A cross-country qualitative analysis of teachers’ perceptions of asthma care in sub-Saharan Africa

Asthma affects approximately one in ten adolescents globally, with some urban settings in sub-Saharan Africa (sSA) reporting symptom prevalence up to 21.7%. Half of adolescents with asthma in sSA experience severe symptoms, and many remain undiagnosed or poorly controlled due to limited access to appropriate treatments. Global reports indicate substantial burdens of severe symptoms, exercise-induced symptoms, sleep disturbance, and nocturnal cough among adolescents with asthma. Poor control is associated with reduced school attendance and academic performance. Education is considered a key intervention in low-resource settings, with schools and teachers being central to holistic asthma care. Evidence from high-income countries highlights teacher knowledge gaps and poorly organized school support systems, and systematic reviews suggest that written school health policies and sustained education programs improve preparedness and teacher knowledge. This study set out to determine teachers’ roles in caring for adolescents with asthma, to identify school-related barriers and facilitators to care in urban sSA contexts, and to assess teachers’ perceptions of asthma care within schools.

Prior work indicates high asthma symptom prevalence and severity among adolescents, particularly in sSA, with poor control linked to inadequate access to essential medicines. The Global Asthma Network and ISAAC studies report significant rates of severe symptoms and nocturnal cough, with educational interventions shown to improve asthma control and knowledge in various contexts. School-based policies and continuous education improve preparedness for acute episodes. Multiple studies document teacher knowledge deficits, reduced self-efficacy in managing acute asthma, and concerns about technical aspects of inhaler use and dosing. Health literacy among adolescents, caregivers, and teachers is emphasized as fundamental to better asthma control. Evidence also supports appointing school-based ‘asthma champions’ to improve advocacy, communication, and management across stakeholders. Despite these insights, there is limited Africa-specific, multi-country qualitative evidence on teachers’ perspectives, which this study addresses.

Design: Qualitative component of the NIHR-funded ACACIA observational cohort across Ghana, Malawi, Nigeria, South Africa, Uganda, and Zimbabwe. Objective: identify school-based barriers/facilitators to asthma care and inform school interventions. Selection: Teachers were recruited from at least three schools per city where adolescents with physician-diagnosed asthma and those with asthma symptoms without diagnosis had been identified via a Breathing Survey based on Global Asthma Network items. Sampling was convenience-based among consenting teachers. Setting: Government and private, residential and non-residential schools in Kumasi, Blantyre, Lagos, Durban, Kampala, and Harare. Timing: 01 Nov 2020–30 Jun 2021. Data collection: Face-to-face FGDs (5–8 participants per group), in English, moderated by at least two facilitators (one site investigator), 40–60 minutes, audio-recorded, transcribed verbatim. A standardized semi-structured guide (covering understanding of asthma, experiences in school, acute episode responses, confidence needs, school impact, and improvement ideas) was used across all sites. COVID-19 regulations were observed. Analysis: NVivo 1.6 was used. An inductive thematic approach was conducted by a 10-member cross-country coding team. Each transcript was independently coded by at least two investigators. Through iterative discussions, a codebook was developed following published guidelines and finalized upon code saturation. Braun and Clarke’s six-step thematic analysis identified patterns, minor themes, sub-themes, and major themes, with consensus across the multi-country team. Patient and public involvement: The FGD process was co-developed with local school staff; questions were piloted in Nigeria. Adolescents and teachers were involved at several stages of ACACIA but not directly in FGD recruitment/conduct. Ethics: Approvals included Ghana (CHRPE/AP/074/19; CHRPE/AP/071/20), Malawi (COMREC/P.10/18/2494), Nigeria (LREC/06/10/1084), Uganda (MHREC/1514; UNCST/SS4940), Zimbabwe (MRCZ/A/2415), South Africa (BREC/BF002/19). Written informed consent obtained; data de-identified and securely stored. Trial registration: 269211.

Participants: 20 FGDs across six countries; n=153 teachers (mean 7–8 per FGD). Distribution: Ghana 4 FGDs/33 participants (21.6%); Malawi 3/10 (6.5%); Nigeria 2/24 (15.7%); South Africa 7/57 (37.2%); Uganda 2/15 (9.8%); Zimbabwe 2/14 (9.2%). Demographics/experience: 66.7% (n=102) female; 55.9% (n=84) knew someone with asthma; 11.1% (n=17) self-reported asthma; 29.4% (n=45) had formal asthma training. Major themes: (1) Barriers to care; (2) Suggestions to improve care. Barriers sub-themes: • Lack of knowledge and skills among teachers, adolescents, and caregivers on mitigating triggers and managing acute episodes, creating anxiety and low confidence. • Traditional beliefs (e.g., emotions as triggers; reliance on herbal or alternative practices; religious attributions) affecting recognition and management. • Impact on adolescents: sport hesitancy, frequent sick days, curtailed social activities, stigma and nondisclosure, parental overprotectiveness and anxiety. • Restrictions on school-based care: limited school health services and nurses focused mainly on immunizations; policies preventing teachers from administering medications without parental consent. Suggestions sub-themes: • Inclusive, innovative asthma training for teachers, adolescents, and caregivers, with practical focus on acute management (e.g., inhaler technique) and trigger mitigation; use of engaging formats (drama, music, assemblies) to sustain interest. • Appoint teachers with personal asthma experience as ‘asthma champions’ to lead advocacy, support peers, and assist students. • System-level improvements: annual school health screening to identify asthma and maintain updated records; provision of inhalers on-site, especially in residential schools; clearer guidance on teachers’ roles in acute medication administration. Overall: Barriers and proposed solutions were consistent across all six countries.

The study addresses the knowledge and systems gaps hindering effective school-based asthma care in sSA. Teachers’ perceived deficits in knowledge and practical skills undermine confidence in managing acute episodes and guiding trigger avoidance. Findings align with global literature showing that teacher education alone may be insufficient unless embedded within a broader, inclusive strategy engaging adolescents and caregivers, and tailored to practical skills such as inhaler technique. Innovative educational modalities can also counter misconceptions, reduce stigma, and support participation in sports and other school activities. The suggestion to establish ‘asthma champions’ among teachers offers a feasible approach in contexts with scarce school nursing, enhancing advocacy, communication, and preparedness. Formalizing annual screening and record keeping can improve readiness for acute care and inform trigger management, while policy clarity on teachers’ roles in medication administration is crucial in LMIC settings. Collectively, these measures can contribute to a more seamless continuum of care across home, school, and health services.

This multi-country qualitative study identifies common barriers to school-based asthma care across six sSA countries, chiefly inadequate knowledge and skills, traditional beliefs, stigma, and policy restrictions on medication administration. Teachers recommend inclusive, practical, and engaging asthma education for teachers, adolescents, and caregivers; appointment of teacher ‘asthma champions’; annual health screening with robust record keeping; on-site availability of inhalers; and clearer policy guidance for acute care. These insights inform the design of comprehensive, school-centered asthma interventions in resource-limited contexts. Future research should evaluate the effectiveness and scalability of inclusive training models, asthma champion programs, and policy reforms, including in rural settings.

The sample was drawn from urban schools only, limiting generalizability to rural contexts. Member checking was not conducted. As with qualitative research, researcher bias is a potential risk; reflexivity and multidisciplinary team discussions were used to mitigate this. Convenience sampling may introduce selection bias. Findings reflect perceptions and may not capture all contextual variability across or within countries.