The primary aim of this study was to elicit the views of children and adolescents regarding PA, asthma and pollution and to explore any potential interaction between them. Overall, the participants understood the concept and importance of PA for health, with those with asthma also aware of its role within the management of the disease. Individuals with asthma showed a heightened awareness of the presence of indoor air pollution. All participants, irrespective of an asthma diagnosis, identified the presence of outdoor air pollution but some gaps were evident in the participants’ understanding of pollution, indoor air pollution and asthma, and their interaction. This is unsurprising given there is much debate around these topics in current research with research by Kim et al., [22] also finding indoor air pollution to be particularly poorly understood. Importantly, there was a clear willingness to enhance their understanding, highlighting the need, and opportunity, for an educational element in future interventions seeking to increase PA levels among children – particularly those with asthma.
The majority of participants were able to define the term pollution. However, even the adolescents struggled to develop a simple descriptor, often commenting “I don’t think anyone has ever sat down with me and talked to me about what it actually is…just what is affecting it” (F4, 17 years old, asthma diagnosis). The role of schools in the education of children was mentioned by nine of the 25 individuals interviewed, whilst only one child identified the media, suggesting that the recent campaigns for better air quality are not accessible to, or noticed by, children and adolescents. Most children were enthusiastic about the opportunity to increase their awareness, demonstrating that children have the desire to learn about environmental issues. The age at which children gain the level of cognitive development to conceptualise pollutants as invisible, yet present, particles requires further research. Some suggest children to be incapable of appreciating the closely woven interrelationships of environmental issues [4, 33] whilst others believe children conceptualise such scientific concepts in unique, idiosyncratic ways [9]. This study would tentatively support the later, with 88% of participants demonstrating an awareness of pollution, which could be utilised to introduce such concepts into the curriculum. However, some inaccuracies were noted regarding the understanding of ‘pollution’. Younger children often associated the term with smell, citing bonfire smoke, perfume or candles, suggesting young children do not differentiate a pollutant from an odour. This is in line with research by Bu et al., [7] who found children to use the term odour as proxy for dry air or poor indoor air quality. They determined that the presence of dry or irritating indoor compounds were found to be a surrogate for poor indoor air quality, which was positively correlated to the presence of asthma in young children.
Further confusion was evident with participants identifying solid waste as a source of air pollution, likely the result of the children looking to find a tangible representation for their idea of pollution. It would be beneficial to explore such idiosyncrasies further through other questioning techniques, such as drawing. Noonan et al., [25] through their “write, draw, show and tell” method determined that using a range of methods when working with children was not only more interactive but also more inclusive than traditional methodological approaches. This allowed for greater confidence in the results, as well as enhanced data credibility. Despite this, the ability to rationalise the problems pollution causes and identify solutions was mentioned by 76% of participants, with the concept of hybrid or electric vehicles being mentioned, or strategies such as ‘no parking outside of schools during school hours’ being suggested.
In exploring the children’s conceptualisations, only 13 children (52%) were able to acknowledge the existence of indoor pollutants. This concurs with Stevens et al., [36] who also reported some confusion when trying to recognise and distinguish indoor pollutants. Those diagnosed with asthma showed greater awareness of sources of indoor pollution (73%) than those without (27%), likely due to experiencing one or more ‘triggers’, such as aerosols, dust or smoke. This is supported by current research identifying ambient particulate matter as a significant contributor to poor asthma control [37], and the indoor environment being responsible for increased medication use and emergency hospital admissions [24]. The incorrect notion that indoor pollution is a product of something originating outside, that enters via windows and doors, was alluded to by several participants who believed outdoor pollution to be worse than indoor. Only one child correctly identified the need for good ventilation within the home. The identified misconceptions surrounding indoor and outdoor air pollution highlight the need for awareness campaigns to be targeted towards a greater age range, perhaps specifically targeting the younger population. Furthermore, for future interventions targeting behaviours based upon reducing exposure during PA to succeed, an educational arm is strongly advised to ensure children appreciate why such interventions are necessary. Without greater awareness, young people are unlikely to engage with intervention strategies post study, thus reducing clinical benefit.
In accordance with Fan et al., [12] 88% of the children interviewed in this study identified vehicle emissions as the main source of pollution and described a negative association with their respiratory health. Individuals in this study living in more densely populated areas, and those suffering from asthma, appeared more aware of TRAP than those living in more rural areas, with 91% believing it to negatively affect their asthma control. This concurs with recent meta-analysis by Khreis et al., [21] where a significant positive association was found between asthma and exposure to particulate matter. There is an increasing body of evidence linking air pollution, and in particular TRAP, to incidence of asthma and respiratory issues [26, 18, 13]. However, none of these studies have sought the opinions of, or understanding, of either parents or children.
More disparity was noted between participants’ perceptions of the lasting effects of pollution. Whilst some children (52%), most noticeably those with a diagnosis of asthma, believed poor air quality affected their health, others did not feel pollution was detrimental to their health. Specific groups perceived as being at an increased risk from exposure to pollution were those with lung disease or asthma (52%), the young and elderly (16%) and those with chronic health conditions (16%). All bar one participant was aged over 11 years, indicating an increased understanding of the deleterious effects of exposure to pollution with age. The children who identified at risk groups identified a weakened immune system and inability to fight off illness and ailments, suggesting a clear level of understanding. It is also worth noting that whilst 52% of participants highlighted those with asthma to be at greater risk, this may simply be the result of their awareness of the condition being a focus of the interview.
There is an abundance of research covering the importance and benefits of leading an active lifestyle, whilst simultaneously highlighting our failure to meet the recommended PA outcomes suggested by the WHO (2020) [40]. Despite understanding the importance of engaging in PA, the children interviewed rarely chose active behaviours during their free time. Sex and age appeared to play a central role, with boys, in accordance with Bean, Forneris & Fortier [5], reporting to engage in more active play than girls. However, contrary to Rota et al., [34] there was no suggestion by the participants in this study, that children with asthma were more sedentary than their healthy counterparts. Whilst research investigating the PA levels of youth with asthma remains equivocal, the current study provides further support to research by Winn et al., [39] which reported that 81% of those diagnosed with asthma identified engagement in PA as a favourite activity. Despite finding PA challenging, 91% of individuals with asthma engaged in PA as a means to control their condition. The potential interactive effect the severity of disease may have on PA levels was highlighted by three adolescents, all with asthma. This suggests that more differentiated research in this area is needed when measuring PA among those with asthma and lends support to emerging research by Pike et al., [30] who acknowledge the role disease severity may play.
Few studies have explored young people’s perceptions of asthma, despite research suggesting that parents’ perceptions of asthma and PA are less reliable then their children’s [27]. It is also possible that the perceptions of children’s healthy peers may affect participation in PA. Similar gaps in the literature were highlighted by Winn et al., [39] who found limited evidence of studies that involved adolescents with asthma in study design. Indeed, 64% of children and adolescents with asthma in this study believed that their condition was difficult to comprehend and often misunderstood by others with one individual stating “unless you experience it yourself. It’s unknown to them and as many diagrams that they can use, you go through it. It’s not the same” [F6, 17 years old, asthma diagnosis]. Whilst the views shown by the healthy participants in this study suggest no misconceptions or negative opinions are held against those with asthma, whether real or perceived, addressing such ideas may improve the management of the condition leading to improved overall health.
One of the strengths of this study is the in part inductive, in part deductive approach, coupled with the use of pen profiles to present the data. This enables the reader to gain a diagrammatic overview of key emergent themes clearly and succinctly. Analysis and presentation of qualitative data in such a manner not only limits the analysis being skewed by key dominant participants, but presents the data in a more objective manner [23]. Due to the current COVID-19 pandemic, in-person interviewing was not feasible, but video interviews over Zoom provided both a time- and cost-effective solution. The increased accessibility removed many logistical factors, such as geographical location, meaning we were able to reach a wider number of individuals [16]. However, participant recruitment also relied heavily on social media, thus determining the demographic of volunteers and limiting those able to participate to those with access to a computer and the internet.
Whilst there are numerous strengths associated with this study, several limitations are noteworthy. In any situation where individuals put themselves forwards an element of self-selection bias may be present. There is also the possibility of social desirability with participants giving the answer they believe the researcher wishes to hear, although the interviewer made sure to emphasise that there were no right or wrong answers. It is also beyond the scope of the current study to explore the influence of factors such as sex, ethnicity and socioeconomic status on barriers and facilitators, and their interaction with pollution, although this does warrant further investigation. Specifically, some participants were unwilling to share their home postcode, limiting our insights to participant’s socio-economic status. Whilst an inclusive approach to recruitment was taken, the subsample (88% of the total sample) of socio-economic data we were able to collect suggested a predominantly upper quartile bias to the SES of the participants. It is therefore possible that the opinions of the participant’s in this study are influenced by a higher literacy ability, as has been previously shown [19], and the generalisability of the findings to other SES quartiles should be considered. Future research should also seek to integrate parental views, which may help determine how, when and why children develop the perceptions they do.
