Response to the COVID-19 pandemic has challenged even robust healthcare systems in high-income countries. Syria, a country experiencing protracted conflict, has the largest internally-displaced population globally with most displaced settlements in opposition-controlled areas governed by local and international NGOs. This study aimed to explore community perspectives on challenges and potential solutions to reduce COVID-19 transmission among displaced communities in opposition-controlled Northwest Syria. We used a qualitative study design, conducting 20 interviews with displaced Syrians in opposition-controlled camps in Northwest Syria between April-May 2020 and ensuring over half our interviewees were women. We analysed data thematically. Participants described already difficult camp conditions that would be detrimental to an effective COVID-19 response, including household crowding, inadequate sewerage and waste management, insufficient and poor-quality water, and lack of cleaning supplies. Participants most frequently mentioned internet as their COVID-19 information source, followed by NGO awareness campaigns. Men had access to more accurate and comprehensive COVID-19 information than women did. Isolating (shielding) high-risk people within households did not appear feasible, but participants suggested ‘house-swapping’ approaches might work. While most participants had sufficient knowledge about COVID-19, they lacked practical tools to prevent transmission. This study is the first to explore perspectives and lived experiences of internally-displaced Syrians in the weeks prior to the COVID-19 epidemic in Northwest Syria. The challenging living conditions of internally-displaced people in Syria are further threatened by the spread of COVID-19. Tailored control measures are urgently needed to reduce COVID-19 transmission in camps.

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.

Introduction The Syrian conflict, which has included mass killings, displacement, infrastructure destruction and illegal targeting of health facilities and staff mainly by the Syrian government and allies, is in its 10th year. This study explored the lived experiences of women within healthcare, both as health workers and service users, in Syrian opposition-controlled areas (OCAs). Methods We chose a qualitative study design, with 20 in-depth interviews conducted remotely over WhatsApp and Messenger with purposively sampled Syrian women (ie, 15 health workers, 5 service users). We analysed data using interpretative phenomenological analysis. Results Anxiety, fear and horror affected women’s everyday work and wellness. Excess workload and insecurity were major challenges for women health workers, who also had household and caring responsibilities. Coping mechanisms included: (1) normalising death; (2) acceptance of God’s will; and (3) focusing on controllable issues such as health services provision while accepting the reality of insecurity and death. Conflict contributed to changing social norms and expectations, and women became key actors in healthcare provision, though this did not translate directly into greater decision-making authority. Structural biases (eg, lack of maternity leave) and gender-based violence (eg, increased harassment and child marriage) inordinately affected women. Conclusion This is a first effort to amplify women’s voices in health policy and systems research on the Syrian conflict. Women have become key healthcare providers in OCAs but remain under-represented in decision making. While the conflict-related social transformation, increasing the role of—and demand for—women health workers could be viewed positively for women’s empowerment, the reality is complex and long-term implications are unclear.

Ten years of conflict has displaced more than half of Northwest Syria's (NWS) population and decimated the health system, water and sanitation, and public health infrastructure vital for infectious disease control. The first NWS COVID-19 case was declared on July 9, 2020, but impact estimations in this region are minimal. With the rollout of vaccination and emergence of the B.1.617.2 (Delta) variant, we aimed to estimate the COVID-19 trajectory in NWS and the potential effects of vaccine coverage and hospital occupancy. We conducted a mixed-method study, primarily including modeling projections of COVID-19 transmission scenarios with vaccination strategies using an age-structured, compartmental susceptible-exposed-infectious-recovered (SEIR) model, supported by data from 20 semi-structured interviews with frontline health workers to help contextualize interpretation of modeling results. Modeling suggested that existing low stringency non-pharmaceutical interventions (NPIs) minimally affected COVID-19 transmission. Maintaining existing NPIs after the Delta variant introduction is predicted to result in a second COVID-19 wave, overwhelming hospital capacity and resulting in a fourfold increased death toll. Simulations with up to 60% vaccination coverage by June 2022 predict that a second wave is not preventable with current NPIs. However, 60% vaccination coverage by June 2022 combined with 50% coverage of mask-wearing and handwashing should reduce the number of hospital beds and ventilators needed below current capacity levels. In the worst-case scenario of a more transmissible and lethal variant emerging by January 2022, the third wave is predicted. Total COVID-19 attributable deaths are expected to remain relatively low owing largely to a young population. Given the negative socioeconomic consequences of restrictive NPIs, such as border or school closures for an already deeply challenged population and their relative ineffectiveness in this context, policymakers and international partners should instead focus on increasing COVID-19 vaccination coverage as rapidly as possible and encouraging mask-wearing.

Introduction Governance of COVID-19 responses has been challenging for all countries. Syria has been particularly challenged due to protracted multiparty conflict and debilitated health systems fragmented across different areas of control. To improve response governance, better understanding of frontline response policy implementation across the country is needed. This study thus explored perspectives of COVID-19 response governance among frontline healthcare providers over time and across major areas of control. Methods We used a qualitative longitudinal study design, conducting five rounds of remote semistructured interviews in Arabic (ie, approximately eight interviews each in March 2020, July 2020, September 2020, December 2020 and September 2021) with 14 purposively sampled public and private healthcare providers in the three main areas of control (ie, opposition-controlled area, Autonomous Administration-controlled area and al-Assad government-controlled area (GCA)). We conducted integrative thematic analysis in Arabic within and across geography and time. Results Almost all participants across all areas and rounds expressed distrust of local health authorities and dissatisfaction with COVID-19 response governance. This was most apparent in initial rounds and in GCA. Response planning was identified as insufficient, non-participatory and non-transparent. Limited infrastructure and resources were the main challenges across time, though anticipated rapid virus spread and health systems’ collapse did not occur and participant optimism increased over time. Public adherence to prevention measures varied—initially weak due to general scepticism, increasing after first cases were confirmed and then fluctuating with case numbers and challenges of insecurity and misinformation. Perceptions of COVID-19 vaccination varied, with low uptake and hesitancy attributed to misinformation, disinformation and disinterest. Suggested improvements to COVID-19 response governance focused on strengthening health systems’ capacity and coordination. Conclusion This is a unique longitudinal study of COVID-19 responses. Addressing transparency and misinformation should be a first step to improving public engagement and trust and thus response governance for health emergencies in Syria.

COVID-19 vaccine hesitancy is a new phenomenon in Syria, about which relatively little is known. We aimed to explore this, drawing from 37 semi-structured interviews with frontline health-workers and service-users across Syria’s major military areas-of-control. We found COVID-19 vaccine hesitancy was common and increasing among service-users and less common, but still present, among health-workers in all areas. Interrelated reasons included pragmatic fears of novel vaccine risks, unreliable information, and conflict-related hesitancies as a form of resistance or reasserting some perceived control, particularly outside Al-Assad government-controlled areas. Vaccine hesitancy has thus become a socio-political issue, requiring macro-level responses, across Syria.