1. INTRODUCTION

It is well known that education in a child’s life has the power to develop him/her personally, socially, as well as economically. Owing to the value of education and its significance, governments, Non-Governmental Organizations (NGOs), as well as educational institutions are investing more than ever on education. To bring improvements to this sector, some of the factors influencing the academic performance of students such as attitude, leadership aspects, and psychological and health-related factors are being studied thoroughly.

Since the eruption of the Syrian conflict in 2013, Lebanon began hosting fleeing refugees [1]. Because of Lebanon’s open border policy with Syria, the country has sheltered around 1.5 million Syrian refugees, as estimated by the Lebanese government and a number of local NGOs. According to a report published by the United Nations High Commissioner for Refugees in 2016, the refugees were spread all over the country as follows: Bekaa (36%), Beirut (26%), North Lebanon (26%), and South Lebanon (12%) [2]. Unfortunately, Syrian refugees live under very poor conditions. Inadequate sanitation, lack of access to clean water, overcrowding in their temporary settlements as well as limited access to healthcare infrastructure favor the spreading of a number of communicable diseases, such as hepatitis A, influenza, leishmaniasis, and so on [3].

Leishmaniasis is a parasitic zoonosis caused by protozoans of the genus Leishmania. The pathogen is transmitted by insects known as phlebotomine sand flies, which are found in wild or urban environments [4,5]. Transmission of the disease occurs mainly through the infected insects; non-vector transmission is rare. There are three main forms of leishmaniasis: visceral leishmaniasis (VL), cutaneous leishmaniasis (CL), and mucocutaneous leishmaniasis (ML) [6]. Cutaneous leishmaniasis is the most common form of leishmaniasis, characterized by skin manifestations causing skin lesions, papules, and nodules that may ulcerate leaving scars and serious disability [7].

Leishmaniasis is an endemic disease in Syria, and the presence of war/conflict has greatly increased the risk for new disease cases in the country as well as in the surrounding areas of the Middle East [8–10]. Population displacement, poverty, and the poor living conditions, among other factors, help in the rapid transmission of the infection [11,12]. Following the civil war in Syria, the Syrians started migrating to Lebanon and living in low-income, low-sanitation, and high-population camps on the border with Syria, where the highest prevalence of leishmaniasis is recorded [13]. As young people usually are the most affected due to their lack of previous exposure to the disease, students in school are one of the main populations affected by this problem [14–16].

The number of studies tackling issues related to Syrian refugees in Lebanon have been on the rise recently. However, there are no studies that approach the correlation between Leishmania and school performance. This study aims to assess the effect of leishmaniasis on the academic performance of elementary school students in Bekaa, Lebanon.

2. MATERIALS AND METHODS

3. RESULTS

4. DISCUSSION

Our results show that there is a correlation between the performance and attendance of students when infection with leishmaniasis is present. Students infected with Leishmania were underperforming and not attending their classes regularly. The effect of CL on attendance – and by corollary – on the students’ performance was quantitatively analyzed in two ways: (a) by comparing the averages of some of the affected students before and after infection (disregarding the material taught during the days of infection) to those of the corresponding classes, all while eliminating the mathematical contribution of the studied subjects from the overall averages (Table 2); and (b) by comparing the total averages of the same CL-affected students before and after infection (disregarding the material taught during the days of infection) with a cohort of students having had similar averages in previous years/semesters (Table 3).

It is obvious from the data shown in Table 2 that all the infected students who were compared with their peers before and after infection suffered a considerable drop in their academic performance, as assessed by their grade averages. It is worth noting here that such a drop is ubiquitous, meaning it affected both the students who had higher or lower averages than their corresponding classes.

Table 3 shows a comparison in the performance of the CL-affected students vis-à-vis their retrospective cohorts. A group of students whose averages in the immediate previous semester/year were almost identical to any one of the CL-affected students in the current semester/year was selected as a benchmark cohort. The averages of such cohorts in the current semester/year were then calculated and compared with those of the CL-affected subjects. It is clear that, although the averages of all the cohort groups ameliorated, the averages of all of the infected students exacerbated. This is another indication that leishmaniasis indeed affects the academic performance of the infected student.

Several studies have already proved that there is a strong correlation between attendance and academic performance [19,20]. Therefore, it comes as no surprise that with the decreased attendance students are facing due to their infection with Leishmania, their academic performance has decreased as well. The issue thus diverts into the cause behind the spread of this disease and the stigma behind it, which are affecting attendance and academic performance. Students affected with this disease were possibly also missing extra school days because of the bad reputation associated with it. The presence of this disease in the Bekaa area and particularly among elementary students can be explained by a number of reasons.

First, the Lebanese health system is composed of services rendered by the public and the private sectors, as well as the NGO sector. The dominant sector is the private one, as it provides most of the services [21]. Around 50% of Syrian refugees live in the poorest areas of Lebanon, informally [21]. Consequently, in the 6 years of Syrian crisis, the healthcare services rendered across the Syrian refugee population in Lebanon was below appropriate standards, and explains the spread of infection and in turn the decreased attendance and underperformance of affected students.

Second, with the high influx of Syrian refugees into Lebanon, a sudden increase in Leishmania cases was noted. Syrians have been known to be infected with this parasite since 1990 [22]. This new outbreak of leishmaniasis in Lebanon is the first of its kind for over a decade [13]. The LMoPH implemented an active surveillance for leishmaniasis since the beginning of the Syrian conflict; LMoPH diagnosed the cases by traditional techniques of smear, histological analysis of skin biopsies, and parasite culture [13,23–25]. Leishmaniasis is considered one of the most neglected diseases in the world, in the time where the parasite may be able to propagate in different areas in Lebanon, particularly in Bekaa district, where the vector may find a favorable habitat and where appropriate zoonotic reservoirs are present. This increased influx as well as suitable habitat is another reason for the spread of the diseases among individuals in the area of our study. Tactics such as the ones formed by other countries including South American and East Asian countries to combat infection can be used to halt the propagation of the disease in Lebanon [26].

The problem of Syrian refugee influx is not only contained to Lebanon. Other countries in the Middle East, such as Jordan, Iraq, and Egypt [27,28], like Lebanon, have been plagued with some diseases spread among the Syrian refugee populations they have been hosting. Leishmaniasis was one of the most common diseases reported in the Syrian refugee camps in these countries. Risk factors such as malnutrition, poverty, population displacement, poor housing, and decreased hygiene are all met among the refugees and the camps they are settling in among host countries [29]. Therefore, precautions and healthcare plans such as immediate containment and treatment of affected personnel were made to halt spread of Leishmania among the host populations and avoid further disease propagation. Workshops and campaigns were also introduced in a few neighboring countries of Syria to train medical personnel to recognize the disease promptly to deal with the issue as soon as possible and prevent further spreading of leishmaniasis [4].

Third, political tensions and strings attached to the different Lebanese ministries (e.g., Public Health, Social Affairs, Refugees and Displaced, Education, and so on), and the political conflicts that may exist between the heads of these ministries in the Lebanese cabinet pose another problem in combating leishmaniasis and, by proxy, in solving the issue of performance and attendance among students [30–33]. A clear indication to such an argument was the lack of coordination between the schools (under the control of the Ministry of Education), NGOs (under the control of the Ministry of Social Affairs), and primary healthcare centers (under the control of the MoPH). Our study reported that 64.3% of the schools lacked any kind of coordination with the LMoPH centers, whereas only 28.6% of the schools were in direct relationship with the LMoPH offices. Such an argument is further corroborated by the fact that the LMoPH provided the necessary medicines and vaccines to 70% of the reported cases.

Another matter that is affected by the political tensions in Lebanon is the lack of funding and development present in public schools, the place where most Syrian refugee children go. Owing to the low standards of health education present in these schools (only 20% had formal awareness campaigns about communicable diseases such as Leishmania) and administrations, as presented by the school administrators, fighting the spread of Leishmania among children of these institutions is even more difficult, exacerbating the matter of attendance and academic performance among students.

Younger age groups were shown to be the most infected in our study. This is due to the fact that they are immunologically immature compared to adults and do not have the biological means to fight off the disease [34]. More efforts must be put into prevention among the younger age groups by attempting increased screening and increased vaccination and immunity boosters to help this vulnerable population. Increased research is also key to develop prevention techniques and therapies for such diseases in the Arab world in general and Lebanon in specific [35–37].

A majority of parents were exposed to some awareness campaigns concerning leishmaniasis. This is imperative to stop the spread and management of the disease.

5. RECOMMENDATIONS

On the basis of our results, the following recommendations and directions for further studies are proposed: first, additional research is needed to determine the factors that affect students’ attendance and other health-related factors that may affect students’ attendance and performance. Second, educating parents on the importance of attending school daily in early ages to improve the overall academic performance of students. Third, establishing control programs and awareness campaigns for various communities. Fourth, create and increase coordination between schools (under the control of Ministry of Education), NGOs (under the control of Ministry of Social Affairs), and primary healthcare centers (under the control of LMoPH). Coordination among these agencies will help in preventing infection with leishmaniasis and other communicable diseases. Fifth, develop vaccines against all types of vaccine preventable diseases, especially for Leishmania, where vaccination remains the most promising approach for prevention. Sixth, increase funds to ensure equitable provision of health services to meet essential health needs at the primary, secondary, and tertiary healthcare levels. Seventh, avoid political strings attached to the different Lebanese ministries (Public Health, Social Affairs, Refugees and Displaced, and Education), in addition to the conflicts existing between the heads of these ministries. Finally, develop public awareness among Syrian refugees to assess the effects of communicable diseases on children’s education.

6. LIMITATIONS

The validity of our data relies on the validity of the responses presented by the interviewees. Completely objective assessments such as test scores and an exact count of days missed because of the disease were not possible to collect because of the lack of accurate data from the source (schools and respective administrations). Not all subjects’ academic records were accessible due to either endless bureaucratic processes or the unwillingness of the school principals to share such data. Another limitation was that none of the interviewees consented to be quoted in this work.

7. CONCLUSION

Evidence accumulated has shown that refugee camps are not good for anyone, especially for the youth. In this study, we addressed one communicable disease; however, there are still more issues that remain to be answered. These factors include – but are not limited to – psychological stress during and after migration, challenges that affect the ability of the refugee students to adapt to the host schools’ system, and so on. This is despite the fact that educational access and opportunities for refugee children remains low. In conclusion, our study raises a critical point of the effect of communicable diseases on the performance of elementary students, in particular the Syrian refugees. Leishmaniasis is an example of one factor that keeps children out of the classroom. How other health-related factors may also affect could be further evaluated. In addition, public awareness within Syrian refugees might also be a subject of further investigation to assess its effect on children’s education. This can be further implemented by school administration and their partnership with parents and/or guardian of the refugee students. The main question that remains to be answered with respect to the Lebanese community is whether the Lebanese authorities have enough knowledge in dealing with such education-related health problems despite the fact that leishmaniasis is not endemic in Lebanon.

CONFLICTS OF INTEREST

The authors declare they have no conflicts of interest.

AUTHOR CONTRIBUTIONS

H.H.K., F.J.Z., N.H. and H.M.K. were responsible for study conceptualization and writing (original draft) the manuscript. Data curation and formal analysis were carried out by H.H.K., E.S. and W.R. Project administration and supervision was carried out by H.M.K. Review and editing of the final manuscript was done by H.H.K. and H.M.K.