The Journal of School Nursing2022, Vol. 38(1) 61–73© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211026328journals.sagepub.com/home/jsn
Diabetes management at school demands close collaboration of multiple stakeholders, including students with diabetes and parents, school nurses, teachers/staff, and local health care providers. This scoping review identified and synthesized evidence concerning factors that contributed to the quality and effectiveness of diabetes care implementation in U.S. K-12 schools. Forty-six studies met the eligibility criteria and were included. Five common factors emerged surrounding training and experiences, communications, parent engagement, resource allocations, and school environment. Complex interactions between multiple stakeholders jointly determined the quality of school diabetes care. A conceptual model was established to elucidate the complex interactions between multiple stakeholders and the relevant facilitators and barriers. Future research should improve sample representativeness, contrast school diabetes care practices to the national guidelines, and assess the impact of the social, economic, and political environment at federal, state, local/district levels on school diabetes care implementation.
Diabetes is one of the most common chronic diseases of childhood (Miller et al., 2016). In the United States, approximately 210,000 children and adolescents live with diagnosed diabetes (Centers for Disease Control and Prevention, 2020; Cizza et al., 2012). The majority of them spend many years at school. School personnel play a crucial role in students’ diabetes management, which reduces the risk of short- and long-term complications of diabetes and ensures that students are well positioned for optimal academic performance and normal growth (Jackson et al., 2015; Wright & Chopak-Foss, 2020). Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act, and the Individuals with Disabilities Education Act require schools to provide diabetes care during the school day, field trips, and all school-sponsored events, so that students with diabetes may fully participate in school activities with little disruption (Rapp et al., 2015; Wood, 2013). In 2016, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) issued a detailed guideline for school personnel to implement evidence-based diabetes care in school settings (NIDDK, 2016). However, the unmet needs of students with diabetes have been widely reported. Many experience discrimination at school (Siminerio et al., 2014; Wang et al., 2013). They may be prohibited from consuming needed snacks in the classroom and not receive assistance for monitoring blood glucose and administering insulin (Hayes-Bohn et al., 2004; Kise et al., 2017; Lineberry et al., 2021; Schaumleffel, 2020). Some schools require students to attend a different school from their assigned one in order to receive diabetes care (Amillategui et al., 2009; Nabors et al., 2003).
Diabetes management at school is a complex undertaking that demands close collaboration of multiple stakeholders, including parents and students with diabetes, school nurses, teachers and staff, and local health care providers. Various factors at the individual, school, and social levels may potentially impact the implementation of school diabetes care, such as school nurses’ training and skills, school staff and teachers’ awareness and knowledge, student characteristics, parental and community engagement, culture and social norms, and school district, local, and state policies. Six existing reviews assessed diabetes care practices and outcomes in educational settings from different perspectives. Among them, two reviews primarily focused on school-based interventions. Specifically, Tolbert (2009) reviewed studies that described the care of students with type 1 diabetes at school and interventions to improve care quality. Pansier and Schulz (2015) reviewed school-based diabetes interventions between 2000 and 2013 and found that the quality of life of students with diabetes was improved by comprehensive interventions that promoted better care coordination and a safer school environment. The other four reviews examined school diabetes care implementation in nonexperimental settings. Kelo et al. (2011) reviewed studies on self-care in school-age children with type 1 diabetes from the viewpoint of patient education. Marks et al. (2013) reviewed diabetes care practices and management in primary schools. Edwards et al. (2014) reviewed the determinants of self-care by children and young adults with type 1 diabetes in K-12 schools and universities. Stefanowicz and Stefanowicz (2018) reviewed the roles school nurses played in the care of students with type 1 diabetes.
Building upon the previous literature, this study aimed to systematically identify and synthesize the scientific evidence concerning the factors that contributed to the quality and effectiveness of school diabetes care. It differed from previous reviews in three aspects. First, this study assessed the facilitators of and barriers to the implementation of school diabetes care for students with both type 1 and type 2 diabetes. Second, it exclusively focused on diabetes care in K-12 schools in the United States. Third, it adopted a multistakeholder perspective, intending to map the specific roles of and interactions between various players in school diabetes management in a conceptual model.
A scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Moher et al., 2009).
Studies that met all of the following criteria were included in the review: (a) study aim: to assess diabetes care programs and practices in K-12 schools in the United States; (b) study designs: all types of designs, including experimental studies (e.g., randomized, controlled trials [RCT] and pre–post studies), observational studies (e.g., longitudinal studies, cross-sectional studies, and case–control studies), and qualitative studies (e.g., case studies and interview or focus group studies); (c) study participants: students with type 1 or type 2 diabetes, parents and guardians, school nurses, and other school personnel who were involved in diabetes care; (d) school type: public and private K-12 schools; (e) article type: peer-reviewed publications; (f) time window of search: from the inception of an electronic bibliographic database to August 10, 2020; and (g) language: articles written in English.
Studies that met any of the following criteria were excluded from the review: (a) studies concerning diabetes prevention rather than diabetes care; (b) studies not conducted in the United States; (c) articles not written in English; and (d) letters, editorials, review articles, and nonpeer-reviewed articles.
A keyword search was conducted in three electronic bibliographic databases: the Cochrane Library, PubMed, and Web of Science. The search algorithm included all possible combinations of keywords from two groups: (a) “school” or “schools”; and (b) “diabetes,” “diabetic,” or “diabetics.” medical subject headings terms “schools” and “diabetes mellitus” were included in the PubMed search (See Appendix S1 for detailed search strategy). Title and abstract screening were conducted on the articles identified from the keyword search. Potentially eligible articles were retrieved, and their full texts were evaluated. Two coauthors of this review independently performed title and abstract screening. Cohen’s kappa (κ = 0.70) was used to assess interrater agreement. Discrepancies between the coauthors were resolved through discussion.
A reference list search (i.e., backward reference search) and a cited reference search (i.e., forward reference search) were conducted based on the full-text articles meeting the study selection criteria that were identified from the keyword search. Articles identified from the backward and forward reference search were further screened and evaluated using the same study selection criteria. The reference search was repeated on all newly identified articles until no additional relevant article was found.
A standardized data extraction form was used to collect the following study-level characteristics: authors, year of publication, study design, statistical model, student grade level, and sample size. Study findings were summarized and classified into three dimensions. The first dimension covered the 15 outcomes of school diabetes care implementation. These outcomes were underscored in the NIDDK’s guidelines, including: (a) school diabetes team formation and responsibilities, (b) communication and cooperation, (c) diabetes knowledge and training, (d) individual medical management plans, (e) hypoglycemia symptom recognition and treatment, (f) blood glucose monitoring and testing, (g) insulin and glucagon administration, (h) insulin availability and storage, (i) ketone testing and diabetic ketoacidosis management, (j) emergency management and hospitalization, (k) food and dietary management, (l) physical activity management, (m) self-care and support, (n) emotional and social care, and (o) law and policy know-how. The second dimension covered seven stakeholder types, including (a) students with diabetes, (b) parents or guardians, (c) school nurses, (d) classroom teachers, (e) physical education (PE) teachers and coaches, (f) other unlicensed school health personnel, and (g) schools. The third dimension covered facilitators and barriers. In sum, each facilitator of and barrier to a specific outcome among a specific stakeholder type was classified and summarized in tables. Besides, based on the review findings, a conceptual model was constructed to illustrate the complex interactions between various stakeholders that jointly influenced the implementation of diabetes care in schools.
The quality of the studies included in the review was evaluated using the following 13 assessment criteria: (a) Were the research questions or study hypotheses clearly stated? (b) Was the study design guided by a well-accepted theoretical framework? (c) Was the study design appropriate to address the research questions or hypotheses? (d) Were data used in the analyses retrieved or collected from credible sources? (e) Did the study adopt an experimental design (e.g., RCT or pre–post trial)? (f) Did the study measure the same outcomes more than once over time? (g) Were data representative of the population of concern? (h) Did the study adopt validated measures for the key variables? (i) Did the study adopt widely accepted and rigorous data analysis methodologies? (j) Did the study explore facilitators of and barriers to school diabetes care from the views of multiple stakeholders (e.g., students, parents, and school nurses) or at multiple levels (e.g., individual, school, community, and society)? (k) Were the data analysis procedures and results documented in detail? (l) Was the discussion of the key findings supported by the data and modeling results? and (m) Were implications for school diabetes care policies, practices, or implementation provided? For each criterion, a score of one was assigned if “yes” was the response, whereas a score of zero was assigned otherwise. A studyspecific global score, ranging from 0 to 13, was calculated by summing up scores across all criteria. Study quality assessment measured the strength of scientific evidence but was not used to determine the inclusion of studies.
Figure S1 shows the study selection flowchart. A total of 1,331 articles were identified from the keyword search, including 78 articles from the Cochrane Library, 843 from PubMed, and 410 from Web of Science. After removing duplicates, 1,114 unique articles underwent title and abstract screening, in which 71 articles were selected for full-text review. Besides, 12 additional articles were identified from the forward and backward reference search. The full texts of those 83 articles were reviewed against the study selection criteria. Of those, 37 articles were excluded: 23 focused on the prevention (rather than care) of childhood obesity or type 2 diabetes (Beach et al., 2018; Berquist, 2015; Castelli et al., 2011; Coleman et al., 2010; DeBar et al., 2009, 2011; Drews et al., 2009; Fenn et al., 2007; Foster et al., 2008; Gefter et al., 2014; Geria & Beitz, 2018; Gillis et al., 2009; The HEALTHY Study Group et al., 2012; Holcomb et al., 1998; Lipman et al., 2011; Mobley et al., 2012; Rosenbaum et al., 2007; Schneider et al., 2013; Shaw-Perry et al., 2007; Siega-Riz et al., 2011; Sweat et al., 2012; Treviño et al., 2004; Venditti et al., 2014); five did not focus on diabetes care in school settings (Clarke & Snyder, 1990; Gefter et al., 2016; Goddu et al., 2015; Hall et al., 2014; Herbert et al., 2017); five were not conducted in the United States (Amillategui et al., 2007; Boden et al., 2012; de Cássia Sparapani et al., 2017; Holmström et al., 2018; Ludvigsson, 1977); and the remaining four were non-original studies (Goodrich & McDermott, 1989; MacLeish et al., 2013; Melton & Henderson, 2007; Noyes et al., 2020). Therefore, a total of 46 articles were included in this review.
Table S1 summarizes the basic characteristics of the 46 studies. All but two were published between 1999 and 2020. Fifteen studies adopted an experimental study design, including four RCTs and 11 pre–post studies, 17 adopted a crosssectional study design, and 14 adopted a qualitative study design, including 12 interviews and two focus group studies. Among the 23 studies that reported student grade levels, 15 included all grades from K-12, four included K-5, two included K-8, and the remaining one included grades 6–8. Studies recruited various stakeholders of school diabetes care, including students with diabetes (n = 18), school nurses (n = 14), teachers (n = 8), other nonmedical school personnel or staff (n = 11), and parents (n = 19). Moreover, 15 studies recruited more than one type of stakeholder (e.g., teachers, students, and parents). Sample sizes varied substantially across studies and stakeholder types from a little above ten to a few hundred.
Table S2 classifies study findings by three dimensions: outcome, stakeholder type, and facilitator or barrier. This section summarizes the common facilitators of school diabetes care.
Facilitators to forming a responsible and efficient school diabetes management team included competent school nurses, engaged parents of students with diabetes, responsible teachers, well-informed school leaders, adequate resources and professional support, and frequent and timely communication among stakeholders. More specifically, for school nurses, facilitators to the successful fulfillment of their responsibilities included adequate work experience (Bachman & Hsueh, 2008; Bobo et al., 2011; Darby, 2006; Engelke et al., 2011; Fisher, 2006; Izquierdo et al., 2009; Lineberry et al., 2018; March et al., 2020; Schwartz et al., 2010; Wagner et al., 2006), high confidence in performing care tasks (Berget et al., 2019; Fisher, 2006; Perfect & Jaramillo, 2012; Smith et al., 2012), higher education level (Bachman & Hsueh, 2008; Lineberry et al., 2018; March et al., 2020) reasonable workload (Engelke et al., 2011), sound decisions about assigning care tasks to nonmedical school personnel (Nimsgern & Camponeschi, 2005), differentiated care for younger and older students with diabetes (Nabors et al., 2005), and a close connection to the students’ physicians (Radjenovic & Wallace, 2001). For parents of students with diabetes, regular school visits and educating classmates about diabetes were essential (Joshi et al., 2008). School leaders and teachers should continuously follow the health status and academic performance of students with diabetes (Lewis et al., 2003; Nguyen et al., 2008; Sato et al., 2008; Siminerio et al., 2014). Resources and professional support, such as from diabetes specialists (Hellems & Clarke, 2007), and the use of telemedicine services (Izquierdo et al., 2009), could be beneficial. Communication among stakeholders should be enhanced through learning common terminologies of diabetes therapy and performing trust-building activities (Fisher, 2006).
Facilitators to improving diabetes care knowledge and training skills for school nurses included access to educational materials on the Internet (Bachman & Hsueh, 2008; Breneman et al., 2015; Joshi et al., 2008; March et al., 2020), up-to-date reference materials at the office (Fisher, 2006), and timely support from peer health care providers and local hospitals or clinics (Bobo et al., 2011; Darby, 2006). For teachers and nonmedical school personnel, diabetes-related training improved their knowledge and confidence to perform daily care tasks (Gutierrez, 2020; Nimsgern & Camponeschi, 2005; Radjenovic & Wallace, 2001; Wagner & James, 2006). Cumulating real-world experience of patient care (e.g., being a caregiver for a family member with diabetes) was helpful in improving one’s diabetes care skills (Siminerio & Koerbel, 2000; Smith et al., 2012).
Facilitators to developing students’ individual medical management plan included having medical information or plans prepared by parents, having well-documented 504 plans, and having experienced school nurses drafting the medical management plan (Freeborn et al., 2013; Herbert et al., 2015; Jacquez et al., 2008; Nabors et al., 2005).
Facilitators of hypoglycemia symptom recognition and treatment included supportive classmates, engaged parents, school nurses, and nonmedical personnel with adequate diabetes care skills and the use of a continuous glucose monitor (CGM) (Benassi et al., 2013; Erie et al., 2018; Jacquez et al., 2008; Nguyen et al., 2008; Siminerio & Koerbel, 2000; Skelley et al., 2013; Smith et al., 2012).
Facilitators of insulin and glucagon administration included designated locations for medicine administration and having experienced school nurses manage medicines and pump problems (Darby, 2006; Engelke et al., 2011; Jacquez et al., 2008; Siminerio & Koerbel, 2000).
Facilitators of emergency preparedness included parent engagement, school nurses’ routine classroom visits, school teachers and staff receiving comprehensive diabetes training provided by school nurses, and adequate communication between school nurses and physicians of students with diabetes (Lehmkuhl & Nabors, 2008; Nabors et al., 2005; Rickabaugh & Saltarelli, 1999; Skelley et al., 2013).
Facilitators of dietary management for students with diabetes included the provision of nutritious food choices in the school cafeteria, carbohydrate counting and nutrition analysis provided by school nurses, and in-class snacking allowed by classroom teachers (Engelke et al., 2011; Peery et al., 2012; Schwartz et al., 2010). Parents bringing lunches from home to compensate for menu deficiencies could also be helpful (Schwartz et al., 2010).
Facilitators of physical activity management for students with diabetes included after-school activities and improvement of physical education (PE) teachers’ knowledge about pre-exercise hyperglycemia (Lehmkuhl & Nabors, 2008; Nabors et al., 2003; Rickabaugh & Saltarelli, 1999; Skelley et al., 2013).
Facilitators to supporting student self-care included the use of CGM, students’ ability to make sound choices regarding diabetes care, higher self-efficacy and independence, and reminders from teachers and school nurses (Carroll & Marrero, 2006; Erie et al., 2018; Peery et al., 2012; Rickabaugh & Saltarelli, 1999; Wagner & James, 2006).
Facilitators of emotional and social care for students with diabetes included educating classmates about diabetes and teachers respecting the privacy of students with diabetes (Lehmkuhl & Nabors, 2008; Perfect & Jaramillo, 2012; Sato et al., 2008; Wagner & James, 2006).
Barriers to forming a responsible and efficient school diabetes management team included lacking training and education for students with diabetes, school nurses, classroom teachers, and other nonmedical school personnel (Carroll & Marrero, 2006; Darby, 2006; Driscoll et al., 2015; Fisher, 2006; Gesteland et al., 1989; Hayes-Bohn et al., 2004; Herbert et al., 2015; Joshi et al., 2008; Lewis et al., 2003; Lindsay et al., 1987; Nabors et al., 2003; Sato et al., 2008; Skelley et al., 2013; Wagner & James, 2006; Wilt, 2020). The heavy workload of school nurses and diabetes professionals, lacking attention and involvement from teachers and other nonmedical school personnel, unclear division of responsibilities and tasks between team members, and lacking effective communication between team members and parents served as additional barriers (Driscoll et al., 2015; Hellems & Clarke, 2007; Herbert et al., 2015; Jacquez et al., 2008; Lehmkuhl & Nabors, 2008; Lewis et al., 2003; Lindsay et al., 1987; Nabors et al., 2003; Skelley et al., 2013).
Barriers to training school nurses about diabetes care skills included time constraints (school nurses were too busy to participate in training programs), difficulties in initiating and continuing training programs, and school nurses’ lack of experience due to only one or a few students with diabetes at school to provide care for (Herbert et al., 2017; Joshi et al., 2008; Rickabaugh & Saltarelli, 1999).
Barriers to hypoglycemia symptom recognition and treatment included classroom teachers, PE teachers, school nurses, and classmates’ lack of knowledge and experience about behavioral changes resulting from glucose fluctuations (Lindsay et al., 1987; Nabors et al., 2003; Rickabaugh & Saltarelli, 1999; Siminerio & Koerbel, 2000; Skelley et al., 2013).
Barriers to blood glucose testing and medicine administration included lacking communication between parents and school nurses when students with diabetes brought a new medical device to school for the first time, lacking Wi-Fi or Bluetooth connection required by the CGM at school, and equipment failures (Darby, 2006; March et al., 2020; Peery et al., 2012). Students with diabetes sometimes were not allowed to check blood glucose in class or keep smartphones at school (Engelke et al., 2011; Hayes-Bohn et al., 2004; Hellems & Clarke, 2007; Jacquez et al., 2008; Lewis et al., 2003). Ambiguous division of duties among school diabetes management team members resulted in incorrect doses of medicine administration (Driscoll et al., 2015; March et al., 2020).
Barriers to dietary management for students with diabetes included unavailability of nutritious foods and snacks (Hayes-Bohn et al., 2004; Jacquez et al., 2008; Lewis et al., 2003; Nabors et al., 2005), improper lunch schedules (Freeborn et al., 2013; Hayes-Bohn et al., 2004), absence of nutrition analyses in the school cafeteria (Hayes-Bohn et al., 2004; Wagner et al., 2006), improper eating habits (Nabors et al., 2003), poor diet adherence due to peer-effect (Joshi et al., 2008), and a “no food, no drink” classroom policy (Hayes-Bohn et al., 2004).
Barriers to physical activity management for students with diabetes included lack of support during field trips and after-school activities (Powell et al., 2015; Rickabaugh & Saltarelli, 1999; Skelley et al., 2013; Wagner & James, 2006), no school nurses during those events (Benassi et al., 2013; Lehmkuhl & Nabors, 2008; Nabors et al., 2003), and individual medical management plan not covering afterschool activities (Nabors et al., 2003, 2005).
Multiple barriers were present concerning self-care support, emotional care, and knowledge about diabetes-related laws. School nurses (Nabors et al., 2005; Wilt, 2020), teachers (Nabors et al., 2005), and counselors (Wagner & James, 2006) were reported as being less flexible in supporting students’ self-care. Some school policies were in conflict with the selfcare needs of students with diabetes. For example, students were not allowed to possess syringes in some schools (Hayes-Bohn et al., 2004). Some students with diabetes had problems with their peers (Wagner & James, 2006) and felt sad or unfair that they had diabetes (Carroll & Marrero, 2006; Nabors et al., 2003). Students with diabetes did not want to be treated differently at school due to emotional concerns (Joshi et al., 2008; Schwartz et al., 2010). Some parents (Jacquez et al., 2008) and teachers (Siminerio & Koerbel, 2000) were unaware of federal laws protecting the rights of students with diabetes at school.
Figure 1 illustrates the conceptual model of school diabetes care. The model adopted the Consolidated Framework For Implementation Research (CFIR) (Divers et al., 2020), with constructs related to outer setting (i.e., resources and policies outside school), inner setting (i.e., school environment), individual characteristics (i.e., traits and roles of stakeholders), and their interactions. The core players within schools include students with diabetes, school nurses and other health professionals, school teachers (both PE and classroom teachers) and staff, and student peers. The core players outside schools include health care providers and parents of students with diabetes. All players interact with each other through one or more activities, including training, consulting, education, communication, emergency management, peer effect, medicine administration, and dietary and physical activity arrangement. These activities jointly determine the quality of school diabetes care and students’ health outcomes, academic performances, and overall well-being. In the meantime, the implementation of school diabetes care is profoundly influenced by the political and social environment, including state, local, and school district policies and community resources.
Table S3 reports the criterion-specific study quality assessment. The included studies, on average, scored 8.4 out of 13, with a range from 4 to 12. All studies (n = 46) clearly stated the research questions or hypotheses, retrieved or collected data from credible sources, and provided implications on school diabetes care policies, practices, or implementation. All but one study applied appropriate study designs to address the research questions or hypotheses. A total of 41 (89.1%) studies adopted validated measures for key variables. A total of 36 (78.3%) studies adopted widely accepted and rigorous data analysis methodologies. A total of 31 (67.4%) studies documented data analysis procedures and results in detail. A total of 27 (58.7%) studies had key findings supported by data and modeling results. A total of 10 (21.7%) studies applied a wellaccepted theoretical framework. A total of 10 (21.7%) studies adopted an experimental study design (i.e., RCT or pre–post trial) and measured the same outcomes more than once over time. A total of 10 (21.7%) studies utilized data representative of the population of concern.
This review identified a number of facilitators and barriers to school diabetes care implementation and effectiveness. From them, several common factors emerged surrounding training and experience, communication, parent engagement, resource allocation, and school environment. First, adequate diabetes education and training, and enhanced diabetes care experiences for school nurses, nonmedical school personnel, and classroom and PE teachers were essential. Second, frequent and efficient communication was called for between health care providers and school nurses, between parents of students with diabetes and school diabetes management team members, and within the school diabetes management team. Third, adequate parent engagement was advised—parents with diabetes should periodically pay school visits and provide diabetes education to their children’s classmates. Fourth, schools should allocate sufficient financial and human resources to provide proper infrastructure for daily diabetes care, reduce the workload of school nurses and nonmedical personnel, and ensure the continuity of care for field trips and school-sponsored events. Finally, schools should build a policy and cultural environment that supports students’ self-care, respects confidentiality, and prevents discrimination.
Our findings concerning the importance of school-level facilitators and barriers coincided with those from a previous review. Pansier and Schulz (2015) appraised school-based diabetes interventions. Comprehensive interventions that aimed to enhance coordination between multiple stakeholders and promote a safe and supportive school environment were found to outperform interventions that focused on a single parameter, such as training school nurses or classroom teachers. A systematic approach to address school diabetes care quality and effectiveness calls for comprehensive school and district capacity building (Black, 2003; Crowther, 2010; Stoll, 2009).
Capacity refers to both the willingness and ability of schools to be productive and effective in delivering services for students with diabetes and their families (Children’s Bureau, 2017; Dymnicki et al., 2014). Three commonly identified factors that contribute to organizational readiness (Scaccia et al., 2015) include motivation (i.e., belief that improving diabetes care is needed and important), general capacity (i.e., leadership and resources available, physical environment, and food and dietary environment, shown in Figure 1), diabetes care-specific capacity (i.e., diabetes care knowledge, skills and ability of teachers, school nurses and other personnel, and relationship and networks with agents outside the school environment, shown in Figure 1). The starting point of integrating evidencebased practice into daily diabetes care is to develop a comprehensive implementation strategy.
The Expert Recommendations for Implementing Change (ERIC) project identified a large number of specific strategies that had the potential to be used in isolation or combination in implementation research and practice (Powell et al., 2015). Lyon et al. (2019) further rated the importance and feasibility of each ERIC implementation strategy. The study revealed that it could be crucial to prioritize implementation strategies based on specific settings and overarching goals. The building blocks of a practical implementation plan include a clearly defined problem in existing practice, an analysis of the root of the problem, a clear pathway from problem recognition to goal setting, a team to guide the change, and a comprehensive assessment of the school/districts’ readiness for change (Capacity Building Center for States, 2018a; Children’s Bureau, 2014). A solid implementation plan should document the critical steps before and during the implementation process (Capacity Building Center for States, 2018b). The plan should explain how a school or a district will prepare to implement a diabetes care intervention, identify the specific roles and responsibilities of school/district leaders, nurses, teachers, and other stakeholders, set the timeframes and milestones, and coordinate and monitor the activities for change. The current review summarized the barriers and facilitators pertaining to school diabetes care. While a “headcount” is arguably an indispensable first step, a “head-to-head” comparison between alternative determinants and corresponding strategies to address the barriers or improve the facilitators is ultimately called to form a shortlist for policy recommendation.
The studies included in the review paid much attention to the intrapersonal (e.g., training and work experience of school nurses) and interpersonal (e.g., communication within school diabetes management team members) factors and the school environment (e.g., school policies). However, little attention has been paid to the contextual factors outside schools at the national, state, and schooldistrict levels that may influence school diabetes care implementation. Many essential questions remain to be answered: To what extent do school district policies and guidelines affect the adoption of evidence-based diabetes care practices at schools?, How do the connections between schools and local communities and agencies impact the establishment and daily functioning of school diabetes management teams?, What policies at the federal and state level and social norms should be modified to form an environment conducive to the protection of legal rights and improvement of the overall well-being of students with diabetes?
Several limitations of this review and the included studies should be noted. First, due to the considerable heterogeneity in study designs, outcome measures, stakeholders of focus, and school characteristics, it proved infeasible to conduct a meta-analysis to quantify the study findings. Therefore, the study narratively synthesized the existing scientific literature. Second, keywords search did not include databases such as ERIC and Cumulative Index of Nursing and Allied Health Literature (CINAHL), and additional relevant articles may have been found. Third, few studies contrasted school diabetes care practices to evidence-based guidelines established by the NIDDK (2016). Entitled “Helping the Student with Diabetes Succeed: A Guide for School Personnel,” the guidelines specifies the roles and responsibilities of various stakeholders, such as school nurses, classroom and PE teachers, school and district administrator and staff, and parents and students with diabetes, in the daily implementation of diabetes management at school. Fourth, the included studies primarily focused on stakeholder- and school-level correlates of diabetes care, whereas social, economic, and political factors at national, state, and school district levels were rarely considered. Finally, most studies were small in sample size and geographical scale (e.g., covering one or two schools), which confined the generalizability of study findings to the regional or national level.
This study systematically identified and synthesized scientific evidence on the implementation of diabetes care at K-12 schools in the United States. A total of 46 studies met the eligibility criteria and were included in the review. Study findings were classified by the outcome, stakeholder type, and facilitator or barrier. A conceptual model was established to elucidate the complex interactions between multiple stakeholders that jointly determined the quality of school diabetes care. Future research should improve sample representativeness, contrast school diabetes care practices to the NIDDK’s evidence-based guidelines, and assess the impact of the social, economic, and political environment at national, state, district levels on diabetes care implementation in K-12 schools.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Center for Diabetes Translation Research (CDTR) at Washington University in St. Louis.
Danyi Li, MPP, MSP https://orcid.org/0000-0003-1138-9181
Supplemental material for this article is available online.
Amillategui, B., Calle, J. R., Alvarez, M. A., Cardiel, M. A., & Barrio, R. (2007). Identifying the special needs of children with type 1 diabetes in the school setting. An overview of parents’ perceptions. Diabetic Medicine, 24(10), 1073–1079. https://doi.org/10.1111/j.1464-5491.2007.02250.x
Amillategui, B., Mora, E., Calle, J. R., & Giralt, P. (2009). Special needs of children with type 1 diabetes at primary school: Perceptions from parents, children, and teachers. Pediatric Diabetes, 10(1), 67–73. https://doi.org/10.1111/j.1399-5448.2008.00457.x
Bachman, J. A., & Hsueh, K. H. (2008). Evaluation of online education about diabetes management in the school setting. The Journal of School Nursing, 24(3), 151–157. https://doi.org/10.1177/1059840533445566
Beach, L. B., Turner, B., Felt, D., Marro, R., & Phillips, G. L. (2018). Risk factors for diabetes are higher among nonheterosexual US high-school students. Pediatric Diabetes, 19(7), 1137–1146. https://doi.org/10.1111/pedi.12720
Benassi, K., Drobny, J., & Aye, T. (2013). Real-time continuous glucose monitoring systems in the classroom/school environment. Diabetes Technology and Therapeutics, 15(5), 409–412. https://doi.org/10.1089/dia.2012.0314
Berget, C., Nii, P., Wyckoff, L., Patrick, K., Brooks-Russell, A., & Messer, L. H. (2019). Equipping school health personnel for diabetes care with a competency framework and pilot education program. Journal of School Health, 89(9), 683–691. https://doi.org/10.1111/josh.12806
Berquist, M. J. (2015). Understanding type 2 diabetes in students with obesity and the role of the school nurse. NASN school nurse (Print), 30(2), 81–84. https://doi.org/10.1177/1942602X15571368
Black, L. (2003). Critical review of the capacity-building literature and discourse. Development in Practice, 13(1), 116–120. https://doi.org/10.1080/0961452022000038017
Bobo, N., Wyckoff, L., Patrick, K., White, C., Glass, S., Carlson, J. P., & Perreault, C. (2011). A collaborative approach to diabetes management: The choice made for Colorado schools. Journal of School Nursing, 27(4), 269–281. https://doi.org/10.1177/1059840511408323
Boden, S. K., Lloyd, C. E., Gosden, C., Macdougall, C., Brown, N., & Matyka, K. A. (2012). The risk management of childhood diabetes by primary school teachers. Health, Risk and Society, 14(6), 551–564. https://doi.org/10.1080/13698575.2012.701276
Breneman, C. B., Heidari, K., Butler, S., Porter, R. R., & Wang, X. (2015). Evaluation of the effectiveness of the HANDS.SM program: A school nurse diabetes management education program. Journal of School Nursing, 31(6), 402–410. https://doi.org/10.1177/1059840514568895
Capacity Building Center for States. (2018a). Change and implementation in practice: Overview. Children’s Bureau, Administration for Children and Families, U.S. Department of Health and Human Services. Retrieved March 25, 2021, from https://library.childwelfare.gov/cwig/ws/library/docs/capacity/Blob/119888.pdf?r=1&rpp=10&upp=0&w=+NATIVE(%27recno=119888%27)&m=1
Capacity Building Center for States. (2018b). Strategic planning in child welfare: Integrating efforts for systems improvement. Children’s Bureau, Administration for Children and Families, U.S. Department of Health and Human Services. Retrieved March 25, 2021, from https://capacity.childwelfare.gov/pubPDFs/cbc/integrating-systems-improvement-cp-00030.pdf
Carroll, A. E., & Marrero, D. G. (2006). How do parents perceive their adolescent’s diabetes: A qualitative study. Diabetic Medicine, 23(11), 1222–1224. https://doi.org/10.1111/j.1464-5491.2006.01961.x
Castelli, D. M., Goss, D., Scherer, J., & Chapman-Novakofski, K. (2011). Healthy outcomes for teens project: Diabetes prevention through distributed interactive learning. Diabetes Technology and Therapeutics, 13(3), 359–364. https://doi.org/10.1089/dia.2010.0125
Centers for Disease Control and Prevention. (2020). National Diabetes Statistics Report 2020. Estimates of diabetes and its burden in the United States. Retrieved December 1, 2020, from https://www.cdc.gov/diabetes/data/statistics-report/index.html
Children’s Bureau. (2014). A guide for implementing improvement through the CFSP and CFSR. Administration for Children and Families. U.S. Department of Health and Human Services. Retrieved March 25, 2021, from https://www.cfsrportal.acf.hhs.gov/resources/program-improvement-planning-tools
Children’s Bureau. (2017). What is organizational capacity and what does it look like in child welfare? Author. Retrieved March 25, 2021, from https://www.jbassoc.com/wp-content/uploads/2018/08/What_Is_Organizational_Capacity.pdf
Cizza, G., Brown, R. J., & Rother, K. I. (2012). Rising incidence and challenges of childhood diabetes. A mini review. Journal of Endocrinological Investigation, 35(5), 541–546. https://doi.org/10.3275/8411
Clarke, W. L., & Snyder, A. L. (1990). Hypoglycemia: Can the school respond? Diabetes Care, 13(10), 1097–1098. https://doi.org/10.2337/diacare.13.10.1097
Coleman, K. J., Ocana, L. L., Walker, C., Araujo, R. A., Gutierrez, V., Shordon, M., Oratowski-Coleman, J., & Philis-Tsimikas, A. (2010). Outcomes from a culturally tailored diabetes prevention program in Hispanic families from a Low-income school. The Diabetes Educator, 36(5), 784–792. https://doi.org/10.1177/0145721710377360
Crowther, F. (2010). Parallel leadership: The key to successful school capacity-building. Leading and Managing, 16(1), 16– 39. https://doi.org/10.3316/informit.430646213333539
Darby, W. (2006). The experiences of school nurses caring for students receiving continuous subcutaneous insulin infusion therapy. The Journal of School Nursing : The Official Publication of the National Association of School Nurses, 22(6), 336–344. https://doi.org/10.1177/10598405060220060501
DeBar, L. L., Schneider, M., Drews, K. L., Ford, E. G., Stadler, D. D., Moe, E. L., White, M., Hernandez, A. E., Solomon, S., Jessup, A., & Venditti, E. M., & the HEALTHY study group. (2011). Student public commitment in a school-based diabetes prevention project: Impact on physical health and health behavior. BMC Public Health, 11(1), 711. https://doi.org/10.1186/1471-2458-11-711
DeBar, L. L., Schneider, M., Ford, E. G., Hernandez, A. E., Showell, B., Drews, K. L., Moe, E. L., Gillis, B., Jessup, A. N., Stadler, D. D., & White, M. (2009). Social marketing-based communications to integrate and support the healthy study intervention. International Journal of Obesity, 33(Suppl 4), S52– S59. https://doi.org/10.1038/ijo.2009.117
de Cássia Sparapani, V., Liberatore, R. D. R., Damião, E. B. C., de Oliveira Dantas, I. R., de Camargo, R. A. A., & Nascimento, L. C. (2017). Children With type 1 diabetes Mellitus: Self-management experiences in school. Journal of School Health, 87(8), 623–629. https://doi.org/10.1111/josh.12529
Divers, J., Mayer-Davis, E. J., Lawrence, J. M., Isom, S., Dabelea, D., Dolan, L., Imperatore, G., Marcovina, S., Pettitt, D. J., Pihoker, C., Hamman, R. F., Saydah, S., & Wagenknecht, L. E. (2020). Trends in incidence of type 1 and type 2 diabetes Among youths — selected counties and Indian reservations, United States, 2002–2015. MMWR. Morbidity and Mortality Weekly Report, 69(6), 161–165. https://doi.org/10.15585/mmwr.mm6906a3
Drews, K. L., Harrell, J. S., Thompson, D., Mazzuto, S. L., Ford, E. G., Carter, M., Ford, D. A., Yin, Z., Jessup, A. N., & Roullet,
J. B. (2009). Recruitment and retention strategies and methods in the HEALTHY study. International Journal of Obesity, 33(S4), S21–S28. https://doi.org/10.1038/ijo.2009.113
Driscoll, K. A., Volkening, L. K., Haro, H., Ocean, G., Wang, Y., Jackson, C. C., Clougherty, M., Hale, D. E., Klingensmith, G. J., Laffel, L., Deeb, L. C., & Siminerio, L. M. (2015). Are children with type 1 diabetes safe at school? Examining parent perceptions. Pediatric Diabetes, 16(8), 613–620. https://doi.org/10.1111/pedi.12204
Dymnicki, A., Wandersman, A., Osher, D., Grigorescu, V., & Huang, L. (2014). Willing, able, ready: Basics and policy implications of readiness as a key component for implementation of evidence-based interventions (ASPE issue brief). U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Retrieved March 25, 2021, from https://aspe.hhs.gov/pdf-report/willingable-ready-basics-and-policy-implicationsreadiness-key-componentimplementation-evidence-based-interventions
Edwards, D., Noyes, J., Lowes, L., Haf Spencer, L., & Gregory, J. W. (2014). An ongoing struggle: A mixed-method systematic review of interventions, barriers and facilitators to achieving optimal self-care by children and young people with type 1 diabetes in educational settings. BMC Pediatrics, 14(1), 1–27. https://doi.org/10.1186/1471-2431-14-228
Engelke, M. K., Swanson, M., Guttu, M., Warren, M. B., & Lovern, S. (2011). School nurses and children with diabetes: A descriptive study. North Carolina Medical Journal, 72(5), 351–358. https://doi.org/10.18043/ncm.72.5.351
Erie, C., Van Name, M. A., Weyman, K., Weinzimer, S. A., Finnegan, J., Sikes, K., Tamborlane, W. V., & Sherr, J. L. (2018). Schooling diabetes: Use of continuous glucose monitoring and remote monitors in the home and school settings. Pediatric Diabetes, 19(1), 92–97. https://doi.org/10.1111/pedi.12518
Faro, B., Ingersoll, G., Fiore, H., & Ippolito, K. S. (2005). Improving students’ diabetes management through school-based diabetes care. Journal of Pediatric Health Care, 19(5), 301–308. https://doi.org/1016/j.pedhc.2005.03.004
Fenn, J., Rosales, C., & Logue, C. (2007). Sir Insulin monk versus the evil Diana Betes. The Diabetes Educator, 33(3), 455–459. https://doi.org/10.1177/0145721707301910
Fisher, K. L. (2006). School nurses’ perceptions of self-efficacy in providing diabetes care. The Journal of School Nursing: The Official Publication of the National Association of School Nurses, 22(4), 223–228. https://doi.org/10.1177/10598405050220040701
Foster, G. D., Sherman, S., Borradaile, K. E., Grundy, K. M., Vander Veur, S. S., Nachmani, J., Karpyn, A., Kumanyika, S., & Shults, J. (2008). A policy-based school intervention to prevent overweight and obesity. Pediatrics, 121(4), e794–e802. https://doi.org/10.1542/peds.2007-1365
Freeborn, D., Loucks, C. A., Dyches, T., Roper, S. O., & Mandleco, B. (2013). Addressing school challenges for children and adolescents With type 1 diabetes: The nurse practitioner’s role. Journal for Nurse Practitioners, 9(1), 11–16. https://doi.org/10.1016/j.nurpra.2012.11.005
Gefter, L., Morioka-Douglas, N., Srivastava, A., & Rodriguez, E. (2016). Supporting at-risk youth and their families to manage and prevent diabetes: Developing a national partnership of medical residency programs and high schools. PLoS ONE, 11(7), e0158477. https://doi.org/10.1371/journal.pone.0158477
Gefter, L., Rosas, L. G., Rodriguez, E., & Morioka-Douglas, N. (2014). Training at-risk youth to become diabetes self-management coaches for family members: Partnering family medicine residents with underserved schools. The Diabetes Educator, 40(6), 786–796. https://doi.org/10.1177/0145721714549676
Geria, K., & Beitz, J. M. (2018). Application of a modified diabetes prevention program with adolescents. Public Health Nursing, 35(4), 337–343. https://doi.org/10.1111/phn.12379
Gesteland, H. M., Sims, S., & Lindsay, R. N. (1989). Evaluation of Two approaches to educating elementary schoolteachers about insulin-dependent diabetes Mellitus. The Diabetes Educator, 15(6), 510–513. https://doi.org/10.1177/014572178901500607
Gillis, B., Mobley, C., Stadler, D. D., Hartstein, J., Virus, A., Volpe, S. L., Ghormli, L. E. L., Staten, M. A., Bridgman, J., & McCormick, S. (2009). Rationale, design and methods of the HEALTHY study nutrition intervention component. International Journal of Obesity, 33(S4), S29–S36. https://doi.org/10.1038/ijo.2009.114
Goddu, A. P., Roberson, T. S., Raffel, K. E., Chin, M. H., & Peek, M. E. (2015). Food Rx: A community-university partnership to prescribe healthy eating on the south side of Chicago. Journal of Prevention & Intervention in the Community, 43(2), 148–162. https://doi.org/10.1080/10852352.2014.973251
Goodrich, S. W., & McDermott, R. J. (1989). Changing roles and challenges for teachers of students with diabetes. Journal of School Health, 59(8), 341–345. https://doi.org/10.1111/j.1746-1561.1989.tb04741.x
Gutierrez, C. (2020). Improving the care of students with diabetes in rural schools utilizing an online diabetes education program for school personnel. Rural and Remote Health, 20(1), 5596. https://doi.org/10.22605/RRH5596
Hall, W. J., Schneider, M., Thompson, D., Volpe, S. L., Steckler, A., Hall, J. M., & Fisher, M. R. (2014). School factors as barriers to and facilitators of a preventive intervention for pediatric type 2 diabetes. Translational Behavioral Medicine, 4(2), 131–140. https://doi.org/10.1007/s13142-013-0226-z
Hayes-Bohn, R., Neumark-Sztainer, D., Mellin, A., & Patterson, J. (2004). Adolescent and parent assessments of diabetes mellitus management at school. Journal of School Health, 74(5), 166– 169. https://doi.org/10.1111/j.1746-1561.2004.tb08215.x
Hellems, M. A., & Clarke, W. L. (2007). Safe at school: A Virginia experience. Diabetes Care, 30(6), 1396–1398. https://doi.org/10.2337/dc07-0121
Herbert, L. J., Clary, L., Owen, V., Monaghan, M., Alvarez, V., & Streisand, R. (2015). Relations among school/daycare functioning, fear of hypoglycaemia and quality of life in parents of young children with type 1 diabetes. Journal of Clinical Nursing, 24(9–10), 1199–1209. https://doi.org/10.1111/jocn.12658
Herbert, L. J., Wall, K., Monaghan, M., & Streisand, R. (2017). Parent employment and school/daycare decisions among parents of young children with type 1 diabetes. Children’s Health Care, 46(2), 170–180. https://doi.org/10.1080/02739615.2015.1124776
Holcomb, J. D., Lira, J., Kingery, P. M., Smith, D. W., Lane, D., & Goodway, J. (1998). Evaluation of Jump Into Action : A program to reduce the risk of Non-insulin dependent diabetes Mellitus in school children on the Texas–Mexico border. Journal of School Health, 68(7), 282–286. https://doi.org/10.1111/j.1746-1561.1998.tb00584.x
Holmström, M. R., Häggström, M., & Söderberg, S. (2018). Being facilitators in a challenging context-school personnel’s experiences of caring for youth with diabetes type 1. Journal of Pediatric Nursing, 43, e114–e119. https://doi.org/10.1016/j.pedn.2018.08.007
Izquierdo, R., Morin, P. C., Bratt, K., Moreau, Z., Meyer, S., Ploutz-Snyder, R., Wade, M., & Weinstock, R. S. (2009). School-Centered telemedicine for children with type 1 diabetes Mellitus. Journal of Pediatrics, 155(3), 374–379. https://doi.org/10.1016/j.jpeds.2009.03.014
Jackson, C. C., Albanese-O’neill, A., Butler, K. L., Chiang, J. L., Deeb, L. C., Hathaway, K., Kraus, E., Weissberg-Benchell, J., Yatvin, A. L., & Siminerio, L. M. (2015). Diabetes care in the school setting: A position statement of the American Diabetes Association. Diabetes Care, 38(10), 1958–1963. https://doi.org/10.2337/dc15-1418
Jacquez, F., Stout, S., Alvarez-Salvat, R., Fernandez, M., Villa, M., Sanchez, J., Eidson, M., Nemery, R., & Delamater, A. (2008). Parent perspectives of diabetes management in schools. Diabetes Educator, 34(6), 996–1003. https://doi.org/10.1177/0145721708325155
Joshi, A., Komlodi, A., & Arora, M. (2008). School nurses’ perceived barriers to diabetes knowledge, communication and management in children with type 1 diabetes. School Nurse News, 25(3), 24–29. https://doi.org/10.1177/1059840509348221
Kelo, M., Martikainen, M., & Eriksson, E. (2011). Self-care of school-age children with diabetes: An integrative review. Journal of Advanced Nursing, 67(10), 2096–2108. https://doi.org/10.1111/j.1365-2648.2011.05682.x
Kise, S. S., Hopkins, A., & Burke, S. (2017). Improving school experiences for adolescents With type 1 diabetes. Journal of School Health, 87(5), 363–375. https://doi.org/10.1111/josh.12507
Lehmkuhl, H., & Nabors, L. (2008). Children with diabetes: Satisfaction with school support, illness perceptions and HbA1C levels. Journal of Developmental and Physical Disabilities, 20(2), 101–114. https://doi.org/10.1007/s10882-007-9082-4
Lewis, D. W., Powers, P. A., Goodenough, M. F., & Poth, M. A. (2003). Inadequacy of in-school support for diabetic children. Diabetes Technology and Therapeutics, 5(1), 45–56. https://doi.org/10.1089/152091503763816463
Lindsay, R., Jarrett, L., & Hillam, K. (1987). Elementary Schoolteachers’ understanding of diabetes. The Diabetes Educator, 13(3), 312–314. https://doi.org/10.1177/014572178701300315
Lineberry, M., Noland, M., & Wilson, J. F. (2021). Intentions of Kentucky school nurses to delegate diabetes-related tasks to unlicensed assistive personnel. The Journal of school nursing: the official publication of the National Association of School Nurses, 37(2), 99–108. https://doi.org/10.1177/1059840519849098
Lineberry, M., Whitney, E., & Noland, M. (2018). The role of school nurses, challenges, and reactions to delegation legislation: A qualitative approach. Journal of School Nursing, 34(3), 222–231. https://doi.org/10.1177/1059840517741526
Lipman, T. H., Schucker, M. M. G., Ratcliffe, S. J., Holmberg, T., Baier, S., & Deatrick, J. A. (2011). Diabetes risk factors in children. MCN: The American Journal of Maternal/Child Nursing, 36(1), 56–62. https://doi.org/10.1097/nmc.0b013e3181fc0d06
Ludvigsson, J. (1977). Diabetics in school: Knowledge and attitudes of school staff in relation to juvenile diabetics. Scandinavian Journal of Public Health, 5(1), 21–30. https://doi.org/10.1177/140349487700500104
Lyon, A. R., Cook, C. R., Locke, J., Davis, C., Powell, B. J., & Waltz, T. J. (2019). Importance and feasibility of an adapted set of implementation strategies in schools. Journal of School Psychology, 76, 66–77. https://doi.org/10.1016/j.jsp.2019.07.014
MacLeish, S. A., Cuttler, L., & Koontz, M. B. (2013). Adherence to guidelines for diabetes care in school: Family and school nurse perspectives. Diabetes Care, 36(4), e52. https://doi.org/10.2337/dc12-2083
March, C. A., Nanni, M., Kazmerski, T. M., Siminerio, L. M., Miller, E., & Libman, I. M. (2020). Modern diabetes devices in the school setting: Perspectives from school nurses. Pediatric Diabetes, 21(5), 832–840. https://doi.org/10.1111/pedi.13015
Marks, A., Wilson, V., & Crisp, J. (2013). The management of type 1 diabetes in primary school: Review of the literature. Comprehensive Child and Adolescent Nursing, 36(1–2), 98– 119. https://doi.org/10.3109/01460862.2013.782079
Melton, D., & Henderson, J. (2007). Do public schools provide optimal support for children with diabetes? Preventing Chronic Disease, 4(3), A78. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1955407/
Miller, G. F., Coffield, E., Leroy, Z., & Wallin, R. (2016). Prevalence and costs of five chronic conditions in children. Journal of School Nursing, 32(5), 357–364. https://doi.org/10.1177/1059840516641190
The HEALTHY Study Group, Mobley, C. C., Stadler, D. D., Staten, M. A., El ghormli, L., Gillis, B., Hartstein, J., Siega-Riz, A. M., & Virus, A. (2012). Effect of nutrition changes on foods selected by students in a middle school-based diabetes prevention intervention program: The HEALTHY experience. Journal of School Health, 82(2), 82–90. https://doi.org/10.1111/j.1746-1561.2011.00670.x
Mobley, C. C., Stadler, D. D., Staten, M. A., El ghormli, L., Gillis, B., Hartstein, J., Siega-Riz, A. M., & Virus, A. (2012). Effect of nutrition changes on foods selected by students in a middle school-based diabetes prevention intervention program: The HEALTHY experience. Journal of School Health, 82(2), 82–90. https://doi.org/10.1111/j.1746-1561.2011.00670.x
Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA statement. PLoS Medicine, 6(7), e1000097. https://doi.org/10.1371/journal.pmed.1000097
Nabors, L., Lehmkuhl, H., Christos, N., & Andreone, T. L. (2003). Children with diabetes: Perceptions of supports for selfmanagement at school. Journal of School Health, 73(6), 216– 221. https://doi.org/10.1111/j.1746-1561.2003.tb06563.x
Nabors, L., Troillett, A., Nash, T., & Masiulis, B. (2005). School nurse perceptions of barriers and supports for children with diabetes. Journal of School Health, 75(4), 119–124. https://doi.org/10.1111/j.1746-1561.2005.tb06655.x
National Institute of Diabetes and Digestive and Kidney Disease. (2016). Helping students with diabetes succeed. Retrieved December 1, 2020, from https://schoolnursenet.nasn.org/blogs/susan-hoffmann/2016/11/02/helping-students-with-diabetes-succeed
Nguyen, T. M., Mason, K. J., Sanders, C. G., Yazdani, P., & Heptulla, R. A. (2008). Targeting blood glucose management in school improves glycemic control in children with poorly controlled type 1 diabetes Mellitus. The Journal of Pediatrics, 153(4), 575–578. https://doi.org/10.1016/j.jpeds.2008.04.066
Nimsgern, A., & Camponeschi, J. (2005). Implementing a new diabetes resource for Wisconsin schools and families. Preventing Chronic Disease, 2 Spec no (Spec No), A11. www.pediatrics.org/cgi/doi/10.1542/peds.2004-0953
Noyes, J., Allen, D., Carter, C., Edwards, D., Edwards, R. T., Russell, D., Russell, I. T., Spencer, L. H., Sylvestre, Y., Whitaker, R., Yeo, S. T., & Gregory, J. W. (2020). Standardised self-management kits for children with type 1 diabetes: Pragmatic randomised trial of effectiveness and costeffectiveness. BMJ open, 10(3), e032163. https://doi.org/10.1136/bmjopen-2019-032163
Pansier, B., & Schulz, P. J. (2015). School-based diabetes interventions and their outcomes: A systematic literature review. Journal of Public Health Research, 4(1), 467. https://doi.org/10.4081/jphr.2015.467
Peery, A. I., Engelke, M. K., & Swanson, M. S. (2012). Parent and teacher perceptions of the impact of school nurse interventions on children’s self-management of diabetes. Journal of School Nursing, 28(4), 268–274. https://doi.org/10.1177/1059840511433860
Perfect, M. M., & Jaramillo, E. (2012). Relations between resiliency, diabetes-related quality of life, and disease markers to schoolrelated outcomes in adolescents with diabetes. School Psychology Quarterly, 27(1), 29–40. https://doi.org/10.1037/a0027984
Powell, B. J., Waltz, T. J., Chinman, M. J., Damschroder, L. J., Smith, J. L., Matthieu, M. M., Proctor, E. K., & Kirchner, J. A. E. (2015). A refined compilation of implementation strategies: Results from the expert recommendations for implementing change (ERIC) project. Implementation Science, 10(1), 21. https://doi.org/10.1186/s13012-015-0209-1
Radjenovic, D., & Wallace, F. L. (2001). Computer-based remote diabetes education for school personnel. Diabetes Technology and Therapeutics, 3(4), 601–607. https://doi.org/10.1089/15209150152811225
Rapp, J. A., Arent, S., Dimmick, B. L., Gordon, K., & Jackson, C. (2015). Legal rights of students with diabetes (3rd ed.). American Diabetes Association. Retrieved December 1, 2020, from http://www.diabetes.org/living-with-diabetes/know-yourrights/for-lawyers/education-materials-for-lawyers/legal-rightsof-students-with-diabetes.html
Rhodes, D., Visker, J., Larson, K., & Cox, C. (2019). Rapid E-learning for professional development in school-based diabetes management. Nurse Education in Practice, 38(May), 84–88. https://doi.org/10.1016/j.nepr.2019.06.009
Rickabaugh, T. E., & Saltarelli, W. (1999). Knowledge and attitudes related to diabetes and exercise guidelines among selected diabetic children, their parents, and physical education teachers. Research Quarterly for Exercise and Sport, 70(4), 389–394. https://doi.org/10.1080/02701367.1999.10608059
Rosenbaum, M., Nonas, C., Weil, R., Horlick, M., Fennoy, I., Vargas, I., Kringas, P., & Camino Diabetes Prevention Group (2007). School-based intervention acutely improves insulin sensitivity and decreases inflammatory markers and body fatness in junior high school students. The Journal of Clinical Endocrinology and Metabolism, 92(2), 504–508. https://doi.org/10.1210/jc.2006-1516
Sato, A. F., Berlin, K. S., Hains, A. A., Davies, W. H., Smothers, M. K., Clifford, L. M., & Alemzadeh, R. (2008). Teacher support of adherence for adolescents with type 1 diabetes: Preferred teacher support behaviors and youths’ perceptions of support. The Diabetes Educator, 34(5), 866–873. https://doi.org/10.1177/0145721708322858
Scaccia, J. P., Cook, B. S., Lamont, A., Wandersman, A., Castellow, J., Katz, J., & Beidas, R. S. (2015). A practical implementation science heuristic for organizational readiness: R = MC2. Journal of Community Psychology, 43(4), 484–501. https://doi.org/10.1002/jcop.21698
Schaumleffel, C. (2020). School nurse barriers to caring for students with diabetes at school. Health Behavior and Policy Review, 7(5), 432–439. https://doi.org/10.14485/hbpr.7.5.5
Schneider, M., Debar, L., Calingo, A., Hall, W., Hindes, K., Sleigh, A., Thompson, D., Volpe, S. L., Zeveloff, A., Pham, T., & Steckler, A. (2013). The effect of a communications campaign on middle school Students’ nutrition and physical activity: Results of the HEALTHY study. Journal of Health Communication, 18(6), 649–667. https://doi.org/10.1080/10810730.2012.743627
Schwartz, F. L., Denham, S., Heh, V., Wapner, A., & Shubrook, J. (2010). Experiences of children and adolescents with type 1 diabetes in school: Survey of children, parents, and schools. Diabetes Spectrum, 23(1), 47–55. https://doi.org/10.2337/diaspect.23.1.47
Shaw-Perry, M., Horner, C., Treviño, R. P., Sosa, E. T., Hernandez, I., & Bhardwaj, A. (2007). NEEMA: A school-based diabetes risk prevention program designed for African-American children. Journal of the National Medical Association, 99(4), 368–375. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2569665/
Siega-Riz, A. M., El Ghormli, L., Mobley, C., Gillis, B., Stadler, D., Hartstein, J., Volpe, S. L., Virus, A., & Bridgman, J. (2011). The effects of the HEALTHY study intervention on middle school student dietary intakes. International Journal of Behavioral Nutrition and Physical Activity, 8, 7. https://doi.org/10.1186/1479-5868-8-7
Siminerio, L. M., Albanese-O’Neill, A., Chiang, J. L., Hathaway, K., Jackson, C. C., Weissberg-Benchell, J., Wright, J. L., Yatvin, A. L., & Deeb, L. C. (2014). Care of young children with diabetes in the child care setting: A position statement of the American diabetes association. Diabetes Care, 37(10), 2834–2842. https://doi.org/10.2337/dc14-1676
Siminerio, L. M., & Koerbel, G. (2000). A diabetic education program for school personnel. Practical Diabetes International, 17(6), 174–177. https://doi.org/10.1002/1528-252X(200009)17:6<174:: AID-PDI105>3.0.CO;2-4
Skelley, J. P., Luthin, D. R., Skelley, J. W., Kabagambe, E. K., Ashraf, A. P., & Atchison, J. A. (2013). Parental perspectives of diabetes management in Alabama public schools. Southern Medical Journal, 106(4), 274–279. https://doi.org/10.1097/SMJ.0b013e31828de4a4
Smith, C. T., Chen, A. M. H., Plake, K. S., & Nash, C. L. (2012). Evaluation of the impact of a diabetes education curriculum for school personnel on disease knowledge and confidence in caring for students. Journal of School Health, 82(10), 449–456. https://doi.org/10.1111/j.1746-1561.2012.00721.x
Stefanowicz, A., & Stefanowicz, J. (2018). The role of a school nurse in the care of a child with diabetes Mellitus type 1 – The perspectives of patients and their parents: Literature review. Zdravstveno varstvo, 57(3), 166–174. https://doi.org/10.2478/sjph-2018-0021
Stoll, L. (2009). Capacity building for school improvement or creating capacity for learning? A changing landscape. Journal of Educational Change, 10(2–3), 115–127. https://doi.org/10.1007/s10833-009-9104-3
Sweat, V., Bruzzese, J. M., Albert, S., Pinero, D. J., Fierman, A., & Convit, A. (2012). The Banishing Obesity and Diabetes in Youth (BODY) project: Description and feasibility of a program to halt obesity-associated disease among urban high school students. Journal of Community Health, 37(2), 365– 371. https://doi.org/10.1007/s10900-011-9453-8
Tolbert, R. (2009). Managing type 1 diabetes at school: An integrative review. Journal of School Nursing, 25(1), 55–61. https://doi.org/10.1177/1059840508329295
Treviño, R. P., Yin, Z., Hernandez, A., Hale, D. E., Garcia, O. A., & Mobley, C. (2004). Impact of the Bienestar school-based diabetes mellitus prevention program on fasting capillary glucose levels: A randomized controlled trial. Archives of Pediatrics & Adolescent Medicine, 158(9), 911–917. https://doi.org/10.1001/archpedi.158.9.911
Venditti, E. M., Giles, C., Firrell, L. S., Zeveloff, A. D., Hirst, K., & Marcus, M. D. (2014). Interactive learning activities for the middle school classroom to promote healthy energy balance and decrease diabetes risk in the HEALTHY primary prevention trial. Health Promotion Practice, 15(1), 55–62. https://doi.org/10.1177/1524839912469377
Wagner, J., Heapy, A., James, A., & Abbott, G. (2006). Brief report: Glycemic control, quality of life, and school experiences among students with diabetes. Journal of Pediatric Psychology, 31(8), 764–769. https://doi.org/10.1093/jpepsy/jsj082
Wagner, J., & James, A. (2006). A pilot study of school counselor’s preparedness to serve students with diabetes: Relationship to self-reported diabetes training. Journal of School Health, 76(7), 387–392. https://doi.org/10.1111/j.1746-1561.2006.00130.x
Wang, Y. L., Brown, S. A., & Horner, S. D. (2013). The schoolbased lived experiences of adolescents with type 1 diabetes. Journal of Nursing Research, 21(4), 235–243. https://doi.org/10.1097/jnr.0000000000000003
Williams, L. F., Russ, M., & Perdue, B. J. (2019). Exploration of school Nurses’ perception of self-efficacy in providing care and education to children with type 1 diabetes Mellitus. Journal of National Black Nurses’ Association: JNBNA, 30(2), 34–37. https://doi.org/10.1177/1059840512447123
Wilt, L. (2019). The relationships among school nurse to student ratios, self-efficacy, and glycemic control in adolescents with type 1 diabetes. Journal of School Nursing: The Official Publication of the National Association of School Nurses, 1–11. https://doi.org/10.1177/1059840519870314
Wilt, L. (2020). The role of school nurse presence in parent and student perceptions of helpfulness, safety, and satisfaction with type 1 diabetes care. Journal of School Nursing: The Official Publication of the National Association of School Nurses, 1–12. https://doi.org/10.1177/1059840520918310
Wood, J. M. (2013). Protecting the rights of school children with diabetes. Journal of Diabetes Science and Technology, 7(2), 339–344. https://doi.org/10.1177/193229681300700208
Wright, A., & Chopak-Foss, J. (2020). School personnel knowledge and perceived skills in diabetic emergencies in Georgia public schools. Journal of School Nursing, 36(4), 304–312. https://doi.org/10.1177/1059840518820106
Ruopeng An, PhD, MPP, is an associate professor at Brown School, Washington University in St. Louis, MO, USA.
Danyi Li, MPP, MSP, is an MPH student at Brown School, Washington University in St. Louis, MO, USA.
Marjorie Cole, MSN, RN, is a state school Nurse Consultant at the Missouri Department of Health & Senior Services, MO, USA.
Katherine Park, DNP, RN, NCSN, is currently serving as the director for health services in Parkway school district in St. Louis, MO, USA.
Aaron R. Lyon, PhD, is an associate professor in the University of Washington Department of Psychiatry and Behavioral Sciences in Seattle, WA, USA.
Neil H. White, MD, CDE, is a professor of pediatrics at the School of Medicine, Washington University in St. Louis, MO, USA.
1 Brown School, Washington University, St. Louis, MO, USA
2 Missouri Department of Health & Senior Services, Jefferson City, MO, USA
3 Pierremont Elementary School, Manchester, MO, USA
4 Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
5 School of Medicine, Washington University, St. Louis, MO, USA
Corresponding Author:Danyi Li, MPP, MSP, Brown School, Washington University, St. Louis, MO, USA.Email: danyi@wustl.edu
