Project description:ObjectivesDomestic violence against women harms individuals, families, communities and society. Perpetrated by intimate partners or other family members, its overlapping forms include physical, sexual and emotional violence, control and neglect. We aimed to describe the prevalence of these forms of violence and their perpetrators in informal settlements in Mumbai.DesignCross-sectional survey.SettingTwo large urban informal settlement areas.Participants5122 women aged 18-49 years.Primary and secondary outcome measuresPrevalence and perpetrators in the last year of physical, sexual and emotional domestic violence, coercive control and neglect. For each of these forms of violence, responses to questions about individual acts and composite estimates.ResultsIn the last year, 644 (13%) women had experienced physical domestic violence, 188 (4%) sexual violence and 963 (19%) emotional violence. Of ever-married women, 13% had experienced physical or sexual intimate partner violence in the last year. Most physical (87%) and sexual violence (99%) was done by partners, but emotional violence equally involved marital family members. All three forms of violence were more common if women were younger, in the lowest socioeconomic asset quintile or reported disability. 1816 women (35%) had experienced at least one instance of coercive control and 33% said that they were afraid of people in their home. 10% reported domestic neglect of their food, sleep, health or children's health.ConclusionsDomestic violence against women remains common in urban informal settlements. Physical and sexual violence were perpetrated mainly by intimate partners, but emotional violence was attributed equally to partners and marital family. More than one-third of women described controlling behaviours perpetrated by both intimate partners and marital family members. We emphasise the need to include the spectrum of perpetrators and forms of domestic violence-particularly emotional violence and coercive control-in data gathering.Trial registration numberISRCTN84502355; Pre-results.

Project description:The COVID-19 pandemic has magnified the multiple vulnerabilities of people living in urban informal settlements globally. To bring community voices from such settlements to the center of COVID-19 response strategies, we undertook a study in the urban informal settlements of Dharavi, Mumbai, from September 2020-April 2021. In this study, we have examined the awareness, attitudes, reported practices, and some broader experiences of the community in Dharavi with respect to COVID-19. We have used a mixed-methods approach, that included a cross-sectional survey of 468 people, and in-depth interviews and focus group discussions with 49 people living in this area. Data was collected via a mix of phone and face-to-face interviews. We have presented here the descriptive statistics from the survey and the key themes that emerged from our qualitative data. People reported high levels of knowledge about COVID-19, with television (90%), family and friends (56%), and social media (47%) being the main sources of information. The knowledge people had, however, was not free of misconceptions and fear; people were scared of being forcefully quarantined and dying alone during the early days of COVID-19. These fears had negative repercussions in the form of patient-related stigma and hesitancy in seeking healthcare. A year into the pandemic, however, people reported a shift in attitudes from 'extreme fear to low fear' (67% reported perceiving low/no COVID risk in October 2020), contributing to a general laxity in following COVID-appropriate behaviors. Currently, the community is immensely concerned about the revival of livelihoods, that have been adversely impacted due to the lockdown in 2020 as well as the continued 'othering' of Dharavi for being a COVID hotspot. These findings suggest that urban informal settlements like Dharavi need community-level messaging that counters misinformation and denial of the outbreak; local reinforcement of COVID-appropriate behaviours; and long-term social protection measures.

Project description:BackgroundThe global nutrition transition is associated with increased consumption of ultra-processed snack foods and sugar-sweetened beverages (UPF/SSB), contributing to the double burden of child obesity and undernutrition.MethodsThis cross-sectional study describes the prevalence of maternal and child UPF/SSB consumption and the factors associated with frequent consumption in a convenience sample of 749 children ages 6 months through 6 years and their mothers participating in a community-based child oral health program in five informal settlement communities in Mumbai, India. Mothers were interviewed regarding maternal and child oral health and nutrition characteristics, including consumption of beverages and foods associated with tooth decay-milk, soda, tea with sugar, sweets, and chips/biscuits-using standardized questionnaires. Spearman correlations were used to assess for associations between various social factors and the frequency of maternal and child consumption of the five food categories. Chi-square tests were used to assess differences in child consumption patterns by age groups.ResultsThough reported soda consumption was low among both mothers and children, nearly 60% of children consumed sweets and chips/biscuits daily, four to five times the rate of mothers. Factors associated with children's frequent consumption of UPF/SSB included lower maternal education level, frequent maternal consumption of UPF/SSB, greater number of household members, greater amount of money given to the child, and closer proximity to a store.ConclusionOur findings demonstrate social factors that may promote UPF/SSB consumption. The nutritional dangers of sugary drinks and non-nutritious snacks for mothers and young children should be addressed across maternal-child health, education, and social service programs. Early childhood nutrition interventions should involve the entire family and community and emphasize the need to limit children's consumption of unhealthy foods and beverages from an early age.

Project description:BackgroundYoung psychoactive substance users exhibit high-risk behaviours such as unprotected sexual intercourse, and sharing needles and syringes, which increases their risk of Hepatitis B infection. However, there is limited evidence of screening, and vaccination status of this subgroup. The aim of this study was to establish the predictors of screening and completion of the hepatitis B vaccination schedule.MethodsA cross-sectional study using respondent driven sampling was used to enrol respondents from twelve out of fifty-seven informal settlements in Kampala city. Data were collected using an electronic structured questionnaire uploaded on the KoboCollect mobile application, and analysed using Stata version 14. A "modified" Poisson regression analysis was done to determine the predictors of screening while logistic regression was used to determine the predictors of completion of the Hepatitis B vaccination schedule.ResultsAbout 13.3% (102/768) and 2.7% (21/768) of the respondents had ever screened for Hepatitis B, and completed the Hepatitis B vaccination schedule respectively. Being female (aPR 1.61, 95% CI: 1.11-2.33), earning a monthly income >USD 136 (aPR 1.78, 95% CI: 1.11-2.86); completion of the Hepatitis B vaccination schedule (aPR 1.85, 95% CI: 1.26-2.70); lack of awareness about the recommended Hepatitis B vaccine dose (aPR 0.43, 95% CI: 0.27-0.68); and the belief that the Hepatitis B vaccine is effective in preventing Hepatitis B infection (aPRR 3.67, 95% CI: 2.34-5.73) were associated with "ever screening" for Hepatitis B. Knowledge of the recommended Hepatitis B vaccine dose (aOR 0.06, 95% CI: 0.01-0.35); "ever screening" for hepatitis B (aOR 9.68, 95% CI: 2.17-43.16) and the belief that the hepatitis B vaccine is effective in preventing Hepatitis B infection (aOR 11.8, 95% CI: 1.13-110.14) were associated with completion of the hepatitis B vaccination schedule.ConclusionsOur findings indicate a low prevalence of Hepatitis B screening and completion of the Hepatitis B vaccination schedule among young psychoactive substance users in informal settings. It is evident that lack of awareness about Hepatitis B is associated with the low screening and vaccination rates. We recommend creation of awareness of Hepatitis B among young people in urban informal settlements.

Project description:Rapid urbanization and a high unmet need for family planning in urban informal settlements point to the significance of identifying gaps that exist in the path of voluntary uptake of contraceptives. We undertook this study to better understand the perspectives related to family planning among women living in informal settlements of Mumbai. We used a mixed-methods approach, including a cross-sectional survey with 1407 married women of reproductive age and face-to-face in-depth interviews with 22 women, both users and non-users of modern contraceptives. 1070 (76%) of the participants were using modern contraceptives and women's age, education, parity, socioeconomic status and exposure to family planning interventions were the main determinants of contraceptive use. Poor contraceptive awareness before marriage coupled with social norms of early childbearing and completing family resulted in unplanned and less spaced pregnancies even among current users. In such cases, women either continued with the pregnancy or opted for abortion which sometimes could be unsafe. The decision to use contraceptives was taken in most cases after achieving the desired family size and was also influenced by belief in traditional methods, fear of side effects, spousal/family awareness and counselling by frontline workers. We recommend strengthening of sexual and reproductive health component of adolescent health programs. It is pertinent to inform women about their reproductive rights and most importantly empower them to practice these rights. This can be achieved by increasing women's age at marriage and continued promotion of formal education. Widespread misconceptions related to the side effects of modern methods need to be mitigated via counselling. Referral, follow-up, and suggestions on available choices of contraceptives should be given in case women face any side effects from the use of contraceptives. At the same time, improving spousal awareness and communication regarding family planning will allow couples to make informed decisions. Finally, roping in role models in the community will create an environment conducive to operationalizing rights-based family planning.

Project description:We evaluated an adaptation of a large-scale community-based management of acute malnutrition program run by an NGO with government partnerships, in informal settlements of Mumbai, India. The program aimed to reduce the prevalence of wasting among children under age 3 and covered a population of approximately 300,000.This study used a mixed-methods approach including a quasi-experimental design to compare prevalence estimates of wasting in intervention areas with neighboring informal settlements. Cross-sectional data were collected from March through November 2014 for the baseline and October through December 2015 for the endline. Endline data were analyzed using mixed-effects logistic regression models, adjusting for child, maternal, and household characteristics. In addition, we conducted in-depth interviews with 37 stakeholders (13 staff and 24 mothers) who reported on salient features that contributed to successful implementation of the program.We interviewed 2,578 caregivers at baseline and 3,455 at endline in intervention areas. In comparison areas, we interviewed 2,082 caregivers at baseline and 2,122 at endline. At endline, the prevalence of wasting decreased by 28% (18% to 13%) in intervention areas and by 5% (16.9% to 16%) in comparison areas. Analysis of the endline data indicated that children in intervention areas were significantly less likely to be malnourished (adjusted odds ratio, 0.81; confidence interval, 0.67 to 0.99). Stakeholders identified 4 main features as contributing to the success of the program: (1) tailoring and reinforcement of information provided to caregivers in informal settings, (2) constant field presence of staff, (3) holistic case management of issues beyond immediate malnourishment, and (4) persistence of field staff in persuading reluctant families. Staff capabilities were enhanced through training, stringent monitoring mechanisms, and support from senior staff in tackling difficult cases.NGO-government partnerships can revitalize existing community-based programs in urban India. Critical to success are processes that include reinforced knowledge-building of caregivers, a high level of field support and encouragement to the community, and constant monitoring and follow-up of cases by all staff levels.

Project description:BackgroundThe burden of Non-Communicable Diseases (NCDs) in urban informal settlements across Lower and Middle Income Countries is increasing. In recognition, there has been interest in fine-tuning policies on NCDs to meet the unique needs of people living in these settlements. To inform such policy efforts, we studied the care-seeking journeys of people living in urban informal settlements for two NCDs-diabetes and hypertension. The study was done in the Mumbai Metropolitan Region, India.MethodsThis qualitative study was based on interviews with patients having diabetes and hypertension, supplemented by interactions with the general community, private doctors, and public sector staff. We conducted a total of 47 interviews and 6 Focus Group Discussions. We synthesized data thematically and used the qualitative software NVivo Version 10.3 to aid the process. In this paper, we report on themes that we, as a team, interpreted as striking and policy-relevant features of peoples' journeys.ResultsPeople recounted having long and convoluted care-seeking journeys for the two NCDs we studied. There were several delays in diagnosis and treatment initiation. Most people's first point of contact for medical care were local physicians with a non-allopathic degree, who were not always able to diagnose the two NCDs. People reported seeking care from a multitude of healthcare providers (public and private), and repeatedly switched providers. Their stories often comprised multiple points of diagnosis, re-diagnosis, treatment initiation, and treatment adjustments. Advice from neighbors, friends, and family played an essential role in shaping the care-seeking process. Trade-offs between saving costs and obtaining relief from symptoms were made constantly.ConclusionOur paper attempts to bring the voices of people to the forefront of policies on NCDs. People's convoluted journeys with numerous switches between providers indicate the need for trusted "first-contact" points for NCD care. Integrating care across providers-public and private-in urban informal settlements-can go a long way in streamlining the NCD care-seeking process and making care more affordable for people. Educating the community on NCD prevention, screening, and treatment adherence; and establishing local support mechanisms (such as patient groups) may also help optimize people's care-seeking pathways.

Project description:BackgroundAround 105 million people in India will be living in informal settlements by 2017. We investigated the effects of local resource centres delivering integrated activities to improve women's and children's health in urban informal settlements.MethodsIn a cluster-randomised controlled trial in 40 clusters, each containing around 600 households, 20 were randomly allocated to have a resource centre (intervention group) and 20 no centre (control group). Community organisers in the intervention centres addressed maternal and neonatal health, child health and nutrition, reproductive health, and prevention of violence against women and children through home visits, group meetings, day care, community events, service provision, and liaison. The primary endpoints were met need for family planning in women aged 15-49 years, proportion of children aged 12-23 months fully immunised, and proportion of children younger than 5 years with anthropometric wasting. Census interviews with women aged 15-49 years were done before and 2 years after the intervention was implemented. The primary intention-to-treat analysis compared cluster allocation groups after the intervention. We also analysed the per-protocol population (all women with data from both censuses) and assessed cluster-level changes. This study is registered with ISRCTN, number ISRCTN56183183, and Clinical Trials Registry of India, number CTRI/2012/09/003004.Findings12 614 households were allocated to the intervention and 12 239 to control. Postintervention data were available for 8271 women and 5371 children younger than 5 years in the intervention group, and 7965 women and 5180 children in the control group. Met need for family planning was greater in the intervention clusters than in the control clusters (odds ratio [OR] 1·31, 95% CI 1·11-1·53). The proportions of fully immunised children were similar in the intervention and control groups in the intention-to-treat analysis (OR 1·30, 95% CI 0·84-2·01), but were greater in the intervention group when assessed per protocol (1·73, 1·05-2·86). Childhood wasting did not differ between groups (OR 0·92, 95% CI 0·75-1·12), although improvement was seen at the cluster level in the intervention group (p=0·020).InterpretationThis community resource model seems feasible and replicable and may be protocolised for expansion.FundingWellcome Trust, CRY, Cipla.

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COVID-19 vaccine rollout: data from informal settlements in Harare, Kampala, Lilongwe and Mumbai

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