ORIGINAL ARTICLE

W. Maziak Æ K. D. Ward Æ F. Mzayek Æ S. RastamM. E. Bachir Æ M. F. Fouad Æ F. Hammal Æ T. AsfarJ. Mock Æ I. Nuwayhid Æ H. Frumkin Æ F. Grimsley

M. Chibli

Mapping the health and environmental situation in informal zonesin Aleppo, Syria: report from the Aleppo household surveyReceived: 17 October 2004 / Accepted: 2 March 2005 / Published online: 6 July 2005� Springer-Verlag 2005

Abstract Objectives: Despite large communities living ininformal zones around major cities in Syria, there iscurrently no information on the health and environ-mental situations in these areas. From May to August2004, the Syrian Center for Tobacco Studies (SCTS)conducted the first household survey aiming to provide abaseline map of main health problems and exposuresaffecting these communities in Aleppo, the second larg-est city in Syria (2,500,000 inhabitants). Methods:Information on 1,021 participants randomly selectedusing stratified cluster sampling were available (46%males, mean age 34±11.7, age range 18–65 years, re-sponse rate 86%), including self-reported health/dis-ability, 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 ofconcern include high fertility rates, overcrowded housingconditions, and gender inequality in education andwork. Household features likely to reflect negatively onresidents‘ health include the use of diesel chimneys forheating and lack of smoking restrictions. Overall, resi-dents of informal zones suffer from substantial physicaland mental health problems and are exposed to highlevels of indoor air pollution. All seem to affect womenand the elderly disproportionately, while men are moreaffected by smoking, occupational respiratory expo-sures, and injuries. Both infectious and non-infectiousrespiratory outcomes were very common among studyparticipants. Chronic and degenerative disease, includ-ing CVD and joint problems, were a source of sub-stantial morbidity among the studied communities.Conclusions: This study highlights major health andenvironmental specificities of marginalized populationsliving in Aleppo, where women seem to bear a dispro-portionate burden of poor health and disability. Smok-ing and exposure to tobacco smoke seem among themajor exposures facing these populations.

Keywords Respiratory Æ Environmental Æ Risks ÆInformal zones Æ Urban Æ Aleppo Æ Syria

Introduction

One of the key economic development trends with po-tential to threaten human health in many developingcountries is mass rural–urban migration resulting inhaphazard urban growth (Brennan 1999). Over the pastcentury the proportion of the world’s population livingin large towns and cities has increased from 5 to 45%,and it is expected to reach about two-thirds by the year2030 (Howson et al. 1998), mostly at the expense ofincreasing urbanization in developing countries (Popu-lation Reports 2002). In Syria, current estimates showthat half of the Syrian population lives in urban areas

W. Maziak Æ K. D. Ward Æ S. Rastam Æ M. E. BachirM. F. Fouad Æ F. Hammal Æ T. AsfarSyrian Center for Tobacco Studies, Teshrin St., 16542, Aleppo,Syria

W. Maziak (&)Institute of Epidemiology and Social Medicine, Muenster,GermanyTel.: +963-21-2644246Fax: +963-21-26499150

K. D. WardDepartment of Health Sport Sciences, University of Memphis,Memphis, TN, USA

K. D. WardCenter for Community Health, University of Memphis, Memphis,TN, USA

F. MzayekDepartment of Epidemiology, Tulane School of Public Health andTropical Medicine, New Orleans, LA, USA

J. MockDepartment of Medicine, University of California, San Francisco,CA, USA

I. NuwayhidDepartment of Environmental Health, Faculty of Health Sciences,American University of Beirut, Beirut, Lebanon

H. FrumkinDepartment of Environmental and Occupational Health, RollinsSchool of Public Health of Emory University, Atlanta, GA, USA

Int Arch Occup Environ Health (2005) 78: 547–558DOI 10.1007/s00420-005-0625-7

and that urbanization of the Syrian population isincreasing steadily (Population Reference Bureau 2003;UNPD 2000). Driven by economic factors and dispari-ties in provided services between rural and urban areas,waves of migration from rural areas and small townstend to target major urban centers forming largeneighborhoods with diverse populations. As a result, thetwo major cities in Syria—Damascus and Aleppo—arenow home to more than a third of the Syrian population(UNPD 2000). Most migrants tend to settle on theperiphery of cities forming clusters of haphazard resi-dential areas, where homes are built without formalground plans or approval from the municipal authori-ties. Aleppo in particular has become the northern cen-ter of Syrian economic and commercial activities,making it a favorable destination for waves of economicmigration from its surrounding countryside as well asadjacent minor towns. It is likely that informal settle-ment zones surrounding Aleppo occupy about 40–45%of the city’s inhabited area, where an estimated onemillion people live (i.e., about half of Aleppo’s area andpopulation belong to this type) (Chibli and Sakkal1999). People living in these informal zones are not onlydeprived of basic physical assets, but also lack politicalinfluence and access to services or social capital, ren-dering them most vulnerable to environmental healthrisks (WHO 1995). These communities are thus likely tocombine the traditional health problems of poverty,such as respiratory and enteric infections, with those ofpoor housing and erratic industrialization (McMichael2000).

Moreover, the seriousness of the smoking problem inSyria, combined with poor housing conditions in infor-mal zones, makes indoor air pollution (IAP) due tosmoking a major source of environmental hazards facingthese communities (Maziak et al. 2005; Smith et al.2000). Research done at the Syrian Center for TobaccoStudies (SCTS) shows that about half of men in Syriaand one fifth of women currently smoke cigarettes, andthat most of households have at least a smoker amongstthem (Maziak and Tabbah 2005). In addition, Syria aswell as the whole Arab region is witnessing an alarmingspread of waterpipe smoking (Maziak et al. 2004;Rastam et al. 2004). There is currently inadequateknowledge about waterpipe smoking, which can occur athome or outdoors (cafes, restaurants), or about itscontribution to indoor air quality and health problemsof households.

Still despite the large size of communities living ininformal areas in Aleppo and the expected huge mag-nitude of their health and environmental problems, thereis currently no health surveillance system in place toassess the health needs of these communities. Little isknown in addition, about environmental hazards andtheir relation to economic and socio-cultural attributesof these communities. Since research/intervention workrelevant to health problems of residents of informalzones is prohibitive without basic orientation about theirmain demographic, socioeconomic, environmental,

cultural, and health attributes, SCTS has conducted in2004 the first population-based health and environ-mental survey in Syria (Aleppo Household Survey,AHS) to address this information void. From Aleppo’shistoric perspective, being arguably the oldest inhabitedcity in the world, the current study represents the firsteffort to address the environmental health of Allepiansin more than four millennia.

Materials and methods

Setting, population, and sampling

Informal zones refer to residential areas where housingis not in compliance with current planning and buildingregulations. These zones have been clustering in threemajor blocks on the northern, eastern and southernsides, since the western side is the main direction ofplanned expansion of Aleppo. The population density inthese areas ranges from 200 to 750 person per hectare(pph) in areas where multi-level buildings exist.

The target population of AHS was adults 18–65 yearsof age, who reside in Aleppo and could understand thestudy procedures and provide verbal consent. A two-stage, stratified, cluster sampling was used, with thetarget population divided into two strata, formal andinformal zones, according to Aleppo municipality’s re-cords. In this study we focus on informal zones (stra-tum), where from a total of 27 neighborhoods 18 wererandomly selected with probability proportional to size(PPS) with an aim for a minimum of 1,000 householdsfrom each stratum (Maziak et al. 2005). With the help ofenlarged maps a ‘‘starting point’’ in each neighborhoodwas selected, and from it every fifth household was in-cluded in the study according to specified plan. In eachparticipating household an adult from all eligible resi-dents was selected randomly, and a second interview wasscheduled if he/she was not available. Because womengenerally were more available at home our sample hadslight female/male predominance.

Survey development and administration

Prior to survey, formative work with key informants andresidents of the target neighborhoods was conducted todetermine main environmental and household features(energy, water, sewage, population composition, wastemanagement, proximity to hazardous industries, feasi-bility of survey and sampling strategy) (Hammal et al.submitted). The survey questionnaire was developedfrom standardized instruments that were utilized ininternational settings (preferably in Arabic), as well asthose used by us previously in Syria (World HealthSurvey 2000–2001; Maziak 2002; Maziak et al. 2005). Itincluded eight main sections; demographics, generalhealth and disability, chronic disease, respiratory health,

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household members’ health, environmental health,smoking, ETS exposure. Later, the survey was piloted in20 households to fine-tune the sampling and data col-lection procedures and to assess the suitability of thelanguage and terminology used for the target popula-tion. Mixed gender teams of interviewers used notebookcomputers to record questionnaire responses and mea-surements using a custom data entry program to preventmissing or wrong entries, time the procedures (qualitycontrol), and simplify survey administration.

To avoid contamination, three of the teams that werenon-smokers were assigned for the collection of salivaspecimens from all non-smoking respondents. Based onlevels of adult smoking in Aleppo we estimated to haveto have at least 200 non-smokers from the informalstratum for cotinine analysis. Saliva collection was doneby asking non-smokers to put dental roles in theirmouth for 5 min and then the absorbed saliva was ex-tracted by squeezing the roles through a 5 ml syringe(Jarvis et al. 2003). Saliva samples were then kept frozenat �20�C, until they were shipped by courier to ABSLaboratories in England for analysis using gas chro-matography with a lower detection limit of 0.1 ng/ml(Feyerabend and Russel 1990). To exclude potentialcurrent smokers from the analysis of cotinine results, werestricted the analysis to self-reported non-smokers withcotinine levels £15 ng/ml (Jarvis et al. 1987). The pro-tocol and informed consent document were approved bythe IRBs at the University of Memphis and SCTS.

Analysis and results

Data are presented in Tables 1, 2, 3, 4, 5, 6, and 7, andwording of items in the tables resemble the phrasingused during the interview. For example, to assess per-ceived general health, respondents were asked to ratetheir overall health and were given the choices excellent,good, fair, bad, very bad (Table 2). Frequency tableswere calculated for dichotomous and categorical re-sponses, while continuous variables were expressed asmean ± standard deviation (SD). Data were mainlystratified by age and gender. Age was categorized into 3groups (younger 18–29 years, middle 30–45 years, andolder 46–65 years) to allow for meaningful comparisonsand reflect to some extent the age composition of theSyrian population (Population Reference Bureau 2003).As it is evident from the tables most responses pertain tothe past year period (e.g., doctor’s diagnosed states, selfrating of health and disability), while shorter recallperiod are clearly identified.

Socio-demographics

Overall, 1,021 participants gave valid responses for theanalysis (46% were men, mean age 34 ± 11.7 years,response rate 86%). Most residents have lived for

many years (more than 10 years, on average) in theseneighborhoods, and about a quarter of them moved totheir current residence from rural areas, while the restmoved from urban areas (Table 1). Although educa-tional attainment seems to have improved for a size-able proportion of respondents compared to theirparents, the situation with education is neverthelessworrisome (Table 1). Illiteracy (total inability to readand write) is high, especially among women, reaching38% of them, while only about 4% of men and wo-men in the studied communities reached the universitystage (Table 1).

Also of concern is women’s participation in thegeneration of family income. Only 8.9% of women inthe studied communities have a paid job. Poverty,according to multiple indicators seems to be a commonfeature of the studied communities, with about 3% ofhouseholds earning more than US $400/month. Most ofthe studied households suffer from overcrowded condi-tions, where only 3.2% of them have a density of lessthan one individual per room (DI). While most houseshave TV and half of them have satellite dishes, onlyabout 5% of the studied households own a computer.Married couples have high fertility rate reaching fivechildren per couple, and marriages among relatives, awell established risk of birth defects (Stoll et al. 1999),were very common among the studied communities(about a third of respondents are married to their cousinor niece). Polygamy, which was previously shown to beassociated with mental morbidity among women inAleppo (Maziak et al. 2002), was reported by 7.5% ofparticipants.

Household characteristics

Although most of housing in the studied areas is illegal,it seems that they have gradually been incorporated bysome of the basic city services as evidenced by electricity,city drinking water, and city sewage reaching most of theinvestigated households (Table 2). Most households usepropane for cooking (a relatively clean source of cook-ing energy, Ezzati and Kammen 2002). About a quarterof households use cooking-place ventilation, and 86%have a designated area for cooking (kitchen). Althoughrelatively expensive, olive oil is the main cooking oilamong the studied communities used by about half ofhouseholds. Diesel chimneys were the method of heatingused by the vast majority of respondents. Most oflaundry in the studied households is done by electricwashing machines, which is a semi-closed method oflaundry (hot water and detergent are put in the basinthen gets mixed with an electric powered rotating head).Exposure to outdoor air and noise pollution was as-sessed indirectly by inquiring about the degree ofannoyance caused by noise or air pollution (assessedseparately) when opening the household windows. Thesepollutions seem a common nuisance for the studiedcommunities, where about a third of surveyed reported

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Table 1 Basic socio-demographic indicators of study participants from informal zones in Aleppo, Syria

Men n (%) Women n (%)

Age groups18–29 years 162 (34.5) 241 (43.7)30–45 years 210 (44.7) 229 (41.6)46–65 years 98 (20.9) 81 (14.7)RaceArabs 356 (75.7) 429 (77.9)Non-Arabs 114 (24.3) 122 (22.1)ReligionMuslim 469 (99.8) 547 (99.3)Non-Muslims 1 (0.2) 4 (0.7)Moved to current residence fromUrban areas 343 (73.0) 416 (75.5)Rural areas 127 (27.0) 135 (24.5)EducationIlliterate 102 (21.7) 207 (37.6)£6 years 203 (43.2) 232 (42.1)7–12 years 144 (30.6) 92 (16.7)Over 12 year 21 (4.5) 20 (3.6)Father’s educationIlliterate 272 (57.9) 274 (49.7)£6 years 157 (33.4) 211 (38.3)7–12 years 35 (7.4) 57 (10.3)Over 12 years 6 (1.3) 9 (1.6)Mother’s educationIlliterate 431 (91.7) 461 (83.7)£6 years 31 (6.6) 73 (13.2)7–12 years 7 (1.5) 16 (2.9)Over 12 years 1 (0.2) 1 (0.2)Household self-reported monthly income (from all sources)<10,000 Syrian Lira (SL)/month (US $ <200 334 (71.1) 393 (71.3)10,000–20,000 SL/month (US $200–400) 125 (26.6) 137 (24.9)>20,000 SL/month (US $ >400 USD) 11 (2.3) 21 (3.8)Household ownership ofPhone 157 (33.4) 186 (33.8)Cell phone 152 (32.3) 173 (31.4)TV 463 (98.5) 540 (98.0)Satellite dish 228 (48.5) 271 (49.2)Air conditioning 13 (2.8) 10 (1.8)PC 24 (5.1) 30 (5.4)Private car 21 (4.5) 22 (4.0)Main occupation (practiced for the longest period)Student 15 (3.2) 17 (3.1)Employed (government-private) 128 (27.3) 23 (4.2)Self employed (professional) 194 (41.3) 17 (3.1)Employer 4 (0.9) 3 (0.5)Manual worker 94 (20.0) 8 (1.5)Retired 17 (3.6) 1 (0.2)Unemployed 18 (3.8) 482(87.5)Marital statusMarried 396 (84.3) 425 (77.1)Single, divorced, widowed 74 (15.7) 126 (22.9)Polygamous marriages 14 (3.5) 48 (11.2)ConsanguinityNon-relatives 176 (44.4) 200 (47.1)First degree relatives 137 (34.6) 129 (30.4)Other relatives 83 (21.0) 96 (22.6)

Mean±SD Mean±SDNumber of years in current residency 13.4±10.7 10.7±9.2Number of children for married couples 4.9 ± 3.8 4.8±4.0Number of household membersTotal 7.7 ± 3.8 7.4±3.1Adults 3.5 ± 2.1 3.5±1.8Children 4.2 ± 2.7 3.9±2.4Number of household members involved in income generation 1.8 ± 1.5 1.8±1.2Density index (DI, no. of household divided by no. of rooms) 2.7 ± 1.3 2.7±1.4

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that opening the windows is very annoying because ofair or noise pollution (Table 2). Animals in the housewere found in 13.5% of households with cats and birdsconstituting the majority (data not shown).

Health behavior

Despite assessing only few food items, responses showthat residents of informal zones eat more vegetables thanfruits, still a good proportion of them seem to haveinadequate amounts of these food items (Table 3). Teawas a very popular beverage across age and gendergroups. Potato chips, an example of a recently intro-duced ‘‘Western’’ food in Syria, were not commonlyconsumed but seem to be gaining ground, especiallyamong younger women. Women are likely to be moreexposed to indoor air pollutants by virtue of spendinglonger hours indoors and where cooking and laundryare done. On the other hand, occupational exposure torespirable pollutants seems a serious hazard to men inthe studied communities, especially in the absence ofprotection measures (only 6.3% of exposed used masks).Overall, only a minority of participants practice regularsporting activity, but it appears that some workout isperformed as part of everyday activities, especially thoserelated to work (Table 3). For example, about threequarters of working people among these communitieshave a non-sitting (non-office) job. Alcohol use was notcommon, reported by fewer than 10% of men (Table 3).

Smoking and ETS exposure

The situation with smoking and ETS exposure looksserious (Table 4). Overall, 62% of men and 21% ofwomen currently smoke cigarettes. On top of that, 16%of men and 4% of women currently smoke waterpipe.Mean number of smokers within households is 1.1 forcigarettes, 0.1 for waterpipe, and 0.2 for both (total 1.4).Assessment of ETS exposure using different self-re-ported and objective indicators suggests that it is hard toescape being exposed to others smoke in these commu-nities. But while men are mostly exposed outside thehouse, women’s exposure seems to occur mainly in-doors. This exposure can reach significant intensity asabout a quarter of those surveyed reported some degreeof eye and nose irritation due to exposure to others’tobacco smoke in the past week (Table 4). Finally, mostof the studied households (81%) have no restrictionsregarding smoking inside the house, which is quiteworrisome given the high rates of smoking reported(Tables 2 , 4).

Self-rated health and disability

Overall, the majority of residents perceive their generalhealth to be satisfactory (i.e., fair, good, or excellent),except for women in the older age group of whom aboutone third rated their overall health as bad or very bad(Table 5). When asked about specific problems, womenfare less favorably than men on all studied dimensionsand this is seen especially in the oldest age group (46–65 years). The most frequently reported indices of poor

Table 2 Main household features related to environmental situa-tion in informal zones in Aleppo, Syria

n (%)

Drinking water sourceCity water service 948 (92.9)Well 52 (5.1)Water tank 19 (1.9)Other 2 (0.2)SewageCity sewage 986 (96.6)Other 35 (3.4)Main cooking energyElectricity 2 (0.2)Gas 1,018 (99.7)Open fire 1 (0.1)Cooking emission ventilationOver-cook vent 75 (7.3)Kitchen aspirator/ventilator 39 (3.8)Other ventilation 169 (16.6)Main cooking placeKitchen 876 (85.8)Other room indoors 132 (12.9)Outdoors 13 (1.3)Main cooking oilVegetable margarine 345 (33.8)Animal margarine (Arabic margarine) 32 (3.1)Vegetable oil 156 (15.3)Olive oil 472 (46.2)Other 16 (1.6)Main heating sourceDiesel chimneys 975(95.5)Central heating 1 (0.1)Electric coils 28 (2.7)Open fire 2 (0.2)Other (mainly gas chimneys) 15 (1.5)Main laundry methodAutomatic washing machine 139 (13.6)Electric washing machine (semi-closed) 867 (84.9)Manual washing 15 (1.5)Outdoor air pollution (annoyancefrom outdoor air pollution whenopening the windows)None 347 (34.0)Somewhat 152 (14.9)Much 212 (20.8)Very much 310 (30.4)Outdoor noise pollution (annoyancefrom outdoor noise whenopening the windows)None 270 (26.4)Somewhat 135 (13.2)Much 221 (21.6)Very much 395 (38.7)Animals in the house 138 (13.5)Household policy regardingsmoking in the houseSmoking is not allowed at all 23 (2.3)Smoking is allowed for few guests 83 (8.1)Smoking is allowed in special places 72 (7.1)Smoking is not restricted at al 827 (81.0)It differs for cigarettes and waterpipe 16 (1.6)

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Table 3 Individual behaviors related to health and exposure of residents of informal zones in Aleppo, Syria stratified by age and gender

Age groups Men, n (%) Women, n (%)

18–29 years 30–45 years 46–65 years 18–29 years 30–45 years 46–65 years

Past month eating habitsVegetablesNone or little 12 (7.4) 7 (3.3) 7 (7.1) 11 (4.6) 8 (3.5) 4 (4.9)One to two times weekly 28 (17.3) 29 (13.8) 11 (11.2) 28 (11.6) 32 (14.0) 15 (18.5)Three or more times per week 40 (24.7) 51 (24.3) 24 (24.5) 54 (22.4) 50 (21.8) 21 (25.9)More than once daily 82 (50.6) 123 (58.6) 56 (57.1) 148 (61.4) 13 (60.7) 41 (50.6)FruitsNone or little 45 (27.8) 74 (35.2) 52 (53.1) 99 (41.1) 101 (44.1) 45 (55.6)One to two times weekly 74 (45.7) 85 (40.5) 30 (30.6) 81 (33.6) 75 (32.8) 23 (28.4)Three or more times per week 20 (12.3) 23 (11.0) 8 (8.2) 32 (13.3) 30 (13.1) 6 (7.4)More than once daily 23(14.2) 28 (13.3) 8 (8.2) 29 (12.0) 23 (10.0) 7 (8.6)Olive oilNone or little 23 (14.2) 16 (7.6) 7 (7.1) 32 (13.3) 33 (14.4) 6 (7.4)One to two times weekly 17 (10.5) 26 (12.4) 9 (9.2) 21 (8.7) 30 (13.1) 13 (16.0)Three or more times per week 20 (12.3) 25 (11.9) 12 (12.2) 19 (7.9) 18 (7.9) 10 (12.3)More than once daily 102 (63.0) 143 (68.1) 70 (71.4) 169 (70.1) 148 (64.6) 52 (64.2)CoffeeNone or little 74 (45.7) 78 (37.1) 48 (49.0) 112 (46.5) 81 (34.4) 42 (51.9)One to two times weekly 23 (14.2) 17 (8.1) 7 (7.1) 33 (13.7) 19 (8.3) 7 (8.6)Three or more times per week 8 (4.9) 11 (5.2) 3 (3.1) 14 (5.8) 13 (5.7) 6 (7.4)More than once daily 57 (35.2) 104 (49.5) 40 (40.8) 82 (34.0) 116 (50.7) 26 (32.1)TeaNone or little 11 (6.8) 13 (6.2) 11 (11.2) 16 (6.6) 17 (7.4) 10 (12.3)One to two times weekly 1 (0.6) 4 (1.9) 1 (1.0) 9 (3.9) 3 (1.3) 2 (2.5)Three or more times per week 2 (1.2) 1 (0.5) 1 (1.0) 4 (1.7) 9 (3.9) 2 (2.5)More than once daily 148 (91.4) 192 (91.4) 85 (86.7) 212 (88.0) 200 (88.0) 76 (82.7)Potato chipsNone or little 110 (67.9) 178 (84.4) 90 (91.8) 136 (56.4) 181 (79.4) 70 (86.4)One to two times weekly 37 (22.8) 24 (11.4) 4 (4.1) 48 (19.9) 28 (12.2) 4 (4.9)Three or more times per week 6 (3.7) 1 (0.5) 2 (2.0) 27 (11.2) 8 (3.5) 5 (6.2)More than once daily 9 (5.6) 7 (3.3) 2 (2.0) 30 (12.4) 12 (5.2) 2 (2.5)

Hours spent daily indoors (including sleeping hours)Less than 8 h 22 (13.6) 26 (12.4) 12 (12.2) 0 (0.0) 2 (0.9) 1 (1.2)8–14 h 114 (70.4) 138 (65.7) 51 (52.0) 23 (9.5) 22 (9.6) 4 (4.9)More than 14 h 26 (16.0) 46 (21.9) 35(35.7) 218 (90.5) 205 (89.5) 76 (93.8)

Hours spent daily where food is being cookedLess than 1 h 157 (96.9) 197 (93.8) 94 (95.9) 91 (37.8) 52 (22.7) 43 (53.1)1–3 h 4 (2.5) 12 (5.7) 4 (4.1) 143 (59.3) 151 (65.9) 35 (43.2)More than 3 h 1 (0.6) 1 (0.5) 0 (0.0) 7 (2.9) 26 (11.4) 3 (3.7)Practice of regular sports activity 38 (23.5) 26 (12.4) 9 (9.2) 32 (13.3) 19 (8.3) 5 (6.2)

Past-month walking for more than 10 min/dayLittle or none 17 (10.5) 32 (15.2) 25 (25.5) 86 (35.7) 62 (27.1) 18 (22.2)One to two times per week 15 (9.3) 14 (6.7) 10 (10.2) 80 (33.2) 71 (31.0) 21 (25.9)Three or more times per week 130 (80.2) 164 (78.1) 63 (64.3) 75 (31.1) 96 (41.9) 42 (51.9)

Type of job (for working participants)Sedentary job (sitting) with minimal movement 34 (23.4) 58 (29.1) 17 (22.4) 7 (28.0) 8 (36.4) 2 (66.7)Non-sedentary job 109 (76.6) 141 (70.9) 59 (77.6) 18 (72.0) 14 (63.3) 1 (33.3)

Current occupational exposure to respiratory pollutants (dust, foams, smoke, respirable particles)No 24 (16.6) 35 (17.6) 11 (14.5) 8 (32.0) 8 (32.0) 0 (0.0)Mild (a day or less weekly) 15 (10.3) 14 (7.0) 4 (5.3) 2 (8.0) 0 (0.0) 0 (0.0)Moderate (more than day/week, less than daily) 9 (6.2) 5 (2.5) 8 (8.2) 2 (8.0) 2 (9.1) 1 (33.3)Severe (daily or on most work days) 97 (66.9) 145 (72.9) 53 (69.7) 13 (52.0) 12 (54.5) 4 (66.6)Use of protection mask (for those exposed) 8 (6.6) 14 (8.5) 0 (0.0) 1 (5.9) 1 (7.1) 0 (0.0)

Hours per day spent in front of a screen (TV, PC, games, etc.)<1 h 42 (25.9) 60 (28.6) 46 (46.9) 39 (16.2) 69 (30.1) 40 (49.4)1–3 h 74 (45.7) 89 (42.4) 31 (31.6) 93 (38.6) 95 (41.5) 22 (27.2)3–5 h 27 (16.7) 40 (19.0) 10 (10.2) 50 (20.7) 34 (14.8) 7 (8.6)>5 h 19 (11.7) 21 (10.0) 11 (11.2) 59 (24.5) 31 (13.5) 12 (14.8)Current alcohol use (past month) 11 (6.8) 17 (8.1) 4 (4.1) 0 (0.0) 0 (0.0) 0 (0.0)

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health and disability are difficulty with mobility amongmen and women in the older age group; suffering frombodily aches and pains particularly for the older agegroup; difficulties with concentration and rememberingthings especially among women in the older age group;difficulty in personal relationships and participation inthe community for women of all ages; difficulty withvision among women in the older age group; sleepdifficulty among women; difficulty with energy for menand women of all ages; depressive symptoms especiallyamong women (with a staggering two thirds reportingmoderate to severe depressive symptoms in the past yearin the middle and older age groups); same high rateswere reported for symptoms of stress/anxiety especiallyamong women in the middle and older age groups;suffering from dental and gum problems was a consid-erable complaint especially in the older age groups; andfinally back pain was a particular source of suffering formany women (Table 5).

Physician-diagnosed health conditions

A major area of concern among physician-diagnosedstates is hypertension among older women, which wasreported by about half of 45–65-year old individuals

(Table 6). Ischemic heart disease was also commonamong the older groups affecting more than 15% of menand women. Diabetes was more common among womenand was mostly confined to the older age group affectingabout fifth of respondents. On the other hand, althoughpsychiatric ailments are stigmatized in the Syrian soci-ety, diagnosed depression was reported by about 9% ofwomen in the middle and older age groups. Rheumatismwas very common among women, reported by abouthalf of the older age group. Peptic ulcer was reported bya considerable number of men and women reachingabout quarter of women in the older age group (27%).Although it mostly affects children in Syria (Ashfordet al. 1993), past-year cutaneous leishmaniasis (endemicin certain areas in Aleppo, as to bear the name ‘‘AleppoSore’’) was reported by 28 (2.7%) of study participants.Urinary disease was quite common among women in theolder age group with renal calculi and infection/inflam-mation accounting for most cases, while hepatic diseasewas rarely reported.

Respiratory health

The burden of respiratory health outcomes (e.g., asth-ma, bronchitis) in this study was assessed using multiple

Table 4 Reported smoking and ETS exposure among residents of informal zones in Aleppo, Syria

Age groups Men, n (%) Women, n (%)

18–29 years 30–45 years 46–65 years 18–29 years 30–45 years 46–65 years

Current smokingCigarettes 99 (61.6) 141 (67.1) 50 (51.0) 36 (14.9) 67 (29.3) 10 (12.3)Waterpipe 36 (22.2) 33 (15.7) 4 (4.1) 10 (14.1) 9 (3.9) 1 (1.2)Spouse’s smoking 8 (8.8) 35 (16.9) 15 (15.3) 94 (67.1) 148 (69.2) 47 (58.8)Past year regular exposure to others’ smoking 139 (85.8) 184 (87.6) 79 (80.6) 197 (81.7) 181 (79.0) 61 (75.3)Exposure to ETS at current work 119 (82.1) 165 (82.9) 60 (78.9) 18 (69.2) 12 (54.5) 2 (66.7)Eye and nose irritation from ETSin the past week)None 119 (73.5) 166 (79.0) 84 (85.7) 169 (70.1) 167 (72.9) 59 (72.8)Somewhat 32 (19.8) 31 (14.8) 10 (10.2) 58 (24.1) 39 (17.0) 10 (12.3)Frequently 11 (6.8) 13 (6.2) 4 (4.1) 14 (5.8) 23 (10.0) 12 (14.8)Reported average total number ofcigarettes smoked daily in the house0 30 (18.5) 42 (20.0) 24 (24.5) 30 (12.4) 41 (17.9) 16 (19.8)<5 31 (19.1) 51 (24.3) 13 (13.3) 52 (21.6) 46 (20.1) 23 (28.4)5–10 39 (24.1) 41 (19.5) 18 (18.4) 59 (24.5) 47 (20.5) 8 (9.9)11–20 25 (15.4) 36 (17.1) 14 (14.3) 41 (17.0) 39 (17.1) 8 (9.9)>20 37 (22.8) 40 (19.0) 29 (29.6) 59 (24.5) 56 (24.5) 26 (32.1)Reported average total number ofwaterpipes smoked daily in the house0 149 (92.0) 199 (94.8) 96 (98.0) 223 (92.5) 217 (94.8) 76 (93.8)1–2 12 (7.4) 10 (4.8) 2 (2.0) 16 (6.6) 9 (3.9) 4 (4.9)3–5 1 (0.6) 0 (0.0) 0 (0.0) 1 (0.4) 2 (0.9) 1 (1.2)>5 0 (0.0) 1 (0.5) 0 (0.0) 1 90.4) 1 (0.4) 0 (0.0)

Men (mean ± SD) Women (mean ± SD)Saliva cotinine levels (ng/ml)of non-smokersa (n =232)

2.2 ± 2.1 1.7 ± 1.3

Number of smokers in the houseCigarettes 1.1 ± 1.1 1.2 ± 1.1Waterpipe 0.1 ± 0.3 0.1 ± 0.3Both 0.2 ± 0.5 0.2 ± 0.5

a Only non-smokers with salivary cotinine £15 ng/ml are included

553

Table 5 Self-rated health and disability in the past year for residents of informal zones in Aleppo, Syria stratified by age and gender

Age group Men, n (%) Women, n (%)

18–29 years 30–45 years 46–65 years 18–29 years 30–45 years 46–65 years

Self-rated general healthExcellent 66 (40.7) 49 (23.3) 18 (18.4) 43 (17.8) 38 (16.6) 2 (2.5)Good 61 (37.3) 91 (43.3) 26 (26.5) 95 (39.4) 73 (31.9) 16 (19.8)Fair 28 (17.3) 57 (27.1) 38 (38.8) 89 (36.9) 87 (38.0) 36 (44.4)Bad 6 (3.7) 10 (4.8) 10 (10.2) 11 (4.6) 24 (10.5) 23 (28.4)Very bad 1 (0.6) 3 (1.4) 6 (6.1) 3 (1.2) 7 (3.1) 4 (4.9)Difficulty with mobility (moving and walking)?None 112 (69.1) 120 (57.1) 40 (40.8) 140 (58.1) 93 (40.6) 10 (12.3)Mild 21 (13.0) 35 (16.7) 16 (16.3) 29 (12.0) 44 (19.2) 16 (19.8)Moderate 18 (11.1) 31 (14.8) 13 (13.30 46 (19.1) 38 (16.6) 21 (25.9)Severe 11 (6.8) 24 (11.4) 29 (29.6) 26 (10.8) 54 (23.6) 34 (42.0)Difficulty with self care, such as bathing or dressingNone 145 (89.5) 186 (88.6) 80 (81.6) 205 (85.1) 192 (83.8) 57 (70.4)Mild 5 (3.1) 7 (3.3) 3 (3.1) 10 (4.1) 14 (6.1) 8 (9.9)Moderate 10 (6.2) 9 (4.3) 6 (6.1) 20 (8.3) 12 (5.2) 4 (1.9)Severe 2 (1.2) 8 (3.8) 9 (9.2) 6 (2.5) 11 (4.8) 12 (14.8)Bodily pains and achesNone 83 (51.2) 86 (41.0) 25 (25.5) 70 (29.0) 47 (20.5) 12 (14.8)Mild 24 (14.8) 35 (16.7) 21 (21.4) 55 (22.8) 50 (21.8) 9 (11.1)Moderate 37 (22.8) 53 (25.2) 18 (18.4) 67 (27.8) 70 (30.6) 14 (17.3)Severe 18 (11.1) 36 (17.1) 34 (34.7) 49 (20.3) 62 (27.1) 46 (56.8)Difficulty with concentrating or remembering thingsNone 90 (55.6) 106 (50.5) 62 (63.3) 97 (40.2) 84 (36.7) 30 (37.0)Mild 24 (14.8) 44 (21.0) 17 (17.3) 55 (22.8) 52 (22.7) 13 (16.0)Moderate 24 (14.8) 33 (15.7) 12 (12.2) 54 (22.4) 47 (20.5) 14 (17.3)Severe 24 (14.8) 27 (12.9) 7 (7.1) 35 (14.5) 46 (20.1) 24 (29.6)Difficulty in personal relationship or participation in the communityNone 99 (61.1) 147 (70.0) 74 (75.5) 121 (50.2) 110 (48.0) 39 (48.1)Mild 22 (13.6) 15 (7.1) 8 (8.2) 33 (13.7) 23 (10.0) 12 (14.8)Moderate 20 (12.30 23 (11.0) 9 (9.2) 49 (20.3) 41 (17.9) 12 (14.8)Severe 21 (13.0) 25 (11.9) 7 (7.1) 38 (45.8) 55 (24.0) 18 (22.2)Difficulty with vision (either reading or recognizing people from a distance)None 123 (75.9) 152 (72.4) 38 (38.8) 187 (77.6) 167 (72.9) 28 (34.6)Mild 14 (8.6) 31 (14.8) 26 (26.5) 30 (12.4) 30 (13.1) 13 (16.0)Moderate 16 (9.9) 23 (11.0) 22 (22.4) 14 (5.8) 18 (7.9) 27 (33.3)Severe 9 (5.6) 4 (1.9) 12 (12.2) 10 (4.1) 14 (6.1) 13 (16.0)Sleep difficulty (drowsiness, initiation, continuation)None 88 (54.3) 124 (59.0) 57 (58.2) 98 (40.7) 87 (38.0) 25 (30.9)Mild 31 (19.1) 33 (15.7) 9 (9.2) 51 (21.2) 45 (19.7) 9 (11.1)Moderate 19 (11.7) 25 (11.9) 11 (11.2) 50 (20.7) 45 (19.7) 21 (25.9)Severe 24 (14.8) 28 (13.3) 21 (21.4) 42 (17.4) 52 (22.7) 26 (32.1)Difficulty with energy (feeling tired and exhausted during the day)None 60 (37.0) 60 (28.6) 40 (40.8) 66 (27.4) 43 (18.8) 16 (12.3)Mild 34 (21.0) 35 (16.7) 14 (14.3) 64 (26.6) 56 (24.5) 11 (13.6)Moderate 40 (24.7) 66 (31.4) 28 (28.6) 67 (27.8) 71 (31.0) 21 (25.9)Severe 28 (17.3) 49 (23.3) 16 (16.3) 44 (18.3) 59 (25.8) 39 (48.1)Depressive symptoms (feeling blue, depressed, or empty)None 71 (43.8) 92 (43.8) 52 (53.1) 65 (27.0) 45 (19.7) 16 (19.8)Mild 28 (17.3) 38 (18.1) 13 (13.3) 52 (21.6) 33 (14.4) 8 (9.9)Moderate 32 (19.8) 28 (13.3) 14 (14.3) 48 (19.9) 56 (24.5) 20 (24.7)Severe 31 (19.1) 52 (24.8) 19 (19.4) 76 (31.5) 95 (41.5) 37 (45.7)Anxiety and stressNone 74 (45.7) 71 (33.8) 46 (46.9) 70 (29.0) 46 (20.1) 11 (13.6)Mild 24 (14.8) 40 (19.0) 12 (12.2) 45 (18.7) 40 (17.5) 13 (16.0)Moderate 30 (18.5) 44 (21.0) 20 (20.4) 63 (25.1) 55 (24.0) 21 (25.9)Severe 34 (21.0) 55 (26.2) 20 (20.4) 63 (26.1) 88 (38.4) 36 (44.4)Dental and gum problemsNone 82 (50.6) 85 (40.5) 33 (33.7) 121 (50.2) 84 (36.7) 34 (42.0)Mild 28 (16.0) 35 (16.7) 18 (18.4) 42 (17.4) 48 (21.0) 9 (11.1)Moderate 29 (17.9) 43 (20.5) 21 (21.4) 27 (11.2) 37 (16.2) 14 (17.3)Severe 25 (15.4) 47 (22.4) 26 (26.5) 51 (21.2) 60 (26.2) 24 (29.6)Back painNone 83 (51.2) 104 (49.5) 40 (40.8) 97 (40.2) 52 (22.7) 20 (24.7)Mild 37 (22.8) 42 (20.0) 25 (25.5) 51 (21.2) 49 (21.4) 14 (17.3)Moderate 25 (15.4) 39 (18.6) 14 (14.3) 52 (21.6) 46 (20.1) 16 (19.8)Severe 17 (10.5) 25 (11.9) 19 (19.4) 41 (17.0) 82 (35.8) 31 (38.3)

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identifiers including symptoms, doctors’ diagnosis, andhealth care utilization because of respiratory problems.Overall, data indicate that respiratory illness constitutesa source of considerable morbidity among the studiedpopulation, judged not only by the frequency of re-ported symptoms and diagnosis, but also by past yearutilization of health services and past month medicationuse for respiratory problems (Table 7). Both infectiousand non-infectious outcomes were common in thestudied population, with older women being most af-fected and most likely to utilize health services or receivemedical treatment for respiratory disease. However,nasal allergies and related problems such as sinusitiswere more common among the younger and middle agegroups (Table 7).

Discussion and remarks

The lack of information about the wellbeing of a hugeand rapidly increasing segment of the population livingin informal zones in Syria represents a major gap in thehealth information system in this country as well asmany developing countries. This first report from AHSaims to provide baseline documentation of the mainhealth and environmental descriptors of communitiesliving in informal areas, in order to guide furtherproblem-oriented research and intervention work. The

broad-based nature of the presented data is provisionedto provide a single, reliable, and readily available refer-ence for a variety of prevention and intervention initia-tives targeting these communities.

This study relies mainly on self-report, which is sub-ject to bias due to a variety of factors. Every effort wasmade in this survey to ensure reliable reporting throughintensive training of surveyors, strict quality control,proper choice of recall period, and piloting. Naturally,objective assessment of relevant exposures especially inthe indoor environment (air, water) is needed for theunderstanding of health problems of the studied com-munities. However, it would be unwise to go into thislaborious and expensive stage without proper orienta-tion of what constitutes priority exposures/outcomes, aswell as without proper knowledge of the main householdand socioeconomic features of the target communities.On the other hand, although every effort was made toensure confidentiality of interviews, the overcrowdednature of many of the studied households made thissometimes impossible. Moreover, although we usedstandard descriptors of symptoms and definitions ofhealth problems, some of the terms used in the ques-tionnaire had to be modified to conform to the commondialect doctors usually use within the studied commu-nities. For example, ‘‘rheumatism’’ is used by doctorslocally to describe a broad range of arthritic and muscleproblems, while infection/inflammation are used inter-

Table 6 Past year doctor’s diagnosed major health problems of residents of informal zones in Aleppo, Syria stratified by age and gender

Age group Men n (%) Women n (%)

18–29 years 30–45 years 46–65 years 18–29 years 30–45 years 46–65 years

Ischemic heart disease(ischemia, angina, infarction)

0 (0.0) 7 (3.3) 17 (17.3) 1 (0.4 10 (4.4) 15 (18.5)

Proportion treated 0 (0.0) 1 (14.3) 14 (82.4) 0 (0.0) 4 (40.0) 10 (66.7)Hypertension 5 (3.1) 12 (5.7) 13 (13.3) 15 (6.2) 30 (13.1) 42 (51.9)Proportion treated 1 (20.0) 4 (33.3) 7 (53.8) 1 (6.7) 10 (33.3) 35 (83.3)Stroke 0 (0.0) 1 (0.5) 3 (3.1) 2 (0.8) 3 (1.3) 4 (4.9)Proportion treated 0 (0.0) 0 (0.0) 3 (100.0) 0 (0.0) 1 (33.3) 4 (100.0)High blood cholesterol 1 (0.6) 5 (2.4) 9 (9.2) 0 (0.0) 5 (2.2) 12 (14.8)Proportion treated 0 (0.0) 1 (20.0) 5 (55.6) 0 (0.0) 3 (60.0) 7 (58.3)Diabetes 2 (1.2) 4 (1.9) 13 (13.3) 0 (0.0) 5 (2.2) 18 (22.2)Proportion treated 0 (0.0) 4 (100.0) 12 (92.3) 0 (0.0) 3 (60.0) 16 (88.9)Depression 3 (1.9) 9 (4.3) 5 (5.1) 15 (6.2) 21 (9.2) 8 (9.9)Proportion treated 1 (33.3) 3 (33.3) 1 (20.0) 5 (33.3) 9 (42.9) 7 (87.5)Rheumatism 12 (7.4) 26 (12.4) 17 (17.3) 17 (7.1) 47(20.5) 42 (51.9)Proportion treated 3 (25) 7 (26.9) 10 (58.8) 4 (23.5) 20 (42.6) 23 (54.8)Peptic ulcer 11 (6.8) 31 (14.8) 15 (15.3) 17 (7.1) 40 (17.5) 20 (24.7)Proportion treated 6 (54.5) 20 (64.5) 12 (80.0) 9 (52.9) 18 (45.0) 15 (75.0)Intestinal worms 1 (0.6) 6 (2.9) 1 (1.0) 5 (2.1) 3 (1.3) 2 (2.5)Proportion treated 0 (0.0) 2 (33.3) 0 (0.0) 1 (20.0) 0 (0.0) 0 (0.0)Cutaneous leishmaniasis 7 (4.3) 3 (1.4) 6 (6.1) 8 (3.3) 2 (0.9) 2 (2.5)Proportion treated 1 (14.3) 0 (0.0) 1 (16.7) 0 (0.0) 0 (0.0) 0 (0.0)Urinary disease (renal calculi,infection/inflammation, failure, other)

11 (6.8) 24 (11.4) 12 (12.2) 33 (13.7) 45 (19.7) 22 (27.2)

Proportion treated (of all cases) 4 (36.4) 6 (25.0) 3 (25.0) 12 (36.4) 12 (26.7) 11 (50.0)Liver disease (hepatitis/jaundice,failure/cirrhosis, other)

0 (0.0) 1 (0.5) 1 (1.0) 2 (0.8) 1 (0.4) 4 (4.9)

Proportion treated 0 (0.0) 0 (0.0) 1 (100.0) 0 (0.0) 0 (0.0) 3 (75.0)Cancer 0 (0.0) 1 (0.5) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)Proportion treated 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)Tool, burn, fire arms, other) 18 (11.1) 18 (8.6) 8 (7.1) 16 (6.6) 16 (7.0) 4 (4.9)

555

changeably in the common medical dialect in Aleppo.Diseases that exhibit serious symptoms only in advancedstages (some cancers, chronic liver disease), or thatproduce non-specific symptoms (cough in chronicbronchitis) may also be under-estimated in our study.Therefore, for main outcomes of interest we relied onmultiple indicators including specific symptoms, doc-tor’s diagnosis, health care utilization, as well as objec-tive measurement of lung function (not reported here).

Current understanding of environmental influenceson health emphasizes the multi-level nature of interac-tions in the exposure/outcome relationship, whichshould be considered for the development of actionstrategies to reduce the burden of health risks (WHO1999; von Schirnding 2002). As such, economic forcesthat drive people to reside in the informal areas, envi-ronmental characteristics of these areas, housing char-acteristics, socio-economic attributes of the studiedpopulation, as well as individual attributes related tohealth and environmental exposures, all co-act to shapethe health and wellbeing of members of the studiedcommunities. Initial insights gained from applying thismulti-dimensional model in the planning and analysis ofAHS data point at important areas of concern on top ofshared background of poverty. Clearly, the studiedcommunities have high fertility rates, overcrowdedhousing conditions, and gender inequality in educationand work. Recent study of the socio-economic situationin Arab societies identifies lack of women’s empower-ment as one of three major hurdles to development inthe Arab World (UNDP 2002).

On the household level, some positive findings werenoted such as the access to electricity, piped water, city

sewage, and the use of relatively clean energy forcooking by the majority of households, indicating thatdespite the illegal nature of these neighborhoods theyhave been gradually incorporated by basic municipalityservices. Household features that can influence healthand exposure are mainly related to the use of dieselchimneys for heating, which can be an important sourceof indoor combustion gases (Lighty et al. 2000; Zhanget al. 2002) especially if not installed or ventilatedproperly. Above all, the lack of household restrictionsregarding smoking indoors, coupled by the overcrowdedhosing conditions, as well as widespread of smokingamong the studied population, potentially put exposureto ETS as a leading environmental risk for the studiedcommunities. This is confirmed by objective measure-ment of exposure via saliva cotinine, showing significantexposure of most of the studied. Women (and mostlikely children) are likely to be more exposed to IAP byvirtue of spending longer hours indoors, and where foodand laundry are being done, while men are more exposedto occupational respiratory pollutants and ETS outsidetheir houses. Generally, men seem to be more exposed toETS, possibly because they spend more time with menwho smoke.

Some individual behavior patterns raise some con-cern in the studied communities, such as the lack ofphysical activity coupled with prolonged time in front ofthe TV screen, especially in women. This informationcan be of value for studies looking at obesity and othercardiovascular risks among the studied population.Probably because of spending longer periods outside thehouse and of occupational risks men were more likely tohave injuries than women. Men were also more exposed

Table 7 Past year respiratory health of residents of informal zones in Aleppo, Syria stratified by age and gender

Age groups Men, n (%) Women, n (%)

18–29 years 30–45 years 46–65 years 18–29 years 30–45 years 45–65 years

Past year wheezing/whistling in the chest

21 (13.0) 32 (15.3) 14 (14.3) 19 (7.8) 40 (17.4) 23 (28.3)

Past year recurrent coughing(>3 recognizable episodes)

46 (28.4) 41 (19.5) 22 (22.4) 47 (19.5) 54 (23.6) 28 (34.6)

Ever diagnosed asthma (asthma,allergic bronchitis, chest allergy)

9 (5.6) 23 (11.0) 8 (8.2) 22 (9.1) 31 (13.5) 18 (22.2)

Ever diagnosed chronicbronchitis-emphysema

5 (3.1) 11 (5.2) 4 (4.1) 8 (3.3) 13 (5.7) 8 (9.9)

Past year suffering of tuberculosis(doctor’s diagnosed)

0 (0.0) 0 (0.0) 1 (1.0) 1 (0.4) 1 (0.4) 0 (0.0)

Past year hay fever (sneezing,runny-blocked nose when nothaving a cold, together withwatery/itchy eyes)

13 (8.0) 22 (10.5) 5 (5.1) 37 (15.4) 41 (17.9) 12 (14.8)

Past year suffering from sinusitis(doctor’s diagnosed)

15 (9.3) 23 (11.0) 6 (6.1) 21 (8.7) 23 (10.0) 5 (6.2)

Past year suffering from acutelower respiratory infection(doctor’s diagnosed bronchitis,pneumonia)

12 (7.4) 26 (12.3) 10 (10.2) 19 (7.8) 22 (9.6) 9 (11.1)

Past year doctor’s or hospital visitbecause of respiratory problem

14 (8.6) 27 (12.9) 9 (9.2) 27 (11.2) 28 (12.2) 25 (30.9)

Past month medical treatment(medicines) for a respiratory problem

10 (6.2) 9 (4.3) 9 (9.2) 18 (7.5) 28 (12.2) 15 (18.5)

556

to occupational respiratory hazards, especially as pro-tection measures are virtually absent. Cigarette smokingremains the most important risk behavior in informalzones, practiced by about two thirds of men and onethird of women in the middle age group. Such rates areamongst the highest ever reported on the global level(Tobacco Country Profiles 2003), and mean that it ishard for anyone to escape exposure to ETS. They alsomean that smoking has become the norm in thesecommunities, where children will grow up perceivingsmoking as an integral constituent of their environment(DiFranza et al. 2004). Waterpipe smoking is anunderstudied risky health behavior is gaining groundamong the studied communities especially for youngmen (22%), and it can be an important source of mor-bidity to smokers and their households.

Based on different indicators of symptoms, diagno-sis, and treatment the studied communities seem tosuffer considerably from physical and mental ill healthand disability. This suffering seems to be affectingwomen and the elderly disproportionately. Of particu-lar concern is mental and psychological suffering sincethis is mostly a hidden problem in the Syrian society.So even if we consider that women in this region tendto somatize their psychiatric problems (Al-Subaie et al.1998), the high prevalence of both physical and mentalhealth complaints among women in the studied com-munities suggests that they suffer disproportionatelyfrom these ailments. Women not only have problemswith concentration/memory and depressive symptomsbut they also report more problems with their personalrelationships and integration in the community. It isknown that mental disease is stigmatized in most Arabsocieties so it is likely to be under-reported and under-recognized. The situation of women in the studiedcommunities is likely thus, to represent an iterativecycle, where many factors, both proximal and distal,feed into their ill-being. Physical, mental, and socialproblems can cause and aggravate each other. Finally,women also seem to suffer more of doctor’s diagnosedconditions, whereby a considerable proportion of themare currently treated for these conditions. Differentialmedical seeking behavior is an unlikely explanation thiswomen predominance, as more men (8.6%) than wo-men (5.1%) did routine visits to a health clinic in thepast year (analysis not shown).

Conclusions

The presented figures, although not intended to providea count of cases of different disease states, provide ablueprint of major sources of morbidity as well asenvironmental characteristics and risks facing commu-nities living in informal zones in Aleppo. Our hope isthat these data can guide and stimulate more in depthresearch into health problems and exposures relevant toresidents of informal zones in Aleppo. Although it seems

that the studied informal zones are being incorporatedby most of city services, the burden of disease indicates afailure of preventive, curative, and even palliative healthcare services. Among areas of concern revealed by thisstudy is the situation with women, who seem to beardisproportionately the physical and psychological bur-dens of life’s hardship in these communities. Illiteracyand economic dependence can certainly aggravate wo-men’s suffering as they deprive them of resources tobetter their lives. In addition, the high fertility wouldlimit women’s actual ability to do anything but child-bearing and housekeeping. Confined to their houses,women are not only deprived of social and economicsupport but subjected to indoor air pollutants, especiallyETS. The root causes of women’s situation can lie in thesocio-cultural attributes and gender roles/balance of thesociety at large, which can hard to change. Some mea-sures however, such as focusing on women’s educationand economic participation can influence both thematerial and the cultural aspects of the society in favorof women. Giving incentives for women’s education andoccupational rehabilitation, focusing on birth control,providing smoking cessation services, and promotinghousehold restrictions on tobacco use can form aworking agenda for health authorities in Syria. Becauseof its universal reach in the studied communities, tele-vision can be utilized to deliver relevant messages tothese poor communities, including the economic gains ofquitting smoking and limiting ETS exposure for wholehouseholds. Primary care services, should respond to thegrowing magnitude of chronic conditions of oldermembers of the community, by incorporating servicesrelated to non-communicable and degenerative disease.This can improve the confidence and cooperation ofcommunities with these services, and enable the later tobe involved in effective advocacy of healthy lifestyles inthese communities.

Acknowledgement This work is supported by USPHS grants R21TW006545, R01 TW05962.

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