Article Text

Download PDFPDF

P75 Contextual influences on chronic disease: a multi-level analysis in the twin city of Ramallah and Al Bireh in the occupied palestinian territory
  1. Ahmad Alkhatib,
  2. Jonathan Olsen,
  3. Richard Mitchell
  1. MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK


Background The features of the urban environment can support human health as well as harm it, but less is known about the context of middle eastern countries. The association between green space and the political classification of the urban environment and the risk of chronic illness was investigated in a novel setting, the twin city of Ramallah and Albireh in the occupied Palestinian territory.

Methods We used multi-level regression analysis to link the 2017 census data with contextual characteristics from Geographic Information System data. The outcome variable is the presence or absence of chronic illness. The contextual explanatory variables are: the proportion of three types of green space in the areas of residence (mixed trees, crop trees and open space with little or no vegetation); the locality of residence (Ramallah, Albireh and Refugee camps); and political land classification (Area A, B, and C). Generalised multi-level analysis was conducted in R using ‘lme4’ package, with individuals at level one (n=54693) and areas of residence at level two (n=228), adjusting for individual demographic and socioeconomic characteristics.

Results Just over 13% of the chronic illness risk variation was attributed to the area of residence. On the political dimension and while accounting for the individual-level factors, only living in the context of a refugee camp had a significant positive association (OR 1.91 CI [1.17–3.09]). However, the association between refugee camps and chronic illness rendered non-significant when green space variables were entered into the model. In the final model, only the proportions of ‘mixed’ tress in the residential areas had a significant inverse association with the risk of chronic illness (OR 0.96 CI [0.95–0.97]), all else being equal.

Conclusion Within the confines of a cross-sectional, observational study, the findings shed light on the possible role of the urban environment context as a determinant of health, irrespective of individual-level factors. Our ability to differentiate between several types of green space was important, as findings demonstrated that not all types are associated with reduced risk of chronic illness. Our results from a middle eastern setting add to the existing evidence, largely in Western countries, that trees in urban settings are important and beneficial to human health. Also, to reduce inequalities in health researchers and policymakers should give more attention to the disadvantaged contexts of refugee camps.

  • Urban Environment
  • Chronic illness
  • Multi-level methods

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.