Discussion ·

In the context of a megapolis such as Delhi, any study on health would focus on macro issues

relatl.!d to the environment and housing, Public facilities, settlement patterns and networks. This

study too draws from a large canvas and attempts an understanding of various issues that influence

the health perceptions and response-pattern of people to some selected health

problems.Simultaneously it examines the family environment oflow-income households across three

colonies in Khan pur area of South Delhi.

Some issues related-to Intra-urban poverty are examined in their relation to health.Problems that

have arisen directly or indirectly as a result ofrapid,haphazard urban growth in Delhi are increasingly

receiving the attention ofhealth researchers.

"Substandard and badly built urban infrastructure creates a wide variety of problems for those

who I ive here. The city is characterised by rapid increases in population, excessive density;

suffocating and cripplin-g pollution; chronic shortage ofbasic and essential amenities;increasing

squalor of the deprived areas; inequalities inthe distribution of education, health, housing and welfare

services; ...... " (VHAI 1993).

This study is restricted to three colonies situated within Khan pur area in South Delhi. South Delhi

is the more affluent area in Delhi and provides housing to the elite, powerful and rich among the

residents of Delhi. Typically reflective of the megapolis in a third world country however is the

juxtaposition of poverty and affluence within specific areas or zones.

Adjacent to·the relatively affluent Saket and situated on the outer limits ofSouth.Delhi, Khanpur

houses people oflow income who earn their livelihood by work in salaried jobs or through petty

businesses that serve their affluent neighbourhood. Khanpurwas selected as the study area and was

chosen over other areas surveyed as it comprises of three colonies in close proximity to each other.

The glaring variations between the multiplying deprived areas and the islands of glory demand

immediate actions" (VHAI 1993 ).As a first step towards this action, research on various issues

documenting intra-urban differences in poverty requires to be conducted in the context ofDelhi. This

study is a humble and modest endeavour to understand issues related to health in Khanpur in the

larger context of its location in South Delhi.

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The lens is then focussed more sharply on intra-area issues in Khan pur and this is facilitated by

an examination of three purposively selected colonies within Khanpur. These three colonies lie

adjacent to each other in close proximity within Khanpur,however, there are glaring differences

across these colonies in terms of~ocio-demographic profile of its people. Each of these selected

colonies represent one type of settlement pattern that provides housing for the economically weaker

sections (of the five types of colonies described by the D.D.A.). In this study it is observed that in

Khan pur the unauthorised colony offers housing to people of relatively the lowest income while the

urban village comprises of more families that are relatively affluent in comparison to the other two

colonies.

The colonies are not matched in size however an approximate matching has been attempted by

(I) including only one block in the resettlement colony of the four blocks that it comprises of. This

block was selected as it is situated closest to the other two selected colonies. (2) including the entire

unauthorised colony that consists of two camps and (3) including the houses that belong only to the

original area of the urban village. Khanpur Gaon, like a typical urban village has grown in the last few

decades in a haphazard manner and much of the neighbouring villages have been attached to the area

now clubbed together as Khanpur Gaon. However the area residents have a very definite and clear

idea (consistent between residents) regardiQg the limits of Khan pur Gaon. Therefore the selection

of this colony relies on these accounts to a great extent and the limits have been verified across

families that reside here.

The aim of this study has been to examine the psychosocial aspects related to selected health

problems and the term psychosocial in this study includes the perceptions (psychological and socio­

cultural framework) of people across the colonies as also the physical, social and family environment

that nurtures them.

Within this framework, this study simultaneously draws insights at various levels. At the first

level, an understanding is developed with ~egard to several socio-demographic variables across

three colonies. The next level of understanding is in the associations between the Family and Physical

Environments reported by the respondents. At another level differences if any, are documented

225

between how people perceive physical health problems and mental health problems. The question

addressed at this juncture, is whether people would perceive and respond differently to physical and

mental health problems. Health response patterns are examined after gaining an understanding of the

social support that people utilise, the kind of treatment they opt for and the actions· that they resort

to in the event of selected health problems.

An important aspect of this study is that qualitative and quantitative data supplement each other

inthe presentation of the observations and results. Case-studies are presented to highlight certain

relevant aspects related to family environment, health perception and response pattern to selected

health problems. The names and some particulars of the persons in the case-studies have been

changed to protect the identity of those who participated in the exercise.

The unauthorised colony lies at one end of the spectrum even among the low income colonies as

it has little or no basic amenities. In Delhi most of the slums including squatters clusters are formed

by the process of invasion or illegal take-over ofland (Sabir Ali 1996). In the Harijan Basti and

Banjara Camp too (the unauthorised colony selected for inclusion in this study) the origins of the

colony as reported by the residents support this statement. This colony which consists of over 500

jhuggis grew as a result of the first 15 families that settled on the land of the colony many years ago.

They too report that they occupied the land as it was vacant and invited relatives from their villages

in Rajasthan to settle in Delhi. Networks grew and the population in the colony increased.

Approximately 15-20 years after this colony had begun to grow, another group of people settled on

vacant land at the other end of the colony and both these 'camps' grew and merged their boundaries.

The colony is yet to be 'regularised' by the government authorities which, in essence, means that

they have no electricity and little water as well as the fact that they live in substandard houses. Most

of the residents in this colony who were interviewed reported that they first came to Delhi in search

of employment.

This is typically reflective of the growth process ofslums in megapolises and the simultaneous

increase in poverty (Mishra and Gupta 1981; Prasad 1995). The attempts at regularisation is at a

crucial stage now with the Delhi state government promising to regularise all unauthorised colonies

(numbering more than 1 000) within this year.

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The sample of 40 households in the unauthorised colony comprised of only two muslim families

among a majority of Hindu families. There was no family professing any other faith in the sample

studied however this is not surprising since the history and the development of the colony suggests

that families grew due to the strong pastassociations between them and that often relatives were

invited over.Community or caste affiliations are an important association when inviting families over

to settle.(Majumdarl981)

The development of the resettlement colony on the other hand owes its origin to policy planning

and government initiative and families that had earlier occupied government land were 'resettled' .In

this process, care was taken by formal and informal methods not to disturb old associations and

networks hence while there are six families in this colony that profess the muslim faith, it is interesting

to note that they reside within close proximity of each other in the block that was selected for study.

Likewise caste affiliations are strong among the Hindu families in this block and though they offer

good emotional and social support to one another their proximity also reportedly generates a lot of

problems between them related to daily living.

In the urban village of Khan pur Gaon the development of the old village situated in the then rural

area, incorporated initially as 'outskirts' and thereafter transformed (approximately two decades

ago) into an 'urban village', the composition is still reflective of the original pattern of settlement in

that it is dominated by the Gujjar-Yadav families. This is typical ofmany urban villages situated in

outer Delhi. Following itsdeclaration as an urban village, sale of agricultural land and the advantages

of modem development and technology, many families of this village are increasingly earning better

income (due to sale of property ,business such as ownership and running of bus transport etc.) The

change is reflected immediately in the construction of newer and bigger houses as well as in the

increase in letting out houses on rent to 'tenants' who seek low cost housing. In this village ,in a

sample of forty houses there was one Christian and one Sikh family and two muslim families all of

whom belong to the low-income group and are tenants in this village. Ownership ofhouses rests

primarily with the original residents of the village.

The residents of Khan pur Gaon report that there is a drastic difference in life-style as compared

to the time when their village was rural. The changes are obvious in the dress, language education

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acq~isition ofluxury items etc. and are more subtly evident in the customs, practices and beliefs of

the prople in the village. This observation finds support in literature that has earlier recorded these

changes in the contextofurbanisation(Mishraand Gupta 1981; Singh 1996; Trivedi 1976). The case

studies of families in Khanpur Gaon) included in this study draw attention to these aspects. In this

context the concept of urbanisation as described by Friedmann (Prasad 1995) is particulrly relevant

as the concept discusses two forms of urbanisation. The process of urbanisation referring to

settlements and economic location and the second form which refers to the diffusion of urban values,

behaviour, organisations and institutions. Khan pur Gaon may be assessed in relation to both these

forms.

The composition of the colonies with reference to caste has been dealt with rather briefly. The

task of documenting the caste was made particularly difficult because the families in the resettlement

colony and unauthorised colony often specified a sub-caste or typing that was difficult to fit in a

framework by which comparisons could be drawn. The urban village had a majority of people of the

Gujjarcommunity (75%). Of the remaining Hindus 10% were Yadavs and 5% were Brahmans by

caste.

There was much discussion in the unauthorised colony whether or not 'Banjaras' belonged to the

scheduled caste or tribes and opinion was equally divided among the residents. Therefore caste and

sub-caste studied in this research do not conclusively document the composition with regard to these

aspects.

The occupation of a primary earner in the family was studied in order to understand the socio­

economic aspects related to the composition of people across the colonies. Expectedly ,due to the

fact that they have higher incomes, a relatively higher number of people engaged in petty business

are present in the urban village ( 42.5%) but this is followed closely by the unauthorised colony

( 40% ). However analysis reveals that the nature ofbusinesses vary across these colonies and the

difference in income earned across the colonies is stark.

People of the urban village earn much higher levels of income. The residents of the unauthorised

colony own petty shops, are traders and engage in businesses such as news-vending, auto-rickshaw

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transport etc. The residents of the urban village on the other hand, own property-dealing businesses

which were flourishing (by their own reports). Others in this colony owned a few buses which they

hired out on commercial basis. A number of these people owned shops in the village itself and the

income level of these people was much higher (they collected rent on their houses as well). It is of

course relevant to consider the mean size of families in this colony which was much higher.

An equal percentage of the sample studied in each colony had a primary earner who was

employed in a private firm or establishment. The resettlement colony had the relatively highest

number of persons employed (as class IV employee) with the government followed by the urban

village. Here too the difference in the nature of work is relevant to record. The resettlement colony

had mainly employees withtheDESU(Iinesmen);Delhi Police (constables) and MCD (Safai

Karmachari). The three government employees in the unauthorised colony were Safai Karamcharis

in the MCD. The urban village however had more lower-division clerks and people engaged in other

clerical jobs and one driver employed with the DTC.

These observations are relevant in understanding the socio-demographic profile of people in

each of the colonies. The profile is not different in any other part of Delhi and the selected colonies

to that extent are 'typical' of the kind of colonies chosen for study.

Perceived status ofn!sidence was assessed in the families included in the sample in each colony.

A very high number of families perceive their status as 'permanent residents' ofDelhi in all colonies.

The resettlement colony interestingly had relatively the highest number of informants who perceive

themselves as 'migrants' (20% ). This colony has been provided by the government to 'legalize' the

residence of former squatters and illegal occupants of vacant land (Jain 1990; Mishra and Gupta

1981) and therefore it is interesting to note that 8 families in the resettlment colony perceive

themselves to be 'migrants'. Some of these 'migrant'families own the house they live in and the adult

members hold steady jobs as well, however many of them own land in their village of origin and have

fa~ily members who continue to live there. Those interviewed in this study considered themselves

'working life migrants' and expressed definite plans for settling in their village following retirement

of the adult male in the family. However the validity of a prospective opinion of this nature requires

to be assessed overtime before drawing conclusions with regard to migrant population in this colony.

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Likewise the 'migrants' in the urban village (family described in case no. 3) expr~ssed a definite

desire to leave Delhi when they have earned enough to reach them to their village 'respectably'. In

the unauthorised colony the 'migrants' considered themselves as such because of their relatively

short duration of residence in Delhi as compared to others in the colony and were unsure of whether

they would continue to stay in Delhi or not. In this colony, five families reported a stay in Delhi of

less than five years and this was relatively high as compared to the other two colonies which

comprised of a majority of families that had resided in Delhi for over I 0 years.

Therefore the perception of status of residence is linked to their plans of stay as well as to the

length of their stay {past) in Delhi.

Environment has been defined as "All that which is external to the individual human host and can

be divided into physical, Biological social, cultural etc., any or all of which can influence health status

of populations"~··

This is the broad framework within which this study ofKhanpur studies aspects related to

physical, social and cultural' environment' that have a bearing on health perceptions and response

patterns.

0

The observations and results ofthis study focusses on the state and perception of Physical

Environment both of which exert an influence on the health of an individual. In this context the

physical environmental aspects related to housing, water and electricity have been described and a

description of management of needs such as defecation etc. have been included. The relevance of

eacll of these aspects have been described in literature in relation to health (Jacob and Stevenson

1981; Songsore and McGranahan 1993; Stephens 1995;Prasad 1995). The neglect by both

authorities and the people residing in the colonies in Delhi resulting in substandard living and poor

state ofhygiene in resettlement colonies (Mishra and Gupta 1981) and unauthorised colonies and

sh.ims(Jain 1990; Prasad 1995) and in urban villages has been well documented.

Bansal(l996) and Singh (1996) call for a review of planning options and policies in the context

of urban villages which have grown at a rapid rate and in an unplanned manner despite the Master

Plan ofDelhi that provides for its development.

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In this study of colonies in Khan pur it is observed that such a growth has resulted in the poor

maintenanceofthe core village, lack of adequate facilities such as street lighting and maintenance of

roads. The outer limits of the village which lie adjacent to the Mehrauli Badarpur Road is busy and

the noise level is very high and eften reported to be a nuisance by residents. However report

satisfaction with the physical environment.

The case no. 6 documents the perceptions regarding 'change' in the village over the year. This

is described further in Case no. 9 as well. In the resettlement colony the Case no. 1 describes the

perception of a resident about the physical environment being poor in comparison to her village of

origin while in Case no. 4, a resident's perception of the social environment characteristics of this

colony are documented. Most case studies presented include the perceptions related to physical

environment.

Garbage disposal methods used by people in these three colonies was studied and largely as a

result of poor facilities (or its maintenance) more than a third of the residents in the sample across

the colonies admit to throwing the daily garbage on the street or in the neighbourhood. In the colonies

many residents complained about the situation of the municipal disposal area (in the resettlement

colony where it is situated at one end of the colony) and about the irregularity of government cleaning

and maintenance staff. Almost two-thirds of the sample in the unauthorised colony report using a

disposal area (identified by neighbours) as a dumping ground situated within the colony. Over a third

confess that it adds to the problem ofhygiene attracting flies and rodents. Even in the urban village

where the economic and education standards are higher,just over 55% use the municipal bins while

65% of them complain about the level of cleanliness. All the colonies lack adequate facilities however

in addition, they also lack in a general effort to maintain the cleanliness of the colony resulting in many

health problems. Stagnant water in areas within the colony and 'blocked' drains that are open and

run along the line ofhou.ses are important problems to consider while discussing issues related to

health. All residents report that diarrhoea and fever are among the most commonly occuring I

problems in their colony and informal discussions revealed that 'malarial' fever was common. The

more recent epidemic (or now endemic) Dengue fever too was discussed as a major health hazard

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related to life style practises of the people in these colonies. Undeniably there is a role for policy

planners and bureaucrats in the provision of facilities however Zurbrigg ( 1984) draws attention to

the issues of dependency and unjust social structures in a discussion on health and poverty. She

states "the notion that 'basic needs' for hundreds of millions of people can be externally provided

from above is as unrealistic as it is ulteriorly motivated". She argues that provision (which itself

'betrays a paternalistic' thinking) ofbasic needs by the ruling class to the poor who are forced to

sell their labour cheaply in order to "provide basic needs for the country (food, construction of

housing etc.) is an unfair and reality-distorting suggestion. She calls for a change in this thinking.

Even among the three colonies in Khanpur the relatively lowest paid people belong to the

unauthorised colony and these families are the ones who have the poorest houses (Jhuggis 8 feet by

6 feet) with little or no ventilation; no legally sanctioned electricity and water supply poor in quality

and quantity. Often these families visit neighbouring areas in order to collect daily water supply for

all their cooking and toilet needs. This is further described in the case studies of the unauthorised

colony. The psychological and social disturbance' apart, these families also admit to high and frequent

occurrence of illness. Contagion of disease due to inadequate living space and crowding too has

been reported in some of the case studies. All three colonies have problems related to physical

environment but the results clearly weigh heavily against the unauthorised colony while discussing

issues related to provision as well as access tofacilities. There are many structures that prevent the

maintainenoe of cleanliness in this colony. Both male and female adult residents of this colony often

need to work towards raising the monthly income which leaves the children unattended to or at home

with neighbours. There is a pressure and premium on time and each day is reported (case studies)

by them to be a struggle. Illness or sickness in a family adds further strain on an over-burdened family

system and in itself takes its toll on the health of the family. Alcoholism across the colonies is

reportedly high and some of the cases present the alcohol abusing members rationale for consuming

it in relation to disatisfaction with the physical environment. " ... the man-made environment of slums, I

restricted living space and noise are attheir worst, and the changes in the social environment have

aggrauated poverty, alienation and social disorganization leading to mental ill health (Sharma and

Davis 1986). The residents in the unauthorised colony in Khanpurdiscussed the issues of inadequate

232

living space with relation to rest and sleep. They discussed the_ effect of the environment generating

disturbance and noise (due to the presence of alcoholism related marital discord and quarrels. Some

others added that there was no space to sleep in comfort if the family had more than two adults. The

disturbed sleep following a physically exhaustive day at work was discussed by many of the

residents. Schroeder (reported in Jacobs and Stevens on 1981) examined the issues related to

"houses unfit for use" and its relationship to mental health problems. Health and housing have a

definite correlation and in India Jain (1987) has examined the psychological consequences of

crowding and discussed paucity of resources in relation to perception of crowding.

Nagar ( 1985) and Tripathi ( 1986) (both reported in Jain 1987) discuss the issues of noise,

density of population and crowding and its bearing on mental ill health. Sharma (1985) in a

presidential address to the Indian psychiatric society drew attention to issues related to poverty,

health and quality oflife.

Moving from the physical environmental issues, the micro unit of the family is examined next in

this study. The' unit of study' is the family and family environment has been examined and assessed

through qualitative means as well as through the use of the Family Environment Scale. "All

constituents of the environment in our planet - rainforests, troposphere, seas and biological

environment- ultimately exert an influence on human health and well-being. However the environment

which exerts the greatest and most immediate influence on the lives of the people their health and

well-being is the immediate environmentoftheir home and neighbourhood. A health promoting home

and urban environment embody the fundamental aspirations of the majority of people, where the

quality of their lives depends on having a clean, decent safe home in which to live and raise a family."

(Novick 1990 quoted in songsore and McGranahan 1993 ).

The above quote links all the relevant issues of environment to health and does so in the context

of the family and this study ofKhanpurreflects these issues in seeing health in the family as linked

to various issues.

Literature review reveals that The importance of the family environment and its influence on

health has been relation to many illness categories. The illnesses (health problems studied in relation •'

233

to family environment) mostly have a strong psychological basis such as low back pain (Feuerstein

et al1985); Hypertension (Gillum et all985); Premenstrual syndrome (Kuczmierczyk et al1991 ).

Family Environment has been studied with reference to mental illness like schizophnenia (Canive et

al 1995) and major depression (Keitner et al 1995) and in the Indian context with regard to

schizophenia, affective disorders and neurosis (Kamal and Gautam 1992) and in the context of child

psychiatry (Sethi 1995).

In this study of the three colonies in Khan pur family one informant per family was administered

the Family Environment Scale (FES) to assess information regarding the family environment.

Families across the colonies were observed to be high on cohesion and although conflict was

reported to be high (information collected through qualitative means) the scale revealed a low mean

1. 95 (urban village) 3.5(> (resettlement colony and 3.83 in the unauthorised colony). Conflict was

attributed to various factors such as alcoholism/substance abuse, poor neighbourhood quality,

stressors at work, low income levels etc. Domestic violence was reportedly high in some of these

families (case studies). Literature in psychology makes reference the positive relationship between

high density and aggression (Hutt and Vaizey in Jain 1987); density and manic depressive mental

illness (Faris and Dunham 1939). Violence is aggression misdirected (Sharma and Davis 19~6) and

is reported to be high particularly in the unauthorised colony in Khanpurwhich houses people of

relatively the lowest income in the three colonies.

It is the contention of the researcher in this study that the psycho -social factors predisposing the

individual to alcohol use/abuse reveal that Substance abuse in this colony is a result of poverty and

is not a cause of it. The poor, particularly in the unauthorised colony admit to using/abusing

substances to 'relieve' their physical exhaustion at the end of the day. They confess that they require

an artificial stimulant to "numb their senses" and to aid in increasing their appetite or restful sleep.

The case studies presented in each segment highlight this.

The FES also assesses 'Moral-Religious Emphasis' and 'Active Recreational Orientation'

through two subscales. The inclusion of these subscalesin the study warrant discussion. The FES was

administered through a hindi adaptation of the scale. Many residents across the colonies initially

234

expressed surprise, irritation and even anger (urban village and unauthorised colony) regarding the

scale as it obviously documents initmate family details. The researcher was able to explain the use

of the scale,its relevance and thereafter all but one (who too later agreed) of the 120 households were

willing to participate in this study. Literature has not made much reference to this aspect of the scale

administration and the obvious reason for this lies in the fact that most (if not all) the literature

reviewed (by this researcher) in relation to family environment refer to studies where the FES has

been used on clinical populations. A clinical sample is possibly more willing to answer questions

related to relevant aspects of their illness and secondly, the clinical sample was most often to do with

illness which has a strong psycho-social basis underlying the relevance of such details. In this

research in the open community ofKhartpur the use of a scale assessing intimate family details and

in connection with a numberofselectedhealthproblems (both physical and mental)was initially (and

understandably so) regarded with suspicion. The scale however has a limited but relevant role in the

collection of data on Family environment. It measures some important variables (in relation to its

bearing on this study) such as cohesion, conflict and expressiveness (the relationship dimension).

Altlwugh the variables assessing moral-religious emphasis and active-recreational orientation could

have tremendous significance in studies related to health perception and response, these subscales

were observed to be inappropriate in this study. The social and cultural aspects related to life in

these low-income colonies warrant the use of other tools that can more reliably document these

aspects. For example an item in the subscale assessing Moral-Religious Emphasis seeks response

to whether family members visit temples, churches etc. often. The colonies studied comprise of

people who have a tremendous pressure on their time and the women rarely go out of the house

(unl-.!ss they attend work). Prayer needs in such houses are satisfied within the confines·oftheir house

and hence most people tended to reply in the negative although many of them are very religious (as

evidenced by qualitative data).

In colonies where there are few open spaces, no parks (unauthorised colony) and marty

structures th~t prevent people from spending their 'leisure' (if they have any) items that measure

response to whether or not the family goes out for films, camps or outings together is irrelevant and

inappropriate. Quality family time in the urban village is often shared within the house in families that

235

may not go out together.

Aspects related to the use ofthe subscale on 'intellectual-cultural orientation' too had similar

drawbacks as it measured family attendance at concerts and cultural activities besides their visits to

libraries. Some of these are inappropriate in their cultural relevance to the people of the colonies in

Khan pur. The system-maintenance dimension assesses both' control' and' organization'. In the

discussions with each family several residents in the urban village expressed strong' control' by the

- elders in their house however, the FES data on control in this colony revealed a low score presenting

a contrast in the information collected through qualitative and quantitative means.

Next this study of the three colonies in Khanpur presents results on health perceptions tn

reference to selected health problems. In this context it examines their perceptions related to the

most commonly occurring illnesses in their respective family. Fever and diarrhoea ranked highest in

the list across the colonies. The problem of'fcver' was generally an 'unqualified fever' (Bukhar)

although few did specify 'malaria' or 'typhoid'. Most people discussed the issues of environment and

the role of poor hygiene as a factor in the causation of diarrhoea. The informal group discussions and

time spent with each family during administration of the schedule revealed that although awareness

of dean and safe drinking (water) practises was prevalent in almost all the families, the environment

did not offer much of an op_portunity to prevent the occurrence of illness. The barriers that prevented

the people from its occurrence included ( 1) work-pressures that prevented mothers from close

supervision at home of their children (particularly in the unauthorised colony), (2) little access (in the

resettlement colony) orvirutally no access (in the unauthorised colony) to potable and clean drinking

water, (3) garbage disposal methods that are unclean thus attracting flies, ( 4) sale of poor quality

edibles attracting children customers within the colony (in both the resettlement and unauthorised

colony). Most families expressed their ina~ility to and helplessness in dealing with the problem of

frequent occurrence of illness. Across the colonies people spontaneously discussed Oral Rehydration

Therapy and its benefit.

Awareness of mental illness was assessed and it was found that about a third of those that

participated in the study across the colonies had partial awareness. The unauthorised colony had the

most number of people with good awareness of mental illness ( 65%) while the urban village (50%)

236

and resettlement colony (35%) ranked lower.

Interestingly only one person in the unauthorised colony could be assessed as having 'no

awareness' of mental illness while this figure was much higher in the other colonies {35% in the

resettlement colony and 22.5% in the urban village). However when response to mental illness was

assessed, of those that participated in the study only 55% in the unauthorised colony stated that they

would visit a doctor in the case of major mental illness and only 20% of those interviewed said that

they would visit a doctor for the treatment of alcoholism, 45% for the treatment of epilepsy and an

equal number for the care of mental retardation. In comparison despite the fact that 35% of the

sam~le in the resettlement colony had 'no awareness' when 'response' was assessed 63.5% of them

said they would visit a d<:>ctor for treatment of psychoses in the family, 42.5% stated they would do

so for alcoholism, 70% for epilepsy and 55% for mental retardation. In the urban village the

corresponding figures were 67.5% (psychoses); 20%(alcoholism); 47.5%(epilepsy)and37.5% (in

the case of mental retardation).

Therefore high perception and awareness in the unauthorised colony does not appear to exert

a positive influence on response pattern.

Perceptions related to awareness of consequence on neglect of a health problem was assessed

with regard to selected health problems. Across all colonies awareness related to negative

consequence or to neglectoffever,diarrhoea, T.B.,gynaecological problems, STD'sand AIDS was

higher than in relation to mental retardation, epilepsy, and psychoses which were lower. Although

awareness was present about the ill effects of alcoholism 'response' to this problem was not

adequate to meet with a resolution or control of the problem. In the case of diarrhoea 85% of those

in the urban village, 62.5% in the unauthorised colony and 75% of the resettlement colony expressed

that neglect of the condition would worsen or that it could lead to death. More than 75% in each

colony felt similarly about the consequence of neglect of alcohol sm.

The informants in each family were also asked about their perceptions of the type/place of

treatment that would be most effective in the case of selected health problems and later response in

the case of each health problem was assessed with regard to type of treatment as well as to the place

237

of treatment (private clinic, hospital, government dispensary, homeopathy/ayurved clinic, healing

etc.). There is a difference in the perception and in the action (response) that they may take for each

health problem. An explanation offered to understand this apparent discrepancy is that their

perception is reflective of what they may consider, the "ideal" place for treatment whereas the

·response pattern' may be indicative of their "reality-orientation" and taking cognizance of the

factors that prevent/promote utilitzation of a certain type of/place of treatment. In other words, this

discrepancy between two sets of observations may not be indicative of inconsistency in response but

have more to do with the ideal/real dichotomy that exists.

Some information regarding the barriers that prevent that ill from resorting to a course of action

(such as hospital visits) was collected however greater attention on these aspects is required and this

study focusses on many variables with regard to eleven health problems across three colonies,

therefore, a more detailed examination regarding these barriers was not possible. However even the

limited information collected in this regard in valuable as it documents the problems faced by people

in the utilization ofhealth services across the three colonies. It also documents the problems faced

by these people in utilizing the networks within the colony and briefly assesses their support system

within the colony as well as their expectations with regard to support from family relatives,

neighbours and health service institutions. The findings of this study regarding their satisfaction with

different health service institutions is interesting.People were asked to rate different health service

institutions in terms of their satisfaction in treatment ofhealth problems and while over 90% each in

the three colonies rated the private clinic/practioner/nursing home as satisfactory only 70%-92.5%

stated that they were satisfied with government hospital/dispensary and between 17.5% and 30%

across the colonies rated the option of other service institutions (Ayurved, Homeopathy, etc.) as

'satisfying'. Their responses with reference to utilization of such facilties reveals that a majority

(75%) in the resettlement colony would resort to private clinics for treatment of skin infections and

fever and more than 75% of those in the unauthorised colony would utilize private clinics for fever,

diarrhoea and skin infections whereas 62.5%-72.5% in the urban village would do so for these

problems.

More people in each colony would use the government hospital for treatment of all mental illness

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as well as T.B., gynaecological illness, STD's and AIDS. Bhatnagar et al (1988) studied the

utilization of health services institutions in urban slums of Delhi and observed that for chronic

sickness (lasting more than 3 months) over 60% of the slum dwellers in three clusters across Delhi

prefer to use the facility of private-practitioners for treatment.

Prasad (1995) studied satisfaction in health services institutions in Hyderabad and observes that

of a sample of 607 households (slums) 68.5% are satisfied with the use of private clinics as compared

to 46.6% who report satisfaction with government hospital.

There are many factors that prevent the utilization and access (Qadeer 1985) to health service

system. In this study ofKhanpur, people expressed "high-handed attitude of doctors in hospitals",

financial factors, attitude of care giving staff(nurses etc.) and also mentioned that the systemic

problems (Queues, timing of services, coordination between investigations and diagnosis) as factors

responsible for their disatisfaction and under/non utilization ofhospitals. The case studies document

perceptions related to their satisfaction as well as access to the private clinics situated in their colony.

Utilisation patterns in health care for users of private and government medical services studied

among 20 users in Nand Nagri resettlement colony (East Delhi) also indicated similar results and

over 60% of those interviewed resorted to private practitioners and 20% opted for the government

hospital (VHAI 1993).

Dutton ( 1986) reviewed factors that affect the utilization of health care facilities and observed

that several financial, professional and organizationals factors prevent people from the use of

facilities for medical care. She discusses the role of potential structures such as exorbitant medical

fees, travel· and waiting·time as a 'non monetary price', overburdened system and factors reflecting

in the quality of care provided. The use of appointments, week day consultations etc. too are

described as potential organizational barriers.

Despite the difference of over two decades and the obvious differences in samples, the findings

of the 1971 study are relevant to the current one in Khan pur in enabling an understanding of different

f~ctors that prevent/promote health service institutions. Zurbrigg ( 1984) draws attention to the

239

barriers and structures of ill health through the narration of a story about a poor woman (Rakku) in

rural Tamil Nadu. The implications of the story and the analysis of the health service development

and system however makes it relevant in any study ofhealth in India.

In the current study ofKhanpur, resort to 'healers' and 'babas' is minimal in the urban village

and higher in the resettlement colony however the unauthorised colony has the maximum number of

persons who admit to resorting to 'alternative' forms of care such as healing by faith. The case

studies also document this (particularly case no. 8 where Shanti admits to seeking treatment for

tuberculosis from a faith healer). What sets this apart is that few others admit to opting for such

treatment in the case of physical health problems such as T .B. Across the colonies more number of

the respondents stated that they would resort to faith healing in the case of mental illness as compared

to physical illness. In particular, more people said they would consult a 'baba' or 'fakir' in the case

of epilepsy. The obvious confusion that prevails between an attack suggestive of poor coping with

stressors (hysteria) as compared to 'genuine', neurological seizures is evident and this is reflected

in the kind of treatment that people perceive necessary for cessation of the' attacks'; 'smelling a

shoe, offerin advise placing a metal/key in the hand' etc. are myths that were observed to be present

in the people of the colonies (between I 0 and 12.5% in each colony).

Faith-healers are preferred in the case of psychoses as well. A good number particularly in the

unauthorised colony said they would opt for faith healers in the treatment ofSTD 's. This would

ensure privacy and confidentiality in treatment according to them. In gynaecological problems

related to conception (p~rticularly lack of it) "treatment" was reportedlysought from faith healers

by people in the unauthorised colony. Studies conducted in the west by Loud ell Snow and others

(Ccv:kerham 1986) reveal that although folk healers are used to a significantly less extent in the

United States of America, there is a tendecny oflow income Black American people to use their

services. Folk healers have been described as 'good listeners' 'astute' in their diagnosis and

, treatment and often people prefer to visit them because they emphasize spiritual, psychological

social or 'magical' bases to the aetiology of illness and are able to pay attention to the socio-cultural

milieu of the ill person which most modern allopathic doctors find difficult to do. In the unauthorised

colony, informal discussions and interviews revealed that the number of person who opt for faith-

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healing or have belief in its practise is more than what was recorded in reference to each health

problem in this study. Modern allopathic medicine does not have an answer or solution to many

illnesses and conditions and several new health problems are being identified every year in the face

of rapid urbanisation and haphazard growth. In the study ofKhanpur it is observed that even if folk

healers are unable to cure the illnesses themselves many of them resort to strategies that alleviate the

symptoms or improve the person's coping with the illness. These insights are drawn from the many

discussions and interviews_ with several of the families over repeated visits in the duration of four

years.

Finally in the assessment of networks and social support system, this study of Khan pur observes

that families, neighbours, relatives and friends (in that order) offer good to little support. 'Neighbours'

in the unauthorised colony were rated as very helpful as also were 'relatives'. However this

discussion also records at this juncture that in all three colonies, settlement patterns indicate that

neighbours are often relatives and vice-versa and therfore which component of the two plays a

greater role in the support offered is a difficult question to resolve. Suffice it to say that even in the

case of neighbours who are not relatives, support receiVed has been expressed as satisfying and

strong whereas many of the informants expressed that relatives who lived in other areas of the city

were often oflittle or no support. Explanations offered by the informants for this had to do with

'barrier' of'physical distance' however it would be too simplistic (and erroneous) to suggest that

proximity in residence engenders or nurtures support. Increasingly literature makes reference to the

importance of neighbourhood and 'neighbours' are beginning to replace other secondary forms of

supp<trt in urban areas (Davies et al1993; DeSousa 1978; Harvey 1989).

In the present study the need for a strong social support system that would aid people in the city

and'where older and more traditional networks may not be present is recognized. In the urban village

the $lrength of old networks of the community (foreg. Gujjars) is strong and offers good emotional,

practical and at times financial support as well. In the unauthorised colony, neighbours offer good 1

support to each other however Quarrels and conflict among them is also reported to be high

(particularly over Queues for water supply). In the resettlement colony too this is noticed to be

present. However all of them express that they are able to easily overcome their daily problems with

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each other in the face of emergency or health problem. There are no Non-governmental agencies

(NGO) reported working in the colonies studied on a regular basis. From time to time an NGO takes

initiative in organising programmes related to health but there is a clear need for an ongoing and

regular initiative in health and development.

The implications of this study ofKhanpur would fall within the scope ofboth urbanization and

health. Viewed within a socia science perspective, the observations and results of this study highlight

the movement of people from poverty to poverty (except for a few families in the urban village). The

five year plans, development and welfare objectives of the government and particularly the move to

'resettle' or 'regularise' the residence of urban poor have done little to improve the condition of

people who live in Delhi. In order to eke out their livelihood a majority of the poor sell their labour

cheap and exist in substandard and difficult conditions. The social psychological persepective of

Maslow with regard to heirachy of needs and their gratification is of particular relevance in

understanding the existence of people in these colonies through a psycho-social perspective. The

'basic needs' of shelter and food are still to be realised adequately or satisfactorily.

The implication of policy decisions on the incorporation of once rural stretches into the urban

mainstrem on the inhabitants of these areas (reference to Khan pur Gaon) are all too well documented.

The creation of disparity in income between the people of a village (due to purchase ofland that

depends on what is 'prime' to the government) and the associated problems of a sudden rise in

income coupled with a loss in their primary occupation of agriculture are psychosocial aspects that

merit the attention of health researchers. The fall out of such rapid urban growth in Khan pur Gaon

is seen in the attitudes, perceptions and response to health problem, the physical family and socio­

cultural environment. Inter-generational and Inter-gender differences in lifestyle, practises and

beliefs due to urban growth disturb the homeostasis of a once stable family and result in 'mixed'

families. If they also report high cohesion the credit may be attributed to the stability of their system

of functioning over the years.

More striking and indeed a concern for researcher is that alongside these disrpting changes that

occur as a direct result of the government planning and policy initiatives, there is little benefit that

accrue to the people of the village. There is poor maintenance ofthe village, problems in water and

242

electricity supply, general insanitation and the population in the area by many accounts has rapidly

multiplied. The rise in occurrence of illness (as reported in the case studies) the increase in mental

illness and stress alongwith the disappearance of traditional family systems in medical care (at home

through herbal-based remedies harided down over generations) have all come about due to the rapid

urban growth and the attendant life-style changes in the people.

The pressures on people to work in trying conditions in the unauthorised colony (as the case

studies highlight) inter-personal problems at work and home and the increasing need expressed by

people to relieve their stress through use/abuse of astifical stimulants and substances have a positive

direct relationship with their health condition.

Having briefly addressed both psychological and sociological implications, an attempt is now

made to understand the relevance of this study ofKhanpur in the framework of professional social

work. J>rofessional social work is a helping profession which addresses itscl fto human problems

through the use ofknowldege, skills and training received from various social science disciplines. It

is an application of social science in the field area.

Social work is practised in a range of settings and deals primarily with indi vid~als, groups and

families, and the community at large. This research has been conducted in Khanpurwith the family

as unit of study. Individual perceptions regarding the family has been documented and it is a

community study of three urban colonies that house low-income groups.

Critics of social works' largely 'remedial' approach have urged the profession to engage more

extensively in activities that will 'prevent' social problems and promote the 'social well-being'

(Midley 1996). There are proponents who urge the need for a 'developmental' perspective

(although this is not a new approach in social work) emphasising the need to use established social

work practise in creation and emhancement of programme that promote economic development.

Research and documentation of problems seen in a macro politico-economic perspective is an

initial and necessary step towards this perspective. The contribution of this profession may be both

direct (through provision of services) and indirect (through research, action-projects and study).

This would entail the identification of problems that not only affect the individual, family and

243

community but in clearly delineating factors that are responsible for the creation of these problems

and documentation of such factors that impede, hinder and block the growth and development of

communities at large.

Social work researchers can be involved in reference to 'human capital formation' and 'social

capital formation' (Midgley 1996). Investments by the government and development organizations

in education nutrition, health care (human capital formation) have shown net economic gains to a

great extent. Creation of economic and social infrastructure such as clinics, schools, water drinking

systems etc. (social capital) and the softer issues of social capital that deal with 'social integration'

emphasize the role of social workers in creating 'social relationships conducive to development'.

In this research on Khanpur, an exploration of the networks, support systems and social

relationships underline the need of strong support system particularly during the time ofhealth

problems or illness. Nurturance and strengthening of these system that people maintain following an

understanding of what problems they face in enlisting help and support is the role for a social

worker.

lfsocial work profession has been viewed as 'professional imperialism' that is a result of the

industrial and colonial era (Hugman 1996) it is the contention of many professionals (including the

view of this researcher) to discard this image and view social problems in the context of relevant

macro issues.

A reconfiguration of community social work (Banks and Wideman 1996) is emerging and

qualitative approaches to research in social work is increasingly emphasised (Halmi 1996).

The strength of the present study lies in the fact that data has been collected using both qualitative

and quantitative research methods.

Qualitative methods refers to research that "is multi-method in focus, involving an interpretative

naturalistic approach to its subject matter" (Halmi 1996). The use of case-studies alongwith other

qualitative and quantitative methods in the present study stresses its importance as a tool in assessing

perceptions of people. A descriptive narrative format is followed in the case studies and this

244

followed with some insights and analysis in the subsequent chapters. Quantitative analysis has also

been used to a limited extent in the data of the FES.

The issues of poverty, development as well as the role of environment in the health of people is

of tremendous significance and in Khan pur people were asked about their perceptions regarding

these components. This research emphasizes the relationship between physical and family

environment. Perceptions of people regarding these were studied and the case studies highlight the

resception of families regarding the relationship between the two environments. Poor sanitation and

hygiene, lack of clean and age drinking water, inadequate or inappropriate shelter, level of pollution

(air & noise) reflect on the family environment being disturbed. The case study ofRishi Pal Singh's

family specifically addresses the direct relationship between the perception offamily with regard to

physical environment and the family environment. Similarly the case study ofPradeep Kumar too

makes a reference to quality of social environment and its effect on family environment.

Equally important is the relationship ofthese environments on the health perceptions and

response patterns of the people. A disturbed family environment influences the way in which people

perceive he lath problems and to a greater extent would determine how people respond to a health

problem. Poor support from within the family in a disturbed family hinders health-care and treatment

in addition to imposing additional health (mental health) burden.

A positive and nurturing family environment pays adequate attention to health problems seeking

help promptly and appropriately. International research too substantiates this and there is a more

concerted role by profesionals in the health field therefore to strengthen family support systems.

Findings of this study in Khan pur reveal that over two thirds of the families in the resettlement

colony have a 'problem with the level of cleanliness and move than half of them rate their colony as

'not clean'. When informants were asked to rate their family environment. Only 4 7.5% in the

resettlement colony rated it as 'positive' satisfaction with physical environment was assessed and

only 7.5% of those in the reset'tlementcolonyrated that they were 'satisfied', while more than half

said they were 'neither satisfied nor disatisfied' and 40% stated they were 'disatisfied'. 3 0% of those

in the resettlement colony stated that they and 'negative'.

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In this study of Khan pur, while 40% in the resettlement colony stated they were 'disatisfied' with

the physical environment. In the urban village only 25% said that they were disatisfied with the

physical environment. In the unauthorised colony while only 22.5% stated that they were 'disatisfied'

with their physical environment. People were also asked about the level of cleanliness in the colony.

A majority of the people in the resettlement colony and urban village expressed that cleanliness was

poor in their colony while very few in the unauthorised colony considered it a problem.

The implications of these findings are that there is a high perception of the problem of cleanliness

and significant disatisfaction with the physical environment in the resettlement colony while in the

urban village there is high perception regarding the poor level of cleanliness and moderately low

disatisfaction expressed.

In the unauthorised colony a moderatley low number expressed disatisfication in their physical

environment and a slightly higher number agreed that there was a problem related to cleanliness.

The results of the present study also indicate that families in the urban village reported better

and'positive' environmentexpressinglowerscoreson 'conflict' and 'control' as compared to the

other two colonies. The resettlement colonies expressed moderate to positive environments and

scores on most of the sub-scales lay between those of the other two colonies. Significantly the family

environment in the unauthorised colony was expressed most (in comparison with the two other

colonies) as being 'negative'. Higher conflict and perception of 'control' was expressed by these

families. Therefore more number offamilies expressed 'positive' family environment in the urban

village and the least number of families in the unauthorised colony expressed 'positive' environments.

Social support networks were expressed as most satisfying in the urban village and to a lesser

extent in the other colonies.

Health perceptions in relation to selected health problems was observed to be better in the urban

village and in the unauthorised colony (other than in relation to alcoholism) as compared to the

· resettlement colony.

Health responses wre assessed to be good in the urban village and in the ressettlement colony

as compared to the unauthorised colony.lt is also observed that there is more similarity across

246

colonies in their response to physical health problems as compared to their response to mental health

problems which wre dissimilar. Morepeple in the unauthorised colony report use of'healing' as

treatment of selected health problems while more people in the resettlement colony report satisfaction

in use of Ayurved and other systems of medicine (in comparison to the other two colonies).

Awareness on mental illness and AIDS was reported to be high (over 60%) in the unauthorised

colony where 40% people rated that they had a 'negative' family environment. In the resettlement

colony an almost equal number of persons each were rated as having good, partial or no awareness

(approximately a third each) and a similar number rated their family environment as 'negative'. In the

urban village about half the respondents were rated as having 'good awareness of mental illness and

AIDS and.this colony reported a very small number who perceived that they had a negative family

environment. Perceptions related to possibility of treatment of Alcoholism when compared with the

respondents subjective rating of family environment reveals that more people in the unauthorised

colony as compared to the people or other colonies perceive that there is no treatment possible for

alcoholism and this colony also reports the highest number of people who rate their family

environment as' negative'. About two thirds in each colony perceive that death is a distinct possibility

if the treatment of alcoholism is neglected and alcoholism as well as alcholism related marital discord

and sometimes violence is reported more in the unauthorised colony.

More people in each colony stated that they would visit a doctor in response to physical health

problems (fever, diarrhoea, T.B., skin infections, STD's and gynaecological problems). A good

number said that in the case of psychoses they would visit a doctor. However in the case ofboth

mental retardation and alcoholism the group that said they would visit a doctor was small (in the

unauthorised colony and urban village). While the urban village had more people who rated their

family 'positive', rated better cohesion and less conflict, the unauthorised colony had more

'negative' family environment and expressed more conflict and less cohesion.

It is observed that those who have negative environments in the unauthorised colony repond to

physical health problems better and mental health problems to a lesser extent. Those with positive

family environments respond well to most health problems but their perceptions and response to

problems like alcoholism are possibly a function of other influences. In both these colonies almost

247

halfthe respondents (47.5% in unauthorised colony, 45% in the urban village) said that they would

not seek help at all for alcoholism when the stage ofhelp seeking was assessed.

Social support and networks wre expressed to be strong in all colonies. Neighbours were rated

as most reliable support by more people in the resettlement colony and unauthorised colony where

less people rated their own family environment as 'positive'. On the other hand 'relatives' were rated

as most supportive in the urban village where 'positive family environment' was higher.

Therefore positive family environment appears to have a direct relationship to positive support

from relatives and conversely. Positive support from neighbours is linked to the family environment.

The above findings are significant as the observations document differences between three types

of colonies within a single area. Even within a geographical area (Khanpur) it appears that family

environment does depend on physical realities of existence. The unauthorised colony reports the

poorest family environment and also the poorest physical environment and infrastructurc.lt is also

observed that family environment does appear to affect health perceptions and response to health

problems. Both the resettlement colony and unauthorised colony which report poorer family

environement show poorer perceptions and response to health problems in comparison with the

urban village.

The physical environment and the socio-economic conditions of existence also appears to affect

social support system. This is turn appear to affect both health perceptiooo and response pattern to

health problems. The urban village even within Khan pur lies at one end of the spectrum in terms of

the socio-economic condition of its people who have higher incomes, more eudcation better housing

and amenities. This colony also reports more joint family structures and rates theri satisfaction in all

support system (relatives, family, community members, institutions) as very satisfying. The resettlement

colony lies in the middle of the spectrum and are only marginally better with regard to quality oflife

as compared to the unauthorised colony which lies at the other end of the spectrum in terms of its

quality oflife. Both these colonies that report poor quality oflife and physico-socio-economic'

condition report moderate to high satisfaction in support received from neighbours and to a

significantly less extent in other forms of support (relatives, institutions).

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This appears to affect the health perception and response in there colonies specially adversely

in the unauthorised colony.

The people who belong to such colonies live in squalid and miserable conditions and the dictates

of their existeace, are to say the least, harsh and cruel. Squatting and residence of people of this end

of the spectrum of socio-economic condition cannot be easily resolved as the causes are embedded

in socio-political structures. However importantly, the recommendation of this study suggests that

if such colonies are a reality brought about by urbanisation and socio-political causes then attention

of researchers and professionals need to be addressed to organising better networks while

strengthening existing ones for people oflow income groups. Such efforts would reduce the effects

that such existence can have on both health perception and response.

Three colonies in proximify and within one area of Khan pur have been studied and it does

appears that the benefits of one colony (urban village) of strong networks and support have not

· spi lied-over' to the neightbouring colonies.

Finally, the study reveals that there is a direct, linear relationship in the influence of physical and

family environments on the health perceptions and response patterns people. Poor physical

environment adversely affects and influences family environment and such· disturbed' or 'negative'

environments directly influence the way in which.people perceive health problems and/or the manner

in which they respond to them.

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