Cancer Kids Tutors

Pediatric cancer patients face challenges during treatment that interfere with proper education. Many patients are often unable to return to school during treatment because of demanding treatment schedules, their immunosuppressed status, or parents' fear of exposing the child patient to school. The COVID pandemic and political turmoil have worsened the quality of education.

In El Salvador, in-person schooling began in 2022 and the past two years of public schooling have been online. This virtual modality consists of children studying the government-created guidelines on their own, with no online classes from teachers.  Many children lack access to internet connectivity and the knowledge and motivation to educate themselves. According to the Ministry of Education, in 2021 41% of the Salvadorean population aged 0-18 were not enrolled in school, and between 18-65% of students have access to the internet or devices to complete the school guidelines. Furthermore, according to the law, no child can be retained, so children are promoted to the next grade regardless of successful completion of the required work. Education is not only lacking but deficient and demotivating. The pediatric oncology program has approximately 350 patients in treatment and our 2022 records indicate that for children with cancer school abandonment is higher than the national mean;  approximately 62% of these patients are not enrolled in school because they are unable to attend a school or unable to comply with virtual teachings. 

In addition to not being able to attend to virtual teachings due to treatment, there is a technological gap both in access and skills. In our experience, students who are enrolled in virtual modalities often feel discouraged because they do not know how to use the platforms or have a stable internet connection at home or on their portable devices. Although there is the opportunity to continue with education through the school in their communities, most families choose not to because there is no support from regular teachers who are limited to send and score weekly school work. 

At this time, opportunities for schooling for children in El Salvador are scarce and for children with cancer even more so. School teachers are not trained to teach chronically ill children and lack the experience and the legal duty to design individualized study programs. Community-based special education is usually poor in coverage, most times limited to greater cities, leaving behind a large number of children. Although there is a special education school program at our partner hospital, only one teacher has been assigned to our center and continues to deliver virtual teaching in 2022.  One teacher is not enough to cover all 350 patients in active treatment. According to our records, last year (2021) only 17 of our patients were enrolled in this program and our follow-up showed poor educational, coverage, and satisfaction outcomes from this school.  

Our solution is to create a hospital-based tutoring program that aims to support children enrolled at regular school with their education by maintaining contact with their schools and helping them keep up the schoolwork while children are at the hospital and online while at home. 

The process consists of the patient's schools being informed of the tutoring program through a letter. Weekly guidelines, classes, homework, and evaluations will be shared with the hospital´s tutors by the school teachers.  In addition to schoolwork, teachers will be able to submit objectives and indicators as well as comments and requests for the tutor. Patients will work with the tutors when they attend hospital appointments and during hospitalizations. The patient's time at the hospital is variable, with some patients attending every 21 days, once a week, up to four days a week, and admissions of up to 21 days.  The tutoring at the hospital will help students catch up with missed work and aid with learning issues due to cancer treatment to facilitate academic progress through shared objectives and fluent communication between the teachers and tutors. The tutors will help with school work, communicate with teachers to help understand the disease and treatment process, support with school planning and organization, and assist in the patient's return to school. Patients at home will receive tutoring sessions using Google Meet to ensure that the service is available outside the hospital.  

At the end of every week, completed school work will be sent back electronically to the regular classroom teacher, who will be responsible for grading and evaluating if the objectives and achievement indicators were met. Other types of evaluations such as tests and quizzes will be provided and graded by the teachers. This will be considered earned credit to pass the school year. 

In addition to academic tutoring, a Social Emotional Learning (SEL) program will be part of our solution. Tutors will be responsible for teaching these contents in collaboration with the psychology team. SEL programs allow students to increase motivation and manage their own emotions towards education.   

Our solution relies on Learning Management Systems (LMS), information will be shared through Google Classrooms, a familiar tool to public school teachers because it was used during the pandemic. Communication with patients at home will be held through Google Meet.

Our solution will serve children diagnosed with cancer in El Salvador. The program has national coverage of pediatric cancer and receives 200 new childhood cancer cases annually and treats 350 patients per year in an age range of 0-<18 years. Treatment is free of charge for patients, but the disease incurs a lot of out-of-pocket expenses, like travel allowance. Leukemia (48%) is the most frequent pediatric cancer in our community, followed by Lymphomas (13%) and Central Nervous System Tumors (12%). The treatment for patients can last a minimum of nine months to a maximum of two years and a half.  According to socioeconomic interviews, 51% of our pediatric cancer population lives in extreme poverty and 49% of our patients live within a sustainable economy.  Most (75%) children with cancer in El Salvador have to travel between 2-12 hours to reach the hospital, and only 25 % of the patients live in the surrounding cities near the hospital. 

Progress in childhood cancer treatment has resulted in survival rates of over 80% in high-income countries (HIC). The reality is different in low and middle-income countries, where approximately 80% of children with cancer are diagnosed but only 20% are cured. In El Salvador, cure rates are 65%.  Abandonment of treatment rates in low and middle-income countries is high due to poverty, lack of access to treatment, and socioeconomic factors.  El Salvador has an abandonment of treatment rate of less than 1%, primarily fostered by education to the caregiver and a tracking protocol that allows healthcare personnel to detect absences in real-time. 

El Salvador is the smallest country in Central America, bordered by the North Pacific Ocean and located between Guatemala and Honduras; it has a land area of 20,721 km2 and 320 km2 in water. The Gross Domestic Product (GDP) growth in El Salvador reached 1.862 percent in 2019, but the country has registered persistently low economic growth levels due to violence and poverty. According to the International Monetary Fund, GDP per Capita is equal to $ 9,139.70 per year. The publication entitled "Projections and Estimates of the Population of El Salvador (1950-2050)", produced by the Ministry of Economic and General Office of Statistics and Censuses, reports the projection of El Salvador's total population for the year 2020 of               6,765,935 inhabitants. The pediatric population (0-18 years) constitutes 35%, comprising 2,387,091 inhabitants.

El Salvador´s National Childhood Cancer Program, supported by Ayúdame a Vivir Foundation in alliance with Children National Hospital Benjamin Bloom and St. Jude Children's Research Hospital, was established in 1993.  Since its beginnings, the program seeks access to comprehensive treatment for Salvadoran children with cancer, improving their quality of life and their family in all stages of the disease. 

Public educational levels in El Salvador are low compared to private education.  The entry-level age is 7 years old. Education is free up to the 9th grade but only 41% of the population aged 4-18 years are enrolled in school. The most frequent cause of dropping out of school in public schools is poor performance. The rate of this cause of dropping out is 36% versus 8% in private schools. Public schools have an average of 35 students per teacher versus only 20 in private schools.  The COVID pandemic has affected education furthermore.  The country had one of the harshest lockdowns, and in-person schooling has been one of the last restrictions to be lifted. During two years, public school students learned through a YouTube channel through a program called “Aprendamos en Casa” (Learning at Home). Students were expected to receive classes through the channel at their homes. Guidelines were also given through the internet. The lack of human interaction with teachers, and the limited access to the internet in many rural areas has debilitated education. In 2022, students are returning to in-person classes. 

The current educational situation in El Salvador is alarming, but even more for our patients with lower school enrollment. Despite our best efforts, children with cancer continue to be an underserved minority. Research shows that low academic levels positively correlate with low economic positions. Considering that most of our patients come from low-income families this lack of educational efforts adds new layers of vulnerability. Because cure rates have increased in the last years, educational continuity must be ensured to prevent children from increasing their vulnerability. 

This is the case for education, where there are no official plans in place and educational continuity relies solely on the families and our team, with no legal guarantees to protect their human right to education.

The psychology team is composed of three people, Carmen, Carolina, and Alvaro. Regarding proximity, together we are in contact with all patients of the pediatric cancer program. Our office is based at our center, which means we have daily contact with patients and their families. To understand the needs of our patients, every week we devote time to assess our patient’s educational status through interviews and we provide support when necessary.  

We represent this community in their school continuity as we are responsible for advocating for school reincorporation during and after treatment.  We are aware from interviews with parents and children that the school system is deficient, patients lack the motivation to return, and face setbacks and challenges as they grow older because they lack the knowledge required to be on a level with their classmates. Thus many end up dropping out of school.  The team is responsible for talking with parents about the importance of school, sending letters and brochures to schools to explain the cancer process, and communicating with teachers. 

We plan to send a letter to all schools to explain the tutoring program and ask for teachers' collaboration in sharing the classroom material in Google Classroom. Teachers and directors will be included in the solution, asking for their feedback.  Most teachers with whom we have had contact show concern and engagement with cooperating towards a successful reincorporation of students. 

Our proposal has been influenced by what we found during our interviews with patients and their families. For example, we decided to implement a communication process because we have found that children find it discouraging not having support from an educator. We also have based our program on an LMS to help close the gap. Most children want to go to school but there is little support from the institutions who are also overwhelmed with a workload burden and the reincorporation of all students after the COVID pandemic. With aid from our institution, we believe teachers will have a more fluid incorporation of cancer patients to school.

We apply because Fundación Ayúdame a Vivir shares Solve’s commitment to an education that enables children to achieve meaningful learning through overcoming gaps in access to education and technology. We believe that being able to have access to school is just the first step, to achieve real impact, patients need tools and foundational skills to be productive and independent. 

Solve’s power to connect entrepreneurs can help us find long-term solutions to make education more accessible for children with cancer. Through technical and financial support, we expect that our future alliance may help in two different domains: (a) extend educational options for our patients in accessible and creative manners(so we can include special education, extracurricular activities, vocational training, and higher education in a manner that allows our patients to continue with their treatments and be prepared for their productive lives) and (2) refine our educational model to achieve sustainability. In fact, our pediatric cancer program has been recognized as one of the four most cost-effective programs in our income category. We are committed to sustainability through innovation and Solve can provide the environment and connections to find better practices to achieve this goal. 

The current approach is based on three possible scenarios: (a) Enrolled students get in contact with the school after diagnosis, the school can offer a range of alternatives depending on their capabilities and disposition. Most schools agree to continue with the virtual modality. Children receive at the beginning of the week a guide with content and school. At the end of the week, students are expected to send over their schoolwork and take exams and other evaluations. With this approach, students are forced to work in a self-paced fashion with little to no support from their teacher. Currently, the Ministry of Education works on the basis that the guides posted online are enough and there is no teaching or follow-up. 

(b) Teachers will recommend that patients wait until a later phase in their treatment (mostly maintenance chemotherapy) or (c) will grade assignments as if they were done by the students in order to help them pass the academic year. 

With our solution, we will directly tackle this deficiency while keeping our patients in their regular schools in their communities. This program will act as a catalyst to increase participation in school work. Tutors will be available by request and will accompany our patients in their daily school work. This will provide them with the opportunity to clarify doubts, get instruction, and have a range of resources available to comply with their homework such as tablets with an internet connection, school supplies, books, printers, and other materials necessary. This supportive approach, in contrast with the current approach, will allow students to reach meaningful learning and skills. 

Addressing technological gaps is also part of our solution. Our experience shows that not being able to use Learning Management Systems is discouraging to our patients and a cause for dropping out of school. Since technology is every time more embedded inside and outside the classroom, proper training on how to use these platforms will be provided through our tutors. Our patients and their tutors will have tablets and internet connections available. These resources will also allow us to connect our students with other educational innovations such as digital Social Emotional Learning (SEL) programs. 

In contrast with the current approach, the core process of teacher-tutor communication will complete the circle. Tutoring sessions will be incomplete without proper assessment. Teachers will be able to share indicators, objectives, and evaluations from the regular curriculum, therefore tutors can follow the official guidelines to help patients achieve promotion. Quizzes and exams can be performed through Google Classroom and weekly school work graded as well to obtain credits. This means our program will allow students to reach the educational goals described for their age and grade. 

Our solution not only offers tutoring and educational support for patients. It goes beyond that. We believe children in El Salvador are lacking a proper education due to a lack of financial investment in schools, poor infrastructure, lack of qualified teachers, and inadequate teaching material. The long-term consequences of this are a society with poor health knowledge, poverty, unemployment, gender inequality, and social and political isolation. We want to break this cycle with our small community and empower education and patients with the skills and knowledge to create meaningful lives and improve the lives of their community. 

Our impact goal within the next year is to have at least 75% of our patients in active treatment enrolled in school and 50% of them enrolled in the tutoring program. We aim to increase enrollment at regular schools in our patient population and through the tutoring program help patients master the basic skills they have missed due to the interruption in education caused by the pandemic and their disease. 

Over the next five years, we aim at regularizing school enrollment in patients with cancer. 

The transformational impact will be reached by providing patients with foundational skills that allow them to reach higher educational levels, thus better employment opportunities. For the next five years we project the following impact goals: 

-Patients who were enrolled in the program have reached salaries over the minimum wage. 

-At least 15% of patients that have attended the program have reached the minimum academic degree available in El Salvador (“Técnico”). 

-Al least 80% of pediatric cancer patients in El Salvador are enrolled in the program.

At our organization, we measure progress through patient-generated data. We have informatic systems enabled to generate and report data. Our IT team is able to introduce new modules to the already existing ones in our support system to track the progress of this project. For example, we are able to track survivorship data as well as patients in active treatment. All indicators described below can be measured through the routine follow-up that already exists. 

The following indicators are already being measured:

-Percentage of patients enrolled in schools. 

-Distribution of modalities patients attend to. 

-Survivors' occupations and educational status. 

-Frequency of contact from available educational opportunities. 

We plan to add the following indicators for our solution: 

-Number of patients enrolled in the tutoring program.

-Percentage of patients of school age enrolled in school.

-Number of in-person and online tutoring sessions.

-Number of Social Emotional Learning (SEL) sessions provided. 

-Number of patients who leveled their educational delay after participating in the tutoring program.

-Number of patients who remained in school after treatment. 

-Number of survivors who achieved a post-secondary degree or diploma.

-Number of survivors earning a salary/monthly income higher than the national minimum.

Pediatric cancer patients in El Salvador have challenges in education due to demanding treatment schedules. With 62% of the patient population currently not enrolled in school, advocating for education is crucial. But enrolling in school is not enough. Those who are enrolled have academic difficulties and the system does not benefit students who are unable to attend classes permanently. Furthermore, not all students have access to the internet to have continuity in classes.  By creating a tutoring program at the hospital, children who are enrolled at school can advance on their schoolwork while at the hospital, decrease falling behind in school, foster security, and motivate patients.  Our ultimate goal is to implement a tutoring program that will have a transformative change among cancer patients enrolled at school, motivating those who are not enrolled to continue their education process, better preparing them academically, and contributing to helping them become prepared problem solvers who will contribute to their communities and countries.  We believe that all children who are enrolled at regular school and attend the hospital for appointments and chemotherapy can benefit from the tutoring program by fostering greater confidence academically and motivating them to continue school and that those patients who are not enrolled in school will be more motivated to continue with school with the available help. The tutoring program will be available every day at the hospital and may continue virtually when children are at home. Tutoring will directly improve academic performance and indirectly foster students´ confidence. 

This program will also impact teachers at regular schools. Teachers will take on the responsibility of uploading students' work and guidelines in Google Classroom and providing feedback on the patient students' performance. Parents of patients will also have to be involved in the process by supervising their child´s work. 

Inputs include:

-Staff: Hiring preschool primary, middle and high school teachers. 

-Material goods: School supplies, books, furniture.  

-Equipment: Purchase informatic equipment such as tablets. 

-Services: Availability of internet connection, license for Google Classroom, access to a Social Emotional Learning platform. 

-Skills: Training teachers for the application of an evidence-based Social Emotional Learning (SEL) program.

The activities to perform with the inputs are the following:

-Dissemination of new educational services among families.

-Online meetings with teachers to request their support and explain what’s expected from them (providing weekly school work).

-Teachers provide weekly school work and evaluation to tutors through Google Classroom. 

-Daily tutoring sessions for patients diagnosed with pediatric cancer through in-site and online.

-Periodical evaluation by teacher's request (i.e, exams, projects).

-Weekly socioemotional education sessions for patients.

We propose the following outputs:

-90% of families with school-aged children have been informed about the program.

-70% of eligible teachers have compromised with the tutoring program and comply with providing weekly assignments. 

-Every week tutors hold a minimum of 60 tutoring sessions. 

-Every week tutors hold a minimum of 20 Social Emotional Learning sessions both in individual and group format

-Enrolled students present at least 75% of school work requested by their teachers.

-Students solve at least 85% of their written evaluations. 

Our outcomes are the following. 

Initial Outcomes (up to 6 months)

-50% of patients enrolled in the Pediatric Cancer Program have enrolled in the school and receive support from tutors. 

Intermediate outcomes (2-3 years):

-85% of enrolled students have completed at least one grade and have an official promotion certificate issued by the Ministry of Education. 

-60% of students enrolled in high school reach at least a global “Intermediate” level in AVANZO evaluation (standardized national test)

-The program has reached the national enrollment levels within the pediatric cancer population (88% for primary school, 65% for patients in middle school, 37% for high school level)  

Long-term outcomes/Goals (3-5 years):

-The program has overpassed the national enrollment levels (90% for primary school, 80% for middle school, 95% for high school).

-80% of students enrolled in high school reach at least a global “Intermediate” level in AVANZO evaluation (standardized national test)

The core process of our solution is the communication between teachers and tutors. Because we’ll work with the schools our patients regularly attend, and these schools are scattered all over the country, the only way to achieve fluent communication is through reliable and socially-accepted technology. Thus, we have considered that Learning Management Systems (LMS) such as Google Classroom are the alternative of choice. 

Several reasons justify our choice. In the first place, Google Classroom is the most commonly used LMS in Salvadorean public schools since in 2020, due to COVID the Ministry of Education provided training to teachers all across the country. This means additional training won’t be necessary to send school work. Another reason is that by using this software we can directly address the technological gap we have described above, as we have identified that students feel discouraged because they can’t use this platform, this will allow our program to leverage patients with current educational practices so when they return to their school they already have all the necessary knowledge to succeed.

The Google Suite also offers many different possibilities. With a Gmail account, students and tutors can also access a range of applications such as Google Forms that can be used to present exams. Google Meet will be particularly meaningful for those patients who receive their tutoring sessions online while at home. Therefore, our program relies heavily on technology to keep students up to date with their education in their communities. 

Hardware choice has been carefully considered for this solution. Our project will rely on tablets where communicational and educational processes will be performed. The selection of tablets as the main hardware is due to social acceptability and penetration since most of our patients use mobile devices to communicate and study.

Fundación Ayúdame a Vivir(FAV) is an organization that promotes equity and diversity. FAV focuses on creating a workplace environment where our employees are treated with respect, autonomy, and value. All employees, from the oncology director to the cleaning staff are treated with the same respect. The oncology team, administrative and clinical, have worked together for many years and on many projects, sharing common goals, expectations, and a passion for the pediatric oncology program. We have respect and appreciation for the contributions each team member delivers and with this respect for each other comes a fair distribution of power, recognition, and risks. We share the same values and goals: union and passion, respect and compassion, and honesty Currently, 60% of the staff at FAV are women and 75% of the head positions are held by women. Employees and people applying to work at our foundation are not discriminated against based on gender, age, race, social class, religion, or disabilities. 

Our center has an entrance with a ramp for people with disabilities and the availability of wheelchairs at our entrance.  

We provide multidisciplinary care to pediatric oncology patients and their families. Patients receive treatment for cancer and the family receives support and care from other disciplines in the program. The majority of these patients come from low-income backgrounds who would otherwise be unable to pay for the medical service and medicines to treat childhood cancer. FAV covers everything from chemotherapy, antibiotics, the human resource to provide this care, and the infrastructure to run a pediatric oncology program.  The program offers care from oncologists, psychologists, social workers, pharmacists, surgeons, nurses, nurse educators, physical therapists, ophthalmologists, nutritionists, among other disciplines. 

Our stronger stakeholders are the Salvadorean government, which provides about 50% of the budget of the oncology program, and the fixed donors of the Foundation. We also obtain grants through local donor programs of important companies and international grants. The biggest cost of the program comes from chemotherapy and salaries. 

We are a non-profit organization, our funds come from donations and grants, we’ve been working under this scheme for 30 years. To achieve financial sustainability we have relied on our strong fundraising department. This team will be key to becoming financially sustainable. Through our fundraising department, we can obtain funding to maintain hired staff, purchase supplies, and pay for services at the end of our partnership with Solve. 

One story of success in previous grants of our Foundations is the St. Baldrick´s International Scholars Grant, which was awarded to Dr. Soad Fuentes, a pediatric oncologist from El Salvador. This a grant awarded to a pediatric oncologists from low and middle-income countries to train them in research. Dr. Fuentes studied the epidemiology and biology of childhood cancer in South America and has set up the first Central America cancer registry, which allows pediatric oncologists to see which communities are most affected in the country. Through this registry, clinicians were able to see the cancer registry was actually 33% higher than previously thought and has set up a movement to mobilize the government´s involvement in childhood cancer in El Salvador. 

Fundraising has also been successful at FAV. In the COVID pandemic, donations from fixed donors decreased. An emergency fundraising campaign was made and in three days 100,000 was collected. FAV has also begun a cooperative business model with its members/donors. All donors who donate more than $10 on a monthly basis receive benefits from restaurants, pharmacies, stores, among others. The number of donors has increased as well as the quantity of monthly donations from current donors.