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Original Paper

Indoor and Built

Indoor and Built Environment
2019, Vol. 28(10) 1422–1430

Evaluating the relationships ! The Author(s) 2019

Article reuse guidelines:

between air pollution and

DOI: 10.1177/1420326X19842302
environmental parameters

with sick building syndrome

in schools of Northern Iran

Abdoliman Amouei1,2 , Zahra Aghalari3, Ahmad Zarei3,

Mojtaba Afsharnia3, Zahra Geraili4 and Mehdi Qasemi3

The present study was conducted to determine the relationship between air pollution and environmen-
tal parameters with sick building syndrome (SBS) symptoms in schools of northern Iran. This study was
conducted on 759 students from a total of 52 primary, guidance and high schools in northern Iran.
Selection of schools, classes in each school and students in each class was performed using a multi-
stage random sampling method. Carbon dioxide (CO2), temperature and humidity were measured. Data
on the SBS symptoms were collected using a standard questionnaire via interview. Measurements in
215 classes showed the highest levels of CO2, temperature and humidity were 4263 ppm, 25.2 C and
82.5%, respectively. A t-test showed that there were significant correlations between CO2 and temper-
ature with SBS symptoms (p ¼ 0.01). In Winter, dizziness (44.4%) was the most common symptom
among 12 SBS symptoms, and fatigue (37.2%) was the most common symptom in Spring. Statistical
analysis showed that there was a significant relationship between the types of ventilation, cooling and
heating systems with the SBS symptoms in both seasons (p ¼ 0.001). The SBS symptoms in students
were considered to be mild. Considering the poor physical conditions in some schools and the lack of
proper space and ventilation systems, the health authorities in cooperation with the Education
Department should create better educational environments.

Indoor air pollution, Carbon dioxide, Sick building syndrome, School
Accepted: 15 March 2019

Environmental Health Research Center (EHRC), Health
Introduction Research Institute, Babol University of Medical Sciences,
Babol, Iran
One of the most important environmental problems 2
Social Determinants of Health Research Center, Health
facing all countries of the world is air pollution.1 Air Research Institute, Babol University of Medical Sciences,
pollution means the presence of one or more pollutants Babol, Iran
Department of Environmental Health, Gonabad University of
in the air that are harmful for the lives of humans,
Medical Sciences, Gonabad, Iran
animals and plants and for property and objects.2 4
Department of Biostatistics, Babol University of Medical
The overall classification of air pollution is based on Sciences, Babol, Iran
the type of environment, which is divided into two
Corresponding author:
types of indoor and outdoor air pollution. Air pollu- Zahra Aghalari, Department of Environmental Health, Gonabad
tion in indoors is far more important than that in out- University of Medical Sciences, Gonabad, Iran.
doors.3 Today, people spend 90% of their daily time in Email:
Amouei et al. 1423

indoors and are unintentionally exposed to various learning and performance. Students must have an
types of indoor air pollutants.4,5 Air pollutants have appropriate educational environment and acceptable
adverse effects on human health, which appear as air quality to assist learning. Therefore, the present
short-term (acute) and long-term (chronic) effects.6 study was conducted to determine the relationship
Air pollution sometimes has harmful effects on between air pollution and environmental parameters
people over many years and imposes a large financial with SBS symptoms in schools of northern Iran in
burden on individuals and health systems. Respiratory Winters of 2017 and 2018.
disorders, acute heart attacks, anaemia, deaths due to
heart attack and stroke, gene mutations, abortions,
Materials and methods
mental retardation of children are recognized as the
most important adverse effects of air pollution on In order to measure CO2, temperature and humidity as
humans.7 In Iran, the frequency of problems and ill- parameters of air pollution and environmental factors,
nesses caused by indoor air pollution was reported 10% of a total of 552 urban and rural schools were
as 17%.8 selected by using multistage random sampling
The accumulation of air pollutants in indoors leads method. Selection of schools and classrooms in each
to various symptoms and diseases including sick build- school was randomly performed. An instrument TES
ing syndrome (SBS).9 SBS is a condition in which 1370 (Megatek, Taiwan) was used to measure CO2,
people living in the building suffer from a series of temperature and humidity. When measuring CO2,
symptoms and feelings of lethargy that may be TES 1370 was placed at a height of 1.2 m above floor
improved by leaving the building.10 Researchers have level of each class. Also, information such as type of
identified various parameters such as the environment, area (urban or rural), age of school building, apartment
pollutants, temperature, humidity, Carbon dioxide or villa, type of ventilation, heating and cooling sys-
(CO2) as well as occupant and building characteristics tems, number of students in a class and duration of
as factors influencing on SBS.11–13 student presence in the classroom was obtained.
CO2 is one of the gases in the air and one of the To create the same sampling conditions in classes,
environmental factors that can correlate with SBS the sampling of environmental parameters (carbon
symptoms. CO2 level may be directly related to pollu- dioxide, temperature and humidity) was performed
tants in indoors.14 The CO2 concentration in indoors is during 1 h in classes whose doors and windows were
higher than that in outdoors because the CO2 increases closed and opened less than two or three times, and in
through human respiration in addition to CO2 natural- classes whose doors and windows were continuously
ly presenting in ventilation air. The CO2 concentration opened. The sample size was determined using the
is usually influenced by the number of inhabitants, Morgan table, so that 380 of 41643 urban students
their ages, their physical activity and physical charac- and 379 of 29472 rural students were selected. In
teristics of the building such as the size of rooms and order to determine the frequency of the SBS symptoms
the existence and type of ventilation system.4 in different student groups, the sampling was taken
The usual concentration of CO2 in outdoor air is from elementary, guidance and high schools. To
about 380 ppm, but is more than 500 ppm in some achieve this, the numbers of students were obtained
urban areas.15 High CO2 concentration is a type of from Babol Education Department, and sample sizes
air pollution that can lead to respiratory problems, were determined using the Morgan table.22 As a result,
reduced comfort and even death.16 410 students from 26 primary schools, 152 students
In some studies, CO2 concentration has been identi- from 15 guidance schools and 197 students from 11
fied as an effective factor on the SBS symptoms.17 high schools were selected. In relation to the school
Studies in the American, European and Asian countries sampling, each of the 52 schools was considered as a
have illustrated that SBS was associated with indoor air cluster. From each cluster (school), the selection of
pollution, ventilation system and CO2 concentration.18 classes was randomly performed to measure the envi-
Sepp€ anen et al.19 found that the risk of diseases related ronmental parameters, and random sampling of stu-
to air pollutants was reduced at CO2 concentrations dents was done based on the student list of each
less than 800 ppm. class. Therefore, randomized multistage sampling was
Students spend more than 30% of their lives in used in this study.
schools and about 70% of the time in the indoor class- The sampling method was randomly performed in
rooms.20 Lack of access to good air quality can lead to each class. Students were selected based on the number
reduced comfort and increased risk of illnesses such as of classes and students, and the questionnaires were
SBS in students, and affect their learning and efficien- completed in an interview. A standard questionnaire,
cy. Soughnessy et al.21 stated that air pollution in class- Miljomedicine 040 (MM040EA, Kjell Andersson,
rooms had unfavourable effects on student attendance, Sweden), as a Persian version, the reliability and
1424 Indoor and Built Environment 28(10)

validity of which were confirmed by Iranian research- 4500 4263

ers, was used to collect data on SBS symptoms.23 In 4000 3760

Co2 Concentration (PPm)

some Iranian papers, its reliability has been 0.75 using 3500

Cronbach’s alpha test.24,25 This questionnaire collects 2500

information about the SBS, the individual situation, 2000

the status of classroom and school environments and 1000
963 1005
861 806 817 804

diseases and complications in the past and present. 500

SBS symptoms are eye problems (itching and irrita- Primary
High School Primary
High School

tion), nasal problems (runny nose, congestion and Highest

Different educational levels

sneeze), dryness of the throat, cough, red/dry facial

skin, itching or scaling of ears and scalp, redness or
Figure 1. Comparison of CO2 concentration in Winter and
itching of the hands, fatigue, headache, dizziness,
Spring at 215 classes.
nausea or vertigo and problems with concentration.
Students expressed their opinions about symptoms in
the form of ‘often’ (symptoms occurred more than
three times per week), ‘sometimes’ (once or twice a 30
week) and ‘never’. Students were divided into four 25
25 25.1

groups based on the frequency of SBS: the first group

Temperature (C)
20 19 18.7 19 19 18.7
had no symptoms, the second group was students with 15

‘mild symptoms’ (with one to four symptoms), the 10 Spring

third group was students with ‘moderate symptoms’ 5


(with five to nine symptoms) and the fourth group 0

Primary Guidance High School Primary Guidance High School
was students with ‘severe symptoms’ (more than School School School School
Highest Lowest
10 symptoms). After collecting questionnaires and Different educational levels
encoding them, data from each questionnaire were
entered into the statistical package for the Social
Figure 2. Comparison of temperature in Winter and Spring
Sciences (SPSS, 22th version, USA). Descriptive indi-
in 215 classes.
cators, such as the means for quantitative variables and
frequency tables, were used to express the results of
qualitative variables analyses. Data were analysed
exceeded 1500 ppm, which was higher than the recom-
using statistical tests, such as Chi-square, ANOVA
mended level for schools. Ramalho et al.29 evaluated
and t-test. The significance level was considered as 0.05.
CO2 concentration in 489 classes in France and
observed that CO2 concentration was higher than
Results and discussion 1700 ppm in 33% of classes. The present study, consis-
CO2 measurement was performed in 52 primary, guid- tent with the above studies, found that CO2 concentra-
ance and high schools (215 classes) during two consec- tions in classrooms were high, which could be due to
utive seasons of Winter and Spring. The highest level of the lack of proper ventilation and the large number of
CO2 was 4263 ppm for primary schools in Winter, and students in classrooms. In this study, the number of
the lowest one was 804 ppm for high schools in Winter students was 42 in some classes. Therefore, the appro-
(Figure 1). ANOVA test showed that no significant priate ventilation should be used according to the
relationship was found between CO2 levels in Spring number of students in classrooms or the number of
(p ¼ 0.090) and Winter (p ¼ 0.90) at different educa- students should be appropriate to the ventilation
tional levels. In addition, the mean concentration of environment.
CO2 was lower in Spring than in Winter, which can Temperature measurements in classrooms in both
be due to opening the windows and doors in the Winter and Spring showed that the highest temperature
Spring, leading to a reduction of CO2 concentration was 25.2 C in Winter in guidance schools and the
in indoors (Figure 1). lowest was also in guidance schools in Winter at
Peng et al.26 studied schools in China and showed 17.4 C (Figure 2). ANOVA test demonstrated no sig-
that the highest concentration of CO2 was 4692 ppm. nificant relationship between temperatures at different
A study by Haverinen-Shaughnessy et al.27 on 100 pri- educational levels in Winter (p ¼ 0.26), but there was a
mary schools in the south-west America suggested that significant relationship between temperatures at differ-
87% of classrooms had poor air quality. A study con- ent educational levels in Spring (p ¼ 0.001).
ducted in East London by Griffiths and Eftekhari28 The relationship between inadequate indoor air
found that CO2 concentrations in most classrooms quality and ventilation has been proven in several
Amouei et al. 1425

studies.18,30 In most schools, natural ventilation from an increase humidity could exacerbates SBS symptoms.
opening of doors and windows was used as a way to Also, a relationship between CO2 and humidity with
control the indoor air quality of classrooms. In China, SBS symptoms has been reported in various stud-
mechanical air conditioning systems are not used in ies.31,32 Chi-square testing showed that there was a sig-
schools, and the only way to get fresh air into class- nificant relationship between humidity and SBS, so
rooms is to open windows and doors, through which that the SBS symptoms were higher at higher humidity,
particles and other air pollutants can easily enter the consistent with Wang et al.’s study. Basic measures
classroom. In addition in China, the outdoor air pol- should be taken to reduce the CO2 concentration in
lution is very poor in Winter, but doors and windows indoors and to control the humidity level, especially
are often closed to keep the classroom warm, resulting in wet regions such as northern Iran.
in poor air supply and increased indoor air pollution.26 The t-test showed that there was a significant rela-
Ventilation is an important factor in the indoor envi- tionship between CO2 and temperature with SBS symp-
ronment, especially in schools. Therefore, school toms in Winter (p ¼ 0.01). In the Spring, there was a
authorities should prevent the development of diseases significant relationship between CO2 (p ¼ 0.001) and
associated with indoor air pollution by installing humidity levels (p ¼ 0.003) with SBS symptoms, so
appropriate ventilation systems in schools. that in classes with higher levels of humidity and
Humidity measurements in Winter and Spring CO2, more students complained about SBS symptoms.
showed that the highest humidity level in high schools The present study found that 72% and 69% of 759
was 82.5% RH, in Winter and the lowest was 49%RH students had SBS symptoms in Winter and Spring,
in Spring (Figure 3). ANOVA testing illustrated that respectively. Moreover, the division of the SBS symp-
there was a significant relationship between humidity toms into four categories showed that the highest
levels at different educational levels in Winter and number of students had ‘mild symptoms’ in two sea-
Spring (p ¼ 0.001). Wang et al.31 have reported that sons. Only 0.6% of students, in Winter, were in the
group of ‘severe symptoms’ and none were included
in this category in Spring. In a study on bank employ-
81 79.3 80 81.2 80 82.5 ees in Mazandaran province in 2016, the prevalence of
SBS symptoms among employees was 79.6%, of which
Humidity percantage

51 51.5 52
53 35.3% and 10% were moderate and severe,
Spring In Winter, among the 12 SBS symptoms, the most
20 common symptom was dizziness, with a frequency of
44.4%. In Spring, the most common symptom was
High School Primary
High School
fatigue, with a frequency of 37.2% (Figure 4).
Different educational levels
L ow e s t
In the current study, about three-quarters (75%) of
students had at least one symptom of SBS in Winter
and Spring. Probably, one of the reasons for this high
Figure 3. Comparison of humidity percentage in Winter
prevalence of SBS could be that the school buildings
and Spring in 215 classes.
and classrooms did not meet health standards or that

350 327 337

300 283 284 275


149 153 139 145 141 144 152
150 125 137
115 109 106 105 118
100 84
50 26 35 Spring
0 Winter

Figure 4. Frequency of SBS symptoms in selected schools in Winter and Spring.

1426 Indoor and Built Environment 28(10)

Table 1. Relationship between some factors associated with air pollution and SBS symptoms in
selected schools in Winter and Spring.


No Yes
Variables Seasons Mean  SD Mean  SD P

CO2 (ppm) Winter 1688.44  503.02 2221.69  728.50 0.001

Spring 1536.95  390.93 2063.19  588.46 0.001
Temperature Winter 20.82  1.32 21.46  1.56 0.001
Spring 20.94  1.11 21.40  1.13 0.076
Humidity Winter 63.29  6.28 67.01  7.07 0.094
Spring 61.94  6.00 62.27  7.13 0.003
Age Winter 12.18  3.73 12.43  3.47 0.011
Spring 11.60  3.67 12.71  3.43 0.056
The number of Winter 29.57  8.47 34.37  6.91 0.001
students in a class Spring 29.96  7.69 34.41  7.27 0.098
SBS: sick building syndrome.

there was a symptom like fatigue as a general symptom Table 2. Classification of SBS symptoms in the selected
of SBS. Headache and fatigue were the most common schools in Winter and Spring.
symptoms in the study of Lu et al.34 on 3845 residents Classification
of Chinese residential buildings. In 2012, a study on of symptoms Seasons Number Percentage
2134 students of 44 classes from 10 schools in
Taiyuan City, south-west of Beijing, demonstrated No symptom Winter 212 28
Spring 235 31
that the highest occurrence frequency of SBS was
1–4 symptoms Winter 405 53.4
33% showing for general SBS symptoms and the
Spring 389 51.2
lowest frequency was 6% reporting skin symptoms.35 5–9 symptoms Winter 138 18.1
Fatigue and headache are a common symptom of SBS, Spring 135 17.8
which are the highest symptoms in the majority of stud- More than Winter 4 0.6
ies on different target groups.33,34 10 symptoms Spring 0 0
The SBS symptoms in students were divided into
four groups, and the highest number of students was
in the group of one to four symptoms, meaning those
with ‘mild symptoms’. In total, 524 (69%) students had radiative heating and air heating, respectively. Chi-
SBS symptoms and 235 (31%) had no symptoms in square test represented that there was a significant rela-
spring and 547 (72%) students had SBS symptoms tionship between SBS and heating systems, so that the
and 212 (28%) had no symptoms in winter (Table 2). SBS symptoms were higher in classes with radiators
In the present study, 215 classes were classified into (Table 3). Further, there was a significant relationship
two groups according to the type of ventilation system. between gender and SBS symptoms in Winter, so that
Fifty-six (26.1%) classes had ventilation systems, and the prevalence of SBS symptoms was higher in girls
159 (73.9%) had natural ventilation through doors and than in boys.
windows. Chi-square test suggested that there was a De Magalh~aes Rios et al.36 investigated SBS in office
significant relationship between SBS and the type of workers and stated that SBS was more common in
air conditioning system, so that the SBS symptoms women than in men. In previous SBS studies37,38 on
were higher in classrooms with no air conditioning both males and females, women have been noted as
(AC) (Table 3). Regarding the type of cooling systems, vulnerable groups.
172 (80%) classes were equipped with ceiling fans and Among the studied risk factors, the highest number
43 (20%) were equipped with split AC. Chi-square test of students complained of noise as an annoying factor
indicated that there was a significant relationship in classrooms and schools. However, there was no sig-
between SBS and type of cooling systems, so that the nificant relationship between reported noise and SBS
SBS symptoms were higher in classrooms with ceiling symptoms based on a Chi-square test. In Winter, a
fans. Regarding the type of heating systems, 139 significant relationship was found between reported
(64.6%) and 76 (35.4%) classes were equipped with ‘dry air’ and SBS symptoms (p ¼ 0.011), and there
Amouei et al. 1427

Table 3. Relationship between the physical characteristics of classes and some demographic characteristics of students with
SBS symptoms in Winter and Spring.


Yes No
Physical factors Number Number
of classes Seasons Level (percentage) (percentage) p

Region Winter Urban 272 (71.6) 108 (28.4) 0.763

Rural 275 (72.6) 104 (33.7)
Spring Urban 252 (66.3) 128 (33.7) 0.104
Rural 272 (71.6) 107 (28.2)
Type of building Winter Building age more than 10 453 (75) 151 (25) 0.001
Building age less than 10 94 (60.6) 61 (39.4)
Spring Building age more than 10 173 (71.4) 173 (28.6) 0.006
Building age less than 10 93 (60) 62 (40)
Floor Winter Ground or first 432 (71.4) 173 (28.6) 0.393
Second 98 (73.1) 36 (26.9)
Third 17 (85) 3 (15)
Spring Ground or first 402 (66.4) 203 (33.6) 0.008
Second 107 (79.9) 27 (20.1)
Third 15 (75) 5 (25)
Ventilation system Winter Yes 52 (48.1) 56 (51.9) 0.001
No 495 (76) 156 (24)
Spring Yes 54 (50) 54 (50) 0.001
No 470 (72.2) 181 (27.8)
Cooling system Spring Fan 470 (72.2) 181 (27.8) 0.001
Split 54 (50) 54 (50)
Heating system Winter Air heating 240 (65.8) 125 (34.2) 0.001
Radiative heating 307 (77.9) 87 (22.1)
Gender Winter Female 303 (75.9) 96 (24.1) 0.012
Male 244 (67.8) 116 (32.2)
Spring Female 276 (69.2) 123 (30.8) 0.933
Male 248 (68.9) 112 (31.1)
Education level Winter Elementary 290 (70.7) 120 (29.3) 0.014
Guidance 122 (81.3) 28 (18.7)
High 135 (67.8) 64 (32.2)
Spring Elementary 263 (64.1) 147 (35.9) 0.002
Guidance 119 (79.3) 31 (20.7)
High 142 (71.4) 57 (28.6)
SBS: sick building syndrome.

Table 4. Relationship between risk factors and SBS symptoms in Winter and Spring.


Yes No
Number Number
Risk factors Seasons Level (percentage) (percentage) p

Noise Winter Yes 362 (74.8) 122 (25.2) 0.026

No 185 (67.3) 90 (32.7)
Spring Yes 315 (68.3) 146 (31.7) 0.600
No 209 (70.1) 89 (29.9)
Low light Winter Yes 60 (75) 20 (25) 0.537
No 487 (71.7) 192 (28.3)
Spring Yes 128 (87.7) 18 (12.3) 0.001
No 396 (64.6) 217 (35.4)
1428 Indoor and Built Environment 28(10)

Table 4. Continued.

Yes No
Number Number
Risk factors Seasons Level (percentage) (percentage) p

High light Winter Yes 23 (69.7) 10 (30.3) 0.756

No 524 (72.2) 202 (27.8)
Spring Yes 38 (77.6) 11 (22.4) 0.183
No 486 (68.5) 224 (31.5)
Very cold air Winter Yes 209 (73.9) 74 (26.1) 0.399
No 338 (71) 138 (29)
Spring Yes 178 (72.4) 68 (27.4) 0.171
No 346 (67.4) 167 (32.6)
Very hot air Winter Yes 107 (74.3) 37 (25.8) 0.506
No 440 (71.5) 175 (28.5)
Spring Yes 107 (70.4) 45 (29.6) 0.686
No 417 (68.7) 190 (31.3)
Dry air Winter Yes 58 (85.3) 10 (14.7) 0.011
No 489 (70.8) 202 (29.2)
Spring Yes 62 (72.9) 23 (27.1) 0.409
No 462 (68.5) 212 (31.5)
Wet air Winter Yes 172 (75.8) 55 (24.2) 0.138
No 375 (70.5) 157 (29.5)
Spring Yes 175 (72) 68 (28) 0.223
No 349 (67.6) 167 (32.4)
Unpleasant odours Winter Yes 196 (74.2) 68 (25.8) 0.330
No 351 (70.9) 144 (29.1)
Spring Yes 231 (74.3) 80 (25.7) 0.009
No 293 (65.4) 1555 (34.6)
SBS: sick building syndrome.

was a significant relationship between low reported heating systems and students with the SBS symptoms
brightness and SBS symptoms in Spring (p ¼ 0.001). in both seasons. The present study showed that at dif-
Regarding the risk factors affecting the SBS, in both ferent educational levels, CO2 concentration was high
Winter and Spring, 74.8% and 68.3% of students in most classes during two seasons of Winter and
reported noise as the most important annoying risk Spring and had a significant relationship with SBS
factor in schools and classrooms, respectively. The symptoms. Although SBS symptoms in students were
presence of noise in schools and classrooms is natural mild, the health authorities in cooperation with the
due to the number of students. Nevertheless, excessive Education Department should improve educational
noise leads to headaches, lack of concentration and environment because of poor physical conditions in
decrease of comfort and learning in students.39 some schools and the lack of proper space and venti-
Therefore, the noise risk factor should be controlled lation system. Thus, we recommend that the state of
or noise barriers should be used to prevent the sound school environments should be examined for all aspects
transmission from one classroom to another. of health, especially indoor air quality.

Conclusions This paper was derived from the MSc thesis (IR.GMU.
The present study was conducted to determine the rela- REC.1396.148) of Miss. Zahra Agharari, graduate from
tionship between air pollution and environmental Gonabad University of Medical Sciences in the major of
Environmental Health Engineering. This thesis was per-
parameters with SBS symptoms in schools of northern
formed as a common project with the guidance of
Iran. In Winter, dizziness was the most common symp- Department of Environmental Health Engineering in Babol
tom of 12 SBS symptoms, and fatigue was the most University of Medical Sciences and Gonabad. Therefore, the
common symptom in Spring. There was a significant authors would like to thank these Departments for spiritual
relationship between types of ventilation, cooling and and financial support, the staff of the Education Department
Amouei et al. 1429

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