Since the discovery of the novel coronavirus disease 2019 (abbreviated as COVID-19) in China in December 2019, the disease has spread quickly across the globe. Despite the lockdown measures adopted by the Chinese authorities, virus positive cases were reported in many other counties. In response to this serious situation, the World Health Organization declared COVID-19 as a pandemic (1). Despite its strong foothold in the region, particularly in Lebanon, Jordan, and Iran, the spread of COVID-19 in Syria was late. The first COVID-19 laboratory-confirmed case was reported on 22 March (2), with the first fatality reported a week later (3). The disease has spread quickly, and by July 0, 2020, there were 328 laboratory-confirmed cases and 10 deaths. Case counts come only from data provided by the Syrian Ministry of Health, because COVID-19 tests are centrally carried out by the Public Health Laboratory in Damascus.
There are some concerns and suspicions on the accurateness and validity of these figures. This is partially due to limited testing capacity of COVID-19 owing to limited resources and sanctions imposed on Syria (4). Syrian health authorities used purchased and gift kits to conduct approximately one hundred tests daily in Damascus (5) that reached around 2.700 tests as of May 8 (6). Moreover, many cases are probably not reported because they have not been formally diagnosed. In addition, only people who show clear symptoms or have contact with confirmed cases or deaths are tested, whereas asymptomatic people are not at all tested.
Given the speed with which COVID-19 overtakes even at the most sophisticated health systems in many developed countries, COVID-19 is expected to be of a great challenge to the Syrian war-torn health system. The World Health Organization warned that Syria is at high risk of a major outbreak because of its fragile health system aggravated by the lack of sufficient equipment (7) and the absence of adequate health care workers. In 2018, the Syrian government spent less than one percent of its total government expenditure on health (9), which is among the lowest in the region. The UN reports stated that around 70% of the Syrian health workers had left the country as migrants or refugees (8). The number of beds is disproportionally distributed between cities and among private and government hospitals with an average number of population of 699 per bed (9). The total number of intensive care unit (ICU) beds is approximately 650 in hospitals all over Syria (excluding the city of Idlib) (8). Although private hospitals provide relatively better healthcare services compared to public hospitals, they suffer of similar shortages and problems as government hospitals. Consequently, Syria does not have adequate infrastructure or personnel to hospitalize high numbers of infected people.
The Syrian government has imposed similar measures to those adopted by other countries to stem the spread of the disease. That is, on March 24, a curfew was declared from 6 pm to 6 am, in addition to the closure of shops, markets, parks, and public transport. Classes at schools and universities were curtailed, travel between cities was banned, and all incoming and outgoing flights were also suspended. In addition, lockdown was imposed on areas where confirmed or suspected infections or deaths were reported. On May 26, the government decided to gradually loosen curfew restrictions in order to bring people back to work and salvage the economy.
Summary of the Existing Literature
Good knowledge, attitudes and practices (KAP) among the public are essential for successful control and outbreak prevention of pandemics. Particularly, the literature on severe acute respiratory syndrome (SARS) in 2003 ascertained that personal knowledge and perceptions play important role in subsequent behavior change (10, 11, 12). High-perceived threat of the disease led to higher rate of positive behavior change (13, 14). Similarly, KAP factors also influenced both self- and community protective behavior in an anticipated H5N1 epidemic (15), Swine Flu (16, 17), and H1N1 (20, 21), and COVID-19 (22, 23, 24).
In order to introduce effective control measures against pandemics, it is vitally important to investigate public knowledge about the disease and their commitment to these control measures. This study, conducted in the Syrian territories, aims to assess the public understanding towards COVID-19, and investigate their attitudes and practices during COVID-19 quarantine. In Syria, there is no published study of public knowledge, attitude, and behavior regarding any pandemic disease neither before nor after the crisis.
This paper aims at investigating the knowledge, attitudes and practices of Syrians towards COVID-19 pandemic in a post-conflict context. While the Syrian health authorities aim their control measures will curtail the spread of the pandemic, their effectiveness will depend on the individual and societal awareness and practices. Understanding how Syrians perceive the disease and their attitudes and practices towards it helps the Syrian health authorities formulate suitable measures to counter COVID-19 spread. It is interesting to find out how similar measures can be perceived differently in different contexts; particularly in the Syrian special case where underdeveloped health system associates conflict.