{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,19]],"date-time":"2026-07-19T23:03:10Z","timestamp":1784502190540,"version":"3.55.0"},"reference-count":18,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2026,5,22]],"date-time":"2026-05-22T00:00:00Z","timestamp":1779408000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,7,20]],"date-time":"2026-07-20T00:00:00Z","timestamp":1784505600000},"content-version":"vor","delay-in-days":59,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"name":"Union of Medical Care and Relief Organizations-Canada"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Confl Health"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Thirteen years of conflict have profoundly disrupted Syria\u2019s health system. In northwest Syria, constraints such as deliberate attacks on healthcare, chronic underfunding, and a fragmented health system have created a fragile surgical ecosystem in which health workers operate under extreme resource constraints, patients struggle to access care, and postoperative complications are increasingly likely. In this study, we aim to assess the burden of postoperative complications by examining patient-reported outcomes and barriers to care while integrating this data with insights from health workers and non-governmental organization (NGO) stakeholders.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This mixed-methods study uses secondary data from a cross-sectional survey of 261 adult patients who underwent surgery in hospitals in northwest Syria. Firth\u2019s logistic regression was used to estimate adjusted odds of complications by surgery type. To contextualize these findings, a workshop engaged 31 surgeons, hospital administrators, and surgeons to identify perceived drivers of complications and prioritize interventions across the WHO health system building blocks.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Barriers to seeking postoperative follow-up care were reported by 57.5% of participants, with transportation, cost, appointment availability, and proximity among the most prevalent barriers. Trauma and orthopedic surgeries demonstrated notably higher odds of adverse outcomes. Workshop participants identified workforce shortages, surgeon rotation across hospitals, fragmented health information systems, and underfunded systems as factors perceived to be associated with these challenges. Workshop participants proposed interventions focused on expanding clinical training, strengthening infection prevention and control, improving provider\u2013patient communication, and establishing governance mechanisms that incentivize quality care.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Our findings illustrate how systemic vulnerabilities shaped outcomes for surgical patients and the surgical ecosystem in northwest Syria. Although data collection occurred during the Assad regime, the findings provide relevant insights for Syria\u2019s health system reconstruction, as addressing the identified challenges will be critical not only for strengthening the surgical ecosystem but also for supporting long-term recovery and resilience efforts.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s13031-026-00802-4","type":"journal-article","created":{"date-parts":[[2026,5,22]],"date-time":"2026-05-22T10:34:38Z","timestamp":1779446078000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Postoperative care in conflict-affected northwest Syria: a mixed-methods study assessing the perspectives of patients, health workers, and non-governmental organizations"],"prefix":"10.1186","volume":"20","author":[{"given":"Camila","family":"Polinori","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maia C.","family":"Tarnas","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kelli","family":"Wagner","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohammad","family":"Darwish","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefany M.","family":"Lazieh","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ahmad","family":"Alnasser","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ahmad","family":"Ghandour","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ismail","family":"Alkhatib","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Saverio","family":"Bellizzi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bara","family":"Zuhaili","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gilbert","family":"Burnham","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,5,22]]},"reference":[{"key":"802_CR1","doi-asserted-by":"publisher","unstructured":"Abbara A, Marzouk M, Mkhallalati H. (2021). Health system fragmentation and the Syrian conflict. In J. Bseiso, M. Hofman, & J. Whittall, editors, Everybody\u2019s War: The Politics of Aid in the Syria Crisis (Chap. 2, pp. 33\u201357). Oxford University Press. https:\/\/doi.org\/10.1093\/oso\/9780197514641.003.0003","DOI":"10.1093\/oso\/9780197514641.003.0003"},{"key":"802_CR2","doi-asserted-by":"publisher","unstructured":"Haar R, Rayes D, Tappis H, Rubenstein L, Rihawi A, Hamze M, Almhawish N, Wais R, Alahmad H, Burbach R, Abbara A. The cascading impacts of attacks on health in Syria: A qualitative study of health system and community impacts. PLOS Global Public Health. 2024;4(6). https:\/\/doi.org\/10.1371\/journal.pgph.0002967. Article e0002967.","DOI":"10.1371\/journal.pgph.0002967"},{"key":"802_CR3","unstructured":"United Nations Syria. (2024). 2024 UN country results report \u2013 Syrian Arab Republic. United Nations. https:\/\/syria.un.org\/sites\/default\/files\/remote-resources\/33d19682cc97050012d0145da64b8088.pdf"},{"issue":"1","key":"802_CR4","doi-asserted-by":"publisher","first-page":"111","DOI":"10.1186\/s12992-021-00762-9","volume":"17","author":"MHDBA Alhaffar","year":"2021","unstructured":"Alhaffar MHDBA, Janos S. Public health consequences after ten years of the Syrian crisis: A literature review. Globalization Health. 2021;17(1):111. https:\/\/doi.org\/10.1186\/s12992-021-00762-9.","journal-title":"Globalization Health"},{"key":"802_CR5","unstructured":"United Nations Office for the Coordination of Humanitarian Affairs. (2024). Syrian Arab Republic annual report 2023: Humanitarian response, January\u2013December 2023. OCHA. https:\/\/www.unocha.org\/publications\/report\/syrian-arab-republic\/syrian-arab-republic-annual-report-2023-humanitarian-response-january-december-2023"},{"issue":"1","key":"802_CR6","doi-asserted-by":"publisher","first-page":"44","DOI":"10.1186\/s13031-020-00287-9","volume":"14","author":"Y Bdaiwi","year":"2020","unstructured":"Bdaiwi Y, Rayes D, Sabouni A, Murad L, Fouad F, Zakaria W, Hariri M, Ekzayez A, Tarakji A, Abbara A. Challenges of providing healthcare worker education and training in protracted conflict: A focus on non-government controlled areas in northwest Syria. Confl Health. 2020;14(1):44. https:\/\/doi.org\/10.1186\/s13031-020-00287-9.","journal-title":"Confl Health"},{"issue":"10306","key":"802_CR7","doi-asserted-by":"publisher","first-page":"123","DOI":"10.1016\/S0140-6736(25)00406-4","volume":"405","author":"M Alkhalil","year":"2025","unstructured":"Alkhalil M, Abdallah AJ, Alhaffar MHDBA, Abbara A. Rebuilding trust and equity in Syria\u2019s health system: a governance agenda. Lancet. 2025;405(10306):123\u20135. https:\/\/doi.org\/10.1016\/S0140-6736(25)00406-4.","journal-title":"Lancet"},{"issue":"2","key":"802_CR8","doi-asserted-by":"publisher","first-page":"e0004116","DOI":"10.1371\/journal.pgph.0004116","volume":"5","author":"A Khan","year":"2025","unstructured":"Khan A, Ammar U, Abbara A, Hariri M, Darwish A, Alawa J. Peripheral extremity surgery performed during the Syrian conflict \u2013 a scoping review. PLOS Global Public Health. 2025;5(2):e0004116. https:\/\/doi.org\/10.1371\/journal.pgph.0004116.","journal-title":"PLOS Global Public Health"},{"issue":"1","key":"802_CR9","doi-asserted-by":"publisher","first-page":"e001236","DOI":"10.1136\/bmjph-2024-001236","volume":"3","author":"SM Lazieh","year":"2025","unstructured":"Lazieh SM, Tarnas MC, Wagner K, Alkhatib I, Polinori C, Netfagi M, Ghandour A, Qaddour S, Zuhaili B, Burnham G. Healthcare workers\u2019 perceptions of postoperative care and implementation challenges in conflict-affected northwest Syria: a mixed-methods analysis. BMJ Public Health. 2025c;3(1):e001236. https:\/\/doi.org\/10.1136\/bmjph-2024-001236.","journal-title":"BMJ Public Health"},{"issue":"2","key":"802_CR10","doi-asserted-by":"publisher","first-page":"205213","DOI":"10.1097\/01.sla.0000133083.54934.ae","volume":"240","author":"D Dindo","year":"2004","unstructured":"Dindo D, Demartines N, Clavien P. Classification of surgical complications. Ann Surg. 2004;240(2):205213. https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC1360123\/.","journal-title":"Ann Surg"},{"key":"802_CR11","unstructured":"De Savigny D, Adam T, editors. (2009). Systems thinking for health systems strengthening. Alliance for Health Policy and Systems Research, World Health Organization. https:\/\/iris.who.int\/handle\/10665\/44204"},{"key":"802_CR12","doi-asserted-by":"publisher","DOI":"10.1016\/s0140-6736(25)00265-x","author":"S Marzouk","year":"2025","unstructured":"Marzouk S, Nasari A, Spiegel PB. Syria\u2019s health crisis transition: challenges and opportunities. Lancet. 2025. https:\/\/doi.org\/10.1016\/s0140-6736(25)00265-x.","journal-title":"Lancet"},{"issue":"6","key":"802_CR13","doi-asserted-by":"publisher","first-page":"e0002967","DOI":"10.1371\/journal.pgph.0002967","volume":"4","author":"R Haar","year":"2024","unstructured":"Haar R, Rayes D, Tappis H, Rubenstein L, Rihawi A, Hamze M, Almhawish N, Wais R, Alahmad H, Burbach R, Abbara A. The cascading impacts of attacks on health in Syria: A qualitative study of health system and community impacts. PLOS Global Public Health. 2024;4(6):e0002967\u20130002967. https:\/\/doi.org\/10.1371\/journal.pgph.0002967.","journal-title":"PLOS Global Public Health"},{"issue":"9","key":"802_CR14","doi-asserted-by":"publisher","first-page":"815","DOI":"10.1001\/jamasurg.2016.1297","volume":"151","author":"H Mowafi","year":"2016","unstructured":"Mowafi H, Hariri M, Alnahhas H, Ludwig E, Allodami T, Mahameed B, Koly JK, Aldbis A, Saqqur M, Zhang B, Al-Kassem A. Results of a Nationwide Capacity Survey of Hospitals Providing Trauma Care in War-Affected Syria. JAMA Surg. 2016;151(9):815. https:\/\/doi.org\/10.1001\/jamasurg.2016.1297.","journal-title":"JAMA Surg"},{"issue":"2","key":"802_CR15","doi-asserted-by":"publisher","first-page":"e0004116","DOI":"10.1371\/journal.pgph.0004116","volume":"5","author":"A Khan","year":"2025","unstructured":"Khan A, Ammar U, Abbara A, Hariri M, Darwish A, Alawa J. Peripheral extremity surgery performed during the Syrian conflict \u2013 A scoping review. PLOS Global Public Health. 2025;5(2):e0004116\u20130004116. https:\/\/doi.org\/10.1371\/journal.pgph.0004116.","journal-title":"PLOS Global Public Health"},{"key":"802_CR16","doi-asserted-by":"publisher","unstructured":"Trelles M, Dominguez L, Tayler-Smith K, Kisswani K, Zerboni A, Vandenborre T, Dallatomasina S, Rahmoun A, Ferir M-C. Providing surgery in a war-torn context: the M\u00e9decins Sans Fronti\u00e8res experience in Syria. Confl Health. 2015;9(1). https:\/\/doi.org\/10.1186\/s13031-015-0064-3.","DOI":"10.1186\/s13031-015-0064-3"},{"key":"802_CR17","doi-asserted-by":"publisher","first-page":"109308","DOI":"10.1016\/j.surg.2025.109308","volume":"181","author":"K Garber","year":"2025","unstructured":"Garber K, Dicker R, Guo WA, Jawa RS, Linchevskyy O, Brahmbhatt TS, Buhavac M, Gaarder C. Preparing for the unthinkable: A call for trauma system preparedness in conflict-vulnerable settings. Surgery. 2025;181:109308. https:\/\/doi.org\/10.1016\/j.surg.2025.109308.","journal-title":"Surgery"},{"key":"802_CR18","doi-asserted-by":"publisher","unstructured":"Ladadwa R, Hariri M, Alatras MM, Elferruh Y, Ramadan A, Dowah M, Bawaneh YM, Aljerk W, Patel P, Ekzayez A, Achi NE. Health information management systems and practices in conflict-affected settings: the case of northwest Syria. Globalization Health. 2024;20(1). https:\/\/doi.org\/10.1186\/s12992-024-01052-w.","DOI":"10.1186\/s12992-024-01052-w"}],"container-title":["Conflict and Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s13031-026-00802-4","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s13031-026-00802-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s13031-026-00802-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,19]],"date-time":"2026-07-19T22:56:04Z","timestamp":1784501764000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1186\/s13031-026-00802-4"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,22]]},"references-count":18,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,12]]}},"alternative-id":["802"],"URL":"https:\/\/doi.org\/10.1186\/s13031-026-00802-4","relation":{},"ISSN":["1752-1505"],"issn-type":[{"value":"1752-1505","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,22]]},"assertion":[{"value":"1 October 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"29 April 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"22 May 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"This project was deemed exempt by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board (#24730) as it did not qualify as human subjects research.","order":1,"name":"Ethics","label":"Ethics approval and consent participate","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Not applicable.","order":2,"name":"Ethics","label":"Consent for publication","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The authors declare no competing interests.","order":3,"name":"Ethics","label":"Competing interests","group":{"name":"EthicsHeading","label":"Declarations"}}],"article-number":"65"}}