A conceptual framework on pre- and post-displacement stressors: the case of Syrian refugees

Researchers have documented multiple stressors and mental health problems along the journey of refugees as they are displaced to seek refuge in nearby and remote host countries. This article examines published research on Syrian refugees to propose a framework to conceptualize Syrian refugees' pre- and post-stressors and their collective impact on their mental health. The proposed framework provides a comprehensive understanding of the interconnected pathways between pre-displacement stressors, post-displacement stressors, and mental health outcomes for Syrian refugees. Pre-displacement stressors are best captured by the concept of trauma centrality and emotional suppression. Post-displacement stressors, categorized under financial, political, and social themes, have a direct impact on the mental health of the refugees, but could also play a partial mediating role on the impact of pre-displacement stressors on mental health. The framework suggests a direct pathway between the experience of war-related traumatic events and mental health and introduces the country of residence as a potential moderator of the severity of mental health. The latter is primarily influenced by local policies and the host communities' acceptance of refugees. We believe that the proposed framework can guide the work of researchers, policymakers, and practitioners concerned with the mental health and well-being of Syrian refugees. Additionally, although based on the experience of Syrian refugees, it presents a holistic perspective that could be adapted in other refugee settings.

Barriers to sustainable health research leadership in the Global South: Time for a Grand Bargain on localization of research leadership?

BACKGROUND

Strong Global South (GS) health research leadership, itself both dependent on and a requisite for strong health research systems, is essential to generate locally relevant research and ensure that evidence is translated into policy and practice. Strong GS health research systems and leadership are important for health development and in turn for strong health systems. However, many GS countries struggle to produce research and to improve performance on widely used research metrics measuring productivity and reflecting leadership. Drawing on literature from a rapid review, this viewpoint paper considers the barriers to GS health research leadership and proposes strategies to address these challenges.

FINDINGS

GS researchers and institutions face numerous barriers that undermine health research leadership potential. Barriers internal to the GS include researcher-level barriers such as insufficient mentorship, limited financial incentives and time constraints. Institutional barriers include limited availability of resources, restrictive and poorly developed research infrastructures, weak collaboration and obstructive policies and procedures. Structural barriers include political will, politicization of research and political instability. External barriers relate to the nature and extent of Global North (GN) activities and systems and include allocation and distribution of funding and resources, characteristics and focus of GN-GS research collaborations, and publication and information dissemination challenges.

CONCLUSIONS

Strengthening GS health research leadership requires acknowledgement of the many barriers, and adoption of mitigating measures by a range of actors at the institutional, national, regional and global levels. Particularly important are leadership capacity development integrating researcher, institutional and systems initiatives; new GN-GS partnership models emphasizing capacity exchange and shared leadership; supporting GS research communities to set, own and drive their research agendas; addressing biases against GS researchers; ensuring that GS institutions address their internal challenges; enhancing South-South collaborations; diversifying research funding flow to the GS; and learning from models that work. The time has come for a firm commitment to improving localization of research leadership, supported by adequate funding flow, to ensure strong and sustainable research systems and leadership in and from the GS. Just as the humanitarian donor and aid community adopted the Grand Bargain commitment to improve funding flow through local and national responders in times of crisis, we strongly urge the global health research community to adopt a Grand Bargain for research leadership.

Conflict-related health research in Syria, 2011-2019: a scoping review for The Lancet - AUB Commission on Syria

BACKGROUND

The volume of health-related publications on Syria has increased considerably over the course of the conflict compared with the pre-war period. This increase is largely attributed to commentaries, news reports and editorials rather than research publications. This paper seeks to characterise the conflict-related population and humanitarian health and health systems research focused inside Syria and published over the course of the Syrian conflict.

METHODS

As part of a broader scoping review covering English, Arabic and French literature on health and Syria published from 01 January 2011 to 31 December 2019 and indexed in seven citation databases (PubMed, Medline (OVID), CINAHL Complete, Global Health, EMBASE, Web of Science, Scopus), we analyzed conflict-related research papers focused on health issues inside Syria and on Syrians or residents of Syria. We classified research articles based on the major thematic areas studied. We abstracted bibliometric information, study characteristics, research focus, funding statements and key limitations and challenges of conducting research as described by the study authors. To gain additional insights, we examined, separately, non-research publications reporting field and operational activities as well as personal reflections and narrative accounts of first-hand experiences inside Syria.

RESULTS

Of 2073 papers identified in the scoping review, 710 (34%) exclusively focus on health issues of Syrians or residents inside Syria, of which 350 (49%) are conflict-related, including 89 (25%) research papers. Annual volume of research increased over time, from one publication in 2013 to 26 publications in 2018 and 29 in 2019. Damascus was the most frequently studied governorate (n = 33), followed by Aleppo (n = 25). Papers used a wide range of research methodologies, predominantly quantitative (n = 68). The country of institutional affiliation(s) of first and last authors are predominantly Syria (n = 30, 21 respectively), the United States (n = 25, 19 respectively) or the United Kingdom (n = 12, 10 respectively). The majority of authors had academic institutional affiliations. The most frequently examined themes were health status, the health system and humanitarian assistance, response or needs (n = 38, 34, 26 respectively). Authors described a range of contextual, methodological and administrative challenges in conducting research on health inside Syria. Thirty-one publications presented field and operational activities and eight publications were reflections or first-hand personal accounts of experiences inside Syria.

CONCLUSIONS

Despite a growing volume of research publications examining population and humanitarian health and health systems issues inside conflict-ravaged Syria, there are considerable geographic and thematic gaps, including limited research on several key pillars of the health system such as governance, financing and medical products; issues such as injury epidemiology and non-communicable disease burden; the situation in the north-east and south of Syria; and besieged areas and populations. Recognising the myriad of complexities of researching active conflict settings, it is essential that research in/on Syria continues, in order to build the evidence base, understand critical health issues, identify knowledge gaps and inform the research agenda to address the needs of the people of Syria following a decade of conflict.

Introduction to collection: confronting the challenges of health research in humanitarian crises

Background

Humanitarian crises, such as armed conflict, forced displacement, natural disasters, and major disease outbreaks, take a staggering toll on human health, especially in low-resource settings. Yet there is a dearth of robust evidence to inform the governments, non-governmental organizations (NGOs), and other humanitarian organizations on how to best respond to them. The Fogarty International Center of the U.S. National Institutes of Health commissioned a collection of Research in Practice articles that highlights the experiences of scientists conducting research in the context of humanitarian crises. Unlike traditional research papers, the case analyses in this collection go beyond what research was completed and focus on why the research was important and how it was conducted in these extremely challenging settings.

Discussion

The papers selected for this collection span 27 countries, cover a broad range of humanitarian crises, and discuss a wide variety of disease and health risk factors. Of the 23 papers in the collection, 17 include an author from the affected country and five papers were authored by humanitarian NGOs. Throughout the collection, 43% of the authors were from low- and middle-income countries.

Across the collection, some general themes emerged that are broadly applicable. Importantly, there is a clear need for more, high-quality research to address evidence gaps. Community engagement, already a key element to global health research, was highlighted as especially important for research involving populations dealing with severe trauma and disruption. Partnership with humanitarian actors, including local governments, local and international NGOs, and UN agencies, was found to be a critical strategy as well.

Conclusion

A variety of audiences will find this collection useful. Global health educators can utilize papers to facilitate discussion around public health practice and equitable partnerships, among other topics. Humanitarian response organizations may use the collection to consider how research may inform and improve their work. Global health researchers, funders, and other stakeholders may use the collection to stimulate dialogue around key scientific research questions and better appreciate the importance of conducting research in humanitarian crises in the context of achieving broader global health goals.

Policies on return and reintegration of displaced healthcare workers towards rebuilding conflict-affected health systems: a review for The Lancet-AUB Commission on Syria

Background

War and armed conflicts severely disrupt all health system components, including the healthcare workforce. Although data is limited on the scale of health care worker (HCW) displacement in conflict zones, it is widely acknowledged that conflict conditions result in the displacement of a significant portion of qualified HCWs from their country of origin. While voluntary HCW return is integral to health system rebuilding in conflict-affected and post-conflict settings, there has been little exploration of the nature of national or international policies which encourage HCW return and reintegration to their home countries in the post-conflict period.

Methods

We conducted a systematic review to identify policies and policy recommendations intended to facilitate the return of displaced HCWs to their home countries and acknowledge their contribution to rebuilding the post-conflict health system. We searched three bibliographic databases and a range of organisational and national health agency websites to identify peer-reviewed articles and grey literature published in English or Arabic between 1 January 1990 to 24 January 2021, and extracted relevant information. We classified policies and policy recommendations using an adapted version of the UNHCR 4Rs Framework.

Results

We identified nine peer-review articles and four grey literature reports that fit our inclusion criteria, all of which were published in English. These covered issues of repatriation (n = 3), reintegration (n = 2), health system rehabilitation and reconstruction (n = 2); six documents covered several of these themes. Information was available for nine conflict contexts: Afghanistan, Iraq, Kosovo, Lebanon, Namibia, Northern Uganda, South Sudan, Timor Leste, and Zimbabwe. Findings demonstrate that health system rebuilding and rehabilitation serve as precursors and reinforcers of the successful return, repatriation, and reintegration of displaced HCWs.

Conclusions

Despite the significant numbers of HCWs displaced by conflict, this study identified few specific policies and limited information explicitly focused on the repatriation and reintegration of such workers to their home country in the post-conflict period. Additional research is needed to understand the particular barriers faced by conflict-displaced HCWs in returning to their home country. Conflict-affected and post-conflict states should develop policies and initiatives that address factors within and beyond the health sector to encourage displaced HCW return and provide sustainable reintegration solutions for those who return to post-conflict health systems.

Attitudes and practices of public health academics towards research funding from for-profit organizations: cross-sectional survey

Objectives

The growing trend of for-profit organization (FPO)-funded university research is concerning because resultant potential conflicts of interest might lead to biases in methods, results, and interpretation. For public health academic programmes, receiving funds from FPOs whose products have negative health implications may be particularly problematic.

Methods

A cross-sectional survey assessed attitudes and practices of public health academics towards accepting funding from FPOs. The sampling frame included universities in five world regions offering a graduate degree in public health; 166 academics responded. Descriptive, bivariate, and logistic regression analyses were conducted.

Results

Over half of respondents were in favour of accepting funding from FPOs; attitudes differed by world region and gender but not by rank, contract status, % salary offset required, primary identity, or exposure to an ethics course. In the last 5 years, almost 20% of respondents had received funding from a FPO. Sixty per cent of respondents agreed that there was potential for bias in seven aspects of the research process, when funds were from FPOs.

Conclusions

Globally, public health academics should increase dialogue around the potential harms of research and practice funded by FPOs.

Electronic supplementary material

The online version of this article (10.1007/s00038-020-01416-0) contains supplementary material, which is available to authorized users.

Health research in humanitarian crises: an urgent global imperative

Globally, humanitarian crises—such as armed conflict, forced displacement, natural disasters and major disease outbreaks—affect more people today than at any point in recorded history. These crises have immense acute and long-term health impacts on hundreds of millions of people, predominantly in low and middle-income countries (LMIC), yet the evidence base that informs how humanitarian organisations respond to them is weak. Humanitarian crises are often treated as an outlier in global health. However, they are an increasingly common and widespread driver of health that should be integrated into comprehensive approaches and strategies, especially if we hope to achieve ambitious global health targets such as the Sustainable Development Goals. The academic research community can play an important role in addressing the evidence gap in humanitarian health. There are important scientific questions of high public health relevance that can only be addressed by conducting research in humanitarian settings. While working in these settings is uniquely challenging, there are effective strategies that can be employed, such as using flexible and adaptive research methodologies, partnering with non-governmental organisations and other humanitarian actors, and devoting greater attention to issues of research ethics, community engagement, local LMIC-based partners, building humanitarian research capacity and collaborating across disciplines.

Schools of public health in low and middle-income countries: an imperative investment for improving the health of populations?

BACKGROUND

Public health has multicultural origins. By the close of the nineteenth century, Schools of Public Health (SPHs) began to emerge in western countries in response to major contemporary public health challenges. The Flexner Report (1910) emphasized the centrality of preventive medicine, sanitation, and public health measures in health professional education. The Alma Ata Declaration on Primary Health Care (PHC) in 1978 was a critical milestone, especially for low and middle-income countries (LMICs), conceptualizing a close working relationship between PHC and public health measures. The Commission on Social Determinants of Health (2005-2008) strengthened the case for SPHs in LMICs as key stakeholders in efforts to reduce global health inequities. This scoping review groups text into public health challenges faced by LMICs and the role of SPHs in addressing these challenges.

MAIN TEXT

The challenges faced by LMICs include rapid urbanization, environmental degradation, unfair terms of global trade, limited capacity for equitable growth, mass displacements associated with conflicts and natural disasters, and universal health coverage. Poor governance and externally imposed donor policies and agendas, further strain the fragile health systems of LMICs faced with epidemiological transition. Moreover barriers to education and research imposed by limited resources, political and economic instability, and unbalanced partnerships additionally aggravate the crisis. To address these contextual challenges effectively, SPHs are offering broad based health professional education, conducting multidisciplinary population based research and fostering collaborative partnerships. SPHs are also looked upon as the key drivers to achieve sustainable development goals (SDGs).

CONCLUSION

SPHs in LMICs can contribute to overcoming several public health challenges being faced by LMICs, including achieving SDGs. Most importantly they can develop cadres of competent and well-motivated public health professionals: educators, practitioners and researchers who ask questions that address fundamental health determinants, seek solutions as agents of change within their mandates, provide specific services and serve as advocates for multilevel partnerships. Funding support, human resources, and agency are unfortunately often limited or curtailed in LMICs, and this requires constructive collaboration between LMICs and counterpart institutions from high income countries.

Occupational health and safety in hospitals accreditation system: the case of Lebanon

Introduction

Hospital accreditation can be an incentive to improve occupational health and safety (OHS) performance.

Objective

This study assesses the relationship between status of accreditation among private Lebanese hospitals and compliance with OHS accreditation standards.

Methods

A survey was administered to 68 private Lebanese hospitals to assess accreditation status and specific indicators related to each of the 9 OHS codes in the Lebanese accreditation manual. Chi-square, Fisher’s exact test, and independent sample t-tests compared the OHS standards between accredited and non-accredited hospitals.

Results

Fifty-six percent of participating private hospitals were accredited. Accredited hospitals reported statistically better OHS performance than non-accredited hospitals based on the standards outlined in the accreditation manual. However, there was inconsistent performance on numerous OHS indicators among participating hospitals.

Conclusion

The gaps in OHS performance suggest the need for strengthened OHS guidelines in the national accreditation process to safeguard workers’ health. Strategies to fortify OHS performance include tying service reimbursement to OHS compliance and linking OHS standards with national labor legislation.

Health and ecological sustainability in the Arab world: a matter of survival

Discussions leading to the Rio+20 UN conference have emphasised the importance of sustainable development and the protection of the environment for future generations. The Arab world faces large-scale threats to its sustainable development and, most of all, to the viability and existence of the ecological systems for its human settlements. The dynamics of population change, ecological degradation, and resource scarcity, and development policies and practices, all occurring in complex and highly unstable geopolitical and economic environments, are fostering the poor prospects. In this report, we discuss the most pertinent population-environment-development dynamics in the Arab world, and the two-way interactions between these dynamics and health, on the basis of current data. We draw attention to trends that are relevant to health professionals and researchers, but emphasise that the dynamics generating these trends have implications that go well beyond health. We argue that the current discourse on health, population, and development in the Arab world has largely failed to convey a sense of urgency, when the survival of whole communities is at stake. The dismal ecological and development records of Arab countries over the past two decades call for new directions. We suggest that regional ecological integration around exchange of water, energy, food, and labour, though politically difficult to achieve, offers the best hope to improve the adaptive capacity of individual Arab nations. The transformative political changes taking place in the Arab world offer promise, indeed an imperative, for such renewal. We call on policy makers, researchers, practitioners, and international agencies to emphasise the urgency and take action.

Using epidemiology and neurotoxicology to reduce risks to young workers

Children around the world are working in hazardous or unsafe conditions and they are at risk to injury through manual labor and susceptible to poisoning due to chemical exposures in the work place. Because of their behavior and the developmental changes occurring throughout childhood and adolescence children are more vulnerable to injury. Often children work because of economic necessity, coming from families living in extreme poverty, with poor housing conditions, unsafe water supplies, poor sanitation, and inadequate food supplies making them even more vulnerable to poor developmental outcomes. This presents a multifaceted problem that can be challenging to address. Although many studies have examined occupational risks among adults very few studies have examined the impact of these risks on children. This paper reflects a summary of the talks from the symposium "Using Epidemiology and Neurotoxicology to Reduce Risks to Young Workers" presented at the 13th International Neurotoxicology Association Meeting and the 11th International Symposium on Neurobehavioral Methods and Effects in Occupational and Environmental Health in Xi'an China in June 2011. Epidemiological studies have demonstrated that children are exposed to various neurotoxicants, show increased symptoms and health problems and are working in hazardous conditions with minimal safety restrictions. Other studies have identified neurotoxicology effects in children from occupational exposures. Prevention methods have potential for reducing risks to young workers short of eliminating child labor and should be addressed to multiple stakeholders, parents, employers and children.

Occupational exposure to neurotoxic substances in Asian countries - challenges and approaches

The fact that a conference on neurotoxicity was held in China triggered the idea to provide an insight into occupational diseases, their development and the approaches to investigate them in Asian countries. A historical review, a meta-analysis, and studies on humans and animals provide impressions on past and current problems. The Korean example showed that each newly introduced industry is accompanied by its own problems as regards occupational diseases. Mercury and carbon disulfide were of importance in the beginning, whereas solvents and manganese became important later. Outbreaks of diseases were important reasons to guide both the public and the governmental attention to prevention and allowed within a relatively short time considerable progress. As the example on the replacement of 2-bromopropane by 1-bromopropane showed, also the introduction of chemicals that are more beneficial for the environment may result in additional occupational risks. A lower mutagenicity of 1-bromopopane was shown to be associated with a greater neurotoxicity in Japanese studies. Although occupational health and diseases are commonly related to adults, child workers exposed to solvents were examined in a Lebanese study. The study started outlining the health hazards in young workers because they might be at a much greater risk due to the not yet completed maturation of their nervous system. That some occupational diseases are not yet a focus of prevention was shown by the study on pesticides. If at all, the serious health consequences resulting from excessive exposure were investigated. Research enabling precautionary actions was not available from the international literature. Despite globalization the knowledge on occupational diseases is not yet "globalized" and each country obviously undergoes its own development triggered by local experiences. Economic development that requires a healthy workforce, but also public interest that challenges governmental regulations further efforts on the prevention of occupational diseases. The paper reflects a summary of the talks presented at the symposium "Occupational Neurotoxicities in Asian Countries" as part of the 11th International Symposium on Neurobehavioral Methods and Effects in Occupational and Environmental Health.

Summer 2006 war on Lebanon: a lesson in community resilience

The internally displaced persons (IDPs) during the July 2006 war in Lebanon exhibited a high level of community resilience, affirmed by relief agencies and public health professionals. Data from personal observations, interviews, meetings and published material were used to examine factors contributing to this resilience. Findings suggested that community resilience is a process rather than an outcome. The sense of a collective identity, prior experience with wars and social support networks have contributed to building up IDP's resilience over time, while community cohesiveness, adequate public health interventions, social solidarity and a connected political leadership helped to sustain it during and shortly after the war. This paper examines implications for public health professionals and argues for a paradigm shift in disaster relief practice.

The challenges of sustainable access to safe drinking water in rural areas of developing countries: case of Zawtar El-Charkieh, Southern Lebanon

Adequate and safe water is important for human health and well-being, economic production, and sustainable development. Failure to ensure the safety of drinking water may expose the community to the risk of outbreaks of waterborne and infectious diseases. Although drinking water is a basic human right, many people do not have access to safe and adequate drinking water or proper sanitation facilities. The authors conducted a study to assess the quantity, cost, continuity, coverage, and quality of drinking water in the village of Zawtar El-Charkieh, Lebanon. Their aim was to identify the challenges of sustainable access to safe drinking water in order to determine the short-term management actions and long-term strategies to improve water quality. Results revealed that contamination of the source, absence of any disinfection method or insufficient dose, poor maintenance operations, and aging of the networks are significant factors contributing to water contamination during the storage and distribution process. Establishing a comprehensive drinking water system that integrates water supply, quality, and management as well as associated educational programs in order to ensure the safety and sustainability of drinking water supplies is essential.

Neurobehavioral impairment in children occupationally exposed to mixed organic solvents

BACKGROUND

Our previous work has demonstrated adverse effects on neuropsychological and neurobehavioral function in solvent-exposed working children compared to non-exposed working and school children. The aim of this paper was to examine the dose-response relationships between neurobehavioral function and solvent exposure in children.

METHODS

We tested 120 male children aged 10-17 years (100 working solvent-exposed, 10 working children, 10 school children). Neurotoxic effects were assessed through a questionnaire and a selection of neurobehavioral tests. Workplace exposure to a mixture of solvents was measured using personal passive samplers.

RESULTS

Children with higher solvent exposure showed significantly higher reporting of neurotoxic symptoms (P=0.02). Importantly, multiple regression models revealed significant dose-response relationships, with higher cumulative exposure associated with poorer performance on the Choice Reaction Time, Symbol Digit, Continuous Performance, Digit Span and Grooved Pegboard tests.

CONCLUSIONS

This study provides the first empirical evidence of a dose-response association between exposure to solvents and neurobehavioral performance in working children. This finding implies that solvent-exposed working children are at high risk of developing neurobehavioral impairments. These impairments are likely to interfere with their capacity to respond quickly and safely to new demands and to learn new information.

Effect of women's perceptions and household practices on children's waterborne illness in a low income community

An ecosystem approach to human health was adopted in a community-based study carried out in Bebnine, an underserved town in Lebanon. The objective of the study is to examine the association between women's household practices and diarrhea among children in a setting where contaminated drinking water and intestinal diseases are common. A total of 280 women were randomly selected and interviewed using a structured questionnaire. Data were collected on 712 children between the ages of 6 and 14. The study instrument included determinants of diarrhea such as sociodemographic characteristics, water, sanitation, hygiene practices, gender variables, and behavioral risk factors. Multivariate regression analysis was employed to examine the association between water handling practices and diarrhea. The prevalence of diarrhea is 5%. Female children are more likely to suffer from diarrhea than male children (OR = 2.58; 95% CI: 1.19-5.62). Treatment of drinking water at the household level and the use of drinking water for cooking and the preparation of hot beverages are protective against diarrhea (OR = 0.15; 95% CI: 0.03-0.65). Female caretakers' behaviors such as daily bathing and seeking medical care at times of illness are protective against diarrhea in children. The findings suggest that diarrhea is a gendered health problem. Female children, who are generally more involved in household activities than male children, are at higher risk of suffering from diarrhea. Female caretakers' personal hygiene, household practices, and perceptions of diarrhea are additional risk factors. Intervention activities would be more effective if based on a better understanding of gender roles and household power relations.

Did a ban on diesel-fuel reduce emergency respiratory admissions for children?

This paper assesses whether a ban on diesel-powered motor vehicles in Lebanon has reduced emergency respiratory admissions for children less than 17 years of age in Beirut. Monthly admissions for total respiratory complaints, asthma, bronchitis, pneumonia, and upper respiratory tract infections, from October to February, were compared before and after the ban, using Poisson regression models and adjusting for rainfall, humidity and temperature. Analyses were repeated excluding the flu months of January and February. A test of significance of p < or = 0.05 was used. Air pollution is not systematically monitored in Lebanon and no ambient particulate concentration data were available. A significant drop in admissions for respiratory symptoms (p < or = 0.05) and upper respiratory tract infection (p < or = 0.001) from 1 year pre-ban to 1 year post-ban has been recorded. When flu months are excluded, a significant drop (p < or = 0.001) in admissions for all studied categories, except pneumonia, is observed. The effect of the ban however was negligible in the second year. When 2 year pre-ban versus 2 year post-ban are considered excluding flu months, statistically non-significant reductions are recorded for asthma and upper respiratory tract infection (p < or = 0.1). The study hence suggests an impact of the diesel ban on respiratory health only during the first year after the ban. This finding is weakened by the absence of supporting evidence from air quality monitoring and speciation of particulate matter, which are lacking in Lebanon and most developing countries.

Can action on health achieve political and social reform?

Public debate about health is rare in Arab countries. But getting the social and political issues underlying health problems onto the agenda could have wider effects on the region's political stagnation

Older adults in the division of domestic labor in communities on the outskirts of Beirut

The gendered division of domestic labor has been widely studied over the last three decades. However, older adults' contribution to housework, especially in patriarchal communities in the Middle East, has been largely overlooked. This article examined the participation of older members of the household in domestic labor in three communities in the outskirts of Beirut, the capital of Lebanon. Drawing on a sample of 2,797 households, the results revealed that three salient factors seemed to have the major impact on older adults' participation in domestic labor; these were the presence of adult women (18-59 years old) in the household, the marital status and age of older adults. Older men's participation in domestic labor was much lower than that of older women, suggesting that a gender divide exists among older adults in the patriarchal setting of the study. Housework remains feminized in the later stage of life.

Musculoskeletal disorders among full-time homemakers in poor communities

OBJECTIVE

To examine factors associated with self-reported musculoskeletal disorders (MSD) among full-time female homemakers.

METHODS

Data on socio-demographic characteristics, lifestyle and health were collected on 1266 married women aged 15-59 years living in poor suburbs in the outskirts of Beirut, Lebanon. Independent associations with MSD of factors and characteristics were examined using odds ratios (ORs) derived from multiple logistic regression.

RESULTS

Women's age, weight, and number of children were significantly, positively, independently associated with self-reported MSD, while women's conduct of specific household tasks were not. Women with MSD were more likely to be stressed than women without MSD (OR = 1.5).

CONCLUSION

A major finding of this study was the positive association between distress and musculoskeletal disorders. The measures used to assess women's involvement in housework did not account for the duration of time spent performing each household task. Better measures of domestic labor, including housework and childcare, are required to understand better their impact on the health of full-time homemakers and on MSD in particular. Intervention programs to alleviate MSD in full-time homemakers should address psychosocial factors.

Why do neighbors have different environmental priorities? Analysis of environmental risk perception in a Beirut neighborhood

Differences in environmental priorities within an urban neighborhood of Beirut are analyzed. The explanatory capabilities of five categories of contextual variables are compared: socioeconomic status, locality, health, behavior, and environmental beliefs. Semi-structured interviews with key individuals in the community and residents were first conducted. Four environmental issues of concern were identified. A survey was carried out to identify the relative priority accorded by respondents to these four issues, and to measure variables likely to explain differences of opinion. Bivariate and multivariate logistic regression analyses were conducted for each of the four problems. The 99% confidence interval (CI) of the odds ratio (OR) was used as a test of significance. Respondents suffering from a respiratory disease (OR = 6.94, 99%CI = 1.54-31.25), those living in less crowded houses (OR = 4.88, 99%CI = 1.38-17.24), and those not living close to the neighborhood's industrial street (OR=5.26, 99%CI = 1.01-27.78) are significantly more likely to rank poor air quality first. Significant associations are found between poor water quality as first priority and nonpresence of a smoker in the household (OR = 6.12, 99%CI = 1.84-20.32) and perception of water salinity as a problem (OR = 7.46, 99%CI = 1.50-37.03). Males (OR = 6.94, 99%CI = 1.02-47.62) and tenants versus owners (OR = 10.49, 99%CI = 1.36-80.61) are significantly more likely to rank the residential-industrial mix first. Socioeconomic variables retain their explanatory capability in the studied neighborhood, despite relatively small income disparities. Behavioral variables, such as smoking, may be causative factors of priorities. Analyzing relative priorities, rather than "concern" or lack of it, reveals more complex patterns of association. Identifying environmental-perception divide lines can help develop a more inclusive and effective participatory environmental management.

Determinants of the willingness-to-participate in an environmental intervention in a beirut neighborhood

Participatory environmental management can empower communities and enhance the sustainability of environmental interventions. However, existing power structures and inequalities along class, gender, or ethnic lines could prevent part of the community from accessing the full benefits of the intervention. An analysis of determinants of the willingness-to-participate in an environmental intervention in a Beirut neighborhood is conducted. Socioeconomic, health-risk distribution, and perception of community efficacy are used as predictors. A randomly selected sample of residents was surveyed. Respondents were asked to specify the frequency with which they were willing to be involved in an intervention to address priority environmental problems in the neighborhood. Bivariate and multivariate ordinal regression analyses were conducted. Tests of significance were based on the 95% confidence intervals (CI) of the odds ratio (OR). Males versus females (OR = 4.89, P < 0.001), respiratory patients versus nonsufferers (OR = 5.65, P < 0.001), tenants versus house owners (OR = 2.98, P < 0.01), and the less educated versus the more educated (OR = 2.42, P < 0.05) were significantly more likely to be willing to participate. The reluctance of female community members to participate might be a major hindrance to community-based environmental protection and special strategies must be devised to overcome it. On the other hand, respondents suffering from an illness perceived to be related to environmental toxins are likely to be strong participants in environmental conservation efforts. Finally, the study yielded no evidence that belief or lack of it in the efficacy of community action is a good predictor of the willingness-to-participate in such action.

The effects of solvent exposure on memory and motor dexterity in working children

OBJECTIVES

Children working in vehicle spray-painting, mechanical, and other trade workshops are at significant risk of exposure to organic solvents and, as a result, may be at significant risk of developing clinical and subclinical signs of neurotoxicity. This study reports on the association between exposure to solvents and neurobehavioral performance on a number of non-computerized tests for working children exposed to solvents in comparison with nonexposed working children and nonexposed children at school.

METHODS

A convenience cross-sectional sample of 300 male children aged 10-17 years was recruited for study. The exposed working group and the two nonexposed groups (working and nonworking school) were matched, as far as possible, on geographic location of residence and age. Neurotoxic effects were assessed through a questionnaire and the child's performance on a selection of neurobehavioral tests.

RESULTS

Exposed working children scored worse on the overall neurotoxicity symptoms score (mean=6.8; standard deviation [SD]=3.6) compared with the nonexposed working children (mean=1.3; SD=2.0) and school children (mean=1.2; SD=1.8). Analysis of the non-computerized neurobehavioral tests demonstrated that exposed working children performed significantly worse than the two nonexposed groups on the motor dexterity and memory tests. Results of the mood test showed that exposed working children were more angry and confused than the nonexposed groups.

CONCLUSION

There is an association between exposure to solvents and lower neurobehavioral performance, with significant neurobehavioral deficits among children exposed to solvents in comparison with working children not exposed to solvents and nonworking school children. Memory and motor dexterity appear to be particularly affected in solvent-exposed working children.

Mapping the health and environmental situation in informal zones in Aleppo, Syria: report from the Aleppo household survey

OBJECTIVES

Despite large communities living in informal zones around major cities in Syria, there is currently no information on the health and environmental situations in these areas. From May to August 2004, the Syrian Center for Tobacco Studies (SCTS) conducted the first household survey aiming to provide a baseline map of main health problems and exposures affecting these communities in Aleppo, the second largest city in Syria (2,500,000 inhabitants).

METHODS

Information on 1,021 participants randomly selected using stratified cluster sampling were available (46% males, mean age 34+/-11.7, age range 18-65 years, response rate 86%), including self-reported health/disability, exposures, and saliva cotinine measurement.

RESULTS

Some positive findings include better than expected access to electricity, piped water, city sewage, and the use of propane for cooking. Particular areas of concern include high fertility rates, overcrowded housing conditions, and gender inequality in education and work. Household features likely to reflect negatively on residents' health include the use of diesel chimneys for heating and lack of smoking restrictions. Overall, residents of informal zones suffer from substantial physical and mental health problems and are exposed to high levels of indoor air pollution. All seem to affect women and the elderly disproportionately, while men are more affected by smoking, occupational respiratory exposures, and injuries. Both infectious and non-infectious respiratory outcomes were very common among study participants. Chronic and degenerative disease, including CVD and joint problems, were a source of substantial morbidity among the studied communities.

CONCLUSIONS

This study highlights major health and environmental specificities of marginalized populations living in Aleppo, where women seem to bear a disproportionate burden of poor health and disability. Smoking and exposure to tobacco smoke seem among the major exposures facing these populations.

Evidence of neurotoxicity in working children in Lebanon

The potential for exposure to neurotoxicants in Lebanon is high, especially in the absence of strict control and regulatory measures in workplaces. Children working in mechanical and other trade workshops are at significant risk of exposure to organic solvents and as a result at significant risk to develop clinical and subclinical signs of neurotoxicity. This study investigated the association between exposure to solvents and neurobehavioral performance of 10-17 years old working children in comparison to groups of non-exposed working children and non-exposed children at school. A convenience cross-sectional sample of 100 working children (10-17 years) exposed to organic solvents at work, a positive control of 100 non-solvent exposed working children, and a negative control of 100 non-working, non-exposed school children were recruited to the study. The exposed and non-exposed groups were, as far as possible, frequency matched on geographic location of residence and on age. Neurotoxic effects were assessed through a questionnaire and the child's performance on a battery of neurobehavioral tests, which were specifically selected for a non-English speaking population and were tailored to assess the specific modalities of the central nervous system commonly known to be affected by the neurotoxicants identified. Children in the non-exposed groups (working and non-working) performed better than the working exposed group on reaction speed for the choice reaction time, symbol-digit and dual task tracking tests, but accuracy of performance was not affected on these tests. Children in the working exposed group also complained of more headaches, loss of concentration, memory deficits and higher irritability. This study identifies an association between exposure to solvents and lower neurobehavioral performance. Response speed appears to be particularly affected in solvent exposed working children.

Work-related injuries in Lebanon: does nationality make a difference?

BACKGROUND

To compare the type, severity, cause, and cost of work-related injuries between Lebanese and non-Lebanese workers in insured workplaces in Lebanon.

METHODS

A total of 4,186 claims and medical reports for 3,748 work-related injuries filed in 1998 at five major insurance companies were reviewed.

RESULTS

Non-Lebanese workers (46%) were younger (29 vs. 31 years), belonged mainly to the construction sector (62% vs. 29%), and were paid less (365 dollars vs. 438 dollars/month) than Lebanese workers. Non-Lebanese construction workers reported more feet and eye injuries. Falls were more common among Lebanese workers while non-Lebanese workers commonly reported being struck by an object. No differences were noted in the severity of injuries (workdays lost; hospitalization) between the two groups, but, overall cost per injury was higher among the Lebanese workers.

CONCLUSIONS

There were no salient differences between Lebanese and non-Lebanese workers regarding severity of work injuries, which may reflect the disparity in access to the Lebanese heath care system by nationality. Syrian migrant workers appear to represent a special group in Lebanon. Additional, in-depth analysis of the social, political, and workplace mechanisms leading to work injuries is recommended.

Blood lead concentrations in 1-3 year old Lebanese children: a cross-sectional study

BACKGROUND

Childhood lead poisoning has not made the list of national public health priorities in Lebanon. This study aims at identifying the prevalence and risk factors for elevated blood lead concentrations (B-Pb >or= 100 microg/L) among 1-3 year old children. It also examines the need for universal blood lead screening.

METHODS

This is a cross-sectional study of 281 well children, presenting to the pediatric ambulatory services at the American University of Beirut Medical Center in 1997-98. Blood was drawn on participating children for lead analysis and a structured questionnaire was introduced to mothers asking about social, demographic, and residence characteristics, as well as potential risk factors for lead exposure. Children with B-Pb >or= 100 microg/L were compared to those with B-Pb < 100 microg/L.

RESULTS

Mean B-Pb was 66.0 microg/L (median 60.0; range 10-160; standard deviation 26.3) with 39 (14%) children with B-Pb >or= 100 microg/L. Logistic regression analysis showed that elevated B-Pb was associated with paternal manual jobs (odds ratio [OR]: 4.74), residence being located in high traffic areas (OR: 4.59), summer season (OR: 4.39), using hot tap water for cooking (OR: 3.96), exposure to kohl (OR: 2.40), and living in older buildings (OR: 2.01).

CONCLUSION

Lead screening should be offered to high-risk children. With the recent ban of leaded gasoline in Lebanon, emphasis should shift to other sources of exposure in children.

Cost of work-related injuries in insured workplaces in Lebanon

OBJECTIVE

To estimate the medical and compensation costs of work-related injuries in insured workplaces in Lebanon and to examine cost distributions by worker and injury characteristics.

METHODS

A total of 3748 claims for work injuries processed in 1998 by five major insurance companies in Lebanon were reviewed. Medical costs (related to emergency room fees, physician consultations, tests, and medications) and wage and indemnity compensation costs were identified from the claims.

FINDINGS

The median cost per injury was US dollars 83 (mean, US dollars 198; range, US dollars 0-16,401). The overall cost for all 3748 injuries was US dollars 742,100 (76% of this was medical costs). Extrapolated to all injuries within insured workplaces, the overall cost was US dollars 4.5 million a year; this increased to US dollars 10 million-13 million when human value cost (pain and suffering) was accounted for. Fatal injuries (three, 0.1%) and those that caused permanent disabilities (nine, 0.2%) accounted for 10.4% of the overall costs and hospitalized injuries (245, 6.5%) for 45%. Cost per injury was highest among older workers and for injuries that involved falls and vehicle incidents. Medical, but not compensation, costs were higher among female workers.

CONCLUSION

The computed costs of work injuries--a fraction of the real burden of occupational injuries in Lebanon--represent a considerable economic loss. This calls for a national policy to prevent work injuries, with a focus on preventing the most serious injuries. Options for intervention and research are discussed.

Respiratory health effects of industrial air pollution on children in North Lebanon

This study assesses the association between the proximity of residence to cement and fertilizer plants in industrialized districts and respiratory health complaints among children (5-15 years old) in Northern Lebanon. A multi-stage random sample of households was selected from two exposed districts and a third non-industrialized. One child was randomly selected from each household for a total of 486 children. Living within 0-3 km of industries, as compared to living farther away (4-7 km), was associated with a statistically significant increase in the risk for cough with colds (adjusted odds ratio (OR) = 3.40), phlegm with colds (OR = 2.14), yearly episodes of cough and phlegm (OR = 4.63), yearly chest colds (OR = 4.12), and wheezing (OR = 2.23). When compared to living in the non-industrialized district, children living within 0-3 km of industries showed a significantly higher risk for yearly chest colds (OR = 2.30). However, living in the 4-7 km region of industries was associated with a lower risk of respiratory complaints, as compared to living in the comparison area. This was attributed to higher altitudes and different meteorological characteristics. A higher risk of respiratory problems was reported among children living close to cement than fertilizer industries. Policy intervention measures are recommended.

Inadequacies of death certification in Beirut: who is responsible?

OBJECTIVE

To assess the completeness of data on death certificates over the past 25 years in Beirut, Lebanon, and to examine factors associated with the absence of certifiers' signatures and the non-reporting of the underlying cause of death.

METHODS

A systematic 20% sample comprising 2607 death certificates covering the 1974, 1984, 1994, 1997 and 1998 registration periods was retrospectively reviewed for certification practices and missing data.

FINDINGS

The information on the death certificates was almost complete in respect of all demographic characteristics of the deceased persons except for occupation and month of birth. Data relating to these variables were missing on approximately 95% and 78% of the certificates, respectively. Around half of the certificates did not carry a certifier's signature. Of those bearing such a signature, 21.6% lacked documentation of the underlying cause of death. The certifier's signature was more likely to be absent on: certificates corresponding to the younger and older age groups than on those of persons aged 15-44 years; those of females than on those of males; those of persons who had been living remotely from the registration governorate than on those of other deceased persons; and those for which there had been delays in registration exceeding six months than on certificates for which registration had been quicker. For certificates that carried the certifier's signature there was no evidence that any of the demographic characteristics of the deceased person was associated with decreased likelihood of reporting an underlying cause of death.

CONCLUSION

The responsibility for failure to report causes of death in Beirut lies with families who lack an incentive to call for a physician and with certifying physicians who do not carry out this duty. The deficiencies in death certification are rectifiable. However, any changes should be sensitive to the constraints of the organizational and legal infrastructure governing death registration practices and the medical educational systems in the country.

Prevalence of hepatitis B infection markers in Lebanese children: the need for an expanded programme on immunization

This multi-centre, cross-sectional study was designed to reveal the present status of hepatitis B infection markers among Lebanese children, and provide recommendations regarding childhood immunization policies. A total of 841 children, aged between 6 months and 6.5 years, were enrolled from Lebanon's five districts. Their sera were tested for hepatitis B surface antigen and hepatitis B core IgG. The overall prevalence of hepatitis B virus infection markers was 0.8% with increasing age-specific rates from 0% at 6 months to 1.3 % at > 5 years. There was no statistically significant association between the presence of hepatitis B markers and family characteristics or risk factors for infection. The highest prevalence rates were among children from Beirut suburbs (2.9 %) and South Lebanon (1.6%). The risk of horizontal transmission of hepatitis B to uninfected children increased substantially after the age of 2 years. An expanded programme on immunization that integrates hepatitisB vaccine during the first year of life is needed.

Determinants of elevated blood lead levels among working men in Greater Beirut

This cross-sectional study reports the blood lead levels (BLL) among different working groups in Beirut and identifies the risk factors associated with elevated BLLs. A total of 579 men of 18 years of age or older (response rate 96%) working in Greater Beirut were interviewed. Of those, 315 (54.4%) provided a blood sample of which 291 were analyzed for lead. The mean BLL of the 134 men working in white-collar jobs (offices, retail shops) was 12.7 microg/dl (SD 3.7); statistically significantly lower than the mean BLL (18.4 microg/dl; SD 9.8) of the 157 men working in blue-collar occupations (such as gas station attendants, painters, mechanics). A blood lead level of 15 microg/dl or more was associated with blue-collar jobs, number of cigarettes smoked, commuting > or = 3 km to work, years in current occupation, and younger age. A BLL of at least 20 microg/dl was associated with eating lunch at work, in addition to blue-collar jobs, smoking, commuting, years of work, and younger age. The study findings suggest that environmental exposure (those not otherwise exposed to occupational lead) is mainly determined by smoking and exposure to leaded gasoline (commuting). Occupational exposure to lead is prevalent among a wide spectrum of Lebanese workers. Physicians are called upon to inquire more about the potential for lead exposure, especially among blue-collar workers. A policy action to improve working conditions and to phase out the use of leaded gasoline is recommended.

The impact of occupational injury on injured worker and family: outcomes of upper extremity cumulative trauma disorders in Maryland workers

BACKGROUND

Surveys have identified a dramatically rising incidence of work-related upper extremity cumulative trauma disorders (UECTDs). Outcome studies have addressed time lost from work and cost of compensation; omitting other significant consequences. We assess health, functional and family outcomes.

METHODS

We identified 537 Workers' Compensation UECTD claimants. A computer-assisted telephone questionnaire was used to elicit symptom prevalence, functional impairment, depressive symptoms (CES-D scale), employment status.

RESULTS

One to 4 years post-claim, respondents reported persistent symptoms severe enough to interfere with work (53%), home/recreation activities (64%) and sleep (44%). Only 64% of responses to the activities of daily living scale items indicated "normal" function. Job loss was reported by 38% of respondents, and depressive symptoms by 31%.

CONCLUSIONS

Work-related UECTDs result in persisting symptoms and difficulty in performing simple activities of daily living, impacting home life even more than work. Job loss, symptoms of depression, and family disruption were common.

Patterns and predictors of employer risk-reduction activities (ERRAs) in response to a work-related upper extremity cumulative trauma disorder (UECTD): reports from workers' compensation claimants

BACKGROUND

Despite being preventable, work-related upper extremity cumulative trauma disorders (UECTDs) remain problematic. This study is unique in its focus on predictors of employer risk-reduction activities (ERRAs) in response to a UECTD case.

METHODS

Workers' compensation claimants (N = 537) completed a telephone survey about employer risk-reduction activities, workplace characteristics, safety programs, and physician recommendations for job modifications.

RESULTS

Only 52% of respondents reported employer actions to investigate or reduce UECTD risk. Engineering and pace changes were prominent for keyboard workers and transfer to another job for manufacturing workers. Safety programs and physician recommendations increased the likelihood of risk-reduction activities.

CONCLUSIONS

An opportunity to intervene post-injury to reduce risks for the injured worker and prevent new UECTD cases is being missed. Physician recommendations are strongly associated with specific ERRAs thought to be most effective. Educating employers and physicians about ergonomics could result in prevention of UECTDs.