The quality of Syrian healthcare services during COVID-19: A HEALTHQUAL approach

Translation, cultural adaptation and linguistic validation of the postgraduate hospital educational environment measure into Arabic

BACKGROUND

Assessment of the clinical learning environment (CLE) is an essential step that teaching hospitals routinely undertake to ensure the environment is conducive, learning-oriented and supportive of junior doctors' education. The Postgraduate Hospital Educational Environment Measure (PHEEM) is an internationally recognized tool for assessing the CLE with evidence of high reliability and validity. Translation of PHEEM into other languages such as Spanish, Japanese and Persian enabled wider adoption of the instrument in the world. However, in Syria and other Arabic countries, a validated Arabic translation of PHEEM is still not available, making it difficult to adopt it and use it in Arabic contexts. This study aims to translate and culturally adapt the PHEEM from English into Arabic.

METHODS

This study followed the structured translation and validation process guideline proposed by Sousa & Rojjanasrirat 2010. First, the PHEEM went through forward translation by three translators, then reconciled with the aid of a fourth translator. Afterwards, two professional bicultural and bilingual translators conducted back translation into English and compared it with the original version. This formed the Pre-final Version (PFV) which was then pretested for clarity on a sample of medical residents in Damascus, Syria. Following appropriate modifications, the PFV was sent to a panel of experts for a comprehensive review of language clarity and to assess content validity.

RESULTS

A total of thirty-five medical residents were recruited. Ten items with language clarity issues were identified and modified according to the elicited suggestions. Thereafter, the modified PFV was presented to ten subject experts who identified three items in need of revision. The item-content Validity Index (CVI) was over 0.78 for all of the 40 items; the calculated scale-CVI was 0.945.

DISCUSSION

This study provided the first linguistically valid Arabic translation of the widely used PHEEM inventory. The next step is to conduct a full psychometric analysis of the Arabic PHEEM to provide further evidence of validity and reliability.

A study on siting of emergency shelters for dam failure floods considering population distribution and weather effects

In recent years, dam failures have occurred frequently because of extreme weather, posing a significant threat to downstream residents. The establishment of emergency shelters is crucial for reducing casualties. The selection of suitable shelters depends on key information such as the number and distribution of affected people, and the effective capacity and accessibility of the shelters. However, previous studies on siting shelters did not fully consider population distribution differences at a finer scale. This limitation hinders the accuracy of estimating the number of affected people. In addition, most studies ignored the impact of extreme rainfall on the effective capacity and accessibility of shelters, leading to a low applicability of the shelter selection results. Therefore, in this study, land-use and land-cover change (LUCC) and nighttime lighting data were used to simulate population distribution and determine the number and distribution of affected people. Qualified candidate shelters were obtained based on screening criteria, and their effective capacity and accessibility information under different weather conditions were quantified. Considering factors such as population transfer efficiency, construction cost and shelter capacity constraints, a multi-objective siting model was established and solved using the non-dominated sorting genetic algorithm II (NSGA- II) to obtain the final siting scheme. The method was applied to the Dafangying Reservoir, and the results showed the following: (1) The overall mean relative error (MRE) of the population in the 35 downstream streets was 11.16 %, with good fitting accuracy. The simulation results truly reflect the population distribution. (2) Normal weather screening generated 352 qualified candidate shelters, whereas extreme rainfall weather screening generated 266 candidate shelters. (3) Based on the population distribution and weather factors, four scenarios were set up, with 63, 106, 73, and 131 shelters selected. These two factors have a significant impact on the selection of shelters and the allocation of evacuees, and should be considered in the event of a dam-failure floods.

Predictors of antibiogram performance and antibiotic resistance patterns in the northern Syrian region: A cross-sectional investigation

Introduction

Antibiogram use is crucial in the fight against antibiotic resistance in Syria, helping to guide treatment decisions, monitor resistance trends, and implement measures to mitigate this global health threat. This study explores the predictors of antibiogram performance and antibiotic resistance patterns in hospital settings in the Northern Syrian region.

Methods

An observational cross-sectional study was performed over six months, from the beginning of September 2022 to February 2023, targeting patients admitted to two hospitals in Syria with susceptibility to infection. The study excluded patients who did not consent or were unwilling to participate, while all individuals admitted due to infectious diseases, regardless of age, sex, or race, were included in the research. Data were collected prospectively, and antimicrobial susceptibility evaluations were performed using the disc diffusion method (the Kirby-Bauer test). Statistical analyses, including the analysis of the results, were conducted utilizing the Statistical Package for Social Sciences (SPSS Inc., Chicago, Illinois) Version 29.

Results

Of 300 hospitalized patients taking antibiotics, an antibiogram was performed for 200 individuals (cases), while 100 patients (controls) received direct treatment. One-hundred eighty-five cases had a positive culture (69.7% Gram-negative and 30.3% Gram-positive) and subsequently underwent assessment for antibiotic resistance. Cases comprised more females (56.0%) than controls (48.0%), with no statistically significant differences (p > 0.05). Significantly more patients between 25 and 63 were cases (63.8%) than controls (51.0%), while older ages were notably higher among controls (31.7%; p = 0.044), history of cardiovascular diseases was higher among controls (59.0%) than cases (47.0%; p = 0.050). Escherichia coli (N = 60; 30%), Klebsiella (N = 37; 18.5%), and Streptococcus (N = 32; 16%) were the most common bacteria. The study explored antibiotic resistance patterns among identified germs, emphasizing the high sensitivity of all identified germs for broad-spectrum antibiotics, including meropenem, amikacin, gentamicin, and fluoroquinolones (levofloxacin, ciprofloxacin). High resistance (%Sensitivity below 60%) was noted for Sulfamethoxazole, nalidixic acid, amoxiclav, lincomycin cefotaxime, ceftriaxone, and cefixime. Specifically, Escherichia coli exhibited robust sensitivity to meropenem (100%), amikacin (93.2%), and ciprofloxacin (92.7%). However, notable resistance was observed against sulfamethoxazole (68.8%), amoxicillin-clavulanate (78.3%), and cefotaxime (88.3%). For Klebsiella, resistance rates were prominent, particularly against sulfamethoxazole (69.4%), amoxicillin (83.8%), and nalidixic acid (100%). Among Gram-positive bacteria, Staphylococcus demonstrated significant resistance to sulfamethoxazole (95.2%) and ceftriaxone (78.3%) while maintaining high sensitivity to meropenem (100%) and vancomycin (100%). Streptococcus exhibited notable resistance against sulfamethoxazole (87.5%) and cefotaxime (90.6%).

Conclusion

The increase in resistance to penicillins, sulfonamides, and cephalosporins, along with continued sensitivity to broad-spectrum antibiotics, including aminoglycosides, carbapenems, and fluoroquinolones, emphasizes the importance of promoting antibiogram use and antibiotic stewardship programs. The limited availability of new antibiotics reinforces the need for urgent efforts to optimize antibiotic use and improve clinical outcomes in Northern Syria.

Lessons learnt from the first wave of COVID-19 in Damascus, Syria: a multicentre retrospective cohort study

OBJECTIVES

The decade-long Syrian war led to fragile health infrastructures lacking in personal and physical resources. The public health of the Syrian population was, therefore, vulnerable to the COVID-19 pandemic, which devastated even well-resourced healthcare systems. Nevertheless, the officially reported incidence and fatality rates were significantly lower than the forecasted numbers.

DESIGN

A retrospective cohort study.

SETTING

The four main responding hospitals in Damascus, which received most of the cases during the first pandemic wave in Syria (i.e., June-August 2020).

PARTICIPANTS

One thousand one hundred eighty-four patients who were managed as inpatient COVID-19 cases.

PRIMARY AND SECONDARY OUTCOME MEASURES

The records of hospitalised patients were screened for clinical history, vital signs, diagnosis modality, major interventions and status at discharge.

RESULTS

The diagnostic and therapeutic preparedness for COVID-19 was significantly heterogeneous among the different centres and depleted rapidly after the arrival of the first wave. Only 32% of the patients were diagnosed based on positive reverse transcription-PCR tests. Five hundred twenty-six patients had an indication for intensive care unit admission, but only 82% of them received it. Two hundred fifty-seven patients needed mechanical ventilation, but ventilators were not available to 14% of them, all of whom died. Overall mortality during hospitalisation reached 46% and no significant difference was found in fatality between those who received and did not receive these care options.

CONCLUSIONS

The Syrian healthcare system expressed minor resilience in facing the COVID-19 pandemic, as its assets vanished swiftly with a limited number of cases. This forced physicians to reserve resources (e.g., ventilators) for the most severe cases, which led to poor outcomes of in-hospital management and limited the admission capacity for milder cases. The overwhelmed system additionally suffered from constrained coordination, suboptimal allocation of the accessible resources and a severe inability to informatively report on the catastrophic pandemic course in Syria.

Health-care provider burnout in Syria during COVID-19 pandemic's Omicron wave

Health-care workers (HCWs) have dealt with various psychological problems during the COVID-19 epidemic, including sadness, mental discomfort, anxiety, and poor sleep. Burnout is a state of prolonged work-related psychological, emotional, and physical stress brought on by emotional weariness, depersonalization, and decreased professional success. This study aimed to determine how many HCWs burned out during the Omicron wave of the COVID-19 pandemic and determine what factors put them at risk for this psychological effect. This cross-sectional research was performed in Syria during the current Omicron wave of the COVID-19 pandemic to evaluate the burnout experienced by Syrian physicians who treat COVID-19 patients. The inclusion criteria were all Syrian HCWs who treated COVID-19 patients during the current Omicron wave of COVID-19. The data was collected between April 3 and March 20, 2022. We investigated whether the questionnaire used was valid and understandable to the participants. A total of 729 health-care providers were inquired in our study; however, 30 participants were disqualified because their answers were not fully completed. The overall age of the participants was 31 ± 9, and the ratio of males to females was almost equal. The majority (47.5%) of the sample study's participants are residents, and 72.8% who cared for COVID-19 patients. The prevalence of high levels of burnout in the sample study was 41.6%. Compared to men (22.3%), women were much more likely (27.9%) to report experiencing a high degree of emotional exhaustion; also, the participants who cared for COVID-19 patients were much more likely (30.1%) to report experiencing a high degree of emotional exhaustion compared to others, which individuals who cared for COVID19 patients were 1.76 times more likely than participants who did not care for COVID19 patients to experience severe burnout (odds ratio: 1.766, 95% confidence interval:1.2-2.4, P value < .001). Our research found severe burnout among Syrian health-care providers during the omicron wave of COVID-19, with clinicians caring for COVID-19 patients being considerably more likely to express high burnout than others.

"They cannot afford to feed their children and the advice is to stay home. How‥?": A qualitative study of community experiences of COVID-19 response efforts across Syria

Introduction

COVID-19 highlighted the importance of meaningful engagement between communities and health authorities. This is particularly challenging in conflict-affected countries such as Syria, where social protection and food security needs can hinder adherence to non-pharmaceutical interventions (NPIs) and vaccine uptake. This study explored community perspectives of COVID-19 and health authority responses across the three main areas of control in Syria, i.e. Syrian government-controlled areas (GCA), autonomous administration-controlled areas (AACA), and opposition-controlled areas (OCA).

Methods

We conducted a qualitative study, interviewing 22 purposively-sampled Syrians accessing health services in AACA, GCA, or OCA in 2021 to provide approximately equal representation by governance area and gender. We analysed data thematically using deductive and inductive coding.

Findings

Interviewees in all areas described how their fears of COVID-19 and willingness to adhere to NPIs decreased as their local COVID-19 epidemics progressed and NPIs disrupted access to household essentials such as work and food. Community-level responses were minimal and ad hoc, so most people focused on personal or household protective efforts and many mentioned relying on their faith for comfort. Misinformation and vaccine hesitancy were common in all areas, linked to lack of transparency from and mistrust of local health authorities and information sources.

Conclusions

The COVID-19 pandemic has increased health actors’ need to engage with communities to control disease spread, yet most NPIs implemented in Syria were inappropriate and adherence decreased as the pandemic progressed. This was exemplified by lockdowns and requirements to self-isolate, despite precarious reliance on daily wages, no subsidies for lost income, individual self-reliance, and mistrust/weak communication between communities and health authorities. We found minimal community engagement efforts, consisting entirely of informing with no efforts to consult, involve, collaborate, or empower. This contributed to failures of health actors to contextualise interventions in ways that respected community understandings and needs.