Identifying the special needs of children with Type 1 diabetes in the school setting. An overview of parents' perceptions

Quality of life among schoolchildren with type 1 diabetes mellitus and the satisfaction of their guardians towards school health care in Saudi Arabia

AIMS

This study aimed to assess the quality of life of schoolchildren with type 1 diabetes mellitus (T1DM) and determine their guardians' satisfaction of diabetes health care in Saudi Arabian schools.

METHODS

A cross-section multicenter study was conducted from February to July 2022 among Schoolchildren with T1DM in Saudi Arabia. The study included T1DM school children aged 6-18 years. The patients' health-related quality of life (HRQoL) data were collected and determined using a modified version of the PedsQL 3.0 Diabetes Module.

RESULTS

The grand total median PedQL-DM score among the included participants (N = 283) was 64.7, while items related to diabetes symptoms and diabetes management were 61.1 and 68.7, respectively. Schoolchildren who have lower HbA1c levels and take care of regular monitoring of their blood glucose showed significantly better quality of life concerning diabetes symptoms. A significant number of guardians claimed they were not satisfied with the current status of diabetes management at schools.

CONCLUSIONS

The overall HRQoL among schoolchildren with T1DM was average and acceptable to some extent. The PedsQL-DM median score was higher among those who received health care during school time. The guardians' satisfaction of diabetes health care was low, emphasizing the role of health clinics in schools.

Family and Community Nurses as a Resource for the Inclusion of Youths with Type 1 Diabetes at School

School nurses can facilitate the inclusion of students with type 1 diabetes (T1D) at school; this model has been widespread in some countries but not in Italy, which is due to the insufficient number of school nurses that are able to provide medical attention at all times. The National Recovery and Resilience Plan (PNRR) devised a series of aids and support for the reorganization of the Italian National Health System (NHS) through the creation of community houses in addition to family and community nurses (FCNs), who will operate in these structures to promote the integration of the various professional figures and community services. In this study, starting with the needs and suggestions of teachers (No. 79) and parents (No. 48) collected using a survey, we developed a new model for the inclusion of students at school where FCNs who have experience in pediatric T1D have the role of an educator, coordinator, and facilitator' they cannot be on site and available all the time during school hours, so they must make many efforts to improve the school staff's knowledge, intervene to offer training when requested, and solve new emerging problems.

Knowledge of School Nurses on the Basic Principles of Type 1 Diabetes Mellitus Self-Control and Treatment in Children

School nurses should participate in the care of children with type 1 diabetes mellitus. The aim of this study was to assess the level of knowledge of school nurses about the basic principles of self-control and the treatment of type 1 diabetes mellitus and to attempt to determine the factors that influence this level of knowledge. A cross-sectional survey was conducted among school nurses from October 2018 to November 2019 in the Pomeranian Voivodeship. The study was conducted using a self-constructed questionnaire. The survey included questions about the sociodemographic characteristics of the respondents, and a test of the knowledge and skills regarding the principles of self-control and the treatment of type 1 diabetes mellitus (16 test questions). This study included 168 Polish school nurses (mean age ± SD = 55.1 ± 8.9 years). Most of the nurses had a secondary education (81%), worked in a municipal educational institution (78.6%), and provided care to more than one student with type 1 diabetes mellitus at school (70.2%). The average level of knowledge of school nurses was 12.5 ± 2.0 points (maximum 16). The nurses working in a village school and those who worked only in one school had lower levels of knowledge. Only 85.7% of nurses reported that they could independently perform a blood glucose measurement with a glucometer, and as many as 56.5% were unable to determine the level of ketone bodies in the urine with Keto-Diastix test strips. Only 62.5% of nurses had a glucometer and glucometer strips in their nursing office. A total of 19.6% of nurses did not have glucagon (1 mg GlucaGen HypoKit^®, Novo Nordisk A/S, Bagsværd, Denmark) or an ampoule with 20% glucose for an intravenous administration. The knowledge of school nurses about the principles of self-control and the treatment of type 1 diabetes mellitus is insufficient. Due to the strong increase in the incidence of type 1 diabetes mellitus among children and adolescents, it is important to organize permanent, continuous, and mandatory training on the principles of self-control and the treatment of type 1 diabetes mellitus for school nurses. The equipment in Polish school nurses' offices should be supplemented with a working glucometer and blood glucose test strips, and the set of obligatory medications in the school nurse's office should be supplemented with glucagon for students with type 1 diabetes mellitus.

Educational Attainment and Childhood-Onset Type 1 Diabetes

OBJECTIVE

To quantify associations of educational outcomes with type 1 diabetes status and glycemic management (HbA1c).

RESEARCH DESIGN AND METHODS

This was a record linkage study of schools and higher (college) education data sets linked to national diabetes audits. The population includes all Welsh children attending school between 2009 and 2016, yielding eight academic cohorts with attainment data, including 263,426 children without diabetes and 1,212 children diagnosed with type 1 diabetes. Outcomes include standardized educational attainment for those aged 16 years, higher education participation for those aged ≥18 years, and school absences among those aged 6-16 years.

RESULTS

Comparison between children with type 1 diabetes and children without diabetes showed no strong evidence of associations for student attainment (0.001 SD, 95% CI -0.047 to 0.049, P < 0.96, n = 1,212 vs. 263,426) or higher education entry rates (odds ratio 1.067, 95% CI 0.919-1.239, P < 0.39, n = 965 vs. 217,191), despite nine more sessions of absence from school annually (P < 0.0001). However, attainment in children in the most optimal HbA1c quintile was substantially better than for children without diabetes (0.267 SD, 95% CI 0.160-0.374, P < 0.001) while being worse than for children without diabetes in the least optimal quintile (-0.395 SD, 95% CI -0.504 to -0.287, P < 0.001). Attainment did not differ by duration of "exposure" to diabetes based on age at diagnosis.

CONCLUSIONS

Despite more school absences, diabetes diagnosis is not associated with educational attainment or entry into higher education, although attainment does vary by HbA1c level, which may be explained in part (or wholly) by unobserved shared personal, family, or socioeconomic characteristics associated with both success in education and effective glycemic self-management.

Care and Safety of Schoolchildren with Type 1 Diabetes Mellitus: Parental Perceptions of the School Nurse Role

Schoolchildren with type 1 diabetes mellitus (T1DM) need supervision in the management of their disorder by the school nurse, securing proper care and safety in the school environment. The aim of this study was to investigate the parents’ perceptions regarding the care and safety of their children with T1DM at school. In this cross-sectional study, 356 parents of children with T1DM attending primary and secondary school (convenience sample) completed the “Parents’ Opinions about School-based Care for Children with Diabetes” and the “Safety of children with T1DM at school”. The majority (58.8%) noted that their children received some care from a school nurse, less than half (44.6%) declared feeling very safe concerning diabetes care, and 42.5% reported high levels of diabetes management satisfaction. Younger age of the child (p < 0.001), school nurses’ advanced diabetic care skills (p < 0.001), existence of school nurse’s office (p < 0.05) and higher educational level of the father were positively correlated with higher parental feelings of safety and satisfaction. The presence of a school nurse was associated with higher academic performance (p < 0.001), significantly fewer absences due to the disorder (p < 0.001) and better diabetes management (p < 0.043). The daily presence of a school nurse in school decreases absenteeism, greatly improves school performance and enhances diabetic management of schoolchildren with T1DM.

Comparison of Visual Motor Integration, Participation and Hand Skills in Children with and Without Type 1 Diabetes

Our aim in this study was to compare hand skills, visual-motor integration ability, and participation in daily living activities of children with and without Type 1 diabetes (T1DM). In this prospective cross-sectional study, we included 44 children withT1DM (17 males, 27 females; aged 8-12 years) and a control group of 45 healthy age-matched children without T1DM (22 males, 23 females). We compared group scores on the Jebsen-Taylor Hand Function Test (JTHFT), the Beery-Buktenica Developmental Visual Motor Integration Test (Beery VMI), and on the Participation and Environment Measure - Children and Youth (PEM-CY). The JTHFT and Beery VMI scores of children with T1DM were significantly lower than those of the control group (p ≤ 0.005); on the PEM-CY, children with T1DM were found to have more barriers in the community than controls. Relative deficits in hand skills and visual motor integration of children with T1DM should be managed with greater attention and assistance.

Implementation of School Diabetes Care in the United States: A Scoping Review

Diabetes management at school demands close collaboration of multiple stakeholders, including students with diabetes and parents, school nurses, teachers/staff, and local health care providers. This scoping review identified and synthesized evidence concerning factors that contributed to the quality and effectiveness of diabetes care implementation in U.S. K-12 schools. Forty-six studies met the eligibility criteria and were included. Five common factors emerged surrounding training and experiences, communications, parent engagement, resource allocations, and school environment. Complex interactions between multiple stakeholders jointly determined the quality of school diabetes care. A conceptual model was established to elucidate the complex interactions between multiple stakeholders and the relevant facilitators and barriers. Future research should improve sample representativeness, contrast school diabetes care practices to the national guidelines, and assess the impact of the social, economic, and political environment at federal, state, local/district levels on school diabetes care implementation.

Teachers and Parents' Perceptions of Care for Students with Type 1 Diabetes Mellitus and Their Needs in the School Setting

The high incidence of Type 1 Diabetes Mellitus (DM1) increases the likelihood of teachers having students with this illness in their classrooms. The objective of this study is to investigate the needs of students with DM1 during the school day from the perspective of both teachers and parents. A mixed methods study was designed and a questionnaire was administered to practicing teachers in Pre-primary Education, Primary Education, Compulsory Secondary Education, and Further Education, as well as Vocational Education within both the province and the city of Burgos (Castile and Leon, Spain) who may have students with DM1. Semi-structured interviews were also conducted with mothers and fathers, members of the Burgos Diabetics Association (ASDIBUR). In the questionnaires administered to the teaching staff, 54.8% affirmed that they knew of students with DM1 at their centers. Of those questioned, 51.2% affirmed that they knew of the existence of action protocols on DM, and 45.2% declared that they had received specialized information on the illness; 92.8% believed that there was no discrimination at their center towards students with DM, and 82.8% thought that the educational center raised no objections to students with DM departing on trips during the school year. In their interviews, both family and teachers assessed the material and human resources as insufficient and called for the presence of school nurses at the educational centers. It is important to raise the awareness of the educational community about the needs of students with DM1 and to provide guidelines on emergency situations to teachers and staff at the centers.

Understanding the Lived Experience of Children With Type 1 Diabetes in Kenya: Daily Routines and Adaptation Over Time

Focusing only on biomedical targets neglects the important role that psychosocial factors play in effective diabetes self-management. This study aims to understand the lived experiences of children with Type 1 Diabetes (T1DM) in Kenya. Children (n = 15) participated in focus group discussions and photo diary data collection. Focus group discussions and semi-structured interviews were also conducted with caregivers (n = 14). We describe an adaptation to diabetes over time, identifying four overarching themes: knowledge and awareness, economic exclusion, the importance of social support, and striving for normality. Photo diaries are then categorized to explore daily realities of diabetes management. Children with T1DM in Kenya face varied barriers to care but can lead a "normal" and fulfilling life, provided adequate support is in place. To improve the lives of children with diabetes in this context and others like it, stakeholders must take note of children's experiences and recognize their multidimensional needs.

Deterioration in glycemic control on schooldays among children and adolescents with type 1 diabetes: A continuous glucose monitoring-based study

BACKGROUND

To investigate the effect of school life by comparing the glycemic control between holidays and schooldays in children and adolescents with type 1 diabetes (T1D).

METHODS

This observational study enrolled school-aged students with T1D (aged 6-19) from September 2019 to July 2021. Continuous glucose monitoring (CGM) records were processed and divided into holidays and schooldays. Other information was collected via questionnaires. We compared the results using paired T-test, Wilcoxon paired test and logistic regression analysis.

RESULTS

78 paticipants were included (40 boys, mean age 9.95 years). A total of 142,945 h of CGM data were analyzed. Overall, TIR (3.9-7.8 mmol/L) during holidays was better than schooldays [56.97 (SD 15.03) vs. 55.87 (15.06), %, p = 0.039]. On nocturnal (0-6 am) glycemic fluctuation, TIR was longer in children aged 6-10 [60.54 (17.40) vs. 56.98 (SD 16.32), %, p = 0.012] during holiday and TAR (7.8 mmol/L) was shorter [31.54 (17.54) vs. 35.54 (16.95), %, p = 0.013], compared with schooldays. In adolescents aged 10-19 years, TAR was also significantly shorter during holidays. Stratified analysis showed that girls, patients with longer duration, and insulin pump users had more pronounced worsening of nighttime glycemia on schooldays. Logistic regression analysis showed that girls had higher risk of worse nocturnal glycemic control [3.26, 95% CI: (1.17, 9.72), p = 0.027] and nocturnal hyperglycemia [OR = 2.95, 95% CI: (1.08, 8.56), p = 0.039], compared to boys.

CONCLUSIONS

Children and adolescents with T1D were found to have worse glycemic control in nighttime during schooldays.

Attitudes and Perceptions of School Teachers in Melilla Regarding the Care Provided to Students with Type 1 Diabetes

The main objective of the study was to assess the perception of non-university teachers in the city of Melilla to help students with type 1 diabetes mellitus (T1DM), as well as their attitudes towards helping these students in diabetic emergencies. This observational, descriptive, cross-sectional study analyzed the answers given by 441 teachers from 25 public institutions in the city of Melilla to a survey on the attitude and perception regarding the capacity of educational institutions (16 questions) to help and manage students with T1DM. Out of 47.6% of teachers who represent having had students with TIDM, only 4.8% acknowledged having been trained in diabetes. The percentage that has experienced a hypoglycaemia episode at the institution was 29.9%. More than half of participants acknowledged that their educational institution is not prepared to manage diabetic emergencies. Only 5.7% stated their institutions have glucagon in their first-aid kit and less than half of participants (44.7%) would be willing to administer it if necessary. Teachers of educational institutions believe they have not been particularly trained in the care of students living with T1DM and point out that their educational institutions are not prepared to help in diabetic emergencies.

Care of children with type 1 diabetes mellitus in school - An interventional study

OBJECTIVES

Paucity of data from India on care of children with Type 1 diabetes in schools. Aims: To study assess the knowledge, attitude, practices and fear of Type 1 diabetes in school teachers and to assess the impact of an educational model on the fear of teachers and care of children in Type 1 DM at school hours.

METHODS

A community based study, involving school teachers and the intervention being educating them about diabetes conducted. Data pertaining to basic demography, attitude of teachers towards diabetic children, Hypoglycemia fear factor survey- parent version with worries domain and preparedness of school was collected. An education program was conducted on diabetes care in children. Immediately and after three months, the proforma details and HFSP-W scores reassessed.

RESULTS

Forty two teachers (mean age: 38.7±5.4; M:F ratio 2:40) participated in the study. Post intervention, a higher willingness to have the diabetic child in class (100 vs. 57.1%; p>0.05), better support in daily care (100 vs. 92%; p>0.05), participation in sports activities (100 vs. 7.1%; p<0.05) observed. HFSP-W scores were 38.8±4.5 (pre-intervention), 22.5±4.3 (immediate post intervention) and 29.5±3.2 (at 3months) (p<0.05). To study the determinants of improvement in HFSP-W a regression analysis was performed: presence of glucometer the most likely determining factor (T=1.999, p=0.05).

CONCLUSION

There is a significant element of fear in the minds of teachers towards hypoglycemia which improves with a structured education program.

Are the health needs of children with disabilities being met at primary schools?

The aim of this study was to provide current information about the health profile and needs of mainstreamed primary school children with disabilities and special educational needs during their school hours. The Study population is composed of students with special educational needs and disabilities attending mainstream primary schools located in three selected Turkish districts with low, moderate, and high socioeconomic status and literacy rates separately. Parents of 404 students from 72 primary schools constituted the research sample. The study showed that 13.4% of the students with disabilities had chronic illnesses and 8.9% had health problems requiring access to emergency medical care when the condition recurs (such as epileptic seizures, fainting, or falling). Of the students with disabilities, 39.9% usually or sometimes needed medical care during school hours in the previous week. Health needs of nearly half of the students with disabilities were met at school. Special health needs and risks of children with disabilities also continue at school along with other possible health concerns.

S.O.S! My Child is at School: A Hermeneutic of the Experience of Living a Chronic Disease in the School Environment

PURPOSE

The purpose of the present study is to understand the experience of living a chronic disease in the school, from the perspective of the parents.

DESIGN AND METHODS

A Grounded Theory study was proposed with a sample of 14 affected families with children between three and eleven years old, all of them from the west and south of Spain. Information was collected using semi-structured surveys and the constant comparative method was used for the analysis.

RESULTS

Results are divided into three main themes: SOS! My child is at school, The Systems (don't) Answer and Families Answer. Parents live school enrolment in a state of constant alertness, characterized by distrust, worry, fear, anguish, and indignation. The responses to the problem given by the education and health systems are insufficient, uncoordinated and inefficient. Therefore, parents end up not expecting anything, they transmit the information, organize training sessions, and solve any occurring incident by themselves, often at the expense of quitting their jobs.

CONCLUSION

The presence of a school nurse would mean for these parents the integration between the education and health systems.

PRACTICE IMPLICATIONS

As findings highlight, more collaboration and sensitivity between the healthcare and educational system is needed, and the school nurse has been indicated as a crucial figure in this matter.

Evaluation of a Province-Wide Type 1 Diabetes Care Plan for Children in the School Setting

OBJECTIVES

The aim of this study was to identify perceptions of safety and effectiveness of a provincial type 1 diabetes school care plan, and to best inform future improvements in school care to accommodate the shifting needs of families, best clinical practices and new medical technologies.

METHODS

A cross-sectional satisfaction and feedback questionnaire to inform quality improvement was offered to both families of children with type 1 diabetes who receive care at school through a Delegated Diabetes Care Plan and to their program coordinators during the 2017‒2018 school year.

RESULTS

The response rate was 29.8% (160 of 537) for families and 68.2% (45 of 66) for coordinators. The majority of parents and coordinators reported that the care plan is meeting both safety and diabetes management needs. On a 7-point Likert scale, the safety score, expressed as mean (standard deviation), was 6.0 (1.2) by families and 5.7 (1.3) by coordinators, with higher scores reflecting greater satisfaction. Diabetes management was rated 5.6 (1.2) out of 7 by families, and 5.4 (0.8) out of 7 by coordinators. Families and coordinators expressed the need for individualization of care, and suggested modifications to how information is presented. There was near-unanimous support for future integration of continuous glucose-monitoring devices into the school setting.

CONCLUSIONS

British Columbia's provision of diabetes care in the school setting is overall perceived to be safe and is generally well received by families and coordinators. In this study, we provide valuable information to improve the care of children with type 1 diabetes in schools, including support for further individualization of care and future integration of diabetes technology into the school setting.

Teachers' Perspectives on Children With Type 1 Diabetes in German Kindergartens and Schools

The number of children with type 1 diabetes is rising, and these children must manage their diabetes during the day while in kindergarten or school. A total of 678 German kindergarten and school teachers (89% female) attended a structured training program for supporting children with type 1 diabetes in their diabetes management. The teachers completed questionnaires on their overall self-perception of their ability to handle diabetes and institutional factors supporting children with type 1 diabetes. Of these teachers, 251 who were currently working with a child with type 1 diabetes provided further insight into the experiences of children with diabetes in school and kindergarten. Teachers reported deficits in three areas: knowledge about diabetes and diabetes management, institutional support, and communication with parents and health professionals. On average, they gave themselves only fair ratings on both their knowledge about diabetes (3.60 ± 1.10 on a 5-point scale) and their ability to assist children with their diabetes management (3.67 ± 1.09). Whereas general information about supporting children with type 1 diabetes seemed to have been provided by almost half of the institutions (43%), specific school policies for sports (30%), extracurricular activities such as field trips (20%), or activities including sleepovers (16%) were rare. Poor communication between teachers, parents, and health professionals was reported. These deficits indicated by kindergarten and school teachers underline the importance of structured trainings and written policies on type 1 diabetes to improve the status of children with type 1 diabetes in school and kindergarten.

Diminished school-based support for the management of type 1 diabetes in adolescents compared to younger children

AIMS

To evaluate diabetes management at school in a large cohort of adolescents with type 1 diabetes and to compare the level of support provided to adolescents with that provided to younger children.

METHODS

Questionnaires were distributed to adolescents with type 1 diabetes attending nine regional and tertiary paediatric diabetes services in the Republic of Ireland. The data collected included patient demographics, treatment regimen and support provided for self-care management. Results were compared with a similar cohort of primary school children with type 1 diabetes, studied using similar methodology.

RESULTS

The study cohort comprised 405 adolescents with a median age of 15 years, of whom 215 (54%) were on multiple daily injections and 128 (32%) were on pump therapy. Eighty-five percent of pump users administered their bolus insulin in classrooms, whereas 76% of those on a multiple daily injection regimen injected outside the classroom. Girls were less likely to administer bolus insulin in an office (10% vs 19%) and more likely to administer it in the bathroom (50% vs 34%; P=0.01). Twenty-five adolescents (12%) on multiple daily injection regimens did not administer bolus insulin at school. Compared to primary school children with type 1 diabetes, adolescents were less likely to use pump therapy, have an emergency treatment plan and have a designated staff member responsible for care needs.

CONCLUSIONS

Support provided to adolescents with type 1 diabetes is diminished compared with that provided to younger schoolchildren.

The Role of School Nurse Presence in Parent and Student Perceptions of Helpfulness, Safety, and Satisfaction With Type 1 Diabetes Care

Adolescents with type 1 diabetes (TID) and their parents depend on school nurses to keep students safe in school. Parent satisfaction with T1D care is impacted by school factors including school nurse presence. The purpose of this study was to determine the relationships among parental satisfaction with diabetes care in school, parental report of diabetes-related safety, adolescent report of school nurse helpfulness, and school nurse presence represented by school nurse to student ratios. The sample consisted of 89 parent-adolescent dyads. Adolescents 10-16 years old with T1D completed a questionnaire that included perceptions of school nurse helpfulness. Parents completed a questionnaire that included perceptions of T1D safety and satisfaction. Diabetes-related safety was positively correlated with parental satisfaction and school nurse helpfulness and inversely correlated with age and school nurse to student ratios. Findings validate the importance of school nurse presence to adolescents with T1D and their parents with implications for school nursing policy, practice, and research.

Effects of an education program on knowledge and self-perception of school personnel in preparing to care for type 1 diabetes students

Objective

To assess the academic and professional background of school personnel; to assess the impact of the Diabetes + Support given by School Personnel to Children with Type 1 Diabetes Program on the school personnel’s knowledge and confidence to support students with type 1 diabetes; to compare their level of knowledge with the academic and professional variables of the school personnel.

Methods

A quasi-experimental pre-test/post-test study design without a Control Group. Study with a sample of 129 (before intervention – T0) and 113 (after intervention – T1) pre-school to secondary school personnel from participating schools, with at least one student with type 1 diabetes. The project was approved by the Ethics Committee of the Portuguese Ministry of Education.

Results

Most school personnel included in the study were teachers (51.2%). After training, they were more confident than before to support children with type 1 diabetes (p<0.05). Regarding knowledge levels, the differences between T0 (10.8±2.8; P ₅₀ =11) and T1 (13.7±2.1; P ₅₀ =11) were statistically significant (p<0.001). Of the 113 school personnel who participated in the final assessment, 89 (78.85%) increased their level of knowledge.

Conclusion

The program was effective to enhance knowledge and boost confidence to support students with diabetes.

Type 1 diabetes mellitus and educational attainment in childhood: a systematic review

OBJECTIVES

The primary objective of this systematic review was to evaluate available literature on whether type 1 diabetes mellitus (T1DM) has an impact on educational attainment in individuals undertaking high stakes standardised testing at the end of compulsory schooling.

DESIGN

A systematic review was undertaken comparing educational attainment for individuals with and without T1DM who have undertaken high stakes testing at the end of compulsory schooling.

DATA SOURCES

A comprehensive search of MEDLINE, MEDLINE (epub ahead of print, in-process and other non-indexed citations), EMBASE, Web of Science, British Education Index, Education Resources Information Center and Cumulative Index to Nursing and Allied Health Literature was undertaken on 15 January 2018 and updated on 17 January 2019.

ELIGIBILITY CRITERIA

Included studies fulfilled the following criteria: observational study or randomised controlled trial; included individuals who have undertaken high stakes testing at the end of compulsory schooling; compared the grades obtained by individuals with T1DM with a representative population control.

DATA EXTRACTION AND SYNTHESIS

Two reviewers performed study selection and data extraction independently. Quality and risk of bias in the observational studies included were assessed using the Newcastle-Ottawa Scale. A detailed narrative synthesis of the included studies was completed.

RESULTS

3103 articles were identified from the database search, with two Swedish cohort studies (using the same linked administrative data) meeting final inclusion criteria. A small but statistically significant difference was reported in mean final grades, with children with T1DM found to have lower mean grades than their non-diabetic counterparts (adjusted mean difference 0.07-0.08).

CONCLUSIONS

More contemporary research is required to evaluate the impact of T1DM in childhood on educational attainment in individuals undertaking high stakes standardised testing at the end of compulsory schooling, taking into consideration the substantial advances in management of T1DM in the last decade.

PROSPERO REGISTRATION NUMBER

CRD42017084078.

Parental levels of stress managing a child diagnosed with type 1 diabetes in Riyadh: a cross sectional study

BACKGROUND

Caring for a child with Type 1 Diabetes (T1D) pose a significant burden on parents especially when they struggle with their child's T1D management. The experience of not coping or struggling to cope increases the level of stress in parents, which may adversely affect their child's diabetic control (Al Dubayee et al, Horm Res Paediatr 88:2019). In this study, we assessed the level of stress parents experience in caring for a child diagnosed with T1D in four different domains.

METHODS

This was a cross-sectional study conducted in two specialized diabetic centers in Riyadh, Saudi Arabia, from February to May 2015 (Al Dubayee et al, Horm Res Paediatr 88:2019). We used an Arabic translation of the validated Pediatric Inventory for Parents (PIP) questionnaire. The frequency and perceived difficulty of stressful events were rated by interviewing parents caring for children with T1D using two 5-point Likert scales.

RESULTS

The sample realized as 390 parents. The level of stress increased in separated and unemployed parents. The frequency (mean 64.9/210, SD 7.529) and difficulty (mean 65.3/210, SD 9.448) indices of the parental level of stress were compared with variables possibly associated with stress. Both of the frequency difficulty indices correlated with the marital status, the father's level of education and occupation as well as HbA1c level (P-value < 0.05). In addition, the frequency index correlated with the frequency of hypoglycemia and the difficulty index correlated with the number of children in the family (P-value < 0.05).

CONCLUSION

Parents of children with T1D in Riyadh experience a significant level of stress that may affect the child's glycemic control (Al Dubayee et al, Horm Res Paediatr 88:2019). Assessing the level of stress and providing support for these families has the potential to improve the clinical outcome.

"How am I gonna cope?": Caregivers of adolescents with diabetes in Jamaica

Objective

To determine the challenges, coping strategies and needs of urban and rural Jamaican caregivers of adolescents with diabetes, and suggest ways to assist coping.

Methods

This qualitative study comprised four focus groups (two urban and two rural) with a total of nineteen caregivers of adolescents with diabetes. Thematic analysis was conducted on the data.

Results

The main challenges caregivers faced were keeping their children healthy, managing conflict with their children, and financial concerns. They met these challenges with problem-focused and emotion-focused coping strategies. Caregivers used the problem-focused strategies of vigilance, advocacy, minimising their children’s negative emotions, coercion, education, and seeking support, and the emotion-focused strategies of relying on their identity as parents and turning to their faith. Caregivers wanted assistance acquiring medication and equipment, increased diabetes education, and support groups.

Discussion

More resources should be channelled toward provision of diabetes supplies. Diabetes education is necessary in schools and for the general public. Healthcare practitioners should explore issues beyond diabetes management, such as caregivers’ coping and the caregiver-child relationship. Support groups are needed to facilitate learning. Special attention must be paid to rural areas: rural residents appeared to be in greater need than their urban counterparts.

Improving the school experience of children with diabetes: Evaluation of the KiDS project

BACKGROUND

The International Diabetes Federation (IDF) launched the Kids and Diabetes in School (KiDS) project in collaboration with the International Society for Paediatric and Adolescent Diabetes (ISPAD) and Sanofi Diabetes to inform and teach school staff, children and parents on the management of diabetes in school. Brazil and India were chosen as pilot countries.

METHODS

The evaluation was conducted using a qualitative methodology using semi-structured face to face in-depth interviews. Five out of fifteen schools were selected, where teachers and parents of children with and without diabetes were interviewed. Interviews took place one and three months after the implementation of KiDS.

FINDINGS

Diabetes knowledge among the school staff and parents of children without diabetes was very limited prior to the KiDS Project in both countries. After introducing the KiDS information pack both groups mentioned increased knowledge on the management of diabetes. This was reflected through healthier food choices at school and the encouragement of physical activities. Increased awareness and understanding in the school staff were observed by parents of children with diabetes.

INTERPRETATION

The KiDS project received positive feedback on the educational materials. The pack was deemed informative, interesting and engaging, creating increased awareness and understanding among school staff, parents and children. The project has created a demand for diabetes intervention in schools. The pack has been translated into fourteen languages and was downloaded over 17,000 times by November 2018.

[Needs of schoolchildren with type 1 diabetes in Extremadura: Family perceptions]

INTRODUCTION

School-aged children with type 1 diabetes (DM1) require access to appropriate and safe care for their disease during their stay in the educational centre.

OBJECTIVE

To identify the needs perceived by families of schoolchildren with DM1 that affect their educational integration, safety, and well-being during the school day.

METHODOLOGY

A descriptive and cross-sectional study was conducted using a questionnaire based on information and opinions provided by families of 362 schoolchildren between 3 and 16 years old with DM1 registered in their health history in the Public Health System of Extremadura.

RESULTS

The response rate was 56.9% (206). It was shown that 35% of schoolchildren with DM1 were treated with continuous subcutaneous insulin infusion therapy. Almost all of them (95.1%) required glucose monitoring, and 57.8% required insulin administration during the school day. Most (88%) children had adjusted well to school and did not describe any type of discriminatory treatment (87.4%). Glucagon is available in 82% of educational centres, in which 43.7% had a trained adult person to administer it. That teachers could recognise a hypoglycaemia was expressed by 21.4% of the families, and 29.1% were unaware of the existence of coordination protocols in the school. More than half (58.7%) claimed that the information available in schools about diabetes was low, and 77.2% stated that the control of the disease would improve if more training was provided to teachers.

CONCLUSIONS

There are aspects optimally covered in the care of schoolchildren with DM1 in the schools of Extremadura. Among situations identified with potential room for improvement were adherence to the coordination protocol, information about diabetes, and training of adults to deal with emergency situations.

Teachers' knowledge about type 1 diabetes in south of Spain public schools

AIMS

To evaluate the knowledge of teachers in educative public centres (pre-, primary, and secondary schools) about type 1 diabetes (T1D) in the Puerto Real University Hospital area (Cadiz, Spain).

METHODS

Descriptive observational study in which 756 teachers' answers on the Test of Diabetes Knowledge for Teachers (TDKT) were analysed. Teachers from 44 educative public centres in the Puerto Real University Hospital area (Cadiz, Spain) were selected by randomized sampling (mean age, 44.3 ± 8 years; 61.7% women).

RESULTS

Although 43.2% survey respondents recognised having had or currently having children or adolescent students with T1D, most demonstrated they did not have enough knowledge about T1D (mean score, 6.0 ± 4.3 points from a maximum of 16), and only 5.1% had sufficient knowledge (13-16 points) to be an effective support person to students with diabetes in school. However, the vast majority of survey respondents correctly answered questions about symptoms (74.2%) and hypoglycaemia treatment (85.9%). Univariate analysis of factors associated with teachers' knowledge about diabetes revealed that teachers with ≤ 15 years of teaching experience and physical education teachers had better knowledge than their co-workers.

CONCLUSIONS

It is necessary to improve teachers' knowledge about diabetes in our health area with the aim of improving the security of children and adolescent students with T1D in school centres.

The Role of a School Nurse in the Care of a Child with Diabetes Mellitus Type 1 - The Perspectives of Patients and their Parents: Literature Review

INTRODUCTION

The aim of this literature review was to explore the views of parents and children with type 1 diabetes mellitus regarding having a school nurse.

METHODS

Six databases were selected for the analysis. The research strategy was based on the PICO model. The research participants were children with type 1 diabetes mellitus and/or their parents.

RESULTS

The present review of research papers includes 12 publications. The majority of works deal with the perspectives of children with type 1 diabetes and their parents on various aspects related to the role of a school nurse in the care of a child with type 1 diabetes:the presence of a school nurse;the role of a school nurse in the prevention and treatment of hypoglycaemia, in performing the measurements of blood glucose, and in insulin therapy;the role of a nurse in improving metabolic control of children with type 1 diabetes;a nurse as an educator for children with type 1 diabetes, classmates, teachers, teacher's assistants, principals, administrators, cafeteria workers, coaches, gym teachers, bus drivers, and school office staff;a nurse as an organiser of the care for children with type 1 diabetes.

CONCLUSIONS

According to parents and children with type 1 diabetes mellitus, various forms of school nurse support (i.e., checking blood glucose, giving insulin, giving glucagon, treating low and high blood glucose levels, carbohydrate counting) are consistently effective and should have an impact on the condition, improvement of metabolic control, school activity and safety at school.

Facilitation of Intensive Insulin Therapy in the Early Primary School Setting: Narratives of Australian Diabetes Educators

The number of early primary school (EPS) children (aged 4-8 years) with type 1 diabetes mellitus (T1DM) rises each year. Intensive insulin therapy (IIT) can be challenging for these children, as adult support may not be available in the school setting. Diabetes educators (DEs) working in the health system facilitate school diabetes care, which can be time-consuming given the large numbers of children with diabetes. These factors are potential barriers for IIT use in the EPS setting. To explore the experiences of Australian DEs who facilitate IIT use in the EPS setting, a qualitative, narrative inquiry method was used to conduct semi-structured telephone interviews with Australian DEs (n = 13) between December 2014 and June 2016. The interview transcript data were analyzed using a narrative analytical approach. Approaches to facilitate IIT use in the EPS setting were normalizing IIT at diagnosis, simple care plans and insulin pump therapy, prioritizing school support, DEs in private practice, and working with school nurses and parents. Despite numerous barriers, Australian DEs implemented varied methods to facilitate IIT use in the EPS setting.

Teachers' attitudes and perceptions about preparation of public schools to assist students with type 1 diabetes

OBJECTIVE

To assess teachers' attitudes and perceptions about preparation of public primary and secondary education schools in the Puerto Real University Hospital (Cádiz, Spain) area to care for students with type 1 diabetes mellitus (T1DM) METHODS: A descriptive observational study where answers to an attitude and perception questionnaire on the preparation of schools to care for pupils with T1DM were analyzed. A total of 765 teachers (mean age, 44.3±8.8 years; 61.7% women) from 44 public schools in the area of the Puerto Real University Hospital were selected by random sampling.

RESULTS

Overall, 43.2% of teachers surveyed had or had previously had students with T1DM, but only 0.8% had received specific training on diabetes. 18.9% of teachers reported that one of their students with T1DM had experienced at least one episode of hypoglycemia at school, and half of them felt that their school was not prepared to deal with diabetic emergencies. 6.4% stated that their school had glucagon in its first aid kit, and 46.9% would be willing to administer it personally. Women, physical education teachers, and headmasters had a more positive perception of the school than their colleagues. Teachers with a positive perception of school preparation and with a positive attitude to administer glucagon were significantly younger than those with no positive perception and attitude.

CONCLUSIONS

The study results suggest that teachers of public schools in our health area have not been specifically trained in the care of patients with T1DM and perceive that their educational centers are not qualified to address diabetic emergencies.

Improving the Care of Youth With Type 1 Diabetes With a Novel Medical-Legal Community Intervention: The Diabetes Community Care Ambassador Program

Purpose The purpose of this study was to examine the feasibility and efficacy of the Diabetes Community Care Ambassador (DCCA) Program, a novel medical-legal community intervention designed to support high-risk youth with type 1 diabetes. Methods Study eligibility criteria: ages 3-19 years, A1C ≥8.5% (≥69 mmol/mol) and/or recent diabetic ketoacidosis hospitalization, type 1 diabetes duration ≥1 year, and English- or Spanish-speaking. Eighty-nine youth and their caregivers participated in the 9- to 12-month intervention, which included diabetes education and support through 3 home visits, 1 to 2 school visits, and phone support from a lay health worker, as well as legal support from a medical-legal partnership attorney. Feasibility was assessed; change in A1C was compared in a linear mixed model. Results Of the 89 DCCA Program participants, 80% completed the program, with the majority of participants rating their DCCA favorably. Sixty-two percent reported ≥1 unmet legal need, of whom 29% accepted legal counsel. Youth enrolled in the DCCA Program demonstrated an improvement in glycemic control as their mean A1C decreased from 9.71% (83 mmol/mol) at the start of the program to 9.40% (79 mmol/mol) at the end of the intervention period ( P = .03). Participants with public health insurance experienced the greatest differential A1C reduction (9.79% to 9.11%, 83 mmol/mol to 76 mmol/mol). Conclusions The DCCA Program represents a promising intervention for improving care of high-risk youth with type 1 diabetes. A significant proportion of caregivers of youth reported having an unmet legal need. Participants remained highly engaged and demonstrated improved glycemic control, particularly youth with public health insurance.

"You Cannot Cure It, Just Control It": Jamaican Adolescents Living With Diabetes

Although adolescence is considered a difficult time for diabetes management, there is little published qualitative research on adolescent Jamaicans with diabetes. This study investigates the experiences of Jamaican adolescents living with diabetes to determine how their needs can be addressed. Nineteen adolescents participated in two urban and two rural focus groups and were asked to draw pictures representing their experiences. Thematic analysis was used to analyze their narratives, while their drawings were analyzed using a variation of Lauritsen and Mathiasen's (2003) method. Results show that control was the central theme: children felt controlled by diabetes and the people in their lives. Diabetes restricted their activities and imposed a sense of difference. Support from those around them could be both helpful and constricting. Children tried to resist control through disregarding the rules, being secretive, defiant, and manipulating others into allowing nonadherence. They also tried to adhere to the rules, find a balance between following them and engaging in desired activities, and to be positive. Those most positive about living with diabetes did not feel controlled by diabetes or others' understandings of it and, with loved ones' support, had rejected diabetes' negative meanings. Extreme distress was felt by rural children. All children had been noncompliant. Healthcare practitioners and policymakers should provide education in schools to facilitate fair and effective treatment. Mental health specialists should assist children to negotiate stigma and distress. Group sessions with significant others are important for collaborative decisions on enabling support.

Improved diabetes management in Swedish schools: results from two national surveys

BACKGROUND

Support in diabetes self-care in school is essential to achieve optimal school performance and metabolic control. Swedish legislation regulating support to children with chronic diseases was strengthened 2009.

OBJECTIVE

To compare the results of a national survey conducted 2008 and 2015 measuring parents' and diabetes specialist teams' perceptions of support in school.

METHOD

All pediatric diabetes centers in Sweden were invited to participate in the 2015 study. In each center, families with a child being treated for T1DM and attending preschool class or compulsory school were eligible. The parents' and the diabetes teams' opinions were collected in two separate questionnaires.

RESULTS

Forty-one out of 42 eligible diabetes centers participated and 568 parents answered the parental questionnaire in 2015. Metabolic control had improved since the 2008 survey (55.2 ± 10.6 mmol/mol, 7.2% ± 1.0%, in 2015 compared with 61.8 ± 12.4 mmol/mol, 7.8% ± 1.1% in 2008). The proportion of children with a designated staff member responsible for supporting the child's self-care increased from 43% to 59%, (P < .01). An action plan to treat hypoglycemia was present for 65% of the children in 2015 compared with 55% in 2008 (P < .01). More parents were satisfied with the support in 2015 (65% compared with 55%, P < .01).

CONCLUSIONS

This study shows that staff support has increased and that more parents were satisfied with the support for self-care in school in 2015 compared with 2008. More efforts are needed to implement the national legislation to achieve equal support in all Swedish schools.

Improving School Experiences for Adolescents With Type 1 Diabetes

BACKGROUND

Diabetes mellitus (diabetes) is one of the most common metabolic diseases in children worldwide and the incidence of type 1 diabetes (T1D) is growing. T1D is complicated to manage and adolescents with diabetes face unique, age-specific challenges. The purpose of this article is to discuss ways in which schools can create a positive environment and improve the experiences and outcomes for adolescents with T1D.

METHODS

The Cumulative Index of Nursing and Allied Health Literature (CINAHL) and PubMed databases were searched and yielded a total of 27 articles that were used in this integrative literature review.

RESULTS

Common concerns identified by students with T1D and their parents included a lack of full-time school nurses, lack of teacher knowledge of diabetes, lack of access to diabetes tools, lack of freedom to perform diabetes self-care, lack of nutritional information in cafeterias, and lack of communication between parents and school personnel. Students who are unable to attend school on a daily basis may not be able to achieve their academic potential.

CONCLUSIONS

Implications for school health including specifics for school nurses, teachers, students, and school environment were identified.

School-based diabetes interventions and their outcomes: a systematic literature review

Type 1 diabetes is one of the most common chronic childhood diseases, while type 2 diabetes in children is increasing at alarming rates globally. Against this backdrop, the school is a critical environment for children with diabetes. They continue to face barriers to education that may lead to depression, poor academic performance, and poor quality of life. To address these challenges, diabetes interventions have been implemented in school and the goal was to systematically review these interventions and their outcomes between 2000 and 2013. Fifteen studies were included in the narrative synthesis. Education of school personnel was the main focus before 2006. Studies reported gains in knowledge and perceived confidence of school staff. Since 2006, more comprehensive interventions have been developed to promote better care coordination and create a safe school environment. These studies reported improved diabetes management and quality of life of students. Assessment tools varied and study design included randomized controlled trials, quantitative and qualitative methods. Although many of the studies reported a significant difference in the parameters measured, it was not possible to determine optimal ways to improve the health, quality of life and academic performance of children with diabetes, given the disparity in scope, assessment tools and measured outcomes. Experimental designs, longer follow-up studies, larger sample sizes, and a higher number of participating schools are critical issues to consider in future studies. Most of the research was conducted in North America and further research is needed in other parts of the world.

Teachers' perspectives of supporting pupils with long-term health conditions in mainstream schools: a narrative review of the literature

Teachers are supporting an increasing number of pupils with long-term health conditions in mainstream schools. The aim of this literature review was to critically appraise and synthesise research that has examined teachers' perceptions of the key barriers and facilitators to supporting pupils with long-term conditions, teachers' training needs and interventions that aim to improve teachers' knowledge of long-term conditions, and teachers' confidence in supporting children and young people. A narrative literature review was conducted using a systematic search of computerised databases and manual searches of key journals and reference lists to retrieve studies published between 2003 and 2013. Studies were critically appraised and key themes across studies identified. In total, 61 papers from 58 studies were included in the review. The findings suggest that teachers receive little formal training relevant to long-term condition management and are fearful of the risks involved in teaching children and young people with long-term conditions. Communication between families, school and health and social care services appears to be poor. Educational programmes developed in conjunction with and/or delivered by healthcare professionals seem to have the potential to increase teachers' knowledge and confidence. This review suggests that healthcare professionals have an important role to play in supporting teachers in identifying and meeting the needs of pupils with long-term conditions. It is vital that pupils with long-term conditions receive appropriate care and support in schools to ensure their safety and help them to integrate with their peers and achieve their academic potential. Limitations in the current evidence are highlighted and implications for future research are identified.

An ongoing struggle: a mixed-method systematic review of interventions, barriers and facilitators to achieving optimal self-care by children and young people with type 1 diabetes in educational settings

BACKGROUND

Type 1 diabetes occurs more frequently in younger children who are often pre-school age and enter the education system with diabetes-related support needs that evolve over time. It is important that children are supported to optimally manage their diet, exercise, blood glucose monitoring and insulin regime at school. Young people self-manage at college/university.

METHOD

Theory-informed mixed-method systematic review to determine intervention effectiveness and synthesise child/parent/professional views of barriers and facilitators to achieving optimal diabetes self-care and management for children and young people age 3-25 years in educational settings.

RESULTS

Eleven intervention and 55 views studies were included. Meta-analysis was not possible. Study foci broadly matched school diabetes guidance. Intervention studies were limited to specific contexts with mostly high risk of bias. Views studies were mostly moderate quality with common transferrable findings.Health plans, and school nurse support (various types) were effective. Telemedicine in school was effective for individual case management. Most educational interventions to increase knowledge and confidence of children or school staff had significant short-term effects but longer follow-up is required. Children, parents and staff said they struggled with many common structural, organisational, educational and attitudinal school barriers. Aspects of school guidance had not been generally implemented (e.g. individual health plans). Children recognized and appreciated school staff who were trained and confident in supporting diabetes management.Research with college/university students was lacking. Campus-based college/university student support significantly improved knowledge, attitudes and diabetes self-care. Self-management was easier for students who juggled diabetes-management with student lifestyle, such as adopting strategies to manage alcohol consumption.

CONCLUSION

This novel mixed-method systematic review is the first to integrate intervention effectiveness with views of children/parents/professionals mapped against school diabetes guidelines. Diabetes management could be generally improved by fully implementing and auditing guideline impact. Evidence is limited by quality and there are gaps in knowledge of what works. Telemedicine between healthcare providers and schools, and school nurse support for children is effective in specific contexts, but not all education systems employ onsite nurses. More innovative and sustainable solutions and robust evaluations are required. Comprehensive lifestyle approaches for college/university students warrant further development and evaluation.

Relations among school/daycare functioning, fear of hypoglycaemia and quality of life in parents of young children with type 1 diabetes

AIMS AND OBJECTIVES

To investigate the type 1 diabetes-related school/daycare experiences of parents of young children and to examine the relationship among child school/daycare functioning, parent fear of hypoglycaemia and parent type 1 diabetes-related quality of life.

BACKGROUND

Parents of young children who attend school/daycare must rely on others for daily type 1 diabetes management. Worry about school/daycare type 1 diabetes management may cause parental distress and contribute to diminished parent quality of life. Parental concerns about type 1 diabetes management in young children in the school/daycare setting have not been well described in the literature.

DESIGN

Descriptive correlational and cross-sectional parent report of questionnaires design.

METHODS

As part of a randomised controlled trial for parents of young children with type 1 diabetes, 134 parents completed self-report measures at baseline. Data included demographic, school/daycare, and medical information, parent reports of child school/daycare functioning, parent fear of hypoglycaemia and parent type 1 diabetes-related quality of life.

RESULTS

Parents of younger children, children on a more intensive medical regimen and children who had experienced type 1 diabetes-related unconsciousness or seizures had more school/daycare concerns. Parents who perceived their children had higher school/daycare functioning had less fear about hypoglycaemia and reported better type 1 diabetes-related quality of life. School/daycare functioning and fear of hypoglycaemia were significantly associated with parent type 1 diabetes-related quality of life.

CONCLUSIONS

Parents' concerns about school/daycare functioning and fear of hypoglycaemia play an important role in parents' type 1 diabetes-related quality of life.

RELEVANCE TO CLINICAL PRACTICE

Members of the healthcare team should be aware of concerns related to children attending school/daycare and provide additional support as warranted.

The management of type 1 diabetes in Australian primary schools

AIM

The aim of this study was to explore the management of type 1 diabetes in Australian primary schools: kindergarten-Year 2, from the parent's perspective. The study questions were: What diabetes treatment is being delivered? Who is providing the treatment? Where is the treatment given?

METHODS

A cross sectional, descriptive approach was used to collect data from parents (66) of children with type 1 diabetes attending an Australian primary school (kindergarten-Year 2). An online self-administered questionnaire was designed in Survey Monkey and was available via a dedicated Facebook page. Data were analysed using statistical analysis (SPSSv21).

RESULTS

Blood glucose testing was occurring for all children, with 49% of children self testing. 77% of children were receiving an insulin bolus or injection at school. 34% was provided by the child and 53% of insulin was given via pump. Teachers, parents and teacher's aides also provided insulin at school. There was a statistically significant association between the number of children receiving insulin at school and the insulin delivery device, χ(2 )= 16.75, df = 1, p ≤ 0.000). Children using insulin pump therapy were more likely (97%) to receive insulin at school than children who used injections (55%). Children who were able to self-administer insulin were more likely to receive insulin (93%) at school than children who were unable to self-administer insulin (65%) (χ(2 )= 7.38, df = 1, p = 0.007) 81% of children received diabetes treatment in the classroom, with the remainder in the school administration office.

CONCLUSION

Insulin administration across Australian primary schools was inconsistent. Not all children were receiving the recommended insulin treatment. Insulin pump therapy appears to increase access to this treatment at school.

Developing and evaluating a child-centred intervention for diabetes medicine management using mixed methods and a multicentre randomised controlled trial

Aim

To develop and evaluate an individually tailored age-appropriate diabetes diary and information pack for children and young people aged 6–18 years with type 1 diabetes to support decision-making and self-care with a specific focus on insulin management and blood glucose monitoring, compared with available resources in routine clinical practice.

Design

Four-stage study following the Medical Research Council framework for designing and evaluating complex interventions. Stage 1: context – brief review of reviews and mixed-method systematic review; updating of database of children’s diabetes information; children’s diabetes information quality assessment and diabetes guideline analysis; and critical discourse analysis. Stage 2: intervention development – working with expert clinical advisory group; contextual qualitative interviews and focus groups with children and young people to ascertain their information preferences and self-care practices; ongoing consultation with children; development of intervention programme theory. Stage 3: randomised controlled trial (RCT) to evaluate the diabetes diaries and information packs in routine practice. Stage 4: process evaluation.

Findings

The RCT achieved 100% recruitment, was adequately powered and showed that the Evidence into Practice Information Counts (EPIC) packs and diabetes diaries were no more effective than receiving diabetes information in an ad hoc way. The cost per unit of producing the EPIC packs and diabetes diaries was low. Compared with treatment as usual information, the EPIC packs fulfilled all NHS policy imperatives that children and young people should receive high-quality, accurate and age-appropriate information about their condition, self-management and wider lifestyle and well-being issues. Diabetes guidelines recommend the use of a daily diabetes diary and EPIC diaries fill a gap in current provision. Irrespective of allocation, children and young people had a range of recorded glycated haemoglobin (HbA1c) levels, which showed that as a group their diabetes self-management would generally need to improve to achieve the HbA1clevels recommended in National Institute for Health and Care Excellence guidance. The process evaluation showed that promotion of the EPIC packs and diaries by diabetes professionals at randomisation did not happen as intended; the dominant ‘normalisation’ theory underpinning children’s diabetes information may be counterproductive; risk and long-term complications did not feature highly in children’s diabetes information; and children and young people engaged in risky behaviour and appeared not to care, and most did not use a diabetes diary or did not use the information to titrate their insulin as intended.

Limitations

Recruitment of ‘hard to reach’ children and young people living away from their families was not successful. The findings are therefore more relevant to diabetes management within a family context.

Conclusions

The findings indicate a need to rethink context and the hierarchical relationships between children, young people, parents and diabetes professionals with regard to ‘partnership and participation’ in diabetes decision-making, self-care and self-management. Additional research, implementation strategies and service redesign are needed to translate available information into optimal self-management knowledge and subsequent optimal diabetes self-management action, including to better understand the disconnection between children’s diabetes texts and context; develop age-appropriate Apps/e-records for recording blood glucose measurements and insulin management; develop interventions to reduce risk-taking behaviour by children and young people in relation to their diabetes management; reconsider what could work to optimise children’s self-management of diabetes; understand how best to reorganise current diabetes services for children to optimise child-centred delivery of children’s diabetes information.

Study registration

Current Controlled Trials ISRCTN17551624.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Strategies of adherence promotion in the management of pediatric chronic conditions

Children and families often have difficulty following prescribed medical treatment for chronic pediatric conditions. Such nonadherence has a significant impact on children's health care outcomes and the costs of their care. This review describes a comprehensive approach to increase treatment adherence in chronic pediatric illnesses and lessen its impact. Key elements of this proposed model of adherence promotion include the following: (1) a core approach to adherence promotion to be implemented by pediatric health care providers; (2) follow-up and ongoing management; and (3) tailoring and targeting specific more intensive family-centered interventions to children and adolescents who demonstrate clinically significant treatment nonadherence or risk for nonadherence. Behavioral specialists have important roles in conducting research on adherence promotion, training health care providers, and delivering services to children and adolescents with clinically significant adherence problems.

The concerns of school staff in caring for children with diabetes in primary school

OBJECTIVES

Primary school children spend 25% of their waking hours in school. Education authorities have a duty of care to support children with chronic illnesses within schools, but this is very variable. This study has examined the concerns of primary school staff working with children with Type 1 diabetes and their parents, and related these concerns to the views of health-care professionals (HCP) working with school personnel.

METHODS

We undertook in-depth, semi-structured face-to-face interviews with 22 primary school staff and 5 multidisciplinary HCP from the local healthcare team. Interview transcripts were analysed using a structured, iterative approach grouping together key themes and issues to create a coding scheme.

RESULTS

Primary school staff expressed a range of concerns about injecting and blood glucose testing, the ability of children to mishandle their condition, and corresponding reactions of parents to school decisions on health-based matters. These fears had some convergence with the perspectives of HCP who also highlighted the institutional nature of primary schools and dynamics of home/family life as factors impacting upon care of children with diabetes at school.

CONCLUSIONS

Increased training for teachers having direct and current responsibility for children with diabetes was thought to lessen anxiety. Greater and more accessible knowledge about diabetes for all staff was requested. A range of practical management strategies were highlighted, including fostering good communication and teamwork between child, parent, school, and HCP. Professionals felt that support services would improve by using community-based dieticians and including psychological input into the diabetes team.

Pediatric self-management: a framework for research, practice, and policy

Self-management of chronic pediatric conditions is a formidable challenge for patients, families, and clinicians, with research demonstrating a high prevalence of poor self-management and nonadherence across pediatric conditions. Nevertheless, effective self-management is necessary to maximize treatment efficacy and clinical outcomes and to reduce unnecessary health care utilization and costs. However, this complex behavior is poorly understood as a result of insufficient definitions, reliance on condition-specific and/or adult models of self-management, failure to consider the multitude of factors that influence patient self-management behavior, and lack of synthesis of research, clinical practice, and policy implications. To address this need, we present a comprehensive conceptual model of pediatric self-management that articulates the individual, family, community, and health care system level influences that impact self-management behavior through cognitive, emotional, and social processes. This model further describes the relationship among self-management, adherence, and outcomes at both the patient and system level. Implications for research, clinical practice, and health care policy concerning pediatric chronic care are emphasized with a particular focus on modifiable influences, evidence-based targets for intervention, and the role of clinicians in the provision of self-management support. We anticipate that this unified conceptual approach will equip stakeholders in pediatric health care to (1) develop evidence-based interventions to improve self-management, (2) design programs aimed at preventing the development of poor self-management behaviors, and (3) inform health care policy that will ultimately improve the health and psychosocial outcomes of children with chronic conditions.

The ALBA project: an evaluation of needs, management, fears of Italian young patients with type 1 diabetes in a school setting and an evaluation of parents' and teachers' perceptions

OBJECTIVE

To determine how Italian parents and school personnel of 6-13-year-old children with type 1 diabetes (T1D) manage during school hours, including insulin administration, management of hypoglycemia, and glucagon use. A further aim was an investigation into the responsibilities and training of school personnel regarding diabetes.

RESEARCH DESIGN AND METHODS

After an initial qualitative phase, semi-structured questionnaires were completed by a sample of parents and teachers.

RESULTS

220 parent and 52 teacher questionnaires were completed. 43.6% of parents said diabetes had negatively influenced school activities. Children either self-administer insulin, or have help from a parent, since there is very rarely a nurse present (3.6%) or a teacher who will take responsibility for the treatment (2.9%). Most parents (55.9%) stated either that the school had no refrigerator to store glucagon or that they did not know if the school was so equipped. A small percentage of teachers considered their schools to be equipped to manage an emergency (23%) and said they would use glucagon directly in an emergency (14.9%). Only 40.4% of teachers said that they had received any specific training.

CONCLUSIONS

The study shows that people who are not directly involved have superficial knowledge of the different aspects of diabetes, even though no parents reported episodes of neglect/incorrect management. There is no legislation which clearly defines the role of the school in the care of children with T1D, and teachers are not trained to help them. Training sessions for school personnel and greater legislative clarity about the 'insulin and glucagon question' are key factors that may improve the full integration of the child with diabetes.

Self-care of school-age children with diabetes: an integrative review

AIM

This paper is a report of an integrative review of findings from empirical studies on self-care in school-age children with type 1 diabetes. The purpose is to generate insight into opportunities to develop empowering patient education.

BACKGROUND

Managing diabetes is demanding and requires parental involvement in care. Good self-care forms the basis for diabetes management and self-care patterns are established at school age, but how and to what extent school-age children increase their self-care capabilities is unclear.

DATA SOURCES

A search for studies from 1998 to 2010 focusing on self-care in school-age children with diabetes was conducted through electronic databases.

REVIEW METHODS

Using integrative methods, quantitative and qualitative papers surveyed were analysed separately, but the themes that arose were combined at the end of the analysis.

FINDINGS

Self-care is formed in a learning process involving the objectives of normality, being able to cope and independence. The content of self-care is a combination of knowledge and skills. Children have the technical skill, but they need their parents to participate in the care and share responsibility for it. The factors related to self-care comprised the characteristics of the child; the nature of the illness and care; and support from the parents, school environment, peers and healthcare team.

CONCLUSION

A balance between diabetes care requirements and a child's maturity should be found. Nurses must adopt an empowering manner of education and recognize and assess a child's readiness to learn diabetes care and bear responsibility for it. Nurses must also help parents and other adults to gradually shift the responsibility to the children.

School-based lived experiences of adolescents with type 1 diabetes: a preliminary study

BACKGROUND

Diabetes self-management is challenging for adolescents with type 1 diabetes mellitus (T1DM). School plays a crucial role in the adolescents' lives. However, evidence of inadequate quality of school-based diabetes care has been reported in the literature.

PURPOSE

The purpose of this preliminary study was to obtain an initial understanding of school-based lived experiences of adolescents with T1DM to serve as a foundation of future research.

METHODS

The Heideggerian hermeneutic phenomenological approach served as the philosophical underpinning for this study. Two Taiwanese adolescents with T1DM were purposively recruited. Individual, audio-recorded, semistructured interviews were conducted. Verbatim transcripts were analyzed through hermeneutic circle.

RESULTS

Participants described their school-based lived experiences as a dynamic learning process. Four interwoven themes were discovered: (a) learning to be master of their disease, (b) learning to find ways to feel comfortable, (c) learning to not be different, and (d) learning to not let others (especially parents) worry about them.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Diabetes care professionals, school nurses, school personnel, and parents should help strengthen resilience of the adolescents to overcome common social obstacles in schools. Creating a supportive learning environment is warranted to help incorporate diabetes management into their daily lives. Future studies should consider specific situational obstacles that the adolescents face to design effective interventions to improve school-based diabetes care.