In Austria, about 190,000 children and adolescents suffer from a chronic disease (heart defects, cancer, etc.) and are only able to attend school to a limited extent or not at all due to medical treatment or hospitalisation (Bundesministerium für Gesundheit, 2016).  Absences from school have serious consequences such as early school leaving, frequent class repetition, social isolation, reduced sense of belonging or psychological sequelae, etc. (Blum, 2005; Kirkpatrick, 2020; Ginsburg, Jordan, & Chang, 2014; Maes, et al., 2017). Due to their illness, the affected pupils not only suffer physically but are also excluded from participating in class activities. In this respect, exclusion takes place on several levels. 

Telepresence systems such as avatars, virtual classrooms, and mobile telepresence robots have been discussed in recent years as promising approach to improve school participation for children and adolescents with chronic illnesses (Ahumada-Newhart et al., 2016; Gilmour et al., 2015; Soares et al., 2017). Studies points out the potential of telepresence systems for the integration of children and adolescents with chronic illnesses having a positive impact on their psychological and social development. Therefore, telepresence systems, creating a sense of physical presence at a remote location using multimedia, are used to remedy this situation. 

In the present study, the technical telepresence system avatar AV1 is investigated in terms of pediatric patients sense of belonging to the school community during their physical absence from school. The AV1 sits in the classroom, is controlled via tablet. Avatar AV1 is ear and voice of the child, it can turn around and can make facial expressions.

The aim of the study is to investigate the changes, opportunities and obstacles of the use of an avatar AV1 for the actors involved in the school system, based on current topics in educational research (inclusion and participation, digitalised teaching, class management, teaching-learning relationships, social inclusion). The study is intended to provide insights into the sense of belonging of children in chronic health conditions and their relevant environments (parents, classmates, teachers), the specific lesson design of the teachers and the further development of the possibilities of using telepresence systems. 

In order to sustainably improve the clinical and psychosocial care children in chronic health conditions, the first study in Austria on the avatar AV1 telepresence system pursues both a qualitative and a quantitative approach. As part of the quantitative examination, effects of the avatar AV1 on sense of belonging, health-related quality of life and social inclusion in pediatric patients, their parents and teachers are investigated (questionnaires) at three survey points. The sample consists of patients aged from 6 to 18 years who have already attended school for at least one semester, cannot attend school regularly for at least six weeks and therefore receive an avatar AV1. Within the framework of the qualitative study, the changes, chances and hurdles of the avatar use for the involved actors in the school system are conducted after six to eight weeks of avatar use by means of a structured guideline interview with the patients, their parents, classmates and teachers. The structured guided interview is particularly suitable for the present research design due to its combination of a pre-designed guideline and openness in the interview (Flick 2009). In this interview, the interviewee is a person who is part of the social system under study and can thus narrate and comment on autobiographical or authentic experiences. The interviewee is given the opportunity to answer open-ended questions, whereby the interviewer can inquire about individual aspects addressed in greater depth (Klemann et al., 2009, p. 208.). The interview guide was adapted to the age group of the pupils and adapted accordingly for parents and teachers. A total of 24 interviews were conducted and analysed using the method of structuring qualitative content analysis described by Kuckartz (2016). In addition, interactive group interviews were conducted with classmates using the SWOT analysis method. The group interviews were evaluated according to the 4 categories of the SWOT analysis.

Within the framework of the analyses, categories on attitudes, wishes and uncertainties, frequency of use and interactions with teachers and classmates regarding avatar AV1 use could be found. The study shows that a positive attitude and identification with the avatar are central factors for strengthening the sense of belonging. Only when the AV1 is not only experienced as a "foreign" technical device in the school community, the interaction with teachers and classmates is experienced as profitable and relationship-strengthening. It was found that the technical device took a back seat to the interaction of the participants. The collaboration between teachers, fellow students and patients is essential in this context. Results indicate that the patient's psychological condition and integration into the class before the illness play an important role and influence the sense of belonging. Using case vignettes and presentations of the central categories from the qualitative study, this paper will present the results and critically discuss them in context. The question to what extent the use of the avatar AV1 can contribute to the social participation and inclusion of children with chronic diseases at school will be addressed and opportunities for digitised teaching will be discussed. Conclusion: In order to strengthen the sense of belonging of children with chronic diseases, the technical prerequisites and the provision of an avatar AV1 are necessary. Furthermore, the pedagogical-interactional component must not be disregarded. The paediatric patients can only benefit in the best possible way and experience the time with the Avatar AV1 profitably through a routine handling of the device, a positive attitude towards the Avatar AV1 and the pedagogical-didactic adaptations in the classroom.

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