Supporting participation in physical education at school in youth with type 1 diabetes

Abstract

It is not clear how best to support youth with type 1 diabetes to participate in physical education (PE) at school. The aim of this study was to explore perceptions of facilitators and barriers to PE in youth with type 1 diabetes and to determine how schools can help these individuals to be physically active. Interviews and focus groups were conducted with youth with type 1 diabetes aged 7–9 (n = 8) and 12–14 (n = 8) years with type 1 diabetes, their parents (n = 16), diabetes professionals (n = 9) and schoolteachers (n = 37).

Data were thematically analysed. Four main themes were identified relating to support needs of youth with diabetes in school in general and specifically in PE lessons: (1) differences between primary and secondary schools; (2) areas requiring address in all schools; (3) what teachers can do to help accommodate youth with type 1 diabetes; and (4) what schools can do to help accommodate youth with type 1 diabetes.

Diabetes support varied across schools. Primary schools in particular could improve communication between schools and primary specialist PE teachers regarding youth with type 1 diabetes to aid participation in PE. Diabetes knowledge was limited among all teachers. Participants felt that diabetes could be used as an excuse to sit out of PE and that teachers’ fears could facilitate this.

Improved and consistent diabetes management training and guidance on the responsibilities of teachers is necessary. Better communication between schools, teachers, parents, youth with type 1 diabetes and diabetes professionals is also required. The findings have helped produce suggestions for practice and research on how to improve support for youth with type 1 diabetes in schools in general and specifically in PE lessons.

Keywords

Qualitative children adolescents type 1 diabetes

Introduction

Physical activity is any body movement that results in an increase in energy expenditure above resting values and incorporates any activity done throughout the day in any location (Bouchard et al., 2006). Therefore, physical activity not only encompasses structured exercise and sport but other forms of physical activity including active travel (e.g. walking to and from school or the shops), play, and activities of daily living (e.g. household chores or carrying books to the locker in school).

In Scotland, primary (elementary) schools educate children aged 4–11 years and secondary (high) schools include adolescents aged 12–17 years. At school, physical activity can be undertaken in curricular or extra-curricular time. Throughout Europe, physical education (PE) in primary and early secondary school consists of mandatory physical activity classes undertaken during curricular time as part of the school timetable (European Commission/EACEA/Eurydice, 2013). Optional additional PE classes can be taken after reaching secondary year three in Scotland. Extra-curricular physical activities are done at school or in an external location with teachers from school/coaches external to school, outside of the school timetable.

This paper focuses solely on physical activity undertaken at school during curricular PE time. The majority of secondary schools in Europe, including Scotland, have specialist PE teachers based within single schools (European Commission/EACEA/Eurydice, 2013). Primary schools in Europe have generalist or specialist PE teachers (European Commission/EACEA/Eurydice, 2013). In Scotland, primary specialist PE teachers teach at several schools, or generalist teachers based within a single primary school lead PE sessions.

As for most European countries (Oja et al., 2010), in the UK it is recommended that youth achieve a minimum of 60 minutes of moderate-to-vigorous intensity physical activity per day (UK Department of Health, 2011). Approximately 50% of European countries have national PE strategies, highlighting the recognition of the importance of promoting physical activity in schools (European Commission/EACEA/Eurydice, 2013). The total amount of school time dedicated to PE, however, varies significantly across European schools, with mandatory PE equating to roughly 50–80 hours per year (European Commission/EACEA/Eurydice, 2013). There is a target for all schools in Scotland to deliver a minimum of two hours (primary) or two periods (secondary) of mandatory PE per week (Scottish Executive, 2007). A significant proportion of youth’s physical activity requirements can thus potentially be attained in PE (Ward et al., 2007). Participation in PE can result in not only physical health improvements in youth but can also benefit lifestyle, social, cognitive and affective areas of development (Bailey, 2006).

Type 1 diabetes is one of the most common long-term conditions in youth (Torpy et al., 2007). The UK currently has the fifth greatest rate of type 1 diabetes in youth in the world, after Finland, Sweden, Saudi Arabia and Norway, with 24.5 per 100,000 youth aged 14 and under diagnosed annually and approximately 26,500 confirmed cases (Diabetes UK, 2013).

As one per every 700–1000 youth in the UK are living with type 1 diabetes (Diabetes UK, 2012), it is likely that at some point in their career PE teachers will have a pupil with type 1 diabetes in their class. The condition requires appropriate management for safe participation in physical activity (American Diabetes Association, 2004; Robertson et al., 2008). Effective management requires the balancing of external insulin intake (via injection or insulin infusion pump therapy), carbohydrate intake and physical activity, with the aid of regular blood glucose monitoring. Over or under estimation of insulin or carbohydrate intake in relation to the amount of physical activity undertaken can result in blood glucose levels which are lower (hypoglycaemia) or higher (hyperglycaemia) than the normal range for people with diabetes. Acute hypoglycaemia and hyperglycaemia can negatively affect cognitive functioning and mood (Gonder-Frederick et al., 2009; Sommerfield et al., 2004), and untreated hypoglycaemia and hyperglycaemia is life threatening. Over the long-term, poor blood glucose control can lead to the development of complications (Cho et al., 2011; Margeirsdottir et al., 2007; Scanlon, 2008; Snell-Bergeon and Nadeau, 2012) such as kidney disease, blindness, and cardiovascular disease.

As the process of managing diabetes is complex for youth with type 1 diabetes, it is recommended that parents and teachers provide support, particularly during physical activities, to ensure good blood glucose control (American Diabetes Association, 2004; Robertson et al., 2008). Without support, blood glucose management may be inadequate, putting the patient at an immediate risk of negative effects and at a long-term increased risk of developing complications. In a study including 499 parents, 51% reported that their children had experienced hypoglycaemia during PE (Amillategui et al., 2007). Regular participation in physical activity in youth with type 1 diabetes can significantly improve health outcomes (MacMillan et al., 2013).

Despite the existence of physical activity guidelines for youth (UK Department of Health, 2011) and specific recommendations for the management of diabetes during physical activity (Robertson et al., 2008), studies from England, Switzerland, Italy and the US indicate that youth with type 1 diabetes do not meet the recommendations (Cuenca-Garcia et al., 2012; Maggio et al., 2010; Michaliszyn and Faulkner, 2010), and/or that they are less active than their peers without diabetes (Fintini et al., 2012; Maggio et al., 2010).

School provides many challenges for youth with type 1 diabetes. In Scottish high schools the structure of the day is known in advance, with timetables provided to pupils so that they are aware of when they have PE lessons. In primary schools, however, the structure of the day is flexible, with the content and timing of lessons in the hands of the teacher, and subject to change on a daily basis. This provides an extra challenge for the individual with type 1 diabetes in terms of their diet and insulin regimen, and particularly in relation to preparation for PE.

Set breaks are built into both primary and high school days for recess and lunch. Depending on the individual’s insulin regimen, youth may need to test their blood glucose, administer insulin or consume snacks outside of break time (e.g. during class time). The majority of schools have strict no eating in class policies. If the teacher does not have sufficient knowledge and understanding of diabetes they may not allow the individual to consume snacks during class time. If the teacher does allow youth with diabetes to manage their condition in class, this can result in the individual being singled out, teased or bullied by class peers if classmates do not understand the individual’s condition. Youth may not want to perform a finger-prick blood glucose test or administer insulin in front of their peers, and if teachers do not allow youth to leave the class, this could lead to them feeling uncomfortable or could result in them not testing their blood glucose or administering insulin. If youth with diabetes are allowed to leave the class there may not be a suitable, safe place where insulin can be administered in private.

Allowing pupils to bring packed lunches to schools, the food contents of canteens, and availability of healthy food options also vary across schools. Advance notice of menu contents may not be provided to pupils and foods do not always provide sufficient nutritional information, causing difficulty for youth in calculating insulin requirements. Finally, the level of diabetes knowledge and understanding of youth with type 1 diabetes to manage their own condition, and/or support available to them, will also affect their diabetes management in school.

All youth should be treated equally in schools, regardless of any disability they may have, including type 1 diabetes (Gooding, 1994; United Nations, 2002). A lack of translation of anti-discrimination legislation to implementation of diabetes support in schools is evident in most countries, with confusion over the roles and responsibilities of teachers (Lange et al., 2009). The American Diabetes Association has published recommendations on caring for youth with diabetes in school (American Diabetes Association, 2012). Despite legislation and recommendations in place, research has identified that diabetes care in schools is not always sufficient (Lange et al., 2009; Tolbert, 2009).

A review published in 2009 exploring the management of type 1 diabetes in schools identified: a lack of diabetes knowledge and need for education in staff and class peers; a lack of school nurse support; a need for better communication between those involved with youth with type 1 diabetes; a need for healthy food choices and foods with nutritional labels; and a need for improved extra-curricular support so that coaches are aware of care plans on how to manage diabetes (Tolbert, 2009). The review included 11 articles, all but one of which had been conducted in the US, highlighting the need for research in schools to be conducted elsewhere (Tolbert, 2009).

No studies have explored specifically issues related to diabetes management and support for participation in PE in schools, and limited research has explored if the lack of anti-discrimination legislation translation affects participation in PE in youth with type 1 diabetes.

This research is part of a larger qualitative study examining physical activity and sedentary behaviour (sitting time) and perceived support needs for youth with type 1 diabetes in youth with type 1 diabetes, parents, diabetes professionals and schoolteachers. This paper aims to provide guidance for schools on how to help support participation in PE in youth with type 1 diabetes to help guide future intervention research.

The overall aim of this study was to identify diabetes support needs in PE for youth with type 1 diabetes in order to aid the development of future interventions targeting teachers and schools. However, after data collection it became apparent that diabetes support in general in schools is inadequate. Hence, themes relating to diabetes support in school in general are also reported in this paper.

Materials and method

Participants and recruitment

Purposeful samples of youth with type 1 diabetes and teachers were recruited to explore differences between primary and secondary schools. Youth with type 1 diabetes and parents were recruited from a diabetes clinic in a Scottish city into a concurrent study measuring physical activity and sedentary behaviour in youth with type 1 diabetes. The first eight youth with type 1 diabetes and their parents recruited into the measurement study were invited and agreed to participate in the current study.

Physical activity and sedentary behaviour of youth with type 1 diabetes were measured using accelerometers (Actigraph Model GT3X+; Manufacturing Technology Inc., Pensacola, FL, USA), with time in health enhancing moderate-to-vigorous physical activity (Puyau et al., 2002) and sedentary behaviour (Fischer et al., 2012) determined using validated cut-points.

Eight children (5 F; 3 M) aged 7–9 years (elementary grade 1–4 (US); primary year 3–6 (UK)) and eight adolescents (4 F; 4 M) aged 12–14 years (middle or high grade 6–9 (US); secondary 1st–4th year (UK)) and their parents (2 M, 14 F; aged 32–52 years, mean age 41.9 ±5.9 years), participated in interviews (individually or in the presence of each other or with both parents/carers present). Youth with type 1 diabetes varied in diabetes duration (2.3–13.4 years), physical activity level (22.0–123.3 minutes of health enhancing physical activity/day) and sedentary behaviour level (7.0–12.3 hours).

Teachers varied in terms of experience (student or fully qualified practicing teachers), age (21–62 years; mean 37.5 ±15.1 years), and gender (26 F; 10 M). Five secondary schools were invited via telephone/email to the head teacher or head of the PE department. Three schools responded positively and two schools participated in focus groups held in the schools (one school changed their mind due to time commitments). The lead primary specialist teacher for the county area was approached via email to invite teachers to participate in focus groups held in a primary school where the teachers meet regularly.

Student teachers were recruited from two universities via email from course leaders from the following three courses: general primary teaching (undergraduate Bachelor of Education level (BEd primary)); primary specialist PE teaching (Professional Graduate diploma level (PGDE primary specialist)); and secondary PE teaching (Professional Graduate diploma level (secondary PGDE PE)). The lead researcher sent an email inviting students to participate, with a detailed study information sheet attached, to course leaders, who then forwarded the email to all students on their course. Inclusion of student teachers allowed us to explore current training of teachers in regards to managing type 1 diabetes in school and PE and to determine new teachers’ concerns about working with youth with type 1 diabetes.

Student teachers participated in four focus groups consisting of 4–5 students (BEd primary (n = 4), PGDE primary specialist (n = 4), secondary PGDE PE students (n = 9)). Practising teachers participated in four focus groups consisting of 2–8 teachers (primary specialist PE (n = 13) and secondary PE teachers (n = 7)).

Diabetes professionals were invited from the same clinic as youth with type 1 diabetes via a letter from the researcher distributed at team meetings by the lead physician. Eighteen letters were provided and nine diabetes professionals (6 F; 3 M), aged 33–53 (mean 44.2 ±8.1 years), replied positively and participated. Two physicians, three dieticians and four specialist nurses participated in two focus groups (n = 4 in each) and an individual interview (n = 1).

Adults and adolescents provided written consent. Children <12 years provided assent. University (teachers) and National Health Service (youth with type 1 diabetes, parents, diabetes professionals) ethical approval were obtained. Local authority approval was received to approach schools to recruit practising teachers.

Data collection

Focus groups and interviews lasting approximately 30–45 minutes were conducted using broad topic guides and interview questions. Focus groups and interviews can be utilised to describe, understand and explain areas/topics of interest (Barbour, 2000). A mixture of focus groups and interviews were used for convenience (e.g. geographic location of patient and parents’ homes was widespread, thus arranging group discussions in one location would have been challenging).

The following topics were explored with youth with type 1 diabetes, parents and diabetes professionals: knowledge, attitudes and experiences of physical activity, sedentary behaviour and type 1 diabetes individually and as combined experiences (e.g. physical activity and type 1 diabetes); the effect of influential figures on behaviour and their role in helping change behaviour; and current support characteristics and ideas for future support. Diabetes professionals were also directly asked about school performance of youth with type 1 diabetes and current clinic care for type 1 diabetes.

Teacher discussions covered the following areas: knowledge of type 1 diabetes in general and in relation to physical activity; influencers and influential figures for PE and physical activity participation in type 1 diabetes; teaching practice and ideas to accommodate youth with diabetes; and current diabetes support and training for teachers and perceived needs.

Focus groups with teachers were conducted at universities (student teachers) and schools (practising teachers). Focus groups and an individual interview were conducted with diabetes professionals at the diabetes clinic. Individual interviews with youth with type 1 diabetes and parents were conducted in their homes (n = 31) or another convenient location (n = 1). Data was collected by a researcher with extensive knowledge of physical activity and diabetes, and experience in conducting qualitative research. Discussions were audio recorded and researcher/s took notes on non-verbal cues during discussion. Demographic data were captured by questionnaire. Recordings were transcribed verbatim.

Data analysis

Thematic analysis was the qualitative research analytic approach used in this study (Boyatzis, 1998; Braun and Clarke, 2006). Thematic analysis is a qualitative approach adopted by numerous fields such as psychology and sociology. It seeks to systematically identify, analyse, and report patterns in the data, and can be understood as a tool to assist with data organisation, description, and analysis. While the epistemic foundations of thematic analysis are poorly articulated in comparison to more popular research traditions (such as grounded theory or phenomenology), it is compatible with both realist–positivist and interpretive–constructivist ontological and epistemological viewpoints. In this regard, it is compatible both with researchers who believe that there are real experiences and true facts to be reported, as well as those who consider knowledge to be a socially and historically situated production between the research and participant. Thus in this study, a constructivist thematic analysis approach was adopted and used to organise and explain the physical activity and health experiences of children living with type 1 diabetes from multiple perspectives.

Coding was done initially by a single researcher. Themes are patterns within data. Tables collating all excerpts relating to major and sub-themes were created to highlight the meaning of themes and to provide an indication of frequency. Three separate reports of findings from youth with type 1 diabetes/parents, teachers, and diabetes professionals, were produced before comparisons were made between participants. Rigour was ensured using the following multiple-coding checks. Due to the large number of transcripts (78 in total), a sub-set of transcripts were independently coded by two external members to the research team to consolidate the original coding as recommended by Barbour (2001). Previously published guidance was followed (Lombard et al., 2004), so that 10% of the total data was re-coded (four transcripts for each independent researcher). Additionally, two researchers from the study team read excerpts arranged under themes to check for agreement in coding of: all 32 interviews with patients and parents; teacher excerpts from 2/8 focus groups; and diabetes professional excerpts from 2/3 discussions. Discussions with internal or external researchers and the main researcher were held to discuss discrepancies in coding and vocabulary used for coding until consensus was met.

Results are presented in relation to the major themes with example excerpts provided in Tables 1–4 illustrating themes. In the text it is indicated if themes related to PE lessons only, school in general (e.g. encompassing all lessons, school breaks and extra-curricular activities) or if themes were mentioned by participants both in relation to PE lessons specifically and school in general. Excerpt numbers link table excerpts to the related results section. The type of respondent (patient, parent, professional, teacher (student or practising; primary or secondary teacher), and study participant identification number are provided with excerpts. Tables 3 and 4 also include suggestions for teachers and schools to help support youth with type 1 diabetes in school, and in particular to accommodate participation in PE at school.

Results

Four main themes arose relating to support needs for accommodating youth with type 1 diabetes specifically in PE and in the school context in general: (1) differences between primary and secondary schools; (2) areas requiring address in all schools; (3) what teachers can do to help accommodate youth with type 1 diabetes; and (4) what schools can do to help accommodate youth with type 1 diabetes.

Differences between primary and secondary schools

PE specific and school in general

Experiences and diabetes support in general at school and specifically in PE lessons varied considerably across schools. The majority of parents mentioned better teacher diabetes knowledge and/or support (such as nurses) in secondary compared to primary schools, as shown in Table 1 (excerpt 1.0).

Table 1.

Theme: differences between primary and secondary schools.

Sub-themes	Example excerpts highlighting sub-theme meaning	Excerpt number relating to text
Secondary schools have better facilities, equipment, variety and exposure to physical activity and greater teacher diabetes knowledge and support	‘I don’t think that uhm PE in primary is as good as it is in secondary schools… in secondary schools you’ve got specialists and in secondary schools it’s set up, the equipment is set up… very well. Plus you have really good facilities… secondary schools is set up to give you such a varied eh kind of selection.’ – mother of an adolescent boy (119)	1.0
Primary teachers are less aware of pupils with medical conditions and alert teachers based in the school regarding diabetes issues	‘I once had a child who was diabetic and had just been diagnosed and… her medication wasn’t settled and a few times she came to gym she took a hypo which is very scary and then she left the school so I don’t really know what happened but it made me kind of read up, well not read up, but find out a wee bit more about it because up until that point I hadn’t had anyone… We [primary specialists] are visiting people… The teachers and the classroom assistants took the responsibility, because I think in our situation where we don’t have the same class all day, they only come to us for a period and then they are away, we might not even have them the whole year, so we tend not to have the responsibility although… certainly in anytime I’ve diabetics, there tends to be a back-up.’ – primary teacher 127 (F2)	1.1
Peer support may be useful, particularly in secondary schools	‘Especially because like in high school uhm it’s probably, a lot of the kids will probably be like “that kid’s got diabetes” and they can tell the teacher as well. Whereas in primary you’ve got like 33 kids [laughs] and they’re all running riot in the gym hall [laughs] and you don’t know!’ – primary student teacher 138 (F2)	1.2
Diabetes professional visits in primary compared to secondary school	‘With the primary school, with the nurse coming in then, that would work fine. But I think when you go into secondary school that would be more of an “Oh no that’s so embarrassing”… And if they told them outside the school, if they had like, spoke to the diabetes nurse whatever outside the school they’d be like quite, they would be ok and confident in themselves… But I think that coming in to secondary would be a no-go.’ – primary student teacher 138 (F2)	1.3

PE specific

Several parents spoke of there being better facilities and equipment, more variety and greater exposure to physical activity in secondary compared to primary schools (excerpt 1.0). From discussions with teachers, it appeared that primary specialist PE teachers were least aware of which pupils had medical conditions and had the least communication and support with schools regarding medical conditions (excerpt 1.1). Primary specialist PE teachers mentioned they teach at several schools, making it challenging to learn about individual pupils’ needs. Primary specialist PE teachers felt the responsibility of care for those with diabetes should be with full-time staff within schools (excerpt 1.1), which was in agreement with some secondary teachers who felt that it was their responsibility to learn about and deal with diabetes. Classroom peers were mentioned by teachers as potentially useful for providing diabetes support in PE, but more so in secondary schools when youth with type 1 diabetes are older than in primary schools (excerpt 1.2).

School in general

Some teachers felt that school visits from diabetes professionals may be viewed negatively by secondary school aged youth with type 1 diabetes but useful for primary aged youth (excerpt 1.3).

Areas requiring address in all schools

Diabetes knowledge and support – PE specific and school in general

Teachers (student and practising) had limited diabetes knowledge, with areas of confusion that could potentially result in very serious consequences, particularly in PE settings, as highlighted in Table 2 (excerpt 2.0). Only a couple of youth with type 1 diabetes actually mentioned inadequate teacher knowledge or support in general at school or specifically in PE (excerpt 2.1a). The benefits of physical activity on health in general were well known by teachers. Teachers, diabetes professionals (excerpt 2.1b) and parents (excerpt 2.1c), however, often highlighted the limited knowledge, training, and support teachers (in general and specifically PE teachers) received regarding diabetes management. Most teachers had acquired their diabetes knowledge from knowing/teaching someone with diabetes, with no teachers reporting training in dealing with diabetes during university.

Table 2.

Theme: areas requiring address in all schools.

Sub-themes	Example excerpts highlighting sub-theme meaning	Excerpt number relating to text
Diabetes knowledge and support
Limited teacher diabetes knowledge that could result in serious consequences	‘I think that also it’s being able to recognise the difference between a hypo and a hyper… I think that’s important – I mean my understanding is you always give sugar? Is that correct?’ – specialist primary teacher 118 (F1)	2.0
Limited diabetes knowledge, training and support for teachers	‘I do tell them [teachers] but they don’t actually realise, if I’m actually going to be low but I do tell them… Once eh, eh I had my lunch, I was low before it. Had my lunch, they test me after it, I was… well high, of course that was supposed to happen… They didn’t know that. So then they had to make me run about and that… affect[ed] me to go low again… I don’t think they realised how high it could go.’ – young boy (110) ‘I have great sympathy actually for the schools. Although legally they are supposed to provide the same level of care that they would receive at home, teachers, they train to teach. And the sad fact is that uhm, is not just diabetes that… impinges on their time: asthma, epilepsy. And these also will have impacts on physical activity too. So I do have sympathy for teachers who are suddenly asked to give an injection, eh and monitor blood sugars… but things are moving in the right direction, it’s just that I think uhm [pause], education needs more support. And that, whether that comes from the education world or whether it’s actually a health issue I’m not entirely sure but there used to be school nurses in school for example. There aren’t now. There’s one for every five schools. Now that’s never going to solve this issue.’ – physician (109) ‘I’ll go to the school every lunch-time anyway to give them their insulin if they don’t come home for lunch… There is no registered nurse going in to the school, otherwise she would probably not need to go in.’ – mother of a young girl (123)	2.1a 2.1b 2.1c
Effects of having type 1 diabetes on school and PE performance
Youth with type 1 diabetes should not be singled out or treated any differently to those without diabetes	‘There was one instant when, it was when X [daughter] had not long been diagnosed with type 1 diabetes and it was high, her blood sugar, and they took her out of the school classroom and made her run around the gym hall. Which I know might be a good thing to do if it’s high but to do it in the middle of school and take her out! I, I was really annoyed… So I don’t think they [school] handle things that well to be honest with you… I’ve always tried to say to them [teachers] that they shouldn’t treat her any differently to, to any of the other kids cause I don’t want her to be singled out’ – mother of a young girl (105)	2.2
Inappropriate action regarding diabetes control (in this case teacher/patient preparation)	‘X [daughter] was doing cross country running and I said “who takes your monitor? Who takes your lucozade?” “Well no I get it when I come back.” And I’m like “Oh my good lord!” So I spoke to the teacher and they went “should we have?” And I said “of course! This activity of all!” – mother of an adolescent girl (103)	2.3
Using diabetes as an excuse to get out of PE	‘That has happened with X [my daughter] where she’s been told “just sit out the class.” And I’ve said, “no, absolutely [not]”… you don’t want them sitting out the class, you don’t want them thinking you know, “Oh I don’t feel well, right I won’t do the class.” Cause children will use that, manipulate that!… “I’m not doing it!”’ – mother of an adolescent girl (103)	2.4
Mind-set barrier not a diabetes related barrier to PE participation	‘There’s not really a… diabetic barrier. There’s… a mind-set barrier. But I’m not certain that that mind-set doesn’ae [doesn’t] always come from protecting themselves from diabetes. I think it’s the mind-set of eh “I don’t like physical education” or “I don’t like school” or some kind of combination of that. They’re the ones we have the barrier with and unfortunately nobody’s produced the thing that gets you over that hurdle… just having eh diabetes uhm is not a precursor for having to… limit participation, particularly in school PE where we rarely work to extremes… So the ones who are interested in sport will overcome… their diabetes and get on wi[th] it… I don’t think it’s the illness. I think there’s a mind-set… that indicates what they’ll do and how much they’ll do.’ – secondary PE teacher 116 (F2)	2.5
Teachers’ fear of diabetes related illness resulting in over caution during physical activity	‘Teachers… Might molly coddle them… So reacting the wrong way about someone who is independent… and “oh you just take a wee rest whenever you want”… or “just do what you can.”’ – specialist primary teacher 124 (F2)	2.6
Risks of physical activity in type 1 diabetes are often over-stated	‘In many, eight years, of diabetes camps, I’ve seen one child ‘slump’ with a hypo who needed a bit of glucagel or hypostop. I’ve never seen anyone have a convulsion. I’ve never seen anyone seriously unwell from a hypo. Uhm [pause] I’ve never had to for example give glucagon or had to give them a drip. That has never happened… And yet the sporting activity we’ve done has been… intense, very intense… and also has been totally out of the [pause] normal activity pattern of the child… So uhm I think the dangers are over-stated.’ – physician (109)	2.7
Missing class and difficulty concentrating	‘Sometimes when I’m in school when I feel hypo and I have to go check my bloods I miss things.’ – young girl (105)	2.8

The effects of having type 1 diabetes on performance – PE specific and school in general

Parents felt strongly that their children should not be singled out and treated differently to youth without diabetes in school in general and during PE lessons (excerpt 2.2). Although diabetes professionals mentioned that diabetes discrimination in schools was less apparent now than in the past, parents and diabetes professionals mentioned a few instances when youth with type 1 diabetes had been singled out because of their diabetes or inappropriate action regarding diabetes control had been taken in school or specifically in PE (excerpt 2.3).

The effects of having type 1 diabetes on performance – PE specific

Several teachers, parents and diabetes professionals perceived that some youth with type 1 diabetes would use their diabetes as an excuse to sit out of PE (excerpt 2.4), and that there were no diabetes related barriers to PE but rather the individual’s attitude towards PE determined participation (excerpt 2.5). Participants spoke of PE teachers’ fears of diabetes related illness as being a potential barrier to encouraging and supporting physical activity, as teachers may treat youth with type 1 diabetes with excessive caution (excerpt 2.6). Diabetes professionals pointed out that the risks of physical activity in type 1 diabetes are often over-stated (excerpt 2.7).

The effects of having type 1 diabetes on performance – school in general

Youth and parents mostly said that diabetes did not affect youth with type 1 diabetes in school. A few youth and parents mentioned negative effects of diabetes when blood glucose control was poor, such as their child missing/disrupting classes and having difficulty concentrating (excerpt 2.8).

What teachers can do to help accommodate PE participation and inclusion in school in general of youth with type 1 diabetes

Table 3 summarises what participants felt teachers could do to aid participation in PE and for general inclusion of youth with type 1 diabetes in school.

Table 3.

Theme: what teachers can do to accommodate PE participation and inclusion in general at school in youth with type 1 diabetes.

Sub-themes	Example excerpts highlighting sub-theme meaning	Suggestion for teachers	Excerpt number relating to the text
Educate all pupils on diabetes	‘The girl in my class actually her mum came and spoke to the whole class, which was quite good cause I think we were all a bit like “why is he going out to eat toffee crisps?” I’d be like, “why is she getting that and nobody else?” You know we didn’t understand it cause we were so young so her mum actually came in and spoke to us about it… so that was quite good to have an insight why X… needs to go cause she’s not feeling well or whatever… I think having a shared understanding then X wasn’t singled out having to leave the class the whole time, you knew why.’ – primary teacher student 135 (F2)	Ensure all pupils are educated on diabetes to avoid the patient being viewed as different/socially excluded. Provide general information regarding diabetes without identifying the individual with diabetes unless you have asked them and you are sure that they are comfortable with the class knowing about their condition.	3.0
Peer buddies	‘I don’t know if I’m right with this… not to give any responsibility to any other pupils but maybe just have a, a buddy next to them or someone that, that knows them quite well that they feel safe with… Because if they go into that emergency situation yes as a teacher you’re there but it’s eh [pause], you know it’s, it’s nice having somebody next to you that maybe knows how it works as well…’ – secondary PE teacher student 109 (F1)	Consider pairing up youth with type 1 diabetes with a ‘buddy’ (another pupil) to help watch for diabetes symptoms	3.1
Appropriate planning and procedures	‘I would plan the week before and say to them next week we’re going to be doing a higher level of exercise… so that they could… adjust their sugars… But the thing is you need to know that a diabetic needs to know that. And I wouldn’t know that had it not been for my circumstances… I wouldn’t know that just by being a teacher… I have learned a lot through the circumstances.’ – primary specialist teacher 119 (F1)	Provide advanced warning of the content of the next PE class to youth with type 1 diabetes and be aware of procedures for diabetes management or in case of emergency	3.2
Provide a supportive and comfortable environment	‘It’s a case of you making them feel comfortable in the environment and not feel isolated.’ – secondary PE teacher 112 (F1)	Ensure the patient feels supported, comfortable and included in the class	3.3
Communication between teachers, parents and youth with type 1 diabetes	‘Maybe just kind of half way through the lesson just kind of as they’re all busy doing activity you can just kind of go off and just go “everything ok?” Usually… the kid just doesn’t want to be spoken to or kind of singled out so if you do it when everyone’s busy, everyone’s not really watching and you can just kind of walk past and just go “everything alright” and you’d just get a wee [little] thumbs up… just engaging the child and just speaking to them to make the child and yourself aware that I know that you may need some extra help or that you may need to leave… I like that… link idea. If everyone’s kind of got this… shared goal and the point of… achievement is just to kind of get them involved… kind of give them as best experience as they can possibly achieve through the teaching that they receive and as their parents backing it up at home kind of thing… If you’re maybe kind of struggling with the people in school you can maybe talk to parents. The message can be reinforced at home. And it’s kind of very much a two way street in a sense, you can actually share a lot of information, “has he changed at home” or… “are things ok in school” that’s very much, parents can then really get involved.’ – secondary PE teacher student 106 (F1)	Subtly communicate with the patient during physical activity. Communicate with parents if necessary to aid the patient’s participation in physical activity	3.4
Develop trust between the patient and teacher	‘I think trust’s probably an important word. They need to trust that you know they can go down there and participate in the way they want to and they’re never going to feel embarrassed or even if there is a situation the teacher’s going to deal with it.’ – secondary PE teacher 111 (F1)	Build trust with the patient	3.5
Show teacher confidence to deal with diabetes	‘Maybe the teachers’ attitude as well. You could probably think that they’d [teachers] sort of molly coddle them in a way as well because of, well obviously we’ve all said that we’re not confident and that we wouldn’t know what to do so the teacher might be kind of like “right you don’t need to do this part.” And if it’s a child that isn’t confident or isn’t that interested they would just be like “oh right, fine, not bothered.”’ – primary teacher student 138 (F2)	Ensure you show confidence to deal with diabetes so that the patient does not use their condition as an excuse to sit out of physical activity	3.6
Have a positive teacher approach to diabetes	‘I think having a positive approach… that’s probably the most important thing… if they think that you actually… care about… what you’re doing for them and, “it is to your benefit,” and it’s trying to get that across to these… young people because it’s not easy.’ – secondary PE teacher 112 (F1)	Show youth with type 1 diabetes that you care and highlight the benefits of being physically active for the patient	3.7
Adjust encouragement for diabetes management based on age and diabetes duration	‘And also if you had a really young child with diabetes you wouldn’t expect them to… it takes them a long time before they can understand the feelings.’ – primary specialist teacher 123 (F2) ‘Yes and I think initially it takes a wee while to get the, well to understand the levels and when they need to have or take or do anything about it. I think it’s harder initially.’ – primary specialist teacher 130 (F2)	Provide more or less support depending on the age and diabetes duration of the patient	3.8
Target everyone, not just the most physically active pupils	‘School’s important but again schools’ view of exercise is gym, football, hockey, rugby – it’s not keeping moving, it’s not generally… I’m quite certain that although they have an obligation to make everybody do these things, they put all their efforts into the people that are good at them, because they get a reward out of that as well – the team wins a football cup or whatever. That’s, that’s good for them so they’re not really going to bother about the folk that don’t care… They’re not going to go beyond their statutory obligation.’ – physician (106)	Provide equal support to youth with type 1 diabetes of all physical activity levels	3.9
Allow the patient to provide some guidance	‘I would let them help guide me… so once if I’ve set the class up and say “ok if you get to the stage where you’re not feeling [well] then you have to tell me straight away.”’ – primary specialist teacher 121 (F1) ‘But are you not doing that with all children anyway?… So you wouldn’t necessarily only do it for a diabetic.’ – primary specialist teacher 119 (F1)	Allow the patient to help guide you but not to use their condition as an excuse	3.10

PE specific and school in general

Ensuring that youth with type 1 diabetes are surrounded by peers who perceive diabetes as not being a ‘big deal’ was viewed as important to avoid youth with type 1 diabetes from feeling isolated in school in general and specifically in PE. Although some participants felt educating pupils on diabetes was a way of ensuring this (excerpt 3.0), concerns from other participants of youth with type 1 diabetes being singled out (as mentioned earlier and in Table 2 – excerpt 2.2) suggests this may not be an appropriate approach for all. Perhaps providing only general information on diabetes, without identifying the individual with diabetes, would be appropriate in this instance. Another approach would be the introduction of peer buddies during PE to support youth with type 1 diabetes, as suggested by some teachers (excerpt 3.1).

PE specific

Appropriate planning and procedures in place, including advanced warning for youth with type 1 diabetes (excerpt 3.2), so the child feels supported and comfortable (excerpt 3.3) to participate in PE and physical activity in school, was one of the most important diabetes related facilitators to participation. Communication between teachers and youth with type 1 diabetes and their parents was seen as essential for effective planning and management of diabetes during PE (excerpt 3.4). Trust between the patient and teacher was perceived necessary (excerpt 3.5). Teacher confidence to deal with diabetes (excerpt 3.6) and having a positive attitude towards diabetes (excerpt 3.7) were perceived as helpful for encouraging diabetes management and participation in physical activity through motivation and reassurance. Encouragement for diabetes management during physical activity required from teachers was seen as age and diabetes duration dependent (excerpt 3.8). Diabetes professionals felt that schools provide most support to highly active pupils (excerpt 3.9). Teachers, however, spoke of being guided by the patient and providing an individualised experience in physical activity based on the patient’s needs, as for any pupil (excerpt 3.10). Teachers described their roles during physical activity as: watching for symptoms of illness, alerting the appropriate person in case of emergency, and carrying diabetes support bags. Peer support and enjoyment were the main general facilitators for PE and physical activity in and outside school for any youth, including those with diabetes.

What schools can do to help support PE participation and diabetes support in general in youth with type 1 diabetes

Continuity and knowledge exchange – PE specific

Continuity in the school timetable to aid diabetes preparation for physical activity and PE was mentioned as important, as shown in Table 4 (excerpt 4.0). Knowledge exchange between schools was mentioned by teachers as potentially useful for gaining ideas on best practice for inclusion of youth in PE and physical activity (excerpt 4.1).

Table 4.

Theme: what schools can do to accommodate PE participation and diabetes support in general in youth with type 1 diabetes.

Sub-themes	Example excerpt highlighting sub-theme meaning	Suggestions for schools	Excerpt relating to text
Continuity and knowledge exchange
Continuity	‘In school the timing of their lessons doesn’t necessarily fit with their injection and eating regime.’ – primary specialist teacher 119 (F1)	Provide continuity to avoid disruption to diabetes regimens	4.0
Knowledge exchange between schools	‘What we don’t know is what else is there… that we don’t know… so it might be quite good once your findings are… sharing practice yep… pass them back to us.’ – secondary PE teacher 112 (F1)	Knowledge exchange between schools on the care of youth with type 1 diabetes in PE could be useful	4.1
Facilities and communication
Facilities	‘When he was in primary school he had to go in the disabled toilet to do his injections. So I just felt the standards then, so I brought it to their attention… I think eventually I think by the time he was just leaving school, primary 7, they let them go into… the office thing to do his injection. So I just don’t feel there’s somewhere there for them to do injections aha. And I feel to let them go into a toilet and do it, I think that’s appalling.’ – mother of an adolescent boy (116)	Provide a private space for youth with type 1 diabetes if they do not wish to test their blood glucose or administer insulin around others	4.2
Communication between schools and clinics	‘“Oh we’ve, we’ve, we’ve had hundreds of diabetics through the school,” is what they’ll say to you and you’ll go, “yeah but that implies every diabetic’s the same,” but they are not… They as, as a group of teachers of all that should be made aware of it that… I think from an activity point of view PE teachers could be made much, much more knowledgeable about managing the condition… Whereas I don’t think they [PE teachers] really know how to do that and the difficulty is what will make X high [will] make another child hypo… this umbrella term “diabetes” is just that… Very poorly understood.’ – mother of an adolescent girl (103)	Utilise diabetes professional visits and communication to gain individual information about youth with type 1 diabetes	4.3
Schools have a responsibility to inform teachers of youth with medical conditions and the teacher’s role in helping support youth with diabetes in PE and physical activity	‘You’ve got like so many other children in the class and they pure like “oh freaking out,” you know yourself you’d be freaking out as well if they were having a hypo. So it’s just like making sure like everyone, all the teachers in the school are aware of the child’s, uhm diagnosis so they can all help out… I think like more information we need as well on like responsibility cause we were talking about “oh do you send them to the office and stuff” at schools and then in other schools it might be a case of you know that’s your… the teacher’s responsibility or it’s all on the child and I, I think obviously it would differ between cases but you just wouldn’t even know [laughs]… like responsibilities, whose role.’ – primary teacher student 138 (F2)	Schools should have procedures in place so that teachers are aware of youth with medical conditions. Schools should clearly state the roles of teachers in the support of youth with diabetes	4.4
Training and support requirements
Practical hands-on diabetes training	‘What’s needed [for teachers] is one to one or maybe one to three… practical [pause] guidance on this is how you put a pen together, this is how you add the needle, this is how you [pause] prepare a pen, this is how you give the injection uhm. This cannot be done in a, in a broad sense with a lecture you know or with 30 or 40 or 100 people… I would think you could do general discussion. But I think a lot of it now is coming down to very [pause] precise, hands-on, information. How do you do a blood glucose? What had, what do you do with the lancet once you’ve finished with it? What do you do with the pen, needle? Uhm these practical things are very, very important uhm with risks of needle stick injury and all the rest of it. Plus the fact that you’re giving something that potentially is lethal. So you know there, understandable concerns.’ – physician 109	Universities during teacher training and/or schools should provide practical training for student and practising teachers on dealing with diabetes	4.5
Education on diabetes at school	‘I think that in their in-service days… every year as a teacher I have to go through training on… child protection. Why can’t they have something on medical conditions?… I think it should be part of their training. And it should be every year. So that they get bored silly with it… because it’s been reinforced. They know what routine, what if he has a hypo in class.’ – mother of an adolescent boy (119)	Schools should provide regular education on medical conditions for teachers (such as yearly in-service training days)	4.6
Extra support above parental expectations	‘I organised a meeting with the head teacher, the deputy-head, a nurse, a nutritionist and the class teacher and me [before a school trip]… we uhm got the menus for two weeks, we did all the calculations on it… I’ve written out all the protocols… they [teachers] were excellent cause they would phone me and they sent me pictures of him having a good time… it was all about… speaking to the people that were taking care of him… We couldn’t have been any more prepared. And then it was just for me, I had to wave him goodbye.’ – mother of an adolescent boy (119)	Schools should consider additional support that they can provide for youth with type 1 diabetes, such as contact with parents or hiring nurse assistants during school trips	4.7

Facilities and communication – school in general

A couple of parents highlighted limited facilities in school for diabetes preparation/management (excerpt 4.2). Communication between schools and clinics and parents was perceived essential. Some parents and teachers mentioned that schools had declined visits from diabetes professionals, as they perceived they already had sufficient knowledge about diabetes. Parents pointed out that each youth with diabetes differs and therefore individualised advice for each person should be welcomed by schools (excerpt 4.3). The majority of teachers felt that schools have a responsibility to ensure that procedures are in place so all teachers know which youth have medical conditions and what the teachers’ responsibilities are in the support of the individual with diabetes (excerpt 4.4).

Training and support requirements – PE specific and school in general

Youth with type 1 diabetes, parents and diabetes professionals spoke of a lack of training and support for teachers on dealing with diabetes. The majority of participants felt practical hands-on diabetes training in schools is needed (excerpt 4.5) as well as education to increase diabetes knowledge (excerpt 4.6). A couple of parents spoke of times when their child’s school had provided extra support above and beyond their expectations to cater for their child with diabetes, such as extensive contact with parents or hiring of diabetes assistants during school trips (excerpt 4.7).

Discussion

The findings of this study highlight the need for improved support from schools and teachers to support youth with type 1 diabetes to participate in PE in school. Better and consistent training in diabetes management for teachers is required to help achieve improved support for youth in school. Procedures for communicating which pupils have medical conditions, how to manage diabetes and the responsibilities of teachers varied considerably across schools.

Differences in primary and secondary schools were highlighted, suggesting different intervention support may be required. In summary, primary schools could ensure greater variety and exposure to physical activity, and better diabetes support including improved communication between schools and primary specialist teachers regarding youth with type 1 diabetes. Previous research has indicated poor communication in schools. A study conducted in Spain reported that 22% of 499 parents perceived that their children’s PE teachers did not know that their children aged 3–18 years had diabetes (Amillategui et al., 2007). Procedures could be in place in schools so that teachers know which pupils have medical conditions and teachers could be informed of their responsibilities and roles towards helping manage diabetes.

Diabetes knowledge in all teachers (primary and secondary) was limited. Several teachers did not mention and/or were not clear of what hypoglycaemia was, which in a PE setting is the most likely diabetes problem to occur. The recognition and management of hypoglycaemia are highly specific and essential skills for anyone working with youth with diabetes. The present study identified that teachers require better professional development in regards to dealing with diabetes (and medical conditions in general) in PE settings and regular continuing professional development should be provided. Approximately 20–30% of adolescents have a chronic health condition (Yeo and Sawyer, 2005). As highlighted by several teachers in this study, an overview of dealing with the main chronic conditions prevalent in youth could be extremely important in helping support all youth to participate to their full capacity in PE. Inclusion of primary specialist teachers, who move between schools, should be considered when delivering training. Previous research acknowledged the need for general diabetes management training in teachers (Pinelli et al., 2011). Data from a survey identified 58% of 1905 youth, 73% of 4099 parents and 86% of 650 diabetes professionals perceived that teachers should have better diabetes knowledge and/or support (Lange et al., 2009).

Schools could consider continuity in timetabling and informing youth/parents of changes in timetabling to support the complexity of diabetes regimens, in alignment with published guidance (American Diabetes Association, 2012). An appropriate location where the individual can perform blood glucose checks and administer insulin in privacy should be available, and school support should be in place so parents are not required to attend to administer insulin (American Diabetes Association, 2012). A survey conducted in the UK of 3000 schools identified that 70% of schools anticipated that parents would visit the school to administer insulin if youth were not able to manage diabetes independently (Diabetes UK, 2009). Another study including 499 parents reported that 16% of their children’s diabetes regimens had to be adjusted because schools were not providing sufficient support to continue with the individual’s normal routine (Amillategui et al., 2007).

The present study identified inclusion of youth with type 1 diabetes in PE as an important issue, with several participants believing that youth would use their condition as an excuse to sit out of PE. Parents felt strongly that their children should be treated as normal and did not want their children using diabetes as an excuse. Teachers, diabetes professionals and parents spoke of teachers’ fears of diabetes illness during physical activity, which could encourage the individual to sit out of PE.

Low teacher confidence to deal with type 1 diabetes in general in school has been reported elsewhere (Amillategui et al., 2007; Pinelli et al., 2011), and for dealing with asthma specifically in PE settings (Williams et al., 2010). Determining youth who were unmotivated from those who were not physically able to participate in PE was, as in the present study in relation to diabetes, found to be an issue for teachers of youth with asthma (Williams et al., 2010). To boost the teacher’s confidence in encouraging participation in youth with type 1 diabetes, communication with parents/carers and being aware of procedures and responsibilities for managing diabetes in the school was perceived in the present study as important.

Strategies teachers could use to ensure an inclusive, supportive and comfortable atmosphere for participation in PE include: communicating with youth during activity; providing advanced warning of class content to aid diabetes management; educating all pupils on diabetes (in general or specific to the individual if they are comfortable with having their condition disclosed to others in the class); building trust with youth; displaying teacher confidence to handle diabetes and awareness of the benefits of physical activity for diabetes; allowing the individual with diabetes to help guide the teacher; and including peer ‘buddies’ to support the individual.

Training from diabetes professionals was perceived important in the current study to effectively prepare for individual differences in support needs. Schools could therefore be encouraged to accept training from diabetes professionals. Only 33.3% of schools in Italy received training from diabetes professionals as reported by parents (Pinelli et al., 2011). Training from diabetes professionals was perceived as necessary for teachers by 60.8% of parents (Pinelli et al., 2011). Although 40.4% of teachers reported that they had completed diabetes management training, only 33.3% of teachers had received training from diabetes professionals, with most teachers gaining training from parents (Pinelli et al., 2011). The American Diabetes Association and the International Society for Paediatric and Adolescent Diabetes recognise the responsibility of parents to provide teachers and coaches with written and verbal information on hypoglycaemia risk, symptoms and treatment regarding the individual (American Diabetes Association, 2005; Robertson et al., 2008).

Only a few parents and youth mentioned that nurse support in school was or had been available in the past. Another study also reported low or no availability of nurse support in school (Pinelli et al., 2011). A previous study found that although a large portion of parents felt blood glucose control was at an acceptable level at school, 72% and 66% perceived the inclusion of a school nurse or trained teacher, respectively, would result in better control (Amillategui et al., 2007).

In a previous study (Amillategui et al., 2007), 16% of parents reported challenges (relating to the schools’ responsibilities) in including their children with type 1 diabetes in one-day extra-curricular physical activity trips. In the current study, discrimination actually stopping participation in physical activity was rare. Some parents, however, spoke of inappropriate actions to treat diabetes.

This study focused on PE lessons at school. PE teachers are often coaches for extra-curricular activities. The findings in regards to extra-curricular activities will also be applicable to PE teachers acting as coaches. Future studies should capture the perceptions of coaches, other than those trained as PE schoolteachers, on supporting physical activity participation in youth with type 1 diabetes, to identify their concerns and support needs. Several discussions were conducted from multiple perspectives in this study, ensuring trustworthiness. Multiple coding and checking of data coding, using the coding scheme developed by the initial researcher, were used to further ensure rigour. Saturation was reached for youth, parent and teacher discussions – no new major themes arose nearing the end of data collection. Only two focus groups and one interview were conducted with diabetes professionals due to the limited number of professionals working within the clinic. Although the same themes arose from the three discussions with diabetes professionals, it is difficult with such a small number of discussions to know if true saturation was met. The clinic from which youth/parent and diabetes professionals were recruited spans a large city and its outskirts in Scotland, with over 600 youth with type 1 diabetes registered at the clinic. At the time of conducting this study there were 18 diabetes professionals working at the clinic, of which half were successfully recruited. Youth and parents lived in a widespread area, with youth attending many different schools. The practising teachers recruited into this study also taught in different parts of the city and student teachers were recruited from two universities within the city. Suggestions have been made in Tables 3 and 4 as to how schools and teachers can help support youth with type 1 diabetes in school generally and to participate in PE specifically. Future research should now explore diabetes support in PE quantitatively in other locations to determine if the findings are generalisable and if research is warranted to explore the use of the strategies suggested here, in relation to the management and support of diabetes by teachers and schools.

Guidance for managing diabetes in schools recommends that schools, parents and diabetes professionals should develop individualised diabetes health care plans together, clearly stating the responsibilities of youth with type 1 diabetes, teachers and parents (American Diabetes Association, 2012). The current study confirms that this guidance is not being followed universally across schools in a Scottish city. There is currently no national approach for the care schools should provide for diabetes management in Scotland, as is the case for many countries (Lange et al., 2009). Despite Scotland’s ‘Additional Support for Learning (Scotland) Act 2009’ (Scottish Government, 2010), which advocates that necessary extra support should be provided to youth that require it so that all youth can successfully learn, there is a gap between having and applying legislation (Lange et al., 2009). Although the UK rated adequate for availability of diabetes educational resources and training for school staff in a previous study, a limited rating for legislation allowing nurses or school staff to provide diabetes support and handle emergencies was evident (Lange et al., 2009).

Examples of well-functioning national approaches can be found in Germany, Sweden and the USA (Lange et al., 2009). In Germany, educational training delivered by nurse educators on diabetes is available for primary school teachers. Schools in Sweden have clear definitions of the responsibilities of teachers in the care of diabetes in pupils, and basic diabetes management training can be undertaken during teacher university training. In the USA, detailed anti-discrimination laws, a standard reporting system for parents to report issues at school, and widespread availability of school nurses in schools exist (Lange et al., 2009). At a local level, in Leeds in the UK, close collaboration between families, schools and diabetes clinics has led to the production of individualised diabetes management plans and agreements between school staff, parents and professionals on their roles in the care of the individual with diabetes in school (Hill et al., 2007). These national and local approaches should be aspired to and used to guide future initiatives. Diabetes UK have also suggested strategies to ensure consistent and appropriate care of youth with type 1 diabetes across UK schools (Diabetes UK, 2008).

Teachers and schools, if applying new approaches for diabetes training and support, could attempt to measure the impact of introducing training/support (for example on individuals’ participation in PE and teachers’ confidence) to determine effectiveness. Proving the worth of training/support will help gain backing from funders, local authorities and government legislation, for the implementation of better training and support for diabetes management for schools and teachers.

Conclusion

The findings of this study have helped develop suggestions on how to help encourage participation in PE in youth with type 1 diabetes. The findings will be useful in practice, for teachers and schools, and in future research for the development of interventions. Guidance on developing physical activity interventions for youth, including in school, is available (Kelly et al., 2012; National Institute for Health and Clinical Excellence, 2009; Timperio et al., 2004; Ward et al., 2007). Resources such as these should be consulted alongside the findings of this study to aid the development of interventions for youth with type 1 diabetes.

This study indicated important elements that should be incorporated or targeted by interventions developed for research or practice purposes. The findings of this paper highlight the urgency of better guidance on handling diabetes in PE and in general in schools, and future research should explore the efficacy of interventions aiming to improve teacher support for youth with type 1 diabetes.

Footnotes

Acknowledgments

We wish to thank all study participants and the hospital where this research was undertaken.

Funding

This study was conducted as part fulfilment of a PhD funded by the Scottish Funding Council and the University of Strathclyde.

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