A cross-sectional survey on the effectiveness of public health campaigns for changing knowledge, attitudes, and practices in Kenyan informal settlements during the COVID-19 pandemic.

We performed two cross-sectional surveys across three informal settlements in Kenya (within Kisii county, Nairobi, and Nakuru county) to study the effectiveness of public health interventions during the COVID-19 pandemic. A total of 720 participants were surveyed from 120 randomly selected geographical locations (240 participants/settlement/survey), and a coordinated health promotion campaign was delivered between the two surveys by trained staff. Information relating to knowledge, attitudes, and practices (KAP) were collected by trained field workers using a validated questionnaire. The main outcomes showed improvements in: (i) mask-wearing (% of participants 'Always' using their mask increased from 71 to 74%, and the percentage using their masks 'Sometimes' decreased from 15% to 6%; p<0.001); (ii) practices related to face mask usage (% of subjects covering the mouth and nose increased from 91 to 95%, and those covering only part of their face decreased from around 2.5% to <1%; p<0.001). Significant improvements were also seen in the attitudes and expectations relating to mask wearing, and in the understanding of government directives. Over 50% of subjects in the post-campaign survey reported that social distancing was not possible in their communities and fears associated with COVID-19 testing were resistant to change (unchanged at 10%). Access to COVID-19 testing facilities was limited, leaving a large proportion of people unable to test. As willingness to take a COVID-19 test did not change between surveys (69 vs 70%; p = 0.57), despite increased availability, we recommend that policy level interventions are needed, aimed at mitigating adverse consequences of a positive test. Improvements of KAPs in the more crowded urban environment (Nairobi) were less than at settlements in rural or semi-urban settings (Nakuru and Kisii). We conclude that coordinated public health campaigns are effective in facilitating the change of KAPs amongst people living amidst challenging socio-economic conditions in informal settlements.

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

While the COVID-19 pandemic's effect on the health of low-income urban communities in the global South has not been insignificant, the results of state responses carried out without full consideration of poverty consequences have been very serious. Vaccination, which supports both health and economic recovery, is one way people can reduce the risk of further exclusion. This field note, drawing on surveys from informal settlements in Harare, Kampala, Lilongwe and Mumbai between August and November 2021 by national affiliates of Slum Dwellers International (SDI), provides a snapshot of how global vaccine inequalities have played out across these cities. We find that access to local vaccine programmes is influenced by both global supply and existing local-level inequities; that a low or unreliable supply, among other factors, limits political will to invest in reaching already underserved communities; and that local context and the heterogeneity of communities are key to understanding low vaccine uptake.

Out of sight, out of mind: Understanding the sanitation crisis in global South cities.

Global monitoring efforts do not provide a clear picture of the challenge of managing human waste at the city scale. Where cities do not provide universal access to publicly managed sanitation systems, households and communities find their own solutions resulting in a patchwork of approaches to removing human waste from places where people live. In dense urban environments, the absence of a coordinated approach can create serious public health problems. In the absence of comparable city-level data, we analyze primary and secondary data from 15 cities and 15 informal settlements in sub-Saharan Africa, South Asia, and Latin America. Across these regions, our study finds that 62 percent of human waste is not safely managed. We also find that, while many cities have a proportion of households connected to sewers, none of the 15 cities safely manage human waste at scale. In the absence of sewers, on-site fecal sludge management systems place enormous responsibility on households and private providers, and unaffordable sanitation options result in risky sanitation practices.

COVID-19: what is not being addressed.

As the number of confirmed COVID-19 cases nears 27 million, there is a rush to answer (what next) and a rush to act (to solve the immediate problems of COVID-19). This paper discusses, with a specific focus on urban areas in the global South, what is missing to date from this response. That includes an identification of things that there are too much of, things that are not being done at all, and things that are unbalanced. There has been an enormous upsurge of academic research papers and opinions on COVID-19. "Technological" and "scientific" solutions tend to overshadow other approaches, even if people know that "social is important". Based on our analysis to date, our primary concern is that there is too little understanding about the importance of building dialogue, exploring collaboration and co-producing solutions. There is too little understanding as to why social and cultural responses are important, and how the recognition that they are important can be actioned.

COVID-19 and the case for global development.

COVID-19 accentuates the case for a global, rather than an international, development paradigm. The novel disease is a prime example of a development challenge for all countries, through the failure of public health as a global public good. The COVID-19 pandemic has highlighted the falsity of any assumption that the global North has all the expertise and solutions to tackle global challenges, and has further highlighted the need for multi-directional learning and transformation in all countries towards a more sustainable and equitable world. We illustrate our argument for a global development paradigm by examining the implications of the COVID-19 pandemic across four themes or 'vignettes': global value chains, digitalisation, debt, and climate change. We conclude that development studies must adapt to a very different context from when the field emerged in the mid-20th century.

Social movements and the struggle for shelter: A case study of eThekwini (Durban).

The needs of informal settlement dwellers across towns and cities in the global South are acute. While much emphasis has been placed on income poverty, for urban dwellers affordable access to improved secured accommodation and basic services such as water and sanitation is essential for well-being. In part due to the lack of such access, urban citizens organize in multiple ways to address these needs and to press for state investment and redistribution. South Africa, despite relatively high levels of income and a state with redistributive capacity, is no exception. Indeed, this country is particularly interesting for those seeking to understand effective approaches to addressing housing need because of the efforts that have been made and the resultant scale of state investment in the housing sector. This paper draws on the experiences of urban social movement organizations in South Africa to understand better how shelter needs can be addressed. We reflect on their goals, strategies and activities and explore what this means for themes discussed within the social movement literature. The research has a specific focus on the city of eThekwini/Durban primarily because of the scale of social movement activities there. The paper describes the core concerns with respect to shelter as elaborated by social movement activists, staff of other civil society agencies and officials. While there is a broad consensus about the shelter problems, there is less agreement about solutions. The discussion summarises the shelter objectives and core strategies used by the social movement activists, and considers the success they have had. This includes reviewing their understanding of what success is and how success is achieved. Movement organisations have been able to secure access to the housing subsidy scheme for their members. However, their progress has been limited. The paper concludes that there is a primary focus on what is offered through state programmes and policies despite evident shortcomings. While there is an awareness of the misfit between available programmes, the needs of movement members and more general shelter needs, no fundamental challenge is being made to the dominant approach. A second finding is that while movement members and leaders have an explicit focus on material improvements, underlying their motivations and some of their strategies and actions is the more fundamental goal to be treated as equal citizens. In this dimension, movement organizations seek both recognition of their citizenship as well as the redistribution of state resources. Third, we argue that while social movement progress is related to the political opportunity structures, it also depends on the ability of movement organizations to manage the emerging opportunities, particularly their relationships with the state, professional support organizations and other movement organizations. Relations shift between contention and collaboration to improve negotiating positions, secure access to shelter and achieve greater political inclusion.

Integrated approaches to address the social determinants of health for reducing health inequity.

The social and physical environments have long since been recognized as important determinants of health. People in urban settings are exposed to a variety of health hazards that are interconnected with their health effects. The Millennium Development Goals (MDGs) have underlined the multidimensional nature of poverty and the connections between health and social conditions and present an opportunity to move beyond narrow sectoral interventions and to develop comprehensive social responses and participatory processes that address the root causes of health inequity. Considering the complexity and magnitude of health, poverty, and environmental issues in cities, it is clear that improvements in health and health equity demand not only changes in the physical and social environment of cities, but also an integrated approach that takes into account the wider socioeconomic and contextual factors affecting health. Integrated or multilevel approaches should address not only the immediate, but also the underlying and particularly the fundamental causes at societal level of related health issues. The political and legal organization of the policy-making process has been identified as a major determinant of urban and global health, as a result of the role it plays in creating possibilities for participation, empowerment, and its influence on the content of public policies and the distribution of scarce resources. This paper argues that it is essential to adopt a long-term multisectoral approach to address the social determinants of health in urban settings. For comprehensive approaches to address the social determinants of health effectively and at multiple levels, they need explicitly to tackle issues of participation, governance, and the politics of power, decision making, and empowerment.