The experiences of childhood leukemia survivors in returning to school: An in-depth qualitative study

The experiences of childhood leukemia survivors in returning to school: An in-depth qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The experiences of childhood leukemia survivors in returning to school: An in-depth qualitative study Yunxia Ou, Yan Yang, Chunmei Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4957799/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose To explore and describe the experiences of childhood leukemia survivors in the transition from home to school following cancer treatment. Methods Study participants include 16 survivors who visited a hospital for follow-up care following treatment for leukemia at a university hospital in Wenzhou. We conducted an in-depth, semi-structured interviews with 16 participants. The interview data were analyzed according to the thematic analysis method. Results We extracted 5 themes from the interviews: (a) Being on the right track to school, (b) Perceived personal happiness, (c) Discovering the gap with others, (d) Feelings of being excessive care, and (e) Concerns about returning to school. Five main themes suggest that the return to school hallmarked the beginning of a new life and the experience of a new environment. Participants reported having different feelings after returning to school. On the one hand, personal happiness is enhanced, and on the other hand, individuals need to face up to the practical problems encountered in school. Conclusions Childhood leukemia survivors can seek self-worth and identity after returning to school, but also face friendship, learning and physical difficulties. Medical staff should pay more attention to this group and give them enough support to better adapt to campus life. Leukemia Survivor Return to school Qualitative study 1. Introduction Leukemia is the most common malignancy in childhood. The incidence rate of childhood leukemia (under 15 years old) in China is about 4 to 5 per 100,000 people. If it is expanded to under the age of 18, there are about 15,000 new cases of leukemia in children every year, with an average course of treatment of 2–3 years per case [ 1 ]. At present, the treatment method for leukemia is mainly based on combined chemotherapy, supplemented by other supportive therapies [ 2 , 3 ]. Because of the long duration of treatment, childhood leukemia survivors who received induction therapy, consolidation therapy, central nervous system prophylaxis, and maintenance therapy had more absenteeism than the general population [ 4 ]. With the continuous progress of medical technology, children or adolescents with leukemia have a five-year survival rate of more than 80% in both the United States and China [ 5 , 6 ]. Because of the higher survival rate, leukemia in children and teenagers is now considered a chronic disease. Accordingly, the number of childhood leukemia survivors returning to school, often after a lengthy absence, is also increasing. In general, near-term survivors are those who have completed consolidation or intensive treatment but have not met the 5-year disease-free benchmark that would identify them as long-term survivors [ 7 , 8 ]. Therefore, this study defines childhood leukemia survivors as children or adolescents who have completed consolidation or intensive therapy and patient's condition is stable, but may face various physical, psychological, and social problems. For leukemia, after experiencing 2 years or more from diagnosis to treatment cessation, regular health check-ups will begin immediately and will continue for five years, meaning that the maximum risk of relapse has passed [ 9 ]. This is a transitional period in which the child can return to school and continue a normal life. Childhood leukemia survivors are facing the challenge of returning to school [ 10 , 11 ]. Since Chinese societies were framed by Confucianism, most mothers tended to play the role of benevolent protector in Chinese families. Chinese parents establish rules and guidelines for their children based on their parenting style [ 12 – 14 ]. Most parents show excessive protection for their children because parents believe that illness makes their children more vulnerable. This tends to underestimate their ability[ 15 , 16 ]. Adolescence is a time to achieve important development tasks. But the average treatment time for leukemia is 2–3 years, during which they are repeatedly hospitalized, hindering social communication with teachers, classmates and friends, and eventually leading to the interruption of socialization [ 17 , 18 ]. Even after participants returned to school life, they would generally transfer to a new school or class. As outsiders, they could hardly adapt to the collective life and make new friends in a short time [ 19 , 20 ]. This consequence of cancer survival is a meaningful cause of stress in childhood leukemia survivors. Besides, the most significant area of stress for young Chinese people is the pursuit for academic excellence. In the context of Chinese culture, it is characterized by the pursuit of academics and admission to prestigious schools. However, the adverse effects of chemotherapy or radiotherapy, such as memory decline, and lack of concentration, make it difficult for childhood leukemia survivors to achieve the desired academic achievement [ 21 , 22 ]. However, in, China, participation in school can take on additional significance for children or adolescents with cancer [ 23 , 24 ]. School is an important aspect of childhood leukemia survivors' social lives, and returning to school is conducive to changing attention and starting a new life [ 25 , 26 ]. Because participants spent most of their time in school, they could learn like their peers, which reduced participants' loneliness. Some students abide by their student responsibilities and devote themselves to their studies. In school, participants feel a greater sense of belonging, which is an important milestone for them to "live a normal life" [ 27 ]. The study stated that school education continuity can improve life quality and promote the reconstruction of psychosocial functions in children or adolescents with cancer [ 28 , 29 ]. At present, there has been minimal research in this field based on China's sociocultural context. As a result, the current study aimed to investigate the experiences and adaptation processes of childhood leukemia survivors returning to school in the socio-cultural background of China. 2. Methods 2.1. Design This study is a qualitative study using thematic analysis, conducted to explore the experiences of childhood leukemia survivors in returning to school life following cancer treatment. Thematic analysis is a method for identifying, analyzing, and reporting patterns within data [ 30 ]. The reporting of this article follows the Consolidated Criteria for Reporting Qualitative Research [ 31 ]. 2.2. Participants The participants were selected by purposive sampling from an outpatient hematology/oncology clinic at a Wenzhou medical university-affiliated, tertiary-care pediatric hospital. The data was considered to be saturated when no new recurring themes were identified. Eligible participants (1) had leukemia and no other malignancy at the time of recruitment and interview; (2) were aged 7 to 18 years at the time of recruitment and interview; (3) either consolidation or intensive therapy has been completed and maintenance therapy has been experienced for at least one year. ; (4) had successfully returned to school; and (5) were free of psychiatric illness, capable of normal language communication, and voluntarily participated in the interview. 17 participants met the study eligibility criteria and agreed to participate. One was excluded because he was diagnosed with a cancer recurrence, resulting in a final sample size of 16. Participants ranged in age of diagnosis from 7 to 17 years old. Among them, 9 participants were boys, and 7 participants were girls (Table 1 ). Table 1 General characteristics of the participants Age of diagnosis Gender Siblings status Whether to go back to school A B C D E F G H I J K L M N O P 10 15 9 8 11 8 13 8 13 14 7 8 7 7 13 17 Girl Boy Boy Girl Girl Girl Boy Boy Boy Girl Boy Girl Girl Boy Boy Boy Older sister Older sister Younger brother None Older sister Older sister Older sister None Older sister Older sister Younger brother None Older brother Younger brother None Older sister Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 2.3. Ethical considerations Before data collection, the Institutional Review Board (IRB) of the hospital approved this study. The participants, fully informed about the purpose of the study, assured of anonymity and confidentiality, and told that anyone could drop out at any time, had given informed consent verbally and in writing. Especially for children under the age of 15, this study has also obtained the informed consent of parents. Parents have the right to ask children to withdraw from the study at any time without being unfairly treated. 2.4. Data collection This interview guide was developed by consulting with oncology professionals and reviewing the literature [ 32 , 33 ]. It had eight open-ended questions concerning the experiences of childhood leukemia survivors in returning to school. These questions were as follows: (1) After the treatment, can tell me what it feels like to go back to school? (2) Do you know how to take care of yourself after returning to school? Have you encountered any difficulties? (3) How do you think your performance in school has changed from before? (4) How do you adapt to the various teaching activities in the school? (5) Can you tell me about your peers or your teacher? (6) What do you believe you should do ahead of time to ensure a smooth return to school? Background information was requested at the end of the interview guide. The questions were tested with three boys who met the inclusion criteria but did not participate. The results demonstrated that the interview guide was adequate. 2.5. Procedure The duration of the study was from March 2021 to June 2022. We will prepare gifts for participants before the interview. At the same time, in order to ensure the authenticity of the interview results, try to ensure that the parents are not present when interviewing each participant. However, participants who are too young to understand the interview questions, and their parents will also be invited to an interview. The researchers used the answers of the participants' parents as a supplementary material. But parents did not interfere with their interview when participants encountered questions that could be answered independently. Before data collection, the first author, who had prior experience with qualitative methods, trained four research assistants in interview techniques and data analysis. An interview lasting 30–60 minutes was conducted by the first author. The other two researchers conducted live recordings and text recordings. During the interview, we do not raise inductive questions, do not evaluate the interview content, and do not easily interrupt the interviewees. While the participants shared their stories, researchers objectively recorded non-verbal symbolic information such as tone, intonation, and expression. After each interview, the data were sorted. The interviews continued until data saturation, that is when themes emerged repetitively, and sufficient information was obtained to answer the research question. 2.6. Data analysis The recording materials and the researchers’on-site observations were transcribed within 24 hours after the interview and confirmed by an additional research assistant. And numbered in order of the interview to protect the respondents' privacy. Themes were retrieved in six stages: becoming acquainted with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and providing a report [ 30 ]. Data were organized and coded manually by two researchers and using NVivo 12 software by one of the researchers. Then they labeled the units based on their content, and a list of codes was created. In the next step, patterns in the codes across the whole data set were identified, and related codes were grouped into potential themes by the development of a thematic map. When there are different opinions, the group will determine the sub-theme and the final theme. The final selection of key themes was agreed upon by all authors. 2.7. Rigor To ensure the trustworthiness of this study, the quality of research was monitored applying Guba and Lincoln's criteria of credibility, dependability, and Confirmability [ 34 ]. Data credibility was supported by spending time with the subjects to ensure rapport and clarifying responses, which provided ample opportunity for participants to fully discuss their experiences. Credibility was further enhanced through the use of data and investigator triangulation; specifically, data were gathered from multiple sources including interviews and observational field notes, all members of the investigative team participated actively in data analysis, and regular peer debriefing sessions were held with hematology/oncology team members to gather input throughout the data analysis process. Finally, the confirmability and dependability of the data were ensured through the use of an audit trail consisting of audio recordings, transcriptions, and research field notes. Transcripts were read and coding assignments were discussed between researchers until consensus was reached. 3. Results The experiences of childhood leukemia survivors in returning to school were extracted through interviews in five themes and 11 subthemes (Table 2 ). Table 2 Themes and Subthemes. Themes Subthemes Being on the right track to school Perceived personal happiness Learn to take care of myself Strive to achieve self-worth Feeling less alone The pleasure of receiving a teacher's praise Discovering the gap with others The difficult process of rebuilding the friendship Suffering from decreased physical strength Hard to keep up with learning progress Feelings of excessive care Feeling uncomfortable with parents' overprotection Being burdened by the special treatment of others Concerns about returning to school Worrying about being mocked Feelings of uncertainty about the disease 3.1. Being on the right track to school The two subthemes in the theme conveyed that participants were prepared for a new return to school and revealed the positive significance of return-to-school for childhood leukemia survivors. 3.1.1. Learn to take care of myself During hospitalization, parents played an important role in disease management. Parents would take care of the participants' diets and supervise their medications. After returning to school, some participants could only go home on weekends, meaning they spent most of their time at school. Through the interviews, it was found that the participants had certain self-care abilities and could avoid some risks or bad behaviors. -In the hospital and at home, my parents have always helped me deal with all kinds of things. In school, I could learn to take care of myself and manage diseases so that I could learn to be independent. I would eat well with three meals and would not eat snacks indiscriminately. I would also arrange my time reasonably and I would not stay up late studying and playing games. (Participant E) Some participants were aware of their physical condition and would do what they could to avoid putting themselves in danger. After returning to school, I would pay attention to my body in a physical education class and would not exercise too vigorously. If I felt uncomfortable, I would immediately inform my teacher. (Participant C) After I went to school, my mother often told me not to fight with children so as not to hurt myself. It didn’t matter about running and jumping, and I wouldn't do anything dangerous. Without my mother around, I can take good care of myself. (Participant H) 3.1.2. Strive to achieve self-worth Participants could continue to pursue academic goals after returning to school. Some participants reported that they worked hard and got good results. They hoped to gain admission to prestigious middle schools or universities, pursue their preferred majors, and realize their life goals. I thought I could learn a lot in school. I originally had a good grade, because I was sick and delayed for more than a year, but now I want to catch up with my grades again, hoping to enter a key middle school. (Participant J) I only had more than a year to go to college, and I hoped to do my best to get good grades. After I fell ill this time, I received help from teachers, classmates, and many caring people in society. My dream was to be a doctor and help people like me. (Participant P) 3.2. Perceived personal happiness Two sub-themes of this theme explored participants' improved self-belonging and self-identity after returning to school. 3.2.1. Feeling less alone Returning to school meant being able to live and learn with your peers and making participants' lives more fun and playful. Participants were happier and less lonely than they were in the hospital. I felt much better when I returned to school. I had forgotten about my illness. Maybe it was too stuffy to stay in the hospital, and I just lay in bed every day to play with my phone. Not only did I have no friends to chat with, but I also had to get injections and take medicine. In school, my classmates and I go to class, do homework together, and play together after school. (Participant A) At that time, I wanted to go to school. My teachers and classmates often sent me WeChat messages to let me go back to class early. I also miss them very much. When I went back to school, I at least had the same language as my peers and felt less lonely. (Participant C) 3.2.2. The pleasure of receiving a teacher's praise Participants believed that returning to school could acquire knowledge and skills while being recognized by teachers, which was conducive to better growth of participants. The teacher liked me very much. When I answered questions in class, the teacher would ask me questions and often praised me. Sometimes in the morning, the teacher would ask me to stand on the platform and teach my classmates to read, which made me very proud and gave me a sense of achievement. (Participant D) In the art class, the teacher will usually teach us to draw. Every time my paintings are taken out by the teacher for exhibition in the class. At that time, I was always happy and proud. (Participant M) In class, I always will raise my hand to answer the teacher's questions actively. Although sometimes the answers are not perfect, the teacher will praise. I think this is the teacher's recognition of me. (Participant B) 3.3. Discovering the gap with others After disease treatment, participants perceived their gap with others in re-establishing friendships, learning, and physical strength. 3.3.1. The difficult process of rebuilding the friendship Most of the participants had to interrupt school life due to hospitalization, and childhood leukemia survivors had little time or opportunity to meet their classmates. In the late stage of maintenance treatment, most participants would transfer to a new class or school. As outsiders, it was difficult for them to adapt to the collective life of the new school or class in a short time. I spent most of my time in the hospital, so we slowly got less connected. We also only occasionally contacted them by phone and WeChat. (Participant I) I am not familiar with these students in the new class, and I usually do not take the initiative to greet and talk to them. In my second year in junior high school, my classmates had already been friends since the first year. And they had their fixed friends, just like that. It was a little difficult for me to integrate into it. (Participant J) Participants were emotionally unstable and irritable as a result of the use of hormones, which made their relationships with peers difficult. This lack of peer interaction made participants gradually alienated from their peers, and it was difficult to rebuild the friendships quickly. Since I started taking hormone drugs, my mother always said that my character has become irritable and self-centered, and I lose my temper from time to time. I also felt sulky and didn't know how to get along with others. (Participant G) During the time I was taking (hormone) medication, I felt like I was somehow unhappy and didn't want to play with other kids. (Participant C) 3.3.2. Suffering from decreased physical strength Because of the disease, most of the participants have experienced side effects of drug chemotherapy treatment. Their immunity is generally lower than that of their peers, and their activity tolerance is lower than before they were ill. Therefore, the frequency of participants participating in sports activities has decreased to varying degrees. As my body was a little weak, I couldn't fully participate in physical exercise. The teacher would also let me sit aside and rest. I had to watch them exercise. (Participant L) My physical strength must be a little worse now compared to before I got sick. When I was halfway through my endurance training, my strength dropped a bit, and I couldn't finish the whole race. (Participant P) 3.3.3. Hard to keep up with learning progress Participants with a weak learning foundation may be unable to focus totally on learning as a result of therapy side effects that interrupt learning during treatment. Although they tried to study hard and narrow the gap with their classmates, the learning effect was not obvious. I was going to the second grade of middle school, but after a year of suspension, it was difficult to catch up in a year, so I had to choose to study for another year. Sometimes I will stay up late to study, and my parents will worry about my body and persuade me to go to rest early. I put in a lot of energy in that regard, yet my academic performance was ordinary. (Participant J) I feel that my memory and reflexes are not as good as before. I used to feel that my math was OK, but now I have a little difficulty in learning, and I have not done well in the exams. (Participant O) After returning to school, participants also need to go to the hospital for treatment and examinations intermittently, and each time they need to ask the school for about 1 day off. This made it more difficult for them to catch up with their peers. - I returned to school after several months of treatment. My foundation has been poor, but I still need to go to the hospital once a week. I was very concerned about falling behind in so many courses. My academic performance cannot keep up. (Participant I) 3.4. Feelings of excessive care Some participants reported that their parents were excessively concerned about their health, limiting their participation in activities or contact with their peers, which made participants feel uncomfortable. At the same time, the special treatment from the teachers or others makes the participants feel burdened, which makes the participants feel different from the others. 3.4.1. Feeling uncomfortable with parents' overprotection In the sight of parents Such health-related problems and concerns excluded participants from groups and physical activities, which meant that they lost their competitive qualifications in sports and reduced their opportunities to contact their peers. When the sports meeting came, the students were eager to sign up to participate in the competition. I was also ready to participate in rope skipping. However, my father was worried about my body and he refused my request, which frustrated me. (Participant F) I completely hated the view that parents have, that “you are a sick and weak kid, so s/he can’t do those things. (Participant F) 3.4.2. Being burdened by the special treatment of others Participants hoped that teachers or classmates would not pay too much attention to them, which would burden them. Participants tried to remain unnoticed. Participants hoped that teachers would not take excessive care of them because of illness, whether in terms of study or life, and they hoped to be treated equally. Being treated specifically by others causes participants to think they are different from others. - Because my situation was more special than that of other students, the teacher usually paid special attention to me. When we did something wrong, the teacher criticized other people but didn't say much about me. I didn't like that. It always makes me feel different from others. (Participant B) 3.5. Concerns about returning to school At the beginning of returning to school after cancer treatment, participants also did not know how to talk to others about their illnesses. Participants were concerned about their image, worried about being mocked by their peers when they returned to school, and hoped to be understood and accepted by their peers. At the same time, participants also showed fear of disease recurrence and hoped to receive professional support from medical staff. 3.5.1. Worrying about being mocked Some participants experienced pain caused by disease symptoms and treatment, hoping to gain the understanding and respect of the students. At the early stage of returning to school, participants were worried about being noticed, ridiculed, or discussed behind their backs by their peers, and they hoped that their classmates and friends would not deliberately alienate themselves due to illness. I didn't tell my classmates, or even my best friend, that I had leukemia. I was afraid they would mind this. I hoped they accept me . (Participant O) At first, I was wearing a hat and didn't want to go to a crowded place. At school, I was afraid that my classmates would laugh at me and ask me why I didn't have hair. Some classmates didn't want to play with me. (Participant F) 3.5.2. Feelings of uncertainty about the disease After returning to school, they were worried about the recurrence of the disease. Participants hoped to get long-term attention and follow-up from doctors or nurses to solve their health problems in time. After stepping into the school gate, I often worry that I will be uncomfortable. Schools also regularly carry out safety education, but it was aimed at everyone, not just at my disease. I was worried that (the disease) would recur and I would need to be hospitalized again. (Participant E) It is hard to believe that it happened to me again. How painful it would be if my parents saw me get my chemotherapy again. So I was very worried about it. (Participant P) 4. Discussion Participants consider returning to school after cancer treatment as a complex transition since the occasion represents the end of illness and the beginning of a return to regular life [ 35 , 36 ]. Returning to school is challenging for childhood leukemia survivors, and even if the process is not always smooth, children or adolescents will learn and grow in the process. A smooth transition from hospital to school is both a manifestation of the physical recovery of childhood leukemia survivors and an important dimension of psychosocial recovery in childhood leukemia survivors [ 9 ]. These participants are in a vital stage of learning, habit formation, and interpersonal skill development, and the school provides a learning environment for them. Allow individuals to believe that they, indeed, can achieve their objectives. Additionally, in this study, with the company of friends or encouragement from teachers, participants can feel the existence of self-worth. Our findings were based on prior studies that highlighted the importance of peer networks during treatment for participants' transition back to school following cancer treatment [ 37 , 38 ]. Participants return to school smoothly, which means moving on with their lives and promoting the social development of individuals. Therefore, nursing staff can arrange for survivors who have successfully returned to school to contact participants who are ready to return to school via remote video-sharing sessions to convey their successful experience and perceived benefits of the return to school process. Participants identified a gap between themselves and others. As life began to stretch beyond the hospital, the most prevalent problem that pediatric leukemia survivors faced in their transition from hospital to school was friendship. According to the findings of this study, participants showed rebuilding friendship difficulties. The same concerns have been reported in previous research that cancer survivors experienced difficulties in peer relationships after returning to school and they tended to worry about whether they could make new friends once returning to school [ 39 ]. In addition, lower physical strength may also lead to childhood leukemia survivors being unable to perform daily tasks independently, resulting in a poor school life experience, which can affect their self-confidence and sense of self-worth. Therefore, emotional and social support systems should be integrated into existing educational support systems, such as school passport projects or comprehensive assessment programs for campus activities [ 40 , 41 ]. Our findings also showed that the pediatric leukemia survivors tried hard to study when they returned to school following treatment, yet their academic performance was inadequate. This was similar to the findings of other studies [ 42 ] in which chemotherapy and radiotherapy were demonstrated to cause neurocognitive abnormalities in growing children. In this context, the treatment of the sequelae makes it challenging for pediatric leukemia survivors to catch up with their peers, despite their best efforts to concentrate on academic achievement. Therefore, continuous, lifetime monitoring for neurocognitive late effects is required to improve their education. Participants wanted to be identified, and had a desire to gain the same stable identity as their peers. In this study, the participants' parents' extreme care caused them to rarely participate in sports activities after returning to school, which resulted in reduced opportunities for some participants to interact with their peers. Parents frequently exhibit excessive protection and underestimate the capabilities of their children [ 43 , 44 ]. Consistent with this study, a foreign study found that parental protection and over-surveillance of young leukemia survivors' actions limited their potential to grow into independent adults [ 45 , 46 ]. Additionally, in this study, teachers' excessive attention not only made participants feel burdened but could also be perceived by other students as special treatment. Similar to this study, an earlier study found that teachers' excessive attention made participants feel different from others around them, resulting in negative sensations or experiences [ 47 ]. As a result, participants hoped to be treated equally by teachers. Therefore, caregivers should establish the correct parenting style and give children moderate attention. At the same time, teachers should master cancer knowledge to establish a good support link. There are also many concerns when childhood leukemia survivors return to school. On the one hand, self-image was a crucial factor for childhood leukemia survivors, with significant consequences for their mental health and social interaction development [ 48 ]. In this study, participants were concerned that their friends' attention would be drawn to their short hair and other physical symptoms of sickness treatment, causing them to feel upset and negatively influenced. Distinctions in the look of young leukemia survivors may have an impact on survivors' psychological function following treatment, making it harder to establish self-esteem and self-confidence after returning to school [ 49 ]. They looked forward to being understood and respected by their classmates, which was consistent with the previous research [ 50 ]. On the other hand, they often worry about the recurrence of the disease, which is related to the lack of knowledge of the disease. This was consistent with the previous findings [ 51 – 53 ]. Therefore, it is recommended that healthcare workers explain disease knowledge to childhood leukemia survivors and their caregivers and inform them to follow up regularly. At the same time, tertiary hospitals need to strengthen the guidance of community health service centers and actively engage in telemedicine cooperation. The community then regularly assesses the physical and mental health of survivors using a medical information consultation platform. 5. Limitations Participants in this study experienced different difficulties at different times, thus necessitating long-term follow-up interviews with childhood leukemia survivors when they return to school after treatment. The male-to-female ratio of the participants in this study was uneven, and the age span of the recruited participants was slightly larger, so future studies should stratify the populations of different age groups. At the same time, quantitative research involving a larger number of participants from various regions is required to identify specific difficulties in childhood leukemia survivors based on diagnosis age and treatment periods. 6. Conclusion Childhood leukemia survivors are vulnerable to social, cognitive, and educational changes. In this study, we learned about the benefits and challenges of returning to school. We should meet the reasonable needs of participants to increase their motivation to return to school. Some participants looked forward to returning to school, which gave participants a sense of belonging and identity. Returning to school can further foster participant independence. Recognition of the benefits of return to school could mobilize more childhood leukemia survivors of similar conditions to participate in return to school. However, after the treatment, some participants had some difficulties in rebuilding friendship, learning, and physical appearance. They have difficulty catching up with their peers due to the educational gap caused by disease treatment. As a teenager who naturally values his self-identity, he feels stressed when he is too different from others. As it confirms that participants are what others think they are different from their peers. Therefore, these findings indicate that a plan must be developed to assist childhood leukemia survivors in actively perceiving the benefits of returning to school, while caregivers and healthcare providers should master the challenges faced by childhood leukemia survivors and fully and immediately support them so that they can re-adjust to school life. Declarations Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by Zhejiang Provincial Public Welfare Technology Application Research Project (LGF21G020002) and Major Scientific and Technological Innovation Projects in Wenzhou (ZY2020022). CRediT authorship contribution statement Yunxia Ou: Conceptualization, Methodology, Data collection, Data curation, Data interpretation, Visualization, Writing - original draft. Yang Yan: Conceptualization, Validation, Investigation, Writing - review & editing. Chunmei Zhang: Validation, Investigation, Writing - review & editing, Supervision, Project administration. Declaration of competing interest The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Ethics approval and consent to participate The experimental protocol was established, according to the ethical guidelines of the Helsinki Declaration and was approved by the Ethics Committee of The Second Affiliated Hospital of Wenzhou Medical University (Approval No.: LCKY2020-198). Written informed consent was obtained from individual or guardian participants. Acknowledgments We would like to thank Zhejiang Natural Science Foundation and Wenzhou Science and Technology Bureau for their financial assistance to this project. We would also like to express our gratitude to all participating leukemia survivors for their contributions to the study. References Namayandeh SM, Khazaei Z, Lari Najafi M, Goodarzi E, Moslem A: GLOBAL Leukemia in Children 0-14 Statistics 2018, Incidence and Mortality and Human Development Index (HDI): GLOBOCAN Sources and Methods. Asian Pacific journal of cancer prevention : APJCP 2020, 21(5):1487-1494. Elgarten CW, Aplenc R: Pediatric acute myeloid leukemia: updates on biology, risk stratification, and therapy. CURR OPIN PEDIATR 2020, 32(1):57-66. Chang JH, Poppe MM, Hua CH, Marcus KJ, Esiashvili N: Acute lymphoblastic leukemia. PEDIATR BLOOD CANCER 2021, 68 Suppl 2:e28371. Allison MA, Attisha E: The Link Between School Attendance and Good Health. PEDIATRICS 2019, 143(2). Alvarez EM, Malogolowkin M, Hoch JS, Li Q, Brunson A, Pollock BH, Muffly L, Wun T, Keegan T: Treatment Complications and Survival Among Children and Young Adults With Acute Lymphoblastic Leukemia. JCO Oncol Pract 2020, 16(10):e1120-e1133. Pieters R, Mullighan CG, Hunger SP: Advancing Diagnostics and Therapy to Reach Universal Cure in Childhood ALL. J CLIN ONCOL 2023, 41(36):5579-5591. Doyle N: Cancer survivorship: evolutionary concept analysis. J ADV NURS 2008, 62(4):499-509. Cantrell MA, Conte TM: Between being cured and being healed: the paradox of childhood cancer survivorship. QUAL HEALTH RES 2009, 19(3):312-322. Tremolada M, Taverna L, Bonichini S, Pillon M, Biffi A, Putti MC: Pediatric Patients Treated for Leukemia Back to School: A Mixed-Method Analysis of Narratives about Daily Life and Illness Experience. Behav Sci (Basel) 2020, 10(7). Douvas MG, Riegler LL: Meeting Challenges in the Long-Term Care of Children, Adolescents, and Young Adults with Acute Lymphoblastic Leukemia. Curr Hematol Malig Rep 2022, 17(1):15-24. Wang MJ, Dzifa KL, Lei J, Kan X, Zhang RX: The experiences of children and adolescents with cancer returning to school: A qualitative meta-synthesis. J PEDIATR NURS 2024, 76:140-149. Ding G, Xu L, Sun L: Association Between Parental Parenting Style Disparities and Mental Health: An Evidence From Chinese Medical College Students. Front Public Health 2022, 10:841140. Wang J, Huang X, Li Z, Chen K, Jin Z, He J, Han B, Feng L, Meng N, Yang C et al : Effect of parenting style on the emotional and behavioral problems among Chinese adolescents: the mediating effect of resilience. BMC PUBLIC HEALTH 2024, 24(1):787. Huang L, Wu W, Yang F: Parenting Style and Subjective Well-Being in Children and Youth: A Meta-Analysis. PSYCHOL REP 2024:328561741. Shi H, Zhao H, Ren Z, Li X, He M, Zha S, Qiao S, Li Y, Pu Y, Liu H et al : Associations of parent-adolescent relationship and self-esteem with emotional and behavioral problems among Chinese adolescents. J Affect Disord 2022, 311:126-133. Hua K, Hongwang X, Yujian D, Xuefeng W, Wei Z: Effects of parenting mode on student adaptability: the mediating effect of irrational beliefs. BMC PSYCHIATRY 2022, 22(1):592. Tang X, Mo L, Liu Q, Liu Y, Yu L, Liu Y, Gao C: Adverse experiences of social adaptation in children with leukaemia: a qualitative study from China. BMJ OPEN 2022, 12(3):e51953. Li HC, Lopez V, Joyce CO, Ho KY, Chiu SY: The impact of cancer on the physical, psychological and social well-being of childhood cancer survivors. EUR J ONCOL NURS 2013, 17(2):214-219. Galán S, Tomé-Pires C, Roy R, Castarlenas E, Racine M, Jensen MP, Miró J: Improving the Quality of Life of Cancer Survivors in School: Consensus Recommendations Using a Delphi Study. Children (Basel) 2021, 8(11). Martinez-Santos AE, Fernandez-De-La-Iglesia J, Sheaf G, Coyne I: A systematic review of the educational experiences and needs of children with cancer returning to school. J ADV NURS 2021, 77(7):2971-2994. Semendric I, Pollock D, Haller OJ, George RP, Collins-Praino LE, Whittaker AL: "Chemobrain" in childhood cancer survivors-the impact on social, academic, and daily living skills: a qualitative systematic review. SUPPORT CARE CANCER 2023, 31(9):532. Stefanski KJ, Anixt JS, Goodman P, Bowers K, Leisenring W, Scott BK, Burns K, Howell R, Davies S, Robison LL et al : Long-Term Neurocognitive and Psychosocial Outcomes After Acute Myeloid Leukemia: A Childhood Cancer Survivor Study Report. J Natl Cancer Inst 2021, 113(4):481-495. Vanclooster S, Bilsen J, Peremans L, Van der Werff TBJ, Laureys G, Willems E, Genin S, Van Bogaert P, Paquier P, Jansen A: Short-term perspectives of parents and teachers on school reintegration of childhood brain tumour survivors. DEV NEUROREHABIL 2019, 22(5):321-328. Vanclooster S, Bilsen J, Peremans L, Van der Werff TBJ, Laureys G, Willems E, Genin S, Van Bogaert P, Paquier P, Jansen A: Attending school after treatment for a brain tumor: Experiences of children and key figures. J HEALTH PSYCHOL 2019, 24(10):1436-1447. Helms AS, Schmiegelow K, Brok J, Johansen C, Thorsteinsson T, Simovska V, Larsen HB: Facilitation of school re-entry and peer acceptance of children with cancer: a review and meta-analysis of intervention studies. Eur J Cancer Care (Engl) 2016, 25(1):170-179. Spencer B, Wright J, Flemming K, Cottrell D, Pini S: School lives of adolescent school students living with chronic physical health conditions: a qualitative evidence synthesis. ARCH DIS CHILD 2023, 108(3):225-229. Choquette A, Rennick JE, Lee V: Back to School After Cancer Treatment: Making Sense of the Adolescent Experience. CANCER NURS 2016, 39(5):393-401. Larcombe IJ, Walker J, Charlton A, Meller S, Morris JP, Mott MG: Impact of childhood cancer on return to normal schooling. BMJ 1990, 301(6744):169-171. Tomberli L, Ciucci E: Sense of School Belonging and Paediatric Illness: A Scoping Review. Contin Educ 2021, 2(1):121-134. Braun V, Clarke V: Using thematic analysis in psychology. Qual Res Psychol 2006;3:77–101. Tong A, Sainsbury P, Craig J: Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007, 19(6):349-357. Knoerl R, Grandinetti K, Smener L, Doll E, Fecher LA, Henry NL, Karimi Y, Pettit K, Schuetze S, Walling E et al : Exploring Adolescent and Young Adult Cancer Survivors' Experience with Cancer Treatment-Related Symptoms: A Qualitative Analysis of Semi-Structured Interviews. J Adolesc Young Adult Oncol 2024, 13(4):665-673. Andrés-Jensen L, Larsen HB, Johansen C, Frandsen TL, Schmiegelow K, Wahlberg A: Everyday life challenges among adolescent and young adult survivors of childhood acute lymphoblastic leukemia: An in-depth qualitative study. Psychooncology 2020, 29(10):1630-1637. Lincoln G, Guba EG: How can the naturalist meet these trustworthiness criteria. Nat. Inq 1985; 301, 319. Thavakugathasalingam M, Schwind JK: Experience of childhood cancer: A narrative inquiry. J SPEC PEDIATR NURS 2022, 27(2):e12367. Griffiths M, Schweitzer R, Yates P: Childhood experiences of cancer: an interpretative phenomenological analysis approach. J PEDIATR ONCOL NURS 2011, 28(2):83-92. Lindgren LH, Schmiegelow K, Helms AS, Thorsteinsson T, Larsen HB: In sickness and in health: classmates are highly motivated to provide in-hospital support during childhood cancer therapy. Psychooncology 2017, 26(1):37-43. Ingersgaard MV, Fridh MK, Thorsteinsson T, Adamsen L, Schmiegelow K, Baekgaard LH: A qualitative study of adolescent cancer survivors perspectives on social support from healthy peers - A RESPECT study. J ADV NURS 2021, 77(4):1911-1920. Giovanetti M, Clerici CA, Veneroni L, Casiraghi G, Pagani BE, Ferrari A, Podda M, Chopard S, Massimino M: [Continuity and school reentry support of patients with serious diseases: experiences in pediatric oncology.]. Recenti Prog Med 2019, 110(3):131-137. Tresman R, Brown M, Fraser F, Skinner R, Bailey S: A School Passport as Part of a Protocol to Assist Educational Reintegration After Medulloblastoma Treatment in Childhood. PEDIATR BLOOD CANCER 2016, 63(9):1636-1642. Ellis SJ, Fardell JE, Wakefield CE, Schilstra CE, Burns MA, Donnan B, Walwyn T, Lum A, Marshall G, Carter A et al : Are we meeting the training needs of healthcare and education professionals supporting children with cancer in their return to school? PEDIATR BLOOD CANCER 2019, 66(4):e27575. Bava L, Johns A, Kayser K, Freyer DR: Cognitive outcomes among Latino survivors of childhood acute lymphoblastic leukemia and lymphoma: A cross-sectional cohort study using culturally competent, performance-based assessment. PEDIATR BLOOD CANCER 2018, 65(2). Zhang W, Wei X, Ji L, Chen L, Deater-Deckard K: Reconsidering Parenting in Chinese Culture: Subtypes, Stability, and Change of Maternal Parenting Style During Early Adolescence. J Youth Adolesc 2017, 46(5):1117-1136. Chen P, Zhang J, Li H, Fu M: Relationships between Parenting Behaviors and Adolescents' Creativity in China: The Mediating Role of Autonomous Motivation. J PSYCHOL 2021, 155(5):457-472. Tillery R, Long A, Phipps S: Child perceptions of parental care and overprotection in children with cancer and healthy children. J Clin Psychol Med Settings 2014, 21(2):165-172. Tillery R, Willard VW, Howard SK, Klages KL, Long AM, Phipps S: Impact of the parent-child relationship on psychological and social resilience in pediatric cancer patients. Psychooncology 2020, 29(2):339-346. Çavuşoğlu H, Sağlam H: Examining the perceived social support and psychological symptoms among adolescents with leukemia. J SPEC PEDIATR NURS 2015, 20(1):76-85. Ander M, Thorsell CJ, von Essen L, Hovén E: Exploration of psychological distress experienced by survivors of adolescent cancer reporting a need for psychological support. PLOS ONE 2018, 13(4):e195899. Mertens AC, Brand S, Ness KK, Li Z, Mitby PA, Riley A, Patenaude AF, Zeltzer L: Health and well-being in adolescent survivors of early childhood cancer: a report from the Childhood Cancer Survivor Study. Psychooncology 2014, 23(3):266-275. Martinez-Santos AE, Fernandez-De-La-Iglesia J, Sheaf G, Coyne I: A systematic review of the educational experiences and needs of children with cancer returning to school. J ADV NURS 2021, 77(7):2971-2994. Yi J, Kim MA, Sang J: Worries of childhood cancer survivors in young adulthood. EUR J ONCOL NURS 2016, 21:113-119. Tutelman PR, Heathcote LC: Fear of cancer recurrence in childhood cancer survivors: A developmental perspective from infancy to young adulthood. Psychooncology 2020, 29(11):1959-1967. Wroot H, Afzal AR, Forbes C, Russell KB, Trepanier L, Patton M, Fidler-Benaoudia M, Reynolds K, Schulte F: Fear of cancer recurrence among survivors of childhood cancer. Psychooncology 2020, 29(7):1132-1140. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4957799","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":350161915,"identity":"eca7b89b-394c-4432-97d8-57ee8d0f9c3b","order_by":0,"name":"Yunxia Ou","email":"","orcid":"","institution":"Southwest Hospital Jiangbei Area (The 958th hospital of Chinese People's Liberation Army)","correspondingAuthor":false,"prefix":"","firstName":"Yunxia","middleName":"","lastName":"Ou","suffix":""},{"id":350161916,"identity":"20da21c1-b0fc-451c-bb37-982b5e87ac14","order_by":1,"name":"Yan Yang","email":"","orcid":"","institution":"Southwest Hospital Jiangbei Area (The 958th hospital of Chinese People's Liberation Army)","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Yang","suffix":""},{"id":350161917,"identity":"14fc2f1d-fde1-4e2d-897f-d5790f05373b","order_by":2,"name":"Chunmei Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAw0lEQVRIiWNgGAWjYFAC5sYDIIqfmfngAyK1MDaAtUi2syUbkKbF4DyPmQBRGuTbDzYc5vljF218mMGMgaHGJpqgFoMziUAtPMm52w4zpD1gOJaW20BQCwNIi8QBkJbjBowNhwlrke9/CNRicCB3czNjmwRRWhhugGxJOJC7gZmZjTgtBjceNhyccyA5d8ZhNmaDBGL8It+ffPDBmz92uf395z8++FBjQ4TDgICJB8ZKIEY5CDD+IFblKBgFo2AUjEwAAIJQRHSstK5WAAAAAElFTkSuQmCC","orcid":"","institution":"Yuying Children's Hospital of Wenzhou Medical University","correspondingAuthor":true,"prefix":"","firstName":"Chunmei","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2024-08-22 11:47:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4957799/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4957799/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86913070,"identity":"44b2ef08-bfa7-475c-8981-a418768f2d47","added_by":"auto","created_at":"2025-07-17 05:39:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":895288,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4957799/v1/f9e25ccd-07ee-4fd1-95d1-394971f7d1a3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The experiences of childhood leukemia survivors in returning to school: An in-depth qualitative study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eLeukemia is the most common malignancy in childhood. The incidence rate of childhood leukemia (under 15 years old) in China is about 4 to 5 per 100,000 people. If it is expanded to under the age of 18, there are about 15,000 new cases of leukemia in children every year, with an average course of treatment of 2\u0026ndash;3 years per case [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. At present, the treatment method for leukemia is mainly based on combined chemotherapy, supplemented by other supportive therapies [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Because of the long duration of treatment, childhood leukemia survivors who received induction therapy, consolidation therapy, central nervous system prophylaxis, and maintenance therapy had more absenteeism than the general population [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. With the continuous progress of medical technology, children or adolescents with leukemia have a five-year survival rate of more than 80% in both the United States and China [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Because of the higher survival rate, leukemia in children and teenagers is now considered a chronic disease. Accordingly, the number of childhood leukemia survivors returning to school, often after a lengthy absence, is also increasing.\u003c/p\u003e \u003cp\u003eIn general, near-term survivors are those who have completed consolidation or intensive treatment but have not met the 5-year disease-free benchmark that would identify them as long-term survivors [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Therefore, this study defines childhood leukemia survivors as children or adolescents who have completed consolidation or intensive therapy and patient's condition is stable, but may face various physical, psychological, and social problems. For leukemia, after experiencing 2 years or more from diagnosis to treatment cessation, regular health check-ups will begin immediately and will continue for five years, meaning that the maximum risk of relapse has passed [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This is a transitional period in which the child can return to school and continue a normal life.\u003c/p\u003e \u003cp\u003eChildhood leukemia survivors are facing the challenge of returning to school [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Since Chinese societies were framed by Confucianism, most mothers tended to play the role of benevolent protector in Chinese families. Chinese parents establish rules and guidelines for their children based on their parenting style [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Most parents show excessive protection for their children because parents believe that illness makes their children more vulnerable. This tends to underestimate their ability[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Adolescence is a time to achieve important development tasks. But the average treatment time for leukemia is 2\u0026ndash;3 years, during which they are repeatedly hospitalized, hindering social communication with teachers, classmates and friends, and eventually leading to the interruption of socialization [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Even after participants returned to school life, they would generally transfer to a new school or class. As outsiders, they could hardly adapt to the collective life and make new friends in a short time [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This consequence of cancer survival is a meaningful cause of stress in childhood leukemia survivors. Besides, the most significant area of stress for young Chinese people is the pursuit for academic excellence. In the context of Chinese culture, it is characterized by the pursuit of academics and admission to prestigious schools. However, the adverse effects of chemotherapy or radiotherapy, such as memory decline, and lack of concentration, make it difficult for childhood leukemia survivors to achieve the desired academic achievement [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, in, China, participation in school can take on additional significance for children or adolescents with cancer [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. School is an important aspect of childhood leukemia survivors' social lives, and returning to school is conducive to changing attention and starting a new life [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Because participants spent most of their time in school, they could learn like their peers, which reduced participants' loneliness. Some students abide by their student responsibilities and devote themselves to their studies. In school, participants feel a greater sense of belonging, which is an important milestone for them to \"live a normal life\" [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The study stated that school education continuity can improve life quality and promote the reconstruction of psychosocial functions in children or adolescents with cancer [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt present, there has been minimal research in this field based on China's sociocultural context. As a result, the current study aimed to investigate the experiences and adaptation processes of childhood leukemia survivors returning to school in the socio-cultural background of China.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Design\u003c/h2\u003e \u003cp\u003eThis study is a qualitative study using thematic analysis, conducted to explore the experiences of childhood leukemia survivors in returning to school life following cancer treatment. Thematic analysis is a method for identifying, analyzing, and reporting patterns within data [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The reporting of this article follows the Consolidated Criteria for Reporting Qualitative Research [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Participants\u003c/h2\u003e \u003cp\u003eThe participants were selected by purposive sampling from an outpatient hematology/oncology clinic at a Wenzhou medical university-affiliated, tertiary-care pediatric hospital. The data was considered to be saturated when no new recurring themes were identified. Eligible participants (1) had leukemia and no other malignancy at the time of recruitment and interview; (2) were aged 7 to 18 years at the time of recruitment and interview; (3) either consolidation or intensive therapy has been completed and maintenance therapy has been experienced for at least one year.\u003c/p\u003e \u003cp\u003e; (4) had successfully returned to school; and (5) were free of psychiatric illness, capable of normal language communication, and voluntarily participated in the interview. 17 participants met the study eligibility criteria and agreed to participate. One was excluded because he was diagnosed with a cancer recurrence, resulting in a final sample size of 16. Participants ranged in age of diagnosis from 7 to 17 years old. Among them, 9 participants were boys, and 7 participants were girls (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGeneral characteristics of the participants\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"567\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 9.3917%;\"\u003e\n \u003cp\u003eAge of diagnosis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 19.0008%;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 26.8877%;\"\u003e\n \u003cp\u003eSiblings status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.9624%;\"\u003e\n \u003cp\u003eWhether to go back to school\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.6329%;\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003cp\u003eC\u003c/p\u003e\n \u003cp\u003eD\u003c/p\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003cp\u003eG\u003c/p\u003e\n \u003cp\u003eH\u003c/p\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003cp\u003eJ\u003c/p\u003e\n \u003cp\u003eK\u003c/p\u003e\n \u003cp\u003eL\u003c/p\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003cp\u003eO\u003c/p\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 8.0043%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 19.0008%;\"\u003e\n \u003cp\u003eGirl\u003c/p\u003e\n \u003cp\u003eBoy\u003c/p\u003e\n \u003cp\u003eBoy\u003c/p\u003e\n \u003cp\u003eGirl\u003c/p\u003e\n \u003cp\u003eGirl\u003c/p\u003e\n \u003cp\u003eGirl\u003c/p\u003e\n \u003cp\u003eBoy\u003c/p\u003e\n \u003cp\u003eBoy\u003c/p\u003e\n \u003cp\u003eBoy\u003c/p\u003e\n \u003cp\u003eGirl\u003c/p\u003e\n \u003cp\u003eBoy\u003c/p\u003e\n \u003cp\u003eGirl\u003c/p\u003e\n \u003cp\u003eGirl\u003c/p\u003e\n \u003cp\u003eBoy\u003c/p\u003e\n \u003cp\u003eBoy\u003c/p\u003e\n \u003cp\u003eBoy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 26.8877%;\"\u003e\n \u003cp\u003eOlder sister\u003c/p\u003e\n \u003cp\u003eOlder sister\u003c/p\u003e\n \u003cp\u003eYounger brother\u003c/p\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003cp\u003eOlder sister\u003c/p\u003e\n \u003cp\u003eOlder sister\u003c/p\u003e\n \u003cp\u003eOlder sister\u003c/p\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003cp\u003eOlder sister\u003c/p\u003e\n \u003cp\u003eOlder sister\u003c/p\u003e\n \u003cp\u003eYounger brother\u003c/p\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003cp\u003eOlder brother\u003c/p\u003e\n \u003cp\u003eYounger brother\u003c/p\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003cp\u003eOlder sister\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.9624%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Ethical considerations\u003c/h2\u003e \u003cp\u003e Before data collection, the Institutional Review Board (IRB) of the hospital approved this study. The participants, fully informed about the purpose of the study, assured of anonymity and confidentiality, and told that anyone could drop out at any time, had given informed consent verbally and in writing. Especially for children under the age of 15, this study has also obtained the informed consent of parents. Parents have the right to ask children to withdraw from the study at any time without being unfairly treated.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Data collection\u003c/h2\u003e \u003cp\u003eThis interview guide was developed by consulting with oncology professionals and reviewing the literature [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. It had eight open-ended questions concerning the experiences of childhood leukemia survivors in returning to school. These questions were as follows: (1) After the treatment, can tell me what it feels like to go back to school? (2) Do you know how to take care of yourself after returning to school? Have you encountered any difficulties? (3) How do you think your performance in school has changed from before? (4) How do you adapt to the various teaching activities in the school? (5) Can you tell me about your peers or your teacher? (6) What do you believe you should do ahead of time to ensure a smooth return to school? Background information was requested at the end of the interview guide. The questions were tested with three boys who met the inclusion criteria but did not participate. The results demonstrated that the interview guide was adequate.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Procedure\u003c/h2\u003e \u003cp\u003eThe duration of the study was from March 2021 to June 2022. We will prepare gifts for participants before the interview. At the same time, in order to ensure the authenticity of the interview results, try to ensure that the parents are not present when interviewing each participant. However, participants who are too young to understand the interview questions, and their parents will also be invited to an interview. The researchers used the answers of the participants' parents as a supplementary material. But parents did not interfere with their interview when participants encountered questions that could be answered independently. Before data collection, the first author, who had prior experience with qualitative methods, trained four research assistants in interview techniques and data analysis. An interview lasting 30\u0026ndash;60 minutes was conducted by the first author. The other two researchers conducted live recordings and text recordings. During the interview, we do not raise inductive questions, do not evaluate the interview content, and do not easily interrupt the interviewees. While the participants shared their stories, researchers objectively recorded non-verbal symbolic information such as tone, intonation, and expression. After each interview, the data were sorted. The interviews continued until data saturation, that is when themes emerged repetitively, and sufficient information was obtained to answer the research question.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6. Data analysis\u003c/h2\u003e \u003cp\u003eThe recording materials and the researchers\u0026rsquo;on-site observations were transcribed within 24 hours after the interview and confirmed by an additional research assistant. And numbered in order of the interview to protect the respondents' privacy. Themes were retrieved in six stages: becoming acquainted with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and providing a report [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Data were organized and coded manually by two researchers and using NVivo 12 software by one of the researchers. Then they labeled the units based on their content, and a list of codes was created. In the next step, patterns in the codes across the whole data set were identified, and related codes were grouped into potential themes by the development of a thematic map. When there are different opinions, the group will determine the sub-theme and the final theme. The final selection of key themes was agreed upon by all authors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.7. Rigor\u003c/h2\u003e \u003cp\u003eTo ensure the trustworthiness of this study, the quality of research was monitored applying Guba and Lincoln's criteria of credibility, dependability, and Confirmability [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Data credibility was supported by spending time with the subjects to ensure rapport and clarifying responses, which provided ample opportunity for participants to fully discuss their experiences. Credibility was further enhanced through the use of data and investigator triangulation; specifically, data were gathered from multiple sources including interviews and observational field notes, all members of the investigative team participated actively in data analysis, and regular peer debriefing sessions were held with hematology/oncology team members to gather input throughout the data analysis process. Finally, the confirmability and dependability of the data were ensured through the use of an audit trail consisting of audio recordings, transcriptions, and research field notes. Transcripts were read and coding assignments were discussed between researchers until consensus was reached.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eThe experiences of childhood leukemia survivors in returning to school were extracted through interviews in five themes and 11 subthemes (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eThemes and Subthemes.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" style=\"width: 40.3649%;\"\u003e\n \u003cp\u003eThemes\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 59.4464%;\"\u003e\n \u003cp\u003eSubthemes\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 40.3649%;\"\u003e\n \u003cp\u003eBeing on the right track to school\u003c/p\u003e\n \u003cp\u003ePerceived personal happiness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 59.4464%;\"\u003e\n \u003cp\u003eLearn to take care of myself\u003c/p\u003e\n \u003cp\u003eStrive to achieve self-worth\u003c/p\u003e\n \u003cp\u003eFeeling less alone\u003c/p\u003e\n \u003cp\u003eThe pleasure of receiving a teacher\u0026apos;s praise\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 40.3649%;\"\u003e\n \u003cp\u003eDiscovering the gap with others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 59.4464%;\"\u003e\n \u003cp\u003eThe difficult process of rebuilding the friendship\u003c/p\u003e\n \u003cp\u003eSuffering from decreased physical strength\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 40.3649%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 59.4464%;\"\u003e\n \u003cp\u003eHard to keep up with learning progress\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 40.3649%;\"\u003e\n \u003cp\u003eFeelings of excessive care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 60.7675%;\"\u003e\n \u003cp\u003eFeeling uncomfortable with parents\u0026apos; overprotection\u003c/p\u003e\n \u003cp\u003eBeing burdened by the special treatment of others\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\" style=\"width: 40.3649%;\"\u003e\n \u003cp\u003eConcerns about returning\u003c/p\u003e\n \u003cp\u003eto school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 59.4464%;\"\u003e\n \u003cp\u003eWorrying about being mocked\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" style=\"width: 59.4464%;\"\u003e\n \u003cp\u003eFeelings of uncertainty about the disease\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Being on the right track to school\u003c/h2\u003e \u003cp\u003eThe two subthemes in the theme conveyed that participants were prepared for a new return to school and revealed the positive significance of return-to-school for childhood leukemia survivors.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e3.1.1. Learn to take care of myself\u003c/h2\u003e \u003cp\u003eDuring hospitalization, parents played an important role in disease management. Parents would take care of the participants' diets and supervise their medications. After returning to school, some participants could only go home on weekends, meaning they spent most of their time at school. Through the interviews, it was found that the participants had certain self-care abilities and could avoid some risks or bad behaviors.\u003c/p\u003e \u003cp\u003e \u003cem\u003e-In the hospital and at home, my parents have always helped me deal with all kinds of things. In school, I could learn to take care of myself and manage diseases so that I could learn to be independent. I would eat well with three meals and would not eat snacks indiscriminately. I would also arrange my time reasonably and I would not stay up late studying and playing games.\u003c/em\u003e (Participant E)\u003c/p\u003e \u003cp\u003eSome participants were aware of their physical condition and would do what they could to avoid putting themselves in danger.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eAfter returning to school, I would pay attention to my body in a physical education class and would not exercise too vigorously. If I felt uncomfortable, I would immediately inform my teacher.\u003c/em\u003e (Participant C)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eAfter I went to school, my mother often told me not to fight with children so as not to hurt myself. It didn\u0026rsquo;t matter about running and jumping, and I wouldn't do anything dangerous. Without my mother around, I can take good care of myself.\u003c/em\u003e (Participant H)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e3.1.2. Strive to achieve self-worth\u003c/h2\u003e \u003cp\u003eParticipants could continue to pursue academic goals after returning to school. Some participants reported that they worked hard and got good results. They hoped to gain admission to prestigious middle schools or universities, pursue their preferred majors, and realize their life goals.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eI thought I could learn a lot in school. I originally had a good grade, because I was sick and delayed for more than a year, but now I want to catch up with my grades again, hoping to enter a key middle school.\u003c/em\u003e (Participant J)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eI only had more than a year to go to college, and I hoped to do my best to get good grades. After I fell ill this time, I received help from teachers, classmates, and many caring people in society. My dream was to be a doctor and help people like me.\u003c/em\u003e (Participant P)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Perceived personal happiness\u003c/h2\u003e \u003cp\u003eTwo sub-themes of this theme explored participants' improved self-belonging and self-identity after returning to school.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1. Feeling less alone\u003c/h2\u003e \u003cp\u003eReturning to school meant being able to live and learn with your peers and making participants' lives more fun and playful. Participants were happier and less lonely than they were in the hospital.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eI felt much better when I returned to school. I had forgotten about my illness. Maybe it was too stuffy to stay in the hospital, and I just lay in bed every day to play with my phone. Not only did I have no friends to chat with, but I also had to get injections and take medicine. In school, my classmates and I go to class, do homework together, and play together after school.\u003c/em\u003e (Participant A)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eAt that time, I wanted to go to school. My teachers and classmates often sent me WeChat messages to let me go back to class early. I also miss them very much. When I went back to school, I at least had the same language as my peers and felt less lonely.\u003c/em\u003e (Participant C)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2. The pleasure of receiving a teacher's praise\u003c/h2\u003e \u003cp\u003eParticipants believed that returning to school could acquire knowledge and skills while being recognized by teachers, which was conducive to better growth of participants.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eThe teacher liked me very much. When I answered questions in class, the teacher would ask me questions and often praised me. Sometimes in the morning, the teacher would ask me to stand on the platform and teach my classmates to read, which made me very proud and gave me a sense of achievement.\u003c/em\u003e (Participant D)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eIn the art class, the teacher will usually teach us to draw. Every time my paintings are taken out by the teacher for exhibition in the class. At that time, I was always happy and proud.\u003c/em\u003e (Participant M)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eIn class, I always will raise my hand to answer the teacher's questions actively. Although sometimes the answers are not perfect, the teacher will praise. I think this is the teacher's recognition of me.\u003c/em\u003e (Participant B)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Discovering the gap with others\u003c/h2\u003e \u003cp\u003e After disease treatment, participants perceived their gap with others in re-establishing friendships, learning, and physical strength.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003e3.3.1. The difficult process of rebuilding the friendship\u003c/h2\u003e \u003cp\u003eMost of the participants had to interrupt school life due to hospitalization, and childhood leukemia survivors had little time or opportunity to meet their classmates. In the late stage of maintenance treatment, most participants would transfer to a new class or school. As outsiders, it was difficult for them to adapt to the collective life of the new school or class in a short time.\u003c/p\u003e \u003cp\u003e\u003cul\u003e\u003cli\u003e \u003cp\u003e \u003cem\u003eI spent most of my time in the hospital, so we slowly got less connected. We also only occasionally contacted them by phone and WeChat.\u003c/em\u003e (Participant I)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e \u003cp\u003e \u003cem\u003eI am not familiar with these students in the new class, and I usually do not take the initiative to greet and talk to them. In my second year in junior high school, my classmates had already been friends since the first year. And they had their fixed friends, just like that. It was a little difficult for me to integrate into it.\u003c/em\u003e (Participant J)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e \u003cp\u003eParticipants were emotionally unstable and irritable as a result of the use of hormones, which made their relationships with peers difficult. This lack of peer interaction made participants gradually alienated from their peers, and it was difficult to rebuild the friendships quickly.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eSince I started taking hormone drugs, my mother always said that my character has become irritable and self-centered, and I lose my temper from time to time. I also felt sulky and didn't know how to get along with others.\u003c/em\u003e (Participant G)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eDuring the time I was taking (hormone) medication, I felt like I was somehow unhappy and didn't want to play with other kids.\u003c/em\u003e (Participant C)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003e3.3.2. Suffering from decreased physical strength\u003c/h2\u003e \u003cp\u003eBecause of the disease, most of the participants have experienced side effects of drug chemotherapy treatment. Their immunity is generally lower than that of their peers, and their activity tolerance is lower than before they were ill. Therefore, the frequency of participants participating in sports activities has decreased to varying degrees.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eAs my body was a little weak, I couldn't fully participate in physical exercise. The teacher would also let me sit aside and rest. I had to watch them exercise.\u003c/em\u003e (Participant L)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eMy physical strength must be a little worse now compared to before I got sick. When I was halfway through my endurance training, my strength dropped a bit, and I couldn't finish the whole race.\u003c/em\u003e (Participant P)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003e3.3.3. Hard to keep up with learning progress\u003c/h2\u003e \u003cp\u003eParticipants with a weak learning foundation may be unable to focus totally on learning as a result of therapy side effects that interrupt learning during treatment. Although they tried to study hard and narrow the gap with their classmates, the learning effect was not obvious.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eI was going to the second grade of middle school, but after a year of suspension, it was difficult to catch up in a year, so I had to choose to study for another year. Sometimes I will stay up late to study, and my parents will worry about my body and persuade me to go to rest early. I put in a lot of energy in that regard, yet my academic performance was ordinary.\u003c/em\u003e (Participant J)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eI feel that my memory and reflexes are not as good as before. I used to feel that my math was OK, but now I have a little difficulty in learning, and I have not done well in the exams.\u003c/em\u003e (Participant O)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAfter returning to school, participants also need to go to the hospital for treatment and examinations intermittently, and each time they need to ask the school for about 1 day off. This made it more difficult for them to catch up with their peers.\u003c/p\u003e \u003cp\u003e \u003cem\u003e- I returned to school after several months of treatment. My foundation has been poor, but I still need to go to the hospital once a week. I was very concerned about falling behind in so many courses. My academic performance cannot keep up.\u003c/em\u003e (Participant I)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Feelings of excessive care\u003c/h2\u003e \u003cp\u003eSome participants reported that their parents were excessively concerned about their health, limiting their participation in activities or contact with their peers, which made participants feel uncomfortable. At the same time, the special treatment from the teachers or others makes the participants feel burdened, which makes the participants feel different from the others.\u003c/p\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003e3.4.1. Feeling uncomfortable with parents' overprotection\u003c/h2\u003e \u003cp\u003e In the sight of parents Such health-related problems and concerns excluded participants from groups and physical activities, which meant that they lost their competitive qualifications in sports and reduced their opportunities to contact their peers.\u003c/p\u003e \u003cp\u003e\u003cul\u003e\u003cli\u003e \u003cp\u003e \u003cem\u003eWhen the sports meeting came, the students were eager to sign up to participate in the competition. I was also ready to participate in rope skipping. However, my father was worried about my body and he refused my request, which frustrated me.\u003c/em\u003e (Participant F)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e \u003cp\u003e \u003cem\u003eI completely hated the view that parents have, that \u0026ldquo;you are a sick and weak kid, so s/he can\u0026rsquo;t do those things.\u003c/em\u003e (Participant F)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003e3.4.2. Being burdened by the special treatment of others\u003c/h2\u003e \u003cp\u003eParticipants hoped that teachers or classmates would not pay too much attention to them, which would burden them. Participants tried to remain unnoticed. Participants hoped that teachers would not take excessive care of them because of illness, whether in terms of study or life, and they hoped to be treated equally. Being treated specifically by others causes participants to think they are different from others.\u003c/p\u003e \u003cp\u003e \u003cem\u003e- Because my situation was more special than that of other students, the teacher usually paid special attention to me. When we did something wrong, the teacher criticized other people but didn't say much about me. I didn't like that. It always makes me feel different from others.\u003c/em\u003e (Participant B)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e3.5. Concerns about returning to school\u003c/h2\u003e \u003cp\u003e At the beginning of returning to school after cancer treatment, participants also did not know how to talk to others about their illnesses. Participants were concerned about their image, worried about being mocked by their peers when they returned to school, and hoped to be understood and accepted by their peers. At the same time, participants also showed fear of disease recurrence and hoped to receive professional support from medical staff.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003e3.5.1. Worrying about being mocked\u003c/h2\u003e \u003cp\u003eSome participants experienced pain caused by disease symptoms and treatment, hoping to gain the understanding and respect of the students. At the early stage of returning to school, participants were worried about being noticed, ridiculed, or discussed behind their backs by their peers, and they hoped that their classmates and friends would not deliberately alienate themselves due to illness.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eI didn't tell my classmates, or even my best friend, that I had leukemia. I was afraid they would mind this. I hoped they accept me\u003c/em\u003e. (Participant O)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eAt first, I was wearing a hat and didn't want to go to a crowded place. At school, I was afraid that my classmates would laugh at me and ask me why I didn't have hair. Some classmates didn't want to play with me.\u003c/em\u003e (Participant F)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003e3.5.2. Feelings of uncertainty about the disease\u003c/h2\u003e \u003cp\u003eAfter returning to school, they were worried about the recurrence of the disease. Participants hoped to get long-term attention and follow-up from doctors or nurses to solve their health problems in time.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eAfter stepping into the school gate, I often worry that I will be uncomfortable. Schools also regularly carry out safety education, but it was aimed at everyone, not just at my disease. I was worried that (the disease) would recur and I would need to be hospitalized again.\u003c/em\u003e (Participant E)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eIt is hard to believe that it happened to me again. How painful it would be if my parents saw me get my chemotherapy again. So I was very worried about it.\u003c/em\u003e (Participant P)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eParticipants consider returning to school after cancer treatment as a complex transition since the occasion represents the end of illness and the beginning of a return to regular life [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Returning to school is challenging for childhood leukemia survivors, and even if the process is not always smooth, children or adolescents will learn and grow in the process.\u003c/p\u003e \u003cp\u003eA smooth transition from hospital to school is both a manifestation of the physical recovery of childhood leukemia survivors and an important dimension of psychosocial recovery in childhood leukemia survivors [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. These participants are in a vital stage of learning, habit formation, and interpersonal skill development, and the school provides a learning environment for them. Allow individuals to believe that they, indeed, can achieve their objectives. Additionally, in this study, with the company of friends or encouragement from teachers, participants can feel the existence of self-worth. Our findings were based on prior studies that highlighted the importance of peer networks during treatment for participants' transition back to school following cancer treatment [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Participants return to school smoothly, which means moving on with their lives and promoting the social development of individuals. Therefore, nursing staff can arrange for survivors who have successfully returned to school to contact participants who are ready to return to school via remote video-sharing sessions to convey their successful experience and perceived benefits of the return to school process.\u003c/p\u003e \u003cp\u003eParticipants identified a gap between themselves and others. As life began to stretch beyond the hospital, the most prevalent problem that pediatric leukemia survivors faced in their transition from hospital to school was friendship. According to the findings of this study, participants showed rebuilding friendship difficulties. The same concerns have been reported in previous research that cancer survivors experienced difficulties in peer relationships after returning to school and they tended to worry about whether they could make new friends once returning to school [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. In addition, lower physical strength may also lead to childhood leukemia survivors being unable to perform daily tasks independently, resulting in a poor school life experience, which can affect their self-confidence and sense of self-worth. Therefore, emotional and social support systems should be integrated into existing educational support systems, such as school passport projects or comprehensive assessment programs for campus activities [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Our findings also showed that the pediatric leukemia survivors tried hard to study when they returned to school following treatment, yet their academic performance was inadequate. This was similar to the findings of other studies [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] in which chemotherapy and radiotherapy were demonstrated to cause neurocognitive abnormalities in growing children. In this context, the treatment of the sequelae makes it challenging for pediatric leukemia survivors to catch up with their peers, despite their best efforts to concentrate on academic achievement. Therefore, continuous, lifetime monitoring for neurocognitive late effects is required to improve their education.\u003c/p\u003e \u003cp\u003eParticipants wanted to be identified, and had a desire to gain the same stable identity as their peers. In this study, the participants' parents' extreme care caused them to rarely participate in sports activities after returning to school, which resulted in reduced opportunities for some participants to interact with their peers. Parents frequently exhibit excessive protection and underestimate the capabilities of their children [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Consistent with this study, a foreign study found that parental protection and over-surveillance of young leukemia survivors' actions limited their potential to grow into independent adults [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Additionally, in this study, teachers' excessive attention not only made participants feel burdened but could also be perceived by other students as special treatment. Similar to this study, an earlier study found that teachers' excessive attention made participants feel different from others around them, resulting in negative sensations or experiences [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. As a result, participants hoped to be treated equally by teachers. Therefore, caregivers should establish the correct parenting style and give children moderate attention. At the same time, teachers should master cancer knowledge to establish a good support link.\u003c/p\u003e \u003cp\u003eThere are also many concerns when childhood leukemia survivors return to school. On the one hand, self-image was a crucial factor for childhood leukemia survivors, with significant consequences for their mental health and social interaction development [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. In this study, participants were concerned that their friends' attention would be drawn to their short hair and other physical symptoms of sickness treatment, causing them to feel upset and negatively influenced. Distinctions in the look of young leukemia survivors may have an impact on survivors' psychological function following treatment, making it harder to establish self-esteem and self-confidence after returning to school [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. They looked forward to being understood and respected by their classmates, which was consistent with the previous research [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. On the other hand, they often worry about the recurrence of the disease, which is related to the lack of knowledge of the disease. This was consistent with the previous findings [\u003cspan additionalcitationids=\"CR52\" citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Therefore, it is recommended that healthcare workers explain disease knowledge to childhood leukemia survivors and their caregivers and inform them to follow up regularly. At the same time, tertiary hospitals need to strengthen the guidance of community health service centers and actively engage in telemedicine cooperation. The community then regularly assesses the physical and mental health of survivors using a medical information consultation platform.\u003c/p\u003e"},{"header":"5. Limitations","content":"\u003cp\u003eParticipants in this study experienced different difficulties at different times, thus necessitating long-term follow-up interviews with childhood leukemia survivors when they return to school after treatment. The male-to-female ratio of the participants in this study was uneven, and the age span of the recruited participants was slightly larger, so future studies should stratify the populations of different age groups. At the same time, quantitative research involving a larger number of participants from various regions is required to identify specific difficulties in childhood leukemia survivors based on diagnosis age and treatment periods.\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eChildhood leukemia survivors are vulnerable to social, cognitive, and educational changes. In this study, we learned about the benefits and challenges of returning to school. We should meet the reasonable needs of participants to increase their motivation to return to school. Some participants looked forward to returning to school, which gave participants a sense of belonging and identity. Returning to school can further foster participant independence. Recognition of the benefits of return to school could mobilize more childhood leukemia survivors of similar conditions to participate in return to school.\u003c/p\u003e \u003cp\u003eHowever, after the treatment, some participants had some difficulties in rebuilding friendship, learning, and physical appearance. They have difficulty catching up with their peers due to the educational gap caused by disease treatment. As a teenager who naturally values his self-identity, he feels stressed when he is too different from others. As it confirms that participants are what others think they are different from their peers. Therefore, these findings indicate that a plan must be developed to assist childhood leukemia survivors in actively perceiving the benefits of returning to school, while caregivers and healthcare providers should master the challenges faced by childhood leukemia survivors and fully and immediately support them so that they can re-adjust to school life.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by Zhejiang Provincial Public Welfare Technology Application Research Project (LGF21G020002) and Major Scientific and Technological Innovation Projects in Wenzhou (ZY2020022).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCRediT authorship contribution statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eYunxia Ou:\u0026nbsp;\u003c/strong\u003eConceptualization, Methodology, Data collection, Data curation, Data interpretation, Visualization, Writing - original draft.\u0026nbsp;\u003cstrong\u003eYang Yan:\u0026nbsp;\u003c/strong\u003eConceptualization, Validation, Investigation, Writing - review \u0026amp; editing.\u0026nbsp;\u003cstrong\u003eChunmei Zhang:\u0026nbsp;\u003c/strong\u003eValidation, Investigation, Writing - review \u0026amp; editing, Supervision, Project administration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of competing interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The experimental protocol was established, according to the ethical guidelines of the Helsinki Declaration and was approved by the Ethics Committee of \u0026nbsp;The Second Affiliated Hospital of Wenzhou Medical University (Approval No.: LCKY2020-198). Written informed consent was obtained from individual or guardian participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Zhejiang Natural Science Foundation and Wenzhou Science and Technology Bureau for their financial assistance to this project. We would also like to express our gratitude to all participating leukemia survivors for their contributions to the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNamayandeh SM, Khazaei Z, Lari Najafi M, Goodarzi E, Moslem A: GLOBAL Leukemia in Children 0-14 Statistics 2018, Incidence and Mortality and Human Development Index (HDI): GLOBOCAN Sources and Methods. \u003cem\u003eAsian Pacific journal of cancer prevention : APJCP\u003c/em\u003e 2020, 21(5):1487-1494.\u003c/li\u003e\n\u003cli\u003eElgarten CW, Aplenc R: Pediatric acute myeloid leukemia: updates on biology, risk stratification, and therapy. \u003cem\u003eCURR OPIN PEDIATR\u003c/em\u003e 2020, 32(1):57-66.\u003c/li\u003e\n\u003cli\u003eChang JH, Poppe MM, Hua CH, Marcus KJ, Esiashvili N: Acute lymphoblastic leukemia. \u003cem\u003ePEDIATR BLOOD CANCER\u003c/em\u003e 2021, 68 Suppl 2:e28371.\u003c/li\u003e\n\u003cli\u003eAllison MA, Attisha E: The Link Between School Attendance and Good Health. \u003cem\u003ePEDIATRICS\u003c/em\u003e 2019, 143(2).\u003c/li\u003e\n\u003cli\u003eAlvarez EM, Malogolowkin M, Hoch JS, Li Q, Brunson A, Pollock BH, Muffly L, Wun T, Keegan T: Treatment Complications and Survival Among Children and Young Adults With Acute Lymphoblastic Leukemia. \u003cem\u003eJCO Oncol Pract\u003c/em\u003e 2020, 16(10):e1120-e1133.\u003c/li\u003e\n\u003cli\u003ePieters R, Mullighan CG, Hunger SP: Advancing Diagnostics and Therapy to Reach Universal Cure in Childhood ALL. \u003cem\u003eJ CLIN ONCOL\u003c/em\u003e 2023, 41(36):5579-5591.\u003c/li\u003e\n\u003cli\u003eDoyle N: Cancer survivorship: evolutionary concept analysis. \u003cem\u003eJ ADV NURS\u003c/em\u003e 2008, 62(4):499-509.\u003c/li\u003e\n\u003cli\u003eCantrell MA, Conte TM: Between being cured and being healed: the paradox of childhood cancer survivorship. \u003cem\u003eQUAL HEALTH RES\u003c/em\u003e 2009, 19(3):312-322.\u003c/li\u003e\n\u003cli\u003eTremolada M, Taverna L, Bonichini S, Pillon M, Biffi A, Putti MC: Pediatric Patients Treated for Leukemia Back to School: A Mixed-Method Analysis of Narratives about Daily Life and Illness Experience. \u003cem\u003eBehav Sci (Basel)\u003c/em\u003e 2020, 10(7).\u003c/li\u003e\n\u003cli\u003eDouvas MG, Riegler LL: Meeting Challenges in the Long-Term Care of Children, Adolescents, and Young Adults with Acute Lymphoblastic Leukemia. \u003cem\u003eCurr Hematol Malig Rep\u003c/em\u003e 2022, 17(1):15-24.\u003c/li\u003e\n\u003cli\u003eWang MJ, Dzifa KL, Lei J, Kan X, Zhang RX: The experiences of children and adolescents with cancer returning to school: A qualitative meta-synthesis. \u003cem\u003eJ PEDIATR NURS\u003c/em\u003e 2024, 76:140-149.\u003c/li\u003e\n\u003cli\u003eDing G, Xu L, Sun L: Association Between Parental Parenting Style Disparities and Mental Health: An Evidence From Chinese Medical College Students. \u003cem\u003eFront Public Health\u003c/em\u003e 2022, 10:841140.\u003c/li\u003e\n\u003cli\u003eWang J, Huang X, Li Z, Chen K, Jin Z, He J, Han B, Feng L, Meng N, Yang C\u003cem\u003e et al\u003c/em\u003e: Effect of parenting style on the emotional and behavioral problems among Chinese adolescents: the mediating effect of resilience. \u003cem\u003eBMC PUBLIC HEALTH\u003c/em\u003e 2024, 24(1):787.\u003c/li\u003e\n\u003cli\u003eHuang L, Wu W, Yang F: Parenting Style and Subjective Well-Being in Children and Youth: A Meta-Analysis. \u003cem\u003ePSYCHOL REP\u003c/em\u003e 2024:328561741.\u003c/li\u003e\n\u003cli\u003eShi H, Zhao H, Ren Z, Li X, He M, Zha S, Qiao S, Li Y, Pu Y, Liu H\u003cem\u003e et al\u003c/em\u003e: Associations of parent-adolescent relationship and self-esteem with emotional and behavioral problems among Chinese adolescents. \u003cem\u003eJ Affect Disord\u003c/em\u003e 2022, 311:126-133.\u003c/li\u003e\n\u003cli\u003eHua K, Hongwang X, Yujian D, Xuefeng W, Wei Z: Effects of parenting mode on student adaptability: the mediating effect of irrational beliefs. \u003cem\u003eBMC PSYCHIATRY\u003c/em\u003e 2022, 22(1):592.\u003c/li\u003e\n\u003cli\u003eTang X, Mo L, Liu Q, Liu Y, Yu L, Liu Y, Gao C: Adverse experiences of social adaptation in children with leukaemia: a qualitative study from China. \u003cem\u003eBMJ OPEN\u003c/em\u003e 2022, 12(3):e51953.\u003c/li\u003e\n\u003cli\u003eLi HC, Lopez V, Joyce CO, Ho KY, Chiu SY: The impact of cancer on the physical, psychological and social well-being of childhood cancer survivors. \u003cem\u003eEUR J ONCOL NURS\u003c/em\u003e 2013, 17(2):214-219.\u003c/li\u003e\n\u003cli\u003eGal\u0026aacute;n S, Tom\u0026eacute;-Pires C, Roy R, Castarlenas E, Racine M, Jensen MP, Mir\u0026oacute; J: Improving the Quality of Life of Cancer Survivors in School: Consensus Recommendations Using a Delphi Study. \u003cem\u003eChildren (Basel)\u003c/em\u003e 2021, 8(11).\u003c/li\u003e\n\u003cli\u003eMartinez-Santos AE, Fernandez-De-La-Iglesia J, Sheaf G, Coyne I: A systematic review of the educational experiences and needs of children with cancer returning to school. \u003cem\u003eJ ADV NURS\u003c/em\u003e 2021, 77(7):2971-2994.\u003c/li\u003e\n\u003cli\u003eSemendric I, Pollock D, Haller OJ, George RP, Collins-Praino LE, Whittaker AL: \u0026quot;Chemobrain\u0026quot; in childhood cancer survivors-the impact on social, academic, and daily living skills: a qualitative systematic review. \u003cem\u003eSUPPORT CARE CANCER\u003c/em\u003e 2023, 31(9):532.\u003c/li\u003e\n\u003cli\u003eStefanski KJ, Anixt JS, Goodman P, Bowers K, Leisenring W, Scott BK, Burns K, Howell R, Davies S, Robison LL\u003cem\u003e et al\u003c/em\u003e: Long-Term Neurocognitive and Psychosocial Outcomes After Acute Myeloid Leukemia: A Childhood Cancer Survivor Study Report. \u003cem\u003eJ Natl Cancer Inst\u003c/em\u003e 2021, 113(4):481-495.\u003c/li\u003e\n\u003cli\u003eVanclooster S, Bilsen J, Peremans L, Van der Werff TBJ, Laureys G, Willems E, Genin S, Van Bogaert P, Paquier P, Jansen A: Short-term perspectives of parents and teachers on school reintegration of childhood brain tumour survivors. \u003cem\u003eDEV NEUROREHABIL\u003c/em\u003e 2019, 22(5):321-328.\u003c/li\u003e\n\u003cli\u003eVanclooster S, Bilsen J, Peremans L, Van der Werff TBJ, Laureys G, Willems E, Genin S, Van Bogaert P, Paquier P, Jansen A: Attending school after treatment for a brain tumor: Experiences of children and key figures. \u003cem\u003eJ HEALTH PSYCHOL\u003c/em\u003e 2019, 24(10):1436-1447.\u003c/li\u003e\n\u003cli\u003eHelms AS, Schmiegelow K, Brok J, Johansen C, Thorsteinsson T, Simovska V, Larsen HB: Facilitation of school re-entry and peer acceptance of children with cancer: a review and meta-analysis of intervention studies. \u003cem\u003eEur J Cancer Care (Engl)\u003c/em\u003e 2016, 25(1):170-179.\u003c/li\u003e\n\u003cli\u003eSpencer B, Wright J, Flemming K, Cottrell D, Pini S: School lives of adolescent school students living with chronic physical health conditions: a qualitative evidence synthesis. \u003cem\u003eARCH DIS CHILD\u003c/em\u003e 2023, 108(3):225-229.\u003c/li\u003e\n\u003cli\u003eChoquette A, Rennick JE, Lee V: Back to School After Cancer Treatment: Making Sense of the Adolescent Experience. \u003cem\u003eCANCER NURS\u003c/em\u003e 2016, 39(5):393-401.\u003c/li\u003e\n\u003cli\u003eLarcombe IJ, Walker J, Charlton A, Meller S, Morris JP, Mott MG: Impact of childhood cancer on return to normal schooling. \u003cem\u003eBMJ\u003c/em\u003e 1990, 301(6744):169-171.\u003c/li\u003e\n\u003cli\u003eTomberli L, Ciucci E: Sense of School Belonging and Paediatric Illness: A Scoping Review. \u003cem\u003eContin Educ\u003c/em\u003e 2021, 2(1):121-134.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V: Using thematic analysis in psychology. Qual Res Psychol 2006;3:77\u0026ndash;101. \u003c/li\u003e\n\u003cli\u003eTong A, Sainsbury P, Craig J: Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. \u003cem\u003eInt J Qual Health Care\u003c/em\u003e 2007, 19(6):349-357.\u003c/li\u003e\n\u003cli\u003eKnoerl R, Grandinetti K, Smener L, Doll E, Fecher LA, Henry NL, Karimi Y, Pettit K, Schuetze S, Walling E\u003cem\u003e et al\u003c/em\u003e: Exploring Adolescent and Young Adult Cancer Survivors\u0026apos; Experience with Cancer Treatment-Related Symptoms: A Qualitative Analysis of Semi-Structured Interviews. \u003cem\u003eJ Adolesc Young Adult Oncol\u003c/em\u003e 2024, 13(4):665-673.\u003c/li\u003e\n\u003cli\u003eAndr\u0026eacute;s-Jensen L, Larsen HB, Johansen C, Frandsen TL, Schmiegelow K, Wahlberg A: Everyday life challenges among adolescent and young adult survivors of childhood acute lymphoblastic leukemia: An in-depth qualitative study. \u003cem\u003ePsychooncology\u003c/em\u003e 2020, 29(10):1630-1637.\u003c/li\u003e\n\u003cli\u003eLincoln G, Guba EG: How can the naturalist meet these trustworthiness criteria. Nat. Inq 1985; 301, 319.\u003c/li\u003e\n\u003cli\u003eThavakugathasalingam M, Schwind JK: Experience of childhood cancer: A narrative inquiry. \u003cem\u003eJ SPEC PEDIATR NURS\u003c/em\u003e 2022, 27(2):e12367.\u003c/li\u003e\n\u003cli\u003eGriffiths M, Schweitzer R, Yates P: Childhood experiences of cancer: an interpretative phenomenological analysis approach. \u003cem\u003eJ PEDIATR ONCOL NURS\u003c/em\u003e 2011, 28(2):83-92.\u003c/li\u003e\n\u003cli\u003eLindgren LH, Schmiegelow K, Helms AS, Thorsteinsson T, Larsen HB: In sickness and in health: classmates are highly motivated to provide in-hospital support during childhood cancer therapy. \u003cem\u003ePsychooncology\u003c/em\u003e 2017, 26(1):37-43.\u003c/li\u003e\n\u003cli\u003eIngersgaard MV, Fridh MK, Thorsteinsson T, Adamsen L, Schmiegelow K, Baekgaard LH: A qualitative study of adolescent cancer survivors perspectives on social support from healthy peers - A RESPECT study. \u003cem\u003eJ ADV NURS\u003c/em\u003e 2021, 77(4):1911-1920.\u003c/li\u003e\n\u003cli\u003eGiovanetti M, Clerici CA, Veneroni L, Casiraghi G, Pagani BE, Ferrari A, Podda M, Chopard S, Massimino M: [Continuity and school reentry support of patients with serious diseases: experiences in pediatric oncology.]. \u003cem\u003eRecenti Prog Med\u003c/em\u003e 2019, 110(3):131-137.\u003c/li\u003e\n\u003cli\u003eTresman R, Brown M, Fraser F, Skinner R, Bailey S: A School Passport as Part of a Protocol to Assist Educational Reintegration After Medulloblastoma Treatment in Childhood. \u003cem\u003ePEDIATR BLOOD CANCER\u003c/em\u003e 2016, 63(9):1636-1642.\u003c/li\u003e\n\u003cli\u003eEllis SJ, Fardell JE, Wakefield CE, Schilstra CE, Burns MA, Donnan B, Walwyn T, Lum A, Marshall G, Carter A\u003cem\u003e et al\u003c/em\u003e: Are we meeting the training needs of healthcare and education professionals supporting children with cancer in their return to school? \u003cem\u003ePEDIATR BLOOD CANCER\u003c/em\u003e 2019, 66(4):e27575.\u003c/li\u003e\n\u003cli\u003eBava L, Johns A, Kayser K, Freyer DR: Cognitive outcomes among Latino survivors of childhood acute lymphoblastic leukemia and lymphoma: A cross-sectional cohort study using culturally competent, performance-based assessment. \u003cem\u003ePEDIATR BLOOD CANCER\u003c/em\u003e 2018, 65(2).\u003c/li\u003e\n\u003cli\u003eZhang W, Wei X, Ji L, Chen L, Deater-Deckard K: Reconsidering Parenting in Chinese Culture: Subtypes, Stability, and Change of Maternal Parenting Style During Early Adolescence. \u003cem\u003eJ Youth Adolesc\u003c/em\u003e 2017, 46(5):1117-1136.\u003c/li\u003e\n\u003cli\u003eChen P, Zhang J, Li H, Fu M: Relationships between Parenting Behaviors and Adolescents\u0026apos; Creativity in China: The Mediating Role of Autonomous Motivation. \u003cem\u003eJ PSYCHOL\u003c/em\u003e 2021, 155(5):457-472.\u003c/li\u003e\n\u003cli\u003eTillery R, Long A, Phipps S: Child perceptions of parental care and overprotection in children with cancer and healthy children. \u003cem\u003eJ Clin Psychol Med Settings\u003c/em\u003e 2014, 21(2):165-172.\u003c/li\u003e\n\u003cli\u003eTillery R, Willard VW, Howard SK, Klages KL, Long AM, Phipps S: Impact of the parent-child relationship on psychological and social resilience in pediatric cancer patients. \u003cem\u003ePsychooncology\u003c/em\u003e 2020, 29(2):339-346.\u003c/li\u003e\n\u003cli\u003e\u0026Ccedil;avuşoğlu H, Sağlam H: Examining the perceived social support and psychological symptoms among adolescents with leukemia. \u003cem\u003eJ SPEC PEDIATR NURS\u003c/em\u003e 2015, 20(1):76-85.\u003c/li\u003e\n\u003cli\u003eAnder M, Thorsell CJ, von Essen L, Hov\u0026eacute;n E: Exploration of psychological distress experienced by survivors of adolescent cancer reporting a need for psychological support. \u003cem\u003ePLOS ONE\u003c/em\u003e 2018, 13(4):e195899.\u003c/li\u003e\n\u003cli\u003eMertens AC, Brand S, Ness KK, Li Z, Mitby PA, Riley A, Patenaude AF, Zeltzer L: Health and well-being in adolescent survivors of early childhood cancer: a report from the Childhood Cancer Survivor Study. \u003cem\u003ePsychooncology\u003c/em\u003e 2014, 23(3):266-275.\u003c/li\u003e\n\u003cli\u003eMartinez-Santos AE, Fernandez-De-La-Iglesia J, Sheaf G, Coyne I: A systematic review of the educational experiences and needs of children with cancer returning to school. \u003cem\u003eJ ADV NURS\u003c/em\u003e 2021, 77(7):2971-2994.\u003c/li\u003e\n\u003cli\u003eYi J, Kim MA, Sang J: Worries of childhood cancer survivors in young adulthood. \u003cem\u003eEUR J ONCOL NURS\u003c/em\u003e 2016, 21:113-119.\u003c/li\u003e\n\u003cli\u003eTutelman PR, Heathcote LC: Fear of cancer recurrence in childhood cancer survivors: A developmental perspective from infancy to young adulthood. \u003cem\u003ePsychooncology\u003c/em\u003e 2020, 29(11):1959-1967.\u003c/li\u003e\n\u003cli\u003eWroot H, Afzal AR, Forbes C, Russell KB, Trepanier L, Patton M, Fidler-Benaoudia M, Reynolds K, Schulte F: Fear of cancer recurrence among survivors of childhood cancer. \u003cem\u003ePsychooncology\u003c/em\u003e 2020, 29(7):1132-1140.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Leukemia, Survivor, Return to school, Qualitative study","lastPublishedDoi":"10.21203/rs.3.rs-4957799/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4957799/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo explore and describe the experiences of childhood leukemia survivors in the transition from home to school following cancer treatment.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e Study participants include 16 survivors who visited a hospital for follow-up care following treatment for leukemia at a university hospital in Wenzhou. We conducted an in-depth, semi-structured interviews with 16 participants. The interview data were analyzed according to the thematic analysis method.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe extracted 5 themes from the interviews: (a) Being on the right track to school, (b) Perceived personal happiness, (c) Discovering the gap with others, (d) Feelings of being excessive care, and (e) Concerns about returning to school. Five main themes suggest that the return to school hallmarked the beginning of a new life and the experience of a new environment. Participants reported having different feelings after returning to school. On the one hand, personal happiness is enhanced, and on the other hand, individuals need to face up to the practical problems encountered in school.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eChildhood leukemia survivors can seek self-worth and identity after returning to school, but also face friendship, learning and physical difficulties. Medical staff should pay more attention to this group and give them enough support to better adapt to campus life.\u003c/p\u003e","manuscriptTitle":"The experiences of childhood leukemia survivors in returning to school: An in-depth qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-27 08:28:44","doi":"10.21203/rs.3.rs-4957799/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1ff6443a-495a-4481-824e-55450cf95e2b","owner":[],"postedDate":"September 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-17T05:39:05+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-27 08:28:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4957799","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4957799","identity":"rs-4957799","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}