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Abstract
Objective To identify factors associated with accessing and utilisation of healthcare and provision of health services in slums.
Design A scoping review incorporating a conceptual framework for configuring reported factors.
Data sources MEDLINE, Embase, CINAHL, Web of Science and the Cochrane Library were searched from their inception to December 2021 using slum-related terms.
Eligibility criteria Empirical studies of all designs reporting relevant factors in slums in low and middle-income countries.
Data extraction and synthesis Studies were categorised and data were charted according to a preliminary conceptual framework refined by emerging findings. Results were tabulated and narratively summarised.
Results Of the 15 469 records retrieved from all years, 4368 records dated between 2016 and 2021 were screened by two independent reviewers and 111 studies were included. The majority (63 studies, 57%) were conducted in Asia, predominantly in India. In total, 104 studies examined healthcare access and utilisation from slum residents’ perspective while only 10 studies explored provision of health services from providers/planners’ perspective (three studies included both). A multitude of factors are associated with accessing, using and providing healthcare in slums, including recent migration to slums; knowledge, perception and past experience of illness, healthcare needs and health services; financial constraint and competing priorities between health and making a living; lacking social support; unfavourable physical environment and locality; sociocultural expectations and stigma; lack of official recognition; and existing problems in the health system.
Conclusion The scoping review identified a significant body of recent literature reporting factors associated with accessing, utilisation and provision of healthcare services in slums. We classified the diverse factors under seven broad categories. The findings can inform a holistic approach to improving health services in slums by tackling barriers at different levels, taking into account local context and geospatial features of individual slums.
Systematic review registration number https://osf.io/694t2.
- health services administration & management
- international health services
- public health
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.
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Strengths and limitations of this study
We conducted literature search in multiple databases using generic terms related to slums to ensure that a wide range of relevant studies was captured.
A conceptual framework explaining factors associated with accessing and utilisation of healthcare by slum residents as well as provision of healthcare in slums was developed and used to categorise identified studies and factors.
We examined barriers and facilitators of accessing healthcare and service provision from the perspectives of both demand side (slum residents) and supply side (healthcare providers and service planners).
Only studies published in academic journals between 2016 and 2021 in English language were included, and methodological quality of each included study was not examined because of time constraint.
We did not explore the complex relationships and interactions between various factors in different contexts at different slum locations, but our mapping of these factors to the conceptual framework should facilitate further in-depth analyses.
Introduction
Rapid urbanisation has resulted in a growing number of residents in slums1 who face ongoing problems such as unemployment, poor sanitation, lack of transport, high level of crime and haphazard development.2 In 2018, over 1 billion people were living in slum-like conditions, and Central, South and South-East Asia and sub-Saharan Africa accounted for 80% of them.1 Even though various definitions of slums exist, there is no universally agreed definition of what constitutes ‘a slum’, and the term itself is widely debated and contested.3 4 For the purpose of this scoping review, we refer to slums as densely populated areas characterised by lack of basic services, substandard housing, overcrowding, unhealthy living condition, insecure tenure and poverty,4 5 taking into account the crucial concepts of place and space that are important in shaping health outcomes and community access to health services in these urban settings.4
Previous studies have reported various risk factors affecting health of slum residents such as physical environment,6 sanitation,7 social capital8 9 and water governance,10 and have observed in some cases that slum residents have worse health status compared with non-slum urban and/or rural residents. For example, Ezeh et al found that children living in slums had higher mortality than rural and non-slum urban populations.3 Poorer height for age for children11 and higher prevalence of childhood illnesses and malnutrition12 have also been observed in slums compared with non-slum urban and rural settings. In addition, slum residents are susceptible to unhealthy behaviours.13 14 Living in slums has been found to be associated with low physical activity,13 poor diet14 and poor knowledge about the cause and preventability of diseases.15
Despite the unfavourable health status and environment, and consequently the potential high level of healthcare needs, previous studies showed that slum residents were less likely to seek and use healthcare services than their non-slum counterparts in the cities.16 17 Slum residents have been found to have lower rates of healthcare utilisation in antenatal services16 and services for non-communicable diseases17 compared with residents of urban ‘formal’ settings. One study in Iran showed that only about half of slum households that required outpatient services could use them.18 Another study in Haiti also reported that one-third of slum households were not able to access medical care for their children when it was needed in the past year.19
While the health status and needs of slum residents have been described in previous reviews,3 20 factors associated with healthcare-seeking behaviour and healthcare utilisation of slum residents and factors related to the provision of health services in slums have not been systematically examined (with the exception of immunisation services).21 This scoping review aims to fill in these evidence gaps and inform efforts to improve healthcare delivery to people in slums.
Methods
This scoping review was performed according to current best practice guidance.22 The broad question of interest was: ‘What factors are associated with slum residents’ accessing and utilisation of health care and/or the provision of health services in slum settings in low and middle income countries (LMICs)?’. The protocol for this review was registered in Open Science Framework.23
Literature search and study selection
A broad search of five databases (MEDLINE, Embase, CINAHL, Web of Science and the Cochrane Library) was conducted in April 2020 and updated in December 2021. Searches were limited to English language. Key terms related to slums were used: slum or slums or ghetto or ghettos or informal settlement$ or shantytown$ or shanty town$ or favela$ (online supplemental appendix 1). We did not include terms related to other concepts in order to maximise the sensitivity of our searches. In addition, we searched the organisational websites of Slum Dwellers International, UN HABITAT, United Nations and WHO but did not identify relevant studies.24–27
Supplemental material
Records retrieved from databases (after duplicates were removed) were initially screened by one reviewer (J-EP) and those which did not meet the inclusion criteria were disregarded. After that, a second reviewer (PK, GY, OO) examined the remaining records independently based on titles and abstracts. When the decisions of two reviewers differed, the discrepancy was resolved based on full texts and/or by discussion with a third reviewer (Y-FC) or the broader review team. This study-screening process started from records of the most recent years (ie, in the past 3 years) and then proceeded to prior years. Due to the larger than expected volume of the literature, we eventually screened records between 2016 and 2021 and did not cover earlier records in order to synthesise and present the findings from latest evidence in a timely fashion to inform the wider project hosting this review.28 29
Inclusion and exclusion criteria
A study was included when it: (1) described factors related to slum residents’ accessing or utilisation of healthcare or the provision of health services in slums; and (2) was conducted in relation to slums in LMICs. Only articles written in English were included. A study was excluded when it was a commentary, opinion or narrative review; described slum residents’ utilisation of health services or the provision of health services without exploring the associated factors; investigated informal care at home; or included mixed slum and non-slum populations without separately reporting data for slum residents or investigating residency in slums as a factor for healthcare access.
During our updated search in December 2021, we found several studies reporting healthcare utilisation28 and provision related to COVID-19 in slums.30 These studies were not included in this scoping review, since the factors associated with healthcare utilisation and health service provision under the pandemic situation are dramatically different and warrant a separate synthesis.
We included both primary studies and systematic reviews that examine data collected empirically and that derive their findings based on the data. Both quantitative and qualitative studies (and by extension, mixed methods studies) were considered. Even though slums have existed in both high-income countries and LMICs, the context may be quite different between these countries. For example, while all slums are vulnerable to natural disasters such as tropical cyclones, the impact of these could be far more severe in slums of LMICs due to the different socioeconomic contexts.31 In this review, we focused on settings in LMICs and excluded studies conducted in high-income countries.
Study coding and data extraction/charting
Eligible studies were coded and data extracted/charted according to a prespecified preliminary framework shown in figure 1. The preliminary framework was developed by the review authors based on existing conceptual models related to healthcare access and service delivery32–35 and was modified during the scoping review process to accommodate new factors/themes identified from the literature. The refined conceptual framework is shown in figure 2.
Preliminary framework for factors influencing slum residents’ healthcare-seeking behaviour and utilisation of health services and the provision of services in slum settings.
Updated framework of factors influencing healthcare-seeking behaviour/healthcare utilisation/provision of healthcare services in slums.
Based on the refined conceptual framework, each eligible study was coded as being associated with one or more of the three phenomena of interest, namely slum residents’ healthcare accessing (which covered perception of needs/desire for care, healthcare seeking and healthcare reaching as defined by Levesque et al 34), healthcare utilisation and provision of health services (which covered various arrangements related to service delivery) in slum settings (figure 2).
In addition, to facilitate the organisation of complex evidence in this review, diverse factors reported in the included studies were initially classified into six different categories according to the preliminary framework shown in figure 1. However, during the data-charting process, we realised that many factors such as perception of symptoms and experience from past use of healthcare services did not fit into one of these six original categories. A new category of ‘cognitive and experiential factors’ was therefore added to the refined conceptual framework (figure 2) to reflect the emerging themes, which include seven categories:
Personal and biological factors: these relate to personal characteristics of slum residents, including age, sex, ethnicity and the nature and severity of health conditions.
Cognitive and experiential factors: these relate to personal awareness, knowledge, perception, attitude, belief and experience, etc, formed through cognitive process based on upbringing and past events.
Socioeconomic factors: these include income and wealth, economic hardship/poverty and economic opportunities, marital status, education, crime, social capital (such as bonding, trust and reciprocity between close relatives, neighbours and community members),36 use of technologies for social and economic purposes, commercial and charitable organisations and activities.
Physical environment: this covers natural environment such as proximity to a health facility, built environment and infrastructure such as water supply, transport and mobile/internet networks, as well as weather conditions and environmental pollutions.
Cultural and religious factors: these include cultural and religious beliefs and activities, and local and national customs.
Legal, political and policy factors: these include government policies and issues related to legal, justice and political systems.
Health system factors: these relate to historical and current organisation and provision of healthcare that may impact on provision and delivery of health services in individual slum communities and the services experienced by slum residents.
In addition to the ‘cognitive and experiential factors’ category, another major difference between the preliminary (figure 1) and refined (figure 2) conceptual framework relates to the definition of healthcare access. Our preliminary framework adopted the definition by Levesque and colleagues, who defined healthcare access as ‘the possibility to identify healthcare needs, to seek healthcare services, to reach the healthcare resources, to obtain or use health care services, and to actually be offered services appropriate to the needs for care’.34 However, during our study-screening and data-charting process, we found that it would be helpful to make a distinction between the process of ‘accessing’ healthcare (which covers gaining awareness of needs, forming an intention to seek healthcare and taking an action to reach healthcare) and the actual receipt and utilisation of healthcare (‘accessed care’) when examining empirical evidence, as healthcare needs could only be met when the latter occurs and this depends on both factors related to service users (demand side) and factors related to service providers/planners (supply side). Therefore, we separated out utilisation of healthcare from ‘accessing health care’ to highlight that it requires a match between demand and supply side factors.
Data on study population, study design, country in which the study was conducted, methodology and associated factors were extracted using a data-charting spreadsheet which was developed and continuously updated as the review progressed by two of the reviewers (J-EP and Y-FC). Whether a study was conducted exclusively within slums and whether a comparison was made between slum and non-slum urban or rural residents were also noted. Coding of phenomena and factors and data charting were conducted by one reviewer (J-EP) and checked by a second reviewer (PK, GY, OO, Y-FC). Disagreements were discussed between reviewers until consensus was reached.
Patient and public involvement
Given the focus of this scoping review on published literature, we did not directly involve residents and service providers/planners from slum settings. Nevertheless, our wider project has a work package that specifically engages with slum residents and service providers and planners,28 and early plans and findings of this review were shared with the wider project team who provided comments based on their experiences of community engagement.
Results
The reporting of this review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.37 Using the search strategy described earlier, a total of 15 469 records were retrieved from the initial and updated searches (MEDLINE 4688, Embase 5090, Web of Science 3553, Cochrane 381, CINAHL 1757), with 9916 records remaining after excluding duplicates. Two additional articles18 38 were identified from references of the included studies. As described earlier, screening was limited to the 4368 records published from 2016 onwards.
A total of 111 articles were included in this scoping review (figure 3). Thirty-two studies reported factors associated with healthcare accessing of slum residents, 73 studies reported factors related to healthcare service utilisation and 10 articles reported the factors related to provision of healthcare services in slums (four studies reported factors related to more than one phenomenon of interest). Seventy-four of the 111 studies were quantitative studies, 21 studies were qualitative studies and 14 studies were undertaken using mixed methods. The remaining two studies were systematic reviews. A total of 42 (38%) studies were conducted in India, followed by Kenya (14 studies, 13%) (table 1).
Characteristics of included studies
Flow chart.
Participants, country, study design, methodology, observed phenomena and outcomes, and factors of interests for each study are described in online supplemental tables 1–3. Online supplemental table 1 shows 32 studies reporting factors associated with general healthcare-seeking behaviours; healthcare seeking for children or women; slum residents’ preference for healthcare providers; and healthcare seeking related to HIV testing. Online supplemental table 2 presents various factors reported in 73 studies related to general healthcare utilisation as well as use of specific services such as childhood immunisation, maternal healthcare and possession of health insurance. In online supplemental table 3, ten studies reporting factors related to the provision of health services in slums are summarised. Key findings are described below.
Supplemental material
Supplemental material
Supplemental material
Demand side: factors associated with healthcare accessing and healthcare utilisation of slum residents
We found 104 articles which identified many different factors affecting healthcare accessing and utilisation. These factors are often inter-related and exert their influence at different levels (eg, from personal, family to community level) in different circumstances. We classified various factors into seven categories (figure 2). Factors particularly relevant to slum settings and other commonly identified factors within each category are highlighted below.
Personal and biological factors: The common factors associated with healthcare accessing and utilisation included intrinsic factors such as age,21 39–55 sex18 21 41 45 51 53 55–58 and ethnicity,21 familial factors such as birth order of the sick child,21 46 59–61 as well as personal health and type of illness,45 58 disability47 and morbidity,21 51 62 63 and the specific features of the health condition.52 55 64 Slum residents are more likely to seek healthcare services when sick children are younger,48 49 52 55 but evidence on the association between mother’s age and child’s vaccination was inconsistent.21 39 Healthcare seeking and utilisation were different by sex, but the association was context dependent. Several studies reported higher healthcare utilisation among female slum dwellers,18 51 55 57 while other studies showed male children had higher vaccination coverage56 and incurred more medical expenditure.58 Major life events such as recent migration21 49 65–67 and relocation48 into slums tend to be associated with lower healthcare seeking and utilisation. Recency of migration to slums was also related to lower uptake of Rashtriya Swasthya Bima Yojana (RSBY), a national health insurance programme run by the Indian government for poor families.68 People with specific symptoms (such as fever, tachypnoea, persistent vomiting),52 55 64 disability47 and illnesses including chronic disease21 51 53 62 63 tend to use healthcare services more. Although people with tobacco habit were less likely to participate in breast cancer screening, they were more likely to take part when they had family history of cancer or history of cancer screening.69 Lower birth order of the child was associated with increased utilisation of hospitals for childbirth,21 46 59–61 while the use of family planning service46 and out-of-pocket expenditure was higher in multigravida than primigravida.62
Cognitive and experiential factors: These factors were not included in our initial conceptual framework but rather emerged inductively from our data. Consequently, their identification led us to revise the conceptual framework for this scoping review. A wide range of factors formed through cognitive processes and influenced by individual’s upbringing, past experience and surrounding environment were reported to be associated with both healthcare seeking and healthcare utilisation of slum residents. Perception,39 50 52 67 70–76 knowledge52 77–82 and experience of symptoms and illnesses50 were commonly found to influence healthcare seeking and utilisation. Mothers who experienced child death and subsequently planned pregnancy showed higher use of antenatal healthcare services.50 When people perceived the symptom or disease to be serious they tend to seek healthcare services.52 70 72 76 Although lack of knowledge could be a barrier to accessing healthcare services,77 78 one study showed caregivers with good knowledge of child danger signs were less likely to seek healthcare services timely.52 People perceiving their health status as good showed lower odds of having insurance,83 but awareness and knowledge of health problems led people to use healthcare services.39 73 75 79 80 82 Home remedy and home management delayed healthcare-seeking behaviour.52 70 81 84 In addition, perception,21 42 63 75 83 85–89 knowledge21 42 48 60 67 74 81 85 90–95 and experience of healthcare services39 49 59 61 66 69 74 79 86 96 97 including fear and distrust of healthcare services,21 38 67 71 74 75 78 88 98–100 and preference related to care provider’s gender87 101 were frequently cited factors. Provider shopping associated with distrust of healthcare providers and denial of diagnosis delayed first care seeking and treatment initiation of patients with pulmonary tuberculosis in India.70 Perception or experience of healthcare services also affected uptake or renewal of health insurance.83 94
Socioeconomic factors: Socioeconomic status was associated with utilisation of healthcare services,21 39 40 46 56 61 81 102 and even though one study showed that slum residents of lower socioeconomic class were more likely to enrol in health insurance than slum residents of higher socioeconomic class,40 the latter were more likely to use healthcare services.39 46 56 61 One study reported higher public hospital visits (compared with private hospital visits) among lower socioeconomic status.103 Income and wealth21 41 48–50 60 65 67 80 104–108 including financial constraint19 21 38 45 73 76 78 84 86 89 100 102 109–113 featured prominently. Higher education level39 48 55–58 60 61 65–67 69 80–82 106–108 114–116 and higher income21 48–50 55 57 60 65 67 80 104 106–108 117 were associated with more seeking and utilisation of healthcare services. With some exceptions,66 104 previous studies reported that employed slum residents tend to seek and use healthcare services more frequently than unemployed slum residents and housewives.48 50 65 66 69 80 82 83 118 Even though married people tend to seek and use more healthcare services,18 69 the reported influence of family type was inconsistent.39 50 115 Female slum residents in nuclear family used more antenatal services than those in joint family type,50 but female slum residents in joint family type used more postnatal service39 and immunisation service for their children.115 Smaller family size used more maternal healthcare services,66 and bigger households had higher odds of having health insurance.68 The socioeconomic challenges faced by slum residents also manifested as competing priorities73 93 119 and lack of time21 100 120 for healthcare seeking and utilisation, because they did not want to or could not afford to miss work and lose income,21 70 which can be exacerbated by lack of social support.74 76 87 93 99 121
Physical environment. Slum residents considered proximity of healthcare facilities,21 38 46 76 80 84 85 95 108 122–126 transport such as travel assistance,76 lack of transportation,38 82 102 traffic congestion127 and environment of residence area when they sought and used healthcare services. Long distance from health facility,38 54 76 84 101 122 no transportation or travel assistance38 82 102 and unsafe environment of residential area such as darkness at night were reported as barriers to reaching healthcare facilities.99
Cultural and religious factors: These included religion41 56 59 69 75 114 128; sociocultural influence93 101 such as exposure to media79 97; stigma associated with unplanned/extramarital pregnancy,78 93 postpartum depression129 and other illnesses such as contagious skin disease, barrenness and female sexually related problems101; and use of traditional/home medicine.75 86 99 Women in slums could not go to hospital because they had difficulties in disclosing the symptoms, postponed their health issues because of their responsibilities at home and engaged in self-treatment practices such as home remedies recommended by grandmother and friends because of sociocultural influences towards healthcare-seeking behaviour.77 Women in Ethiopia reported not returning to postnatal care due to religious and cultural expectation for the mother and the baby to stay home for 80 days after birth.93 One Indian survey showed that some women could not seek healthcare services during labour since their husband or family did not allow that.38
Legal, political and policy factors: Type of slums (in terms of official recognition and availability of basic facilities) and possession of a ration card were found to be associated with uptake of the Indian RSBY national health insurance programme.68 One study reported that slum residents could not seek healthcare facilities for abortion because of the perceived illegality of abortion.78
Health system factors: Slum residents were also influenced by many factors related to health systems when they sought healthcare. These included accessibility associated with the location21 101 and timing of services21 84 86; quality of healthcare services38 66 85 86 101 112 124 such as delay in advising patients to go for related tests or referral,70 likelihood of receiving appropriate examination84 109 and adverse events.75 Slum residents considered service organisation including medical turnover,130 availability of supplies/healthcare workers,46 84 109 112 attitude of healthcare providers,86 type of healthcare facilities38 85 116 131 and waiting time.72 84–86 109 111 132 Slum residents tend to seek government and non-governmental organisation facility117 and avoid private hospitals38 for healthcare services. Healthcare utilisation was higher among slum residents with healthcare insurance than those without it,18 82 and households with higher quarterly out-of-pocket healthcare expenditure had lower scores for an index of access to primary healthcare.133
In an Ethiopian study, some participants reported unavailability of female birth attendants as a reason for not delivering at healthcare facilities112 (table 2).
Factors associated with healthcare accessing and healthcare utilisation in slums from service user’s (demand side) perspective
Supply side: provision of healthcare services
Ten articles described factors associated with provision of healthcare services in slums from the service providers’ perspective. None of the studies reported personal and biological factors. Factors related to other categories are summarised below.
Cognitive and experiential factors: Odhiambo et al reported slum residents’ fear of side effects, size of tablet and misconceptions regarding treatment as the factors hindering drug administration activities by healthcare workers for a deworming programme in Kenya.134 On the other hand, this study also reported a high demand for drugs from slum residents in the final year of this programme because people realised that free treatment was to be ended.134
Socioeconomic factors: Effective community mobilisation was a facilitator134 whereas poor community support135 and insufficient time allocated for providers to implement healthcare programmes134 were barriers for provision of healthcare services in slums. In the deworming programme mentioned above, community health workers reported that direct observation of slum residents taking deworming drugs after meals was sometimes not feasible because slum residents skipped meals or ate late at night due to food shortage.134 Some slum residents demanded money to take the deworming drugs, either to facilitate purchase of food or to have their own share of the money that they perceived the community health workers would be paid by the programme if they complied with taking the drugs.134
Physical environment: Poor sanitation,134 136 presence of rodents and no pavement136 and bushy and unprotected environment134 were reported as factors making the provision of healthcare services difficult in slums.
Cultural and religious factors: Religious beliefs and mistrust of interventions,134 lack of a shared understanding of the needs, purposes and consequences of family planning and pregnancy-related services among slum residents and healthcare providers73 were the barriers for healthcare service provision. In the previous deworming programme, portrayal of unrelated death being linked to the programme and related negative publicity affected participants’ compliance.134
Legal and political factors and policy: Devolution of service delivery through downward transfer of funds and responsibilities from central/national government level to elected local bodies; management by professional managerial and technical cadres; tight organisation of public health services; and professional support from the state directorate of public health were found to strengthen public health service provision in Chennai slums compared with Delhi.137 One study reported that policies affected healthcare provision negatively because of staff shortage arising from change and suspension of the appointment of health promoters, which led to overwork and lack of time to provide required care by other healthcare staff.132 In Brazil, home visits for the provision of healthcare services were hampered because slum residents could not present documents required to register for healthcare.136 On the other hand, giving priority to socially less developed areas for strengthening the Family Health System in Brazil might have been associated with better service coverage for slum residents with tuberculosis compared with their urban non-slum counterparts.138
Health system factors: Pay scale of frontline healthcare workers,135 knowledge of intervention area by community health workers,134 issues related to rigid task assignment by service managers,136 requirement to follow standardised protocol,136 demands from the management,136 work burden132 136 and no incentive,135 insufficient time,134 attitude73 and support of healthcare providers,135 ill-defined geographical boundary of service with unserved areas and left-out urban slum pockets139 were associated with healthcare service provision in slums.
Lack of community-based care (such as school-based education for reproductive health and community support networks for women),132 unreliable immunisation and household data128; and inefficient utilisation of funds,128 affordability (price) and availability of medicine,140 limited medical supplies73 135 and infrastructural facilities,135 inadequate space and equipment,136 139 suboptimal training of staff,139 insufficient availability of logistics and health manpower139 also affected service provision (table 3).
Factors associated with provision of healthcare services in slums from service provider’s (supply side) perspective
Comparison between slums and other settings
Seven studies which met our inclusion criteria also included data from non-slum urban and/or rural areas and potentially allowed exploration of factors associated with healthcare access across different settings. Key findings from these studies are summarised in table 4.
Studies that examined factors associated with healthcare seeking and utilisation in both urban slum and non-slum urban and rural settings
These recent studies showed a mixed and dynamic picture of healthcare access across slum and other settings and reported various factors associated with this. For example, the proportion of young children fully immunised was found to be lower in slums compared with non-slum urban setting but was higher than rural settings in Nigeria. Nevertheless, the coverage improved over time across all settings.59 While many common factors associated with full immunisation of young children were identified, giving birth in health facilities (as opposed to home) had a larger positive effect on subsequent immunisation coverage in slums compared with non-slum urban and rural settings.59 A narrowing of gaps in delivery by skilled birth attendants between slum and non-slum urban settings over time and a reverse of the trend from having lower usage to higher usage of modern contraceptive methods by married women in slums versus urban non-slums were reported in Bangladesh.46 Slum residents reported financial issues being the main reason for not taking prescribed drugs whereas getting better was the cited main reason for urban non-slum residents in Iran.113 Better coverage of services and higher rates of treatment completion were reported for patients with tuberculosis in slums compared with non-slum urban setting in two studies in Brazil,51 138 where a higher priority given to enhancing the Family Health System in socially less developed areas in recent years was suggested to be a likely factor associated with better service provision in slums138 (table 4).
Discussion
Statement of principle findings
This scoping review of recent literature examined the demand side factors associated with slum residents’ healthcare accessing and utilisation, as well as supply side factors associated with provision of health services in slums. We found over 104 studies related to the former but only 10 studies related to the latter. We identified different factors associated with accessing, utilisation and provision of health services in slums, and mapped them to a conceptual framework developed and refined for this review into seven broad categories (figure 2).
Findings in the context of existing literature
Even though previous reviews have investigated factors associated with healthcare access in various settings,141 142 to our best knowledge this scoping review is the first that has examined wide-ranging factors across different service areas of healthcare in slums. Our findings are consistent with previous studies which highlighted common factors associated with healthcare seeking and utilisation such as age, income and education.141 143 We identified several factors that are particularly pertinent in slum settings, such as costs of healthcare,19 21 73 76 78 84 89 100 102 109–111 lack of time due to slum residents’ competing priorities21 100 120 and issues arising from adverse physical environment,82 102 134 136 security,99 136 fear of formal registration due to distrust of the authorities136 and proximity of healthcare facilities.21 76 80 84 85 108 122–125 In addition, included studies showed that the effects of a given factor may differ between slum, urban non-slum and rural settings.59
Healthcare cost is a major barrier between the intention to seek care and actual utilisation of services.109 144 Healthcare provision supported by tax-based financing and/or various forms of social and private insurance that reduce out-of-pocket expenditure at point of care could be potential measures to overcome this barrier and help achieve universal coverage goals. Limited evidence showed that initiatives prioritising primary healthcare coverage in slums could improve access,138 but there is insufficient evidence from studies included in this review to determine the best model of healthcare financing for improving healthcare access and coverage in slum settings.
Although possession of/coverage by health insurance was associated with higher levels of utilisation of health services among slum residents,18 82 studies showed that uptake of government-run public insurance among slum residents was low.68 83 This may be attributed to lack of awareness, difficulties in navigating through the health system and in obtaining official proof of identity required for enrolment68 and poor quality of care and range of services offered.68 83 Even among slum residents covered by health insurance, access to care was often refused and additional charges were frequently requested.94 Policies that aim to improve access to healthcare services among slum residents through public health insurance will need to address these challenges.
Several studies reported lack of time and competing priorities as a factor affecting healthcare-seeking behaviour100 119 120 and health service utilisation.21 73 93 This suggests a delicate balance between factors that individual slum residents have to strike when making decisions on healthcare seeking and utilisation. van der Heijden et al showed that health was considered as an asset for working ability in slums,119 but paradoxically the ability to work often seems to impede healthcare seeking for health issues. This highlights the importance of considering slum residents’ interest and priorities when providing healthcare services and promoting healthcare utilisation in slums.
Strengths and weaknesses of the review
This scoping review has several strengths. We conducted a comprehensive literature search using generic terms related to slums with few other restrictions. The search was therefore likely to be sensitive for identifying relevant literature. Contemporary methodological guidelines for undertaking scoping reviews were followed,22 and a conceptual framework which was adapted based on emerging findings was used to facilitate the organisation of evidence.
The review has enabled theory building and refinement of a conceptual framework. Our preliminary framework included six categories (figure 1). During data coding and extraction, it emerged that many studies reported perception, knowledge and experience of slum residents being associated with their healthcare seeking and utilisation. We subsequently classified these factors as cognitive and experiential factors, which primarily consist of three subcategories: knowledge/experience of illness, perceived needs for accessing healthcare services and perception/experience of healthcare services. These factors were influenced by other factors included in our original conceptual framework, but highlighted the crucial links between those factors and the ultimate actions by individual slum residents to access health services. Future interventions to promote health service utilisation for slum residents145 could make use of our framework to develop programme theories and map out causal pathways.
This review also has some limitations. Given time constraint, we were only able to examine the most recent literature published in English in academic journals, and have not examined the methodological quality of individual studies (which we noted to be quite varied) in detail. We attempted some preliminary synthesis to configure the identified evidence but have not explored the complex relationship between the factors identified and their interplay with the context of individual slums in depth. Nevertheless, the findings from this scoping review will provide a good foundation for further syntheses.
Methodological considerations
A number of challenges in the process of classifying and coding data are worth mentioning. First, access to healthcare has been conceptualised and defined in various ways in previous studies. The WHO suggested six building blocks of a health system including service delivery, health workforce, health information systems, access to essential medicines, financing and leadership/governance to strengthen health systems146 and, in its report, defined access to healthcare as public responsibility for ensuring all citizens’ entitlements to the protection of their health beyond simply a proportion of a target population that benefits from an intervention, towards universal coverage.146 They also pointed out system constraints such as financial access difficulty, physical access difficulty, low knowledge and skills, poorly motivated staff, weak leadership and management, ineffective intersectoral action and partnership as barriers to access.146 The WHO’s definition and conceptual framework focus on health system-level factors and would be particularly useful when examining supply side factors, which seem to be understudied based on our findings. As described in the Methods section, we primarily adopted the conceptual model of healthcare access developed by Levesque and colleagues given our shared focus on service users. However, in our conceptual model, we separated the dynamic stages of ‘accessing’ healthcare from the actual ‘accessed’ healthcare (utilisation) to highlight the crucial match required between the demand side and supply side factors to facilitate utilisation of healthcare when there is a need.
Several factors associated with healthcare accessing and utilisation can be viewed from different perspectives and therefore potentially be coded under different categories. For example, barriers for healthcare seeking and utilisation related to costs can be considered as socioeconomic issues from the slum dwellers’ perspective but can also be viewed as health system issues for not offering the services in an affordable way. Indeed, previous access frameworks suggested that access is created and negotiated in a dynamic interchange between households/communities and healthcare workers/systems (ie, demand and supply) on each access dimension.34 147 In such situations, we tried to code a factor under the category that most directly reflects the original data through discussions within the review team (in the example of healthcare cost, the factor was coded primarily under socioeconomic factors rather than health system factors when the factor was reported by slum residents as a barrier); otherwise, more than one category was coded (eg, bad experience from previous utilisation of health services was coded both as a cognitive and experiential factor and a health system factor).
Implication for research and practice
The multitude of factors identified in this review are often inter-related and interacting, and span across personal, family, community and society levels. For example, the association between occupation and healthcare utilisation was reported in several studies.48 60 66 80 82 104 The effect of predominantly casual work undertaken by slum residents on their healthcare access could be mediated through working hours, income level, knowledge of health and available services, etc. There is also possibility that occupation was associated with health status and hence needs for healthcare services, instead of/in addition to behaviour of using healthcare services. Teasing out the complicated relationships between various determinants and their interaction with the diverse contexts of slums will require in-depth analysis and a more holistic approach to synthesising the evidence. Given the unique features of individual slums, service planners and policy makers will need to examine these relationships with due consideration to the context specific to each locality and geospatial features and neighbourhood effects that characterise slum settings.4
We found far fewer studies that have examined health service providers’ perspective than studies that have investigated factors associated with accessing healthcare from slum residents’ perspective. There may be scope for greater research and policy attention to supply side factors, including experiences and practices of local frontline healthcare providers, availability of healthcare facilities and infrastructure and policy to support them in order to overcome the many barriers highlighted from both supply and demand sides.
Although only six of the included studies explored factors associated with healthcare access or health service provision across slum and non-slum settings, they showed a generally encouraging picture that access to and provision of healthcare are continuously evolving (and often improving) in slums and other settings, and equality between different settings is not beyond reach.
Conclusion
This scoping review summarises a large body of recent literature evaluating factors associated with seeking and utilisation of healthcare by slum residents, but found substantially fewer studies examining factors associated with provision of health services from providers’ perspective. Recent migration into slums; knowledge, perception (including misconception and distrust) and past experience of illness, healthcare needs and health services; financial constraint, competing priorities and inadequacy of social support; adverse physical environment and unfavourable locality; sociocultural expectations and stigma; lack of official recognition; and various problems in existing health system all contribute towards the challenges faced by slum residents. Future research and policy aimed at improving healthcare services in slums should pay more attention to supply side issues ranging from individual healthcare providers and practices to structural and policy-level factors to tackle different barriers faced by slum residents, which in turn need to be evaluated holistically and take into account local context and geospatial features of slums.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
This realist synthesis included literature that is available in the public domain and did not involve the collection of personal data.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @GodwinYeboah, @yfchen12
Collaborators The Improving Health in Slums Collaborative: African Population and Health Research Centre (APHRC), Nairobi, Kenya: Pauline Bakibinga, Caroline Kabaria, Ziraba Kasiira, Peter Kibe, Lyagamula Kisia, Catherine Kyobutungi, Nelson Mbaya, Blessing Mberu, Shukri Mohammed, Anne Njeri. Aga Khan University, Karachi, Pakistan: Iqbal Azam, Romaina Iqbal, Ahsana Nazish, Narjis Rizvi. Independent University, Dhaka, Bangladesh: Syed Shifat Ahmed, Nazratun Choudhury, Omar Rahman, Rita Yusuf. Nigerian Academy of Sciences, Lagos, Nigeria: Doyin Odubanjo. University of Ibadan, Ibadan, Nigeria: Motunrayo Ayobola, Olufunke Fayehun, Akinyinka Omigbodun, Mary Osuh, Eme Owoaje, Olalekan Taiwo. University of Birmingham, Birmingham, UK: Richard Lilford, Jo Sartori, Samuel Watson. University of Lancaster, Lancaster, UK: Peter Diggle. University of Warwick, Coventry, UK: Navneet Aujla, João Porto de Albuquerque, Yen-Fu Chen, Paramjit Gill, Frances Griffiths, Bronwyn Harris, Jason Madan, Oyinlola Oyebode, Ji-Eun Park, Simon Smith, Grant Tregonning, Olalekan Uthman, Ria Wilson, Godwin Yeboah.
Contributors J-EP, BH, MMA, FG and Y-FC conceptualised the scoping review. J-EP carried out literature searches. J-EP, PK, GY, OO and Y-FC participated in study screening and coding. J-EP and Y-FC performed data charting and drafted the initial manuscript. NA, PG and RJL provided critical input during the drafting of the manuscript. All authors commented on and contributed to the revision of subsequent versions and approved the final version for submission. Y-FC is the guarantor for this article.
Funding This research is funded by the NIHR Global Health Research Unit on Improving Health in Slums using UK aid from the UK government to support global health research. MMA gratefully acknowledges the support provided by the Warwick Institute of Advanced Study Global Challenges Research Fund Fellowship (IAS/32013/1914). FG receives funding as South Africa Research Chair in Health Policy and Systems from the National Research Foundation, South Africa. RJL is supported by the NIHR Applied Research Collaboration (ARC) West Midlands, UK. Y-FC is supported by Warwick Evidence, which is a Technology Assessment Review team funded by the NIHR Evidence Synthesis Programme. PG is NIHR Senior Investigator and supported by the NIHR ARC West Midlands. Upon submission, NA had joined the Population Health Sciences Institute, Newcastle University (UK).
Disclaimer The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK Department of Health and Social Care.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
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