Asthma is a prevalent chronic respiratory disease among adolescents globally, with a disproportionately high burden of severe asthma in Sub-Saharan Africa (SSA). Many adolescents with asthma in SSA remain undiagnosed, and even those diagnosed often experience poorly controlled asthma due to limited access to appropriate treatments. The Global Asthma Network (GAN) reports highlight the significant impact of poor asthma control on school attendance and academic performance. Education on asthma is crucial for better control, especially in low-resource settings. Schools and teachers play a vital role in holistic asthma care, yet data on teachers' perceptions and knowledge in Africa is limited. Previous studies in high-income countries indicate a perceived lack of knowledge among teachers regarding asthma management, while the organization of school support systems for asthma care in Africa is often inadequate. A systematic review suggests that written school health policies and sustained asthma education programs improve preparedness for acute asthma episodes and overall asthma knowledge in teachers. This study aimed to determine teachers' roles in asthma care, identify barriers and facilitators related to the urban school environment in SSA, and assess teachers' perceptions of asthma care within the school setting.

Existing literature reveals a global knowledge deficit among teachers regarding asthma management, particularly concerning the technical aspects of inhaler use and fear of overdosing. Studies from high-income countries highlight the perceived lack of knowledge and self-efficacy among teachers when managing acute asthma episodes. The need for comprehensive asthma education involving all stakeholders (adolescents, parents, and teachers) is widely acknowledged. While some studies show that isolated teacher training improves knowledge, the overall impact on asthma care remains limited, emphasizing the need for an inclusive approach. The concept of 'health literacy'—the ability to access, understand, and utilize health information—is crucial, as low health literacy among teachers exacerbates anxiety and hinders effective management. Creative educational modalities, such as drama and music, have shown promise in sustaining interest and addressing misconceptions related to asthma. The role of 'asthma champions'—teachers with personal experience with asthma—in improving outcomes and advocacy is also supported by research.

This cross-sectional qualitative study employed focus group discussions (FGDs) as its primary data collection method. The study, part of the NIHR-funded ACACIA project, took place in six Sub-Saharan African countries (Ghana, Malawi, Nigeria, South Africa, Uganda, and Zimbabwe) between November 1, 2020, and June 30, 2021. Teachers from at least three schools in each participating city were recruited using a convenience sampling method. The FGDs were conducted face-to-face, adhering to COVID-19 regulations. A standardized, semi-structured interview guide (Table 1) was used, with discussions lasting 40-60 minutes and audio-recorded and transcribed verbatim. Data analysis used NVivo 1.6 software, employing an inductive approach with a ten-member coding team to ensure standardization across countries. The Braun and Clarke six-step thematic analysis framework was used to identify patterns and themes. The coding and theme identification involved an iterative process, achieving consensus among investigators. Ethical approval was obtained from all study sites, and participants provided written informed consent.

Data analysis from 20 FGDs involving 153 teachers revealed two major themes: barriers to asthma care and suggestions to improve care. **Barriers to Asthma Care:** * **Lack of Knowledge and Skills:** Teachers reported deficiencies in their knowledge and skills regarding asthma management, particularly concerning acute episodes and trigger mitigation. This lack of knowledge influenced teachers’ experiences when managing adolescents with acute asthma attacks. Teachers experienced these episodes as 'daunting' and 'scary'. * **Traditional Beliefs:** Traditional beliefs, including the role of emotions in triggering asthma and the use of alternative treatments, were prevalent, impacting effective asthma management. * **Impact on Adolescents:** Uncontrolled asthma negatively affected adolescents' school attendance, participation in sports, and social activities. Stigma associated with asthma also contributed to delayed diagnosis and management. * **Restrictions on Care:** Limited school health services and legal restrictions on teachers administering medication without parental consent presented significant barriers. **Suggestions for Improvement:** * **Inclusive Training:** Comprehensive asthma training programs involving adolescents, parents, and teachers were recommended, utilizing creative methods to engage learners. * **Asthma Champions:** Utilizing teachers with personal asthma experience to lead and promote care was suggested to enhance teacher confidence and provide peer support. * **Annual Screening and Inhalers:** Annual asthma screening and providing inhalers in schools were deemed essential for early identification and prompt management of acute episodes.

This study's findings corroborate existing literature on the knowledge deficits among teachers regarding asthma management. The lack of comprehensive knowledge and skills compromises the provision of seamless asthma care across home, school, and healthcare facilities. The emphasis on inclusive training programs for all stakeholders addresses the limitations of isolated teacher training. The suggested use of creative training methods aims to address misconceptions and improve the engagement of adolescents and their parents. The identification of 'asthma champions' among teachers provides a practical solution to address the scarcity of healthcare professionals in many African schools. The recommendations for annual screening and clear policies on teachers’ roles in administering medication in acute episodes aim to improve preparedness and reduce anxiety.

This study underscores the need for comprehensive interventions to improve asthma care in Sub-Saharan African schools. Inclusive asthma training programs, utilizing creative methods and involving all stakeholders, are crucial. Empowering teachers with personal experience as 'asthma champions' can significantly enhance care delivery. Implementing annual health screenings and addressing legal restrictions on medication administration will further optimize asthma management in schools. Future research should explore the effectiveness of these recommended interventions and investigate the specific needs of rural schools.

This study focused primarily on urban schools, limiting the generalizability of findings to rural areas. The absence of member checks and potential researcher bias, inherent in qualitative studies, should also be considered. The inductive approach used may have influenced interpretation. Despite these limitations, the study provides valuable insights into teachers' perspectives across multiple countries.