Discuss about the Thematic Synthesis of Qualitative Research.
Asthma is a chronic inflammatory disease condition affecting health of more than 300 million people globally (Ozturk & Iliaz, 2016). The symptom of wheeziness, breathlessness and coughing occurs because of underlying processes like chronic inflammation of the airways, reversible obstruction of the airways and reaction of airways to stimuli (Bonini & Usmani, 2015). Although the disease is most commonly observed in children, however asthma can be diagnosed in adulthood too. The diagnosis of asthma is associated with substantial disease burden and reduction in the quality of life. The burden of disease is measured by disability and premature death (Ehteshami-Afshar et al., 2016). 14% of total children in the world are diagnosed with asthma and 8.6% adults between 18-45 years experience symptoms of asthma. Young people between the age of 30-34 years have lowest impact, however children aged 10-14 and elderly people ages above 75-79 years experience greatest burden. In older people, burden of the disease is defined by premature death (globalasthmareport.org, 2014). Although the prevalence of condition in children has been widely published, much less information exists regarding prevalence in older adults. Hence, focusing on the elderly population group is necessary to reduce the burden of asthma in developing countries.
With the increase in ageing population, asthma in the elderly will be one major public health concern. The number of people above 65 years of age is increasing rapidly and it is expected that by 2030, the number of people above 65 years in developing countries will double (Ortman, Velkoff & Hogan, 2014). Due to such expected increase in the ageing population and prevalence of asthma in the elderly, having understanding about asthma in the elderly population is essential. It may help to gain information regarding severity, spectrum of symptoms, treatment response and level of inflammation in the elderly population (Song & Cho, 2015). Research in this area is essential because due to ageing factor, the presentation and management of asthma is phenotypically different compared to young population group. Some of the ageing related factors that increase risk of uncontrolled disease due to asthma in elderly population include poor memory, poor hearing and vision, low education and neuromuscular issues in learning about self-management plans and inhaler use (Ozturk & Iliaz, 2016). Hence, these factors can increase the likelihood of comorbidities and symptom deterioration in elderly population. Therefore, in-depth exploration of challenges in management of asthma is necessary to understand the factors that deteriorates or improves condition of elderly people and find out solution to effectively manage asthma in elderly population (Scichilone et al., 2014). The main purpose of the research is to conduct a systematic review to understand how multiple chronic disease and comorbidities lead to poor asthma outcomes in patient and evaluate interventions to manage asthma and its comorbidities in the elderly.
The main research problem is increase in elderly population and risk of uncontrolled disease due to diagnosis of asthma and presence of multiple chronic disease. The research question related to the research problem represented in PICO format is as follows:
‘Is management of asthma (I) easier for elderly population (P) compared to young population group (C) in reducing asthma symptoms (O)?
The main aim of the systematic review is to gain in-depth understanding about the range of factors increasing challenges for elderly patient in the management of asthma. The main objectives of the systematic review are as follows:
Electronic databases: To find research articles suitable to the research question, all health and social care and biomedical databases like Medline, CINAHL, PubMed and EMBASE will be searched. The interface that will be used for databases searching includes EBSCO and nhs, which are the leading provider of research databases, e-journals, books and other work. The main search filter that will be used for all databases included setting publishing date of articles from the year 2009 to 2018 and setting type of resource to journal articles. This will help in the inclusion of research articles published within 10 years and evaluate effect of recent interventions on management of asthma in elderly people. Relevant articles related to the research question will be obtained by adding primary search terms like ‘asthma management in elderly’ and ‘challenges in the management of asthma in the elderly population’. After review of research articles by entering primary search terms, more specific search terms related to intervention uses for elderly people or other ideas will be used as secondary search term to enhance the search process. Boolean operators such as ‘AND’ and ‘OR’ will be used for conducting search in CINAHL database. Use of this approach will help in the selection of relevant articles related to the topic (Peters et al., 2015).
The inclusion criteria will be the eligibility criteria for the selection of articles. However, extraction of research articles will be done after the review of full-text article and reference list of the article. To include research articles in systematic review, two experts from the field of epidemiology will be contacted regarding the decision for final selection of research articles. Both the reviewers will cross check abstract and title of the articles first. In the second phase of searching, reference will be checked and included after achieving consensus for eligibility.
The inclusion criteria is the main eligibility criteria for selection of articles and the evaluation of the two articles will be done by two reviewers on the basis of research question (Whiting et al., 2016). The main rational for including two reviewers is to eliminate selection bias and prevent influence of individual judgment during the selection process. The two reviewers will first screen title and abstracts of articles for relevance and then full-text article will be reviewed to fulfill study objective. The reference list of selected articles will also be reviewed to find additional articles relevant to the research question. At this point, the reviewers will also exclude research articles which are not published in English language, which has no human participants and those which does has asthma as the study of interest. The two reviewers will independently extract data for research, however in case of disagreements, an independent researcher will settle cases of disagreement.
To enhance the validity and credibility of the research work, quality assessment of included studies is necessary. This process will be necessary to make the research more specific and transparent (Almeida & Goulart, 2017). By the use of relevant quality assessment tools, assessment of research articles based on research rigour, clear research objective and systematic representation of research findings can be done (Ahmed, Sutton & Riley, 2012). To evaluate the quality of research articles selected for the literature review, risk of bias assessment will be done by using the Cochrane Risk of Bias Assessment tool. It is an appropriate tool for assessment of different kinds of bias in research such as selection bias, performance bias, detection bias, attrition bias, reporting bias and other kinds of bias. The tool contains six domains such as random sequence generation, allocation concealment, blinding of participants, blinding of outcome assessment, incomplete outcome data, selective reporting and other source of bias to rate the quality of studies (Cochrane Methods, 2018). Based on these six domains, the judgment for quality of research articles will be done by the use of three categories such as low, moderate and high quality study.
To reduce the time taken to complete a systematic review, the specific method used to extract data can be useful. Systematic review aims to identify, synthesize and interpret published evidence to improve decision making process for clinicians, policy makers and other stakeholders. The strategies used to extract data determine the time consumed in conducting the review (Jonnalagadda, Goyal & Huffman, 2015). For the research on challenges in management of patient with asthma, a summary table will be used to summarize eligible studies. The following information will be extracted from eligible research articles:
After the extraction of research data, the analysis of research evidence will be done by thematic analysis process (Thomas & Harden 2008). Meta-analysis has not been chosen for this systematic review because meta-analysis is done when the purpose is to identify consistency between research studies based on treatment effect. However, the effect of treatment is not the main purpose of this systematic review. Hence, meta-analysis is not necessary for the research. Instead of meta-analysis, thematic review method will be adopted for analysis to categorize challenges for elderly patient under different themes. Thematic analysis is an effective approach to link selected studies with the research objective and study conclusion. Thematic analysis is a commonly used approach to analyze qualitative data and it helps to refines research findings into major themes (Bearman & Dawson, 2013). The categorization of research finding into different themes will help to process text and refine study findings. This process will also help reader to make critical assessment of the work.
The following tables will be included in the final paper after the completion of research:
Table 1: Summary table:
|
Author |
Country and year of publication |
Research sample |
Study setting |
Details of symptoms |
Type of intervention |
Duration of study |
Study design |
Outcome |
Table 2: Quality assessment table (Risk of bias summary)
|
References |
Sequence generation |
Allocation concealment |
Blinding of participants |
Blinding of outcome assessor |
Incomplete Outcome date |
Other source of bias |
|
Author et al. year |
+ |
+ |
? |
– |
+ |
– |
The above signs in the table indicate the signs that will be used judge high, low and unclear risk of bias. Positive sign will indicated by high risk of bias, negative sign will indicate low risk and question mark sign will mean unclear risk of bias.
The flow chart of results included and studies summarized will also be included which will give detail on identification, screening, eligibility and number of articles included for the study.
The systematic review process will be completed in several stages like literature searching, quality appraisal, data extraction, synthesis and writing up. The timeline for each of the stages are as follows:
|
Stages of systematic review |
June 2018 |
July 2018 |
August 2018 |
Sept 2018 |
Oct 2018 |
|
Literature searching |
|||||
|
Quality appraisal |
|||||
|
Data extraction |
|||||
|
Synthesis |
|||||
|
Writing up |
Reference:
Ahmed, I., Sutton, A. J., & Riley, R. D. (2012). Assessment of publication bias, selection bias, and unavailable data in meta-analyses using individual participant data: a database survey. Bmj, 344, d7762, doi: https://doi.org/10.1136/bmj.d7762
Almeida, C. P. B. D., & Goulart, B. N. G. D. (2017). How to avoid bias in systematic reviews of observational studies. Revista CEFAC, 19(4), 551-555, Doi: https://dx.doi.org/10.1590/1982-021620171941117
Bearman, M., & Dawson, P. (2013). Qualitative synthesis and systematic review in health professions education. Medical education, 47(3), 252-260, doi:10.1111/medu.12092
Bonini, M., & Usmani, O. S. (2015). The role of the small airways in the pathophysiology of asthma and chronic obstructive pulmonary disease. Therapeutic advances in respiratory disease, 9(6), 281-293.
Cochrane Methods (2018). Assessing Risk of Bias in Included Studies. Retrieved from: https://methods.cochrane.org/bias/assessing-risk-bias-included-studies
Ehteshami-Afshar, S., FitzGerald, J. M., Doyle-Waters, M. M., & Sadatsafavi, M. (2016). The global economic burden of asthma and chronic obstructive pulmonary disease. The International Journal of Tuberculosis and Lung Disease, 20(1), 11-23, DOI: https://doi.org/10.5588/ijtld.15.0472
globalasthmareport.org (2014). The Asthma Global Report 2014. Retrieved from: https://www.globalasthmareport.org/resources/Global_Asthma_Report_2014.pdf
Jonnalagadda, S. R., Goyal, P., & Huffman, M. D. (2015). Automating data extraction in systematic reviews: a systematic review. Systematic reviews, 4(1), 78, doi: 10.1186/s13643-015-0066-7
Ortman, J. M., Velkoff, V. A., & Hogan, H. (2014). An aging nation: the older population in the United States (pp. 25-1140). United States Census Bureau, Economics and Statistics Administration, US Department of Commerce, https://bowchair.com/uploads/9/8/4/9/98495722/agingcensus.pdf
Ozturk, A. B., & Iliaz, S. (2016). Challenges in the management of severe allergic asthma in the elderly. Journal of asthma and allergy, 9, 55, doi: 10.2147/JAA.S85420
Peters, M. D., Godfrey, C. M., Khalil, H., McInerney, P., Parker, D., & Soares, C. B. (2015). Guidance for conducting systematic scoping reviews. International journal of evidence-based healthcare, 13(3), 141-146, DOI: 10.1097/XEB.0000000000000050
Scichilone, N., Pedone, C., Battaglia, S., Sorino, C., & Bellia, V. (2014). Diagnosis and management of asthma in the elderly. European journal of internal medicine, 25(4), 336-342, DOI: https://doi.org/10.1016/j.ejim.2014.01.004
Song, W. J., & Cho, S. H. (2015). Challenges in the management of asthma in the elderly. Allergy, asthma & immunology research, 7(5), 431-439.
Thomas, J., & Harden, A. (2008). Methods for the thematic synthesis of qualitative research in systematic reviews. BMC medical research methodology, 8(1), 45, Doi: https://doi.org/10.1186/1471-2288-8-45
Whiting, P., Savovi?, J., Higgins, J. P. T., Caldwell, D. M., Reeves, B. C., Shea, B., … ROBIS group. (2016). ROBIS: A new tool to assess risk of bias in systematic reviews was developed. Journal of Clinical Epidemiology, 69, 225–234. https://doi.org/10.1016/j.jclinepi.2015.06.005
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