Effectiveness of 36 hospital learning centers in Thailand: continuation of child patient education, parent attitudes toward child’s illness and service satisfaction

Adidsuda Fuengfoo; Kim Sakulnum; Sumitra Owjinda

doi:10.12688/f1000research.26599.1

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Research Article

Effectiveness of 36 hospital learning centers in Thailand: continuation of child patient education, parent attitudes toward child’s illness and service satisfaction

[version 1; peer review: 1 approved, 1 not approved]

Adidsuda Fuengfoo ^1,2, Kim Sakulnum³, Sumitra Owjinda³

PUBLISHED 11 Dec 2020

Author details Author details

¹ Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, Queen Sirikit National Institute of Child Health, Bangkok, Thailand
² College of Medicine, Rangsit University, Bangkok, Thailand
³ Division of Child Early Stimulation, Department of Nursing, Queen Sirikit National Institute of Child Health, Bangkok, Thailand

Adidsuda Fuengfoo
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Kim Sakulnum
Roles: Data Curation, Project Administration, Validation

Sumitra Owjinda
Roles: Investigation, Methodology, Software

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background: This study aimed to determine the effectiveness of 36 hospital learning centers for the continued education of sick children using electronic distance learning television (eDLTV), parents’ attitudes toward their child’s illnesses and education, and service satisfaction of the centers.
Methods: The sample included 4,430 children aged 4-18 years old with common illnesses, chronic illnesses and developmental disorders, as well as 4,430 parents who had taken care of the child for at least 6 months. The methods included attitude surveys, which were analyzed using chi-square tests and t-tests.
Results: The factors associated with education continuation of the children were illness types (parents were less worried about children with common illness and more concerned about education of children with chronic diseases and children with disabilities), distance from home to school, transportation type, parents’ education level, marital status, and family income. About 99.8% of patients with common illnesses continued their education, followed by 99.3% of disabled children, and 95.9% of chronic patients. Satisfaction score towards the services at the learning centers were high (mean scores: 4.28 and 4.43 respectively, out of 5 = strongly satisfied).
Conclusion: After completing an education program through eDLTV at a center, a total of 97.7% of children continued their education and were highly satisfied with the service at the center. Parents had positive attitudes towards their child’s illnesses and education.

Keywords

child illness, education service, school engagement, satisfaction, hospital learning center

Corresponding authors: Adidsuda Fuengfoo, Kim Sakulnum, Sumitra Owjinda

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2020 Fuengfoo A et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Fuengfoo A, Sakulnum K and Owjinda S. Effectiveness of 36 hospital learning centers in Thailand: continuation of child patient education, parent attitudes toward child’s illness and service satisfaction [version 1; peer review: 1 approved, 1 not approved]. F1000Research 2020, 9:1446 (https://doi.org/10.12688/f1000research.26599.1) First published: 11 Dec 2020, 9:1446 (https://doi.org/10.12688/f1000research.26599.1) Latest published: 13 Apr 2022, 9:1446 (https://doi.org/10.12688/f1000research.26599.2)

Introduction

As a crucial foundation for development, education should be equally accessible to all children, regardless of differences in social or physical status. Today medical advancements have increased the survival rate of children with chronic diseases to 90%, reducing mortality rates and complications¹, and increasing life expectancy by as much as 20 years longer². The prevalence of children with chronic diseases differs depending on definition. A survey in the United States indicated that approximately 20% of children had chronic illnesses³. In Thailand, the number is still unclear because chronic illness is defined as a long-term illness involving treatments that might affect the lifestyles of children and families^4–6. Such changes can include absence from school, which could affect learning and social activities^7,8.

The UN Convention of the Rights of the Child states that every child has the right to be protected and receive equal education⁹. As a member of the UN, Thailand implemented a law stipulating that “education is not only limited to the classroom”. Therefore, medical institutes have merged with special education centers to establish “learning centers in the hospital” so that pediatric patients can continue to have equal access to education. Making use of information technology to support education, the project is called “The Information Technology Project under the Initiative of Her Royal Highness Princess Maha Chakri Sirindhorn”. Similar learning centers in other countries involve the coordination of multidisciplinary teams to enhance social and learning activities or sick children.

The Queen Sirikit National Institute of Child Health (QSNICH) Learning Center in Thailand has been operating for 20 years. In the past¹⁰, education for sick children supported academic knowledge and daily living skills which made them feel included in society, and reflected educational and social perceptions of the related life adjustments and psychological conditions. QSNICH has previously conducted research¹¹ on education for sick children, aiming to determine the effectiveness of learning centers in 36 provinces in Thailand. With official ministry-level collaboration among various parties to obtain operational results regarding continued learning for sick children and the associated factors¹², QSNICH has provided a model for other hospitals across Thailand to ensure that all sick children have equal access to education.

Objectives

This study has been extended from previous research¹³ on the effectiveness of the learning center at QSNICH, which investigated the associated factors affecting further education of children with special needs. The aims of this study were to determine the effectiveness of 36 other network learning centers across Thailand for the continued education of pediatric patients, as well as the factors associated with the patients’ further education. It also evaluated parents’ attitudes toward their children’s illness and education, as well as service satisfaction of the center.

Methods

Study design

A cross-sectional study was conducted to collect information from the target population at 36 learning centers in the hospitals across Thailand under the supervision of Thai Ministry of Public Health. The study used a survey to collect information (Extended data¹⁴). The study was conducted from January 1, 2018, to December 31, 2018.

Participants

The target population included 4,430 child patients aged 4-18 years as well as 4,430 parents who had taken care of the child for at least six months, meaning that the total study population included 8,860 individuals. The sample size calculation was based on Wayne¹⁵. The total number of pediatric patients from 36 learning centers at the hospitals was 30,000 (n=30,000), and the incidence of children who went back to school was 80% (p=0.8))

Systematic random sampling was used to select parents and children from the lists of patients at the 36 learning centers. If any individual refused to participate, the next name would be selected.

The survey was conducted by the researchers after the parents gave written informed consent for their child to participate. For children aged 4–7 years, parents were asked to participate in the survey on behalf of the child. The session was audio recorded for data analysis.

Eligibility criteria

Inclusion criteria: 1) Pediatric patients age between 4–18 years who are attending learning centers at the hospital; 2) Pediatric patients who have attended learning centers more than 2 times; 3) pediatric patients with chronic illnesses who are admitted at the hospital or needed consecutive follow-up.

Exclusion criteria: pediatric patients with serious illness and life-threatening conditions.

Data collection

The survey was divided into four parts: (1) demographic information of the children and parents (gender, age, cause of admission and length of stay (Table 1)), (2) information about the patient-parent relationship, and (3) satisfaction with service at the learning centers (measured using Likert scales of 1=unsatisfied, 2=poor, 3=fair, 4=satisfied, 5=very satisfied).

Table 1. Demographic information about the child patients.

	Common illnesses	Chronic illnesses	Developmental disorders	All
Total, n	1764	2384	282	4430
Gender, n (%)
Male	952 (53.97)	1244 (52.18)	196 (69.50)	2392 (54.00)
Female	812 (46.03)	1140 (47.82)	86 (30.50)	2038 (46.00)
Missing data	0 (0.00)	0 (0.00)	0 (0.00)	0 (0.00)
Age (years)
Mean (SD)	8.91 (3.30)	9.81 (3.41)	9.07 (3.01)	9.40 (3.37)
Median (IQR)	8.69 (6.17 - 11.19)	9.65 (7.10 - 12.44)	8.85 (6.90 - 11.11)	9.21 (6.76 - 11.86)
Min, max	2.68, 19.91	3.11, 20.89	3.00, 20.21	2.68, 20.89
Missing data, n (%)	3 (0.17)	0 (0.00)	2 (0.71)	5 (0.11)
CAUSES OF ADMISSION
Common diseases, n (%)
Respiratory system e.g. pneumonia bbronchitis	284 (16.10)			284 (6.41)
Neurological disorder e.g. seizure	53 (3.00)			53 (1.20)
Gastrointestinal disorders (e.g. enteritis, stomachache, vomiting)	487 (27.61)			487 (10.99)
Accident	213 (12.07)			213 (4.81)
Urinary system (e.g. Urinary Tract Infection, acute pyelonephritis)	128 (7.26)			128 (2.89)
Infection (e.g. dengue fever, Influenza, encephalitis)	328 (18.59)			328 (7.40)
Other types of illness, e.g. fever, operation, appendicitis	294 (16.67)			294 (6.64)
Chronic diseases
Heart disease		119 (4.99)		119 (2.69)
Cancer		526 (22.06)		526 (11.87)
Kidney disease		153 (6.42)		153 (3.45)
Blood disorders		1055 (44.25)		1055 (23.81)
Chronic lung diseases/ pneumonitis /asthma		265 (11.12)		265 (5.98)
Ulcerative colitis/gastritis		29 (1.22)		29 (0.65)
Neurological disorder/ epilepsy / tumors		106 (4.45)		106 (2.39)
Diabetes		61 (2.56)		61 (1.38)
High blood pressure		7 (0.29)		7 (0.16)
Other, e.g. lupus, allergies, bone diseases		90 (3.78)		90 (2.03)
Developmental disorders, n (%)
Learning disability			56 (19.86)	56 (1.26)
Attention deficit hyperactivity disorder			92 (32.62)	92 (2.08)
Autism			33 (11.70)	33 (0.74)
Intellectual disability			90 (31.91)	90 (2.03)
Other types of developmental disorder, e.g. cerebral palsy, literacy, motion disorders			30 (10.64)	30 (0.68)
Length of stay, n (%)
1–5 days	1222 (69.27)	1225 (51.38)	235 (83.33)	2682 (60.54)
6–10 days	448 (25.40)	514 (21.56)	33 (11.70)	995 (22.46)
11–15 days	51 (2.89)	223 (9.35)	3 (1.06)	277 (6.25)
> 15 days	43 (2.44)	422 (17.70)	11 (3.90)	476 (10.74)
Missing data	0 (0.00)	0 (0.00)	0 (0.00)	0(0.00)

Statistical analysis

SAS 9.4 software was used for data management. Descriptive statistics, including percentages, means, and standard deviations, were used to analyze the population data and SAS 9.4 software was used to calculate frequency, percentage, mean, and standard deviation to measure the attitudes and satisfaction of the parents and children. Satisfaction data were divided into five levels, from strongly agree to strongly disagree, based on the statistical test results. Chi-square tests and t-tests were used to assess the variables associated with education continuance at the learning center.

Ethics statement

This study and the selection of the participating hospitals were approved by the Office for Ethics in Human Research, Ministry of Public Health, Thailand in 2018 (ref. REC.024/2561), and was conducted in accordance with the Declaration of Helsinki.

Results

Caregiver information

The patient population was classified into three groups: those with common illnesses, chronic illnesses, and developmental disorders (n=4,430). There were a total of 4,430 caregivers: 82.94% were caregivers for patients with common illnesses, 82.68% chronic illnesses, and 72.34% developmental disorders. Biological parents or relatives comprised 17.07% of the common illnesses group, 17.28% chronic illnesses, and 26.95% development disorders; foster parents or teachers accounted for 0.06%, 0.04%, and 0.71%, respectively. Most caregivers were women (75.74%, 80.83%, and 82.62%, respectively), of Thai nationality (99.26%, 99.33%, and 99.65%, respectively), and Thai ethnicity (97%, 98.83%, and 99.65%, respectively). Other ethnicities included Akha, Lahu, and Burmese. The main religion was Buddhism (92.01%, 94.51%, and 97.87%, respectively), followed by Islam and Christianity. Most caregivers were aged 31–40 years (43.71%, 39.89%, and 34.40%, respectively), followed by those aged 41–50 years (23%, 39%, and 40%, respectively) and 21–30 (17.29%, 13.7%, and 18.86%, respectively). Most parents had completed vocational level, or high -school level education, followed by those with a primary or secondary educational level. Most parents were employed in labor (41.5%), agriculture (23.09%), and sales (11.22%). Most parents were married, separated, or divorced and had monthly household incomes of 10,0000–30,000 baht, followed by 5,000-10,000 baht; only a small number had incomes of >30,000 baht or <5,000 baht. Most families owned a house, while some rented a house or room. Only a small number lived with a relative. Most repondents lived in the northeastern part of Thailand.

Parent-child relationship

Of the 4,430 patients, 1,764 patients had common illnesses, 2,384 chronic illnesses, and 282 developmental disorders. In general, the caregivers of all three types of patients rated the following issues similarly. Regarding illness severity, 29.9% rated it at the minimum level, 33.6% moderate, and 20% somewhat high. Regarding when the child became ill, 43.8% of caregivers always informed teachers while 24.02% often did so. Approximately 35.7% were somewhat highly confident that their child could get along with their peers, while 24.0% were somewhat confident and 24% were highly confident. Likewise, 37.8% of caregivers put somewhat high effort to into helping their child, while 25.0% made a high-level effort. Approximately, 37.6% frequently explained the assignments to their child, and 27.5% always did so. About 37.6% had high confidence that the school provided appropriate study plans for their child, 25.5% were moderately confident, and 26.1% were extremely confident. About 34.6% of patients discussed what happened in school with their child, and 23.3% did so all the time. Regarding caregivers’ confidence in encouraging their child to control their emotions, 37.6% were somewhat highly confident, 23.5% moderately confident, and 19.6% extremely confident. About 84% of caregivers sent their child to school every day.

During hospitalization, 25.1% of the patients were in kindergarten, 58.7% in primary school, and 13.8% in secondary school. After discharge, 22.3% in kindergarten, 57.5% in primary school, and 15.6% in secondary school. About 20.9% of the patients lived <1 km from school, 53.4% lived 1–5 km away, and 25.3% lived the same distance as before joining the learning center. About 57.0% traveled to school by bicycle/motorcycle, 17.3% by private car, and 20.0% by public transportation; the means of transportation remained almost the same before and after being treatment at the center.

Children with common illnesses

As shown in Table 2, 28.5% of common illness patients were in kindergarten, 57.1% in primary school, and 13.2% in secondary school. After discharge, 28.0% were in kindergarten., 57.3% in primary school, and 13.3% in secondary school. Approximately, 15.7% lived 1 km or less from school, 56.8% 1– 5 km, and 27.5% the same distance as before entering the center. About 56.4% traveled to school by bicycle/motorcycle, 16.9% by personal vehicle, and 21.5% by public transportation. Transportation type remained largely the same before and after the treatment at the center.

Table 2. Educational background before and after entering learning centers, categorized by illness type.

	Before entering the center	After entering the center
	n (%)	N (%)
Children with common illness
Total	1764	1764
Level of education
Kindergarten	502 (28.46)	494 (28.00)
Primary school	1007 (57.09)	1010 (57.26)
High school	232 (13.15)	235 (13.32)
Vocational education	3 (0.17)	3 (0.17)
Nonformal education	17 (0.96)	18 (1.02)
Other types of education, e.g. YMCA Child Development Center	3 (0.17)	0 (0.00)
Missing data	0 (0.00)	4 (0.23) *
Distance from home to school, km
<1	277(15.70)	275(15.59)
1–5	1001(56.75)	1001(56.75)
>5	485(27.49)	484(27.44)
Missing data	1(0.06)	4(0.23)
Transportation to school
Walk	78(4.42)	78(4.42)
Bicycle/ motorcycle	995(56.41)	990(56.12)
Personnel vehicle	298(16.89)	297(16.84)
Car hire/ school bus	380(21.54)	382(21.66)
Other types of transportation, e.g. public transport or attending a boarding school	12(0.68)	13(0.74)
Missing data	1 (0.06)	4 (0.23)
Children with chronic illness
Total	2384	2384
Level of education
Kindergarten	556 (23.32)	440 (18.46)
Primary school	1420 (59.56)	1361 (57.09)
High school	354 (14.85)	429 (17.99)
Vocational education	8 (0.34)	9 (0.38)
Nonformal education	16 (0.67)	40 (1.68)
Other, e.g. stopping school temporarily, attending nursery or a child development center	30 (1.26)	7 (0.29)
Missing data	0 (0.00)	98 (4.11)^a
Distance from home to school, km
<1	579 (24.29)	548 (22.99)
1–5	1224 (51.34)	1161 (48.70)
>5	565 (23.70)	575 (24.12)
Missing data	16 (0.67)	100 (4.19)
Transportation to school
Walk	105 (4.40)	82 (3.44)
Bicycle/ motorcycle	1389 (58.26)	1345 (56.42)
Personnel vehicle	417 (17.49)	411 (17.24)
Car hire/ school bus	439 (18.41)	428 (17.95)
Other, e.g. public bus, parent pick-up/drop-off	18 (0.76)	19 (0.80)
Missing data	16 (0.67)	99 (4.15)
Developmental disorders
Total	282	282
Level of education
Kindergarten	55 (19.50)	52 (18.44)
Primary school	173 (61.35)	176 (62.41)
High school	27 (9.57)	27 (9.57)
Vocational education	0 (0.00)	0 (0.00)
Nonformal education	2 (0.71)	4 (1.42)
Other, e.g. special education center, nursery or no education	25 (8.87)	21 (7.45)
Missing data	0 (0.00)	2 (0.71)^a
Distance from home to school, km
<1	68 (24.11)	66 (23.40)
1–5	142 (50.35)	141 (50.00)
>5	70 (24.82)	73 (25.89)
Missing data	2 (0.71)	2 (0.71)
Transportation to school
Walk	16 (5.67)	15 (5.32)
Bicycle/ motorcycle	142 (50.35)	142 (50.35)
Personnel vehicle	52 (18.44)	53 (18.79)
Car hire/ school bus	65 (23.05)	65 (23.05)
Other, e.g. attending a boarding school	5 (1.77)	5 (1.77)
Missing data	2 (0.71)	2 (0.71)

^aDid not study = 34 cases, Study drop = 70 cases

Children with chronic illnesses

Before entering the center, 23.3% were in kindergarten, 59.6% in primary school, and 14.9% in secondary school. After discharge, 18.5% were in kindergarten., 57.1% in primary school, and 18.0% in secondary school. About 24.3% of patients lived less than 1 km from school, 51.3% 1–5 km, and 23.7% the same distance as before entering the center. About 58.3% traveled to school by bicycle/motorcycle, 17.5% by personal car vehicle, and 18.4% by public transportation. Means of transportation were mostly the same before and after treatment.

Children with developmental disorders

Before entering the center, 19.5 % of patients were in kindergarten, 61.4% in primary school, and 9.6% in secondary school. After discharge, 18.4% were in kindergarten, 62.4% in primary school, and 9.6% in secondary school. About 24.1% of the patients lived less than 1 km from school, 50.4% 1–5 km. away, and 24.8 the same distance as before. About 50.4% traveled to school by bicycle/motorcycle, 18.4% by private vehicle, and 23.1% by public transportation. The means of transportation were slightly different before and after entering the center.

As shown in Table 3, satisfaction surveys were distributed to two groups of patients: those who continued their education and those who did not. Scores were classified into five ranges (1.00-1.80 = strongly disagree, 1.81-2.60 = disagree, 2.61-3.40 = uncertain, 3.41-4.20 = agree, and 4.21-5.00 = strongly agree). The average satisfaction score of the two groups was 4.21-5.00. Patients who continued their education thought that the lessons in the classroom were interesting; they scored this item higher than the other group did. Entertainment had been used to provide amusing and relaxed learning for these children. The patients who did not continue their education were those in final stage of life.

Table 3. Mean scores and standard deviations for service satisfaction at the center from the patient satisfaction survey.

Satisfaction	Continued education		Did not continue education
	Mean	SD	Mean	SD
I am learning interesting lessons at the center	4.31	0.52	4.48	0.64
I enjoy learning new things at the center	4.32	0.52	4.45	0.54
I look forward to receiving services at the center	4.27	0.55	4.38	0.61
The atmosphere and facilities make me want to learn	4.27	0.55	4.40	0.57
There are various up-to-date learning materials available for me.	4.26	0.59	4.38	0.67
I am satisfied with the center	4.26	0.59	4.50	0.65
Total score	4.28	0.55	4.43	0.61

Table 4 shows the factors associated with education continuation. About 99.8%, 95.9%, and 99.3% of common, chronic, and development disorder patients continued their education, respectively. Significantly fewer chronic patients continued their education compared to common illness patients (OR=0.05; 95% CI: 0.02-0.14). About 97.8%, 97.5%, and 97.9% of kindergarten, primary school, secondary school students continued their education, respectively. There were no statistically significant differences between the three groups. Regarding distance from home to school, 97.1% <1 km away, 97.7% 1–5 km, and 98.7% >5 km; there were no statistically significant differences among the three groups. Regarding transportation to school, about 95.0% walked, 97.7% traveled by bicycle/motorcycle, 97.5% used a personal car, and 99.0% used public transportation. For those who continued their education, there were significant differences between patients who traveled by bicycle/motorcycle (OR=2.292; 95% CI: 1.152-4.560) and public transportation (OR=5.144; 95% CI: 2.062-12.833).

Table 4. Factors related to education continuation at the learning centers by the patients.

	Continue education	Discontinue education	Odds ratio (95% CI)	p-value
	n (%)	n (%)
Child’s illness
Common illness	1760 (99.77)	4 (0.23)	1	<0.0001*
Chronic illness	2286 (95.89)	98 (4.11)	0.05 (0.0 - 0.14)
Development disorders	280 (99.29)	2 (0.71)	0.3 (0.06 - 1.75)
Educational level (before entering learning center)
Kindergarten	1089 (97.84)	24 (2.16)	1	0.7248
Primary school	2535 (97.50)	65 (2.50)	0.860 (0.535- 1.380)
Secondary school	702 (97.91)	15 (2.09)	1.031 (0.537- 1.980)
Length of hospital stay (days)
<5	35 (100)	0 (0)	1	0.0392*
5–10	106 (97.72)	5 (2.28)	1.289 (0.807- 2.059)
>10	44 (63.76)	15 (21.73)	2.217 (1.172- 4.194)
Distance to school (km)
<1	897 (97.08)	27 (2.92)	1	0.0492*
1–5	2313 (97.72)	54 (2.28)	1.289 (0.807 - 2.059)
>5	1105 (98.66)	15 (1.34)	2.217 (1.172 - 4.194)
Transportation to school
Walk	189 (94.97)	10 (5.03)	1	0.0140*
Bicycle/motorcycle	2469 (97.74)	57 (2.26)	2.292 (1.152 - 4.560)
Personal vehicle	748 (97.52)	19 (2.48)	2.083 (0.953 - 4.554)
Car hire/ school bus	875 (98.98)	9 (1.02)	5.144 (2.062 - 12.833)
Other	34 (97.14)	1 (2.86)	1.799 (0.223 - 14.512)
Relationship between caregivers and children
Father/mother	3555 (97.72)	83 (2.28)	1	0.5334
Relatives/others	771 (97.35)	21 (2.65)	0.857 (0.528- 1.392)
Gender of caregiver
Male	916 (98.07)	18 (1.93)	1	0.3409
Female	3410 (97.54)	86 (2.46)	0.779 (0.466 - 1.302)
Nationality of patient
Thai	4296 (97.64)	104 (2.36)	1	0.9801
Other	30 (100.00)	0 (0.00)	-^[2]
Ethnicity of patient
Thai	4244 (97.61)	104 (2.39)	1	0.9784
Other	82 (100.00)	0 (0.00)	-^[2]
Religion of patient
Buddhist	4057 (97.71)	95 (2.29)	1	0.3140
Christianity/ Islam/ other	269 (96.76)	9 (3.24)	0.700 (0.349 - 1.402)
Age of caregiver (years)
≤30	686 (98.42)	11 (1.58)	1	0.1474
>30	3640 (97.51)	93 (2.49)	0.628 (0.334 - 1.179)
Education level of caregiver
None	194 (97.29)	6 (2.71)	1	0.0002*
Elementary school	644 (98.17)	12 (1.83)	1.498 (0.555 - 4.039)
Primary school	814 (95.43)	39 (4.57)	0.582 (0.243 - 1.394)
Secondary school	658 (97.48)	17 (2.52)	1.080 (0.421 - 2.774)
High school/vocational certificate	1160 (98.64)	16 (1.36)	2.023 (0.783 - 5.229)
Associate’s Degree /Vocational Certificate/ bachelor's degree or above	835 (98.35)	11 (1.65)	1.664 (0.632 - 4.382)
Caregiver’s occupation
Unemployed/ retired/ student	374 (95.65)	17 (4.35)	1	0.0188*
Agriculture	992 (96.97)	31 (3.03)	1.455 (0.796 - 2.660)
Manufacturing	165 (98.80)	2 (1.20)	3.750 (0.857 - 16.418)
Worker/laborer	1789 (98.13)	34 (1.87)	2.392 (1.323 - 4.327)
Salesperson	484 (97.38)	13 (2.62)	1.693 (0.812 - 3.529)
Government officer/ state enterprise/ office worker/ other	522 (98.68)	7 (1.32)	3.390 (1.392 - 8.257)
Marital status of parents
Married	3502 (97.93)	74 (2.07)	1	0.0108*
Separated	513 (97.53)	13 (2.47)	0.834 (0.459 - 1.514)
Divorced	178 (95.70)	8 (4.30)	0.470 (0.223 - 0.990)
Widowed	107 (93.86)	7 (6.14)	0.323 (0.145 - 0.718)
Unspecified	26 (92.86)	2 (7.14)	0.275 (0.064 - 1.178)
Family income/month (baht)
≤5,000	598 (96.92)	19 (3.08)	1	0.0351*
5,001–10,000	1674 (97.16)	49 (2.84)	1.085 (0.634 - 1.859)
≥10,001	2054 (98.28)	36 (1.72)	1.813 (1.032 - 3.184)
Type of family accommodation
Own a house	3638 (97.80)	82 (2.20)	1	0.1512
Rent	688 (96.90)	22 (3.10)	0.705 (0.437 - 1.136)

Most students (97%) continued their education regardless of who they lived with. About 98.1% of students who continued their education lived with male primary caregivers, whereas 97.5% lived with female primary caregivers. A total of 97.6% of Thai patients and 100% of non-Thai patients continued their education. The age, education, and occupation of caregivers were not statistically associated with the decision of the patient to continue their education. Regarding marital status, most parents were married, followed by divorced parents (OR=0.470; 95% CI: 0.223-0.990), while there were significantly fewer widowed parents (OR=0.323; 95% CI: 0.145-0.718).

About 96.9% of households had an average monthly income of <5,000 baht, 97.2% made 5,001-10,000 baht, and 98.3% made >10,000 baht. There were significant differences between households making <5,000 baht and those making >10,000 baht (OR=1.8; 95% CI: 1.032-3.184). Income was not significantly related to education continuation.

Factors associated with education continuation were illness type (more chronic patients discontinued their education), hospitalization period (the longer the stay, the greater the chance of discontinuing education), distance from home to school, transportation type, and factors related to caregivers (i.e., education level, occupation, and marital status).

Discussion

The 36 learning centers in this study were located in primary or secondary hospitals that had accepted patients from local hospitals in the area. Most patients had chronic illnesses, mostly related to hematology, cancer, and heart disease. This study’s results align with those of previous studies^{10,11,13,16,17} of tertiary hospitals. About 45% of patients had common illnesses associated with gastroenterology, respiratory disorders, and accidents. The 282 children in the developmental disorder group had attention deficit hyperactivity disorder, intellectual disability, autism, and learning difficulties.

Compared to research¹⁰ conducted in 2000, the number of children with developmental disorders at the learning centers had increased. This is perhaps attributable to patients with physical and developmental disabilities now having better access to education. The average ages of patients with chronic and common illnesses, and developmental disorders were 9.65 years (7.10-12.44), 8.69 years (6.17-11.19), and 8.85 years (6.90-11.11), respectively. Children with chronic illnesses were more likely to discontinue education because of limitations imposed by their health conditions, namely, a high risk of becoming infected or receiving treatment during the academic year. In such cases, modified education plans were introduced. Distance learning, facilitated by technology, is recommended to help patients to keep up with classes, and stay in touch with friends, which would reduce awkwardness when they returned to school. Mobile education can overcome teacher-related limitations, and it has the advantage of allowing children to select lessons for themselves. Other factors that deprived children to attend school in this study were distance from home to school, type of transportation, education level of parents, marital status, and income. However, other factors such as nationality, ethnicity or religion had no relationship with the continuation of education statistically. The results of this study was different from the a previous study¹¹; travel distance and types of transportation in the city did not affect education as much transportation in the country.

Teachers’ roles must be adjusted in the assessment guidelines^18–20 and they must be able to work with patients who have different physical and psychological conditions and education. Teachers should facilitate extra lessons for patients through special classes or e-learning, and help them pass their exams. International research studies^13,21,22 have found that “bibliotherapy” is an effective method to for reducing anxiety, and developing skills related to learning, emotion regulation, and social interaction.

We found that parents perceived their child’s chronic illnesses as moderately severe to seriously severe. For children with common illnesses, parents found that these illnesses were not moderately severe. Most parents of children with chronic and common illness highly recognized the importance of social modification, they always kept the school updated and were highly confident that the school could provide an appropriate plan for their children. Parents of children with developmental disorders were moderately to highly confident that their child was able to build relationship with friends. Teaching and psychological skills of the teachers were needed because each patient had a different physical condition, education level and psychological condition. They must be able to help the patients reduce anxiety, adjust to their health condition and give appropriate advice. Learning activities could be given anywhere outside the classroom to encourage a learning atmosphere.

In this study, the satisfaction survey of children at the learning center gave a high score of 4.21-5.00 (mean = 4.26, SD = 0.65) for every dimension. The item that was rated the highest score was that the children enjoyed participating in the activities. The item with the second highest score was that there was interesting and up-to-date content (for example, EDLTV is used in teaching according to international standard of the Ministry of Education). The third highest scoring item was that the activities were appropriate for learning (mean = 4.18, SD =0.79). Satisfaction in being part of fun and appropriate activities was rated the fourth highest item, while the item with the lowest score was that there was a variety of material and adequate facilities used in the activities (mean = 4.11, SD = 0.74).

The collaboration between learning centers and schools to monitor and refer patients, establishes a long-term plan and provide appropriate support help the patients a lot. The Cochrane library^13,21 suggests promoting a law that would foster combined work by multidisciplinary teams from hospitals, families, schools, and communities. This way, services could be developed holistically²², and children would be encouraged to continue their education. Social and society family burdens would be reduced, which could achieve the objective of children growing up to be valuable assets of the country.

Conclusion

Most child patients in the learning centers assessed in this study in Thailand decided to continue their education. Factors that were statistically related to discontinuing education were illnesses type, distance from home to school, transportation type, education level, marital status and family income. Appropriate educational management plans are needed to provide for these children. Parents had positive attitudes about illness and education. Children’s satisfaction with the learning center was high.

Key messages

A good education system should allow all children to have equal access to education, including vulnerable children.
Improvement in technology supports distance learning, which combines patient ‘healthcare, education, and social life’, thus enhancing learning equity, and helping them to return to a normal life after reentering society.
The factors affecting education continuation should be recognized and considered in education planning for sick children.
Satisfaction should include every dimension of services for quality improvement.
The support from Special Education Act and multi-disciplinary team will lead to successful hospital learning centers

Limitations

The study population was limited to children at 36 hospital learning centers in Thailand. Respondents from various institutes in other contexts should be included to increase diversity. Since different hospitals provide different types and level of services for patients with different needs, future studies should include learning centers in different types of hospitals throughout Thailand such as primary, secondary and tertiary care facilities.

Data availability

Underlying data

This project contains the following underlying data:

Figshare: Survey data record of 36 learning centers, Thailand https://doi.org/10.6084/m9.figshare.13140659.v1¹⁴

Extended data

Figshare: English survey.pdf, https://doi.org/10.6084/m9.figshare.8208338.v2²³

This project contains the following extended data:

- Copy of the survey with English translation.

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

Acknowledgements

On behalf of the authors, a deep appreciation shall be sent to 36 hospital learning centers across Thailand, Ministry of Public Health and Ethic Committee, and Queen Sirikit National Institute of Child Health for supporting this study.

Faculty Opinions recommended

References

1. Annunziato RA, Rakotomihamina V, Rubacka J, et al.: Examining the effects of maternal chronic illness on child well-being in single parent families. J Dev Behav Pediatr. 2007; 28(5): 386–91. PubMed Abstract | Publisher Full Text
2. Atheros T, Arpaichiratana C: Model of continuing care foe chronically ill children. Thai Journal of Nursing Council. 2011; 26(special issue): 112–25.
3. Enderlein G: Daniel, Wayne W.: Biostatistics – A Foundations for Analysis in the Health Sciences. Wiley & Son New York – Chichester – Brisbane – Toronto – Singapore, 6th ed. 1995, 780 S., 58. - , ISBN 0 – 471 – 58852-0 (cloth). Biom J. 1995; 37(6): 744. Publisher Full Text
4. Law Office of the Basic Education Commission Ministry of Public Health: Education Provision for Persons with Disabilities Act B.E. 2551 and 12 subordinate legislations. Special Education Bureau 2008; (Accessed: 27 January 2020). Reference Source
5. Pompimon J: A study of the organization programs for young chronically ill in-patient children. Bangkok: Chulalongkorn University. 2000.
6. Zuckerman B: Developmental and Behavior Pediatrics: a handbook for primary care. 2^nd edn. Philadelphia: Lippincott William & Wilkins, 2005; 152–7. Reference Source
7. Wijlaars LPMM, Gilbert R, Hardelid P: Chronic conditions in children and young people: learning from administrative data. Arch Dis Child. 2016; 101(10): 881–5. PubMed Abstract | Publisher Full Text | Free Full Text
8. Lum A, Wakefield CE, Donnan B, et al.: Understanding the school experiences of children and adolescents with serious chronic illness: a systematic meta-review. Child Care Health Dev. 2017; 43(5): 645–62. PubMed Abstract | Publisher Full Text
9. Council for Exceptional Children Division of Physical, Health an Multiple Disabilities: School Success for children experience chronic illness: national recommendations for addressing global barriers. Physical Dis. 2017; 36(2): 8–15. Publisher Full Text
10. Stoll BJ, Hansen NI, Bell EF: Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network. Pediatrics. 2010; 126(3): 443–56. PubMed Abstract | Publisher Full Text | Free Full Text
11. Yunak R: Interviewing children with chronic illness in qualitative research. J Nurs Health Sci. 2012; 6: 1–11.
12. LoCasale-Crouch J, Johnson B: Transition from pediatric to adult medical care. Adv chronic kidney Dis. 2005; 12(4): 412–7. PubMed Abstract | Publisher Full Text
13. Fuengfoo A, Leelathanaporn S, Mekrungcharas T, et al.: Effectiveness of the Hospital Learning Center (Queen Sirikit National Institute of Child Health): Satisfaction with service and parents’ attitudes towards children’s illness [version 1; peer review: 2 approved, 1 approved with reservations] F1000Res. 2019; 8: 1616. (Accessed: 15 March 2020). PubMed Abstract | Publisher Full Text | Free Full Text
14. Fuengfoo A: Survey data record of 36 learning centers, Thailand. figshare. Dataset. 2020. http://www.doi.org/10.6084/m9.figshare.13140659.v1
15. Daniel WW: Biostatistics:A Foundation of Analysis in the Health sciences. (6th ed.)John Willey & Sons,Inc. 1995. Reference Source
16. Center for Chronic Disease Prevention and Control: What are chronic and noncommunicable diseases? Ottawa, ON: Public Health Agency of Canada. (Accessed: 18 August 2018). Reference Source
17. Special Education Bureau, Ministry of Education: Guidelines for Performance Evaluation of Learning Center in Hospital for Chronically Ill Patients. Bangkok: Office of the Basic Education Commission 2015; (Accessed: 13 January 2020). Reference Source
18. Bell MF, Bayliss DM, Glauert R, et al.: Chronic Illness and Developmental Vulnerability at school Entry. Pediatric. 2016; 137(5): e20152475. PubMed Abstract | Publisher Full Text
19. Special Education Bureau, Ministry of Education: ‘Practice Guideline for Teachers in Chronic Children Learning Center in Hospital Bangkok: Office of the Basic Education Commission. 2015; (Accessed: 13 January 2020). Reference Source
20. Van Cleave J, Gortmaker SL, Perrin JM: Dynamic of obesity and chronic health conditions among children and youth. JAMA. 2010; 303(7): 623–30. PubMed Abstract | Publisher Full Text
21. Pugbunmee R: Chronically ill adolescents: impact on self-care. Rama Nurse. 1997; 3: 103–9.
22. World Health Organization: innovative care for chronic conditions: building blocks for action. Geneva, Switzerland: world Health Organization 2002; (Accessed: 15 October 2018). Reference Source
23. Fuengfoo A: English Survey.pdf. figshare. Figure. 2019. http://www.doi.org/10.6084/m9.figshare.8208338.v2

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Version 2

VERSION 2 PUBLISHED 11 Dec 2020

Author details Author details

Kim Sakulnum
Roles: Data Curation, Project Administration, Validation

Sumitra Owjinda
Roles: Investigation, Methodology, Software

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (2)

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https://doi.org/10.12688/f1000research.26599.2

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Fuengfoo A, Sakulnum K and Owjinda S. Effectiveness of 36 hospital learning centers in Thailand: continuation of child patient education, parent attitudes toward child’s illness and service satisfaction [version 1; peer review: 1 approved, 1 not approved]. F1000Research 2020, 9:1446 (https://doi.org/10.12688/f1000research.26599.1)

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Reviewer Report 17 Jan 2022

Shervin Assari, Department of Family Medicine, Charles R Drew University of Medicine and Science, Los Angeles, CA, USA

Babak Najand, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA

Not Approved

https://doi.org/10.5256/f1000research.29363.r118876

This is a single-group interventional study. Here are areas for improvement:

The abstract and also the paper should make the design much more clear. Is this a longitudinal one-arm intervention (designed by authors) or is this

This is a single-group interventional study. Here are areas for improvement:

The abstract and also the paper should make the design much more clear. Is this a longitudinal one-arm intervention (designed by authors) or is this a natural experiment designed by a system and the authors just conducted the evaluation?
The result is not just about attitudes. Many other factors such as socioeconomic status predict child educational success, but the title only mentions attitude.
One major problem is that all samples are analyzed together. However, some of these children have physical health problems and some have disabling developmental challenges. These two groups are qualitatively different and cannot be combined. Just controlling for this type as a nominal variable (0/1) does not solve the problem. I think at least for sensitivity analysis, all results should be replicated in a stratified fashion, separately for each of the groups mentioned.
SES and social determinants of health are root causes of health and well-being. The paper, however, does not mention these concepts despite that it measures them.
Overall, I think the data are much stronger than the discussion section. Many more areas could be discussed which are left untouched.
These children are educationally heterogeneous. This includes children at kindergarten to much higher levels. Progress in educational programs is highly dependable on the workload required. So, simply controlling for the educational level does not solve this problem. Overall, the high heterogeneity of the sample is a major problem here.
Sex/gender is beyond a control variable. Parents may differently invest in their boys and girls (gender norms). Similarly, a child may get different attention and investment depending on the number of siblings. Thus, more attention is needed on the composition of the household beyond marital status.
Another important area in this paper is poor eligibility. These poor selection criteria have made it very difficult to know who was in the study. I think the authors need to replicate their findings in groups of patients with more homogenous conditions.
More information is needed on the variation of the adherence to the curriculum across learning centers. How do various centers do their job? Was there any effect on centers?
Participants were nested to centers so they are not independent samples. Please discuss your solution to address this data challenge.

Overall, despite the paper having great potential and focusing on a novel topic that is rarely done by others, authors could do a much better job with inclusion, statistics, and discussion.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

No
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: I am an expert of child development, social inequalities, and longitudinal data analysis. I also work related to chronic disease and mental health problems.

We confirm that we have read this submission and believe that we have an appropriate level of expertise to state that we do not consider it to be of an acceptable scientific standard, for reasons outlined above.

CITE

Report a concern

Author Response 14 Apr 2022

adidsuda fuengfoo, Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, Queen Sirikit National Institute of Child Health, Bangkok, Thailand

14 Apr 2022

Author Response

1. This is a single-group interventional study. Here are areas for improvement: The abstract and also the paper should make the design much more clear. Is this a longitudinal one-arm ... Continue reading 1. This is a single-group interventional study. Here are areas for improvement: The abstract and also the paper should make the design much more clear. Is this a longitudinal one-arm intervention (designed by authors) or is this a natural experiment designed by a system and the authors just conducted the evaluation?

This research was conducted in a form of natural experimental study in which variables are influenced by nature or factors outside of the researchers’ control. A cross-sectional design has been implemented in this study where a group of the population is selected based on the inclusion criteria set for the study: types of illnesses, patient’s and parent’s demographic information in order to measure the effectiveness of the project and to examine the factors correlating with continuing education of children under HSH project, patient’s attitudes and patient’s satisfaction towards HSH project. However, a limitation of a cross-sectional study is that it is difficult to identify causal effects and only describe associations between variables.

2. The result is not just about attitudes. Many other factors such as socioeconomic status predict child educational success, but the title only mentions attitude.

Assessment of the Learning Center in Hospital Program was assessed on the function and effectiveness of children with health problems participating in the Learning Center in Hospital Program. Another angle, besides taking into account accuracy, should also consider preferences along the way. Therefore, it is assessed in various dimensions, such as assessing the perspectives of service users in terms of parental attitudes and the satisfaction of sick children participating in the Hospital Learning Center project, which is a secondary objective of this research and is discussed in the information found for the purpose.

3. One major problem is that all samples are analyzed together. However, some of these children have physical health problems and some have disabling developmental challenges. These two groups are qualitatively different and cannot be combined. Just controlling for this type as a nominal variable (0/1) does not solve the problem. I think at least for sensitivity analysis, all results should be replicated in a stratified fashion, separately for each of the groups mentioned.

The research team would like to accept and appreciate the advice that is very helpful. In the issue of data analysis should be separated into groups, diseases because each group of diseases has a different nature and affects learning. The researcher, therefore, brought this issue to further improve in the analysis of the data to separate the groups into three groups: common disease children, chronic disease children, and children with developmental problems, as shown in the table.

4. SES and social determinants of health are root causes of health and well-being. The paper, however, does not mention these concepts despite that it measures them.

Socioeconomic status is a very important part of healthcare and is the foundation for proper health management and lifestyle. It is a valuable recommendation when further analyzed separately. The disease group found that social socioeconomic status affecting admission to continuing education after discharge from the hospital was associated with all disease groups. When analyzed, it was found that there was still a relationship between chronic disease and chronic disease groups with developmental problems because it is a long continuous treatment, and with costs that depend on severity, complexity, and advances in technology, children with chronic and developmental diseases have a better chance of living longer.

5. Overall, I think the data are much stronger than the discussion section. Many more areas could be discussed which are left untouched.

The researcher agreed and used the data for further analysis, separating the disease groups. We have added more discussion on factors that remained related to children's continued return to school when analyzing disease groups: parents' education, socioeconomic status, family income, number of siblings, etc.

6. These children are educationally heterogeneous. This includes children at kindergarten to much higher levels. Progress in educational programs is highly dependable on the workload required. So, simply controlling for the educational level does not solve this problem. Overall, the high heterogeneity of the sample is a major problem here.

We agree on the issue of diversity in the classroom as one of the limitations of education in nature experimental study. In a future study, we will include prospective follow-up studies and segmented samples for cross-sectional study to reduce such limitations.

7. Sex/gender is beyond a control variable. Parents may differently invest in their boys and girls (gender norms). Similarly, a child may get different attention and investment depending on the number of siblings. Thus, more attention is needed on the composition of the household beyond marital status.

Since gender is an uncontrolled variation, the researcher has selected the factors that are more likely to affect the continuation of children which are the number of siblings and family income. After analyzing separately, the study found that parents with more than 2 children are likely to discontinue education of the child with chronic diseases or with developmental problems. At the same time, families with a monthly income lower than 5,000 baht considered stopping further education of the sick child. With economic constraints, parents may need to think about the cost-effectiveness of sending their child to school. It must be decided that delivering a child without chronic illnesses or developmental delay may be more cost-effective than children with chronic illnesses or developmental delay since education cost is not the only expense under parents’ responsibility, but also healthcare costs or medication costs for the sick child. In contrast, the study found that the number of siblings and hospital length of stay do not correlate with children without chronic illnesses or developmental delay to further education because the normal school system allows them to go back to school after they recover.

8. Another important area in this paper is poor eligibility. These poor selection criteria have made it very difficult to know who was in the study. I think the authors need to replicate their findings in groups of patients with more homogenous conditions.

It is a valuable suggestion that gives the researcher a clearer perspective. Therefore, the researcher has divided the groups to select the pediatric patients by separate disease groups and analyze the factors affecting admission to further education in order to create more homogeneous conditions as shown in the table.

9. More information is needed on the variation of the adherence to the curriculum across learning centers. How do various centers do their job? Was there any effect on centers?

Hospital Learning Centers for sick children use a standardized curriculum established by the Ministry of Education applicable for children at all education levels: pre-kindergarten, primary, secondary, tertiary levels, as well as vocational education. This curriculum is a collaboration between MOU partners: the Ministry of Education, Ministry of Public Health, and Ministry of Science and Technology.

All of the operational processes need to follow the Clinical Practice Guideline (CPG) and pass an external audit from a third party to ensure that the education that is delivered to sick patients in every hospital learning center meets the standard.

10. Participants were nested to centers so they are not independent samples. Please discuss your solution to address this data challenge.

The selection of a sample in this study was a voluntary response sample from all 36 learning centers in Hospitals across Thailand. That is, after the instruction was given to the participants, they were able to participate in the study voluntarily. If the number of participants was more than the expected population, a random sample selection would be implemented. In order to access the data, permission from the Human Ethics Committee of the Ministry of Public Health that oversees all 36 network hospitals must be approved.
1. This is a single-group interventional study. Here are areas for improvement: The abstract and also the paper should make the design much more clear. Is this a longitudinal one-arm intervention (designed by authors) or is this a natural experiment designed by a system and the authors just conducted the evaluation?

This research was conducted in a form of natural experimental study in which variables are influenced by nature or factors outside of the researchers’ control. A cross-sectional design has been implemented in this study where a group of the population is selected based on the inclusion criteria set for the study: types of illnesses, patient’s and parent’s demographic information in order to measure the effectiveness of the project and to examine the factors correlating with continuing education of children under HSH project, patient’s attitudes and patient’s satisfaction towards HSH project. However, a limitation of a cross-sectional study is that it is difficult to identify causal effects and only describe associations between variables.

2. The result is not just about attitudes. Many other factors such as socioeconomic status predict child educational success, but the title only mentions attitude.

Assessment of the Learning Center in Hospital Program was assessed on the function and effectiveness of children with health problems participating in the Learning Center in Hospital Program. Another angle, besides taking into account accuracy, should also consider preferences along the way. Therefore, it is assessed in various dimensions, such as assessing the perspectives of service users in terms of parental attitudes and the satisfaction of sick children participating in the Hospital Learning Center project, which is a secondary objective of this research and is discussed in the information found for the purpose.

3. One major problem is that all samples are analyzed together. However, some of these children have physical health problems and some have disabling developmental challenges. These two groups are qualitatively different and cannot be combined. Just controlling for this type as a nominal variable (0/1) does not solve the problem. I think at least for sensitivity analysis, all results should be replicated in a stratified fashion, separately for each of the groups mentioned.

The research team would like to accept and appreciate the advice that is very helpful. In the issue of data analysis should be separated into groups, diseases because each group of diseases has a different nature and affects learning. The researcher, therefore, brought this issue to further improve in the analysis of the data to separate the groups into three groups: common disease children, chronic disease children, and children with developmental problems, as shown in the table.

4. SES and social determinants of health are root causes of health and well-being. The paper, however, does not mention these concepts despite that it measures them.

Socioeconomic status is a very important part of healthcare and is the foundation for proper health management and lifestyle. It is a valuable recommendation when further analyzed separately. The disease group found that social socioeconomic status affecting admission to continuing education after discharge from the hospital was associated with all disease groups. When analyzed, it was found that there was still a relationship between chronic disease and chronic disease groups with developmental problems because it is a long continuous treatment, and with costs that depend on severity, complexity, and advances in technology, children with chronic and developmental diseases have a better chance of living longer.

5. Overall, I think the data are much stronger than the discussion section. Many more areas could be discussed which are left untouched.

The researcher agreed and used the data for further analysis, separating the disease groups. We have added more discussion on factors that remained related to children's continued return to school when analyzing disease groups: parents' education, socioeconomic status, family income, number of siblings, etc.

6. These children are educationally heterogeneous. This includes children at kindergarten to much higher levels. Progress in educational programs is highly dependable on the workload required. So, simply controlling for the educational level does not solve this problem. Overall, the high heterogeneity of the sample is a major problem here.

We agree on the issue of diversity in the classroom as one of the limitations of education in nature experimental study. In a future study, we will include prospective follow-up studies and segmented samples for cross-sectional study to reduce such limitations.

7. Sex/gender is beyond a control variable. Parents may differently invest in their boys and girls (gender norms). Similarly, a child may get different attention and investment depending on the number of siblings. Thus, more attention is needed on the composition of the household beyond marital status.

Since gender is an uncontrolled variation, the researcher has selected the factors that are more likely to affect the continuation of children which are the number of siblings and family income. After analyzing separately, the study found that parents with more than 2 children are likely to discontinue education of the child with chronic diseases or with developmental problems. At the same time, families with a monthly income lower than 5,000 baht considered stopping further education of the sick child. With economic constraints, parents may need to think about the cost-effectiveness of sending their child to school. It must be decided that delivering a child without chronic illnesses or developmental delay may be more cost-effective than children with chronic illnesses or developmental delay since education cost is not the only expense under parents’ responsibility, but also healthcare costs or medication costs for the sick child. In contrast, the study found that the number of siblings and hospital length of stay do not correlate with children without chronic illnesses or developmental delay to further education because the normal school system allows them to go back to school after they recover.

8. Another important area in this paper is poor eligibility. These poor selection criteria have made it very difficult to know who was in the study. I think the authors need to replicate their findings in groups of patients with more homogenous conditions.

It is a valuable suggestion that gives the researcher a clearer perspective. Therefore, the researcher has divided the groups to select the pediatric patients by separate disease groups and analyze the factors affecting admission to further education in order to create more homogeneous conditions as shown in the table.

9. More information is needed on the variation of the adherence to the curriculum across learning centers. How do various centers do their job? Was there any effect on centers?

Hospital Learning Centers for sick children use a standardized curriculum established by the Ministry of Education applicable for children at all education levels: pre-kindergarten, primary, secondary, tertiary levels, as well as vocational education. This curriculum is a collaboration between MOU partners: the Ministry of Education, Ministry of Public Health, and Ministry of Science and Technology.

All of the operational processes need to follow the Clinical Practice Guideline (CPG) and pass an external audit from a third party to ensure that the education that is delivered to sick patients in every hospital learning center meets the standard.

10. Participants were nested to centers so they are not independent samples. Please discuss your solution to address this data challenge.

The selection of a sample in this study was a voluntary response sample from all 36 learning centers in Hospitals across Thailand. That is, after the instruction was given to the participants, they were able to participate in the study voluntarily. If the number of participants was more than the expected population, a random sample selection would be implemented. In order to access the data, permission from the Human Ethics Committee of the Ministry of Public Health that oversees all 36 network hospitals must be approved.
Competing Interests: No competing interests were disclosed. Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 14 Apr 2022

adidsuda fuengfoo, Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, Queen Sirikit National Institute of Child Health, Bangkok, Thailand

14 Apr 2022

Author Response

1. This is a single-group interventional study. Here are areas for improvement: The abstract and also the paper should make the design much more clear. Is this a longitudinal one-arm ... Continue reading 1. This is a single-group interventional study. Here are areas for improvement: The abstract and also the paper should make the design much more clear. Is this a longitudinal one-arm intervention (designed by authors) or is this a natural experiment designed by a system and the authors just conducted the evaluation?

This research was conducted in a form of natural experimental study in which variables are influenced by nature or factors outside of the researchers’ control. A cross-sectional design has been implemented in this study where a group of the population is selected based on the inclusion criteria set for the study: types of illnesses, patient’s and parent’s demographic information in order to measure the effectiveness of the project and to examine the factors correlating with continuing education of children under HSH project, patient’s attitudes and patient’s satisfaction towards HSH project. However, a limitation of a cross-sectional study is that it is difficult to identify causal effects and only describe associations between variables.

2. The result is not just about attitudes. Many other factors such as socioeconomic status predict child educational success, but the title only mentions attitude.

Assessment of the Learning Center in Hospital Program was assessed on the function and effectiveness of children with health problems participating in the Learning Center in Hospital Program. Another angle, besides taking into account accuracy, should also consider preferences along the way. Therefore, it is assessed in various dimensions, such as assessing the perspectives of service users in terms of parental attitudes and the satisfaction of sick children participating in the Hospital Learning Center project, which is a secondary objective of this research and is discussed in the information found for the purpose.

3. One major problem is that all samples are analyzed together. However, some of these children have physical health problems and some have disabling developmental challenges. These two groups are qualitatively different and cannot be combined. Just controlling for this type as a nominal variable (0/1) does not solve the problem. I think at least for sensitivity analysis, all results should be replicated in a stratified fashion, separately for each of the groups mentioned.

The research team would like to accept and appreciate the advice that is very helpful. In the issue of data analysis should be separated into groups, diseases because each group of diseases has a different nature and affects learning. The researcher, therefore, brought this issue to further improve in the analysis of the data to separate the groups into three groups: common disease children, chronic disease children, and children with developmental problems, as shown in the table.

4. SES and social determinants of health are root causes of health and well-being. The paper, however, does not mention these concepts despite that it measures them.

Socioeconomic status is a very important part of healthcare and is the foundation for proper health management and lifestyle. It is a valuable recommendation when further analyzed separately. The disease group found that social socioeconomic status affecting admission to continuing education after discharge from the hospital was associated with all disease groups. When analyzed, it was found that there was still a relationship between chronic disease and chronic disease groups with developmental problems because it is a long continuous treatment, and with costs that depend on severity, complexity, and advances in technology, children with chronic and developmental diseases have a better chance of living longer.

5. Overall, I think the data are much stronger than the discussion section. Many more areas could be discussed which are left untouched.

The researcher agreed and used the data for further analysis, separating the disease groups. We have added more discussion on factors that remained related to children's continued return to school when analyzing disease groups: parents' education, socioeconomic status, family income, number of siblings, etc.

6. These children are educationally heterogeneous. This includes children at kindergarten to much higher levels. Progress in educational programs is highly dependable on the workload required. So, simply controlling for the educational level does not solve this problem. Overall, the high heterogeneity of the sample is a major problem here.

We agree on the issue of diversity in the classroom as one of the limitations of education in nature experimental study. In a future study, we will include prospective follow-up studies and segmented samples for cross-sectional study to reduce such limitations.

7. Sex/gender is beyond a control variable. Parents may differently invest in their boys and girls (gender norms). Similarly, a child may get different attention and investment depending on the number of siblings. Thus, more attention is needed on the composition of the household beyond marital status.

Since gender is an uncontrolled variation, the researcher has selected the factors that are more likely to affect the continuation of children which are the number of siblings and family income. After analyzing separately, the study found that parents with more than 2 children are likely to discontinue education of the child with chronic diseases or with developmental problems. At the same time, families with a monthly income lower than 5,000 baht considered stopping further education of the sick child. With economic constraints, parents may need to think about the cost-effectiveness of sending their child to school. It must be decided that delivering a child without chronic illnesses or developmental delay may be more cost-effective than children with chronic illnesses or developmental delay since education cost is not the only expense under parents’ responsibility, but also healthcare costs or medication costs for the sick child. In contrast, the study found that the number of siblings and hospital length of stay do not correlate with children without chronic illnesses or developmental delay to further education because the normal school system allows them to go back to school after they recover.

8. Another important area in this paper is poor eligibility. These poor selection criteria have made it very difficult to know who was in the study. I think the authors need to replicate their findings in groups of patients with more homogenous conditions.

It is a valuable suggestion that gives the researcher a clearer perspective. Therefore, the researcher has divided the groups to select the pediatric patients by separate disease groups and analyze the factors affecting admission to further education in order to create more homogeneous conditions as shown in the table.

9. More information is needed on the variation of the adherence to the curriculum across learning centers. How do various centers do their job? Was there any effect on centers?

Hospital Learning Centers for sick children use a standardized curriculum established by the Ministry of Education applicable for children at all education levels: pre-kindergarten, primary, secondary, tertiary levels, as well as vocational education. This curriculum is a collaboration between MOU partners: the Ministry of Education, Ministry of Public Health, and Ministry of Science and Technology.

All of the operational processes need to follow the Clinical Practice Guideline (CPG) and pass an external audit from a third party to ensure that the education that is delivered to sick patients in every hospital learning center meets the standard.

10. Participants were nested to centers so they are not independent samples. Please discuss your solution to address this data challenge.

The selection of a sample in this study was a voluntary response sample from all 36 learning centers in Hospitals across Thailand. That is, after the instruction was given to the participants, they were able to participate in the study voluntarily. If the number of participants was more than the expected population, a random sample selection would be implemented. In order to access the data, permission from the Human Ethics Committee of the Ministry of Public Health that oversees all 36 network hospitals must be approved.
1. This is a single-group interventional study. Here are areas for improvement: The abstract and also the paper should make the design much more clear. Is this a longitudinal one-arm intervention (designed by authors) or is this a natural experiment designed by a system and the authors just conducted the evaluation?

This research was conducted in a form of natural experimental study in which variables are influenced by nature or factors outside of the researchers’ control. A cross-sectional design has been implemented in this study where a group of the population is selected based on the inclusion criteria set for the study: types of illnesses, patient’s and parent’s demographic information in order to measure the effectiveness of the project and to examine the factors correlating with continuing education of children under HSH project, patient’s attitudes and patient’s satisfaction towards HSH project. However, a limitation of a cross-sectional study is that it is difficult to identify causal effects and only describe associations between variables.

2. The result is not just about attitudes. Many other factors such as socioeconomic status predict child educational success, but the title only mentions attitude.

Assessment of the Learning Center in Hospital Program was assessed on the function and effectiveness of children with health problems participating in the Learning Center in Hospital Program. Another angle, besides taking into account accuracy, should also consider preferences along the way. Therefore, it is assessed in various dimensions, such as assessing the perspectives of service users in terms of parental attitudes and the satisfaction of sick children participating in the Hospital Learning Center project, which is a secondary objective of this research and is discussed in the information found for the purpose.

3. One major problem is that all samples are analyzed together. However, some of these children have physical health problems and some have disabling developmental challenges. These two groups are qualitatively different and cannot be combined. Just controlling for this type as a nominal variable (0/1) does not solve the problem. I think at least for sensitivity analysis, all results should be replicated in a stratified fashion, separately for each of the groups mentioned.

The research team would like to accept and appreciate the advice that is very helpful. In the issue of data analysis should be separated into groups, diseases because each group of diseases has a different nature and affects learning. The researcher, therefore, brought this issue to further improve in the analysis of the data to separate the groups into three groups: common disease children, chronic disease children, and children with developmental problems, as shown in the table.

4. SES and social determinants of health are root causes of health and well-being. The paper, however, does not mention these concepts despite that it measures them.

Socioeconomic status is a very important part of healthcare and is the foundation for proper health management and lifestyle. It is a valuable recommendation when further analyzed separately. The disease group found that social socioeconomic status affecting admission to continuing education after discharge from the hospital was associated with all disease groups. When analyzed, it was found that there was still a relationship between chronic disease and chronic disease groups with developmental problems because it is a long continuous treatment, and with costs that depend on severity, complexity, and advances in technology, children with chronic and developmental diseases have a better chance of living longer.

5. Overall, I think the data are much stronger than the discussion section. Many more areas could be discussed which are left untouched.

The researcher agreed and used the data for further analysis, separating the disease groups. We have added more discussion on factors that remained related to children's continued return to school when analyzing disease groups: parents' education, socioeconomic status, family income, number of siblings, etc.

6. These children are educationally heterogeneous. This includes children at kindergarten to much higher levels. Progress in educational programs is highly dependable on the workload required. So, simply controlling for the educational level does not solve this problem. Overall, the high heterogeneity of the sample is a major problem here.

We agree on the issue of diversity in the classroom as one of the limitations of education in nature experimental study. In a future study, we will include prospective follow-up studies and segmented samples for cross-sectional study to reduce such limitations.

7. Sex/gender is beyond a control variable. Parents may differently invest in their boys and girls (gender norms). Similarly, a child may get different attention and investment depending on the number of siblings. Thus, more attention is needed on the composition of the household beyond marital status.

Since gender is an uncontrolled variation, the researcher has selected the factors that are more likely to affect the continuation of children which are the number of siblings and family income. After analyzing separately, the study found that parents with more than 2 children are likely to discontinue education of the child with chronic diseases or with developmental problems. At the same time, families with a monthly income lower than 5,000 baht considered stopping further education of the sick child. With economic constraints, parents may need to think about the cost-effectiveness of sending their child to school. It must be decided that delivering a child without chronic illnesses or developmental delay may be more cost-effective than children with chronic illnesses or developmental delay since education cost is not the only expense under parents’ responsibility, but also healthcare costs or medication costs for the sick child. In contrast, the study found that the number of siblings and hospital length of stay do not correlate with children without chronic illnesses or developmental delay to further education because the normal school system allows them to go back to school after they recover.

8. Another important area in this paper is poor eligibility. These poor selection criteria have made it very difficult to know who was in the study. I think the authors need to replicate their findings in groups of patients with more homogenous conditions.

It is a valuable suggestion that gives the researcher a clearer perspective. Therefore, the researcher has divided the groups to select the pediatric patients by separate disease groups and analyze the factors affecting admission to further education in order to create more homogeneous conditions as shown in the table.

9. More information is needed on the variation of the adherence to the curriculum across learning centers. How do various centers do their job? Was there any effect on centers?

Hospital Learning Centers for sick children use a standardized curriculum established by the Ministry of Education applicable for children at all education levels: pre-kindergarten, primary, secondary, tertiary levels, as well as vocational education. This curriculum is a collaboration between MOU partners: the Ministry of Education, Ministry of Public Health, and Ministry of Science and Technology.

All of the operational processes need to follow the Clinical Practice Guideline (CPG) and pass an external audit from a third party to ensure that the education that is delivered to sick patients in every hospital learning center meets the standard.

10. Participants were nested to centers so they are not independent samples. Please discuss your solution to address this data challenge.

The selection of a sample in this study was a voluntary response sample from all 36 learning centers in Hospitals across Thailand. That is, after the instruction was given to the participants, they were able to participate in the study voluntarily. If the number of participants was more than the expected population, a random sample selection would be implemented. In order to access the data, permission from the Human Ethics Committee of the Ministry of Public Health that oversees all 36 network hospitals must be approved.
Competing Interests: No competing interests were disclosed. Close
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Reviewer Report 17 Feb 2021

Issarapa Chunsuwan, Department of Pediatrics, Faculty of Medicine, Developmental and Behavioral Pediatrics, Thammasat University (TU), Pathum Thani, Thailand

Approved

https://doi.org/10.5256/f1000research.29363.r78813

This is continuing research to find ways to promote education for children in hospitals. The hospital school model was further implemented in 36 centers in Thailand in which many children have received services. In this paper, the authors aim to ... Continue reading

For a clearer understanding, the Authors should give more information about the 36 learning centers, such as how they are settled in hospitals (place, operational time), who are teachers in the centers, how they select pediatric patients to attend the centers (by doctor referral or who else) and how they provide educational service (curriculum, activity)? And also, more information about eDLTV may help readers who are not in Thailand understand it. The Authors may add information about how the QSNICH learning center supervises the other 36 learning centers.

Methodology

A flow chart that shows how 4430 participants in this study were recruited from 30,000 pediatric patients of the 36 centers could be helpful to show a clear overview of the recruitment process.
There are 4430 data in the research rather than 8860. The author can explain that 4430 children included in the research and 4430 parents were interviewed.
Definition for classifying common illness from chronic illness should be mentioned (depend on the type of disease or hospital day)
The questionnaires used in the study should be defined in detail for better understanding, such as numbers of items in the satisfactory scales and how is the total score obtained, what are questions asked in the demographic data and validation process of the questionnaire.

Results

The main research findings on effectiveness may not yet clear to readers. The authors may adjust or add a table that defines the effectiveness of the program. For example, in Table 3, statistical analysis of differences in satisfaction between 2 groups could add more information about effectiveness.
In table 4, Is not clear that the heading "continue education" means continue education at a learning center or at a formal school. and also the distance from school means the formal school or learning center.

Key messages

The main result of this study about effectiveness should be added as the key message.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Developmental and behavioral pediatrician

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Version 2

VERSION 2 PUBLISHED 11 Dec 2020

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Issarapa Chunsuwan, Thammasat University (TU), Pathum Thani, Thailand
Shervin Assari, Charles R Drew University of Medicine and Science, Los Angeles, USA

Babak Najand, Charles R. Drew University of Medicine and Science, Los Angeles, USA
Banchaun Benjasuwantep, Srinakharinwirot University, Nakhon Nayok, Thailand
Nutthaporn Chandeying, Navamindradhiraj University, Bangkok, Thailand

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09 Sep 2024 | for Version 2

Nutthaporn Chandeying, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand

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Reviewer comment

Abstract

A Correct subject-verb agreement throughout the manuscript. For example, "Satisfaction score towards the services at the learning centers were high" should be "Satisfaction scores towards the services at the learning centers were high."
Improve clarity and conciseness. For example, "Parents were less worried about children with common illness and more concerned about education of children with chronic diseases and children with disabilities" can be revised to "Parents were less worried about children with common illnesses and more concerned about the education of children with chronic diseases and disabilities."
Use correct terminology consistently. For example, "About 99.8% of patients with common illnesses continued their education, followed by 99.3% of disabled children, and 95.9% of chronic patients." Consider revising to "About 99.8% of children with common illnesses continued their education, followed by 99.3% of children with disabilities, and 95.9% of children with chronic illnesses."

Introduction

There is inconsistency in the use of terms, such as "chronic diseases" and "chronic illnesses." Choose one term and use it consistently throughout the manuscript to avoid confusion.
The background lacks detailed information on how the QSNICH and other learning centers operate and the specific roles of different ministries. Provide more details about the operation of these centers, including the roles of the Ministry of Education, Ministry of Public Health, and Ministry of Science and Technology. Explain how the collaboration works and the specific contributions of each ministry.
There are several grammatical issues that need attention, such as subject-verb agreement and punctuation. Revise sentences for grammatical correctness.

- "All of the operational process needs to follow Clinical Practice Guideline (CPG) and pass an external audit from the third party" should be "All operational processes need to follow Clinical Practice Guidelines (CPG) and pass an external audit by a third party."
- Original: "Today medical advancements have increased the survival rate of children with chronic diseases to 90%, reducing mortality rates and complications1, and increasing life expectancy by as much as 20 years longer2."
Issue: Comma needed after "Today"; "as much as 20 years longer" is redundant.
Revision: "Today, medical advancements have increased the survival rate of children with chronic diseases to 90%, reducing mortality rates and complications, and increasing life expectancy by up to 20 years."
- Original: "The UN Convention of the Rights of the Child states that every child has the right to be protected and receive equal education9."
Issue: "of" should be "on."
Revision: "The UN Convention on the Rights of the Child states that every child has the right to be protected and receive equal education."
- Original: "Similar learning centers in other countries involve the coordination of multidisciplinary teams to enhance social and learning activities or sick children."
Issue: "or" should be "for."
Revision: "Similar learning centers in other countries involve the coordination of multidisciplinary teams to enhance social and learning activities for sick children."
- Original: "Hospital Learning Centers for sick children uses standardized curriculum established by Ministry of Education applicable for children at all education levels: pre-kindergarten, primary, secondary, tertiary levels, as well as vocational education."
Issue: "uses" should be "use"; "established by Ministry of Education" needs an article.
Revision: "Hospital Learning Centers for sick children use a standardized curriculum established by the Ministry of Education, applicable for children at all education levels: pre-kindergarten, primary, secondary, tertiary, and vocational education."
- Original: "This curriculum is a collaboration between MOU partners: Ministry of Education, Ministry of Public Health and Ministry of Science and Technology."
Issue: Comma needed before "and."
Revision: "This curriculum is a collaboration between MOU partners: the Ministry of Education, the Ministry of Public Health, and the Ministry of Science and Technology."
4. The objectives section can be made clearer and more precise. Clearly state the specific objectives of the study in bullet points or a numbered list for better readability. For example: This study extends previous research on the QSNICH learning center's effectiveness, focusing on factors affecting further education for children with special needs. The aims are To determine the effectiveness of 36 network learning centers across Thailand in providing continued education for pediatric patients.

To identify factors associated with the continuation of education for pediatric patients.
To evaluate parents' attitudes toward their children's illnesses and education.
To assess service satisfaction at the learning centers.

Methods

Lack of clarity in the description of statistical methods. Clearly describe the statistical methods used, including the rationale for choosing chi-square tests and t-tests. Explain how data were managed.
Several grammatical errors, including subject-verb agreement and punctuation issues. Revise sentences for grammatical correctness. Ensure subject-verb agreement, proper punctuation, and correct use of articles as the followings:

- Original: "This research was conducted in a form of natural experimental study which variables are influenced by nature or factors outside of the researchers' control."
Issue: "in a form of" should be "as a"; "which variables are" should be "where variables are."
Revision: "This research was conducted as a natural experimental study where variables are influenced by nature or factors outside of the researchers' control."
- Original: "Cross-sectional design has been implemented in this study where a group of population from all the 36 learning centers in the hospitals across Thailand was selected based on the inclusion criteria set for the study: types of illnesses, patient's and parent's demographic information in order to measure the effectiveness of the project and to examine the factors correlating with continuing education of children under HSH project, patient's attitudes and patient's satisfaction towards HSH project."
Issue: "Cross-sectional design has been implemented" should be "A cross-sectional design was implemented"; "group of population" should be "group of participants"; "in the hospitals" is redundant.
Revision: "A cross-sectional design was implemented in this study, selecting a group of participants from all 36 learning centers across Thailand based on the inclusion criteria set for the study: types of illnesses, patients' and parents' demographic information. The study aimed to measure the effectiveness of the project and examine factors correlating with the continuation of education for children under the HSH project, as well as patients' attitudes and satisfaction with the HSH project."
- Original: "The total number of pediatric patients from 36 learning centers at the hospitals was 30,000 (n=30,000), and the incidence of children who went back to school was 80% (p=0.8))."
Issue: Redundant parentheses; awkward phrasing.
Revision: "The total number of pediatric patients from the 36 learning centers was 30,000 (n=30,000), with an incidence of 80% (p=0.8) for children returning to school."
- Original: "The selection of a sample in this study was a voluntary response sample from all 36 learning centers in Hospitals across Thailand."
Issue: "Hospitals" should not be capitalized; awkward phrasing.
Revision: "The sample selection in this study was a voluntary response sample from all 36 learning centers across hospitals in Thailand."
- Original: "That is, after the instruction was given to the participants, they were able to participate in the study voluntarily."
Issue: Redundant phrasing; "instruction" should be "instructions."
Revision: "After receiving instructions, participants were able to voluntarily participate in the study."
- Original: "If the number of participants were more than expected population, a random sample selection would be implemented."
Revision: "If the number of participants exceeded expectations, a random sample selection would be implemented."
- Original: "The session was audio recorded for data analysis."
Issue: "audio recorded" should be "audio-recorded."
Revision: "The session was audio-recorded for data analysis."
- Original: "In order to access the data, a permission from the Human Ethics Committee of the Ministry of Public Health that oversees all 36 network hospitals must be approved."
Issue: "a permission" should be "permission"; "must be approved" should be "was required."
Revision: "To access the data, permission from the Human Ethics Committee of the Ministry of Public Health overseeing all 36 network hospitals was required."
- Original: "Pediatric patients age between 4-18 years who are attending learning centers at the hospital;"
Issue: "age" should be "aged."
Revision: "Pediatric patients aged between 4-18 years who are attending learning centers at the hospital;"
- Original: "Pediatric patients who have attended learning centers more than 2 times;"
Issue: "more than 2 times" should be "more than twice."
Revision: "Pediatric patients who have attended learning centers more than twice;"
- Original: "pediatric patients with chronic illnesses who are admitted at the hospital or needed consecutive follow-up."
Issue: "admitted at the hospital" should be "admitted to the hospital"; "needed" should be "need."
Revision: "Pediatric patients with chronic illnesses who are admitted to the hospital or need consecutive follow-up."
- Original: "pediatric patients with serious illness and life-threatening conditions."
Issue: "serious illness" should be "serious illnesses."
Revision: "Pediatric patients with serious illnesses and life-threatening conditions."
- Original: "The survey was divided into four parts: (1) demographic information of the children and parents (gender, age, cause of admission and length of stay (Table 1)), (2) information about the patient-parent relationship, and (3) satisfaction with service at the learning centers (measured using Likert scales of 1=unsatisfied, 2=poor, 3=fair, 4=satisfied, 5=very satisfied)."
Issue: "four parts" but only lists three; misplaced parentheses.
Revision: "The survey was divided into four parts: (1) demographic information of the children and parents (gender, age, cause of admission, and length of stay; see Table 1), (2) information about the patient-parent relationship, (3) satisfaction with service at the learning centers (measured using Likert scales of 1=unsatisfied, 2=poor, 3=fair, 4=satisfied, 5=very satisfied), and (4) attitudes toward the HSH project."
- Original: "Chi-square tests and t-tests were used to assess the variables associated with education continuance at the learning center."
Issue: "education continuance" should be "continuation of education."
Revision: "Chi-square tests and t-tests were used to assess the variables associated with the continuation of education at the learning centers."

Results

The presentation of statistical data is inconsistent and sometimes unclear. Percentages are used in some places without clear context or comparison. Present statistical data in a more structured format, such as tables or bullet points, to clearly show the comparison between different groups. Ensure that all percentages are accompanied by the relevant sample size or context as the followings:

- Original: "There were a total of 4,430 caregivers: 82.94% were caregivers for patients with common illnesses, 82.68% chronic illnesses, and 72.34% developmental disorders."
Suggestion: "There were a total of 4,430 caregivers: 3,673 (82.94%) for patients with common illnesses, 3,660 (82.68%) for patients with chronic illnesses, and 3,206 (72.34%) for patients with developmental disorders."
- Inconsistent and unclear presentation of caregiver demographics. Original: "Most caregivers were women (75.74%, 80.83%, and 82.62%, respectively), of Thai nationality (99.26%, 99.33%, and 99.65%, respectively), and Thai ethnicity (97%, 98.83%, and 99.65%, respectively)."
Suggestion: "Most caregivers were women: 3,356 (75.74%) for patients with common illnesses, 3,636 (80.83%) for patients with chronic illnesses, and 3,656 (82.62%) for patients with developmental disorders. The majority were of Thai nationality: 4,396 (99.26%), 4,410 (99.33%), and 4,414 (99.65%), respectively, and of Thai ethnicity: 4,293 (97%), 4,379 (98.83%), and 4,414 (99.65%), respectively."
- Original: "About 57.0% traveled to school by bicycle/motorcycle, 17.3% by private car, and 20.0% by public transportation; the means of transportation remained almost the same before and after being treatment at the center."
Suggestion: "Approximately 2,525 (57.0%) traveled to school by bicycle/motorcycle, 766 (17.3%) by private car, and 886 (20.0%) by public transportation; the means of transportation remained almost the same before and after treatment at the center."

Several sentences contain grammatical errors, awkward phrasing, and inconsistencies in verb tenses. Revise sentences for grammatical correctness. Ensure subject-verb agreement, proper punctuation, and consistent use of verb tenses. For example:

Original: "Most caregivers were women (75.74%, 80.83%, and 82.62%, respectively), of Thai nationality (99.26%, 99.33%, and 99.65%, respectively), and Thai ethnicity (97%, 98.83%, and 99.65%, respectively)."
Revision: "Most caregivers were women (75.74%, 80.83%, and 82.62%, respectively), of Thai nationality (99.26%, 99.33%, and 99.65%), and of Thai ethnicity (97%, 98.83%, and 99.65%)."

Discussion

Several sentences contain grammatical errors, awkward phrasing, and inconsistencies in verb tenses. Revise sentences for grammatical correctness. Ensure subject-verb agreement, proper punctuation, and consistent use of verb tenses. For example:

Original: "Mobile education can overcome teacher-related limitations, and it has the advantage of allowing children to select lessons for themselves."
Revision: "Mobile education can overcome teacher-related limitations and has the advantage of allowing children to select lessons for themselves."

Inconsistent presentation of statistical data and lack of context for percentages.

Present statistical data in a more structured format, such as tables or bullet points, to clearly show comparisons between different groups. Ensure that all percentages are accompanied by the relevant sample size or context. For example:
Original: "In this study, the satisfaction survey of children at the learning center gave a high score of 4.21-5.00 (mean = 4.26, SD = 0.65) for every dimension."
Revision: "In this study, the satisfaction survey of children at the learning center showed high scores in all dimensions, with an overall mean score of 4.26 (SD = 0.65). The highest-rated item was enjoyment of activities (mean = 4.31), followed by interest in content (mean = 4.27)."

Limited discussion of how the study's findings compare with existing literature, and lack of integration of previous studies' findings. More thoroughly compare and contrast the study's findings with those of previous studies. Discuss how this study supports, contradicts, or expands upon existing knowledge. For example:

Original: "This study's results align with those of previous studies10,11,13,16,17 of tertiary hospitals."
Revision: "This study's results align with those of previous studies conducted in tertiary hospitals10,11,13,16,17, which also found high rates of chronic illnesses related to hematology, cancer, and heart disease. However, unlike previous studies, our findings highlight an increase in developmental disorder diagnoses, suggesting improved access to education for these patients."

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Implementation science of maternal and child health

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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14 Views

16 Aug 2024 | for Version 2

Banchaun Benjasuwantep, Department of Pediatrics, Faculty of Medicine, Srinakharinwirot University, Nakhon Nayok, Thailand

14 Views Cite this report Responses(0)

Approved

The article is about hospital learning center in Thailand. The strength of the article is the number of hospital learning centers and participants. However, there are some suggestions.

Objectives
The effectiveness of hospital learning center which the researcher would like to evaluate is not clear. What are the primary and secondary outcomes?

Methods

What were criteria to include the hospital learning center to the research? The author should give information of the learning center.
As the participant in the study was voluntary, how many children were refuse to be in the research? Did the participants represent actual population? It might be research bias if there were a lot of children refuse to participate.

Results

Under the heading of parent-child relationship, the table of the content should be provided.
About table 3, the author mentions that patients who continued their education thought that the lessons in the classroom were interesting, they scored this item higher than the other group did. However, table 3 shows that scoring of “I am learning interesting lessons at the center” for the group of continued education was 4.31 and the group of did not continued education was 4.48. Is this corrected??
Table 4 is about the variables to continuation of education which is interesting part of the article. The author should mention more about the variables that were significant different between the children who continue the education and who did not rather than select a few variables. It is a good idea to separate participants into 3 groups and evaluate the variables associate with continuation of education. However, the author can provide more information about the variables which were different between children who continued to educate and who did not and then separate them into 3 groups as previously done.

Discussion

The last paragraph of page 9, “In this study, the satisfaction survey” should be mentioned in the result section rather than discussion section.
Should discuss more about the effectiveness for the learning center.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Developmental Behavioral pediatrics

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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52 Views

17 Jan 2022 | for Version 1

Shervin Assari, Department of Family Medicine, Charles R Drew University of Medicine and Science, Los Angeles, CA, USA

Babak Najand, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA

52 Views Cite this report Responses(1)

Not Approved

This is a single-group interventional study. Here are areas for improvement:

The abstract and also the paper should make the design much more clear. Is this a longitudinal one-arm intervention (designed by authors) or is this a natural experiment designed by a system and the authors just conducted the evaluation?
The result is not just about attitudes. Many other factors such as socioeconomic status predict child educational success, but the title only mentions attitude.
One major problem is that all samples are analyzed together. However, some of these children have physical health problems and some have disabling developmental challenges. These two groups are qualitatively different and cannot be combined. Just controlling for this type as a nominal variable (0/1) does not solve the problem. I think at least for sensitivity analysis, all results should be replicated in a stratified fashion, separately for each of the groups mentioned.
SES and social determinants of health are root causes of health and well-being. The paper, however, does not mention these concepts despite that it measures them.
Overall, I think the data are much stronger than the discussion section. Many more areas could be discussed which are left untouched.
These children are educationally heterogeneous. This includes children at kindergarten to much higher levels. Progress in educational programs is highly dependable on the workload required. So, simply controlling for the educational level does not solve this problem. Overall, the high heterogeneity of the sample is a major problem here.
Sex/gender is beyond a control variable. Parents may differently invest in their boys and girls (gender norms). Similarly, a child may get different attention and investment depending on the number of siblings. Thus, more attention is needed on the composition of the household beyond marital status.
Another important area in this paper is poor eligibility. These poor selection criteria have made it very difficult to know who was in the study. I think the authors need to replicate their findings in groups of patients with more homogenous conditions.
More information is needed on the variation of the adherence to the curriculum across learning centers. How do various centers do their job? Was there any effect on centers?
Participants were nested to centers so they are not independent samples. Please discuss your solution to address this data challenge.

Overall, despite the paper having great potential and focusing on a novel topic that is rarely done by others, authors could do a much better job with inclusion, statistics, and discussion.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

No
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

I am an expert of child development, social inequalities, and longitudinal data analysis. I also work related to chronic disease and mental health problems.

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Responses (1)

Author Response

14 Apr 2022

adidsuda fuengfoo, Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, Queen Sirikit National Institute of Child Health, Bangkok, Thailand

1. This is a single-group interventional study. Here are areas for improvement: The abstract and also the paper should make the design much more clear. Is this a longitudinal one-arm intervention (designed by authors) or is this a natural experiment designed by a system and the authors just conducted the evaluation?

This research was conducted in a form of natural experimental study in which variables are influenced by nature or factors outside of the researchers’ control. A cross-sectional design has been implemented in this study where a group of the population is selected based on the inclusion criteria set for the study: types of illnesses, patient’s and parent’s demographic information in order to measure the effectiveness of the project and to examine the factors correlating with continuing education of children under HSH project, patient’s attitudes and patient’s satisfaction towards HSH project. However, a limitation of a cross-sectional study is that it is difficult to identify causal effects and only describe associations between variables.

2. The result is not just about attitudes. Many other factors such as socioeconomic status predict child educational success, but the title only mentions attitude.

Assessment of the Learning Center in Hospital Program was assessed on the function and effectiveness of children with health problems participating in the Learning Center in Hospital Program. Another angle, besides taking into account accuracy, should also consider preferences along the way. Therefore, it is assessed in various dimensions, such as assessing the perspectives of service users in terms of parental attitudes and the satisfaction of sick children participating in the Hospital Learning Center project, which is a secondary objective of this research and is discussed in the information found for the purpose.

3. One major problem is that all samples are analyzed together. However, some of these children have physical health problems and some have disabling developmental challenges. These two groups are qualitatively different and cannot be combined. Just controlling for this type as a nominal variable (0/1) does not solve the problem. I think at least for sensitivity analysis, all results should be replicated in a stratified fashion, separately for each of the groups mentioned.

The research team would like to accept and appreciate the advice that is very helpful. In the issue of data analysis should be separated into groups, diseases because each group of diseases has a different nature and affects learning. The researcher, therefore, brought this issue to further improve in the analysis of the data to separate the groups into three groups: common disease children, chronic disease children, and children with developmental problems, as shown in the table.

4. SES and social determinants of health are root causes of health and well-being. The paper, however, does not mention these concepts despite that it measures them.

Socioeconomic status is a very important part of healthcare and is the foundation for proper health management and lifestyle. It is a valuable recommendation when further analyzed separately. The disease group found that social socioeconomic status affecting admission to continuing education after discharge from the hospital was associated with all disease groups. When analyzed, it was found that there was still a relationship between chronic disease and chronic disease groups with developmental problems because it is a long continuous treatment, and with costs that depend on severity, complexity, and advances in technology, children with chronic and developmental diseases have a better chance of living longer.

5. Overall, I think the data are much stronger than the discussion section. Many more areas could be discussed which are left untouched.

The researcher agreed and used the data for further analysis, separating the disease groups. We have added more discussion on factors that remained related to children's continued return to school when analyzing disease groups: parents' education, socioeconomic status, family income, number of siblings, etc.

6. These children are educationally heterogeneous. This includes children at kindergarten to much higher levels. Progress in educational programs is highly dependable on the workload required. So, simply controlling for the educational level does not solve this problem. Overall, the high heterogeneity of the sample is a major problem here.

We agree on the issue of diversity in the classroom as one of the limitations of education in nature experimental study. In a future study, we will include prospective follow-up studies and segmented samples for cross-sectional study to reduce such limitations.

7. Sex/gender is beyond a control variable. Parents may differently invest in their boys and girls (gender norms). Similarly, a child may get different attention and investment depending on the number of siblings. Thus, more attention is needed on the composition of the household beyond marital status.

Since gender is an uncontrolled variation, the researcher has selected the factors that are more likely to affect the continuation of children which are the number of siblings and family income. After analyzing separately, the study found that parents with more than 2 children are likely to discontinue education of the child with chronic diseases or with developmental problems. At the same time, families with a monthly income lower than 5,000 baht considered stopping further education of the sick child. With economic constraints, parents may need to think about the cost-effectiveness of sending their child to school. It must be decided that delivering a child without chronic illnesses or developmental delay may be more cost-effective than children with chronic illnesses or developmental delay since education cost is not the only expense under parents’ responsibility, but also healthcare costs or medication costs for the sick child. In contrast, the study found that the number of siblings and hospital length of stay do not correlate with children without chronic illnesses or developmental delay to further education because the normal school system allows them to go back to school after they recover.

8. Another important area in this paper is poor eligibility. These poor selection criteria have made it very difficult to know who was in the study. I think the authors need to replicate their findings in groups of patients with more homogenous conditions.

It is a valuable suggestion that gives the researcher a clearer perspective. Therefore, the researcher has divided the groups to select the pediatric patients by separate disease groups and analyze the factors affecting admission to further education in order to create more homogeneous conditions as shown in the table.

9. More information is needed on the variation of the adherence to the curriculum across learning centers. How do various centers do their job? Was there any effect on centers?

Hospital Learning Centers for sick children use a standardized curriculum established by the Ministry of Education applicable for children at all education levels: pre-kindergarten, primary, secondary, tertiary levels, as well as vocational education. This curriculum is a collaboration between MOU partners: the Ministry of Education, Ministry of Public Health, and Ministry of Science and Technology.

All of the operational processes need to follow the Clinical Practice Guideline (CPG) and pass an external audit from a third party to ensure that the education that is delivered to sick patients in every hospital learning center meets the standard.

10. Participants were nested to centers so they are not independent samples. Please discuss your solution to address this data challenge.

The selection of a sample in this study was a voluntary response sample from all 36 learning centers in Hospitals across Thailand. That is, after the instruction was given to the participants, they were able to participate in the study voluntarily. If the number of participants was more than the expected population, a random sample selection would be implemented. In order to access the data, permission from the Human Ethics Committee of the Ministry of Public Health that oversees all 36 network hospitals must be approved.

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Competing Interests

No competing interests were disclosed.

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Reviewer Report

15 Views

17 Feb 2021 | for Version 1

Issarapa Chunsuwan, Department of Pediatrics, Faculty of Medicine, Developmental and Behavioral Pediatrics, Thammasat University (TU), Pathum Thani, Thailand

15 Views Cite this report Responses(0)

Approved

For a clearer understanding, the Authors should give more information about the 36 learning centers, such as how they are settled in hospitals (place, operational time), who are teachers in the centers, how they select pediatric patients to attend the centers (by doctor referral or who else) and how they provide educational service (curriculum, activity)? And also, more information about eDLTV may help readers who are not in Thailand understand it. The Authors may add information about how the QSNICH learning center supervises the other 36 learning centers.

Methodology

A flow chart that shows how 4430 participants in this study were recruited from 30,000 pediatric patients of the 36 centers could be helpful to show a clear overview of the recruitment process.
There are 4430 data in the research rather than 8860. The author can explain that 4430 children included in the research and 4430 parents were interviewed.
Definition for classifying common illness from chronic illness should be mentioned (depend on the type of disease or hospital day)
The questionnaires used in the study should be defined in detail for better understanding, such as numbers of items in the satisfactory scales and how is the total score obtained, what are questions asked in the demographic data and validation process of the questionnaire.

Results

The main research findings on effectiveness may not yet clear to readers. The authors may adjust or add a table that defines the effectiveness of the program. For example, in Table 3, statistical analysis of differences in satisfaction between 2 groups could add more information about effectiveness.
In table 4, Is not clear that the heading "continue education" means continue education at a learning center or at a formal school. and also the distance from school means the formal school or learning center.

Key messages

The main result of this study about effectiveness should be added as the key message.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Developmental and behavioral pediatrician

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Respond to this report

Responses (0)

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Effectiveness of 36 hospital learning centers in Thailand: continuation of child patient education, parent attitudes toward child’s illness and service satisfaction

Abstract

Keywords

Introduction

Objectives

Methods

Study design

Participants

Eligibility criteria

Data collection

Table 1. Demographic information about the child patients.

Statistical analysis

Ethics statement

Results

Caregiver information

Parent-child relationship

Children with common illnesses

Table 2. Educational background before and after entering learning centers, categorized by illness type.

Children with chronic illnesses

Children with developmental disorders

Table 3. Mean scores and standard deviations for service satisfaction at the center from the patient satisfaction survey.

Table 4. Factors related to education continuation at the learning centers by the patients.

Discussion

Conclusion

Key messages

Limitations

Data availability

Underlying data

Extended data

Acknowledgements

References

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