The relationship between the mental health of physicians and the quality of medical services has been highlighted (17). This has been directly connected to the prevalence of burnout syndrome and work-related stress (17). In a previous study among medical residents in Syria which is a war-torn County, there has been a significant prevalence of burnout due to the collapsed medical system and high workload (18). Thus, it is vitally important to focus on the mental and physical well-being of HCWs in any environment but more critically in fragile or hostile settings.
The Syrian healthcare system was ravaged by war. Causing the lack of preparedness and protection for the workers. In addition to the lack of diagnostic tools and the lack of availability of equipment. According to a report by the London School of Economics regarding Syria’s response and healthcare capacity, the maximum number of COVID-19 cases that the Syrian healthcare system can properly treat is around 6500 patients (19). Thus, there has been a notable difference in terms of psychological distress between healthcare providers inside and outside Syria.
Many high-income countries are facing problems in providing adequate instruments and preparation of staff. This can easily predict the devastating results that many low- and middle-income countries will face during the pandemic (20). In war-torn countries with a fragile health system and very limited human resources, the problem will be more evident.
The results of our study would give an assumption on the situation in other low- and middle-income countries (21).
Most low- and middle-income countries suffer from the same shortages. for example, shortage of diagnostic and protective tools, intensive care unit beds, oxygen supply, infusion pumps, and mechanical ventilators. (22) These countries typically have overpopulated capitals and urban centers with a mediocre public transport system where social distancing becomes almost impossible. Also, due to the deteriorated economic status, morbidity rates in these countries are higher, thus, hospitals are already suffering affected turnover rate. This in return leads to a lack of capacity to receive new cases, especially during pandemics when a significant number of cases are admitted to hospitals in a short period. All those reasons contribute to the accumulation of a heavy workload on HCWs in these countries (20)
Generalized anxiety disorder (GAD) had a significant relationship with the first announcement of COVID-19 cases in Syria. During the period between the declaration of the pandemic by the WHO and the diagnosis of the first case of COVID-19, there was a considerable amount of uncertainty and confusion about the ability of the healthcare system and the availability of equipment, especially that many facilities went out of service due to the armed conflict (23). It was still unclear whether the healthcare system was ready to manage COVID-19 and absorb the impact of the first wave of cases (7).
There were no adequate official statements regarding the plan or preparedness. It was a time where misinformation and fake news took control.
Some media made things may be worse, as it split very acutely, where different media tools were racing to spread news which made people even more confused, lost, and misinformed.
The panic wave stroke health care workers the most, since they were the first-line responders and had no clear idea of the capabilities of the health system. It was not clear what was the plan, after the announcement of the first case of COVID-19 in Syria, there was even more confusion and panic. A new wave of misinformation strokes the Syrian Society again. Some organizations expected a widespread of cases in Syria like many other countries and with the poor health system preparedness, the pressure was increasing on the medical staff (24), and it was decided that medical staff will have more continuous working hours. For that reason, it may be noted that the psychological distress and sleep quality index had a close relationship with the availability of equipment, as shown in results.
There was no difference in results between HCWs from inside and outside Syria concerning the rest of the measures. This could be because the sample size for professionals from outside Syria was not sufficient to reflect a statistically significant difference since there were only 118 participants, compared to 466 from inside Syria.
It may also be explained by the fact that approximately 5 million Syrian refugees fled to Lebanon, Turkey, Jordan, and other nearby countries (25). Therefore, staff members who answered the survey from outside Syria, are most likely to be in a nearby country, thus a country that is not significantly better in preparedness and equipment.
Another reason could be the relatively low number of confirmed cases in Syria compared to other countries with a higher number of cases. Nonetheless, the psychological effect was not different leading to the conclusion that the healthcare system and thus the healthcare workers are already emotionally exhausted due to the heavy burden during the ongoing war. Therefore, Syrian healthcare professionals have already the same psychological issues that other healthcare professionals in countries with many more cases have reached (19).
It is noted from the results that the outcomes of the first and second samples had no statistically significant differences in both PSQI and GAD scores. This can be explained by the fact that HCWs are already burned out due to the ongoing conflict since 2011. in addition to the possible significant effect of the further deterioration of social and economic status which was significant during the conflict but became worse during the lockdown (24).
This study has some limitations, the study design which is a cross-sectional study can predict a correlation between the variables but not causality, using three different scales. We opted for this to explore, in-depth, all possible mental well-being aspects. Having no timer may be considered a challenge. This was extensively discussed, thus, the mediocrity of internet connection in some areas forced avoiding such tools. Being an online-based questionnaire had may be provided high reachability. It may also be more adequately used in social distancing circumstances. However, within those limitations, this research can reflect the challenges of working as a healthcare provider in a war-torn country.