Asthma is a chronic disease characterized by airway inflammation that causes expiratory airflow limitation, shortness of breath, chest tightness, wheezing and coughs.1 In children and adolescents with asthma, the disease may reduce perceived capability for2 and participation in physical activity (PA).3 Physical activity is defined as any bodily movement such as play, exercise or daily activities produced by the contraction of skeletal muscles that increases energy expenditure above resting levels.4
The PA level may be assessed in terms of the intensity, frequency, type, mode and duration.5 Physical activity can be recorded by objective measures of energy expenditure or movement (e.g. steps per day, distance, accelerometer counts per minute, heart rate or oxygen consumption), by subjective reports of exhaustion or by descriptive measures of the activities.6 Objective measures of acute airflow limitation induced by vigorous PA (exercise-induced bronchoconstriction [EIB]) do not completely explain children's and adolescents’ reports of exercise-induced symptoms.7,8 Nevertheless, exercise limitation and reduced PA are frequently reported to be associated with physiological mechanisms, respiratory symptoms3,9-19 and psychosocial and socioeconomic factors in children and adolescents with asthma.2,9,10,14,18,20-26 Barriers to PA have been described in qualitative research and include fear of breathlessness and misinterpretation of symptoms27 and are influenced by gendered habits,28,29 social support,30-32 role models and efforts to appear similar to peers.33,34
Participation in PA is considered feasible by children and adolescents with asthma when using appropriate controller medications.35-38 Increased PA is associated with increased cardiorespiratory fitness,36,37,39 psychological functioning,38 health-related quality of life,36-40 psychological wellbeing, self-esteem and decreased morbidity.37-39 Increased fitness may also elevate the EIB threshold by reducing ventilatory requirement for any PA involving play or exercise.37,41
There is no consensus in the literature about whether children and adolescents with asthma perform less PA than their healthy peers.38,42 Some studies have reported similar fitness and PA levels in children with asthma compared with controls.43-46 Lower PA and fitness levels2,10,14,15 have been identified in children and adolescents who are newly diagnosed or have poor asthma control.3,19 Asthma control is defined as “the extent to which the manifestations of asthma have been reduced or removed by treatment.”47 (p.545)
Asthma symptoms and lung function may change rapidly in response to the environment and/or treatment, whereas airway wall remodeling and responsiveness tend to change slowly. Thus, the clinical manifestations and the underlying disease mechanisms of asthma do not always correspond.47 An asthma diagnosis may include four domains: symptoms, variable airway obstruction, inflammation and hyperresponsiveness.47 Various combinations of one or more of these four domains and other features are included when defining the disease, and there are also differences in asthma control and severity between study populations. Asthma severity is defined by the treatment intensity required to obtain asthma control.47 Deficient asthma control may also occur through poor compliance, poor inhaler technique, under-prescribing, environmental factors, severe disease and/or resistance to therapy.47 Hence, the association between PA and asthma, asthma control and asthma severity is complex and involves both psychosocial and socioeconomic issues.20
Asthma and PA from childhood into adolescence
The disease,48 level of PA49-51 and management of both asthma and PA continue to develop throughout childhood and adolescence.48,52 Asthma is more common in boys than girls during childhood53 but is more common in girls during adolescence.48,54 Parents are responsible for managing their child's asthma, whereas shared responsibility by the adolescent and parents is encouraged to enhance the adolescent's growing responsibility for managing his/her disease.55
In healthy children, PA level varies according to gender49-51 and social support.50 Peer support positively influences PA across gender,50 age and location.56,57 The influence of social support from parents and teachers and the influence of the physical environment may change with time, location (at school or home, during school or leisure time, and during the week and weekend) and age development.56,57 Such changes may be related to major shifts in autonomy, parental license and movement to different schools during childhood and adolescnce.56 Eighty percent of school-age adolescents worldwide do not reach international recommendations of 60 min/day of moderate-to-vigorous PA.58,59 There is a need for more information about why some individuals are active and others are not, in particular the psychosocial and socioeconomic determinants of differences in PA levels.60
Psychosocial factors include individually measured perceptions or cognitions of intrapersonal factors (motivation, beliefs and cognition), interpersonal factors (support from others and cultural norms and practices) and environmental factors (social, built and natural environment). These factors and their interactions have been described by several theories and models.60 Socioeconomic factors are explained by a multidimensional concept comprising resources, power and/or prestige and include educational level, income and occupation at an individual, household or neighborhood level.61 These measures are not interchangeable61 and in children and adolescents, indicative measures are often used, such as car ownership, internet access and unshared bedrooms.62,63 Such indicative measures must be refined according to economic, technological and societal changes in a given society.63 Hence, transparency concerning the steps taken in the development of instruments and reporting of in-study reliability and validity is needed when mapping knowledge about the associations between these factors and PA in given populations. In addition, mapping of psychosocial and socioeconomic issues in relation to PA by qualitative research may strengthen the evidence derived using quantitative instruments.
Rationale for the review
As outlined above, there is a need for more detailed evidence on the psychosocial and socioeconomic influences on PA level60 in children and adolescents with asthma, especially those with specific challenges to being active because of airflow limitation, who may benefit from increased PA. To our knowledge, there is no consensus about the best instruments to assess psychosocial and socioeconomic factors that may influence PA in children and adolescents with asthma. A scoping review on this topic is therefore needed before further studies or synthesis of research findings can be conducted to identify the factors that may be feasible, appropriate, meaningful and effective for inclusion in interventions aimed at increasing PA level in children and adolescents with asthma. An initial search in the JBI Database of Systematic Reviews and Implementation Reports, PROSPERO, Cochrane Library, PEDro, Embase, CINAHL, MEDLINE, SPORTDiscus, SocINDEX, Academic Search Complete, PsycINFO and ISI Web of Science was conducted. To our knowledge, no systematic or scoping review on this specific topic has been published or is currently under way.
Types of participants
In this review, we will consider studies that include children and adolescents with asthma aged six to 18 years. The given age range includes school-age children and adolescents who are more likely to participate autonomously in physical education and organized sports than preschool children and therefore are more likely to report autonomously about their participation in PA and associated factors. No uniform definition of asthma will be required for inclusion. The definitions of asthma and descriptions of participants with regard to asthma control, severity, comorbidities and other conditions given in the primary studies will be mapped and reported. Studies including caregivers as research participants who report the psychosocial and socioeconomic factors and issues relating to their children's PA participation will be included. The distinction regarding children/adolescents’ own reports and caregivers’ reports will also be mapped and reported.
In this review, we will consider studies that have investigated or explored the psychosocial and socioeconomic factors and issues in relation to the level of and participation in PA.
In this review, we will consider studies including all contexts of PA such as school time, leisure time, time at home and organized exercise time conducted in all countries.
Types of studies
The current review will consider primary research studies only. In accordance with the aim of the review, we will ensure that all known studies identified by the comprehensive literature search are reported only once and are not double-reported in both primary and review studies.
The quantitative component of the review will consider for inclusion both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental studies, before-and-after studies, prospective and retrospective cohort studies, case-control studies, analytical and descriptive cross-sectional studies, case series and individual case reports.
The qualitative component of the review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research, and in which children and adolescents with asthma are interviewed and/or observed themselves.
The search strategy aims to trace both published and unpublished studies. A three-step search strategy will be used for the review. An initial limited search of Medline and SPORTDiscus has been undertaken followed by an analysis of the text words contained in the title, abstract and index terms used to describe each article. Search terms for psychosocial and socioeconomic factors partly covering the concept components did not delimit the search results and were thus excluded. A second search using all identified keywords and index terms will then be undertaken across all included databases. The reference list of all identified reports will then be searched and forward citation searches in ISI Web of Science, Scopus and Google Scholar will be performed. Studies published in English, unrestricted by the date of publication, will be considered for inclusion.
The databases to be searched will include:
MEDLINE, Embase and PsycINFO via Ovid interface, CINAHL, SPORTDiscus, Academic Search Complete and SOCIndex via EBSCHO Host interface, Social Science Index and ISI Web of Science.
The search for unpublished studies will include:
Primo Central Index, ProQuest Nursing & Allied Health Source, ProQuest Health Management, ProQuest Psychology Journals and ProQuest Health & Medical Complete.
The initial keywords to be used will be:
(adolescen* OR child* OR schoolchild* OR teenage* OR young OR youth*) AND ((exercise* OR inactiv* OR motor activ* OR physical activ* OR play* OR sport* OR training*) ADJ41 (amount* OR daily* OR dose* OR duration* OR energy expenditure* OR frequen* OR hour* OR insufficient* OR intens* OR less* OR level OR minute* OR moderate* OR more* OR participat* OR sufficient* OR vigorous* OR week*)) AND asthma*.
For review, relevant descriptive information, data and findings will be extracted and charted from papers included in the review. Appendix I presents the initial information that will be extracted. This form may be expanded and adapted during the course of the review, and changes will be reported in the published scoping review report. In line with the review questions, there will be no attempt to contact authors for extraction concerning information not reported.
Presentation of the results
The presentation of results will follow the logical sequence of the review questions. Identified psychosocial and socioeconomic issues and factors associated with PA level will be classified as intrapersonal, interpersonal or environmental and will be presented in an overview chart, including the references as a way to identify the study characteristics, population and design of each study. The instruments identified will be presented in a separate chart, which will report the instrument's construction and the in-study validity and reliability analyses. A narrative summary will be used to answer each review question and will include commentary on the consensus between studies and gaps in knowledge. In the narrative summaries, if feasible, the key findings will be described in terms of the characteristics of the study population and design.
Librarian Ellen Sejersted at University of Agder assisted the development of the search strategy. Palle Larsen at the Center for Clinical Guidelines, Aalborg University, contributed critical comments to the protocol draft and provided an introduction to the JBI review tools. Kai-Håkon Carlsen at the Faculty of Medicine, University of Oslo, and the Division of Paediatric and Adolescent Medicine, Oslo University Hospital, contributed comments about the background section.
Appendix I: Extraction chart for papers included in the review
1. Global Initiative for Asthma
(GINA). Global strategy for asthma
management and prevention. 2015; Available from: http://www.ginasthma.org/
. [Accessed January 19, 2016].
2. Pianosi PT, Davis HS. Determinants of physical fitness in children with asthma
2004; 113 3:e225–e229.
3. Vahlkvist S, Pedersen S. Fitness, daily activity and body composition in children with newly diagnosed, untreated asthma
2009; 64 11:1649–1655.
4. Caspersen C, Powell K, Christenson G. Physical activity
, exercise and physical fitness: definitions and distinctions for health-related research. Public Health Rep
1985; 100 2:126–131.
5. Montoye HJ. Introduction: evaluation of some measurements of physical activity
and energy expenditure. Med Sci Sports Exerc
2000; 32 9:S439–S441.
6. Norton K, Norton L, Sadgrove D. Position statement on physical activity
and exercise intensity terminology. J Sci Med Sport
2010; 13 5:496–502.
7. Joyner BL, Fiorino EK, Matta-Arroyo E, Needleman JP. Cardiopulmonary exercise testing in children and adolescents with asthma
who report symptoms of exercise-induced bronchoconstriction. J Asthma
2006; 43 9:675–678.
8. Seear M, Wensley D, West N. How accurate is the diagnosis of exercise induced asthma
among Vancouver schoolchildren? Arch Dis Child
2005; 90 9:898–902.
9. Strunk RC, Mrazek DA, Fukuhara JT, Masterson J, Ludwick SK, LaBrecque JF. Cardiovascular fitness in children with asthma
correlates with psychologic functioning of the child. Pediatrics
1989; 84 3:460–464.
10. Chiang L-C, Huang J-L, Fu L-S. Physical activity
and physical self-concept: comparison between children with and without asthma
. J Adv Nurs
2006; 54 6:653–662.
11. Counil F-P, Varray A, Karila C, Hayot M, Voisin M, Prefaut C. Wingate test performance in children with asthma
: aerobic or anaerobic limitation? Med Sci Sports Exerc
1997; 29 4:430–435.
12. Counil FP, Karila C, Varray A, Guillaumont S, Voisin M, Prefaut C. Anaerobic fitness in children with asthma
: adaptation to maximal intermittent short exercise. Pediatr Pulmonol
2001; 31 3:198–204.
13. Anthracopoulos MB, Fouzas S, Papadopoulos M, Antonogeorgos G, Papadimitriou A, Panagiotakos DB, et al. Physical activity
and exercise-induced bronchoconstriction in Greek schoolchildren. Pediatr Pulmonol
2012; 47 11:1080–1087.
14. Lang DM, Butz AM, Duggan AK, Serwint JR. Physical activity
in urban school-aged children with asthma
2004; 113 4:e341–e346.
15. Glazebrook C, McPherson AC, Macdonald IA, Swift JA, Ramsay C, Newbould R, et al. Asthma
as a barrier to children's physical activity
: implications for body mass index and mental health. Pediatrics
2006; 118 6:2443–2449.
16. Firrincieli V, Keller A, Ehrensberger R, Platts-Mills J, Shufflebarger C, Geldmaker B, et al. Decreased physical activity
among Head Start children with a history of wheezing: use of an accelerometer to measure activity. Pediatr Pulmonol
2005; 40 1:57–63.
17. Hsin-Jen T, Tsai AC, Nriagu J, Ghosh D, Gong M, Sandretto A. Associations of BMI, TV-watching time, and physical activity
on respiratory symptoms and asthma
in 5th grade schoolchildren in Taipei, Taiwan. J Asthma
2007; 44 5:397–401.
18. Kitsantas A, Zimmerman BJ. Self-efficacy, activity participation, and physical fitness of asthmatic and nonasthmatic adolescent girls. J Asthma
2000; 37 2:163–174.
19. Vahlkvist S, Inman MD, Pedersen S. Effect of asthma
treatment on fitness, daily activity and body composition in children with asthma
2010; 65 11:1464–1471.
20. Williams B, Powell A, Hoskins G, Neville R. Exploring and explaining low participation in physical activity
among children and young people with asthma
: a review. BMC Fam Pract
21. Tiggelman D, Van De Ven MOM, Van Schayck OCP, Engels RCME. Moderating effect of gender on the prospective relation of physical activity
with psychosocial outcomes and asthma
control in adolescents: a longitudinal study. J Asthma
2014; 51 10:1049–1054.
22. Tiggelman D, Van De Ven MOM, Van Schayck OCP, Kleinjan M, Engels RCME. Sport club participation of adolescents with asthma
: maternal factors and adolescent cognitions. Pediatr Pulmonol
2014; 49 9:835–841.
23. Teng Y-K, Huang J-L, Yeh K-W, Fu L-S, Lin C-H, Ma W-F, et al. Influential factors of insufficient physical activity
among adolescents with asthma
in Taiwan. PLoS One
2014; 9 12:e116417.
24. Quinn K, Kaufman JS, Siddiqi A, Yeatts KB. Parent perceptions of neighborhood stressors are associated with general health and child respiratory health among low-income, urban families. J Asthma
2010; 47 3:281–289.
25. Quinn K, Kaufman JS, Siddiqi A, Yeatts KB. Stress and the city: housing stressors are associated with respiratory health among low socioeconomic status Chicago children. J Urban Health
2010; 87 4:688–702.
26. Vangeepuram N, McGovern KJ, Teitelbaum S, Galvez MP, Pinney SM, Biro FM, et al. Asthma
and physical activity
in multiracial girls from three US sites. J Asthma
2014; 51 2:193–199.
27. Williams B, Hoskins G, Pow J, Neville R, Mukhopadhyay S, Coyle J. Low exercise among children with asthma
: a culture of over protection? A qualitative study of experiences and beliefs. Br J Gen Pract
2010; 60 577:319–326.
28. Westergren T, Lilleaas U-B. Adolescent boys with asthma
; a pilot study on embodied gendered habits. J Multidiscip Healthc
29. Williams C. Doing health, doing gender: teenagers, diabetes and asthma
. Soc Sci Med
2000; 50 3:387–396.
30. Fereday J, MacDougall C, Spizzo M, Darbyshire P, Schiller W. “There's nothing I can’t do – I just put my mind to anything and I can do it”: a qualitative analysis of how children with chronic disease and their parents account for and manage physical activity
. BMC pediatrics
31. Stewart M, Masuda JR, Letourneau N, Anderson S, McGhan S. “I want to meet other kids like me”: support needs of children with asthma
and allergies. Issues Compr Pediatr Nurs
2011; 34 2:62–78.
32. Westergren T, Fegran L, Nilsen T, Haraldstad K, Kittang OB, Berntsen S. Active play exercise intervention in children with asthma
: a PILOT STUDY. BMJ Open
2016; 6 1:e009721.
33. Protudjer JLP, Kozyrskyj AL, Becker AB, Marchessault G. Normalization strategies of children with asthma
. Qual Health Res
2009; 19 1:94–104.
34. Protudjer JLP, McGavock JM, Ramsey CD, Sevenhuysen GP, Kozyrskyj AL, Becker AB. “Asthma
isn’t an excuse, it's just a condition”: youths’ perceptions of physical activity
and screen time. J Asthma
2012; 49 5:496–501.
35. Riner WF, Sellhorst SH. Physical activity
and exercise in children with chronic health conditions. J Sport Health Sci
2013; 2 1:12–20.
36. Chandratilleke MG, Carson KV, Picot J, Brinn MP, Esterman AJ, Smith BJ. Physical training for asthma
. Cochrane Database Syst Rev
37. Wanrooij VH, Willeboordse M, Dompeling E, van de Kant KD. Exercise training in children with asthma
: a systematic review. Br J Sports Med
2014; 48 13:1024–1031.
38. Berntsen S. Physical activity
in childhood asthma
: friend or foe? Am J Lifestyle Med
2011; 5 1:33–39.
39. Eichenberger PA, Diener SN, Kofmehl R, Spengler CM. Effects of exercise training on airway hyper reactivity in asthma
: a systematic review and meta-analysis. Sports Med
2013; 43 11:1157–1170.
40. Pacheco DR, Silva MJ, Alexandrino AM, Torres RM. Exercise-related quality of life in subjects with asthma
: a systematic review. J Asthma
2012; 49 5:487–495.
41. Milgrom H, Taussig LM. Keeping children with exercise-induced asthma
1999; 104 3:e38.
42. Welsh L, Roberts RG, Kemp JG. Fitness and physical activity
in children with asthma
. Sports Med
2004; 34 13:861–870.
43. Berntsen S, Carlsen KCL, Anderssen SA, Mowinckel P, Hageberg R, Bueso AK, et al. Norwegian adolescents with asthma
are physical active and fit. Allergy
2009; 64 3:421–426.
44. van Gent R, van der Ent CK, van Essen-Zandvliet LEM, Rovers MM, Kimpen JLL, de Meer G, et al. No differences in physical activity
in (un)diagnosed asthma
and healthy controls. Pediatr Pulmonol
2007; 42 11:1018–1023.
45. Nystad W. The physical activity
level in children with asthma
based on a survey among 7–16 year old school children. Scand J Med Sci Sports
1997; 7 6:331–335.
46. Rundle A, Goldstein IF, Mellins RB, Ashby-Thompson M, Hoepner L, Jacobson JS. Physical activity
symptoms among New York City Head Start children. J Asthma
2009; 46 8:803–809.
47. Taylor DR, Bateman ED, Boulet LP, Boushey HA, Busse WW, Casale TB, et al. A new perspective on concepts of asthma
severity and control. Eur Respir J
2008; 32 3:545–554.
48. Henriksen AH, Holmen TL, Bjermer L. Gender differences in asthma
prevalence may depend on how asthma
is defined. Respir Med
2003; 97 5:491–497.
49. Nielsen G, Pfister G, Bo Andersen L. Gender differences in the daily physical activities of Danish school children. Eur Phy Educ Rev
2011; 17 1:69–90.
50. Corder K, Craggs C, Jones AP, Ekelund U, Griffin SJ, van Sluijs EM. Predictors of change differ for moderate and vigorous intensity physical activity
and for weekdays and weekends: a longitudinal analysis. Int J Behav Nutr Phys Act
51. Zimmermann-Sloutskis D, Wanner M, Zimmermann E, Martin B. Physical activity
levels and determinants of change in young adults: a longitudinal panel study. Int J Behav Nutr Phys Act
52. Ayala GX, Miller D, Zagami E, Riddle C, Willis S, King D. Asthma
in middle schools: what students have to say about their asthma
. J Sch Health
2006; 76 6:208–214.
53. Carlsen KCL, Håland G, Devulapalli CS, Munthe-Kaas M, Pettersen M, Granum B, et al. Asthma
in every fifth child in Oslo, Norway: a 10-year follow up of a birth cohort study. Allergy
2006; 61 4:454–460.
54. Wennergren G, Ekerljung L, Alm B, Eriksson J, Lötvall J, Lundbäck B. Asthma
in late adolescence – farm childhood is protective and the prevalence increase has levelled off. Pediatr Allergy Immunol
2010; 21 5:806–813.
55. Meah A, Callery P, Milnes L, Rogers S. Thinking ‘taller’: sharing responsibility in the everyday lives of children with asthma
. J Clin Nurs
2010; 19 (13-14):1952–1959.
56. Ommundsen Y, Page A, Ku P-W, Cooper AR. Cross-cultural, age and gender validation of a computerised questionnaire measuring personal, social and environmental associations with children's physical activity
: the European Youth Heart Study. Int J Behav Nutr Phys Act
57. Ommundsen Y, Klasson-Heggebø L, Anderssen SA. Psycho-social and environmental correlates of location-specific physical activity
among 9- and 15- year-old Norwegian boys and girls: the European Youth Heart Study. Int J Behav Nutr Phys Act
58. Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U. Global physical activity
levels: surveillance progress, pitfalls, and prospects. Lancet
2012; 380 9838:247–257.
59. Strong WB, Malina RM, Blimkie CJ, Daniels SR, Dishman RK, Gutin B, et al. Evidence based physical activity
for school-age youth. J Pediatr
2005; 146 6:732–737.
60. Bauman AE, Reis RS, Sallis JF, Wells JC, Loos RJF, Martin BW. Correlates of physical activity
: why are some people physically active and others not? The Lancet
2012; 380 9838:258–271.
61. Braveman PA, Cubbin C, Egerter S, Chideya S, Marchi KS, Metzler M, et al. Socioeconomic status in health research: one size does not fit all. JAMA
2005; 294 22:2879–2888.
62. Currie CE, Elton RA, Todd J, Platt S. Indicators of socioeconomic status for adolescents: the WHO Health Behaviour in School-aged Children Survey. Health Educ Res
1997; 12 3:385–397.
63. Hartley JEK, Levin K, Currie C. A new version of the HBSC Family Affluence Scale – FAS III: Scottish Qualitative Findings from the International FAS Development Study. Child Indic Res
2016; 9 1:233–245.
1 ADJ4 means keywords combined with no more than four other words in between. N4/NEAR4 is also used in different interfaces and databases.