Prevalence of functional difficulty among school-aged children and effect on school enrolment in rural southern India: A cross-sectional analysis

Prevalence of functional difficulty among school-aged children and effect on school enrolment in rural southern India: A cross-sectional analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prevalence of functional difficulty among school-aged children and effect on school enrolment in rural southern India: A cross-sectional analysis Bobeena Rachel Chandy, Calum Davey, William E Oswald, Saravanakumar Puthupalayam Kaliappan, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4154190/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Despite the large number of children in India, there is little information on the impact of children’s disability on school enrolment, and how this differs by population. We estimated the prevalence of childhood disability in two sites in Tamil Nadu, southern India, and the effect of functional difficulty on school enrolment. We used a parent-reported survey containing the UNICEF-Washington Group questions to identify children aged 5 to 17 years with functional difficulty during a census conducted for an ongoing trial. We estimated pooled- and gender-specific prevalence of functional difficulty among 29,044 children. We fitted regression models to identify subgroups with higher rates of functional difficulty and the effect of functional difficulty on reported school enrolment. We estimated the modification of the effect of functional difficulty by age, gender, socioeconomic status, household education, and sub-site, on additive and multiplicative scales. We found of 29,044 children, 299 (1.0%) had any functional difficulty, equal among boys and girls. Being understood (0.5%) and walking (0.4%) were the most common difficulties. Functional difficulty was strongly associated with non-enrolment in school (Prevalence ratio [PR] 4.59, 95% CI: 3.87, 5.43) after adjusting for age, gender, and site. We show scale-dependent differences between age and socioeconomic groups in the effect of functional difficulty on enrolment. This study shows that at least one in a hundred children in this region have severe functional difficulties and nearly half of these children are not enrolled in school, highlighting the need for further efforts and evidence-based interventions to increase school enrolment among these groups. functional difficulty disability school enrolment effect modification India Figures Figure 1 Figure 2 Highlights At least one in a hundred children have severe functional difficulties in this population in Tamil Nadu, India Functional difficulty was a strong predictor of school non-enrolment, independent of age, gender, and sub-site Rates of school inclusion for children with functional difficulties differed between age and socioeconomic groups Introduction Childhood disability continues to be a low priority on the global development and health agenda [ 1 ], despite the large and growing number of children affected, and the fact that the period of childhood and adolescence influences the entire life course [ 2 ]. The 2004 Global Burden of Disease Study estimated that 93 million or 5.1% of children aged 0–14 years had moderate/severe disability, of whom 13 million (0.7%) had severe disability [ 3 , 4 ]. More recent work has put these numbers far higher. For instance, the 2017 Global Burden of Disease Study estimated that there were 291 million (11.2%) children and adolescents with one of four specified “disabilities” (epilepsy, intellectual disability, vision or hearing loss)(5). This figure grows further if more conditions are included, which includes various impediments to functioning [ 1 , 6 ]. Not only is the number of children with disabilities large, but new research shows that it is rising as a result of population growth [ 1 ]. However, uncertainty remains about these figures due to variation in methods used to assess childhood disability, resulting in varying and non-comparable estimates. The UNICEF-Washington Group Child Functioning Module was introduced in 2017 to standardise the assessment of disability in children aged 2–17 years [ 7 ]. Its widespread use should increase the amount and comparability of international estimates, but to date few publications are available that have used this tool. No matter how disability is measured, children who are found to have disabilities are left behind in different domains of life, including in education. A 2018 UNESCO report demonstrated through data from 49 countries that people with disabilities had consistently worse educational outcomes compared to their peers without disabilities, whether measured in terms of school enrolment, school completion, mean years of schooling, or literacy levels [ 8 ]. Data from 6 countries also showed that out-of-school rate was higher among children with disabilities than children without in both primary school (34.5% versus 14.1%) and secondary school (25.7% versus 17.5%). Lower levels of education of children with disabilities were also shown in the 2011 World Report on Disability [ 3 ] and the 2018 Flagship Report on Disability and Development [ 9 ]. For example, having a disability reduced the probability of attending school by 30.9 percentage points in an analysis across 15 low and middle income countries [ 10 ]. The exclusion of children with disabilities from education is a violation of their rights, as set out by the UN Convention on the Rights of the Child (articles 23, 28 and 29) [ 11 ], and the UN Convention on the Rights of Persons with Disabilities (article 24) [ 12 ]. It will also make it more challenging to reach SDG 4 on “inclusive and equitable quality education,” which includes specific targets on eliminating gender disparity and discrimination against people with disabilities, among other priority groups [ 13 ]. Different rights and goals are interlinked, and it will be more difficult to achieve employment for all, as an example, without first reaching all with education. Children with disability are not a homogenous group, and their level of inclusion in education may be affected by a range of factors, such as gender, poverty level and impairment type. However, there is a lack of evidence of predictors of which children with disability are going to school. This gap is important as evidence is needed on which children with disability are most likely to be excluded to plan interventions to promote educational inclusion. Furthermore, there is currently a lack of data on which interventions are effective for improving uptake, and so evidence is first needed on the key issues before appropriate solutions can be developed [ 14 , 15 ]. The limited data that is available suggests that boys with disabilities may fare better than girls. The UNESCO data showed that boys with disabilities had almost one year more of schooling than girls with disabilities (5.4 versus 4.3), and men with disabilities had higher literacy rates than women with disabilities (62% versus 49%) [ 8 ]. Data from Plan International across 30 countries showed that children with certain impairment types were less likely to go to school, especially those with learning or communication impairments [ 16 ]. Generally, however, such data in relation to school attendance is lacking. India is an important country to consider for disability and educational inclusion, given its size and global influence. The 2011 Indian Census, using a simple assessment of disability (“Is this person mentally/physically disabled?”) estimates that 2.2% of the population had disabilities, including 1.5% of children aged 5–9 years and 1.8% of children 10–19 years [ 17 ]. These prevalence estimates are likely to substantially underestimate the true levels, given the simplicity of the question used [ 18 ]. Subsequently, a large community study from five diverse Indian sites showed that pooled estimates of prevalence of neurodevelopmental disorders (visual impairment, epilepsy, cerebral palsy, hearing impairment, speech disorders and autism for all children, and attention deficit hyperactivity disorder and learning disorder among 6–9 year-olds) were 9.2% and 13.6% in children 2–6 years and 6–9 years of age, respectively [ 19 ]. India has established a comprehensive legal framework for inclusive education. The Right to Education (RTE) Act of 2009 confirmed the right of all children to free and compulsory education [ 20 ]. The Rights of Persons with Disabilities Act 2016 made the commitment that “every child with benchmark disability between the age of six to eighteen years shall have the right to free education in a neighbourhood school, or in a special school, of his choice” [ 21 ]. The National Education Policy 2020 went further still and made a range of commitments towards the inclusion of children with disabilities, such as appropriate training of teachers, appropriate learning material (e.g. Braille), accessible facilities and protecting the safety of children with disabilities [ 22 ]. Moreover, India has ratified both the UN Convention on the Rights of Person with Disabilities (2007) and the UN Convention on the Rights of the Child (1992), which protect the right to education for children with disabilities. Barriers to accessing education remain, however, despite these commitments. As a result, school enrolment is far from complete. Estimates from the 2011 census show that 29% of all children aged 5–19 years do not attend school, but this rises to 39% of children with disabilities [ 17 ]. Enrolment was higher in primary than the higher levels of schooling and was better for children with certain types of impairment (hearing – 67%, seeing – 68%) than among children with intellectual impairments (47%), mental health conditions (34%) or multiple disabilities (37%). However, these estimates are now ten years out of date, and preceded some of the new legislation protecting the right to education of children with disabilities. Since 2011, the proportion of children in primary schools with disabilities has increased by 50% (0.8–1.2% of children enrolled in primary school in 2015/2016), although the proportion of children in secondary school with disabilities has remained unchanged (around 0.3%) [ 23 ]. This may represent improved recognition and reporting of disability, and these figures only capture children with official certifications of disability and do not capture children with disabilities out of school. The aim of this study was to use UNICEF-Washington Group questions to estimate the prevalence of childhood disability in a population in Tamil Nadu, India and to estimate the effect of functional difficulty on school enrolment and examine how this effect may differ between sociodemographic groups. Methods Study design and participants The DeWorm3 Project is a multi-country, cluster-randomised, controlled trial conducted in Benin, India, and Malawi to test feasibility of interrupting transmission of soil-transmitted helminths (STH) through three years of expanded mass drug administration (MDA) targeting all community members versus each of the current national STH MDA strategies. Each study site includes a population of at least 80,000 individuals, divided into 40 clusters of at least 1,650 individuals, considering administrative borders and geographic barriers. The trial in India has two sites in Tamil Nadu: the Timiri block in the Vellore Health Unit District (HUD) and villages in the Jawadhu Hills block of the Tiruvanamalai HUD. A census of all individuals residing within the study site is conducted yearly to enumerate the population [ 24 , 25 ]. The current study took place in the India DeWorm3 site, during a trial population census update activity conducted between October 19, 2019 and February 3, 2020. At each household, a structured questionnaire was conducted with the head of household or an equivalent adult resident. The questionnaire collected information on household member demographics, school enrolment or highest education level, household ownership of key assets, and water and sanitation facilities. Age and gender were verified using state or central Government of India issued identification ( Aadhar card, Electoral Identity Card, Driving License, or Birth Certificate). Enumerators observed the material of the floor, walls, and roof and collected Global Positioning System (GPS) coordinates at each household. All data were collected using an electronic questionnaire programmed using SurveyCTO software (Dobility, Inc; Cambridge, MA and Ahmedabad, India) on Android smartphones. The information of all eligible individuals, aged 5 to 17 years and enumerated during the household census visit, was automatically sent to a second electronic questionnaire containing the UNICEF/Washington Group Module on child functioning and disability [ 7 , 26 ]. This parent-reported survey module is designed to identify children with functional difficulties in population-based surveys. For most domains, it scores functional limitation on a scale comprising “no difficulty,” “some difficulty,” “a lot of difficulty,” and “cannot do.” Fieldworkers then conducted the questionnaire with the mothers or reported primary caregivers for each identified eligible child within the household. Outcomes A child was classed as having functional difficulty if they reported “a lot of difficulty” or “cannot do” within the domains of seeing, hearing, walking, self-care, communication, learning, remembering, concentrating, accepting change, controlling behaviour, and making friends or reported “daily” anxiety, nervousness, worry or seeming sad or depressed. During the census update activity, the respondent was asked whether each individual household member aged between 3 and 25 years attended school. Responses were then recorded as “not in education” or the specific level of education ( Anganwadi centre; kindergarten; primary; middle; secondary; higher secondary; college; or ITI/diploma). For the current study, children were classed as not being enrolled in school if they were reported to be “not in education.” Covariates Individual covariates included age in years, categorised as 5–9, 10–13, and 14–17 and male or female gender. Household covariates included: an indicator of household size dichotomised as < 5 or ≥ 5 from the number of residents; reported years in residence; education and marital status of the head of household; reported household caste, religion, and language. A measure of socioeconomic status was derived from a composite wealth index based on a principal component analysis (PCA) using various reported household assets (24). The wealth index was divided into five quintiles, and for the current analysis the lower 3 quintiles were classed as poorer and the upper 2 quintiles were classed as less poor. Statistical analysis We estimated the prevalence of difficulty within each of the functional domains and in any of the domains in total and by gender. We then estimated prevalence ratios between levels of each of the candidate covariates and presence of any functional difficulty and, separately, reported school non-enrolment using modified Poisson regression [ 27 ]. For this, we fit generalised linear models, specifying a Poisson distribution and log link. We estimated robust standard errors at the household level to accommodate the binary outcomes and to account for potential outcome correlation between children for residence within the same household. We excluded individuals with missing outcome or covariate data (0.3%), and assumed these data were missing at random, that is, that the probability of having complete data is independent of the outcome after adjusting for included covariates. We report prevalence ratios with 95% confidence intervals as crude (bivariate) and adjusted for age category, gender, and site. We examined heterogeneity of the effect of functional difficulty upon reported school non-enrolment with an aim towards identifying groups who may benefit from additional interventions to reduce school exclusion. We examined this effect modification by age dichotomised at the median (5–11 years versus 11–17 years), gender (male versus female), SES (higher versus lower), head of household education (any formal versus no formal education), and site (Timiri versus Jawadhu Hills). We estimated this effect modification on both multiplicative and additive scales, the latter of which is considered more meaningful from a public health perspective [ 28 ]. For the latter, we estimated the relative excess risk due to interaction (RERI) [ 28 – 30 ], using the interactionR package with confidence intervals calculated using the MOVER method [ 31 ]. When the exposures of interest have the same direction of effect upon the outcome, a RERI greater than 0 means greater than additive interaction or positivity, whereby we might observe a greater number of outcomes in the presence of the main effect and its modifier than we would expect based on the numbers of outcomes attributed to the effect and modifier separately. A RERI less than 0 means there is less than additive interaction or negative interaction. We adjusted for age, gender, and site in the interactions analysis. All analyses were conducted using R version 4.0.3 (2022-04-29). De-identified data and analysis scripts are available upon request via LSHTM Data Compass. Results A total of 29,044 children aged 5–17 years were included in the analysis, after excluding 84 with missing data (Fig. 1 ). The distribution of functional difficulties are shown in Table 1 by gender. Of 29,044 children, 299 (1.0%) had any functional difficulty. Few children had limitations with seeing, hearing, depression, or anxiety, while 0.3–0.4% of the children were reported to have limitations in the other domains, such as walking, remembering, or accepting change. Table 1 Occurrence of any functional difficulty and difficulty within functional domains by gender among N = 29,044 children in Tamil Nadu, India Male (N = 15,073) Female (N = 13,971) All (N = 29,044) Functional Difficulty n (%) n (%) n (%) Any 149 (1.0) 150 (1.1) 299 (1.0) Seeing 16 (0.1) 18 (0.1) 34 (0.1) Hearing 16 (0.1) 27 (0.2) 43 (0.1) Walking 55 (0.4) 55 (0.4) 110 (0.4) Self-Care 55 (0.4) 44 (0.3) 99 (0.3) Being Understood 68 (0.5) 61 (0.4) 129 (0.4) Learning 51 (0.3) 49 (0.4) 100 (0.3) Remembering 48 (0.3) 44 (0.3) 92 (0.3) Concentrating 43 (0.3) 41 (0.3) 84 (0.3) Accepting Change 40 (0.3) 33 (0.2) 73 (0.3) Controlling Behaviour 45 (0.3) 40 (0.3) 85 (0.3) Making Friends 41 (0.3) 42 (0.3) 83 (0.3) Anxiety 22 (0.1) 20 (0.1) 42 (0.1) Depression 14 (0.1) 15 (0.1) 29 (0.1) Few sociodemographic factors were associated with having any functional difficulty (Table 2 ). Many of the associations were close to the null before and after adjustment for age, gender, and site. There was some evidence of a positive association between any functional difficulty and living in the tribal Jawadhu Hills area as opposed to the rural Timiri area (PR: 1.30, 95% CI: 1.01 to 1.67), adjusting for age and gender. There was some evidence of a small positive association between any functional difficulty and household socioeconomic status, which was attenuated towards the null after adjusting for age, gender, and site. Table 2 Association of functional difficulty with factors for the purposes of targeting and understanding clustering of disadvantage among N = 29,044 children in Tamil Nadu, India Overall Functional Difficulty Crude Adjusted* Variable n (%) n (%) PR (95% CI) PR (95% CI) Age Category (years) 5–9 10,692 (36.8) 97 (0.9) REF REF 10–13 8,864 (30.5) 102 (1.2) 1.27 (0.97, 1.67) 1.27 (0.97, 1.67) 14–17 9,488 (32.7) 100 (1.1) 1.16 (0.88, 1.54) 1.17 (0.88, 1.55) Gender Male 15,073 (51.9) 149 (1.0) REF REF Female 13,971 (48.1) 150 (1.1) 1.09 (0.87, 1.36) 1.09 (0.87, 1.37) School Enrolment Not in education 2,860 (9.8) 129 (4.5) REF REF Anganwadi/Kindergarten 444 (1.5) 2 (0.5) 0.10 (0.02, 0.40) 0.04 (0.01, 0.19) Primary school 10,627 (36.6) 73 (0.7) 0.15 (0.11, 0.20) 0.07 (0.04, 0.12) Middle school 6,551 (22.6) 58 (0.9) 0.20 (0.14, 0.27) 0.11 (0.06, 0.17) Secondary school 4,288 (14.8) 28 (0.7) 0.14 (0.10, 0.22) 0.12 (0.07, 0.19) Higher secondary school 3,170 (10.9) 9 (0.3) 0.06 (0.03, 0.12) 0.07 (0.03, 0.14) College/Diploma/ITI/University 1,104 (3.8) 0 (0.0) 0.00 (0.00, 0.00) 0.00 (0.00, 0.00) Household Size <5 11,320 (39.0) 119 (1.1) REF REF ≥5 17,724 (61.0) 180 (1.0) 0.97 (0.76, 1.23) 0.94 (0.74, 1.20) Socioeconomic Status Less poor (Upper 2 quintiles) 17,563 (60.5) 158 (0.9) REF REF Poorer (Lower 3 quintiles) 11,481 (39.5) 141 (1.2) 1.37 (1.08, 1.73) 1.30 (0.93, 1.83) Residence Time 20 years 15,561 (53.6) 158 (1.0) 0.86 (0.60, 1.23) 0.85 (0.59, 1.22) HoH Education No education 6,893 (23.7) 88 (1.3) REF REF Any primary 5,609 (19.3) 63 (1.1) 0.88 (0.63, 1.24) 0.94 (0.65, 1.36) Any middle 6,215 (21.4) 57 (0.9) 0.72 (0.51, 1.02) 0.77 (0.53, 1.11) Any secondary or higher 10,327 (35.6) 91 (0.9) 0.69 (0.51, 0.93) 0.75 (0.53, 1.06) HoH Marital Status Married 26,192 (90.2) 265 (1.0) REF REF Previously or never married 2,852 (9.8) 34 (1.2) 1.18 (0.82, 1.70) 1.18 (0.82, 1.70) Caste Scheduled tribes 8,322 (28.7) 96 (1.2) REF REF Scheduled caste 6,463 (22.3) 61 (0.9) 0.82 (0.58, 1.15) 1.79 (0.91, 3.51) Backward caste 7,409 (25.5) 78 (1.1) 0.91 (0.67, 1.25) 2.01 (1.03, 3.91) Most backward caste 6,588 (22.7) 63 (1.0) 0.83 (0.59, 1.16) 1.81 (0.92, 3.57) Higher caste 172 (0.6) 0 (0.0) 0.00 (0.00, 0.00) 0.00 (0.00, 0.00) Other 90 (0.3) 1 (1.1) 0.96 (0.14, 6.78) 1.49 (0.21, 10.44) Hindu No 954 (3.3) 10 (1.0) REF REF Yes 28,090 (96.7) 289 (1.0) 0.98 (0.53, 1.83) 0.94 (0.50, 1.76) Tamil Speaker No 840 (2.9) 7 (0.8) REF REF Yes 28,204 (97.1) 292 (1.0) 1.24 (0.59, 2.61) 1.19 (0.57, 2.51) Site Timiri 20,750 (71.4) 197 (0.9) REF REF Jawadhu Hills 8,294 (28.6) 102 (1.2) 1.30 (1.01, 1.67) 1.30 (1.01, 1.67) *Adjusted for age category, gender, and site; PR = Prevalence Ratio; CI = Confidence Interval Several of the analysed factors were associated with reported school non-enrolment (Table 3 ). Among children with functional difficulty, the prevalence of school non-enrolment (43.1%) was 4.59 times higher than that among children without functional difficulty (9.5%), after adjusting for age, gender, and sub-site (95% CI: 3.87 to 5.43). Prevalence of non-enrolment was higher in older age categories, and children aged over 14 years were 8.57 times more likely to be non-enrolled compared to younger children aged 5 to 9 years (95% CI: 7.60 to 9.66), adjusting for gender and site. Figure 2 shows the associations for each domain of the CFM, where the categories measured among older children are associated more strongly with non-enrolment. Gender was also found to be a contributor to non-enrolment, as girls were 16% more likely to not be enrolled as boys (PR: 0.84, 95% CI: 0.79 to 0.90). Prevalence of non-enrolment was observed to be higher in Jawadhu Hills compared to Timiri, after accounting for age and gender. However, after adjusting for area differences, children from poorer households, households in longer residence, or with less educated or unmarried household heads were found to have higher prevalence of non-enrolment. Table 3 Association of selected factors with reported school non-enrolment among N = 29,044 children in Tamil Nadu, India Overall Not enrolled Crude Adjusted* Variable n (%) n (%) PR (95% CI) PR (95% CI) Age Category (years) 5–9 10,692 (36.8) 289 (2.7) REF REF 10–13 8,864 (30.5) 407 (4.6) 1.70 (1.47, 1.96) 1.70 (1.48, 1.96) 14–17 9,488 (32.7) 2,164 (22.8) 8.44 (7.46, 9.54) 8.57 (7.60, 9.66) Gender Male 15,073 (51.9) 1,649 (10.9) REF REF Female 13,971 (48.1) 1,211 (8.7) 0.79 (0.74, 0.85) 0.84 (0.79, 0.90) School Enrolment Not in education 2,860 (9.8) 2,860 (100.0) REF REF Anganwadi/Kindergarten 444 (1.5) 0 (0.0) 0.00 (0.00, 0.00) 0.00 (0.00, 0.00) Primary school 10,627 (36.6) 0 (0.0) 0.00 (0.00, 0.00) 0.00 (0.00, 0.00) Middle school 6,551 (22.6) 0 (0.0) 0.00 (0.00, 0.00) 0.00 (0.00, 0.00) Secondary school 4,288 (14.8) 0 (0.0) 0.00 (0.00, 0.00) 0.00 (0.00, 0.00) Higher secondary school 3,170 (10.9) 0 (0.0) 0.00 (0.00, 0.00) 0.00 (0.00, 0.00) College/Diploma/ITI/University 1,104 (3.8) 0 (0.0) 0.00 (0.00, 0.00) 0.00 (0.00, 0.00) Household Size <5 11,320 (39.0) 1,126 (9.9) REF REF ≥5 17,724 (61.0) 1,734 (9.8) 0.98 (0.91, 1.06) 0.98 (0.92, 1.06) Socioeconomic Status Less poor (Upper 2 quintiles) 17,563 (60.5) 920 (5.2) REF REF Poorer (Lower 3 quintiles) 11,481 (39.5) 1,940 (16.9) 3.23 (2.98, 3.50) 2.01 (1.82, 2.22) Residence Time 20 years 15,561 (53.6) 1,684 (10.8) 1.45 (1.26, 1.68) 1.18 (1.04, 1.35) HoH Education No education 6,893 (23.7) 1,464 (21.2) REF REF Any primary 5,609 (19.3) 567 (10.1) 0.48 (0.43, 0.52) 0.69 (0.63, 0.77) Any middle 6,215 (21.4) 440 (7.1) 0.33 (0.30, 0.37) 0.54 (0.49, 0.60) Any secondary or higher 10,327 (35.6) 389 (3.8) 0.18 (0.16, 0.20) 0.29 (0.26, 0.33) HoH Marital Status Married 26,192 (90.2) 2,457 (9.4) REF REF Previously or never married 2,852 (9.8) 403 (14.1) 1.51 (1.35, 1.68) 1.38 (1.26, 1.52) Caste Scheduled tribes 8,322 (28.7) 1,679 (20.2) REF REF Scheduled caste 6,463 (22.3) 510 (7.9) 0.39 (0.35, 0.43) 0.39 (0.31, 0.49) Backward caste 7,409 (25.5) 309 (4.2) 0.21 (0.18, 0.23) 0.21 (0.16, 0.26) Most backward caste 6,588 (22.7) 352 (5.3) 0.26 (0.24, 0.30) 0.27 (0.21, 0.34) Higher caste 172 (0.6) 4 (2.3) 0.12 (0.04, 0.31) 0.11 (0.04, 0.28) Other 90 (0.3) 6 (6.7) 0.33 (0.15, 0.70) 0.36 (0.17, 0.75) Hindu No 954 (3.3) 64 (6.7) REF REF Yes 28,090 (96.7) 2,796 (10.0) 1.48 (1.15, 1.91) 1.13 (0.88, 1.45) Tamil Speaker No 840 (2.9) 71 (8.5) REF REF Yes 28,204 (97.1) 2,789 (9.9) 1.17 (0.92, 1.49) 0.92 (0.73, 1.16) Site Timiri 20,750 (71.4) 1,232 (5.9) REF REF Jawadhu Hills 8,294 (28.6) 1,628 (19.6) 3.31 (3.06, 3.57) 3.38 (3.14, 3.63) *Adjusted for age category, gender, and site; PR = Prevalence Ratio; CI = Confidence Interval The results of analysis of modification of the effect of any functional difficulty on school non-enrolment by selected factors is shown in Table 4 (domain-specific effects are shown in the Web Appendix ). Table 4 Modification of the effect of functional difficulty on school non-enrolment by selected sociodemographic factors among N = 29,044 children in Tamil Nadu, India, adjusted for age, gender, and site. No Functional Difficulty Any Functional Difficulty Effect of FD EM Measures Non-enrolment n/N (%) PR (95% CI) Non-enrolment n/N (%) PR (95% CI) PR (95% CI) Multiplicative (95% CI) Additive (95% CI) Overall (crude) 2,731/28,745 (10) 1 129/299 (43) 4.54 (3.95, 5.21) Overall (adjusted)* 2,731/28,745 (10) 1 129/299 (43) 4.59 (3.87, 5.43) Age Category (years) 0.27 (0.17, 0.43) 3.74 (-3.33, 10.75) 5–11 295/12,643 (2.3) 1 38/117 (32.5) 12.06 (8.14, 17.87) 12.06 (8.14, 17.87) 12–17 2,436/16,102 (15) 6.49 (5.64, 7.47) 91/182 (50) 21.29 (16.20, 27.98) 3.28 (2.57, 4.19) Gender 1.05 (0.70, 1.59) 0.95 (-0.91, 2.93) Female 1,148/13,821 (8.3) 1 63/150 (42.0) 4.07 (3.04, 5.46) 4.07 (3.04, 5.46) Male 1,583/14,924 (11) 1.22 (1.12, 1.34) 66/149 (44) 5.25 (3.94, 6.99) 4.29 (3.22, 5.70) Socioeconomic Status 0.40 (0.27, 0.60) -2.27 (-5.09, 0.39) Less poor (Upper 2 quintiles) 857/17,405 (4.9) 1 63/158 (39.9) 7.23 (5.39, 9.69) 7.23 (5.39, 9.69) Poorer (Lower 3 quintiles) 1,874/11,340 (17) 2.07 (1.83, 2.35) 66/141 (47) 6.03 (4.48, 8.12) 2.91 (2.19, 3.86) No HoH Education 0.30 (0.20, 0.47) -3.39 (-5.71, -0.92) Any education 1,306/21,940 (6.0) 1 90/211 (42.7) 6.78 (5.31, 8.65) 6.78 (5.31, 8.65) No education 1,425/6,805 (21) 2.26 (2.05, 2.50) 39/88 (44) 4.65 (3.22, 6.70) 2.05 (1.43, 2.95) Site 0.33 (0.21, 0.50) -1.57 (-4.64, 2.07) Timiri 1,146/20,553 (5.6) 1 86/197 (43.7) 7.06 (5.47, 9.10) 7.06 (5.47, 9.10) Jawadhu Hills 1,585/8,192 (19) 3.46 (3.17, 3.78) 43/102 (42) 7.95 (5.58, 11.31) 2.30 (1.62, 3.26) *Adjusted for age category, gender, and site; PR = Prevalence Ratio; CI = Confidence Interval; FD = Functional Difficulty; EM = Effect Modification In the case of age, the multiplicative and additive measures of effect modification differed in direction. In young children, prevalence of non-enrolment among those with any functional difficulty was nearly fourteen times that of children without functional difficulty (PR: 13.92, 95% CI: 9.11 to 21.27), while the same effect in older children was smaller (PR: 3.31, 95% CI: 2.54 to 4.30). Reflecting this, the age interaction measure on the multiplicative scale, equating the ratio of these age stratum-specific PRs, was 0.24 (95% CI: 0.14 to 0.39). The additive interaction measure of 2.03 in turn (95% CI: -6.43 to 9.97) was positive. This result reflects the greater joint association on the additive scale between older age and functional difficulty and not being enrolled in school (PR: 21.43, 95% CI: 15.95 to 28.78), in contrast what might be expected from combining individual effects of functional difficulty (PR: 13.92, 95% CI: 9.11 to 21.27) in the younger age group or age among children without functional difficulties (PR: 6.48, 95% CI: 5.57 to 7.55), and suggests a synergistic interaction of older age and functional difficulty on school enrolment, though the confidence interval included 0. There was no evidence of modification of the effect of functional difficulty on non-enrolment by gender on either the multiplicative or the additive scales. Patterns of modification of the effect of functional difficulty on school non-enrolment by socioeconomic status, education level of the head of household, and site, were similar. The proportion of children without functional difficulty who were not enrolled in school was higher in poorer households, those with a head of household with no formal education, or living in Jawadhu Hills, relative to children in less poor households, with a head of household reporting any formal education, or living in Timiri (PR: 3.36, 95% CI: 3.03, 3.71; PR: 3.52, 95% CI: 3.20, 3.87; PR: 3.47, 95% CI: 3.15, 3.82), respectively. Among children with functional difficulty, the prevalence of non-enrolment was similar across socioeconomic quintiles, head of household education levels, and site. For these factors, on the multiplicative scale, the pattern is shown as the effect of functional difficulty among children in lower socioeconomic conditions, in families with less educated heads of household, or in Jawadhu Hills was of smaller magnitude than that observed among children in less poor or more educated households or those living Timiri. On the additive scale, the results were suggestive of an antagonistic relationship of functional difficulty with each of these factors, particularly education and site, but again confidence intervals included 0. Discussion This large-scale census of children in two sites in Tamil Nadu found that 1.0% of children aged 5–17 years were parent-reported to have disabilities, as assessed through the UNICEF-Washington Group Child Module, and prevalence of functional difficulty was similar between boys and girls. The most prevalent reported functional impairments were being understood and walking. Sensory difficulties (seeing/hearing) or mental health concerns were less commonly reported, which may be because these are more difficult for a parent to recognise in their child. Childhood disability was largely un-related to socio-demographic features but was more prevalent in the Jawadhu Hills compared to Timiri. Children with disabilities were substantially less likely to be enrolled in school compared to children without disabilities (56.9% versus 90.5%). Across the cohort, school exclusion was most prevalent among children with disabilities and 12 + years old. However, the effect of functional difficulty on school exclusion was four times greater among younger children relative to older ones. There was no evidence of heterogeneity in the effect of functional difficulty by gender. The prevalence of childhood disability of 1.0% reported in this study was lower than estimates from the World Report on Disability (5%) [ 3 ] or the Global Burden of Disease (11%) [ 32 ], as well as the 2011 India census estimates (1.5% of children aged 5–9 years and 1.8% of children 10–19 years)[ 17 ], which is already likely to provide an under-estimate of the true prevalence of disability [ 18 ]. These estimates covered children below 5, which may explain some of the discrepancy. It is higher than the India Health and Development Survey (2005), which found a prevalence of 0.37% in children 5–17 years using the Washington Group Short Set (which contains six functional domains rather than the 13 assessed in this study with the Washington-UNICEF Child Functioning Module [ 33 ]. A survey in Andhra Pradesh including 1,383 children aged 0–17 years used modules from the UNICEF-Washington Group module to obtain an estimated prevalence of childhood disability of 2.3% (1.4–3.7%) [ 26 , 34 ]. Measures of behavioural difficulties (e.g. controlling behaviour, play) and mental health (worry) were not included in the Andhra Pradesh survey, which would have pushed the prevalence higher. The Andhra Pradesh survey also used clinical measures to estimate the prevalence of vision, hearing and/or physical impairment or epilepsy, which together affected 2.9% (2.1-4.0%) of children aged 0–17 years. In comparison, our low prevalence might be explained by subjective parent report in comparatively low-and-middle-income settings. Parental perceptions and understanding, their stage of acceptance of disability, and cultural norms can affect parent reporting of symptoms as evidenced from an Indian study [ 35 ]. Surveys from five geographically diverse populations in India have also reported higher prevalence than in the current study. A survey of 3,964 children aged 2–9 years found that 9.2% of children 2-<6 years and 13.6% of children 6–9 years had one of seven neurodevelopmental disorders (vison impairment, epilepsy, neuromotor impairments, hearing impairment, speech and language disorders, autism spectrum disorders, and/or intellectual disability) [ 19 ]. The higher prevalence of neurodevelopmental disorders might be due to additional screening and specific questionnaires used in that study. Consistent with our findings, there was no gender difference or socio-economic correlates of these conditions. Other studies support our finding of the lower levels of school inclusion among children with disabilities compared to those without disabilities, including the 2011 census (school attendance 61% of children with disabilities and 71% of all children) [ 17 ] and the 2015 Andhra Pradesh study (51% versus 91%) [ 26 , 34 ]. Similar to our finding that older children with disability are the most frequently non-enrolled in school, increased enrolment of children with disabilities in primary versus higher school levels were also shown in the census, [ 17 ] official government enrolment numbers [ 23 ], a 2018 national survey [ 36 ], and a case-control study in New Delhi [ 37 ]. However, our analysis allowed us to observe considerable heterogeneity in the impact of functional difficulty on school enrolment between age strata. Specifically, while all children with functional difficulty were less likely to be enrolled than children without disability, the effect of disability on school inclusion was most pronounced in the younger age group, demonstrating how disability can detrimentally impact the life course at an early stage, because educational exclusion will likely persist. In turn, we show this persistence by estimating the prevalence of non-enrolment to be highest among older children with functional difficulty. Our examination of modification of the effect of functional difficulty on school non-enrolment highlights the importance of examining modification of effects on both multiplicative and additive scales [ 29 ]. For age, for example, it was important to show how much stronger the association between disability and non-enrolment is among younger children, but while the children most at risk of non-enrolment were older children with disabilities. Our analysis of the interaction between socioeconomic difficulty, disability, and school enrolment, suggest that there might be competing risks to non-enrolment. For children with disabilities from poorer backgrounds, although less likely to be in school than their better-off peers, their enrolment was less likely to be affected by their disability per se . However, while this is clear on the multiplicative scale, the non-statistically significant interaction on the additive scale warns against over-interpreting the policy implications. Our current analysis shows that, though there is a considerable difference in enrolment between genders overall, there was no difference in the effect of functional difficulty on school enrolment of children based on gender. The 2018 survey and official enrolment numbers showed slightly higher enrolment of boys with disabilities compared to girls across most levels of schooling [ 36 ], while the New Delhi case-control study reported that primary school enrolment was more common in girls with disabilities compared to boys [ 38 ]. Household head education and socio-economic status appeared less relevant as correlates of school enrolment among children with disabilities in the New Delhi study [ 38 ]. In India and other settings, children with severe disabilities are less likely to be enrolled in school [ 39 ]. To address this gap, the Government of India has introduced the Sarva Sikhsha Abhiyan (SSA) where all children irrespective of disabilities can attend school education services [ 40 ]. Additional vulnerabilities as highlighted in this study should be addressed to achieve an optimum implementation. In terms of strengths, this was a large study including 29,044 children identified through an exhaustive census activity. Disability was assessed using the UNICEF-Washington Group Child Functioning Module. Two contrasting sites were included – one rural and one tribal – allowing comparison of findings. There are also important limitations to consider. The functional difficulty measure utilised caregiver reporting of difficulties, and reported disability may be subjective and not fully captured. Caregiver expectations of childhood functioning may be gendered, biasing comparisons between boys and girls. The educational measure was report-based and focussed on current school enrolment only and did not assess other important aspects of schooling, such as quality of education, educational attainment, social inclusion and freedom from violence and bullying. The World Report on Disability found that when children with disabilities did enrol in school, their dropout rates were higher and they were on average at a lower level of schooling for their age [ 3 ], and quality of schooling may be worse for children with disabilities [ 41 ]. Studies from India have also highlighted that although progress has been made, gaps in the provision of inclusive education remain, including in teacher training and provision of appropriate and adequate resources [ 42 , 43 ]. Moreover, it is also known that children with disabilities often experience difficulties at school, such as being more likely to experience violence, whether physical, psychological, or sexual [ 44 ], and these measures were not captured in the study. Further, the correlates of educational enrolment used focussed on individual characteristics of the child (e.g. age, gender, household wealth) rather than features of the environment or school (e.g. accessible facilities, staff trained about disability, inclusive societal attitudes). Implications for policy, practice, and research This study demonstrated that the UNICEF-Washington Group Child Functioning Module could be implemented on a large-scale. It produced a relatively conservative estimate of disability, compared to previous reports in India, and so arguably may provide assessment of more severe functional difficulties, although further research is needed in other parts of the country to validate and to explore this issue. The individual questions on functioning allowed us to estimate prevalence in this context with minimal variation. It may be helpful to reduce the full number of questions to allow implementation in more time-constrained activities (e.g. census). This evidence shows nearly half of children with disabilities are not enrolled in school in this area of Tamil Nadu, despite strong policy commitments made in India towards disability-inclusive education. Monitoring of inclusion therefore remains important, to assess whether these policies are being realised. This exclusion of children with disabilities from education is a violation of their rights. Moreover, education is important for all children, including those with disabilities in terms of improving future job opportunities and earnings, developing friendships and participating in society, and in low resource settings, access to school-based health and nutrition programmes [ 45 ]. Efforts are therefore needed to improve school enrolment of children with disabilities, although the evidence base on which interventions are effective to achieve this goal is currently limited [ 14 , 15 ]. Attending school alone is insufficient, and further investigation is needed to assess the quality of the experience and educational outcomes for children with disabilities, to identify areas where further improvements are needed (e.g. accessibility of facilitates, expertise of teachers, resource allocation) [ 46 ]. Again, evidence is lacking on which interventions are effective at improving these broader educational outcomes for children with disabilities in LMICs [ 14 , 15 ]. The limited data available focusses mostly on interventions that produce individual-level change (e.g. computer skills training of children with disabilities) rather than school/societal interventions (e.g. teacher training on disability, introduction of disability-inclusive educational policies) and so these large evidence gaps need to be addressed with high-quality research. Conclusions At least one in a hundred children in southern India have severe functional difficulties. Among these children with disabilities, nearly half do not attend school. Urgent action is needed to improve educational inclusion of children with disabilities in southern India, and to ensure that they have a quality and safe school experience. List of abbreviations CFM Child Functioning Module CI Confidence Interval HUD Health Unit District MDA Mass Drug Administration PCA Principal Component Analysis PR Prevalence Ratio RERI Relative Excess Risk due to Interaction RTE Right to Educate SES Socioeconomic Status STH Soil-transmitted Helminths UN United Nations UNESCO United Nations Educational, Scientific and Cultural Organization UNICEF United Nations Children's Fund Declarations Ethics approval and consent to participate The DeWorm3 Project was reviewed and approved by the Institutional Review Board at Christian Medical College, Vellore, India, The London School of Hygiene and Tropical Medicine, and the Human Subjects Division at the University of Washington. The trial is registered at ClinicalTrials.gov (NCT03014167). The functional difficulty assessment was approved as a protocol amendment by the Institutional Review Board at Christian Medical College, Vellore, India and The London School of Hygiene and Tropical Medicine. Written informed consent was sought from the household head for households’ participation in the census and functional impairment assessment. The purpose of the survey and use of the data were explained and informed consent to participate was ascertained before collecting any further information. Consent for publication All participants included in this study were informed that their data may be used as part of publications in anonymised form, to which they gave consent. Availability of data and materials The data that support the findings have been archived, but restrictions apply to the availability of these data, and so have not been made publicly available. The data may be made available from the authors upon reasonable request after due oversight from an institutional ethical review process. Competing interests The authors have no competing interests to declare that are relevant to the content of this article. Funding This research was funded by the United Kingdom Foreign, Commonwealth and Development Office (PENDA grant: PO8073). The DeWorm3 study is funded through a grant to the Natural History Museum, London from the Bill and Melinda Gates Foundation (OPP 1129535,PIJLW). SSRA is supported by an Emerging Global Leader Award (K43) from Fogarty International Center, NIH (1K43TW011415). The funders were not involved in the decision to publish the manuscript and had no role in data collection, analysis or publication of study results. Authors' contributions CD, WEO, SPK, SSRA, HK - Conceptualization; SPK, SG, DSK, WEO - Data acquisition and curation; CD, WEO, SPK - Formal analysis; HK, JLW, SSRA - Funding acquisition; CD, WEO, SPK, BRC, BK, SJ, HK - Investigation; CD, WEO, SPK, BRC, SJ, GN, BK - Methodology; SSRA - Project administration; JLW, SSRA - Resources; Software; SPK, KA - Supervision; SPK, KA - Validation; Visualization; CD, WEO, BRC, HK - Roles/Writing - original draft; BRC, CD, WEO, SPK, KA, SJ, GN, JLW, BK, SSA, HK Writing - review & editing. Acknowledgements The authors wish to thank all of the study participants, community members and community leaders who have participated in or supported this study. We also like to thank all members of the DeWorm3 study teams and affiliated institutions. We thank our field managers Rajeshkumar Rajendiran and Chinnaduraipandi Paulsamy, and the field supervisors and field workers at the DeWorm3 study sites in India for data collection. We thank the data managers Gokila Palanisamy, Jannarthanan Maniyarasu, and Nandhini Prabakaran for their support in data collection. We thank Mr. Veeraraghavan Srinivasan, President-Nesam, Timiri, for orienting the study team on disability. References Cieza A, Kamenov K, Sanchez MG, Chatterji S, Balasegaram M, Lincetto O, et al. Burden of disability in children and adolescents must be integrated into the global health agenda. BMJ. 2021;372:n9. Bellis MA, Hughes K, Ford K, Ramos Rodriguez G, Sethi D, Passmore J. Life course health consequences and associated annual costs of adverse childhood experiences across Europe and North America: a systematic review and meta-analysis. Lancet Public Health. 2019;4(10):e517-e28. WHO. World Report on Disability. Geneva: World Health Organisation; 2011. WHO. The global burden of disease: 2004 update. Geneva, Switzerland: World Health Organization; 2004. Olusanya BO, Wright SM, Nair MKC, Boo NY, Halpern R, Kuper H, et al. Global Burden of Childhood Epilepsy, Intellectual Disability, and Sensory Impairments. Pediatrics. 2020;146(1). Scharf RJ, Maphula A, Pullen PC, Shrestha R, Matherne GP, Roshan R, et al. Global Disability: Empowering Children of all Abilities. Pediatr Clin North Am. 2017;64(4):769-84. WG/UNICEF. Module on child functioning: questionnaires Geneva, Switzerland: UNICEF; 2016 [Available from: https://data.unicef.org/resources/module-child-functioning/. UNESCO. Education and Disability: Analysis of Data from 49 Countries 2018 [Available from: http://uis.unesco.org/sites/default/files/documents/ip49-education-disability-2018-en.pdf. UNDESA. UN Flagship Report on Disability and Development. UNDESA; 2018. Mizunoya S, Mitra S, Yamasaki I. Towards inclusive education: The impact of disability on school attendance in developing countries. UNICEF Office of Research – Innocenti; 2016. UN. Convention on the Rights of the Child. New York, USA: United Nations; 1989. UN. Convention on the rights of persons with disabilities. New York: United Nations; 2006. UN. Sustainable Development Goals 2015 [Available from: http://www.un.org/sustainabledevelopment/sustainable-development-goals/. Saran A, White H, Kuper H. Evidence and gap map of studies assessing the effectiveness of interventions for people with disabilities in low‐and middle‐income countries. Campbell Systematic Reviews. 2020;16(1). Kuper H, Saran A, White H. Rapid Evidence Assessment (REA) of What Works to Improve Educational Outcomes for People with Disabilities in Low- and Middle-Income Countries. London: DFID; 2018. Kuper H, Monteath-van Dok A, Wing K, Danquah L, Evans J, Zuurmond M, et al. The impact of disability on the lives of children; cross-sectional data including 8,900 children with disabilities and 898,834 children without disabilities across 30 countries. PloS one. 2014;9(9):e107300. GoI. Census 2011 - Census of India New Delhi, India2011 [Available from: http://censusindia.gov.in/. Dandona R, Pandey A, George S, Kumar GA, Dandona L. India's disability estimates: Limitations and way forward. PloS one. 2019;14(9):e0222159. Arora NK, Nair MKC, Gulati S, Deshmukh V, Mohapatra A, Mishra D, et al. Neurodevelopmental disorders in children aged 2-9 years: Population-based burden estimates across five regions in India. PLoS Med. 2018;15(7):e1002615. GoI. The Right of Children to Free and Compulsory Education Act, 2009. New Delhi, India; 2009. GoI. Rights of Persons with Disabilities Act, 2016. New Delhi, India; 2016. GoI. National Education Policy 2020. New Delhi, India; 2020. Singal N. Inclusive quality education for children with disabilities. 2017. Ajjampur SSR, Kaliappan SP, Halliday KE, Palanisamy G, Farzana J, Manuel M, et al. Epidemiology of soil transmitted helminths and risk analysis of hookworm infections in the community: Results from the DeWorm3 Trial in southern India. PLoS Negl Trop Dis. 2021;15(4):e0009338. Asbjornsdottir KH, Ajjampur SSR, Anderson RM, Bailey R, Gardiner I, Halliday KE, et al. Assessing the feasibility of interrupting the transmission of soil-transmitted helminths through mass drug administration: The DeWorm3 cluster randomized trial protocol. PLoS Negl Trop Dis. 2018;12(1):e0006166. Mactaggart I, Kuper H, Murthy GV, Oye J, Polack S. Measuring Disability in Population Based Surveys: The Interrelationship between Clinical Impairments and Reported Functional Limitations in Cameroon and India. PloS one. 2016;11(10):e0164470. Zou G. A modified poisson regression approach to prospective studies with binary data. American journal of epidemiology. 2004;159(7):702-6. Richardson DB, Kaufman JS. Estimation of the relative excess risk due to interaction and associated confidence bounds. American journal of epidemiology. 2009;169(6):756-60. Knol MJ, VanderWeele TJ. Recommendations for presenting analyses of effect modification and interaction. International journal of epidemiology. 2012;41(2):514-20. Rothman KJ, Greenland S, Lash TL. Modern Epidemiology, 3rd Ed. Philadelphia, PA: Lippincott, Williams, & Wilkins; 2008. Alli BY. interactionR: An R package for full reporting of effect modification and interaction (v0.1.3). Zenodo; 2021. Olusanya BO, Wright SM, Nair MKC, Boo NY, Halpern R, Kuper H, et al. Global Burden of Childhood Epilepsy, Intellectual Disability, and Sensory Impairments. Pediatrics. 2020;146(1). Mizunoya S, Mitra S, Yamasaki I. Disability and school attendance in 15 low- and middle-income countries. World Development. 2018;104:388-403. Mactaggart I, Polack S, Kuper H, Sagar J, Murthy GVS. The Telengana Disability Study, India. London: London School of Hygiene & Tropical Medicine; 2014. Desai MU, Divan G, Wertz FJ, Patel V. The discovery of autism: Indian parents' experiences of caring for their child with an autism spectrum disorder. Transcult Psychiatry. 2012;49(3-4):613-37. GoI. Persons with Disabilities in India. NSS 76th Round. New Delhi, India; 2018. Bakhshi P, Babulal GM, Trani JF. Education of children with disabilities in New Delhi: When does exclusion occur? PloS one. 2017;12(9):e0183885. Bakhshi P, Babulal GM, Trani J-F. Education of children with disabilities in New Delhi: When does exclusion occur? PloS one. 2017;12(9):e0183885-e. Mitra S. Disability, Health and Human Development2018. Kapur A. Sarva Shiksha Abhiyan. SSRN Electronic Journal. 2013. de Wit M. A sign language interpreter in inclusive education: The view of deaf persons on their quality of life. Edinburgh, UK: Heriot Watt University; 2011. Singal N. Challenges and opportunities in efforts towards inclusive education: reflections from India. International Journal of Inclusive Education. 2019;23(7-8):827-40. Taneja-Johansson S, Singal N, Samson M. Education of Children with Disabilities in Rural Indian Government Schools: A Long Road to Inclusion. International Journal of Disability, Development and Education. 2021:1-16. Devries KM, Kyegombe N, Zuurmond M, Parkes J, Child JC, Walakira EJ, et al. Violence against primary school children with disabilities in Uganda: a cross-sectional study. BMC Public Health. 2014;14:1017. Banks LM, Polack S. The Economic Costs of Exclusion and Gains of Inclusion of People with Disabilities. London: International Centre for Evidence in Disability; 2014. Singal N. Education of children with disabilities in India and Pakistan: Critical analysis of developments in the last 15 years. Prospects. 2016;46(1):171-83. Additional Declarations No competing interests reported. Supplementary Files Appendices23MAR24.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 06 Aug, 2024 Reviews received at journal 03 Aug, 2024 Reviewers agreed at journal 25 Jul, 2024 Reviewers agreed at journal 17 Jul, 2024 Reviewers agreed at journal 14 Jul, 2024 Reviewers agreed at journal 18 Jun, 2024 Reviews received at journal 20 Apr, 2024 Reviewers agreed at journal 20 Apr, 2024 Reviewers agreed at journal 17 Apr, 2024 Reviewers invited by journal 16 Apr, 2024 Editor assigned by journal 15 Apr, 2024 Submission checks completed at journal 15 Apr, 2024 First submitted to journal 23 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4154190","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":292187259,"identity":"2d6688a9-71e2-4791-a26c-ad707b5eb81d","order_by":0,"name":"Bobeena Rachel Chandy","email":"","orcid":"","institution":"Christian Medical College","correspondingAuthor":false,"prefix":"","firstName":"Bobeena","middleName":"Rachel","lastName":"Chandy","suffix":""},{"id":292187260,"identity":"910f65f0-1413-44b5-b895-c1ab22eb5a2f","order_by":1,"name":"Calum Davey","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYHACAxAhx8AMF2AjTosxUAtjA0laEoHKidTC38C88TNPxeH07ezMxx8wVNyza5BIS8CrReIAW7E0z5nDuTub2YA2nSlOBmo5QMBVPAaSM9sO5244zGPYwNiWkMwgkd5ASIvxz5n/DqcbkKLFTOJjw+EEmBY7BkIOkzjMVmbx4Vi64YbDbIkzEs4kJLDxPEvAq4W/vXnzjYQaa3mD84cPfPhQkWDPz55mgFcLNNKbIRyg8Ylt+NXDQR2cZU+kjlEwCkbBKBhBAAAJOEHOwanIkQAAAABJRU5ErkJggg==","orcid":"","institution":"National Institute of Teaching","correspondingAuthor":true,"prefix":"","firstName":"Calum","middleName":"","lastName":"Davey","suffix":""},{"id":292187261,"identity":"b6b37540-e41e-4bb1-9990-709520842262","order_by":2,"name":"William E Oswald","email":"","orcid":"","institution":"RTI International","correspondingAuthor":false,"prefix":"","firstName":"William","middleName":"E","lastName":"Oswald","suffix":""},{"id":292187262,"identity":"77532c5f-dfd4-42da-8c12-f6a6c859bfcc","order_by":3,"name":"Saravanakumar Puthupalayam Kaliappan","email":"","orcid":"","institution":"Christian Medical College","correspondingAuthor":false,"prefix":"","firstName":"Saravanakumar","middleName":"Puthupalayam","lastName":"Kaliappan","suffix":""},{"id":292187263,"identity":"8493cb33-7e15-4d81-9cf4-898f2ce7e0bc","order_by":4,"name":"Kumudha Aruldas","email":"","orcid":"","institution":"Christian Medical College","correspondingAuthor":false,"prefix":"","firstName":"Kumudha","middleName":"","lastName":"Aruldas","suffix":""},{"id":292187264,"identity":"269018a4-c8a5-4d19-aac1-d8cbb0ef3721","order_by":5,"name":"Lena Morgon Banks","email":"","orcid":"","institution":"London School of Hygiene \u0026 Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Lena","middleName":"Morgon","lastName":"Banks","suffix":""},{"id":292187265,"identity":"1f32e4db-c660-4472-aa39-285f7a8a43b8","order_by":6,"name":"Smitha Jasper","email":"","orcid":"","institution":"Christian Medical College","correspondingAuthor":false,"prefix":"","firstName":"Smitha","middleName":"","lastName":"Jasper","suffix":""},{"id":292187266,"identity":"ba169efd-e8b5-4a81-832e-b59fb0925831","order_by":7,"name":"Guru Nagarajan","email":"","orcid":"","institution":"Christian Medical College","correspondingAuthor":false,"prefix":"","firstName":"Guru","middleName":"","lastName":"Nagarajan","suffix":""},{"id":292187267,"identity":"1ce5d5a0-a31a-4c00-a574-45e26dc84c2d","order_by":8,"name":"Sean Galagan","email":"","orcid":"","institution":"University of Washington","correspondingAuthor":false,"prefix":"","firstName":"Sean","middleName":"","lastName":"Galagan","suffix":""},{"id":292187268,"identity":"94c1152e-c95d-46ef-8495-f2601fa2ca35","order_by":9,"name":"David S Kennedy","email":"","orcid":"","institution":"London School of Hygiene \u0026 Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"S","lastName":"Kennedy","suffix":""},{"id":292187269,"identity":"9781f04e-84b4-4092-ad89-590f0d7058ca","order_by":10,"name":"Judd L Walson","email":"","orcid":"","institution":"University of Washington","correspondingAuthor":false,"prefix":"","firstName":"Judd","middleName":"L","lastName":"Walson","suffix":""},{"id":292187270,"identity":"3f95b973-a3cc-442b-b7f3-02b0acfae304","order_by":11,"name":"Beena Koshy","email":"","orcid":"","institution":"Christian Medical College","correspondingAuthor":false,"prefix":"","firstName":"Beena","middleName":"","lastName":"Koshy","suffix":""},{"id":292187271,"identity":"cdb5682b-ab55-4938-a25e-3685fc3abaeb","order_by":12,"name":"Sitara SR Ajjampur","email":"","orcid":"","institution":"Christian Medical College","correspondingAuthor":false,"prefix":"","firstName":"Sitara","middleName":"SR","lastName":"Ajjam","suffix":"SR"},{"id":292187272,"identity":"71561340-306e-4b04-b6b0-845cd942b173","order_by":13,"name":"Hannah Kuper","email":"","orcid":"","institution":"London School of Hygiene \u0026 Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Hannah","middleName":"","lastName":"Kuper","suffix":""}],"badges":[],"createdAt":"2024-03-23 11:44:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4154190/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4154190/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":55062300,"identity":"d5bc34eb-c9d8-4b0c-96d5-c26ae1ece464","added_by":"auto","created_at":"2024-04-22 02:55:37","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":104208,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of activities during the DeWorm3 census and assessment for functional difficulties in Tamil Nadu, 2019\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4154190/v1/63457a22055a83d7065ec24a.png"},{"id":55061364,"identity":"97cfb96c-aaee-41a7-8fdd-febacc41d23c","added_by":"auto","created_at":"2024-04-22 02:47:37","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":61551,"visible":true,"origin":"","legend":"\u003cp\u003eAge- and gender-adjusted associations (risk ratios) between domain-specific measures of functional impairment (as opposed to no impairment) and school non-enrolement.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4154190/v1/028ef739377148462281fab1.png"},{"id":55063116,"identity":"244a9abe-c8a8-413b-9691-150a6bbebaed","added_by":"auto","created_at":"2024-04-22 03:03:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":774908,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4154190/v1/7467bb3f-8d97-454e-b3cd-557b42aa79ad.pdf"},{"id":55061365,"identity":"7ef4baa7-dee6-4443-9f61-6a7ab7853c43","added_by":"auto","created_at":"2024-04-22 02:47:37","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":93011,"visible":true,"origin":"","legend":"","description":"","filename":"Appendices23MAR24.docx","url":"https://assets-eu.researchsquare.com/files/rs-4154190/v1/a93e03276f628cc105c1f476.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prevalence of functional difficulty among school-aged children and effect on school enrolment in rural southern India: A cross-sectional analysis","fulltext":[{"header":"Highlights","content":"\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eAt least one in a hundred children have severe functional difficulties in this population in Tamil Nadu, India\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eFunctional difficulty was a strong predictor of school non-enrolment, independent of age, gender, and sub-site\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eRates of school inclusion for children with functional difficulties differed between age and socioeconomic groups\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eChildhood disability continues to be a low priority on the global development and health agenda [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e], despite the large and growing number of children affected, and the fact that the period of childhood and adolescence influences the entire life course [\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]. The 2004 Global Burden of Disease Study estimated that 93\u0026nbsp;million or 5.1% of children aged 0\u0026ndash;14 years had moderate/severe disability, of whom 13\u0026nbsp;million (0.7%) had severe disability [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e]. More recent work has put these numbers far higher. For instance, the 2017 Global Burden of Disease Study estimated that there were 291\u0026nbsp;million (11.2%) children and adolescents with one of four specified \u0026ldquo;disabilities\u0026rdquo; (epilepsy, intellectual disability, vision or hearing loss)(5). This figure grows further if more conditions are included, which includes various impediments to functioning [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e]. Not only is the number of children with disabilities large, but new research shows that it is rising as a result of population growth [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, uncertainty remains about these figures due to variation in methods used to assess childhood disability, resulting in varying and non-comparable estimates. The UNICEF-Washington Group Child Functioning Module was introduced in 2017 to standardise the assessment of disability in children aged 2\u0026ndash;17 years [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e]. Its widespread use should increase the amount and comparability of international estimates, but to date few publications are available that have used this tool.\u003c/p\u003e\n\u003cp\u003eNo matter how disability is measured, children who are found to have disabilities are left behind in different domains of life, including in education. A 2018 UNESCO report demonstrated through data from 49 countries that people with disabilities had consistently worse educational outcomes compared to their peers without disabilities, whether measured in terms of school enrolment, school completion, mean years of schooling, or literacy levels [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]. Data from 6 countries also showed that out-of-school rate was higher among children with disabilities than children without in both primary school (34.5% versus 14.1%) and secondary school (25.7% versus 17.5%). Lower levels of education of children with disabilities were also shown in the 2011 World Report on Disability [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e] and the 2018 Flagship Report on Disability and Development [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]. For example, having a disability reduced the probability of attending school by 30.9 percentage points in an analysis across 15 low and middle income countries [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eThe exclusion of children with disabilities from education is a violation of their rights, as set out by the UN Convention on the Rights of the Child (articles 23, 28 and 29) [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e], and the UN Convention on the Rights of Persons with Disabilities (article 24) [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]. It will also make it more challenging to reach SDG 4 on \u0026ldquo;inclusive and equitable quality education,\u0026rdquo; which includes specific targets on eliminating gender disparity and discrimination against people with disabilities, among other priority groups [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]. Different rights and goals are interlinked, and it will be more difficult to achieve employment for all, as an example, without first reaching all with education.\u003c/p\u003e\n\u003cp\u003eChildren with disability are not a homogenous group, and their level of inclusion in education may be affected by a range of factors, such as gender, poverty level and impairment type. However, there is a lack of evidence of predictors of which children with disability are going to school. This gap is important as evidence is needed on which children with disability are most likely to be excluded to plan interventions to promote educational inclusion. Furthermore, there is currently a lack of data on which interventions are effective for improving uptake, and so evidence is first needed on the key issues before appropriate solutions can be developed [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]. The limited data that is available suggests that boys with disabilities may fare better than girls. The UNESCO data showed that boys with disabilities had almost one year more of schooling than girls with disabilities (5.4 versus 4.3), and men with disabilities had higher literacy rates than women with disabilities (62% versus 49%) [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]. Data from Plan International across 30 countries showed that children with certain impairment types were less likely to go to school, especially those with learning or communication impairments [\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. Generally, however, such data in relation to school attendance is lacking.\u003c/p\u003e\n\u003cp\u003eIndia is an important country to consider for disability and educational inclusion, given its size and global influence. The 2011 Indian Census, using a simple assessment of disability (\u0026ldquo;Is this person mentally/physically disabled?\u0026rdquo;) estimates that 2.2% of the population had disabilities, including 1.5% of children aged 5\u0026ndash;9 years and 1.8% of children 10\u0026ndash;19 years [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]. These prevalence estimates are likely to substantially underestimate the true levels, given the simplicity of the question used [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. Subsequently, a large community study from five diverse Indian sites showed that pooled estimates of prevalence of neurodevelopmental disorders (visual impairment, epilepsy, cerebral palsy, hearing impairment, speech disorders and autism for all children, and attention deficit hyperactivity disorder and learning disorder among 6\u0026ndash;9 year-olds) were 9.2% and 13.6% in children 2\u0026ndash;6 years and 6\u0026ndash;9 years of age, respectively [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]. India has established a comprehensive legal framework for inclusive education. The Right to Education (RTE) Act of 2009 confirmed the right of all children to free and compulsory education [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. The Rights of Persons with Disabilities Act 2016 made the commitment that \u0026ldquo;every child with benchmark disability between the age of six to eighteen years shall have the right to free education in a neighbourhood school, or in a special school, of his choice\u0026rdquo; [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. The National Education Policy 2020 went further still and made a range of commitments towards the inclusion of children with disabilities, such as appropriate training of teachers, appropriate learning material (e.g. Braille), accessible facilities and protecting the safety of children with disabilities [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. Moreover, India has ratified both the UN Convention on the Rights of Person with Disabilities (2007) and the UN Convention on the Rights of the Child (1992), which protect the right to education for children with disabilities.\u003c/p\u003e\n\u003cp\u003eBarriers to accessing education remain, however, despite these commitments. As a result, school enrolment is far from complete. Estimates from the 2011 census show that 29% of all children aged 5\u0026ndash;19 years do not attend school, but this rises to 39% of children with disabilities [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]. Enrolment was higher in primary than the higher levels of schooling and was better for children with certain types of impairment (hearing \u0026ndash; 67%, seeing \u0026ndash; 68%) than among children with intellectual impairments (47%), mental health conditions (34%) or multiple disabilities (37%). However, these estimates are now ten years out of date, and preceded some of the new legislation protecting the right to education of children with disabilities. Since 2011, the proportion of children in primary schools with disabilities has increased by 50% (0.8\u0026ndash;1.2% of children enrolled in primary school in 2015/2016), although the proportion of children in secondary school with disabilities has remained unchanged (around 0.3%) [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]. This may represent improved recognition and reporting of disability, and these figures only capture children with official certifications of disability and do not capture children with disabilities out of school.\u003c/p\u003e\n\u003cp\u003eThe aim of this study was to use UNICEF-Washington Group questions to estimate the prevalence of childhood disability in a population in Tamil Nadu, India and to estimate the effect of functional difficulty on school enrolment and examine how this effect may differ between sociodemographic groups.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design and participants\u003c/p\u003e\n\u003cp\u003eThe DeWorm3 Project is a multi-country, cluster-randomised, controlled trial conducted in Benin, India, and Malawi to test feasibility of interrupting transmission of soil-transmitted helminths (STH) through three years of expanded mass drug administration (MDA) targeting all community members versus each of the current national STH MDA strategies. Each study site includes a population of at least 80,000 individuals, divided into 40 clusters of at least 1,650 individuals, considering administrative borders and geographic barriers. The trial in India has two sites in Tamil Nadu: the Timiri block in the Vellore Health Unit District (HUD) and villages in the Jawadhu Hills block of the Tiruvanamalai HUD. A census of all individuals residing within the study site is conducted yearly to enumerate the population [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eThe current study took place in the India DeWorm3 site, during a trial population census update activity conducted between October 19, 2019 and February 3, 2020. At each household, a structured questionnaire was conducted with the head of household or an equivalent adult resident. The questionnaire collected information on household member demographics, school enrolment or highest education level, household ownership of key assets, and water and sanitation facilities. Age and gender were verified using state or central Government of India issued identification (\u003cem\u003eAadhar\u003c/em\u003e card, Electoral Identity Card, Driving License, or Birth Certificate). Enumerators observed the material of the floor, walls, and roof and collected Global Positioning System (GPS) coordinates at each household. All data were collected using an electronic questionnaire programmed using SurveyCTO software (Dobility, Inc; Cambridge, MA and Ahmedabad, India) on Android smartphones.\u003c/p\u003e\n\u003cp\u003eThe information of all eligible individuals, aged 5 to 17 years and enumerated during the household census visit, was automatically sent to a second electronic questionnaire containing the UNICEF/Washington Group Module on child functioning and disability [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. This parent-reported survey module is designed to identify children with functional difficulties in population-based surveys. For most domains, it scores functional limitation on a scale comprising \u0026ldquo;no difficulty,\u0026rdquo; \u0026ldquo;some difficulty,\u0026rdquo; \u0026ldquo;a lot of difficulty,\u0026rdquo; and \u0026ldquo;cannot do.\u0026rdquo; Fieldworkers then conducted the questionnaire with the mothers or reported primary caregivers for each identified eligible child within the household.\u003c/p\u003e\n\u003cp\u003eOutcomes\u003c/p\u003e\n\u003cp\u003eA child was classed as having functional difficulty if they reported \u0026ldquo;a lot of difficulty\u0026rdquo; or \u0026ldquo;cannot do\u0026rdquo; within the domains of seeing, hearing, walking, self-care, communication, learning, remembering, concentrating, accepting change, controlling behaviour, and making friends or reported \u0026ldquo;daily\u0026rdquo; anxiety, nervousness, worry or seeming sad or depressed.\u003c/p\u003e\n\u003cp\u003eDuring the census update activity, the respondent was asked whether each individual household member aged between 3 and 25 years attended school. Responses were then recorded as \u0026ldquo;not in education\u0026rdquo; or the specific level of education (\u003cem\u003eAnganwadi\u003c/em\u003e centre; kindergarten; primary; middle; secondary; higher secondary; college; or ITI/diploma). For the current study, children were classed as not being enrolled in school if they were reported to be \u0026ldquo;not in education.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eCovariates\u003c/p\u003e\n\u003cp\u003eIndividual covariates included age in years, categorised as 5\u0026ndash;9, 10\u0026ndash;13, and 14\u0026ndash;17 and male or female gender. Household covariates included: an indicator of household size dichotomised as \u0026lt;\u0026thinsp;5 or \u0026ge;\u0026thinsp;5 from the number of residents; reported years in residence; education and marital status of the head of household; reported household caste, religion, and language. A measure of socioeconomic status was derived from a composite wealth index based on a principal component analysis (PCA) using various reported household assets (24). The wealth index was divided into five quintiles, and for the current analysis the lower 3 quintiles were classed as poorer and the upper 2 quintiles were classed as less poor.\u003c/p\u003e\n\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\n\u003cp\u003eStatistical analysis\u003c/p\u003e\n\u003cp\u003eWe estimated the prevalence of difficulty within each of the functional domains and in any of the domains in total and by gender. We then estimated prevalence ratios between levels of each of the candidate covariates and presence of any functional difficulty and, separately, reported school non-enrolment using modified Poisson regression [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eFor this, we fit generalised linear models, specifying a Poisson distribution and log link. We estimated robust standard errors at the household level to accommodate the binary outcomes and to account for potential outcome correlation between children for residence within the same household. We excluded individuals with missing outcome or covariate data (0.3%), and assumed these data were missing at random, that is, that the probability of having complete data is independent of the outcome after adjusting for included covariates. We report prevalence ratios with 95% confidence intervals as crude (bivariate) and adjusted for age category, gender, and site.\u003c/p\u003e\n\u003cp\u003eWe examined heterogeneity of the effect of functional difficulty upon reported school non-enrolment with an aim towards identifying groups who may benefit from additional interventions to reduce school exclusion. We examined this effect modification by age dichotomised at the median (5\u0026ndash;11 years versus 11\u0026ndash;17 years), gender (male versus female), SES (higher versus lower), head of household education (any formal versus no formal education), and site (Timiri versus Jawadhu Hills). We estimated this effect modification on both multiplicative and additive scales, the latter of which is considered more meaningful from a public health perspective [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e]. For the latter, we estimated the relative excess risk due to interaction (RERI) [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e], using the interactionR package with confidence intervals calculated using the MOVER method [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. When the exposures of interest have the same direction of effect upon the outcome, a RERI greater than 0 means greater than additive interaction or positivity, whereby we might observe a greater number of outcomes in the presence of the main effect and its modifier than we would expect based on the numbers of outcomes attributed to the effect and modifier separately. A RERI less than 0 means there is less than additive interaction or negative interaction. We adjusted for age, gender, and site in the interactions analysis.\u003c/p\u003e\n\u003cp\u003eAll analyses were conducted using R version 4.0.3 (2022-04-29). De-identified data and analysis scripts are available upon request via LSHTM Data Compass.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 29,044 children aged 5\u0026ndash;17 years were included in the analysis, after excluding 84 with missing data (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The distribution of functional difficulties are shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e by gender. Of 29,044 children, 299 (1.0%) had any functional difficulty. Few children had limitations with seeing, hearing, depression, or anxiety, while 0.3\u0026ndash;0.4% of the children were reported to have limitations in the other domains, such as walking, remembering, or accepting change.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eOccurrence of any functional difficulty and difficulty within functional domains by gender among N\u0026thinsp;=\u0026thinsp;29,044 children in Tamil Nadu, India\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;15,073)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;13,971)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAll\u003c/p\u003e\n\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;29,044)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eFunctional Difficulty\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAny\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e149 (1.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e150 (1.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e299 (1.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSeeing\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e16 (0.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e18 (0.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e34 (0.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHearing\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e16 (0.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e27 (0.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e43 (0.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eWalking\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e55 (0.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e55 (0.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e110 (0.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSelf-Care\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e55 (0.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e44 (0.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e99 (0.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eBeing Understood\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e68 (0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e61 (0.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e129 (0.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eLearning\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e51 (0.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e49 (0.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e100 (0.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eRemembering\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e48 (0.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e44 (0.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e92 (0.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eConcentrating\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e43 (0.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e41 (0.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e84 (0.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAccepting Change\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e40 (0.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e33 (0.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e73 (0.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eControlling Behaviour\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e45 (0.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e40 (0.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e85 (0.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMaking Friends\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e41 (0.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e42 (0.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e83 (0.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAnxiety\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e22 (0.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20 (0.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e42 (0.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDepression\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14 (0.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e15 (0.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e29 (0.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eFew sociodemographic factors were associated with having any functional difficulty (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Many of the associations were close to the null before and after adjustment for age, gender, and site. There was some evidence of a positive association between any functional difficulty and living in the tribal Jawadhu Hills area as opposed to the rural Timiri area (PR: 1.30, 95% CI: 1.01 to 1.67), adjusting for age and gender. There was some evidence of a small positive association between any functional difficulty and household socioeconomic status, which was attenuated towards the null after adjusting for age, gender, and site.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eAssociation of functional difficulty with factors for the purposes of targeting and understanding clustering of disadvantage among N\u0026thinsp;=\u0026thinsp;29,044 children in Tamil Nadu, India\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eOverall\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eFunctional Difficulty\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCrude\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAdjusted*\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePR (95% CI)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePR (95% CI)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAge Category (years)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5\u0026ndash;9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e10,692 (36.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e97 (0.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u0026ndash;13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e8,864 (30.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e102 (1.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.27 (0.97, 1.67)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.27 (0.97, 1.67)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14\u0026ndash;17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9,488 (32.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e100 (1.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.16 (0.88, 1.54)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.17 (0.88, 1.55)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e15,073 (51.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e149 (1.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e13,971 (48.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e150 (1.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.09 (0.87, 1.36)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.09 (0.87, 1.37)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSchool Enrolment\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNot in education\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2,860 (9.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e129 (4.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAnganwadi/Kindergarten\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e444 (1.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2 (0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.10 (0.02, 0.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.04 (0.01, 0.19)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePrimary school\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e10,627 (36.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e73 (0.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.15 (0.11, 0.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.07 (0.04, 0.12)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMiddle school\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6,551 (22.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e58 (0.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.20 (0.14, 0.27)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.11 (0.06, 0.17)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSecondary school\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4,288 (14.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e28 (0.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.14 (0.10, 0.22)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.12 (0.07, 0.19)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHigher secondary school\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3,170 (10.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9 (0.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.06 (0.03, 0.12)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.07 (0.03, 0.14)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCollege/Diploma/ITI/University\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1,104 (3.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00 (0.00, 0.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00 (0.00, 0.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHousehold Size\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e11,320 (39.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e119 (1.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ge;5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e17,724 (61.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e180 (1.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.97 (0.76, 1.23)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.94 (0.74, 1.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSocioeconomic Status\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLess poor (Upper 2 quintiles)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e17,563 (60.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e158 (0.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePoorer (Lower 3 quintiles)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e11,481 (39.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e141 (1.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.37 (1.08, 1.73)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.30 (0.93, 1.83)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eResidence Time\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;5 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3,385 (11.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e40 (1.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4,062 (14.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e37 (0.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.77 (0.48, 1.24)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.76 (0.48, 1.23)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11\u0026ndash;20 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6,036 (20.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e64 (1.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.90 (0.59, 1.36)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.88 (0.58, 1.33)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;20 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e15,561 (53.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e158 (1.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.86 (0.60, 1.23)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.85 (0.59, 1.22)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHoH Education\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo education\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6,893 (23.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e88 (1.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAny primary\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5,609 (19.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e63 (1.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.88 (0.63, 1.24)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.94 (0.65, 1.36)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAny middle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6,215 (21.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e57 (0.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.72 (0.51, 1.02)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.77 (0.53, 1.11)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAny secondary or higher\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e10,327 (35.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e91 (0.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.69 (0.51, 0.93)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.75 (0.53, 1.06)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHoH Marital Status\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMarried\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e26,192 (90.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e265 (1.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePreviously or never married\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2,852 (9.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e34 (1.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.18 (0.82, 1.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.18 (0.82, 1.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eCaste\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eScheduled tribes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e8,322 (28.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e96 (1.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eScheduled caste\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6,463 (22.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e61 (0.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.82 (0.58, 1.15)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.79 (0.91, 3.51)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBackward caste\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7,409 (25.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e78 (1.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.91 (0.67, 1.25)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.01 (1.03, 3.91)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMost backward caste\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6,588 (22.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e63 (1.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.83 (0.59, 1.16)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.81 (0.92, 3.57)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHigher caste\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e172 (0.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00 (0.00, 0.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00 (0.00, 0.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e90 (0.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1 (1.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.96 (0.14, 6.78)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.49 (0.21, 10.44)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHindu\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e954 (3.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e10 (1.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e28,090 (96.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e289 (1.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.98 (0.53, 1.83)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.94 (0.50, 1.76)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTamil Speaker\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e840 (2.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7 (0.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e28,204 (97.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e292 (1.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.24 (0.59, 2.61)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.19 (0.57, 2.51)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSite\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTimiri\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20,750 (71.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e197 (0.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eJawadhu Hills\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e8,294 (28.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e102 (1.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.30 (1.01, 1.67)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.30 (1.01, 1.67)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\"\u003e*Adjusted for age category, gender, and site; PR\u0026thinsp;=\u0026thinsp;Prevalence Ratio; CI\u0026thinsp;=\u0026thinsp;Confidence Interval\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eSeveral of the analysed factors were associated with reported school non-enrolment (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). Among children with functional difficulty, the prevalence of school non-enrolment (43.1%) was 4.59 times higher than that among children without functional difficulty (9.5%), after adjusting for age, gender, and sub-site (95% CI: 3.87 to 5.43). Prevalence of non-enrolment was higher in older age categories, and children aged over 14 years were 8.57 times more likely to be non-enrolled compared to younger children aged 5 to 9 years (95% CI: 7.60 to 9.66), adjusting for gender and site. Figure\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e shows the associations for each domain of the CFM, where the categories measured among older children are associated more strongly with non-enrolment. Gender was also found to be a contributor to non-enrolment, as girls were 16% more likely to not be enrolled as boys (PR: 0.84, 95% CI: 0.79 to 0.90). Prevalence of non-enrolment was observed to be higher in Jawadhu Hills compared to Timiri, after accounting for age and gender. However, after adjusting for area differences, children from poorer households, households in longer residence, or with less educated or unmarried household heads were found to have higher prevalence of non-enrolment.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eAssociation of selected factors with reported school non-enrolment among N\u0026thinsp;=\u0026thinsp;29,044 children in Tamil Nadu, India\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eOverall\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNot enrolled\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCrude\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAdjusted*\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePR (95% CI)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePR (95% CI)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAge Category (years)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5\u0026ndash;9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e10,692 (36.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e289 (2.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u0026ndash;13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e8,864 (30.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e407 (4.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.70 (1.47, 1.96)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.70 (1.48, 1.96)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14\u0026ndash;17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9,488 (32.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2,164 (22.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.44 (7.46, 9.54)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.57 (7.60, 9.66)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e15,073 (51.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1,649 (10.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e13,971 (48.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1,211 (8.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.79 (0.74, 0.85)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.84 (0.79, 0.90)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSchool Enrolment\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNot in education\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2,860 (9.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2,860 (100.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAnganwadi/Kindergarten\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e444 (1.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00 (0.00, 0.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00 (0.00, 0.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePrimary school\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e10,627 (36.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00 (0.00, 0.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00 (0.00, 0.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMiddle school\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6,551 (22.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00 (0.00, 0.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00 (0.00, 0.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSecondary school\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4,288 (14.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00 (0.00, 0.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00 (0.00, 0.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHigher secondary school\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3,170 (10.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00 (0.00, 0.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00 (0.00, 0.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCollege/Diploma/ITI/University\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1,104 (3.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00 (0.00, 0.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.00 (0.00, 0.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHousehold Size\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e11,320 (39.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1,126 (9.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ge;5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e17,724 (61.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1,734 (9.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.98 (0.91, 1.06)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.98 (0.92, 1.06)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSocioeconomic Status\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLess poor (Upper 2 quintiles)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e17,563 (60.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e920 (5.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePoorer (Lower 3 quintiles)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e11,481 (39.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1,940 (16.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.23 (2.98, 3.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.01 (1.82, 2.22)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eResidence Time\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;5 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3,385 (11.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e252 (7.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4,062 (14.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e333 (8.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.10 (0.93, 1.31)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.97 (0.83, 1.14)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11\u0026ndash;20 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6,036 (20.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e591 (9.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.32 (1.12, 1.54)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.05 (0.91, 1.22)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;20 years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e15,561 (53.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1,684 (10.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.45 (1.26, 1.68)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.18 (1.04, 1.35)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHoH Education\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo education\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6,893 (23.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1,464 (21.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAny primary\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5,609 (19.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e567 (10.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.48 (0.43, 0.52)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.69 (0.63, 0.77)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAny middle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6,215 (21.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e440 (7.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.33 (0.30, 0.37)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.54 (0.49, 0.60)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAny secondary or higher\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e10,327 (35.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e389 (3.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.18 (0.16, 0.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.29 (0.26, 0.33)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHoH Marital Status\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMarried\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e26,192 (90.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2,457 (9.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePreviously or never married\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2,852 (9.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e403 (14.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.51 (1.35, 1.68)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.38 (1.26, 1.52)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eCaste\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eScheduled tribes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e8,322 (28.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1,679 (20.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eScheduled caste\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6,463 (22.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e510 (7.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.39 (0.35, 0.43)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.39 (0.31, 0.49)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBackward caste\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7,409 (25.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e309 (4.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.21 (0.18, 0.23)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.21 (0.16, 0.26)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMost backward caste\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6,588 (22.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e352 (5.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.26 (0.24, 0.30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.27 (0.21, 0.34)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHigher caste\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e172 (0.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4 (2.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.12 (0.04, 0.31)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.11 (0.04, 0.28)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e90 (0.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6 (6.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.33 (0.15, 0.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.36 (0.17, 0.75)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHindu\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e954 (3.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e64 (6.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e28,090 (96.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2,796 (10.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.48 (1.15, 1.91)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.13 (0.88, 1.45)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTamil Speaker\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e840 (2.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e71 (8.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e28,204 (97.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2,789 (9.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.17 (0.92, 1.49)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.92 (0.73, 1.16)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSite\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTimiri\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20,750 (71.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1,232 (5.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eREF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eJawadhu Hills\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e8,294 (28.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1,628 (19.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.31 (3.06, 3.57)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.38 (3.14, 3.63)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\"\u003e*Adjusted for age category, gender, and site; PR\u0026thinsp;=\u0026thinsp;Prevalence Ratio; CI\u0026thinsp;=\u0026thinsp;Confidence Interval\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe results of analysis of modification of the effect of any functional difficulty on school non-enrolment by selected factors is shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e (domain-specific effects are shown in the \u003cstrong\u003eWeb Appendix\u003c/strong\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eModification of the effect of functional difficulty on school non-enrolment by selected sociodemographic factors among N\u0026thinsp;=\u0026thinsp;29,044 children in Tamil Nadu, India, adjusted for age, gender, and site.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003cp\u003eFunctional Difficulty\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAny\u003c/p\u003e\n\u003cp\u003eFunctional Difficulty\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eEffect of FD\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eEM Measures\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNon-enrolment\u003c/p\u003e\n\u003cp\u003en/N (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePR\u003c/p\u003e\n\u003cp\u003e(95% CI)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNon-enrolment\u003c/p\u003e\n\u003cp\u003en/N (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePR\u003c/p\u003e\n\u003cp\u003e(95% CI)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePR\u003c/p\u003e\n\u003cp\u003e(95% CI)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMultiplicative\u003c/p\u003e\n\u003cp\u003e(95% CI)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAdditive\u003c/p\u003e\n\u003cp\u003e(95% CI)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOverall (crude)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2,731/28,745 (10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e129/299 (43)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.54\u003c/p\u003e\n\u003cp\u003e(3.95, 5.21)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOverall (adjusted)*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2,731/28,745 (10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e129/299 (43)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.59\u003c/p\u003e\n\u003cp\u003e(3.87, 5.43)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge Category (years)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.27\u003c/p\u003e\n\u003cp\u003e(0.17, 0.43)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.74\u003c/p\u003e\n\u003cp\u003e(-3.33, 10.75)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5\u0026ndash;11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e295/12,643 (2.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e38/117 (32.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.06\u003c/p\u003e\n\u003cp\u003e(8.14, 17.87)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.06\u003c/p\u003e\n\u003cp\u003e(8.14, 17.87)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12\u0026ndash;17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2,436/16,102 (15)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.49\u003c/p\u003e\n\u003cp\u003e(5.64, 7.47)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e91/182 (50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21.29\u003c/p\u003e\n\u003cp\u003e(16.20, 27.98)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.28\u003c/p\u003e\n\u003cp\u003e(2.57, 4.19)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.05\u003c/p\u003e\n\u003cp\u003e(0.70, 1.59)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.95\u003c/p\u003e\n\u003cp\u003e(-0.91, 2.93)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,148/13,821 (8.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e63/150 (42.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.07 (3.04, 5.46)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.07 (3.04, 5.46)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,583/14,924 (11)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.22\u003c/p\u003e\n\u003cp\u003e(1.12, 1.34)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e66/149 (44)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5.25 (3.94, 6.99)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.29 (3.22, 5.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSocioeconomic Status\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.40\u003c/p\u003e\n\u003cp\u003e(0.27, 0.60)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-2.27\u003c/p\u003e\n\u003cp\u003e(-5.09, 0.39)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLess poor (Upper 2 quintiles)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e857/17,405 (4.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e63/158 (39.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.23\u003c/p\u003e\n\u003cp\u003e(5.39, 9.69)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.23\u003c/p\u003e\n\u003cp\u003e(5.39, 9.69)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePoorer (Lower 3 quintiles)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,874/11,340 (17)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.07\u003c/p\u003e\n\u003cp\u003e(1.83, 2.35)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e66/141 (47)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.03\u003c/p\u003e\n\u003cp\u003e(4.48, 8.12)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.91\u003c/p\u003e\n\u003cp\u003e(2.19, 3.86)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eNo HoH Education\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.30\u003c/p\u003e\n\u003cp\u003e(0.20, 0.47)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-3.39\u003c/p\u003e\n\u003cp\u003e(-5.71, -0.92)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAny education\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,306/21,940 (6.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e90/211 (42.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.78\u003c/p\u003e\n\u003cp\u003e(5.31, 8.65)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.78\u003c/p\u003e\n\u003cp\u003e(5.31, 8.65)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo education\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,425/6,805 (21)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.26\u003c/p\u003e\n\u003cp\u003e(2.05, 2.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e39/88 (44)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.65\u003c/p\u003e\n\u003cp\u003e(3.22, 6.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.05\u003c/p\u003e\n\u003cp\u003e(1.43, 2.95)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSite\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.33\u003c/p\u003e\n\u003cp\u003e(0.21, 0.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-1.57\u003c/p\u003e\n\u003cp\u003e(-4.64, 2.07)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTimiri\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,146/20,553 (5.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e86/197 (43.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.06\u003c/p\u003e\n\u003cp\u003e(5.47, 9.10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.06\u003c/p\u003e\n\u003cp\u003e(5.47, 9.10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eJawadhu Hills\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1,585/8,192 (19)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.46\u003c/p\u003e\n\u003cp\u003e(3.17, 3.78)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e43/102 (42)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.95\u003c/p\u003e\n\u003cp\u003e(5.58, 11.31)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.30\u003c/p\u003e\n\u003cp\u003e(1.62, 3.26)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"8\"\u003e*Adjusted for age category, gender, and site; PR\u0026thinsp;=\u0026thinsp;Prevalence Ratio; CI\u0026thinsp;=\u0026thinsp;Confidence Interval; FD\u0026thinsp;=\u0026thinsp;Functional Difficulty; EM\u0026thinsp;=\u0026thinsp;Effect Modification\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eIn the case of age, the multiplicative and additive measures of effect modification differed in direction. In young children, prevalence of non-enrolment among those with any functional difficulty was nearly fourteen times that of children without functional difficulty (PR: 13.92, 95% CI: 9.11 to 21.27), while the same effect in older children was smaller (PR: 3.31, 95% CI: 2.54 to 4.30). Reflecting this, the age interaction measure on the multiplicative scale, equating the ratio of these age stratum-specific PRs, was 0.24 (95% CI: 0.14 to 0.39). The additive interaction measure of 2.03 in turn (95% CI: -6.43 to 9.97) was positive. This result reflects the greater joint association on the additive scale between older age and functional difficulty and not being enrolled in school (PR: 21.43, 95% CI: 15.95 to 28.78), in contrast what might be expected from combining individual effects of functional difficulty (PR: 13.92, 95% CI: 9.11 to 21.27) in the younger age group or age among children without functional difficulties (PR: 6.48, 95% CI: 5.57 to 7.55), and suggests a synergistic interaction of older age and functional difficulty on school enrolment, though the confidence interval included 0. There was no evidence of modification of the effect of functional difficulty on non-enrolment by gender on either the multiplicative or the additive scales.\u003c/p\u003e\n\u003cp\u003ePatterns of modification of the effect of functional difficulty on school non-enrolment by socioeconomic status, education level of the head of household, and site, were similar. The proportion of children without functional difficulty who were not enrolled in school was higher in poorer households, those with a head of household with no formal education, or living in Jawadhu Hills, relative to children in less poor households, with a head of household reporting any formal education, or living in Timiri (PR: 3.36, 95% CI: 3.03, 3.71; PR: 3.52, 95% CI: 3.20, 3.87; PR: 3.47, 95% CI: 3.15, 3.82), respectively. Among children with functional difficulty, the prevalence of non-enrolment was similar across socioeconomic quintiles, head of household education levels, and site. For these factors, on the multiplicative scale, the pattern is shown as the effect of functional difficulty among children in lower socioeconomic conditions, in families with less educated heads of household, or in Jawadhu Hills was of smaller magnitude than that observed among children in less poor or more educated households or those living Timiri. On the additive scale, the results were suggestive of an antagonistic relationship of functional difficulty with each of these factors, particularly education and site, but again confidence intervals included 0.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis large-scale census of children in two sites in Tamil Nadu found that 1.0% of children aged 5\u0026ndash;17 years were parent-reported to have disabilities, as assessed through the UNICEF-Washington Group Child Module, and prevalence of functional difficulty was similar between boys and girls. The most prevalent reported functional impairments were being understood and walking. Sensory difficulties (seeing/hearing) or mental health concerns were less commonly reported, which may be because these are more difficult for a parent to recognise in their child. Childhood disability was largely un-related to socio-demographic features but was more prevalent in the Jawadhu Hills compared to Timiri. Children with disabilities were substantially less likely to be enrolled in school compared to children without disabilities (56.9% versus 90.5%). Across the cohort, school exclusion was most prevalent among children with disabilities and 12\u0026thinsp;+\u0026thinsp;years old. However, the effect of functional difficulty on school exclusion was four times greater among younger children relative to older ones. There was no evidence of heterogeneity in the effect of functional difficulty by gender.\u003c/p\u003e \u003cp\u003eThe prevalence of childhood disability of 1.0% reported in this study was lower than estimates from the World Report on Disability (5%) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] or the Global Burden of Disease (11%) [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], as well as the 2011 India census estimates (1.5% of children aged 5\u0026ndash;9 years and 1.8% of children 10\u0026ndash;19 years)[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], which is already likely to provide an under-estimate of the true prevalence of disability [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. These estimates covered children below 5, which may explain some of the discrepancy. It is higher than the India Health and Development Survey (2005), which found a prevalence of 0.37% in children 5\u0026ndash;17 years using the Washington Group Short Set (which contains six functional domains rather than the 13 assessed in this study with the Washington-UNICEF Child Functioning Module [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. A survey in Andhra Pradesh including 1,383 children aged 0\u0026ndash;17 years used modules from the UNICEF-Washington Group module to obtain an estimated prevalence of childhood disability of 2.3% (1.4\u0026ndash;3.7%) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Measures of behavioural difficulties (e.g. controlling behaviour, play) and mental health (worry) were not included in the Andhra Pradesh survey, which would have pushed the prevalence higher. The Andhra Pradesh survey also used clinical measures to estimate the prevalence of vision, hearing and/or physical impairment or epilepsy, which together affected 2.9% (2.1-4.0%) of children aged 0\u0026ndash;17 years. In comparison, our low prevalence might be explained by subjective parent report in comparatively low-and-middle-income settings. Parental perceptions and understanding, their stage of acceptance of disability, and cultural norms can affect parent reporting of symptoms as evidenced from an Indian study [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Surveys from five geographically diverse populations in India have also reported higher prevalence than in the current study. A survey of 3,964 children aged 2\u0026ndash;9 years found that 9.2% of children 2-\u0026lt;6 years and 13.6% of children 6\u0026ndash;9 years had one of seven neurodevelopmental disorders (vison impairment, epilepsy, neuromotor impairments, hearing impairment, speech and language disorders, autism spectrum disorders, and/or intellectual disability) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The higher prevalence of neurodevelopmental disorders might be due to additional screening and specific questionnaires used in that study. Consistent with our findings, there was no gender difference or socio-economic correlates of these conditions.\u003c/p\u003e \u003cp\u003eOther studies support our finding of the lower levels of school inclusion among children with disabilities compared to those without disabilities, including the 2011 census (school attendance 61% of children with disabilities and 71% of all children) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and the 2015 Andhra Pradesh study (51% versus 91%) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Similar to our finding that older children with disability are the most frequently non-enrolled in school, increased enrolment of children with disabilities in primary versus higher school levels were also shown in the census, [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] official government enrolment numbers [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], a 2018 national survey [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], and a case-control study in New Delhi [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. However, our analysis allowed us to observe considerable heterogeneity in the impact of functional difficulty on school enrolment between age strata. Specifically, while all children with functional difficulty were less likely to be enrolled than children without disability, the effect of disability on school inclusion was most pronounced in the younger age group, demonstrating how disability can detrimentally impact the life course at an early stage, because educational exclusion will likely persist. In turn, we show this persistence by estimating the prevalence of non-enrolment to be highest among older children with functional difficulty.\u003c/p\u003e \u003cp\u003eOur examination of modification of the effect of functional difficulty on school non-enrolment highlights the importance of examining modification of effects on both multiplicative and additive scales [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. For age, for example, it was important to show how much stronger the association between disability and non-enrolment is among younger children, but while the children most at risk of non-enrolment were older children with disabilities. Our analysis of the interaction between socioeconomic difficulty, disability, and school enrolment, suggest that there might be competing risks to non-enrolment. For children with disabilities from poorer backgrounds, although less likely to be in school than their better-off peers, their enrolment was less likely to be affected by their disability \u003cem\u003eper se\u003c/em\u003e. However, while this is clear on the multiplicative scale, the non-statistically significant interaction on the additive scale warns against over-interpreting the policy implications.\u003c/p\u003e \u003cp\u003eOur current analysis shows that, though there is a considerable difference in enrolment between genders overall, there was no difference in the effect of functional difficulty on school enrolment of children based on gender. The 2018 survey and official enrolment numbers showed slightly higher enrolment of boys with disabilities compared to girls across most levels of schooling [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], while the New Delhi case-control study reported that primary school enrolment was more common in girls with disabilities compared to boys [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Household head education and socio-economic status appeared less relevant as correlates of school enrolment among children with disabilities in the New Delhi study [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. In India and other settings, children with severe disabilities are less likely to be enrolled in school [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. To address this gap, the Government of India has introduced the Sarva Sikhsha Abhiyan (SSA) where all children irrespective of disabilities can attend school education services [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Additional vulnerabilities as highlighted in this study should be addressed to achieve an optimum implementation.\u003c/p\u003e \u003cp\u003eIn terms of strengths, this was a large study including 29,044 children identified through an exhaustive census activity. Disability was assessed using the UNICEF-Washington Group Child Functioning Module. Two contrasting sites were included \u0026ndash; one rural and one tribal \u0026ndash; allowing comparison of findings.\u003c/p\u003e \u003cp\u003eThere are also important limitations to consider. The functional difficulty measure utilised caregiver reporting of difficulties, and reported disability may be subjective and not fully captured. Caregiver expectations of childhood functioning may be gendered, biasing comparisons between boys and girls. The educational measure was report-based and focussed on current school enrolment only and did not assess other important aspects of schooling, such as quality of education, educational attainment, social inclusion and freedom from violence and bullying. The World Report on Disability found that when children with disabilities did enrol in school, their dropout rates were higher and they were on average at a lower level of schooling for their age [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and quality of schooling may be worse for children with disabilities [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Studies from India have also highlighted that although progress has been made, gaps in the provision of inclusive education remain, including in teacher training and provision of appropriate and adequate resources [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Moreover, it is also known that children with disabilities often experience difficulties at school, such as being more likely to experience violence, whether physical, psychological, or sexual [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], and these measures were not captured in the study. Further, the correlates of educational enrolment used focussed on individual characteristics of the child (e.g. age, gender, household wealth) rather than features of the environment or school (e.g. accessible facilities, staff trained about disability, inclusive societal attitudes).\u003c/p\u003e \u003cp\u003eImplications for policy, practice, and research\u003c/p\u003e \u003cp\u003eThis study demonstrated that the UNICEF-Washington Group Child Functioning Module could be implemented on a large-scale. It produced a relatively conservative estimate of disability, compared to previous reports in India, and so arguably may provide assessment of more severe functional difficulties, although further research is needed in other parts of the country to validate and to explore this issue. The individual questions on functioning allowed us to estimate prevalence in this context with minimal variation. It may be helpful to reduce the full number of questions to allow implementation in more time-constrained activities (e.g. census).\u003c/p\u003e \u003cp\u003eThis evidence shows nearly half of children with disabilities are not enrolled in school in this area of Tamil Nadu, despite strong policy commitments made in India towards disability-inclusive education. Monitoring of inclusion therefore remains important, to assess whether these policies are being realised. This exclusion of children with disabilities from education is a violation of their rights. Moreover, education is important for all children, including those with disabilities in terms of improving future job opportunities and earnings, developing friendships and participating in society, and in low resource settings, access to school-based health and nutrition programmes [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Efforts are therefore needed to improve school enrolment of children with disabilities, although the evidence base on which interventions are effective to achieve this goal is currently limited [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Attending school alone is insufficient, and further investigation is needed to assess the quality of the experience and educational outcomes for children with disabilities, to identify areas where further improvements are needed (e.g. accessibility of facilitates, expertise of teachers, resource allocation) [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Again, evidence is lacking on which interventions are effective at improving these broader educational outcomes for children with disabilities in LMICs [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The limited data available focusses mostly on interventions that produce individual-level change (e.g. computer skills training of children with disabilities) rather than school/societal interventions (e.g. teacher training on disability, introduction of disability-inclusive educational policies) and so these large evidence gaps need to be addressed with high-quality research.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eAt least one in a hundred children in southern India have severe functional difficulties. Among these children with disabilities, nearly half do not attend school. Urgent action is needed to improve educational inclusion of children with disabilities in southern India, and to ensure that they have a quality and safe school experience.\u003c/p\u003e"},{"header":"List of abbreviations ","content":"\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eCFM Child Functioning Module\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eCI Confidence Interval\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eHUD Health Unit District\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eMDA Mass Drug Administration\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003ePCA Principal Component Analysis\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003ePR Prevalence Ratio\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eRERI Relative Excess Risk due to Interaction\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eRTE Right to Educate\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eSES Socioeconomic Status\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eSTH Soil-transmitted Helminths\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eUN United Nations\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eUNESCO United Nations Educational, Scientific and Cultural Organization\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eUNICEF United Nations Children's Fund\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThe DeWorm3 Project was reviewed and approved by the Institutional Review Board at Christian Medical College, Vellore, India, The London School of Hygiene and Tropical Medicine, and the Human Subjects Division at the University of Washington. The trial is registered at ClinicalTrials.gov (NCT03014167). The functional difficulty assessment was approved as a protocol amendment by the Institutional Review Board at Christian Medical College, Vellore, India and The London School of Hygiene and Tropical Medicine. Written informed consent was sought from the household head for households\u0026rsquo; participation in the census and functional impairment assessment.\u003c/p\u003e\n\u003cp\u003eThe purpose of the survey and use of the data were explained and informed consent to participate was ascertained before collecting any further information.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eAll participants included in this study were informed that their data may be used as part of publications in anonymised form, to which they gave consent.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe data that support the findings have been archived, but restrictions apply to the availability of these data, and so have not been made publicly available. The data may be made available from the authors upon reasonable request after due oversight from an institutional ethical review process.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors have no competing interests to declare that are relevant to the content of this article.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research was funded by the United Kingdom Foreign, Commonwealth and Development Office (PENDA grant: PO8073). The DeWorm3 study is funded through a grant to the Natural History Museum, London from the Bill and Melinda Gates Foundation (OPP 1129535,PIJLW). SSRA is supported by an Emerging Global Leader Award (K43) from Fogarty International Center, NIH (1K43TW011415). The funders were not involved in the decision to publish the manuscript and had no role in data collection, analysis or publication of study results.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026apos; contributions\u003c/h2\u003e\n\u003cp\u003eCD, WEO, SPK, SSRA, HK - Conceptualization;\u003c/p\u003e\n\u003cp\u003eSPK, SG, DSK, WEO - Data acquisition and curation;\u003c/p\u003e\n\u003cp\u003eCD, WEO, SPK - Formal analysis;\u003c/p\u003e\n\u003cp\u003eHK, JLW, SSRA - Funding acquisition;\u003c/p\u003e\n\u003cp\u003eCD, WEO, SPK, BRC, BK, SJ, HK - Investigation;\u003c/p\u003e\n\u003cp\u003eCD, WEO, SPK, BRC, SJ, GN, BK - Methodology;\u003c/p\u003e\n\u003cp\u003eSSRA - Project administration;\u003c/p\u003e\n\u003cp\u003eJLW, SSRA - Resources;\u003c/p\u003e\n\u003cp\u003eSoftware;\u003c/p\u003e\n\u003cp\u003eSPK, KA - Supervision;\u003c/p\u003e\n\u003cp\u003eSPK, KA - Validation; Visualization;\u003c/p\u003e\n\u003cp\u003eCD, WEO, BRC, HK - Roles/Writing - original draft;\u003c/p\u003e\n\u003cp\u003eBRC, CD, WEO, SPK, KA, SJ, GN, JLW, BK, SSA, HK Writing - review \u0026amp; editing.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe authors wish to thank all of the study participants, community members and community leaders who have participated in or supported this study. We also like to thank all members of the DeWorm3 study teams and affiliated institutions. We thank our field managers Rajeshkumar Rajendiran and Chinnaduraipandi Paulsamy, and the field supervisors and field workers at the DeWorm3 study sites in India for data collection. We thank the data managers Gokila Palanisamy, Jannarthanan Maniyarasu, and Nandhini Prabakaran for their support in data collection. We thank Mr. Veeraraghavan Srinivasan, President-Nesam, Timiri, for orienting the study team on disability.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCieza A, Kamenov K, Sanchez MG, Chatterji S, Balasegaram M, Lincetto O, et al. Burden of disability in children and adolescents must be integrated into the global health agenda. BMJ. 2021;372:n9.\u003c/li\u003e\n\u003cli\u003eBellis MA, Hughes K, Ford K, Ramos Rodriguez G, Sethi D, Passmore J. Life course health consequences and associated annual costs of adverse childhood experiences across Europe and North America: a systematic review and meta-analysis. Lancet Public Health. 2019;4(10):e517-e28.\u003c/li\u003e\n\u003cli\u003eWHO. World Report on Disability. Geneva: World Health Organisation; 2011.\u003c/li\u003e\n\u003cli\u003eWHO. The global burden of disease: 2004 update. Geneva, Switzerland: World Health Organization; 2004.\u003c/li\u003e\n\u003cli\u003eOlusanya BO, Wright SM, Nair MKC, Boo NY, Halpern R, Kuper H, et al. Global Burden of Childhood Epilepsy, Intellectual Disability, and Sensory Impairments. Pediatrics. 2020;146(1).\u003c/li\u003e\n\u003cli\u003eScharf RJ, Maphula A, Pullen PC, Shrestha R, Matherne GP, Roshan R, et al. Global Disability: Empowering Children of all Abilities. Pediatr Clin North Am. 2017;64(4):769-84.\u003c/li\u003e\n\u003cli\u003eWG/UNICEF. Module on child functioning: questionnaires Geneva, Switzerland: UNICEF; 2016 [Available from: https://data.unicef.org/resources/module-child-functioning/.\u003c/li\u003e\n\u003cli\u003eUNESCO. Education and Disability: Analysis of Data from 49 Countries 2018 [Available from: http://uis.unesco.org/sites/default/files/documents/ip49-education-disability-2018-en.pdf.\u003c/li\u003e\n\u003cli\u003eUNDESA. UN Flagship Report on Disability and Development. UNDESA; 2018.\u003c/li\u003e\n\u003cli\u003eMizunoya S, Mitra S, Yamasaki I. Towards inclusive education: The impact of disability on school attendance in developing countries. UNICEF Office of Research \u0026ndash; Innocenti; 2016.\u003c/li\u003e\n\u003cli\u003eUN. Convention on the Rights of the Child. New York, USA: United Nations; 1989.\u003c/li\u003e\n\u003cli\u003eUN. Convention on the rights of persons with disabilities. New York: United Nations; 2006.\u003c/li\u003e\n\u003cli\u003eUN. Sustainable Development Goals 2015 [Available from: http://www.un.org/sustainabledevelopment/sustainable-development-goals/.\u003c/li\u003e\n\u003cli\u003eSaran A, White H, Kuper H. Evidence and gap map of studies assessing the effectiveness of interventions for people with disabilities in low‐and middle‐income countries. Campbell Systematic Reviews. 2020;16(1).\u003c/li\u003e\n\u003cli\u003eKuper H, Saran A, White H. Rapid Evidence Assessment (REA) of What Works to Improve Educational Outcomes for People with Disabilities in Low- and Middle-Income Countries. London: DFID; 2018.\u003c/li\u003e\n\u003cli\u003eKuper H, Monteath-van Dok A, Wing K, Danquah L, Evans J, Zuurmond M, et al. The impact of disability on the lives of children; cross-sectional data including 8,900 children with disabilities and 898,834 children without disabilities across 30 countries. PloS one. 2014;9(9):e107300.\u003c/li\u003e\n\u003cli\u003eGoI. Census 2011 - Census of India New Delhi, India2011 [Available from: http://censusindia.gov.in/.\u003c/li\u003e\n\u003cli\u003eDandona R, Pandey A, George S, Kumar GA, Dandona L. India\u0026apos;s disability estimates: Limitations and way forward. PloS one. 2019;14(9):e0222159.\u003c/li\u003e\n\u003cli\u003eArora NK, Nair MKC, Gulati S, Deshmukh V, Mohapatra A, Mishra D, et al. Neurodevelopmental disorders in children aged 2-9 years: Population-based burden estimates across five regions in India. PLoS Med. 2018;15(7):e1002615.\u003c/li\u003e\n\u003cli\u003eGoI. The Right of Children to Free and Compulsory Education Act, 2009. New Delhi, India; 2009.\u003c/li\u003e\n\u003cli\u003eGoI. Rights of Persons with Disabilities Act, 2016. New Delhi, India; 2016.\u003c/li\u003e\n\u003cli\u003eGoI. National Education Policy 2020. New Delhi, India; 2020.\u003c/li\u003e\n\u003cli\u003eSingal N. Inclusive quality education for children with disabilities. 2017.\u003c/li\u003e\n\u003cli\u003eAjjampur SSR, Kaliappan SP, Halliday KE, Palanisamy G, Farzana J, Manuel M, et al. Epidemiology of soil transmitted helminths and risk analysis of hookworm infections in the community: Results from the DeWorm3 Trial in southern India. PLoS Negl Trop Dis. 2021;15(4):e0009338.\u003c/li\u003e\n\u003cli\u003eAsbjornsdottir KH, Ajjampur SSR, Anderson RM, Bailey R, Gardiner I, Halliday KE, et al. Assessing the feasibility of interrupting the transmission of soil-transmitted helminths through mass drug administration: The DeWorm3 cluster randomized trial protocol. PLoS Negl Trop Dis. 2018;12(1):e0006166.\u003c/li\u003e\n\u003cli\u003eMactaggart I, Kuper H, Murthy GV, Oye J, Polack S. Measuring Disability in Population Based Surveys: The Interrelationship between Clinical Impairments and Reported Functional Limitations in Cameroon and India. PloS one. 2016;11(10):e0164470.\u003c/li\u003e\n\u003cli\u003eZou G. A modified poisson regression approach to prospective studies with binary data. American journal of epidemiology. 2004;159(7):702-6.\u003c/li\u003e\n\u003cli\u003eRichardson DB, Kaufman JS. Estimation of the relative excess risk due to interaction and associated confidence bounds. American journal of epidemiology. 2009;169(6):756-60.\u003c/li\u003e\n\u003cli\u003eKnol MJ, VanderWeele TJ. Recommendations for presenting analyses of effect modification and interaction. International journal of epidemiology. 2012;41(2):514-20.\u003c/li\u003e\n\u003cli\u003eRothman KJ, Greenland S, Lash TL. Modern Epidemiology, 3rd Ed. Philadelphia, PA: Lippincott, Williams, \u0026amp; Wilkins; 2008.\u003c/li\u003e\n\u003cli\u003eAlli BY. interactionR: An R package for full reporting of effect modification and interaction (v0.1.3). Zenodo; 2021.\u003c/li\u003e\n\u003cli\u003eOlusanya BO, Wright SM, Nair MKC, Boo NY, Halpern R, Kuper H, et al. Global Burden of Childhood Epilepsy, Intellectual Disability, and Sensory Impairments. Pediatrics. 2020;146(1).\u003c/li\u003e\n\u003cli\u003eMizunoya S, Mitra S, Yamasaki I. Disability and school attendance in 15 low- and middle-income countries. World Development. 2018;104:388-403.\u003c/li\u003e\n\u003cli\u003eMactaggart I, Polack S, Kuper H, Sagar J, Murthy GVS. The Telengana Disability Study, India. London: London School of Hygiene \u0026amp; Tropical Medicine; 2014.\u003c/li\u003e\n\u003cli\u003eDesai MU, Divan G, Wertz FJ, Patel V. The discovery of autism: Indian parents\u0026apos; experiences of caring for their child with an autism spectrum disorder. Transcult Psychiatry. 2012;49(3-4):613-37.\u003c/li\u003e\n\u003cli\u003eGoI. Persons with Disabilities in India. NSS 76th Round. New Delhi, India; 2018.\u003c/li\u003e\n\u003cli\u003eBakhshi P, Babulal GM, Trani JF. Education of children with disabilities in New Delhi: When does exclusion occur? PloS one. 2017;12(9):e0183885.\u003c/li\u003e\n\u003cli\u003eBakhshi P, Babulal GM, Trani J-F. Education of children with disabilities in New Delhi: When does exclusion occur? PloS one. 2017;12(9):e0183885-e.\u003c/li\u003e\n\u003cli\u003eMitra S. Disability, Health and Human Development2018.\u003c/li\u003e\n\u003cli\u003eKapur A. Sarva Shiksha Abhiyan. SSRN Electronic Journal. 2013.\u003c/li\u003e\n\u003cli\u003ede Wit M. A sign language interpreter in inclusive education: The view of deaf persons on their quality of life. Edinburgh, UK: Heriot Watt University; 2011.\u003c/li\u003e\n\u003cli\u003eSingal N. Challenges and opportunities in efforts towards inclusive education: reflections from India. International Journal of Inclusive Education. 2019;23(7-8):827-40.\u003c/li\u003e\n\u003cli\u003eTaneja-Johansson S, Singal N, Samson M. Education of Children with Disabilities in Rural Indian Government Schools: A Long Road to Inclusion. International Journal of Disability, Development and Education. 2021:1-16.\u003c/li\u003e\n\u003cli\u003eDevries KM, Kyegombe N, Zuurmond M, Parkes J, Child JC, Walakira EJ, et al. Violence against primary school children with disabilities in Uganda: a cross-sectional study. BMC Public Health. 2014;14:1017.\u003c/li\u003e\n\u003cli\u003eBanks LM, Polack S. The Economic Costs of Exclusion and Gains of Inclusion of People with Disabilities. London: International Centre for Evidence in Disability; 2014.\u003c/li\u003e\n\u003cli\u003eSingal N. Education of children with disabilities in India and Pakistan: Critical analysis of developments in the last 15 years. Prospects. 2016;46(1):171-83.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-epidemiology-and-global-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Journal of Epidemiology and Global Health](https://www.springer.com/journal/44197)","snPcode":"44197","submissionUrl":"https://submission.nature.com/new-submission/44197/3","title":"Journal of Epidemiology and Global Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"functional difficulty, disability, school enrolment, effect modification, India","lastPublishedDoi":"10.21203/rs.3.rs-4154190/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4154190/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eDespite the large number of children in India, there is little information on the impact of children\u0026rsquo;s disability on school enrolment, and how this differs by population. We estimated the prevalence of childhood disability in two sites in Tamil Nadu, southern India, and the effect of functional difficulty on school enrolment. We used a parent-reported survey containing the UNICEF-Washington Group questions to identify children aged 5 to 17 years with functional difficulty during a census conducted for an ongoing trial. We estimated pooled- and gender-specific prevalence of functional difficulty among 29,044 children. We fitted regression models to identify subgroups with higher rates of functional difficulty and the effect of functional difficulty on reported school enrolment. We estimated the modification of the effect of functional difficulty by age, gender, socioeconomic status, household education, and sub-site, on additive and multiplicative scales. We found of 29,044 children, 299 (1.0%) had any functional difficulty, equal among boys and girls. Being understood (0.5%) and walking (0.4%) were the most common difficulties. Functional difficulty was strongly associated with non-enrolment in school (Prevalence ratio [PR] 4.59, 95% CI: 3.87, 5.43) after adjusting for age, gender, and site. We show scale-dependent differences between age and socioeconomic groups in the effect of functional difficulty on enrolment. This study shows that at least one in a hundred children in this region have severe functional difficulties and nearly half of these children are not enrolled in school, highlighting the need for further efforts and evidence-based interventions to increase school enrolment among these groups.\u003c/p\u003e","manuscriptTitle":"Prevalence of functional difficulty among school-aged children and effect on school enrolment in rural southern India: A cross-sectional analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-22 02:47:32","doi":"10.21203/rs.3.rs-4154190/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-06T10:10:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-03T18:54:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"253253170539654272185061988771023259883","date":"2024-07-25T08:43:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33976418656393717133939747424056727243","date":"2024-07-17T08:28:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"188273331969308674902904449978173388758","date":"2024-07-14T17:45:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"229568608298345037780319122792691689201","date":"2024-06-18T11:29:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-20T07:01:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2c8a62ca-de95-4996-99c2-75f146a7065a","date":"2024-04-20T06:28:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"ea07a9b0-50ab-46b1-a8d7-ce9763551fcf","date":"2024-04-17T06:43:19+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-16T11:32:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-15T10:04:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-15T08:58:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Epidemiology and Global Health","date":"2024-03-23T11:39:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-epidemiology-and-global-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Journal of Epidemiology and Global Health](https://www.springer.com/journal/44197)","snPcode":"44197","submissionUrl":"https://submission.nature.com/new-submission/44197/3","title":"Journal of Epidemiology and Global Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bec56ee0-6157-4d67-91ef-96896cdbd52d","owner":[],"postedDate":"April 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-08-22T12:09:28+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-22 02:47:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4154190","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4154190","identity":"rs-4154190","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}