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Article
The Impact of Sickle Cell Disease on Academic Performance
among Affected Students
Abdulaziz Alhazmi 1,2, * , Khalid Hakami 3 , Faisal Abusageah 3 , Essa Jaawna 3 , Meshal Khawaji 3 ,
Essam Alhazmi 3 , Basem Zogel 3 , Salman Qahl 3 and Ghadeer Qumayri 3
1
2
3
*
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Citation: Alhazmi, A.; Hakami, K.;
Abusageah, F.; Jaawna, E.; Khawaji,
M.; Alhazmi, E.; Zogel, B.; Qahl, S.;
Qumayri, G. The Impact of Sickle Cell
Disease on Academic Performance
among Affected Students. Children
2022, 9, 15. https://doi.org/10.3390/
children9010015
Received: 12 November 2021
Accepted: 21 December 2021
Published: 27 December 2021
Department of Microbiology and Parasitology, College of Medicine, Jazan University,
Jazan 45142, Saudi Arabia
Emerging and Epidemic Infectious Diseases Research Unit, Medical Research Center, Jazan University,
Jazan 45142, Saudi Arabia
College of Medicine, Jazan University, Jazan 45142, Saudi Arabia; [email protected] (K.H.);
[email protected] (F.A.); [email protected] (E.J.); [email protected] (M.K.);
[email protected] (E.A.); [email protected] (B.Z.); [email protected] (S.Q.);
[email protected] (G.Q.)
Correspondence: [email protected]; Tel.: +966-7-3295000
Abstract: Background: Sickle cell disease (SCD) is a genetic disease that is highly prevalent in Jazan
Province, Saudi Arabia, and is mostly characterized by many complications such as vaso-occlusive
crises (VOC), acute chest syndrome (ACS) and well-documented neurological complications. These
complications may affect patients’ academic performance. Methods: An observational, cross-sectional,
retrospective study was conducted in Jazan Province. General and demographic data were collected
and questions about academic performance of students with SCD were answered. Both t-tests and chisquare tests, along with multiple logistic regression, were used for analysis. Results: 982 participants
were selected for this study with a mean age of 23 years (SD: 7). Most of the participants were female
(64%). The number of participants with SCD was 339 (36%), of whom 42% were male. Students with
SCD recorded lower grade point averages (GPA) and more absences compared to healthy participants.
Further, about 60% of students with SCD thought they performed better than 40% of the participants
without SCD during the COVID-19 pandemic when most of the educational activities were online.
Conclusion: As has been previously reported, this study suggested that the academic performance
of students with SCD is negatively affected compared to healthy individuals, and this is mostly
due to complications associated with the disease. Further, students with SCD acknowledged better
performance with online education, an option that should be considered to improve their academic
performance. National studies on a larger population are required by health and education officials,
and supportive online educational programs are warranted to enhance the academic performance of
this population.
Keywords: sickle cell disease; hemoglobinopathies; Saudi Arabia; Jazan
Publisher’s Note: MDPI stays neutral
with regard to jurisdictional claims in
published maps and institutional affiliations.
Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
1. Introduction
Sickle cell disease (SCD) is a genetically inherited hematological disorder that affects
red blood cells (RBCs) and results in abnormal hemoglobin (Hb) [1–3]. Sickle cell anemia
(SCA) is the most common and severe hereditary form of SCD [1,3]. Affected individuals
are more likely to experience painful episodes known as vaso-occlusive crisis (VOC), which
are considered a hallmark of the disease and which occur due to occlusion of small blood
vessels by abnormally shaped RBCs [1]. Some complications that can occur are chronic
hemolytic anemia, acute chest syndrome (ACS), cerebrovascular accident (CVA), repeated
infections, hypoxia, and growth impairment [4]. According to the Center for Disease
Control and Prevention (CDC), SCD affects millions of people worldwide and is more
common in sub-Saharan Africa, Saudi Arabia, India, south and central America, and the
Children 2022, 9, 15. https://doi.org/10.3390/children9010015
https://www.mdpi.com/journal/children
Children 2022, 9, 15
2 of 12
Mediterranean countries [5]. The estimated number of SCD patients living in the United
States of America (USA) in 2020 was approximately 100,000 [6].
The Middle Eastern and North African regions have a higher prevalence of SCD than
the rest of the world [3] due to multiple factors, such as consanguineous marriages among
first-degree relatives, lack of effective screening programs, and malaria [5,6]. In Africa, it
is estimated that about 12 to 15 million have SCD [7]. In addition, approximately 75% to
85% of children born with SCD are born in different regions of Africa with a mortality rate
that ranges from 50% to 80% for affected children under the age of 5 years [7,8]. In the
Middle East, the highest prevalence of SCD and sickle cell trait (SCT) has been reported
in the eastern region of Saudi Arabia (2.6% for SCD, and 2% to 27% for SCT, respectively)
followed by Jazan [9,10]. Jazan Province, in south-western Saudi Arabia, is considered one
of the most affected regions by this disease. It was found in a study carried out in 2020 that
the complications associated with SCD, such as VOC and ACS, were the most common
cause of hospital admission in Jazan [10]. CVA, VOC, growth impairment, in addition
to central nervous system (CNS) complications, such as stroke, silent cerebral infarction,
and cognitive impairment, could occur in students with SCD and negatively impact their
academic performance, leading to academic achievement challenges, fewer career options,
and in some people could have psychological and social impacts [11]. Thus, in this study,
we aim to evaluate the academic performance of students with SCD compared to healthy
participants, and to assess factors associated with poor academic performance.
2. Methods
We conducted this study using a cross-sectional observational design in Jazan Province
located in the southwest corner of Saudi Arabia. The province harbors almost 1.7 million
inhabitants [12]. We included all students of male and female sex in Jazan Province who
had already been diagnosed with SCD and enrolled in middle school, high school, or
university. A question was directed to the participants about whether they had been
diagnosed with SCD. Individuals with no history of SCD were allowed to continue the
survey for comparison purposes. Our exclusion criteria included individuals’ having
other comorbidities, being primary school students, and being outside of Jazan Province.
Data were primarily collected between August and September 2021 through an online
anonymous self-administrated questionnaire designed via Google Forms to be filled by
the participants. The distribution of the survey was based on the networks of the data
collectors and investigators. The questionnaire was designed after an extensive review
of the literature for related studies and after consulting experts in the field [4,13–15]. The
questionnaire started with demographic questions about matters such as age, gender,
current education level, parents’ monthly income, socio-economic status, level of parents’
education, and whether they had been previously diagnosed with SCD. Following this,
data regarding academic performance, absence and attendance in the last three years were
collected. Finally, participants were asked if their academic performance had been affected
during COVID-19, during which period the educational activities were conducted online.
Before the distribution of the survey, a pilot sample (n = 20) was used to assess the clarity
and wording of questionnaire items. Data from this pilot sample were excluded from the
analysis. For the sample size, we assumed that there were about 4500 patients with SCD in
Jazan Province [16]. The sample size for this study was calculated using the Raosoft sample
size calculator (Raosoft Inc., Seattle, WA, USA, raosoft.com) and 351 patients with SCD
were needed to reach a 95% confidence interval and 5% margin of errors. The sampling
design used was a simple random sampling technique, where we selected students with
SCD from the whole group of participants. Descriptive statistics were reported for the
collected data. Both the chi-square and the t-test were performed, and a multivariate
analysis was performed using SPSS v.23 (IBM Corp., Armonk, NY, USA), with the alpha
criterion for p-value set at 0.05. Ethical approval for conducting this study was obtained
from the ethical approval committee at Jazan University (reference number: REC42/1/087;
Children 2022, 9, 15
3 of 12
date: 22 March 2021). Written consent was obtained from all participants or their tutors
prior to participation in the study.
3. Results
The survey was completed by a total of 928 participants who met our inclusion criteria.
Most of the participants were female (64%), with a mean age of 23 (SD: 7). More than
two-thirds of the participants were currently enrolled at the university, with 21% and 10%
in high school and middle school, respectively. About 36% of the participants had been
diagnosed with SCD (n = 339). More than half of the participants (either with or without
SCD) recorded excellent performance based on their GPA for the previous three years,
between 2018 and 2021. Further, 48% of the participants reported missing between 7 to
14 days in the 2019–2020 academic years, while 33% and 19% reported missing fewer than
7 days and more than 14 days, respectively. These data are summarized in Table 1. We
analyzed the data from the participants who had been diagnosed with SCD (36%, n = 339)
(Table 2). Most of the participants with SCD were female (58%), with a mean age of 21
(SD: 6). Half of the participants with SCD were currently enrolled at the university. The
academic performance of participants with SCD between 2018 and 2021 seemed variable,
with more than one-third of them having either excellent or very good performance, based
on their GPA. About 40% of the participants with SCD reported missing more than 14 days
in the last year and half of them acknowledged better academic performance during the
COVID-19 pandemic, as most academic activities were conducted online. In Table 2, using
univariate analysis, we compared participants who had been diagnosed with SCD with
otherwise healthy individuals. We found the participants with SCD to be significantly
younger compared to those without SCD (21 vs. 24 years, p = 0.0001). Further, we had
more male participants in the SCD group compared to the healthy group (42% vs. 32%).
A significant difference was found between participants with SCD and the healthy group
regarding their city of residence (Table 2). Regarding parents’ education level and monthly
income, no significant difference was recorded. Current education level was significantly
different between the two groups (p = 0.0001 *). Moreover, the healthy group significantly
recorded better academic performance in 2018, 2019 and 2021 (p = 0.0001, p = 0.003 and
p = 0.025, respectively), and they significantly reported missing fewer days, compared
to participants with SCD (p = 0.0001). During the COVID-19 pandemic, the SCD group
answered that they had better academic performance (59% vs. 42%) compared to the
healthy group (p = 0.0001). A multivariate analysis was performed for variables associated
with SCD (Table 2). In Table 3, cumulative GPAs between 2018 and 2021 were calculated
and analyzed for the participants with SCD. Female and younger participants had better
academic performance. Further, better academic performance was associated with higher
educational level and higher monthly income for parents. Participants with better academic
performance reported missing fewer days and acknowledged better performance during
the COVID-19 pandemic.
Table 1. General characteristics of the participants in our study.
Variable
Participants, n = 928
Age, years (mean; SD)
Male, n (%)
23; 7
333 (36%)
Residence, n (%)
Jazan
Abu Arish
Sabya
Samtah
Ahad Almasarhah
Damad
Farasan
Faifa
112 (12%)
122 (13%)
146 (16%)
217 (23%)
138 (15%)
64 (7%)
4 (0.25%)
9 (1%)
Children 2022, 9, 15
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Table 1. Cont.
Variable
Participants, n = 928
Alardah
Ahurrath
Addair
Ad drab
Baish
Alaidabi
35 (4%)
4 (0.25%)
8 (1%)
14 (1.5%)
39 (4%)
16 (2%)
Father’s highest education, n (%)
Uneducated
High school
University level
Postgraduate level
107 (12%)
357 (38%)
415 (45%)
49 (5%)
Mother’s highest education, n (%)
Uneducated
High school
University level
Postgraduate level
276 (30%)
347 (37%)
279 (30%)
26 (3%)
Monthly income (SAR), n (%)
Less than 3000
3000 to 5000
5000 to 10,000
10,000 to 20,000
20,000 to 20,000
More than 30,000
208 (22%)
224 (24%)
172 (19%)
176 (19%)
90 (10%)
58 (6%)
Current education level, n (%)
Middle school
High school
University
95 (10%)
195 (21%)
638 (69%)
Have been diagnosed with sickle cell anemia, n (%)
No
Yes
405 (64%)
339 (36%)
GPA for 2018–2019 academic year, n (%)
Excellent
Very good
Good
Acceptable
Weak
Fail
488 (53%)
294 (32%)
104 (11%)
26 (3%)
4 (1%)
12 (1%)
GPA for 2019–2020 academic year, n (%)
Excellent
Very good
Good
Acceptable
Weak
Fail
519 (56%)
273 (29%)
103 (11%)
15 (2%)
5 (1%)
13 (1%)
GPA for 2020–2021 academic year, n (%)
Excellent
Very good
Good
Acceptable
Weak
Fail
540 (58%)
251 (27%)
102 (11%)
14 (1%)
6 (1%)
15 (2%)
Reported missing school days between 2019 and 2020?
Less than 7 days
Between 7 and 14 days
More than 14 days
303 (33%)
448 (48%)
177 (19%)
Children 2022, 9, 15
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Table 1. Cont.
Variable
Participants, n = 928
Is your academic performance affected during COVID-19?
Not affected
Yes, better performance
Yes, worse performance
303 (33%)
448 (48%)
177 (19%)
SD: Standard deviation. SAR: Saudi Riyals.
Table 2. Comparison between healthy participants and participants with SCD.
Univariate Analysis &
Multivariate Analysis &&
Variable
Participants without
SCD = 589 (64%)
Participants with
SCD = 339 (36%)
p-Value #
aOR
95% CI
Age, years (Mean; SD)
24; 7
21; 6
0.0001 *
0.961 **
0.936–0.988
Male, n (%)
191(32%)
142 (42%)
0.002 *
–
–
Residence, n (%)
Jazan
99 (17%)
13 (4%)
0.134 **
0.035–0.512
Abu Arish
67 (11%)
55 (16%)
–
–
Sabya
96 (16%)
50 (15%)
–
–
Samtah
153 (26%)
64 (19%)
–
–
Ahad Almasarhah
67 (11%)
71(21%)
–
–
Damad
34 (6%)
30 (9%)
–
–
Farasan
3 (0.5%)
1 (0%)
–
–
Faifa
4 (0.5%)
5 (1%)
–
–
Alardah
18 (3%)
17 (5%)
–
–
Ahurrath
1 (0.5%)
3 (1%)
–
–
Addair
4 (0.5%)
4 (1%)
–
–
Ad drab
13 (2%)
1 (0%)
0.580 **
0.005–0.645
Baish
23 (4%)
16 (5%)
–
–
Alaidabi
7 (2%)
9 (3%)
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
0.0001 *
Father’s Highest education, n (%)
Uneducated
68 (12%)
39 (12%)
High school
225 (38%)
132 (39%)
University level
268 (46%)
147 (43%)
Postgraduate level
28 (5%)
21 (6%)
0.779
Mother’s Highest education, n (%)
Uneducated
166 (28%)
110 (32%)
High school
222 (38%)
125 (37%)
University level
186 (32%)
93 (28%)
Postgraduate level
15 (3%)
11 (3%)
0.398
Children 2022, 9, 15
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Table 2. Cont.
Univariate Analysis &
Variable
Participants without
SCD = 589 (64%)
Participants with
SCD = 339 (36%)
Multivariate Analysis &&
p-Value #
aOR
95% CI
Monthly income (SAR), n (%)
Less than 3000
131 (22%)
77 (23%)
–
–
3000 to 5000
150 (25%)
74 (22%)
–
–
5000 to 10,000
100 (17%)
72 (21%)
–
–
10,000 to 20,000
114 (19%)
62 (18%)
–
–
20,000 to 20,000
60 (10%)
30 (9%)
–
–
More than 30,000
34 (6%)
24 (7%)
–
–
3.251 **
1.851–5.708
2.580 **
1.674–3.977
0.49
Current education level, n (%)
Middle school
34 (6%)
61 (18%)
High school
99 (17%)
96 (28%)
University
456 (77%)
182 (54%)
0.0001 *
–
GPA for 2018-2019 academic year, n (%)
Excellent
337 (57%)
151 (45%)
–
–
Very good
184 (31%)
110 (32%)
–
–
Good
57 (10%)
47 (14%)
–
–
Acceptable
6 (1%)
20 (6%)
–
–
Weak
1 (0%)
3 (1%)
–
–
Fail
4 (1%)
8 (2%)
–
–
0.0001 *
GPA for 2019-2020 academic year, n (%)
Excellent
350 (59%)
169 (50%)
–
–
Very good
172 (29%)
101 (30%)
–
–
Good
54 (9%)
49 (14%)
–
–
Acceptable
7 (1%)
8 (2%)
–
–
Weak
1 (0%)
4 (1%)
–
–
Fail
5 (1%)
8 (2%)
–
–
0.003 *
GPA for 2020-2021 academic year, n (%)
Excellent
358 (61%)
182 (54%)
–
–
Very good
160 (27%)
91 (27%)
–
–
Good
55 (9%)
47 (14%)
–
–
Acceptable
7 (1%)
7 (2%)
–
–
Weak
4 (1%)
2 (1%)
–
–
Fail
5 (1%)
10 (3%)
–
–
0.089 **
0.056–0.140
0.340 **
0.217–0.532
–
–
0.025 *
Reported missing school days between 2019 and 2020?
Less than 7 days
376 (64%)
75 (22%)
Between 7 and 14 days
150 (25%)
119 (35%)
More than 14 days
63 (11%)
145 (43%)
0.0001 *
Children 2022, 9, 15
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Table 2. Cont.
Univariate Analysis &
Variable
Participants without
SCD = 589 (64%)
Participants with
SCD = 339 (36%)
Multivariate Analysis &&
p-Value #
aOR
95% CI
–
–
0.008 **
1.183–3.023
–
–
Did your academic performance was affected during COVID-19?
Not affected
218 (37%)
85 (25%)
Yes, better performance
249 (42%)
199 (59%)
Yes, worse performance
122 (21%)
55 (16%)
0.0001 *
SD: Standard deviation. SCD: Sickle Cell Disease. SAR: Saudi Riyals. # The alpha criterion for p-value was set to
0.05. * Significant in univariate analysis. ** Significant in Multivariate analysis. & Chi-squared test and t-test were
used for univariate analysis. && Multiple logistic regression was used for variable significantly associated with
SCD in univariate analysis.
Table 3. Cumulative GPA between 2018 and 2021 for participants with SCD and associated factors.
Variable
Cumulative GPA between 2018 and 2021 for Participants with SCD
Excellent
Very Good
Good
Acceptable
Weak
Fail
n
167
104
48
9
5
6
%
49%
31%
14%
3%
1%
2%
Age, years (Mean; SD)
20; 5
22; 7
22; 5
21; 5
30; 9
34; 5
p-Value #
0.0001 *
Sex, n (%)
Male
Female
54
49
25
4
5
5
38%
35%
18%
3%
4%
4%
113
55
23
5
0
1
57%
28%
12%
3%
0%
1%
0.001 *
Residence, n (%)
Jazan
Abu Arish
Sabya
Samtah
Ahad Almasarhah
Damad
Farasan
Faifa
Alardah
8
0
3
1
1
0
62%
0%
23%
8%
8%
0%
26
17
10
0
1
1
47%
31%
18%
0%
2%
2%
26
17
5
0
0
2
52%
34%
10%
0%
0%
4%
27
19
11
4
2
1
42%
30%
17%
6%
3%
2%
38
22
9
1
0
1
54%
31%
13%
1%
0%
1%
13
10
5
2
0
0
43%
33%
17%
7%
0%
0%
0
1
0
0
0
0
0%
100%
0%
0%
0%
0%
2
3
0
0
0
0
40%
60%
0%
0%
0%
0%
8
6
2
0
1
0
47%
35%
12%
0%
6%
0%
0.926
Children 2022, 9, 15
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Table 3. Cont.
Variable
Ahurrath
Addair
Ad drab
Baish
Alaidabi
Cumulative GPA between 2018 and 2021 for Participants with SCD
Excellent
Very Good
Good
Acceptable
Weak
Fail
2
0
1
0
0
0
67%
0%
33%
0%
0%
0%
3
0
1
0
0
0
75%
0%
25%
0%
0%
0%
1
0
0
0
0
0
100%
0%
0%
0%
0%
0%
7
7
1
0
0
0
47%
47%
6%
0%
0%
0%
6
2
0
1
0
1
60%
20%
0%
10%
0%
10%
p-Value #
Father’s highest education, n (%)
Uneducated
High school
University level
Postgraduate level
17
17
3
2
0
0
44%
44%
8%
5%
0%
0%
56
41
23
4
2
6
42%
31%
17%
3%
2%
5%
76
55
21
3
2
0
48%
35%
13%
2%
1%
0%
18
1
1
0
1
0
86%
5%
5%
0%
5%
0%
0.009 *
Mother’s highest education, n (%)
Uneducated
High school
University level
Postgraduate level
40
40
17
5
2
6
36%
36%
15%
5%
2%
5%
62
37
21
3
2
0
50%
30%
17%
2%
2%
0%
58
24
9
1
1
0
62%
26%
10%
1%
1%
0%
7
3
1
0
0
0
64%
27%
9%
0%
0%
0%
0.027 *
Monthly income (SAR), n (%)
Less than 3000
3000 to 5000
5000 to 10,000
10,000 to 20,000
20,000 to 20,000
24
27
14
4
4
4
31%
35%
18%
5%
5%
5%
35
27
8
2
0
2
47%
36%
11%
3%
0%
3%
35
20
15
2
0
0
49%
28%
21%
3%
0%
0%
40
14
7
1
0
0
65%
23%
11%
2%
0%
0%
15
12
3
0
0
0
50%
40%
10%
0%
0%
0%
0.005 *
Children 2022, 9, 15
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Table 3. Cont.
Variable
More than 30,000
Cumulative GPA between 2018 and 2021 for Participants with SCD
Excellent
Very Good
Good
Acceptable
Weak
Fail
18
4
1
0
1
0
75%
17%
4%
0%
4%
0%
p-Value #
Current education level, n (%)
Middle school
High school
University
30
21
6
2
1
1
49%
34%
10%
3%
2%
2%
40
28
22
1
1
4
42%
29%
23%
1%
1%
4%
97
55
20
6
3
1
53%
30%
11%
3%
2%
1%
0.114
Reported missing school days between 2019 and 2020?
Fewer than 7 days
Between 7 and 14 days
More than 14 days
49
15
11
0
0
0
65%
20%
15%
0%
0%
0%
61
42
14
2
0
0
51%
35%
12%
2%
0%
0%
57
47
23
7
5
6
39%
32%
16%
5%
3%
4%
0.001 *
Was your academic performance affected during COVID-19?
Not affected
Yes, better performance
Yes, worse performance
42
26
12
0
1
4
49%
31%
14%
0%
1%
5%
108
56
26
7
2
0
54%
28%
13%
4%
1%
0%
17
22
10
2
2
2
31%
40%
18%
4%
4%
4%
0.018 *
SD: Standard deviation. SCD: Sickle cell disease. SAR: Saudi riyals. # The alpha criterion for the p-value was set to
0.05. * Significant in univariate analysis.
4. Discussion
SCD is a genetic condition characterized by sickle-shaped RBCs due to abnormal Hb
formation. It causes a shorter lifespan by decreasing oxygen sufficiency of RBCs. Consequently, abnormal Hb and sickle-shaped RBCs harm different organs and cause various
complications [1]. This chronic illness necessitates frequent use of health services at many
levels: screening, immunizations, medications, blood transfusions, and hospitalizations
for various reasons, such as VOC, ACS, and repeated infections. All these measures are
in place to reduce associated morbidity and mortality [17]. Jazan Province has one of the
highest prevalences of SCD in the country. Alsaeed et al. reported that the prevalence of
SCD in Jazan was about 7% in 2017, with VOC and ACS as the major causes for hospital
admission for 56% and 12%, respectively, of this total [18]. Despite this prevalence rate, no
study in the region had assessed the academic performance of SCD patients. Thus, in this
study, we aimed to fill this gap in knowledge, as we found that the academic performance
of participants with SCD was significantly lower than that of healthy participants during
the reported years from 2018 to 2021 (Table 2). These results are in line with those from
another study conducted in Yemen in 2016 [13], which found a correlation between SCD
severity and the academic performance of the affected students. Another study in Iraq, conducted in 2019, reported the same findings: students with SCD recorded lower performance
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compared to their classmates [14]. Lower school performance is usually associated with
absenteeism among students with SCD. In our study, we found that 43% of the participants
with SCD were absent for more than 14 days per annum, compared to 11% of the healthy
participants in the 2019 academic year, i.e., before the COVID-19 pandemic (Table 2). In our
multivariate analysis, healthy students significantly reported missing fewer days compared
to the students with SCD (Table 2), and school absenteeism was significantly associated
with poorer performance among students with SCD (Table 3). This result is consistent
with Al-Saqladi’s data reported from Yemen; more than 60% of the study participants were
absent for more than 20 days between 2013 and 2014 [13]. In another study conducted
between 2015 and 2016, Abid et al. found that students with SCD missed significantly more
school days, with an average of 12 days, compared to the healthy participants (average:
3 days, p < 0.001) [14]. Similarly, in 2016, Olatunya et al. conducted a study in Nigeria and concluded that a lower Hb rate is significantly associated with a higher absence rate [15]. On the other hand, Olusoga et al. found no association between school absenteeism and academic performance of students with SCD. Notably, this was study was conducted in 2005 in Nigeria, and the sample size did not exceed 52 students with SCD [4]. Thus, we believe that the larger sample size used in our study elaborated the association between school absenteeism and academic performance for students with SCD [4]. Epping et al. reviewed the medical records for 197 students with SCD and compared their academic performance with those of their healthy classmates. They concluded that students with SCD are not at high risk for academic difficulties, since children with SCD benefited from the individualized educational programs (IEP) they frequently received [2]. Thus, these kinds of programs are urgently needed in our region and the lack of these programs could explain the significant correlation between school absenteeism and lower performance for students with SCD in the current study and other studies in the region [13,14]. Taken together, these findings elucidate the challenges that students with SCD encounter and necessitate that education officials in the concerned countries take these challenges into consideration, since they add another burden that could negatively affect the quality of life of students with SCD [2,19]. In our study, it seems that students with SCD recorded better performance during the 2021 academic year compared to their performance in 2019 (the percentage of SCD students with excellent GPAs in 2019 and 2021 was 45% and 54% respectively, p = 0.01) (Table 2). During this year, most of the educational activities in Saudi Arabia were held online due to restrictions during the COVID-19 pandemic [20]. Furthermore, almost 60% of the students with SCD acknowledged that they did better during the COVID-19 pandemic, compared to 41% of the healthy students (Table 2), and this was associated with a higher GPA among students with SCD (Table 3). These findings suggest that online IEP could lead to better performance and limit factors that might affect the academic performance of students with SCD, such as place of residence or direct and indirect disease complications [21]. Place of residence appears to have a significant effect when comparing participants with and without SCD (Table 2), and this may be due to consanguineous marriages that traditionally followed in some conservative tribes in Jazan Province and exceeded 55% in some regions of Saudi Arabia [22,23]. Memish et al. have evaluated the outcome over the six years (2004 to 2009) of the premarital screening programs that have been applied. They found that the prevalence of beta-thalassemia was markedly decreased, while the prevalence of sickle cell disease was constant. They concluded that a noticeable reduction was recorded in the number of at-risk marriages [24]. Despite this conclusion, the incidence of SCD in Jazan is still elevated, and follow-up programs and studies are highly warranted to ensure better compliance with the premarital screening program and counseling recommendations [2]. Also, other socioeconomic factors are significantly associated with poorer academic performance among students with SCD, such as parent education level and monthly income (Table 3). This result is consistent with various reports that correlated parents’ education, monthly income and chronic diseases that may affect children at a younger age and negatively affect their academic performance [25,26]. Children 2022, 9, 15 11 of 12 This study is the first to assess the academic performance of students with SCD in Jazan Province and one of the few such studies in Saudi Arabia, a country with a large burden of hemoglobinopathies in general and SCD specifically. We believe that this study may help to pave the way for IEP that can be conducted online for students with SCD, which our findings suggest resulted in a better performance for students with SCD during the COVID-19 pandemic, a period in which most of the educational courses were online. However, this study possesses many limitations. It was based on an online survey that relies on the networks of the investigator and data collectors, and may have led to a nonresponse bias due to the barrier of Internet accessibility in some areas and among a certain type of population. In addition, the questionnaire failed to include a question related to SCD treatment adherence or factors of severity and their direct impact on academic performance. Further, with such a methodology, we would not be able to confirm the disease status of our participants or their GPA. However, we believe that we include real regional data of students with SCD in the Jazan Province and patients’ viewpoints of their disease condition and the manner in which it could affect their academic performance. 5. Conclusions In this study, we found that the academic performance of students with SCD was negatively affected, and that they reported missing more days, compared to healthy students. These findings may be related to direct and indirect disease-related complications. Factors associated with better academic performance among participants with SCD are significantly related to female sex, younger age, having parents of higher education level and monthly income, and reporting fewer days missed and an acknowledged better performance during the COVID-19 pandemic. National studies on a larger population using official records are warranted and utilizing online IEP for students with SCD could result in a better performance for this group. Author Contributions: Writing of the first draft: A.A., K.H., F.A., E.J., M.K., E.A., B.Z., S.Q., G.Q.; Data analysis: A.A.; Editing, review, and revision of the manuscript: A.A.; Participation in data analysis, review of the manuscript, the concept, and the design of the study: K.H., F.A., E.J., M.K., E.A., B.Z., G.Q.; Supervision: A.A. All authors have approved the final manuscript as submitted and agreed to be held accountable for all aspects of the work. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Institutional Review Board Statement: The study was approved by the Research Ethics Committee of Jazan University, Saudi Arabia (IRB Approval number REC42/1/087, date 22 March 2021). Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. Data Availability Statement: The data presented in this study are available on request from the corresponding author. Acknowledgments: The authors are immensely thankful for the data collectors and the participants of this study. Conflicts of Interest: The authors declare no conflict of interest. References 1. 2. 3. 4. CDC. What Is Sickle Cell Disease? Available online: https://www.cdc.gov/ncbddd/sicklecell/facts.html (accessed on 22 October 2021). Epping, A.S.; Myrvik, M.P.; Newby, R.F.; Panepinto, J.A.; Brandow, A.M.; Scott, J.P. 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