Vulnerability To Health in A Ward of Bengaluru: Insights from A Mobile-Based Survey

nutritional


INTRODUCTION
The Slum Areas 'Improvement and Clearance' Act, 1956, defines a 'slum' as a residential area where dwellings are unfit for human habitation by reasons of dilapidation, overcrowding, design of buildings, narrowness or faulty arrangement of streets, lack of ventilation, lack of sanitation facilities or any combination of these factors which are detrimental to safety or health. 1 Rao and Thakur define the term 'vulnerability' as 'able to be easily hurt'. 2 According to Loughhead et al. 2001, 'Vulnerability' can be defined as 'a situation where some people are more prone to face adverse situations, and where there is a higher likelihood of succumbing to those situations'. 3 In the context of public health, however, it implies a situation leading to higher likelihood of morbidity and mortality. 4 The National Urban Health Mission (NUHM) is a submission of National Health Mission which envisages with a special focus on the urban poor and vulnerable addressing the health care needs and reducing out of pocket expense. The term "Vulnerability Assessment" in relation to healthcare has been defined as assessing the level of vulnerability of a slum or household towards ill-health. Vulnerability is commonly associated with poor economic and nutritional status; Overlapping social vectors -quality of housing and public services, occupation, gender, dis-ability, marital status, age, stigmatized and debilitating ailments. 5 Apart from a strong service delivery mechanism, geographical variations, health, social & environmental determinants are essential parameters to estimate the needs, chalk-out an effective response strategy. The mapping of the HHs will provide more granularity to population data. It would also build a platform for easy planning and monitoring of outreach camps, regular health programs like Routine Immunization, Pulse Polio campaign, Leprosy Case Detection Campaign, Active Case Finding of TB, Non-Communicable Diseases mapping & many more.
International health bodies including Indian Council of Medical Research have highlighted the poor data quality in Indian health-care system. 6,7 A major source of data has been the population-based surveys that healthcare workers carry out on a regular basis since the start of National Urban Health Mission. The amount of data generated is of huge quantity. However, the overburdened health-care system does not allow for validation of the data and appropriate compilation of the same. In such situations the data quality remains questionable and the basis of the health planning as well.
The burden of multiple surveys that the community health workers face has been a common cause for health worker attrition. 8 The multiple visits to the same community with similarly designed questionnaires also cause resistance in the urban community. The monetary burden of long paper-based surveys has always been a matter of debate. 9 Data entry and compilation at UPHC level without dedicated data entry operators would make paper-based surveys wasteful. However, in spite of crossing the above hurdles, a possible compiled data would be difficult to be validated due to the sheer amount of data collected per survey. Hence, this app based integrative platform was planned and developed in the background of vulnerability assessment in a ward classified as the urban field practice area of a Government Medical College in Bengaluru city of Karnataka.

OBJECTIVE
The present study was conducted to estimate the vulnerability score among the residents in an urban ward through app-based household survey and also to represent the geo-tagged household level data as a layer of map in GIS.

METHODOLOGY
Based on the requirement from the Office of National Urban Health Mission at the Urban Local Body (ULB), in line with the directives from the Government of India and Karnataka, the Department of Community Medicine was allocated the task of "Vulnerability Assessment and Mapping" activity planning for the en-tire city. However, it was decided that the study will be conducted in detail in the ward, classified as Field Practice Area, under the direct supervision of the Department.
Tool revision and development: The tool for Vulnerability Assessment defined by Government of India and was revised and digitized in a two-step process as below, based on multiple meetings with all stakeholders: I. Analysis of the existing tool for vulnerability assessment: A Questionnaire for Vulnerability Assessment tool by ASHAs had been described in the document: "Guidelines & Tools for Vulnerability Mapping & Assessment for urban health 2017" 5 & same in "Induction Training Module for ASHAs in Urban Areas". 10 The key observations noted in the tool were a) Multiple components were assessed simultaneously in one question, making it difficult for field level response marking; and b) Non-availability of the tool in the local language of Kannada.
In this regard, multiple meetings with the stakeholders were undertaken to segregate components and developed a user-friendly tool for Community Health Workers (CHWs).
II. Android-based app development: The modified vulnerability assessment tool was developed as an Android-based application named: Namma Samudaya with all ASHAs and ANMs enrolled as a user. As compared to paper-based surveys, the data captured directly through app-based surveys have the following advantages: a) cost-effectiveness; b) locating the household surveyed on to the map through GIS mapping; c) Realtime data recording; d) Correction and updation on-the-go; e) Features of drill-down and better visualization due to a more structured data collection; and f) Quick generation of reports on each of the variables as summaries.
The app-based survey form contained a total of 45 questions in the format: a) 37 parent questions and 8 linked by "if <x>, then <y>" logic; b) 7 (out of 45) open-ended questions and rest closed-ended; c) Validation checks for numeric fields; d) Unique User ID & password for each health worker/surveyor; e) All questions were marked "required" for final submission; f) Linking of Community Based Assessment Checklist for NCDs; g) Complete offline support with sync option; and h) Availability in dual language -English & Kannada Key Considerations included -Reliability, Security, Confidentiality, Extensibility, Data Validation, Dashboard generation.
Following the tool finalisation, Institutional Ethical Committee clearance was taken and training modules were designed based on inputs from all stakeholders. Training of surveyors and other stakeholders: A total of 3 sessions were conducted to train the Community Health Workers, volunteers and other stakeholders involved for a period of 7 days.
House-to-house survey: A house-to-house crosssectional descriptive study was carried out in the period of 26 th July to 16 th August 2019 in the ward classified as Urban Field Practice area of Bangalore Medical College & Research Institute. The target HHs being 6047 for the ward, universal sampling technique was used to cover all slum households based on a common decision from the Public Health stakeholders of the Urban Local Body (ULB). This was decided based on Pulse Polio micro plan and Active Case Finding for Tuberculosis-2019. As listed in the Pulse Polio micro plan and based on field visits, all the HHs were classified as High-Risk Area due to multiple accessibility-related issues. A briefing meeting was conducted to explain the purpose of survey permission from local leaders and the jurisdictional heads of the ULB was sought in a briefing stakeholder to conduct health survey in the area and purpose of the same was explained to gain support at the community level.
Data collection was carried out by trained CHWs and Volunteers (students in the Phase III Part I of MBBS and those undergoing compulsory rotatory internship at the field practice hospital). Each team with was given a target of 15 households per day. The head of the household/informant was asked permission to collect information of family members of the household and then consent was taken on an individual basis to collect data. The HHs whose informants refused to give consent & households which were locked (not available for data collection) for two consecutive visits were excluded from the study.

RESULTS
The survey data was exported from the application database as a csv file and analysis was done using MS Excel and SPSS ver 20. The ward has been divided into 12 HRAs grouped into 3 sectors (Table 1), for ease of service delivery and monitoring. Of the 6047 HHs in the ward, the results have been analysed for 3165 HHs (causes for exclusion of 2882 HHs depicted in Figure 2)     12 . The present survey also showed that prevalence of disability being 3% which was almost like that of the national average (Table 4).

HEALTH RELATED VULNERABILITY
72% of the HHs in the slums sought health care services from the Government facilities and 27.8 % from the private providers. 0.2% of them did not seek any health care facilities making them vulnerable to various Communicable and Non-Communicable Diseases ( Table 6).

ANM visit to Household for Health Services
70.5% of the HHs are visited by ANM monthly or twice a month and 19% of the houses are visited once in three months. 10.5% of the houses were never visited by ANM for health care services which show that these are the HHs which need immediate focus and health care workers need to be deployed in these areas.
When enquired regarding any deaths in the HHs in the past 5 years, 71 (2.2%) reported at least 1 death. Heart attack (ischemic heart disease) accounted for 28.2% of households reporting such death (s). Debilitating illnesses were reported as a cause of death in 11 (15.5%) of HHs reporting deaths ( Table 7).

Out of pocket Expenditure (Financial Vulnerability)
1380 (43.60%) and 902 (28.49%) HHs had expenditure for outpatient (in the past 1 month) and inpatient (in the past 1 year) health care services respectively.
642(40.35%) among the HHs who had expenditure on the health care services in the past 1 year had faced catastrophic health expenditure (>10% of their household income was spent on health) 13 which indicates that there is high chance of these HHs being pushed towards impoverishment.      Geographic Information Systems (GIS) and the accompanying methods and data have been adopted increasingly in diverse health-related domains and national settings with the goal of improved response to public health problems. 14,15 Figure 4 shows geographic or spatial mapping of the HHs surveyed during the pilot phase of Vulnerability Assessment carried out at Urban Primary Health Centre catchment area. The objective was to get an accurate map of the HHs present within the slum with all geographic information with respect to NUHM. The base map including knowledge of location of all health facilities (public and private), their catchment areas, slums with population, Anganwadi centres, educational institutions (public and private) Municipal and ward boundaries, major road networks, major landmarks, agriculture land, major water bodies etc. were obtained through Public Health Information and Epidemiological Cell (PHIEC). The layer of the surveyed HHs was added up on the same.

DISCUSSION
The vulnerability assessment at the household level showed that 45.8% (1452) of them were highly vulnerable and 54.2% (1713) were vulnerable whereas the slum level data 50% of the slums were highly vulnerable and other 50% were vulnerable.
Among 3165 HHs -0.2% of the HHs were staying in temporary shelters; 2.7% were seasonal migrants; 25.2% stay besides polluted water, 23.6% besides dumping ground and 2.6% near high tension wire; 0.4% have no access to toilet facilities; and 5.8% of the HHs have irregular water supply.
In a Vulnerability Assessment conducted by BT Rao, JS Thakur by using rapid survey method it was observed that 15 slums (36.6%) were highly vulnerable, 21 (51.2%) were moderately vulnerable and 5 (12.2%) were low vulnerable. 2 Vulnerability assessment conducted in Chandigarh, India (2012) by Subhakanta Mohapatra 16 showed that -in highly vulnerable slums more than 60% of the population suffers from the lack of basic infrastructural facilities include housing structure, access to safe drinking water, poor drainage system, basic sanitation facilities, type and nature of employment and health facilities (immunization, institutionalized delivery).

Figure 4: GIS mapping of the HHS covered during vulnerability assessment
On the other hand, in less vulnerable slums, less than 45% of the population suffers from a lack of these facilities and indicators. There exists a lack of dependable data on the various aspects of slum life. This includes the number of slums, size of slum populations, access to services like water and sanitation, livelihood, morbidity patterns etc.
Vulnerability Survey conducted by Siddharth Agarwal, Shivani Taneja, Pradeep Patra showed that -Government of India 17 study on the condition of urban slums also shows that the respective authorities notified a little more than half of the slums in the urban areas of the country. In Khader Sharif Garden, most floors would be cement and roofs tiled or of asbestos. Here there is a little mobility and excessive crowding. 19 The study conducted by Wankhade K et al. showed that five slums (one from PNP and four from NNP) belonged to the 'moderately vulnerable' category with scores ranging between 16 and 20. The rest of the slums belong to the 'least vulnerable category' with scores ranging between 11 and 15. The scores also indicate that slums are quite homogeneous in terms of their vulnerability. 20

CONCLUSION
The baseline information of slums, vulnerable pockets and their geographic mapping obtained during the survey can be used as foundation for effective planning of delivery of health care services for a given area population. The vulnerability mapping along with the mapping of the health facilities will complement the overall planning exercise and can be used for assistance in the Site Planning for community process activities.

RECOMMENDATION
Also the Medical Colleges can implement the platform at their Urban Health Training Centres under their Department of Community Medicine and their respective catchment areas, which would aid in planning regular follow up visits and in providing Preventive, Promotive and Curative Health Services at the community level."Namma Samudaya" application provides a platform for dashboard generation and monitoring the trends of Communicable and Non-Communicable diseases which can be utilized for decision making, planning and implementing disease specific programs on a long term basis & in sustainable manner. The results obtained can be easily collated through the digital platform and can be utilized for improved continuum of care.