Evidence map›Paper›PMID 39343439›Full record

Observational studyBMJ global health2024

Quantifying the effects of attacks on health facilities on health service use in Northwest Syria: a case time series study from 2017 to 2019.

Ryan Burbach, Hannah Tappis, Aula Abbara, Ahmad Albaik, Naser Almhawish, Leonard S Rubenstein, Mohamed Hamze, Antonio Gasparrini, Diana Rayes, Rohini J Haar

Abstract readObservational Study
PubMed Full text at PMC Publisher
In one paragraph

Observational study in BMJ global health, 2024. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 4 papers, 1 of them a synthesis that pooled it.

0numbers the graph read from it
0cells of the map it votes in
4citing papers in PubMed, 1 pooled it
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

4 citing papers in PubMed, 1 synthesis or guideline pooled it.

  1. Pooled it
  2. Article
  3. Article
  4. Article
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

10 authors.

Ryan BurbachLondon School of Hygiene & Tropical Medicine, London, UK.
Hannah TappisJohns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.ORCID http://orcid.org/0000-0002-4289-5418
Aula AbbaraInfectious Disease, Imperial College Healthcare NHS Trust, London, UK.ORCID http://orcid.org/0000-0002-7049-8399
Ahmad AlbaikSyrian American Medical Society, Washington, District of Columbia, USA.
Naser AlmhawishAssistance Coordination Unit, Gaziantep, Turkey.
Leonard S RubensteinCenter for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
Mohamed HamzeSyrian American Medical Society, Washington, District of Columbia, USA.
Antonio GasparriniPublic Health Environments and Society, London School of Hygiene and Tropical Medicine, London, UK.
Diana RayesJohns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
Rohini J HaarSchool of Public Health, Division of Epidemiology, University of California Berkeley, Berkeley, California, USA rohinihaar@berkeley.edu.ORCID http://orcid.org/0000-0002-9049-984X

Funding

Medical Research Council MR/R013349/1
6 · The paper itself

Abstract

backgroundThroughout the Syrian conflict, the Syrian government has intentionally attacked health facilities, violating International Humanitarian Law. Previous studies have qualitatively described health system disruptions following attacks on healthcare or established associations between armed conflict and health service utilisation, but there are no quantitative studies exploring the effects of health facility attacks. Our unprecedented study addresses this gap by quantifying the effects of health facility attacks on health service use during the Syrian conflict.

methodsThis retrospective observational study uses 18 537 reports capturing 2 826 627 consultations from 18 health facilities in northwest Syria and 69 attacks on these facilities. The novel study applies case time series design with a generalised non-linear model and stratification by facility type, attack mechanism and corroboration status.

resultsThe study found significant, negative associations between health facility attacks and outpatient, trauma and facility births. On average, a health facility attack was associated with 51% and 38% reductions in outpatient, RR 0.49 (95% CI 0.43 to 0.57) and trauma consultations, RR 0.62 (95% CI 0.53 to 0.72), the day after an attack, with significant reductions continuing for 37 and 20 days, respectively. Health facility attacks were associated with an average 23% reduction in facility births, the second day after an attack, RR 0.77 (95% CI 0.66 to 0.89), with significant reductions continuing for 42 days.

conclusionsAttacks on health facilities in northwest Syria are strongly associated with significant reductions in outpatient, trauma and facility births. These attacks exacerbate the adverse effects of armed conflict and impede the fundamental right to health. The findings provide evidence that attacks on health facilities, violations of international humanitarian law by themselves, also negatively affect human rights by limiting access to health services, underscoring the need to strengthen health system resilience in conflict settings, expand systematic reporting of attacks on healthcare and hold perpetrators accountable.

Indexed as

Armed ConflictsHealth FacilitiesPatient Acceptance of Health CareHumansRetrospective StudiesSyriaEpidemiologyPublic Health

Identifiers

PMID39343439
PMCPMC11474958

What OpenQuestion holds

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Registered trials

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.