**Table 3.** *Cont.*


**Table 3.** *Cont.*

Abbreviations: *EAI* = epinephrine auto-injector; *HCP* = healthcare professional; *UK* = United Kingdom; *USA* = United States of America.

Sustained knowledge and confidence levels were also described in one American longitudinal study that followed-up with participants, including teachers and school staff from various grade levels, 3–12 months post-intervention. Participants reported sustained confidence levels in the recognition of signs and symptoms, ability to prevent food allergic reactions, and knowing what to do during an anaphylaxis emergency [35]. Primary key messages recalled by 57.0% of participants 3–12 months post-intervention included EAI administration, reaction signs and symptoms, importance of following an EAP, and providing immediate treatment [35]. A small proportion of participants (*n* = 22) experienced a food allergy emergency post-intervention, 42.8% of which were caused by unknown allergens and 23.8% occurred in primary schools. Of these participants, 81.8% (18/22) had previous training before the study intervention. Nevertheless, 61.9% found that the recognition of food allergic signs and symptoms and 52.3% found the hands-on EAI training useful in real-life situations [35].

In a Houston, USA-based study, the intervention group teachers from economicallydisadvantaged school areas had non-significant higher questionnaire scores post-intervention than teachers from economically-advantaged schools in both intervention and control groups [34]. Another Houston study that compared teachers who received intervention to those who did not, reported that there was no correlation between level of education (<4 years college, 4 years college, and graduate degree) and the survey scores [33]. Spanish primary school teachers and school staff exhibited significantly better food allergy knowledge (*p* < 0.001) through improved recognition of anaphylaxis (40.0% to 81.0%, respectively), knowledge about when (19.0% vs. 100.0%, respectively) and how (13.0% vs. 100.0%, respectively) to use an EAI, albeit authors reported modifying acceptable questionnaire responses as the original questions were "not easy to answer" [40]. Education sessions were deemed useful by Italian primary school teachers (8.6/10 ± 1.67; on a scale of 1–10, where 10 = very useful) [42]. Another group of Italian teachers and principals from various grade levels showed significantly better questionnaire scores post-intervention (mean = 6.6/10 vs. 8.9/10, respectively; *p* < 0.001) [43]. Post-education, the same Italian group of teachers and principals agreed anaphylaxis is manageable at school (82.6% vs. 96.5%, respectively; *p* < 0.001) and school staff are responsible for food allergy management (82.8% vs. 93.9%, respectively; *p* < 0.001) [43].

Interventional education influenced teachers and school staff's beliefs and attitudes about food allergy management. Among Houston, USA-based private school teachers, those in the intervention group, compared to control group teachers who did not receive intervention, tended to show greater agreement about the importance of EAI as a lifesaving measure for anaphylaxis. Although the authors identified an OR = 873.77 (*p* = 0.173), the difference was statistically insignificantly different because, as the authors

noted, "almost all" participants agreed or strongly agreed with the importance of EAI [33]. Similarly, compared to the baseline, intervention group teachers were 3.3 times more likely to recognize the seriousness of food allergies (OR = 3.30; 95% CI = 1.60–6.70; *p* = 0.001) and to agree that students with food allergies are likely to experience discrimination (OR = 3.30; 95% CI = 2.00–5.50; *p* = 0.01) [33]. Intervention teachers were also 52 times (OR = 52.0; 95% CI = 2.90–930.75; *p* < 0.01) more aware, post-intervention, that students with food allergies experienced bullying compared to control teachers, with 26 times increased likelihood of agreement that students with food allergies experienced bullying (OR = 25.55; 95% CI = 9.86–66.25; *p* < 0.001) [33].

Education sessions were associated with increased confidence [35], comfort level [34], and self-efficacy [41,44] in the majority of participants, regardless of whether participants had previous training [35,41,42,44]. The majority of American participants (>94.0%), some of whom were teachers and school staff, answered opinion statements positively postintervention, indicating more confidence in prevention, recognition, and response skills to food allergy emergencies [35]. Significant post-intervention SPSMFAA scores [32] were reported for Spanish teachers and school staff (*p* < 0.05) in food allergy management items, specifically in putting an EAP in place for students with a food allergy, managing students at risk of reactions to food, and recognizing anaphylaxis symptoms and administering EAI in anaphylaxis management [41]. Following a food allergy intervention, Italian teachers' and school staff's post-intervention scores were higher compared to pre-intervention studies. The greatest differences were seen among those with low self-efficacy at baseline [44].
