1 10.1515/sjph-2016-0022_Zdrav Var 2016; 55(3): 185-178 Slabe D, Fink R, Dolenc E, Kvas A. Knowledge of health principles among professionals in Slovenian kindergartens. Zdrav Var 2016; 55(3): 185-194 KNOWLEDGE OF HEALTH PRINCIPLES AMONG PROFESSIONALS IN SLOVENIAN KINDERGARTENS POZNAVANJE OSNOVNIH ZDRAVSTVENIH UKREPOV MED ZAPOSLENIMI V SLOVENSKIH VRTCIH Damjan SLABE1, Rok FINK1, Eva DOLENC1*, Andreja KVAS1 University of Ljubljana, Faculty for Health Sciences, Public Health, Zdravstvena pot 5, 1000 Ljubljana, Slovenia Received: Aug 15, 2015 Accepted: Mar 10, 2016 Original scientific article ABSTRACT Keywords: kindergarten teachers, kindergarten teacher assistants, health principles, knowledge Objectives. Preschool children have significant health issues. From the relevant legislation and regulations, it can be seen that kindergarten teachers (KTs) and kindergarten teacher assistants (KTAs) are expected to be familiarwith the basic hygienic measures and steps for preventing injuries and illnesses, to recognize infectious diseases, and to know how to give the first aid. To gain these skills, a continuous life-long learning is necessary, because the characteristics of diseases are changing. Study design: original research. Methods. 45 kindergartens in Slovenia were randomly selected and a questionnaire with 17 questions on health themes was sent. An analysis was performed via SPSS 17.0, using descriptive methods and nonparametric x2 tests. Results. There were 774 participants, of whom 56% were KTs and 44% KTAs. The share of KTs and KTAs who consider their knowledge of health principles to be very good or excellent is 67%. Their estimation of first aid knowledge is lower. They are also well aware of the importance of health knowledge in their work; a total of 87% strongly agree with this. The results also show that they are familiar with hygiene principles. The x2 test showed there are certain statistically characteristic connections between the age of teachers and their assistants, occupation and work experiences. Conclusions. Because children are a particularly vulnerable group, teachers can encounter injuries and sudden illnesses at their work. Supplementary education is necessary among skilled workers in educational institutions, including kindergartens. IZVLEČEK Ključne besede: vzgojiteljice, pomočnice vzgojiteljic, zdravstveni ukrepi, znanje Uvod. Predšolski otroci so ranljiva skupina s specifičnimi zdravstvenimi težavami. Od vzgojiteljic in njihovih pomočnic se zato pričakuje, da imajo znanja o osnovnih higienskih načelih in ukrepih za preprečevanje nastanka bolezni ali poškodb, da prepoznajo nalezljive bolezni in nudijo prvo pomoč v primeru nastanka poškodbe ali nenadnega obolenja. Slednje je tudi zakonsko opredeljeno. Značilnosti bolezni otrok, vrste kroničnih bolezni in smernice ukrepanja v primeru nastanka poškodb ali nenadnih obolenj se spreminjajo. Znanja, ki jih vzgojiteljice in njihove pomočnice usvojijo med šolskim izobraževanjem, naj bi bila le temelj vseživljenjskemu učenju. Metode. Petinštiridesetim naključno izbranim vrtcem v Sloveniji je bil poslan anketni vprašalnik s 17 vprašanji. S pomočjo programa SPSS 17.0. so bili analizirani pridobljeni podatki, uporabljene so bile opisne metode in neparametrični test x2. Rezultati. V raziskavi je sodelovalo 774 oseb, od tega 56% vzgojiteljic in 44% pomočnic vzgojiteljic. Delež tistih, ki so samoocenile svoje znanje o osnovnih higienskih načelih kot zelo dobro ali odlično, je 67-odstoten, 30% pa je svoje znanje samoocenilo kot dobro. Samoocena znanja prve pomoči je nižja. Največ znanja (skoraj polovico) so anketirani usvojili med izobraževanjem na srednji šoli ali fakulteti. Da je tudi zdravstveno znanje pri delu z otroki zelo pomembno, se močno strinja 87% anketiranih in strinja 13%. Rezultati kažejo, da vzgojiteljice in pomočnice vzgojiteljic v glavnem poznajo pravilne ukrepe v primeru bolezni in akutnih poškodb, pri tem pa obstaja nekaj izjem. V zvezi z boleznimi in akutnimi poškodbami je bilo med anketiranimi ugotovljeno dobro znanje o primernih ukrepih, a ne pri vseh boleznih in stanjih. Anketirane vzgojiteljice in pomočnice vzgojiteljic so dobro seznanjene z osnovnimi higienskimi ukrepi za preprečevanje nastanka bolezni. Rezultati testa x2 kažejo nekatere statistično značilne povezave pri starosti anketirancev, poklicu (vzgojiteljica ali pomočnica) in delovnih izkušnjah. Razprava. V vrtcu lahko hitro pride do bolezni ali poškodb, saj so otroci ranljivejša skupina, zato morajo vzgojiteljice in pomočnice vzgojiteljic znati pravilno ukrepati. Poudarjen je pomen dopolnilnega usposabljanja med delavci v vzgojno-izobraževalnih ustanovah, kamor sodijo tudi vrtci. 'Corresponding author: Tel: ++ 386 40 741 191; E-mail: evkc.dolenc@gmail.com NIJZ Brought to you by | National & University Library Authenticated National Institute i' National Institute of Public Health, Slovenia. ^^ 185 of Public Health This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License. (w£&38.5 °C)? her immediately parents the child from check body to the doctor the class and temperature, wait for parents give some water to come and call parents 0.1 15.5 1.4 [82.9] 0.1 Which are the signs of diabetes High body Incontinence Chest pain Fatigue, I do not know complications? temperature disorders drowsiness, hunger, thirst, shivering 0.1 0.0 0.1 0.3 2.5 A child has an abrasion on his/her I would cover I would first I would first wash I would call I do not know hand. What is the first aid? the abrasion wash the abrasion the abrasion emergency with a clean pad with water and with alcohol and medical services then cover with then cover with immediately a clean pad a clean pad 0.1 0.0 0.1 0.3 2.5 Brought to you by | National & University Library Authenticated Download Date | 11/14/16 8:02 AM 223 10.1515/sjph-2016-0022 Zdrav Var 2016; 55(3): 174-178 Question Statements (%) Have you ever been in a situation when parents brought antibiotics in Yes No I do not remember / / the kindergarten and asked you to give them to their child at a certain time? 40.1 [49.5] 10.4 Note: Correct answers are in brackets. Regarding febrile convulsions (Table 5), KTs and KTAs mostly agreed that they should cool down the child (78%), call emergency medical services (74%), and give medicine against fever, provided they had previously obtained a written authorization to do so (86%). 40% of respondents agreed that they could give medicine against fever convulsions, although the previously obtained written authorization to do so was not included in the statement. The results also show that kindergarten professionals are familiar with hygiene principles. More than two-thirds state that hand washing is necessary after using the toilet, using toys, touching ones' nose and before meals. However, about half believe that hand washing is not so vital after using books (51%) or after shaking hands (45.1%). Since contagious diseases are common among children, preventive measures represent the basis for infection control. All stated measures are particularly valuable for infection control. Room ventilation, disinfection of toys, sneezing and coughing into one's sleeve are all part of good hygiene practice in kindergartens; it can be confirmed that KTs and KTAs are very familiar with such practices (Table 5). The results also show that kindergarten professionals believe that hand disinfection is a preventive measure (81.3%). However, hand disinfection is not a preventive measure in kindergarten due to microbial resistance; therefore, this measure is only for health care services. Table 5. Kindergarten teachers' and their assistants' responsibility related to health principles in percentages. In a kindergarten, a child has febrile seizures. How would you react? Answers Statements (%) Agree Disagree I do not know I would immediately give the child a medication to treat fever I would cool down the child's body I would immediately take the child to the doctor I would give the child a medication to treat fever only in case of previously written authorisation I would call the emergency service 40.1 [49.5] 10.4 [78.4] 15.3 6.1 28.2 [58.0] 13.7 [86.4] 8.9 4.7 [74.0] 18.0 8.0 How important is hand washing for infection prevention? After toilet use [95.5] 0.0 0.5 Before a meal [99.2] 0.1 0.6 After shaking hands [53.1] 45.1 1.8 After touching one's nose [90.5] 8.5 0.9 After using toys [86.7] 12.4 0.9 After using books [47.3] 51.0 1.7 Brought to you by | National & University Library Authenticated Download Date | 11/14/16 8:02 AM 60 10.1515/sjph-2016-0030 Zdrav Var 2016; 55(3): 218-224 How important are the following infection preventive measures? Answers Statements (%) Agree Disagree I do not know Sneezing /coughing into a sleeve Hand washing after touching animals Separation of a sick child from the rest of the group Hand disinfection Preventive vaccination Disinfection of toys Ventilation of rooms Note: Correct answers are in brackets. [96.9] 2.5 0.7 [96.4] 3.1 0.5 [92.5] 5.6 1.9 81.3 [17.7] 1.0 [74.4] 20.6 4.9 [97.7] 2.2 0.1 [99.7] 0.1 0.1 The x2 test has shown there are statistically significant associations between the age of teachers and their assistants and the choice of whether they accompany a child to the doctor in case of emergency. The results show respondents would accompany a child to the doctor in the age group from 40 to 50 years in 32%, followed by the age group from 30 to 40 years (28%), the age group of <30 years (21%) and of >50 years (19%). Furthermore, there are statistically significant associations regarding their reaction to a child having a high fever, where only 17% of respondents in the age group of >50 years would check the child's body temperature, give heror him some water and call their parents. In the age group of <30 years, this would be done by 26% of respondents, 29% in the age group of 30 to 40 years, and 28% in the age group from 40 to 50 years. With regard to occupation, 58% of KTsand 42% of KTAs would monitor temperature and prevent dehydration. Results of our study also show that KT and KTA often face the situation when parents brought antibiotics in the kindergarten and asked to administer them. In the age group of <30 years, 18% of respondents are faced with this kind of situation, 22% in the age group from 30 to 40 years, 27% in the age group from 40 to 50 yearsand 33% in the age group of >50 years. Similar findings are related to the work experiences where respondents <10 years of work experiences were asked to administer antibiotics in 33% and those with >10 years of work experiences in 67%. Results also show that KTs are often asked to provide antibiotics for children (65%) in comparison to KTAs (35%). Statistically significant association was found between the age and last training in health principles, where in the age group of <30 years, 23% attended training in the last year, in the age group from 30 to 40 years 28%, in the age group from 40 to 50 years 30%, and 19% of KTs and KTAs aged >50 years (Table 6). Table 6. Comparison of kindergarten teachers' and their assistants' answers regarding the age, work occupation and years of work experiences. Statistics Questions Age Occupation Work experiences p-value sig. p-value sig. p-value sig. £ Knowledge of health principles is important for KT and KTA 0.913 NS 0.222 NS 0.791 NS 55 Is it true that, in case of acute illness, KT or KTA must inform the 0.319 NS 0.992 NS 0.793 NS NS kindergarten headmaster and parents? O ft Is it true that, in case of emergency, KT or KTA should not 0.000 ** 0.459 NS 0.984 NS RE accompany the child to the doctor? Brought to you by | National & University Library Authenticated Download Date | 11/14/16 8:02 AM 223 10.1515/sjph-2016-0026 Zdrav Var 2016; 55(3): 202-211 Statistics Questions Age Occupation Work experiences p-value sig. p-value sig. p-value sig. A child in the group has celiac disease. What is the correct measure? 0.465 NS 0.411 NS 0.611 NS un in How would you react in case of high fever (>38.5 °C)? 0.000 ** 0.000 ** 0.869 NS j CL I 1 LU O Which are the signs of diabetes complications? 0.008 * 0.890 NS 1.000 NS z O LU _1 5 o z ^ A child has an abrasion on his/her arm. What is the first aid? 0.764 NS 0.960 NS 0.180 NS I < Is it advisable to continue breastfeeding when a child is oneyear old and goesto the kindergarten? 0.619 NS 0.002 * 0.504 NS H Have you ever been in a situation when parents brought antibiotics to the kindergarten and asked you to give them to the child at a certain time? 0.000 ** 0.000 ** 0.000 ** LU O O z o How would you rate your knowledge of health principles? 0.708 NS 0.829 NS 0.166 NS _1 5 k Where did you gain most of your knowledge of health principles? 0.010 A 0.773 NS 0.422 NS o z ^ LU When did you have your last training in health principles? 0.000 AA 0.547 NS 0.694 NS Legend: * statistical significance p<0.05; ** strong statistical significance p<0.001; NS not statistically significant 4 DISCUSSION Life-long education is becoming increasingly important. Supplementary education is necessary among skilled workers in educational institutions, including kindergartens. Because children are a vulnerable population group, teachers can encounter injuries and sudden illnesses at work. The first aid guidelines state that, in such cases, a quick and appropriatesequence of action is necessary (15). To fulfil these demands, KTs and KTAs are extremely well aware that at least a minimum level of knowledge is required. The results show that they attribute immense significance to such knowledge, as only 0.1% do not agree with the statement that the knowledge of health principles is important if one works with children. Self-evaluation of their knowledge on health principles confirms their awareness about its significance; most frequently, the respondents estimate it as very good, 4 (on the level 1-5; 5 is the highest grade). The self-evaluation of their first aid knowledge is worse; most frequently, they deemed it to be 'good', i.e. level 3. Most of their knowledge was obtained in school (almost one half). Especially intriguing were data regarding the most recent education on health principles: all respondents participated in such training less than five years previously, with 80% attended such training one year or less ago. Recommendations for managing cases of emergency and sudden illness symptoms in kindergartens (14) state that it is necessary to call emergency services in life-threatening situations (112), and afterwards, inform the parents as soon as possible. The person who has given first aid accompanies the child to a medical institution and then waits there until the parents or guardians arrive. KTs and KTAs know the first part (calling emergency services) very well (97%), but only a half (51%) of them know that the person who has given first aid has to accompany the child to a medical institution. From the data of other research in Slovenia (16), we can assume that also teachers (all stated > 90% recognition) know very well the emergency number (112). It is not necessary, in some cases, to take a child to a doctor immediately, although it is necessary to give the child appropriate first aid. In case of an abrasion onchild's arm, 85% of respondents would properly take care of it by rinsing it with water and applying sterile coverage and bandages as dictated by the guidelines (17). The results of a similar research proved that skilled workers in kindergartens are theoretically qualified to give first aid in the case of non-life-threatening injuries, such as abrasions, scratches and minor burns. Less than 30% of respondents would take proper measures in case of unconsciousness, cardiac arrest, poisoning or suffocation, in accordance with the valid first aid practices (18). Based on the analysis of 117 documented injuries, for almost half of which medical care was required, Rok Simon (9) found that first aid given by 429 pedagogical workers was adequate only in half of the cases. Parents' first aidgiven to their children was poor: only 10% of questioned parents would use proper methods to remove a foreign body obstruction in the airway of their suffocating child (19). When giving first aid to an unconscious child, only 9.5% Brought to you by | National & University Library Authenticated Download Date | 11/14/16 8:02 AM 191 10.1515/sjph-2016-0026 Zdrav Var 2016; 55(3): 202-211 of respondents would first check responses (20). It has been shown that parents know how to act properly in circumstances that happen most frequently with their children and which could be sometimes fatal for the child (21). Neither Slovenian nor foreign (USA) parents are sufficiently educated in giving first aid to their children or in taking care of their children's wounds and burns (22). In addition to injuries, kindergarten teachers deal with the increasing phenomenon of various chronic diseases, such as celiac disease and diabetes. While celiac disease was relatively rare some years ago, the latest research from around the world has shown that there is at least one patient for every 100 inhabitants (23). This means that about 20,000 people in Slovenia could have celiac disease. The latest data for Slovenia show that the typical kind of celiac disease in children occurs with the frequency of 2/1000 (24). Celiac disease is systematic immune condition disease that most often affects the small intestine. The disease reacts to the consumption of gluten, so patients are obliged to follow a gluten-free diet for the rest of their lives. KTs know this very well; 98% would not give an afflicted child food containing gluten. Similarly, every year in Slovenia, more children fall ill with diabetes. The prevalence of type 1 diabetes among children increases by almost 4% annually (25). In case of diabetes complications, there are guidelines how to act, but one must be able to recognize the complications. Characteristic signs of hypoglycaemia are fatigue, drowsiness, hunger, thirst, shivering (15). A total of 97% of teachers correctly cited these. In Slovenia, the Department of Endocrinology, Diabetes and Metabolic Diseases at the University Children's Hospital Ljubljana, is the national centre for childhood diabetes, where teachers can gain knowledge about diabetes. Many teachers and other caregivers came annually to learn about diabetes in a one-day course (26). Besides the teachers, also children's parents play a crucial role in helping children with diabetes integrate into a new, kindergarten environment. In collaboration with the National Centre for Childhood Diabetes, Association for Children with Metabolic Disorders and Franciscan Family Institute, a parent support group was designed to provide psychosocial support for parents of children with diabetes. The group turned out to be a promising supportive, therapeutic and psychoeducational space. Effective psychosocial support to families is a part of integrative healthcare for children and adolescents with diabetes (27, 28). Some disease conditions, including chronic conditions, require treatment with medication. About half of KTs and KTAs had been in a situation in which parents brought medicationto kindergarten (antibiotics), but we do not have the data as to whether they enclosed instructions and doctor's permission to administer the medicine. Results of statistical analysis show that KTs in the age group of >50 years, those with working experiences of >10 years, are more often faced with this situation than their younger and less experienced colleagues. As a rule, drugs should not be administered in the kindergarten. In exceptional cases, a medication may be given, for example, for a fever, but it is necessary to have parents' or guardians' previously written permission. KT and KTA could give a child a glass of water in case of fever and call parents (83%), as instructed in guidelines. The questionnaire did not give a teacher the opportunity to choose the possibility of administering drugs to a child with fever. In case of a known illness or the worsening of a chronic disease, such as febrile convulsions or asthma, it is necessary to have parents' or guardians' previously obtained written permission, as well as doctor's permission to administer the medicine and instructions on administering the medicine (14). In the hypothetical case of a child with febrile convulsions, teachers indicated agreement with statements about correct measures. As the guidelines indicate, they would cool down the child (78%), call urgentmedical help (74%) and administer medicine against fever, provided they had previously obtained written permission (86%); 40% of respondents said that they would administer medicine for febrile convulsions, although they made no mention of written permission to administer medicines. We found that KTs and KTAs are familiar with the principles of hand washing. Most stated that hand washing is necessary after toilet use, before meals, after touching one's nose, and after playing with toys. Wong et al. (29) determined that a teacher's perception of risk increases after an outbreak of an infectious disease. Another study showed that one of the protective factors for hand-foot-mouth disease in kindergartens is hand washing (30). Our study showed that KTs and KTAs are familiar with the principles of hygiene and disease prevention, except regarding hand disinfection: 80% of respondents believe that this is a valuable preventive measure in kindergartens. Based on the statistical analysis, we can indicate statistical characteristics with regard to age, occupation and work experiences. The results show significant differences (p<0.05) concerning the age of respondents and their choice of whether or not they would accompany a child to a doctor in case of emergency. In the age group from 40 to 50 years, 32% of KTs and KTAs would do so, whereasin the age group from 30 to 40 years 28% of KTs and KTAs would do so, followed by the age group of <30 years in 21% and >50 years in 19%. Moreover, there are statistically significant differences among age groups regarding their reaction to high fever, where in the age group <30 years this would be done by 26% of respondents, 29% in the group from 30 to 40 years, 28% in the group from 40 to 50 years and only 17% of respondents in the age group >50 years. Brought to you by | National & University Library Authenticated Download Date | 11/14/16 8:02 AM 192 10.1515/sjph-2016-0030 Zdrav Var 2016; 55(3): 218-224 Our study is a significant contribution to the understanding of the importance of health education, since we found that age, occupation and years of working experience have no influence (p>0.05) on how KTs or KTAs would take care of children with celiac disease and give first aid for abrasions, and whether they would informa headmaster and parents.Nevertheless, we recognised that antibiotics are still a relevant topic and should be studied in the future. AUTHORS' CONTRIBUTION All authors were involved in the development of the project, study design, data collection and its interpretation. All authors contributed to the preparation of the manuscript and approved the final version of the text. REFERENCES 5 CONCLUSIONS KTs and KTAs are well aware of the importance of being familiar with health principles for children's safety in kindergartens. Kindergarten teachers and their assistants take part in frequent trainings in the principles of healthy ways of life. Therefore, it is understandable that they have evaluated their knowledge rather highly. However, according to their evaluations, their knowledge of basic first aid is rather low. We propose that it would be necessary also to include first aid topics in the on-the-job training, especially in view of recent changes to guidelines for resuscitation. About half of the respondents stated that most of their knowledge about healthy way of living theyacquired during their schooling. This raises questions regarding current students, as the Bologna Process has eliminated health education from the curriculum. In view of the increase of chronic diseases among children and the frequency of injuries, knowledge about correct measures in such cases will become even more necessary. ACKNOWLEDGEMENTS The authors wish to thank all the participants who took part in the anonymous questionnaire. CONFLICTS OF INTERESTS The authors declare that there is no conflict of interest. ETHICAL APPROVAL The kindergartens included in the research were randomly selected and sent the questionnaire. The questionnaire was anonymous and kindergarten staff could choose whether or not to participate in the research. FUNDING This work was funded by the University of Ljubljana, the Faculty of Health Sciences. 1. Statistical Office of the Republic of Slovenia. Kindergartens, detailed data, Slovenia, school year 2012/13 - final data. Available Sept 20, 2013 from: http://www.stat.si/novica_prikazi.aspx?id=4578. 2. World Health Organisation. Pocket book of hospital care for children: guidelines for the management of common childhood illnesses. 2nd ed. Geneva: WHO Press. Available Sept 23, 2014 from: http:// apps.who.int/iris/bitstream/10665/81170/1 /9789241548373_eng. pdf?ua=1. 3. European Child Safety Alliance. Child safety report card 2012: Europe summary for 31 countries. Birmingham: European Child Safety Alliance, Eurosafe. Available Sept 22, 2012 from: http:// www.childsafetyeurope.org/publications/info/child-safety-report-cards-europe-summary-2012.pdf. 4. Rok Simon M. Injuries of children and adolescents: analysis of mortality and morbidity. Ljubljana: National Institute of Public Health, 2007. 5. Government of the Republic of Slovenia. Strategija Republike Slovenije za zdravje otrok in mladostnikov v povezavi z okoljem 2012-2020. Ljubljana, 2011. 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Pediatric first aid knowledge among parents. Pediatr Emerg Care 2004; 20(Suppl 12): 808-11. 23. Fasano A, Berti I, Gerarduzzi T, Not T, Colletti RB, Drago S, et al. Prevalence of celiac disease in at-risk and not-at-risk groups in the United States. Arch Int Med 2003; 163(Suppl 3): 268-92. 24. Slovensko društvo za celiakijo. O celiakiji, 2011. Available Sept 23, 2013 from: http://drustvo-celiakija.si/o_celiakiji/. 25. Battelino T, Phillip M, Bratina N, Nimri R, Oskarsson P, Bolinder J. Effect of continuous glucose monitoring on hypoglycemia in type 1 diabetes. Diabetes Care 2011; 34(Suppl 4): 795-800. 26. Bratina N, Shalitin S, Phillip M, Battelino T. Type 1 diabetes in the young: organization of two national centers in Israel and Slovenia. Zdrav Var 2015; 54: 139-45. 27. Pate T, Rutar M, Battelino T, Drobnič Radobuljac M, Bratina N. Support group for parents coping with children with type 1 diabetes. Zdrav Var 2015; 54: 79-85. 28. Drobnič Radoljubac M, Shmueli-Goetz Y. Attachment to caregivers and type 1 diabetes in children. Zdrav Var 2015; 54: 126-130. 29. Wong EMY, May MH Cheng, Lo SK. Teachers' risk perception and needs in addressing infectious disease outbreak. JOSN 2010; 26(Suppl 5): 398-406. 30. Zhu L, Chen C, Chen Z. Risk factors of hand-foot-mouth disease in kindergartens in Guangzhou. Chinese J School Health 2012; 10: 10-25. Brought to you by | National & University Library Authenticated Download Date | 11/14/16 8:02 AM 223