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J Edu Health Promot 2021,  10:263

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

1 Social Determinants of Health Research Center, Institute for Futures Studies in Health; Department of Health Management, Policy and Economics, Faculty of Management and Medical Information Sciences, Kerman University of Medical Sciences, Kerman, Iran
2 Medical Informatics Research Center, Institute for Futures Studies in Health; Department of Health Management, Policy and Economics, Faculty of Management and Medical Information Sciences, Kerman University of Medical Sciences, Kerman, Iran
3 Health Services Management Research Center, Institute for Futures Studies in Health; Department of Health Management, Policy and Economics, Faculty of Management and Medical Information Sciences, Kerman University of Medical Sciences, Kerman, Iran

Date of Submission16-Dec-2020
Date of Acceptance28-Dec-2020
Date of Web Publication30-Jul-2021

Correspondence Address:
Sara Ghasemi
Ph.D. Candidate Kerman University of Medical Sciences, Haft Bagh Street, Kerman
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jehp.jehp_1628_20

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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.

Keywords: Community empowerment, health promotion, poverty areas, slum, urban slums, Ghetto, wellness program

How to cite this article:
Mehrolhasani MH, Yazdi-Feyzabadi V, Ghasemi S. Community empowerment for health promotion in slums areas: A narrative review with emphasis on challenges and interventions. J Edu Health Promot 2021;10:263

How to cite this URL:
Mehrolhasani MH, Yazdi-Feyzabadi V, Ghasemi S. Community empowerment for health promotion in slums areas: A narrative review with emphasis on challenges and interventions. J Edu Health Promot [serial online] 2021 [cited 2023 Jun 1];10:263. Available from: https://www.jehp.net//text.asp?2021/10/1/263/322568

  Introduction Top

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 Top

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:

  1. ”Slums,” “informal settlement,” “Poverty Area,” “Ghetto,” “shanty town,” “marginal settlement,” and “suburban”
  2. ”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].
Table 1: Inclusion and exclusion criteria

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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.

  Results Top

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].
Figure 1: PRISMA

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[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).
Table 2: Characteristics of included studies

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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].
Table 3: Challenges, actors, interventions, scopes, outcomes identified in the studies

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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]:
Table 4: Classification of community empowerment interventions/strategies in slums

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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].

  Discussion Top

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 Top

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.

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  [Table 1], [Table 2], [Table 3], [Table 4]


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