Implementing information and communication technology education on food allergy and anaphylaxis in the school setting

Abstract Introduction Every year, 1/10,000 children experiences a food‐anaphylactic reaction. Most of these events, including attack‐related deaths, may happen during the school hours. In the current study, we assessed the influence of information and communication technologies (ICT) in the school‐staff's education on food allergy and anaphylaxis (FAA). Methods The target population of this intervention was non‐university teaching centers from the local Regional Education Council, including both state and private institutions. The digital intervention was supported by the free‐of‐charge and open‐source learning‐management Aulatic Educational Platform. Structured questionnaires were developed to evaluate the educators' knowledge, feelings, and self‐efficacy on FAA, in addition to a satisfaction and quality survey of the training program. Results A total of 1748 school‐educators were virtually enrolled from May 2016 to June 2020 in one of the 8‐week course editions, with 80.6% of attendees successfully completing the full training. All scores concerning school‐staff's basic knowledge and self‐efficacy on FAA significantly improved after the educational intervention, reaching a high level of satisfaction among participants (98.5%) over the 4‐year educational program. Conclusion Our results highlighted the effectiveness of a focused e‐learning activity to improve teachers and school caretakers in the management of food allergic scholars and anaphylactic reactions during the school hours. The use of ICTs tools should become an integrated part of curricular frameworks in non‐university education, leading to a better care of FAA school children.


| INTRODUCTION
As the access to and utilization of computers and mobile devices has increased, Internet usage has dramatically risen, placing an unprecedented amount of health information within reach of general consumers. 1,2 Electronic health (eHealth) embraces a diverse group of computer-based technologies to improve the efficacy and efficiency of the health care industry. The application of eHealth not only refers to technological advances but also to a commitment of networked, global thinking to improve health care worldwide. [3][4][5][6] Information and communication technologies (ICTs) are a diverse range of Internet resources that include websites, health apps, podcasts, online interactive programs, and health-related forums. These ICTs can contribute to broadening access to education, improving equity in education, the delivery of quality learning and teaching, teacher professional development, and more efficient education management, governance, and administration. 7,8 Food allergies (FAs) have been recognized as a public health burden in developed countries and are the leading cause of anaphylaxis in community health settings, affecting 2%-8% of people under 18 years of age throughout the world. [9][10][11] FAs and anaphylaxis have a markedly negative impact on one's psychological well-being, with a disproportionately lower quality of life found in allergic children and their families compared with their nonallergic peers. [12][13][14] The pathophysiology of FAs involves several immunological mechanisms that drive reactions, most commonly as immediate hypersensitivity to ingested antigens, in which specific IgE antibodies bound to mast cells and basophils lead to explicit physiological responses in target tissues. 15 Nearly 18% of children have experienced an allergic reaction at school, 16,17 with 25% of first-time anaphylactic reactions occurring during school hours; thus, it is necessary for educators to promptly recognize and deal with these unexpected events. 18 Web-based guidance provides a platform for health professionals to access flexible education to improve awareness, knowledge, and skills in delivering FA and anaphylaxis care. 19 Although many educators have received information on FAs, previous studies have shown this information to have little influence on the outcomes of questionnaires. Additionally, it is possible that participants might attend first-aid courses that fail to provide training on FAs and anaphylaxis, as adrenaline is often not administered, which increases the risk of hospitalization and death. 20,21 In Spain, school nurses have only recently 22 been included in bylaws as permanent staff, but they are not present in all country school facilities; therefore, the management of most students with food allergies depends almost entirely on school personnel with limited medical skills. To address this situation, in 2015, the Ministries of Health and Education, Culture & Sports of Spain published the "National Guidelines for Food and/or Latex Allergic Schoolchildren," which allowed specific computer-based food allergy education for schoolteachers. 23 There is limited research on the effectiveness of educational interventions (EIs) for FAs, and the quality of eHealth resources is uncertain because the developers of eHealth instruments often have no health care training, and health professionals are generally not involved in the design of these tools. Thus, there is a demand for the school and the health system to improve their preparedness to handle students with FAs. 24 In this regard, although eHealth interventions such as computer-based applications, telecommunications, and mobile applications have delivered significant improvements for asthma patients in terms of improving inhaler technique, adherence, and quality of life, evidence for other chronic allergy conditions such as FA and FA anaphylaxis (FAA) is lacking. 25 Previous studies have shown the effectiveness of brief, specific training courses for school staff and parents of children with FA, [26][27][28] but the potential impact of extended eHealth learning on this topic has not been fully assessed. In the current study, we investigated the impact of an eHealth EI, which is supported by board-certified allergists, on educators' knowledge and management of FAA over a 4-year real-world experience within different school settings in our community.

| Study population
The target population of this intervention was teachers who worked in non-university   Each educational unit remained available online for 2 months, allowing users to log in and keep up with the educational tools at any time. The contents could be revisited at will. A digital library con-  � Translational changes to daily teaching practice (i.e., gaining competence to handle an unexpected FA situation within the educational setting, including administering medications).

| Educational materials and interventions
An anonymous analog scoring system was developed to assess each of the aforementioned items (0 = Very poor, 5 = Excellent).
In accordance with local regulations, attendants were initially advised that all the collected data would be kept anonymous and used to investigate the internal efficacy and quality of the e-learning tool.

| Statistics
A descriptive statistical analysis was conducted. For the data analysis, the pre-program and post-program questionnaire answers were compared. A t-test and chi-squared test were used to detect statistically significant differences in the proportions of correct and incorrect answers before and after the intervention. Statistical significance was set at p < 0.05.

| Target population
A total of 1748 teachers attended at least one of the bi-monthly online courses (five per school year) from May 2016 to June 2020 (20 digital editions), representing 6.16% of all regional non-university educators in the Canary Islands. 29 All participants anonymously filled out the pre-course questionnaire. A total of 1409 participants (80.6%) completed the full program, with a dropout rate of less than 20% over the 4-year study period.
Participants from across professional degrees were included in the study (Table 1)

| Trends in registration
The

| Questionnaire assessment
The pre-and post-EI surveys assessed the individual knowledge and awareness of FA and anaphylaxis in the school setting and covered the following topics: -Motivation to accomplish the EI: In the pre-EI survey, more than half of the participants confirmed that the main reason for registering for the EI was "personal interest in FAs and facing the needs of FAs in the school setting." -Awareness of FAs in the school setting: 81.82% of the participants thought that FAs were "troublesome for the school staff", while 64.37% agreed that FAs were mainly an issue of concern for the students. Upon completion of the EI, up to 90% (p < 0.01) of participants stated that FAs were a "worrying complaint in the educa-  under specific circumstances (i.e., in a severe or rapid FA reaction).
According to the post-EI survey, 72.78% of the participants felt "confident in facing an unexpected FA situation within the educational facility" (Figure 3), increasing from an initial 17.9% upon accomplishment of the EI (p < 0.001).

| Quality and overall satisfaction assessment of the EI
A final post-course survey was conducted to evaluate the quality and appropriateness of the activity through a Likert score (0 = Very poor; 10: Excellent). An overall evaluation above eight points was recorded by 90.62% of the participants, and 99.62% stated that they would definitely recommend the EI to a colleague. In addition, 93.4% of participants stated that they would implement changes in their teaching daily practice upon completion of this specific training, with a score of greater than four points (0 = Very poor, 5 = Excellent) from virtually all (98.5%) participants.

| DISCUSSION
Similar to reports from other countries, Spain has seen marked increases in the rates of FA and anaphylaxis over the last decade. 31,32 Only approximately two-thirds of patients with prior anaphylaxis had a prescribed epinephrine autoinjector device available at the time of their subsequent anaphylactic event, contributing to a 35% hospital admission rate for the same medical emergency. 33 As allergic reactions may occur anywhere during school hours, including in the classroom, lunchroom, playground area, on fileld trips, and traveling to and from school, educators are frequently the first adult to respond to these unpredictable events. 34 Although the development of self-efficacy, defined as the belief that an individual can carry out a behavior necessary to reach an expected outcome, has been described as a key factor in improving medical care, 35 it remains unclear whether self-efficacy is related to the management of FA among schoolteachers. 36 Today, the adoption of ICT by educational staff is an ongoing process, developing from acknowledging the possibilities of ICT in education to further evolved   [46][47][48] Our results showed a sustained and significant increase throughout the 4-

| CONCLUSION
The present EI intended to meet the information needs of teachers and other school professionals by addressing the complex issue of FAs and anaphylaxis in the school setting, which is exacerbated by fear, lack of knowledge, and poor training. However, many educators are willing to learn more about these conditions. The accessibility to the virtual EI, the high quality of the content (which was an officially certified training program), and the provision of comprehensive coaching were crucial to enabling a large number of participants to successfully complete the EI.
Although constant improvement to overcome limitations is warranted, such as obtaining evidence on the effectiveness in terms of pedagogical parameters, 49