Prevalence of School Refusal and Associated Factors among First-Grade Elementary School Children in Al-Hillah City, Iraq: A Case-Control Study

Background: School refusal is a significant childhood problem characterized by difficulty attending or remaining at school and is often associated with emotional, psychological, family, and school-related factors. This study aimed to determine the prevalence of school refusal and its associated factors among first-grade elementary school children in Al-Hillah, Babil, Iraq. Methods: A case-control study was conducted among first-grade children aged 6–7 years in 13 urban primary schools in Al-Hillah during March–May 2012. A total of 300 children were included, comprising 150 children with school refusal and 150 controls. Data were collected using a structured questionnaire assessing sociodemographic, health-related, psychological, family, and school-related factors. Results: Among 1,468 assessed children, school refusal was identified in 150 (10.2%). Significant associations were found with maternal unemployment (OR = 3.45), broken family status (OR = 13.40), parental educational level, and poor school performance. School refusal was also strongly associated with crying in class, classroom anxiety and instability, frequent requests to use the washroom, parental threats regarding school attendance, preference to remain at home, somatic complaints, and escaping from lessons (all p < 0.001). Lack of kindergarten attendance and lack of a previous school visit were also significantly associated with school refusal. Conclusion: School refusal affected 10.2% of first-grade children and was associated with multiple family, emotional, behavioral, and school-related factors. Early identification, parental and teacher support, school familiarization, and appropriate psychological and educational interventions are important for improving children's school adjustment and reducing school refusal.