Introduction
Asthma is defined as “a chronic inflammatory disorder associated with variable airflow obstruction and bronchial hyperresponsiveness. It presents with recurrent episodes of wheeze, cough, shortness of breath, and chest tightness.”1(p.978) Between 20% and 50% of children with asthma at 10 years of age reported that the disease limited their physical activity (PA).2,3 Westergren et al.2 reported that perceived limitation was associated with more severe or less-controlled asthma as well as more severe bronchial hyperresponsiveness, allergies, and weight issues. Children and adolescents themselves may report emotional and social discomfort during PA that exceeds physical discomfort.4 In the everyday life of children and adolescents with asthma, PA takes place in active play, daily transportation, physical education, and organized sports. Limitations of PA may therefore influence their ordinary activities. Physical activity is defined as any bodily movement produced by the contraction of skeletal muscles that increases energy expenditure above the resting level.5 Limitations of PA, expressed as a barrier of bodily movement, may relate to physiological discomfort (eg, dyspnea), as well as emotional (eg, anxiety) and social (eg, unwanted attention) discomfort. Conversely, in children with well-controlled asthma, PA and physical fitness have been reported to increase.6 Management of PA in children and adolescents with asthma seems to be closely related to management of the disease. Additionally, seasonal variations of asthma exacerbations may occur.7 From a clinical perspective, Payne8 emphasized the importance of determining how asthma fits with the rest of the adolescent's life while addressing treatment, self-management, health risk behaviors, and mood.
Asthma and changes in childhood and adolescence
Current literature provides perspectives concerning challenges of asthma management in children and adolescents during developmental changes.8-10 Issues influencing asthma management are generally provided from a clinician/expert perspective, including adherence to medical regimens, poor symptom control and treatment outcomes, psychosocial and environmental challenges, and transfer from child to adult care.8-10 Children and adolescents experience physical, psychological, and social developmental changes. For instance, cognitive abilities shift from thinking and understanding that is more concrete to more abstract, multidimensional, and hypothetical.9,10 Children and adolescents become more independent, and socialization with peers increases.9,10 Identity formation may challenge relationships with others and may affect asthma management.9 Moreover, children's daily life may change by moving from elementary to middle schools, and by changes in family life, such as new siblings, change of parental occupational status, and breakdown in parental relationships.10 Social support structures may be more diffuse, peer pressure may be greater, and physical education may be more demanding.10 Maturation of children and adolescents also enables enhanced competencies, and allows transfer of responsibility from parents to their children.10
In children and adolescents with asthma, the cognitive, psychosocial, and environmental changes influence, and are influenced by, their chronic illness. In addition, significant physiological changes appear including puberty, growth, and changes in asthma.9,10 It is also reported that participation in PA tends to decrease as children age, more so in females than males.11 Through childhood and adolescence, PA enhances physical, cognitive, and social development. Furthermore, participation in PA has a dose-response relationship with several indicators of improved health,12,13 and participation in PA is also connected with being socially included in children's and adolescents’ everyday environments.14-16
In a recent scoping review, Westergren et al.17 reported that few psychometric instruments to measure psychosocial and socioeconomic factors had been developed and validated specifically for children and adolescents with asthma. A lack of evidence traces between reported experiences of children and adolescents with asthma and the development of those instruments was also identified. Issues identified through qualitative studies in the review were conflicting feelings and self-esteem concerning PA participation, and experiences of various capability, downplaying of asthma symptoms/restraints, and modification of activities. Moreover, experiences related to being like healthy peers, belonging within arenas of PA, and the importance of social support and gendered roles were also reported. Those issues were covered to a different extent in and between studies, and no further analysis related to age or developmental stages or contexts were reported.17
Rationale for the review
Several original studies and expert reviews exist about living with and managing asthma from childhood into adolescence, or from adolescence into adulthood.8,10,18-22 A narrative review23 exploring low participation in PA among this population highlighted misinterpretation of symptoms and inaccurate attribution of symptoms. The implications from the scoping review by Westergren et al.,17 which have also underpinned the aim of this current review, indicated the need to further explore experiences of PA in children and adolescents with asthma. Knowledge concerning such experiences may also be crucial for feasible, appropriate, effective, and meaningful interventions aiming to increase healthy PA. Two Cochrane reviews evaluating the effects of physical training24 and swimming25 on several health outcomes have been published, but the authors have not identified any review concerning effectiveness of interventions to increase PA in children and adolescents with asthma.
To the authors’ knowledge, based on comprehensive database searches, there have been no qualitative systematic reviews concerning children and adolescents with asthma and their experiences of participation in, and limitation of, PA related to their everyday life, including different social, environmental, and seasonal contexts. Experiences of children and adolescents with asthma are central to tailoring care and building rapport with the individual patient.8 This review would contribute to the development of psychometric measures to assess barriers of PA and implementation of exercise and PA interventions in children and adolescents with asthma in clinical practice. The objective of the present qualitative systematic review is to synthesize existing knowledge about experiences of children and adolescents with asthma that is related to participation in, or limitations of, PA.
Review questions
- i) How do children and adolescents with asthma experience their participation or limited participation in PA?
- ii) How do age; gender; developmental changes; severity of illness; symptom presentation; and social, seasonal, and environmental contexts influence the experiences of children and adolescents with asthma, with regard to PA?
Inclusion criteria
Participants
This review will consider studies that include children and adolescents six to 18 years of age with a clinical or self-/parent-referred diagnosis of asthma. Parent- or clinician-reported experiences concerning children and adolescents will not be included.
Phenomena of interest
This review will consider studies that investigate participants’ subjective experiences related to participation in, or limitation of, PA.
Context
This review will consider studies that investigate participants’ experiences in studies originating from all contexts and countries.
Types of studies
The review will consider descriptive, explorative, and evaluation studies that focus on qualitative data, including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research, and feminist research for inclusion.
Methods
The proposed review will be conducted in accordance with JBI methodology for systematic reviews of qualitative evidence.26 The review title has been registered in PROSPERO: CRD42020164797.
Search strategy
The search strategy will aim to find both published and unpublished studies. An initial limited search of MEDLINE (Ovid) and CINAHL (EBSCOhost) has been undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. This informed the development of a search strategy that will be tailored for each information source. A full preliminary search strategy for MEDLINE is detailed in Appendix I. The authors will conduct backtracking of references, and forward citation searches of all included studies in ISI Web of Science, Scopus, and Google Scholar.
The sources to be searched are MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL (EBSCOhost), SPORTDiscus (EBSCOhost), SocINDEX (EBSCOhost), and Social Science Citation Index.
The search for unpublished studies aims to identify theses and dissertations, and will include ProQuest Nursing and Allied Health Source, ProQuest Health Management, ProQuest Psychology Journals, ProQuest Health and Medical Complete, Open Access Theses and Dissertations, and Oria (the Norwegian Library Database).
Studies indexed in relevant databases and published in English will be included, unrestricted by year of publication.
Study selection
Following the search, all identified citations will be collated and uploaded into Rayyan (Qatar Computing Research Institute, Doha, Qatar)27 and duplicates removed. Titles and abstracts will be screened by two independent reviewers (TW and LF) for assessment against the inclusion criteria for the review. Studies that may meet the inclusion criteria will be retrieved and read in full text, and assessed in detail against the inclusion criteria before being uploaded into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). Full-text studies that do not meet the inclusion criteria will be excluded and reasons for exclusion will be provided in an appendix in the final systematic review. The results of the search will be reported in full in the final review and presented in a PRISMA flow diagram.28 Any disagreements that arise between the reviewers will be resolved through discussion within the entire review/author group.
Assessment of methodological quality
Selected studies will be critically appraised by two independent reviewers at the study level for methodological quality using the JBI Qualitative Assessment and Review Instrument.26 Any disagreements that arise between the reviewers will be resolved through discussion within the entire review/author group. The results of critical appraisal will be reported in narrative form and in a table.
Studies reporting results and conclusions that do not logically and empirically build on the views and words of children and adolescents themselves should not be included in the review. Therefore, studies that do not meet the criterion of conclusions drawn based on data including children's and adolescents’ experiences (Q10 in the JBI Critical Appraisal Checklist for Qualitative Research) will not undergo data extraction and synthesis.
Data extraction
Qualitative data will be extracted from reports included in the review by two independent reviewers using the standardized data extraction tool from JBI SUMARI. The data extracted will include specific details about the populations (age, gender, asthma diagnosis criteria, disease severity, symptom presentation), context (season, social setting, culture, geographical location), study methods, and the phenomena of interest relevant to the review questions and specific objectives.26 Findings, and their illustrations, will be extracted and assigned a level of credibility according to the ConQual process.29 Disagreements will be resolved through discussion between reviewers.
Data synthesis
Qualitative research findings will, where possible, be pooled using JBI SUMARI with the meta-aggregation approach.26 This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings and categorizing these findings based on similarity in meaning. These categories will then be subjected to a synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form.
Assessing confidence in the findings
The final synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings.29 The Summary of Findings will include the major elements of the review and details about how the ConQual score was developed. Included in the table is the title, population, phenomena of interest, and context for the specific review. Each synthesized finding from the review is then presented along with the type of research informing it, a score for dependability, credibility, and the overall ConQual score.
Acknowledgments
Librarian Ellen Sejersted of the University of Agder for assistance in the development of the search strategy.
Professor Lisbeth Uhrenfeldt at Nord University for her participation in discussions concerning the development and design of the protocol as a former member of the PRANSIT network.
Appendix I: Search strategy
MEDLINE (Ovid) - Epub ahead of print, in-process and other non-indexed citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R). 1946 to present.
Search conducted 14 Aug 2018
- 1. adolescent/ or child/ or child, preschool/ (2,797,429)
- 2. (Child∗ or Adolescen∗ or Young or Youth or Teenage∗ or Schoolchild∗ or Toddler∗ or Kid∗).ti,ab. (2,104,744)
- 3. 1 or 2 (3,817,845)
- 4. asthma/ or asthma, exercise-induced/ (118,589)
- 5. asthma∗.ti,ab. (143,386)
- 6. 4 or 5 (163,498)
- 7. exp Exercise/ (167,451)
- 8. exp Sports/ (163,675)
- 9. (physical activ∗ or exercise∗ or sport∗ or motor activ∗ or running or training or play or playing or playtime or inactiv∗).ti,ab. (1,571,910)
- 10. or/7-9 (1,663,736)
- 11. 3 and 6 and 10 (6006)
- 12. Qualitative research/ (40,052)
- 13. (Qualitative∗ or Interview∗ or Experience∗).ti,ab. (1,320,927)
- 14. (Phenomenolog∗ or Audiorecording∗ or Themes or Comprehension∗ or Attitude∗ or Emotion∗ or View∗ or Opinion∗ or Perception∗ or Belie∗ or Feeling∗ or Know∗ or Understand∗ or Adaptation∗ or Perspective∗).ti,ab. (3,808,764)
- 15. 12 or 13 or 14 (4,706,190)
- 16. 11 and 15 (1711)
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