Sudan Journal of Medical Sciences Volume 12, Issue no. 1, DOI 10.18502/sjms.v12i1.857 Production and Hosting by Knowledge E Research Article Assessment of the Primary and Intermediate School Staffs’ Knowledge, Attitude and Practice on Care of Children with Type 1 Diabetes at School, Al-Jouf, Saudi Arabia Al Duraywish A. A. and Abdelsalam M. Nail Diabetes Research Center, College of Medicine, Aljouf University, Sakaka, Saudi Arabia Abstract Background: Children with diabetes type 1 (T1DM) need close monitoring for their blood glucose, food intake, insulin therapy and physical activity during school hours in order to guard against the development of acute and long-term complications. Objectives: To evaluate the current situation of management of T1DM in primary and intermediate schools children through assessment of the working staffs’ attitude, knowledge and practice at Al-Jouf, Saudi Arabia. Materials and Methods: This descriptive cross-sectional study enrolled consented voluntarily participating working staffs from primary and intermediate schools in Al-Jouf region, Saudia Arabia. A questionnaire (included 23 questions) testing knowledge, attitudes and practice regarding T1DM and care of diabetic children was used. Results: 744 teachers were studied (62.1% females) where58.1%of them were working in primary schools. Of all, 69% were class teachers, 20.4% administrators, 8.6% school counselors, and 2% physical education teachers. 75.4% of the participants had adequate general knowledge about diabetes. Only 43.78% of the respondents had specific knowledge about diabetes in the school and teachers with a family diabetic patient showed higher knowledge about diabetes vs. their counterparts. Only 16.0%of the participants reported that their schools have trained personnel in diabetes. Large proportion of study teachers’ (94%) was willing to join a training program for care of diabetic students. Of the total group of teachers, 665 support recruitment of a school nurse. Conclusion: Diabetes care training programs for school teachers and staffs, availability of school nurses and instigating collaboration between the diabetic center and the school is essential for safety of such diabetes student patients in the schools. Keywords: Type 1 Diabetes mellitus, School teachers, Training programs, Diabetes care, Knowledge about diabetes, School nurse, Diabetes care at the school How to cite this article: Al Duraywish A. A. and Abdelsalam M. Nail, (2017) “Assessment of the Primary and Intermediate School Staffs’ Knowledge, Attitude and Practice on Care of Children with Type 1 Diabetes at School, Al-Jouf, Saudi Arabia,” Sudan Journal of Medical Sciences, vol. 12 (2017), issue no. 1, 33–45. DOI 10.18502/sjms.v12i1.857 Page 33 Corresponding Author: Al Duraywish A. A.; email: dr-aaad@hotmail.com Received: 15 December 2016 Accepted: 20 February 2017 Published: 28 May 2017 Production and Hosting by Knowledge E Al Duraywish A. A. and Abdelsalam M. Nail. This article is distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use and redistribution provided that the original author and source are credited. Editor-in-Chief: Prof. Mohammad A. M. Ibnouf http://www.knowledgee.com mailto:dr-aaad@hotmail.com https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ Sudan Journal of Medical Sciences Production and Hosting by Knowledge E دقيقة مراقبة إىل األول النوع من السكري بمرض المصابين األطفال يحتاج الخلفية: ساعات خالل البدين والنشاط باألنسولين، والعالج الطعام، وتناول الدم، سكر لمستوى الدوام المدرسي من أجل الحيلولة دون حدوث مضاعفات حادة أوطويلة األجل. األهداف: تقييم الوضع الحايل إلدارة مرض السكري من النوع األول يف المدارس اإلبتدائية والمتوسطة من خالل تقييم المعرفة والسلوك والتصرف لدى العاملين بمنطقة الجوف، المملكة العربية السعودية. المواد والطرق: شملت هذه الدراسة الوصفية المقطعية الموافق عليها طوعاً الموظفين المملكة الجوف، منطقة يف والمتوسطة اإلبتدائية المدارس من المشاركين العاملين والسلوك المعرفة الختبار سؤاالً) ٢٣ (شمل إستبيان وإستخدم السعودية. العربية والممارسة المتعلقة بمرض السكري من النوع األول ورعاية األطفال المصابين بالسكري. يف يعملون منهم ٪٥٨٫١ كان حيث اإلناث) من ٪٦٢٫١) معلماً ٧٤٤ دراسة تم النتائج: المدارس اإلبتدائية. وكان ٦٩ يف المائة منهم من معلمي الصفوف و ٢٠٫٤ يف المائة من المدراء و ٨٫٦ يف المائة من المرشدين يف المدارس و ٢ يف المائة من معلمي التربية البدنية. وكان لدى المشاركين معرفة كافية حول مرضى السكري. فقط ٤٣٫٧٨٪ من المستطلعين مريض لديهم الذين والمعلمين المدرسة يف السكري مرض عن دقيقة معرفة لديهم بالسكري ىف األسرة أظهروا معرفة أعلى عن مرض السكري مقابل نظرائهم. وأفاد ١٦٫٠٪ نسبة وكانت السكري. مرض يف العاملين دربت قد مدارسهم أن المشاركين من فقط كبيرة من المعلمين ىف الدراسة (٩٤٪) على استعداد لالنضمام إىل برنامج تدريبي لرعاية يدعمون مشاركا ٦٦٥ هناك كان الدراسة، ىف المشاركين مجموع ومن السكري. طالب وجود الممرضة المدرسية. والموظفين، المدارس لمعلمي السكري مرضى رعاية على التدريب برامج اإلستنتاج: أمر والمدرسة السكري مركز بين التعاون على والتشجيع المدارس ممرضات وتوافر ضروري لسالمة مرضى السكري من هؤالء الطالب يف المدارس. 1. Introduction Diabetes mellitus is one of the most prevailing non-communicable diseases in children [1]. In Saudi Arabia, the annual incidence rate of type 1diabetes (T1DM) is 31.4 new children per 100,000 total population. 16,100 children in Kingdom of Saudi Arabia have T1DM which represent 25% of the total population of children with T1DM in the Middle East region’s totaling to 60,700 [2]. These statistics demonstrate the rising incidence of the disease among children and the increased need for diabetes knowledge, care and management. Dia- betes is a chronic, currently incurable disease that needs effective management in order to avoid the risk of emergence of its long-term complications such as blindness, vascular diseases, renal failure and neuropathy [3–5]. DOI 10.18502/sjms.v12i1.857 Page 34 Sudan Journal of Medical Sciences Production and Hosting by Knowledge E The implementation of intensive insulin therapy and such rising prevalence of T1DM highlight the role played by diabetes educators and school staffs. Compliance of the majority of children to the intensive diabetes treatment at school is deficient due mainly to lack of appropriate school staff support [6]. All children including those with diabetes mellitus have the right to learn and continue their education [7]. In order to ensure that such student diabetic patients at school achieve their full capabilities while participating in academic and various school activities, partnership between health and education services is mandatory. Moreover, to assure the imme- diate safety, long-term well-being, and optimal academic performance of student dia- betic patients, such proper diabetes care at school should be reinforced. This care should include blood glucose testing, caloric calculation, administration of insulin, activ- ity and exercise within the school environment, awareness of the impact of stresses within the school environment, assistance if unwell, and emergency management of severe hypoglycemia and ketoacidosis [8]. Since T1DM prevails amongst young school children, basic knowledge about the disease should be indemnified within the schools environment – staffs, administrators, teachers and/or dedicated nurse. Among such young children, to control blood glucose to an optimum level, it is essential to balance carefully food intake, physical activity and insulin [9]. Children with diabetes may require multiple doses of insulin while in school [10]. Some children may require someone to supervise or deliver insulin. Children with T1DM need to be active. Teaching the importance of physical activity is an essential healthy habit to enable the child well into adulthood. However, physical activity also impacts blood glucose levels, and teachers need to know how to respond to these changes [11]. Having trained personnel on care of diabetes, which know how to check blood glucose, inject insulin, and choose an appropriate snack when blood glucose levels are low, provides an enormous preventive measure. The potential cognitive vulnerability associated with hypoglycemic seizures and chronic hyperglycemia among such group of students should be considered by the school teachers. Early detection of minor difficulties should be considered a priority employing assessment of the cognitive skills as a reflection of day-to-day control of the disease [12]. Youth fail to meet HbA1C goals despite advances in diabetes management and their health and safety are at risk when medication, food, and physical activity are not balanced [13]. The responsibility of the school administrators and educators is very critical in the monitoring and management of T1DM among diabetic school children, given the fact that school-age children spend the greater part of their day time in school. At present in Saudi Arabia, responsibility for the management of the disease among diabetic children of school age is often undertaken by the children and their parents. To expand the umbrella of this management, school teacher should be equipped by satisfactory knowledge and get training to change their attitude and practical capaci- ties to share actively in the management of disease. DOI 10.18502/sjms.v12i1.857 Page 35 Sudan Journal of Medical Sciences Production and Hosting by Knowledge E To date, there are no reported studies investigating the awareness of school staffs, administrators, and educators about diabetes in school children in Saudi Arabia. There- fore, this study aimed to assess the knowledge, attitudes and practice of school staffs, administrators, and teachers towards participating in the efforts for managing T1DM and its complications amongst children while at school utilizing the primary and inter- mediate schools at Sakaka City, Al-Jouf, Saudi Arabia as our sample. 2. Materials and Methods This descriptive cross-sectional study was conducted in the period from January 2016 to March 2016 among school staffs, administrators, and educators working in primary and intermediate schools of four Sectors (Sakaka, DomatAljandal, Tabarjal and Sowair) in Al-Jouf region. The study included the respondent 744 participants out of the 1000 teachers targeted. Their socio-demographic data (age, gender, working place, and type of school, job description, academic status and years of experience) were collected. The main study questionnaire included 23 questions testing knowledge, attitudes and practice regard- ing T1DM and care of diabetic children. The knowledge domain included 7 questions about manifestations of T1DM and hypoglycemia and preparation of diabetic children before physical activity sessions. The attitude domain included 5 questions about management of hypoglycemia, will- ingness to have diabetic children in their classes, need for specialized nurse children, and for a training program to increase awareness of diabetes care at school. The practice domain included 11 questions regarding general affection of students with T1DM particularly attendance, academic performance, support of diabetic children, pre- paredness of diabetic children before their physical activity sessions and availability of special meals. Additionally, the sources of the participants’ information about the disease were recorded. The questionnaire was in Arabic language and all were closed-ended with three answers (yes, no, or unsure). A pilot study was done before conducting the survey that included 30 individuals not included in the study to assure validity of the questionnaire and essential modifications were done. Ethical approval was obtained from the Ethics and Research Committees of the College of Medicine, Aljouf University and Directorate of Education of Al-Jouf region. Data analysis utilized the computerized Statistical Packages for the Social Sciences (SPSS; version 16). The demographic variables of participants were presented as num- bers and percentages. For calculation of knowledge score of diabetes, incorrect and unsure answers were given zero, whereas, the correct answer was given one point. The mean score for each section (General knowledge on diabetes, knowledge about diabetes at the school and DOI 10.18502/sjms.v12i1.857 Page 36 Sudan Journal of Medical Sciences Production and Hosting by Knowledge E situation about diabetes at the school) was calculated as the summation of the total possible score in each, and then it was expressed as percentage of total score in each. The diabetes knowledge score was calculated based on the total marks of the three sections. Win Episcope (version 2.0) was used to assess the Chi squire to explore the association between the demographic variables (gender, type of school and family with diabetic children, level of education, years of experience and professional task) and good knowledge on T1DM. We expressed out data as frequency (n and %) and mean ± SDM as appropriate. 3. Results In this study, 744 participants completed the submitted questionnaires (74.4% response rate). Demographics, work description and education background of par- ticipants is depicted in Table 1. General knowledge on diabetes: The results show that the overall general knowl- edge on diabetes of the participating teachersis75.4%.Good level of awareness of the symptoms of DM prevailed among majority of participants (73.4 - 96.8%), while awareness about symptoms of hypo- glycemia was 87.9%. Awareness was low regarding negative effect of T1DM on school children (48.8%), insulin as a replacement therapy (48.5%) and T1DM effect on attendance (47.7%). It was worth noting that awareness for management of hypoglycemia was high (84.3%; Table 2). Regarding their sources of information, 35.5% reported that they had this information as a part of their general knowledge. Teachers with a family diabetic child, with the higher level of education and longer career experience had enhanced knowledge of diabetes vs. their counterparts. Knowledge about diabetes in the school setting: with respect to the presence of diabetic children among the class students, 263 (35.3%) of participants reported presence of diabetic children in the class, 404 (54.3%) stated that they encounter diabetic children in their class, while 16 (2.2%) were unsure about the presence of diabetic children in the class. 617 (82.9%) of participants were welcoming the presence of diabetic children in their class, while 86 (11.6%) stated that they would be worried having diabetic children in their classes, and 63 (5.9%) were unsure about accepting diabetic children in their classes. 561 (75.4%) of the partici- pants answered that diabetic children could attend the physical education sessions. 125 (16.8%) of the teachers declared that they were unsure about this question, while 58 (7.8%) stated that diabetic children are not eligible to attend physical education classes. Only 460 (61.8%) of the participants believed that the diabetic child should take sweets or juices before physical activities. Regarding diabetic emergencies, 558 (75.0%) of the participants reported absence of trained person who could deal with DOI 10.18502/sjms.v12i1.857 Page 37 Sudan Journal of Medical Sciences Production and Hosting by Knowledge E Characteristics Range (Mean ± SDM) or n (%) Age (range and mean ± SDM), Years 23 – 60 (39.2 ± 10.2) Gender, Male/Female 282/462 Residence location: Sakaka 415 (55.8) Domat Al Jandal 212 (28.5) Sowair 64 (07.1) Tarbajal 53 (08.7) Education level: Bachelor’s degree 603 (81) Diploma 118 (15.9) Master’s degree 20 (2.7) Doctorate degree 3 (0.4) Years of experience: <10/≥10 Years 262 (35.2)/482 (64.8) Education sector: Primary/Intermediate 432 (58.1)/312 (41.9) Professional title: Teachers 513 (69) Administrators 152 (20.4) Counselors 64 (8.6) Physical educators 15 (2) T 1: Demographic and work information of the study participants. Questions Answers Yes No Unsure n (%) n (%) DM leads to polyuria in diabetic student 720 (96.8) 8 (1.1) 16 (2.2) DM leads to polydepsia in diabetic student 686 (92.2) 19 (2.6) 39 (5.2) DM leads to fatigue and lack of concentration in diabetic student 569 (76.5) 78 (10.5) 97 (13.0) DM leads to loss of weight in diabetic student 545 (73.3) 85 (11.4) 114 (15.3) Type 1 DM is treated with insulin 361 (48.5) 154 (20.7) 229 (30.8) Tremors and sweating means hypoglycaemia in diabetic student 587 (78.9) 34 (4.6) 123 (16.5) The diabetic student should take sweets or juices before physical activities class 460 (61.8) 110 (14.8) 174 (23.4) T 2: Knowledge indicators about diabetes mellitus (DM) in the school setting among the studied population of teachers. diabetic emergencies in their schools. 178 (23.9%) of teachers knew about presence of a trained personnel for checking blood sugar and giving insulin in the school. Regarding snacks and school lunches for diabetic children, 656 (88.2%) mentioned no snacks or special school lunches presented to diabetic children and 44 (5.9%) were not sure about that. Only 302 (40.6%) of the participants knew that their school have a training program in how to deal with diabetic children in their schools (Table3). DOI 10.18502/sjms.v12i1.857 Page 38 Sudan Journal of Medical Sciences Production and Hosting by Knowledge E Questions Answers Yes No Unsure n (%) n (%) School children are usually affected by Type 1 DM 363 (48.8) 68 (9.1) 313 (42.1) DM affects the student’ academic performance 248 (33.3) 340 (45.7) 156 (21.0) DM increases absence rate of diabetic student 355 (47.7) 253 (34.0) 136 (18.3) Do you have any diabetic student in your class? 263 (35.3) 404 (54.3) 77 (10.3) Do you give support to the diabetic children in your class? 672 (90.3) 34 (4.6) 38 (5.1) Are diabetic children eligible to attend the physical education session? 561 (75.4) 58 (7.8) 125 (16.8) Does your school present special meals for diabetic student? 44(5.9) 656 (88.2) 44 (5.9) Does your school appoint somebody to look after the diabetic students? 154 (20.7) 518 (69.6) 72 (9.7) Is there any trained person to check blood sugar and inject insulin in your school? 178 (23.9) 506 (68.0) 60 (8.1) Is there any trained person in dealing with diabetic emergencies in your school? 119 (16.0) 558 (75.0) 67 (9.0) Does your school have a training program for dealing with diabetic students? 302 (40.6) 398 (53.5) 44 (5.9) T 3: Diabetes mellitus (DM) practice indictors among the studied population of teachers concerning children diabetes at the school setting. Attitude indicators about diabetes at the school setting (Table 4): 587 (78.9%) of the teachers knew that tremors and sweating means hypoglycemia in diabetic stu- dent and 627 (84.3%) mentioned that the diabetic child with hypoglycemia should take sweet juice. Only 475 (63.8%) answered that in case of coma, small amount of jam or honey should be put on the mouth of the diabetic child. 154 (20.7%) of the respondents agreed that somebody should be appointed to look after the diabetic children- including the presence of a dedicated school nurse (665; 89.4%). Effect of gender on the study outcomes: The gender effect on different domains of our study was significantly different comparing male scores vs. females regarding knowledge and training indicators only. The scores regarding general and specific knowledge, symptoms of the disease, emergency responses, practice and training needs was equally distributed between male and female (Table 5). Effect of type of school on the study outcome: Cross-tabulating the effect of nature of school (primary vs. intermediate) on different domains of our study, scores regarding general and specific knowledge, symptoms of the disease, emergency responses, practice and training needs showed significant gender differences. Scores regarding knowledge and training indicators were equally distributed in both primary and intermediate schools (Table 6). DOI 10.18502/sjms.v12i1.857 Page 39 Sudan Journal of Medical Sciences Production and Hosting by Knowledge E Questions Answers Yes No Unsure n (%) n (%) Are you willing to have diabetic children in your class? 617 (82.9) 86 (11.6) 41 (5.5) In case of hypoglycaemia, should the diabetic student take sweet juice? 627 (84.3) 41 (5.5) 76 (10.2) In case of coma, can small amount of jam or honey be put into the mouth of the diabetic student? 475 (63.8) 90 (12.1) 79 (24.1) Would you like to join training program for dealing with diabetic students? 693 (93.1) 41 (5.5) 10 (1.3) Do you support presence of school nurse? 665 (89.4) 67 (9.0) 12 (1.6) T 4: Diabetes mellitus attitude indictors among the studied population of teachers concerning children diabetes at the school setting. Variable Gender n Mean ± SDM P< General knowledge Male 282 2.28 ± 0.304 0.535 Female 462 2.27 ± 0.315 Symptomatology Male 282 2.57 ± 0.360 0.009* Female 462 2.50 ± 0.360 Emergency Response Male 282 2.62 ± 0.398 0.484 Female 462 2.64 ± 0.378 Practice guidelines Male 282 1.42 ± 0.591 0.800 Female 462 1.41 ± 0.559 Training needs Male 282 2.44 ± 0.413 Female 462 2.56 ± 0.411 0.000** T 5: Effect of gender on the scores in different domains of study regarding diabetes. *Significant using independent samples ”t”-Test and assuming equal variance. **Significant using independent samples ”t”-Test but not assuming equal variance. 4. Discussion The mission of the College of Medicine, Aljouf University is community serving and citizenship development. This is why the college adopted the community-oriented education system. The college plan for the establishment of the Diabetes Research Center was to promote diabetes research and improve preventive and clinical commu- nity services. To guarantee the safety and well-being of the child with diabetes at the school setting, partnership between health and education services is indispensable. Assessing the level of school staffs, administrators and teachers’ awareness of dia- betes is supportive for health educators to plan for future enhancement programs. Students with diabetes and their parents report inadequate knowledge, preparation, or support from the school teachers and a lack of education for substitute teachers, bus drivers, coaches, and other ancillary school personnel [14]. DOI 10.18502/sjms.v12i1.857 Page 40 Sudan Journal of Medical Sciences Production and Hosting by Knowledge E Variable School n Mean P< General knowledge Primary 432 2.25 ± 0.323 0.005* Middle 312 2.31 ± 0.290 Symptomatology Primary 432 2.54 ± 0.349 0.284* Middle 312 2.51 ± 0.378 Emergency Response Primary 432 2.65 ± 0.353 Middle 312 2.60 ± 0.425 0.061 Practice guidelines Primary 432 1.33 ± 0.496 Middle 312 1.53 ± 0.643 0.001** Training needs Primary 432 2.47 ± 0.385 Middle 312 2.59 ± 0.445 0.001** T 6: Effect of the type of schools on the scores in different domains of study regarding diabetes. **Significant using independent samples ”t”-Test but not assuming equal variance. *Significant using independent samples ”t”-Test and assuming equal variance. Poor diabetic control for young people is linked to increased heart complications, peripheral nerve function, and other serious complications [15, 16]. Providing training to the school personnels significantly improves the diabetic child’s glycemic control, and furnishes a more supportive school environment [17–19]. Upon proper support of the students withT1DM not only their academic and social but also their medical outcomes improve [20]. We planned the present 3-steps investigation to help establishing guidelines for Managing Diabetes at School in Al-Jouf region. Firstly, questionnaires assessed the extent to which primary and intermediate school teachers are knowledgeable about children diabetes mellitus at school setting. Secondly, we tested how school staffs, administrators and teachers reacted to diabetes needs. Thirdly, we highlighted defi- ciencies in information and training programs that could improve health care for dia- betic children at school setting. We observed adequate general knowledge about dia- betes among school personnels in Al-Jouf regions. This is attributable to the level of education of participants and the high prevalence of the disease in Saudi Arabia [21].However, the study also noticed the lack of enthusiasm of teachers to have dia- betic child in their class and unawareness about the management of diabetic emer- gencies among school personnels in Al-Jouf region. In fact, a diabetic emergency as hypoglycemia is life threatening and occurring more frequently in children with DM. Awareness about complications of DM was found to be similarly low in countries of the region like Bahrain and Turkey [22, 23]. T1DM treatment with insulin needs help from school nurses and teachers. However, the study recorded that only a few schools have school nurses and trained personnels. Consequently, the responsibility of children’s health is shouldered by parents. Regarding the information sources about DM among the participants, 40.6% of them reported acquiring their information as a part of their general education. School nurses were reported to be the major source of information for chronic diseases, and are required to obtain concise disease-specific DOI 10.18502/sjms.v12i1.857 Page 41 Sudan Journal of Medical Sciences Production and Hosting by Knowledge E information [24]. Regarding activity and exercise within the school environment, most of the participants answered that diabetic children could attend the physical activity sessions. However, they were not aware about the measures that should be taken before, during or after any activity - such as blood glucose monitoring before and after any activity, consuming additional carbohydrates, and if using an insulin pump, decisions related to whether the pump should be disconnected or temporary basal rates set [25]. Only one fifth of the participants of our study knew that their schools appoint some- body to look after the diabetic students and/or was trained for checking blood sugar and giving insulin. Less than one fifth of school personnels received training on how to recognize and respond to diabetic emergencies. The study showed that there is deficiency in training programs regarding diabetes at school and the overwhelming majority liked to join such training program. 76.5% of the participating personnels showed willingness to pay the required support to diabetic children at school. This means that majority of personnels would attend and gets benefit from such training programs. Therefore, a positive impact on academic and health performance of dia- betic children would be the gain. A comprehensive review of the published literature that examined publications concerned with care of children with diabetes at school and ways of improving it showed areas of deficiencies to be; communication, after-school support, education of staff and peers, school nurse availability, and lunch choices [26]. 5. Conclusion This is the first report to check the knowledge about diabetes at school among Saudi teachers in Al-Jouf region. Our data shows that primary and intermediate school teach- ers in Al-Jouf region have enough general knowledge on diabetes regarding symp- toms. However, they were deficient regarding diabetes complications and manage- ment. Furthermore, the majority of teachers did not receive training programs on dia- betes at school, although majority of them expressed willingness to pay the required support to diabetic children and attend such programs. Therefore, our study suggests that more efforts should be paid to improve knowledge, practice and attitude of dia- betes at school setting and its associated complications among primary and interme- diate school teachers. We suggest three stages of training as following: 1) Basic understanding targeting all school staffs through training on how to recognize and respond to the signs and symp- toms diabetic emergencies and who to make urgent contacts in case of an emergency, 2) Specific personnels with the responsibility of taking care of diabetic students should receive additional training on managing diabetes, its complications and emergencies, and, 3) Advanced training for a few school staffs should be an in-depth training about diabetes, its routine care and emergencies in support for each student with diabetes. DOI 10.18502/sjms.v12i1.857 Page 42 Sudan Journal of Medical Sciences Production and Hosting by Knowledge E 6. Ethical Clearance Ethical approval was obtained from the Ethics and Research Committees of the College of Medicine, Aljouf University and Directorate of Education of Al-Jouf region. 7. Competing Interests The authors declare that they have no competing interests. 8. Funding None. 9. Authors’ Contributions Both authors contributed in planning the study, collecting data and wrote and read the final version of the manuscript. 10. Acknowledgments We wish to thank all study participants and the schools where this research was under- taken. References [1] International Society of Pediatric and Adolescent Diabetes (ISPAD 2000), Consensus Guidelines for the management of type 1 diabetes mellitus in children and adolescents. [2] M. E. Craig, A. Hattersley, and K. Donaghue, “Epidemiology and Classification. Global IDF/ISPAD Guideline for Diabetes in Childhood and Adolescence,” ISPAD, pp. 8–16, 2011. [3] T. M. Nguyen, K. J. Mason, C. G. Sanders, P. Yazdani, and R. A. Heptulla, “Targeting Blood Glucose Management in School Improves Glycemic Control in Children with Poorly Controlled Type 1 Diabetes Mellitus,” Journal of Pediatrics, vol. 153, no. 4, pp. 575–578, 2008. [4] C. C. Jackson, A. Albanese-O’neill, K. L. 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