Future teachers’ attitudes and knowledge regarding the management of the potential students’ life-threatening allergic reactions in Slovenian schools

Allergic reactions in children are an important health issue in kindergarten and school settings (1, 2). They can manifest in multiple ways, including life-threatening anaphylaxis (3). Between 10% and 18% of children with food allergy experience various allergic reactions to food, including anaphylaxis, at school (3,4,5). According to data from the United Kingdom, 61% of schools have at least one child at risk of anaphylaxis (6). Food allergy, which affects 4-7% of primary school children in Europe, is the most frequent cause of anaphylaxis in children (1).

Poorly developed teachers’ competences for managing children’s allergies can pose a significant problem to the wellbeing of children in the preschool and school environments. Several studies (7,8,9,10,11,12), including the Europreval study (13), have revealed a low level of preparedness for managing children at risk of anaphylaxis in kindergartens and schools. The importance of the knowledge of school personnel in recognising children’s allergic reactions and providing first aid is pointed out in recommendations of the EAACI (European Academy of Allergology and Clinical Immunology) (1, 2) and others (14, 15). These documents also emphasise the importance of the continuous education of teachers and all other school personnel in managing allergic reactions in school (1, 2). However, trials of the efficiency of different models for improving the knowledge of children’s caregivers regarding recognising and treating severe allergic reactions are rare (2). It has been shown that education in managing children’s allergic reactions results in improved knowledge of parents and kindergarten or school employees (16,17,18,19,20), but there is a lack of reports on the long-term efficacy of a coordinated and achievable teaching approach (2).

In Slovenia, courses in allergy management are provided for kindergarten/school personnel, but there is no law to regulate what is expected from the teachers, although parents, public and medical personnel expect from teachers to be able to manage children’s allergic reactions. The preliminary results are promising, with participants reporting enhanced theoretical ability, a willingness to undertake appropriate first-line management of anaphylaxis in children and a sense of being able to do so (21). To put the need for implementing adequate educational models for teachers and future teachers (while they are educated at university to become teachers) into perspective, it should be pointed out that, in Slovenia, in recent years, adrenaline auto injectors (AAI) have been prescribed for 260–350 children per year, with 120–150 being prescribed for the first time (22). There are currently no nurses employed in kindergartens or schools in Slovenia, and they are therefore not able to be present at the time of the allergic reaction of a child. However, according to a comprehensive school health educational programme – Preventive Health Programmes for Children and Adolescents – developed by The National Institute of Public Health (NIJZ), registered nurses employed by local health institutions can be important stakeholders and providers of various health educational programmes when they are invited to the school (23). Future teachers are important stakeholders for successful education outcomes regarding developing competences for managing allergic children before they become teachers and engage in fulltime teaching in schools. According to the available literature, no research has been done on the knowledge and attitudes of future teachers regarding managing allergic children in the international context. However, some results indicating the problems regarding future teachers in Slovene context were already presented (24). In Slovenia, education on allergic reactions is currently routinely available only to future home economics teachers, who will also be responsible for planning and providing food for children in schools (24).

The aim of this study is therefore to provide proper evaluation of the current understanding of the management of allergic reactions in children (aged from 6 to 14) among future teachers, and to understand the impact of different factors (i.e., gender, study programme, participation in an allergy educational programme and attitude towards child health topics) on future teachers’ knowledge and allergy management competences.

The main research problem of this study was to underline how future teachers understand the management of allergic reactions of children in school, and which variables influence their knowledge about allergic reactions and allergy management in school environment. As expected, future teachers’ understanding of managing children’s allergic reactions was average, as education on allergic reactions is currently only routinely available to a small group of future home economics teachers at the Faculty of Education in Ljubljana. The low level of future teachers’ knowledge seemed comparable to (17), or even lower than, the level determined in certain previous studies involving in-service teachers (9, 11, 21). Female future teachers did, however, have a better knowledge of managing children’s allergic reactions than male future teachers, a result that is in line with other studies (25, 26), showing that female future teachers are more intrinsically motivated to learn biology than male future teachers, and that they demonstrate higher achievements in terms of knowledge. However, allergies can be a context that can stimulate future teachers’ learning about health issues, like other medical topics (27) proved to motivate future teachers to deepen their knowledge. The highest scores regarding the management of children’s allergies and anaphylaxis was in fact identified in the subject teachers group, which included future teachers with more scientific background, while the lowest average knowledge levels were observed in the group of social pedagogy, special education and art teachers, future teachers, who do not take science courses at university. Contrary to expectations, self-reported allergy did not raise the knowledge scores.

The subsample of future home economics teachers had taken an educational programme provided by one of the authors of this paper (a paediatrician with a special interest in allergology from a general hospital) in their first year of first cycle study. The programme was a 90-minute lecture with practical learning on how to use AAI similar in content as the educational programme presented in detail further on in the discussion section of this paper. It was a part of the Physiology of Nutrition course. 26 months later, (this study) future home economics teachers scored significantly higher on MCAD than those who had not taken the programme. This allergy management programme has had a positive long-term effect on the participants’ knowledge of allergy and anaphylaxis management. These results are more promising than results reported in previous research involving in-service teachers or parents, which indicated that knowledge diminished gradually at six-month and one-year follow-up (16). Our findings provide additional evidence that teaching future teachers about allergic reactions in children is worthwhile. It is important to be aware that these future teachers study biology or chemistry along with home economics (the programme comprises topics/courses regarding nutrition), and that it can be assumed that they are more interested in health topics.

The future teachers showed positive attitudes towards learning more about different child health issues and most of the future teachers (85%) would like to develop health competences during their future education. This positive attitude of young, enthusiastic future teachers is undoubtedly a valuable attribute enabling them to develop health competences, as already formed in-service teachers are overwhelmed with their teaching activities in schools and may not be so willing to acquire additional knowledge and competences. It is important to emphasise that educational programmes on allergology issues should be implemented already at the university level, in order to develop future teachers’ awareness that knowledge of different health issues is very important for a competent in-service teacher.

The use of AAI is crucial in cases of anaphylaxis, wherever it occurs. Nevertheless, only 43.8% of the future teachers surveyed were willing to administer AAI to a child, with their most frequent concerns being hurting a child with a needle (55.7%), adrenaline side effects (36.9%) and legal consequences (27.5%). The fact that only about 3% of future teachers feel competent to help a child with an allergic reaction should be a huge indicator to implement adequate educational programmes about these topics into the undergraduate teachers’ and teachers’ education. These programmes were developed and implemented in the academic year 2015/16 for the first time. Future teachers were exposed to a 90-minute theoretical lecture supported by PowerPoint presentation about allergy, most common allergens, and basic principles of preventing and managing allergic reactions and anaphylaxis in school. Different case reports of allergic reactions in children and appropriate interventions that teachers could perform to minimise the unwanted consequences were presented. A workshop on how to use adrenalin auto-injector was carried out after the theoretical presentation. Future teachers were divided into groups of eight and each participant tried to apply AAI simulator to their peers, following the instructions given by the instructor. This education is provided by one of the authors of this paper from the University Children’s Hospital in Ljubljana.

Practical topics, such as the side effects of adrenaline and its intramuscular application, should therefore be specifically addressed, as such issues might represent important obstacles to caregivers for administering adrenaline to a child in need. Furthermore, as already recommended by the EAACI (2), a broader coordinated national and EU strategy, including such areas as defining legal aspects – as pointed out by our participants, as well – should be developed. The introduction of a well-defined law on the management of anaphylaxis is an important and necessary step, as demonstrated elsewhere (28).

It is important to emphasise that developing efficient effective educational programme for teachers regarding anaphylaxis, which could be repeated also by other tutors and therefore broadly disseminated across Slovenia, should also be important from the viewpoint of public health. This is especially important because wider availability of adrenaline auto injectors in primary schools has been recently authorised by paediatricians and the National institute of Public Health in Slovenia. Therefore, adequate development of future teachers’ and teachers’ competences for managing children’s severe allergic reactions is needed (29).

There are some limitations of this research. A small sample size of the specific group of home economics future teachers can influence the significance of the results, and they are shown as an illustration of possible positive long-term outcomes of specific medical educational programmes for teachers. It is also important to emphasise that the differences in gender can influence the management of allergic reactions in school children, and since a small group of male future teachers was available in this study, these results are informative. Both groups of participants were available only in small groups, but because the issue is important, the data were analysed, and results presented. However, further study, using bigger samples, should be conducted to confirm these results. It is also important to emphasise that for the purposes of the research problem presented in this paper, only univariate statistics were used. Multivariate analysis should be used for deeper understanding of the possible interdependences of the researched variables. Further research into teachers’ health competences in managing allergic reactions in children in the school environment should concentrate on: (1) determining effective educational approaches to be implemented in future teacher and teacher training, (2) how to stimulate future teachers to develop these competences, (3) determining what influences the development of future teachers’ health competences, (4) how to efficiently identify the attitudes and knowledge of kindergarten and school personnel (especially providers of non-prepared foods) regarding the management of allergic reactions in children, and (5) exploring future teachers’ awareness of the impact of child’s allergic reactions on his/her and teachers’ quality of life.

It can be concluded that all future teachers should develop adequate competences to manage allergic reactions in children before they finish their university studies. The duration of undergraduate education, natural sciences background and self-allergy did not influence the level of knowledge regarding the management of allergic children. Future teachers showed an average level of knowledge about allergic child management, but they expressed a high level of positive attitude and a need to be educated about these topics. There is some evidence already that a basic educational programme in allergy management had a positive effect on future teachers’ knowledge of allergic reactions management in children. However, there is a need for efficient educational programmes capable of developing adequate health competences, since kindergarten and school personnel are expected to be able to provide first aid in the kindergarten/school environment, as already suggested also by some studies (30) in the Slovenian context.