“This illness diminishes me. What it does is like theft”: A qualitative meta‐synthesis of people's experiences of living with asthma

Abstract Background What matters to people in their everyday experiences of living with asthma is influenced by a diverse range of personal, social, medical and environmental factors. Previous reviews of the asthma literature have largely focused on medical aspects of asthma or specific population groups with particular needs. Objective To identify, describe and synthesize from the available qualitative literature the views and experiences of adults living with asthma. Method We systematically searched for qualitative studies reporting on the personal experience of living with asthma. A meta‐synthesis approach was used to analyse and interpret the data. Key themes relating to personal perspectives on asthma were identified and grouped into overarching concepts. Results We identified 26 studies. There was a paucity of literature on the physical burden of asthma symptoms and the role of social support. Our synthesis generated a central concept of the “work” associated with living with asthma: work was of a personal nature, and at times an intensely emotional experience. Individuals tailored their behaviour in response to demands of the physical and social environment, including interactions with health‐care professionals. Conclusion This is the first systematic review of the qualitative literature reporting on people's own perspectives of living with asthma. Our findings draw attention to the nuances and sensitivities surrounding patient experiences of self‐management. Medical care is a central plank of managing chronic conditions, but our health‐care systems are now expected to deliver patient‐centred care. Considering the broader aspects of asthma management, beyond that of symptoms and treatment, will help to facilitate comprehensive care.


| INTRODUCTION
Asthma is a common chronic lung disease that cannot be cured. It affects as many as 334 million people of all ages in all parts of the world, causing an estimated 346 000 deaths annually. 1 It is well established in the existing literature that asthma has a significant impact on physical, psychological and social well-being, albeit with considerable variation between individuals. In 2010, asthma was ranked 14th in the world in terms of extent and duration of disability. 2,3 Asthma often interferes with daily living, 4 is associated with poorer self-assessed health status and is a substantial burden in terms of time off work. 5 Much of this impact comes from the physical effects of asthma symptoms, but there is also a significant social and emotional impact. Previous studies have reported a high rate of mental health problems among people with asthma, [6][7][8][9] including anxiety and panic attacks affecting between 6.5% and 24% of people, 10 a prevalence 3-10 times higher than in the general population. 11,12 Further, the direct and indirect economic burden associated with asthma is one of the highest among chronic disease due to the significant health-care utilization associated with this condition. 13 Not surprisingly, clinical practice guidelines for the management of asthma mainly focus on medical aspects of treatment. Guidelines provide evidence-based recommendations about diagnosis, assessment and appropriate use of medications and non-pharmacological strategies, to minimize asthma symptoms and the risk of adverse outcomes such as flare-ups and asthma-related death. However, despite advances in medical care, poor outcomes for patients persist. Patient adoption of asthma self-management practices, as recommended by health-care professionals (HCPs), remains low. One factor may be discordance between patient goals for managing their asthma and those of the medical profession: an analysis of patients' personal goals found that 35% of those goals did not map to the medical elements of the 2006 Australian asthma guidelines. 14 More recently, asthma guidelines have increasingly emphasized the need for patient-centred care, taking into account the patient's perspective, finding out the patient's own goals for their asthma, and using shared decision making to engage the patient in a partnership to manage their asthma. This has shown to improve asthma outcomes and patient engagement. 15 However, the extent to which a patient-centred approach has been implemented in clinical practice is unclear. It is an on-going challenge for both patients and healthcare professionals to discuss self-management strategies in everyday consultations. 16 One explanation could be a lack of research evidence about the patient's experience of living with asthma. The viewpoints of people about their day-to-day personal experiences of living with asthma, including its management, are extremely important. Reviews conducted so far have focussed on specific medical questions or population groups (eg, adolescents) rather than the broader personal experiences of adults living with asthma. 17,18 Currently, there is considerable disparity between research exploring the health priorities of people living with a range of chronic conditions, including asthma, and the management and treatment priorities of HCPs. [19][20][21][22][23][24][25] This body of research reveals that HCPs focus strongly on asthma symptoms, their triggers and taking medicines, whereas people with chronic conditions are concerned with more personally relevant and broader lifestyle issues such as exercise, fatigue, sleep and stress reduction, with a lesser focus on disease-specific problems such as use of medicines. 18,26 Personal and social factors, life goals and choice all appear to play a role in the ways in which people with chronic illnesses manage their condition. Exploring the perspectives of those most closely concerned-the people living with asthma-is an important step in furthering our understanding of the specific needs of those affected.
Published systematic reviews have examined specific aspects of asthma management, such as asthma action plans. 27 However, there is currently no comprehensive systematic review (qualitative or quantitative) of the personal experiences of adult patients living with asthma.
That is, what matters to people with asthma and how it has affected their lives.
Integrating qualitative research studies into a synthesis will generate new insights and understandings of the existent empirical work in this important area. The objective of this systematic review is to identify, describe and synthesize from the available qualitative literature the views and experiences of adults living with asthma. We ask the question, "How do people living with asthma experience their condition?"

| METHODS
We conducted a systematic review and synthesis of the qualitative evidence describing adult experiences of asthma. The review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement ( Figure 1).   There is evidence for the appropriateness of including the healthtalk.org website as a reliable source of qualitative data. The website was previously used in a systematic review by the Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) on young people and obesity. 54 The EPPI-Centre review found the healthtalk.org website to be a highly rigorous and relevant source. In addition, it was the only study to cover all themes found in their review. 54

| Study eligibility
Studies were included if: (i) the article reported on the personal experience of adults living with asthma. We focused on the literature on adult experiences only because the experiences of children with asthma would be reported mainly through their parents, and adolescents' experiences are distinctly different from those of adults or children; 55 (ii) the data collection and analysis methods were reported as qualitative; (iii) the publication reported original primary data; and (iv) the publication was in English language only, due to lack of resources for translation. This review considered studies that focused on qualitative data or included a qualitative aspect, including, but not limited to, designs such as phenomenology, grounded theory, ethnography, illness narrative and action research. We excluded (i) studies that focused on a specific medical question rather than the personal experience of living with asthma, (ii) studies where participants were preselected by their inclusion in another study, F I G U R E 1 Flow of information through the different phases of a systematic review (based on PRISMA reporting flow chart) because of the potential for sampling bias or modification of their experience, and (iii) studies that were specifically about the experiences of living with "severe asthma"; this condition, affecting around 5%-10% of the asthma population, is characterized by failure to respond to optimized conventional asthma treatment, and the diagnosis is established only following specific detailed investigations. 26 For the same reason, data from interviews in healthtalk.org 28 with patients who were clearly identifiable as having severe refractory asthma were also not included.
We identified 575 reports of which 26 met the inclusion criteria for the synthesis (Figure 1). Results were merged using reference management software (Endnote), and duplicates were removed.

| Data extraction and analysis
Two reviewers (KP and HR) extracted the data onto a data extraction form for qualitative analysis. The data extracted from the studies included specific details about study location, date of publication, qualitative method, participants, recruitment (primary or secondary care), study aim(s), methods for data analysis, principal experience(s) explored, diagnosis and definition of asthma, medications and duration of diagnosis.
This study was a meta-synthesis of the qualitative literature. We

| Quality assessment
Criteria for assessing the quality of published qualitative research are contested. 56 Some authors question the appropriateness of using structured quality appraisal tools to assess qualitative research because of the diversity of approaches in collecting, analysing and interpreting qualitative data. 56,57 There is little empirical evidence in relation to excluding qualitative studies based on quality assessment, and quality appraisal guidelines and checklists do not necessarily produce greater consistency of judgements about which studies to include in a qualitative synthesis. 58 Concerns have been expressed about less well conducted, but more insightful studies being excluded from qualitative syntheses. 58 Accordingly, and like authors of previous qualitative syntheses, [59][60][61] we considered the quality of the studies on the basis of their conceptual contribution, that is the relevance and usefulness of their findings to our research question.

| RESULTS
From 575 potentially relevant studies, 26 satisfied our inclusion criteria (Appendix B). The included papers were published between 1993 and 2014, from the United States (8), Australia (7), United Kingdom (7) and Denmark, Portugal, Turkey, Canada and the Netherlands/Canada (one each).
Participants were mostly recruited from hospitals or hospital emergency departments (number of studies=11) followed by primary care (number of studies=5). The favoured qualitative method was semi-structured interviews, and data analysis was mostly thematic.
The number of participants included in the studies ranged from 4 to 95 people. There was a considerably higher proportion of female participants, consistent with asthma being more prevalent among females than males in the adult population. 3 47 seven on general experiences of asthma, 46,48,50,51,84,85 two articles on asthma and lifestyle issues 49,86 and six on the symptoms and causes of asthma. [30][31][32][33][34][35] The included studies varied in design; both study design and content were considered to be of reasonable quality and of direct relevance to this review.
From the 26 studies, 64 experiences were extracted and grouped into 20 categories. Four synthesized concepts were produced from these categories: 1. Individual experiences of asthma are shaped by diverse physical and social environments (Table 1); 2. Individuals tailor their behaviour to their immediate context ( Table 2);

3.
Living with asthma necessitates on-going periods of cognitive and emotional adjustment (Table 3); and

Living with asthma involves both positive and negative interactions
with the health-care system (Table 4).
We present the summarized results in Tables 1-4. Each table rep-resents collective observations we derived from looking across all studies; they are our interpretation of the evidence. The "categories" were extracted from the data, either in our words or according to how the primary studies categorized the data. The "findings" column presents the experience of asthma as described in the primary studies.
Participant quotations extracted from the original studies illustrate the final four core concepts.
T A B L E 1 Synthesis 1: Individual experiences of asthma are shaped by diverse physical and social environments a

Categories
Findings-the experience The physical burden of asthma Physical symptoms can be frightening "panicky," "choking," "I was fighting" 65,82 "breathing through a straw," "suffocating," "drowning" 34 Feeling embarrassed about having asthma "I find it embarrassing to even have asthma"; 70 "you think you are sort of decrepit if you're asthmatic" 76 Age of diagnosis Childhood diagnosis "It was round when I was about ten, I was playing sport. I used to play a lot of sport when I was younger. I still do now…Initially when I was to go back to it, I found it hard to breathe…and just, just wasn't able to keep up really. And then …your body does adjust even with the inhaler, you get used to it and you find yourself being able to sort of compete with everyone else, being as fit as everyone else." 31 Adulthood diagnosis "I was really shocked [about being diagnosed with asthma], 'cause I just thought 'how can someone as fit as me get asthma?' [laughs]." 32 "I realised that it wasn't just a matter of fitness, it was actually a medical condition that I had then. And that was when I had to, kind of admit to myself that I was a wheezy person…And I was really anti-medicine. So I found it quite hard to take on board that I was an ill person that needed to take medicine…" 32 Childhood diagnosis "it's [asthma] become second nature…once you get into it…you find yourself being able to sort of compete with everyone else…" 31 "There are going to be anger management issues there and resentment that I don't so much have because… I've not known life without it." 32 Learned responses Conditioning: learning from family experiences "smacked" as a child "for keeping people awake" [with her chronic cough]; 65 "It was always [name] and her cough -we all just got used to it" 69 Conditioning: learning from personal experiences "Asthma is part of me like my bad temper" 76 a The categories and themes reported in the following tables represent a synthesis of those reported by the authors of the original studies.

| Synthesized line of argument: "work"
Our synthesis of the findings culminated in a line of argument about the active and passive "work" of living with asthma: "passive" being the more routine aspects of the experience itself, and "active" comprising efforts by the patient to present as living normally or actively defending against asthma. The "work" was at times an intensely emotional experience. A variety of cognitive and behavioural strategies were utilized by people living with asthma to negotiate the demands of their immediate environments, including interactions with health-care professionals (HCPs).

| Individual experiences of asthma are shaped by diverse physical and social environments
As presented in Table 1, some participants judged themselves according to their experience of asthma, and questioned the legitimacy of that experience. Personal experiences were greatly shaped by everyday interactions with the external environment. Some environments were more physically, socially and emotionally challenging to "work" within than others. For example, some participants described delaying seeking health care because they had been conditioned to feel embarrassed by their asthma, while for others asthma was just another part of their personal make-up.
Of note were the participants who reported experiencing negative interactions, judgement or de-valuing of their personal experience by employers, family and health-care professionals; "when I was at the hospital on the Friday, and the doctor said 'You're not sick, go home'. … Yes [I felt judged]. Very much, and very much lately.
Oh yes. We've seen it more and more over the last couple of years. I often wait, I wait until the last minute". 67 For some, those situations served as concrete cues prompting them to question how they relate to their asthma, and subsequent efforts to work with or against their asthma.
T A B L E 2 Synthesis 2: Individuals tailor their behaviour to their immediate context

Categories Findings-the experience
Concern about possible judgement from others Disassociating oneself with "asthmatic" identity Selectively disclosing asthma status "You have to be careful who you tell" 76 Choosing not to talk about asthma with others "I would not just talk about my asthma with others…I don't want them to think I am a pussy" 84 Not participating in activities likely to trigger symptoms in public or inconvenience others "I usually do not take a walk with others because I don't want to slow them down" 84 Concealing taking medication in social situations "If you are with strangers it is embarrassing to take medication in front of them…I do not take my medication in unknown territory" 84 "Sure you have to take your inhalers from time to time, and sometimes, I guess when you go to a new place for instance you join a new club or you're with a new group of people there is a factor where you don't want them to see you blowing on the inhaler, because it looks quite geeky. It looks, it doesn't look too, too cool." 37 "I don't know why. It was just like, it's almost an admission of weakness [using a reliever], you know, there's something…. You know, I don't want to be seen as sickly as weak you know, but it's not, you know, you're not really sickly with it, it's just something that's just gone wrong." 37 Concealing taking medication in the presence of employers Normalizing condition and experience "Soldiering on" "I come out of hospital and go straight back to work……if I'm fit enough to be out of there I'm fit enough to be at work" 64 Avoiding activities that will compromise employment Asthma is routine As "routine as putting one's watch on in the morning" 76 "That's just so important, it's just part of the morning and night routine, before you clean your teeth, you take your inhaler, breathe in, wait for ten seconds breathe out, if you need another dose you take it." 41 "You can always see there's someone with the same symptoms as you or, you know, if not worse than you kind of thing. And that's that is one of the things I think about online forums is that they can be quite reassuring in the sense that you're not the only person that's living with this condition and these symptoms…" 45 Taking proactive measures Seeking information Planning or anticipatory actions "I used to go to bed with my shoes on, it used to be so bad. Now at least I put a pyjama top on" 71 Becoming computer literate to research asthma Obtaining a personal peak flow meter to monitor asthma 72 "I measure my peak flow, that's the volume that you're able to inhale and exhale. I measure that usually three times a day and keep records of it…And if my peak flow shows that I'm sort of 20% below what I ought to be, or below my sort of personal best in terms of peak flow output then I start using prednisolone." 41 T A B L E 3 Synthesis 3: Living with asthma necessitates on-going periods of emotional and cognitive adjustment

Findings-the experience
Managing asthma by denying Denying asthma diagnosis "I don't know if I could cope if I really had it"; 76 "Well the doctors say I've got asthma but I've been hard to convince of that actually" 69 Minimizing experience/condition "I've got a bit of a cough but it doesn't mean I go to an asthma clinic. I wouldn't belong"; 76 "I'm not sick enough" 84 Denying need to take medications Taking medication every day "it's really admitting to yourself that you are an asthmatic with a real problem here" 76 Fearing the associated implications of having asthma Fearing dependency on medications Fearing or experiencing side effects from medication "…I'm not exactly a slim person in the first place, and that's very hard to control, not wanting to eat more, and that's something that I find very hard. But, it's [taking oral steroids] the lesser of the two evils." 38 "I didn't like it at the start because it's almost like just, I mean I think in everybody's head there's a kind of a, don't go there factor with taking steroids because it feels like you're, you know, polluting your body in some way" 38 Fearing unpredictability of asthma "I feel worried about the places I visit, my health, and the possibility of an asthma attack all the time" 85 "… Asthma is an absolutely awful condition because we all take breathing for granted until you can't breathe. To not be able to breathe and …it can also be painful for your chest is terrifying, and you just sometimes think, 'Well, if the next one doesn't kill me the next one might…I'm not enjoying life right now'.

| Individuals tailor their behaviour to their immediate context
For some people, living with asthma was an on-going process of monitoring and appraising themselves, others and their environment for relevant cues, and tailoring their behaviours responsively-according to the messages they received from that immediate context and as we observed, in notably self-protective ways ( Table 2).
Many of the findings of this review indicated that people felt it important to conceal their condition and/or medication use as a means of self-protection from undesirable consequences, such as negative social judgement, "there's a certain amount of the public have a certain amount of baggage about asthma". 83

| Living with asthma necessitates on-going periods of emotional and cognitive adjustment
Our synthesis draws attention to the idea that living with asthma is an on-going "work in progress." The concept of work was not necessarily readily observable, rather "work" of a personal nature, including emotional adjustment and shifting cognitions (Table 3). For example, finding meaning and acknowledgement of loss represented substantial adjustment to changed and changing circumstances; "I'd love to be able to walk … go on a holiday. If I go anywhere, I go out in the car, I've got to think … where's the hospital from there, where's the doctor from there … it's just been horrendous". 83 Our data suggest that living with asthma can be a variable emotional journey. Adjusting to asthma appeared to be a process that evolved via learning and responding to varied circumstances through lived experience. As the natural history of asthma is characterized by variability in its symptoms over time (symptoms may be present or absent at any given moment), individual trajectories varied too: coping and adjusting involved harder work at different points in time, including the emotional impact of the adjustment. Denial was a core experience illustrating the personal and often emotional work involved. This was exemplified through people's belief that they did not actually have asthma, or through efforts to minimize the effect of the condition, or a tension between the need to take medications every day and identification with being a person with asthma.

| Living with asthma involves both positive and negative interactions with the health-care system
Dissatisfaction with primary care was a prominent experience, and an interesting finding given the emotional burden described.
Unfortunately, for some individuals, their asthma experience was not validated by health-care interactions; "some of them don't believe that you're sick; 80 they just placate me … and act like, 'what did you waste my time for'". 71 Some data suggested dismissive and negative judgemental comments from HCPs (Table 4). An inability to afford asthma medications and treatment was also a relatively common concern and in some cases influenced patient interactions with health-care provid-  Accepting inconvenience-"it's nuisance value" but a small price to pay Never been affected by asthma badly and do not look upon it as an illness "I am not bothered by my asthma; it's irrelevant"; 76 "never really thought about asthma. I just had to live with it" 84 "So I just hope that anybody who is watching this and is worried, it's worth just beating it. It's a long term, at the moment a long term and what they call a chronic condition which I hate, I hate the terminology, but it doesn't mean to say that it must rule your life. context. Only one study appears to have directly asked people with asthma about the support they receive from friends, family and other support groups. 28 In addition, this was also the only study to contribute to all themes synthesized in the review. 28 Given the impact of asthma on daily routines and responsibilities for many people, we presume that emotional support could form an integral part of living with and managing asthma, and when present, could offer benefit to lessening the overall workload of living with asthma, particularly its emotional impact. The extant literature suggests a positive relationship between social support and asthma self-management behaviours, 93 and asthma control and quality of life. 94,95 However, in this review, our findings highlight that when social contacts or networks were reported, it was mostly in the context of exerting negative influence and creating social vulnerability.
The relative absence of descriptors of the physical experience of asthma in our review was also notable, except in the Healthtalk resource. 28 Asthma is defined clinically as the combination of variable respiratory symptoms (eg, wheeze, shortness of breath, cough and T A B L E 4 Synthesis 4: Living with asthma involves both positive and negative interactions with the health-care system

Categories Findings-the experience
Receiving different quality health care HCP has poor knowledge about asthma and medications "My GP is a good doctor but he does not know much about asthma" 67 Preferring outpatient care [rather than GP]; outpatient staff know what to do Not given choice to participate in health care; no time available "They give you what they want to give you"; 80 "All they do is give you tablets…take that and go away" 72 Experience dependent on HCP "He [His GP] he's actually an asthma sufferer himself… but he's also reassuring at the same time… he just explained how it hasn't hampered his life…He stays fit and healthy; it's again, positive mindset." 43 The importance of communication and understanding Not being heard "Some of them [HCPs] don't want to listen"; 80 "the doctor was just kind of oblivious…we never actually sat down and made a plan" 68 Receiving insufficient information and advice "My GP gave me a prescription for an inhaler but didn't tell me how to use it" 66 "…he prescribed the preventer and the Salbutamol or Ventolin…And the next time I saw the GP, because I asked for an explanation and she said, 'Oh because you have to'. And she didn't go into details and I'm the sort of person, I like to understand why I'm taking something. Not just because I have to. I need to understand the reason for it. So it helps me to appreciate the seriousness." 43

Asthma management explained well in outpatient clinic
Disagreeing about medical care "So me and the doctor, we couldn't agree about It" 67 Tailoring adherence to recommended prevention and treatment Being limited by inability to afford medications-tailor to suit or go without "I was short of money…so I went without Seretide [a long-term inflammatory medication] for a week and that was a big mistake because I ended up going back in [to hospital]" 64 Asthma medication can be expensive-purchase but with compromises "I can't afford it [Flixotide, a long-term anti-inflammatory medication] financially…I'm trying to compensate by using more Ventolin, more Atrovent [both short-term reliever medications], or something like that. So this has an effect on me too" 83 Being limited by inability to access health care Preferring to manage asthma independently Preferring to self-manage "I understand my asthma better than anyone else. Someone that lives with it. So if they [doctor] don't answer me the way I know they should be I won't go back" 72 Health care is a necessity Not wanting to end up in hospital "…I was hospitalised and nebulised and treated with prednisolone for another attack and that was because I misjudged how far down into breathing difficulties I was because I didn't have a peak flow meter. Asthma has sometimes been discounted as a serious illness, yet patients with even mild asthma can have severe flare-ups that require hospitalization, and for some people, it can be life-threatening. 97 For the past 25 years, asthma has been clearly recognized as an inflammatory medical condition. Prior to this, asthma was often discredited as a "real" illness among health professionals and the community because it was believed to have a psychological basis. 98 This was a particularly prevalent belief in the 1960s, during the childhood of some of the participants in the included studies. This may partly explain the feelings of judgement, either by others or oneself, that were reported in some of the studies in our synthesis.
Anticipating judgement from others was a significant feature influencing people's disease experience. The judgement could be real or perceived, and was of great concern to many participants across the studies. Our synthesis revealed that efforts to work around this involved a variety of cognitive and behavioural strategies, primarily concealment, selective disclosure, normalizing and taking proactive measures. Of note was the overall negative perception of asthma and efforts to hide it, which was of more or less priority depending on the person's context-their social, employment or home environment, alongside the frequency and intensity of their symptoms (requiring more or less effort to conceal). While asthma itself may range from extremely mild to extremely severe, understanding how individuals perceive their environment and respond accordingly is an integral step in addressing and explaining how and why individuals experience asthma differently. This is important because such perceptions could potentially be a barrier to seeking appropriate care, taking medications or seeking help.
Living with a chronic illness can be physically and emotionally challenging. Generally, our findings suggest that these challenges are harder to face when diagnosed as an adult. Those with childhood diagnosed asthma reported not really knowing a life without it and that managing their asthma was a routine experience. In contrast, negative emotions and feelings were typically felt by those who had been diagnosed as adults. 31 Concerns about the future and controlling the condition may have been harder to accept. 31 Thus, our findings suggest that age of diagnosis influences the amount of work involved in living with asthma.
People learn how to live with their asthma and develop personal preferences for management and care. Health-care interactions can play a significant role in a person's illness experience, for example, receiving good quality or conflicting information, or encountering poor health professional knowledge. General practitioners (GPs) are central to the management of asthma in the community, and asthma represents one of the most frequently managed chronic problems by GPs. 99 Our findings suggest that considerable work is invested by people with asthma to manage both the positive and negative interactions they encounter in the health-care system. Unsatisfying health-care experiences may significantly limit the work of individuals in trying to manage their asthma; some studies report associations between regular review with health professionals and medication adherence. 100 Alternatively

| Clinical and policy implications
The topics of the included papers of this review were notably clini- A review by Andrews identified that many self-management programmes focus predominantly on medical management and overlook the social and psychological work of the asthma experience. 102 Our

| Limitations
Some argue that it is difficult to synthesize studies that are carried out in disparate contexts and that attempting to do so ignores the rich detail that characterizes good qualitative research. However, like Britten et al., 104  These studies were mostly conducted in white populations.
However, rates of asthma morbidity, mortality and acute resource utilization are highest among minority, non-white, inner-city populations, and of these groups, our knowledge and understanding of the experience of living with asthma remains poor.
People whose asthma is currently well controlled may be relatively under-represented in existing literature, with 8 of 26 (31%) of the included studies recruiting emergency department attendees or patients admitted to hospital in order to investigate their specific experiences in these settings. However, emergency department visits are surprisingly common even in well-controlled asthma; for example, in a large US survey, one in seven patients with well-controlled asthma reported having an emergency department or urgent care visit in the previous year. 105

| CONCLUSION
We explored the existent qualitative empirical evidence reporting on adult experiences of living with asthma. To our knowledge, this is the first systematic review of the qualitative literature in this area. A key strength of this review was the methodology utilized to examine and interpret the findings from a diverse array of studies. We have brought to the forefront those aspects of the "work" of living with asthma that are important to those who have it, and highlight the unique nature of the personal experience of asthma and diversity in how individuals perceive, manage and relate to their experience. In so doing, we hope this work informs health-care professionals in their care of patients with asthma and facilitates the delivery of a patient-centred care approach to improving patient health and treatment outcomes.