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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 5  |  Issue : 3  |  Page : 107-113

A school-based program for diabetes prevention and management in India – project KiDS and diabetes in schools


1 Health Promotion Division, Public Health Foundation of India, Gurgaon, Haryana; Health Related Information Dissemination Amongst Youth (HRIDAY), New Delhi, India
2 Health Related Information Dissemination Amongst Youth (HRIDAY), New Delhi, India
3 Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India

Date of Submission02-Aug-2019
Date of Decision20-Aug-2019
Date of Acceptance29-Jul-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Dr. Monika Arora
Health Promotion Division, Public Health Foundation of India, Plot No. 47, Sector 44, Institutional Area, Gurgaon - 122 022, Haryana
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jncd.jncd_31_19

Rights and Permissions
  Abstract 


Background: The purpose of this study is to describe the conceptualization and implementation of project KiDS and diabetes in schools (KiDS) in Delhi, India.
Objective: Project KiDS was implemented to foster a supportive school environment for optimal management and care of children with type 1 diabetes (T1D) and the prevention of type 2 diabetes (T2D) through the adoption of healthy lifestyles.
Methods: Project KiDS was initiated with a feasibility study (Phase-1); including a situational analysis through desk review of preexisting epidemiological data, national policies/existing projects focused on diabetes prevention and management for Indian school settings and in-depth Interviews with multiple stakeholders. In Phase-2, the international diabetes federation's global school diabetes information pack was culturally and contextually adapted, pretested and finalized for use in India and implemented in eight private and seven government (public) schools (Grades 1–9) of Delhi, India. Components included: training of school staff, follow-up educational activities with students, and engaging parents through social media.
Results: In Phase-1, nine interviews were conducted with representatives from the Government and nongovernment organizations. Almost all respondents and literature emphasized the need to develop a comprehensive awareness program for the management of T1D and the prevention of T2D in schools. 1149 teachers were trained. Follow-up activities were conducted with 27,937 children. Over 80% of teachers were satisfied with the trainings.
Conclusion: Positive feedback from trainings and implementation of project KiDS has important implications to feed into future programmatic and policy interventions for robust school-based diabetes management and prevention.

Keywords: Children, diabetes, India, management, prevention, school


How to cite this article:
Rawal T, Shrivastav R, Nazar GP, Tandon N, Arora M. A school-based program for diabetes prevention and management in India – project KiDS and diabetes in schools. Int J Non-Commun Dis 2020;5:107-13

How to cite this URL:
Rawal T, Shrivastav R, Nazar GP, Tandon N, Arora M. A school-based program for diabetes prevention and management in India – project KiDS and diabetes in schools. Int J Non-Commun Dis [serial online] 2020 [cited 2020 Dec 3];5:107-13. Available from: https://www.ijncd.org/text.asp?2020/5/3/107/296792




  Introduction Top


The prevalence of diabetes mellitus (DM) has been increasing in low-and middle-income countries.[1],[2] India ranks second in the world, just after China, in terms of the existing number of DM patients.[2] In India, 128,500 children and adolescents (<20 years) were estimated to have type 1 diabetes (T1D).[2] India is experiencing an increasing prevalence of DM among children and adolescents, both T1D[3] and type 2 diabetes (T2D),[4],[5],[6] partly due to rapid urbanization and changing lifestyle. The Indian Council of Medical Research (ICMR) registry data of physician-diagnosed diabetes in individuals <25 years of age suggests that out of 5546 enrolled patients, 63.9% were TID and 25.3% were T2D.[7] Modifiable risk factors such as sedentary lifestyle and unhealthy dietary habits are mainly responsible for the increasing prevalence of T2D among the young population.[8] The school environment, its policies and practices greatly influence behaviors related to a healthy lifestyle in children and adolescents.[9],[10]

Currently, there are no programs/projects in Indian school settings, which specifically focus on diabetes management. Most of the earlier Indian school programs have focused on primary prevention of diabetes and other noncommunicable diseases (NCDs).[11],[12],[13] Project KiDS and diabetes in schools (KiDS) was initiated with the objective of fostering a supportive school environment for students with T1D and to raise awareness on promoting a healthy lifestyle to prevent T2D. Project KiDS[14] was implemented in two countries: India and Brazil. This article describes the conceptualization and implementation of Project KiDS in India.


  Methods Top


Project KiDS was implemented in two phases.

Phase-1 (feasibility study)

Conducted between June and August 2013, the components included: (a) In-depth interviews (IDIs) with nine key multi-sectoral stakeholders from Government and nongovernment organizations (NGOs) with the aim of assessing challenges and opportunities to address management of T1D and prevention of T2D in school settings. Respondents for IDIs were selected using convenience sampling to include representatives in authoritative positions, likely to be involved with school settings. The IDIs were conducted by a qualitative scientist using a semi-structured interview guide [Appendix 1]. Each interview was audio-recorded, transcribed, and translated into English for the analysis. The data were analyzed by a qualitative scientist,. (b) Epidemiological data focused on diabetes, review of literature on stigma against children with diabetes, and knowledge about diabetes, and (c) data on national policies/plans and existing projects/campaigns focused on the management and prevention of diabetes was collected and collated through desk review.

Key literature that was reviewed during the desk review included– Indian studies describing the prevalence of T1D and T2D and risk factors associated with T2D in children, Indian studies presenting estimates of childhood obesity and metabolic syndrome, information about ICMR diabetes registry, Indian studies assessing knowledge and perceptions about diabetes. Information on national programs/policies/projects/plans focused on prevention and management of diabetes in India was obtained from various sources such as published research papers, websites/guidelines/reports from the Ministry of Health and Family Welfare (MoHFW), Government of India (GoI), Central Board of Secondary Education (CBSE), National Council for Educational Research and Training (NCERT), and websites of Indian NGOs/research organizations working in diabetes prevention and management.

Phase-2 (project KiDS and diabetes in schools implementation)

This phase was guided by an advisory committee of international and national experts to provide technical expertise for the implementation of Project KiDS in India. At the national level, key stakeholders were identified to create a working group that comprised representatives from schools, NCERT, MoHFW, GoI, School Health Scheme (SHS), Government of National Capital Territory (NCT) of Delhi, ICMR, and NGOs like Udaan, Swasthya, Diabetes Care, HRIDAY and Public Health Foundation of India. The working group provided overall direction, Governmental perspective and policy guidance for project KiDS activities, guiding the adaptation of the global diabetes information pack (referred as pack in later sections) to local needs, planning, dissemination, and facilitation of the local events organized as part of this project.

Intervention

In Phase-2, the global diabetes information pack (which had four sections for: teachers; parents of a child with diabetes; all parents and children), developed by the International Diabetes Federation (IDF) was culturally and contextually adapted and tailored for use by teachers, students, and parents in India. Teacher's pack included details related to DM and its types (T1D and T2D), the role of teachers in DM management and prevention in schools, guidelines for the management of children with diabetes in the school including emphasizing the importance of insulin for children with T1D, conditions like hypo-and hyper-glycemia and activities planned for schools with children to emphasize the importance of healthy lifestyle. Pack developed for parents of children with diabetes included the role of parents in T1D management. Content related to diabetes prevention was common in all the packs. The pack was also translated in the Hindi language for use in government (public) schools of Delhi. Consultative meetings were organized with working group members wherein feedback was obtained on the content and design of the pack. Cultural adaptation included appropriate illustrations for each section, food pyramid, and other details like name (Arjun instead of Tom) of the character in the comic strips. Suggested revisions were incorporated, followed by pretesting of the pack. Pretesting of the English version of the Indian pack was conducted in one Private school (with 30 teachers and 18 students). The Hindi version was pretested in two government (public) schools of Delhi (with 43 teachers and 54 students), after obtaining permission from the Directorate of Education (DoE), Government of NCT of Delhi. The pretest schools were exclusive of schools enrolled for the main project. The intent of pretesting was to assess the comprehension of terms and language used in the Pack, relevance and familiarity of participants with the subject, and acceptability of the Pack in terms of social and cultural aspects. During pretesting, the Pack was shared with teachers and students. In Hindi Packs, feedback included simplification of language also such as replacing rakht shakra with blood sugar; sharirik period with games period; charbi yukt with wasa or tala hua khana etc. Based on this feedback, the Pack was revised and finalized.

Participants

A total of 15 schools (8 private and 7 government [Public]) of Delhi were purposively selected for Phase-2 with an inclusion criterion that required the schools to have one or more students with T1D. The target group included school students from Grades 1–9 (6–14 years), teachers and school nurses/staff, and parents. All the enrolled students and teachers from each section of these grades, along with other school staff and nurses were eligible to participate in the project. Permissions were sought from the SHS and DoE, Government of NCT of Delhi, for the implementation of Project KiDS in Government schools and from Principals of Private schools. Following directives from the SHS and DoE, teacher and staff trainings were conducted in consultation with District Medical Officers nominated by the SHS, in the selected Government schools.

School-based trainings

After obtaining informed consent from all the selected schools, trainings with teachers and other school staff were organized. The training included a session using presentation, Pack and a hands-on session on the use of glucometer (in each school). The duration of the training session in each school was 60–90 min. Trainings were conducted by the project team including: a doctor/endocrinologist, nutritionist, and health promotion experts.

Centralized trainings

In addition to school trainings, centralized trainings for Principals and teachers of Government (Public) schools were also organized through the State Council for Educational Research and Training (SCERT), under the aegis of the DoE, Government of NCT of Delhi. As a part of posttraining process evaluation, feedback was obtained through a training feedback form [Appendix 2], which was administered immediately after trainings.



Classroom-based activities

Postteachers' trainings, packs were provided as project resources. This was followed by teacher-led age-appropriate health promotion activities (5) being conducted at the classroom-level, over a period of 3 months, including jigsaw puzzles, role plays, etc. Each activity was implemented in one period (approximate 40 min.). The project team members conducted need-based supportive monitoring visits during the implementation of these activities in the enrolled schools.

On world diabetes day (November 14, 2014), inter-school competitions were organized on the theme of “Healthy Living and Diabetes” for the students to provide them an opportunity to apply their skills, which were imparted during the implementation of project KiDS activities.

Optimizing social media for maximizing parent outreach

An interactive online platform was created on Facebook named “Caring for Diabetes.” This platform was designed to encourage parents and caregivers to join and exchange experiences; motivate the adoption of a healthy lifestyle and promote policies that create supportive school environment and; provide support groups, resources, and information for parents and caregivers to better manage T1D (https://m.facebook.com/caringfordiabetes/).


  Results Top


Phase-1 (feasibility study)

In total, 12 related programs were reviewed. Details of programs identified through the desk review are provided as a supplementary file [Appendix 3]. Out of these programs, School Health Program is the only Government program under GoI's National Health Mission which is specifically focused on school-going children and adolescents in the age group of 6–18 years, enrolled in government (public) and government-aided schools. The program is addressing the health needs of children through decentralized management with an emphasis on determinants such as hygiene, nutrition interventions and counseling, safe drinking water, gender, and social concern. In most of the private schools, through their annual health check-ups and student health cards, schools receive information about any significant disease or condition among students, which could require emergency medical assistance. The teachers or any other school staff are not directly involved in the management of DM, whether it is T1D or T2D among students.



In-depth Interviews

All nine interviewees shared that there were currently no initiatives focused on the management of T1D at the school level. One of the respondents expressed, “Acronym for National Program on Prevention of Cancer, Diabetes, Cardiovascular Disease and Stroke only focuses on Type 2 diabetes and not Type 1 diabetes.” Respondents felt that it might be possible to introduce the sensitization of teachers, school nurse staff, and parents on identifying symptoms of T1D. According to them, T1D is a sensitive issue as effective management requires a balance between insulin dose, diet control, and physical exercise. Thus, the introduction of such interventions in schools needs to be carefully planned. However, the stakeholders felt that conducting activities for sensitizing students and teachers about T1D as well as T2D, were possible. Majority of the respondents opined that both Private and Government (Public) schools need to be the focus of such efforts, and the target group should be children and adolescents of age between 9 and 13 years. One of the respondents felt, “Age range of the target children should be 7–12 years because diabetes in very small kids is managed by parents and they can be easily involved in such activities.”

Findings from the IDIs and desk review underscored the need to develop and implement a comprehensive, multi-stakeholder school-based awareness and sensitization program for the management of T1D and prevention of T2D.

Phase-2 (project KiDS and diabetes in schools implementation)

The findings of pretesting (conducted in two government and one private school) of the pack showed that teachers and students in both types of schools found the content of the Pack easy to comprehend. Further, the language used to explain the concept was also easily understood. Illustrations created to show the daily life of a student with T1D were also appreciated by both teacher and student groups. Teachers and students in both the schools recognized the illustrations/situations and identified with them. The problem and situation was found to be known to and relevant for the audience. The Pack was found to be socially and culturally acceptable.

Implementation

Teachers' trainings

Through school-based trainings, 921 teachers from 15 schools (280 from 7 Government [Public] and 641 [including other school staff] from 8 Private schools) were trained. In addition, 228 teachers were trained through centralized SCERT trainings. In total, 1149 teachers were trained.

Quantitative analysis of the training feedback data obtained from teachers and other school staff revealed that over 80% of teachers/other school staff were satisfied with the trainings conducted and over 92% were satisfied with the clarity of information provided. Detailed teachers' feedback is provided in [Figure 1]. Teacher-led classroom activities were conducted with a total outreach of 27,937 students (17,232 from private and 10,705 from government [public] schools) [Figure 1].
Figure 1: Results from implementation of project kids and diabetes in school: Posttraining teachers' feedback (%)

Click here to view


Outreach and dissemination activities

On world diabetes day, inter-school competitions (quiz, street plays, and poster making competitions) were organized in two age categories for students from grades III–V to VI–IX. In total, 135 students and 15 teachers participated in this outreach event.

Social media optimization

More than 13,000 active users are members of the “Caring for Diabetes” page [Figure 2]. Through this medium, online contest/opinion polls were also organized, and information to download the Pack ((http://www.idf.org/education/KiDS)) was disseminated. The global outreach of pack by November 2015 was 7414 downloads by different stakeholders, including health professionals, students, school staff, and relatives of children with diabetes. Out of which 3124 downloads were from South East Asia [Figure 2].
Figure 2: Snapshot of “Caring for Diabetes” page

Click here to view



  Discussion Top


Globally, studies focusing on the management of diabetes among children are mainly clinic-based. Their intervention components include management of diet[24] and other related psychological issues such as confidence and motivation to manage diabetes.[25] For children with diabetes, social integration is still inadequate. Children with diabetes require the active participation of adults at homes, child care facilities, and schools, to administer and monitor their treatment and care. Therefore, training of individuals working with children who have diabetes is essential.[26] Multi-disciplinary teams, including personnel trained in T1D management, can play an important role in the successful integration of individuals with diabetes in different settings.[27] At the school level, there is a need to train teachers to facilitate the integration of children with diabetes.[28] Earlier studies conducted in the USA, with school staff and parents, showed that conducting training sessions and providing resources on diabetes can be an effective strategy to raise awareness about diabetes and improving social and policy environments.[29],[30]

In India, earlier school-based interventions have focused on raising awareness about the importance of being physically active and consuming a healthy diet to prevent diabetes and other NCDs.[31],[32] Project KiDS was a one of its kind innovative and comprehensive program in India designed for school staff, parents and children, to promote a supportive school environment which fosters optimal management and care of children with T1D and at the same time, promotes prevention of T2D, through the adoption of healthy lifestyles. The involvement of subject experts (advisory group) from the initial/planning phase of the project ensured high quality of the intervention and successful implementation of program.

A study conducted among children with diabetes in Bangladesh has highlighted the inclusion of parents and caregivers as an effective strategy for diabetes management and providing skills to teachers to screen children for diabetes-related signs and symptoms.[33] Similarly, several constructive findings emanated from Project KiDS. These were highlighted by the positive feedback for teachers' trainings; wide use and application of the Pack and; receptivity and response of students, teachers and parents to the multiple components of the KiDS intervention.

One inadequately explored intervention component in India, which was integrated into KiDS was the application of social media and online channels for health promotion, which received a marked positive response from nearly 13000 beneficiaries. Literature supports this component. Internet-based participatory communication, like social media, provides an opportunity to promote healthy behavior as it has the potential to reach out to a large and diverse audience.[34] As compared to other tools, it is less expensive and, thus, may support public health interventions in resource-poor settings.[35]

Apart from health literacy, the school environment and the broader health and education sectors need to be equipped to manage children with T1D, by applying sensitive and effective strategies. In Project KiDS, guidelines for the management of children with diabetes in school were provided to the school authorities, to build their capacity for management of T1D. This is corroborated by a qualitative investigation of school-based health promotion interventions, implemented in low- and middle-income countries, which highlighted robust policy environment and stakeholder engagement as important components.[36] Consistent with this observation, it was found that successful implementation of interventions like Project KiDS requires effective engagement of multiple stakeholders, including the departments of health and education.

Developments in the Indian education sector have been encouraging. In 2017, the CBSE permitted students with T1D appearing for external Grades 10 and 12 board examinations, to carry eatables during their examination.[37] This provision has also been extended to TID candidates appearing for the Joint Entrance Examination conducted by CBSE. These progressive changes in regulations bode well not only for children, adolescents and youth with T1D, but also reflect a gradual but important shift in the policies of the education and health sectors, which are conducive to providing a 'safe social space' for diabetes care and management.

The project faced some implementation challenges. One of those was allaying schools' concerns about interfering with the ongoing T1D management schedule of students and expecting the school personnel (teachers or other staff) to discharge the responsibility of a medical professional. They were convinced about their role of providing supportive supervision; offering social support to a child with diabetes; following a prescribed protocol for handling emergency situations; ensuring that the child is taken to a predesignated medical facility, as and when required, during school hours and; maintaining regular contact between schools and parents, related to the child's health. Another challenge was scheduling trainings and activities as per schools' academic calendars. However, through regular follow-up with school authorities, the project components were operationalized successfully, as per project timelines and schools' convenience.


  Conclusion Top


The positive experience of project KiDS indicates the rich potential of school-based, multi-stakeholder initiatives which can have a favorable impact on addressing current multi-pronged challenges in the management of T1D – from a medical as well as sociocognitive perspective. This experience has important implications to feed into future programmatic and policy interventions for robust school-based diabetes management and prevention. Such innovations are tailored to have the potential of plugging existing lacunae in evidence-based interventions to mitigate the national burden of T2D and improve the quality of life of people living with T1D.

Ethical approval

The ethics clearance for Project KiDS evaluation study was obtained from PHFI's Institutional Ethics Committee (IEC)

Financial support and sponsorship

The authors would like to acknowledge the contribution KiDS advisory committee for their guidance and support during the conceptualization and implementation of project KiDS in India. The project was supported by the International Diabetes Federation.

Conflicts of interest

There are no conflicts of interest.


  Appendix 1: Interview guide Top


Date:

Name:

Organization:

Position:

  • To all: Questions to ask to all the interviewees: political representatives, teachers/school directors, parents/parents representative, health professionals, other profiles
  • Political. Representative.: Questions to ask to the political representatives interviewed (at national, regional or local levels)
  • Teachers: Questions to ask to the teachers, teachers representatives and school directors
  • Health Professional: Questions to ask to health professionals, including school nurses, trainers and experts in diabetes


ISSUES TO BE DISCUSSED WITH INTERVIEWEE:

  1. To all: If needed, presentation of ADJ/PHFI


  2. Questions and comments from interviewee

  3. To all: Presentation of the KIDS Project (using PPT presentation)


  4. Questions and comments from interviewee

  5. To all: Are you already involved in initiatives on diabetes (T1D and T2D) management and promotion of healthy diet and physical activity in the school setting? Which ones? How?


  6. ANSWER: If involved, please describe initiatives (region (s) involved, objectives, scope, results, strengths/weaknesses)

  7. To all: In your opinion, what are the main problems and challenges regarding type 1 diabetes management in the school setting (at local, regional or national level)?


  8. ANSWER

  9. To all: What could be your expectations regarding type 1 diabetes management in the school setting?


  10. ANSWER

  11. To all “Have you identified priority regions and neighborhoods where there is a strong need for a better management of type 1 diabetes at school? Public or private schools? Which are they and why are they a priority?”


  12. ANSWER

  13. To all: In your opinion what is the age range of children to target in the aim of helping managing their diabetes at school? Why?


  14. ANSWER

  15. Teachers: Are you aware of the number of students with diabetes (TID, T2D) in the schools?


  16. ANSWER

  17. Teachers: What (infrastructure, training, activities) is already in place in your/the school (s) for managing type 1 diabetes?


  18. ANSWER

    E.g. awareness activities, guidelines, access to a room, role of school nurse, teachers' training

  19. Teachers/Health Pros: What technical organization should be in place in the school setting for a good management of type 1 diabetes?


  20. ANSWER: E.g. awareness activities, guidelines, access to a room, role of school nurse, teachers' training

    Tick relevant options:

    • Training of 1 leader per school
    • Training of all teachers
    • Information to children
    • Information to parents
    • Specific actions for children and parents
    • Other: _____________


  21. To all: In your opinion, what are the barriers (beliefs and operational barriers) to efficiently manage type 1 diabetes in the school setting?


  22. ANSWER

  23. Teachers/Health Pros/Political Representative: How to access the schools? What is the process? How to make sure that children can inject their insulin in the school setting? (Authorization, regular meetings with one specific organization.).


  24. ANSWER

  25. To all: Do you have in mind best practice which may serve as an example for managing type 1 diabetes in the school setting?


  26. ANSWER

  27. To all: What kind of actions could be implemented to help children managing their type 1 diabetes in the school setting?


  28. ANSWER

    Tick relevant options

    • Charter
    • Information
    • Training
    • Specific actions
    • Other: _____________


  29. Teachers/Political Representative: What are the possibilities of integrating information/training on diabetes (T1D, T2D) and promotion of healthy lifestyle in the school curriculum?


  30. ANSWER

  31. To all: What could be your expectations regarding awareness on T1D and T2D and the promotion of healthy diet and physical activity in the school setting?


  32. ANSWER

  33. To all: “Have you identified priority regions and neighborhoods where there is a strong need for awareness on diabetes (T1D and T2D) and for promoting healthy diet and physical activity at school? Public or privates schools? Which are they and why are they a priority?”


  34. ANSWER

  35. To all: In your opinion what is the age range of children to target when raising awareness on diabetes (T1D and T2D) and promoting healthy diet and physical activity at school? Why?


  36. ANSWER

  37. To all: Do you have in mind best practice which may serve as an example on diabetes (T1D and T2D) awareness and for promoting healthy diet and physical activity in the school setting?


  38. ANSWER

  39. To all: What kind of actions could be implemented to raise awareness on diabetes (T1D and T2D) and promote healthy diet and physical activity in the school setting?


  40. ANSWER

    Tick relevant options

    • Charter
    • Information
    • Training
    • Specific actions
    • Other: _____________


  41. To all: What events could be opportunities to talk about diabetes (T1D and T2D), type 1 diabetes management in the school setting, promotion of healthy lifestyle and about the KiDS Project?


  42. ANSWER

  43. To all: How could you contribute to the success of this project?


  44. ANSWER

  45. To all: Do you think of other stakeholders to involve in the project?


  46. ANSWER

  47. To all: Discussion on the role of the interviewee in the KiDS project


  48. COMMENTS

    Tick relevant options

    • Agreement (access to schools, measurements)
    • Sponsorship
    • Advice
    • Training
    • Content development
    • Other: _____________


  49. To all: Participation in the working group of the KiDS Project - Role


  50. COMMENTS

    Yes/No.

    Role

  51. To all: Additional questions

    ANSWERS




 
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