The impact of crisis and COVID-19 on Syrian children growth, health awareness and nutritional practices. a cross-sectional study

It’s more than decade since Syria was plunged into a life-threatening conflict, living conditions have deteriorated, and the recent COVID-19 pandemic has exacerbated an already dire situation and placed more burdens on the public health sector. One of the most affected groups are women and children [1], the reality of health and nutritional status of these vulnerable groups is not well recognized and documented [2, 3]. While most of post-crisis literature has been focusing on deteriorated health conditions, nutritional deficiencies, and educational difficulties of Syrian refugees children in neighbouring countries such as Jordan, Lebanon and Turkey, very little has been investigated about the obstacles of children within Syria [4, 5]. Furthermore, the majority of these studies and humanitarian reports inside Syria focused on the conflict areas in Syria with considerable geographic and thematic gaps [6], such as the north of Syria, that areas have suffered the most and are still suffering from the disruption of government services [7]. We do not find any studies in the under-govermental areas where reconstruction and rehabilitation have begun. Moreover, conducting long-term high quality clinical research was almost impossible. University hospitals did not have an electronic medical record system for archiving patients’ data, which makes extracting and verifying patients data difficult and time consuming, and often unreliable, no funding for any kind of research was provided, internet connection was unreliable and slow, and electrical current was unstable with frequent daily interruptions [8].

Prior to the crisis, Syria was on a developing mode, classified as a middle income country, with a robust national health system head by the public sector, offering free medical services around all country's provinces. Syria was on target to meet the Millennium Development Goals in Maternal Mortality Ratio (MMR), Infant Mortality Rate (IMR) , and with a comprehensive vaccination coverage (100% by 2005) [9]. The rapidly growing private sector has made tremendous achievements in the field of health care and the economic situation in the country in general [3]. Furthermore, the education system was effectively progressing with 97% children antecedence in the primary schools, public schools offered free and fine quality education on all over the country.

The heavy years of war have devastated the country’s critical civilian infrastructure and public services, according to WHO recent report 6.7 million people are internally displaced; 5.6 million people have become refugees, mostly in neighboring countries [10]. Economically, the Syrian Pound lost 78 % of its value and food prices increased by 236 % in 2020, leaving up to ninety percent of the population under the poverty line. This is a 10% increase compared to previous years [10, 11]. At least 12.4 million people are in need of health assistance, with the absence of essential health services due infrastructure destruction and low functioning hospitals and health centers [10]. Furthermore, western sanctions and economic embargoes had massively hampered health services [12, 13]. Half a million children are chronically malnourished and an additional 137000 children under five years of age are suffering from acute malnutrition, heightening their exposure to preventable morbidity and mortality. Child labour and child marriage reported as frequently occurring in 22% and 18% of assessed communities, respectively [10, 14]. Only one third of schools are fully functional, and with schooling becoming unaffordable, 2.45 Million children were out of school in 2020 [11, 14]. Voices have been rising calling international forces to act and save children lives in Syria and end sanctions and violence [15].

The attention to the role of nutrition was in its infancy in Syria prior to the crisis. The Health Sciences collage, which includes the Department of Nutrition, first of its kind in Syria, was established in 2005 by virtue of Republican Decree No. 274 dated 30/1/2005 at AL-Baath University. Moreover, nutrition was not a priority before the crisis considering the low prevalence of global acute malnutrition (GAM) under 5 years old, and the very limited information on nutrition situation, nutritional assessment tools, and feeding practices especially for infants and young children [16]. The nutrition situation evaluation was very limited prior to the crisis, very few reports are available on Syrian children nutritional status and nutrients sufficiency. In the purpose of increasing the country's nutritional profile, the nutrition Sector was established in Syria (Damascus) in 2013 with the cooperation of few partners; these were mainly UN agencies (UNICEF, World Food Programme (WFP) and WHO), the Ministry of Health (MoH) and the Syrian Arab Red Crescent (SARC) [16]. In 2015-2016 the Nutrition Sector, through the MoH and with the financial and technical support of UNICEF, conducted SMART nutrition surveys in accessible areas, including 11 of the 14 governorates in Syria. The SMART surveys identified an acceptable level of global acute malnutrition (GAM) of 3% and severe acute malnutrition (SAM) of 0.6 % in children, moderate levels of acute malnutrition among women (7.8 percent), moderate public health problem levels of anaemia among both women and children, and poor infant and young child feeding practices [17]. In 2019 a nutrition SMART survey was conducted, showing moderate levels of GAM (0.4 %) and stunting (12 %), while maternal anemia (27%) and micro-nutrients deficiencies in children showed high values [18].

It's very expected that COVID-19 pandemic, which has exposed tremendous disability in epidemic response and highlighted the fragility of public health systems throughout the world, will have a devastating impact on under-war countries such as Syria where these weaknesses are more apparent [19]. In Syria, where conflict has been succeeded by sanctions and other, more coercive measures [13], widespread cooperation to ensure efficient delivery of medicines and equipment to combat COVID-19 in Syria is lacking. Number of infected cases is very hard to be detected as the country has very limited resources to conduct tests on a large scale, the demolished public health system is lacking equipment, human resources, and necessary preparedness to contain increasing confirmed cases [20]. Moreover, the majority of Syrian population live in poverty, such deteriorated human conditions will reflect on the ability to follow hygiene and prevention measurements, especially in northern areas where people displaced internally and are suffering from overcrowding, poor hygiene, such poor livelihoods will facilitate the virus spread [20]. This pandemic has increased stress and life hardness for Syrians inside Syria [21, 22]. One truth that has been proved that COVID-19 still down the list of life problems and fears to face for Syrians.

There were 526 valid answered surveys by parents of 662 distributed surveys targeting students’ parents (50.2% female students, 49.8% male students) divided to (320 from private schools, 206 from public schools), 224 valid answered surveys by third grade students (124 private, 100 public), 340 fully recorded anthropometric measurements (206 private, 134 public) (Table 1). This study was conducted at the beginning of 2021, when COVID-19 epidemic was at its peak in Syria, the percentage of student attendance in primary public schools was very low, as measures to reduce Corona virus spread in public schools were almost non-existent, while private schools encouraged more attendance by providing some relatively preventive measures.

Reviewing literature, there is a huge defect in children growth assessment using anthropomorphic indices and nutritional status evaluation within Syria, and no study was conducted for primary school age children. According to the UNICEF the pre-crisis prevalence of stunting , wasting, and underweight were estimated to be 23% , 9.3%, and 10.3% respectively [24]. According to a recent UNOCHA humanitarian report the post-crisis national prevalence of stunting in children was estimated to be at 12.6 percent, with emergency thresholds reached the in sub-districts of Deir-Ez-Zor and Al-Hasakeh (one in five children stunted), Idleb and Aleppo (one in six children stunted) [25]. In northwest Syria camps, stunting was prevalent in more than 25% of children [26]. According to our assessment, the prevalence of stunting was estimated to be 13.8% for primary school age children in Homs city, with a significantly higher prevalence for public schools 21.6% and significantly decreased HAZ compared to private schools, in the same manner the prevalence of underweight was higher in public schools with significantly decreased WAZ compared to private schools. Those results imply to a chronic malnutrition based on socioeconomic indicators. According to human organizations, the number of food insecure people in Syria has increased by 22 percent, from 2019 to 2020, since mid-2019 impotence to meet basic needs reached 82% of families. Almost 600,000 children were chronically malnourished and 90,000 children were acutely malnourished [14]. No wonder that COVID-19 pandemic, that impaired food security globally, will put most pressure on poor economic communities where risk of deteriorated nutritional status will grow among vulnerable groups like women and children [27]. It was estimated that 300,000 jobs lost since the beginning of the COVID-19 pandemic in Syria [14]. Pandemic situation confrontation depends basically on community preventive measurements, social awareness, and individuals immunity system. Such essentials became exorbitant in the Syrian community, which is panting to recover from the destructive, economic and psychological effects of war. Our results were compatible with a previous study that indicated positive and significant correlations between knowledge, attitudes, and practices among Syrians inside Syria in the field of COVID-19 pandemic [28]. This study is an indication of the uneven living situations in Syrian society and refers to a socioeconomic impact on food availability and dietary patterns, which reflects on the health and nutritional status of children. The gap between rich and poor people is growing with increasing number of Syrians unable to meet their daily needs and provide their children appropriate diet to grow well.

Furthermore, the recent crisis grew more obstacles for Syrian mothers and their infants, low breastfeeding rate in our results was compatible with a previous cross sectional study conducted in Syria post-crisis that found 68.6% of mothers were exclusive breastfeeding at 4 months but this ratio dropped to 12.9% at six months [29]. Moreover, the percentage of smoking still high in the Syrian society, a recent study reported the prevalence of smoking among Syrians to be 58.3 % (61.7 % males vs 38.3 % females) [30]. The association between parental smoking and respiratory symptoms in children was previously recorded in Syria [31]. Although, there was a higher rate of smoking fathers in public schools but the total rate of smoking parents in private school was significantly higher compared to public schools, and noticeably smoking mothers rate was higher in private schools compared to public schools which indicate that financial situation has a huge impact on smoking choice in Syria.

Sleep disorders are very common effects of wars and violence traumas and Syrians had lived one of the cruelest violence [32]. Our study is an evidence that children in Syria and especially in public schools are facing a lot of stress and inferior living atmosphere which means more attention should be paid to the psycho-social effects of this crisis on children mental health and investigations are urgent in this aspect. Malnutrition is a part of a vicious cycle that also includes poverty and disease, the three components being interrelated and each contributing to the occurrence and persistence of the others. Recently, studies indicated rising in multi health disorders in Syrian population, with war related under-laying factors and massive burden on vulnerable groups such as women and children [14, 33]. Vaccines related diseases and infections have spread between internal displaced Syrian children and refugees children especially in campuses [34]. Post-crisis reports indicated rise in anemia prevalence between under under five years old children, pregnant and lactating women [14]. High levels of anemia were documented among Syrian children in different ages within and out of Syria [35, 36]. A recent cross-sectional epidemiological survey in Damascus city [37], indicated that caries prevalence to be (79.1%) among 8 to 12 years old schoolchildren based on clinical examination, and in compatible with our study the reasons of this high levels of caries between children especially in public school were post-crisis growing malnutrition, deteriorated living conditions, negative nutritional practices, and poor health services. Children dental caries is developing rapidly post crisis in Syria [38], a characteristic of the epidemiological transition, community based emergency public health interventions should be taken effectively. Reports indicated that Infections were the largest contributor to children morbidity [7]. Respiratory infections have been documented in Syria through conflict mostly in war zones [39]. Moreover, Syrian children mental and emotional health is one of the biggest concerns after this long destructive crisis, child rights violations have been reported overall Syria, indicating critical threat for children mental and physical health. According to human organizations 27% of households reported signs of distress between their children [14]. High prevalence of mental and emotional health disorders has been recorded among children in north Syria related to displacement and poverty [40]. Moreover, It’s very expected that micro-nutrients deficiencies will reach its upper limits on the health of women and children post crisis. Inadequate food intake and disease are the direct causes of malnutrition, while poverty which connected to low parental education, with deteriorated living conditions are the distal factors. Moreover, culture factors influenced by social and economic background played an important role in the etiology of poor growth like low breastfeeding rate and duration, parental smoking, poor infant and young child feeding practices, lack of sanitation and good hygiene practices, and impaired dietary habits and life style.

Despite numerous limitations, this is the first study to be conducted within Syria in purpose of growth, health and nutritional practices assessment for Syrian primary schools’ children, and first study to compare between private and public schools’ students in Syria. Our results define a critical level of stunting among public primary schools’ students which refer to insufficient dietary intake. The hazards of food insecurity and nutrients deficiencies on children within Syria are still rising under the collapsed economic conditions. By comparing public and private schools' students, we revealed growing recede in the living conditions and food security in the society, which left a large segment of children vulnerable to stunted growth and impaired physical and mental development. The huge impact of Syrian crisis followed by COVID-19 epidemic on Syrians living reality within Syria is hard to describe or measure, a lot of work must be done on the level of data collection. Actions must be taken effectively to rise health conscious between parents and family members. This whole generation born and grew up under crisis lesion needs to join hands and make a great efforts to rehabilitate on the educational, health, and living levels.

It is necessary to provide facilities with financial and technical support for community based health research to provide a better picture of the health reality, which helps in determining the most effective measures for intervention and improve the nutritional status of Syrian children.

Schools constitute an important platform for providing health and nutritional support to children and their families. It is important and useful to have a growth monitoring department under the supervision of a nutritionist and health specialists to monitor the growth of children periodically, which provides data that helps in conducting necessary community based studies and facilitates individual assistance when necessary.