Issues in Comprehensive Pediatric Nursing, 2014; 37(3): 168–182 ß Informa Healthcare USA, Inc. ISSN: 0146-0862 print / 1521-043X online DOI: 10.3109/01460862.2014.932860
THE MANAGEMENT OF TYPE 1 DIABETES IN AUSTRALIAN PRIMARY SCHOOLS
Anne Marks, BN (Hons), MN (Nurse Practitioner)1,2, Valerie Wilson, BEdSt, MN (Research), PhD1,3, and Jackie Crisp, BA, PhD1 1
Faculty of Health, University of Technology Sydney, Australia, 2School of Nursing and Midwifery, University of Western Sydney, Australia, and 3 Nursing Research and Practice Development Unit, Sydney Children’s Hospital Network, Australia
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, 2 ¼ 16.75, df ¼ 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%) ( 2 ¼ 7.38, df ¼ 1, p ¼ 0.007) Received 27 March 2014; revised 16 May 2014; accepted 16 May 2014
Correspondence: Anne Marks, University of Western Sydney, School of Nursing and Midwifery, Building G10, Hawkesbury Campus. Locked Bag 1797, Penrith NSW 2751, Australia. Tel: +61 2 45701599, E-mail: [email protected]
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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. Keywords: Children, paediatric, school, type 1 diabetes
INTRODUCTION Type 1 diabetes is one of the most common, and fastest growing, chronic health conditions in childhood. A recent study found that Australia had the sixth highest rate of new cases of type 1 diabetes among children in the world (Catanzariti et al., 2009). In 2008 the prevalence amongst Australian children aged 0–4 years was 28.8 per 100 000 and 128 per 100 000 for children aged 5–9 years (Australian Institute of Health and Welfare, 2011). The prevalence is increasing by 3% per year (Craig et al., 2000; Haynes et al., 2004). Updated data is not yet available, however it was estimated that by 2013 the figures would rise to 35.9 per 100 000 for the 0–4 age group and 136.1 per 100 000 for those aged 5–9 years (Australian Institute of Health and Welfare, 2011). Therefore the number of children with diabetes attending early primary school has increased and is likely to rise even further. This increase will add pressure in terms of resources and planning for the ongoing needs of children, their families and the school system itself. Intensive insulin therapy (four daily injections of insulin or insulin pump therapy) and the rising prevalence of diabetes has increased the need for integration of diabetes care at school. The young child may face obstacles when they enter the school system, as generally parents perform their diabetes treatment due to their limited developmental stage and the complexity of the tasks required. Therefore, children attending early primary school require more planning and resources from parents, school personnel and diabetes educators than older children. Furthermore school encompasses a significant proportion of a child’s day, hence diabetes treatment at school needs to be optimal or they will have poor metabolic control and an increased risk of health complications. Whilst there are a number of international studies (Amillategui et al., 2007, 2009; Hellems & Clarke, 2007; Jacquez et al., 2008; Lin et al., 2008; Newbould et al., 2007; Wagner et al., 2006) on diabetes in the school setting there is a lack of published research in Australia. A review
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of the international literature (Marks et al., 2013) identified that the majority of children were not receiving intensive diabetes treatment at school. When treatment was received, it was most commonly provided by the child (aged over 8 years), a parent or school personnel. Treatment was frequently performed away from the classroom, which can have an impact on class attendance, metabolic control and emergencies. Therefore the aim of this study was to explore diabetes management in Australian schools. METHODS This cross-sectional study collected data to explore three aspects of diabetes care at school: the management of type 1 diabetes, parental concerns and strategies for improvement. This article will report on the first aspect: the management of type 1 diabetes. The study was conducted in Australia and focused on children attending early primary school: kindergarten, Year 1 and Year 2 (aged 4–8 years). The inclusion criteria were: a parent or carer of a child with type 1 diabetes attending an Australian primary school in kindergarten, Year 1 or 2, ability to read and write in English at an eighth grade level and have access to a computer with internet connection. Non-probability, purposive, volunteer sampling was used for this study. A self-administered electronic questionnaire was modeled on an existing tool used by Diabetes Australia (Middlehurst & Morrison, 2008) to survey parents living in New South Wales. The refinement of the questionnaire was also informed by the literature review, questions for the study and the researcher’s professional diabetes experience. The questionnaire was trialed on a small group of participants (5) and then modified based on their feedback. Paediatric diabetes specialist staff reviewed the questionnaire, including: a nurse practitioner (researcher), clinical nurse specialist, dietitian, psychologist and research assistant. After the consultation process and adjustments to the survey tool, it was agreed that the questionnaire had face validity. The self-administered questionnaire was designed and administered via the online survey and evaluation tool, Survey Monkey (Gordon, 2002). The Survey Monkey link was embedded on a dedicated ‘diabetes at school survey’ Facebook page and a direct web link was also created. The final survey responses were downloaded into an excel spreadsheet for analysis with the Statistical Package for Social Sciences (SPSS) version 21. Facebook was used to recruit participants for the study. A Facebook page was created, ‘Diabetes at school survey’ which included
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information about the study and a link to the electronic questionnaire. From February-March 2013, online posts from ‘Diabetes at school survey’ were placed on Facebook pages and groups that were focused on diabetes or parenting a child with diabetes within Australia. The online post included brief details of the study and an electronic link to the Facebook page dedicated to the diabetes at school research. Electronic links were then available for the online anonymous questionnaire if parents chose to participate. Data was statistically analysed using the Statistical Package for the Social Sciences (SPSS) version 21. Summary statistics (mean, median and standard deviation) were used for continuous variables and these were assessed for normality of score distribution. The distribution of all variables were non normal except for the age of the child. Chi-square tests for independence and independent sample t-tests were used to analyse data. RESULTS 66 parents were included in the analysis. Demographic data is outlined in Table 1. According to 2008 data, there were approximately 1731 children in Australia with type 1 diabetes aged between five and nine years (Australian Institute of Health and Welfare, 2011). The percentage of children that were represented in the study was difficult to determine, as the age ranged from four to eight years, however it is estimated at 3.8%. What Diabetes Treatment is Being Delivered? Parents reported that all children were having blood glucose levels (BGLs) tested at school. Most children were having two (20%) or three (21%) tests during the school day. 77% of children received an insulin injection or pump bolus at school. There were similar percentages of females (79%) and males (76%) receiving insulin. Just over half (53%) of the children in the study administered insulin via pump therapy. Of those children receiving insulin injections (47%), the majority (35%) were using insulin pens. Table 2 provides details of the school grade attended, insulin received and type of insulin delivery. There was a statistically significant association between the number of children receiving insulin at school and the insulin delivery device, ( 2 ¼ 16.75, df ¼ 1, p 0.000). Children in the study using insulin pump therapy were more likely (97%) to receive insulin at school than children who used injections (55%). There was no significant difference (t (18) ¼ .164, p ¼ .43, one-tailed) between the age (in months) of
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Table 1. Demographic data related to research participants Variable Participants Mother Father Carer Missing Child’s Gender Male Female Child’s age Years School grade Kindergarten Year 1 Year 2 Type of insulin delivery Insulin Pump Injections Length of diabetes diagnosis Years Recent HbA1c Percentage
n
%
M
SD
6.22
1.1
2.33
1.62
Range
60 91 4 6 1 1 1 1 33 50 33 50 4–8
23 35 23 35 20 30 35 53 31 47 0.08–7
7.6% (60 mmol/mol) 1.17 5.6–12% (38–108 mmol/mol)
Table 2. Comparison of school grade attended
School Grade Received insulin at school Type of insulin delivery Insulin Pump Injections Gender Male Female Length of diabetes diagnosis 1 year or less More than 1 year
Kindergarten
Year 1
Year 2
n (%) 16 (70)
n (%) 22 (96)
n (%) 13 (65)
10 (44) 13 (56)
17 (74) 6 (26)
8 (40) 12 (60)
10 (44) 13 (56)
15 (65) 8 (35)
8 (40) 12 (60)
11 (48) 12 (52)
3 (13) 20 (87)
3 (15) 17 (85)
children receiving insulin (M ¼ 74.47, SD ¼ 12.07) compared to children not receiving insulin (M ¼ 75.26, SD ¼ 17.67). The data indicated a potential disparity across geographical location of residence as, children living in rural (67%) or semi rural areas (71%) were less likely to receive insulin at school than those from small (83%)
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Percentage of children
35 30 25 20 15 10 5 0 Child
Teacher
Parent
Teacher's Office staff aide The person who administers insulin at school
Nurse
Figure 1. The percentage of children self-administering insulin and the percentage receiving insulin from parents or school personnel whilst at school.
and large metropolitan areas (83%). This disparity also seemed apparent in the type of insulin delivery used by children, as rural areas had significantly less insulin pump use (33%) than all other geographical regions including large metropolitan areas (66%). This difference may be due to increased availability of resources in metropolitan areas and requires further exploration. Who is Providing Diabetes Treatment? Parents reported that insulin at school was delivered by the child approximately one third of the time. The remaining two thirds of delivery was spread fairly evenly across teachers, parents and teacher’s aides (Figure 1). The data indicated that children who self-administered insulin were older (M ¼ 6.59 years, SD ¼ 0.9) than children not self-administering insulin (M ¼ 5.9 years, SD ¼ 1.1). When school grades were compared (Table 3), as expected, adults (teachers and parents) administered the majority of insulin for kindergarten students. Only a small percentage of these children were self-administering, which was via an insulin pump. For Year 1 students, school staff (teachers and teacher’s aides) provided most of their insulin. There were more children in Year 1 selfadministering and parents gave only a small percentage. In contrast, children in Year 2 gave a large percentage of insulin. However parents provided a greater percentage of insulin in this grade than Year 1, possibly due to the higher use of insulin injections in Year 2. 38% of children using insulin pumps and 23% using injections selfadministered insulin at school. Parents administered most of the insulin
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Table 3. The person performing insulin administration & blood glucose testing
School Grade Child Insulin BGL Teacher Insulin BGL Parent Insulin BGL Teachers aide Insulin BGL Office staff Insulin BGL Nurse Insulin BGL
Kindergarten
Year 1
Year 2
n (%)
n (%)
n (%)
3 (19) 6 (27)
5 (23) 9 (41)
9 (69) 16 (80)
5 (31) 9 (41)
7 (32) 4 (18)
0 (0) 1 (5)
5 (31) 3 (14)
2 (9) 0 (0)
3 (23) 2 (10)
3 (19) 3 (14)
6 (27) 7 (32)
1 (8) 0 (0)
0 (0) 1 (4)
1 (4.5) 1 (4.5)
0 (0) 1 (5)
0 (0) 0 (0)
1 (4.5) 1 (4.5)
0 (0) 0 (0)
to children on injections. For those using insulin pumps, the majority (38%) of insulin was given by the child. Additionally, teacher’s aides and teachers gave a larger amount of insulin to children using insulin pumps (26% & 30%) compared to injections (6% & 12%). Although nurses and office staff rarely (6%) gave insulin injections, children on pumps did not receive insulin from these staff. There was a significant association between the number of children receiving insulin at school and the ability to self-administer insulin 2 ¼ 7.38, df ¼ 1, p ¼ 0.007). Children in the study who were able to selfadminister insulin were more likely to receive insulin (93%) at school than children who were unable to self-administer insulin (65%). Most blood glucose level (BGL) testing at school was done by the child (49%). The remainder was performed by school staff (43%) and parents (8%). For children in kindergarten, school staff provided most (58%) of the BGL testing and the remainder was provided by the child (27%) and parent (14%). Similarly, Year 1 students also had most (59%) of their BGLs tested by school staff but a larger proportion was done by the child (41%). The majority (80%) of Year 2 students tested their own BGLs, and school staff (10%) and parents (10%) performed a very small amount of testing. It was apparent that older children were more capable of
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self-testing their blood glucose levels in the study. The mean age of those self-testing was 6.7 years (SD ¼ 1.0), which was older than those requiring assistance from school staff (M ¼ 5.7 years, SD ¼ 0.18) or parents (M ¼ 5.5 years, SD ¼ 1.2). Where is the Treatment Given? The majority (81%) of children received insulin in the classroom, with the remainder in the school administration office. 92% of blood glucose testing was also performed in the classroom. Although not statistically significant, the data suggested a possible relationship between the location of insulin administration and the length of diabetes diagnosis. 88% of children with a longer duration of diabetes (more than one year) received insulin in the classroom compared to 70% of children diagnosed for a shorter duration (1 year or less). Additionally 91% of children in the study who were able to self-administer insulin received insulin in the classroom compared to those who required assistance from parents (75%) or school staff (76%). Interestingly, there was little difference in the age of children receiving insulin in the classroom (M ¼ 6.2 years, SD ¼ 0.1) and children receiving insulin in the office (M ¼ 6.0, SD ¼ 1.1). However, 94% of children using insulin pump therapy remained in class for insulin administration compared to 63% of children who used injections. Storage of Diabetes Management Supplies Insulin Parents of children using insulin injections at school were questioned about the location of insulin storage. The majority (58%) stored insulin in the classroom. Eighteen percent of insulin was stored in the office and 12% in both areas. Twelve percent of parents did not store insulin at school and took it with them when they administered the injection at school. Most parents (94%) were happy with the location of insulin storage. Blood glucose meter The blood glucose (BG) meter was mainly stored in the classroom (63%). Some children had BG meters in both the classroom and office (35%) and 2% stored the meter in the office only. Ninety seven percent of parents believed that the current location was where the BG meter should be stored. Some parents expressed the importance of easy access to the BG meter for safety reasons and therefore stored it in more than one location throughout the school.
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Hypoglycaemic treatment Parents in the study reported that hypoglycaemic treatment was stored in the classroom (40%) or both the classroom and the office (60%). Virtually all parents (95%) agreed that whichever location they reported was appropriate. Similarly to the blood glucose meter, some parents (4%) expressed that they wanted hypo treatment located in many places around the school (canteen, gym, library, music). DISCUSSION Insulin delivery at school was an important issue that was highlighted in the findings. Not all children (77%) in the current study received an insulin injection or pump bolus at school, therefore some children are not receiving intensive insulin therapy. This finding is consistent with previous research (Amillategui et al., 2007; Amillategui et al., 2009; Hellems & Clarke, 2007; Jacquez et al., 2008; Middlehurst & Morrison, 2008; Newbould et al., 2007). Just over half of the children in the study were using pumps to deliver insulin. The percentage of insulin pump use was on average 15% higher than reported in previous studies (Jacquez et al., 2008; Middlehurst & Morrison, 2008; Wagner et al., 2006) and Australian data from 2004– 2011 (Australian Institute of Health and Welfare, 2012). The higher percentage of pump use could be attributed to the more recent increases in access and evidence of benefits for younger children. The above changes occurred after the previous studies were conducted. In Australia, funding became available from the government and diabetes organisations to assist families without health insurance to access insulin pump therapy (Australian Institute of Health and Welfare, 2012). Research on safety and benefits of insulin pump therapy for younger age groups also heightened the recommendation for pump use from health care teams (Australian Institute of Health and Welfare, 2012; Nabhan et al., 2009; Peters et al., 2013; Sulmont et al., 2011; Wilson et al., 2005). It was reassuring to see that parents from the current study reported all children were having blood glucose levels tested at school. This was similar to the findings of a number of international studies (Jacquez et al., 2008; Newbould et al., 2007; Wagner et al., 2006) but a great deal more than reported in two Spanish studies (Amillategui et al., 2007; Amillategui et al., 2009). However the number of blood glucose tests performed at school was varied in the current research. The data demonstrated that most children tested between two to three times during the school day. Children who tested more than four times were predominately from Year 2 or on insulin injections. Currently there is
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a lack of research in this area however it does require further investigation as excessive BGL testing at school could impact on class participation or time with peers. Intensive insulin treatment is recommended for children to prevent long-term microvascular complications (Craig et al., 2011). However this treatment has a number of consequences for children in early primary school. One implication is deciding who will provide treatment for this young age group. Generally, parents perform diabetes treatment for young children due to their limited developmental stage and the complexity of the tasks required. In the school setting there is often a shift from parental care to either the child or school staff. Parents in the current study reported that children were the most frequent (33%) providers of insulin compared to parents and teachers. A direct comparison with other research is difficult due to the lack of studies focusing on the early primary school setting. However insulin delivery was provided predominately by the child in the Australian unpublished study (Middlehurst & Morrison, 2008). The study by Hellems and Clarke found that that only 7% of children gave their own insulin in kindergarten to 5th grade. Similarly, Nabors et al identified that 11% of children under the age of 10 years were independent with diabetes treatment. When the child is unable to administer their own insulin their treatment may be modified so that insulin is not required at school (23% in this study). Alternatively, a parent or school staff member is relied on to administer the insulin. Adults provided 67% of insulin to children in the current study. Parents administered approximately one third, class teachers and teacher’s aides provided the remaining two thirds with only a very small amount provided by nursing or administration staff. In contrast the majority of children in kindergarten-5th grade in the Hellems & Clarke (2007) study received assistance from from a nurse (74%), teacher or administrator (29%) or a parent (24%). Similarly, Clay et al. reported most insulin was given by the child (61%) or nurse (28%), with small numbers of teachers or administrators (11%) and nil by parents. As expected only a small percentage of younger children attending kindergarten were self-administering insulin. All of these children were using insulin pump therapy. Teachers and parents administered the majority of insulin for kindergarten students. A greater number of students in Year 1 were giving their own insulin compared to kindergarten, however teachers and teacher’s aides delivered the highest percentage. A definite shift in provision of insulin was noted for this school grade, as parents gave only 9%. Of the six students selfadministering insulin, five of these were using insulin pumps. In contrast, older children in Year 2 gave a much larger percentage of insulin. Six out of nine students who were self-administering were using
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insulin pumps. However a significant amount was still delivered by parents and minimal assistance was provided from teacher’s aides. One explanation for the lack of school staff involvement for Year 2 students compared to the other school grades could be the greater number of students using injections. It is possible that staff are not comfortable with this method of insulin delivery. Middlehurst & Morrison (2008) also commented on this finding, as more than a quarter of parents attended the school to administer insulin to their child in their research. These children were predominately under eight years of age and using insulin injections. There were no children aged less than seven and a half years self-injecting insulin. It is likely that there are a number of factors that influence insulin administration at school. The study data and supporting literature identified two potential influences: (1) the child’s ability to selfadminister insulin and (2) the type of insulin delivery device. Children who were able to self-administer insulin were more likely to receive insulin at school. This could be further influenced by age, gender and length of diabetes diagnosis. It is expected that older children would be more likely to self-administer insulin. However the Amillategui et al. study reported that only 26% of children received insulin at school and 63% were not able to self-administer insulin, even though the median age was 11.5 years. In the current study, children who were self-administering insulin were older (6.5 years) than children unable to selfadminister (5.9 years). However age alone does not explain the reason for increased insulin use at school as older children in Year 2 received less insulin than Year 1 students. The second influence on insulin administration at school was the type of insulin delivery device. Children from the current study were more likely to self-administer insulin if they were using insulin pump therapy. Similarly, Alsaleh et al. found that younger children had greater participation in insulin administration via an insulin pump than injections. It is well documented that children from the age of eight to ten years usually develop the cognitive and physical skills to self inject insulin (Amillategui et al., 2007; Clay et al., 2004; Ekim & Pek, 2010; Hellems & Clarke, 2007; Middlehurst & Morrison, 2008; Nabors et al., 2003). However it is possible that children may develop the required physical skills for pushing buttons on an insulin pump at an earlier age. According to the study data, even when children were not selfadministering insulin, the use of insulin pump therapy remained an influence on insulin delivery at school. The Australian study by Middlehurst & Morrison (2008) also reported this connection. The authors stated that teaching staff were more likely to administer insulin
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via a pump than injection. In addition less parents attended the school when their child was using pump therapy. Therefore it is possible that insulin pump therapy may provide increased access to insulin in the early primary school setting. An important potential impact of the above study findings is the disadvantage that children from rural areas may face. Rural areas had less insulin pump use than all other geographical regions. Large metropolitan areas had double (66%) the percentage of children using insulin pump therapy compared to rural areas (33%). Additionally, children living in rural areas were also less likely to receive insulin at school than those from metropolitan areas. Similarly, the Australian Institute of Health and Welfare (2012) report on insulin pump therapy use in Australia found a disparity between geographical areas. For children aged 0–11 years, 58% of pump use was reported for outer regional/remote areas compared to 68% in major city/inner regional areas. One possible reason for this discrepancy appears to be the lack of specialist diabetes children services that have the resources to provide insulin pump therapy (Australian Institute of Health and Welfare, 2012). Within Australia, insulin pump services are predominantly available in diabetes clinics in large metropolitan teaching hospitals (Australian Institute of Health and Welfare, 2012). This is an area that requires further exploration, as the development of a consistent approach to insulin pump provision will ensure that standard treatment is accessible for all children with type 1 diabetes. Comparably to insulin administration, the majority of blood glucose testing (BGL) at school was also performed by the child. The remainder was done largely by school staff and a small percentage by parents. It is expected that older children would be more capable of self-testing their blood glucose levels and this is evident in the current study findings. For children aged less than seven years, testing was mainly provided by school. For children aged seven years or over, the child provided almost all testing. There was a greater involvement of school staff in blood glucose testing compared to insulin administration. This was also the case in previous studies (Amillategui et al., 2009; Hellems & Clarke, 2007; Middlehurst & Morrison, 2008). The findings suggest that in Australia, teachers and teacher’s aides provide assistance with diabetes care rather than administrators or nurses. However they were less likely to provide care when it was associated with insulin injections rather than insulin via a pump. Additionally the large number of teachers and teacher’s aides providing insulin administration implies that care is provided in the classroom. Therefore it is possible that integration of diabetes care is progressing considerably well in Australia.
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According to the American Diabetes Association (2006) students should be permitted to provide diabetes treatment wherever they are in the school. This is important in order to minimise metabolic, academic and psychosocial impacts of diabetes care. The percentage of diabetes care performed in the classroom in the current study was much higher (92% BGL, 81% insulin) than previous studies: 25–79% for BGL testing (Hellems & Clarke, 2007; Jacquez et al., 2008; Middlehurst & Morrison, 2008; Newbould et al., 2007; Wagner et al., 2006) and 12–66% for insulin administration (Clay et al., 2008; Jacquez et al., 2008; Newbould et al., 2007; Smith et al., 2008; Wagner et al., 2006). The higher percentage could be attributed to further research in school diabetes care and increased advocacy for integration at school. The research study by Wagner et al may have influenced the shift in the location of school diabetes care as they found that children who left class for care had poorer diabetes control (HbA1c 8.4%) than those who remained in class (HbA1c 7.4%). In terms of advocacy and policy development, a number of departments in Australia have produced recommendations for diabetes care at school including the location of treatment, which many schools have adopted into their policies (Diabetes Australia Queensland, 2010; Diabetes Australia Victoria, 2013; NSW Government. Department of Education and Communities, 2013). Limitations There were various study limitations that should be considered when interpreting the findings. The small sample size and the challenges associated with accessing participants through social media such as Facebook, restricted generalisability to the larger population. The sample is biased due to the required access to a computer and Internet connection and the ability to read and write English to participate in the study. Implications Diabetes specialist teams need to take into consideration the impact that treatment regimes may have on the child’s school routine. Where possible intensive insulin treatments such as pump therapy should be prescribed in order to reduce the risk of long-term health complications. However, a collaborative process involving parents and school personnel is necessary in order to provide a safe and inclusive school environment for the child with diabetes. An increase in funding and resource allocation is required to reflect the rising prevalence of type 1 diabetes and the added demands of intensive insulin therapy at school for the child, diabetes professionals and school personnel. Ideally, international
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policies for the management of diabetes at school need to be developed to improve consistency of care and equity for all children. DECLARATION OF INTEREST The authors declare that they have no conflict of interest. REFERENCES American Diabetes Association. (2006). Diabetes care in the school and day care setting: American diabetes association. [Article]. Diabetes Care, 29(1), S49–S55. Amillategui, B., Calle, J., Alvarez, M., Cardiel, M. & Barrio, R. (2007). Identifying the special needs of children with Type 1 diabetes in the school setting. An overview of parents perceptions. Diabetic Medicine, 24(10), 1073–1079. Amillategui, B., Mora, E., Calle, J. R. & Giralt, P. (2009). Special needs of children with type 1 diabetes at primary school: perceptions from parents, children, and teachers. Pediatric diabetes, 10(1), 67–73. Australian Institute of Health and Welfare. (2011). Prevalence of Type 1 diabetes in Australian children 2008. Diabetes series no. 15. Cat. no. CVD 54. Canberra: AIHW. ISBN 978-1-74249-172-1. Australian Institute of Health and Welfare. (2012). Insulin pump use in Australia: AIHW. ISBN 978-1-74249-329-9. Catanzariti, L., Faulks, K., Moon, L., Waters, A. M., Flack, J. & Craig, M. (2009). Australia’s national trends in the incidence of Type 1 diabetes in 0–14-year-olds, 2000–2006. Diabetic Medicine, 26(6), 596–601. Clay, D., Cortina, S., Harper, D. C., Cocco, K. M. & Drotar, D. (2004). Schoolteachers’ experiences with childhood chronic illness. Children’s Health Care, 33(3), 227–239. Clay, D., Farris, K., McCarthy, A., Kelly, M. & Howarth, R. (2008). Family Perceptions of Medication Administration at School: Errors, Risk Factors, and Consequences. The Journal of School Nursing, 24(2), 95–102. Craig, M., Howard, N., Silink, M. & Chan, A. (2000). The rising incidence of childhood type 1 diabetes in New South Wales, Australia. Journal of pediatric endocrinology & metabolism: JPEM, 13(4), 363–372. Craig, M., Twigg, S., Donaghue, K., Cheung, N., Cameron, F., Conn, J., Silink, M. (2011). for the Australian Type 1 Diabetes Guidelines Expert Advisory Group: National evidence-based clinical care guidelines for T1DM diabetes in children, adolescents and adults. Canberra: Australian Government Department of Health and Ageing. Diabetes Australia Queensland. (2010). Students with diabetes. Guidelines for Queensland schools, from http://www.diabetesqld.org.au/media/54537/2012__ may__students_with_diabetes_-_guidelines_for_queensland_schools_final.pdf. Diabetes Australia Victoria. (2013). Diabetes and school Retrieved 13th July from http:// www.diabetesvic.org.au/type-1-diabetes/children-a-adolescents/diabetes-and-school. Ekim, A. & Pek, H. (2010). Insulin administration skills of children with type 1 diabetes. [Report]. Journal of Diabetes Nursing, 14(2), 70–74.
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Gordon, A. (2002). SurveyMonkey. com—Web-Based Survey and Evaluation System: http://www. SurveyMonkey. com. The Internet and Higher Education, 5(1), 83–87. Haynes, A., Bower, C., Bulsara, M. K., Jones, T. & Davis, E. (2004). Continued increase in the incidence of childhood Type 1 diabetes in a population-based Australian sample (1985–2002). Diabetologia, 47(5), 866–870. Hellems, M. A. & Clarke, W. L. (2007). Safe at school: a Virginia experience. Diabetes Care, 30(6), 1396–1398. Jacquez, F., Stout, S., Alvarez-Salvat, R., Fernandez, M., Villa, M., Sanchez, J., Eidson, M., Nemery, R. & Delamater, A. (2008). Parent perspectives of diabetes management in schools. The Diabetes Educator, 34(6), 996–1003. Lin, H., Mu, P. & Lee, Y. (2008). Mothers’ experience supporting life adjustment in children with T1DM. Western Journal of Nursing Research, 30(1), 96–110. Marks, A., Wilson, V. & Crisp, J. (2013). The Management of Type 1 Diabetes in Primary School: Review of the Literature. Issues in comprehensive pediatric nursing, 36(1–2), 98–119. Middlehurst, A. & Morrison, M. (2008). Diabetes management in the school setting. A NSW parent survey. Diabetes Australia (Unpublished). Nabhan, Z. M., Kreher, N. C., Greene, D. M., Eugster, E. A., Kronenberger, W. & DiMeglio, L. A. (2009). A randomized prospective study of insulin pump vs. insulin injection therapy in very young children with type 1 diabetes: 12-month glycemic, BMI, and neurocognitive outcomes. Pediatric diabetes, 10(3), 202–208. Nabors, L., Lehmkuhl, H., Christos, N. & Andreone, T. L. (2003). Children with Diabetes: Perceptions of Supports for Self Management at School. Journal of school health, 73(6), 216–221. Newbould, J., Francis, S. A. & Smith, F. (2007). Young people’s experiences of managing asthma and diabetes at school. Archives of disease in childhood, 92(12), 1077–1081. NSW Government. Department of Education and Communities. (2013). Diabetes at school. NSW public schools. Retrieved 13th July from http://www.schools.nsw. edu.au/studentsupport/studenthealth/conditions/diabetes/atschool/index.php. Peters, J. E., Mount, E., Huggins, C. E., Rodda, C. & Silvers, M. A. (2013). Insulin pump therapy in children and adolescents: Changes in dietary habits, composition and quality of life. Journal of Paediatrics and Child Health, 49(4), E300–305. Smith, F. J., Taylor, K. M. G., Newbould, J. & Keady, S. (2008). Medicines for chronic illness at school: experiences and concerns of young people and their parents. Journal of Clinical Pharmacy & Therapeutics, 33(5), 537–544. Sulmont, V., Lassmann-Vague, V., Guerci, B., Hanaire, H., Leblanc, H., Leutenegger, E., Mihaileanu, M. & Tubiana-Rufi, N. (2011). Access of children and adolescents with type 1 diabetes to insulin pump therapy has greatly increased in France since 2001. Diabetes & metabolism, 37(1), 59–63. Wagner, J., Heapy, A., James, A. & Abbott, G. (2006). Brief report: glycemic control, quality of life, and school experiences among students with diabetes. Journal of pediatric psychology, 31(8), 764–769. Wilson, D. M., Buckingham, B. A., Kunselman, E. L., Sullivan, M. M., Paguntalan, H. U. & Gitelman, S. E. (2005). A two-center randomized controlled feasibility trial of insulin pump therapy in young children with diabetes. Diabetes Care, 28(1), 15–19.
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THE MANAGEMENT OF TYPE 1 DIABETES IN AUSTRALIAN PRIMARY SCHOOLS
Anne Marks, BN (Hons), MN (Nurse Practitioner)1,2, Valerie Wilson, BEdSt, MN (Research), PhD1,3, and Jackie Crisp, BA, PhD1 1
Faculty of Health, University of Technology Sydney, Australia, 2School of Nursing and Midwifery, University of Western Sydney, Australia, and 3 Nursing Research and Practice Development Unit, Sydney Children’s Hospital Network, Australia
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, 2 ¼ 16.75, df ¼ 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%) ( 2 ¼ 7.38, df ¼ 1, p ¼ 0.007) Received 27 March 2014; revised 16 May 2014; accepted 16 May 2014
Correspondence: Anne Marks, University of Western Sydney, School of Nursing and Midwifery, Building G10, Hawkesbury Campus. Locked Bag 1797, Penrith NSW 2751, Australia. Tel: +61 2 45701599, E-mail: [email protected]
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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. Keywords: Children, paediatric, school, type 1 diabetes
INTRODUCTION Type 1 diabetes is one of the most common, and fastest growing, chronic health conditions in childhood. A recent study found that Australia had the sixth highest rate of new cases of type 1 diabetes among children in the world (Catanzariti et al., 2009). In 2008 the prevalence amongst Australian children aged 0–4 years was 28.8 per 100 000 and 128 per 100 000 for children aged 5–9 years (Australian Institute of Health and Welfare, 2011). The prevalence is increasing by 3% per year (Craig et al., 2000; Haynes et al., 2004). Updated data is not yet available, however it was estimated that by 2013 the figures would rise to 35.9 per 100 000 for the 0–4 age group and 136.1 per 100 000 for those aged 5–9 years (Australian Institute of Health and Welfare, 2011). Therefore the number of children with diabetes attending early primary school has increased and is likely to rise even further. This increase will add pressure in terms of resources and planning for the ongoing needs of children, their families and the school system itself. Intensive insulin therapy (four daily injections of insulin or insulin pump therapy) and the rising prevalence of diabetes has increased the need for integration of diabetes care at school. The young child may face obstacles when they enter the school system, as generally parents perform their diabetes treatment due to their limited developmental stage and the complexity of the tasks required. Therefore, children attending early primary school require more planning and resources from parents, school personnel and diabetes educators than older children. Furthermore school encompasses a significant proportion of a child’s day, hence diabetes treatment at school needs to be optimal or they will have poor metabolic control and an increased risk of health complications. Whilst there are a number of international studies (Amillategui et al., 2007, 2009; Hellems & Clarke, 2007; Jacquez et al., 2008; Lin et al., 2008; Newbould et al., 2007; Wagner et al., 2006) on diabetes in the school setting there is a lack of published research in Australia. A review
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of the international literature (Marks et al., 2013) identified that the majority of children were not receiving intensive diabetes treatment at school. When treatment was received, it was most commonly provided by the child (aged over 8 years), a parent or school personnel. Treatment was frequently performed away from the classroom, which can have an impact on class attendance, metabolic control and emergencies. Therefore the aim of this study was to explore diabetes management in Australian schools. METHODS This cross-sectional study collected data to explore three aspects of diabetes care at school: the management of type 1 diabetes, parental concerns and strategies for improvement. This article will report on the first aspect: the management of type 1 diabetes. The study was conducted in Australia and focused on children attending early primary school: kindergarten, Year 1 and Year 2 (aged 4–8 years). The inclusion criteria were: a parent or carer of a child with type 1 diabetes attending an Australian primary school in kindergarten, Year 1 or 2, ability to read and write in English at an eighth grade level and have access to a computer with internet connection. Non-probability, purposive, volunteer sampling was used for this study. A self-administered electronic questionnaire was modeled on an existing tool used by Diabetes Australia (Middlehurst & Morrison, 2008) to survey parents living in New South Wales. The refinement of the questionnaire was also informed by the literature review, questions for the study and the researcher’s professional diabetes experience. The questionnaire was trialed on a small group of participants (5) and then modified based on their feedback. Paediatric diabetes specialist staff reviewed the questionnaire, including: a nurse practitioner (researcher), clinical nurse specialist, dietitian, psychologist and research assistant. After the consultation process and adjustments to the survey tool, it was agreed that the questionnaire had face validity. The self-administered questionnaire was designed and administered via the online survey and evaluation tool, Survey Monkey (Gordon, 2002). The Survey Monkey link was embedded on a dedicated ‘diabetes at school survey’ Facebook page and a direct web link was also created. The final survey responses were downloaded into an excel spreadsheet for analysis with the Statistical Package for Social Sciences (SPSS) version 21. Facebook was used to recruit participants for the study. A Facebook page was created, ‘Diabetes at school survey’ which included
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information about the study and a link to the electronic questionnaire. From February-March 2013, online posts from ‘Diabetes at school survey’ were placed on Facebook pages and groups that were focused on diabetes or parenting a child with diabetes within Australia. The online post included brief details of the study and an electronic link to the Facebook page dedicated to the diabetes at school research. Electronic links were then available for the online anonymous questionnaire if parents chose to participate. Data was statistically analysed using the Statistical Package for the Social Sciences (SPSS) version 21. Summary statistics (mean, median and standard deviation) were used for continuous variables and these were assessed for normality of score distribution. The distribution of all variables were non normal except for the age of the child. Chi-square tests for independence and independent sample t-tests were used to analyse data. RESULTS 66 parents were included in the analysis. Demographic data is outlined in Table 1. According to 2008 data, there were approximately 1731 children in Australia with type 1 diabetes aged between five and nine years (Australian Institute of Health and Welfare, 2011). The percentage of children that were represented in the study was difficult to determine, as the age ranged from four to eight years, however it is estimated at 3.8%. What Diabetes Treatment is Being Delivered? Parents reported that all children were having blood glucose levels (BGLs) tested at school. Most children were having two (20%) or three (21%) tests during the school day. 77% of children received an insulin injection or pump bolus at school. There were similar percentages of females (79%) and males (76%) receiving insulin. Just over half (53%) of the children in the study administered insulin via pump therapy. Of those children receiving insulin injections (47%), the majority (35%) were using insulin pens. Table 2 provides details of the school grade attended, insulin received and type of insulin delivery. There was a statistically significant association between the number of children receiving insulin at school and the insulin delivery device, ( 2 ¼ 16.75, df ¼ 1, p 0.000). Children in the study using insulin pump therapy were more likely (97%) to receive insulin at school than children who used injections (55%). There was no significant difference (t (18) ¼ .164, p ¼ .43, one-tailed) between the age (in months) of
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Table 1. Demographic data related to research participants Variable Participants Mother Father Carer Missing Child’s Gender Male Female Child’s age Years School grade Kindergarten Year 1 Year 2 Type of insulin delivery Insulin Pump Injections Length of diabetes diagnosis Years Recent HbA1c Percentage
n
%
M
SD
6.22
1.1
2.33
1.62
Range
60 91 4 6 1 1 1 1 33 50 33 50 4–8
23 35 23 35 20 30 35 53 31 47 0.08–7
7.6% (60 mmol/mol) 1.17 5.6–12% (38–108 mmol/mol)
Table 2. Comparison of school grade attended
School Grade Received insulin at school Type of insulin delivery Insulin Pump Injections Gender Male Female Length of diabetes diagnosis 1 year or less More than 1 year
Kindergarten
Year 1
Year 2
n (%) 16 (70)
n (%) 22 (96)
n (%) 13 (65)
10 (44) 13 (56)
17 (74) 6 (26)
8 (40) 12 (60)
10 (44) 13 (56)
15 (65) 8 (35)
8 (40) 12 (60)
11 (48) 12 (52)
3 (13) 20 (87)
3 (15) 17 (85)
children receiving insulin (M ¼ 74.47, SD ¼ 12.07) compared to children not receiving insulin (M ¼ 75.26, SD ¼ 17.67). The data indicated a potential disparity across geographical location of residence as, children living in rural (67%) or semi rural areas (71%) were less likely to receive insulin at school than those from small (83%)
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Percentage of children
35 30 25 20 15 10 5 0 Child
Teacher
Parent
Teacher's Office staff aide The person who administers insulin at school
Nurse
Figure 1. The percentage of children self-administering insulin and the percentage receiving insulin from parents or school personnel whilst at school.
and large metropolitan areas (83%). This disparity also seemed apparent in the type of insulin delivery used by children, as rural areas had significantly less insulin pump use (33%) than all other geographical regions including large metropolitan areas (66%). This difference may be due to increased availability of resources in metropolitan areas and requires further exploration. Who is Providing Diabetes Treatment? Parents reported that insulin at school was delivered by the child approximately one third of the time. The remaining two thirds of delivery was spread fairly evenly across teachers, parents and teacher’s aides (Figure 1). The data indicated that children who self-administered insulin were older (M ¼ 6.59 years, SD ¼ 0.9) than children not self-administering insulin (M ¼ 5.9 years, SD ¼ 1.1). When school grades were compared (Table 3), as expected, adults (teachers and parents) administered the majority of insulin for kindergarten students. Only a small percentage of these children were self-administering, which was via an insulin pump. For Year 1 students, school staff (teachers and teacher’s aides) provided most of their insulin. There were more children in Year 1 selfadministering and parents gave only a small percentage. In contrast, children in Year 2 gave a large percentage of insulin. However parents provided a greater percentage of insulin in this grade than Year 1, possibly due to the higher use of insulin injections in Year 2. 38% of children using insulin pumps and 23% using injections selfadministered insulin at school. Parents administered most of the insulin
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Table 3. The person performing insulin administration & blood glucose testing
School Grade Child Insulin BGL Teacher Insulin BGL Parent Insulin BGL Teachers aide Insulin BGL Office staff Insulin BGL Nurse Insulin BGL
Kindergarten
Year 1
Year 2
n (%)
n (%)
n (%)
3 (19) 6 (27)
5 (23) 9 (41)
9 (69) 16 (80)
5 (31) 9 (41)
7 (32) 4 (18)
0 (0) 1 (5)
5 (31) 3 (14)
2 (9) 0 (0)
3 (23) 2 (10)
3 (19) 3 (14)
6 (27) 7 (32)
1 (8) 0 (0)
0 (0) 1 (4)
1 (4.5) 1 (4.5)
0 (0) 1 (5)
0 (0) 0 (0)
1 (4.5) 1 (4.5)
0 (0) 0 (0)
to children on injections. For those using insulin pumps, the majority (38%) of insulin was given by the child. Additionally, teacher’s aides and teachers gave a larger amount of insulin to children using insulin pumps (26% & 30%) compared to injections (6% & 12%). Although nurses and office staff rarely (6%) gave insulin injections, children on pumps did not receive insulin from these staff. There was a significant association between the number of children receiving insulin at school and the ability to self-administer insulin 2 ¼ 7.38, df ¼ 1, p ¼ 0.007). Children in the study who were able to selfadminister insulin were more likely to receive insulin (93%) at school than children who were unable to self-administer insulin (65%). Most blood glucose level (BGL) testing at school was done by the child (49%). The remainder was performed by school staff (43%) and parents (8%). For children in kindergarten, school staff provided most (58%) of the BGL testing and the remainder was provided by the child (27%) and parent (14%). Similarly, Year 1 students also had most (59%) of their BGLs tested by school staff but a larger proportion was done by the child (41%). The majority (80%) of Year 2 students tested their own BGLs, and school staff (10%) and parents (10%) performed a very small amount of testing. It was apparent that older children were more capable of
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self-testing their blood glucose levels in the study. The mean age of those self-testing was 6.7 years (SD ¼ 1.0), which was older than those requiring assistance from school staff (M ¼ 5.7 years, SD ¼ 0.18) or parents (M ¼ 5.5 years, SD ¼ 1.2). Where is the Treatment Given? The majority (81%) of children received insulin in the classroom, with the remainder in the school administration office. 92% of blood glucose testing was also performed in the classroom. Although not statistically significant, the data suggested a possible relationship between the location of insulin administration and the length of diabetes diagnosis. 88% of children with a longer duration of diabetes (more than one year) received insulin in the classroom compared to 70% of children diagnosed for a shorter duration (1 year or less). Additionally 91% of children in the study who were able to self-administer insulin received insulin in the classroom compared to those who required assistance from parents (75%) or school staff (76%). Interestingly, there was little difference in the age of children receiving insulin in the classroom (M ¼ 6.2 years, SD ¼ 0.1) and children receiving insulin in the office (M ¼ 6.0, SD ¼ 1.1). However, 94% of children using insulin pump therapy remained in class for insulin administration compared to 63% of children who used injections. Storage of Diabetes Management Supplies Insulin Parents of children using insulin injections at school were questioned about the location of insulin storage. The majority (58%) stored insulin in the classroom. Eighteen percent of insulin was stored in the office and 12% in both areas. Twelve percent of parents did not store insulin at school and took it with them when they administered the injection at school. Most parents (94%) were happy with the location of insulin storage. Blood glucose meter The blood glucose (BG) meter was mainly stored in the classroom (63%). Some children had BG meters in both the classroom and office (35%) and 2% stored the meter in the office only. Ninety seven percent of parents believed that the current location was where the BG meter should be stored. Some parents expressed the importance of easy access to the BG meter for safety reasons and therefore stored it in more than one location throughout the school.
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Hypoglycaemic treatment Parents in the study reported that hypoglycaemic treatment was stored in the classroom (40%) or both the classroom and the office (60%). Virtually all parents (95%) agreed that whichever location they reported was appropriate. Similarly to the blood glucose meter, some parents (4%) expressed that they wanted hypo treatment located in many places around the school (canteen, gym, library, music). DISCUSSION Insulin delivery at school was an important issue that was highlighted in the findings. Not all children (77%) in the current study received an insulin injection or pump bolus at school, therefore some children are not receiving intensive insulin therapy. This finding is consistent with previous research (Amillategui et al., 2007; Amillategui et al., 2009; Hellems & Clarke, 2007; Jacquez et al., 2008; Middlehurst & Morrison, 2008; Newbould et al., 2007). Just over half of the children in the study were using pumps to deliver insulin. The percentage of insulin pump use was on average 15% higher than reported in previous studies (Jacquez et al., 2008; Middlehurst & Morrison, 2008; Wagner et al., 2006) and Australian data from 2004– 2011 (Australian Institute of Health and Welfare, 2012). The higher percentage of pump use could be attributed to the more recent increases in access and evidence of benefits for younger children. The above changes occurred after the previous studies were conducted. In Australia, funding became available from the government and diabetes organisations to assist families without health insurance to access insulin pump therapy (Australian Institute of Health and Welfare, 2012). Research on safety and benefits of insulin pump therapy for younger age groups also heightened the recommendation for pump use from health care teams (Australian Institute of Health and Welfare, 2012; Nabhan et al., 2009; Peters et al., 2013; Sulmont et al., 2011; Wilson et al., 2005). It was reassuring to see that parents from the current study reported all children were having blood glucose levels tested at school. This was similar to the findings of a number of international studies (Jacquez et al., 2008; Newbould et al., 2007; Wagner et al., 2006) but a great deal more than reported in two Spanish studies (Amillategui et al., 2007; Amillategui et al., 2009). However the number of blood glucose tests performed at school was varied in the current research. The data demonstrated that most children tested between two to three times during the school day. Children who tested more than four times were predominately from Year 2 or on insulin injections. Currently there is
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a lack of research in this area however it does require further investigation as excessive BGL testing at school could impact on class participation or time with peers. Intensive insulin treatment is recommended for children to prevent long-term microvascular complications (Craig et al., 2011). However this treatment has a number of consequences for children in early primary school. One implication is deciding who will provide treatment for this young age group. Generally, parents perform diabetes treatment for young children due to their limited developmental stage and the complexity of the tasks required. In the school setting there is often a shift from parental care to either the child or school staff. Parents in the current study reported that children were the most frequent (33%) providers of insulin compared to parents and teachers. A direct comparison with other research is difficult due to the lack of studies focusing on the early primary school setting. However insulin delivery was provided predominately by the child in the Australian unpublished study (Middlehurst & Morrison, 2008). The study by Hellems and Clarke found that that only 7% of children gave their own insulin in kindergarten to 5th grade. Similarly, Nabors et al identified that 11% of children under the age of 10 years were independent with diabetes treatment. When the child is unable to administer their own insulin their treatment may be modified so that insulin is not required at school (23% in this study). Alternatively, a parent or school staff member is relied on to administer the insulin. Adults provided 67% of insulin to children in the current study. Parents administered approximately one third, class teachers and teacher’s aides provided the remaining two thirds with only a very small amount provided by nursing or administration staff. In contrast the majority of children in kindergarten-5th grade in the Hellems & Clarke (2007) study received assistance from from a nurse (74%), teacher or administrator (29%) or a parent (24%). Similarly, Clay et al. reported most insulin was given by the child (61%) or nurse (28%), with small numbers of teachers or administrators (11%) and nil by parents. As expected only a small percentage of younger children attending kindergarten were self-administering insulin. All of these children were using insulin pump therapy. Teachers and parents administered the majority of insulin for kindergarten students. A greater number of students in Year 1 were giving their own insulin compared to kindergarten, however teachers and teacher’s aides delivered the highest percentage. A definite shift in provision of insulin was noted for this school grade, as parents gave only 9%. Of the six students selfadministering insulin, five of these were using insulin pumps. In contrast, older children in Year 2 gave a much larger percentage of insulin. Six out of nine students who were self-administering were using
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insulin pumps. However a significant amount was still delivered by parents and minimal assistance was provided from teacher’s aides. One explanation for the lack of school staff involvement for Year 2 students compared to the other school grades could be the greater number of students using injections. It is possible that staff are not comfortable with this method of insulin delivery. Middlehurst & Morrison (2008) also commented on this finding, as more than a quarter of parents attended the school to administer insulin to their child in their research. These children were predominately under eight years of age and using insulin injections. There were no children aged less than seven and a half years self-injecting insulin. It is likely that there are a number of factors that influence insulin administration at school. The study data and supporting literature identified two potential influences: (1) the child’s ability to selfadminister insulin and (2) the type of insulin delivery device. Children who were able to self-administer insulin were more likely to receive insulin at school. This could be further influenced by age, gender and length of diabetes diagnosis. It is expected that older children would be more likely to self-administer insulin. However the Amillategui et al. study reported that only 26% of children received insulin at school and 63% were not able to self-administer insulin, even though the median age was 11.5 years. In the current study, children who were self-administering insulin were older (6.5 years) than children unable to selfadminister (5.9 years). However age alone does not explain the reason for increased insulin use at school as older children in Year 2 received less insulin than Year 1 students. The second influence on insulin administration at school was the type of insulin delivery device. Children from the current study were more likely to self-administer insulin if they were using insulin pump therapy. Similarly, Alsaleh et al. found that younger children had greater participation in insulin administration via an insulin pump than injections. It is well documented that children from the age of eight to ten years usually develop the cognitive and physical skills to self inject insulin (Amillategui et al., 2007; Clay et al., 2004; Ekim & Pek, 2010; Hellems & Clarke, 2007; Middlehurst & Morrison, 2008; Nabors et al., 2003). However it is possible that children may develop the required physical skills for pushing buttons on an insulin pump at an earlier age. According to the study data, even when children were not selfadministering insulin, the use of insulin pump therapy remained an influence on insulin delivery at school. The Australian study by Middlehurst & Morrison (2008) also reported this connection. The authors stated that teaching staff were more likely to administer insulin
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via a pump than injection. In addition less parents attended the school when their child was using pump therapy. Therefore it is possible that insulin pump therapy may provide increased access to insulin in the early primary school setting. An important potential impact of the above study findings is the disadvantage that children from rural areas may face. Rural areas had less insulin pump use than all other geographical regions. Large metropolitan areas had double (66%) the percentage of children using insulin pump therapy compared to rural areas (33%). Additionally, children living in rural areas were also less likely to receive insulin at school than those from metropolitan areas. Similarly, the Australian Institute of Health and Welfare (2012) report on insulin pump therapy use in Australia found a disparity between geographical areas. For children aged 0–11 years, 58% of pump use was reported for outer regional/remote areas compared to 68% in major city/inner regional areas. One possible reason for this discrepancy appears to be the lack of specialist diabetes children services that have the resources to provide insulin pump therapy (Australian Institute of Health and Welfare, 2012). Within Australia, insulin pump services are predominantly available in diabetes clinics in large metropolitan teaching hospitals (Australian Institute of Health and Welfare, 2012). This is an area that requires further exploration, as the development of a consistent approach to insulin pump provision will ensure that standard treatment is accessible for all children with type 1 diabetes. Comparably to insulin administration, the majority of blood glucose testing (BGL) at school was also performed by the child. The remainder was done largely by school staff and a small percentage by parents. It is expected that older children would be more capable of self-testing their blood glucose levels and this is evident in the current study findings. For children aged less than seven years, testing was mainly provided by school. For children aged seven years or over, the child provided almost all testing. There was a greater involvement of school staff in blood glucose testing compared to insulin administration. This was also the case in previous studies (Amillategui et al., 2009; Hellems & Clarke, 2007; Middlehurst & Morrison, 2008). The findings suggest that in Australia, teachers and teacher’s aides provide assistance with diabetes care rather than administrators or nurses. However they were less likely to provide care when it was associated with insulin injections rather than insulin via a pump. Additionally the large number of teachers and teacher’s aides providing insulin administration implies that care is provided in the classroom. Therefore it is possible that integration of diabetes care is progressing considerably well in Australia.
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According to the American Diabetes Association (2006) students should be permitted to provide diabetes treatment wherever they are in the school. This is important in order to minimise metabolic, academic and psychosocial impacts of diabetes care. The percentage of diabetes care performed in the classroom in the current study was much higher (92% BGL, 81% insulin) than previous studies: 25–79% for BGL testing (Hellems & Clarke, 2007; Jacquez et al., 2008; Middlehurst & Morrison, 2008; Newbould et al., 2007; Wagner et al., 2006) and 12–66% for insulin administration (Clay et al., 2008; Jacquez et al., 2008; Newbould et al., 2007; Smith et al., 2008; Wagner et al., 2006). The higher percentage could be attributed to further research in school diabetes care and increased advocacy for integration at school. The research study by Wagner et al may have influenced the shift in the location of school diabetes care as they found that children who left class for care had poorer diabetes control (HbA1c 8.4%) than those who remained in class (HbA1c 7.4%). In terms of advocacy and policy development, a number of departments in Australia have produced recommendations for diabetes care at school including the location of treatment, which many schools have adopted into their policies (Diabetes Australia Queensland, 2010; Diabetes Australia Victoria, 2013; NSW Government. Department of Education and Communities, 2013). Limitations There were various study limitations that should be considered when interpreting the findings. The small sample size and the challenges associated with accessing participants through social media such as Facebook, restricted generalisability to the larger population. The sample is biased due to the required access to a computer and Internet connection and the ability to read and write English to participate in the study. Implications Diabetes specialist teams need to take into consideration the impact that treatment regimes may have on the child’s school routine. Where possible intensive insulin treatments such as pump therapy should be prescribed in order to reduce the risk of long-term health complications. However, a collaborative process involving parents and school personnel is necessary in order to provide a safe and inclusive school environment for the child with diabetes. An increase in funding and resource allocation is required to reflect the rising prevalence of type 1 diabetes and the added demands of intensive insulin therapy at school for the child, diabetes professionals and school personnel. Ideally, international
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