High School Teachersí Awareness of
Diabetes In High School Students
Abstract Discussion Introduction Relative Links Method References Results Acknowledgements
Keywords: Diabetes; Teacher Awareness and Diabetes; Hypoglycemic
Unawareness; Contact Hypothesis; Negative
Reinforcement; Stress; Adolescence
Diabetes affects people of all different ages and races; however, the diabetic population that needs to be studied more closely is adolescents. Most diabetes research focuses on elementary school children because they are not cognitively capable of independently managing their diabetes. Adolescents with diabetes are a fragile and understudied population because they are learning to be responsible for the management of their disease so as to avoid any unnecessary complications later in life. The purpose of this research was to examine whether or not there are differences in the level of diabetes knowledge between high school science/physical education teachers and teachers of other disciplines because teachers are significantly involved in the exposure to and care of diabetic adolescents.
During the adolescent years, most teenagers are often trying to fit in with their peers, in short to be ďnormal.Ē This is extremely difficult for the diabetic adolescent because he or she leads a lifestyle that is necessarily different from his or her peers. Unlike most others in his or her peer group, a diabetic adolescent might have to test their blood sugar levels in class, have a snack during class or leave class to test his or her blood sugar to avoid an emergency with hyper- or hypo-glycemia. These requirements and their resultant actions make adolescent diabetics act and feel differently from their peers. According to Phillips (2000), children, but more specifically adolescents with diabetes, want to fit in with their peers and be part of the crowd. To an adolescent, peer relationships are extremely important (Phillips, 2000). To a diabetic, this importance of ďfitting inĒ may outweigh the importance of following the somewhat strict regimen for testing for hyper- or hypo-glycemic conditions and treatment of such conditions.
Additionally, another aspect of adolescent development that can aversely affect the overall well-being of a diabetic adolescent is the need for independence (Phillips, 2000). At this point in life, adolescents want to be treated like adults, at least as they perceive that state of being, and most often want to take full responsibility for their diabetes. Independence is an important step in human development, but it can be a negative one if the child does not take proper care of his or her diabetes. This has long been a concern of parents because, as Bond, Aiken, and Somerville (1992) stated, the quality of diabetes care is more often diminished in adolescence compared to care during preadolescence, perhaps because of decreased parent intervention in diabetes management. These researchers also found that compliance with glucose monitoring and diet regimens declines in adolescence. Several factors including the desire to conform to the norms of peer groups or the need for increased independence from ďparentalĒ supervision may contribute to this decline. Although adolescents need their independence, they sometimes require reinforcement and prompting from others, including teachers, who can encourage and help these students learn, or at least comply with, what the proper management of diabetes entails.
Teachers who are uninformed about diabetes may unconsciously or unintentionally have negative effects on the psychology of a diabetic student. If a teacher is unaware of the symptoms associated with either hypoglycemia or hyperglycemia, he or she can form negative stereotypes of the diabetic student. The student may be behaving differently (often acting as if he or she is inebriated when hypoglycemic) and the teacher may form a negative impression of this student, simply because the teacher does not recognize the symptoms of hypoglycemia. This can, in turn, affect the psychology of the adolescent because he or she may begin to fear or become anxious about the teacherís reaction, becoming hypoglycemic, having to eat during class, or leaving the classroom to test. The student may then attempt to avoid the class or the teacher in order to decrease the stress or anxiety caused by the stimuli. This unintentional and perhaps unnoticed avoidant behavior is a form of operant conditioning that may negatively reinforce such behavior. In the above-mentioned situations, class, school, and a teacherís insufficient knowledge of diabetes can all be considered negative stimuli which the student will attempt to avoid so he or she does not experience the anxiety that signals the presence of that stimuli. Negative reinforcement occurs when escape or avoidance allow an individual to subtract or avoid aversive experiences from his or her life (Baldwin and Baldwin, 2001). Although this negative reinforcement may only have occurred on one occasion, Baron (1992) states negative reinforcement exerts powerful effects on behavior. Therefore, it is important for teachers to be knowledgeable about the diabetic condition so that the frequency of situations of negative reinforcement is minimized. One reason teachers should have diabetes knowledge is because if a student fears a teacherís reaction to a low blood sugar event, he or she may frequently focus on avoiding hypoglycemia rather than focusing on what is happening in class.
Stress and Diabetes
Stress is another factor that has negative effects on an adolescent with diabetes. During adolescence, stress levels are increased due to the growth and development of the young person. Research shows that stress has negative effects on diabetes because it impairs blood sugar control (Sarafino, 1994). During times of stress, the adrenal gland releases epinephrine and cortisol. Epinephrine causes the pancreas to decrease insulin production. Cortisol, on the other hand, causes the liver to increase glucose production and body tissues to decrease their use of glucose (Sarafino, 1994). The combination of these two events can lead to hyperglycemia. Therefore, increased stress caused by a anxiety about teacher/reaction or anxiety about a teacherís lack of knowledge about diabetes can adversely affect good metabolic glucose control. Since diabetic adolescents spend a majority of their day in school, teachers could significantly improve the experience of the diabetic student if teachers were more informed about diabetes. They would be able to assist the diabetic student in achieving optimal, or perhaps even significantly better diabetes management.
Diabetic children spend approximately six hours of their day in school without sufficient support from an educator experienced in care of diabetes. Recently, teachers and school nurses have been asked to play a more active role in the management and care of a studentís diabetes. Several studies have been conducted to assess the amount of knowledge school teachers have about diabetes. Melchionne (1994) found that there was a definite lack in teacher awareness about diabetes and the effects it has on a childís academic performance. According to the results presented by Melchionne, a teacher has a one in twenty chance of getting a student with diabetes in the classroom. This statistic supports the argument for having a mandatory educational program on diabetes for all teachers due to the increased chances of having a diabetic student in class. The purpose of this study is to assess teacher knowledge of diabetes in high school students. It is thought that increased teacher knowledge of the disease will ease the anxieties of students with the disease in the classroom and will minimize negative reinforcement of an adverse classroom experience.
Societal misconceptions of
diabetes can also be examined in the classroom. In an article published
by Cialdini, Kenrick, and Nueberg (1999) the authors wrote that the contact
hypothesis states that stereotypes and prejudices toward a group will decrease
as contact with the group increases. According to Slininger, Sherrill,
and Jankowski (2000), major theorist Allport recommended the use of intellectual
education. Allport believed that structured direct experience should
be supplemented with information designed to correct any misconceptions
about the population and to facilitate the formation of positive beliefs
(Slininger, Sherrill, and Jankowski, 2000). The contact hypothesis
can be applied on a smaller scale to teacherís attitudes towards diabetics
and the somewhat unexpected or unplanned disruptions care of diabetes may
cause in the classroom environment and to the teacherís comfort level.
If a teacher has had repeated exposure to diabetics or even information
about diabetes, particularly in symptom recognition and treatment of potential
health problems then he or she will become more familiar with the disease
and therefore become more comfortable dealing with a diabetic student in
the classroom. The contact hypothesis will be examined in the present
study by the questionnaire. The questionnaire will examine if there
is a correlation between teachersí previous exposure to a diabetic student
and their comfort level in having this student in their classroom.
The teacherís lack of diabetes knowledge has been shown to lead not only to increased student anxiety, but also to increased teacher anxiety levels when he or she has a diabetic in the classroom. This increased anxiety may then lead teachers to treat diabetic students differently and damage the child psychologically or physically. Ayana, Trowe, and Benavent (1994), found that 44.3% of teachers who participated in their study admitted anxiety about having a diabetic child in their classroom. This anxiety may lead teachers to allow diabetic students to pass work in late or give them special treatment. This may in turn cause the child psychological or physical harm depending upon the special treatment that he or she receives from the teacher. Special treatment may foster peer conflicts and do a great disservice by inhibiting an adolescent diabeticís desire to fit in with peer groups (Phillips, 2000). Approximately 94.3% of the participants in Ayana, Trowe, and Benaventís study wanted information about diabetes and its effect on a childís academic performance. The research by Ayana, Trowe, and Benavent demonstrates that teachers are insufficiently informed and more education on Type One diabetes should be included in teacher training sessions.
Surprisingly, most teachers have an above-average knowledge of the physiology of insulin dependent diabetes. Greenbalgh (1997) found that 57.7% of secondary school teachers demonstrated adequate knowledge of diabetic physiology. Although this statistic is promising, teachers did not relate their physiological knowledge of diabetes to everyday aspects of diabetes care (treatment and identification of symptoms) perhaps because of nervousness or anxiety about improperly treating the symptoms, lack of confidence in their knowledge or lack of exposure to the diabetic population. The most startling statistic presented by Greenbalgh was that only 27% of secondary school teachers, who were not science or physical education teachers, were found to have adequate knowledge of diabetes. For example, Greenbalgh found that teachers have an inability to recognize the signs and symptoms of Diabetic ketoacidosis, perhaps because it does not occur as frequently as hypoglycemia. Greenbalghís study implies that even though a teacher may know information about Diabetic ketoacidosis, he or she does not apply this information in emergencies. Further research is necessary to determine ways in which teachers may better apply their knowledge of diabetes to emergencies.
A group that may have been overlooked by the research, excepting Greenbalgh, is the high school population. High school teachers should be evaluated for their knowledge of diabetes because although adolescents are more independent than young children, they still need low levels of supervision to identify when a problem may be occurring. A diabetic student may not be able to identify easily the symptoms of impending physical problems; therefore, the student may need a teacher to prompt him or her to do something to avoid severe consequences. Adolescence is hard enough to handle without a chronic illness, and therefore, knowing that teachers know about diabetes and what symptoms to look for may make coping with diabetes easier for adolescents by giving them one less problem about which to worry or about which to be concerned. If a student is confident that his or her teacher has diabetes knowledge, the student will be able to focus more on other aspects of life in the classroom. Adolescents need to be prompted to manage their diabetes properly by the teacher because hypoglycemia can go unnoticed by the student and because of the effects it has on cognition. This may lead the development of hypoglycemic unawareness.
According to Sheridan Waldrop (2000), ďhypoglycemic unawareness is the loss of early autonomic warning symptoms when a low blood glucose level occurs. The early autonomic warning symptoms prompt the individual to treat the blood sugar level before the blood sugar falls to a dangerously low level.Ē Hypoglycemic unawareness causes the diabetic to be unable to treat the blood sugar before he or she reaches the unconscious state. Often, diabetics become confused and do not recognize symptoms of hypoglycemia; therefore, if a teacher knows the symptoms of low blood sugar he or she would be able to identify when these symptoms are occurring and assist the student in treating the low blood sugar. Teacher awareness of diabetes is imperative to the overall social and academic success of the adolescent, especially since hypoglycemia has a negative effect on cognition.
The inability of a teacher to recognize that hypoglycemia has negative effects on cognition is manifested when the teacher makes an inappropriate decision when sending a student to seek treatment from a school nurse for a hypoglycemic episode. The lack of understanding is found in results from research published by Diabetes Forecast (1997), which showed that 40% of parents reported that their child is left alone or sent to seek treatment when his or her blood glucose is hypoglycemic. A diabetic experiencing a low blood sugar should not be sent to seek treatment alone because the student may pass out or even get lost on the way. There is also a possibility that the diabetic could be so low that he or she starts seizing, indicating that blood and oxygen flow to the brain has decreased, possibly leading to possible brain damage or even death. These scenarios would all endanger the health and welfare of the student. Psychologically, the aforementioned scenarios can damage the studentís academic performance because, as stated previously, the teacher is negatively reinforcing the diabetic studentís negative avoidant behavior and because of those negative reinforcements the child may be uncomfortable or stressed when in class. This can lead the child to try to avoid the teacher or the class so as not to have to deal with the consequences of the teacherís lack of knowledge about diabetes.
Participants for this study included 100 teachers from various private and public high schools in the New England area. School sizes ranged from small (200-400) to large (600+). Participants included teachers from all different disciplines. Three teachers were from the science discipline, one from physical education, and the rest were from various other disciplines. Participation in the study was voluntary and anonymous. A questionnaire designed for this study was used to assess level of knowledge of diabetes and level of prior contact with diabetics. The questionnaire consisted of three sections.
The questionnaire used for this study was a new questionnaire created by the researcher to examine teacher knowledge of diabetes. The first section of the questionnaire contained basic background information, such as, subject taught, gender, age, relationship with anyone with Type I diabetes, and prior diabetes education. The second section of the questionnaire consisted of sixteen diabetes knowledge questions. The questions inquired about symptoms and treatment of hypoglycemia and hyperglycemia, diet, exercise, and the impact of diabetes on cognitive function. Teachers were asked not to consult any references when responding to the questionnaire. The teachers were given five options for answers on the second section of the questionnaire. The possible answers were false, generally false, unsure, generally true, and true. The teachers were then asked to rate their confidence on each question on a three-point Likert scale from, 1= Highly confident to 3= Not confident. This measure will allow the researcher to examine teachersí perception of his or her knowledge level of diabetes. This will also allow the researcher to determine if there is a correlation between confidence level and knowledge level. The third section of the questionnaire consisted of four open-ended questions that examined each teacherícomfort level, personal assessment of diabetes knowledge, and desire to have more diabetes education.
After contact with
school administrators surveys were mailed to the schools and distributed
to the teachers by a chosen staff member. Teachers were asked to
fill out and return the anonymous survey to the chosen faculty, who then
mailed the surveys to the researcher. Informed consent was given
by returning the survey. The survey was accompanied by a debriefing
statement and teacher letter explaining the survey. One-hundred surveys
were distributed, with a return rate of 34%.
An Independent Samples T-test was used to determine if there was a difference between the overall knowledge scores between groups (science/physical education teachers and other). The t-test yielded a t(29)=1.622 and no significance (p>.05, p=.255, df=29). The mean total knowledge score for science and physical education teachers was 73.43 with a standard deviation of 5.98 and a standard error of the mean of 2.99. The mean total knowledge score for teachers in other disciplines was 60.42 with a standard deviation of 15.7 and a standard error of the mean equal to 3.02.
An second Independent
Samples T-test was used to determine if there was a significant difference
between the knowledge teachers who either knew or had known someone with
diabetes and teachers who did not know anyone with diabetes. A significant
difference was found t(32)=.885, p<.05). The mean total knowledge
score for teachers who know or had known someone with diabetes other than
a student was 64.2045 with a standard deviation of 10.41. The mean
total for teachers who did not know anyone with diabetes was 59.38 with
a standard deviation of 21.57. These means are consistent with the
prediction that increased exposure to the diabetic population will increase
the teacherís performance on the questionnaire.
It was found in the current study that teachers with prior exposure to the diabetic population performed better by a statistically significant amount on the questionnaire than those without prior exposure to the population regardless of the subject taught. These findings support the contact hypothesis, which states that repeated exposure to a certain group will decrease prejudices and negative stereotyping regarding this group (Cialdini, Kenrick & Nueberg, 1999). If teachers are more educated about diabetes, they are more likely to be comfortable having a diabetic student in the classroom and treating any complications that may develop while the student is in that teacherís care. No other significant findings were revealed in any other areas of this study.
The current study found that the many teachers have less percieved confidence than their actual performance on the questionnaire merits. This finding may need to be examined in future research to determine if the lack of confidence interferes with a teacherís comfort level. Future research should attempt to determine whether a teacher who is less confident in his or her knowledge will be less comfortable having a diabetic student in the class and less able to care for a diabetic student.
The first factor that should be taken into consideration for future studies is sample size. Although the return rate was high (34%), only four of the thirty-four returned surveys were from science or physical education teachers. Three returned surveys did not list a discipline. This may have contributed to the lack of significance in the results. A larger sample size that is more carefully targeted to the desired population may yield results that would be more accurate and/or meaningful.
The second factor for further research that should be taken into consideration is that the measure used to determine teacherís knowledge of diabetes may not have been sensitive enough to assess the information that the researcher desired. Although the instrument showed adequate reliability, changes to the instrument may have improved the effectiveness. Issues concerning validity and reliability should be examined in every study, but especially in this particular one because the measurement was newly created. The researcher chose not to use one of the instruments used in prior research studies because she wanted to examine other aspects of teacher knowledge that have been of concern to diabetics and their families (Diabetes Forecast, 1996). Increasing both reliability and validity may impact the accuracy and significance of the results.
The third factor that may have improved the results is the simplification of the term Type I diabetes to Insulin Dependent Diabetes Mellitus (IDDM). This should be taken into consideration for future research because the researcher inferred from the notes written from participants on the questionnaire that several either did not know that two types of diabetes exist or did not read the directions properly. The term Insulin Dependent Diabetes Mellitus makes it easier to decipher the condition from the more common Non-Insulin Dependent Diabetes Mellitus (NIDDM) or Type 2 Diabetes. The reason that the use of the phrase Insulin Dependent Diabetes Mellitus would have improved the questionnaire is because this term is more specific than the Type 1 diabetes term, which is broader and less descriptive.
Another critique of the study can be made about the questions asked. A majority of the questions were subjective and did not truly examine teacher knowledge of diabetes or more specifically, how to handle certain emergency situations. Altering some of the question to be more objective and oriented towards diabetes knowledge and teacher involvement in treatment may have yielded more valid results.
Additionally, the items in the questionnaire should specifically have asked about treatment of hypoglycemia or low blood sugar. This would have tested to see whether or not teachers knew what to do if an emergency situation arose and they were the only person present to assist the student in treating the low blood sugar. Teachers performed well when asked to identify the symptoms of hypoglycemia but the questionnaire failed to examine teacherís knowledge of the proper treatment of low blood sugar.
The results of the study support the findings of several other studies, which found that teachers should be better educated about diabetes so that teachers can increase their comfort level and decrease the anxiety level of the diabetic student (Greenbalgh, 1997). The education of teachers regarding diabetes may help to reduce any negative stereotypes associated with diabetes. Also, this education will help to decrease the anxiety level of the diabetic student who may be concerned about being different from peers or even from having to treat hypoglycemia during class. Diabetic students will benefit from increased teacher knowledge because their anxiety levels will decrease when they are in situations requiring assistance if they know their teachers are educated about diabetes. This will in turn allow the student to focus on school rather than frequently worrying about having an adverse reaction during class. In addition, if the teacher is aware of the studentís condition, he of she will not react negatively to behavior that is associated with hypoglycemia and hyperglycemia, thus decreasing the negative reinforcement.
Another way in which this study is beneficial to both diabetic students and teachers is that teachers who have been educated in diabetes can help support the adolescent in decision making about the disease. Because diabetic adolescents have been found to have less compliance with prescribed diabetes management (Bond, Aiken, and Somerville, 1992), teachers can serve as a support system, or at the very least not exhibit the disapproval of the effects that such management has on the classroom experience.
The benefits of teacher education about diabetes and teacher exposure to the diabetic population can be found in the description of contact theory, which states that increased exposure or knowledge of a particular groups will decrease prejudices and stereotyping (Cialdini, Kenrick, Neuberg, 1999). If a teacher is more comfortable with having a diabetic student in his or her class, then the student may be more comfortable in that class. Therefore, there may be a rough correlation between a studentís awareness of a teacherís adequate knowledge of diabetes and improved diabetes management or better academic performance. This correlation may occur because the student knows that the teacher understands the disease and is capable of assisting him or her when necessary, which may in turn ease some of the his or her anxieties about being in the class with the condition. The above-mentioned correlation should be studied to determine whether increased teacher understanding of diabetes leads to decreased diabetic student anxieties.
This study does present a valid argument that science and physical education teachers do have more overall knowledge of diabetes, but some of that knowledge can be examined further in future research to determine exactly where teachers are deficient in diabetes knowledge. The idea that science and physical education teachers possess more diabetes knowledge than teachers of other disciplines may only exist on a theoretical level; therefore, future research may examine teacherís practical knowledge. For example, a study could be conducted in which teachers of different disciplines are placed in a simulated situation where a student is having a hypoglycemic reaction. One could then examine the reaction of the teacher to the situation and if the teacher took the proper measures to deter any further problems. This type of study would help to determine if teachers of particular disciplines are actually capable of taking appropriate remedial actions for a diabetic if the need should arise.
Finally, future research may perform a Solomonís four-group design analysis to examine whether or not teacher knowledge of diabetes is improved with formal diabetes training. In a Solomonís four-group design, there would be four groups. One of the groups would be pretested, given the diabetes education, and then posttested. The second group would not be pretested, but instead they would receive the diabetes education and then be posttested. The third group would be pretested and retested but would not receive the diabetes education. The fourth group (control group) would only be posttested without receiving any diabetes education or pretesting. This type of study would help to determine whether teachers are benefiting from the education they are given.
In sum, the results
of this study indicated that although no significant difference was found
between the knowledge levels of science/physical education teachers and
teachers of other disciplines, the results were in the predicted direction.
This means that science and physical education teachers do possess more
knowledge than teachers of other disciplines do. However, teachers
overall did not perform extremely well on the questionnaire, which supports
the idea that teachers need to be more educated about diabetes. Teachers
play a special role in the growth and development of the future generations,
and a better understanding of diabetes may help teachers to influence positively
the life of a diabetic student beyond the classroom.
More Diabetes Information
St. Anselm College Home
Senior Theses Page
Aiken, CS, Bond, GG, Somerville, SC (1992). The belief model and adolescents with insulin dependent diabetes mellitus. Health Psychology, 11, 190-198.
American Diabetes Association (2002). Basic Diabetes Information. Retrieved April 1, 2002, from www.diabetes.org.
American Diabetes Association (2002). Facts and Figures. Retrieved April 1, 2002, from www.diabetes.org.
Ayarra, NG, Trave, TD, Benavent, MM (1994). Diabetologic education of the school teachers. Enfermeria Clinica, 4, 64-67.
Baldwin, J, Baldwin, JA (2001). Behavior Principles in Everyday Life (pp. 339). Upper Saddle River, NJ: Prentice Hall.
Baron, R. (1992). Psychology. (168-205). Boston: Allyn and Bacon.
Cialdini, RB, Kenrick, DT, Neuberg, SL (1999). Social Psychology: Unraveling the Mystery. (pp. 422-426). Boston: Allyn and Bacon.
Greenbalgh, S. (1997). Improving school teachersí knowledge
of diabetes. Professional Nurse, 13, 150-156.
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