Winnipeg-based elementary school teachers’ perspectives on food allergy management: a qualitative analysis

To our knowledge, this is the first study to qualitatively explore elementary school teachers’ perceptions on food allergy management. Teachers likely have some degree of health literacy at baseline, and are primarily responsible for supervising and caring for children with food allergy, among other health conditions, for most of their waking hours at school. Yet, teachers have minimal food allergy policies and training provided. In our study, we identified four themes that underscored teachers’ perceptions and experiences managing food allergy.

Themes 1 and 2 highlighted teachers’ experiences navigating the inconsistent food allergy-related policies among Winnipeg schools, and teachers’ perceived lack of knowledge and confidence. Most teachers did not have experience managing anaphylaxis however teachers speculated different ways to manage it if an emergency was encountered. Themes 3 focused on the lack of, and the need for, standardized food allergy education. Teachers had varied experiences that may be attributed to personal experiences, and URIS-provided education on anaphylaxis management, among other sources. These themes collectively highlight the juxtaposition between structured approaches to students (i.e. discipline, behaviour management, assessment) and incoherent food allergy-related education and policies.

Unfortunately, inconsistent food allergy management practices and related policies have been previously reported in the literature [13, 14]. In a recent scoping review from our group, based on studies from Canada, the United States, Australia, and Europe, teachers had variable baseline knowledge, and confidence and self-efficacy, and qualitatively discussed feeling insecure about managing an emergency [13]. Classroom management of food allergies also varied widely, even within individual studies. For example, Eldredge et al. reported that an estimated 25% of participating schools in Wisconsin, USA had no guidelines, whereas others had detailed policies and required individual action plans [25]. Teachers reported having poor knowledge on food allergy management but acknowledged its importance and desire to learn more about preventative and emergency management practices [13]. Teachers in our study described similar needs. At baseline, teachers demonstrated some degree of knowledge, acquired from previous (e.g. URIS) training, which is available to all Winnipeg teachers. This training is mandatory, however, it is brief and is embedded within training for other chronic conditions that require management in school. Additionally, if a teacher is absent from work on the training day, they would have to actively request training or learn from their colleagues who attended. Teachers reported learning how to administer an EAI but teachers also demonstrated inconsistent knowledge of available resources (i.e. URIS program, list of children with chronic disease, location of EAI) in their schools. Interestingly, teachers who had more experience (i.e., lived experience), appeared to have more knowledge in preventing anaphylaxis, and managing food allergy.

Theme 4 emphasized the importance of effective communication amongst all parties. Teachers described relying on families for food allergy-related information and contacting families if questions arise related to food brought into the classroom. Teachers also created their own resources and handouts to communicate food allergy-related information.

Bullying is an aggressive, repeated behaviour that may be verbal, physical, cyber and/or social in nature [26]. In our study, some teachers described witnessing such behaviours, although they did not label is as bullying per se. This is concerning, as teachers may witness food allergy-related bullying, but may not perceive it as such. Of note, school-based, food allergy-related bullying has been reported elsewhere [27, 28]. Yet, a recent quantitative study of Winnipeg-based teachers further supported that teachers believe that food allergy educational topics are of varying importance. While approximately 55% of teachers noted that food allergy was important overall, a majority reported that prevention (e.g. preventing cross-contact between foods), management (recognition of reactions, use of an EAI) and awareness (seriousness of food allergy) were important, while only about half reported that food allergy-related bullying should be discussed [29].

Further, teachers identified areas wherein communication can be improved. Teachers in our study have reported miscommunication with families, and other school staff. This is concerning as miscommunication may put students with food allergy at risk of an allergic reaction. This call for open communication echoes calls from a previous qualitative study, involving parents of children with food allergy, in two Canadian provinces [30]. In one province, namely Ontario, parental advocacy was reduced subsequent to the implementation of a province-wide act requires safeguards to be in place to support students at risk of anaphylaxis. In contrast, the neighbouring province of Quebec lacked legislation regarding food allergy management in schools, and which resulted in parental perceptions of feeling “threatened by the variability and inconsistency of school policies” (p.238). Yet, the need for open communication persisted across both provinces when “dealing with uninformed people” (p. 237) [30]. Thus, policies alone insufficiently contribute to consistent policy. Ongoing training of food allergy and anaphylaxis management must also remain, even subsequent to policy or legislation to protect children at risk of anaphylaxis. Of note, anaphylaxis mismanagement due to the lack of standardized communication practices and/or a lack of available EAI additionally increases the risk of fatal anaphylaxis [1], thereby reinforcing the need to develop consistent, and uniformly applied policies coupled with ongoing education.

Our study involved teachers based in Winnipeg, which is the capital city of the Province of Manitoba. Unlike the Provinces of Ontario [31] and Alberta, [32] which have legislation enacted to protect students at risk of anaphylaxis, no such legislation exists in Manitoba. Moreover, food allergy-related policies differ across intraprovincial jurisdictions. For example, one school division has a policy mandating stock epinephrine autoinjectors, [33] this is not applicable to all Manitoba schools. Of note, all Manitoba-based teachers and school staff are required to complete URIS training, the content of which was developed in consultation with health professionals with expertise in anaphylaxis and community health [34]. While there are no publicly-available intended learning outcomes for the URIS program, the anaphylaxis manual details food allergy management practices, including consideration to age-appropriate practices, as well as anaphylaxis recognition and emergency treatment [34].

Our study results echoed the themes identified in Hinton & Kirk (2015)’s narrative review of teachers’ perspectives teaching children with chronic disease. Although this review focused on students with asthma, epilepsy and diabetes, teachers in this study wanted and needed more education, training and resources to increase their confidence to teach, care for and manage their students with chronic disease. Expectedly, increased communication and educational programs were deemed beneficial for teachers [35], In our study, all teachers spoke about benefitting from more frequent education and emergency management training. This suggests that teachers, regardless of whether they had previous experience of food allergy or not, valued shared knowledge and shared responsibility amongst families, students and all school staff.

Teachers also collectively voiced their recognition and want for standardized food allergy education. Food allergy education would be beneficial for all paid adults in the school, who may witness a food allergy emergency in the school, including student teachers, substitute teachers, lunch supervisors and all support staff. Further, providing standardized food allergy resources (i.e. infographics, emergency plan) in every classroom may facilitate better decision making and increase confidence should an emergency occur.

Like all qualitative studies, our study findings are not generalizable but may be transferable to similar populations. Our participants taught mostly younger grades (K-Grade 3), therefore, these findings may not be transferable to teachers who have older students. While a few teachers in our study described witnessing bullying-like actions, these actions were not widely described, possibly as these teachers taught younger children. In contrast, self-reported food allergy-related bullying amongst older school children has been reported as being common, with as many as one-in-three youth reporting such bullying [26]. We also note that teachers who participated in our study were likely more motivated to speak and learn about food allergy, while some teachers may perceive food allergy management as being beyond their current scope or bandwidth.

A strength of this study is reporting an in-depth analysis of 16 teachers’ perceptions and experiences managing food allergy in their classrooms and schools. Layers of lived experiences and pedagogical principles ultimately shape the way teachers experience, perceive and therefore create the truth (25). Through these interviews, we identified ways in which food allergy management can be improved by way of more education and training related to prevention and treatment of food allergic reactions, better and ongoing communication between and amongst relevant parties and standardization of policies related to food allergy, including recommendations on how teachers should manage unintended consequences or situations related to those policies. Teachers’ interest to participate in these interviews in a time when schools were subjected to many COVID-19-related changes [20] was also a study strength. In addition, these interviews were conducted during a time when birthday parties and field trips, were not possible due to COVID. Mentioning these events during interviews, in relation to food allergy, spoke to how much teachers thought, and perhaps worried, about food allergy management though special occasions were not as relevant during the pandemic.