We searched PubMed, Web of Science and Google Scholar—considered as a database for grey literature—for literature published in English and German and available in full text; no restrictions were placed on the date and type of publication. We also searched the reference lists of the papers for further relevant literature. The search string included the principal terms “war,” “armed conflict,” “Public Health,” “Public Health framework” and “interven*,” “prevent*,” “measure*,” “action*.” The search was performed in February 2023 using the following search string in PubMed:

The search string was adapted to the other databases accordingly.

We screened titles and abstracts of records against a set of pre-defined inclusion and exclusion criteria. To cover a wide range of literature and existing definitions (see introduction), we use the terms war and armed conflict. To be eligible, records had to include the search terms “war,” “armed conflict” or any of the terms related to public health contained in the search string in their title or abstract. References had to describe public health approaches, frameworks or guidance reporting on primary prevention measures, actions or recommendations regarding war and/or armed conflict. We aim to provide an overview of the existing literature, so we posed no restrictions regarding the type of article (empirical, conceptual, etc.). Records focusing on consequences, outcomes, or impact of war, armed conflict, or (bio)terrorism on population health were excluded. We retrieved full texts of potentially eligible references and re-assessed them against the inclusion and exclusion criteria (see Table 1).

We extracted data using a template covering features of primary prevention strategies regarding war and/or armed conflict. In addition, we documented challenges and limitations raised in the references to provide suggestions for further research. We followed the principles of narrative synthesis based on the Guidance on the Conduct of Narrative Synthesis in Systematic Reviews which is the most appropriate approach for analyzing diverse evidence [16]. Scoping reviews do not require a formal quality assessment; which in addition would have been challenging due to the many different types of papers included. This scoping review did not involve primary research with human subjects and therefore did not require institutional ethical approval.

Twelve of the 15 references [5, 12, 18–21, 25–30] mentioned the aspect of examining the root causes of war and/or measuring health consequences as first basic actions to prevent war and armed conflict.

According to the American Public Health Association [18], continuous research into the causes of wars/armed conflicts is essential to prevent them. They argue that wars and armed conflicts need to be investigated not only when they break out, but already before. This would require a refinement and more effective design of public health tools to produce pre-conflict estimates on, for example, deaths to raise awareness and ongoing surveillance during conflicts regarding the impact on health systems [18]. Burkle [19] and De Jong [20] support these approaches, but focus on interdisciplinary collaboration in research and surveillance, particularly between natural and social sciences, such as in global health. The problem, according to Burkle [19], is that it is currently unclear to what extent such collaboration is actually taking place. Murray et al. [27] go into more detail here, emphasizing the importance of collaboration between political scientists and public health researchers. In addition, Sidel and Levy [29] argue for a surveillance system to monitor health outcomes. Another approach also proposes the development of such a system but with a focus on risk factors of war and armed conflict [28]. At the same time, the risk and protective factors of war and armed conflict are poorly confirmed by research, and little is known about the extent to which these factors operate alone or in combination with other factors [20, 25, 28]. Building on this, it is relevant for the primary prevention of war to conduct regular risk and policy analyses and environmental assessments, especially those involving multiple stakeholders [12, 30].

Building on the identification of risk and protective factors, public health professionals should also develop and assess interventions for the primary prevention of armed conflict and its health consequences, according to Reza et al. [28]. As strategies to be evaluated, they list, for example, economic sanctions, peacekeeping measures by the United Nations or education about the danger of landmines as preparation of the civilian population for a possible war [28].

11/15 references [5, 12, 18, 20, 22–26, 28, 30] mentioned educating professionals and the public as well as raising awareness on the consequences of war and promoting peace as further fundamental public health approaches to the primary prevention of war and armed conflict.

According to APHA (American Public Health Association) [18] and De Jong [20], it is relevant to educate public health professionals, policymakers, and the public about the expected consequences of war and to advocate for alternative solutions to conflict. They, as well as Hagopian and Jabbour [22], argue that it is necessary for professionals to address and be encouraged to address the prevention of war and to build a movement for peace. APHA [18] recommends that public health professionals should advocate for legislation related to the arms trade, ratification of treaties and military spending, financial and political engagement in peace operations, and development programs that address the structural causes of war. Professionals should also address the public health impact of war [18]. To achieve this, the (primary) prevention of war and armed conflict should be included in school curricula [18, 30]. Particular important would be the promotion of the peace-making function of public health professionals [18]. De Jong [20] supports these approaches. He argues that access to health and education services is often limited due to various factors, and military action often undermines public health programs. Therefore, he points out that health, education, and other sectors could promote reconciliation and cooperation by, for example, setting policies to strengthen equitable health and education services, developing human resources through a cascade of training levels, providing educational materials, and establishing a monitoring and supervision system [20]. Wiist et al. [30] mention necessary skills of Public Health professionals regarding trust- and peacebuilding. Thus, professionals could bring parties together to cooperate and coordinate health activities. The World Health Organization (WHO) [12] supports this approach and suggests the design of peace-responsive health interventions with the aim to improve trust between potential groups of conflict. First, they point out that it would be important to improve the trust between the state and its citizens by, for example, expanding social protection and justice in underserved areas. Second, public health professionals could serve as a platform for state belligerents restoring contacts and collaborations [12]. Finally, trust-building and inclusive processes that promote dialogue are needed to improve the relations between individuals and communities; health dialogue and diplomacy are considered particularly important [12]. Levy [26] supports the approach of dialogue and diplomacy, describing the latter one of the most important approaches to preventing wars, as it can prevent disputes and conflicts from arising through various forms of dialogue such as face-to-face negotiations and conferences.

A higher-level public health issue that we found in eight out of 15 [18, 20, 22–26, 30] of the references was the primary prevention at the policy and administrative level.

Five Refs. [20, 23, 24, 26, 30] refer to (stronger) control, reduction and outlawing of weapons within states, for example, through appropriate legislation, or multilateral or bilateral treaties. Lang et al. [23] advocate that states should be disarmed or at least be reduced to a minimum of weapons, with a strong international capacity to mediate and intervene. A framework based on De Jong [20] emphasizes the need for effective police authority and fair criminal and dispute resolution systems. Furthermore, international law should focus on three areas: human rights, humanitarian laws and non-violent alternatives to dispute resolution. Humanitarian laws include the need to legally underpin United Nations field operations and should also take into account the needs of vulnerable groups, religious freedom and the right to preserve non-harmful cultural practices [20, 25].

Beyond legislation, more fundamental initiatives such as rural development, for example, increasing food production, can help to strengthen economic capacity and improve food security, resilience and quality of life [20]. Particularly in areas of increasing instability, such projects can compensate for the lack of land and prevent competition between the local populations and internally displaced people or refugees [20]. This framework, based on a selective literature review that translates risk factors into preventive interventions at multiple levels, also suggests reducing unemployment and poverty, protecting the environment and ensuring basic security, wellbeing and justice [20]. In addition, discrimination and ethnic inequalities must be reduced and societies rebuilt [20]. States should remove barriers to equal opportunities by providing equal access to basic facilities/services such as health services and education [20]. Leaders of poverty-stricken countries, for example, that have abundant oil, minerals and other resources can use these resources to fight extreme poverty and socio-economic inequities [26]. Poor governance can also contribute to the emergence of wars. Improving citizen participation, for example, through free elections, can make the government more accountable and strengthens governance [26]. Levy et al. [25] also highlight the work to reduce poverty, income inequality and ethnic hatred, and also mention other causes that need to be addressed such as climate change and environmental degradation. Another approach identifies strategies related to governance and economics, geography, level of development, cultural factors and individual incentives. Finally, Hagopian and Samer [22] point out that it is important to consider the aspects of corruption and greed in the war industry. The World Health Organization [12] suggests—in their report on the work on conflict instead of only in conflict—to focus on those drivers that can be adequately addressed through interventions and are linked to health concerns.

The approaches identified also raise criticism. APHA [18] and Wiist et al. [30] argue that the public health profession avoids activities that could prevent wars because they are too controversial or political. Accordingly, they call for an updating and strengthening of the role of public health professionals [18, 30]. So far, these have focused on the effects of war rather than on its prevention [30]. Grundy et al. [21] argue that the decision to go to war is generally made regardless of the threat to public health. They criticize that public health remains on the margins of conflict awareness, decision-making, and mitigation, while political, technocratic, legal, and military advocates play the primary role [21].

Additionally, the references often do not directly distinguish between war and armed conflict in their approaches; the terms are mostly used synonymously. However, based on our definitions of these terms (see background chapter), primary prevention approaches can be derived for both wars of aggression and armed conflicts.

By conducting a scoping review, we were able to examine a broad range of themes and identify gaps in the evidence of primary preventive measures regarding wars and armed conflicts in public health. Our search was extensive and based on defined inclusion and exclusion criteria. Upcoming issues were resolved in consultation with the co-authors. However, several limitations must be mentioned. Firstly, the primary search in the databases was conducted by a single reviewer, which may have led to bias regarding the decision (not) to include literature. To minimize this bias, a second reviewer checked the results and suggested additional references. The inclusion and exclusion criteria are very broad to be able to include as many studies as possible. This may make it difficult for other researchers to evaluate the findings. Another limitation is the lacking differentiation of the definitions of war and armed conflict due to the high heterogeneity of the use of these terms in the present studies. This has made our analysis very broad. There may also have been a bias in identifying and documenting findings due to the restriction to German and English articles.

The aim of this review was to survey the literature on existing public health approaches to primary prevention of war and armed conflict to provide an overview of the topic and identify key gaps, including suggestions for future research needs. Notable were the focus on armed conflict rather than on wars of aggression; and the small number of concrete measures addressing the primary prevention of war from a public health perspective.

The results can be condensed in a two-tiered conceptual framework:

To prevent wars between states, public health can promote human rights and the rule of law, either directly through political work or indirectly through equitable access to justice and interventions against discrimination or gender-based violence.

To prevent armed conflicts within states, public health interventions should address the social determinants of health and aim to reduce poverty and inequality. This can be achieved by improving access to education and healthcare. Education can promote understanding and dialogue between groups. Such interventions can strengthen social cohesion and help reduce the likelihood of conflict and violence. Economic development also plays a role, but falls outside the scope of public health (apart from the fact that health is a prerequisite for participation in the labor market). Again, public health can promote human rights and the rule of law, either directly through policy work or indirectly through equitable access to justice and interventions against discrimination or gender-based violence.

Further research should focus not only on armed conflicts but also on wars of aggression. Researching the causes of armed conflicts and wars as well as their influence on each other is a prerequisite for developing preventive measures and testing their effectiveness. Since wars and armed conflicts are often associated with poverty or social inequality, a holistic society approach is needed for their primary prevention.