatives combined fee removal with investments in surgical capacity, timely reimbursement, and transparent accountability. Future CS policies must integrate real-time monitoring of equity and quality and adopt robust quasi-experimental designs to enable mid-course correction. Full article

Today, due to the widening of the wealth gap, the intensification of climate change, and the acceleration of both population growth and population aging, our cities are being tested by multiple economic, environmental, and social challenges, including, but not limited to, urban sprawl, urban gentrification, marginalization, housing crisis, tent city, urban flooding, urban heat island, environmental migrants, urban slums, tent cities, urban aging, and empty nesters [...] Full article

The National Adaptation Plan of Bangladesh identifies eleven climate-stressed zones, placing nearly 100 million people at high risk of climate-related hazards. Vulnerable groups such as the poor, floating populations, daily laborers, and slum dwellers are particularly affected. However, there is a lack of data on climate-sensitive diseases and related hospital visits in these areas. This study explored the prevalence of such diseases using the Delphi method through focus group discussions with 493 healthcare professionals from 153 hospitals in 156 upazilas across 21 districts and ten zones. Participants were selected by district Civil Surgeons. Key climate-sensitive diseases identified included malnutrition, diarrhea, pneumonia, respiratory infections, typhoid, skin diseases, hypertension, cholera, mental health disorders, hepatitis, heat stroke, and dengue. Seasonal surges in hospital visits were noted, influenced by factors like extreme heat, air pollution, floods, water contamination, poor sanitation, salinity, and disease vectors. Some diseases were zone-specific, while others were widespread. Regions with fewer hospital visits often had higher disease burdens, indicating under-reporting or lack of access. The findings highlight the need for area-specific adaptation strategies and updates to the Health National Adaptation Plan. Strengthening resilience through targeted investment and preventive measures is crucial to reducing health risks from climate change. Full article