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Medicine and SocietyTHE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 13, No.6, 2000

School drop-out: A public health approach

VIKRAMPATEL, NANDITADESOUZA

INTRODUCTIONThe recent Human Development Report has reminded us of thestark truth that South Asia is the most illiterate region in theworld.' One of the major reasons for the persistently high levelsof illiteracy and poor educational achievement is the low schoolretention rate. Thus, 2 out of 5 children entering primary schoolwill not graduate to secondary school. As a result of highrepetition rates, nearly one-fifth of students in primary schooldo not belong to the primary school age group.' The publichealth and economic implications of high drop-out and repeti-tion rates are all too obvious. Thus, nowhere in the world is theproblem of child labour so glaring. More than 50 million childrendo not receive education, many of them spend their childhoodworking at home, in the fields or in factories.' Besides the lossof the unique childhood opportunity of education, children outof school are more likely to suffer from poor health, in part dueto consequences of working. Lack of education permanentlylimits the opportunity of acquiring a secure job in adulthoodand escaping from poverty. Adult health is also compromised;low education is linked to poorer mental and physical healthoutcomes." Indeed, a low school completion rate is one of thebiggest threats to human development in India. It is imperativeto find ways to reduce this and, to do so, one must examine thepotential risk factors for the high drop-out rate.

We attempt to provide a fresh perspective on school drop-out so that preventive interventions could be planned. Weconsidered the existing evidence on potential risk factors forschool drop-out, and hypothesized that a range of neglectedfactors related to child development and family environment areimportant causes of school drop-out. The determinants of thiscomplex educational outcome extend beyond the boundaries ofsocio-demography and academics. Finally, we describe a re-search design, based on treating school drop-out as an adversehealth outcome, which can unravel the various causal mecha-nisms involved and provide the evidence base for interven-tions.

RISK FACTORS FOR SCHOOL DROP-OUTWhy do children drop out of school in India? The most widelyaccepted hypothesis is that poverty is the major risk factor."The hypothesized mediating routes linking poverty with drop-out most commonly include the fact that children in poorfamilies need to work and contribute to the household income,

Institute of Psychiatry, London, UKVIKRAM PATEL MacArthur Population FellowSangath Centre for Child Development and Family Guidance,

Goa 403521, IndiaNANDITA DE SOUZA Developmental Paediatrician

Correspondence to VIKRAM PATEL, Sangath Centre, 841/1Porvorim, Goa 403521; vpatel@goaI.dot.net.in

© The National Medical Journal of India 2000

and that poor families are less likely to be motivated to ensureschool completion. This implies that alleviating poverty is thekey intervention to reducing school drop-out. However, theevidence linking poverty with school drop-out is entirely basedon cross-sectional survey data. Therefore, it is also possiblethat child labour and poor parental motivation are the result ofschool drop-out, or that low parental motivation is the result ofpoor educational standards. Another common assumption isthat parental motivation to send children to school is low.Again, this assumption has been shown to be unfounded by therecent Public Report on Basic Education which sampled 188villages in 5 large and poor Indian states." More than 98% ofparents reported that they felt that it was important for a boy tobe educated (and 89% reported the same for girls). Ecologicalevidence also suggests that the linkage between poverty anddrop-out is likely to be confounded by other mediating factors.For example, Kerala which is a relatively poor state has very highschool completion rates, while Goa, a much wealthier state, iscomparatively worse off; of the 34 350 students enrolled in thethird year of primary education in Goa in 1982-83, less than one-third completed their secondary schooling." Thus, the associa-tion between poverty and drop-out, though demonstrable incross-sectional survey data, does not offer clues towardspractical interventions. While poverty may, in some children,directly lead to drop-out, it is highly likely that a range of'confounders' associated both with poverty and drop-out alsoplaya major and, as yet, undefined role. Identifying these moreproximal mediating risk factor variables is an important tasksince they may provide better opportunities for preventiveinterventions.

If we consider the analogy of diarrhoeal diseases in children,poverty is a clearly demonstrable risk factor. However, themediating processes are varied and include, for example, unhy-gienic living conditions and contaminated drinking water. Whilethe long term strategies for control of diarrhoeal diseases clearlyinclude poverty alleviation, strategies aimed at improving per-sonal hygiene, use of oral rehydration salts and other methodscan contribute significantly to reducing morbidity and mortality.

What are the possible mediating processes or other riskfactors for drop-out? Figure 1 provides a framework for consid-ering the multifactorial basis for the aetiology of drop-out. Themajor mediating factor immediately proximal to drop-out islearning under-achievement. The PROBE study found thatunder-performance of children in the existing educational sys-tem was one of the commonest reasons for drop-out. 4 Themagnitude of low learning achievement is best demonstrated bythe 1991 survey of 65000 grade 4 rural students which found thatthe average achievement was less than 50% in basic skills ofmathematics, reading comprehension and spelling.' Learningunder-achievement, in turn, is the result of a number of other

MEDICINEAND SOCIETY

POVERTY--.--------.------------~

~Child development factorse.g. iodine deficiency,learning disabilities;environmental toxins (e.g.lead); attention-deficithyperactivity disorder

tSocial and family factorse.g. domestic violence; poorparental supervision, first-generation learners

Scholastic and pedagogic factorse.g. poor school facilities;inappropriate curriculum;language difficulties

~LEARNING UNDER-ACHIEVEMENT

+DROP-OUT~~~--------------~FIG 1. The pathways from poverty to school drop-out

factors, many of which are also strongly associated with pov-erty and may thus be confounders or mediators for the associa-tion between poverty and drop-out. Of these, pedagogic fac-tors have received some attention with the evidence of poorschool facilities, teaching standards and inappropriate cur-ricula being cited by other authors.'>

CHILD MENT AL HEALTH AND LEARNING DISABILITYOne group of factors, which has been largely ignored in thedebate on learning under-achievement and drop-out in India,concerns child development and mental health. Epidemiologi-cal research from many developing countries shows that thesedisorders are common and that, although there are reliablemethods of detecting them, the problems are unrecognized inthe vast majority of children+" Studies specifically examiningthe causes of school failure have found that emotional andlearning disorders are among the most important factors. Astudy which screened 2190 Zulu children who had to repeatschool entry grades showed that sensory deficits, a lack ofeducational preparation, starting school too young and verystrict discipline leading to student anxiety were factors thatcontributed to failure." A Kenyan study showed that among441 students referred by primary schools for poor academicperformance, learning disabilities and emotional problems werethe commonest causes." An American study reported thatadolescents facing academic challenges due to learning dis-abilities and language deficits, with the resulting inability tomeet the demands of the school environment, can present withschool refusal."

A handful of Indian studies also demonstrate a high preva-lence of child development disorders and their linkage to poorscholastic performance. A survey of 1535 primary school child-

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ren from schools in Bangalore city found that about 18%suffered from psychological disturbance and 15% from learningdisability. The authors of this study describe the impact oflearning problems as including inferior school work, poor con-centration, failure to carry out tasks, low motivation and under-achievement. 11 In rural primary school children observed fortwo years, 13% of those having an IQ = 90 were found to havepoor achievement in arithmetic and teachers' assessment."This study suggested a high prevalence of specific learningdisabilities in these children, none of which were recognized bythe education or health providers. Learning disabilities arecommoner in poorer children for a variety of reasons. Theseinclude biological factors related to poor nutrition'? and greaterexposure to environmental toxins such as lead as well aspsychosocial factors such as poorer learning environments athome and lack of parental supervision." In educational systemsalready stretched by inadequate resources, crowded class-rooms and inconsistent quality, it is plausible to hypothesizethat learning and emotional problems account for a significantproportion of the drop-out rate. Indeed, there exists a small bodyof evidence linking learning disabilities with drop-out andrepetition in Indian schools. One study in rural Maharashtrafound on the basis of a psychological screening test that morethan 80% of the 172 children in the drop-out group had somedegree of learning disability.

EPIDEMIOLOGICAL FRAMEWORKThere is a serious risk that the gains made by increasing primaryschool enrolment in India may be considerably offset by thehigh drop-out and repetition rates. It is estimated that economicreturns from primary education are reduced by 34% to 52%when repetition and drop-out rates are taken into account." Wehypothesize that a significant proportion of children may leaveschool because of a learning disability, behavioural problem orfamily pathology which is potentially amenable to specificeducational, social and health interventions. Programmes aimedat reducing school failure include a multifaceted range ofinterventions such as early diagnosis and management of childdevelopmental and mental health problems, anticipatory guid-ance for parents and interventions geared to family problems."

The obvious implication of this hypothesis is that one neednot wait for poverty alleviation, a distant goal in South Asia, toassure higher school completion rates. Interventions geared toindividual children and families may lead to improved retentionrates in all economic classes. An epidemiological frameworkwhich treats school drop-out as an outcome can provide thenecessary evidence on which intervention strategies may bedesigned. One possible design may be a school-based studywhich identifies children who drop out prospectively and useschild, teacher and parent interviews, records data pertaining tochild development and home environment.

Multivariate analyses of demographic, economic, child devel-opment and other factors may then provide a clue as to the keypredictors of drop-out and thus, the potential short term interven-tion strategies. The ultimate goal must be to return the childrenwho drop out back to mainstream schooling through adequatemodifications to meet their specific educational needs. Thepresent strategy of providing non-formal or vocational educa-tion for children out-of-school may well serve as a pragmaticalternative for some children but cannot be a suitable substitutefor mainstream schooling because it risks the creation of a two-tier system which leads one tier (the rich) to educational qualifi-

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cations and the hope of future prosperity and security, and theother tier (the economically disadvantaged) to the hope ofachieving literacy with nebulous long term goals.

Children who drop out should be helped to return to main-stream school after assessment and remediation of the prob-lems. This should be the long term objective for all children. Thecreation of a child surveillance system involving child guidanceprofessionals and educationists would help to do this. It is clearthat partnerships in mental health, social work and educationare required to devise models for investigation and interventionin school drop-out. Such an integration of perspectives wouldbe imperative to adequately address a problem that cuts acrossdisciplines and has an effect on the quality of life of individualsand the wealth and health of nations.

ACKNOWLEDGEMENTSWe are grateful to Robert Goodman and Martin Prince for theircomments on the current version of this paper, and to H. P. S. Sachdevwho reviewed an earlier version.

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ObituariesMany doctors in India practise medicine in difficult areas under trying circum-stances and resist the attraction of better prospects in western countries and in theMiddle East. They die without their contributions to our country being acknowl-edged.

The National Medical Journal of India wishes to recognize the efforts ofthese doctors. We invite short accounts of the life and work of a recentlydeceased colleague by a friend, student or relative. The account in about 500 to1000 words should describe his or her education and training and highlight theachievements as well as disappointments. A photograph should accompany theobituary.

-Editor