“Ten years of crisis, repeated attacks on health care, death and displacement of health-care workers, and an increase in hostilities towards the end of 2019 have all posed significant challenges for the ability of the health system in northwest Syria to respond to COVID-19,” says Dr Mohamed Altwaish, a dentist by training who serves as Public Health Coordinator for Hand in Hand for Aid and Development (HIHFAD), a WHO implementing partner in northwest Syria.

Since the first cases were identified on 9 July, COVID-19 has disproportionately impacted health-care workers, who comprise 23 (43%) of all 54 identified cases reported by WHO. This has placed significant pressure on the already fragmented health infrastructure across the region (nearly 30% of health facilities are considered nonfunctional), including in Idleb and Aleppo governorates, which have been strained by years of crisis.

He stresses the critical work spearheaded by local health-care workers to mobilize COVID-19 preparedness and response efforts in collaboration with the WHO Emergency Field Programme in Gaziantep, Turkey, and the coordination of the Turkey Hub Health Cluster’s COVID-19 Taskforce, established in March 2020.

“Even before there were cases identified in northwest Syria, health-care workers were technically and logistically mobilizing local response efforts to combat COVID-19,” says Dr Altwaish. HIHFAD worked closely with WHO to establish isolation and treatment centres for suspected cases of COVID-19, ensure access to proper personal protective equipment for health-care workers across health facilities, and scale up training for community health workers to disseminate public health advice.

Leading training efforts for community health workers is another of Dr Altwaish’s roles. “I provide 1-day trainings for community health workers to engage local communities in COVID-19 prevention efforts as well as provide them with the skills to train other non-medical staff in how to distribute and disseminate these messages.”

Health-care workers have played a vital role in fostering community awareness of the growing threat of COVID-19, which has been one of the most challenging parts of the preparedness and response effort in northwest Syria.

“Health-care workers have struggled a lot to gain the acceptance of the local community, particularly in wearing masks and practising social distancing,” Dr Altwaish says. “Stigma was an issue from the beginning, particularly when the first case was identified among a member of the health-care workforce. Individuals started to assume that if you are a health-care worker, then you must have COVID-19.” He emphasizes the resulting psychological stress and pressure on the health-care workers to ensure the safety of their patients while continuing to provide essential services.

The protection of health-care workers continues to be a priority for WHO and local implementing partners in northwest Syria. Attacks on health care – a hallmark of the conflict in Syria – have brought the number of health facilities down further and deprived civilians of basic access to medical care. Now, with COVID-19 on the rise, stigma and barriers to care have added new challenges for the health-care workforce.

“When a fellow member of the health-care workforce tested positive for COVID-19, the event was an alert to the entire community in northwest Syria to better prepare and plan and avoid this in the future.”

How does a better understanding of masculinity help us to create better mental health policies? How does a culture-centred approach to health literacy improve knowledge about sexual and reproductive health among Iranian and Afghan minority groups in Sweden? And why don’t enough people in Romania get vaccinated?

Behavioural and cultural insights are still relatively underutilized in global health. By drawing on fields outside of medicine such as the social sciences and health humanities (including anthropology, history, sociology and psychology), it is possible to develop more effective health interventions.

“Recognizing and understanding the rich and diverse social, cultural, political and historical dimensions that affect health in the WHO European Region is essential to provide actionable support to countries that is tailored to their needs,” said WHO Regional Director for Europe Dr Hans Henri P. Kluge. “The Insights Unit will help health authorities to improve how their services meet citizens’ expectations – delivering respectful and people-centred care,” he concluded.

A new unit at WHO/Europe

Recognizing that, in terms of health policies, a one-size-fits-all approach is not always the most effective, WHO/Europe identified behavioural and cultural insights as a flagship area for the Region in the coming years. It established the Insights Unit to collaborate with partners and across sectors, academic disciplines and technical areas. The Unit is guided by 4 key principles:

• evidence – draw on evidence, test and evaluate it, and disseminate good practices;
• context – generate socially nuanced, culturally sensitive, people-centred health insights;
• scale – support the scale-up of interventions with proven impact; and
• partnership – work with experts, transformers, colleagues and critics.

The Unit works to identify barriers to and drivers of healthy practices. There is ample opportunity to encourage national health programmes and health authorities to use these insights to design more effective health interventions by ensuring they are relevant to their populations.

Behavioural and cultural insights in practice

Across the European Region, there are many cases of behavioural and cultural insights being used in practice.

For example, Kyrgyzstan has experienced measles outbreaks among internal migrants with low vaccination rates. Research to identify the reasons behind these low rates showed that a legislative barrier faced by people migrating from rural to urban areas was preventing them from getting routine vaccinations – an issue that could be changed to improve vaccination coverage and prevent measles.

High rates of cervical cancer incidence and mortality in Romania also reveal how cultural contexts impact health behaviours. Historical and ethnographic research has looked at the lasting legacy of pronatalist policies introduced during the Ceaușescu regime (1966–1989) and how associations with these policies have led to considerable stigma against cervical cancer screening and human papillomavirus (HPV) vaccination. People-centred health promotion efforts that acknowledge this historical stigma are needed if policies are to succeed in bringing down cervical cancer rates in Romania.

Another example is WHO/Europe’s ongoing work to support Member States across the Region to conduct behavioural insights studies in the context of COVID-19. Knowledge about the public’s fears and worries, levels of trust and risk perceptions, as well as their views on restrictions, testing and tracing, and a future COVID-19 vaccine, helps governments shape their pandemic responses.

If you want the answers to the questions posed in the beginning of this article, listen to the Health in Europe podcast, where Katrine Bach Habersaat, Nils Fietje and Anastasia Koylyu explain examples of how behavioural and cultural insights have been used to reveal the impact of social expectations on mental health, improve health literacy and understand low rates of vaccination.

Flagship initiatives

The work of the Insights Unit contributes to one of WHO/Europe’s 4 flagship initiatives to complement the European Programme of Work, which sets out health priorities for the coming 5 years. These initiatives – the Mental Health Coalition, Empowerment through Digital Health, the European Immunization Agenda 2030, and Healthier Behaviours: Incorporating Behavioural and Cultural Insights – are intended as accelerators of change. They mobilize action on critical issues that feature prominently on the agendas of Member States and for which high-visibility, high-level political commitment can be transformative.

Humanitarian worker Aron Kassahun Aregay joined the WHO Country Office in Ukraine in late 2019. From having worked as an epidemiologist in numerous emergency settings on the African continent, he was now in charge of information management, coordinating the health cluster response in the eastern conflict areas.

“The challenges I witnessed in Ukraine were somewhat different from what I had experienced in other settings. In Ukraine, I see elderly people and people with disabilities struggle the most, being isolated with limited capacity to face the challenges of this humanitarian crisis,” Aron explains.

“COVID-19 has increased their difficulties and suffering, and of course the sufferings of all affected people in the conflict areas. For us humanitarian workers, COVID-19 has undoubtedly added to the existing challenges.”

Saving lives, supporting health systems

In protracted emergencies, such as the ongoing conflict in eastern Ukraine, lack of access to essential health services is one of the biggest challenges for people living in emergency settings. The health system in eastern Ukraine was in a fragile state already before the onset of the COVID-19 pandemic. Many health-care workers had left the region, and health facilities had been neglected for years.

“WHO’s core principle not only to assist people who are in crisis, but also support and sustain the existing health-care system, is at the centre of our work as humanitarians,” says Aron. “We provide technical trainings to health-care professionals and help deliver life-saving equipment.”

With COVID-19, Aron soon found his tasks broadened. Supporting the Incident Management System, he initially disseminated information about COVID-19 to all partners working in the east; advocating, preparing and aligning all response activities; shifting the priority of all the humanitarian actors in the eastern conflict area to plan and prepare for the outbreak.

Now Aron is leading one of the major pillars in the COVID-19 response with the WHO Health Emergencies Programme in Ukraine, that of health information, epidemiology (surveillance) and contact tracing – working in close collaboration with other response pillars. His work also covers predictive modelling of the outbreak and assessing health system readiness to cope with potential surges of new infection.
“For me, being a humanitarian means that your ultimate goal is to save lives at any cost. Whether in the eastern conflict areas or any other areas with emergencies, in whatever context, whether during a pandemic or not,” says Aron.

“We don’t take sides in a conflict or political crisis and we maintain a neutral position in all situations we are faced with,” Aron explains. “Impartiality is one of the most important things in crisis and emergency response. Those who are most in need should be the first to receive help and support. You kind of have to be a conscious and compassionate superhero.”

World Humanitarian Day

World Humanitarian Day, observed each year on 19 August, comes as the world continues to fight the COVID-19 pandemic. Aid workers are overcoming unprecedented challenges to assist people in humanitarian crises in 54 countries all over the world, all with their specific environments, challenges and hurdles.

World Humanitarian Day is dedicated to recognizing the work of humanitarian personnel and those who have lost their lives working for humanitarian causes.