Mapping Research Evidence on Children With Atopic Dermatitis and Quality of Life in Sub-saharan Africa: a Scoping Review Protocol

Background: Atopic dermatitis (AD) is a chronic, debilitating disease affecting children worldwide. Several studies have explored the disease causes a signicant problem leading to a diminished quality of life, for the affected children but systematic evaluation of such studies in Africa is yet to be reported. Therefore, this scoping review aims to map research evidence on children with AD and their quality of life (QoL) in sub-Saharan Africa. Methods: The scoping review will follow the Arksey and O’Mally methodological framework. The electronic databases to be searched will include: PubMed, EBSCOhost (Academic search complete, CINAHL PsycINFO, and Health Sources), Scopus, and Google Scholar for published literature between 2000 and 2021. Only literature written in English will be included. The search strategy for the databases will include keywords, Medical Subject Headings terms and Boolean operators. The reference list of the included sources of evidence, and the WHO website will also be consulted for evidence relating to QoL of children with AD in Sab-Saharan Africa (SSA). Following title searching, two independent reviewers will conduct screening of abstracts and full text articles. Eligibility criteria will guide the screenings. This review will include studies conducted in SSA, publication focusing on quality of life and associated factors of AD in children. Data will be extracted from the included studies, analyzed qualitatively; NVIVO software V.11 will be usedand the emerging themes reported narratively. The mixed-method appraisal tool (MMAT) will be employed for quality appraisal of included studies. Discussion: We look forward ndings of several studies that describe the QoL and associated factors among children AD that report using different diagnostic criteria, severity scaling and QoL measuring scale tools used to ascertain the presence of AD, scale severity of AD and impact of AD on quality The will peer-reviewed

included sources of evidence, and the WHO website will also be consulted for evidence relating to QoL of children with AD in Sab-Saharan Africa (SSA). Following title searching, two independent reviewers will conduct screening of abstracts and full text articles. Eligibility criteria will guide the screenings. This review will include studies conducted in SSA, publication focusing on quality of life and associated factors of AD in children. Data will be extracted from the included studies, analyzed qualitatively; NVIVO software V.11 will be usedand the emerging themes reported narratively. The mixed-method appraisal tool (MMAT) will be employed for quality appraisal of included studies.
Discussion: We look forward to ndings of several studies that describe the QoL and associated factors among children with AD and that report on using different diagnostic criteria, severity scaling and QoL measuring scale tools used to ascertain the presence of AD, scale severity of AD and impact of AD on quality of life among children. The study ndings will be disseminated through publication in a peerreviewed journal, peer presentations, and presentations at relevant conferences.

Background
Atopic Dermatitis (AD) is a chronic, intensely itchy in ammatory skin disease that starts in childhood. It is a debilitating disease that affects up to 25% of children and 3% of adults, but varies signi cantly on a global scale (1,2). While the prevalence of AD in Africa and Middle Eastern countries has generally been lower than in Europe and North America, recent trends show an increasing AD prevalence in developing countries (3,4). Worldwide prevalence of AD for 6-to 7-year-old children was 14.2%. Also, the prevalence in age between 13 to 14 years was reportedly moderate in the eastern Mediterranean (10.8%) and Africa (15.2%) in comparison to the global prevalence of 12.8% for children in this age group. The prevalence of AD among children in different African countries Nigeria and Ethiopia (respectively 7.8% and 9.6%) varies greatly (5, 6).
AD is a multifactorial disease, and studies suggest that the development of AD may be linked to genetic susceptibility, environmental and lifestyle factors (7). The main clinical feature of AD includes intractable itching, eczematous skin lesion that can be acute (erythema, vesicular eruption), sub-acute (ill-de ned weepy crusted plaques), or chronic ( well de ned dry licheni ed plaques) and age of onset, xerosis, family history of atopy are some of essential features of AD (8). AD is diagnosed based on a clinical presentation using standardized diagnostic criteria in the absence of any de nitive laboratory test to diagnose the condition.
Treatment for AD includes frequent application emollients, avoidance of irritating factors education on the progress of the diseases and application of topical steroids which can be complicated, uncomfortable, and stressful for children, their families, or caregivers. Not only does AD increase the nancial burden on the family but it is also closely associated with asthma and allergic rhinitis and results in signi cant morbidity, leading to school absenteeism and emotional stress in children (11).
Studies have reported how AD in uences the quality of life of children and their families or caregivers (11). Sleep deprivation, irritability, anxiety, poor school performance, diminished self-esteem, and psychological disorder can be experienced by children with AD (12,13). As for their families or caregivers, studies have reported substantially greater levels of anxiety and depression due to sleep disturbance and absence from work, (12) Quality of Life (QoL) is de ned as "the individual's perception of their position in life in the context of culture and value systems in which they live concerning their goals, expectations, standards, and concerns" (14). Health-related quality of life (HRQoL) measures the quality of life only in the context of the patient's medical condition. In general, QoL comprehends impact on living circumstances, family life, and school functioning (15). Studies conducted in Western, European, and Asian countries con rmed the correlation between the severity of AD with QoL of the affected child and their families (5,6,11). There is, however, limited data on the QoL of AD in the African setting. It is, therefore, necessary to assess the QoL in children with AD and identify the factors that affect QoL to improve e cient treatment and understand the factors that negatively impact AD in SSA countries. Therefore, this scoping review aims to map research evidence on QoL and associated factors of AD in children in this region. It is anticipated that the review will reveal literature gaps and guide future research to inform policy-decisions in sub-Saharan Africa.

Methodology
This scoping review will constitute the rst part of a large-scale study to investigate the Quality of Life in AD in children in Ethiopia. The scoping review method will allow us to systematically map literature and describe existing research relating to AD in children in SSA. Aside from this, it will enable us to identify literature gaps, and inform subsequent systematic review and primary study questions on AD in children.
The scoping review will follow the steps outlined by Arksey

Identifying the research question
The main research question that this scoping review will address is: What research evidence exists on children (age 0 to 15 years) with atopic dermatitis and their quality of life within the last twenty years in SSA?
1. What research evidence exists on the QoL in children with AD? 2. What research evidence is available on the associated/contributory factors that impact on QoL of children with AD?
3. What instruments or assessment tools are available for assessing the QoL of children with AD?
Eligibility criteria Table 1 presents this review's eligibility criteria as part of the Population, Concept, Context (PCC) framework de ning the review question. Identifying relevant evidence sources Searches will be conducted on PubMed, EBSCOhost (Academic search complete, CINAHL with full text, PsycINFO, and Health Sources), Scopus, and Google Scholar from 2000 to 2021 for relevant published evidence sources to answer the review question. The search will employ keywords, Boolean terms ("AND" and "OR"), and medical subject headings to develop a comprehensive search strategy ( Table 1). The syntax will be modi ed where needed. The team will also use the services of an experienced subject librarian to ensure that a robust review search strategy is followed. Limitations on study design and language will be removed during the search. The search records will be documented appropriately. That is search date, database, keywords, search results, and count of eligible articles. To guide the electronic search strategy, the PRESS (Peer Review of Electronic Search Strategies) statement will be used. The reference list of the included sources of evidence, and the WHO website will also be consulted for evidence relating to QoL of children with AD in SSA. To compile all relevant evidence sources, identify and remove duplicate records, we will use the EndNote X9 reference manager. AGK will search for the evidence sources assisted by the review team and import them onto an EndNote library created for this review. Selection of evidence source Following the compilation of all evidence sources, the EndNote library will be cleaned by deleting all duplicate records. All tools or forms that will be used for the selection of the evidence sources will be piloted tested, and the needed amendments made to ensure their accuracy and reliability. Subsequently, the EndNote library will be shared among the review team. To reduce selection bias, two reviewers will conduct the title and abstract, and the full-text article screening independently. Guided by this scoping review eligibility criteria, the evidence sources will be sorted into either "include" or "exclude" group by two independent reviewers. At the abstract stage, discrepancies that may arise will be discussed by the review team until a consensus is reached. A third reviewer will address at the full-text screening stage. The University of KwaZulu-Natal library services will be used to retrieve all full-text articles with closed access publications. Also, we will send emails to the original authors for e-copies of relevant full-text articles if needed. The various stages of the evidence sources selection will be appropriately documented using the PRISMA ow diagram (Figure 1).
Charting the data A data charting form will be used to electronically capture relevant information from each included study.
The extracted data will include the following elds ( Table 3). The data extraction form will be piloted for consistency and reliability by two reviewers independently and amend if needed to ensure extraction of all relevant data. A narrative report will be produced to summarize the extracted data around the following outcomes: region of study, clinical severity and quality of life measuring tools, quality of life of children with AD.
However, Tables and graphs will be used to present the study characteristics if essential. Thematic analyses will be used to collate, summarise and report the results in the context of the overall study purpose. The authors will read and reread the articles thoroughly noting down the initial ideas to nd codes. Coding interesting features of the data systematically across the entire articles and collating data relevant to each code will be done. We will develop the codes into potential themes. The description of the coding tree and thematic content analysis will be used to analyze the data. Data related to the quality of life and AD severity scoring tools, factors related to the quality of life, and quality of life children with AD will be extracted and coded. The analysis process will use the following steps (1) Coding data from the selected articles, (2) categorizing the codes into themes, (3) displaying the data, (4) identifying key patterns in the data, and identifying sub-themes, (5) summarizing and synthesizing.

Quality Appraisal
The Mixed Method Appraisal Tool (MMAT) (20), will be adapted to assess the quality of the included primary studies. This scoping review will include study designs of qualitative, quantitative descriptive, and mixed methods studies. The speci c criteria to determine the appropriateness of each included study are outlined in Appendix.
Two (AGK and WE) reviewers will retrieve data and go through assign a scores to assess each article that will assess the appropriateness of the study aims and its relevance for inclusion based on selected review criteria and then AM can verify and go through any that do not correlate and come to nal list..
The overall quality for each included study will be calculated according to the following MMAT guidelines (score = number of criteria met/total score in each domain). 1 point will be given for each question and a total score out of 5 will be calculated. This will be represented as a percentage that correlates to the quality of the included studies. (Table 4) The results will use the following descriptors. research, and audit reasons, and can guide the management and inform decisions in resource allocation during policy development (21,22). Quality of Life (Q.O.L) measures have been studied to evaluate outcomes for children with chronic health conditions. It is also a good index to monitor patient progress and response to provided treatment (23). Parents of affected children report social di culties and feelings of worry, guilt, blame, and frustration due to their child's skin disorder (7,24). In most developed countries the QoL among children with AD was well researched(6, 11), and a certain limited research in the context of Africa countries. Studies for eg. in South Africa and Uganda reveals that AD has an impact on physical discomfort, low self-esteem, emotional and social isolation to children and families (25,26). The authors declare that they have no competing interests.

Consent for publication
Not applicable

Availability of data and materials
We have duly cited all studies, and data is presented in a form of references.

Not Applicable
Authors' contributions AGK conceptualized the study and wrote the protocol. WE, AM and JMW contributed to the writing and critically reviewed the draft protocol. AGK wrote the nal manuscript, and all authors approved the nal draft.