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Informal Urban Settlements and Slums’ Upgrading: Global Case Studies

Resilience of Informal Areas in Megacities – Magnitude, Challenges, and Policies

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Rachid Choghary

Sustainable Development

Andrew Jorgenson

Current History

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The Challenge of Slums presents the first global assessment of slums, emphasizing their problems and prospects. It presents estimates of the numbers of urban slum dwellers and examines the factors that underlie the formation of slums, as well as their social, spatial and economic characteristics and dynamics. It also evaluates the principal policy responses to the slum challenge of the last few decades. The report argues that the number of slum dwellers is growing and will continue to increase unless there is serious and concerted action by all relevant stakeholders. ---------------------------------------------------------------------------------------------------- This book is 20 years old, but still contains much important material. It was my major undertaking after working in and with UN-Habitat for ten years. Many people contributed to the book and I edited the submissions into a consistent style and narrative. My main direct contribution was the material about inequality in Chapters 2, 3 and 4,. It was very controversial and full credit is due to UN-Habitat for slipping the yoke of WB/IMF and publishing it. I was also responsible for the material about cultural innovations emerging from "vibrant mixed urban communities'. The process of development of the report was heavily contested, due to UN-Habitat's desire to use it for advocacy, while the authors were more concerned with accuracy and clarity. First, researchers thought that 'slum' was not a viable concept for statistical purposes, and could not be defined, but UN-Habitat wanted it. Next they they wanted a billion slum dwellers. I considered that from the definitions laid down by the Expert Group there were 'only' half a billion. This was not good enough. So UN-Habitat wrote the first chapter with a billion slum dwellers. This was the main factoid publicising the report World Bank were not happy and commissioned an audit. It emerged that a billion was the number of people who did not have adequate sanitation, which included very many in China not living in "slums". Despite these disputes, the report stands as the flagship introduction to informal settlements "slums" globally.

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Slums are a structural feature of urbanization, and shifting urbanization trends underline their significance for the cities of tomorrow. Despite their importance, data and knowledge on slums are very limited. In consideration of the current data landscape, it is not possible to answer one of the most essential questions: Where are slums located? The goal of this study is to provide a more nuanced understanding of the geography of slums and their growth trajectories. The methods rely on the combination of different datasets (city-level slum maps, world cities, global human settlements layer, Atlas of Informality). Slum data from city-level maps form the backbone of this research and are made compatible by differentiating between the municipal area, the urbanized area, and the area beyond. This study quantifies the location of slums in 30 cities, and our findings show that only half of all slums are located within the administrative borders of cities. Spatial growth has also shifted outwards. However, this phenomenon is very different in different regions of the world; the municipality captures less than half of all slums in Africa and the Middle East but almost two-thirds of all slums in cities of South Asia. These insights are used to estimate land requirements within the Sustainable Development Goals time frame. In 2015, almost one billion slum residents occupied a land area as large as twice the size of the country of Portugal. The estimated 380 million residents to be added up to 2030 will need land equivalent to the size of the country of Egypt. This land will be added to cities mainly outside their administrative borders. Insights are provided on how this land demand differs within cities and between world regions. Such novel insights are highly relevant to the policy actions needed to achieve Target 11.1 of the Sustainable Development Goals (“by 2030, ensure access for all to adequate, safe and affordable housing and basic services, and upgrade slums”) as interventions targeted at slums or informal settlements are strongly linked to political and administrative boundaries. More research is needed to draw attention to the urban expansion of cities and the role of slums and informal settlements.

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Over 1 billion people currently live in slums, with the number of slum dwellers only expected to grow in the coming decades. The vast majority of slums are located in and around urban centres in the less economically developed countries, which are also experiencing greater rates of urbanization compared with more developed countries. This rapid rate of urbanization is cause for significant concern given that many of these countries often lack the ability to provide the infrastructure (e.g., roads and affordable housing) and basic services (e.g., water and sanitation) to provide adequately for the increasing influx of people into cities. While research on slums has been ongoing, such work has mainly focused on one of three constructs: exploring the socio-economic and policy issues; exploring the physical characteristics; and, lastly, those modelling slums. This paper reviews these lines of research and argues that while each is valuable, there is a need for a more holistic approach for studying slums to truly understand them. By synthesizing the social and physical constructs, this paper provides a more holistic synthesis of the problem, which can potentially lead to a deeper understanding and, consequently, better approaches for tackling the challenge of slums at the local, national and regional scales.

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• Published: 09 January 2018

Survey-based socio-economic data from slums in Bangalore, India

• Debraj Roy   ORCID: orcid.org/0000-0003-3579-7219 1 , 2 ,
• Bharath Palavalli 3 ,
• Niveditha Menon 4 ,
• Robin King 5 , 6 ,
• Karin Pfeffer 1 ,
• Michael Lees 1 , 7 &
• Peter M. A. Sloot   ORCID: orcid.org/0000-0002-3848-5395 1 , 2 , 7  

Scientific Data volume  5 , Article number:  170200 ( 2018 ) Cite this article

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In 2010, an estimated 860 million people were living in slums worldwide, with around 60 million added to the slum population between 2000 and 2010. In 2011, 200 million people in urban Indian households were considered to live in slums. In order to address and create slum development programmes and poverty alleviation methods, it is necessary to understand the needs of these communities. Therefore, we require data with high granularity in the Indian context. Unfortunately, there is a paucity of highly granular data at the level of individual slums. We collected the data presented in this paper in partnership with the slum dwellers in order to overcome the challenges such as validity and efficacy of self reported data. Our survey of Bangalore covered 36 slums across the city. The slums were chosen based on stratification criteria, which included geographical location of the slum, whether the slum was resettled or rehabilitated, notification status of the slum, the size of the slum and the religious profile. This paper describes the relational model of the slum dataset, the variables in the dataset, the variables constructed for analysis and the issues identified with the dataset. The data collected includes around 267,894 data points spread over 242 questions for 1,107 households. The dataset can facilitate interdisciplinary research on spatial and temporal dynamics of urban poverty and well-being in the context of rapid urbanization of cities in developing countries.

Machine-accessible metadata file describing the reported data (ISA-Tab format)

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Background & Summary

Cities have become engines of accelerated growth as they are centres of high productivity and provide easy access to resources 1 . The outcome of this high rate of urbanization has been the rise of informal settlements or ‘slums’, characterized by a lack of adequate living space, insecure tenure and public services 2 . In 2010, an estimated 860 million people were living in slums worldwide with around 60 million added to the slum population between 2000 and 2010. In sub-Saharan Africa, the slum population doubles every 4.5 years 3 . In the past decade, over 22 million people have migrated from rural to urban areas in India 4 . While official estimates indicate that the number of slum dwellers in India increased from 30 million in 1981 to over 61 million in 2001 4 , a UN Habitat report estimates the number of slum dwellers in India to be over 100 million. In 2011, 200 million people in urban Indian households were considered to live in slums 5 , of which over a third were in million-plus cities of India.

In this paper, we present granular data about slums from the city of Bangalore in India. Bangalore grew exponentially from 1941 to 1971 6 and is now rapidly growing due to the establishment of the software industry in the city. The urban agglomeration of Bangalore is the administrative capital of the state of Karnataka in India, with a metropolitan population of about 11.52 million and a population growth rate of 47.18% 5 , making it the third most populous city and fifth most populous urban agglomeration in India. The city has seen phases of growth that correspond to the different waves of industrialization and immigration. The first wave of immigration took place between 1880 and 1920, when the textile industry developed in the western part of the city. The second wave of industrialization took place in the eastern and northern areas, when a slew of state owned industries were created between 1940 and 1960. At the same time, state owned research and development establishments were created in the north western region of the city. The final wave can be characterized post 1990, with the establishment of special economic zones for electronics and the IT industry (which was initiated in the 1980s by the state government). To meet housing needs, in the period between the 1980s–1990s, state owned bodies created townships for their employees at the periphery, while housing co-operative societies met the demand for those in the formal sector 6 . A rapid shortage of housing and increased demand for manpower in the city has led to the growth and emergence of slums in Bangalore. The number of slums in Bangalore has grown from 159 in 1971 to over 2000 slums (notified and non-notified) in 2015. Those living in slums accounted for just over 10% of the city’s population in 1971 and an estimated 25 to 35% in 2015.

However, one of the biggest problems associated with studying slum populations is that, despite being ubiquitous, their needs, issues and problems are often invisible due to lack of representation. In this data collection effort the lack of accessibility to slums because of the social distance between the researcher and the respondent was overcome by the use of participatory methods. In order to measure poverty in slums, previous studies have often relied on consumption and income indicators. A Basic Needs Index requires data on literacy, water (piped), sanitation facilities and food requirements 7 . Well-being and vulnerability indicators have used household assets, access to financial services and formal safety nets and social networks 8 . In order to acknowledge the shift in thinking towards multi-dimensional poverty, we ensured that the survey moved away from consumption indicators to well-being and vulnerability indicators. The primary questions for this survey included the economic contribution of the urban poor in the city, the affordability and accessibility of infrastructure facilities, the various migration streams and access to financial systems. Using a participatory method, the survey was conducted in 1,107 households in 36 slums, with each household answering 242 questions. This study and the data descriptor provides a template for future data that can be collected to provide a better understanding of slums in other cities. The data can be used to generate a wide range of measures to study the impact of various programs on the slum dwellers, their expenditure patterns and the economic profile of the slums.

The main purpose of the study was to obtain a better understanding of the nature of urban poverty, to unpack the needs, issues and problems of slum dwellers, but also how slum-dwellers contribute to the urban economy and why households live in slums. The primary research questions were:

What is the economic contribution (labour, production aspects) of the urban poor to the city’s economy?

What are the infrastructure facilities (health, education, water, mobility, sanitation) that are available? Are they affordable, accessible and who pays for it (state/private)?

What are the key drivers of migration flows in and out of the city? When do people enter/leave a slum?

What is the demographic and economic profile of the people living in slums?

Do slum dwellers have access to financial systems and savings?

What are the expenditures of people in the slums?

We combined a structured survey with focus groups and personal interviews. While the structured survey supported the systematic data collection, the use of the qualitative methods such as focus group discussions. Personal interviews allowed for individuals living in the slums to articulate their concerns and also supported further processing of the data, for instance to create categories. The design of the questionnaire was informed by our research questions and former surveys carried out in Bangalore, a survey developed earlier by the Word Bank 9 and surveys reported in literature 10 – 12 . The slum-survey was done in collaboration with slum dwellers to get access to slum areas and have sufficient trust between surveyor and respondent to obtain a higher validity in the answers. The following sections describe the sampling strategy used to randomly select households and individuals for the survey and survey implementation.

Sampling strategy

The slums in Bangalore were stratified based on the following parameters: Age of the Slum (Old, New), Location in the city (Core, Periphery, North, South, East, West); Size of the slum; Land Type (whether the slums are on Public land or Private land); Declaration Status (Declared or Not Declared); Major Linguistic Group (slums that contain a majority of Kannada, Tamil, or Telugu speakers); Major Religious Group (slums that contain a majority of Hindi, Muslim, or Christian populations) and State of Development (Redeveloped slums, Resettled slums, In situ developed and Planned slums). A list of 597 slums was compiled using the notified, non-notified and de-notified slums published by Karnataka Slum Clearance Board (now the Karnataka Slum Development Board). A total of 51 slums were short-listed based on the stratification criteria, after which 36 were surveyed based on verbal consent provided by the slum leaders. The following question guides the calculation of samples.

How many households should be surveyed to estimate the true proportion of households who are below the poverty line (or do not have access to finance/ water etc), with a 95% confidence interval 6% wide? The 95% confidence interval is a standard used across disciplines. We have used a width of 6% instead of 10% (standard used across disciplines) to overestimate the number of samples (in case of missed households).

The required sample size ( X ) for the slum households was then calculated using the following formula 13 :

where, N is the entire population of slum households in Bangalore and

where Z is the Z-score ( Z is 1.96 for a 95% confidence level), D is the margin of error (3%), P is the estimated proportion of an attribute (such as households below poverty line) that is present in the population, Q is 1− P . Therefore, P × Q is the estimate of variance of the attribute in the population. Because a proportion of 0.5 indicates the maximum variability of an attribute in a population, it is often used in determining a more conservative sample size. Therefore, applying equation (2), we get n =1,067. The total number of slum households in Bangalore was estimated to be 321,296 (N ) as per the report released by the Karnataka Slum Development Board in 2010. Since, N ≫ n , in equation (1), the calculated sample size is 1,067.

Survey implementation

The social survey was implemented in the city of Bangalore, India with the assistance of Fields of View (FoV), a non-profit research organization, highly experienced in data collection. FoV together with Slum Jagaththu provided intensive training on survey tools, data collection methodology and ethical grounds of social data collection. The questionnaire was designed based on the research questions, after which the stratification and identification of slums (described in section Sampling Strategy) was performed. After the slums were identified, the questionnaire was modified to include questions based on the input and needs of the slum dwellers (see Table 1 ). A set of qualitative interviews on thematic topics were carried out based on the request from the slum dwellers, which served as a reference point for comparison with past surveys. The questionnaire was piloted in 2 slums and then revised after a round of feedback (see Table 2 ). A typical survey procedure consisted of the field coordinator speaking to the local leaders in each slum before the team conducted the survey. The coordinator would then introduce the enumerator team covering that slum to the slum leaders. If the slum leaders were agreeable, they would survey 10% of the slum, based on the procedure elaborated above. Informed consent was obtained at 3 different levels. First, local slum leaders were apprised of the objectives of the survey and the methods. Once local slum leaders approved the survey, we identified and approached community leaders within a slum. After the consent of the community leaders was obtained we approached individual slum households. Efforts were made to ensure that all respondents were appropriately informed about the study and thoroughly understood their participation in the study was voluntary. In the cases where slum leaders or community leaders did not agree to the survey we did not proceed further. In all cases where community leaders agreed to be a part of the survey, all households complied to the request. Participation was voluntary and interviewers ensured that participants knew that refusal to participate would not lead to any adverse consequences. If the main earner was not available at the time of interview then the enumerator excluded that household and moved to the next selected household and then reverted to the normal pattern.

The data was captured in paper questionnaires with handwritten responses, with most answers coded into structured replies (as indicated in the validation section), in addition to a few open-ended questions. Several case studies on thematic topics such as the homeless, informal workers and street vendors were also conducted. These case studies were conducted based on qualitative interviews with the participants and the data is not included in the datasets. The survey was administered by women participants from the slums in order to increase the level of comfort and trust with the participants. The enumerators comprised of fourteen women, who conducted the surveys in teams of two. The questionnaire was developed in English and then translated into Kannada (the local language of the state of Karnataka). To ensure quality of the data, a monitoring team from FoV checked one percent of the data and held periodic meetings to provide necessary feedback regarding the field work. The survey was completed in two stages, the first beginning in June 2010 included 20 slums and the second, beginning in March 2011 included 16 slums (see Table 3 ). Direct observation or spot checking in selected houses and re-interviewing with a quality control questionnaire in selected households formed part of the monitoring process. Survey data and accompanying questionnaires are available on the ReShare Repository ( Data Citation 1 ).

The data collected from this survey underwent cleaning and was stored in a relational database for further analysis. More specifically, the data was vetted by the enumerators and research team by randomly picking households and a site visit with field verification was carried out. Once the data was verified by the surveyors, the filled-in questionnaires were translated to English and then digitized by an independent group. The research team then carried out two rounds of validation, in the first round, the data was checked for consistency and outliers and in the second round, the research team coordinated with the enumerators to validate any discrepancies. This paper describes the relational model of the database, how to use it, the variables in the dataset, the variables constructed for analysis and the issues identified with the dataset. The data collected included 267,894 data points spread over 242 questions for 1,107 households.

Code availability

This study did not use any computer codes to generate the dataset. A MySQL relational database was used to store the collected data. A set of SQL queries were used to verify and validate the data.

Data Records

The Survey data is provided in SQL format ( Data Citation 1 ). All 242 questionnaire variables are named according to their number in the questionnaire and fully described in the variable labels. The household listing and survey instruments can be downloaded in English which acts as the code book for the datasets ( Supplementary File 1 ).

Technical Validation

The technical validation and quality control comprised of three stages. The first stage of quality control was done before the survey was carried and it involved: a) thorough pre-testing of the questionnaire; b) translating the questionnaire into Kannada, including local terminology and reverse translating to check quality of translations; c) recruitment of women enumerators from slums and comprehensive training in survey implementation. The survey questionnaire was designed based on the research questions of the project, using questions from other surveys already implemented in India and drawing on the qualitative data collection and expert judgement to create new questions. To ensure that the questions are relevant and meaningful, pre-testing of the quantitative questionnaire was conducted in the study area through pilot surveys and focus group discussions (described in Survey Implementation) prior to finalisation of the questions. Training of the enumerators is essential for effective implementation of a survey. A deep understanding of the questions and philosophy of the survey ensured that enumerators can help the surveyed households in answering the questions properly. To achieve this, the enumerator team was selected from the local slums (described in Survey Implementation). Role play and field practice was carried out for every section of the questionnaire.

The second stage of validation was performed during the survey and it involved field quality control questionnaires being carried out alongside the main data collection as described below. A quality control team was assigned in the field to monitor data collection. The field quality control involved quality control visits, spot check visits and checking of forms as recommended by the Demographic Surveillance Systems guidelines. Quality control visits was done by the supervisor on 5% 14 , 15 of the households in each round of data collection. It provided a way of cross-checking the accuracy and completeness of the data. Random and unannounced spot check visits were conducted to ensure that the data collection was being done as per the schedule. Finally, during the survey a field supervisor checked all the completed forms for completeness (no missing values and units) and accuracy before they were submitted for data entry. To ensure the data is accurate all possible inconsistencies (e.g., range checks, checking that only females have given birth) were checked. Forms with omissions and obvious errors were returned to the fieldworker for correction or revisits. The field quality control exercise demonstrated that most respondents were not willing to disclose their caste as it is considered sensitive in India. At the point of data entry a further checking of the forms is performed and forms that have errors or inconsistencies were returned to the fieldworker via his/her supervisor. The built-in validation during data entry comprised of standard methods such as uniqueness check, referential integrity, presence check, length check, data type check, fixed value check and cross field check 16 .

The final stage of validation was after the survey was completed and it involved checking data entry, detecting typing errors and comparison with previous studies. Two-pass verification, also called double data entry was performed to ensure correct data entry. To identify data entry errors, individual and composite variables were summarised as minimum, median, mean, maximum and compared between the two data entries. The original paper version has been retained to allow the team to check individual records in the digital dataset if necessary. Further, in this section we present a detailed quantitative validation of the survey data by comparing frequency distributions with previous studies and census surveys. First, we validate the demographic variables in the survey.

The median household size in the slums of Bangalore is 5. We find that 25% of the families have a household size of up to 4 members and 75% of the slum dwellers have a household size of up to 6 members. The maximum size of a household in the survey is 13. Figure 1 shows the family size distribution across the 36 surveyed slums in Bangalore. Table 4 indicates that the gender ratio (female to male ratio) is around 1, which is different to the trend in non-slum urban households where there are around 966 female per 1,000 male. A similar deviation has been observed in the Census of India 2011 5 and other slum studies in Bangalore 17 . Table 4 also shows that the population in the slum is young, with 35% of the respondents under the age of 18 and around 70% under the age of 35. The age distribution is consistent with the data from Census of India 2011 5 . The majority of surveyed households (67%) are Hindus. About 20% of the respondents are Muslims and 8% are Christians. The native language of 45% of surveyed households is Tamil, while 17% speak Kannada and 15% speak Telugu. Analysis of the migration data from slums show that 73% of migrants are from rural areas within Karnataka itself while the remaining 27% migrated from the rest of India, which indicates that the native language may not be an indication of migration. The above social and demographic distribution are similar to values reported in various slum studies of Bangalore 17 – 21 .

The data indicates that the average age at marriage is 24 for men and 17 for women. This is lower than the average of non-slum urban households in Bangalore, where the average age of marriage is 27.5 for men and 24 for women 5 . The median age of marriage has been rising in India. However, 49% of all women in the survey, were married before the age of 17. The median age at first pregnancy in slums of Bangalore is around 18 years, which is significantly lower than the median age of 25 years for non-slum urban households in Bangalore 5 . The average age at marriage and pregnancy are similar to the reported values in various slum studies of Bangalore 22 , 23 .

Second, we validate the data pertaining to income, expenditure and assets in the survey. The income distribution (see Fig. 2 ) shows that 25% of sample respondents earn a monthly income of less than 2,000 INR (31 USD), out of which they spend 93% on basic amenities. Around 75% of the sample respondents earn a monthly income lower than INR 4,000 (62 USD) and spend 91% of their income on basic amenities. Around 13% of households earn more than 10,000 INR (156 USD) per month and spend around 77% of their income on basic amenities. The monthly median income of slum dwellers in Bangalore is around 3,000 INR (47 USD). The median income reported in previous studies is around 3,500 INR (54 USD) 17 – 19 . Table 5 shows that the slum households spend the majority of their income on food items. The reasons for this high percentage are low income level coupled with high food inflation based on the Consumer Price Index (CPI) which was 12.56% during 2013. Hence, money available for other activities is very low. Education is a priority for the urban poor, but only the top 10% highest earning households can afford a school education for their children. The other key components which contribute to the expenditure are home appliances, rent, healthcare and clothing. The expenditure patterns observed in the data are consistent with previous findings 17 , 18 .

In the surveyed slums, television sets, mobile phones and electric fans are the common asset types, with more than 75% reporting ownership of each of these assets. The least common form of assets are cars, trucks and agricultural land, possessed by less than 1% of all slum households. Bicycles or motorcycles/scooters are also owned by fewer than 20% of these households. The asset distribution we observe is similar to previous studies in the slums of Bangalore 17 , 18 .

When we examine the employment patterns in the slums, we find that most slum dwellers are employed in the informal sector, primarily working as domestic help or as manual labour. Only 13% of the sample respondents are employed in the formal sector (White collar, blue collar and sales occupations). These findings are similar to the reported values in various slum studies of Bangalore 17 – 21 . Further, we find that the slum-based micro enterprises are not served by traditional financial institutions due to their informal status ( Table 6 ). Again, this is consistent with previous studies, for example the study conducted by Society for Participatory Research in Asia 17 .

Finally, we validate the data pertaining to physical structure of the houses and tenure in the survey. The survey data indicates that around 40% of the slum households have Hakku Patra , which is an important document given by Tehsildar for land ownership indicating title to the dwelling. This indicates that the majority of slum dwellers possess legal titles. Households with a legal title to their dwelling usually live in pukka structures. A pukka structure is a semi-permanent structure with a tiled or stone roof and walls that are wooden, metal, asbestos sheets, burnt brick, stone, concrete or cement bricks. Around 20% of the households have a Possession Certificate document and live in semi-pukka houses. The remaining 40%, who have either migrated from neighbouring districts or other states, do not have any proper ownership to land and live in kutcha structures. A kutcha structure is one whose roof is built using grass, thatch, bamboo, plastic, polythene, metal, asbestos sheets and walls that are grass, thatch, bamboo, plastic, polythene, mud, burnt brick, wood, metal, asbestos sheets (See Table 7 ). Analysis of ration card data from the slums in Bangalore shows that around 3% of households have Antyodaya cards, 60% possess below poverty line (BPL) cards and 17% have the above poverty line (APL) card. A comparison with the study conducted by Society for Participatory Research in Asia 17 shows that the above distributions are comparable.

Usage Notes

Data access conditions.

A benefit of the data is its spatial nature, which allows social factors to be analysed in the context of environmental conditions and resources. However, this increases the sensitivity of the data as it creates the potential for households within each slum to be identified from the survey data. As such, the data has been made available as safeguarded on the UK Data Archive’s data repository ReShare. In order to download safeguarded data the user must register with the UKDA and agree to the conditions of their End User Licence (For conditions of the End User Licence see: https://www.ukdataservice.ac.uk/get-data/how-to-access/conditions ). For commercial use, please contact the UK Data Service at [email protected].

The diversity of variables collected in the survey instrument create a high possibility for reuse of this dataset. Furthermore, certain variables are comparable with the standard National Family Health Survey v.2,3,4 surveys of Bangalore and the national census, offering the possibility of longitudinal analysis. The dataset can be used to test key associations between social and land-use outcomes that are critical for environmental policy and development strategies for Bangalore.

For example, there are a range of variables that will allow researchers to examine the social relationships that affect livelihoods in slums such as money lending, informal labour, remittances and assets. Comprehensive data on expenditure, income and livelihood choices could be used to model growth and emergence of slums (e.g., ref. 24 ) and design strategic slum management interventions, ranging from improvements in public distribution system, through to social interventions in availability of credit, or supporting mobility and migration. The dataset can be disaggregated by group identities, and crucially includes information on seasonal variation in occupation and livelihoods, a critical issue in the variation of well-being and poverty.

Additional information

How to cite this article: Roy, D. et al. Survey-based socio-economic data from slums in Bangalore, India. Sci. Data 5:170200 doi: 10.1038/sdata.2017.200 (2018).

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Roy, D., Palavalli, B., Menon, N., King, R., & Sloot, P. M. UK Data Service ReShare https://doi.org/10.5255/UKDA-SN-852705 (2017)

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Acknowledgements

The authors acknowledge the support from the Dutch NWO, eScience project number 027.015.G05 ‘DynaSlum: Data Driven Modelling and Decision Support for Slums’, Russian Science Foundation project number 14-21-00137 ‘Supercomputer modelling of critical phenomena in complex social systems’, SimCity project of the Dutch NWO, eScience agency under contract C.2324.0293. The authors also acknowledge the support of Mr. Isaac Arul Selva from ‘Slum Jagaththu’ for his contribution towards collecting the data as the liaison with the slums (access to the slums and data collection) and Ms. Bhagyalakshmi Srinivas from ‘Fields of View’ for training the field surveyors and cleaning the data. The survey was carried out with grants from Jamshedji Tata Trust, India and the Next Generation Infrastructure Foundation, Netherlands.

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Niveditha Menon

Urban Development, Ross Center for Sustainable Cities, World Resources Institute, Washington, DC 20002, USA

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D.R. wrote sections of this paper and led the writing of the paper, carried out technical validation and quality control of the database received from the survey team; M.L. is also the principal investigator of the DynaSlum project and helped in writing the paper and acted as the daily supervisor for D.R.; K.P. helped in writing the paper and served as the supervisor for B.M.P.; B.M.P. was involved in conceptualization, data collection, verification, data cleaning, analysis, qualitative research and prepared sections of the manuscript; N.M. was involved in conceptualization, analysis, qualitative research and helped with preparing the manuscript; R.K. was the principal investigator for the survey, led the design of the qualitative research of the study; P.M.A.S. is the principal investigator of the SimCITY project and contributed to the design of the study.

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Socio-economic and environmental vulnerability of urban slums: a case study of slums at Jammu (India)

• Environmental Pollution led Vulnerability and Risk Assessment for Adaptation and Resilience of Socio-ecological Systems
• Published: 03 November 2023
• Volume 31 , pages 18074–18099, ( 2024 )

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• Shehnaz Khan 1 ,
• Dheeraj Rathore 2 ,
• Anoop Singh 3 ,
• Rekha Kumari 1 &
• Piyush Malaviya   ORCID: orcid.org/0000-0002-8857-5540 1  

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Rapid urban population growth, the urbanization of poverty, and the proliferation of slums are being driven to a great extent by this dynamic form of globalization. Consequently, the multifaceted effects of globalization on the poor and low-income populations in the cities need to be better understood in this context, both at the individual level and within the community. Therefore, the present study was conducted to highlight the various determinants affecting the lives and enhancing the vulnerability of the dwellers of four slum settlements present in various areas of Jammu City, India. Emphasis was made to integrate biological, physical, social, and spatial facets of vulnerability to understand the complex dynamics of urban areas in developing countries. A descriptive survey design was used for questions concerning the social and environmental aspects. Social aspects including age, sex, education, religion, caste, profession, and family income that correspond to social stratification acted as baseline information, while both indoor and outdoor environments such as housing conditions, sanitation, personal habits, solid waste disposal, disaster proneness, and air and water pollution problems were taken into consideration to assess the environmental aspect. Results indicated that the slum settlement has a migratory population with permanent or temporary settlements. The status of education and skill level is poor which results in poor economic development and social well-being of the dwellers in slums. The study also identified vulnerability of the population on social and environmental front which could result into severe health issues. The study concluded and recommended policy planning specified for slums for uplifting such unprivileged populations.

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Shehnaz Khan, Rekha Kumari & Piyush Malaviya

School of Environment and Sustainable Development, Central University of Gujarat, Gandhinagar, Gujarat, India

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Department of Scientific and Industrial Research (DSIR), Ministry of Science and Technology, Government of India, New Mehrauli Road, 110016, New Delhi, India

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The study was conceptualized and designed by P. M. Experiments and data collection were conducted by S. K. Data analysis was performed by R. K. and S. K. The first draft of the manuscript was written by S. K., D. R., A. S., R. K., and P. M., and all authors commented on subsequent versions of the manuscript. The overall study was supervised by P. M. All authors read and approved the final manuscript.

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Khan, S., Rathore, D., Singh, A. et al. Socio-economic and environmental vulnerability of urban slums: a case study of slums at Jammu (India). Environ Sci Pollut Res 31 , 18074–18099 (2024). https://doi.org/10.1007/s11356-023-30630-5

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Community empowerment for health promotion in slums areas: A narrative review with emphasis on challenges and interventions

Mohammad hosein mehrolhasani.

1 Social Determinants of Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran

4 Department of Health Management, Policy and Economics, Faculty of Management and Medical Information Sciences, Kerman University of Medical Sciences, Kerman, Iran

Vahid Yazdi-Feyzabadi

2 Medical Informatics Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran

Sara Ghasemi

3 Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran

Community empowerment has been proposed since the 1980s as a way to increase people's power to influence social determinants of health. However, community empowerment for health promotion in urban slums still faces challenges. The present study examined interventions, challenges, actors, scopes, and the consequences mentioned in various studies and with emphasizing interventions and executive challenges tried to create a clear understanding of empowerment programs in slums and improving their health. Narrative review method was used to conduct the study. Databases including PubMed, Scopus, Embase, Web of Science, and Cochrane were searched. The selection of studies was done according to the “community empowerment” defined by the World Health Organization, the concept of bottom–up approach for health promotion of Laverack and Labonte's study and definition of slums by UN-HABITAT. Finally, Hare and Noblit's meta-synthesis was used to analyze the studies. From 15 selected studies, the most intervention proposed for empowerment was identified to be “residents' participation in expressing problems and solutions.” The challenge of “creating a sense of trust and changing some attitudes among residents” was the greatest challenge in the studies. Moreover, “improving living conditions and health services” were the most important outcomes, “slum residents” and “governments” were the most important actors, and “sanitation” was the most important scope among the studies. Having a comprehensive view to the health and its determinants and attention to the factors beyond neighborhood and health sector would lead to fewer implementation challenges and better intervention choices to health promotion of slum dwellers.

Introduction

More than 55% of the world's population live in urban areas. This number is expected to increase to 68% by 2050.[ 1 ] However, the rapid increase in urbanization is accompanied by warnings of higher urban poverty. About one billion people in the world live in slums.[ 2 ] According to the UN-HABITAT, slum dwellers are a group of people who live in similar conditions as in the urban areas that do not have one or more of the following advantages: sustainable and firm housing, access to public health, easy access to safe drinking water, sufficient living space, and property security.[ 3 ] In addition to inadequate health infrastructure, lack of safe water and suitable food and other items, living in marginal and poor urban areas is also accompanied by various crimes and social deprivation.[ 4 , 5 ]

Resolving health challenges and improving the health of urban slum dwellers require understanding the effects of the urban environment on health and generally understanding the effect of social determinants of health.[ 6 , 7 ] Vulnerable urban populations are often more influenced by social determinants than other urban residents.[ 8 ] Social determinants of health include the conditions, under which people live and work. In fact, these factors refer to economic, social, political, and environmental structures and access to health-care services.[ 9 , 10 ]

Differences in the distribution of social determinants of health in a society or between different societies provide a basis for some discrimination and differences in access to resources and cause some to be more deprived than others.[ 10 ] According to the World Health Organization (WHO), deprivation includes “dynamic and multifaceted processes that are manifested at different levels through unequal power relations in interacting with the four main economic, social, political, and cultural areas.”[ 11 ] Powerlessness or inability in a community means that the community has little control over the social determinants of health and life. Therefore, giving power and empowering these groups can improve their health.[ 12 , 13 ]

Empowerment is the process of participation and distribution of power in such a way that people can control the factors and decisions shaping their lives and health. Empowerment can be discussed at three individual, community, and social levels.[ 14 ] Emphasis on community and collective level in the category of empowerment can be observed in the speech of many thinkers. For example, Hoyt-Oliver (2020) with emphasizes on community empowerment, stating that communities can be more organized than individuals alone, and even individual empowerment projects should consider community, values, and cultures.[ 15 ]

As defined by the WHO, “community empowerment refers to the process of enabling communities to increase control over their own lives. Community are groups of people who share common interests, concerns, or identities and may or may not be spatially connected to each other. These communities can be local, national, or international, with specific or broad interests.”[ 16 ]

With regard to the urban context and its complexities, empowerment at the community level, with people's participation in interventions, leads to transparency and accountability. This is further used especially in developing countries where marginalization and informal settlements are more prevalent.[ 17 , 18 ] However, it should be noted that any participation is not considered empowerment and sometimes participations can be created passively, superficially, and partially in the short term or as a means to provide the interests of those in power.[ 19 , 20 , 21 , 22 ]

Community empowerment for health promotion in urban slums still faces challenges. There is not much knowledge about how urban characteristics influence human health. Public health studies focus less on the impact of urban environmental characteristics and often emphasize individual behaviors.[ 23 ]

Since the 1980s, many studies have been conducted on empowerment to improve people's health.[ 24 ] Empowerment in health promotion thinking was legalized by the Ottawa Charter in 1986. However, empowerment in health promotion has always been a controversial concept. According to Laverack and Labonte's study, there have always been tensions in implementing the concept of empowerment and using bottom–up approaches in health promotion.[ 25 ] Woodall et al . (2010) mentioned that there is unclear relationship between empowerment strategies and health promotion and acknowledged the complexity of the empowerment processes in health field.[ 26 ] Hence, it could be predicted that the interventions defined for empowerment in practice are still not professional and standard, and there is a considerable gap between the empowerment evidences and the practice of empowerment.[ 27 ]

These challenges in urban slums are more pronounced due to the complexities of the urban environment. Moreover, unlike rural areas, community empowerment for urban health is still in its infancy and more discussions and studies are needed.[ 17 , 28 ] Corburn (2017) remarks when it discussed “health” in “slum upgrading programs”, it is often limited to a specific disease, exposure to a particular risk factor, and so forth; social determinants of health is less considered. Furthermore, interventions in the slum upgrading, including community empowerment, are less commonly known as an intervention to improve health justice.[ 28 ]

Since the health, urban life, and justice are intertwined issues, therefore, review of various studies in the field of empowerment in urban slums to health promotion can be helpful in making better interventions and strategies to eliminate health injustices in cities and create innovations in this area. Moreover, multiple studies have been conducted on urban management and health in relation to community empowerment. Summary of these studies can be led to a clear understanding of the concept of community empowerment, create the systemic perspectives, comprehensive planning, and standard interventions. In addition, identifying various challenges occurring during the community empowerment process in slums and eliminating these challenges would help to provide a background for improving empowerment implementation processes in slums and health promotion.

Therefore, this study seeks to answer the following questions: What are the challenges related to empowerment of slum residents and promoting their health? What interventions to slum dwellers empowerment are done in the world, in what scopes and what effects? Paying attention to which aspects of community empowerment could result to better planning to improve the health of slum dwellers?

In addition, this study intends to making a step toward bringing the concepts of slum upgrading projects closer to health promotion. Hence, the present study aims to use perspectives, knowledge, and experiences in various scientific articles for identifying, summarizing, and discussing in case of interventions, challenges, actors, scopes, and outcomes in these areas.

Materials and Methods

This study is a narrative review that has been done by searching articles on scientific databases.

Research design

Review studies are conducted to investigate what has already been published and to collect the best available evidence. Narrative reviews are conducted with the aim of identifying and summarizing what has been published, avoiding duplication, and searching for new areas of studies that have not yet been addressed.[ 29 ] The present study reviewed articles related to community empowerment in urban slums. Therefore, narrative review was used.

Search strategy

At the beginning of the article search process, the definitions of slum areas and community empowerment were determined according to the literature review. Then, the keywords were searched according to EMtree, MeSH, and Thesaurus.

Keywords to be searched were defined in two categories as follows:

• ”Slums,” “informal settlement,” “Poverty Area,” “Ghetto,” “shanty town,” “marginal settlement,” and “suburban”
• ”community empowerment,” “health empowerment,” “empowerment,” “health participation,” “health Involvement,” “people Engagement,” “people participation,” “people Involvement,” “community based,” “community resource,” “community Mobilization,” “health enabling,” and “health engagement.”

PubMed, Scopus, Embase, Web of Science, and Cochrane databases were used to search the studies. A manual search was also performed separately. Google Scholar was also searched and the first ten pages were examined.

Inclusion and exclusion criteria

According to the research question and the definition of community empowerment by the WHO,[ 16 ] the concept of bottom–up approach to health promotion and its difference with the top–down approach is mentioned in Laverack and Labonte's study (2000),[ 25 ] as well as the definition of the UN-HABITAT from slums,[ 3 ] the selection of scientific articles, and definition of inclusion and exclusion criteria were done. It is shown in Table 1 .

There was no time limit for the search operation.

Studies' selection

After searching and removing duplicate articles, the titles of all articles were read after entering the EndNote software (Version 8.0.2 Build 10858; Thomson Scientific company, Toronto, Ontario, Canada) and thus articles related to the title were identified. Then, the abstract of related articles was studied, and finally, the completely related articles were selected from the remaining articles to review the full text. To more accurately select the studies from the remaining articles for the full text, triangulation[ 30 ] was used and three researchers reviewed the studies separately. Finally, differences between the researchers were resolved.

Data extraction and data analysis

”Hare and Noblit's method” was used to analyze and synthesis the data.[ 31 ] After the final selection of the studies, included articles were read and re-read carefully for selecting the key concepts and their themes. Then, details of each article were considered and their relationship with each other was investigated. Finally, the key concepts were extracted and put together.

Pieces of data related to a particular topic, in relation to each research question, were identified and highlighted in each article's PDF. Then, the identified codes were placed as items and summaries in the tables created in Excel software under the column related to each question (Excel file is attached). In the last step, the data were combined and interpreted; that is, the concepts related to each item were placed in more general categories, and thus, tables were drawn in Word software. Finally, new themes were produced. These steps were performed using investigator triangulation and each researcher extracted and analyzed the data separately. Differences between the researchers were resolved.

Out of a total of 2695 articles found, 1891 articles remained after they fined the duplicated articles and deleted them. Finally, out of the remaining 115 articles for full-text review, 15 articles were included in the study (PRISMA) [ Figure 1 ].

Table 2 lists the general characteristics of the included studies. Most of the included studies have been conducted in the last decade and after 2010. Most of the studies have been related to Asian countries. Studies have often described, studied, and analyzed intervention projects (participatory action research).

Characteristics of included studies

According to the findings of the present study, the most used strategy for empowerment in urban slums, residents' participation in identifying problems and providing solutions, the main challenge, creating a sense of trust and changing some beliefs and perspectives among slum dwellers, the main actors, slum residents and governments, the most studied scope, sanitation, and the main case that has been mentioned as the ultimate outcome of empowerment projects have been related to the improvement in the living conditions and access to health services. A few numbers of studies were conducted only within the health system (without cooperation with other sectors); the scope of these studies is limited to physical health or access to services. challenges, actors, Interventions, scopes, outcomes identified in the studies have been indicated in Table 3 .

Challenges, actors, interventions, scopes, outcomes identified in the studies

Identified interventions and strategies

According to the present research findings, the most commonly used strategy for empowerment in urban slums is the residents' participation in identifying problems and providing solutions for them. In general, the interventions and strategies used to empower slum dwellers fall into several categories, including residents' participation in expressing problems and providing solutions, building self-confidence in community to negotiate and bargain for resource use, and awareness of the citizenship right and sensitization, creating and increasing organizational capacity, assigning full management of a slum improvement project to the residents (design and implementation), participating in building and improving the environment, financial assistance and loans, training, increasing, and improving skills, using other urban residents' skills and literacy. Most studies have used a combination of the above strategies for empowerment. According to the scientific definitions of empowerment and bottom–up and top–down approaches, which were mentioned in the introduction, and the findings of this study, the above strategies could be classified into two main and helpfully/ancillary strategies as follows [ Table 4 ]:

Classification of community empowerment interventions/strategies in slums

Identified challenges

According to the findings and classification of different challenges mentioned in the studies, lack of equal opportunities for all residents to participate in empowerment interventions, the challenge of creating a sense of trust and changing some attitudes among residents, creating a sense of responsibility and sustainable change in the neighborhood, demographic diversity of residents and high diversity of attitudes and needs, negative consequence of some political relations and government approaches about slums on empowerment programs, defects in the three key elements of commitment, skills, and interest in the actors involved in the empowerment programs, challenges in establishing cooperation and coordination between different institutions, the existence of bureaucratic structures in some organizations involved in empowerment, and solutions that ultimately could not meet the needs of residents were identified as community empowerment programs' challenges in slums area.

The challenge of creating a sense of trust and changing some attitudes among residents are the main challenges in the studies. Findings showed that this challenge has been often mentioned in relation to studies whose main activities have been carried out in more sensitive and controversial scopes than in the scopes of providing and accessing services, for example, security, reducing risky behaviors, women empowerment, and distributing power. Therefore, it could be said that to make fundamental changes in urban slums, changes must first be made in the beliefs and views of residents regarding the new reforms. The negative effect of political approaches and government thinking in related to the marginalized has been also one of the main challenges in the studies, which creates obstacles to the formation of community-based organizations, nongovernmental organization (NGO) efforts, and implementation of some other empowerment actions in the slums.

Identified actors

The actors involved in the process of empowerment of slum residents were categorized as follows:

Slum residents, local leaders, NGOs, CBOs, educational centers, governmental institutions and organizations (municipal and …) and political leaders, health centers and health system, social organizations and intermediary institutions, private sector, and international organizations.

The findings of the study indicated that the most involved actors are slum residents and government. These findings demonstrated a minor role of the private sector in community empowerment process in the slums.

Identified effects/outcomes

The effects of these programs and interventions were evaluated in five categories. Some effects may not have been considered or measured by the studies. These assessments have been seen in the form of improving living conditions and access to services, improving residents' capacity and distribution of power, increasing trust, motivation and solidarity, improving health status, and increasing awareness and skills in different studies. Moreover, the improved living conditions and access to services have been mentioned as the most effective element by various studies, which can be due to the simplicity of evaluating interventions with this measure. Study data are provided in Appendix 1 .

The present study reviewed the interventions, executive challenges, actors, areas, and outcomes presented in the empowerment studies of slum residents and summarized these items to create a comprehensive view of empowerment programs, urban slums, and justice in health.

The findings showed that how to change some people's attitudes and gain their trust are the main challenges in empowerment programs. Residents' trust in empowerment actions will increase their sense of commitment to these interventions and their sustainability in the neighbourhood.[ 32 , 45 ] To eliminate the challenges and barriers related to low trust, it is helpful to find leaders among the residents who act as a bridge between people and officials.[ 46 ] Involving people and their participation in empowerment programs is especially important. The level of people's participation can be influenced by the community cultural values. For example, in a study in Thailand, cultural values based on the concept of “individualism” have been mentioned as an obstacle to community-based and participatory manners.[ 47 ]

Corburn's 6P model (2017) is one urban health model on the relationship between various political, cultural, social, and environmental aspects and health issues. One of the important components in this model is “people.” Corburn's study and some of other studies found that considering “people's” culture, values, knowledge, health literacy, education, and attitudes are very important for empowerment planning and their health promotion.[ 23 , 48 , 49 ]

The other challenge identified in relation to the “people,” is how increasing of responsibility and commitment among people. Lack of a sense of responsibility may reduce people's participation in slum improvement programs. Increasing awareness can help to create commitment in people. The more people's awareness of an issues, the more their power of responsibility.[ 14 ] In this study, raising awareness has been identified as one of the main empowerment strategies.

In a study conducted in a slum in Kenya, the author refers to the challenge of increasing a sense of responsibility among residents and sustainable changes in the neighborhood and saying that it is difficult for people to participate in volunteer activities in an environment where they have no source of income. According to him, sometimes people cooperate in participatory programs as long as there is income, and then cooperation and sense of responsibility may decline. Hagen considers this issue as more relevant to developing countries.[ 32 ]

In developing countries, national and local governments play an important role in providing urban services.[ 50 ] Since the main actors in slum empowerment programs are slum residents and the government; the main challenges have also been identified in relation to the “people” and the “government.” These challenges, according to this study, are often related to beliefs and attitudes.

An important and frequent challenge in the included articles is related to the negative governments' attitude to the issues of marginalization. Winayanti and Lang's study has considered low local government cooperation with the community as a challenge to empowerment and public participation and attributes this to the government's belief that slum dwellers occupy government lands. The study also notifies the government regulations to support public participation but notes that these regulations have been not clearly formulated. This study was conducted in Indonesia. Indonesia is a developing country and transparency and supervision mechanisms in developing countries seem to be more difficult than the developed countries.[ 34 , 51 ]

Espinisa's study, also, found that the existence of this idea in the government that marginalized residents live in an illegal area could be an obstacle to actions for eliminating marginalization problems or allocating adequate funding for such activities.[ 38 ] Decreases in quality and quantity of the efforts to empowerment and participate in the slums after the change of political party have also been mentioned as the challenges to government attitudes in Walker's study.[ 40 ]

The government as a main actor in the empowerment program must be delegated some of its power to slum dwellers, nongovernmental institutions, or the private sector. Therefore, if the government is not ready to share its power and does not intend to abandon the top–down approach; empowerment programs are also unlikely to be successful.[ 38 ]

The challenges related to coordination and cooperation between different institutions, defects in some skills of some institutions, and lack of commitment in some governments and bureaucracies in some government's bodies, which hurt the implementation of the project empowerment, indicate that some government structures are not ready to power distribution and decentralization.

Sometimes, the distribution of power is done but may not include the poorest people. Another challenge identified in this study is related to this issue. It is the lack of equal opportunities for all residents in empowerment-related activities. In his book “Pathology of Power,” Paul Farmer describes how poor people are more vulnerable to injustice and human rights abuses, resulting in poor health and ultimately unnecessary death among such people.[ 52 ] Rana and Piracha's study mention that the poorest people usually have less opportunity to join the community-based organization.[ 20 ] This issue has been proposed in a different way in Winayanti's study and considered women to have less opportunity to participate in empowerment programs in slums.[ 34 ] Stall's (2008) study concluded that the basis for a community organization is mostly male centered.[ 53 ] Moreover, the problems and deprivations in the slum regions influence women more than men.[ 54 ]

One of the most important reasons for these challenges is probably the lack of a systemic view, weakness in comprehensive planning, and the existence of cross-sectional programs that cannot solve problems completely.[ 55 ] It should be noted that community empowerment activities are implemented in a larger stratum of society (economic, social, and political).[ 56 ] The socio-ecological model of Larson et al .'s study states that systematic analysis of the health of marginalized people creates multidimensional interventions and identifies all stakeholders and actors.[ 57 ]

In addition to identifying the challenges of empowerment programs, this study has identified various actors in the form of governmental, nongovernmental, and private institutions. In addition to slum residents and governments, one of the important actors identified in this study is NGO, including NGOs and CBOs. The ability of the urban poor to be heard and the government's willingness to respond have a lot to do with the conditions of civil society.[ 58 ] Elements of civil society create the poor's voice on the policy agenda.[ 59 ]

A study (2009) in India investigated the effect of public–private partnerships on slum upgrading in Ahmadabad and finally concluded that not only the public and private sectors but also the cooperation of voluntary sectors such as NGOs are needed to improve the slum conditions.[ 60 ] Moreover, Tukahirwa and Oosterveer (2011) concluded that without the intervention of NGOs and CBOs, a large number of poor people will suffer from inadequate health services and their health-related effects. In addition, it was found that cooperation between the people and these organizations builds commitment and trust in the community.[ 61 ]

In addition to the various actors and challenges, the strategies used in slum empowerment programs were also identified in this study. Since the genuine approach to empowerment is bottom–up, participation is introduced as the main strategy of community empowerment.[ 62 ] The strategy of raising awareness is different from the educating and training strategy, which is part of the top–down approaches,[ 25 ] and is a kind of people sensitization to participate and increase their capacity. Awareness empowers community members to identify problems and possibilities and find solutions. Sensitizing people to their needs also increases their demanding.[ 63 ]

In addition, the helpfully strategies were identified in this study. However, they have been used along with the main strategies in many studies and it seems that they can be helpful for empowerment. According to Peter Walter's study, establishment of Centers for Disease Control and Prevention committees and development of a community for women and girls to participate in the committee have been proposed as the main intervention. In addition to this, creation of the UPPR project, which includes granting, improving services and physical environment, has been also mentioned.[ 35 ]

In addition to interventions, actors and challenges, the outcomes that examined in various studies were also identified. Most studies have ultimately measured improvement of physical environment and access to services as the main consequences of the projects. This is probably due to these consequences are easier to measure and more visible than other consequences. Consequences such as health improvement, social capital, trust, and ability to negotiate have been less measured. Some studies have reported that articles in slum upgrading often do not measure the health outcomes of empowerment projects and deal with issues such as improvement in infrastructures and environmental and economic changes or that measuring health outcomes is limited to its physical dimension.[ 25 , 26 , 28 , 64 , 65 ]

Finally, it is of high importance to understand how all empowerment issues in urban slums relate to each other and with what processes ultimately lead to consequences. This is referred to as the “process” in Corburn's model; that is, who (actors) with what interests in what political system and with what social and economic conditions, with how much power, understanding, and awareness in what environmental conditions and finally with what policies and strategies participate in empowerment.[ 23 ] The consequences are not discussed here, and the process and how to construct a general narrative of the work is considered. Stories and narrations that are narrated from the implementation of each empowerment program are specific to the same program and the same place because if the solutions are the same, each neighborhood has its own challenges, attitudes, perceptions, and feelings. Therefore, it is important how they relate to each other if all the elements are available to create empowerment programs.

This study looks at the issue of health promotion in urban slums beyond the health sector. It provides an overview of slum upgrading, community empowerment, and health promotion programs. However, it does not claim to have reviewed all existing studies in this area, but has been tried to include studies that have extensive information to answer the study questions. It is possible that not all challenges, actors, scopes, interventions, and outcomes are identified. It is suggested that future studies examine articles, with different perspectives.

Conclusions

In formulation of empowerment plans for health promotion of slum dwellers, first, there should be more consideration to the factors beyond the neighborhood, sanitation, and health services, including the culture of the community, the political situation, the government's views on marginalization and power redistribution, the functioning of various actors, and so forth. Second, there is a need of identifying different actors and also creating a transparent and correct view of main empowerment strategies, furthermore, a common view to the health in all these stakeholders.

It should be noted which interventions follow bottom–up approaches and are considered as “empowerment actions,” and which are not. Policymakers and planers on health empowerment projects, should in addition to sanitation and physical health alone, pay more attention to some scopes, such as increasing self-confidence, changing some residents' beliefs and views, social capital, and critical thinking. Finally, to examine the outcomes of these programs, it should not be limited to improving services or the physical dimension of health. The need for a broader view to the health and its determinants, creation of systemic programs, and attention to the relationship between governments and slum dwellers and their impact on executive challenges are other results of this study.

Financial support and sponsorship

The present article was extracted from the thesis written by Sara Ghasemi and was financially supported by Kerman University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.

Data of article

Everyday Life of Slum Children: A Case Study from Education Perspective

Every year, the city of Pune attracts migrant workers due to urbanization, and these migrants form residential pockets called slums. Today, around 40% of Pune's population lives in urban slums, around 11% of children, who have little or no access to education with the everyday hand-to-mouth struggle for survival. This study explores the lives of slum children and their educational conditions. Three case studies were conducted with three slums from uptown areas of Pune. Focus group discussions, interviews, and visual survey methods were employed, leading to qualitative analysis. Analysis threw light on the everyday challenges faced by slum children in accessing education. The visual studies imply the need for architectural intervention. The findings also suggest policy implications towards the provision of education towards the betterment of the lives of slum children. Working and learning are the two social processes; without breaking the legal structures on child labor, children working within the home as domestic labor or in the household enterprise is a common occurrence in urban centers, particularly among those who are household income is derived from the informal sector and who have lower income levels. Working modes and times differ depending on the situation. Owing to the size of India's informal economy and attempts to reduce child labor trafficking, a strong emphasis has been placed on developing and implementing social policies that address child labor.

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Fenomena migrasi yang dilakukan oleh para buruh migran Indonesia di Malaysia menyisakan cerita terutama bagi anak-anak yang lahir dan ikut bersama orangtuanya bermigrasi. Orangtua yang memiliki fungsi pendidikan dalam keluarga dituntut mampu memberikan pendidikan informal kepada anak-anak mereka untuk selalu mencintai dan menanamkan jiwa nasionalisme dalam diri mereka. Penelitian ini bertujuan untuk mengetahui dan menganalisis pengaruh pendidikan karakter nasionalisme dalam keluarga terhadap karakter nasionalisme pada anak-anak buruh migran Indonesia di Malaysia. Studi ini merupakan penelitian korelasional yang dilakukan kepada 30 anak-anak di PKBM X Estate, Bintulu, Serawak, Malaysia. Hasil menunjukan bahwa terdapat pengaruh yang positif pendidikan karakter nasionalisme dalam keluarga terhadap karakter nasionalisme anak. Koefisien determinasi yang diperoleh dalam penelitian ini sebesar 25,50% yang menunjukkan bahwa besarnya karakter nasionalisme anak yang dipengaruhi oleh pendidikan karakter nasionalisme dalam keluarga. Hal tersebut menunjukan bahwa keluarga terutama orangtua memiliki peran yang penting dalam menciptakan dan mengembangkan karakter nasionalisme anak meskipun sedang berada dan tinggal di luar Indonesia. Kata Kunci: anak buruh migran, fungsi keluarga, karakter nasionalisme, pendidikan karakter    "I Still Love Indonesia": Study of Nationalism Character Education in Families in Indonesian Migrant Worker in Malaysia Abstract The migration phenomenon conducted by Indonesian migrant workers in Malaysia leaves stories especially for children born and who are with their parents migrating. Parents who have the function of education in the family are required to provide informal education to their children to always love and instill the soul of nationalism within them. This study aims to determine and analyze the influence of character education of nationalism in the family against the character of nationalism on the children of Indonesian migrant workers in Malaysia. This is a correlational study conducted to 30 children in Community Learing Center (CLC) X Estate, Bintulu, Sarawak, Malaysia. The result shows that there was a positive correlation between character education of nationalism in the family and nationalism character of migrant labor children. It shows that family especially parents have important  role to create and develop child nationalism whether they live in out of Indonesia. Keywords: character education, child labor migran, family function, nationalism character

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Community stigma, victimization, and coping strategies among gay, bisexual, and other cis-gender men who have sex with men in slum communities in Ghana. BSGH-003

• Osman Wumpini Shamrock 1 , 2 , 7 ,
• Gamji Rabiu Abu-Ba’are 1 , 2 , 4 , 6 , 7 ,
• Edem Yaw Zigah 2 ,
• Henry Delali Dakpui 2 ,
• Gideon Adjaka 3 ,
• Natalie M. LeBlanc 1 , 6 ,
• Amina P. Alio 4 &
• LaRon Nelson 5 , 6  

BMC Public Health volume  24 , Article number:  966 ( 2024 ) Cite this article

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Gay, bisexual, and cis-gender men who have sex with men (GBMSM) face severe consequences, especially within stigmatized environments. However, very little is known about the experiences of GBMSM living in slums in SSA and Ghana. This study investigates the experiences of stigma, victimization, and coping strategies and proposes some interventional approaches for combating stigma facing GBMSM in slum communities.

We engaged GBMSM living in slums in two major Ghanaian cities. We used a time-location sampling and collected data through in-depth individual interviews. Two major themes emerged from the study: (1) insecurities and criminalization of GBMSM activity, and (2) GBMSM coping strategies.

Findings show GBMSM experienced negative attitudes from the community due to their sexual behavior/orientation. GBMSM also developed coping strategies to avert negative experiences, such as hiding their identities/behavior, avoiding gender non-conforming men, and having relationships with persons outside their communities.

We propose interventions such as HIV Education, Empathy, Empowerment, Acceptance, and Commitment Therapy as possible measures to improve the experiences of GBMSM living in Ghanaian slum communities.

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Introduction

In Ghana, research shows that gay, bisexual, and other cis-gender men who have sex with men (GBMSM) experience significant criminalization and stigma from individuals in almost every facet of society [ 1 , 2 , 3 ]. Hence, they choose to live a closeted lifestyle by utilizing exceptional discretion and past experiences [ 4 , 5 , 6 , 7 ]. Currently, Ghanaian law criminalizes same-sex penetrative behavior [ 8 , 9 ]. The vagueness of the law on sexuality in the country makes its application inconsistent, resulting in exceptional sexual discretion by enforcement agencies [ 10 , 11 ].

The language used in Ghanaian criminal law contains ambiguity, leading many individuals and law enforcement agents to self-interpret and determine how to apply it to LGBTQI + people [ 8 ]. The term “unnatural carnal knowledge” used in the Ghanaian Criminal Code Amendment Act, 2003, does not explicitly mention LGBTQI+; however, it has served to justify the criminal attacks and stigma on members of the groups [ 8 , 12 , 13 ]. According to Atuguba (2019), the law on “unnatural carnal knowledge,” which indicates an unusual form of penetration uncommon in Ghanaian societies, does not extend to sexual desires or expressions. Persons identifying with the LGBTQI + community and not seen engaging in sexual activity involving penetration do not commit offenses connected to the Criminal Code Amendment Act 2003. However, identifying as a member of an LGBTQI + can put an individual at risk of stigma and discrimination [ 14 , 15 , 16 , 17 ]. A member of parliament in Ghana has proposed an anti-LGBTQI + bill termed “Promotion of Proper Human Sexual Rights and Ghanaian Family Values, 2021,” which proposes to enact legislation to direct the activities of people in the country [ 18 ]. The Ghanaian parliament may approve a proposed anti-LGBTQ + bill that criminalizes any persons engaging in LGBTQ+-related activities [ 19 , 20 ]. At the time of this writing, the Ghanaian parliament is deliberating on passing the Ghanian anti-LGBTQ bill formally named “The Promotion of proper human sexual rights and Ghanaian family values bill,” proposes to among others, criminalize same-sex marriage, same-sex intercourse, intersex, gender-non-conforming behavior, allyship or advocacy for LGBTQ+, with up to five years in prison sentence for offenders [ 21 , 22 , 23 ].

While little is known about the experiences of GBMSM in Ghana, the experiences of those living in slum communities remain unaccounted for, yet they face high stigma and negative health outcomes [ 24 ]. Slums in Ghana are characterized by unstructured housing settlements, dense population, and poor access to safe drinking water, schools, hospitals, entertainment venues, and transportation [ 25 , 26 , 27 ]. Residents within these communities are characterized as violent and having low educational attainment, which is perceived to contribute towards engagement in culturally unacceptable behavior like premarital, extramarital heterosexual sex, and not conforming to heteronormative identities and behavior deemed acceptable by local cultural norms [ 28 ]. Coupled with other characteristics, the level of violence in slums can have severe effects and an added safety concern for GBMSM living in these communities.

According to Pebody (2011), GBMSM living in hostile communities such as slums may experience significant violence, harassment, and discrimination from other community members within and external to slum neighborhoods and law enforcement officials [ 29 ]. This stigma and discrimination result in adverse health outcomes, including an increased risk of acquiring HIV/STI susceptibility and a lack of engagement in HIV/STI treatment and care [ 30 , 31 ]. In addition to the legal and social barriers faced by GBMSM, those living in slum communities face multiple economic and social challenges, such as poor living conditions, limited access to healthcare, and limited employment opportunities [ 30 , 32 ].

In an already stigmatized climate for the LGBTQI + community in Ghana, this study explores how such stigma manifests specifically in the slums for GBMSM [ 1 , 33 , 34 , 35 , 36 , 37 , 38 ].. The absence of literature on GBMSM living in slums within the Ghanaian context means their experiences related to how others treat them are not fully understood. We address this gap by employing the following methodology and discuss how slum conditions and social behaviors by others may influence GBMSM experiences around crime and stigma.

Methodology

Research design.

The study employed a qualitative narrative design approach [ 39 , 40 , 41 ] to understand the lived experiences of GBMSM in Ghanaian slum communities. The narrative design was a conscious approach to gathering firsthand narratives of how the intersectional stigma of LGBTQ criminalization, poverty and slum community stigma affect GBMSM and the mechanisms men use to cope with these adverse experiences. The qualitative narrative design approach also allowed us to interpret their experiences in the context of the current Ghanaian criminal legal system.

Study setting

Ghana is located in the Western part of Africa. The dominant religions in the country are Christianity (71%), Islam (18%), and African Traditional Religion/Traditionalist (5%) [ 42 ]. The Ghanaian education profile indicates that as of 2020, 71% of children completed primary education, 47% completed lower secondary school, and 35% completed upper secondary school [ 43 ]. Studies in Ghana show 52.2% of MSM comprising transgender, gay, bisexual, and straight were educated, with 16.8% with tertiary or higher educational attainment [ 33 ]. The same study showed 44.1% of MSM were employed, with 44.1% reporting single or never married [ 33 ]. The official language in Ghana is English, however, the indigenous languages are spoken with Twi 16%, Ewe 14%, Fante 11.6%, Boron (Brong) 4.9%, Dagomba 4.4%, Dangme 4.2%, Dagarte (Dagaba) 3.9%, Kokomba 3.5%, Akyem 3.2%, Ga 3.1%, other 31.2% [ 44 ]. Slum communities in these two regions were purposefully chosen due to the presence of key population organizations and the ease this provided for the research team when sampling our GBMSM.

Sampling and recruitment procedure

Recruitment activities were led by our community partner organizations located in Southern Ghana in Accra. To ensure this hard-to-reach population was engaged in data collection, a time-location sampling method was employed. The time-location sampling method has shown to be an effective technique in studying similar population within the LGBTQI + communities [ 45 , 46 , 47 ]. The authors purposefully employed this method due to the stigmatizing environment in Ghana for LGBTQI+ [ 35 , 36 , 37 , 38 , 48 , 49 ] and enabled researchers to access the sample in safe locations and at optimal times. The method also ensured diversity of participants by providing equal opportunities for inclusion as GBMSM were randomly sampled from multiple visits of the research team to organized monthly meetings GBMSM had with community-based organizations. This sampling method was used to recruit GBMSM in slum communities [ 50 ]. Our community-based organizations have been engaged in working with GBMSM in Ghana and have a long history of working with study researchers to recruit and implement studies among GBMSM in the country 1. Community partners screened participants at secured locations to ensure they matched the study criteria for inclusion. Twelve participants were sampled; they reached saturation in responses after the 8th interview. However, community partners continued to interview an additional 4 participants to reach full information saturation.

Participants

GBMSM participants were at least 18 years and resided in a slum community within Kumasi and Accra, Ghana. Participants age ranged from 18 to 24 years. All participants self-identified as cisgender men having had sexual intercourse with another cis-gender man in the past six months prior to enrollment. For the purpose of this study, we define cis-gender men as individuals whose gender identity corresponds with what was assigned at the time of their birth [ 51 ].

Data collection

Upon completion of screening, research assistants consented GBMSM to the study, which involved reading the consent form aloud, obtaining signatures as consent to participate in the study, and providing further explanations when needed. Each participant was provided with a copy of the consent form. Research assistants employed in-depth in-person interview to collect data which occurred in anonymous locations to ensure subjects’ identities were always protected. All in-depth interviews were audio were recorded. Four of the 12 interviews were conducted in Twi, a Ghanaian language, as some participants could not effectively express themselves in English; the remainder were in English. Data were collected from participants in January 2022.

Nature of questions

The research assistants received training on qualitative interviews using the checklist generated for the study. Consistent with our design, the checklist focused on allowing free and open conversation rather than a typical question-and-respond interview process. Participants were asked to provide personal narratives about their background, experiences of sex, and gender expectations. They also described their experiences of community stigma, openness, and coping strategies about sexuality or sexual behavior and how legislation such as the anti-LGBTQI + bill affected their treatment in their communities.

Analytical strategy

Trained research assistants transcribed the audio interview recordings verbatim and deidentified the transcripts by removing specific descriptions that could allow others to identify the participant. We then subjected the transcripts to a multiple-reviewer summative content analysis process [ 52 , 53 ]. Our team has successfully used this analytical process to understand critical factors in participant accounts [ 1 ] We assigned each transcript to at least two reviewers. Each reviewer examined and then reviewed the transcripts to identify the most salient factors raised by the participants, which they independently reported using between 100 and 200 words. The lead author reviewed all summaries and organized the salient points from each write-up into a data spreadsheet, which guided the identification of clusters in the qualitative data and showed the factors that frequently appeared in the transcripts and summaries.

Description of participants

Out of 12 GBMSM who participated in the study, two were Muslim, six were Christian, and the remaining four mentioned practicing a mix of Islam and Christianity. Most participants had received formal education. One did not have a Junior High School level education. Six had Senior High School Education, and five had university or tertiary level Education. Six participants indicated they were not employed. The other six were engaged in part-time and full-time jobs.

Description of themes and categories

Two overarching themes emerged from participant narratives: (1) insecurities and criminalization of GBMSM and (2) GBMSM coping strategies. Within the first theme, two categories emerged: [ 1 ] Harm towards GBMSM; and [ 2 ] Uncertainty of LGBTQI + bill content and future repercussions for GBMSM (seeking refuge). Categories under the second theme included: [ 1 ] Hiding one’s sexuality or conforming to gender norms, and [ 2 ] Avoiding gender non-conforming men.

Insecurities and criminalization of GBMSM

The theme of insecurities and criminalization of GBMSM describes a critical component of GBMSM lives that characterize their interaction with others in their communities and subsequent strategies they employ for anonymity and safety. GBMSM reported that they perceived community members to view them differently as persons who did not conform to the dominant community assigned sex and gender behaviors in the slum, leading to discrimination and marginalization. Within this theme, there were two categories: Harm toward GBMSM and Uncertainty of LGBTQI + bill content and future repercussions for GBMSM (seeking refuge).

Physical assaults and harm from the community

The hostile attitudes of some slum community members towards GBMSM put them at heightened risk of physical assault. Participants recounted instances where they witnessed other community members physically assaulting their peers because of their sexuality. The fear of bodily harm forced GBMSM to adopt closeted lifestyles, such as associating with GBMSM outside their communities and keeping their sexual behavior/orientation hidden. Speaking on how closeted lifestyles could prevent GBMSM from physical harm, one of the participants mentioned:

I meet my partners secretly, so my sexuality is unknown to my community. Sometimes my friends talk about how they will treat anyone caught in that act. Because I am into guys, I always listen to them closely and ensure they don’t know about my sexuality. (GBMSM Participant)

To avoid physical harm, participants indicated they developed coping strategies to avoid getting caught by others living in the slums. One participant stated:

I always sneak from them (community members), attend to my clients (sex partners), and sneak back to without them knowing them my movement. If they get to know who I am, they can harm me, so I am always careful. (GBMSM Participant)

Another participant mentioned:

I am MSM and prefer that I have my associations outside my community so that when I return home to the community at the end of the day, that would be better. If someone comes into your community to harm you, your community members would disagree because they never see you associating yourself with MSM. It is safer because if you propose to people in your community, and when an issue comes, those people can testify, which would be a problem. So, if I enjoy being outside the community and return when I am okay, it’s better than doing it in my community and facing disgrace later. (GBMSM participant)

Four indicated they had never experienced any form of physical assault or harm from members of their communities. However, past experiences and narrations from others in the LGBTQI + community informed how they navigated the social environment to avoid physical harm. Reported lynching and near-death experiences of other GBMSM manifested mistrust for anyone in the community, including close acquaintances of participants who did not endorse their sexual behavior/orientation. According to one of the participants:

I have never been mistreated or stigmatized, but I have witnessed someone lured to the community, and they almost killed him if not the chief Imam (local religious leader) who came to his rescue. (GBMSM participant)

I have learned to be extra careful since that incident (violence) because now I know if I should get caught, they will not spare me. So, I am always careful with regard to my sex life. (GBMSM participant)

Uncertainty of LGBTQI + bill content and future repercussions for GBMSM

Participants indicated the Ghanaian anti-LGBTQ bill criminalizes their activities, affecting their behaviors and believed it to be contributing to the adverse treatment they receive from others in the slums. Participants also mentioned current and proposed legislation did not support their activities. According to one of the participants:

When I heard about it, I was very scared. I didn’t know what to say because you can’t even tell your friends about it, your straight friends, or those in your community. When you try to defend the community, they will begin to suspect you. So, you have to keep quiet. But within me, I know the bill isn’t going to help us at all. Because there are some people, who are straight men, even though they are girly. Also, some people in the community are transgender or girly. You can’t do anything about their sexuality. If they are walking on the street and you think they are girly, you send them to prison? It will affect our country, productivity, and everything. (GBMSM participant)

Participants stressed the bill violates their fundamental human rights to live freely and would support the legalization of discrimination and marginalization of GBMSM by others whose beliefs depart from those who identify with LGBTQI+. Though the bill is in development, it affects how others treat them in the slums. They also described the Ghanaian government’s role as an institution responsible for preventing the passing of the LGBTQI + bill. According to one of the participants:

It would be nice if the government accepted LGBTQ and gave us our rights. I will be very happy. Because even a man and a woman don’t stand and kiss and have sex; they do it in their rooms. So, you giving us our rights doesn’t mean we are going to do it outside our rooms, so I don’t know why everyone is upset because everyone does their things inside their rooms. The law they want to bring sometimes worries me because I have feminine friends, so sometimes, I ask myself, what if this law is passed? The guys and boys will tag them and set them up (blackmail). Even now that there are no laws, they are setting them up. If it is passed, it will hurt me. (GBMSM participant)

Participants also blamed various media outlets as a medium through which anti- LGBTQI + legislation was propagated. One participant said:

I believe the media feeds society with false information about the community. (GBMSM participant)

GBMSM coping strategies

The GBMSM in this study reported developing coping strategies to survive the immense marginalization and discrimination they faced in the slum communities. Within this theme were two categories. (1) Hiding sexuality/conforming, and (2) Avoiding gender non-conforming men.

Hiding sexuality/conforming

GBMSM physical appearances and behaviors determined how others treated and perceived them within slum communities. Participants reported that people whose behavior and presentations that did not conform to culturally determined gender rules, roles, norms, and expectations of men and women faced greater levels of stigma and resentment from the community.

I have been threatened before. Like when I’m walking, they warn me that if I don’t walk like a man, they will beat me. (GBMSM participant) It was a girlish guy. If he goes to his partner at night, he will dress like a lady with makeup. They suspected him as MSM in our area because of his behavior. One night, he was seen entering one guy’s place wearing a lady’s nightgown. The guy’s mother saw the girlish guy wearing the nightgown enter her son’s room, so later, she went inside the room to check what they were doing. She saw them in bed having fun and called the area guys. The area guys came and beat both of them. Later, both of them left the community (GBMSM participants).

GBSMSM reported that men who did not exhibit stereotypical feminine behavior did not experience, but rather ascribed to masculine local socially acceptable gender norms adopted certain behaviors to maintain physical safety. Nonetheless, they were extra cautious, not to say they were LGBTQ or MSM, disassociated from non-conforming men, and did not engage in relationships with people who appeared or behaved in a stereotypically feminine manner. According to participants:

They are okay with me because they don’t know anything about my sexuality. So, they treat me normal as any other human being. (GBMSM participant) I haven’t opened up to anyone in my community about who I am. So, they don’t know. I don’t have feminine features, and I also don’t have feminine friends. And so, they don’t know (GBMSM participant).

Avoiding gender non-conforming men

The marginalization and discrimination of GBMSM resulted in a desire to only engage in sexual relationships with persons outside their communities. Participants who wanted to keep appearing as conforming to community-ascribed sex and gender roles and identities chose to associate with sex partners outside the slum community to remain hidden and keep appearing compliant with community norms and expectations. Participants indicated associating with non-gender-conforming men could place one at risk of being suspected of being GBMSM.

I live in Borhu (a slum community), a slum with lots of rough guys. I particularly don’t mingle in my area. I don’t have friends in my community because I don’t like their behavior and lifestyle. (GBMSM participant) Sometimes, if you work with feminine guys, they think you are also like that. And they will think something bad. I don’t mingle with my community friends. I mingle with outsiders far from my community because it’s my secret (GBMSM participant).

This study’s findings describe the stigma and victimization experiences and coping behaviors of GBMSM who reside in slum communities in Southern Ghana. Prior studies have shown that GBMSM face multiple forms of stigma and marginalization in other countries [ 54 , 55 , 56 , 57 , 58 ]. However, in Ghana, little research has described GBMSM experiences, especially those living in slum communities [ 1 , 59 ].

The study showed that GBMSM face the threat of physical assault and harm from their communities as some community members physically assaulted them due to their sexual orientation and non-conforming behaviors. Studies have revealed individuals in the LGBTQI + community are four times likely to experience harm from violence [ 60 ]. Comparatively, research show the rate of stigma and harm decreases for heterosexual individuals [ 60 , 61 ]. The findings here align with the global literature that demonstrates, similar to those experiences of GBMSM residing in Ghana’s slums, mistreatment through physical assault and harm to GBMSM are common occurrences [ 62 , 63 , 64 ]. Thus, contributing to the evidence that suggests experiences of mistreatment of GBMSM are universal [ 65 ].

Within Ghana, research has shown GBMSM face various threats of physical assault and harm from persons with an anti-same-sex intercourse stance [ 1 , 35 , 36 , 37 , 38 ]. Despite interventions proposed by the Ghana Aids Commission to reduce GBMSM stigma through community dialogue, community involvement in stigma and discrimination planning, and awareness raising through traditional leaders [ 66 ], the intervention by the commission does not consider the experiences of GBMSM in slums. Also, other interventions that adopt a structural approach to reduce stigma, such as those proposed by (Gyamerah et al., 2020), may present different outcomes when considering the dynamics of living experiences of GBMSM in slum communities to those in urban centers in the country.

We found from this study that the proposed LGBTQI + bill in Ghana facilitated adverse experiences for GBMSM in the slum communities. Though in its development stage, previous research shows that similar bills developed into laws and further criminalized GBMSM. Previous and current laws in other African countries, such as, the Same-Sex Marriage (Prohibition) Act, 2013 of the Republic of Nigeria, the Criminal Code of the Federal Democratic Republic of Ethiopia, Proclamation No. 414/2004 of Ethiopia, the Penal Code of 1998 of Guinea, and the Penal Code Chap. 7:01 Laws of Malawi, and the past Criminal Code of 250 of Mauritius, which was later struck down by the country’s supreme court [ 67 ], all detail penalties for persons who do not ascribe to sex-based gender norms and serve as legislative instruments to undermine same-sex activities and relationships [ 68 ]. In some African countries such as Uganda and Cameroon these anti-gay legislations direct strict penalties such as life imprisonment, the death penalty for same-sex relations with persons diagnosed with HIV, and the prohibition of LGBTQ in the media spaces [ 69 , 70 ]. These laws seemingly suggest legislative initiatives in Ghana and in other African countries can be associated with negative consequences for LGBTQ individuals and underscore the challenging and potentially dangerous environments for the community [ 71 ].

The study’s findings support existing reports of the role of the media in supporting anti-LGBTQI + and circulating disinformation that contributes to their adverse experiences 10,52. The findings in the study align with the literature that demonstrates media influence on shaping public perception and treatment of LGBTQI + individuals [ 72 , 73 , 74 ].

The findings show that socially ascribed gender roles and behaviors were taken seriously among slum community inhabitants. These gender expectations were separated using cues similar to those in Cameroon and South Africa [ 75 ], such as behavior and appearance. For locally contextualized non-conforming GBMSM, challenging local (or Westernized) gender/sex binary definitions presented them with potential harm from individuals in the community. As such, some presented themselves as heterosexual men, yet had sex with men anonymously, thus providing further evidence to support the assertions that while one might identify with LGBTQI+, their identity maybe be internalized, and behavior expressed in anonymity [ 76 , 77 ]. As indicated by participants, the fear of physical assault and harm also manifested in GBMSM living a closeted lifestyle and having sexual relations with others outside their slum communities where they stood the chances of being less recognized, thus reducing the chances of being caught and providing them with the necessary space to operate as GBMSM in communities that were less dense like slums. Whereas we did not find reports from slum communities, previous studies report that generally, GBMSM in Ghana and West Africa who showed mannerisms customarily associated with women were likely to face various forms of discrimination for not conforming to traditional gender-based norms [ 78 , 79 , 80 , 81 ].

Similarly,Lewis et al. (2023) found that, aside from presenting as conforming to gender and sex-ascribed roles and identities within stigmatized communities, GBMSM sought partners outside their societies to avoid violence and stigma [ 82 ]. This study presents a possible third reason: security against threats from people outside their communities who suspect them of engaging in same-sex sexual behaviors. GBMSM used the existing criminal and stigmatized environments as a protective measure. We believe this has not been captured previously in literature among GBMSM living in slum communities in Ghana and is a practice worth noting in literature when understanding coping strategies for these populations.

This study showed GBMSM avoided getting close or forming sexual associations with other GBMSM, particularly gender-nonconforming men in the slums they resided, to avoid being associated with GBMSM and experiencing stigma. While this coping mechanism can protect one from stigma and harassment, it also leads to interpersonal stigma where gender-conforming GBMSM are stigmatized and sometimes assaulted by peers who conform to traditional gender norms [ 83 , 84 ].To avoid the stressors of being part of a stigmatized group, this finding explicitly shows the extent of personal preservation in the context of internalized homophobia, shame, and guilt toward themselves and other GBMSM [ 85 , 86 ]. These stressors can lead to other adverse health outcomes for GBMSM such as anxiety, substance abuse, suicide and depression [ 54 , 87 ]. Highlighting the importance of interventions to address stigma, especially within place and sexuality GBMSM [ 88 , 89 ].

We identify HIV Education, Empathy, and Empowerment (HIVE 3 ), the Dennis Peer Support Model-based approach to guide and develop peer mentoring and support for GBMSM in Ghana [ 90 ]. HIVE 3 and the Dennis Peer Support Model aim to reduce social isolation and stigma and increase peer social support [ 91 , 92 ]. The intervention, if adequately adopted within the study’s context, will allow members of one group to develop empathy, understanding, and positive attitudes toward another group. We also suggest adopting an Acceptance and Commitment Therapy intervention as adopted by past researchers to understand and create solutions for GBMSM who face significant mental health stress, depression and other forms of social problems due to the stigma and discrimination they face [ 93 , 94 , 95 ]. We recommend adopting these interventions to reduce community stigma and victimization for GBMSM in Ghanaian slum communities and promote acceptance, support and empowerment.

Limitations and future research

The research identified two significant limitations. The first limitation of this study was the absence of comparative literature on GBMSM living in slum communities in Ghana. Given this limitation, it was difficult to determine whether the experiences of GBMSM living in slums have improved or worsened over time. Another associated challenge with the lack of previous literature was whether or not a previous intervention was implemented to curb the adverse experiences of GBMSM living in other Ghanaian slum communities.

The second limitation was the lack of information on GBMSM who moved from urban centers to slums, as well as from rural communities or from other northern parts of Ghana. We propose more studies be conducted on GBMSM living in more Ghanaian slum communities. We also suggest future studies focus on their experiences before they moved to the slums to identify if there are notable differences in experiences for those living in these areas.

In the study, a religious cleric was described to prevent the near-death experience of a GBMSM, which highlights the potential role of religious and traditional leaders in regulating the legal environment within stigmatized communities such as GBMSM in Ghanaian slums. As a result, we recommend future research be conducted to explore this further.

The study identified two themes that describe the insecurities and criminalization of GBMSM activities and coping strategies. The responses gathered from participant responses show GBMSM in slum communities from within Ghana face significant challenges related to how others treat them and the coping strategies they employ to stay safe. GBMSM in Ghanaian slums showed some innovative techniques in sexual relations by engaging with others outside their communities to reduce the likelihood of stigma or potential harm. GBMSM also revealed they associated with others outside the slums as a way of guaranteeing protection from their slum inhabitants in the event they were accused by outsiders engaged in same-sex sexual behaviors.

The study shows the need to pay attention to the marginalization and discrimination towards GBMSM in Ghanaian slum communities. It is imperative for research moving forward to emphasize the misinformation through media sources as a facilitator of hate sentiments targeted toward GBMSM. Support systems targeted at GBMSM should be appropriately integrated into media discussions when discussing GBMSM topics.

Data Availability

All data generated or analyzed during this study are included in this published article.

Abbreviations

Gay, Bisexual, and other Cis-Gender Men Who have Sex with Men

HIV Education, Empathy, and Empowerment

Abubakari GMR, Nelson LRE, Ogunbajo A, Boakye F, Appiah P, Odhiambo A et al. Implementation and evaluation of a culturally grounded group-based HIV prevention programme for men who have sex with men in Ghana. Glob Public Health. 2021;16(7).

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Acknowledgements

The authors would like to thank the study participants, community partner organizations, and the University of Rochester, School of Nursing Interdisciplinary Sexual Health and HIV Research Group.

Funding was received from Yale University.

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Conceptualization (OWS, GRA, EYZ), investigation (OWS, GRA, EYZ, HDD, GA), methodology (OWS, GRA, EYZ, HDD, GA), formal analysis (OWS, GRA, EYZ, HDD, GA NML, APA, LN), visualization (OWS, GRA, EYZ, HDD, GA), project administration (OWS, GRA, EYZ, HDD, GA), funding preparation (GRA, EYZ), Writing (OWS, GRA, HDD, NML, APA, LN), Review & Editing (OWS, GRA, NML, APA, LN), project administration (OWS, GRA, EYZ, HDD, GA), supervision (NML, APA, LN).

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Researchers sought ethical clearance from the Institutional Review Board at Yale University (IRES IRB #RNI00002010) and the Ghana Health Service (GHS-ERC 001/10/21) ethics committees for the grant study titled, “Formative research to adapt a community-based HIV self-testing education and promotion (STEP) intervention for men who have sex with men (MSM) living in slum settlements in Ghana.”

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Shamrock, O., Abu-Ba’are, G., Zigah, E. et al. Community stigma, victimization, and coping strategies among gay, bisexual, and other cis-gender men who have sex with men in slum communities in Ghana. BSGH-003. BMC Public Health 24 , 966 (2024). https://doi.org/10.1186/s12889-024-18242-1

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Creating a Corporate Social Responsibility Program with Real Impact

• Emilio Marti,
• David Risi,
• Eva Schlindwein,
• Andromachi Athanasopoulou

Lessons from multinational companies that adapted their CSR practices based on local feedback and knowledge.

Exploring the critical role of experimentation in Corporate Social Responsibility (CSR), research on four multinational companies reveals a stark difference in CSR effectiveness. Successful companies integrate an experimental approach, constantly adapting their CSR practices based on local feedback and knowledge. This strategy fosters genuine community engagement and responsive initiatives, as seen in a mining company’s impactful HIV/AIDS program. Conversely, companies that rely on standardized, inflexible CSR methods often fail to achieve their goals, demonstrated by a failed partnership due to local corruption in another mining company. The study recommends encouraging broad employee participation in CSR and fostering a culture that values CSR’s long-term business benefits. It also suggests that sustainable investors and ESG rating agencies should focus on assessing companies’ experimental approaches to CSR, going beyond current practices to examine the involvement of diverse employees in both developing and adapting CSR initiatives. Overall, embracing a dynamic, data-driven approach to CSR is essential for meaningful social and environmental impact.

By now, almost all large companies are engaged in corporate social responsibility (CSR): they have CSR policies, employ CSR staff, engage in activities that aim to have a positive impact on the environment and society, and write CSR reports. However, the evolution of CSR has brought forth new challenges. A stark contrast to two decades ago, when the primary concern was the sheer neglect of CSR, the current issue lies in the ineffective execution of these practices. Why do some companies implement CSR in ways that create a positive impact on the environment and society, while others fail to do so? Our research reveals that experimentation is critical for impactful CSR, which has implications for both companies that implement CSR and companies that externally monitor these CSR activities, such as sustainable investors and ESG rating agencies.

• EM Emilio Marti is an associate professor at the Rotterdam School of Management, Erasmus University. His research focuses on corporate sustainability with a specific focus on sustainable investing.
• DR David Risi is a professor at the Bern University of Applied Sciences and a habilitated lecturer at the University of St. Gallen. His research focuses on how companies organize CSR and sustainability.
• ES Eva Schlindwein is a professor at the Bern University of Applied Sciences and a postdoctoral fellow at the University of Oxford. Her research focuses on how organizations navigate tensions between business and society.
• AA Andromachi Athanasopoulou is an associate professor at Queen Mary University of London and an associate fellow at the University of Oxford. Her research focuses on how individuals manage their leadership careers and make ethically charged decisions.

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Out of the park: New research tallies total carbon impact of tourism at Yellowstone

People depend on natural ecosystems of trees, grasses and shrubs to capture carbon from the atmosphere and pull it underground to slow the decline toward climate-change disaster. Ironically, these same protected spaces also tend to be highly photogenic hot-spots for tourism.

New research from the Quinney College of Natural Resources and the Institute of Outdoor Recreation and Tourism makes a case study of one such place -- Yellowstone National Park -- to calculate surplus carbon visitors from across the world add to the atmosphere each year as a direct result of a park visit.

Emily Wilkins and Jordan Smith from the Department of Environment and Society and colleagues leveraged existing data to create a tally of carbon emissions generated by one year of tourist visits to Yellowstone National Park, a popular destination that can receive over 4 million visitors per year. They estimated that recreation visits to the park produce just over one megaton of carbon emissions per year, an average of 479 kilograms attributable to each visitor (about the weight of a grand piano).

The bulk of those emissions occur before a visitor even spies a geyser or a wandering wolf pack. Travel to and from the park entrance accounts for almost 90 percent of the total. Another 5 percent is produced as visitors move from place to place within park boundaries and four percent is sourced in overnight accommodations. Just 1 percent of the total comes from park operations such as visitor centers, museums, shops and restaurants.

Just over one-third of visits to Yellowstone involve someone taking a flight, but those particular trips accounted for a whopping 72 percent of the emissions for out-of-park transit.

"As the tourism industry explores strategies to reduce their carbon impact, this could be low-hanging fruit," said Wilkins, who now works with the U.S. Geological Survey. "Future campaigns to encourage a greater proportion of visitors from nearby locations rather than Europe or Asia, or encouraging driving over flying, have potential for big impacts on reducing these emission numbers."

But it seems that carbon accounting for Yellowstone National Park is still in the black.

"Interestingly, ecosystems within the park boundary pull around 1.5 megatons of carbon from the atmosphere each year," Smith said. "So, even accounting for the significant impact of tourism, there is a net benefit in the system as a carbon sink."

This is almost certainly not the case for smaller parks with high visitation numbers, he said.

This new method for calculating the carbon impact of tourism for national parks is designed to be adaptable for application to other parks and protected areas, Smith said, to help decision makers evaluate the effectiveness of potential emission reduction strategies.

Tourism is no lightweight player in the world's total carbon tally. By one account, tourism accounted for 8 percent of annual global carbon emissions, with the U.S. earning the dubious honor of the highest total tourism carbon footprint in the world. And that number is expected to grow.

It's important to note that this research was not a comprehensive policy analysis, according to the authors. Ecotourism has other costs and benefits that weren't under consideration in this particular research. For example, while tourism does contribute significantly to carbon emissions globally, positive experiences and education at parks like Yellowstone have potential to lead to indirect environmental benefits, such as encouraging pro-environmental behaviors back at home.

"We really need more research on both the effect of tourism on climate change, and the effect of climate change on tourism," Wilkins said. "These topics both have major economic and environmental repercussions. Managers and decision makers need a more complete perspective for how tourism to parks is contributing to a vulnerable global climate system."

• Global Warming
• Air Quality
• Travel and Recreation
• Environmental Policies
• World Development
• Ocean Policy
• Yellowstone Caldera
• Carbon dioxide sink
• Carbon cycle
• Mount Rainier
• Geology of the Capitol Reef area
• Carbon dioxide
• Air pollution

Story Source:

Materials provided by S.J. & Jessie E. Quinney College of Natural Resources, Utah State University . Original written by Lael Gilbert. Note: Content may be edited for style and length.

Journal Reference :

• Emily J. Wilkins, Dani T. Dagan, Jordan W. Smith. Quantifying and evaluating strategies to decrease carbon dioxide emissions generated from tourism to Yellowstone National Park . PLOS Climate , 2024; 3 (4): e0000391 DOI: 10.1371/journal.pclm.0000391

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Title: prompting for numerical sequences: a case study on market comment generation.

Abstract: Large language models (LLMs) have been applied to a wide range of data-to-text generation tasks, including tables, graphs, and time-series numerical data-to-text settings. While research on generating prompts for structured data such as tables and graphs is gaining momentum, in-depth investigations into prompting for time-series numerical data are lacking. Therefore, this study explores various input representations, including sequences of tokens and structured formats such as HTML, LaTeX, and Python-style codes. In our experiments, we focus on the task of Market Comment Generation, which involves taking a numerical sequence of stock prices as input and generating a corresponding market comment. Contrary to our expectations, the results show that prompts resembling programming languages yield better outcomes, whereas those similar to natural languages and longer formats, such as HTML and LaTeX, are less effective. Our findings offer insights into creating effective prompts for tasks that generate text from numerical sequences.

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Use of Abortion Pills Has Risen Significantly Post Roe, Research Shows

By Pam Belluck

Pam Belluck has been reporting about reproductive health for over a decade.

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On the eve of oral arguments in a Supreme Court case that could affect future access to abortion pills, new research shows the fast-growing use of medication abortion nationally and the many ways women have obtained access to the method since Roe v. Wade was overturned in June 2022.

The Details

A study, published on Monday in the medical journal JAMA , found that the number of abortions using pills obtained outside the formal health system soared in the six months after the national right to abortion was overturned. Another report, published last week by the Guttmacher Institute , a research organization that supports abortion rights, found that medication abortions now account for nearly two-thirds of all abortions provided by the country’s formal health system, which includes clinics and telemedicine abortion services.

The JAMA study evaluated data from overseas telemedicine organizations, online vendors and networks of community volunteers that generally obtain pills from outside the United States. Before Roe was overturned, these avenues provided abortion pills to about 1,400 women per month, but in the six months afterward, the average jumped to 5,900 per month, the study reported.

Overall, the study found that while abortions in the formal health care system declined by about 32,000 from July through December 2022, much of that decline was offset by about 26,000 medication abortions from pills provided by sources outside the formal health system.

“We see what we see elsewhere in the world in the U.S. — that when anti-abortion laws go into effect, oftentimes outside of the formal health care setting is where people look, and the locus of care gets shifted,” said Dr. Abigail Aiken, who is an associate professor at the University of Texas at Austin and the lead author of the JAMA study.

The co-authors were a statistics professor at the university; the founder of Aid Access, a Europe-based organization that helped pioneer telemedicine abortion in the United States; and a leader of Plan C, an organization that provides consumers with information about medication abortion. Before publication, the study went through the rigorous peer review process required by a major medical journal.

The telemedicine organizations in the study evaluated prospective patients using written medical questionnaires, issued prescriptions from doctors who were typically in Europe and had pills shipped from pharmacies in India, generally charging about $100. Community networks typically asked for some information about the pregnancy and either delivered or mailed pills with detailed instructions, often for free.

Online vendors, which supplied a small percentage of the pills in the study and charged between $39 and $470, generally did not ask for women’s medical history and shipped the pills with the least detailed instructions. Vendors in the study were vetted by Plan C and found to be providing genuine abortion pills, Dr. Aiken said.

The Guttmacher report, focusing on the formal health care system, included data from clinics and telemedicine abortion services within the United States that provided abortion to patients who lived in or traveled to states with legal abortion between January and December 2023.

It found that pills accounted for 63 percent of those abortions, up from 53 percent in 2020. The total number of abortions in the report was over a million for the first time in more than a decade.

Why This Matters

Overall, the new reports suggest how rapidly the provision of abortion has adjusted amid post-Roe abortion bans in 14 states and tight restrictions in others.

The numbers may be an undercount and do not reflect the most recent shift: shield laws in six states allowing abortion providers to prescribe and mail pills to tens of thousands of women in states with bans without requiring them to travel. Since last summer, for example, Aid Access has stopped shipping medication from overseas and operating outside the formal health system; it is instead mailing pills to states with bans from within the United States with the protection of shield laws.

What’s Next

In the case that will be argued before the Supreme Court on Tuesday, the plaintiffs, who oppose abortion, are suing the Food and Drug Administration, seeking to block or drastically limit the availability of mifepristone, the first pill in the two-drug medication abortion regimen.

The JAMA study suggests that such a ruling could prompt more women to use avenues outside the formal American health care system, such as pills from other countries.

“There’s so many unknowns about what will happen with the decision,” Dr. Aiken said.

She added: “It’s possible that a decision by the Supreme Court in favor of the plaintiffs could have a knock-on effect where more people are looking to access outside the formal health care setting, either because they’re worried that access is going away or they’re having more trouble accessing the medications.”

Pam Belluck is a health and science reporter, covering a range of subjects, including reproductive health, long Covid, brain science, neurological disorders, mental health and genetics. More about Pam Belluck