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Review of food security and nutrition amongst urban poor

Summary of review1

Location: Kenya, Niger, Bangladesh

What we know: A significant and increasing proportion of the world population resides in urban slums. Achieving food security and adequate nutrition is a challenge amongst the urban poor.

What this adds: The urban poor face unique challenges compared to the rural poor in the same country. They are particular vulnerable to price rises and market shocks and exposure to poor water and sanitation is compounded by high population density that impacts health. Urban specific strategies, approaches and tools and disaggregation of data are needed.

Save the Children UK commissioned NutritionWorks2 to undertake a review of what is known about the mechanisms by which poor people attempt to achieve food security in urban slums. Part of the review involved examining if and how this is related to their nutritional status and where possible, how it compares to the rural poor in the same countries.

The aims were:

The review involved use of ‘grey’ and published research and literature and there was an emphasis on Kenya, Niger, Bangladesh and Myanmar. A summary of the case study in Bangladesh is included in Box 1.

Key findings

Urbanisation, the urban poor and their characteristics

The world’s population is expected to grow from 6.7 billion to 9.2 billion between 2007 and 2050. Virtually all of the 2.5 billion increase will occur in the developing world’s urban areas. Today, approximately 828 million urban residents are living in slum conditions, compared to 657 million in 1990. Sub-Saharan Africa is thought to have the highest number of urban slums with 62% of the urban population living in slums, followed by Southern Asia, with 35% (UN 2010).

Social networks in urban areas are based on political, religious, economic and ethnic connections. Social support systems are weaker for the most food insecure in urban areas, as they often do not have the same access to kin, political or religious groups to offer and provide support as in rural areas. All of which affects their social capital. Migration between rural and urban areas is two-way and often very context-specific depending on economic, social and political factors. It is essential to understand rural-urban linkages in analysis of the livelihoods and food security of the urban poor, as there is a high level of interdependency in many contexts and households may exploit opportunities for seasonal migration to mitigate risk.

Food security and nutrition among the urban poor (and causes of malnutrition)

The main determinants of food, livelihood and nutrition security are the same for urban and rural areas. However, there is a wide variation in the factors that affect these determinants. For example, urban households are more dependent on food purchase, which, if they have sufficient purchasing power, can lead to a more varied diet and higher reliance on ‘ready-made’ and fast foods, compared to rural households. Food access has a direct impact on dietary diversity and has been seriously affected by rising food and fuel prices, conflict, and the primary or secondary effects of natural disasters in urban areas across the globe.

Poor female-headed urban households or those with high dependency ratios tend to have a dietary diversity equal to that of the rural poor. However, existing tools for analysis, such as food consumption scores, tend to be misleading in urban areas where diets may appear diverse, but quantities of dairy products or meat consumed might be negligible. As the urban poor tend to be dependent on income from precarious informal sector jobs that rarely meets their consumption needs, they are more likely to employ risky coping mechanisms, including high levels of debt. Women are more likely than men to have less secure and irregular jobs that are not subject to labour laws and do not offer social or medical benefits. This affects breastfeeding, infant feeding and child care practices, especially for those without family support who must adapt their work patterns or use poor quality childcare.

Environmental issues (e.g. over-crowding, poor water and sanitation, pollution, open sewerage and contamination) are most acute in cities and exacerbated in slums. They have a significant impact on child and household health. Where urban data has been disaggregated by wealth group or studies have focused on the urban poor, high rates of undernutrition (both acute and chronic malnutrition) have been recorded for children under 5 years of age, which are comparable with, or higher than, the rates in rural under-5s. Data that exists for urban poor women reveals both high rates of undernutrition, combined with rising levels of overweight or obesity in some cases, reflecting the ‘double burden of malnutrition’(see excerpts from Bangladesh case study).

Urban food security and nutrition programming

Significant challenges are faced in urban food security and nutrition programming (by government, United Nations (UN) agencies and international non-governmental organisations (INGOs). First, there are assessment and targeting issues when faced with a highly mobile, densely packed population, where in- and out-migration is a constant feature. Although urban areas have traditionally been considered better served in terms of healthcare, education and sanitation, a closer look at the evidence reveals that proximity does not equate to access. Both cost of services and urban livelihood strategies, including long journeys to places of work and long working hours, limit access by the urban poor to healthcare, community nutrition services or improved water sources. Programmes have struggled to transplant rural approaches into the urban arena and are increasingly learning that there is a need to adapt, work with existing networks, organisations and systems, and conduct a thorough context-specific analysis prior to intervening. Social protection and cash transfer programmes are promising approaches in urban areas, with evidence to suggest that they improve dietary diversity, but as yet there remains a lack of evidence of their impact on the nutritional status of children under 5 years of age. The evidence clearly points to the need for multi-sectoral, integrated programming and an enhanced role for coordination between actors.

Funding urban food security and nutrition programmes

As far as this review could establish, no donors currently have an urban funding strategy, although the Swedish International Development Cooperation Agency (SIDA) are in the process of developing one, and DFID and ECHO are in the process of considering the way forward. This is a big gap in urban programming as, without funding, it will be difficult to develop the knowledge, skills, tools and experience to respond to needs arising in emergency, transition or long-term contexts.

Conclusions

The urban poor living in informal settlements and slums face a unique set of challenges compared to their rural counterparts. Almost exclusively dependent on the market for food and other necessary items, slum dwellers are very vulnerable to price increases and other market shocks. The population density of slums, in combination with poor sanitation and limited access to clean water, also translates into high transmission risk for communicable diseases. Despite the urban poor increasing in proportion to the overall population there is little disaggregated data, available between both rural and urban contexts, and between slums / non-slums. Although this is changing with new research focusing on slum dwellers, the body of knowledge on basic indicators, particularly health, food security and nutrition, is still limited. It is clear that urban-specific skills are needed in a number of areas, including analysis (especially related to gender roles), governance, and programme design within INGO’s, Governments, UN, the private sector and donors.

Recommendations emerging from this review include:

Box 1: Bangladesh case study summary

Bangladesh has an estimated urban population of more than 39 million (27% of its total population) made up of one third slums. Largely due to rural-urban migration, the slums are growing at a rate of 7% p.a., more than twice the overall urban growth rate (2.8%) and considerably higher than rural (0.4%). Urban population density is 200 times greater than the national figure.

The urban poor broadly belong to three occupational categories: self-employed (petty shopkeepers, beggars, vegetable vendors, tailors), day labourers (domestic help, rickshaw pullers, construction workers) and the working class (garment workers, car drivers, security guards, dairy farm workers) (Bangladesh Household Income and Expenditure Survey, 2005).

Slum landlords lack official ownership of their shanties, resulting in constant risk of eviction and lack of investment in sanitation infrastructure. More recently, distribution of the ownership of slum land has shifted heavily toward the private sector improving security of tenure. Only 72% of the urban population has access to the water supply while the sewerage system serves only 20% of its population.

Health indicators for the urban poor are worse than those for the rural poor due to the unavailability of urban primary health care and poor living conditions. In urban slums, minor diseases of children are usually treated by dispensaries/chemist shops or traditional healers and children are only taken to hospitals or clinics, usually with end-stage complications. Cost is a major barrier to accessing health care services. Street dwellers are not on the list of the local healthcare service providers, as they do not have any address and are not traceable.

A selection of studies over the past 10 years gives insight into the health and nutrition profile of the urban poor. They found that:

Adult (especially female) and child ill-health was common. A survey of 72% of female street dwellers had a current illness, of which only half sought treatment (often simply visiting drug sellers). All under-five children living in streets presented symptoms of acute respiratory infection, while 35% were suffering from diarrhoea (source: ICDDR’B3).

Overweight and obesity, chronic energy deficiency and underweight were prevalent amongst urban adults with variations between slum v non-slum dwellers. In a 2007 study4, overweight prevalence was found to be significant and increased among the urban poor (and rural women), (9.1% urban, 4.1% rural, 2000-2004 prevalence). The prevalence of Chronic Energy Deficiency (CED) was especially high (29.7% urban, 38.8% rural). Thinness (BMI < 18.5) was more common in the slums (27% of women and 35% of men) compared with the non-slums (13% of women and 19% of men). Obesity and overweight was more common in 2006 survey of the non-slum population (34% of women and 18% of men) but is also significant in slum dwellers (15% of women and 7% of men), especially in the wealthiest group (48% of women and 31% of men in the top fifth) (Bangladesh Urban Health Survey, 2006).

Urban/rural patterns of CED were similar. The high prevalence of CED in women of reproductive age (one quarter of women, with a seasonal peak) in urban areas mirrored the pattern in rural Bangladesh, where CED is even higher. (HKI/IPHN, 20065).

Energy intake was inadequate. One quarter of households (24%) in a survey of a selection of Dhaka slums had an energy intake of less than 1805 kcal/person/day, classified as an indicator of ‘extreme’ poverty. (HKI, 2002).

Child mortality rate and low birth weight prevalence was high. UNICEF reports the under-5 mortality rate to be almost 50% higher in the urban poor areas in comparison with rural areas (2011)6. A study from 2000 in Dhaka slums found a prevalence of low birth weight of 46.4% among 1654 infants, attributed to intrauterine growth retardation.

The Bangladesh Urban Health Survey (UHS) of 2006 found that:

  • In the four years pre-survey, childhood mortality rates in slums were 14 times that of the urban non-slums, and double that of the District Municipalities. The mortality decline observed in the 2006 survey was less rapid in slum areas.
  • There was no clear relationship between the education of respondents, household wealth quintiles and mortality. However, the mortality rates in the highest education group and highest wealth quintiles were always lowest (as compared to the rates in other categories), except for neonatal mortality in the non-slums.
  • The prevalence of stunting, wasting and underweight in slums was respectively 55.9% (36% in non-slums), 17.4% (9.8% in non-slums) and 45.6% (28.1% non-slums).
  • Maternal height and BMI were strong predictors of childhood stunting; 68% of children born to short mothers and 61% born to thin mothers were stunted. Maternal education and household wealth had strong inverse relationships with stunting levels.
  • Maternal BMI was a strong predictor of childhood wasting, with thin mothers (BMI<18.5) three times more likely to have wasted children and almost eight times more likely to have severely wasted children
  • In the slum areas, males had higher mortality during the neonatal period while females had higher mortality during the post-neonatal period and early childhood. In slum and non-slum areas, boys were thinner than girls.

A 2005 HKI survey found wasting in the urban poor mirrored the seasonal trends of rural Bangladesh. This study found minimal differences in stunting and underweight prevalence rates between urban poor and rural children aged 0-59 months (stunting: 39.2% urban, 39.2% rural; underweight: 45% urban, 45.7% rural).

Sub-optimal infant and young child feeding practices was common. A UNICEF Multiple Indicator Cluster Survey (MICS) 2009 reported that the percentage of women who started breastfeeding within one hour of birth increased nationally from 36% in 2006 to 50% in 2009. There was no difference between rural and urban areas in 2006 or 2009. Timely initiation of breastfeeding has improved substantially in all areas, with the exception of slums (39%).

In the HKI Nutritional Surveillance Project, 2005, exclusive breastfeeding practice was less common among the urban poor than in rural Bangladesh, with only 66% of infants exclusively breastfed in the first month of life, reducing to 16% at 4-5 months. Another study on breastfeeding practices found that urban working mothers in Dhaka slums found it difficult to breastfeed exclusively because they were away from their homes for long periods during the day. Strategies mothers employed to care for their infants included bringing adult family members from the village to feed and care for the baby during mother’s absence, and breastfeeding when she returned home; employing people to care for the baby and to bring the baby to the workplace to breastfeed, or returning home to breastfeed during the working day; or taking the baby to work along with an older sibling who looked after the baby.’

This case study and a case study from Kenya are annexed in the full report.

Show footnotes

1Urban malnutrition: a review of food security and nutrition among the urban poor. Lili Mohiddin, Laura Phelps and Tamsin Walters. NutritionWorks. Report. 8 October 2012. Available at: http://www.nutritionworks.org.uk

2An International Public Nutrition Resource Group, http://www.nutritionworks.org.uk/

3International Centre for Diarrhoeal Disease Research, Bangladesh

4Shafique S, Akhter N, Stallkamp G, de Pee S, Panagides D, Bloem M.W, 2007. Trends of under- and overweight among rural and urban poor women indicate the double burden of malnutrition in Bangladesh. Int J Epidemiol. 2007 Apr;36(2):449-57. Epub 2007 Jan 22.

5http://www.hki.org/research/NSP_Ann_Report_FactsFigures_2005.pdf

6http://www.unicef.org/bangladesh/media_7455.htm

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Review of food security and nutrition amongst urban poor. Field Exchange 46: Special focus on urban food security & nutrition, September 2013. p28. www.ennonline.net/fex/46/foodsecurity