Community engagement and adherence to COVID-19 prevention measures in Northwest Syria: a systematic review

ABSTRACT The COVID-19 pandemic has increased the burden on the collapsing health system in northwest Syria. The situation was exacerbated by the low rates of adherence to preventive measures and acceptance of the COVID-19 vaccine. In this study, we systematically analysed studies related to Risk Communication and Community Engagement programs, and community awareness in northwest Syria in order to determine the most widespread prevention methods, the community’s perspectives and knowledge of epidemic prevention, and the factors that prevent effective community engagement and uptake of COVID-19 prevention precautions in an area that has been suffering from the scourge of conflict for more than ten years. Based on the research findings, low adherence to COVID-19 prevention measures is mainly due to external factors related to socioeconomic status, scarcity of resources, and poor living conditions. Therefore, this study suggested that integrated multi-sectoral humanitarian programs that address these factors holistically are more effective than solely public health interventions in involving the community to become an active part of the Risk Communication and Community Engagement programs and ensuring their effectiveness.


Introduction
On 11 March 2020, the World Health Organization (WHO) declared a coronavirus disease 2019 (COVID-19) pandemic (Polack et al. 2020). After two years, the ongoing pandemic is severely straining healthcare systems across the world (Kotlar et al. 2021). Even the wealthiest and most stable societies have been unable to avoid severe problems and consequences (Lal et al. 2021). Implementing prevention measures and securing public compliance have been challenging (Abeya et al. 2021). Countries facing pre-existing crises, such as Syria, have struggled even more (Douedari et al. 2020). Governments around the world have developed response strategies to counter the risk of the spread of COVID-19 and its consequences for the health system (Yan et al. 2020). In the case of northwest Syria (NWS), where there is no legitimate governance structure to lead the response strategy , the health cluster for humanitarian response led the process to develop the COVID-19 Preparedness and Response Plan PRP which was endorsed by the World Health Organization -Gaziantep office and issued in March 2020. The PRP consisted of 9 pillars, including the Risk Communication and Community Engagement RCCE pillar (OCHA 2020;Brennan, Hajjeh, and Al-Mandhari 2020;WHO 2020). Leadership and governance of an effective intervention through a robust health system is pivotal to achieving the strategic objective of a response plan (Sagan et al. 2021). However, this was an issue of concern in the case of NWS because of the fragmented health system and poor socioeconomic conditions. (Douedari and Howard 2019).
Infection prevention interventions to control the spread of COVID-19 include covering the nose and mouth with face masks to contain respiratory secretions, early identification and isolation of suspected cases, environmental disinfection, hand hygiene, social distancing, and using personal protective equipment (PPE) like eye or face protection (Bazant and Bush 2021;Park 2020;Abramowicz et al. 2020). Assessing community adherence to prevention strategies can be measured following three themes; exploring the context-specific available prevention measures, identifying the population's knowledge about these measures, and identifying factors that might hinder compliance with preventive measures (Yapi et al. 2021). Implementation of prevention strategies requires adequate awareness among the people and the realization of appropriate public health regulations in order to follow up compliance with prevention recommendations (Amir, Dulebenets, and Goniewicz 2021;SoleimanvandiAzar et al. 2021). Applying these measures in conflict and emergency settings, such as NWS, might be difficult for several reasons, including health system collapse, a deterioration in socioeconomic conditions, inequitable access to health services, and a shift in priorities to the short-term and life-saving model of medical care (Hick et al. 2021;Al-Abdulla and Alaref 2022). In Bangladesh, for example, it was found that government instability and a fragile health system were associated with increased community transmission and limited implementation of COVID-19 prevention measures (Shammi et al. 2020;Bodrud-Doza et al. 2020). A study by Douedari et al. of perceptions and response to the COVID-19 outbreak in NWS established evidence of the association between the poor socioeconomic conditions, protracted crisis, war-related trauma experienced by people, and a failure of community engagement and risk communication programs (Douedari et al. 2020).
The spread of SARS-COV-2 in NWS since July 2020 has increased the burden on the dilapidated health system (Almhawish et al. 2021). The health system in Syria has been facing enormous challenges since the start of the conflict in 2011. Internal displacement, overcrowding, poverty, and a deterioration in socioeconomic status have been overwhelming the health system for more than ten years of conflict (Fouad et al. 2017). NWS refers to the territories in Idleb and Aleppo governorates controlled by opposition armed groups (Blanchard, Humud, and Nikitin 2014). The political instability in NWS resulted in the fragmentation of the health system in the region, whereby the Syrian Interim Government (SIG) and provincial health directorates partially control the governance system in the north, and the Syrian Salvation Government (SSG), which is affiliated with Hay'at Tahrir al-Sham HTS (Al-Nusra Front or Jabhat al-Nusra) control governance in the west (Bdaiwi et al. 2020;Navvar 2020). With the increased number of Internally Displaced Persons (IDPs), poor living conditions, lack of resources, and livelihood challenges, many studies have predicted catastrophic scenarios as a result of the spread of COVID-19 in inequitable contexts of low-income countries such as Syria (Saalim et al. 2021;Ekzayez et al. 2020). The COVID-19 epidemic poses particularly serious challenges in a war-torn country like Syria due to the fragile health system and socioeconomic deterioration (Douedari and Howard 2019;Gharibah and Zaki 2020). Moreover, the low-income levels and unhygienic conditions make it impossible to adhere to the prevention measures and precautions, especially in crowded settlement settings like camps (OCHA 2021). Despite the resources invested in the COVID-19 outbreak response, community engagement programs were ineffective in improving communities' response and adherence to preventive measures. If there was a failure in implementing COVID-19 PRP in NWS, it was at the level of community engagement, not the medical, operational, or technical level (Douedari et al. 2020). Multiple surveys have been carried out to investigate the attitudes and perspectives towards COVID-19 prevention measures and how they reflect on prevalence among the population (Marzouk et al. 2022). COVID-19 prevention measures include improved hygiene, social distancing, wearing face masks, home health care programs, and vaccination programs (Güner, Hasanoğlu, and Aktaş 2020;Fathollahi-Fard, Ahmadi, and Karimi 2021;Pedersen and Favero 2020;Sarah, Pudalov, and Fu 2020). By the time of writing this paper (29 December 2021), the region of NWS has witnessed three waves of COVID-19 with a total of 92,944 detected cases, 2316 deaths, and with only 2.85% of the population fully vaccinated (at least two doses of COVID-19 vaccine) (WHO 2021). Despite the coordination led by the health cluster and WHO in Syria in general, the transmission of the SARS-COV-2 virus in the communities was very high for multiple reasons, including the failure to detect COVID-19, a poor surveillance system, weak community participation and engagement, a collapsed health system, a deterioration in the humanitarian and socio-economic situation, and the low level of community adherence to prevention measures (WHO 2021a).

Research objective
This paper aims to study the existing literature regarding risk communication and community engagement in NWS to provide a systematic analysis and understanding of the community uptake of precautionary measures and health-seeking behaviours and the existing factors that prevent an efficient community engagement and adherence to these measures in NWS, including in COVID-19 vaccine uptake. Later we make specific recommendations as a result of our findings to overcome these obstacles.

Search strategy
Electronic databases, including Google, PubMed, and the ReliefWeb Syria website (https://reliefweb.int/country/syr) were searched using specific keywords and terms related to the research topic: 'COVID-19', 'prevention', 'risk communication', 'community engagement', and 'northwest Syria', and all possible combinations. The present review was performed based on Preferred Reporting Items for the Systematic Review and Meta-Analysis (PRISMA) statement ( Figure 1) (Moher et al. 2016).

Inclusion criteria
We retrieved published articles and studies that included community engagement and prevention measures in NWS. Because the available literature on COVID-19 outbreak response and preparedness in NWS is limited, we had to extend our inclusion criteria to involve, besides academic articles, humanitarian reports related to COVID-19 prevention and community engagement in NWS. No date restrictions were applied.

Exclusion criteria
Non-English language publications were excluded. Additionally, online data published in a format that was not part of a report or research article structure were excluded. Articles and research publications that lacked evidence of NWS population inclusion and did not take into account the geopolitical dimensions of the crisis in Syria were excluded.

Study selection
The authors performed title-abstract screening on all studies identified (after removing duplicates), then the full text of the selected articles and reports were reviewed thoroughly. In cases of similar research studies, academic research articles with Digital Object Identifier were considered. After screening the identified publications, only eight Records identified from: Databases (n = 52) Registers (n = 44) Records removed before screening: Duplicate records removed (n = 5) Records removed for other reasons (n = 3)

Identification of studies via databases and registers Identification
Records screened title-abstract (n = 44) Records excluded: (n = 11) Records assessed for eligibilityfull text (n = 33) Records excluded (n = 25): Reason 1: did not report sufficient details on the COVID-19 preventive measures and KAP among the population. Reason 2: did not report original data (e.g. UN reports). Reason 3: did not provide evidence of considering the context of NWS. publications were considered eligible for the systematic review (Douedari et al. 2020;Ekzayez et al. 2020;Said 2020;Shibani et al. 2021;Mohsen et al. 2021; REACH Initiative 2020a; Jammoul and Altaleb 2020; .

Data extraction and analysis
Following the selection of publications, the extracted data were categorized into three themes: i) information about COVID-19 available prevention measures; ii) Knowledge, Attitudes, and Practices (KAP) among the population regarding COVID-19 prevention measures, barriers; and iii) constraints that prevent community engagement and use of these measures. Thematic analysis of the data was performed later.

Results
The initial search yielded 52 published articles, studies, and reports. However, only eight published articles and reports were considered eligible for review (Table 1). While several published studies addressed the topic of interest, they were excluded because they either did not include clear evidence of considering the geopolitics of NWS or were not specific to the context. The majority of the identified publications did not report original data (e.g. United Nations UN reports and Gaziantep health cluster bulletins).

Available COVID-19 prevention measures in NWS
According to the reviewed studies and reports, the prevention measures in NWS (defined in Table 2) varied from global measures to context-specific measures. All the studies mentioned wearing face masks, handwashing and hygienic precautions, and public awareness campaigns as the most common measures in NWS. Four studies discussed social distancing as one of the applicable prevention measures but without detailed figures about its prevalence among the population. However, one of the studies discussed social distancing as not being a feasible method of prevention in the context of NWS due to crowded households, attitudes towards the risk of the virus compared with living requirements, and what the life and work circumstances dictate as possible to do (Douedari et al. 2020). One study mentioned disinfection campaigns as a means of prevention without further figures or discussion on its feasibility and effectiveness in the context of NWS . Isolation, quarantine, lockdown and curfews, and control of border and crossing points appeared less frequently in the reviewed publications.

KAP among the population regarding COVID-19 prevention measures
The most common prevention measures in NWS were using face masks, applying hygienic measures such as hand washing, and public health awareness campaigns. The reviewed studies did not report exact figures regarding wearing face masks (range: 15% − 35%, average 25%). While not all the studies reported values on the prevalence of hygienic measures among the population, the average ratio of adhering to hygiene precautions such as hand washing was 25% based on data reported by a few of the reviewed studies. Detailed figures about social distancing were not discussed in any of the selected studies. Public health awareness campaigns were among the most prevalent measures in NWS besides face masks. The studies showed that the majority of people in NWS are aware of the outbreak, disease risk, and prevention measures. Four studies discussed the people's perspectives on the importance of prevention measures to prevent infection. One of these studies showed that 48.9% of people know the benefits of face masks to limit the spread of the virus (Jammoul and Altaleb 2020). Findings of another research concluded that there was a fair level of awareness (70.7%) regarding COVID-19 transmission pathways, and 88.8% of people are aware of the prevention practices, such as washing hands, avoiding crowds, home isolation, and wearing face masks (Mohsen et al. 2021). A survey report by REACH Initiative showed that 64% of people mentioned that they had undertaken prevention measures to mitigate the risk of the virus (REACH Initiative 2020a). According to one of the reports, the most common source of information regarding COVID-19 was community health programs, relatives and family, and social media. The same report has addressed isolation through the COVID-19 Community Treatment Centers (CCTCs) in NWS. Despite the high awareness rate about the epidemic, the report showed that only 19% of those diagnosed with COVID-19 accepted isolation in one of the CCTCs in NWS  . Lockdown and curfew were discussed in one of the research articles. The article concluded that they are ineffective prevention measures in the emergency context of NWS, in which it would be challenging to enforce these measures among the population (Douedari et al. 2020).

Constraints that prevent community engagement and uptake of precautionary measures
The eight selected studies discussed the reasons preventing effective community engagement and adherence to the precautionary recommendations in NWS. The most apparent reasons were the deterioration in socioeconomic conditions, poor living conditions such as household overcrowding, poor hygienic conditions, including waste management and insufficient water, the stigma of wearing face masks, and lack of conviction of the risk of the disease and the importance of the prevention measures. The average ratios of the constraints that prevent community engagement and uptake of precautionary measures are shown in Table 3.

Low levels of COVID-19 vaccine uptake
Only one of the studies discussed the communities' perspectives and attitudes towards the COVID-19 vaccine in NWS. Presenting disturbing figures regarding the people's perspectives on the vaccine, the report showed that Table 3. Reasons, details and ratios that prevent community engagement and uptake of precautionary measures according to KAP surveys and questionnaires.
Reasons that prevent community engagement and uptake of precautionary measures Details Average ratio Deterioration in socioeconomic conditions and the lack of sources of income Due to poor socioeconomic conditions, people are not able to follow isolation or social distancing recommendations because that will limit their access to their daily source of income 43.9%

Stigma
Hesitating to wear face masks because of community pressures and fear that others will think that the person is infected 13.4% Lack of conviction People do not believe that COVID-19 is a lifethreatening disease and think it could be a conspiracy for financial purposes or against their beliefs, culture, and norms.

7.5%
Poor hygiene conditions, including waste management and insufficient water Following hygiene precautions is difficult because of overcrowding and the lack of resources, such as clean water and hygiene materials.

50.0%
Poor living conditions (household overcrowding) Overcrowded households prevent people from following social distancing and quarantine measures.

50.0%
only 37% of the population would accept to receive the vaccine. 32% of the people completely rejected the idea of the vaccine, and 31% were hesitant. The main reasons behind the low level of acceptance were related to the lack of confidence in the vaccine, fear of experiencing side effects, and the conspiracy theory that the disease was created by vaccine manufacturing companies to market their products (Shibani et al. 2021).

Discussion
Our study was carried out to understand the community perspectives on COVID-19 outbreak risks and prevention and the factors that impede RCCE programs and adherence to public health precautions. A systematic review of eight research articles and reports was undertaken according to PRISMA statement. Thematic analysis of available prevention measures, population KAP regarding the COVID-19 outbreak, and challenges to effective community engagement was performed.
In March 2020, WHO Gaziantep for Syria Crisis Response activated the Risk Communication and Community Engagement (RCCE) Group to engage communities and communicate essential risks and information relevant to COVID-19 (OCHA 2020). However, the overall adherence to COVID-19 preventive measures in NWS was low. Many challenges hinder the community's capacity to respond to COVID-19 risks, including overcrowding, weak health infrastructure, and deteriorating socioeconomic status (Pascual-Garciá et al. 2021). In conflict zones, many unpredictable socio-economic, cultural, and environmental factors make the population less willing or unable to follow the prevention protocols. The protracted violence has negatively affected the mental and physical resilience of the people in Syria. People cannot stay home and practice social distancing because their livelihood is dependent on going out to work. Poor health and inadequate nutrition are commonplace in NWS. The hope for an ordinary life has eroded during the years of war (Gharibah and Zaki 2020).
Two months after the first confirmed COVID-19 case in NWS, almost 63% of people reported that they had undertaken preventive measures to mitigate the risk of contracting COVID-19. The most common practices were using a face mask, washing hands, disinfecting objects and surfaces, and avoiding crowds. Notably, praying was considered a prevention measure by 14% of people in NWS. Different kinds of myths about prevention measures were circulating among the population. The most common myth was that to drink or eat certain foods or be exposed to high temperatures would prevent infection (REACH Initiative 2020b).
From the research results, it was clear that people are aware of the disease, paths of contamination, and prevention measures. Nevertheless, the findings showed that fewer people are interested or engaged in the precaution recommendations. One of the studies found that while 78% of people confirmed that they would move to a CCTC if they were infected, only 19% of people who were infected moved to CCTCs . Furthermore, the data from the NWS COVID-19 dashboard (WHO 2021) show low occupancy rates since the spread of the outbreak in NWS. In addition, the selected studies showed low rates of many prevention measures among the population, specifically, social distancing, lockdown, and isolation. These measures impose an interruption in work and livelihoods and thus affect sources of income. The consequences of these measures will primarily be on socioeconomic conditions (Koren and Pető 2020). In protracted emergencies, such as in NWS, where the socio-economic conditions are dire, these measures seem inapplicable.
In spite of its low prevalence (35%), wearing face masks seems to be among the most common and acceptable methods of prevention in emergency settings, such as NWS. This statement was confirmed by multiple essays and articles (OCHA 2021;WHO 2021b). The impact of face masks on COVID-19 dynamics was evidenced in many studies (Howard et al. 2021;Chu et al. 2020;Al-Abdulla et al. 2021).
During outbreaks and pandemics, some prevention rules cannot be expected to be followed without government laws and procedures in place that require these rules to be applied (Bernadette et al. 2021). In the case of NWS, this is almost impossible due to the weakness or absence of a legitimate administrative government structure. The fragmented government structure in NWS played a role in hindering the coordination and implementation of RCCE programs, especially in Idleb where SSG has exploited the pandemic and used it as a political tool to secure international recognition and gain legitimacy (Furlan 2020). Moreover, among the population, neither of the governments is trusted to be capable of handling the COVID-19 crisis and providing efficient prevention or disease control. Both institutions were considered participants in the armed conflict, and their reputation was damaged by corruption, violent policies, and the inability to fulfil their government responsibilities (Beaujouan, El Hafi, and Ghreiz 2021). In conjunction with the complex political situation, the health system in Syria has been severely affected by the conflict and violence (Kallström et al. 2022). With high-density rates of displaced people, lack of resources, and economic collapse, the outbreak has had a devastating impact on the fragile health system in NWS , which is maintained currently through the support of the UN agencies (e.g. WHO) and Non-Governmental Organizations (NGOs) (Bdaiwi et al. 2020). The devastating state of the health system in NWS has prevented an effective collection and use of information about the pandemic in order to evaluate and develop context-specific response plans.
The thematic analysis showed that external factors, which are related to the deterioration of humanitarian conditions in NWS, were the main reasons influencing effective community engagement. Fear of losing the source of income and poor living and hygiene conditions were the main factors that prevented community uptake of COVID-19 prevention measures. These factors were stated by the majority of the respondents according to the results of the selected articles. These findings are logical in communities that have been suffering from the scourge of war for more than ten years. Stigma, lack of conviction and internal factors were less frequently reported.
The selected studies did not provide rigorous evidence of the communities' perspectives and acceptance of the COVID-19 vaccine. The amount, reliability, and credibility of data related to KAP and the challenges of the COVID-19 vaccination campaigns in NWS were not sufficient to be analysed and interpreted in this study.

Conclusion
In this systematic review, we investigated the existing articles and reports on RCCE in NWS to provide academic evidence on the current KAP and factors that prevent the population from adhering to COVID-19 prevention measures, in order to arrive at context-specific recommendations to deal with these factors.
The findings of our study revealed that the external factors of socioeconomic status, lack of income and resources, and poor living and hygiene conditions significantly contribute to preventing people from following precautionary measures. These factors are mainly related to the deterioration in humanitarian conditions in NWS. Moreover, these factors are not solely specific to public health, meaning that a coordinated multi-sectoral intervention with considerable resource mobilization is required to efficiently address these challenges.
While the underlying factors behind the low level of adherence to COVID-19 prevention measures are identified through several studies in the region, the response mechanism to address these factors, which is of high importance in improving the outbreak control in a war-torn country such as Syria, was not researched. The research findings pose questions about the efficiency of public health awareness and community engagement programs. Although the majority of people in NWS have good knowledge about outbreak risk and prevention, the levels of adherence to precautionary measures were low. These findings reflect indifference among the population to the risk of the disease. It could be said that carelessness to the risk of disease in NWS is due to years of experiencing poor socio-economic conditions, fear of death, displacement, suffering, and loss of faith in a better future. Therefore, COVID-19 response in protracted emergencies must not be merely the delivery of medical services. Health-integrated mental health and psychosocial support, cash-based interventions, non-food items distribution, and shelter programs are critical not only to address the needs but also to engage the community in becoming an active part of the RCCE programs and ensuring their effectiveness.
Information about COVID-19 vaccination strategies, community acceptance, and challenges is scarce. In fact, the lack of academic publications complicated the systematic analysis of community engagement and uptake of COVID-19 prevention measures. This proves the need for further research on the COVID-19 outbreak in NWS. Specifically, more academic context-specific studies on community engagement challenges, best practices, and vaccine uptake are essential to evaluate and develop effective response and control strategies in protracted emergency settings.