Allergy and school: nothing to be sneezed at!

Background: Allergic diseases account for the largest proportion of chronic diseases in childhood and adolescence and place a significant burden on everyday family, social, and in particular school life. Without appropriate education, affected individuals often have little of the knowledge required to understand and deal safely with their allergic disease, and their social environment (school) generally offers insufficient information. An interdisciplinary project involving the Bielefeld Community Foundation (“Bielefelder Bürgerstiftung”), the Children’s Center Bethel, and the local school authority investigated the current knowledge, possibilities for increasing that knowledge, as well as pupils’ and teachers’ perception of the problems experienced by fellow pupils, while at the same time collecting current prevalence figures on allergic diseases among primary school children. Methods: All Bielefeld primary schools were invited to participate in the 3 years between 2008 and 2010. A teaching session on allergic diseases held by specialists from the pediatric hospital formed the core of the project. A standardized survey of children – which also addressed non-affected children for the first time in Germany – on the effects of, their knowledge of, and their attitudes toward allergic diseases, as well as an assessment of their quality of life (cross-sectional study), was conducted prior to and following each session. Parents were also surveyed. Results: In all, 24 schools per year, each with around 60 classes and 1,250 pupils aged 9 years, took part between 2008 and 2010. Approximately 30 % reported suffering from an allergic disease themselves, of which – with regard to single entries – 16 % were “allergies,” 4 % “asthma,” and 5 % atopic dermatitis. Figures collected from parents were only slightly lower than those from their children. Clear deficits that existed in terms of factual knowledge and/or correct conduct in allergic disease – among affected children as well as in their social environment – prior to the education program were noticeably improved by the teaching session. Discussion: The prevalence data gathered here confirm the high numbers recently found in the KiGGS study. Thus, allergic diseases represent a considerable disease risk and potential burden in school children. Providing affected children and their social environment (teachers, fellow pupils) with specialist education can bring about considerable improvements in everyday school life.


Background
Allergic diseases take rst place among chronic diseases in childhood and adolescence: according to the 2003-2006 German Children and Adolescent Health Survey ("Kinder-und Jugendgesundheitssurvey", KiGGS; basic examination) conducted nationwide by the Robert Koch Institute (RKI), the combined 12-month prevalence of asthma, hay fever, and atopic eczema/dermatitis was 16.7 % [1]. is gure was con rmed in the 2009-2012 follow-up study "Welle 1" ("Wave 1"), with altogether 17.0 % of individuals being a ected by at least one of the atopic diseases mentioned above.
In addition to the direct health-related impairments these diseases cause, they also result in a sometimes considerable burden on the individual in everyday social and, in particular, school life; increased absenteeism, reduced participation in physical education classes, reduced ability to concentrate, comparatively worse grades, as well as stigmatization and social exclusion [1,3,4].
is baseline situation led to an interdisciplinary primary school project in Bielefeld, Germany, in 2006: on the initiative of the Bielefeld Community Foundation ("Bielefelder Bürgersti ung"), which focused on children and adolescents, a collaboration was initiated with the Children's Center Bethel of the Bielefeld Evangelical Hospital (EvKB) and the Bielefeld school authority. On the basis of the good response to a 2007 pilot project, the decision was taken to extend the project and include scienti c research. is was followed by yearly project phases; the present article reports on the years 2008-2010. e goals of the project were to convey basic information, generally increase pupils' safety in dealing with their allergic disease, and promote sensitization to and tolerance for a ected fellow pupils, as well as to gather data on the prevalences of allergic diseases and the level of knowledge and attitudes among primary school children in relation to these diseases.

Methods
e study population comprised third graders, i. e., children aged around 9 years. e majority of allergic symptoms have already become manifest by this age [1], in addition to which this age group is capable of adequately following a respective course of instruction and taking part in a survey [5].
ere are 48 primary schools in Bielefeld: 46 municipal and two confessional schools. All schools received a written invitation to take part in the project from the local school authority. In participating schools, information evenings for parents and school personnel were organized. e core of the project was a 2-h teaching session (TS) held by specially trained and experienced professionals from the Children´s Center (specialist pediatric nurses, some with an additional quali cation as prevention assistants, asthma and atopic dermatitis trainers, and lecturers from the German Academy for Prevention and Health Promotion in Childhood and Adolescence ["Deutsche Akademie für Prävention und Gesundheitsförderung im Kindes-und Jugendalter e. V.", DAPG]), aimed at conveying "child-oriented" knowledge on and promoting attitudes toward allergies, asthma, and atopic dermatitis. e educational content of the TS: children were divided into small groups and given "topic boxes" containing materials on allergies, asthma, and atopic dermatitis. ey were then given basic information on the structure and function of the relevant organs or systems. Exercises in self-awareness of the disease symptoms, e. g., breathing through a straw, formed an essential part of the sessions. To conclude, rules on how to respond to classmates a ected with allergic diseases were proposed. Further details can be found on the project website [6]. TS were all conducted in the second half of the school year.
Data was collected using questionnaires completed by the children during class time 1 week before and 1 week a er the TS -at both the rst and second time of investigation (TOI). e questionnaire covered 20 items altogether: 10 on the extent to which children were themselves a ected by allergic disease and their knowledge of or attitudes to these diseases, as well as 10 on health-related quality of life ("KIDSCREEN®-10 Index" [7]; see [8] for more details on methodology). e extent to which children were themselves a ected was ascertained with the following questions: "Do you yourself su er from an allergy, asthma, or atopic dermatitis?" and (if yes) "Please specify." At the rst TOI, children were also given questionnaires for their parents, which were collected at the second TOI. Parents were asked: "Has your child su ered from an allergy, asthma, or atopic dermatitis in the last 12 months?" and again asked to specify in the case of a positive response. Possibly available medical data was not retrieved.
In order to assess the extent to which the e ects of the education program were sustained, data was collected in a follow-up questionnaire completed by the fourth graders that had participated in 2010 as third graders. e fourth graders completed the same questionnaire as the year before; this time, however, without a prior TS [9].
Data storage and analysis were carried out using IBM SPSS Statistics (v.20). e McNemar test -to assess the e ect of the education program -and the Wilcoxon test -to assess the e ect of the intervention on health satisfaction -were used as statistical tests.

Study collective
In all, 24 of the 48 Bielefeld primary schools (accounting for around 60-65 of all 140 third grades, i. e., In each of the 3 years, complete data on age and sex were obtained from 97 %-98 % of questionnaires at the rst TOI. e average age was 8.9 years in all 3 years, with a standard deviation of 0.6 and a median of 9 years. e age range was 7-11 years for all years; however, only a scant number of children were aged 7 (2008-2010: n = 2, 7, and 11, respectively) or 11 years (n = 13, 11, and 4, respectively). e gender ratio was evenly balanced, with girls accounting for between 49 % and 50 % in all 3 years (Tab. 1).

Epidemiological data
Over the 3 years, 29.3 %-33.8 % of children answered positively to the question: "Do you yourself su er from an allergy, asthma, or atopic dermatitis?" Children were able to provide additional, free textbased information to the question: "Please specify." e information most frequently given here related to "allergies," "asthma," and "atopic dermatitis." A number of children made multiple entries relating to allergic diseases. Results were subdivided accordingly into "single responses" relating to the above-mentioned allergic diseases and "cumulative entries," including "multiple entries." Conditions that could not be classi ed as allergic disease were recorded under "others." Relatively constant rates were seen over the 3 years for: allergies, 16 % "single" and 18 % "cumulative"; asthma, 4 % and 6 %, respectively; atopic dermatitis, 5 % and 7 %, respectively (Tab. 2).
A further di erence was seen in how information on disease changed: a slight rise in rates was observed between the rst and second TOI in two of the three survey years; although these were very low for "allergies" and "asthma," the rates for "atopic dermatitis" rose by over 50 %, from around 4.5 % to 6.5 %.
At the rst TOI, parents were asked whether their child had developed an "allergy," "asthma," or "atopic dermatitis" within the previous 12 months. Parent information was largely in line with that provided by their children (Tab. 2). Looking at the diseases individually, one notices that parent data on "allergies" and "asthma" pointed to a slightly lower incidence than did the children's data -parent data on "atopic dermatitis," however, indicated a higher incidence.
In addition to data on allergic diagnoses, it was also possible to identify factors that were linked to these diseases and which were classi ed into various categories for analysis purposes (Tab. 3). We subdivided these reported factors into "speci c allergens" and "nonspeci c triggers," whereby the "speci c allergens" are clearly de ned; for "nonspeci c triggers," on the other hand, data such as "sun allergy," "citrus fruits"/"other fruits," as well as other foodstu s, care products, drugs, etc., that are not clearly linked to allergies were recorded.
In all 3 years, "house dust mite (feces)" and "tree/ grass pollen" were the most frequently reported "speci c allergens," followed by "animals/animal hair (dander)." Similarly, any entries made by the parents were recorded and compared with those of their children. Parents reported more "speci c allergens," or fewer "nonspeci c" triggers, compared with their children; overall, however, parent data on allergies were largely in line with the children's data in terms of allergen identi cation and frequency (Tab. 3).
In 2008, 65.6 % and 78.5 % of children responded at the rst and second TOI, respectively, with "Yes" to the question "Do you know a child that has an allergy, asthma, or atopic dermatitis?"; in 2009, these gures were 64.9 % and 80.6 %, respectively, and in 2010 68.5 % and 80.5 %, respectively. In other words, TS raised awareness among children of their fellow pupils' disease by 12 %-15 %.

Questions on knowledge and behavior
e children's level of knowledge and behavioral attitudes toward allergic diseases were surveyed using seven questions considered relevant on the basis of experience gained in allergy and asthma training. Only the responses of children for whom questionnaires from the rst and second TOI were available were analyzed, in order to ensure before-and-a er comparisons in the sense of a paired sample. Two results were particularly striking: Firstly, only around a third of children at the rst TOI believed (correctly) that it is possible to participate in sports despite su ering from asthma; this proportion doubled to around two thirds of children at the second TOI. Secondly, only around 40 % of children initially believed (correctly) that atopic dermatitis is not infectious; by the second TOI, this number had also doubled, reaching 80 %-85 %. When questioned about how to behave in the case of an asthma attack, only around 15 % of children answered correctly -a er the education program, however, 45 %-50 %. Similar increases in knowledge were also seen for the other questions. ese e ects were observed in all 3 project years; the McNemar test yielded signi cant di erences (p < 0.001) for all 3 years (Tab. 4).

Health satisfaction
e following was a universal question in the KID-SCREEN®-10 Index: "How would you describe your general health?" with potential answers rang-ing from 1 for "excellent" to 5 for "poor." Again, as with the questions on knowledge, this item was only compared in those children for whom responses at both the rst and second TOI were available. Analysis was also di erentiated on the basis of children "a ected" and "not a ected" by an allergic disease.
is yielded an improvement in mean values among "not a ected" children from 2.1 to 1.9, among "a ected" children from approximately 2.5 to 2.3, and for all children from 2.3 to 2.0 (all values signi cant in the Wilcoxon test).

Follow-up survey
e enduring e ects of the education program were evident in the follow-up survey conducted in 2011 among the children that had taken part in the 2010 survey. Although only around 43 % of children had responded correctly to questions 4-7 at the rst TOI in 2010, this percentage rose to 82 % at the second TOI and was still 75 % among the same pupils a year later in 2011 [9]. Discussion is article presents the results of an education program and survey conducted in Bielefeld primary schools on allergies, asthma, and atopic dermatitis. Data was collected on prevalences, pupil knowledge, as well as self-and external evaluations in relation to these diseases. Results show that the allergy prevalences recorded in this study were largely in line with the KiGGS study data. Marked de cits were seen at the outset in terms of factual knowledge and correct conduct in allergic diseases; these, however, could be distinctly improved through the teaching program. is clearly highlights the need for structured educational courses for pupils in this age group on one of the most frequent diseases in childhood. e corresponding KiGGS data -considered hitherto the most extensive and di erentiated source for the prevalences of allergic diseases in children in Germany -show that the prevalences of "asthma, hay fever, and atopic dermatitis" in the "7to 10-year-old" age group are already close to the highest achievable rates in the various age groups [1], thus making the 9-years age group addressed in this study appear a useful target group. Data from large prospective birth cohorts also show that the highest prevalences of allergic asthma, atopic dermatitis, and food allergy have already been reached by this age, and that an additional increase is seen only for allergic rhinitis in the second decade of life [10,11].

Tab. 3: Allergen entries: child and parent information
Our study was based on self-reported information provided by children on existing allergic diseases where applicable. Complementary medical examinations or inquiries at the responsible pediatrician or family physician were considered the gold standard. In lack of these, the corresponding data provided by the parents were used as a control. Considerable concordance was seen between data provided by parents and children. A Swedish study in 12-year-old children showed good concordance between the children's self-reported information and the data provided by their parents on allergic symptoms [12]. Prevalences in the KiGGS study in the corresponding "7-to 10-years" age group were based solely on parent information. A Norwegian study found high concordance rates between parent information and medical examinations for allergic diseases, whereby, interestingly, simple questions such as "Does your child su er from asthma?" exhibited higher validity than those relating to speci c asthma symptoms [13].
It is worthy of note that, although parent data on "allergies" and "asthma" indicated lower rates than that of their children, parents reported more " atopic dermatitis." Combined with the observation that children reported "atopic dermatitis" signicantly more o en at the second TOI compared with the rst, this could mean that the children were either unaware of or preferred to conceal their disease prior to the education program. e fact that children were more likely to admit to this diagnosis and align themselves with their parents' (more valid) information a er the TS and the acceptance they experienced there speaks for the latter. e option in our study to make supplemental entries relating to allergens cannot be directly compared with the KiGGS, since the latter study performed quantitative detection of speci c immunoglobulin (IgE) anti bodies; this, however, was only reported cumulatively, or at least not di erentiated according to the di erent allergens tested [1]. Given that around 50 % of third graders in Bielefeld were surveyed, one can speak of good population-based coverage. KiGGS data were based on 167 single samples in urban vs. rural areas located throughout Germany. Although the basic publication di erentiates between social and migration status, it does not take urban vs. rural environment into consideration. Selection e ects were possible due to the voluntary participation in our study of schools assumed to have varying social backgrounds. A separate analysis of the catchment areas for the relevant primary schools based on social data made available on a small scale by the City of Bielefeld showed no associations between social or migration status and allergy prevalence from which generalized conclusions could be drawn [14]. e KiGGS data indicate higher allergy prevalences among children of higher social status or without a migrant background (attributed, among others, to greater recourse to medical care).

Tab. 4: Questions on children´s knowledge and understanding of allergic diseases
e prevalences found in our study, with around 25 %-30 % of children a ected, are quantitatively higher compared with the comparable data (7-to 10-years age group) from the two KiGGS surveys [1,4]. However, this discrepancy can be largely explained by the use of a di erent term for allergy: while the KiGGS asked explicitly about "hay fever," we accepted all allergies. Reducing our prevalences, however, to only those with "pollen" in the allergen information yields comparable prevalences. It has also to be pointed out that the KiGGS, like our study -in the "parent-information only" 7-to 10-years age group -asked parents about a 12-month prevalence, whereas no such time limit was put on our children. e results of annual school entry health examinations [15] reported in the Nordrhein-Westfalen Center for Health ("Landeszentrum Gesundheit Nordrhein-Westfalen", LZG.NRW) put the 2011-2013 gures at 1.6 %-2.1 % for "allergic rhinitis," 2.2 %-2.6 % for "bronchial asthma," and 2.8 %-3.0 % for "eczema." Remarkably, these gures are on the whole 50 % lower compared with KiGGS data for the corresponding "3-to 6-years" age group [1,4]. A recent study found prevalences for asthma of 4.7 %, hay fever 10.0 %, and atopic dermatitis 13.3 % -"doctor-diagnosed" according parent information -in primary school children aged 8.5 years in Innsbruck [16]. A 2005/2006 French study found an asthma prevalence (regarding treatment in the last 12 months) of already 9.9 % in children aged just under 6 years, at the transition from nursery school to school [17].
In terms of a ected children, it is established that well-founded asthma education is e ective on several levels, e. g., symptom control and the reduction of absenteeism [18]. Many children a ected by asthma and other allergic diseases, in particular atopic dermatitis, have already participated in education programs of this kind. To our knowledge, the present study was the rst in Germany to also primarily address non-a ected children. e project was able to stimulate considerable interest and achieved a marked increase in knowledge. However, a health technology assessment (HTA) report summarized that, although it was possible to improve children's knowledge, changing their attitudes and behaviors is a more challenging task [19] -a phenomenon not unknown in health promotion. Nevertheless, one should take advantage of the possibilities in the school context to promote children's health [5,20].
Our 2011 follow-up study demonstrated that the increase in knowledge was sustained, i.e., the children's level of knowledge decreased only slighthly, from 82 % correct answers a er the TS 1 year previously to 75 %, but remained well above the 37 % recorded prior to the TS [9]. Comparative data for other specialist subjects in primary school education are not available.
In particular pupils with asthma are frequently excused from school sports, since parents, teachers, and family physicians misjudge the children's exercise capacity or have concerns about adverse incidents [6]. However, it is generally accepted that deterring asthmatic children from sports and exercise is "fatal," and that an age-appropriately active way of life can contribute signi cantly to successful asthma management [21]. Too little is expected of asthmatic children in physical education at school, and rather than their exclusion appearing justi ed, it serves to stigmatize them further [22]. Training programs to promote physical exercise among children and adolescents reduce hospitalization periods, the frequency of asthma attacks, absenteeism from school, the number of visits to doctors, as well as medication use [23]. Teaching personnel need to be included in such programs in order to ensure that lessons are structured appropriately for a ected children on the one hand, and that the correct response is given in the case of an acute asthma attack on the other [24,25].
Epidemiological studies to date on the health status and behavior of children and adolescents in German-speaking countries have paid little attention to subjective health parameters, such as health-related quality of life [26]. Chronic disease received no particular attention in an initial KiGGS analysis of risks and resources for children's psychological development [27]. As recently as 2009, it was still being reported that most publications on healthrelated quality of life in children dealt with -comparatively far rarer -diseases in the elds of oncology and transplantation medicine, and only rarely addressed asthma and other common chronic diseases [28]. is gap is gradually closing, for instance in relation to quality of life among food-allergic children. A recent overview looked rst at the restrictions placed on a ected children in daily life, went on to discuss the risks of the o en unexpected onset of medical incidents, including anaphylaxis, and concluded by compiling a broad list of the possible interactions in the family and wider social environment, e. g., school [29]. A number of instruments have been developed to collect data on health-related quality of life especially in the eld of food allergies, while this appears to be the exception for asthma [30]. With KIDSCREEN-10, on the other hand, we have used a comprehensive instrument that is now well validated [31] and which was also applied in the KiGGS study (however, a comparison of our KIDSCREEN results with KiGGS is not possible, since KiGGS data have been converted to a di erent scale).
Reference is made in our original publication [8] to other relevant school projects and concepts. Particularly worthy of note is, e. g., the project initiated by the German Respiratory Tract League ("Deutsche Atemwegsliga e. V."), "Gleiche Chancen!? Asthma in der Schule" ("Equal Chances!? Asthma at School") [6,33], which aims, among other things, to reduce or compensate for the existing disadvantages experienced by a ected children and adolescents and, in collaboration with schools, to create an equal opportunities basis to ensure equal participation in social life in school and free time. Given the relevance of the problem to society as a whole, as well as the positive experience with our project to date, it would be desirable for further initiatives of this kind to be set-up or expanded.