Introduction, Justification and Objectives Introduction: Children are the greatest national resource of any country. So their education is very important to build a well equipped country. Sri Lanka recognized the right for education in year 1940 legally. Sri Lanka takes several measures to provide education for all since last two decades. In accordingly this signed in the “World conference on Education for All� held in Thailand and in Senegal in year 1990 and in year 2000 respectively. Sri Lanka has its own five year plane for education (FYPPE 2000-2004) which has its own objectives to gain some goal in education and to increase the completion rate of primary education among children. This takes the first place among the whole objectives.
Furthermore Sri Lanka is a country providing educational services satisfactorily for the children with special needs. There are special schools and centers all over the country and it is legislated to form a special unit under every provincial government since 1998. But the consideration given to the chronically ill children (CIC) is comparatively less. Specific data found on this group of children is inadequate and it can be a reason for the lack of concern.
Normally children with chronic illnesses have school absenteeism due to several reasons. The level of school absenteeism among these children varies and some times there can be school drop outs when there is minimum consideration given on these children. The common reasons for absenteeism among school children are familial factors, financial factors and personal factors. The personal factors include their chronic illness as a major factor.
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Development of a child is influenced by several factors. This has been proven that the genetic factors and the environmental factors have a role in determination of the development. Because IQ of a child is determined by the above two factors and the developmental age of a child determines the IQ. Development of a child includes several components which are motor development, visual development and hearing and speech. Each of this component is influenced by the factors which are already mentioned.
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Justification: The importance of this study can be justified using several factors. As already mentioned there is not enough information available about the chronically ill children on their school absenteeism and development. So there is no specific data available to assess the level of absenteeism and to assess the development of these children in Sri Lanka.
Studies done in the past revealed some evidence and the importance of carrying out this kind of a study. A study done on school going children in Sri Lanka gives personal factors (chronic ill health, disabilities, and learning difficulties) as the reason for more than 40% of school absenteeism. Another study in China on hospitalized children showed the effect of illness on education, where the self concept of the children has been assessed by using education as one of the factors.
The study carried out will reveal the extent of effect of chronic illness on schooling and child’s development. This in tern will help in the improvement of future management plans and in our national achievements in education. E.g.: Millennium goal for education.
We believe that our research will show the real picture of the chronically ill children and the results of this research may show the importance to enhance the schooling of these children as we are studying the level of absenteeism and the factors causing it. About the development of these children our study will reveal the real situation of their development and performance and depending on that future interventions can be planed.
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Objectives In this study our general objective is to describe School absenteeism and development of chronically ill children.
Our specific objectives are
To describe the level of school absenteeism among CIC.
To describe the development within specific age groups of CIC.
To describe the development between total sample of CIC.
To describe the underlying factors for absenteeism.
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Literature review We tried to find out the facilities available to these chronically ill children in Sri Lanka to continue their education without any problems. With this purpose we went through certain reports and books which are mentioned below. We found the following services and policies available in Sri Lanka to enhance education.
‘Examples of Inclusive Education’ by UNICEF published in year 2003 has explained the educational facilities available in Sri Lanka and it further elaborates on the special educational program available to children with special needs.
The “Millennium development goal for education” emphasizes on the completion of primary schooling in goal 2, target 3. The purpose of this target is to ensure that by year 2015 children from every where boys and girls will be able to complete a full course of primary education.
Conference on “Education for All” held in Thailand in year 1990 and in Senegal in year 2000 lead all the countries develop their own plane for education. In accordingly Sri Lanka also developed its plan. Which was analyzed by Angella.W.Little and she published the following report “Policy and planning from Sri Lanka”. Here she mentions about the available educational programs in Sri Lanka.
Further more Sri Lanka has developed a five year plane for primary education (FYPPE) and it has several goals. It planes to increase the completion of primary education as the 1st goal. Here it has planed to establish schools in every province to educate the children with special needs.
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The all above evidences show that there are no considerations has been given to chronically ill children to enhance their education.
Studies which have been done in Sri Lanka and in other countries show the level of school absenteeism and the impact of illness in the development of child. We couldn’t able to get access to all the available works done in this area and we found limited number of works in this area.
“ensuring education for all; non schooling, early drop outs and high absenteeism” is a study done in Sri Lanka has described the level of school drop outs and school absenteeism in general population of school going children. This study has categorized the reasons for absenteeism and school drop outs. The main factor for school drop outs and school absenteeism are the personal factors. In explaining the personal factors the study describes the following 1. Chronic illness 2. Disability 3. Learning difficulties These all factors count for 40 percentage of the total population taken for the study. This study has been done by Prof. Chandra Gunawardena (Open University of Sri Lanika) and by Mrs. Swarna Jayaweera (Centre for Women’s research)
Another study done in China on hospitalized children to assess the self concept includes education as a factor for the assessment. Here they have shown that their education is affected by the illness. Hu Yan RN, MSN, Seaphen Kantawang RN, BSN, MSN, and Yang Yinghina RN, BSN 6
IQ of a child is assessed from the developmental age. But this is dependent on genetic factors and environmental factors equally. Indirectly saying that the development of the child is dependent on the above two factors. Is your IQ really determined by genes?
Peter Archold, Oct 25, 2006
So it can be considered that these chronically ill children are having a different sort of environment and there can be effect on their development.
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Methodology
Study design – Cross sectional descriptive study.
Study set up – All the pediatric wards and in all the pediatric clinics at Lady Ridgeway Hospital of Sri Lanka (LRH) on CIC.
Study period – 3 weeks from 24th of July to 14th of August 2008.
Study population – School going CIC within 6 to 12years old with a history of a chronic illness for more than 6months.
Study sample – All the children under inclusion criteria presented to all pediatric wards and pediatric clinics at Lady Ridgeway Hospital within the period of data collection.
Sampling techniques- No sampling technique used. All the children under the inclusion criteria were selected.
Inclusion criteria- School going CIC between 6 to 12years old with a history of a chronic illness for more than 6months were included in our study group.
Chronic illnesses – Include Bronchial Asthma, Diabetes mellitus, Epilepsy, Thallasemia, Systemic Lupus Erythematosis, Nephrotic syndrome, Chronic anemic conditions, Hemolytic 8
conditions, Bleeding disorders, Congenital heart disease, Rheumatic heart diseases, Rheumatic chorea, and Chronic renal failure.
Exclusion criteria – Children who are mentally and physically dependent were not being included in the study. Children with acute illness were not included in the study.
Variables- School absenteeism and developmental age of the chronically ill children are used.
Interventions done- Parents and guardians were advised on preventable factors of absenteeism which they had.
Study instrument – An Interviewer administered questionnaire- (annexure 01) Part A) Used to measure the degree of absenteeism. Here the average number of days per month a child gets absent specifically asked. Here the duration of illness in years also collected to categorize the children in data analysis.
B) Used to find out the underlying factors for absenteeism. There is a set of reasons given and asked which of the factors they have as a reason and it is marked as yes or no. The reasons which were asked:
Due to repeated hospital admissions
Due to physical discomfort a) Due to the illness
b) Due to the drugs 9
Friends making fun of the child
Teachers’ negligence
Due to financial problems
Due to any difficulties in studying
Due to transport difficulties
Other reasons
To assess the development: Following routine tests were used to asses the development of children. Children were asked to draw some pictures in both of these tests.
1.
Good enough-Harris draw a man test (reliability coefficient 74). This normally assesses over all development of a child. (Annexure 02). The drawing of a child here assessed and every part of the body is given a mark according to the guidelines and the total mark is used to find the developmental age.
2.
Bender Gestalt test (correlation coefficient >.80). This assesses the performance of a child and this is a visual motor development test. (Annexure 03). Here the child is asked to copy a set of diagrams and the drawings are compared with the diagrams given to each age group in the guidelines to get the developmental age. 10
Data collection- This was done by our selves during three weeks from 24th July to 14th August 2008 at Lady Ridgeway Children hospital. The questionnaire completed with the help of parents and the child. The tests to assess the developmental age were done with children by asking them to draw.
Ethical Reviews – The ethical clearance was obtained from the Ethics Review Committee of Faculty of Medicine, University of Colombo (annexure 04). Permissions to carry out the study in hospital were obtained from the hospital director (annexure 05) and from every Consultant using a request letter. In the consent procedure, information sheet was prepared in English, Sinhala and Tamil to be read and understood by the parents/ guardian. Then informed consent was obtained from the parents/ guardian on behalf of the children for their participation and also to complete the questionnaire. The participant had the right to refuse for the study at any point. The data that was collected didn’t include the name and was be given a serial number. Data collected will be maintained under maximum confidentiality and the data won’t be used for any purpose other than the study.
Data analysis- School absenteeism was taken as an average number of days per month and the different levels of absenteeism have been described using the percentage of children for the total sample. Then the developmental age obtained using the Draw a man test and the Bender Gestalt test has been described as the percentage of children who are having developmental delay and the percentage of children who are having normal development. This has been described for each age group and for total sample separately. Data processing has been done using the spss software.
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Data cleaning- The name will not be used in any documents except the consent form. The consent form will be destroyed after that initial process. Accoring to that other documents will be given serial numbers. After data analysis all the data collected from participants will be kept in a file and in a place nobody can get access except the investigators and supervisors. These all data will be burnt after 2months from data analysis.
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Results Our sample that we collected from LRH has following numbers of children in each age group in both genders. This is shown in the table below.
Table01. Distribution of the sample according to the age Age( in years) 06 07 08 09 10 11 12 Total
No. of children 11 10 14 13 10 10 16 84
No. of boys 07 06 05 09 05 07 07 46
No. of girls 04 04 09 04 05 03 09 38
Table02. Distribution of sample according to the duration of illness Duration of illness
No. of children
Percentage of children (%)
6 month-1 year
15
17.86
1 year- 3 years
24
28.57
3 years- 5 years
27
32.14
> 5 years
18
21.43
Total
84
100
Most no. of children (32.14%) is having illness for 3-5 years.
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School absenteeism We categorized the absenteeism in every age group and our findings are illustrated in the following table.
Table03. Absenteeism in each age group Age (in years)
No. of children
06 07 08 09 10 11 12 Total
06 09 10 08 08 07 15 63
Percentage (%of the total sample) 7.14 10.71 11.90 9.53 9.53 8.33 17.86 75.00
This table shows that 63 children (75% of total sample) have absenteeism and 21 children (25% of children) are not having absenteeism.
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Even though we found absenteeism among 75% of children we differentiated the absenteeism to the following levels.
Table04. Levels of absenteeism Level of absenteeism ( no. of days per month)
No. of children
Percentage (%)
No absenteeism
21
25
01-05
44
52.38
06-10
10
11.90
>10
09
10.72
Total
84
100
This table shows that 52.38% of total population is having absenteeism between 1-5 days per month.
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Table05. Absenteeism VS duration of illness Duration of illness
No. of children
Percentage of children (% of total sample)
6 month-1 year
12
14.29
1 year- 3 years
11
13.09
3 years- 5 years
22
26.19
> 5 years
18
21.43
Total
63
75
This table shows that 26.19% of children with illness for 3-5 years have more absenteeism.
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Developmental age in each age group Using the Draw a man test:
Findings of Draw a man test done on all the children have been described in the table according to the age group.
Table06. Development in each age group using Draw a man test Age No. of Percentage (in children with (%of total years) developmental population) delay
No. of Percentage Children (%of total without population) delay
06
04
4.76
07
8.33
07
06
7.14
04
4.76
08
09
10.71
05
5.95
09
09
10.71
04
4.76
10
09
10.71
01
1.19
11
09
10.71
01
1.19
12
09
10.71
07
8.33
Total
55
65.45
29
34.55
Except 6 years old children other age groups are having more number of children with developmental delay comparing to the children without delay in each age group.
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Using Bender Gestalt test: Bender Gestalt test done on all of this children showed the following findings in each age group.
Table07. Development in each age group using Bender Gestalt test Age (in years)
No. of children with developmental delay
Percentage (%of total population)
No. of Children without delay
Percentage (%of total population)
06
05
5.95
06
7.14
07
04
4.76
06
7.14
08
08
9.52
06
7.14
09
09
10.71
04
4.76
10
09
10.71
01
1.19
11
06
7.14
04
4.76
12
11
13.09
05
5.95
Total
52
61.88
32
38.12
The table shows that among 6 and 7 years old children less number of them are having developmental delay comparing to children without delay in those age groups. But the rest of the age groups are showing more number of delayed children among them.
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Developmental age in the total sample
Table08. Children showing developmental delay only in Draw a man test, in Bender Gestalt test and in both Draw a man test and Bender Gestalt test Age (in years )
Both D& B
Percentage Draw a (%of total man only sample)
Percentage (%of total sample)
Bender Gestalt only
Percentage (%of total sample)
06
03
3.57
01
1.19
02
2.38
07
04
4.76
02
2.38
00
00
08
08
9.52
01
1.19
00
00
09
09
10.71
00
00
00
00
10
09
10.71
00
00
00
00
11
06
7.14
03
3.57
00
00
12
09
10.71
00
00
02
2.38
Total
48
57.12
07
8.33
04
4.76
D- Draw a man test
B-Bender Gestalt test
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Table09. Development of the children for total sample Test
Frequency
Percentage of the total sample (%)
Bender Gestalt only delay
O4
4.76
Draw a man only delay
O7
8.33
Both Bender Gestalt and Draw a man tests
48
57.12
Total no. of children with delay
59
70.21
Children without delay
25
29.79
Chart 01. Development of children in the total sample 50 40 30 frequency 20 10 0 B only
B- Bender Gestalt test
D only
B&D
No delay
D- Draw a man test
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We categorized the children with developmental delay according to the tests that we carried out. The above charts and tables show the same findings in different methods.
Among the total sample 59 children (70.21% of total sample) are having developmental delay in Bender Gestalt test or Draw a man test.25 children (29.79%) are not having any delay in any of the above tests.
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Table10. Levels of developmental delay in Draw a man test Levels of delay
No. of children
Percentage of children (% of total sample)
No delay
29
34.55
1-2 years
16
19.05
3-4 years
27
32.14
>4 years
12
14.29
Total
84
100
Most of the children (32.14%) show developmental delay by 3-4 years.
Table11. Levels of delay in Bender Gestalt test Levels of delay
No. of children
Percentage of children (% of total sample)
No delay
32
38.12
1-2 years
20
23.81
3-4 years
23
27.38
>4 years
09
10.71
Total
84
100
Most number of children (27.38) shows developmental delay by 3-4 years.
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Table12. Duration of illness Vs Levels of developmental delay in Draw a man test Duration of illness
1-2 years delay
3-4 years delay
>4 years delay
6months-1 year
3(3.57)
4(4.76)
2(2.38)
1-3 years
6(7.14)
6(7.14)
3(3.57)
3-5years
4(4.76)
9(10.71)
5(5.95)
>5 years
3(3.57)
8(9.52)
2(2.38)
Total
16(19.05)
27(32.14)
12(14.29)
(Percentages of children among the total sample is shown within brackets) Developmental delays by 1-2 years are common among children with illness for 1-3 years. Developmental delays by 3-4 years are common among children with illness 3-5 years. Developmental delays by more than 4 years are common among children with illness for 3-5 years.
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Table13. Duration of illness Vs Levels of developmental delay in Bender Gestalt test Duration of illness
1-2 years delay
3-4 years delay
>4 years delay
6months-1 year
3(3.57)
3(3.57)
2(2.38)
1-3 years
5(5.95)
6(7.14)
3(3.57)
3-5years
7(8.33)
7(8.33)
3(3.57)
>5 years
5(5.95)
7(8.33)
1(1.19)
Total
20(23.81)
23(27.38)
9(10.71)
(Percentages of the children among the total sample is shown within brackets)
Developmental delays by 1-2 years are common among children with illness for 3-5 years. Developmental delays by 3-4years are common among children with illness for more than 3 years. Developmental delays by more than 4years are common among children with illness for 1-5 years.
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Underlying factors for absenteeism
We studied the following factors and we found what percentages of children have each of the factors as a reason for absenteeism.
Table14. Underlying factors for absenteeism Reasons
Frequency
Percentage (% of total absenteeism)
Repeated hospital admissions
38
60.32
Physical discomfort due to illness
35
55.56
Friends making fun of the 15 child
23.81
Teachers’ negligence
13
20.63
Financial problems
24
38.10
Difficulties in studying
29
46.03
Transport difficulties
19
30.16
Other reasons
05
7.94
Recurrent hospital admission is the main reason for absenteeism. This is complained by 60.32% of children among the total number of absenteeism.
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Discussion
Research about school absenteeism and development of chronically ill children mainly aimed to find out the extent of their absenteeism and their developmental delay. As already mentioned in the introduction and justification we feel the importance of this research. This is a research should be carried out in a large number of sample for a longer duration. We were only able to collect 84 samples due to the limitation we had with time.
We were only able to carry out a cross sectional descriptive study due to the difficulty in accommodating a control group which is compatible with the sample.
We collected data using an interviewer administered questionnaire, Draw a man test and Bender Gestalt test. The questionnaire collected data about school absenteeism and the underlying factors for absenteeism. Here we gathered data from parents/guardian and child to complete the questionnaire.
Draw a man test and Bender Gestalt test are used world widely to assess the development and the performance of children. We decided to use these tests after discussing with child psychiatrists and child psychologists.
Our study gave us several findings in relation to absenteeism, development and the underlying factors for absenteeism. We found that 75% of total sample is having absenteeism and there is varying degree of absenteeism among them.
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Developmental ages we gained from Draw a man test revealed that 55 children (65.45%) among 84 children as having developmental delay. Bender Gestalt test showed delay in 52 children (61.88%) among 84 children.
But 48 children (57.12%) showed developmental delay in both Bender Gestalt test and draw a man test. The total number of children with delay in any of the tests we used is 59 (70.21%) among the total sample. 25 children (29.79%) didn’t show any delay in any of the tests.
Among the underlying factors for absenteeism recurrent hospital admissions and physical discomfort due to illness are complained by more than 50% of children among the absenteeism.
Discussing about the validity and reliability of the above findings we assessed the absenteeism from the data given by parents/ guardians and the data collected here is a numerical value and not a subjective one.
Regarding the developmental age we used two standard tests. Which are used world widely and the findings from these tests are much reliable and reflect the real development and the performance of the children.
Previous studies about absenteeism done among school going children within the general population in Sri Lanka mentioned that 40% of children have absenteeism and school drop outs due to personal factors (which include chronic illnesses as a factor). In our study among chronically ill children we found that 75% of the children are having absenteeism.
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Study done in China on hospitalized children emphasized that self concept of a child is affected by chronic illnesses. The self concept includes the education of a child. We in our research found 70.21% of total sample have developmental delay.
We appreciate further studies in this area in a large scale including children from all the parts of island and a reasonable number of children in every age group. We hope that having a control group of apparently healthy children will show the significant of absenteeism and developmental delay more clearly among chronically ill children.
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Conclusions and recommendations
Conclusions: Our study showed the effect of chronic illness on school absenteeism and the development.
There is more percentage of absenteeism among the chronically ill children comparing to the total non absenteeism among these children. These children have varying levels of absenteeism. 52.38% of children have absenteeism of 1-5 days per month and more than 10 days of absenteeism is shown by10.71% of children.
70.21% of children show developmental delays in any of the test that we used to assess the developmental age. 29.79% of children are not having any developmental delay.
The most common underlying factors for absenteeism complained by children are 1. Frequent hospital admissions
(60.32%)
2. Physical discomfort due to illness
(55.56%)
3. Difficulties in studying
(46.03%)
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Recommendations:
Regarding absenteeism: In order to minimize the absenteeism in chronically ill children
Proper education to parents and guardians of the children on preventable underlying factors for absenteeism.
Arranging special schooling system for children with high degrees of absenteeism.
Making tertiary health care in an easily accessible distance can prevent a certain degree of absenteeism.
Regarding developmental delay:
Early identification of the disease will help to plan the improvement of the child from the younger ages. So proper screening programs should be implemented.
At tertiary care hospitals with normal medical treatment a separate system to assess the development can be introduced. This will minimize the delay by some early interventions.
Introducing a proper monitoring and documenting system for absenteeism and development at hospital will help the patient by leading to a complete caring system.
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Limitations
We were not able to accomplish minimum sample size of 100. because the time duration we had for data collection was restricted to three weeks after completing all the procedures in getting ethical clearance from the hospital.
During the data collection period of three weeks we were only able to collect 84 samples. Because for a sample it took more than 15 min to collect data and this lead to inadequacy of time.
We found difficulty in getting reasonable number of samples which full fill our inclusion criteria during this period. Because we were dependent on the admissions to all medical wards and clinics at LRH.
We could not able to accommodate a control group. Because there was difficulty in finding a control group which is socio economically and with the other factors (children in equal number in each age group, children from schools with same standard) compatible with the study group.
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References 1. Angela.W.L Education for all: policy and planning lessons from Sri Lanka p18 Available from http://www.csnis.lk
2. UNICEF2003, Regional office for South Asia, Examples of inclusive education Sri Lanka Available from http://www.unicef.org/rosa/inclusiveslk.pdf
3. Chandra G, Swarna J Ensuring education for all: on schooling, early drop outs and high absenteeism in Sri Lanka Available from http://www.pcf4.com
4. Hu yan, Seepan.K, Yang.Y Selected factors influencing self concept among hospitalized Chinese children: International journal of Nursing practice; March1999 (5)(1):38-46
5. Peter.A October25, 2006 is your IQ really predetermined by genes? Available from http://www.Quazen>Scicence.com
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Annexes 01. Interviewer administered questionnaire 02. Draw a man test 03. Bender Gestalt test 04. Copy of ethical clearance letter from Ethics Review Committee of Faculty of Medicine, University of Colombo 05. Copy of ethical clearance letter from Lady Ridgeway Hospital
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