Of 2,088 papers identified in the scoping review, 708 (34%) exclusively focus on health issues of Syrians inside Syria, of which 350 (49%) are conflict-related. Of these 350 conflict-related publications, 89 (25%) are research papers and form the material of this analysis. We also identified 31 field and operational activities papers focused on health inside Syria and eight personal narrative reflections, which we examine separately.
Table 1 presents summary characteristics of the 89 conflict-related research papers. The conflict in Syria started in 2011 but there were no research papers published during 2011–2012. Thereafter the annual volume of research increased over time, from one publication in 2013, three in 2014, to 27 publications in each of 2018 and 2019. There is considerable variation in the governorates studied by thematic focus and over time (Table 1, Fig. 1). Damascus is the most frequently studied governorate (n = 33), followed by Aleppo (n = 25), Idlib (n = 20), Lattakia (n = 15) and Hama (n = 14). Deir Al Zour (n = 3), Quenietra (n = 3) and Al-Sweida (n = 3) are the least frequently studied. Thirteen papers have a national scope. Several papers do not identify specific governorates, instead referring to the controlling factions, describing for example opposition-controlled territories generally. There are no papers on health in areas while controlled by the so-called Islamic State (IS).
Papers have used a wide range of research methodologies, including primary quantitative methods (n = 40) such as surveys, questionnaires and clinical trials; secondary quantitative data analysis (n = 28) mainly using surveillance system, medical record or program data, and qualitative methodologies (n = 15). Six papers used mixed methods (Table 1).
For the majority of papers, the country of institutional affiliation(s) of first and last (assumed to be the senior) authors are Syria (n = 30, 20 respectively), the United States (n = 25, 19 respectively) or the United Kingdom (n = 12, 10 respectively). For 19 papers (21%), both first and last authors had a Syrian affiliation. Of the 37 papers reporting a specific funding source, five listed Syrian universities as the funding source.
Table 2 presents detailed summaries of each research paper.
Health status is the most frequently researched theme, examined in 38 research papers covering nutrition (Hoetjes, Rhymer et al. 2014, Vernier, Cramond et al. 2019), communicable diseases and/or vaccination status (Alasaad 2013, Tajaldin, Almilaji et al. 2015, Ismail, Abbara et al. 2016, Sparrow, Almilaji et al. 2016, Alsaied, Mawas et al. 2017, Baaity, Almahmoud et al. 2017, Hawat, Husein et al. 2017, van Berlaer, Elsafti et al. 2017, de Lima Pereira, Southgate et al. 2018, Khamis and Ghaddar 2018, Rehman, Walochnik et al. 2018, Muhjazi, Gabrielli et al. 2019, Vernier, Cramond et al. 2019, Youssef, Harfouch et al. 2019), mental health (Charlson, Lee et al. 2016, Al-Saadi, Addeen et al. 2017, Mohammad, Rafea et al. 2017, Hamid and Dashash 2018, Kubitary and Alsaleh 2018, Kubitary and Alsaleh 2018, Perkins, Ajeeb et al. 2018, Falb, Blackwell et al. 2019, Roumieh, Bashour et al. 2019, Vernier, Cramond et al. 2019), child (Elsafti, van Berlaer et al. 2016, van Berlaer, Elsafti et al. 2017, Meiqari, Hoetjes et al. 2018, Terkawi, Bakri et al. 2019) and maternal (Terkawi, Bakri et al. 2019) health, oral health (Ballouk and Dashash 2018, Hamid and Dashash 2018, Alhaffar, Alawabdi et al. 2019, Ballouk and Dashash 2019), gender-based violence (Blackwell, Casey et al. 2019), anaemia (Albaroudi, Khodder et al. 2018) and non-communicable diseases (Mohammad, Rafea et al. 2017, Hamzeh, Almhanni et al. 2019, Vernier, Cramond et al. 2019). Of studies examining injuries, three are studies of hospital patients (Arafat, Alsabek et al. 2017, Darwish, Mahfouz et al. 2018, Okeeffe, Vernier et al. 2019), one examines injury burden among children surveyed at home and in internally displaced population (IDP) camps (van Berlaer, Elsafti et al. 2017) and one reports injury counts among children and the general population as provided by key informants(Diggle, Welsch et al. 2017). One additional study reports reasons for patient encounters at health facilities (Alsaied, Mawas et al. 2017).
Of these health status studies, a few also report on socioeconomic associations with disease burden (Albaroudi, Khodder et al. 2018, Alhaffar, Alawabdi et al. 2019, Falb, Blackwell et al. 2019, Roumieh, Bashour et al. 2019), health seeking behaviours (Hamzeh, Almhanni et al. 2019, Terkawi, Bakri et al. 2019) and exposure to violence as a determinant of health (Vernier, Cramond et al. 2019). Several other papers focus primarily on health determinants and risks, including neighbourhood socioeconomic status (Ahmad 2014, Ahmad, Fouad et al. 2018), occupational stress (Othman, Steel et al. 2018), food security (Doocy, Tappis et al. 2017), and smoking prevalence and smoking behaviours before and during the war (Idris, Al Saadi et al. 2018).
Thirty-two research papers examine the various pillars of the health system. Research on health workforce includes studies of the prevalence of psychological symptoms and burnout among medical students and trainees (Al-Saadi, Addeen et al. 2017, Alhaffar, Abbas et al. 2019), workforce training (Abbas, Sawaf et al. 2018), interventions using social media platforms and remote learning as a teaching medium (Alshiekhly, Arrar et al. 2015), consideration of the impact of conflict on workforce size, support or wellbeing (Sekkarie, Zanabli et al. 2015, Mowafi, Hariri et al. 2016, Sahloul, Salem et al. 2017, Footer, Clouse et al. 2018, Fardousi, Douedari et al. 2019, Jamal, Alameddine et al. 2019), including numbers of health workers killed or injured by attacks on health care (Elamein, Bower et al. 2017, Fouad, Sparrow et al. 2017), workforce wellbeing interventions (Othman, Steel et al. 2018), workforce requirements to address estimates of likely disease burden (Charlson, Lee et al. 2016), and studies of medical student career plans (Sawaf, Abbas et al. 2018) and attitudes to research (Turk, Al Saadi et al. 2018).
Health information systems are studied largely in the context of communicable disease surveillance, and comparison of surveillance systems covering government and non-government controlled areas (Tajaldin, Almilaji et al. 2015, Ismail, Abbara et al. 2016, Sparrow, Almilaji et al. 2016). Two papers cover issues of health system governance, one through key informant interviews with health service providers, donors and end-users in opposition-controlled areas (Douedari and Howard 2019) and the other through interviews with UNRWA personnel that included consideration of adaptive mechanisms used to ensure resilience and ongoing function of the UNRWA health system (Jamal, Alameddine et al. 2019). Essential medicines are the focus of two papers, one of which surveyed community pharmacists in Damascus and Damascus countryside regarding prescription drug misuse and characteristics of patients seeking such medications (Alaryan, Hasan et al. 2019), and the other considered impacts of conflict on the UNRWA system, including on availability of medicines and medical supplies (Jamal, Alameddine et al. 2019). There are no studies on health financing.
Twenty-one papers cover Issues of service provision including renal (Sekkarie, Zanabli et al. 2015), mental health (Charlson, Lee et al. 2016, Jefee-Bahloul, Duchen et al. 2016), orthopaedic (Alhammoud, Maaz et al. 2019), cancer (Sahloul, Salem et al. 2017), communicable disease surveillance (Khamis and Ghaddar 2018), respiratory (Mohammad, Shaaban et al. 2019) antenatal (Terkawi, Bakri et al. 2019), mental health (Kubitary and Alsaleh 2018) and trauma services (Mowafi, Hariri et al. 2016, Alothman, Tamer et al. 2019, Okeeffe, Vernier et al. 2019), disruptions to service provision due to attacks on healthcare (Elamein, Bower et al. 2017, Fouad, Sparrow et al. 2017, Footer, Clouse et al. 2018, Haar, Risko et al. 2018, Wong and Chen 2018), challenges of service provision under siege (Morrison 2018, Fardousi, Douedari et al. 2019), factors enabling sustained UNRWA service delivery (Jamal, Alameddine et al. 2019), and interplays of local service provision with cross-border humanitarian assistance (Duclos, Ekzayez et al. 2019).
Humanitarian assistance, response or needs (which included any studies conducted or analysis of services provided by humanitarian agencies) are the focus of 26 papers. These include estimates of IDP size and trends (Doocy, Lyles et al. 2015), humanitarian needs assessments among the general population, many of whom were displaced, in nine predominantly government-controlled governorates in 2014 (Doocy, Delbiso et al. 2015, Doocy, Lyles et al. 2015) and among the general population (Doocy and Lyles 2018) and displaced and female-headed households in 10 largely urban government-controlled areas in 2016 (Doocy and Lyles 2017); identifying optimal shelter (Hallak, Koyuncu et al. 2019) and primary healthcare (Mic, Koyuncu et al. 2019) locations for IDPs in Idlib based on beneficiary needs assessments and modelling, and a snapshot survey of community income and humanitarian assistance in Idlib (Cummins and Moharram 2017). Other studies included analysis of Qatar Red Crescent surveys of the impacts of the conflict on education, family and public health status (Elsafti, van Berlaer et al. 2016) and diagnoses, injuries and comorbidities (van Berlaer, Elsafti et al. 2017) among children in Northern Syria in 2015; and household surveys of water, sanitation and hygiene (WASH) and health outcomes in opposition-controlled Daraa and Quneitra in 2016-17 (Sikder, Daraz et al. 2018). Review of humanitarian programmatic data and operations included middle-upper arm circumference screening, survey of living conditions and food security, and nutritional programming administered by Medecins Sans Frontiers (MSF) in Al-Raqqa in 2013 (Hoetjes, Rhymer et al. 2014), MSF vaccine-preventable disease risk assessment, pre- and post-vaccine coverage surveys and immunization activity in Aleppo in 2015 (de Lima Pereira, Southgate et al. 2018), 2012–2014 surgical data from an MSF field hospital in Northwest Syria (Trelles, Dominguez et al. 2015), blast injuries managed at an MSF-supported facility in Raqqa in 2017-18 (Okeeffe, Vernier et al. 2019), MSF paediatric consultations in Aleppo and Raqqa in 2013-16 (Meiqari, Hoetjes et al. 2018), MSF assessment of health status of recently arrived IDPs in Al-Raqqa in 2017 (Vernier, Cramond et al. 2019), primary care services delivered by 10 Union of Medical Care and Relief Organisations (UOSSM) centres in opposition-controlled territories in 2014–2015 (Alsaied, Mawas et al. 2017), and analysis of data from the humanitarian health response in contested and opposition-controlled areas in 2013-14 (Diggle, Welsch et al. 2017). Additional interventions and program evaluations included delivery and evaluation of an intervention through provision of information and follow-up questionnaire in bread packages being distributed by a humanitarian organization in Northern Syria (El-Khani, Cartwright et al. 2016), evaluation of three modes of food assistance programming in Idlib in 2014-15 (Doocy, Tappis et al. 2017), evaluation of an International Rescue Committee cash assistance program on violence against women in Raqqa (Blackwell, Casey et al. 2019), evaluation of effectiveness of multi-level WASH risk reduction interventions in southern Syria in 2018 (Sikder, Daraz et al. 2018) and examination of the impact of a psychosocial support program on the wellbeing of a control and intervention group of farmers (Ziveri, Kiani et al. 2019). Several papers interviewed humanitarian workers, including humanitarian health staff working on non-communicable disease (NCD) care in Syria (Garry, Checchi et al. 2018) and those involved in the cross-border humanitarian health response from Turkey (Duclos, Ekzayez et al. 2019, Fradejas-Garcia 2019).
Fourteen papers research health issues related to war strategies and alleged IHL violations, including an expert panel review of YouTube videos following a sarin gas attack (Rosman, Eisenkraft et al. 2014) and interviews with healthcare workers in opposition-controlled areas regarding attacks on healthcare and challenges and experiences in responding to chemical attacks (Footer, Clouse et al. 2018). Other research in this theme examined attacks on health care (Elamein, Bower et al. 2017, Fouad, Sparrow et al. 2017, Haar, Risko et al. 2018, Wong and Chen 2018, Ri, Blair et al. 2019), areas under or the effects of siege (Sahloul, Salem et al. 2017, Morrison 2018, Fardousi, Douedari et al. 2019), and war-related mortality (Guha-Sapir, Rodriguez-Llanes et al. 2015, Chen, Shrivastava et al. 2018, Guha-Sapir, Schlüter et al. 2018, Ri, Blair et al. 2019) including a study of characteristics of deceased victims of a chemical weapons attack (Rodriguez-Llanes, Guha-Sapir et al. 2018).
Mortality is the subject of ten papers, which report mortality counts provided by key informants in contested and opposition areas (Diggle, Welsch et al. 2017); examine mortality data documented by the Violations Documentation Centre (VDC) (Guha-Sapir, Rodriguez-Llanes et al. 2015, Guha-Sapir, Schlüter et al. 2018, Rodriguez-Llanes, Guha-Sapir et al. 2018)), examine associations between attacks on healthcare and civilian casualties (Ri, Blair et al. 2019) or confirm conflict events in a fake-news data set (Abu Salem, Al Feel et al. 2019); use capture-recapture methods on four data sets to estimate mortality in two governorates (Price, Gohdes et al. 2015); estimate the number of unique identifiable deaths by deduplicating four data sets (Chen, Shrivastava et al. 2018); use spatio-temporal death data to forecast conflict events (Fujita, Shinomoto et al. 2017) and report on a household survey of IDPs in Raqqa and retrospective one-year mortality, largely conflict-related deaths (Vernier, Cramond et al. 2019).
Research themes by governorate
Themes studied vary by governorate (Table 1, Fig. 1). In Damascus, health status is the most frequently studied theme (n = 14), followed by the healthcare system (n = 13). The healthcare system was also the main theme examined in studies of Aleppo (n = 12) and Idlib (n = 9). Humanitarian assistance, response or needs are most frequently studied in the north-west of Syria, including Aleppo (n = 7), Idlib (n = 6) and Lattakia (n = 6), and of the studies examining specific governorates, all 14 governorates were covered in at least one paper. Of the papers examining war strategies and alleged IHL violations, the majority include a focus on Aleppo (n = 6) or Damascus (n = 5). On the national level, the healthcare system is the most frequently studied theme (n = 7), followed by health status (n = 5), war strategies and alleged IHL violations (n = 4) and mortality (n = 3).
Research themes by author country of affiliation
Themes examined vary by country of affiliation of authors (Table 1). Authors with Syrian affiliations commonly publish on health status (n = 21 for first authors, n = 14 for last authors), the healthcare system (n = 11 for first authors, n = 5 for last authors), and health determinants and risks (n = 4 for first authors, n = 3 for last authors), while the most frequently researched themes among US-affiliated authors are the healthcare system (n = 11 for first authors, n = 10 for last authors), humanitarian assistance, response or needs (n = 9 for first authors, n = 5 for last authors), health status (n = 8 for first authors, n = 3 for last authors) and war strategies and alleged IHL violations (n = 6 for first authors, n = 8 for last authors).
Field and operational activities publications
Table 3 presents a summary of the 31 papers presenting field and operational activities, of which 12 describe humanitarian assessment, responses or needs, including development of a rapid gender analysis tool (Quay 2019), cross-border, sectoral and cluster coordination mechanisms (Dolan 2014, Abdulahi 2017, Abdullah and Baker 2017, Madanİ 2017), and needs assessments and/or operational programming (Harrison, Dahman et al. 2013, Egendal and Badejo 2014, Khudari, Bozo et al. 2014, Kingori, Nasser et al. 2014, Littledike and Beck 2014, Reed 2014, Lester 2018). Nineteen papers discuss various aspects of the health system, most commonly reporting on experiences of establishing and / or presentations to field hospitals (Hasanin, Mukhtar et al. 2013, Sankari, Atassi et al. 2013, Alahdab, Omar et al. 2014, Attar 2014), or establishing or delivering specific services including renal (Al-Makki, Rifai et al. 2014, Saeed 2015), dental (Joury 2014), mental health (Jefee-Bahloul, Barkil-Oteo et al. 2016), obstetric (Hakeem and Jabri 2015) maternal and child health (Aburas, Najeeb et al. 2018), tele-cardiology (Alrifai, Alyousef et al. 2018), tele-intensive care (Moughrabieh and Weinert 2016, Ghbeis, Steffen et al. 2018), and tele-radiology (Mohammad, Mamoun et al. 2017, Masrani, Mamoun et al. 2018) care, and polio outbreak response activities (Mbaeyi, Wadood et al. 2018). Other papers described the national tuberculosis control program (Muhjazi, Baghdadi et al. 2018), activities of Syrian expatriate medical associations in supporting the healthcare system, incldung through training, establishment of hospitals and provision of telemedicine services (Hallam 2013), and translation and uptake of an online medical education platform into Arabic by Syrian medical students (Kouba, Amin et al. 2019). War strategies and alleged IHL violations are the secondary theme of two paper, one describing experiences in besieged settings (Masrani, Mamoun et al. 2018) and one paper reporting birth outcomes by chemical weapons exposure status for pregnant women seen at Al Ghouta hospital in late 2014. (Hakeem and Jabri 2015). Only 12 (39%) of these field and operational activities publications are first-authored by an author with a Syrian affiliation. Of the 21 publications with multiple authors, only 4 (19%) had a senior (last) author with a Syrian affiliation.
Narrative personal reflections
Eight publications were reflections or first-hand personal accounts of experiences inside Syria. These included reflections of an expatriate physician on his missions working in field hospitals (Attar 2016) including in Aleppo in 2013 (Attar 2014); experiences of a resident working in the neurosurgery department of a hospital under siege in Aleppo (Fakhouri 2017); experiences of a medical resident working in Aleppo University Hospital following a chemical weapons attack, including reports of number of patient presentations and outcomes (Kaadan and Cranmer 2018); experiences of medical volunteers during a mission in Idlib (Mahomed, Motara et al. 2016); and personal and professional experiences of a Syrian neurosurgeon working in Syria (Kassem 2016). Two papers are experiences of medical students in conflict-ravaged Syria, one publication reporting experiences in undertaking research and accessing research training (Saadi, Abbas et al. 2018) and another reporting experiences of studying medicine in conflict (Turk, Aboshady et al. 2016).
Challenges reported in researching Syria
Researchers discuss a range of considerations and challenges of conducting research in and on Syria (Table 4). Contextual challenges are largely related to safety and security issues, including the impact of conflict on access to both geographic areas (access often being limited to specific governorates or relatively safer areas) and study participants (including participant willingness to engage). Security considerations have impacted the ability to conduct research as planned.
Researchers report numerous methodological challenges, including limited data availability and access, data quality and completeness concerns, lack of population denominator data, and potential for bias at all stages of the research process.
Administrative considerations are largely related to securing permissions to conduct research and ethical review board processes, most notably the absence of such formal in-country governance structures. Conflict also impacted other aspects of research administration, including the availability of research funding.