title: Health and the urban environment of the twin cities of Ramallah and Albireh in the occupied Palestinian territory
Creators: name: Alkhatib, Ahmad Mousa
Publisher: name: University of Glasgow
Year: 2022

description: Background: Features of the urban environment can support human health as well as harm it. Evidence has accumulated for the links between different place-based characteristics and physical and mental health. However, this evidence stems primarily from highly developed countries. The extent to which it is generalisable to other locations, such as the Middle Eastern Arab region, which has unique political, socio-cultural, and climatic environments, is not clear. Aims and setting: This thesis aims to investigate health in relation to the urban environment in the twin cities of Ramallah and Albireh in the occupied Palestinian territory. Specifically, it will examine the associations between the risk of chronic illness and: a) politically created area disadvantage (refugee camps and 'Area C’); b) urban green space. It will also explore the interaction between these area-level features and age, sex, and household assets in their association with chronic illness. Methods: Area-level variables were linked with individual respondents to the 2017 census using a Geographic Information System. The analytical sample was 54693 individuals living in 228 residential areas. The outcome variable was the presence/absence of chronic illness. The area-level variables were the politically created disadvantage indicated by Refugee camps and political land classification ‘Area C’ (controlled by Israel); the proportion of mixed trees, crop trees and open space with little/no vegetation; Individual-level variables included twelve demographic and socioeconomic characteristics. Multi-level logistic regression models examined associations and interactions between individual and area-level variables and the probability of chronic illness risk. Results: On the political dimension, living in the context of a refugee camp was associated with greater odds of chronic illness (OR 1.91 CI [1.17-3.09]). This association was attenuated and rendered non-significant when adjusting for green space. The proportions of ‘mixed’ trees in residential areas had an independent inverse association with chronic illness (OR 0.96 CI [0.95-0.97]). There was no/weak evidence for an association between the context of ‘Area C’ and the proportion of crop trees and open space with the risk of chronic illness. A statistically significant interaction was found between sex and living in refugee camps. Females living outside refugee camps have a significantly lower risk of chronic illness compared to males but not for those living inside refugee camps; females inside refugee camps had a higher risk of chronic illness compared to males (though not a significant difference). There was no/weak evidence for interactions between the other area characteristics and age, sex, and household assets. Conclusion: This is the first study in the Palestinian context, and among the few from the Arab World, to investigate links between the urban environment and health. As expected, living in the disadvantaged context of refugee camps is associated with a higher likelihood of chronic illness. Not all greenspace types were associated with improved health outcomes, but mixed trees were, and the green environment appeared implicated in the association between refugee camps and poor health. These results from a Middle Eastern Arab setting add to the evidence, largely from Western countries, that mixed trees in urban environments benefit health. Researchers and policymakers interested in reducing health inequalities should give more attention to refugee camps and green typologies, especially to females living in the disadvantaged contexts of refugee camps who may gain greater benefits. Research with a broader scope is needed to investigate the impact of political land classification on health.