Food Allergy Knowledge and Attitudes Among School Teachers in Jazan, Saudi Arabia

Results: The results revealed that almost (59.7%) of the schoolteachers had a medium insufficient knowledge about food allergy; only 17.3% had good knowledge about food allergy. Female teachers had higher knowledge scores (58.5 ± 17.2) as compared to male (51.8 ± 16.0) with statistically significant difference (p = 0.017). The majority of schoolteachers have a significantly poor knowledge in most of food allergy domains. More than half of responders either do not know or they disagree that the food allergy is a serious problem and can lead to death. Regression analysis revealed that participant’s level of knowledge is significantly associated with school teacher’s attitudes towards food allergy (OR = 0.06, 95% CI: 0.39 0.92, p = 0.01), practice (OR = 1.68, 95% CI: 1.11 2.56, p = 0.01), and years of experiences (OR = 1.8, 95% CI; 1.15 2.98, p = 0.011).


INTRODUCTION
Food allergy is a common problem in children as well as in adults, and its prevalence is well discussed and estimated in developed countries [1]. There is a significant gap in estimating the prevalence of food allergy in developing countries and particularly in Middle East Arabian Countries [2].
Food allergy is an abnormal immune body reaction to some food contents, the symptoms of reaction usually present as an immediate presentation, but some time can be late. Skin rash and hives usually are the main presentations [3].
When two systems are involved in the reaction (skin, cardiovascular, respiratory or gastrointestinal) then it is termed as anaphylaxis [4]. Anaphylaxis is a serious medical problem leading to food allergic reactions [5] and requiring a prompt treatment [6].
Food allergy can be a serious and fatal illness [7]. Severe fatal food allergy reaction at school is rare but have been reported [8]. Safety and management of food allergy reaction is an issue that is gaining increasing attentions [9] and mainly the problem of school preparedness [10]. Nearly all schools in developed countries are supplemented with food allergy guidelines [11,12].
To our knowledge there is no written policy or guideline existing at our schools in Saudi Arabia about food allergy precaution and management. There is no previous study estimating the prevalence of food allergy either in Jazan region or in Saudi Arabia. Some studies estimate the rate of food allergy in other atopic diseases [3,4] but not for general population. The current study aims to assess the knowledge of schoolteachers about food allergy and to determine the need for urgent strategic plan in order to set up a policy and procedure for ensuring wellbeing of children in their schools.

Study Design, Area and Participants
An observational cross-section study was conducted in Jazan Province during the period between May 2013 and February 2014. The province is located in the southwest corner of Saudi Arabia and lies on the western coast of the Red Sea. The population is estimated at 2365110 according to the latest population census. The study population was schoolteachers of Jazan province. The inclusion criteria included teachers currently working at governmental schools belonging to Jazan educational administration during the academic year 2013/2014.

Study Instrument
A validated previously published questionnaire was used for data collection purposes [1]. Two independent translators who were well versed in both languages and are associated with health services validated the Arabic translation. The questionnaire consists of four parts; a knowledge section to address identification of food allergies, the risk and the causes, the practice section includes what teachers will do in case of food allergy, and the attitudes section was devoted to feelings towards children with food allergy. The last section of the questionnaire covered a set of sociodemographic questions.

Data Collection Technique and Sampling Procedures
The questionnaire was uploaded onto a website and the link of the questionnaire was distributed to different selected schools. Schools were randomly selected from the different educational sectors of Jazan to ensure the optimal population representation. A sample of 500 participants was estimated for the purpose of this study. The sample size was calculated using the formula for a single cross-sectional survey, n = [(z 2 * p * q)]/d 2 . The sample size was calculated using the following parameters: p = prevalence of food allergy knowledge = 50%, Z = 95% confidence interval, d = error ≤ 5%, and a 25% non-response rate.

Statistical Analysis
All the collected data was analyzed using SPSS version 20. Descriptive characteristic of the studied sample was evaluated by determining the percentages and mean ± Standard Deviation (SD). Itemized knowledge, attitude and practice of the teachers about food allergy were calculated. Mean and SD of the knowledge scores was determined. Based on the mean and SD, the knowledge was categorized into three categories. Good knowledge was determined by scores greatest than (mean + SD), Intermediate knowledge (scores between Mean -SD) and poor knowledge (scores less the mean -SD). Students t test and one-way ANOVA was used to compare mean knowledge scores. For logistic regression analysis, the teachers who scored above the mean value were termed as high and the teachers who scored equal or below the mean were termed as low. After the dichotomous categorization regression was performed keeping knowledge (high/low) as the dependent variable. A p value less than 0.05 was used to indicate statistical significance ( Table 1).

RESULTS
The response rate was estimated at 72% (360 out of 500). The distribution of study participants according to gender showed 13% were males and 83% were females. Some of the subjects (nearly 4%) did not reveal their gender. The distribution of the subjects according to different age categories showed that majority of them 81.1% belong to the age group 25-44 years. Nearly 95% of the study populations were Saudi nationals indicating a homogenized study sample (table not provided).
The total scores were computed and classified, as mentioned in the methodology section. Moreover, the overall mean score of food allergy was presented. As shown in Table 2, most teachers (59.7%) have intermediate food allergy knowledge (overall mean = 57.2, SD = 17.6). No significant difference was found between food allergy scores of the study participants according to age groups, years of education past years of experiences with food allergy and or college type (p = 0.186, and 0.166 and 0.818 respectively). The mean scores are significantly higher for female than in males (58.5± 17.2 and 51.8± 16.0 respectively p = 0.017). Table 2 presents itemized knowledge of schoolteachers about food allergy. According to the table More than half of responders either do not know or they disagree that the food allergy is a serious problem and can lead to death. One third of study participants reported that food allergy means food is harmful. The majority of teachers do not have much idea about the common food are causing allergy. Around 60% of responders were able to recognize the immediate reaction from food allergy, 80% of them were aware about the skin rashes as a common presentation of food allergy. Most common allergic (tree nuts almonds walnuts) 0(0.0) Table 3 displays itemized attitude of schoolteachers towards food allergy. According to the table around 60% of study participants disagree that Children with food allergies are teased at school, while 83.4 agree that It is difficult for people with food allergies to safely eat at restaurant. Regarding the School should have plans for keeping children with food allergies safe at school majority or 99% of them agree with this statement. Majority of study participants 82.8% stated that Special places for food allergic students might be good practice for children with food allergy. Moreover 61.7% of schoolteacher agree that it is unfair to band a food because some student allergic to it ( Table 4).   Table 5 illustrates the results of the logistic regression analysis. The analysis shows that participant level of knowledge is significantly associated with school teacher's attitudes (OR= 0.06, 95% CI; 0.39 -0.92, p = 0.01), practice (OR =1.68 95% CI: 1.11-2.56 p = 0.01), and years of experiences (OR= 1.8, 95% CI; 1.15-2.98 p = 0.011).

DISCUSSION
To our knowledge this is the first study in Saudi Arabia conducted on food allergy knowledge, attitudes, and beliefs among school teachers. We believe that the schoolteachers are an important population segment in any country, and we proposed that the assessment of their awareness about food allergy would weigh the magnitude of problems and help students suffering from food allergy.
We found that schoolteachers have a significant poor knowledge in most of food allergy domains. More than half of responders either do not know or they disagree that the food allergy is a serious problem and can lead to death. The majority of teachers do not have much idea about the common food causing allergy and as we know that peanut and nuts are known to be the top listed foods that cause fatal reaction [13] but, here in our study 100% responded nut as not a food allergy causing substance. 65% of responders felt the same for peanut, and that could highlight the rarity in knowledge of these food causing allergy substances in our community. Around 60% of responders were able to recognize the immediate reaction from food allergy, 80% of them aware about the skin rashes as a common presentation of food allergy. However, a frequent misconception that food allergy is a cause of chronic nasal congestion was a finding in our study [14].
Milk allergy is related to milk proteins [15] and 70% of participants responded incorrectly to low fat milk causing food allergy. 80% considered lactose intolerance as a form of food allergy. There is a significant lack of knowledge about incidence and daily treatment of food allergy in face of a lot of hope in finding a cure. Our major concern is the poor knowledge about the main stay of treatment of severe form of food allergy which is the Epinephrine auto-injector [16,17].
To the best of our knowledge there is no policy to keep Epinephrine auto-injector in the school in Saudi Arabia, having this treatment in the school and training on how to use it, mandate a clear legislation [18], and we hope that this study will bring a positive change leading to such action. School teachers agree on having a safety plan for children with food allergy, but 70% of them do not believe that students with food allergy can be teased because of this problem [19]. The participants were mostly aware about the avoidance as the only prevention of food allergy [20] and they feel in 65% how difficult is staying away from offending food, there is a current food labeling law in Saudi Arabia [21], but more than half of responders are not aware of it. Majority of teacher felt worry about having student with food allergy in their class, with some concern of inability to recognize early reaction of incidental ingestion of the offending food.

LIMITATIONS
This study has several limitations, first, is the ratio of male responders to females are not reflecting the actual school teacher's population, this was due to the high non-response among male teachers compared to female teachers. The web-based survey is a valid and reliable means of data collection, but it has some limitations like high nonresponse rate [1]. Second the study was based on a cross-sectional study design, so study results should be understood in this context.

CONCLUSION
In conclusion, participants of our study showed significant poor basic knowledge of food allergy, there is a major concern of fatal reaction recognition as result of incidental ingestion of food causing allergic reaction, importance of epinephrine auto-injector as the main treatment of sever food allergy is not well acknowledged by school teachers, our finding put safety of children with food allergy in the school as a top urgent topics to be discuss with authorities to introduce a policy regarding food allergy in the schools along with educational intervention and action plan that ensure the optimal treatment of food allergy in case of severe and fatal reaction. We recommend keeping epinephrine autoinjector in the school with teaching on how and when to use it [22].

AVAILABILITY OF DATA AND MATERIALS
The datasets used and/or analyzed during the present study available from the author on reasonable request.