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= Education as a Social Determinant in Syrian Refugee Populations =

Introduction
Syria is a Mediterranean country with a diverse history, cultural background, and population. A majority Islamic state, Syria has been rife with conflict and growth throughout its ancient to modern history - with its more recent history taking it from Christian crusader control, to belonging to the ottoman empire, to operating under French control, and to its final independence after the first world war (Mazigh, 2016). Since the outbreak of the Syrian conflict in March of 2011, an irrefutable crisis has been caused by the influx of over 6.7 million refugees being forced to flee their country; with an additional 6.7 million being internally displaced. Originally a Christian land, Syria fell to the string of Islamic conquests following the death of the prophet Muhammad in the early 600s AD; although Syria's constitution, created in 1946 following its independence, dictates Syria as a secular state - the country is comprised of an 87% Muslim population, with various tertiary judicial entities utilizing religious laws and customs in specialised court systems for each community (Central Intelligence Agency, 2022) (Esq, 2022). For the significant majority of the population, Halal restrictions are a ubiquitous dietary facet of nutrition in Syria – and these traditions are upheld by a multitude of cultural norms surrounding gender-roles in meal preparation and social interactions surrounding food. This paper will aim to elucidate the social determinant of Education surrounding the at-risk population of Syrian refugees by, analysing the other socioeconomic health determinant variables contributing to their disanalogous health outcomes, researching the current global/local interventions for said outcomes and providing additional recommendations for areas of improvement in interventional approaches. This will be done by utilising the Framework of Socioeconomic Health Determinants – a conceptual model dividing said factors into Upstream (Marco Health Determinants and Governmental Policies e.g., Economies, Welfare etc.), Midstream (Psychosocial Factors and Health Behaviours e.g., Diet/Nutrition, Mental Health etc.) and Downstream (Isolated physiological factors e.g., comorbidities, health detriments etc.) - seeking to critically analyse the differences in health disparities not only between Syrian refugees before and after their displacement, but also against the broader population.

Socioeconomic Health Determinants
To begin, social concerns of this at-risk group remain primarily consequences of issues resulting from displacement; these issues become increasingly concerning given the younger-aged demographics of this population – such as the Syrian refugees of Jordan and Lebanon comprising up to 81% persons under age 35 – and almost 20% children aged 0 to 4 years old (Verme et al., 2016). Before the civil war of 2011, enrolment in schools in Syria was almost ubiquitous for all primary grade students - with an average of 76% attendance for secondary school enrolment; during the crisis however, there was a 44% decrease in overall enrolment - with surveys expressing the primary factors for this being safety concerns (e.g. Travel to/from school was dangerous), financial concerns (Children needing to work to support their family's income), supply issues (Lack of tuitions or facilities) and demand factors e.g., trauma, lack of financial security, which made education as a priority a difficult decision (UNICEF Syria, 2016).

Upstream (Macro) - Global Forces and Governments; Determinants of Health
A major upstream factor of this, as substantiated by the prior survey, is the areas of residence/housing opportunities of this community. Currently, foreign housing consists of primitive informal tents; such as the ones found in Lebanon with an eighth of the population being made up by Syrian refugees. Approximately 96% of Syrian refugees in Turkey, 70% of which are women and children, primarily reside in outdoor camps and urban regions - with 40% of such children not attending any schooling; these educational disparities compound in the multitude of traumatic disruptions resulting from forced migrations by children, including abduction, child marriages, death, estrangement, sexual violence and prejudice and discrimination (Dolapcioglu & Bolat, 2019). In Syria, 6,765 persons received waterproof floor matting for tents and 4,920 Syrians received alternative heating fuel, with another few thousand metal supplied for damaged shelters; as such, the struggle is not only those who have been forced to evacuate the country but also those internally displaced throughout Syria ("Housing Conditions | Refugee Protection International", 2022). This is in the broader context of economic disparities within Syria, with the suspected cost of infrastructure damage due to the conflict at approximately $41 Billion USD in equivalent, and the loss in GDP compared to a non-conflict projection stated to be close to $200-300 billion USD (Shantayanan & Lili, 2017). Education and employment present concomitantly in the disparities between informal and formal working opportunities for Syrian refugees in various host countries. For example, in 2019 31,000 Syrian immigrants had documentation supporting their work (Less than 2% of the Syrian population in Turkey around working age), with a majority of this group working informal and inconsistent occupations with poor compensation, conditions and benefits; this is regardless of the educational status of applying workers, as even though a notable number of refugees in turkey have university qualifications - they are still forced to work in unskilled labour forces (Center for Global Development, 2019). Turkey itself has invested $40 billion into their ‘Refugee Bill’, aiming to facilitate employment for Syrian refugees, although this sudden influx of unofficial workforces in the unskilled private sector has contributed to significant unemployment in the native population; the native unemployment rate in turkey was at 14.1% in 2019 compared to 8% in 2012, and as this trend is emulated in other countries accepting Syrian refugees – animosity, prejudice and discrimination against this at-risk population continues to increase (Trading Economics, 2022) (Yücel, 2021). As such, detriments and effects of education disparities can be seen to not only arise from the initial Syrian conflict – but also the economic contexts of the foreign environments in which prior, touted education prospects are undervalued. To finish, the factors surrounding education in employment, income and general economics remain intertwined with the finances and economy of the destination countries themselves – and this must be considered in prevent further prejudice or discrimination in the pursuit of rectified health detriments secondary to these elements.

Midstream (Intermediate) - Psychosocial Factors and Health Behaviours
In addition, midstream factors in the form of health behaviours and psychosocial metrics appear to arise from a combination of traumatic experiences, historical behaviours and cultural expectations and experiences. As previously mentioned, the majority religion among Syrians is Islam, with the restrictions accompanying ‘Halal’ diets typically facilitated in said country in the form of regular halal meat producers, restaurants and pre-set sanctions on materials such as alcohol and recreational drug availability. Relating to the latter, a study by Lindert et al in 2021 investigated the prevalence of substance use among Syrian male refugees; they found that while religious and cultural backgrounds were protective factors against drug and alcohol use, the social circumstances of Germany (Being open and available drug/alcohol availability and acceptance), in addition to the traumatic psychological effects of war and migration, resulted in substance use for purposes such as 'escaping the present', or self-medicating in the wake of significant family separation, reliance and distress relating to loneliness, high expectations of host countries and boredom. Unhealthy dietary patterns are also noted negative behaviours observed in Syrian refugees in Germany, with western dietary habits, initially foreign to said groups, being functionally forced onto immigrants with a lack of resources - reducing access to diets intrinsic to their native meals. Middle eastern diets are both diverse and complex. As such, while the distinctions between Syrian diets are difficult to make, the prevalence of Syrian refugees that intake large amount of cheap, fast food in western environments is a significant health concern; this persists with the cultural and gender norms of females preparing meals for their families in these communities, with Syrian males in Germany demonstrating a lack of previous knowledge in nutrition and food preparation, and a lack of willingness to learn (Either expecting the female members of their family to shop and prepare food, or, in the case of single males, choosing to consume unhealthy foods until finding a partner who can fulfil the prior role) (Sauter et al., 2021). Education disparities continue to comingle with cultural presuppositions in perspectives surrounding mental health and psychosocial disparities. A study by Nguyen et al in 2022 investigated the prevalence of mental disorders in adult Syrian refugees living in western countries, finding that over a third of demonstrated having either PTSD, depressions or anxiety disorders. This is especially concerning given the prevalence of taboo and stigma surrounding mental health treatment in Syria and among this population, with participants in Paudyal et al's study on mental health and coping mechanisms on Syrian refugees in the UK reporting that their families would, ‘Not understand’ their mental ailments – and that faith-based interventions are preferred (e.g.,, Reciting/Reading the Qur'an); this is worsened in the increased hazard of gender-based sexual violence, intimate partner violence and overall underestimated physical and psychological toll of mass migration. As such, education as a social determinant can be seen as a pervasive element in general health through understanding nutrition and dieting, and in psychological detriments when cultural elements are considered.

Downstream (Micro) - Individual Health and Physiology
Finally, the more individual aspects of physiology and health intrinsic to Syrian refugee populations must be acknowledged in light of educational disparities in foreign contexts. A major concern in refugee children is the prevalence of genetic blood disorders and anaemia secondary to nutritional deficiencies and/or infectious disease; refugee children in Jordan, for example, up to 48% suffered from some form of anaemia, with noted evidence of growth deficiencies and other related nutrition deficits - with increased concerns of infectious diseases such as Hepatis B resulting from perinatal infections from pregnancies in unsafe conditions (Baauw et al., 2019). The combination of ceased vaccination programs in Syria, with overcrowded areas, reduced health care facilities and poor living conditions has resulted in significant outbreaks of known preventable ailments - including measle and polio - in noted large Syrian refugee camps; this concern is elevated in the prevalence of Hepatitis A among similar communities in higher income countries, whereas the Syrian refugee population is relatively young - the severity of hepatitis A increasing with age becomes more worrying in higher income areas with older populations (Melhem et al., 2016). As can be seen, the sub-group at risk in this context are specifically the children of Syrian Refugees who were not able to utilise the ubiquitous vaccination programs available in Syria prior to the conflict – leaving them vulnerable to preventable diseases. In Lebanon, where 53% of Syrian refugees are children, it was noted that 74.1% had complete vaccinations in said country - with factors increased the likelihood completion being, children with a mother who had a university degree, had knowledge of the process of vaccine schedules and who trusted vaccination as a medical treatment (Almidani, 2020).

Current Interventions
Overall, the primary issues requiring intervention in the social determinant of Education are employment and housing opportunities to facilitate schooling and study for at-risk youth, sociocultural and psychological interventions for the pervasive mental health stigma and poor health behaviours, and general health interventions for women and children in at-risk environments. The World Food Programme provides cash and vouchers to vulnerable families and individuals, allowing the purchase of fresh foods in the pursuit of traditional meal supplements and local market strengthening; implemented by the United Nations, this method aimed to reduce the food insecurity found among Syrian refugees in destination countries - however as of 2022, the data suggests food insecurity still persists in close to 91% of Syrian refugees in Lebanon (Talhouk et al., 2022) (World Food Programme, 2011). Examples of direct governmental interventions for education and health disparities include the Service Access Cards for refugees in Jordan; these identifications allow refugees to receive free healthcare and education from the public services available in Jordan, although - the relegated 50% attendance rate of Syrian children is still contributed by financial issues (Inability to afford books or uniforms etc.), logistical concerns (Schooling only available outside of regular Jordan school times due to population sizes reducing attendance) and bureaucratic barriers (Time spent navigating multiple public entities preventing seeking/maintaining work for parents) (Verme et al., 2016).

Alternative Interventions
Alternative solutions for food provisions show integrational methods such as meals at schools or community kitchens as much more effectively measures in reducing food insecurity; this also acts to promote cultural stability in facilitating traditional meals, and offsets the concerns many refugee women report in feeling unsafe shopping in foreign environments (Nisbet et al., 2022). In terms of education, the UNICEF’s Syria Education Sector Analysis (2016) recommendations include regular psychosocial counselling/group sessions in schools, increased study opportunities for women and girls with unfinished education due to early marriage, remedial/catch-up/evening classes, increasing safety/weather proofing of school facilities, establishing emergency plans involving parents and students to promote safety and confidence, and structured recreational and cultural activities to aid in psychosocial healing. Primary concerns surrounding vaccines are those of typically non-mandatory vaccines (e.g. HPV) in this population, whilst mandatory vaccines (E.g. Polio, Hep B etc.) maintain a high adherence rate in destination countries - the lack of education on, and out of pocket cost of, elective vaccinations is directly linked to reduced compliance; it must also be noted that the main variable in vaccination status was country of origin, as such given Syrians in Lebanon have higher vaccination compliance than the native population - justifying the necessity of both subsidising and educating this population for palpable population health effects (Kmeid et al., 2019).

Conclusion
In conclusion, Syrian refugees remain a significantly at-risk population in both their internal and international settings as a consequence of the conflict in their nation. Education as a social determinant has been shown to play a palpable role in either uplifting or hindering a variety of socioeconomic health factors including, but not limited to, policies surrounding housing, economics, employment, transportation and income, factors and behaviours contributing to health deficiencies and psychosocial status and direct health deficits in the form of individual physiological ailments and deficiencies. Multiple global and country-based interventions have been described in this paper including cash supplements for food and public access to schooling and health in destination countries; however overall, the recommendations outside of the already existing interventions surrounding compound approaches to integrating Syrians into their wider communities as well as providing the static resources necessary for survival (e.g., Community kitchens, facilitating education detriments due to early marriages, education on non-mandatory vaccines etc.). Thus, while the many risk factors attributed to this population are substantial – the promotion of collaboration and cultural integration as added factors to current measures can help to alleviate almost every concerning at risk factor in these cases.

Media

 * 1) UNICEF. (2022). Maisa, 3, receiving oral polio vaccine (OPV) in Al-Hol camp, northeast Syria, as part of a five-day national immunization campaign aiming to reach 2.7 million children across Syria. [Image]. Retrieved 1 June 2022, from https://www.unicef.org/press-releases/unicef-and-partners-provide-vaccination-against-polio-and-measles-nearly-232000.
 * 2) Beauchamp, Z. (2015). The Syrian refugee crisis, explained in one map [Image]. Retrieved 1 June 2022, from https://www.vox.com/2015/9/27/9394959/syria-refugee-map.
 * 3) Channel 4 News. (2015). Syrian refugees: the women fleeing domestic violence [Video]. Retrieved 11 June 2022, from https://www.youtube.com/watch?v=pmI3dimX8w0&ab_channel=Channel4News.