The data were transcribed and analysed from 20 FGDs across six countries. A total of 153 teachers were included as study participants, averaging between seven and eight participants per FGD (Table 2). Of these teacher participants (n = 153), 66, 7% (n = 102) self-identified as female, 55.9% (n = 84) knew someone with asthma, 11.1% (n = 17) suffered themselves from asthma, and 29.4% (n = 45) indicated that they had had formal training in asthma.

After coding the data, multiple themes were identified that related to teacher perspectives on asthma care in school. Those themes were found to be common across all countries and were then selected and categorised as minor -themes. Investigators then clustered these 30 minor themes into seven sub-themes that reflected aspects of asthma care within schools. Minor themes had to resonate around a common aspect of care that affected teachers’ perspectives on managing adolescents with asthma in the school for these to be aggregated into a sub-theme. This iterative process focused on perspectives considered most influential on asthma care in all countries. These sub-themes were only finalised when all investigators from all countries had reached a consensus. Investigators’ perspectives then focused these sub-themes into major themes based on the overall aim of the study to determine factors either enabling better care or creating barriers to asthma care within schools. The two major themes were categorised as (1) barriers to caring for adolescents with asthma in school and (2) suggestions to improve the care of adolescents with asthma in school. Figure 1 illustrates the inter-relationship of the minor themes, sub-themes and major themes identified.

Within the first major theme, multiple sub-themes were identified: lack of knowledge and skills on mitigating asthma triggers and managing an acute asthma episode; traditional beliefs – this was defined as commonly held understandings by teachers on causes and management of asthma that are different than those understandings generally accepted within the allopathic understanding of asthma; Impact of asthma on adolescents (sick days, sport hesitancy, stigma from other adolescents, parental denial) and restrictions on teachers administering asthma care in school. In the second theme, the following subthemes were identified: providing inclusive asthma training (involving adolescents, caregivers, and teachers); appointing teachers who have personal experience with asthma to lead and promote care for adolescents with asthma in schools, and improving care for adolescents with asthma with annual asthma screening and provision of inhalers onsite in school.

Lack of knowledge, skills and support in mitigating asthma triggers and managing acute asthma episodes was a universal finding in all FGDs. Teachers identified deficiencies in their knowledge and skills regarding asthma. This lack of knowledge was primarily attributed to a ‘lack of formal training’ on asthma care in schools and created a general ‘need (for) more information at school level, especially in relation to the technique issues.’ (ZA, FGD 1).

Teachers were particular about which aspects of knowledge and skills in asthma they perceived themselves, the adolescents and their families to have deficiencies in. The deficiencies were related to an inability to adequately care for adolescents during acute asthma episodes and to mitigate against asthma triggers, (Table 3, quotes 1 and 2). This lack of adequate knowledge influenced teachers’ experiences when managing adolescents with acute asthma attacks. Teachers experienced these episodes as ‘daunting’ and ‘scary’. Furthermore, teachers observed that adolescents were unaware of their condition as asthma or of the severity. There was also a lack of adequate understanding of the role of triggers (exercise, sporting activities, smoke, and dust) and how avoidance of these should be navigated within the school environment.

The most common traditional beliefs held were related to the dominant role emotions play in triggering asthma attacks and the use of alternative treatments for asthma, e.g., traditional herbs, (Table 3, quote 4). There were also various religious beliefs on the causes and potential cures for asthma. Attributing a religious aetiology to asthma was predominant in all FGDs across the countries but noticeably absent from South African FGDs, (Table 3, and quote 3). Within this sub-theme, teachers identified emotions as a major trigger for acute asthma episodes in schools. However, they also believed that some reported asthma episodes among adolescents were indeed more emotional outbursts than true asthma symptoms, (Table 3, quote 5). Teachers’ reflected on the impact that uncontrolled asthma had on various learning activities. These included taking frequent sick days and sports hesitancy, leading to many adolescents not participating in scheduled school and physical activities, (Table 3, quotes 7 and 8). Sport and physical activity hesitancy were noted with ‘some of those parents who do not allow the kids to even participate in sport’, and parents are seen to ‘molly-coddle’ or be ‘overprotective’. The impact of parental anxiety leads to adolescents ‘who shy away from participating because they believe that’s what they feel’. (ZA, FGD 4). Stigma associated with having an asthma diagnosis among adolescents was included in this sub-theme. Having asthma was stigmatising among adolescents with asthma and was associated with denial and failure to disclose the diagnosis to teachers, thereby delaying or preventing proper management, (Table 3, quote 9). The aspects noted in this sub-theme that impacted asthma care, included the limited scope of school health services in most African countries and the prohibition of teachers from administering medicines without parental consent. Regarding school health services, teachers noted that school nurses mostly focused on immunisation programmes and had little to do with health screening or first-line management of medical problems, (Table 3, quote 10). Secondly, teachers were not empowered by any legislation to administer medicines without parental consent. These restrictions make many teachers feel less comfortable giving adolescents’ inhalers when needed, (Table 3, quote 11).

Teachers suggested using all-inclusive training to improve asthma knowledge in parents, teachers and adolescents, (Table 4, quote 12). A strong willingness and openness to training in asthma were seen where teachers, parents and adolescents could create ‘an environment that is positive for the child to actually feel, if they have asthma, but they can still do exercise, they can still swim, they can still take part in sport because they are comfortable that the people around them are educated enough to know that when they are going to be in danger.’ (ZA, FGD 1). For training and information dissemination to be effective it should be for ‘everyone, for doctors, nurses, parents, learners, so it is not only learners or people that need to be taught about it…’ (ZA FGD 3). Teachers indicated that parents and adolescents must be involved in proposed asthma education for schools, emphasising an inclusive approach in these programmes. Using creative methods such as drama (plays) and music to educate adolescents, specifically on asthma, was seen as important as the training content, particularly to sustain learner interest, (Table 4, quote 13).

Teachers expressed a view that their colleagues with personal experiences with asthma (either being asthma sufferers themselves or caring for close members of their family with asthma) had a better understanding of how to relate to adolescents with asthma than teachers with no such experience, (Table 4, quotes 14 and 15). Teachers’ across most countries expressed concern that annual screening for asthma and other chronic diseases was not uniformly performed across all schools. They supported the interventions of annual health screening for common conditions, including asthma, which should include disclosing medical conditions by all adolescents. This would allow teachers to be aware of potential challenges with the adolescents during the year, (Table 4, quote 16). Teachers also indicated that providing metered dose inhalers in all schools, especially in residential (boarding) schools, would assist adolescents having acute asthma episodes, (Table 4, quote 17).