https://orcid.org/0000-0003-0131-440X
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Abstract
Introduction
Children in boarding schools spend most of their time without their parents or caregivers, causing concerns about the suitability of such schools for children with asthma. This study assessed individuals’ opinions regarding the suitability of boarding secondary schools for children with asthma.
Methods
A qualitative design was adopted for this study using a focus group discussion held on a social media platform (WhatsApp®) of the Asthma Awareness and Care Group (AACG), The group comprised 150 registered members. The study was guided by a structured protocol and based on a vignette comprising three questions. Data were analysed via thematic analysis using framework principles.
Results
Out of the 150 eligible members, there were responses from only 19 participants. Majority of the respondents were aged ≤ 30 years (n = 17, 89.5%). The three main themes generated from the thematic analysis include the appropriateness of boarding schools for children with asthma; facilities necessary for boarding schools to cater to children with asthma; and outright rejection of children with asthma by boarding schools. Respondents conceptualised the appropriateness of boarding schools for students with asthma in six distinct sub-themes: asthma severity and extent of control, child’s self-efficacy and assertiveness, child equipped with tools (knowledge, inhalers, and asthma control diary), school awareness, facilities, and active support, availability of a guardian, and the knowledge and perception of teachers and schoolmates about asthma. The sub-themes associated with the themes were presented, alongside exemplar quotes from respondents. The majority of the respondents (61.5%) were in support of allowing children with asthma attend boarding schools but with some caveats such as without liability to the school, if facilities are unavailable.
Citation: Amorha KC, Ochie KM, Ogbodo SC, Akunne OZ, Obi OC, Ene NT, et al. (2024) Are boarding secondary schools suitable for students with asthma? An asynchronous online focus group discussion among members of an asthma awareness group. PLoS ONE 19(9): e0304123. https://doi.org/10.1371/journal.pone.0304123
Editor: Nabeel Al-Yateem, University of Sharjah, UNITED ARAB EMIRATES
Received: May 6, 2023; Accepted: May 7, 2024; Published: September 6, 2024
Copyright: © 2024 Amorha et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper.
Funding: The authors received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Childhood asthma, recognised as the most common chronic respiratory disease among children, poses the highest disability burden in this population and accounts for most cases of school absenteeism [1, 2]. Asthma is a multifactorial disease caused by a combination of genetic, host, and environmental factors [3, 4]. The global prevalence of asthma has increased significantly in the last forty years, with the World Health Organization (WHO) estimating that 300 million people currently live with asthma, and this is projected to reach 400 million by 2025 [1]. In terms of mortality, 250,000 people die from asthma annually, with a reported mortality rate of up to 0.7 per 1000 among children [1, 5].
Nigeria has one of the highest burdens of childhood asthma in Africa, with a rapidly increasing prevalence from 10.7% in 1999 to about 20% in 2014 [6]. Nigeria currently follows the Universal Basic Education (9-3-4 system of education), a transition from the 6-3-3-4 system [7]. The 9-3-4 system entails nine years of basic education, three years of senior secondary education, and four years of tertiary education. The curriculum for the 9-3-4 system of education was designed to meet the Millennium Development Goals (MDGs) by 2020 [7]. Students can be in boarding schools from the seventh to the ninth year of basic education and during the three years of senior secondary education. There is an option of having children going from home (day students) or living and studying in the school during the school term (boarders) [8].
In Nigeria, five of every 100 adolescents in Nigeria who are school children, especially those in secondary schools, are in boarding schools [9]. Many parents or caregivers lean towards the option of boarding schools as it helps children build independence, limits access to distracting technology, and provides an established learning community where they can easily form study groups [10].
Since basic education is a legal right in Nigeria, as with most other countries, the management of asthma among children within the school system has become a central issue [11]. The Global Initiative for Asthma (GINA) estimated that 14% of school-aged children have had at least one episode of wheezing in the past 12 months [12]. For children attending “day” schools, their parents or caregivers have ample opportunity to monitor and manage their asthma, as they return home, daily, after school. This is less feasible for boarding school children who enjoy significantly reduced parental oversight. Hence, boarding school children with asthma often have to take up greater responsibility for managing their triggers, symptoms, and attacks alone or with the help of the school management. As such, many parents/guardians of children with asthma may be skeptical about sending their children to boarding schools.
It has been documented that children with asthma face significant challenges in school which can affect their academic performance and quality of life [11]. Acute asthma attacks in school children account for 2–10% of emergency hospital visits in Nigeria, largely because most schools lack appropriate facilities and health services to manage asthma episodes [13, 14]. Students with asthma may also experience stigmatisation through exclusion from school programmes like sports and other physical activities [15, 16]. Although studies have shown that incorporating asthma-related topics in school curricula will improve students’ and teachers’ knowledge of asthma and improve the experience of children with asthma, parents and caregivers are still faced with the dilemma of the suitability of boarding schools for their children with asthma [17, 18].
Thus, this study was designed to evaluate individual perceptions and opinions regarding the appropriateness of boarding schools for students with asthma, particularly in Nigeria. It further aimed to elicit perspectives about the facilities, appropriate training, and conditions that would enable the effective management of students with asthma in boarding schools.
Methods
Study design
This was a qualitative study involving a focus group discussion held on the social media platform (WhatsApp®) of the Asthma Awareness and Care Group (AACG). The discourse, which was held on 22 March 2023, was guided by a structured protocol. It was based on a case study comprising three questions. The vignette was posted in the Group, without previous publicity. Members of the Group were informed that only comments received within a specified time frame would be utilised for the study (14:00–21:00 hours). A 7-hour time frame was fixed, considering that the discussion was impromptu. This asynchronous online focus group (AOFG) research design using a specified timeframe has been recommended due to the flexibility it affords respondents to participate in qualitative research [19, 20]. The discourse was moderated by the Founder of the Group. AACG is a team of asthma enthusiasts who aim to improve asthma awareness and care, in communities [15].
Ethical approval
The study did not require ethical approval. It was a focus group discussion conducted online, in a closed group on WhatsApp®. The group is restricted to members of the Asthma Awareness and Care Group (AACG). Participation of members of the Group was voluntary. Members who participated were informed that their comments would be extracted for research purposes. They were also informed that the authors would be members of AACG who could identify individual participants during or after data collection.
Eligibility criteria
Eligibility criteria comprised members of the Asthma Awareness and Care Group (AACG) who were registered on the AACG WhatsApp® platform. As of the time the study was conducted, there were 150 registered members on the AACG WhatsApp® platform. Members of the Group were majorly Pharmacists (n = 142, 94.7%), with a large proportion having not more than 10 years of experience. The Pharmacists practiced in community, hospital, academia, industry, and administrative pharmacy settings. Other members of the Group included: five undergraduate pharmacy students, one Public Relations Professional, one Economist, and one Mechanical Engineer. Only comments received within the 7-hour time frame were included.
Sample size and selection
The sample size was not calculated. All registered members of the AACG WhatsApp® platform were eligible for participation. A convenience sampling technique, within a specified timeline, was employed. Comments were received from 19 participants who responded within the allotted timeframe for data collection.
Data collection
This vignette was posted on the AACG WhatsApp® platform:
AB is an 11-year-old known patient with asthma.
As the closest healthcare provider to her family:
- Would you advise AB to go to a Boarding School? Kindly justify your position.
- What facilities would you advise Boarding Schools to have, to cater to students with asthma?
- Should Boarding Schools simply reject patients with asthma i.e., better safe than sorry?
The comments from the participants provided data for the study. Demographic data were collected for each respondent.
Data analysis
After the group discussion, a thematic analysis was conducted using framework analysis principles and generally adhering to the five stages of familiarization: identifying a thematic framework, indexing, charting, mapping, and interpretation.
For the identification of a thematic framework, nine researchers independently acquainted themselves with the transcripts, acquiring a general feel for the data and noting emergent ideas on the margins. The researchers identified key themes in the transcript. This was similar to a study conducted on the challenges and expectations of the Mental Capacity Act of 2005 where an in-depth qualitative methodology was adopted. Three a priori questions formed the thematic framework, based on the codes and sub-themes that were subsequently identified [21, 22]. The thematic framework included three central themes: 1) appropriateness of boarding schools for children with asthma; 2) facilities necessary for boarding schools to cater for children with asthma; and 3) outright rejection of children with asthma by boarding schools.
For the “indexing” stage, the nine researchers were assigned different parts of the transcripts, which they iteratively read to identify ideas and assign codes to portions of text. This generated a coding framework. This process was repeated until no new codes were generated. Discrepancies between the nine researchers’ codes were resolved through discussion and a unified coding framework was obtained [22]. These codes were initially identified under the three broad themes in the thematic framework, after which similar codes were clustered to form sub-themes.
In the “charting” step, these themes, subthemes, and codes were presented in a chart and discussed at team meetings, enabling the re-ordering of the subthemes as necessary. This made it possible to extract relevant details from the data, including elements that may have been missed if a purely a priori approach was employed [23].
In the “mapping and interpretation” stages, the themes and subthemes were tabulated alongside exemplar quotes from participants. This process produced a ’tree structure’ featuring interconnected themes, subthemes, and supporting quotes. Finally, these identified ideas were interpreted to answer the research questions and identify areas for public health action.
Results
Nineteen respondents participated in the focus group discussion, comprising 11 females and eight males. Majority of the respondents were aged ≤ 30 years (n = 17, 89.5%), Table 1.
The thematic analysis produced three themes: the appropriateness of boarding schools for children with asthma (Table 2); the facilities necessary for boarding schools to cater to children with asthma (Table 3); and the outright rejection of children with asthma by boarding schools (Table 4).
Respondents conceptualised the appropriateness of boarding schools for students with asthma according to six distinct sub-themes: asthma severity and extent of control, child’s self-efficacy and assertiveness, child equipped with tools (knowledge, inhalers, and asthma control diary), school awareness, facilities, and active support, availability of a guardian, and the knowledge and perception of teachers and schoolmates about asthma.
The subthemes associated with each of these themes are presented, alongside exemplar quotes from respondents.
Discussion
The findings of this study address the issue of appropriateness of boarding schools for children with asthma. The respondents were stakeholders involved in asthma care and knowledgeable about the resources necessary for adequate management of asthma.
Theme 1: Appropriateness of boarding schools for children with asthma
The question of whether or not boarding schools are appropriate for students with asthma is a complex issue that requires careful consideration of several factors. The opinions expressed by the respondents indicate that there is no clear consensus on the matter and that the decision should be based on a case-by-case evaluation.
The majority of the participants (61.5%) consented that children with asthma can be allowed to attend boarding schools with strict conditions. For instance, asthma must be well-controlled based on the Asthma Control TestTM (ACTTM), the children must be well-equipped by their parents or caregivers with skills for asthma self-management such as proper inhaler and asthma diary use, they must be assertive about their rights, and have good support systems in form of teachers and schoolmates who are trained and have a positive perception of asthma. A study opined that parents should inform teachers about their children’s written asthma action plans to guide teachers during emergencies, rather than waiting for parents to pick up their children from school while taking no life-saving actions [24]. Another study documented that school-based educational interventions led to improvement in teachers’ knowledge, self-management, and health outcomes of asthma students [25]. All these are to abate the poorer quality of life, frequent emergency department visits, hospitalizations, and school absenteeism that emanates from uncontrolled asthma [26, 27].
Some participants believed that boarding schools are not appropriate for students with asthma, regardless of the asthma severity and control. They cited concerns about the change of environment, exposure to allergens (including unknown ones), emotional unrest, lack of supervision, and the living conditions in most boarding schools in Nigeria. This opinion is similar to several studies that have reported that children with asthma are at increased risk of being bullied and victimised in school [28]. Another survey conducted in Nigerian primary and secondary schools leaves much to be desired as the majority of public schools in rural and poor urban slums have substandard environments that are suboptimal for not just students with asthma but non-asthmatics as well [29, 30].
Theme 2: Facilities necessary for boarding schools to cater for students with asthma
From the responses provided, it is evident that there is a consensus on the facilities required to manage students with asthma in boarding schools. This indicates that there are measures that must be put in place by boarding schools to cater to the needs of students with asthma. These facilities include adequate and functional medical facilities with health professionals such as nurses, emergency asthma kits, and an ambulance to transport students to the hospital when necessary. Unfortunately, this seems not to be the case as an assessment of school health services in Nigeria revealed poor and sub-standard health facilities in most public and even private schools [14]. A study in Lagos State, Nigeria, revealed that only 16% out of 54 schools surveyed had a school clinic; only 7.4% had a school health worker, and none of the schools had facilities for asthma emergency care [31].
Findings from this study also indicate that effective referral systems for severe emergencies are necessary, including retaining an agreement with a standard hospital or a pulmonologist. Additionally, the school must minimise exposure to environmental triggers like dust, pollen, and cold. It is also essential that the school and parents/guardians work together to provide proper communication, medication, and necessary resources to keep children with asthma safe in school. Training and re-training of staff and students to recognize asthma symptoms and provide help is crucial.
Theme 3: Outright rejection of children with asthma by ill-equipped boarding schools
Regarding the outright rejection of children with asthma by boarding schools, most respondents agreed that boarding schools should not simply reject students with asthma. Instead, boarding schools should provide the necessary facilities and resources to create an inclusive and supportive environment for all students, including those with asthma. Asthma is a common chronic condition, and with proper management and support, students with asthma can thrive academically and socially. Therefore, rejecting students with asthma is discriminatory and can limit their opportunities for personal and academic growth.
However, some respondents further noted that boarding schools should reject known asthmatics if they are not equipped to take care of them. This is to avoid any negative consequences that may arise from accepting students without adequate facilities to manage them. If a boarding school is not equipped to handle students with asthma, they should inform the parents or guardians and advise them to opt for day school. Some participants thought that even schools that do not have all it takes to manage such conditions in place could also accept such students, on the condition that they explain their shortcomings to the parents or guardians of these children. This could prevent their actions from being misconstrued as the stigmatisation of children with asthma and might ensure parents/guardians are held responsible for whatever happens to the child if they eventually decide to enrol.
This study is an attempt to evoke a thought process on whether children with asthma should be in boarding schools. It suggests that the suitability of boarding schools for children with asthma is dependent on many factors. Boarding schools should create an inclusive and supportive environment for students with asthma.
Boarding school administrators should ensure that they have adequate facilities to manage patients with asthma. This includes a functional sick bay and health professionals who would be available whenever needed. The sick bay should have medicines for the management of acute and chronic asthma, as well as asthma devices such as peak flow meters and nebulisers.
The boarding school should have links with registered hospitals that can handle referrals. There should be collaborative efforts amongst the teachers, students, parents, and school administrators to ensure students with asthma have a good quality of life while at school.
Asthma education programmes should be conducted for all active players (students, parents, teachers, and school administrators). There should be training and re-training for staff and active players who can serve as first responders if there is an asthma attack.
The boarding school should have asthma-friendly environments. All possible asthma triggers should be eliminated.
Policymakers and those who approve schools to take boarding students should ensure that the facilities and environments are suitable for patients with asthma. Lists of items that need to be put in place should be provided to school administrators. Policymakers should form a think tank using this study as a baseline to provide a policy framework that will guide the educational sector to make important changes to the boarding schools that would host students with asthma.
Future studies should consider quantitative assessments. Questionnaires could be administered to a larger sample size to quantify the prevalence of specific opinions and perceptions related to boarding schools for children with asthma. Longitudinal studies could also be conducted to provide valuable insights into the dynamics of opinions regarding boarding schools for children with asthma and allow for a deeper understanding of the factors influencing these perspectives. Mixed-method analysis could be done to better understand the experiences and health outcomes of children with asthma attending boarding schools in comparison to those attending day schools.
Building upon the findings of this study, future research could focus on developing and implementing interventions aimed at improving the management and support systems for children with asthma who are in boarding schools. Evaluating the effectiveness of interventions, such as asthma education programmes for teachers and students, improved medical facilities and resources, and strategies to reduce stigma and promote inclusivity could provide evidence-based recommendations for creating asthma-friendly environments in boarding schools.
Limitations of the study
The study was conducted within the confines of a closed social media group, the Asthma Awareness and Care Group (AACG), which is predominantly made up of healthcare professionals and enthusiasts involved in asthma care. These participants may possess a higher level of knowledge and expertise regarding asthma management than the general population and may not fully represent a general perspective on the subject matter. Furthermore, their expertise and familiarity with the subject matter might have influenced their responses and recommendations. In addition, the study employed convenience sampling without calculating the sample size. As a result, the sample size may not be sufficiently large or diverse to capture the wide range of opinions and experiences related to boarding schools and asthma management in Nigeria. Future studies should consider a more diverse range of participants.
Conclusion
This study, in an attempt to address the issue of the appropriateness of boarding schools for children with asthma, has identified children’s age, autonomy, asthma management status, and the school’s readiness, as important considerations for the safe attendance of children with asthma at boarding schools. With childhood asthma being common, we therefore recommend, that schools put measures in place to ensure that students with asthma can lead active lives. They should be able to learn in a safe environment without fear of stigmatisation or lack of facilities/medications/expertise/referral systems, in emergencies.
Acknowledgments
The authors appreciate all members of the Asthma Awareness and Care Group (AACG) for their participation and responses which were the basis for the study. AACG also appreciates the Respiratory Pharmacists of Nigeria (RPN) which is a specialty group under the Clinical Pharmacists Association of Nigeria (CPAN). The case study used in this research was coined by Pharmacist Billy Shoaga of RPN/CPAN.
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