Mental health in the slums of Dhaka - a geoepidemiological study

Mental health conditions are of rising concern as they increasingly contribute to the global burden of disease [1]. Neuropsychiatric disorders (including depression, alcohol-and substance abuse, or psychoses) add to the so-called disability-adjusted life-years (DALYs). This contribution is further projected to increase worldwide, from 13.5% in 2005 to 14.4% in 2030 [2, 3].

In low-income countries for example, depression has become almost as prevalent as malaria (3.2% versus 4% of the total disease burden) [4] and this number is projected to further increase to ~5% in 2030 [2]. However, mental health issues tend to be overtaken by other health problems, especially in the rapidly urbanising megacities of developing countries, where a growing number of people are living in slums and unhealthy environments [5]. High levels of environmental pollution, lack of adequate water and sanitation, overcrowding, insecurity of tenure, and non-durability of housing could adversely affect the health of slum dwellers [6–8]. To date, little is known about the burden of disease in urban slums [9] and research on the mental well-being of slum residents is lacking [10].

Dhaka, the capital of Bangladesh, is one of the fastest growing megacities in the world and in 2005, approximately 3.4 million out of the city's 12.6 million inhabitants were living in slums [11, 12]. Today, the city comprises approximately 14 million inhabitants [12] with more than 300,000 new migrants, mainly the rural poor, moving to Dhaka each year [13, 14]. As most of these new immigrants initially concentrate in slums [15, 16], Dhaka's population growth led to an increase in the proportion of slum dwellers from 20% in 1996 to 37% in 2005 [11], which presents a daunting challenge for local health authorities [11, 17].

The lack of data on the burden of disease morbidity and mental health status in slums hampers the efficient allocation of health care initiatives and the provision of appropriate disease prevention services [9]. Given that psychological well-being is associated with physiological well-being [3], assessing the factors that describe the mental well-being of poor populations residing in urban slums is urgently needed.

In this paper, we applied a geo-epidemiological approach combining very high-resolution land cover information with geo-referenced survey data for obtaining exposure information i.e., both pathogenetic and salutogenetic factors from the socio-ecological environment and personal characteristics. We assumed that these factors contribute to the mental well-being among slum residents in Dhaka. A socio-ecological conceptualisation of the environment allows for identifying both health threatening and health-promoting physical and social features of environments. As such these features are assumed to affect the emotional, physical, and social well-being of individuals and groups [cf. [18]]. Since mental well-being and physical well-being are interrelated [3], we used the findings of Gruebner et al. [19] for interpretation. In our conceptual framework for urban health, the urban context is defined by these socio-physical environments that ultimately influence urban health across all scale levels [18–20]. We focused exclusively on slum dwellers and considered three different levels: the neighbourhood, the household, and the individual level. We asked respondents: How would they generally rate their health (self-rated health)? And whether respondents had suffered from any disease within three months preceding the survey? We used the WHO-5 Well-being Index as a localised measure for self-rated mental well-being. The WHO-5 is a quick, reliable, and valid measure for assessing psychological well-being [21–25]. Although other indexes exist that are covering a wider spectrum of mental health status including mental illness such as the Beck Depression Inventory (BDI), comprised of 21 questions [26], the Centre for Epidemiological Studies Depression Scale (CES-D) [27] with 20 items, the General Health Questionnaire, composed of 12 questions (GHQ-12), or the Patient Health Questionnaire, composed of 9 questions (PHQ-9) [28], the WHO-5 is brief enough for population based studies [29]. The WHO-5 can thus easily be extended to a larger sample of slum population. It primarily targets hedonic well-being [29] by reflecting happiness rather than just the absence of depressive symptoms [25]. It was further successfully applied in both, developed [28, 30–32] and developing countries [21, 33, 34]. Although the WHO-5 was not yet validated in Bangladesh, it was found reliable and effective among elderly Indian communities [21], which are socio-economically similar to Bangladeshi communities.

We hypothesised that the mental well-being of slum dwellers is associated with the social and physical environment even when controlling for the impact of personal factors such as age, gender and diseases.

The socio-physical environments of slums are diverse and can compromise and support health in a variety of ways. We analysed the determinants of mental well-being among slum dwellers in Dhaka. We found that mental well-being was unequally distributed among the population and younger, male, and more affluent dwellers enjoyed better health [cf. [10, 45, 46]]. Furthermore, physical well-being was associated with mental well-being [cf. [3]]. This study adds evidence regarding factors determining mental well-being of slum residents in Dhaka and hence in comparable settings worldwide.

At the individual level mental well-being was positively associated with environmental health knowledge, which reflects a person's awareness of environmental threats (i.e., that polluted, stagnant water and garbage near one's house could spread disease and that air pollution increases the risk of poor health). Such knowledge may justify protective measures and eventual adaptation strategies of the local residents. An interesting fact is the observed negative relationship between mental well-being and personal health knowledge, which reflects a person's awareness of the effects of personal sedentary lifestyles and other activities that can cause poor health, such as smoking or less physical exercise. One explanation for this relationship could be that a higher awareness of health issues might cause a tendency to be dissatisfied with the overall poor living conditions.

Actively participating within the community may play a role when the focus is on eudaemonic well-being, which is a concept incorporating for example positive relation with others [29, 47]. Weich et al. [29] for example, found in a sample of adults in England that items like getting on with the family or belonging and enjoying spare time were more related to eudaemonic well-being. As a hedonic concept of mental well-being however, the WHO-5 focuses on happiness, which was in the case of Dhaka not related to actively participating in the local community. Further individual level factors such as smoking behaviour, using bed net, the level of education, marital status, and migration background did also not contribute to the slum dwellers' mental well-being in Dhaka.

Although having measured all variables at the individual level, we conceptualised the HDF at the different levels for ease of interpretation. Most HDF at the household level, for instance, relate to the built environment. Unfavourable housing quality is thereby assumed to cause poor health by provoking asthma and other respiratory conditions, injuries, psychological distress, or by hindering child development [48]. Good sanitation (i.e., garbage disposal and the quality of the toilet facility) can decrease the risk of infectious disease and other ailments, such as gastro intestinal diseases or respiratory diseases [48]. In accordance with these relationships, mental well-being in the slums of Dhaka was positively associated with good sanitation. Furthermore, the quality, sufficiency, and durability of housing were found to be positively associated with mental well-being. In contrast, household's wealth reflected by the household's number of available rooms and items such as radio or TV plaid no role in shaping the mental well-being of slum residents in Dhaka. Neither did the households' availability of basic services, such as water and electricity supply. However, each of the predictors from the built environment could capture the socio-economic status (SES) of an individual or household that is well known to be associated with mental well-being [45, 49, 50]. These predictors can define the frame of action within which a household can respond to health threats [19, 51]. Hence, these factors could also be conceptualised as belonging to the economic environment. In any case, these factors may shape the intrinsic ability of an individual or household to resist or cope with the impact of a possible physical or social event [51] and were therefore crucial determinants of mental well-being in our study. Furthermore, our study revealed a positive association of well-being with income generation and job satisfaction, describing the ability to generate income as well as satisfaction and safety at work. More than 80% of adult slum dwellers are engaged in the informal sector which provides a means of survival for a substantial section of the workforce [52]. This sector offers a flexible labour market, absorbs most of the workforce and provides income-generating opportunities and services for a large number of unskilled and manual labours [53]. Although the informal sector substantially contributes to the national and urban economy [54, 55], informal sectors are often associated with unfavourable conditions with regard to e.g. working and living conditions, pollutants, discrimination, exploitation, income, occupational safety, and legal and social security [19, 56]. Against this background, it becomes clear why good income generation and job satisfaction showed up as important predictors for good mental well-being among Dhaka's slum dwellers.

For mental well-being, population density was also an important factor in our study. We hypothesised that in the slums of Dhaka, crowding put enormous stress on residents with consequent implications for mental well-being, possibly due to a lack of privacy. Other studies showed that social norms in densely populated urban areas may further support individual or group behaviours that affect health outcomes (e.g. smoking, diet, exercise, sexual behaviour) [20].

For a profound discussion on the association between mental well-being and the 'natural environment' as well as with flood non-affectedness, refer to Gruebner et al. [36]. In brief, the risk of flooding is relatively common in Dhaka due to its unique low lying geography and its extremely rapid urban growth combined with an urban mismanagement [36, 57–59]. In the slums, vegetation cover is scarce, and green areas turned out to be low-lying and regularly flooded areas. Combined with poor sanitation, open waste water drainage and garbage disposal, such vegetation patches increase the risk for infectious diseases (e.g., diarrhoea). Our analysis thus identified environmental disservices [60] rather than services, which shall explain the negative association of the HDF natural environment and mental well-being as well as the positive association with flood non-affectedness.

We included a large number of variables from different sources and at different levels. However, the natural environmental variables drawn from satellite analysis preceded the survey-based outcome variables by three years. But both data sources were collected in the same season in order to obtain similar phenological and hydrological situations and thus the temporal mismatch is unlikely to cause large biases in the results. Second, given the large number of potential influential predictors and the limited knowledge on HDF in the slums of Dhaka we had to test a large number of hypotheses using a stepwise model selection procedure. This method has been criticized [61] and the share of concerns raised. Nevertheless, we had to rely on the method since there were no obvious testable sets of predictors. The results should be interpreted with respect to that: the selected regression model can be considered the best fitting model but other models with slightly worse selection criteria exist. Third, the nine selected slums may not fully represent the ~4900 slums of Dhaka. Fourth, the replacement of respondents (interviewees) for the selected households (based on our systematic sampling) by the respondents from the subsequent houses was done to achieve our sample target. This sampling procedure may cause bias, yet, the share of non-respondents was very small and thus this bias is negligible. Fifth, although the WHO-5 is a reliable measure for psychological well-being [25], it has thus far not been validated in a slum of a developing country. More effort should be invested by specialists in this research domain in order to provide reliability studies from the psychological point of view. Sixth, we might have missed some influential HDF in our model (e.g., air pollution, social capital, or accessibility to health care facilities). Seventh, the cross-sectional and quantitative nature of our study could certainly not cover all aspects of mental well-being. However, our study revealed plausible results which could be embedded with other studies on health and the environment. The study of mental well-being in slums should be further supported by longitudinal quantitative studies in combination with qualitative research. Furthermore, multilevel studies are needed to assess the neighbourhood effects of e.g. SES in slums, which are likely to affect health status independently from personal SES as has been shown by many studies in higher income countries' cities [62].

From this study we could inform about the status of mental well-being in Dhaka's slums. The important factors that determine the mental well-being relate to the socio-economic (job satisfaction, income generation ability, population density) and physical environment (environmental pollution, lower flood risk, better sanitation and quality, sufficiency and durability of the house). Individual level characteristics such as diseases, gender, and knowledge upon environmental health threats are important mental well-being determinants. Given that mental well-being is associated with physical well-being, our study provides crucial information for developing better health care and disease prevention programmes in slums of Dhaka and comparable settings worldwide.