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INNOVATIVE CARE Teacher Training and Children with Type 1 Diabetes Jennifer M Henderson Division of Education, University of Sheffield.

The diabetic child has the equivalent potential of peers in all school activities, providing that a balance is maintained between insulin injections and a regulated diet, coupled with regular exercise. However, to achieve this the rigorous self-care required from children with diabetes and their families needs to be supplemented by a sound knowledge of diabetes in teachers. Parents are obviously concerned about the safety of their diabetic child in school. Children need to eat main meals and snacks at regular times and extra carbohydrates are required before strenuous exercise. The greatest problem in school is a serious hypoglycaemic reaction and it is in this area that many teachers lack understanding. A safe environment for the student is essential and this requires the teacher to have a basic understanding of the nature of diabetes, the principles of management and the implications of these for the child at school. Teachers must be aware and have insight into the condition to assist children in managing their diabetes with minimal disruption to school activities. There are few studies on school teachers’ knowledge of diabetes, and only two published studies in Britain.lp2 All suggest an inadequate level of knowledge among school staff. A study in Utah, USA3 revealed a poor understanding of basic physiology and little knowledge of how to recognise and treat hypo- and hyperglycaemia. Gesteland et a/ 4 highlighted the problems involved in educating teachers in service about diabetes. The present study examines the knowledge and understanding of diabetes by students working for their Post Graduate Certificate in Education (PGCE) and attempts to evaluate two approaches to educating the student teachers about diabetes.

Methods and Data Collection The survey was based on the 1990-1 991 cohort of student teachers studying for a PGCE (secondary) in the Division of Education, University of Sheffield. Within the course of 36 weeks, there are two periods (each of 8 weeks) when teaching practice takes place in comprehensive schools. The first is in the autumn term and the second in the spring term. The

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survey conducted in the summer term addressed 137 students, who were asked to complete questionnaires. Of the 97 who responded, 14 intended teaching biology/ science, 4 chemistry/science, 8 physics/ science, 12 English, 12 geography, 11 history, 9 mathematics and 27 modern languages. O f the respondents, 27 had graduated in 1990, 58 between 1985 and 1989, 8 between 1980 and 1984, and 4 before 1980. Ages ranged from 21 to ‘over 35’ with approximately half the students aged between 22 and 24. The group comprised 35 males and 62 females, 10 students who had children of their own and 14 who had diabetic members of their family. Of these, 13 had encountered diabetic children during teaching practice and only 3 of the 97 students were

aware of a school policy for diabetic pupils. An overwhelming majority were of the view that teachers who encounter diabetic children should have access to an educational programme on diabetes. The students were divided randomly into 3 groups:

Group 7: the Programme Group (42 students) Group 2: the Self-Taught Group (27 students) Group 3: the Control Group (28 students). The Programme Group received a 90minute presentation (referred to as an ‘intervention’) from the Training Officer of the British Diabetic Association (BDA). This included a 20-minute videotape

DT17 entitled ‘Getting the Balance Right’ (prepared for teachers and youth leaders by Clwyd Education Committee), a discussion of the video and a review of the Teachers’ Information Pack produced by the BDA. Members of the Self-Taught Group received the Information Pack and were told that the video was available to review during the next 6 weeks (an intervention). The Control Group received no intervention until after the post-test, when they received the BDA Information Pack. All 3 groups of students completed a two-part questionnaire: Part 1 gained general information (subject, gender, age etc); Part 2, a pre-test, assessed their basic knowledge of Type 1 diabetes prior to the interventions. The pre-test, based on previous surveys of school teachers,lI4 consisted of 21 questions requiring a ‘yes’ or ’no’ answer and two that required a value judgement of ‘high’ or ‘low’ to give a total score of 23 (Table 1). The same questions to assess basic knowledge of Type 1 diabetes were posed as a post-test 6 weeks after the interventions. Total individual scores were calculated for each respondent. The percentage of students in the 3 groups answering each question correctly was computed. For analysis purposes the questions were divided into 3 categories: Questions 1, 4, 5, 7, 11, 16a, 16d and 16e in Table 1 appear under ‘pathophysiology’ in Table 2; Questions 2 and 3 in Table 1 appear under ‘treatment’ in Table 2; Questions 6, 8, 9, 10, 12, 13, 14, 15a, 15b, 15c, 15d, 16b and 16c in Table 1 appear under ‘management’ in Table 2. Student’s t-test evaluated statistically significant differences among the observations.

In the pre-test no major differences were apparent between Control, Programme and Self-Taught groups. The maximum possible score was 23 and the mean score for all students was 16.2 (70.4 %). In the pre-test 31 of the 97 students achieved a score of above 75 YO, 61 between 50 and 75 YOand 5 scored less than 50 %. Further, in the pre-test, there were no appreciable differences in total scores when students were grouped according to age, the year in which they graduated, whether they had children of their own or whether they had come across diabetic children during teaching practice. The mean score for science students was higher than that for other subject areas. Students with diabetic members of their family

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scored higher and the score for female was higher than that for male students. In the post-test, the scores of students in the Programme Group and those in the Self-Taught Group who had reviewed the materials improved. Students in the Control Group improved by an average of 2.2 YO, those in the Self-Taught Group by 5.1 o/o and those in the Programme Group by 10.2 YO.However, the highest scores were achieved by students in the Self-Taught Group who had reviewed the written materials. These students improved by an average of 13.1 O/O compared with an average increase of 0.5 Yo in those who did not review the materials. The responses, assessed separately as pathophysiology, treatment and management, revealed that only in the treatment questions did a marked improvement appear (Table 2).

Discussion A teacher‘s understanding of Type 1 diabetes is crucial in schools’ endeavours to provide a safe environment for pupils with diabetes. In the Bristol study6 of support for families with diabetic children, parents were asked from whom they had received assistance. Although 94 YO of cases had been in contact with teachers, it was teachers who, in the families’ opinion, provided the least support. Almost all the parents in the study had been in contact with school teachers regardingtheir child‘s diabetes but 36 YO had not found teachers supportive. This lack of support may be related to their poor understanding of diabetes. Since children are in school for long periods this obviously causes great concern among parents. Previous studies have demonstrated an inadequate understanding of diabetes by school teachers. Following a scoring procedure used in previous investigations,’J

scores of above 75 Yo were rated as adequate, scores of 50-75 YO as unsatisfactory and scores of below 50% as an insufficient knowledge of diabetes. In one study1 only 25 YO of teachers were found to have an ‘adequate’ knowledge. Furthermore, cross-tabulations of individual questions revealed inconsistencies in the knowledge of teachers. For example, some teachers who correctly identified the symptoms of hypoglycaemia or hyperglycaemia were not able to say correctly which of these could be managed at school or did not know the correct treatment for hypoglycaemia. In another survey of 475 teachers,3 a similar lack of undertanding was apparent. For example, only 54 % recognised that diabetes reflected an insulin deficiency and only 55% recognised sleepiness as a possible symptom of hypoglycaemia. In another survey2 of 99 secondary teachers who had regular contact with diabetic children, only onethird were found to have ‘adequate’ overall knowledge of diabetes and onethird had ‘insufficient’ knowledge. Just over one-quarter were unaware that a pupil with whom they had contact had diabetes. Ludvigsson5 reported that 6080 % of teachers considered their knowledge to be insufficient to deal with diabetic pupils. The present study is the second to evaluate approaches to educating teachers about diabetes. There was a noticeable improvement in the treatment questions in the groups receiving information. The Programme Group showed an average improvement of 44.4 % on the two treatment questions while the Self-Taught Group improved by 36.8 YO. The Utah study4 reported that although there was improvement in groups receiving information, the overall results were ’distressing’. These investigators were not surprised that the Programme Group’s post-test score did not show sufficient improvement. They particularly noted

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INNOVATIVE CARE inattention and preoccupation with the other demands of teaching. The improvement among the PGCE students in this group in the present study probably reflects both the excellent quality of the presentations and the fact that this information was given during the training year before the students had embarked upon the pressures of full-time teaching. Students in the Self-Taught Group who had reviewed the materials in the Information Pack scored best in the test, suggesting that this too is an effective method of teaching, providing student teachers can be persuaded to allocate the time in a very full programme. Where time is set aside by tutors, students gave their complete attention to the presentation and the personal contact between students and the presenter resulted in the most effective method of teaching the group as a whole. Previous studies2.7 indicated that teachers would like to learn more about diabetes and its management in relation to the school child. Anderson et a17 noted that teachers were of the view that knowledge of diabetes was preferably

acquired by professional instruction rather than by assimilation from family and friends. Bradbury and Smith,' in an investigation of possible sources of information about diabetes, found that only 10.3 % of teachers questioned had received any information during their teacher training. The lack of knowledge among teachers highlights the need for urgent improvements in the provision of information to, and the education of, teachers with regard to diabetes in school children. The present study shows that this provision should begin with a full and systematic integration of health education in common childhood health problems in teacher training courses. Acknowledgements

I especially thank Judith North, Training Officer of the British Diabetic Association, for her presentations to the students, for providing Information Packs to all the participants in the study and for her continued support. My thanks are also due to Dr Liam OToole, Information Scientist at the BDA for his enthusiastic input to this programme.

References 1. Bradbury AJ, Smith CS. An assessment of the diabetic knowledge of school teachers. Archives o f Diseases in Childhood 1983; 58: 692-696. 2. Warne J. Diabetes in school: A study of teachers' knowledge and information sources. Practical Diabetes 1988; 5: 210215. 3. Lindsay RN, Jarrett L, Hillam K. Elementary schoolteachers' understanding of diabetes. Diabetesfducator1987; 13:312-314. 4. Gesteland HM, Sims S, Lindsay RN. Evaluation of two approaches to educating elementary schoolteachers about insulindependent diabetes mellitus. Diabetes Educator1987; 15: 510-513. 5. Ludvigsson J. Diabetics in school: Knowledge and attitudes of school staff in relation to juvenile diabetes. Scand j Soc Med 1977; 5: 21-30. 6. Challen AH, Davies AG, Williams RJ, Baurn ID. Support for families with diabetic children: Parents' views. Practical Diabetes 1990; 7: 26-31. 7. Anderson RM, Hess GE, Hiss RG. The knowledge and attitudes of elementary and junior high school teachers regarding diabetes. Diabetes Education 1989; 15: 314-318.

The Role of Adult Physicians in the Care of Diabetic Adolescents Robert Young Consultant Physician, Hope Hospital, Salford.

Adolescence may be defined as the period between childhood and adulthood, which usually occurs in the age range 12-21 years in females and 14-25 years in males. Paediatricians and adult physicians are often extremely proprietorial about their role in the care of young people with diabetes-hence the need for this article. One suspects that professional attitudes are not always struck in accordance with optimising the environment for growing up with diabetes. My own personal belief is that the interests of young diabetic patients are best served by a joint adulvpaediatric approach to management in the transition period. What then is the legitimate claim for the adult physician to be involved? Firstly, it has to be accepted that the adolescent is developing, not regressing. He is moving towards adulthood and away from childhood. Psychologically, an independence of spirit, a sense of responsibility and personal accountability for action are evolving. Authority is increasingly resented. The negotiating style of an adult consultation, second nature to adult physicians, is perhaps more appropriate to achieving understanding and motivation than the

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necessarily didactic and often parent-channelled, style of paediatric consultation. Sexual maturation of course accompanies psychological maturation. Most teenage girls will be sexually experienced and some will become pregnant. Contraceptive advice, pre-pregnancy counselling and joint diabetes/obstetric management are properly the concern of adult physicians. Possibly adult physicians also have more awareness of how people with diabetes actually face up to the issues of smoking and drinking, which are common adolescent preoccupations. The adult physician's practice will also encompass more frequently the not uncommon problems of eating disorders found in young women and which usually start in the teenage years. As the adolescent starts work or further education and leaves home he develops the more complex, less regular lifestyle of the late teenage years for which a flexible approach to insulin and dietary management are essential. This is often also a requirement during the phase of accelerated growth when insulin requirements increase very rapidly. Adult physi-

cians generally have more experience with a wide range of insulin regimens and perhaps a better understanding of adult eating behaviour. Finally, and regretfully,'diabetes complications including retinopathy, nephropathy, hypertension and neuropathy, begin to manifest themselves towards the end of the second and beginning of the third decade. Their evaluation and management is the daily fare of adult physicians with an interest in diabetes but a rare encounter for paediatricians. I believe, therefore, that adult physicians should be involted in the care of adolescents with diabetes. Ideally the primary locus of care should be constantly reassessed as the young person grows up. Joint decisionmaking is the ideal. It should focus on the needs of the young person with diabetes and, most importantly, should seek to ease the sometimes difficult transition from paediatric to adult services which, for the young diabetic person, accompanies the journey from childhood to adulthood. I do not see how rigidly protected services and inflexible age-related transfer arrangements can possibly achieve this.

Teacher training and children with type 1 diabetes.

Dm INNOVATIVE CARE Teacher Training and Children with Type 1 Diabetes Jennifer M Henderson Division of Education, University of Sheffield. The diabe...
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