Empowering school teachers: Changes in knowledge among teachers after a training program on type 1 diabetes mellitus

INTRODUCTION

Type 1 diabetes mellitus (T1DM) is a chronic autoimmune illness characterized by the inability to produce insulin due to the destruction of pancreatic β cells and is one of the most common chronic illnesses among children.^[1] T1DM affects 1,211,900 children and adolescents under 20 years of age worldwide.^[2] Children with T1DM spend a significant portion of their day at school, increasing the likelihood of experiencing diabetes-related complications, such as hypoglycemia or diabetic ketoacidosis, during school hours. As more young individuals with T1DM attend school, the need for comprehensive support from families, healthcare professionals, and school personnel is becoming increasingly important. The International Society of Pediatric and Adolescent Diabetes (ISPAD) emphasizes the importance of a collaborative approach involving parents, healthcare teams, and school staff, enhanced by technological advancements, to support effective diabetes management in the school setting. Active participation of school personnel is essential to ensure normal growth, academic achievement, and to reduce the risk of both acute and long-term complications. Therefore, it is vital that teachers and school staff are trained to recognize signs of diabetes-related emergencies and that schools are equipped to respond appropriately.^[3] Optimal glycemic control depends on regular blood glucose monitoring, balanced nutrition, insulin administration (via injections or pumps), physical activity, and understanding how these factors influence glucose levels. Trained school staff, including nurses, play a crucial role in the daily management of T1DM in school environments.^[4]

The “Mittayi” program, launched by the Government of Kerala in 2018 under the Kerala Social Security Mission, provides comprehensive care for children and adolescents with T1DM. By integrating medical, educational, and psychosocial support, “Mittayi” serves as a model public health initiative, aiming to ensure equitable, sustained care and improve outcomes for children living with T1DM in the state.^[5]

This study aimed to evaluate the knowledge gaps and perceptions of class teachers regarding T1DM despite the efforts of the Mittayi program and to assess the impact of a structured training session on their understanding of its management.

MATERIAL AND METHODS

A cross-sectional study was conducted among class teachers of children with T1DM from various primary and secondary schools in the Kozhikode and Wayanad districts of Kerala, India, using convenience sampling between October 2023 and May 2024 over a period of 8 months. Written informed consent was obtained from all participating teachers, who were actively employed at the time of the study and had obtained approval from the institutional ethics committee. The objective of this study was to assess their knowledge and perceptions of T1DM and its management. A semi-structured questionnaire specifically developed for this study was used as the research tool. The questionnaire was in English and was translated by the same pediatric endocrinologist into Malayalam as needed during both sessions. The first section of the questionnaire gathered sociodemographic information, including name, gender, age, education level, years of experience, workplace, and whether the participant had family members with diabetes mellitus (DM).

The second section consisted of 13 questions designed to assess participants’ understanding of T1DM self-management and treatment principles. These questions covered the disease’s definition and symptoms, the age groups most affected, blood glucose monitoring, recognition and management of hypoglycemia, meal planning, and participation in physical education activities. The third section explored teachers’ personal opinions regarding students with T1DM [Supplementary File].

Following the initial survey, a 1-day training session was organized to educate teachers about various aspects of T1DM and its management. The physical training program was conducted in Malayalam over 1 day, including two sessions over 6 h, by three pediatric endocrinologists, a dietician, and a clinical psychologist. The entire process was monitored by a senior pediatric endocrinologist with over 20 years of experience in pediatric endocrinology. The topics covered as lectures during the morning training were pathophysiology of T1DM, the differences between T1DM and T2DM, meal planning and exercise in T1DM, management of hypoglycemia and recognizing symptoms of hyperglycemia. This was followed by hands-on training in the insulin administration technique. After the training, the participants were asked to complete the questionnaire again. Thirteen knowledge-based questions from the original survey were reassessed.

A correct response was assigned a score of 1, while incorrect or “don’t know” responses were scored 0, yielding a maximum knowledge score of 13. Statistical analyses were performed using MS Excel and Epi Info version 7.0. Quantitative data are expressed as mean ± standard deviation or median with interquartile range (IQR). Qualitative data were expressed as frequencies and percentages. Pre- and post-training scores were compared using the Wilcoxon signed-rank test. Statistical significance was set at P < 0.001.

RESULTS

Baseline awareness and knowledge about diabetes

Before the training session, 91.3% (n = 73) of the teachers had not received any formal education on T1DM. While many were aware of T2DM, primarily through family experience, newspapers, or the Internet, 72.5 % (n = 58) were unable to differentiate between T1DM and T2DM. Overall, knowledge of T1DM management was limited. For example, only 31.25% (n = 25) of teachers understood that children with T1DM do not require a special diet, and 20% (n = 16) believed that physical activity should be restricted. Awareness of hypoglycemia and its management was especially poor, with 81.5% (n = 65) of the teachers unaware of the appropriate interventions. However, we did not observe a significant difference in the knowledge scores between aided and government schools [Table 2 and Figure 1].

Table 2: Baseline practices and training outcomes.

Practices	Outcomes
Awareness of appropriate meal planning for children with T1DM	55 (68.75%) Believed abouta special diet
Understanding safe physical activity practices in T1DM management	50 (62.5%) Participated in sports and extracurricular activities
Hypoglycemia management	28 (35%) Aware about hypoglycemia management
Availability of the school nurse	2 (2.5%)
Teachers aiding insulin administration	33 (41.25%)
Pretraining knowledge score	5/13 (3–8)
Posttraining knowledge score	9.5/13 (7–11)

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Figure 1:

This horizontal bar chart highlights key gaps in awareness, including lack of prior education on type 1 diabetes mellitus (T1DM), confusion between T1DM and type 2 diabetes mellitus (T2DM), and misconceptions about diet, physical activity, and hypoglycemia management.

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Training outcome

Knowledge scores before training ranged from 0 to 10, with a median score of 7 (IQR: 5–8). Following the training session, scores improved significantly, ranging from 2 to 13, with a median score of 9.5 (IQR: 7–11). This improvement was statistically significant (P < 0.001), indicating that the training effectively enhanced teachers’ understanding of T1DM and its management in the school setting [Figure 2].

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Figure 2:

This bar chart shows a clear improvement in teachers’ knowledge scores following the training, with an increase in both the median score and the interquartile range.

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DISCUSSION

Students with T1DM spend much of their day in school, where they are at heightened risk of diabetes-related emergencies. Effective integration of T1DM management into the school environment is essential, with teachers and staff playing a pivotal role in ensuring safety, particularly in acute situations such as hypoglycemia and hyperglycemia. However, global evidence consistently reports inadequate training among school staff,^[6,7] a finding echoed in our study, where none of the participating teachers had received formal instruction on diabetes management.

Targeted interventions, including educator workshops, continuous medical education sessions, newsletters, online modules, and structured training programs, can bridge this gap.^[7] Every child with diabetes requires an individualized care plan, regularly reviewed with parental input. Schools must support flexible insulin regimens tailored to student needs, with adequate government funding to ensure safety and inclusiveness. Despite improvements in some areas, many teachers still feel unprepared for diabetes-related emergencies, and parents continue to advocate for more comprehensive training. School staff have a duty of care to support students with diabetes and to create a safe, inclusive learning environment.^[3,8,9]

Although children with T1DM generally do not require academic modifications, they need supervision during physical activities and meals, along with regular glycemic monitoring to adjust insulin doses. Few studies have specifically evaluated teachers of children with T1DM after online education program,^[10] our study focused on this group and assessed knowledge improvement after an in-person training program. Notably, baseline knowledge in our cohort was higher than in similar studies, possibly reflecting Kerala’s improved awareness through initiatives such as the Mittayi Scheme. Post-training, teachers demonstrated significant gains, especially regarding hypoglycemia management, diet, and the ability of children with T1DM to participate in sports.

International data mirrors our findings. A German study involving 678 kindergarten teachers identified key deficiencies in diabetes knowledge, parent–school communication, and institutional support.^[8] Similarly, Virmani et al. reported concerning gaps in 397 child-parent pairs in Indian schools, with limited glucose monitoring (24.4%), insulin administration (47.4%), and participation in sports or excursions (17.9%), and in some cases, enforced secrecy (12.9%) about the diagnosis.^[11] By contrast, our study revealed better awareness, though largely from teachers’ perspectives.

Comparable challenges persist in other countries. In Saudi Arabia, <11% of teachers had formal training despite teaching students with T1DM, paralleling our findings. Although the teachers demonstrated a fair overall knowledge score, it fell short of equipping them to serve as effective support persons for students with T1DM.^[12]

While diagnostic capabilities have improved, many rural primary care centers in India still lack infrastructure, and insulin storage remains problematic for up to 80% of children.^[13] Encouragingly, most teachers in our study reported access to refrigeration facilities.

Our training session successfully emphasized distinctions between T1DM and T2DM, clarified the importance of blood glucose monitoring and pre-meal insulin at school, and corrected misconceptions about dietary restrictions and physical activity. Teachers reported increased confidence in supporting students and recommended periodic parental visits. Similar to earlier international findings, our pre-training results reflected inadequate understanding, but post-training improvements suggest that such interventions are highly effective.

Despite progress, significant challenges remain. Stigma, lack of resources, and variability in care standards across regions hinder comprehensive support for children with T1DM. To the best of our knowledge, this is the first Indian study to evaluate changes in teacher knowledge scores using a study-specific questionnaire combined with physical training. While encouraging, limitations of our study include a small sample size, a lack of validated assessment tools, and the single-day format. Larger, multi-day studies would provide more robust evidence.

CONCLUSION

Schools must employ health workers to assist with insulin administration and adopt written action plans for glycemic emergencies. Strong collaboration between schools, parents, and healthcare professionals is vital to reducing stigma and ensuring equal opportunities for children with T1DM. Expanding regional initiatives such as the Mittayi Scheme nationwide could further strengthen care. We recommend regular teacher training programs, periodic knowledge assessments, and structured parent–school communication to improve diabetes management in schools. Ultimately, disparities in socioeconomic status, education, and access to care must be addressed through joint efforts of healthcare providers, educators, and policymakers. The overarching goal should be that no child is denied safety, inclusion, or opportunity due to DM.