ADC Online First, published on July 30, 2013 as 10.
1136/archdischild-2011-301621
Correspondence to
Dr Alon Unger, Division of
Hospital Medicine, University
of California, San Francisco,
533 Parnassus Avenue,
Suite U127A, Box 0131,
San Francisco,
CA 94143-0131, USA;
Alon.Unger@ucsf.edu
Received 22 December 2012
Accepted 5 July 2013
To cite: Unger A. Arch Dis
Child Published Online First:
[please include Day Month
Year] doi:10.1136/
archdischild-2011-301621
Copyright Article
Unger A. Arch author
Dis Child
2013;0:1–7. their employer) 2013. Produced by BMJ Publishing Group Ltd (& RCPCH) under licence.
Global child health
Children’s health in slum settings
Alon Unger
ABSTRACT
Rapid urbanisation in the 20th century has been
accompanied by the development of slums. Nearly one-
third of the world’s population and more than 60% of
urban populations in the least developed countries live
in slums, including hundreds of millions of children.
Slums are areas of broad social and health disadvantage
to children and their families due to extreme poverty,
overcrowding, poor water and sanitation, substandard
housing, limited access to basic health and education
services, and other hardships (eg, high unemployment,
violence). Despite the magnitude of this problem, very
little is known about the potential impact of slum life on
the health of children and adolescents. Statistics that
show improved mortality and health outcomes in cities
are based on aggregated data and may miss important
intraurban disparities. Limited but consistent evidence
suggests higher infant and under-five years mortality
for children residing in slums compared with non-slum
areas. Children suffer from higher rates of diarrhoeal
and respiratory illness, malnutrition and have lower
vaccination rates. Mothers residing in slums are more
poorly educated and less likely to receive antenatal care
and skilled birth assistance. Adolescents have earlier
sexual debut and higher rates of HIV, and adopt risky
behaviours influenced by their social environment. We
also know little about the consequences of this form of
early childhood on long-term health-related behaviour
(eg, diet and exercise) and non-communicable disease
outcomes, such as obesity, heart disease and mental
illness. Further attention to understanding and
addressing child health in slum settings is an important
priority for paediatricians and those committed to child
health worldwide.
INTRODUCTION AND SCALE OF THE PROBLEM
Children and adolescents are increasingly growing
up in an urban world. Urban population growth is
most concentrated in the least developed countries,
where 90% of this growth takes place.1 Children
and young people make up a large proportion of
urban populations in the poorest countries, and
their population growth reflects this broader trend2
as can be seen in figure 1. The rapid and unplanned
growth of cities has also given rise to informal or
illegal settlements, commonly known as slums.
These poor urban areas grow at up to two times
the rate of the surrounding city. Today, nearly
one-third of the world’s population lives in slums,
and over 90% of slum dwellers live in low-income
and middle-income countries, including hundreds
of millions of children2 3 (table 1 and figure 2).
Several authors have called attention to the chal-
lenges that urbanisation and slums present to public
health, yet little is known about the potential
impact of slum life on the health of children and
adolescents.4 5 Studies of child health outcomes
(ordoi:10.1136/archdischild-2011-301621
frequently demonstrate overall improvements in
urban areas, and also better outcomes than in rural
areas.6 However, statistics of child health in cities
are often based on aggregated data and may miss
important intraurban disparities, particularly in
slums that often have unregistered residents.7 There
is limited but consistent evidence suggesting poorer
health outcomes for children and adolescents in
slums compared with those from non-slum areas of
the same city. This review describes what is known
about child health in slum settings, and the poten-
tial implications for paediatricians and those com-
mitted to child health worldwide.
BACKGROUND: CITIES, SLUMS AND CHILD
HEALTH
For most of the 20th century, urban areas were
associated with improved child health and lower
mortality than rural areas.6 8 They concentrated
the benefits of Chadwick’s sanitary revolution in
safe water and sanitation, access to vaccinations and
antibiotics, and safe childbirth and perinatal care.
Cities provided families with more economic and
educational opportunities, improved nutrition and
more possibilities for healthcare.9 However, despite
overall favourable health statistics in cities, several
authors have pointed out large variations between
countries and within cities, and the potential influ-
ence of slums on these variations.6 10 11
Slums are the product of rapid and unplanned
growth of urban areas predominantly over the last
50 years. They accompanied the economic growth
of cities as new industries created jobs and wealth
attracting immigrants from beleaguered rural areas.
Slums offered cheap and available housing in cities
that promised more secure food and water security
and public services.12 In addition to demographic
forces, the coupling of urban growth and slums was
fuelled by ill-equipped transitioning economies,
inadequate urban planning and overwhelmed or
negligent political systems.13 Slums are a diverse set
of communities, located centrally and in the per-
iphery of cities, on floodplains and hillsides, poorly
constructed and ranging from thousands to millions
of residents. See figure 3. The UN operationally
defines them as having at least one of five character-
istics: insecure residential status, poor structural
quality of housing, overcrowding and inadequate
access to safe water, sanitation and other
infrastructure.12
In addition to the UN legal and physical defin-
ition, conditions of slum life are also characterised
by extreme poverty and exceedingly substandard
living conditions. They are also areas of broader
social disadvantage to children and their families
with limited access to basic healthcare, schools and
important municipal services, such as safe public
transportation, policing, playgrounds or recreational
1
 Global child health

Table 1 Urban population living in slums by region, 2010

Estimated slum Proportion of urban
Region population population (%)

Developing regions 827 690 000 32.7

Sub-Saharan Africa 199 540 000 61.7
Southern Asia 190 748 000 35.0
Southeast Asia 88 912 000 31.0
East Asia 189 621 000 28.2
West Asia 35 713 000 24.6
Oceania 556 000 24.1
Latin America and Caribbean 110 763 000 23.5
North Africa 11 836 000 13.3
Source: UN-HABITAT estimates (based on United Nations Population Division, World
Urbanisation Prospects: The 2007 Revision).

employment, poor or dangerous working conditions and threat

Figure 1 Urban population growth over time in millions, 0–19 years
old. (Adapted from (UNICEF, 2012), UNDESA, Population Division).
facilities.12 Social problems commonly affect these communities
(eg, fragmented families, low educational achievement, economic
or sexual exploitation, alcohol and drug trafficking and abuse).
Families also experience high unemployment or informal
of violence, eviction or natural disaster. They are also often
removed from the protective benefits of tradition, extended
family and community support14 15 (see table 2 and box 1).
Social determinants may affect child and adolescent health in
various ways. The effects may be immediate or cumulative, and
early life experiences may have latent consequences on future
adult health or set individuals on trajectories that influence
health and well-being16 17 (see box 2). Nonetheless, evidence of
the causal link is limited and often difficult to establish in
complex slum settings where data are sparse. Associations may
be found from the level of the individual and household to the
neighbourhood, and factors may be proximate (eg, open sewers)
or further ‘upstream’ or structural (eg, geography, political pol-
icies).18–20 Table 2 provides an overview of possible adverse

Figure 2 Urban population living in slums, 2005.

2 Unger A. Arch Dis Child 2013;0:1–7. doi:10.1136/archdischild-2011-301621


Figure 3 Saidapet (Chennai, India) Muslim side (credit: Lee Riley, MD).
health outcomes associated with slum settings. The next section
outlines what is known about specific child health outcomes in
slum settings and the possible connection with conditions of
slum life.
SELECT CHILD HEALTH CHALLENGES IN SLUMS
Mortality
Demographic data show declines in under-five year mortality in
urban areas and lower rates of mortality than rural areas.
However, these declines have stagnated in some areas of high
slum prevalence, such as sub-Saharan Africa.6 In Nairobi, where
more than 60% of the urban population lives in slums on 5% of
the land, the under-five year mortality is now higher than it was
20 years ago and also higher than rural areas of Kenya. Overall
child mortality in Nairobi slums, like Kibera and Mathare, are
2.5 times greater than in other areas of the city.21 22 Similar
Table 2 Characteristics of slums—UN operational definition*
Characteristic
Insecure residential status
▸ Lack formal title deeds to land or residence
▸ No proof of tenure
Poor structural quality of housing
▸ Inferior building materials (cardboard, tin, mud,
low-grade concrete)
▸ Substandard construction
Overcrowding
▸ Less than 5 square metres per person
▸ More than 2 people per room
Inadequate access to safe water
▸ Less than 50% have access to household connection,
public stand pipe or rainwater collection
Inadequate access to sanitation and other infrastructure
▸ Less than 50% have public sewer, septic tank,
pour-flush latrine or ventilated pit latrine
*The UN created a unifying operational definition of the physical and legal characteristics shared by slums in 2002.
Unger A. Arch Dis Child 2013;0:1–7. doi:10.1136/archdischild-2011-301621
Global child health
findings in Bangladesh and Nigeria also reflect high child mor-
tality in slums and heterogeneous urban areas with varying mor-
tality based on residence.23 24 The disparity in mortality based
on location of urban residence is not exclusive to developing
nations and has been demonstrated in wealthier countries, such
as higher black infant mortality by degree of residential segrega-
tion in the USA.25
Communicable diseases
Water-borne and vector-borne diseases
Slums concentrate many known risk factors for parasitic, water-
borne and vector-borne diseases, including: flooding, poor
water drainage, open sewers and overcrowding.26 These charac-
teristics of the physical environment are exacerbated by poor
hygiene practices and high rates of malnutrition in children, and
affect the burden of intestinal parasites and diarrhoeal diseases,
such as persistent entero-aggregative Escherichia coli diar-
rhoea.27 28 In slums, infants who live without piped water may
have up to 4.8 times the risk of death from diarrhoea.26 29 In
New Delhi, diarrhoea is accountable for 36% of infant mortal-
ity and 50% of child mortality under 7 years of age.27 30
Cholera also disproportionately affects these urban settlements,
with the heaviest burden on young children.31 Standing water in
slums is associated with increased risk of mosquito-borne and
other vector-borne diseases in children, such as dengue, which
is further exacerbated by poor housing and high population
densities.32 Persistent or recurrent ill health due to infectious
diseases also has broader effects on child well-being, including
poor school attendance, and has been implicated in poor school
achievement and long-term cognitive function.33
Vaccine-preventable and respiratory diseases
Lower immunisation coverage contributes to more frequent out-
breaks of vaccine-preventable diseases, such as pertussis, measles
and diphtheria, and they cluster in areas of high population
Physical/legal outcome Potential adverse health outcome
▸ Threat of eviction ▸ Poor access to health sector
▸ Exposure to hazardous environments (eg, ▸ Low service utilisation
pollution, flooding) ▸ Unable to advocate for self
▸ Lack of access to formal health care ▸ Exposed to accidental injuries
infrastructure ▸ Poisoning or respiratory diseases, for example,
▸ No data for health service planning asthma
▸ Industrial/polluted areas
▸ Risk from natural or other disasters (flooding, ▸ Unintentional injuries
landslides, fire) ▸ Falls, burns, drowning, electrocution
▸ Poor ventilation ▸ Asthma or infectious respiratory illness
▸ Susceptible to collapse
▸ Social stressors ▸ Stress
▸ Facilitates disease transmission ▸ Scabies
▸ Tuberculosis and other respiratory illnesses
▸ Contaminated water ▸ Diarrhoeal diseases, cholera, typhoid, hepatitis
▸ Privatisation and high cost of water ▸ Poor hygiene and bacterial skin infections
▸ Water scarcity
▸ Increased rat density ▸ Water-borne or vector-borne diseases
▸ Open or broken sewers ▸ Under-usage of services, maternal health
▸ Inadequate or inappropriate municipal services complications, vaccine-preventable diseases
(eg, waste disposal, policing) ▸ Mental illness
▸ Drug-resistant infections
▸ Lack of prevention for non-communicable diseases,
for example, HTN, DM
3
 Global child health

Box 1 Other features of slums settings Box 2 Health outcomes linked to childhood
socioeconomic environment
State level
▸ Absence or inadequate state recognition All-cause mortality
▸ Lack of political will or interest (eg, ethnic, racial or political Cause-specific mortality
reasons) ▸ Alcoholic cirrhosisCancer, smoking-related
▸ State occupied with other demographic or political priorities ▸ Cancer, stomach
(eg, conflict, political or economic transitions, natural ▸ Cardiovascular diseases
disasters, HIV/AIDS epidemics) ▸ Diabetes
▸ Unable to keep pace with rapid or uncontrolled urban ▸ Respiratory diseases
growth or reach geographically challenging locations Cardiovascular disease
▸ Weak political or public infrastructure ▸ Carotid atherosclerosis
Community/neighbourhood level ▸ HTN
▸ Vulnerable groups: high proportions of young people, ▸ Coronary artery disease
migrants, refugees or internally displaced groups, exploited ▸ Ischemic heart disease
groups (informal/child labourers, sex workers) ▸ Myocardial infarction
▸ Generalised unemployment due to geographic limitations, ▸ Stroke
legal (informal/illegal residents or vulnerable group) or lack Metabolic disease
municipal resources (eg, public transportation) ▸ Insulin resistance
▸ Threat of violence due to gangs, political or ethnic conflicts, ▸ Obesity
crime ▸ Type 2 diabetes
▸ Patchwork of unregulated health services and poor access to Mental illness
health centres, antenatal care, skilled birth assistance ▸ Depression
▸ Lack of public infrastructure, including food scarcity or ▸ Post-traumatic stress disorder
scarcity of healthy food choices, electricity, educational Behavioural outcomes
services, recreational areas ▸ Alcoholic or drug abuse
Household/individual level ▸ Smoking
▸ High unemployment and low levels of educational ▸ Poor diet
achievement and health literacy Other outcomes
▸ Working single parents, often daily wage earners with ▸ Functional limitations
irregular pattern, hazardous work (eg, rag picking, recycling, ▸ Inflammatory markers
sex trade) ▸ Periodontal disease
▸ Absence of extended family and social support ▸ Self-rated health
▸ Breakdown of traditional values ▸ Revised from Braveman 2009
▸ Gender-based violence
▸ High levels of illness and recurrent illness, and
disproportionately affected by diseases with long-term disaggregated data shows that some urban poor, particularly
outcomes, for example, low birth weight, malnutrition, STDs women, have significantly higher risks of HIV infection than
and HIV/AIDS their urban non-poor counterparts.42 43 In Kenya, sexual experi-
▸ High levels of risk behaviours, for example, sexual risk and ence before age of 15 confers a 62% higher risk of HIV in slum
diet residents, where girls in this age groups had higher likelihood
(14.8%) of having sex compared with their counterparts in
non-slum areas (8.7%).42 In these slum communities, the preva-
density, household overcrowding and poor nutrition.34–36 lence of HIV was more than eight times higher for all adoles-
Several studies demonstrate lower rates of complete immunisa- cents in slums aged 15–19 years (5.0%) compared with
tion in slums compared with other urban areas,14 37 as well as a adolescents from non-slum urban areas (0.6%.42 The risk to
shortage of health centres and immunisation programmes near adolescents in urban poor communities may be exacerbated by
slums.38 The lack of information and low levels of education the limited availability of recreational facilities, absence of par-
among mothers also contribute to poor vaccination coverage in ental or community supervision, and influence of community
slums.39 Immunisation coverage in Niger was 35% in slums norms.44 Urban poverty and residence in informal settlements
compared with 86% in non-slum urban areas.40 Slum condi- have also been associated with poor prenatal care and preven-
tions may also facilitate other non-vaccine preventable respira- tion of mother-to-child transmission in areas of high HIV preva-
tory diseases by respiratory droplets or airborne transmission, lence and less access to antiretroviral therapy.45 Lastly, families
such as respiratory viruses (eg, SARS, H1N1, N meningitidis) weakened by illness and poverty are also limited in their ability
and tuberculosis. For instance, in squatter settlements in Manila, to diminish the impact that HIV/AIDS has on affected
children were nine times more likely to have tuberculosis than children.46
other urban children.14
Non-communicable diseases
Malnutrition
HIV/AIDS Malnutrition makes a central contribution, up to 56%, to child
Studies have previously suggested that poverty was protective mortality worldwide and is a recognised problem in informal
against risk of HIV infection in urban areas.41 New settlements.47 48 Compared with their urban counterparts,

4 Unger A. Arch Dis Child 2013;0:1–7. doi:10.1136/archdischild-2011-301621


children in slums are more likely to be undernourished and
stunted.10 49 These findings may be due to prolonged or recur-
rent episodes of hunger or specific nutritional deficiencies (eg,
caloric, protein, micronutrient), and also to persistent or recur-
rent ill health.50 In Nairobi, the prevalence of stunting is 57%
for children in slums compared with 28% in urban Kenya as a
whole.2 Similar findings are present in Ethiopia, Niger and
India.2 28 51 Malnutrition in slum children is closely associated
with maternal education and breastfeeding practices.48 Mothers
in informal settlements may not breast feed due to work, lack of
knowledge or education, and breakdown of traditional prac-
tices.10 49 Poor nutrition in slums may have long-term effects on
infectious disease risk and cognitive development.52 There is
also evidence that childhood nutritional stunting is associated
with obesity, and slum communities have a mixture of under-
nutrition and over-nutrition.53–56 Children from informal settle-
ments are at higher risk of obesity from poor diet, lack of
healthy food options and recreation facilities,57 58 and have
higher rates of obesity-related conditions, such as obstructive
sleep apnoea.59
Accidental and non-accidental injuries
The built and natural environment in informal settlements is fre-
quently dangerous for children. Slums are vulnerable to natural
disasters from the combination of poor material and construc-
tion, overcrowding and precarious geography, as was dramatic-
ally demonstrated in the earthquake in Haiti in 2010.60
Children are extremely susceptible to injury and death, and can
account for up to one-third of the victims of disasters.61
Pollution and environmental conditions also have detrimental
effects on child health outcomes, such as asthma.62–64 Insecure
residential status also makes it difficult for families to advocate
for safer conditions, respond to and recover from disasters.12
The built environment also provides few safe play spaces, and
puts children at risk for accidental injuries due to falls, drown-
ing, electrocution, exposure to pollutants and road traffic injur-
ies, the latter of which is the second leading cause of death for
children aged 5–14 years worldwide.2 Violence is also a notable
threat to children and adolescents in slums.65–67 For example,
the rates of violent deaths in adolescents in Brazilian slums are
higher than in wealthier parts of the same cities.68
Mental illness
Living in slums presents children and their families with various
stresses, including overcrowding, noise and environmental pollu-
tion, domestic and community violence, scarce formal employ-
ment opportunities and limited future prospects.2 Slum residents
emphasise the negative impact of these stresses on the quality of
their lives.69 There are important links between conditions of
slum life and mental health, and a WHO literature review found
that slum residents suffer from higher rates of mental illness and
suicide than other urban residents.66 70–72 Children exposed to
slum settings may also suffer from behavioural and emotional
problems and poor school performance.67 Child labour is also
more frequent among children in slums and exposes them to
work-related injuries, physical and other abuse and traffic-related
injuries, and have deleterious effects on the well-being of chil-
dren and adolescents.2 Moreover, children and adolescents in
slums are more vulnerable to sexual exploitation.66
FUTURE DIRECTIONS AND IMPLICATIONS FOR
PAEDIATRICIANS
The growth of slums poses important challenges to those who
are charged with caring for children, from parents to their
Unger A. Arch Dis Child 2013;0:1–7. doi:10.1136/archdischild-2011-301621
Global child health
paediatricians and public health advocates. Ultimately, many
improvements will require changing political and economic pol-
icies and addressing broader structural or ‘upstream’ factors.
However, there are more immediate actions that may improve
understanding of the problem and allow for short-term advo-
cacy and interventions to mitigate child health disparities in
cities.
Data collection and research
The scale of intraurban inequalities in child health is still largely
unknown. More than one-third of children born in urban areas
are not registered at birth, including nearly 50% of children in
urban areas of sub-Saharan Africa and South Asia.73 It will be
important to collect reliable and disaggregated urban data. Even
disaggregated city data or census data that include slums may
miss the most vulnerable ones that are frequently not
counted.37 48 In one Indian study, malnutrition was more closely
associated with slums not officially recognised in the census com-
pared with those that were counted.48 Methodologies, such as
expanded or focused data collection, over-counting specific
urban areas, and standardising measures or gradients of socio-
economic status in areas of generalised poverty must also be
explored to capture these populations.74 75 Important research
questions also remain unanswered on the ways that conditions of
slum life affect child health at the level of the individual or house-
hold, and the potential neighbourhood effects on health out-
comes.18 Studies of slum-upgrading interventions have been
limited by inadequate study designs and inconsistent health and
social outcomes between studies.69 More research is needed on
which interventions would give the most benefit to child health,
improve utilisation for families and their children, and employ
the most efficacious delivery channels.76
Address the social determinants as well as the disease
While investment in child health infrastructure is necessary, not
all solutions will come from treating the child. The health of
children depends greatly on the health and well-being of their
mothers and families, and their ability to provide for an
adequate education and safe areas to play and grow. For
instance, the presence of family planning may be a simple and
effective intervention to improve maternal health and reduce
infant mortality.77 It is important to recognise and address the
complex forces driving slum growth; however, good urban gov-
ernance and simple interventions in water and sanitation, health
education and infrastructure may have important and immediate
life-saving effects.76 John Snow’s contribution to the removal of
the Broad Street pump handle, and interruption of cholera
transmission in London in 1854, is an early and compelling
intervention in urban upgrading. Upgrading physical features of
slums, water and sanitation, waste collection and drainage, may
have effects on limiting disease, particularly reducing diarrhoea
and water-related expenses.69 This may also require advocacy
on the part of paediatricians in the political and government
sector.
Improve and involve the entire community
In informal settlements, as elsewhere, the health of children is
closely related with the well-being of mothers. Maternal educa-
tion and literacy have been shown to influence the likelihood of
complete immunisations and the mother’s use of antenatal care
and skilled birth assistance in slums.50 78 Mothers and families
in slums often have few accessible and affordable sources of
healthcare for their children, which is closely linked to child
health practices, such as immunisation uptake.38 Many slums
5
 Global child health
are renowned for their industry, such as Dharavi in Mumbai,
and community leaders can make important contributions to
urban transformation.2 Community training and participation
have also proved successful in many informal settlements, from
preventing HIV to curbing violence.26
SUMMARY
Existing data suggests that the child health benefits of living in
cities are attenuated in slums. Emphasising the urban health
advantage may no longer be appropriate in heterogeneous
modern cities, particularly in the setting of slums. Many indica-
tors of child health are worse in slums than in neighbouring
urban areas or even rural ones. The conditions of slum life con-
centrate the ill effects of extreme poverty, inadequate living con-
ditions and sanitation, and deleterious social forces. Addressing
demographic, socioeconomic and political factors will also be
central to long-term improvements of child health in slums.
There are many areas illuminated above that may be targets for
immediate action to mitigate the effects of slums on child
health. Further attention to measuring child health in slum set-
tings and addressing social determinants of disease are import-
ant priorities for paediatricians and those committed to child
health worldwide.
Acknowledgements The author would like to thank Lee Riley and Nick Brown for
their contributions.
Competing interests None.
Provenance and peer review Commissioned; externally peer reviewed.
REFERENCES
1 [UNDESA] UNDoEadA. World urbanization prospects. The 2009 revision. New York:
United Nations, 2010. http://esa.un.org/unpd/wup/Documents/WUP2009_
HIghlights_Final.pdf (accessed 12 Oct2012).
2 [UNICEF] UNCsF. The state of the world’s children 2012. Children in an urban
world. New York: United Nations, 2012. http://www.unicef.org/sowc2012 (accessed
12 Oct 2012).
3 Pfeifer ME. State of the world’s cities, 2010–2011: bridging the urban divide.
Choice: Curr Rev Acad Libr 2011;48:1003.
4 Sclar ED, Garau P, Carolini G. The 21st century health challenge of slums and
cities. Lancet 2005;365:901–3.
5 Riley LW, Ko AI, Unger A, et al. Slum health: diseases of neglected populations.
BMC Int Health Hum Rights 2007;7:2.
6 Garenne M. Urbanisation and child health in resource poor settings with special
reference to under-five mortality in Africa. Arch Dis Child 2010;95:464–8.
7 Timaeus IM. Intra-urban differentials in child health. Health Transit Rev
1995;5:163–90.
8 Leon DA. Cities, urbanization and health. Int J Epidemiol 2008;37:4–8.
9 Harpham T, Molyneux C. Urban health in developing countries: a review. Prog Dev
Stud 2001;1:113–37.
10 Fotso JC. Child health inequities in developing countries: differences across urban
and rural areas. Int J Equity Health 2006;5:9.
11 Gould WTS. African mortality and the new ‘urban penalty’. Health Place
1998;4:171–81.
12 [UN-HABITAT] UNHSP. The challenge of the slums: global report on human
settlements. Nairobi: United Nations, 2003. http://www.unhabitat.org/downloads/
docs/GRHS.2003.0.pdf (accessed 12 Oct 2012).
13 Davis M. Planet of slums. London, New York: Verso, 2006:228.
14 Fry s, B. C, Olivola K. Health of children living in urban slums in Asia and the near
east: review of existing literature and data. Agency for International Development,
2002. http:http://www.ehproject.org/PDF/Activity_Reports?AR109AMEUrbHlthweb.
pdf (accessed 12 Oct 2012).
15 Gracey M. Child health in an urbanizing world. Acta Paediatr 2002;91:1–8.
16 Marmot M. Social determinants of health inequalities. Lancet 2005;365:1099–104.
17 Marmot M. Social determinants and adolescent health. Int J Public Health 2009;54
(Suppl 2):125–7.
18 Diez Roux AV. Investigating neighborhood and area effects on health. Am J Public
Health 2001;91:1783–9.
19 Galea S, Freudenberg N, Vlahov D. Cities and population health. Soc Sci Med
2005;60:1017–33.
6 Unger A. Arch Dis Child 2013;0:1–7. doi:10.1136/archdischild-2011-301621
20 Northridge ME, Sclar ED, Biswas P. Sorting out the connections between the built
environment and health: a conceptual framework for navigating pathways and
planning healthy cities. J Urban Health 2003;80:556–68.
21 [APHRC] APaHRC. Population and health dynamics in Nairobi’s informal
settlements. African Population Health Research Centre, 2002. http://www.aphrc.
org/insidepage/?articleid=113 (accessed 12 Oct 2012).
22 Kyobutungi C, Ziraba AK, Ezeh A, et al. The burden of disease profile of residents
of Nairobi’s slums: results from a demographic surveillance system. Popul Health
Metrics 2008;6:1.
23 Barrett JR. A marked disadvantage: rapid urbanization and mortality of young
children in Nigeria. Environ Health Perspect 2010;118:A259.
24 [UNICEF] UNCsF. Understanding urban inequalities in Bangladesh: a prerequisite for
achieving Vision 2021: a study based on the results of the 2009 Multiple Indicator
Cluster Survey. http://www.unicef.org/bangladesh/Urban_paper_lowres.pdf (accessed
12 Oct 2012): Bangladesh: United Nations, 2010.
25 Polednak AP. Trends in US urban black infant mortality, by degree of residential
segregation. Am J Public Health 1996;86:723–6.
26 WHO. Hidden cities: unmasking and overcoming health inequities in urban settings.
Geneva: World Health Organization, 2010. http://www.hiddencities.org/downloads/
WHO_UNHABITAT_Hiddent_Cities_Web.pdf (accessed 12 Oct 2012)..
27 Butala NM, VanRooyen MJ, Patel RB. Improved health outcomes in urban slums
through infrastructure upgrading. Soc Sci Med 2010;71:935–40.
28 Awasthi S, Agarwal S. Determinants of childhood mortality and morbidity in urban
slums in India. Indian Pediatr 2003;40:1145–61.
29 Victora CG, Smith PG, Vaughan JP, et al. Water supply, sanitation and housing in
relation to the risk of infant mortality from diarrhoea. Int J Epidemiol
1988;17:651–4.
30 Singhal PK, Mathur GP, Mathur S, et al. Neonatal morbidity and mortality in ICDS
urban slums. Indian Pediatr 1990;27:485–8.
31 Sur D, Deen JL, Manna B, et al. The burden of cholera in the slums of Kolkata,
India: data from a prospective, community based study. Arch Dis Child
2005;90:1175–81.
32 Gubler DJ. Cities spawn epidemic dengue viruses. Nat Med 2004;10:129–30.
33 Taylor-Robinson DC, Maayan N, Soares-Weiser K, et al. Deworming drugs for
soil-transmitted intestinal worms in children: effects on nutritional indicators,
haemoglobin and school performance. Cochrane Database Syst Rev 2012;(11):
CD000371.
34 Siegel C, Davidson A, Kafadar K, et al. Geographic analysis of pertussis infection in
an urban area: a tool for health services planning. Am J Public Health
1997;87:2022–6.
35 Fotso JC, Ezeh AC, Madise NJ, et al. Progress towards the child mortality
millennium development goal in urban sub-Saharan Africa: the dynamics of
population growth, immunization, and access to clean water. BMC Public Health
2007;7:218.
36 Lodha R, Dash NR, Kapil A, et al. Diphtheria in urban slums in north India. Lancet
2000;355:204.
37 Agarwal S, Bhanot A, Goindi G. Understanding and addressing childhood
immunization coverage in urban slums. Indian Pediatr 2005;42:653–63.
38 Jamil K, Bhuiya A, Streatfield K, et al. The immunization programme in Bangladesh:
impressive gains in coverage, but gaps remain. Health Policy Plan 199914:49–58.
39 Ghei K, Agarwal S, Subramanyam MA, et al. Association between child
immunization and availability of health infrastructure in slums in India. Arch Pediatr
Adolesc Med 2010;164:243–9.
40 Groves R. State of the world’s cities 2006/7: the millennium development goals and
urban Sustainability. Housing Stud 2007;22:984–5.
41 Mishra V, Assche SB, Greener R, et al. HIV infection does not disproportionately
affect the poorer in sub-Saharan Africa. Aids 2007;21(Suppl 7):S17–28.
42 Magadi MA. The disproportionate high risk of HIV infection among the urban poor
in sub-Saharan Africa. AIDS Behav 2013;17:1645–54.
43 Awusabo-Asare K, Annim SK. Wealth status and risky sexual behaviour in Ghana
and Kenya. Appl Health Econ Health Policy 2008;6:27–39.
44 Akers AY, Muhammad MR, Corbie-Smith G. “When you got nothing to do, you do
somebody”: a community’s perceptions of neighborhood effects on adolescent
sexual behaviors. Soc Sci Med 2011;72:91–9.
45 Barcellos C, Acosta LM, Lisboa E, et al. Surveillance of mother-to-child HIV
transmission: socioeconomic and health care coverage indicators. Rev Saude Publica
2009;43:1006–14.
46 Desmond C. Consequences of HIV for children: avoidable or inevitable? AIDS Care
2009;21(Suppl 1):98–104.
47 Pelletier DL, Frongillo EA Jr, Schroeder DG, et al. The effects of malnutrition on
child mortality in developing countries. Bull World Health Organ 1995;73:443–8.
48 Swaminathan H, Mukherji A. Slums and malnourishment: evidence from women in
India. Am J Public Health 2012;102:1329–35.
49 Sverdlik A. Ill-health and poverty: a literature review on health in informal
settlements. Environ Urban 2011;23:123–55.
50 Bhutta ZA, Chopra M, Axelson H, et al. Countdown to 2015 decade report (2000–
10): taking stock of maternal, newborn, and child survival. Lancet
2010;375:2032–44.

51 Srivastava A, Mahmood SE, Srivastava PM, et al. Nutritional status of school-age
children—a scenario of urban slums in India. Arch Public Health 2012;70:8.
52 Tarleton JL, Haque R, Mondal D, et al. Cognitive effects of diarrhea, malnutrition,
and Entamoeba histolytica infection on school age children in Dhaka, Bangladesh.
Am J Trop Med Hyg 2006;74:475–81.
53 Hoffman DJ, Sawaya AL, Verreschi I, et al. Why are nutritionally stunted children at
increased risk of obesity? Studies of metabolic rate and fat oxidation in shantytown
children from Sao Paulo, Brazil. Am J Clin Nutr 2000;72:702–7.
54 Grow HM, Cook AJ, Arterburn DE, et al. Child obesity associated with social
disadvantage of children’s neighborhoods. Soc Sci Med 2010;71:584–91.
55 Garasky S, Stewart SD, Gundersen C, et al. Family stressors and child obesity. Soc
Sci Res 2009;38:755–66.
56 Kimbro RT, Denney JT. Neighborhood context and racial/ethnic differences in young
children’s obesity: Structural barriers to interventions. Soc Sci Med 2012 Oct 6.
57 Lovasi GS, Hutson MA, Guerra M, et al. Built environments and obesity in
disadvantaged populations. Epidemiol Rev 2009;31:7–20.
58 Prentice AM. The emerging epidemic of obesity in developing countries. Int J
Epidemiol 2006;35:93–9.
59 Spilsbury JC, Storfer-Isser A, Kirchner HL, et al. Neighborhood disadvantage as a
risk factor for pediatric obstructive sleep apnea. J Pediatr 2006149:342–7.
60 Bilham R. Lessons from the Haiti earthquake. Nature 2010;463:878–9.
61 Weiner DL, Manzi SF, Briggs SM, et al. Response to challenges and lessons
learned from Hurricanes Katrina and Rita: a national perspective. Pediatrics 2011;
128(Suppl 1):S31–3.
62 Wigle DT, Arbuckle TE, Walker M, et al. Environmental hazards: evidence for effects
on child health. J Toxicol Environ Health B Crit Rev 2007;10:3–39.
63 Bruce N, Perez-Padilla R, Albalak R. Indoor air pollution in developing countries: a
major environmental and public health challenge. Bull World Health Organ
2000;78:1078–92.
64 Benicio MH, Ferreira MU, Cardoso MR, et al. Wheezing conditions in early
childhood: prevalence and risk factors in the city of Sao Paulo, Brazil. Bull World
Health Organ 2004;82:516–22.
65 Winton A. Urban violence: a guide to literature. Environ Urban 2004;16:165–84.
Unger A. Arch Dis Child 2013;0:1–7. doi:10.1136/archdischild-2011-301621
Global child health
66 Fraser B. Growing up in Rio’s favelas. Lancet 2011;377:1735–6.
67 Viner RM, Ozer EM, Denny S, et al. Adolescence and the social determinants of
health. Lancet 2012;379:1641–52.
68 Press NA. Cities transformed: demographic change and its implications for the
developing world. National Academies Press, 2003. http://www.nap.edu/catalog.
php?record_id=10693 (accessed 12 Oct 2012).
69 Turley R, Saith R, Bhan N, et al. Slum upgrading review: methodological challenges
that arise in systematic reviews of complex interventions. J Public Health
2013;35:171–5.
70 Baker-Henningham H, Meeks-Gardner J, Chang S, et al. Experiences of violence
and deficits in academic achievement among urban primary school children in
Jamaica. Child Abuse Negl 2009;33:296–306.
71 Caracci G. Urban mental health: an international survey. Int J Ment Health
2006;35:39–45.
72 Handzel JM, Brodsky N, Betancourt L, et al. Longitudinal follow-up of poor
inner-city youth between ages 8 and 18: intentions versus reality. Pediatrics
2012;129:473–9.
73 Smith T, Brownlees L, [UNICEF] UNCsF. Age Assessment Practices: A literature
review and annotated bibliography. Discussion paper, Child Protection Section.
New York: United Nations, 2011. http://www.unicef.org/protection/Age_
Assessment_Practices_2010.pdf (accessed 12 Oct 2012).
74 Ompad DC, Galea S, Caiaffa WT, et al. Social determinants of the health of urban
populations: methodologic considerations. J Urban Health 2007;84(3 Suppl):i42–53.
75 Oakes JM, Rossi PH. The measurement of SES in health research: current practice
and steps toward a new approach. Soc Sci Med 2003;56:769–84.
76 Chopra H, Chheda P, Kehoe S, et al. Dietary Habits of Female Urban Slum-dwellers
in Mumbai. Indian J Matern Child Health2012;14:1–13.
77 Friberg IK, Kinney MV, Lawn JE, et al. Sub-Saharan Africa’s mothers, newborns, and
children: how many lives could be saved with targeted health interventions? PLoS
medicine 2010;7:e1000295.
78 Fotso JC, Ezeh A, Oronje R. Provision and use of maternal health services among
urban poor women in Kenya: what do we know and what can we do? J Urban
Health 2008;85:428–42.
7