The characteristics and effectiveness of school-based educational interventions in the management of children with food allergies: a systematic review

Food allergy (FA) is a potentially life-threatening condition caused by exposure to a specific food allergen. Healthcare professionals play a critical role in providing educational programs for children affected by FA and their caregivers. Equally important is training for all school staff so that they have the knowledge and skills to manage an allergic emergency and minimize the risk of complications. This review was performed to summarize the evidence of school-based educational intervention for management of FA. Relevant studies were identified in the MEDLINE and CINAHL databases, up to June 2024. Thirteen articles resulted eligible for inclusion and data analysis as they investigated the effectiveness of school-based intervention with pre-post evaluation for several outcomes, such as knowledge, attitudes, experiences, and self-efficacy. Although the interventions were very heterogeneous (mostly mixed or based on digital methods), all studies showed that the different educational programs resulted in a significant improvement in the various parameters taken into consideration. The current evidence therefore supports the effectiveness of expert educational interventions in school and the importance of strong collaboration between school and health systems. Studies that carefully evaluate the efficacy of each intervention and the quality of methodology are needed to identify the best educational strategy.

INTRODUCTION

Food allergy (FA) is a potentially life-threatening condition caused by an immediate IgE-correlated reaction to a specific food allergen ¹. Any food can be a potential trigger of an allergic reaction, but some cause the majority of reactions, such as milk, eggs, peanuts, soy, wheat, nuts, shellfish, fish and sesame ². The allergy to foods is frequent in children and allergies to some specific foods may persist throughout life, although the majority are outgrown by adulthood. In recent years, the prevalence of food allergies has increased worldwide and at any age, with a marked increase in industrialized countries ^3,4. Food allergy affects about 8% of children worldwide, although the prevalence varies depending on the food ^5,6. The global prevalence of anaphylaxis appears to vary from 0.3 to 3.1% ^6-8. Children with severe allergies, in particular those at risk of anaphylaxis, can experience isolation and increased anxiety, especially in social and school settings where accidental exposure to allergens is possible ^8,9. The emotional burden on families is further exacerbated by the need for constant vigilance in order to avoid allergens and by the challenges associated with preparing meals, especially away from home ¹⁰. Teenagers may face even greater psychological challenges as their growing independence and increased social interactions expose them to more risks, further affecting their quality of life ^8,11.

Comprehensive allergy management typically involves three components: allergen avoidance, pharmacological treatments and/or immunotherapy ¹. In addition to preventing the onset of clinical symptoms, certain interventions are aimed at reducing the stress of managing the condition. In this regard, healthcare professionals play a critical role in providing educational programs for patients and their families or caregivers. These programs should include training in recognizing the symptoms of allergic reactions, safe food handling, food label interpretation, and emergency procedures ¹². Children spend a significant proportion of their time at school, and thus effective allergy management in this setting is particularly important. Similar training for all school personnel, including teachers, is therefore equally important, so that they can increase the basic knowledge and skills to manage an anaphylactic emergency and minimize the risk of delaying intervention and the subsequent risk of life-threatening complication ¹³. The safety and quality of life of children with food allergies depends on parents, educators, and healthcare professionals working together ¹⁴.

In this systematic review we aimed to investigate the evidence on educational interventions implemented in schools to improve skills for the management of FA, exploring the various modalities, characteristics, and effectivenes.

MATERIALS AND METHODS

This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. ¹⁶ Two investigators searched the bibliographic databases MEDLINE and CINAHL using the following main key words: “education” AND “food allergy” AND “school”. The research string was adapted for each database, incorporating relevant synonyms. The search covered reports published from the inception of the databases to June 1, 2024. Only studies in English and Italian were included, while no date restriction was applied. Duplicate articles were removed, and the title and abstract of all retrieved records were screened. Studies not meeting the inclusion criteria were excluded. Full texts of relevant articles were examined by two researchers. Disagreements were resolved through discussion.

We included all educational interventions aimed to improve knowledge, attitudes, practices, and management of food allergy reactions. Specifically, we included studies that: I) were reported in English; II) were realized in school setting, at any educational level; III) evaluated the effectiveness of the training intervention; and IV) with pre-post evaluation or controlled study design. Studies that: I) did not include an educational intervention; II) without school setting; III) did not evaluate the impact of the training; IV) with focus only on epinephrine autoinjector were excluded. We also excluded studies that were not published in peer-reviewed journals, were not available in English, or that lacked sufficient data to describe educational strategies.

For each record included, two reviewers independently extracted the following information using a standardized data abstraction form: author/year/country, study design, outcome, sample, type of intervention and results. Discrepancies were resolved by discussion.

RESULTS

Thirteen ^17-29 articles were eligible for inclusion and data analysis. The literature search identified 3260 potentially relevant articles. After removing duplicates, titles and abstracts were read and reviewed, and ineligible articles were excluded. After reading and reviewing the full text of the remaining articles, 294 studies were excluded. Figure 1 shows the flowchart for searching and selecting literature.

We included two randomized controlled trials with pre-posttest ^17,22, which we defined as ‘quasi-experimental studies with a control group’ because the randomization process was not described in detail. The remaining included studies were before-after studies without a control group.

The sample sizes of the included studies ranged from 18 to 1745 participants. Table I shows the characteristics of the studies included.

Educational strategies

The method of delivery of the educational interventions was heterogeneous and tailored to the setting of the research group and schools. In four studies, with non-interactive computer module ²⁰, video training ²⁸, virtual classroom ²⁹, and digital education module ²⁵. Some of the studies also included practical workshops, mainly demonstrating the management of severe allergic reactions, e.g. with scenario presentations, practical use of adrenaline autoinjectors ^{19,21,23,26,27}. The majority of the studies took place mainly in primary and secondary schools, including nursery schools ^24,25,28. This is consistent with the age when FA is most prevalent. Some studies did not specify the level of schools included ^20-23.

The healthcare workers involved in the educational intervention were mainly allergy specialists or physicians, and in some studies nurses ^23,26,27. Two trials also included other professionals such as lawyers ²⁴, psychologists ²⁴ and experts in communication ¹⁸. Although in some studies it was not clear which health professional provided the training, it could be inferred that it was an expert or the whole research group ^19,21,27,28.

The content of the training was usually developed by experts and/or based on guidelines. It was comprehensive in all the studies and included recognition of allergic reactions, the identification of allergens, methods of allergy prevention, and emergency treatment. The target group consisted mainly of teachers in all studies except one that was targeted at students ²⁹. Moreover, some studies also included other school staff, such as canteen staff, support team ^20,23-25, and school nurses ¹⁹ .

Outcome

Three studies assessed self-efficacy ^21,24,27; one study assessed both self-efficacy and practical experience acquired ¹⁹. Three studies assessed only the level of knowledge acquired ^17,18,23; five other publications assessed not only knowledge but also other outcomes such as possible changes in attitudes, beliefs, feelings, and confidence ^{20,22,25,28,29}. One study looked at level of practical preparedness ²⁶. Significant improvements in these outcomes were reported in all research. All outcomes were assessed using questionnaires, most of which were not validated. Only four studies ^22,24,27,28 used validated questionnaires, such as SPSMFAA-T (School Personnel’s Self-Efficacy in Managing Food Allergy and Anaphylaxis Scale) and S.PER.SE-FAAQ (School Personnel Self-Efficacy-Food Allergy and Anaphylaxis Questionnaire).

DISCUSSION

This systematic review examined educational interventions aimed at improving management of FA in school settings. The results of the studies included highlight several key components of effective food allergy management in schools, with a focus on staff training, emergency preparedness, and consistent application of policies across institutions. The review highlights the critical role of collaboration between schools, students, families, and healthcare providers in developing comprehensive food allergy management strategies. This is particularly relevant in Italy, where school staff do not include nurses and where the educational and management policies are heterogeneous across regions.

Several cross-sectional studies have been carried out with school staff as the target group. The overall aim is to explore their knowledge and perceptions of the chronic diseases of children that have the greatest impact on their quality of life, such as epilepsy and allergies ^30-34. Concerning FA, the results of all studies are consistent and agree in their conclusions. They highlighted that school staff on average have large knowledge gaps about allergic diseases in general and the dangers they pose. School workers cannot identify many important warning signs of anaphylaxis and consequently are unable to manage anaphylactic emergencies or provide first aid ^35-40. It follows that the conclusions are rigorous: it is necessary to intensify efforts to spread training to all schools and adopt standardized protocols for both risk prevention and emergency response. The results of this review therefore have a strong practical and political value: the evidence collected leaves no doubt and reinforces the belief that educational campaigns in schools aimed at training school staff are urgent, important, and sometimes life-saving interventions.

Pediatric allergology, strengthened by this evidence, should urge policy makers to consider and finance training programs in this field, but should at the same time monitor the methodological correctness and the outcomes of current training courses with specific evaluation tools.

The most significant improvements that emerged from our research were levels of knowledge and self-efficacy. These objectives, to be achieved, must follow a precise and impeccable methodology that is built on knowledge of the specific beliefs of teachers. Their attitudes and beliefs are in fact able to influence their decisions, aspirations, efforts, and perseverance, and therefore the competence and confidence of their work. In social cognitive theory, perceived efficacy is fundamental for human action and therefore in the intervention scheme it must be addressed and discussed in depth with school staff in order to support their self-confidence and optimize the effectiveness of the intervention (self-efficacy), especially when, as guidelines underline, there are no healthcare workers who act as a reference ^41-43.

In practice, it was not possible to identify the best educational strategy and those adopted were extremely heterogeneous. Some applied mixed strategies ^{18,19,23,24,26,27}, and others digital interventions ^20,25,28,29 or standard classroom ^17,21,22. The current trend is to use informative workshops completed by laboratory or simulation activities that give operators a lot of security, because practical activities allow to apply theoretical knowledge in real life contexts, which improves understanding and acquisition of skills ⁴⁴.

From this literature review the opportunity to extend training to canteen staff and other staff involved in food preparation and service also emerged, providing them with simple and practical information on food allergies. Operators must be well trained on safe food handling practices, adequate cleaning protocols, and greater supervision during meals, (especially in primary schools, with younger children) ^33,45,46.

In spite of its strengths, our review also has some limitations. Firstly, it is important to highlight some methodological aspects of the included studies: mainly self-report measures were used and the authors did not include repeated measures over time to verify the retention of what was learned during training. Secondly, the lack of rigorous randomized controlled trials limits the strength and generalizability of the conclusions. Moreover, although all studies agree on the usefulness of the intervention, the outcomes used were too heterogeneous to allow us to identify an optimal parameter for evaluating its effectiveness.

Finally, we included studies generally related to FA, while excluding those solely focused on emergency reactions, despite their relevance for schools. Only two search engines, though fully accredited, were used to search for sources, and we did not evaluate the quality of the studies. However, to our knowledge, this is the first review summarizing the educational strategies of such interventions, offering valuable insights for future guidelines in school setting..

CONCLUSIONS

The implementation of clear and personalized emergency action plans and the organization of regular meetings between teachers, students, parents, and school staff are essential to improve communication and ensure that all parties are fully aware of their role in preventing allergic reactions and in responding appropriately in an emergency. It is essential that allergy physicians and nurses make a collective effort to create standardized school programs that can provide the necessary skills to those involved in the education and training of children with FA.

Acknowledgements

None.

Ethical consideration

This systematic review is based solely on previously published studies and did not involve direct contact with human participants or animals. Therefore, no ethical approval was required.

Funding

We would like to acknowledge that this research did not receive any specific funding.

Conflict of interest

The authors declare no conflict of interest.

Authors contributions

M.R. conceptualized the study, designed the methodology, analyzed data, drafted the manuscript. A.D. was involved in data collection and extraction and drafted the manuscript. M.D. conceptualized the study, drafted, reviewed and revised the manuscript and, approved the final version. A.M.Z. conceptualized the study, drafted, reviewed and revised the manuscript and, approved the final version.

History

Received: December 2, 2024

Published: March 27, 2025

Figures and tables

FIGURE 1. Flow diagram of the review process.

TABLE I. Data Extraction.

Author, year, country	Study design	Outcome	Sample	Intervention	Results
Shah et al, 2013, USA Texas 17	Controlled group-study	Knowledge (questionnaire*)	Teachers (n = 26-64 per school — 4 schools) [elementary schools]	Teaching session with slide presentation by physician	Significant results in intervention group
Ravarotto et al, 2014, Italy 18	Before-After study	Knowledge (questionnaire)	Teachers (n = 158) [primary schools]	Workshops with slides presentation and discussion, by experts in allergy and communication	Significant improvement
Sasaki et al, 2014, Japan 19	Before-After study	Self-efficacy, Experience	Teachers, school nurses, childcare workers (n = 276) [elementary or junior high school, nurseries]	Workshop with theoretical/practical session and discussion	Significant improvement
White et al, 2015, USA, Massachusetts 20	Before-After study	Knowledge, Confidence, Attitude (questionnaire)	Teachers, other school staff (administrators, secretaries, cafeteria staff) (n = 143)	Non-interactive computer module, created by allergists	Significant improvement
Gonzalez-Mancebo et al. 2018, Spain 21	Before-After study	Self-efficacy (questionnaire)	Teachers, cooks, dining-room monitors, summer-camp leaders. (n = 191)	Educational Conference by allergists	Significant improvement
Canon et al. 2019, Spain 22	Controlled group-study	Knowledge, Attitudes, Beliefs (questionnaire)*	Teachers (n = 375)	Educational Session by one HCW	Significant results in intervention group
Rodriguez Ferran et al, 2019 Spain 23	Before-After study	Knowledge (questionnaire)	Teachers, school canteen staff (n = 53)	Theoretical presentation by allergist and practical sessions by nurse	Significant improvement
Polloni et. al, 2020, Italy 24	Before-After study	Self-efficacy (questionnaire*)	Teachers and school caretakers (n = 592) [nursery, primary, middle, high schools]	Intensive education session with presentation and discussion, by allergists, psychologist, lawyer	Significant improvement
Poza-Guedes et al, 2021, Spain 25	Before-After study	Knowledge, Attitudes, Feelings (questionnaire)-Quality /satisfaction	Teachers, supporting teams and state officials (n = 1403 + 225 + 117) [nursery, elementary, secondary, vocational education, language schools, arts, others]	Electronic learning intervention (5 units, digital instructional materials, videos, virtual forum) of allergists	Significant improvement
Raptis et al, 2021, UK 26	Before-After study	Preparedness	Head teachers (n = 18) [secondary schools]	Theoretical and a practical workshop by allergy specialist	Significant improvement
Yıldırım et al, 2023, Turkey 27	Before-After study	Self-efficacy (questionnaire*)	Teachers (n = 90) [primary, middle schools]	Diversified group training, with theoretical/practical parts and discussion	Significant improvement
Lejtman et al, 2024, France 28	Before-After study	Knowledge, Confidence (questionnaire*)	Teachers (n = 218) [primary, nursery schools]	Video-training program	Significant improvement
Licata et al, 2024, USA 29	Before-After study	Knowledge, Confidence levels (Questionnaire)	Students (n = 63) [8th-grade schools]	Virtual synchronous classrooms	Significant improvement
* Validated