Effectiveness of the Hospital Learning Center (Queen Sirikit National Institute of Child Health): Satisfaction with service and parents’ attitudes towards children’s illness

Study design

A cross-sectional survey was conducted to obtain information about the parents and the children who entered the learning center at QSNICH, Bangkok, Thailand between January 1 and December 31, 2018.

Sample size and selection

The total population was 400 persons, consisting of 200 parents and 200 sick children from the learning center in hospital at the QSNICH from January 1, 2018 to December 31, 2018. The sample size was calculated based on a previously described method¹¹ by reviewing the number of children who returned to school (80% of all children), given p = 0.8, N = 1000. The computed result gave a sample size of 198 which led to the number of 200 children and 200 parents, giving 400 persons in total. The inclusion criteria were sick children at the learning center aged between 4 and 18 years, sick children who visited the learning center more than twice and sick children with critical illnesses at the hospital or home who still having continual treatment. The exclusion criterion was sick children at terminal stage of life or having critical illnesses. Informed consent for study participation was obtained from child patients and parents.

Data collection

Researchers used systematic random sampling in which the children on the name list at the learning center, QSNICH were selected in order. If any respondents refused to answer the questions, the latter name would be selected. After giving consent, the researcher started interviewing parents and sick children. For children from 4 to 7 years of age, parents were asked to join the interview¹². The answers were noted, checked, and recorded for data analysis.

The questionnaire was divided into four parts; demographic data of parents, relationship between parents and children, children’s personal information and satisfaction with service at learning center using a Likert scale. The rating scores were divided into five levels. The questionnaire used, alongside an English translation, is available as Extended data¹³.

The variables associated in this research included parents and children’s relationship, educational level, parent’s occupation, family income, home town, severity of diseases, period of hospitalization, and satisfaction with service at the learning center.

Statistical analysis

Levels of significance based on satisfaction scores of the learning center at the hospital and were divided into five levels: Strongly agree (4.21–5.00 points), agree (3.41–4.20 points), uncertain (2.61–3.40), disagree (1.81–2.60), strongly disagree (1.00–1.80). P < 0.05 was considered to indicate statistical significance.

DataFax was used for data management. Descriptive statistics, including percent, mean and standard deviation were used for analyzing population data and SAS 9.4 software was used to calculate frequency, percentage, mean and standard deviation to measure attitude and satisfaction of parents and children at the center. Data on satisfaction was divided into 5 levels: strongly agree, uncertain, disagree, strongly disagree based on statistical test results. Chi-square test and t-test were used to assess variables associated with continuation of education at the learning center.

Ethical statement

This study was been approved by the Office for Ethics in Human Research, Queen Sirikit National Institute of Child Health in 2018 (ref. REC.010/2562), and was conducted in accordance with The Declaration of Helsinki

Background of caregivers

The study categorized the children into three groups: those with common illness, those with chronic conditions and disabled children. The other population studied was the 200 caregivers, the largest percentage of which was the biological parents of the children at 87.9%, 91.5% and 93.3% for the three groups, respectively; caregivers who are relatives were caregivers for 12.1%, 8.5% and 6.7%, respectively. Neither foster parents nor teachers were guardians. The majority of caregivers were female (90%, 90% and 53% for those with common illness, those with chronic conditions and disabled children, respectively), of Thai nationality (100%, 100%, and 93%, respectively) and Buddhist religion (97%, 100%, and 93%, respectively); the non-Thai caregivers were from Myanmar and other religions included Islam and Christianity. Most parents were 31 to 40 years of age (46.1%, 44.7%, and 53.3% for those with common illness, those with chronic conditions and disabled children, respectively). Those 41 to 50 years old constituted 23%, 39%, and 40%, respectively, while parents who were 21 to 30 years old were involved with only 21%, 9%, and 0% of the children, respectively. Most parents had a bachelor’s degree or vocational education, but a small percentage went to secondary school. Occupations of most parents were in sales and agriculture or laborers. Most were married, separated, or divorced. The majority had income in the range of THB 10,000-30,000, with the rest earning THB 5,000-10,000, and only a small proportion receiving more than THB 30,000 or less than THB 5,000. The study families in general were home owners, while some rented a house or apartment and lived in the central part of Thailand. Only a few lived with relatives.

According to Table 1, for the 200 child patients, 91 caregivers (45.5%) were parents of children with common illnesses, 94 (47%) were parents of children with chronic illnesses and 15 (7.5%) were parents of children with disabilities. In general, parents of the three categories of sick children rated each question similarly. Regarding the severity of the illnesses, 12.0% rated them at the minimum level, 46.5% at the moderate level, and 39.5% at the high level. Whenever the patients get ill, 74.5% of the caregivers always reported it to school authorities while 20.5% frequently did so. About 34.0% were very confident that their children got along well with their peers, 31.0% were moderately confident and 29% highly confident. Similarly, 44.5% of caregivers attempted to help their children with school work at a moderate level, while 23.5% had tried at a higher level. Overall, 34.5% often explained the classwork to their children and 33.5% did it all the time. About 11% were moderately confident that the school arranged good study plans for their children, 47% were moderately confident and 38.5% were highly confident. Overall, 44% of the child patients talked about what happened in their school and 18.5% did it all the time. Regarding the caregivers’ confidence to help their children to control their emotions, about 42% were very confident, and about 17% were moderately confident and 34% were extremely confident. In total, 91.37% of caregivers took their children to school on a daily basis.

Children with common illnesses

As shown in Table 2, 23.1% of children with common illness were in kindergarten, 64.8% in primary school and 10.9% in secondary school before entering the learning center. After discharge, 20.8% were in kindergarten, 67.0% were in primary school and 10.9% were in secondary school. The distances from home to school before and after attending the learning center did not differ. Approximately, 16.5% lived less than 1 km away, 60.4% lived 1–5 km away and 23.1% lived the same distance as before entering the learning center. The data also showed that 29.7% went to school by bicycle or motorcycle, 39.6% by personal car, and 28.6% by public transportation; the mean of transportation was not much different from before and after entering learning center.

Children with chronic illness

For patients with chronic illnesses, 10.6% were in kindergarten, 68.1% were in primary school and 21.3% were in secondary school; none of them attended vocational education. After discharge, 10.6% adopted a modified study plan for non-formal education; 6.4% of parents lived less than 1 km away while 56.4% lived 1–5 km away from school and 41.5% were the same distance before and after attending the center. With regard to transportation, 37.2% went to school by bicycle or motorcycle, 25.5% by personal vehicle, and 33.0% by public transportation; the transportation data were almost the same before and after attending the center.

Children with disabilities

For children with disabilities, while being treated and attending the center, 13.3% were in kindergarten, 66.7% in primary school, 13.3% in secondary school, and 6.7% attended an individualized education program (IEP); after discharge, 13.3% were in kindergarten, 6.7% were in primary school and 6.7% in secondary school, 73.3% attended an IEP. After discharge, none of the parents live closer to the center than 1 km, 53.3% lived 1–5 km away and 46.7% live more than 5 km away from the center. The distance was almost the same before and after being attending school at the center. For transportation, 33.3% go to school by bicycle or motorcycle, 46.7% by personal vehicle, and 20.0% by public transportation; the transportation percentages are almost the same before and after going to the center.

As shown in Table 3, the factors relating to modifications of the education plan of the school were subjected to logistic regression. Nearly 100% of the children as general patients, chronic patients, and patients with developmental problems continued their education. Patients with common illness did not adjust their education plan, although 10.6% of chronic patients and 73.3% of special patients did modify their plan. The number of chronic patients who modified their education plan was significantly greater than the number of general patients (OR = 0.05; 95% CI: 0.02-0.14). In terms of education level, 95.5% of primary school students and 53.2% of secondary school students had their education plan modified. The number of primary school students who modified their education plan was significantly higher than those at kindergarten level (OR = 2.08; 95% CI: 0.95-4.55).

As recorded in Table 4, parents’ opinions about each question across all types of illnesses are different. Considering the topic of learning, 74.7% of general patients, 69.2% of chronic patients, and 66.7% of disabled patients stated that the subjects at the center were interesting while 24.2% of general patients, 30.8% of chronic patients, and 33.3% of disabilities patients strongly agreed with this. More than half of the children enjoyed learning new things at the center (75.8% of patients with common illnesses, 70.2% of chronically ill patients and 73.3% of disabled patients). In terms of patients overall, 26.5% (23.1%, 29.8%, and 26.7% for those with common illness, those with chronic conditions and disabled children, respectively) strongly agreed that that learning at the center was enjoyable. In terms of looking forward to receiving services from the center, about 69.0% of all patients (73.6% of general patients, 65.9% of chronic patients, and 60.0% of patients with disabilities) agreed with this issue; and 22.2% of all patients (22.0% of general patients, 20.0% of chronic patients, and 22.0% of disabled patients) strongly agreed with this issue. Regarding the proper facilities supporting learning environment at the center, about 69.5% of all patients (71.4% of general patients, 67.0% of chronic patients, and 73.3% of special patients) agreed with this issue; and 31.9% of all patients (28.3% of general patients, 34.2% of chronic patients, and 35.1% of special patients) strongly agreed with this issue. In terms of advancement, varieties and adequacy of the study plan of the center, about 60.9% of all patients (65.6% of general patients, 57.7% of chronic patients, and 59.2% of special patients) agreed with this issue; and 30.0% of all patients (27.5% of general patients, 33.0% of chronic patients, and 26.7% of special patients) strongly agreed with this issue. The students also reported a variety of learning materials used in the classroom: 70.5% of patients used textbooks, (63.4% of general patients, 75.53% of chronic patients, and 80.0% of special patients) 76.0% of patients (78.0% of general patients, 80.8% of chronic patients, and 33.3% of special patients) used computer/notebooks or laptops, 48.0% of patients (52.8% of general patients, 47.9% of chronic patients, and 20.0% of special patients) used DVD/CVD and 17.0% of patients (14.3% of general patients, 19.2% of chronic patients, and 20.0% of special patients) used the Mobile Education Kit (MEK) eBooks, web-links, blogs/technical papers and mobile apps. MEK was made to develop a practical teaching and learning environment.

Regarding satisfaction with services at the center, about 53.0% of all patients (66.5% of general patients, 55.6% of chronic patients, and 46.1% of special patients) were highly satisfied with the services; and 42.0% of all patients (40.7% of general patients, 42.6% of chronic patients, and 46.7% of special patients) were extremely satisfied. After completing education program at the center, about 100.0% (100.0% of general patients, 100% of chronic patients, and 100% of disabled patients) continue further education. About 20.0% (22.0% of general patients, 20.2% of chronic patients, and 6.7% of disabled patients) said that the center encouraged them to continue further education. About 48.5% (50.5% of general patients, 49.0% of chronic patients, and 33.3% of disabled patients) rated their satisfaction towards the learning center at a high level; and about 30.0% (27.5% of general patients, 28.7% of chronic patients, and 53.3% of special patients) rated at very high level.

Key findings

Education management should be supported and promoted to encourage students to continue their studies in the regular education system. If a student’s treatment schedule causes them to miss classes, the learning center will modify their study plan by providing extra classes during hospitalization, allowing them to interact with teachers at the learning center. Teachers at the learning center coordinate their curriculum with that of regular school teachers. After being discharged, the children continue their education in the same class. Education^19,20, as well as social and behavioral interactions, are very important for children during hospitalization.

Limitations

The clinical demographic groups in this study were only selected from children at the Queen Sirikit National Institute of Child Health. The respondents from other institutes should be included as well to increase diversity through a variety of contexts. Future studies should involve learning centers in different types of hospitals such as primary, secondary and tertiary care facilities in each region in Thailand since they all provide different levels of services for patients with different needs.

Implications

Learning via social media^20–22 are some of the available channels allowing the children to keep in touch with friends and teachers, reduce stress and the feeling of being left out, and prevent social problems after returning to school. They can also share experience at the hospital, turn crisis situations into opportunities and add their own perspectives and ideas about making life better for hospitalized children. Comprehensive^19,22 planning will enhance children’s skill in social interaction, education and life adjustment.

Our study found that ten chronically ill children were evaluated, and their non-formal education plans were adjusted appropriately. Similarly, ten disabled children enrolled in IEPs, which provide customized curricula for special needs children that are approved by family and school. Chronically ill and disabled children seem to benefit most from the statistically significant modifications in their education plans. Children with illnesses at the secondary level will be enrolled in non-formal education programs. The study plan of children who stay in the hospital for more than 20 days is more likely to be adjusted than for a five-day period of hospitalization. Other factors studied include the demographics, economic status, occupation and distance from home to school; however, these showed no statistical significance in curriculum adjustment.

From the results of our study, it is clear that we should consider evaluating the appropriateness of an education plan by having the teachers at the hospital learning center work closely with regular school teachers to perform long-term monitoring and appropriate planning. The study of parents’ attitudes towards their children’s illnesses and education found that most think chronic diseases are very severe, but parents of special needs children and those with common illnesses do not think this is a serious issue and give more attention to education of their children. Parents of chronically ill children and those with common ailments always inform the school when the patients will be absent, but only about half of the parents of children with disabilities do so because they already have individual education plans and they know that school teachers and administrators will arrange appropriate plans to accommodate the students. Social adjustment^19–21,23 is a major concern of parents, most of whom have little confidence that schools can provide adequate services in this area to sick children. On the other hand, parents of disabled children feel moderately to highly secure that the teaching staff at special needs schools will involve their children in building good relationships with friends. In order to arrange learning activities for sick children, teachers must have broad knowledge including educational psychology and a good understanding of the medical conditions because each child has a different set of physical and mental states that require different educational approaches. Most children worry about their illness and this can strongly affect their lifestyle^18,21,24 so appropriate guidance is also needed in addition regular coursework.

Recommendations

Mobile learning center are good for child patients because their environments are flexible, and they are less likely to feel trapped in a hospital room. Children who must stay in bed will be offered bedside teaching programs. The mobility of educational settings has been greatly improved through use of electronic devices to provide the same standards as obtained in more formal schools. After analyzing the satisfaction result at the learning center, the highest score was from 4.21 to 5.00 (mean = 4.28, SD = 0.62). Considering each item, the respondents reported that having up to date teaching methods and innovative learning activities ranked as the most satisfying features while interesting subject matter and knowledge were second highest because of using technology to help with learning like Electronic Distance Learning Television computer programs to meet international standards as stated by the Ministry of Education.

The third highest score was enjoyment in the educational entertainment activities, while the fourth ranking went to setting up an environment most conducive to learning. (mean = 4.18, SD = 0.79). Having enough modern learning materials came in fifth. Compared to previous studies^10,15, our results demonstrated the importance of adjustments in educational programs as needs changed in line with new teacher guidelines, evaluations of the work of the center, greater involvement of learning materials and technology as standard requirements of the course, and ways to reduce problems between teachers and students with regard to using mobile education. However, new materials, equipment and programs still need to be developed. Based on studies in other countries^22,24,25, we concluded that the best educational environment can be achieved with a mix of technology and conventional teaching. The unique, multidisciplinary educational system for sick children in a hospital needs to be supported by hospital, family, and community in concert with local laws. Everyone can support continuing education as a holistic system, reducing the burden on families and society and meeting the purpose of building valuable infrastructure to develop the country’s human resources into the future.

Underlying data

Figshare: Data record of the survey. https://doi.org/10.6084/m9.figshare.8479352.v2¹⁴.

This project contains the raw survey responses of each participant.

Extended data

Figshare: English Survey.pdf. https://doi.org/10.6084/m9.figshare.8208338.v2¹³.

This project contains the following extended data:

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).