Facility-level determinants of quality routine intrapartum care in Afghanistan.

BACKGROUND: Although there have been notable improvements in availability and utilization of maternal health care in Afghanistan over the last few decades, risk of maternal mortality remains very high. Previous studies have highlighted gaps in quality of emergency obstetric and newborn care practices, however, little is known about the quality of routine intrapartum care at health facilities in Afghanistan. METHODS: We analyzed a subset of data from the 2016 Afghanistan Maternal and Newborn Health Quality of Care Assessment that comprised of observations of labor, delivery and immediate post-partum care, as well as health facility assessments and provider interviews across all accessible public health facilities with an average of five or more births per day in the preceding year (N = 77). Using the Quality of the Process of Intrapartum and Immediate Postpartum Care index, we calculated a quality of care score for each observation. We conducted descriptive and bivariate analyses and built a multivariate linear regression model to identify facility-level factors associated with quality of care scores. RESULTS: Across 665 childbirth observations, low quality of care was observed such that no health facility type received an average quality score over 56%. The multivariate regression model indicated that availability of routine labor and delivery supplies, training in respectful maternity care, perceived gender equality for training opportunities, recent supervision, and observation during supervision have positive, statistically significant associations with quality of care. CONCLUSIONS: Quality of routine intrapartum care at health facilities in Afghanistan is concerningly low. Our analysis suggests that multi-faceted interventions are needed to address direct and indirect contributors to quality of care including clinical care practices, attention to client experiences during labor and childbirth, and attention to staff welfare and opportunities, including gender equality within the health workforce.

Factors associated with health facility deliveries among mothers living in hospital catchment areas in Rukungiri and Kanungu districts, Uganda.

BACKGROUND: Health facility deliveries are generally associated with improved maternal and child health outcomes. However, in Uganda, little is known about factors that influence use of health facilities for delivery especially in rural areas. In this study, we assessed the factors associated with health facility deliveries among mothers living within the catchment areas of major health facilities in Rukungiri and Kanungu districts, Uganda. METHODS: Cross-sectional data were collected from 894 randomly-sampled mothers within the catchment of two private hospitals in Rukungiri and Kanungu districts. Data were collected on the place of delivery for the most recent child, mothers' sociodemographic and economic characteristics, and health facility water, sanitation and hygiene (WASH) status. Modified Poisson regression was used to estimate prevalence ratios (PRs) for the determinants of health facility deliveries as well as factors associated with private versus public utilization of health facilities for childbirth. RESULTS: The majority of mothers (90.2%, 806/894) delivered in health facilities. Non-facility deliveries were attributed to faster progression of labour (77.3%, 68/88), lack of transport (31.8%, 28/88), and high cost of hospital delivery (12.5%, 11/88). Being a business-woman [APR = 1.06, 95% CI (1.01-1.11)] and belonging to the highest wealth quintile [APR = 1.09, 95% CI (1.02-1.17)] favoured facility delivery while a higher parity of 3-4 [APR = 0.93, 95% CI (0.88-0.99)] was inversely associated with health facility delivery as compared to parity of 1-2. Factors associated with delivery in a private facility compared to a public facility included availability of highly skilled health workers [APR = 1.15, 95% CI (1.05-1.26)], perceived higher quality of WASH services [APR = 1.11, 95% CI (1.04-1.17)], cost of the delivery [APR = 0.85, 95% CI (0.78-0.92)], and availability of caesarean services [APR = 1.13, 95% CI (1.08-1.19)]. CONCLUSION: Health facility delivery service utilization was high, and associated with engaging in business, belonging to wealthiest quintile and having higher parity. Factors associated with delivery in private facilities included health facility WASH status, cost of services, and availability of skilled workforce and caesarean services.

Indoor levels of polycyclic aromatic hydrocarbons (PAHs) from environment tobacco smoke of public bars.

In this work level of Polycyclic Aromatic Hydrocarbon (PAHs) from indoor Environment Tobacco Smoke (ETS) of pubic bars in Nigeria was investigated. Indoor air samples were obtained from different public bars using Polyurethane foam (PUF) passive samplers. Analysis of PAHs was carried out using GC-MS operated in selected ion monitoring mode. Result showed the average concentration range of 2.71-9.69 ng/m3 while the ∑ 16 PAHs range from 43.43 to 155.11 ng/m3. The incremental lifetime cancer risk (ILCR) values from inhalation of PAHs in these bars ranged from 2.4×10-7-5.2×10-7 while non-carcinogenic risk, Hazard Quotient (HQ) ranged from 2×10-4-4.5×10-4. Although these values are lower than WHO permissible limit, nevertheless the study underscores the danger associated with the inhalation of ETS in the public bars in Nigeria.

[Certification of medical care facilities in Mexico: analysis of the incentives for its continuity.] / Certificación de establecimientos de atención médica en México: análisis de los incentivos para su continuidad.

OBJECTIVE: To analyze the possible effect of certification models and healthcare organizations' (HOs) participation incentives in the General Health Council certification process in the 1999-2017 period. MATERIALS AND METHODS: Official printed and online documents about HOs' certification were collected. Information from instances related to the process was requested through transparency mechanisms. Health organizations' participation in political-administrative periods between 1997-2017 was analyzed. RESULTS: The annual average participation in the certification process during the 1999-2000 period was 259.5 HOs; during the 2013-2016 period, the average was 72.5. Public units' participation in this process has been decreasing. In 2017, certified HO were <1%. CONCLUSIONS: No positive effects of adjustments to the certification model or the incentives applied were identified. Conversely, there is decreasing participation in the different political-administrative periods. The National HO Certification System and its possible effect on clinical quality must be thoroughly evaluated.

OBJECTIVE: Analizar el posible efecto de los modelos de certificación y de los incentivos implementados en la participación de establecimientos de atención médica (EAM) en la certificación del Consejo de Salubridad General entre 1999-2017. MATERIALS AND METHODS: Se colectaron documentos oficiales, impresos y en línea, sobre la certificación de EAM y se solicitó información a diversas instancias relacionadas mediante mecanismos de transparencia. Se analizó la participación de EAM en los períodos político-administrativos entre 1999-2017. RESULTS: El promedio anual de participación entre 1999-2000 fue de 259.5 EAM; entre 2013-2016, de 72.5. La participación de EAM públicos es decreciente. En 2017, los EAM certificados eran <1%. CONCLUSIONS: No se identificaron efectos positivos ni sostenidos de ajustes al modelo, ni de los incentivos implementados. Se observa disminución de la participación en los distintos periodos político-administrativos. Debe evaluarse profundamente el Sistema Nacional de Certificación de EAM y su posible efecto en la calidad clínica.

Availability of Public Toilets in Parks and Recreational Sites in Selected US Cities.

PURPOSE: The principal aim of this study was to map and describe the availability of parkland public toilets in major US cities per population and area. DESIGN: Observational and descriptive. SUBJECTS AND SETTING: Data were collected from the following cities: Austin, Texas; Minneapolis-St Paul (MSP), Minnesota; Nashville, Tennessee; New York City (NYC), New York; Philadelphia, Pennsylvania; San Francisco, California (SFC); Seattle, Washington; and Tampa, Florida. These cities are located throughout the United States. METHODS: Data from the US Census and cities' parks/recreation departments about publicly owned and operated permanent toilet facilities were analyzed and then mapped using geographic information systems. Toilet density by population and residential area (mi) was calculated, and toilet distribution was visualized. RESULTS: When calculated per 100,000 residents, MSP had the most parkland public toilets with 24; Tampa, Seattle, and Philadelphia had 17 to 22; and Nashville, NYC, and SFC had the fewest, around 7 toilets. Parkland public toilet density per residential area was highest in NYC and Philadelphia (>2/mi), followed by MSP, Seattle, and SFC (1/mi), then Tampa, Austin, and Nashville (<1/mi). The proportion of Census tracts containing parkland public toilets was more than 0.4 in MSP, Seattle, Tampa, and Philadelphia, more than 0.20 in Nashville and Austin, and less than 0.20 in the other cities. Toilet mapping showed fairly even distribution across Census tracts in MSP, Seattle, Tampa, and Philadelphia. CONCLUSIONS: Availability of parkland public toilets was highest in MSP and lowest in SFC. Findings inform WOC nurses for counseling incontinent patients about self-management strategies. Urban planning that provides an adequate number and distribution of parkland public toilets may improve quality of life.

'When helpers hurt': women's and midwives' stories of obstetric violence in state health institutions, Colombo district, Sri Lanka.

BACKGROUND: The paper explores how age, social position or class, and linguistic and cultural background intersect and place women in varying positions of control and vulnerability to obstetric violence in state health institutions in Colombo district, Sri Lanka. Obstetric violence occurs during pregnancy, childbirth and the immediate postpartum period; hence, it is violence that directly affects women. The authors aim to break the traditional culture of silence around obstetric violence and bring attention to the resulting implications for quality of care and patient trust in obstetric care facilities or providers. METHODS: Five focus group discussions were held with 28 public health midwives who had prior experience working in labor rooms. Six focus group discussions were held with 38 pregnant women with previous childbirth experience. Additionally, 10 of the 38 women, whom felt they had experienced excessive pain, fear, humiliation, and/or loss of dignity as patients in labor, participated in individual in-depth interviews. An intersectional framework was used to group the qualitative data into categories and themes for analysis. RESULTS: Obstetric violence appears to intersect with systems of power and oppression linked to structural gender, social, linguistic and cultural inequities in Sri Lanka. In our dataset, younger women, poorer women, and women who did not speak Sinhala seemed to experience more obstetric violence than those with relevant social connections and better economic positions. The women in our study rarely reported obstetric violence to legal or institutional authorities, nor within their informal social support networks. Instead, they sought obstetric care, particularly for childbirth, in other state hospitals in subsequent pregnancies. CONCLUSIONS: The quality of obstetric care in Sri Lanka needs improvement. Amongst other initiatives, policies and practices are required to sensitize health providers about the existence of obstetric violence, and repercussions are required for abusive or discriminatory practices. The ethics of care should be further reinforced in the professional training of obstetric health providers.

Signal functions for emergency obstetric care as an intervention for reducing maternal mortality: a survey of public and private health facilities in Lusaka District, Zambia.

BACKGROUND: Zambia's maternal mortality ratio was estimated at 398/100,000 live births in 2014. Successful aversion of deaths is dependent on availability and usability of signal functions for emergency obstetric and neonatal care. Evidence of availability, usability and quality of signal functions in urban settings in Zambia is minimal as previous research has evaluated their distribution in rural settings. This survey evaluated the availability and usability of signal functions in private and public health facilities in Lusaka District of Zambia. METHODS: A descriptive cross sectional study was conducted between November 2014 and February 2015 at 35 public and private health facilities. The Service Availability and Readiness Assessment tool was adapted and administered to overall in-charges, hospital administrators or maternity ward supervisors at health facilities providing maternal and newborn health services. The survey quantified infrastructure, human resources, equipment, essential drugs and supplies and used the UN process indicators to determine availability, accessibility and quality of signal functions. Data on deliveries and complications were collected from registers for periods between June 2013 and May 2014. RESULTS: Of the 35 (25.7% private and 74.2% public) health facilities assessed, only 22 (62.8%) were staffed 24 h a day, 7 days a week and had provided obstetric care 3 months prior to the survey. Pre-eclampsia/ eclampsia and obstructed labor accounted for most direct complications while postpartum hemorrhage was the leading cause of maternal deaths. Overall, 3 (8.6%) and 5 (14.3%) of the health facilities had provided Basic and Comprehensive EmONC services, respectively. All facilities obtained blood products from the only blood bank at a government referral hospital. CONCLUSION: The UN process indicators can be adequately used to monitor progress towards maternal mortality reduction. Lusaka district had an unmet need for BEmONC as health facilities fell below the minimum UN standard. Public health facilities with capacity to perform signal functions should be upgraded to Basic EmONC status. Efforts must focus on enhancing human resource capacity in EmONC and improving infrastructure and supply chain. Obstetric health needs and international trends must drive policy change.

Satisfaction with emergency obstetric and new born care services among clients using public health facilities in Jimma Zone, Oromia Regional State, Ethiopia; a cross sectional study.

BACKGROUND: The 2005 report of United Nations Millennium Project of Transforming Health Systems for women and children concluded that universal access to Emergency Obstetric and New born Care could reduce maternal deaths by 74%. Even though some studies investigated quality of Emergency Obstetric and New born Care in different parts of the world, there is scarcity of data regarding this issue in Ethiopia, particularly in Jimma zone. Therefore, the aim of this study was to assess satisfaction with Emergency Obstetric and new born Care services among clients using public health facilities in Jimma zone, Southwest Ethiopia. METHODS: A facility-based cross sectional study was conducted in Jimma Zone from April 01-30, 2014. The data were collected by interviewing 403 clients, who gave birth in the past 12 months prior to data collection in 34 randomly selected public health facilities. The collected data were entered by using Epi-info version 3.5.4 and analysed using SPSS version 20.0. Linear regression analysis was done to ascertain the association between covariates and the outcome variable, and finally the results were presented using frequency distribution tables, graphs and texts. RESULTS: The overall mean client satisfaction with Emergency Obstetric and New born Care services in this study was 79.4%; 95% CI (75%, 83%). The result of linear regression analysis revealed that a unit decrease in satisfaction to availability of drugs and equipment, decreased overall clients' satisfaction by 0.23 unit 95% CI (0.15, 0.31). CONCLUSIONS: The level of clients' satisfaction with Emergency Obstetric and New born Care services was low in the study area. Factors such as availability of essential equipment and drugs, health workers' communication, health care provided, and attitude of health workers had positive association with client satisfaction with Emergency Obstetric and New born Care services. This in turn could affect utilization of Emergency Obstetric and New born Care services and play a role in contribution to maternal and new born mortality. Therefore, the efforts of health facilities leaders and health care providers towards improvement of quality of care could contribute more for better maternal satisfaction.

Using an integrated approach to evaluate "Where do Flint's families play".

BACKGROUND: Once home to a thriving auto industry, Flint, Michigan, is now an economically distressed city of just over 100 000 people. With more than one-third of the population obese and one-third of the population younger than 18 years, it is essential to have safe spaces for children and families to be physically active. To address this, the Healthy Kids, Healthy Communities Flint Community Partnership (Partnership) worked to revitalize local parks and evaluate these efforts to effectively guide future park resource allocation, investments, and approaches to create a more equitable, vibrant parks system. METHODS: After 2 years of initial park investments, 2 intervention parks (Max Brandon Park and Bassett Park) and 2 comparison parks (Brennan Park and Whaley Park) were selected for direct observation to determine whether parks that experienced investment had more use and users participating in higher levels of physical activity than in parks with no investment. In addition, the Partnership implemented community engagement strategies to hear residents' needs and desires for parks, as well as technical assessments such as a park facilities assessment, policy review, and equity analysis. RESULTS: Intervention parks had a higher number of uses and higher physical activity levels than comparison parks. This complemented community engagement results that highlighted people do not use parks that are perceived as unsafe and in poor condition. Even though demand for parks can be met with the current supply of park space, many parks had outdated and hazardous equipment; this, plus inconsistent maintenance, (perceived) lack of safety, and lack of activities were the main deterrents to using city parks for physical activity. CONCLUSIONS: Parks receiving investment had higher use and physical activity levels; thus, investing in park facilities and programming could increase opportunities for Flint residents to lead more active, healthy lifestyles.

Redesigning a neighborhood park to increase physical activity: a community-based participatory approach.

BACKGROUND: Community collaboration and active engagement of neighborhood residents in park redesign are promising strategies for creating public spaces that support physical activity. OBJECTIVE: This research brief describes the process of community engagement and discusses outcomes of a participatory park redesign project. METHODS: A community design charrette was held in collaboration with community organizations. Environmental audits of park features and amenities were completed before and after implementation of park redesign. A guided discussion with stakeholders following the park redesign was conducted to discuss challenges, successes, and next steps. RESULTS: Although level of activity among youth observed in the post implementation observations did not differ, there were a greater variety of activities observed among both children and adolescents. Furthermore, the goals of the project related to capacity building and meeting residents' needs were accomplished. CONCLUSIONS: Active participation of residents in a neighborhood park redesign requires time, commitment, and communication from a variety of stakeholders. However, the creation of a park that supports a variety of activity types, and builds community capacity, supports the need for involving stakeholders in redesigning neighborhood parks.

The impact of neighborhood park access and quality on body mass index among adults in New York City.

OBJECTIVE: To evaluate the association between adult individuals' body mass index (BMI) and characteristics of parks (size and cleanliness) in an urban environment taking into account the physical and social environments of the neighborhood. METHODS: Cross-sectional, hierarchical linear models were used to determine whether park effects were associated with BMI using self-reported height and weight data obtained from the Community Health Survey in New York City (2002-2006). RESULTS: Both the proportion of the residential zip code that was large park space and the proportion that was small park space had significant inverse associations with BMI after controlling for individual socio-demographic and zip code built environment characteristics (-0.20 BMI units across the inter-quartile range (IQR) for large parks, 95% CI -0.32, -0.08; -0.21 BMI units across the IQR for small parks, 95% CI -0.31, -0.10, respectively). Poorer scores on the park cleanliness index were associated with higher BMI, 0.18 BMI units across the IQR of the park cleanliness index (95% CI 0.05, 0.30). CONCLUSIONS: This study demonstrated that proportion of neighborhoods that was large or small park space and park cleanliness were associated with lower BMI among NYC adults after adjusting for other neighborhood features such as homicides and walkability, characteristics that could influence park usage.

Association of outdoor recreation availability with physical activity and weight status in Minnesota youth.

OBJECTIVE: Examine macro-level associations of youth physical activity (PA) and weight status with availability of outdoor recreation resources (i.e., parkland, forestland, natural preserves, nonmotorized trails, and motorized trails) across counties in Minnesota. METHODS: Hierarchical regression models examined if availability of recreation resources significantly improved prediction of PA and weight status of 9th and 12th grade boys and girls (2010) across Minnesota counties. RESULTS: The inclusion of county-level densities of recreational land variables did not produce a significant increase in R(2) for any of the models predicting 9th grade outcomes, yet county-level densities of recreational trails did significantly increase R(2) for both levels of PA and weight status. In contrast, the inclusion of recreational trails did not produce any significant increases in R(2) for 12th grade outcomes, although the inclusion of recreational land did significantly increase the R(2) for 12th grade girls achieving 30min of PA 5 or more days of the week. CONCLUSION: Findings indicate that various recreational land and trail types may have different impacts on and associations with PA and health outcomes. As such, it is important that future studies focus not only on parks, but also on other types of recreational lands and trails as well.

Involving community stakeholders to increase park use and physical activity.

OBJECTIVE: The aim of this study is to describe implementation of a randomized controlled trial of community-based participatory research (CBPR) approaches to increase park use and physical activity across 33 diverse neighborhoods in Los Angeles. METHODS: Fifty parks were randomly assigned based on park size, facilities and programs, and neighborhood socio-demographic characteristics to: park director (PD, 17 parks); PD and park advisory board of interested community members (PD+PAB, 16 parks); and no-intervention control (17 parks) arms. Between 2007 and 2012, PDs and PABs from the 33 intervention parks participated in community engagement, baseline assessment, marketing training, intervention design and implementation, and follow-up assessment. RESULTS: Intervention parks (PD and PD+PAB) invested in new and diversified signage, promotional items, outreach or support for group activities like fitness classes and walking clubs, and various marketing strategies. Scaling up CBPR methods across parks in 33 diverse neighborhoods was challenging. Working with departmental management and established structures for community input (PABs) and park policy (PDs) facilitated implementation and sustainability. CONCLUSION: Scaling up CBPR methods across diverse communities involved tradeoffs. CBPR is useful for tailoring research and enhancing community impact and sustainability, but more work is needed to understand how to conduct multi-site trials across diverse settings using CBPR.

Risk factors and monitoring for water quality to determine best management practices for splash parks.

Splash parks have been associated with infectious disease outbreaks as a result of exposure to poor water quality. To be able to protect public health, risk factors were identified that determine poor water quality. Samples were taken at seven splash parks where operators were willing to participate in the study. Higher concentrations of Escherichia coli were measured in water of splash parks filled with rainwater or surface water as compared with sites filled with tap water, independent of routine inspection intervals and employed disinfection. Management practices to prevent fecal contamination and guarantee maintaining good water quality at splash parks should include selection of source water of acceptable quality.

A nordic charter for universal design.

AIMS: The aim of this paper is to present the result of a pioneer project; A Nordic Charter for Universal Design, which was initiated by the Norwegian Directorate for Children, Youth and Family Affairs in 2011. The purpose of the Charter was to present rationales that stated prerequisites for successful investment in Universal Design, and to establish a platform for further research and good practice. It was also meant to contribute to spreading of information and knowledge about the importance of guidance by the concept of Universal Design of initiatives with effects on the public arena. METHOD: A Nordic group of researchers and professionals in the field ended up after 8 months of work with a written document: "A Nordic Charter for Universal Design", which was presented at the International Conference in Universal Design in Oslo, Norway (UD 2012). RESULT: A Nordic Charter for Universal Design. CONCLUSIONS: Persons with disabilities often experience the public arenas environments, products and services as poorly-designed to fit their abilities and/or their needs. Together with the demographic changes in the Nordic societies with an increasing number of elderly people, it needs initiatives to improve independence, accessibility and participation in society. A strategy which aims to make design and composition of different environments, products, communication, information technology and services accessible, usable and understandable to as many as possible is Universal Design.

Tobacco control policies in outdoor areas of high volume American transit systems.

Very little is known about how smoking and other tobacco use is regulated in outdoor and semi-enclosed spaces across transit systems. The purpose of this study was to understand how American transit systems are regulating cigarettes and other tobacco products, including smokeless tobacco and e-cigarettes, in outdoor or quasi-outdoor spaces. Within four regions of the United States, a purposive convenience sample was taken of the top five volume American transit systems (n = 20) based on annual ridership. Each transit authority website was systematically reviewed to produce a cross-sectional study of the published policies regarding tobacco product use for indoor, outdoor, and quasi-outdoor spaces of transit property; rules regarding cigarettes, smokeless tobacco and electronic cigarettes were identified. Policies regulating tobacco use were enacted by transit systems and/or the cities and states in which transit systems are located. The majority (80%) of transit systems banned smoking in outdoor areas; few prohibited smokeless tobacco use (15%, n = 3) and some disallowed e-cigarettes (30%, n = 6). Violation consequences ranged widely from none to verbal warnings, ejection from transit property, fines, and imprisonment. Regulating smoking in outdoor or quasi-outdoor environments is common in American transit environments. These policies can help protect vulnerable populations from exposure to secondhand smoke and communicate a tobacco-free norm.

The association of state law to breastfeeding practices in the US.

We assessed the relationship between breastfeeding initiation and duration with laws supportive of breastfeeding enacted at the state level. We analyzed breastfeeding practices using the 2003-2010 National Health and Nutrition Examination Survey. We evaluated three measures of breastfeeding practices: Mother's reported breastfeeding initiation, a proxy report of infants ever being breastfeed, and a proxy report of infants being breastfeed for at least 6 months. Survey data were linked to eight laws supportive of breastfeeding enacted at the state level. The most robust laws associated with increased infant breastfeeding at 6 months were an enforcement provision for workplace pumping laws [OR (95 % CI) 2.0 (1.6, 2.6)] and a jury duty exemption for breastfeeding mothers [OR (95 % CI) 1.7 (1.3, 2.1)]. Having a private area in the workplace to express breast milk [OR (95 % CI) 1.3 (1.1, 1.7)] and having break time to breastfeed or pump [OR (95 % CI) 1.2 (1.0, 1.5)] were also important for infant breastfeeding at 6 months. This research responds to breastfeeding advocates' calls for evidence-based data to generate the necessary political action to enact legislation and laws to protect, promote, and support breastfeeding. We identify the laws with the greatest potential to reach the Healthy People 2020 targets for breastfeeding initiation and duration.

Quality of antiretroviral therapy in public health facilities in Nigeria and perceptions of end users.

AIM: This paper describes perceptions of the end users on quality of antiretroviral therapy (ART) in public health facilities in Nigeria. BACKGROUND: Health care services in Nigeria face challenges of meeting end users' requirements and expectations for quality ART service provision. METHOD: A qualitative design was followed. Unstructured focus group discussions were conducted with end users (n = 64) in six locations across the six geopolitical zones of Nigeria. RESULTS: The findings indicate that end users were satisfied with uninterrupted antiretroviral drug supplies, courtesy treatment, volunteerism of support group members and quality counselling services. CONCLUSION: End users expect effective collaboration between healthcare providers and support group members, to enhance the quality of life of people living with HIV. IMPLICATIONS FOR NURSING MANAGEMENT: A best practice guideline for the provision of end user focused ART service provision was developed for nurse managers.

[To the issue on the optimization and regulation of microclimate in the subway trains and stations].

There is presented an overview of currently existing regulatory framework governing the parameters of the microclimate in the salons of subway passenger cars and stations. Analysis of the normative documents indicated that they contain very incomplete, contradictory, often unfounded information about the parameters of microclimate parameters in salons of subway rolling stock. Also, there are no clear cut hygienically-sound requirements for the work of imposed on the rolling stock subway systems provide microclimate, including new systems for air conditioning and disinfection.

Second-hand smoke and indoor air quality in public places in Gaza City.

Second-hand smoke is a major cause of preventable disease and death in the Eastern Mediterranean Region. To assess how second-hand smoke impacts air quality, respirable suspended particles (PM2.5) which are emitted during cigarette and waterpipe smoking, were measured inside and outside of 18 smoking and 5 nonsmoking public venues in Gaza city. Median PM2.5 level inside the smoking venues was 117 microg/m3, which exceeds the WHO guidelines for daily PM2.5 exposure (25 microg/m3) by more than 4-fold. The median level inside the smoking venues (117 microg/m3) was significantly higher than outside the venues (43 microg/m3), and significantly higher than the median level inside non-smoking venues (40 microg/m3). By contrast particulate levels outside non-smoking venues (35 microg/m3) did not differ from the corresponding levels inside (40 microg/m3). To protect employees and the public from second-hand smoke exposure, policies prohibiting sinoking in public niaces are needed in Gaza city.