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Abstract Introduction Attacks on healthcare have been committed throughout the Syrian conflict in violation of International Humanitarian Law (IHL), contributing to the devastation of the country’s healthcare system. The conflict has also forcibly displaced over half of Syria’s pre-conflict population, 7.2 million of whom are internally displaced. In this retrospective analysis, we aim to assess the relationships between (1) healthcare attacks and general conflict and (2) healthcare attacks and forced displacement between 2016 and 2022. Methods Data on healthcare attacks, conflict events, and displacement were extracted from the Syrian American Medical Society (SAMS), Uppsala Conflict Data Project, and OCHA Türkiye, respectively. The analysis addresses three research questions: the associations between (1) healthcare attacks and conflict events, (2) healthcare attacks and conflict events in the week after an attack on a healthcare facility, and (3) healthcare attacks and forced displacement. For each, we used generalized additive models with a negative binomial distribution that also accounted for spatial and temporal factors. Results SAMS recorded a total of 541 attack events, comprising 650 attack rounds over 235 facilities between 2016 and 2022. Conflict events were significantly associated with healthcare attacks in the same week (IRR: 1.14, 95% CI 1.12–1.17), and healthcare attacks in one week were associated with a maximum of 1.44 greater risk (95% CI 1.08–1.91) of conflict events in the following week, even when accounting for general conflict levels in the previous weeks. Healthcare attacks were also significantly associated with increased displacement up to three months following the attacks. Discussion We find that healthcare facilities are not avoided during conflict (as obliged under IHL), and that healthcare attacks significantly precede an escalation of general conflict in the same area. Healthcare attacks are also significantly associated with displacement for months following the attacks, even when accounting for conflict levels. Based on these findings, we present a framework outlining one pathway through which healthcare attacks may contribute to larger conflict tactics. Our findings highlight the critical role of healthcare infrastructure in conflict and reaffirm calls to hold perpetrators of these attacks accountable.

Abstract Background Mental health and psychosocial support (MHPSS) is increasingly considered vital for addressing the needs of displaced communities. The mental health of young people in Lebanon, including members of the host community and refugees, has been severely affected by multiple crises. Physical activity (PA) is an effective means for enhancing mental health, but evidence of PA’s impact on mental health among forcibly displaced populations is still emerging and often varies widely across studies. Method In this waitlist-controlled study, we examined the effectiveness of an 8-week psychosocial bouldering group intervention offered by the nonprofit organization ClimbAID on psychological well-being, distress, self-efficacy, and social cohesion in a group of mostly Syrian refugee adolescents residing in the Bekaa Valley, Lebanon. The intervention consisted of 8 sessions and took place once a week for 2 h in a group of up to 12 adolescents with 2 trained facilitators and up to 2 volunteers, supervised by a climbing instructor and a social worker. Multilevel analyses were performed for all outcomes. Results 233 people were included in the study. The dropout rate was approximately 33%. The IG improved significantly more than the waitlist group in terms of overall mental well-being and psychological distress. Group allocation was a significant predictor of improvements in mental well-being and psychological distress and showed a trend toward predicting self-efficacy. There was no positive impact of the intervention on social cohesion. Conclusions Even in complex humanitarian settings of forced displacement, a psychosocial bouldering intervention reduces psychological distress and increases well-being in a mixed group of host and refugee youth in Bekaa, Lebanon. Trial registration Prospectively registered with ISRCTN 13005983, registered April 1st, 2022.

Abstract Background The recent earthquake in Syria has caused widespread devastation, leading to extensive damage and loss of life. Considering the diverse range of disasters and conflicts that have affected Syrian society, health workers must possess essential competencies to effectively manage various types of disasters, including earthquakes. Therefore, this study was undertaken to identify the specific competencies required by Syrian health workers to respond efficiently and effectively to earthquakes. Methods An exploratory qualitative study was conducted at the Medical Education Program MEP of the Syrian Virtual University SVU. Nine members of the research team of the MEP, who represent various health specializations in medicine, dentistry, nursing, and pharmacy, accepted to take part in this study. Among these, three members have been actively involved in providing health care in hospitals and the field during the Syrian earthquake on 6 February 2023. The Delphi process was adopted to identify competencies. Health workers involved in earthquake response were categorized into nine groups including medical doctors, dentists, pharmacists, nurses, psychological support professionals, medical students, allied healthcare professionals, on-site disaster teams, and managers. The final list was accepted if it achieved more than 80% agreement among the participants in the first, second, and final rounds. Results The study identified 74 competencies (12 knowledge items, 35 skills, and 27 attitudes) essential for health workers to respond effectively to earthquakes. They are categorized into five domains: "Preparing the team for the rescue process during and, after earthquakes, Implementation of the rescue process, Education and psychological support, Research, and development". Conclusion A list of earthquake competencies was identified for health workers. It is hoped that this list will enhance a country’s resilience and will enable decision–makers to support health workers in acquiring these competencies within a very strained health system in Syria and other countries.

Abstract 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.

BackgroundThe Syrian conflict has dramatically changed the public health landscape of Syria since its onset in March of 2011. Depleted resources, fractured health systems, and increased security risks have disrupted many routine services, including vaccinations, across several regions in Syria. Improving our understanding of infectious disease transmission in conflict-affected communities is imperative, particularly in the Syrian conflict. We utilize surveillance data from the Early Warning Alert and Response Network (EWARN) database managed by the Assistance Coordination Unit (ACU) to explore trends in the incidence of measles in conflict-affected northern Syria and analyze two consecutive epidemics in 2017 and 2018.MethodsWe conducted a retrospective time-series analysis of the incidence of clinically suspected cases of measles using EWARN data between January 2015 and June 2019. We compared regional and temporal trends to assess differences between geographic areas and across time.ResultsBetween January 2015 and June 2019, there were 30,241 clinically suspected cases of measles reported, compared to 3193 cases reported across the whole country in the decade leading up to the conflict. There were 960 regional events that met the measles outbreak threshold and significant differences in the medians of measles incidence across all years (p-value

Abstract Background Northwest Syria (NWS) is a complex and extremely fragile operating environment, with more than 2.8 million people needing humanitarian assistance. To support a common standard of care delivery and enable coordination among the multiple providers in NWS, WHO developed an Essential Health Services package (EHSP) in 2016-17 and subsequently supported a facility network model to deliver the EHSP. This article provides an evaluation of the network to date, aiming to inform further development of the network and draw wider lessons for application of similar approaches in complex emergency settings. Methods This mixed method study included document review, participatory, qualitative and quantitative data, gathered in the first half of 2021. Participatory data came from two group model building workshops with 21 funders and implementers. Semi-structured interviews with 81 funders, health professionals and community members were also conducted. Analyses of the workshops and interviews was inductive, however a deductive approach was used for synthesising insights across this and the document review. The final component was a survey of health providers (59 health care professionals) and service users (233 pregnant women and 214 persons living with NCDs) across network and other comparable facilities, analysed using routine descriptive and inferential statistics. Findings across all methods were triangulated. Results The study finds that the network and its accompanying essential service package were relevant to the dynamic and challenging context, with high but shifting population needs and multiple uncoordinated providers. Judged in relation to its original goals of comprehensive, coordinated services, equitable access and efficient service delivery, the data indicate that gains have been made in all three areas through the network, although attribution is challenging, given the complex environment. The context remains challenging, with shifting boundaries and populations displaced by conflict, difficulties in retaining staff, the need to import medicines and supplies across borders, and governance gaps. Conclusion This study adds to a very limited literature on coordinated network approaches used to raise care quality and improve referrals and efficiency in a complex emergency setting. Although areas of ongoing challenge, including for sustainability, are noted, the network demonstrated some resilience strategies and can provide lessons for other similar contexts.

Abstract Background Thalassaemia affects many families in Northeast Syria, an area devastated by over a decade of conflict which has significantly impacted their health system. People with thalassaemia require holistic multidisciplinary care for the clinical complications of thalassaemia. The risks of thalassaemia treatment include blood-borne viral infections secondary to unsafe transfusion, increased vulnerability to serious bacterial infection following splenectomy, and complications of both iron overload and iron chelation therapy. Médecins Sans Frontières (MSF) provided outpatient thalassaemia care programmes in northeast Syria between April 2017 October 2019 in a complex conflict context challenged by population displacement, the destruction of medical facilities, and periods of insecurity. Methods We performed a secondary descriptive analysis of the thalassaemia cohort data to describe basic clinical and demographic characteristics of the patient population. A desk review of internal and publicly available documents was supplemented by informal interviews with MSF staff to describe and analyse the programmatic approach. Case description MSF delivered programmes with thalassaemia investigations, provision of blood transfusion, iron chelation therapy, and psychosocial support. Thalassemia programmes were novel for the organisation and operational learning took place alongside service implementation. Lessons were identified on equipment procurement and the requirements for the implementation of vital investigations (including ferritin testing), to inform clinical decision making. Lessons included the importance of supply planning for sufficient blood products to meet diverse clinical needs in a conflict area, so those with thalassaemia have continued access to blood products among the competing priorities. Iron chelation therapy met a large need in this cohort. Adapted protocols were implemented to balance social factors, hygiene considerations, toxicity, tolerability, and adherence to therapy. Wider service needs included considerations for family planning advice and services, continuity of care and patient access through decentralised services or laboratory access, psychosocial support, and improved data collection including quality of life measurements to understand the full impact of such programmes. Conclusions Although this type of programming was not “routine” for the organisation, MSF demonstrated that life-sustaining thalassaemia care can be provided in complex conflict settings. International non-governmental organisations can consider this care possible in similar contexts.

Abstract Background The COVID-19 pandemic has escalated the use of telemedicine in both high and low resource settings however its use has preceded this, particularly in conflict-affected settings. Several countries in the WHO Eastern Mediterranean (EMR) region are affected by complex, protracted crises. Though telemedicine has been used in such settings, there has been no comprehensive assessment of what interventions are used, their efficacy, barriers, or current research gaps. Main body A systematic search of ten academic databases and 3 grey literature sources from January 1st 2000 to December 31st 2020 was completed, identifying telemedicine interventions in select EMR conflict-affected settings and relevant enablers and barriers to their implementation. Included articles reported on telemedicine use in six conflict-affected EMR countries (or territories) graded as WHO Health Emergencies: Afghanistan, Gaza, Iraq, Libya, Syria and Yemen. Data were extracted and narratively synthesised due to heterogeneity in study design and outcomes. Of 3419 articles identified, twenty-one peer-reviewed and three grey literature sources met the inclusion criteria. We analysed these by context, intervention, and evaluation. Context: eight related to Afghanistan, eight to Syria and seven to Iraq with one each in Yemen and Gaza. Most were implemented by humanitarian or academic organisations with projects mostly initiated in the United States or Europe and mostly by physicians. The in-country links were mostly health professionals rather than patients seeking specialist inputs for specialities not locally available. Interventions: these included both SAF (store and forward) and RT (real-time) with a range of specialities represented including radiology, histopathology, dermatology, mental health, and intensive care. Evaluation: most papers were observational or descriptive with few describing quality measures of interventions. Conclusions Telemedicine interventions are feasible in conflict-affected settings in EMR using low-cost, accessible technologies. However, few implemented interventions reported on evaluation strategies or had these built in. The ad hoc nature of some of the interventions, which relied on volunteers without sustained financial or academic investment, could pose challenges to quality and sustainability. There was little exploration of confidentiality, ethical standards, data storage or local healthcare worker and patient acceptability.

Abstract Background Older Syrian refugees in Lebanon are a marginalized population with under-recognized health needs. The inclusivity of this population within the humanitarian response is poorly understood. This study aims to identify the unique needs of older Syrian refugees in the context of recent concurrent crises in Lebanon, and explore the extent to which they are being met and prioritized by local and international aid agencies. Methods We conducted in-depth interviews with a snowball sample of 26 stakeholders from 11 organizations operating in the health, nutrition, and water, sanitation, and hygiene sectors. Data analysis followed principles of thematic analysis. Results Concurrent political, economic, and public health crises in host country promoted income insecurity among older refugees and increased dependency on younger relatives, leading to food insecurity, neglect, and poor health outcomes, including the sequelae of untreated non-communicable diseases. Mental illness was perceived to be exacerbated by Covid-19 related challenges, including social isolation, uncertainty about the future, and additionally due to feelings of guilt related to economic dependence and fundamental exclusion from labor force participation. Despite their vulnerability, older refugees are overlooked by the humanitarian response, which may be related to a lack of data. Pervasive medication shortages in the setting of the economic collapse, as well as inaccessible physical environments and competing interests were all identified as major barriers to care. Conclusions Older Syrian refugees in Lebanon experience dual vulnerability that is acutely exacerbated in the setting of concurrent crises. Sociopolitical, economic, and cultural barriers promote social exclusion and may confer an increased risk of income and food insecurity in this population, with significant implications for health. Humanitarian aid agencies operating in the context of fragmented, under-resourced health systems are currently unable to sufficiently address multi-faceted needs of this community. We recommend moving away from a donor-dependent model of aid by allocating resources toward strengthening inclusive national health systems that emphasize preventative care. We further call for age-disaggregation of routine data and normalization of data sharing among stakeholders in the academic and public health sectors in order to develop evidence-based initiatives that can meet the needs of this under-served community.

Abstract Background In Canada, approximately 13% of the population lives with multiple chronic conditions. Newcomers, including refugees, have the same or higher risk of developing chronic diseases as their host population. In 2015–2016, Canada welcomed almost 40, 000 newcomers from Syria. This study aimed to (1) understand adult newcomer health needs for self-management of non-infectious chronic conditions; and (2) identify strategies to improve access to health care services to meet these needs. Methods This study used a qualitative descriptive design. Interviews and focus groups were conducted with consenting newcomers, service providers and community agency administrators. Interview guides were developed with input from community partners and snowball sampling was used. Results Participants included 22 Syrian newcomers and 8 service providers/administrators. Findings revealed the initial year of arrival as one of multiple adjustments, often rendering chronic disease management to a lower priority. Self-care and self-management were not routinely incorporated into newcomer lives though community health agencies were proactive in creating opportunities to learn self-management practices. Gaps in access to care were prevalent, including mental health services which typically were not well developed for trauma and post-traumatic stress disorder (PTSD), particularly for men. Newcomers expressed frustration with lengthy wait times and not being able to access specialists directly. Youth frequently played a key role in translation and disseminating information about services to their families. Conclusion Chronic disease management was a low priority for newcomers who were focussed on resettlement issues such as learning English or finding work. Provision of practical supports such as bus tickets, translation, and information about the healthcare system were identified as means of improving access to care.

Abstract Background The Syrian conflict has endured for a decade, causing one of the most significant humanitarian crises since World War II. The conflict has inflicted massive damage to civil infrastructure, and not even the health care sector has been spared. On the contrary, health care has been targeted, and as a result, many health professionals have left the country. Despite the life-threatening condition, many health professionals continued to work inside Syria even in the middle of the acute crisis. This qualitative study aims to determine the factors that have motivated Syrian health professionals to work in a conflict-affected country. Methods The research is based on 20 semi-structured interviews of Syrian health care workers. Interviews were conducted in 2016–2017 in Gaziantep, Turkey. A thematic inductive content analysis examined the motivational factors Syrian health care workers expressed for their work in the conflict area. Results Motivating factors for health care workers were intrinsic and extrinsic. Intrinsic reasons included humanitarian principles and medical ethics. Also, different ideological reasons, patriotic, political and religious, were mentioned. Economic and professional reasons were named as extrinsic reasons for continuing work in the war-torn country. Conclusions The study adds information on the effects of the Syrian crisis on health care—from healthcare workers' perspective. It provides a unique insight on motivations why health care workers are continuing their work in Syria. This research underlines that the health care system would collapse totally without local professionals and leave the population without adequate health care.

Abstract Background Valid measures of sexual violence stigma that can be readily incorporated into program monitoring and evaluation systems are needed to strengthen gender-based violence (GBV) services in humanitarian emergencies. This study sought to assess the psychometric properties, construct validity, and measurement invariance of sexual violence stigma scales among female Somali GBV survivors in Kenya and Syrian GBV survivors in Jordan to identify an abbreviated scale that could be used across humanitarian contexts. Methods We administered measures of sexual violence stigma to 209 female survivors of sexual violence aged 15 and older in Kenya and Jordan. Exploratory factor analysis was used to assess the underlying latent structure, and Item Response Theory was used to estimate item difficulty and discrimination parameters to guide efforts to shorten the scales. Differential item functioning (DIF) by site was assessed using Multiple Indicators, Multiple Causes models. Construct validity of the sexual violence stigma scales was assessed by estimating correlations with functional impairment, depression, and disability. Results The sexual violence stigma measure exhibited distinct factor structures among Somali and Syrian GBV survivors. Among Somali survivors, a two-factor model with separate felt (10 items) and enacted (4 items) stigma constructs was identified, with scales for both domains exhibiting good internal consistency (Cronbach’s alpha = 0.93 and 0.88, respectively). In Jordan, a single factor solution was uncovered for a 15-item stigma scale with good internal consistency (alpha = 0.86). The shortened core sexual stigma scale consisting of the 4 items that did not exhibit DIF had a Cronbach’s alpha of 0.82 in Kenya and 0.81 in Jordan. The felt stigma scale in Kenya, the full stigma scale in Jordan, and abbreviated core stigma scales in both countries were meaningfully correlated with depression, while correlations with functional impairment were weaker and inconsistent across scales. Conclusions An abbreviated core set of invariant perceived and internalized sexual violence stigma items demonstrated evidence of construct validity in two diverse settings. The ability of this measure to be efficiently administered as a part of routine program monitoring and evaluation activities, with the potential addition of items from a measurement bank to improve contextual relevance, can facilitate improvements in the delivery and quality of gender-based violence programs in humanitarian emergencies.

Abstract Background The Syrian conflict has dramatically changed the public health landscape of Syria since its onset in March of 2011. Depleted resources, fractured health systems, and increased security risks have disrupted many routine services, including vaccinations, across several regions in Syria. Improving our understanding of infectious disease transmission in conflict-affected communities is imperative, particularly in the Syrian conflict. We utilize surveillance data from the Early Warning Alert and Response Network (EWARN) database managed by the Assistance Coordination Unit (ACU) to explore trends in the incidence of measles in conflict-affected northern Syria and analyze two consecutive epidemics in 2017 and 2018. Methods We conducted a retrospective time-series analysis of the incidence of clinically suspected cases of measles using EWARN data between January 2015 and June 2019. We compared regional and temporal trends to assess differences between geographic areas and across time. Results Between January 2015 and June 2019, there were 30,241 clinically suspected cases of measles reported, compared to 3193 cases reported across the whole country in the decade leading up to the conflict. There were 960 regional events that met the measles outbreak threshold and significant differences in the medians of measles incidence across all years (p-value

Abstract Child protection and mental health during conflict intersects with a variety of adverse conflict-related factors, and intervention outcomes in the field are often difficult to predict. Using the casefiles of 376 school children registered in a Mental Health and Psychosocial Support (MHPSS) project in the Northwest governorate of Idleb in Syria, this study aimed to determine (i) the rates of various protection concerns (potential mental health conditions, psychosocial deprivation issues, and social, behavioural and emotional issues) for students enrolled in this project, (ii) whether the rates of any of the protection concerns varied between children and adolescents, or between boys and girls, and (iii) which of the identified demographic and protection sector factors predicted the presence of potential mental health conditions and MHPSS intervention outcomes. MHPSS interventions (including individual MHPSS sessions tailored for children in conflict, resilience building activities, tutoring, peer building activities, community awareness, and other tailored services) were implemented at schools operated by the UK-based organization, Syria Relief. The variables tested included demographic variables of age group (208 children, aged 4–9 years; 168 adolescents, aged 10–14 years) and gender (211 males, 165 females), and 23 protection sector variables including 11 potential mental health problems (anxiety, attention deficit hyperactivity disorder, conduct disorder, autism, epilepsy, motor tics, depression, post-traumatic-stress disorder, social phobia, specific phobia, learning disability), 7 psychosocial deprivation (PSD) variables (war injury, child labour, loss of caregiver, neglect, domestic abuse, displacement, poverty), and 5 social, behavioural and emotional (SBE) variables (low/abnormal socialization, emotional issue, peer issues/being bullied, peer issues/being aggressive, educational decline). Within the sample, 73.7% were found with a probable mental health problem, with 30.6% showing signs of anxiety, 36.2% of depression and 26.6% showing signs of post-traumatic-stress disorder. Additionally, 74.5% of the sample had at least one form of PSD present (42.6% were displaced, 39.6% suffered from abject poverty), and 64.9% had a reported SBE concern. Children were more likely to have a potential mental health concern, especially autism and PTSD, and poor socialization; while adolescents were more likely to engage in child labour, experience abject poverty, exhibit aggressive behaviour, and educational decline. Male gender was associated with child labour and aggressive behaviour while female gender was associated with the presence of potential mental health problems, especially depression, and loss of caregiver, and poor socialisation. Odds ratios (ORs) indicated significant negative impact of the presence of SBE concerns (any), 4.45 (95% CI: 1.68–12.7), emotional issue, 11.02 (95% CI: 2.76–74.49), low/abnormal socialization, 8.37 (95% CI, 2–57.71), and displacement, 2.91 (95% CI, 1.21–7.48) on the child’s mental health. MHPSS intervention outcomes were categorized as case improvement, decline, or incomplete/limited information available; with case improvement noted for 63.6% of the sample, decline noted for 14.4%, and incomplete treatment/limited follow-up noted for 22.1% of the sample. Additional analysis of predictors of treatment success found that child labour was significantly associated with a lack of treatment success, OR 0.24 (95% CI, 0.07–0.92). These findings provide important insights into the complex tailoring needs that protection and MHPSS field projects require.

Abstract The need to generate evidence in spaces considered insecure and inhabited by potentially extremely vulnerable individuals (e.g. conflict-affected people who may not have means to move) has led researchers to study conflict-affected settings remotely. Increased attention to remote research approaches from social scientists, due to COVID-19-related travel restrictions, is sparking interest on appropriate methods and tools. Drawing on several years’ experience of remotely conducting qualitative research in Syria, we discuss challenges and approaches to conducting more inclusive, participatory, and meaningful research from a distance. The logistics, ethics, and politics of conducting research remotely are symptomatic of broader challenges in relation to the decolonisation of global and humanitarian health research. Key to the success of remote approaches is the quality of the relationships researchers need to be able to develop with study participants without face-to-face interactions and with limited engagement ‘in the field’. Particularly given overdue efforts to decolonise research institutions and methods, lead researchers should have a meaningful connection with the area in which they are conducting research. This is critical both to reduce chances that it will be extractive and exploitative and additionally for the quality of interpretation.

Abstract Background Conducting ethical and rigorous research to measure the effectiveness of humanitarian programs is urgently needed given the global level of displacement and conflict, yet traditional approaches to evaluation research may be too slow and disruptive for acute humanitarian settings. The current case study utilizes an experience of implementing a mixed methods evaluation conducted between March–August 2018 in northern Raqqa Governorate, Syria. The key research objectives were to examine the influence of an unconditional, three-month cash transfer program on household basic needs and women’s wellbeing, including experiences of violence. This setting was selected for the research as it shared many aspects of an acute emergency within a protracted conflict given its recent opening of access to humanitarian aid programming following the withdrawal of ISIS as well as influxes of internally displaced persons fleeing airstrikes and fighting in Raqqa City in late 2017. Discussion The current case study was scientifically important as the use of cash assistance in emergencies has increased exponentially in recent years. Yet, little is still known about how cash assistance designed to help households meet their basic needs may also influence women’s overall wellbeing in the home. Challenges of conducting the research included selecting an emergency site appropriate for research, implementing an evaluation that would not delay or disrupt critical cash assistance programming, and measurement of sensitive violence against women outcomes. Four strategies were identified to meet the challenges of conducting an evaluation in such a setting, which included: (1) developing clear decision-making criteria for assessing feasibility; (2) frontloading processes to reduce time lag in launching research; (3) integrating the research approach within programming; and (4) closely collaborating with practitioners throughout the study, especially for research on sensitive topics like violence against women. Conclusions Advance consideration of these factors through a pre-positioning process will allow for timely, ethical, and rigorous research to be implemented in the immediate aftermath of a crisis. Such studies should be prioritized to ensure the highest effectiveness and efficiency of humanitarian aid for populations grappling with acute emergencies.

Abstract Lebanon, a middle-income country with ongoing political turmoil, unstable economic situation, and a fragmented and under-resourced health system, hosts about one million Syrian refugees since 2011. While the country is currently experiencing substantial COVID-19 epidemic spread, no outbreaks have been reported yet among Syrian refugees. However, testing of this population remains limited and exposure levels are high given dire living conditions and close interaction with the host community. Here, we use quantitative insights of transmission dynamics to outline risk and contextual factors that may modulate vulnerability of Syrian refugees in Lebanon to potentially large COVID-19 epidemics. Syrian refugees live in close contact with the host community, and their living conditions are favorable for epidemic spread. We found that the high levels of crowding within Syrian refugee households and among those in informal tented settlements, the inadequate water supply and sanitation, limited use of masks, inadequate access to health care, and inadequate community awareness levels are vulnerability factors that directly impact important parameters of transmission dynamics, leading to larger epidemic scale. Poverty, stigma, and fear of legal consequences are contextual factors that further exacerbate this vulnerability. The relatively high prevalence of non-communicable diseases in this population could also affect the severity of the disease among those infected. Mathematical modeling simulations we conducted illustrated that even modest increases in transmission among Syrian refugees could result in a large increase in the incidence and cumulative total number of infections in the absence of interventions. In conclusion, while the young age structure of the Syrian refugee population might play a protective role against the scale and disease-burden severity of a potential COVID-19 epidemic, the epidemic potential due to several vulnerability factors warrants an immediate response in this population group. Local and international actors are required to mobilize and coordinate efforts to prevent the transmission of COVID-19, and to mitigate its impact amongst the vulnerable refugee populations globally.

Abstract Introduction Armed conflict may influence the size and scope of research in Arab countries. We aimed to assess the impact of the 2011 Syrian conflict on health articles about Syria published in indexed journals. Methods We conducted a scoping review on Syrian health-related articles using seven electronic databases. We included clinical, biomedical, public health, or health system topics published between 1991 and 2017. We excluded animal studies and studies conducted on Syrian refugees. We used descriptive and social network analyses to assess the differences in rates, types, topics of articles, and authorship before and after 2011, the start of the Syrian conflict. Results Of 1138 articles, 826 (72.6%) were published after 2011. Articles published after 2011 were less likely to be primary research; had a greater proportion reporting on mental health (4.6% vs. 10.0%), accidents and injuries (2.3% vs. 18.8%), and conflict and health (1.7% vs. 7.8%) (all p

Abstract Without healthcare workers (HCWs), health and humanitarian provision in Syria cannot be sustained either now or in the post-conflict phase. The protracted conflict has led to the exodus of more than 70% of the healthcare workforce. Those remaining work in dangerous conditions with insufficient resources and a healthcare system that has been decimated by protracted conflict. For many HCWs, particularly those in non-government-controlled areas (NGCAs) of Syria, undergraduate education and postgraduate training has been interrupted with few opportunities to continue. In this manuscript, we explore initiatives present in north west Syria at both undergraduate and postgraduate level for physician and non-physician HCWs. Conclusion: Challenges to HCW education in north west Syria can be broadly divided into 1. Organisational (local healthcare leadership and governance, coordination and collaboration between stakeholders, competition between stakeholders and insufficient funding.) 2. Programmatic (lack of accreditation or recognition of qualifications, insufficient physical space for teaching, exodus of faculty affecting teaching and training, prioritisation of physicians over non-physicians, informally trained healthcare workers.) 3. Healthcare system related (politicisation of healthcare system, changing healthcare needs of the population, ongoing attacks on healthcare.) Locally implementable strategies including dedicated funding are key to supporting retention of HCWs and return during post-conflict reconstruction.

Abstract Background More than 5.5 million Syrian refugees have fled violence and settled in mostly urban environments in neighboring countries. The Middle East and North Africa (MENA) region accounts for 6% of the global population but 25% of the population are ‘of concern’ to the UN Refugee Agency. In addition to large amounts of forced migration, the region is also undergoing an epidemiologic transition towards a heavier burden of noncommunicable diseases (NCDs), which in 2018 accounted for 74% of all deaths in the region. To address NCD needs globally, a myriad of policies and interventions have been implemented in low-income stable country settings. However, little is known about which policies and interventions are currently being implemented or are best suited for refugee hosting countries across the Middle East and North Africa. Methods A scoping review of peer-reviewed literature was conducted to identify policies and interventions implemented in the Middle East and North Africa to address the needs of urban refugees with noncommunicable diseases. Results This scoping review identified 11 studies from Jordan, Lebanon, Iran, West Bank, Gaza and Syria. These studies addressed three foci of extant work, (1) innovative financing for expensive treatments, (2) improvements to access and quality of treatment and, (3) efforts to prevent new diagnoses and secondary complications. All interventions targeted refugee populations including Palestinians, Sudanese, Syrians, Afghans and Iraqis. Discussion The scoping review highlighted five key findings. First, very few studies focused on the prevention of noncommunicable diseases among displaced populations. Second, several interventions made use of health information technologies, including electronic medical records and mHealth applications for patients. Third, the vast majority of publications were solely focused on tackling NCDs through primary care efforts. Fourth, the literature was very sparse in regard to national policy development, and instead favored interventions by NGOs and UN agencies. Last, the perspectives of refugees were notably absent. Conclusion Opportunities exist to prioritize prevention efforts, scale up eHealth interventions, expand access to secondary and tertiary services, address the scarcity of research on national policy, and incorporate the perspectives of affected persons in the broader discourse.

Abstract Background Since the Syrian civil war began in March 2011, more than half of the Syrian population was forced to escape from their homes, and more than 5 million of them fled their country. The aim of the present study is to estimate the psychological consequences of this conflict among the refugee population who fled to Iraq. Method In 2017, a team of locally trained psychologists and social workers interviewed 494 married couples (988 individuals) who were Syrian Kurdish refugees in the Kurdistan Region of Iraq. Validated Kurdish Kurmanji and Arabic versions of post-traumatic stress disorder (PTSD) Checklist for DSM-5 and depression section of Hopkins Symptom Checklist-25 were used for assessing PTSD and depression symptoms. Results Almost all of the participants (98.5%) had experienced at least one traumatic event and 86.3% of them experienced three or more traumatic event types. The prevalence of probable PTSD was about 60%. Gender, length of time in the camp, area in which participants were grown up, and the number of traumatic event types were significant predictors for the presence of PTSD symptoms. Approximately the same rate of participants (59.4%) experienced probable depression, which was associated with gender, age, time spent in the camp, and the number of traumatic event types. Conclusion PTSD and depression are prevalent among refugees exposed to traumatic events, and various variables play important roles. The pattern of risk factors in this population is consistent with findings from war-affected populations in other regions and should be considered for intervention within this population and more broadly.

Abstract Background Syrian healthcare workers (HCWs) are among those who fled the Syrian conflict only to face further social and economic challenges in host countries. In Lebanon, this population group cannot formally practice, yet many are believed to be operating informally. These activities remain poorly documented and misunderstood by the academic, policy and humanitarian communities. This study aims to understand mechanisms of informal provision of services, the facilitators and barriers for such practices and to present policy recommendations for building on this adaptive mechanism. Method A qualitative descriptive study based on an in-depth interview approach with a sample of Syrian informal healthcare workers (IHCWs) residing in Lebanon was adopted. Known sponsor networks followed by snowball sampling approaches were used to recruit participants. Data collection occurred between September and December 2017. All interviews were audio-recorded, transcribed and translated into English. An inductive thematic analysis was used. Results Twenty-two participants were recruited. Motivational factors that led HCWs to practice informally were personal (e.g. source of income/livelihood), societal (cultural competency), and need to fulfill a gap in the formal health service sector. Being connected to a network of IHCWs facilitated initiation of the informal practice until eventually becoming part of a community of informal practice. The central challenge was the informal nature of their practice and its negative consequences. Most IHCWs were afraid of arrest by the government upon identification. Most interviewees indicated being discriminated against by host communities in the form of differential wages and tense interpersonal relationships. Almost all recommended a change in policy allowing them to practice formally under a temporary registration until their return to Syria. Conclusion Our study confirmed the presence of IHCWs operating in Lebanon. Despite its informal nature, participants perceived that this practice was filling a gap in the formal health system and was helping to alleviate the burden of IHCWs and refugee health needs. In line with interviewees’ views, we recommend that policy decision makers within humanitarian agencies and the Government of Lebanon explore the possibilities for allowing temporary registration of displaced Syrian IHCW to benefit local host communities and refugee populations.

Abstract Background Literature on the burden and management of atherosclerotic cardiovascular disease (ASCVD) in humanitarian settings is limited. This study aimed to describe patient characteristics and explore both service use and use of recommended secondary prevention drugs in Syrian refugee patients with ASCVD attending two Médecins Sans Frontières (MSF) clinics in Lebanon. Methods This study comprised a cross-sectional survey of ASCVD patients attending either MSF clinic over a four-week period in early 2017. Using descriptive statistics, we explored patient demographic characteristics, cardiovascular risk factors and assessed ASCVD secondary prevention medication prescription and patient adherence with a 7-day self-report scale. A retrospective study of routine clinical data explored workload and trends in patient loss to follow-up. We performed logistic regression modelling to explore risk factors for loss to follow-up. Results We included 514 patients with ASCVD in the cross-sectional study, performed in 2017. Most (61.9%) were male and mean age was 60.4 years (95% CI, 59.6–61.3). Over half (58.8%) underwent revascularization and 26.1% had known cerebrovascular disease. ASCVD risk factors included 51.8% with diabetes and 72.2% with hypertension. While prescription (75.7 to 98.2%) and self-reported adherence rates (78.4 to 93.9%) for individual ASCVD secondary prevention drugs (ACE-inhibitor, statin and antiplatelet) were high, the use of all three was low at 41.3% (CI95%: 37.0–45.6). The 5-year retrospective cohort study (ending April 2017) identified 1286 patients with ASCVD and 16,618 related consultations (comprising 24% of all NCD consultations). Over one third (39.7%) of patients were lost to follow-up, with lower risk among men. Conclusions The burden of ASCVD within MSF clinics in Lebanon is substantial. Although prescription and adherence of individual secondary prevention drugs is acceptable, overall use of the three recommended drugs is suboptimal. Loss to follow-up rates were high. Further studies are needed to evaluate innovative strategies to increase the use of the multiple recommended drugs, and to increase the retention of patients with ASCVD in the care system.

Abstract Background The displacement crisis in Syria poses challenges for tuberculosis (TB) control across the region. Since 2012 in Jordan and 2013 in Lebanon, the International Organization for Migration (IOM) has supported the National TB Program (NTP) in detecting and treating TB among Syrian refugees. In December 2016, IOM asked US Centers for Disease Control and Prevention (CDC) staff to evaluate its program of support to Jordan and Lebanon’s NTPs for TB control among Syrian refugees. This manuscript focuses on case-finding, including contact investigations, and treatment components of the IOM program during 2013–2015 in Jordan and 2015 in Lebanon. Methods The evaluation consisted of a retrospective review of de-identified Jordan and Lebanon line lists of TB cases and of investigated contacts (Lebanon only). Syrian refugee TB cases were categorized by sex, age group (age

Abstract Background Health needs of displaced Syrians in refugee hosting countries have become increasingly complex in light of the protracted Syrian conflict. The primary aim of this study was to identify the primary health needs of displaced Syrians in Iraq, Jordan, Lebanon, Turkey, and Syria. Methods A systematic review was performed using 6 electronic databases, and multiple grey literature sources. Title, abstract, and full text screening were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The target population was Syrian individuals displaced due to conflict in Syria and its neighboring countries. The outcomes of interest were health needs (i.e. health problems that can be addressed by health services), gaps in health services, training, and workforce. Studies on mixed refugee populations and Syrians displaced prior to the conflict were excluded. Results The Lebanon-specific results of the review were validated through two stakeholder roundtable discussions conducted with representatives from primary healthcare centers, non-governmental organizations and humanitarian aid agencies. A total of 63 articles were included in the analysis. Mental health and women’s health were identified as the greatest health needs in the region. The most common health problems were Non-communicable diseases in Jordan, women’s health in Lebanon and mental health in Turkey. Studies addressing gaps in services found the highest gap in general healthcare services, followed by women’s health, mental health, and vaccinations. Sub-optimal training and availability of health workers was also noted particularly in Syria. Results from the stakeholders’ discussions in Lebanon showed communicable diseases, women’s health and mental health as the main health needs of Syrian refugees in Lebanon. Reported barriers to accessing health services included geographical barriers and lack of necessary awareness and education. Conclusion There is a need for an enhanced synchronized approach in Syria’s refugee hosting neighboring countries to reduce the existing gaps in responding to the needs of Syrian refugees, especially in regards to women’s health, mental health, and communicable diseases. This mainly includes training of healthcare workers to ensure a skilled workforce and community-based efforts to overcome barriers to access, including lack of knowledge and awareness about highly prevalent health conditions.

Abstract Background The year 2015 marked the highest number of refugees globally and included record numbers of Syrians moving to neighboring countries. Half of the Syrians were children aged ≤18 years. Our study sought to examine undernutrition and overnutrition among a group of Syrian refugee children who underwent medical screening by IOM for resettlement. Methods This is a retrospective review of Syrian refugee children aged 6 to 59 months from January 1, 2015 to December 31, 2016. The World Health Organization (WHO) Stata package computed Z-scores based on available weight and height data. Prevalence estimates of undernutrition (wasting and stunting) and overnutrition (overweight and obesity) were made using WHO standards. Multivariate analysis was used to determine the factors associated with wasting, stunting, and overnutrition, adjusting for age, sex, family size, and country of health assessment. Results A total of 14,552 Syrian refugee children aged 6 to 59 months underwent health assessments in Jordan (43·1%), Lebanon (38·8%), Turkey (7·0%), Greece (6·7%), Egypt (2·4%), and Iraq (2·1%). Overall, this group of Syrian refugee children had a low prevalence of wasting (< 5%) and stunting (< 10%), and high prevalence of overweight or obese (10.6%). Differences were observed in the prevalence of wasting by country of health assessment. In the multiple regression analysis, the prevalence of stunting and overnutrition decreased with increasing age, and being male was associated with overnutrition but not wasting and stunting. Conclusions Findings revealed an overall low prevalence of undernutrition among this group of Syrian children assessed, although prevalence varied by age group. This low prevalence may reflect the effectiveness, as well as expose possible gaps, of refugee nutrition programs or interventions in countries of asylum. Further studies are recommended to evaluate other possible contributors to malnutrition in this refugee group.

Abstract Background In June 2017, the U.S.-backed Syrian Democratic Forces (SDF) launched a military operation to retake the city of Raqqa, Syria, from the so-called Islamic State. The city population incurred mass numbers of wounded. In the post-offensive period, the population returned to a city (Raqqa) contaminated with improvised explosive devices (IEDs) and explosive remnants of war (ERWs), resulting in a second wave of wounded patients. Médecins Sans Frontières (MSF) supported a hospital in Tal-Abyad (north of Raqqa) and scaled up operations in response to this crisis. We describe the cohort of blast-wounded cases admitted to this hospital in order help prepare future humanitarian responses. Methods We retrospectively extracted data from clinical charts in the MSF-supported hospital. We included all new admissions for blast-wounded patients with key data elements documented. We performed comparative analyses from the offensive period (June 6, 2017 to October 17, 2017) and the post-offensive period (October 18, 2017 to March 17, 2018). Results We included 322 blast related injuries. There were more than twice the number of cases with blast injuries in the post-offensive period as the offensive period (225 vs. 97, p =

Abstract Background In a growing number of humanitarian crises, “remote management” is negotiated across borders and implemented by humanitarian agencies through “local actors” to deliver assistance. However, the narrative describing the involvement of local actors in the delivery of humanitarian aid in armed conflict settings remains reductionist and unreflective of the complex and circular course of the “localisation of aid”. This paper explores cross-border humanitarian assistance within the Syrian conflict. We document how humanitarian actors operate to deliver humanitarian health care in North-West Syria (Turkish border), explore their challenges and critique the language used within current debates on the localisation of aid. Methods We undertook key informant interviews with Turkey-based humanitarian aid professionals involved in the humanitarian health response inside Syria. We integrated data previously collected for The Lancet-American University of Beirut Commission on Syria during field work in Gaziantep, Turkey, through meetings, conversations, discussions and expert consultations with Syrian health professionals, WHO-Turkey staff members and members of Syrian health directorates. We also drew from background desk reviews conducted by the Commission on health systems responses and timeline of events in Turkey during the Syrian conflict. Results This paper uncovers creative and effective bottom-up strategies that enhanced cross-border coordination of aid delivery into Syria. Our findings unravel the key role played by Syrian providers in accessing vulnerable populations and in reshaping coordination and funding mechanisms inside Syria, as well as the disproportionate risks local actors bear within the response. Our findings also reveal an iterative negotiation of decision-making dynamics, a “low-profile approach” promoted to gain access to populations of concerns, and an environment that is heavily shaped by close interpersonal relationships and social trust. Conclusions Our multifaceted narrative unpacks circular flows of interactions among actors and uncovers strategies developed by practitioners on the field, which are often left undocumented. We argue that there is an opportunity for the humanitarian sector to learn from these synergies to rethink how medical humanitarianism is framed (hopefully leading to a more collaborative framing that resists mainstreaming “local” actors within a “traditional” system). There is also an opportunity for the humanitarian and global health communities to reflect on how value attributed to human lives needs to be questioned in contexts where national staff face a disproportionate risk to deliver aid.

Abstract The escalation of conflict in the Middle East coincides with an emerging trend of attacks on healthcare. Protection of health personnel, health services and humanitarian workers is no longer respected. This compromises the achievement of the United Nations Sustainable Development Goals 3 – towards health for all, and 16 – towards justice and peace. The Centre for Global Health at the University of Oslo, the Peace Research Institute Oslo and the Norwegian Red Cross co-organised a meeting exploring how conflict impacts health systems and potential solutions to protect and maintain health care services.

Abstract Health sciences research is a major tool in exchanging publications and knowledge between the various countries of the world. Researchers in developing countries barely have any financial funding from governmental or educational institutes to support their research. In low-income countries such as Syria, With less than 30$ per month and almost no financial support, Syrian residency doctors are fighting to push the scientific research reality of this ongoing crisis country forward and without a doubt, APC waiver plays a crucial role in this continuing mission.

Abstract Background There has been increasing focus on tackling the growing burden of non-communicable diseases (NCD) in crisis settings. The complex and protracted crisis in Syria is unfolding against a background of increasing NCD burden. This study investigated factors influencing implementation of NCD healthcare in Syria. Methods This is a qualitative study, whereby semi-structured interviews were conducted with fourteen humanitarian health staff working on NCD healthcare in Syria. Results Challenges to NCD care implementation were reflected at several stages, from planning services through to healthcare delivery. There was a lack of information on unmet population need; little consensus among humanitarian actors regarding an appropriate health service package; and no clear approach for prioritising public health interventions. The main challenges to service delivery identified by participants were conflict-related insecurity and disruption to infrastructure, hampering continuity of chronic illness care. Collaboration was a key factor which influenced implementation at all stages. Conclusions The historical context, the conflict situation, and the characteristics of health actors and their relationships, all impacted provision of NCD care. These factors influenced each other, so that the social views and values (of individuals and organisations), as well as politics and relationships, interacted with the physical environment and security situation. Infrastructure damage has implications for wider healthcare across Syria, and NCD care requires an innovative approach to improve continuity of care. There is a need for a transparent approach to resource allocation, which may be generalisable to the wider humanitarian health sector.

Abstract Background In response to the influx of displaced Syrians since 2011, the Jordanian National Tuberculosis Program (NTP) implemented a specific Tuberculosis (TB) reduction strategy, including contact-tracing (CT). Contacts of all refugees diagnosed with pulmonary TB (PTB) were registered by the International Organization for Migration and screened for active & latent TB infection (LTBI) in 6 NTP centres. The objectives of this study were to assess prevalence of active TB and LTBI, risk factors for LTBI as well as program performance. Methods We performed a retrospective study among contacts (N = 481) of all PTB cases diagnosed between March 2011 and May 2014 (N = 76). CT was performed using verbal screening of TB-related symptoms, tuberculin skin test (TST) and chest X-ray. Results LTBI was diagnosed in 24.1% of contacts tested with TST while active TB was diagnosed in 2.1% of contacts. Main risk factors for positive TST included smear-positive index case (IC) (OR: 6.33) and previous TB infection in the family (OR: 4.94). Among children, the risk of LTBI was higher when their IC was a care-giving female (OR: 2.83). Prevalence of active TB was two times higher in children under five (U5 s) (5.3%) compared to adults (2.5%). Conclusion We found a high prevalence of active TB and LTBI among contacts of PTB cases in the Syrian refugee population, emphasizing the urgent need for host countries to implement CT strategies for refugees. Our results underscore the vulnerability of U5s and contacts of smear-positive IC highlighting the need for specific actions focusing on those groups.

Abstract Background Tackling the high non-communicable disease (NCD) burden among Syrian refugees poses a challenge to humanitarian actors and host countries. Current response priorities are the identification and integration of key interventions for NCD care into humanitarian programs as well as sustainable financing. To provide evidence for effective NCD intervention planning, we conducted a cross-sectional survey among non-camp Syrian refugees in northern Jordan to investigate the burden and determinants for high NCDs prevalence and NCD multi-morbidities and assess the access to NCD care. Methods We used a two-stage cluster design with 329 randomly selected clusters and eight households identified through snowball sampling. Consenting households were interviewed about self-reported NCDs, NCD service utilization, and barriers to care. We estimated the adult prevalence of hypertension, diabetes type I/II, cardiovascular- and chronic respiratory conditions, thyroid disease and cancer and analysed the pattern of NCD multi-morbidities. We used the Cox proportional hazard model to calculate the prevalence ratios (PR) to analyse determinants for NCD prevalence and logistic regression to determine risk factors for NCD multi-morbidities by calculating odds ratios (ORs). Results Among 8041 adults, 21.8%, (95% CI: 20.9–22.8) suffered from at least one NCD; hypertension (14.0, 95% CI: 13.2–14.8) and diabetes (9.2, 95% CI: 8.5–9.9) were the most prevalent NCDs. NCD multi-morbidities were reported by 44.7% (95% CI: 42.4–47.0) of patients. Higher age was associated with higher NCD prevalence and the risk for NCD-multi-morbidities; education was inversely associated. Of those patients who needed NCD care, 23.0% (95% CI: 20.5–25.6) did not seek it; 61.5% (95% CI: 54.7–67.9) cited provider cost as the main barrier. An NCD medication interruption was reported by 23.1% (95% CI: 20–4-26.1) of patients with regular medication needs; predominant reason was unaffordability (63.4, 95% CI: 56.7–69.6). Conclusion The burden of NCDs and multi-morbidities is high among Syrian refugees in northern Jordan. Elderly and those with a lower education are key target groups for NCD prevention and care, which informs NCD service planning and developing patient-centred approaches. Important unmet needs for NCD care exist; removing the main barriers to care could include cost-reduction for medications through humanitarian pricing models. Nevertheless, it is still essential that international donors agencies and countries fulfill their commitment to support the Syrian-crisis response.

Abstract Background By 2017, more than 500,000 Syrian refugees had passed through Greece seeking safety and asylum. Understanding how their health needs evolved over the refugee crisis in Greece and in relation to changing migration policy, and exploring the challenges involved in delivering their healthcare is timely as non-governmental organizations (NGOs) transition health service provision to the Greek health authorities. Methods We conducted a qualitative study to explore stakeholders’ perspectives on delivering health services to Syrian refugees over the course of the humanitarian response in Greece from 2015 to 2017. Twenty-five in-depth interviews were conducted face-to-face or by Skype with healthcare providers, NGO staff, and organizational and government representatives involved in coordinating and managing healthcare for the Syrian refugee population in Greece. Following informed consent, interviews were audio-recorded or detailed summaries were manually recorded. Data were coded inductively to identify emerging themes. Results Following the implementation of the European Union-Turkey agreement in 2016, healthcare providers in refugee camps reported a shift from acute physical health issues to mental health disorders, and heightened risks of gender-based violence among Syrian refugees. Key challenges to service delivery included a narrow model of healthcare provision and insufficient referral mechanisms for social support and mental health services. Language and gender differences between refugees and healthcare providers, and a lack of privacy and space in clinics impeded the quality of care. Stakeholders observed deterioration in refugees’ mental health in relation to longer periods spent in the camps. Many also emphasized that services for gender-based violence and mental health should be prioritized. Conclusion This study provides stakeholders’ perspectives on changes in refugee health needs over the course of the humanitarian response in Greece. With protracted encampment resulting from migration policy, addressing mental health disorders and gender-based violence should be prioritized, including psychosocial training for healthcare providers and strengthening referral mechanisms for specialized care. The findings also emphasize the importance of providing human-centered care and gender concordant services by incorporating female healthcare providers and interpreters into medical teams. Strategic communication and coordination is needed between NGOs and Greek health authorities to facilitate the transition of health service delivery to the Greek healthcare system and to improve access and quality of care for refugees.

Abstract Background In the ongoing conflicts of Syria and Yemen, there have been widespread reports of attacks on health care facilities and personnel. Tabulated evidence does suggest hospital bombings in Syria and Yemen are far higher than reported in other conflicts but it is unclear if this is a reporting artefact. Objective This article examines attacks on health care facilities in conflicts in six middle- to high- income countries that have occurred over the past three decades to try and determine if attacks have become more common, and to assess the different methods used to collect data on attacks. The six conflicts reviewed are Yemen (2015-Present), Syria (2011- Present), Iraq (2003–2011), Chechnya (1999–2000), Kosovo (1998–1999), and Bosnia and Herzegovina (1992–1995). Methods We attempted to get the highest quality source(s) with summary data of the number of facilities attacked for each of the conflicts. The only conflict that did not have summary data was the conflict in Iraq. In this case, we tallied individual reported events of attacks on health care. Results Physicians for Human Rights (PHR) reported attacks on 315 facilities (4.38 per month) in Syria over a 7-year period, while the Monitoring Violence against Health Care (MVH) tool launched later by the World Health Organization (WHO) Turkey Health Cluster reported attacks on 135 facilities (9.64 per month) over a 14-month period. Yemen had a reported 93 attacks (4.65 per month), Iraq 12 (0.12 per month), Chechnya > 24 (2.4 per month), Kosovo > 100 (6.67 per month), and Bosnia 21 (0.41 per month). Methodologies to collect data, and definitions of both facilities and attacks varied widely across sources. Conclusion The number of reported facilities attacked is by far the greatest in Syria, suggesting that this phenomenon has increased compared to earlier conflicts. However, data on attacks of facilities was incomplete for all of the conflicts examined, methodologies varied widely, and in some cases, attacks were not defined at all. A global, standardized system that allows multiple reporting routes with different levels of confirmation, as seen in Syria, would likely allow for a more reliable and reproducible documentation system, and potentially, an increase in accountability.

Abstract Background Water, sanitation, and hygiene (WASH) are immediate priorities for human survival and dignity in emergencies. In 2010, > 90% of Syrians had access to improved drinking water. In 2011, armed conflict began and currently 12 million people need WASH services. We analyzed data collected in southern Syria to identify effective WASH response activities for this context. Methods Cross-sectional household surveys were conducted in 2016 and 2017 in 17 sub-districts of two governorates in opposition controlled southern Syria. During the survey, household water was tested for free chlorine residual (FCR). Descriptive statistics were calculated, and mixed effect logistic regressions were completed to determine associations between demographic and WASH variables with outcomes of FCR > 0.1 mg/L in household water and reported diarrhea in children 0.1 mg/L increased from 4.1% to 27.9% over this time, with Water Safety Plan (WSP) programming strongly associated with FCR (mOR: 24.16; 95% CI: 5.93–98.5). The proportion of households with childhood diarrhea declined from 32.8% to 20.4% over this time; sanitation and hygiene access were protective against childhood diarrhea. Conclusions The private sector has effectively replaced decaying infrastructure in Syria, although at high cost and uncertain quality. Allowing market forces to manage WASH services and quantity, and targeting emergency response activities on increasing affordability with well-targeted subsidies and improving water quality and regulation via WSPs can be an effective, scalable, and cost-effective strategy to guarantee water and sanitation access in protracted emergencies with local markets.

Abstract Evidence of use of toxic gas chemical weapons in the Syrian war has been reported by governmental and non-governmental international organizations since the war started in March 2011. To date, the profiles of victims of the largest chemical attacks in Syria remain unknown. In this study, we used descriptive epidemiological analysis to describe demographic characteristics of victims of the largest chemical weapons attacks in the Syrian war. We analysed conflict-related, direct deaths from chemical weapons recorded in non-government-controlled areas by the Violation Documentation Center, occurring from March 18, 2011 to April 10, 2017, with complete information on the victim’s date and place of death, cause and demographic group. ‘Major’ chemical weapons events were defined as events causing ten or more direct deaths. As of April 10, 2017, a total of 1206 direct deaths meeting inclusion criteria were recorded in the dataset from all chemical weapons attacks regardless of size. Five major chemical weapons attacks caused 1084 of these documented deaths. Civilians comprised the majority (n = 1058, 97.6%) of direct deaths from major chemical weapons attacks in Syria and combatants comprised a minority of 2.4% (n = 26). In the first three major chemical weapons attacks, which occurred in 2013, children comprised 13%–14% of direct deaths, ranging in numbers from 2 deaths among 14 to 117 deaths among 923. Children comprised higher proportions of direct deaths in later major chemical weapons attacks, forming 21% (n = 7) of 33 deaths in the 2016 major attack and 34.8% (n = 32) of 92 deaths in the 2017 major attack. Our finding of an extreme disparity in direct deaths from major chemical weapons attacks in Syria, with 97.6% of victims being civilians and only 2.4% being combatants provides evidence that major chemical weapons attacks were indiscriminate or targeted civilians directly; both violations of International Humanitarian Law (IHL). Identifying and quantifying chemical weapons violations requires inter-disciplinary collaboration to inform international policy, humanitarian intervention and legal action.

Abstract Background The repeated use of prohibited chemical weapons in the Syrian conflict poses serious health, humanitarian, and security threats to civilians, healthcare personnel, and first responders. Moreover, the use of chemical weapons constitutes a clear and egregious violation of international law—likely amounting to a war crime—for which continued impunity is setting a dangerous precedent in relation to current and future conflicts. This debate article calls upon concerned states, organizations, and individuals to respond urgently and unequivocally to this serious breach of international legal and humanitarian norms. Main Body Based on health, humanitarian, and legal findings, this article calls for concrete action to: 1) reduce the risk of chemical weapons being used in current and future conflicts; 2) review and support the preparedness equipment and antidote supplies of first responders, humanitarian organizations, and military forces operating in Syria; 3) support international mechanisms for monitoring and enforcing the prohibition on chemical weapons, including through criminal accountability; 4) support civilian victims of chemical weapons attacks, including refugees; and 5) re-commit to the complete elimination of chemical weapons in compliance with the Chemical Weapons Convention (1993), a comprehensive treaty that bans chemical weapons and requires their complete destruction. Conclusion All involved states and organizations should take urgent steps to ensure the protection of the most vulnerable victims of conflict, including victims of chemical weapons attacks in Syria, and to reinforce international law in the face of such serious violations.

Abstract Background The Syrian armed conflict is the worst humanitarian tragedy this century. With approximately 470,000 deaths and more than 13 million people displaced, the conflict continues to have a devastating impact on the health system and health outcomes within the country. Hundreds of international and national non-governmental organisations, as well as United Nations agencies have responded to the humanitarian crisis in Syria. While there has been significant attention on the challenges of meeting health needs of Syrian refugees in neighbouring countries such as Jordan, Lebanon and Turkey, very little has been documented about the humanitarian challenges within Syria, between 2013 and 2014 when non-governmental organisations operated in Syria with very little United Nations support or leadership, particularly around obtaining information to guide health responses in Syria. Methods In this study, we draw on our operational experience in Syria and analyse data collected for the humanitarian health response in contested and opposition-held areas of Syria in 2013–4 from Turkey, where the largest humanitarian operation for Syria was based. This is combined with academic literature and material from open-access reports. Results Humanitarian needs have consistently been most acute in contested and opposition-held areas of Syria due to break-down of Government of Syria services and intense warfare. Humanitarian organisations had to establish de novo data collection systems independent of the Government of Syria to provide essential services in opposition-held and contested areas of Syria. The use of technology such as social media was vital to facilitating remote data collection in Syria as many humanitarian agencies operated with a limited operational visibility given chronic levels of insecurity. Mortality data have been highly politicized and extremely difficult to verify, particularly in areas highly affected by the conflict, with shifting frontlines, populations, and allegiances. Conclusions More investment in data collection and use, technological investment in the use of M- and E-health, capacity building and strong technical and independent leadership should be a key priority for the humanitarian health response in Syria and other emergencies. Much more attention should be also given for the treatment gap for non-communicable diseases including mental disorders.

Abstract Background The growing burden of non-communicable diseases (NCDs) presented new challenges for medical humanitarian aid and little was known about primary health care approaches for these diseases in humanitarian response. We aimed to evaluate Médecins Sans Frontières (MSF’s) use of total CVD risk based prevention strategies amongst Syrian refugees in northern Jordan to identify opportunities to improve total CVD risk based guidance for humanitarian settings. Methods We evaluated CVD risk assessment and management in two outpatient NCD clinics in the Irbid governorate of Jordan using a mixed methods design with qualitative and quantitative strands of equal priority, integrated during data collection and interpretation. World Health Organisation/International Society of Hypertension (WHO/ISH) CVD risk charts requiring measured cholesterol were used in the clinics and in our analysis. An electronic database of routine clinical information was used to determine the CVD risk profile of the clinic population, the pattern and concordance of lipid-lowering treatment prescriptions, and the prevalence and accuracy of documented CVD risk scores. This was combined with semi-structured interviews with MSF health workers, which were recorded, transcribed verbatim, and analysed thematically. Results We reviewed the clinical records of 2907 patients. One fifth (20.9%; 95% CI 19.5, 22.4) of patients had a history of CVD while 56.8% (95% CI 54.9, 58.6) of patients had a WHO/ISH risk of