The Lancet and the American University of Beirut (AUB) have launched the ‘Commission on Syria: Health in Conflict’ to raise the profile of the Syrian crisis in global health. The Commission also aims to provide concrete and evidence-informed recommendations addressing the health needs in Syria. Commissioners include thinkers, academics, researchers, and practitioners from multidisciplinary backgrounds. The first meeting of the Commission held in Beirut, Lebanon, in December 2016 convened commissioners, experts, stakeholders, faculty, students, and the Lancet leadership to define the scope of the work. Given the direct attacks on health care workers and the responsibilities of the international community to protect health care workers, “Health Care Workers in Conflict Areas” emerged as one of the priority themes [1,2].

The Commission invited the Center for Systematic Reviews in Health Policy and Systems Research (SPARK) to conduct a scoping review to identify and map the published evidence to support a policy paper addressing the status of health care workers from Syria. The policy paper has since been published under the title “Health professionals and the weaponisation of healthcare in Syria: A preliminary inquiry for the Lancet-AUB Commission on Syria” [3].

On March 2011, anti-government demonstrations began in Syria as part of what has been labeled as the “Arab Spring”. The civil war in Syria that started as merely peaceful demonstrations amid the regional Arab Uprising, has inflicted devastating losses on all levels and sectors including health [4,5]. According to the World Health Organization (WHO), Syria’s civil war has resulted in more than 250 000 deaths and displaced more than 4.8 millions [6]. Syria’s war has created the worst humanitarian and refugee crisis of our time [7,8].

Throughout the crisis, medical facilities and health care workers were being directly and deliberately targeted [9-11]. Physicians for Humans Rights has reported that, since the start of the conflict till September 2016, 782 medical personnel have been killed [9] and an inestimable number of medical professionals were threatened and detained. For example, Syrian authorities criminalized in 2012 the provision of health care to opposition fighters or supporters [12,13]. This contravened international humanitarian law rule that under no circumstances shall any person be punished for carrying out medical activities compatible with medical ethics, regardless of the person benefiting therefrom [13].

The attack on medical facilities and health workers and the lack of security led to an exodus of skilled health professionals [14]. By 2013, 70% of the health workforce had left the country, leaving enormous breach in practice [12,15]. For example, the Syrian American Medical Society (SAMS) reported that in 2014 only 20 doctors, including 2 vascular surgeons and one plastic surgeon, were remaining in Aleppo [16]. The shortage of medical professionals and the increased burden of war injuries led to worsening the quality of health care provided. In addition, medical students and pharmacists who are not fully qualified to provide health care had to provide care in absence of trained professionals [16]. All these traumatizing experiences subjected the medical personnel to psychological trauma, depression and burn out [15].

The objective of our study was to conduct a scoping review on health care workers in the setting of the Syrian conflict, addressing four topics of interest: violence against health care workers, education, practicing in conflict setting, and migration. Considering the likelihood of scarcity of data, we broadened the scope of the scoping review to include indirect evidence on health care workers from other countries affected by the “Arab Spring”.

We conducted a scoping review, which is typically used to present “a broad overview of the evidence pertaining to a topic, irrespective of study quality, to examine areas that are emerging, to clarify key concepts and to identify gaps” [17]. We followed Joanna Briggs Institute (JBI) guidelines for conducting and reporting scoping reviews [17]. Similarly, and for developing the evidence gap map, we relied on the results of a methodological review on these maps [18].

We developed a protocol for this scoping review following the PROSPERO format, which is available upon request from the corresponding author.

We searched the following electronic databases: MEDLINE, PubMed, EMBASE, Human Resources for Health (HRH) Global Resource Center, the World Health Organization (WHO) global Health Library and the Cochrane Central Register of Controlled Trials (CENTRAL). We ran for each of these databases separate searches for each of the countries of interest starting from the date that country was affected by the conflict, and up to January 12, 2017 (February 2, 2017 for CENTRAL).

We developed the search strategies with the help of an experienced librarian (see Appendix S1 in Online Supplementary Document for details of the search strategies). They included both index terms and free text words for the two following concepts: health care workers and the country of interest. When running the search, we ANDed the terms for these two concepts. We did not limit to specific languages, but limited to human studies. We also screened the reference lists of included studies.

In a first step, teams of two reviewers used the above eligibility criteria to screen titles and abstracts of identified citations for potential eligibility independently and in duplicate. We obtained the full text for citations judged as potentially eligible by at least one of the two reviewers. Next, teams of two reviewers screened in duplicate and independently the full texts for eligibility using standardized and pilot tested screening forms. They resolved disagreements by discussion and when needed with the help of a third reviewer. We conducted calibration exercises to ensure the validity of the selection process.

One reviewer abstracted data using standardized and pilot tested forms and another reviewer verified the abstracted data. Any disagreement between the initial abstractor and the verifier was resolved by discussion and when needed with the help of a third reviewer. We conducted calibration exercises to ensure the validity of the data abstraction process.

We abstracted from each paper the following information:

We conducted descriptive analysis of the general characteristics of the included papers. We graphically represented the annual production of papers by country. We presented a narrative summary of the key findings of the included studies categorized by themes (violence, migration, education and practice in conflict setting). We also used the results of this scoping review to build an evidence gap map. Evidence maps are defined as “a systematic search of a broad field to identify gaps in knowledge and/or future research needs”. These maps present results in a user-friendly format, often a visual figure or graph, cross-tables or a searchable database [18]. We planned to present the gaps by country, study design and topic.

Table 1 presents the characteristics of the included papers. The majority of the articles tackled the issue of violence against health care workers (63%). The first and corresponding authors were affiliated with institutions from non-Arab countries (79% and 79% respectively), mainly United Kingdom (UK) and United States (US). The top countries focus of the articles were Syria (35%), Iraq (33%) and Bahrain (29%). We identified no articles on Tunisia. News, editorials, commentaries and opinion pieces made up 81% of all included papers. Primary studies made up only 9% of the papers. The majority of articles (95%) were published in English.

As shown in Figure 2 , most articles were published in 2011 (N = 36). The publication of papers on Bahrain peaked in 2011 then decreased after 2012. For papers on Syria, the peak of publication was in 2013 then decreased to re-emerge in 2016. The trend of publication of papers on Iraq did not show major fluctuations over the years.

The articles were published across 39 journals. The top journals in which the included papers were published were the BMJ (33.3%), the Lancet (25.0%), Nursing Standard (5.9%), JAMA (3.7%), Deutsche Apotheker Zeitung (3.7%) and CMAJ (3%). The median impact factor of the 39 journals publishing the included articles was 19.967 (interquartile range = 19.967- 44.002).

Figure 3 presents the evidence gap map about health care from Syria and other “Arab Spring” Countries. It provides a visual overview of existing evidence across countries, study designs and subjects. The gap map shows that the primary studies identified in this review were conducted on Iraq across all the topics ( Figure 3 ). Most of the articles about violence against health care workers were on Bahrain, followed by Syria and Iraq. All the articles about violence in Bahrain and the majority of the articles about violence in Syria were news, editorials or correspondence articles.

We organized the key findings of the included papers by themes (education, migration, practice in conflict setting and violence). Table 2 presents the key findings of included studies. We presented the key findings narratively below: