The impacts of the Syrian conflict on child and adolescent health: a scoping review.

BACKGROUND: The Syrian conflict has had a profound impact on Syrian children and adolescents. We sought to determine the extent and range of literature on the conflict's health effects on this vulnerable population. METHODS: A scoping review describing the impact of the Syrian conflict on children was undertaken while utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Reviews methodology. Qualitative thematic analyses were undertaken to both identify patterns of morbidity and mortality and gaps in evidence. RESULTS: A total of 982 articles meeting search criteria were identified between 1 January 2011 and 30 April 2021. After iterative screening, 12 were identified from academic databases and 4 were identified from grey literature and hand searching, yielding a total of 16 studies for final, full-text analysis. Four distinct themes recurred in the literature; these include children suffering from violent injury, a resurgence of communicable diseases, malnutrition and micronutrient deficiency and impacts on their mental health. CONCLUSIONS: The health of children and adolescents in Syria has been significantly impacted by the indiscriminate attacks against civilians, flagrant human rights violations and the disintegration of the national health care system. Neonates were largely absent from the literature. The themes from this scoping review can inform health programming priorities by aid organizations.

The cascading impacts of attacks on health in Syria: A qualitative study of health system and community impacts.

Syria has experienced over a decade of armed conflict, characterized by targeted violence against healthcare. The impacts of these attacks have resulted in both direct and indirect attacks on health and reverberating effects on local communities. This study aims to explore the perspectives of health workers based in northern Syria who have experienced such attacks on health to understand the impacts on the health system as well as communities served. In-depth interviews were conducted with health workers in the northern regions of Syria where attacks on health have been frequent. Participants were identified using purposive and snowball sampling. Interviews were coded and analyzed using the Framework Method. Our inductive and deductive codes aligned closely with the WHO Health System Building Blocks framework, and we therefore integrated this framing into the presentation of findings. We actively sought to include female and non-physician health workers as both groups have been under-represented in previous research in northern Syria. A total of 40 health workers (32.5% female, 77.5% non-physicians) who experienced attacks in northern Syria between 2013 and 2020 participated in interviews in 2020-2021. Participants characterized attacks on health as frequent, persistent over years, and strategically targeted. The attacks had both direct and indirect impacts on the health system and consequently the wider health of the community. For the health system, participants noted compounded impacts on the delivery of care, health system governance, and challenges to financing, workforce, and infrastructure. Reconstructing health facilities or planning services in the aftermath of attacks on health was challenging due to poor health system governance and resource challenges. These impacts had ripple effects on the health of the community, particularly the most vulnerable. The impacts of attacks on health in Syria are multiple, with both short- and long-term consequences for the health system(s) across Syria as well as the health of communities in these respective areas. Though such attacks against healthcare are illegal under international humanitarian law, this and other legal frameworks have led to little accountability in the face of such attacks both in Syria and elsewhere. Characterizing their impacts is essential to improving our understanding of the consequences of attacks as a public health issue and supporting protection and advocacy efforts.

An analysis of paediatric clinical presentations in Northwest Syria and the effect of forced displacement, 2018-2022.

Background: One in six children worldwide lives in a region exposed to armed conflict. In conflicts, children are among the most vulnerable, and at risk of adverse health outcomes. We sought to describe trends in child and adolescent morbidity in northwest Syria (NWS) and understand how forced displacement affects clinical utilisation during the Syrian conflict. Methods: Retrospective data between January 2018 and December 2022 were obtained from the Syrian American Medical Society (SAMS), a non-governmental organisation that operates health facilities in NWS. After initial descriptive analyses were completed, we performed a seasonal-trend decomposition to estimate the seasonality of clinical presentations. We subsequently employed a multivariate regression model incorporating age, gender, residency status, season, and a random district-level intercept to measure the association between the odds of clinical consultation and forced displacement. Findings: Across 51 reporting SAMS facilities, 2,687,807 clinical consultations were studied over a five-year period. Seasonality was demonstrated for every clinical consultation category. Higher levels of forced displacement were associated with increased odds of consultations for nutrition, trauma, NCDs and mental health and decreased odds of consultation for communicable diseases. Aside from traumatic injury, internally displaced persons (IDPs) had higher AORs of clinical consultations compared to host populations. Interpretation: Forced displacement differentially impacts clinical utilisation among children in northwest Syria, and the effects of displacement persist for at least six months. Clinical needs vary by host/IDP status, sex, age, and season. This study can assist policymakers in forecasting the health needs of children in northwest Syria.

Impact of the Syrian conflict and forced displacement on respiratory health: an analysis of primary data from a humanitarian organisation.

BACKGROUND: Despite a decade of conflict, there has been little exploration of respiratory health in Syria, notwithstanding the known impacts of conflict on lung health. Our aim is to explore the burden and trends of respiratory consultations in Syrian American Medical Society (SAMS) facilities in northwest Syria through an ecological analysis. METHODS: We performed a retrospective review of routinely collected data relating to respiratory presentations in SAMS' facilities between March 2017 and June 2020; we compared data by facility type, infectious versus non-infectious aetiologies and age. RESULTS: Data were available for 5 058 864 consultations, of which 1 228 722 (24%) were respiratory presentations, across 22 hospitals, 22 primary healthcare centres, 3 mobile clinics and 1 polyclinic. The median number of respiratory consultations per month was 30 279 (IQR: 25 792-33 732). Key findings include: 73% of respiratory consultations were for children; respiratory presentations accounted for up to 38% of consultations each month, seasonal variation was evident; respiratory tract infections accounted for 91% of all respiratory presentations. A steep decrease in consultations occurred between the end of 2019 (160 000) and the first quarter of 2020 (90 000), correlating with an escalation of violence in Idlib governorate. CONCLUSION: This study presents the largest quantitative analysis of respiratory data collected during the Syrian conflict. It supports the need for improved measures to aid the prevention, diagnosis and management of respiratory conditions during conflict as well as further research to explore the impact of conflict on respiratory health.

"Actually, the psychological wounds are more difficult than physical injuries:" a qualitative analysis of the impacts of attacks on health on the personal and professional lives of health workers in the Syrian conflict.

INTRODUCTION: Attacks on healthcare in armed conflict have far-reaching impacts on the personal and professional lives of health workers, as well as the communities they serve. Despite this, even in protracted conflicts such as in Syria, health workers may choose to stay despite repeated attacks on health facilities, resulting in compounded traumas. This research explores the intermediate and long-term impacts of such attacks on healthcare on the local health professionals who have lived through them with the aim of strengthening the evidence base around such impacts and better supporting them. METHODS: We undertook purposive sampling of health workers in northwest and northeast Syria; we actively sought to interview non-physician and female health workers as these groups are often neglected in similar research. In-depth interviews (IDIs) were conducted in Arabic and transcribed into English for framework analysis. We used an a priori codebook to explore the short- and long-term impacts of attacks on the health workers and incorporated emergent themes as analysis progressed. RESULTS: A total of 40 health workers who had experienced attacks between 2013 and 2020 participated in IDIs. 13 were female (32.5%). Various health cadres including doctors, nurses, midwives, pharmacists, students in healthcare and technicians were represented. They were mainly based in Idlib (39.5%), and Aleppo (37.5%) governorates. Themes emerged related to personal and professional impacts as well as coping mechanisms. The key themes include firstly the psychological harms, second the impacts of the nature of the attacks e.g. anticipatory stress related to the 'double tap' nature of attacks as well as opportunities related to coping mechanisms among health workers. CONCLUSION: Violence against healthcare in Syria has had profound and lasting impacts on the health workforce due to the relentless and intentional targeting of healthcare facilities. They not only face the challenges of providing care for a conflict-affected population but are also part of the community themselves. They also face ethical dilemmas in their work leading to moral distress and moral injury. Donors must support funding for psychosocial support for health workers in Syria and similar contexts; the focus must be on supporting and enhancing existing context-specific coping strategies.

Protracted armed conflict and maternal health: a scoping review of literature and a retrospective analysis of primary data from northwest Syria.

INTRODUCTION: Syria's protracted conflict has devastated the health system reversing progress made on maternal health preconflict. Our aim is to understand the state of maternal health in Syria focused on underage pregnancy and caesarean sections using a scoping review and quantitative analysis; the latter draws on data from the Syrian American Medical Society's (SAMS) maternal health facilities in northwest Syria. METHODS: We performed a scoping review of academic and grey literature on the state of maternal health across Syria since the onset of conflict (taken as March 2011). Identified articles were screened using pre-established criteria and themes identified. We also performed a retrospective quantitative analysis of maternal health data from SAMS' facilities in a microcontext in north-west Syria between March 2017 and July 2020, analysing the trends in the proportion of births by caesarean section and age at pregnancy. RESULTS: Scoping review: of 2824 articles, 21 remained after screening. Main themes related to maternal mortality rates, caesarean sections, maternal age and perinatal care. 12 studies reported caesarean section rates; these varied from 16% to 64% of all births: northern Syria (19%-45%,) Damascus (16%-54%,) Lattakia (64%) and Tartous (59%.) Quantitative analysis: Of 77 746 births across 17 facilities, trend data for caesarean sections showed a decrease from 35% in March 2017 to 23% in July 2020 across SAMS facilities. Girls under 18 years accounted for 10% of births and had a lower proportion of caesarean section births. There was notable geographical and interfacility variation in the findings. CONCLUSION: The quality of available literature was poor with country-level generalisations. Research which explores microcontexts in Syria is important given the different effects of conflict across the country and the fragmented health system. Our quantitative analysis provides some evidence around the changes to caesarean section rates in northwest Syria. Despite limitations, this study adds to sparse literature on this important topic.