Rashes, Chills and Stomach Pain Drive Children Out of School in Ghana, Study Finds

When a child in the Ho Municipality of Ghana falls ill, the consequences often reach far beyond the clinic waiting room. A new study conducted at Ho Polyclinic, the main government primary healthcare facility serving the municipality in the Volta Region, has found that roughly two-thirds of school-aged children who sought care for an illness went on to miss at least one full day of school because of that illness. The finding, published in Public Health in Practice, offers one of the most detailed facility-based pictures yet of how everyday sickness translates into lost classroom time in a low- and middle-income setting, and it challenges some long-held assumptions about which symptoms matter most for school attendance.

The research team, led by Anthoinette A. Ekuban and Frank E. Baiden, enrolled 644 children aged 5 to 17 years who visited Ho Polyclinic between January and June 2025 with a range of disease conditions. Rather than relying on a single snapshot, the investigators used a prospective longitudinal design: after the initial clinic visit, trained research assistants followed each child for fourteen calendar days, corresponding to roughly ten school days, contacting caregivers by phone or in person to record how many school days were missed, whether the child returned to class, and whether any new symptoms emerged. Follow-up data were recorded for 98.1 percent of enrolled children, a remarkably complete capture rate for this kind of fieldwork, and the number of days missed was documented for 426 children.

The headline result was striking. Of the children followed, 66.3 percent missed school due to their illness episode. That figure is far higher than population-based estimates from other settings, such as the 4.9 percent absenteeism reported among school-going children in India or the 5.8 percent chronic absenteeism recorded in the United States, but the comparison comes with an important caveat. Those population figures draw on all school-age children regardless of whether they are unwell, whereas this study sampled only children sick enough to seek care at a clinic. Similar facility-based studies have reported comparable rates, including 72.5 percent absenteeism among clinic-attending school children in Nigeria and frequent class absence among 70 percent of students with malaria in Ibadan. The pattern suggests that once a child is ill enough to reach a health facility, lost schooling is almost the default outcome in this region.

The demographic findings carry their own surprises. In the adjusted multivariable model, both age and educational level were significantly associated with absenteeism, but in opposite directions. Children aged 10 to 13 years had 1.63 times the odds of missing school compared with those aged 5 to 9, and adolescents aged 14 to 17 had 2.51 times the odds. Yet children in junior high school had only 0.41 times the odds of absenteeism, and senior high school students just 0.28 times the odds, relative to primary school pupils. Because age and educational level are tightly correlated in this sample, with older children concentrated in the higher school levels, the authors argue that educational level is the more robust and consistent correlate. Primary school children emerged as the group at consistently highest risk of losing school days to illness.

The researchers offer several possible explanations for this protective pattern among older students. Junior and senior high school students may manage their own illnesses more effectively, feel stronger motivation to attend, or practice what epidemiologists call presenteeism, showing up in class despite mild symptoms. High-stakes examinations at these levels may also incentivise attendance even during illness, which would reduce measured absenteeism without necessarily reflecting better health. Caregiver behaviour may play a role as well: parents tend to be more protective of younger children and more likely to keep them home when they are unwell, while older children may be encouraged to push through minor ailments. The authors caution that the positive age association, once school level is accounted for, may partly reflect a subgroup of older children still enrolled in primary school, perhaps due to delayed enrolment, and they recommend testing an age-by-education interaction in future work. They also acknowledge that household income, parental education, and caregiver health literacy were not measured and could confound these relationships.

Perhaps the most technically interesting part of the study lies in its handling of symptom data. The seven recorded symptoms were severely inter-correlated; headache and fever, for instance, correlated at r = 0.97, and a cluster of chills, abdominal pain, cough, and vomiting showed variance inflation factors between 4.6 and 7.1. Rather than forcing all symptoms into a single mutually adjusted model, which would have produced unstable estimates, the team adjusted each symptom separately for age, sex, educational level, and principal diagnosis. The results upended expectations. Skin rashes showed the strongest association with absenteeism, with an adjusted odds ratio of 1.91, followed by chills at 1.87 and abdominal pain at 1.69. Fever, cough, vomiting, and headache were not significantly associated with missed school once the other factors were accounted for, a genuinely different conclusion from earlier analyses that did not address the underlying collinearity.

The authors had originally hypothesised that fever, cough, and vomiting would dominate, consistent with prior literature linking respiratory and febrile illness to absence. Their interpretation of the actual pattern is that skin conditions, which were the most common principal diagnosis in the sample at 37.3 percent, are visible to caregivers and teachers and therefore prompt more consistent school exclusion, while chills and abdominal pain often signal systemic illness that demands caregiver attention even when fever itself is not documented. Dermatological conditions were followed by respiratory conditions at 11.8 percent, diarrhoeal disease at 11.3 percent, and malaria at 9.5 percent among the principal diagnoses. Notably, no diagnostic category was independently significant in the adjusted socio-demographic and diagnostic model, suggesting that the symptom profile and the child’s school level matter more than the formal diagnosis label in predicting who stays home.

The study’s methodological strengths are considerable for a single-facility investigation. Clinical assessments and laboratory investigations, including haemoglobin testing, malaria rapid diagnostic tests, and sickling tests, allowed diagnoses to be verified rather than relying solely on caregiver recall. The sample of 644 consecutively recruited children yielded 421 events in the main model, an events-per-variable ratio of 28.1, comfortably above accepted thresholds, and model fit was satisfactory by both Hosmer-Lemeshow testing and an area under the receiver operating characteristic curve of 0.648. The prospective two-week follow-up captured additional school days missed beyond the initial visit, and the study addresses an age group, 5 to 17 years, that is chronically under-represented in Ghana’s routine child-health data, which have historically prioritised children under five in line with global child-survival agendas.

The limitations are equally clearly stated. Because the sample was restricted to children who sought care at one polyclinic, the findings likely overestimate absenteeism relative to the general child population and cannot be generalised municipality-wide. Symptoms were recorded as present or absent from caregiver recall at a single time point, without severity or duration, both of which likely influence attendance decisions. Time from symptom onset to care-seeking was not measured, so the high absenteeism may reflect a combination of illness severity, delayed care-seeking, and caregiver decision-making that the present data cannot disentangle. Several adjusted estimates, particularly for mode of transport, carry wide confidence intervals reflecting small subgroup sizes.

The practical implications are nonetheless concrete. The authors recommend that health workers at first-contact facilities routinely ask about school attendance during illness visits, especially when children present with chills, abdominal pain, or skin rashes, so that the educational impact of illness becomes part of clinical management. Schools, particularly primary schools where risk was highest, should implement health programmes and regular screening to detect and treat illness before absences accumulate. Health education targeted at caregivers of primary-school-aged children should address the timing of care-seeking and safe return to school. The authors also flag a double-edged concern: if older students attend school while symptomatic, they may spread infections to classmates and teachers, a possibility with direct implications for outbreak control that deserves dedicated study. As the authors conclude, common acute illnesses remain a major contributor to lost schooling among care-seeking children, and strengthening collaboration between the health and education sectors could convert these epidemiological insights into classrooms that stay full.

Subject of Research: Illness-related school absenteeism and its socio-demographic and clinical correlates among school-aged children in Ho Municipality, Ghana

Article Title: Illness-related school absenteeism among children attending a primary healthcare facility: Socio-demographic and clinical correlates in Ho municipality, Ghana

Article References: Ekuban, A. A., & Baiden, F. E. (2026). Illness-related school absenteeism among children attending a primary healthcare facility: Socio-demographic and clinical correlates in Ho municipality, Ghana. Public Health in Practice, 12, Article 100863. https://doi.org/10.1016/j.puhip.2026.100863

Image Credits: AI Generated

DOI: 10.1016/j.puhip.2026.100863

Keywords: school absenteeism, child health, Ghana, primary healthcare, skin rashes, chills, abdominal pain, malaria, dermatological conditions, public health, sub-Saharan Africa, school health programmes