It is worth noting that, although many of our respondents had already received some form of information on FA, it had no influence on the outcome of the questionnaire. Their knowledge came not only from mass media, but mostly from first aid courses and/or other health-related training, raising concern that some participants may have attended first-aid courses that failed to provide training on how to manage FA and anaphylaxis. Other studies have shown that, although the school system does its best to try and manage emergencies, when it comes to FA they are often very badly prepared [9, 14]. This points out the need for both, the school and the health system, to focus on preparedness of school personnel to manage food allergic students.
The aim of this study was to investigate what school teachers and principals knew about FA and anaphylaxis, and their related thoughts and feelings. Regarding their knowledge, it is interesting to note that they overestimated the prevalence of FA in children: this might reflect increasing concern in schools about FA and their lack of preparation to deal with what is seen as a growing problem for schools . It might also relate to the fact that “food allergy” is often misused as a generic label for food-related problems; for instance, as demonstrated, many people do not know the difference between “food allergy” and “intolerance” .
The present questionnaire identified an encouragingly high percentage of participants who were able to identify the commonly-involved foods and most frequent symptoms of FA and anaphylaxis correctly. On the other hand, a much lower proportion of them knew that adrenaline is the best medication for anaphylactic shock. The most worrying finding, however, was that only 34.5% of respondents knew there are no absolute contraindications to administer self-injectable adrenaline in children, which stands for many school teachers were reluctant to use it because of supposed side effects in childhood. It is a common myth that a life-saving drug can be harmful, and there is fear and mistrust surrounding the use of adrenaline, even though it has become well established as the best treatment for anaphylaxis, and endorsed by medical experts. A delay in administering epinephrine is a common factor associated with fatal outcomes of FA in children and adolescents . The usage of self-injectable adrenaline is still quite low; it was highlighted the paucity of knowledge concerning when and how to use the device, and reported that adequate first-aid measures were not in place for the majority of school-going children [16, 17]. Care-givers need to be trained continually and given support on first-aid anaphylaxis management [17, 18]. Previous studies reported also that teachers have very limited knowledge about anaphylaxis. This observation prompts the need to inquire into the allergy management plans and policies in schools [17, 18]. A comprehensive educational program for teachers is considered imperative when no school nurse is available .
Food preparation represents an essential issue when dealing with FA. The study questioned participants about their understanding of dietary requirements. The majority recognized the need to prevent cross-contaminations of food and the importance of reading food labels. Nonetheless, only 48.5% really knew what an exclusion diet is, and the questionnaire startlingly revealed that many respondents thought that an exclusion diet meant eating fresh or home-made food, with no additives or preservatives. Just over half of the teachers rightly acknowledged that children on exclusion diets might be at risk of nutritional deficiencies and/or social limitations. The latter issue relates to the fact that food has a social value because it is often associated with relationships. Going out with friends, eating in the canteen, even going to parties may pose problems for allergic children and adolescents, and/or their families, with fallout on their quality of life .
Primary schools had higher overall scores than nursery or secondary schools when it came to the teachers’ knowledge of FA: this may reflect the composition of our sample (the primary school teachers were numerically better represented). On the other hand, it may relate to the epidemiology of FA. It has been estimated that FA affects up to 4-7% of primary school children , so teachers of this age group are likely to be more aware of the problem and more motivated to obtain information on how to deal with the related problems.
A purpose of the questionnaire was to investigate what participants thought about FA and anaphylaxis. This was important with a view to establishing whether school teachers had any prejudiced or misconceived ideas about FA that might influence how the condition is managed at school. Only a very small percentage acknowledged that a student with FA could have academic difficulties. FA is often accompanied by respiratory allergies  and it has been demonstrated that respiratory diseases can affect a student’s performance . Another significant issue is that students with allergies have to see doctors more often, meaning they are often absent from class and this influences their school results [22, 23].
Only 10.2% of our respondents recognized that allergic students may suffer from relational difficulties, and 37.2% felt that they might have emotional problems. Although it has been demonstrated in the literature that allergic patients can have various severe relational and emotional difficulties , more than half of the participants believed that students with FA suffered no such consequences of this condition. Less than half of the teachers acknowledged the importance of creating opportunities in class for listening and sharing the students’ challenges. These findings give cause for concern, since they could mean that school teachers tend to underestimate some students’ important issues, and they are ill-prepared to manage the psychological issues associated with FA. Many of the respondents said that the main difficulty of managing FA at school was the lack of specific training, confirming previous research and experts’ reports [2, 17, 18]. Most of the teachers recognized that multidisciplinary courses are needed to manage all aspects of FA adequately. On the other hand, an encouraging finding was that most of the participants felt that FA and anaphylaxis can be managed at school, and that it is up to the teachers to do so, showing a proactive approach and willingness to do better. This is likely linked also to the fact that Italian school health policy does not employ school nurses. In the case of managing FA at school Veneto Region had a law in place that recommends the collaboration among schools, patients’ families, health professionals and local health services. Specific training for school personnel is required, but not mandatory. The findings of the study highlighted the need for policy changes and reform to support and empower the school system in adequately managing food allergic students.
The final part of the questionnaire focused on how the teachers felt about managing FA and anaphylaxis at school. It is important to understand their feelings to ensure their full cooperation in managing FA. It is common knowledge that anxiety and fear can make people freeze in an emergency situation; these feelings can also lead to unnecessarily restrictive school environments as well as affect health care planning, giving rise to conflicts within families and with physicians and the school community . The main feeling reported by our participants was “concern”; only 15.8% mentioned “anxiety” and 7% felt “helpless”. Encouragingly, only 3.7% said they were fearful about FA. Even more positive is the fact that 9.3% mentioned “other” feelings, which they later described as the hope the child would recover from the allergy and their wish to do something useful to help allergy sufferers. The results did not differ for respondents working at different types of school (nursery, primary or secondary school teachers). Teachers’ attitudes have proved to be an important factor in ensuring appropriate treatment for allergic children [8, 17]. In general, the findings showed an apprehension felt by school teachers relating to children with FA. These feelings were not seen as an obstacle and they could be managed and turned to positive account. It can be supposed they reflect the need of school to be better supported in managing food allergic students, for example considering the availability of school nurses or mandatory training programs. The management of FA in the school setting should also include providing resources for school officials to help them develop FA management protocols .
In addition, an assessment of the answers before and after the course was performed. When the questionnaire was completed again, there was a significant increase in the overall scores about knowledge and in the frequency of participants thinking that anaphylaxis could be managed at school and that it is the responsibility of the school personnel. A modest lessening in the frequency of “concern” answers was registered. Results confirmed a general positive effect of the course on the participants’ understanding of FA and anaphylaxis. As expected, changing personal opinions and feelings seems to need more time and efforts than modifying knowledge. Further and long-term studies are needed to know the effectiveness of multidisciplinary courses in terms of reducing the number of reactions and increasing food allergic students’ quality of life at school.
The study is descriptive in its nature and it depends mostly upon impressions from the questionnaire; however, this limitation could be balanced by the big large of the sample (1184 school workers), so results seem to be in any case informative. Another limit could be the fact that national differences in school policy do not allow for generalization of findings, however it can be useful to learn about and compare different practices for managing allergy and anaphylaxis with a view to improving regulations and guidelines for schools.
Results from Veneto Region could represent a starting point toward validation of multidisciplinary educational trainings that could be used on a larger scale with a benefit for all Italian schools. This is indeed the first study, as far as we know, assessing Italian school personnel attitudes toward the management of FA and anaphylaxis in the school setting. The gaps identified could form the basis for improvements of local and national legislation in order to ensure implementation of specific educational interventions for an adequate management of FA and anaphylaxis at school. Physician and Referral Health Centre can play an important role in educating school personnel about the treatment of food allergies . As recommended by the European Academy of Allergology and Clinical Immunology , an education network involving health care and education providers is crucial in ensuring that the school staff is alerted and trained, and specific allergy management plans initiated. This should be achieved through the empowerment of key stakeholders and supported by continuing education of all school staff.