The impact of the Syrian conflict on population well-being

The Syrian conflict, beginning in 2011 as part of the Arab Spring and escalating into a protracted armed conflict, has resulted in massive loss of life and displacement. Beyond mortality and displacement, the conflict disrupted healthcare, housing, and food systems, elevating infectious disease risks and interrupting chronic disease management. Psychological harm from exposure to violence and the destruction of social networks further threatens well-being. Objective health assessments are impeded by attacks on healthcare and data scarcity, highlighting the value of self-reported well-being aligned with WHO’s holistic definition of health. This study asks how Syrians’ physical, mental, and social well-being changed before and during the conflict, whether changes differed by sex, age, social support, and direct exposure, and how Syria’s trends compare globally, including to countries experiencing war, protests, or natural disasters.

Prior research on major population events often focuses on single events and rarely compares across contexts. Studies reported little to no long-term reductions in mental well-being following the 2007–2008 global financial crisis, the 2011 Fukushima disaster, or the 2015 Paris terrorist attacks, supporting a hypothesis that life circumstances have limited long-term effects on well-being. However, disaster and public health literatures document substantial adverse effects of conflict and disasters on physical and mental health. The apparent divergence motivates a global comparative approach to situate Syria’s well-being changes relative to regional and worldwide trends, including countries undergoing armed conflict, social unrest, and natural disasters.

Design and data sources: Secondary analysis of Gallup World Poll (GWP) serial cross-sectional data. Syria had face-to-face surveys in 13 of 14 governorates across 2008, 2009, 2010, 2011, 2012, 2013, and 2015 (n=11,452; annual samples ~1,000–2,100). Global comparisons used national-level data from 163 territories (including Syria) from 2006–2016 (n=1,722,558; 1,435 country-years). Sampling: Stratified random sampling with PSUs proportionate to subnational populations; random-route household selection; Kish grid for respondent selection; trained interviewers; weights applied for representativeness. Due to security, some PSUs and Homs were partially excluded or replaced in 2012–2015, limiting representativeness for exposure to conflict. Measures: Thirteen well-being indicators covering physical (health problems limiting activities; physical pain yesterday; well-rested yesterday; satisfaction with availability of quality healthcare; inability to afford food; inability to afford shelter), mental (negative emotions yesterday: worry, sadness, stress, anger; positive emotions yesterday: enjoyment, smile/laugh; life satisfaction via Cantril ladder 0–10; hope in five years via Cantril ladder 0–10), and social domains (social support: someone to count on; respect yesterday; satisfaction with freedom of choice). Exposure to conflict (2013, 2015 only): self or family displacement; household death or injury due to violence; household loss of main income source. Exposure coded as any “Yes.” Country classifications: WHO regions (Africa, Americas, South-East Asia, Europe, Eastern Mediterranean, Western Pacific). Event-based groups: countries with military conflict (≥1,000 conflict deaths/year, UCDP), major protests (≥800 protest-related arrests/injuries/deaths), and major disasters (≥1,000 deaths/year, EM-DAT). Analytic strategy (Syria individual-level): Multilevel linear/logistic regressions predicting each outcome from a linear time trend coded 0=2008 to 1=2015, with random intercepts and random slopes by governorate; survey weights applied. Sex- and age-specific trends tested via interactions with time. Geographic differences estimated via governorate random slopes. Exposure and social support analyses: Compared outcomes by direct exposure (2013, 2015) and assessed moderation by social support pre- vs during conflict; tested multiplicative and additive interactions (e.g., ratio of ORs; RERI). Missing data handled with multilevel joint modelling multiple imputation (MCMC): 100 datasets; 50,000 burn-in; 5,000 between-imputation iterations; estimates combined with Rubin’s rules; complete-case sensitivity analyses conducted. Analytic strategy (national-level): Multilevel models with random intercepts and slopes at country level predicting each outcome from survey year (scaled −0.29=2006 to 1.14=2016), WHO region dummies (Syria reference), and year×region interactions. Separate models aligned time to event for comparisons with war/protest/disaster countries, requiring at least one pre- and post-event year. Software: R 3.3.3.

• Across Syria (2008–2015), 11/13 indicators worsened; exceptions: reported health problems and physical pain. Examples: • Dissatisfaction with healthcare: participants were 3.57 times more likely in 2015 vs 2008 (95% CI 3.13–4.17). • Inability to afford food increased sharply (OR=6.74, 95% CI 5.67–8.02); inability to afford shelter increased (OR=3.45, 95% CI 2.94–4.05). • Negative emotions prevalence rose by 41.4% (95% CI 39.3%–43.5%). • Life satisfaction (0–10) fell by about half: 5.15 (95% CI 5.06–5.24) in 2008 to 2.55 (95% CI 2.32–2.78) in 2015. • Social support collapsed: during the conflict, Syrians were five times less likely to have someone to count on (OR=0.20, 95% CI 0.17–0.23). - Demographics and geography: Sex- and age-based differences in trends were small. Geographic disparities were substantial: • Rural Damascus: 15× (95% CI 13.9–17.5) less likely to be satisfied with healthcare in 2015 vs 2008 (country overall ≈3.6×). • Aleppo had the steepest decline in hope (−2.22 units, 95% CI −2.29 to −2.16) vs Ar-Raqqah (−0.20, 95% CI −0.55 to 0.16). - Exposure and social support: Directly exposed individuals (2013, 2015) did not show worse well-being on most indicators compared to non-exposed, except higher odds of difficulty affording food (OR=1.36, 95% CI 1.10–1.67) and shelter (OR=1.24, 95% CI 1.01–1.51). Pre-conflict, social support was protective (e.g., well-rested OR=1.46, 95% CI 1.22–1.75); this association weakened during conflict (ratio of ORs=0.50, 95% CI 0.15–0.85; RERI=−0.54, 95% CI −0.90 to −0.18). Sensitivity analyses were consistent. - Global context: Before the conflict, Syria’s well-being was comparable to regional levels. From 2008–2015, Syria’s changes were markedly worse than the Eastern Mediterranean and other WHO regions. Example: healthcare dissatisfaction change in Eastern Mediterranean: ~+1.2% (95% CI −5.7% to 3.3%) vs Syria: +31.7% (95% CI 11.7% to 51.6%); negative emotions increased 38.6% (95% CI 26.7%–50.6%) in Syria vs 4.0% (95% CI 1.5%–6.5%) in the Eastern Mediterranean. Social support declined by 36.0% (95% CI −49.6% to −22.5%) in Syria vs −4.6% (95% CI −7.5% to 1.7%) regionally. Across 163 countries, Syria had the worst decline in 11/13 indicators (exceptions: health problems, physical pain), including the largest drop in life satisfaction (−2.4 points). Compared with countries experiencing war, protests, or disasters, Syria’s declines were still substantially greater (e.g., healthcare satisfaction fell 36.4%, 28.7%, and 35.0% more than those groups, respectively; negative emotions rose 37.5% more vs war countries; social support fell 39.3% more). - Notable anomalies: Reported health problems and physical pain did not worsen, potentially reflecting sampling constraints and prevalence-induced concept change.

The study demonstrates pervasive and unprecedented declines in Syrians’ physical, mental, and social well-being during the conflict, far exceeding regional and global trends and surpassing declines observed in other war-torn or disaster-affected countries. Life satisfaction declined by ~1.1 SD on average, larger than typical effects of major life events like bereavement or disability, contradicting the view that circumstances minimally influence long-term well-being. The lack of stronger decrements among directly exposed individuals, alongside the erosion of social support’s protective effect, suggests powerful nationwide spillover effects and systemic breakdowns in social capital under extreme, prolonged conflict. Counterintuitive stability or improvements in reported health problems and pain likely reflect sampling limitations in highly insecure areas and context-dependent judgments (prevalence-induced concept change), indicating that observed declines in other indicators may be conservative. The findings underscore the necessity of integrating psychosocial interventions with humanitarian responses and highlight peace as foundational for restoring health and social fabric.

Using nationally representative, serial cross-sectional data linked to global comparisons, the paper documents unmatched declines across physical access (healthcare, food, shelter), mental health (emotions, life satisfaction, hope), and social well-being (support, respect, freedom) in Syria during the conflict. The work clarifies that Syria’s declines are not artifacts of regional or global trends and exceed those in other countries experiencing war, protests, or disasters. Policy implications include prioritizing peace-building alongside scaling evidence-based psychological interventions for Syrians within and outside the country. Future research should: (1) track post-2015 developments with continued population monitoring; (2) complement self-reports with validated multi-item measures and objective indicators where feasible; (3) utilize longitudinal cohorts to map heterogeneous trajectories and recovery; and (4) examine mechanisms of spillover and social capital erosion to inform interventions.

• Design: Serial cross-sectional data preclude within-person change estimation and may differ from panel data, though they avoid panel conditioning biases. - Measures: Reliance on brief, often single-item, self-reported indicators; limited availability of gold-standard measures and objective records due to conflict. - Sampling/representativeness: Security constraints led to exclusion or replacement of highly dangerous PSUs (e.g., Homs periods), under-representation of directly exposed individuals (e.g., 19% internally displaced in sample vs ~33% nationally), and potential sampling bias. - Response rates: Not publicly reported by Gallup during conflict; pre-conflict rate in 2009 Arab survey in Syria was 59%, likely lower during conflict (possible healthy responder bias). - Cultural and cross-national comparability: Global analyses may be influenced by cultural response styles, though dichotomous items were used to mitigate this. - Aggregation: Country-year averages may mask acute, localized declines in countries with more localized events; last Syria data collection was 2015, limiting capture of later conflict dynamics.