Surveys for Urban Equity: getting, and using, the data needed to respond to neglected non-communicable diseases in urban areas in LMICs

Non-communicable diseases (NCD) are a major public health issue in South Asia (S Asia), accounting for 60% of deaths. Urbanisation is a key driver, increasing mental stress and injuries and risk factors such as tobacco use, poor diet and inadequate physical activity. Public health decision-makers in LMICs need unbiased, precise and accessibly-presented data to inform equitable urban development. Nationally representative surveys are the main data source used to inform decision-making in LMICs, e.g. Demographic and Health Surveys (DHS) and STEPS NCD Risk Factor Surveillance are used in over 90 LMICs. This approach has many problems: it excludes unofficial poor settlements and peri-urban areas beyond administrative boundaries; definitions of a 'household' overlook multiple occupancy by poor urbanites; current methods for ranking wealth are not sensitive to urban poverty; and NCDs currently assessed in these surveys do not include injuries and mental ill-health, conditions that disproportionately affect the urban poor. These methodological constraints leave policy makers with no way of understanding or responding to the NCD burden and inequities found within urban areas in LMICs. Furthermore, the way data is currently presented - in long wordy reports - undermines decision-makers' ability to find and interpret data for planning and managing health programmes. We will capitalise on existing partnerships and develop new ones, to i) identify and test questions on mental health and injuries, ii) test cheap and efficient novel methods to reduce bias in urban surveys iii) explore alternative approaches to defining households, measuring and ranking wealth iv) develop data visualisation tools to support decision-makers' use of survey data. We will conduct this foundation work in Nepal, Bangladesh and Vietnam as their different urban characteristics increase our works applicability to other LMICs and we have existing strong partnerships. We will hold two meetings and facilitate ongoing interaction with international and national bodies to share expertise and build capabilities on the novel survey methods, measures of wealth and NCDs, data visualisation and use of data to address urban inequities. We will conduct a systematic search of questionnaires and draw on our own work assessing injuries and mental health to identify the best questions for LMIC urban areas. We will finalise the questionnaire in collaboration with government stakeholders after checking its comprehensibility in urban slums.
We will pilot our novel survey sampling and mapping methods in Kathmandu, where our initial pilot of these methods was curtailed by the 2015 earthquake. Our novel methods use satellite imagery, mobile phone and census data, to identify the entire urban population including those not captured by the census. Once sampled, we will use a web-based app to accurately map communities. Smaller feasibility studies of the methods and developed questionnaire will be conducted in Hanoi and Dhaka.
We will explore household types and identify wealth indicators in urban slums. Using our pilot data, we will explore associations between household consumption, assets and income to develop an appropriate measure of urban wealth. In each country, we will assess the extent to which data is used in urban planning and management through interviews with decision-makers. Through the establishment of communities of practice within municipalities, we will co-produce appropriate data visualisation tools to support planning and management. This foundation grant has the potential to i) transform survey methods used in all LMICs, enabling more accurate assessment of health inequities in urban areas ii) provide questions on mental health and injuries for use in other surveys in LMICs, and iii) ensure data informs the health-sector response to NCDs in LMICs.

Rapid urbanisation is driving the NCD epidemic in S Asia. For decision-makers to respond to NCDs among the urban poor, proper measurement of disease prevalence and risk factors is a crucial first step. In over 90 LMICs, household surveys - e.g. DHS and STEPS - provide vital data to inform the health sector nationally. However, the way these surveys are currently designed and presented undermines their use to plan and monitor intra-urban health and respond to the needs of the poor. Data on mental ill-health and injuries - NCDs experienced disproportionately by the urban poor - are not collected; the urban poor are under-represented in sampling frames; and methodologies for calculating wealth quintiles and definitions of a household are not sensitive to urban poverty. We will use existing validated questionnaires, and our own work assessing injury and mental health, to develop a questionnaire on NCD risk factors, injury and mental ill-health relevant to urban areas. We will use qualitative methods in urban slums to explore household types and indicators of wealth, and test the questionnaire. We will test the feasibility, cost and appropriateness of novel sampling methods using (a) satellite imagery, mobile phone and census data to identify the entire urban population including those not captured by the census, and (b) gridded sampling to select areas. Once sampled, we will use a web-based app to accurately map sampled areas. In Kathmandu, we will sample 1200 households to see the extent to which our approach identifies the urban poor, and to estimate key indicators with a maximum margin of error of +/- 4.27% at 95% confidence. Smaller feasibility studies of the methods and questionnaire will be conducted in Hanoi and Dhaka. Throughout we will work closely with governments to understand data needs and co-produce appropriate data visualisation tools to enable use of data generated for equitable planning and monitoring in urban areas.

Understanding the health needs of the urban poor is vital to addressing the changing disease burden in rapidly urbanising LMICs. Our work to improve the representation of the poor in surveys, which inform the allocation of resources, will ensure that the health issues of the poor are no longer concealed by the better health outcomes among the urban wealthy.

Our project also emphasises support to municipalities to use this improved data on poor people in urban areas. This means that this more accurate understanding of urban health inequities is likely to have a substantial impact on decision-making and resource allocation leading to improvements in health services (preventative and curative) and ultimately, the health of the urban poor. In the long term, more equitable allocation of resources to improve the health of the urban poor will have wide social and economic benefits across LMICs. For the urban poor, ill-health - particularly chronic health problems such as mental ill-health, injuries and CVD-diabetes - can result in catastrophic expenditure on health and loss of daily wages. While in rural areas major gains have been made in providing free, quality primary care services, this is not the case in urban areas, where the poorest predominantly use private clinics risking poor quality care and financial exploitation. Focusing resources on prevention and improving quality health services accessible to the urban poor is vital. If healthy in mind and body, poor urbanites can begin to realise the benefits from the economic and social advancement that urban living can bring. This will benefit individuals and communities, and ultimately enhance the economic and social development of LMICs.

The other, more immediate beneficiaries include: i) LMIC municipal and national governments; ii) global health and survey organisations; iii) LMIC health research and survey institutions; iv) donors; v) academics.The Pathways to Impact outlines our strategies for realising benefits for these stakeholders. They will benefit in the following ways:
i) LMIC governments: Improved capability and experience of local government staff in using data for planning and management of urban health. The provision of a visualisation tool and the training/guides to its use will enable benefits to spread beyond the small number of officials that we will engage directly.
ii) Global health organisations: if our survey methods are found to be effective at improving the representation of the urban poorest, and affordable, they have the potential to be adopted by survey programmes such as DHS and WHO's STEPS. Given that these surveys are conducted in over 90 LMICs, the potential for impact on the lives of the urban poor is significant. The identification of appropriate mental health and injury questions to be included in household surveys will make a major contribution to the tools that can be recommended by WHO, benefiting any academic or organisation seeking to measure these neglected NCDs in urban areas. Our existing links with DHS and WHO indicate their interest in neglected NCDs and new approaches to deal with the methodological problems created by urbanisation in LMICs.
iii) LMIC research institutions: Enhanced skills in novel methods and increased leadership taken in ensuring appropriate design of surveys and use of survey data. These skills will be concentrated in our partner organisations in the three countries, but the outputs and networks created in this foundation work will increase their accessibility for others.
iv) Donors: better data to inform funding decisions to address inequities.
v) Advancements in knowledge on novel survey methods to improve representation of 'hidden' populations, on measuring injury and mental ill-health, understanding urban poverty and ranking wealth is expected within this foundation stage. The Academic Beneficiaries section provides further details.