An investigation of the effects of the education given to teachers on food allergy and anaphylaxis management self-efficacy and level of knowledge

Abstract

Background:

The most effective approach to food allergy management is to avoid consuming the specific allergens that trigger an allergic reaction. It is crucial to make school environments prepared for the potential of food allergic reactions, including anaphylaxis, which is a rare but documented outcome. The high prevalence of anaphylactic reactions in children makes food allergy and anaphylaxis management important topics in schools.

Aim:

This study aimed to determine the effects of food allergy and anaphylaxis management education on teachers’ food allergy and anaphylaxis management self-efficacy and level of knowledge in Türkiye.

Methods:

This study used a random experimental design with a pre-test and post-test group. The study was conducted with 84 teachers who worked in kindergartens (school year prior to starting Grade 1) and primary schools in a city centre in eastern Turkey between September 2022 and January 2023. Data were collected through a socio-demographic form and the Food Allergy and Anaphylaxis Management Self-Efficacy Scale for School Personnel. Data analysis was performed using t-tests for independent groups, Chi-square tests and McNamara analyses.

Results:

The average age of the teachers was 31.08 ± 6.70 years, and the average years of experience in the profession was 6.68 ± 6.99 years. All the teachers wanted to learn about food allergy and anaphylaxis management, 59.5% did not know whether their schools had an emergency action plan for food allergy and anaphylaxis, 63.1% reported not having the necessary emergency treatment medicine for anaphylaxis in their school and 57.1% reported having no educated school personnel to administer the first intervention in case of a serious allergic reaction at school. While the mean scale score of the experimental group was 25.88 ± 7.26 before the training, it was 30.78 ± 6.98 after the training. While no differences were detected between the experimental and control groups’ pre-test scale mean scores, the experimental group’s post-test scale mean score was found to be statistically significantly higher (d = 0.79, p < .05). The results also indicate that the rates of providing correct responses to questions regarding what the most common symptom in a student with a food allergy is, and what the first intervention should be when a serious reaction develops in a student, increased significantly level.

Conclusions:

This study found that the health education given to teachers led to an increase in teachers’ food allergy and anaphylaxis management self-efficacy.

Keywords

Anaphylaxis child education food allergy school health nursing teacher

Introduction

Food allergy is defined as an immune response to food. If untreated, it can result in life-threatening anaphylaxis. Food allergy is more common in children than adults (Haney et al., 2019). It is seen in 1 in every 12 children and ranges from 4% to 8% among school children in Europe and from 5.7% to 6.4% in Türkiye (Haney et al., 2019). It is reported that 10%–18% of allergic responses and anaphylaxis cases happen in the school environment (Gonzalez-Mancebo et al., 2019). In addition, many children who do not have a known history of allergy experience their first anaphylaxis reaction at school (Polloni et al., 2020).

The priority and most effective approach to food allergy management is to avoid consuming the specific allergens that trigger an allergic reaction. It is therefore crucial to ensure that school environments are prepared for the potential of food allergic reactions, including anaphylaxis, which is a rare but documented outcome (Bock et al., 2007; Turner et al., 2017). The high prevalence of anaphylactic reactions in children makes food allergy and anaphylaxis management important topics in schools (Wang et al., 2019).

Research internationally has shown that teachers are often unknowledgeable about food allergy symptoms and have limited knowledge about anaphylaxis. Few schools have a suitable management plan for food allergy and anaphylaxis management and those that do often fail to implement them. Many schools do not have the necessary medicine for anaphylaxis (Alsuhaibani et al., 2019; Aslan and Bakan, 2022; Dumeier et al., 2018; Gonzalez-Mancebo et al., 2019; Haney et al., 2019). Besides, teachers are often not competent in administering adrenaline auto-injectors, which have a key role to play in cases of anaphylaxis, and there is a general lack of education on the topic (Polloni et al., 2020).

A study conducted by Sasaki et al. (2015) in Japan investigated the use of adrenaline auto-injectors and found that school nurses had the highest self-efficacy levels among different school personnel and noted that other school personnel’s self-efficacy about the use of adrenaline auto-injectors could be increased through education (Sasaki et al., 2015). Studies including educational interventions have shown that education can help increase knowledge and self-efficacy regarding food allergy and anaphylaxis issues (Gonzalez-Mancebo et al., 2019; Polloni et al., 2020).

In low- and middle-income countries with a limited number of school nurses and other health personnel, teachers have the most interaction with students during the day, so they have the major responsibility for the management of food allergy and anaphylaxis. Therefore, it is important to increase teachers’ awareness, education, self-efficacy and skills in schools that do not have health professionals. In this regard, this study aimed to determine the effects of food allergy and anaphylaxis management education on teachers’ food allergy and anaphylaxis management self-efficacy and levels of knowledge.

Methods

This study used an experimental design with a pre-test and post-test control group and was conducted in kindergartens (school year prior to starting Grade 1) and primary schools in a city centre in eastern Türkiye between September 2022 and January 2023. The target population for the study was teachers who worked in kindergartens and primary schools located in the city centre. The sample size of the study was calculated using the Gpower programme (Faul et al., 2007). Calculations including α = .05 level, high effect size (t-test in independent groups) (d = 0.8) (Cohen, 2013) and 95% power indicated that a total of 70 participants, 35 in the experimental group and 35 in the control group, should be included in the study. According to the data from a descriptive study on the topic conducted by the researchers beforehand (Aslan and Bakan, 2022), teachers in the schools were ranked by their food allergy and anaphylaxis management self-efficacy scores from the lowest to the highest scores. Out of 399 teachers, those with the lowest mean scores were selected for inclusion in this study. Considering potential data loss in the process, the first 90 teachers were chosen. These teachers were assigned to experimental and control groups (45 participants in the experimental group and 45 participants in the control group) through randomisation (random.org). In the event, four participants in the experimental group did not participate in the education provided and one individual in the control group did not respond to the questions asked in the post-test data form, Hence, the study was undertaken with 40 experimental group participants and 44 control group participants.

Inclusion criteria

Teachers with a low food allergy and anaphylaxis management self-efficacy mean score, who actively worked during the period when the study was conducted, who could be accessed online and who agreed to participate in the study were included in the study.

Ethical considerations

Ethics committee approval was received from the Scientific Research Ethics Committee of the Agri Ibrahim Cecen University (Reference E-95531838, dated 26.05.2021), and permission was obtained from the Directorate of National Education (Reference E. 78971437, dated 31/12/2021). The teachers who agreed to participate in the study were provided with information about the study, and written consent was received. The necessary permissions were obtained from the authors of the scale used in the study.

Measurement

Data were collected through a socio-demographic form and the Food Allergy and Anaphylaxis Management Self-Efficacy Scale for School Personnel (FAMSES).

Socio-demographic form

This form was prepared by the researchers in a manner informed by the literature (Haney et al., 2019; Ozdemir et al., 2019). It included 22 questions about teachers’ descriptive characteristics as well as their experience and knowledge of food allergy and anaphylaxis management.

Food Allergy and Anaphylaxis Management Self-Efficacy Scale for School Personnel

The scale, developed by Polloni et al. (2016), assessed the perceived self-efficacy of school personnel (teachers, care providers, health personnel, etc.) to manage food allergy and anaphylaxis in the school environment. This Likert-type-type scale included eight items and two sub-scales. The total score was obtained by summing the items with a range from 8 to 40, and higher scores indicating high self-efficacy levels (Polloni et al., 2016). The reliability and validity of the scale as assessed by Haney et al. (2019) resulted in a Cronbach’s alpha value of 0.91. In this study, Cronbach’s alpha value was found to be 0.892 in the pre-test and 0.914 at post-test. The scale includes eight items and assesses school staff’s self-efficacy in two domains: the management of food allergy (items 1, 2, 5, 6 and 7), and anaphylaxis management (items 3, 4 and 8). Items are responded on a 5-point Likert scale (I can never do = 1 and I can certainly do = 5). The total score is obtained by summing the items ranging from 8 to 40, with higher scores indicating higher self-efficacy levels. A Cronbach’s alpha of 0.85 was obtained for anaphylaxis management and of 0.75 for the management of food allergy in the reliability analysis of the original scale (Polloni et al., 2016). Reliability and validity of the Turkish version of the scale were assessed by Haney et al. (2019) and found to be as follows: reliability, Cronbach’s alpha = 0.91, item-total correlations = 0.50–82; and validity, χ² = 176.05, df = 91, p < .001, χ²/df = 3.20, Goodness-of-Fit Index = 0.96, Comparative Fit Index = 0.99, Root-Mean-Square Error of Approximation = 0.080. Confirmatory factor analysis confirmed the original structure of the two-factor scale.

Data collection/procedure

Data were collected from the teachers who agreed to participate in the study based on self-report. Pre-test data for the experimental and control groups were collected in an online environment one week before the education. Post-test data were collected from both groups in a similar way within one week following the education.

Intervention

The teachers in the experimental group were given online (synchronous) education by a specialist researcher (DDSM) who was a general practitioner and school physician. The education was delivered in one session lasting 60 minutes. The content of the education included topics such as food allergy, allergens in foods, common symptoms, diagnostic methods, anaphylaxis, prevention, treatment, food allergy and anaphylaxis management in school, anaphylaxis emergency case action plan samples and cases encountered in practice. First, participants were provided with lecture-based instruction on the topic and involved in question-answer activities. Then, experiences related to real cases were introduced. Information was given about the use of an auto-injector as well as relevant legal issues.

Study variables

Independent variables

Food allergy and anaphylaxis management education were the independent variables in the study.

Dependent variables

Mean scores obtained on the FAMSES were the dependent variables.

Data analysis

Data were analysed using SPSS. Descriptive statistical analyses were used to determine numbers, percentages, means, histograms, skewness and kurtosis values, and Shapiro-Wilk and Kolmogorov analyses were to determine whether the data were normally distributed in the data set. As the data proved to be normally distributed, an independent sample t-test was used to compare the mean scores of two independent groups. While the Chi-square test was used to conduct a comparison of categorical data from the two independent groups, a paired t-test was used to compare the mean scores in dependent groups, and a McNamara analysis was used to compare categorical data in dependent groups. The effect size belonging to the change in the pre-test and post-test mean scores was calculated using the suitable (test value/√n) formula. Statistical significance was set at p < 0.05.

Results

Variables controlled for in the study included having encountered a student with food allergy before; having a student with food allergy currently; having received education about food allergies and anaphylaxis before; having received first aid education after starting work as a teacher; thinking that managing food allergy and anaphylaxis at school was a teachers’ duty; emotions experienced/likely to be experienced when managing a child with food allergy at school and having a student who carried medicines for allergic reactions (Table 1).

Table 1.

Control variables (N = 84).

Variable		Experimental group		Control group		χ²	p
Variable		n	%	n	%
Have you had a student who had food allergy before?	Yes	2	5.0	10	22.7	5.377	.020
Have you had a student who had food allergy before?	No	38	95.0	34	77.3	5.377	.020
Do you currently have a student with food allergy?	Yes	2	5.0	9	20.5	4.618	.099
	No	32	80.0	28	63.6
	I do not know	6	15.0	7	15.9
Have you received any education on food allergy and anaphylaxis before?	Yes	0	0	2	4.5	0.495*	.271
	No	40	100	42	95.5	0.495*	.271
Have you received any first aid education after you started working?	Yes	23	57.5	19	43.2	1.718	.190
	No	17	42.5	25	56.8	1.718	.190
Do you think that food allergy and anaphylaxis management in schools is the teacher’s duty?	Yes	21	52.5	21	47.7	0.191	.662
	No	19	47.5	23	52.3	0.191	.662
What is the most frequent feeling you experience/would experience while managing a child who has food allergy?	Fear/anxiety	25	62.5	22	50.0	2.340	.310
	Panic/helplessness	8	20.0	8	18.2
	None	7	17.5	14	31.8
Do you have any students who carry medicine for allergic reactions?	No	31	77.5	37	84.1	0.590	.442
	I do not know	9	22.5	7	15.9	0.590	.442

Fisher’s exact Chi-square value was used.

The average age of the participating teachers was 31.08 ± 6.70 years, and the average years of experience in the profession was 6.68 ± 6.99 years. Notably, 70.2% of the teachers were female, 57.1% were married, 60.7% did not have a child, 63.1% were classroom teachers and 96.4% had undergraduate degree; 59.5% of teachers did not know whether their schools had an emergency action plan for food allergy and anaphylaxis, 63.1% did not have necessary emergency treatment medicine for anaphylaxis in their school and 57.1% reported having no educated school personnel to administer first intervention in case of a serious allergic reaction at school. All the teachers wanted to learn about food allergy and anaphylaxis management, 97.6% needed education on food allergies and 71.4% reported that the ingredients part was the most critical part of a food label to read in order for students with a food allergy to avoid an anaphylactic reaction (Table 2).

Table 2.

Teachers’ socio-demographic characteristics (N = 84).

		n	%
Sex	Female	59	70.2
Sex	Male	25	29.8
Marital status	Married	48	57.1
Marital status	Single	36	42.9
Having children	Yes	33	39.3
Having children	No	51	60.7
Area of expertise for teacher	Pre-school teacher	20	23.8
	Classroom teacher	53	63.1
	Specialty teacher (Math teacher, Art teacher, English teacher, etc.)	11	13.1
Education level	Undergraduate	81	96.4
Education level	Postgraduate	3	3.6
Is there an emergency action plan for food allergy and anaphylaxis in your school?	Yes	1	1.2
	No	33	39.3
	I do not know	50	59.5
Is there emergency treatment medicine necessary for anaphylaxis in your school?	Yes	1	1.2
	No	53	63.1
	I do not know	30	35.7
Is there educated school personnel who can administer the first intervention in terms of a serious allergic reaction?	Yes	4	4.8
	No	48	57.1
	I do not know	32	38.1
Would you like to know about food allergy and anaphylaxis management?	Yes	84	100.0
	No	0	0
Do you think you need education on food allergy?	Yes	82	97.6
Do you think you need education on food allergy?	No	2	2.4
What is the most critical part of a food label a teacher needs to read for as a measure of the nutrition of a student diagnosed with food allergy?	Ingredients	60	71.4
	Other (expiration date, calorie amount, storage conditions, etc.)	24	28.6
	$\bar{X}$ ± SD	Min.	Max.
Age	31.08 ± 6.70	23	58
Professional experience (year)	6.68 ± 6.99	1	36

The experimental and control groups were found to be similar in terms of the control variables. Only the number of teachers who had had a student with a food allergy before was found to be higher in the control group compared with the experimental group (Table 2).

McNemar test results revealed significant differences in the experimental group teachers’ responses to the question ‘What is the most common symptom seen in a student who has food allergy and experiences an acute reaction to a certain food?’ between pre-test and post-test (p < .05). The number of teachers who responded to this question correctly was found to increase in the post-test. Experimental group teachers were also found to show significant differences in terms of the responses to the questions ‘What would your first response be in case of a serious reaction that develops in your student?’ (p < .05). In the post-test, there was an increase in the number of participants who responded to this same question correctly (Table 3).

Table 3.

Change in the responses of experimental group teachers to knowledge questions before and after the education (N = 40).

			Post-test		Total	χ²	p
			Correct Response	I do not know/incorrect response
What is the most common symptom seen in a student who has food allergy and experiences an acute reaction to a certain food?	Pre-test	Correct response	1	1	2	4.900	.021*
		I do not know/incorrect response	9	29	38
		Total	10	30	40
What would your first response be in case of a serious reaction that develops in your student?	Pre-test	Correct response	4	4	8	5.263	.019*
		I do not know/incorrect response	15	17	32
		Total	19	21	40

p < 0.05.

McNemar test results indicated that the responses of control group teachers to the question ‘What is the most common sign seen in a student who has food allergy and experiences an acute reaction to a certain food?’ showed differences pre-test and post-test (p < .05). In the post-test, there was an increase in the number of participants who answered this question correctly. No significant differences were detected in the answers given to the question ‘What would your first response be in case of a serious reaction that develops in your student?’ (p > .05) (Table 4).

Table 4.

Change in the responses of control group teachers to knowledge questions (n = 44).

			Post-test		Total	χ²	p
			Correct Response	I do not know/incorrect response
What is the most common symptom seen in a student who has a food allergy and experiences an acute reaction to a certain food?	Pre-test	Correct Response	2	2	4	6.667	.007
		I do not know/incorrect response	13	27	40
		Total	15	29	44
What would your first response be in case of a serious reaction that develops in your student?	Pre-test	Correct response	7	7	14	1.250	.263
		I do not know/incorrect response	13	17	30
		Total	20	24	44

The experimental group showed a significant increase in FAMSES mean scores from pre- to post-test (p < .05, d = 0.79). When the FAMSES pre-test and post-test mean scores of the control group were compared, a statistically significant increase was also detected, but with a smaller increase in Cohen’s d (p < .05, d = 0.33). No significant differences were detected between the FAMSES pre-test mean scores for the experimental and control groups; FAMSES post-test mean scores for the experimental group were found to be significantly higher (p < .05) (Table 5).

Table 5.

Comparison of the pre-test and post-test FAMSES mean scores of the groups (N = 84).

Variables	Group		Between groups
	Experimental group (n = 40)	Control group (n = 44)
	$\bar{X}$ ± SD	$\bar{X}$ ± SD
Pre-test	25.88 ± 7.26	23.91 ± 6.71	t = –1.289 p = .201
Post-test	30.78 ± 6.98	26.30 ± 6.67	t = –3.006 p = .004
In-group	t = –5.028 p = .001	t = –2.189 p = .034
d (test value/√n	0.79	0.33

Discussion

The prevalence and growth of food allergies in children is an important public health issue, affecting morbidity and mortality as well as social engagement (Polloni et al., 2020). Children, who spend much of their time in the school environment, meet their food and beverage needs at cafeterias, so the majority of allergic reactions happen at school. Therefore, teachers, who are in constant communication with students all day, have an important role to play in coordinating the management and support of students who have a food allergy (Gonzalez-Mancebo et al., 2019; Polloni et al., 2020).

This study investigated the effect of education given to teachers on food allergy and anaphylaxis management self-efficacy and level of knowledge. At baseline, all the teachers wanted to learn more about food allergies and anaphylaxis management, needed education about food allergies, but lacked experience and knowledge about performing the first intervention. At post-test, a significant increase was reported in the food allergy and anaphylaxis management self-efficacy scores of the experimental group that was given education, and this increase had a major effect. The control group which was not given education also demonstrated a statistically significant increase in their food allergy and anaphylaxis management self-efficacy mean scores, but with a smaller effect.

In the UK, a comprehensive study of food allergy education and management practices and gaps at schools also reported that the majority of the teachers wanted to know more about food allergies and anaphylaxis management and volunteered to participate in other training after the initial education had been given (Santos et al., 2022). Similar studies conducted with a wider range of school personnel (including cafeteria and canteen personnel) have also reported that participants did not have adequate knowledge and needed education (Alsuhaibani et al., 2019; Gonzalez-Mancebo et al., 2019; Haney et al., 2019).

Yıldırım (2019) used the FAMSES scale in a study conducted in Turkey and found that all the items showed positive improvements after the education, and teachers had higher self-efficacy about learning about anaphylaxis symptoms, the need to provide students with a safe school environment and administering auto-injectors following the education (Yıldırım, 2019).

A study that provided school personnel with education on food allergy and anaphylaxis management reported a significant improvement in all scale items, and an important improvement in the participants’ level of knowledge about recognising food allergy symptoms and anaphylaxis management (Gonzalez-Mancebo et al., 2019).

In Germany, preschool teachers who were provided with education on anaphylaxis emergencies and how to use allergy and adrenaline auto-injectors reported an increase in the participants’ food allergy and anaphylaxis management self-efficacy (Dumeier et al., 2018). A study in Italy found that school personnel were unclear about anaphylaxis symptoms and administering adrenaline auto-injectors, but that their recognition of anaphylaxis symptoms and their administering auto-injector skills improved significantly following education (Polloni et al., 2020).

Limitations

This study has several limitations that should be acknowledged. First, the experimental and control groups were not similar in terms of the number of teachers who had encountered students with food allergy before. Second, the sample size of the study was relatively small, which may limit the generalisability of the findings to a broader population. In addition, the study was conducted only in one location, which may restrict the applicability of the results to other settings or populations. There was no mechanism in place to assess whether members of the control group were influenced or motivated to seek further information about anaphylaxis and its management after consenting to participate in the study. This lack of control over potential external influences could have introduced bias or confounding factors into the results.

Conclusion

In this study, teachers in the experimental group showed a statistically significant increase in their food allergy and anaphylaxis management self-efficacy following the intervention. The control group was also found to have a statistically significant (but smaller) increase in their food allergy and anaphylaxis management self-efficacy. In addition, the post-test FAMSES scale mean score for the experimental group was significantly higher than that of the control group. Experimental group teachers’ correct responses to the questions about information were also found to increase significantly.

Footnotes

Acknowledgements

The authors wish to thank all the participants for engaging in this study. They are grateful to Duygu Ispinar for proofreading the manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iDs

Gülpınar Aslan

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