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Open Access

Study Protocol

Experiences and impact of living with incontinence associated stigma: A protocol for a systematic review and narrative synthesis of qualitative studies

  • Cathy Murphy ,

    Roles Conceptualization, Project administration, Supervision, Writing – original draft, Writing – review & editing

    c.murphy@soton.ac.uk

    Affiliation University of Southampton, Southampton, United Kingdom

    ⨯
  • Miriam Avery,

    Roles Conceptualization, Writing – original draft, Writing – review & editing

    Affiliation University of Southampton, Southampton, United Kingdom

    ⨯
  • Margaret Macaulay,

    Roles Conceptualization, Writing – original draft, Writing – review & editing

    Affiliation University of Southampton, Southampton, United Kingdom

    ⨯
  • Mandy Fader

    Roles Conceptualization, Writing – original draft, Writing – review & editing

    Affiliation University of Southampton, Southampton, United Kingdom

    ⨯

Abstract

Introduction

Incontinence is global health and social issue, with urinary incontinence alone affecting over 400 million people. Incontinence can lead to physical harms such as skin damage, but it also commonly causes social and psychological harms, including those associated with stigma. For many people, treatment to cure incontinence does not work or is not suitable and they live with the long-term consequences of incontinence. At the moment, no stigma reduction interventions (increasingly used with other conditions such as mental health problems and HIV) have been developed for people living with incontinence. As a starting point for developing such an intervention, this review will address the questions 1) What are the incontinence (urinary or faecal) associated experiences of stigma of people living with incontinence? 2) What is the impact of incontinence associated stigma on their lives?

Methods

The reviewers will search Embase, Medline, PsychINFO and the Cumulative Index to Nursing and Allied Health Literature using controlled vocabulary and relevant search terms. Articles assessed to meet inclusion criteria will be included. Once duplicates have been removed, titles and abstracts will be screened and full texts of selected research articles will be reviewed. An adapted Joanna Briggs Institute Data Extraction Form will be used to collect the data and quality will be assessed using the Joanna Briggs Institute checklist for qualitative research appraisal tool. A framework approach (using the Revised Framework for Understanding Non-communicable Disease Related Stigma) will be used to organise, integrate, interpret and summarise findings from included articles. The review will be reported in accordance with the Enhancing Transparency in reporting the synthesis of qualitative research statement. Prospero registration number CRD42021259065.

Discussion

The systematic review described in this protocol will provide the first in-depth, comprehensive understanding of people’s experiences of the stigma associated with incontinence and the impact that it has on their lives. It will identify broader influences of contextual variables such as age, sex, cause and type of incontinence, socio-economic culture and geographical location. The review aims to provide insights to support the development of incontinence associated stigma reduction interventions.

Citation: Murphy C, Avery M, Macaulay M, Fader M (2022) Experiences and impact of living with incontinence associated stigma: A protocol for a systematic review and narrative synthesis of qualitative studies. PLoS ONE 17(7): e0270885. https://doi.org/10.1371/journal.pone.0270885

Editor: Jeffrey Jutai, University of Ottawa, CANADA

Received: October 25, 2021; Accepted: June 14, 2022; Published: July 8, 2022

Copyright: © 2022 Murphy et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Research data will be made publicly available when the study is completed and published.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Incontinence (the involuntary leakage of either urine or faeces) is recognised as a significant global health issue [1–3]. Urinary incontinence alone is estimated to affect 12% of women and 5% of men worldwide [4]. Incontinence (either urinary or faecal) is a symptom with many underlying causes. Many major conditions such as some cancers [5, 6], stroke [7], obesity [8], dementia [9], inflammatory bowel disease [10], childbirth [11] and menopause [12] are linked to an increased risk of incontinence.

Healthcare professionals should always seek to reverse the cause of incontinence, but this is often not possible or can take time; many people live with temporary or permanent incontinence [13]. There is a myriad of physical and psychological harms associated with incontinence, including skin breakdown [14], increased risk of falls [15], depression and anxiety [16]. One commonly reported incontinence associated harm is the experience of stigma and the negative impact on people’s quality of life is widely acknowledged [17].

Goffman’s 1963 seminal work explained that stigma is directed at people perceived to have an undesirable attribute that sets them apart from others by others in society [18]. Stigma is now well-documented as a driver of poor health outcomes [19]. Numerous frameworks and models building on Goffman’s work have been developed, including Bos et al’s conceptualisation of four interrelated manifestations of stigma; public stigma (reactions to someone perceived to have a stigmatising condition), self-stigma (impact of possessing a stigma), stigma by association (reactions to people associated with a stigmatised person) and structural stigma (perpetuation of stigmatised status by institutions and ideology) [20]. The impact of stigma can be difficult to estimate, but it is known to affect important outcomes such as help seeking, quality of life and care engagement [21–23]. Therefore, it is unsurprising that a considerable amount of work has been put into developing stigma reduction interventions (SRI) for other high stigma conditions such as epilepsy [24], HIV/AIDS [25] or mental health disorders [26]. However, there are no reports of the development or use of SRIs for incontinence associated stigma. This is despite the fact that incontinence is considered significantly more taboo than, for example, cancer or depression [27].

A rapid review of the literature on incontinence associated stigma undertaken to support designing this protocol demonstrated that, whilst it is highly prevalent and harmful, stigma and its impact appears to vary with group characteristics, for example, the underlying cause of incontinence [28], sex of the person [29], cultural differences [30] and type and severity of incontinence [31, 32] all seem to play a role in the experience of stigma. However, as yet, no systematic review on the topic has been published and understanding is limited. It is hoped that the review described in this protocol will provide greater understanding of incontinence associated stigma and consequently aid the development of one or more SRIs with the potential to decrease the negative impact of stigma.

Given the knowledge gaps in this area, the proposed systematic review with narrative synthesis of qualitative research aims to address the questions:

  1. What are the incontinence associated experiences of stigma of people living with incontinence?
  2. What is the impact of incontinence associated stigma on people’s lives?

The objective of the review is to identify, appraise and synthesise findings from qualitative studies (including qualitative elements of mixed method studies) that address the research questions. The review will include existing evidence provided by people living with incontinence and also their unpaid carers. It is important to include the views of unpaid carers for two reasons; firstly to avoid the exclusion of populations who might otherwise have a less heard voice (e.g. those with dementia or learning difficulties) and secondly because the stigma of incontinence has an impact on carers and the caring relationship that warrants investigation.

Methods

Study design

A systematic review of published evidence on the experiences and impact of incontinence associated stigma will identify and synthesise what is known on the topic, providing a comprehensive and structured understanding of qualitative research in the area. Using a framework-based qualitative synthesis approach, the review will appraise and interrogate results from included papers with the aim of providing insights into the experiences and impact of incontinence associated stigma. The processes described will be undertaken by at least two members of the team, with any differences discussed by at least three team members.

The framework approach to thematic synthesis will be facilitated by the use of Rai and colleagues’ Revised Framework for Understanding Non-communicable Disease Related Stigma [32]. This framework provides a conceptualisation of stigma in five categories: 1) sources of stigma,

2) biopsychosocial mechanisms/drivers (causative mechanisms), 3) manifestations of stigma, 4) consequences of stigma and 5) mitigating factors/strategies to curb/overcome stigma. This framework was chosen as it provides both sufficient conceptual breadth to include a range of non-communicable conditions (such as incontinence) and a useful organisational structure for findings from different populations. Use of this framework is described in the Data Extraction and Synthesis section.

Protocol registering and reporting

The review will be reported in accordance with the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) [33] statement, as was this protocol. Additionally, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) [34] statement was used to guide reporting in this protocol. This review protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO) database (registration number CRD42021259065).

Eligibility criteria

The SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type) tool [35] was used to support the development of both the research question and eligibility criteria. The inclusion criteria are as follows.

  • Sample: People (from any clinical population or their unpaid carers) living with urinary and/or faecal incontinence who describe the experience and/or impact of stigma associated with the incontinence.
  • Phenomenon of interest: Incontinence associated stigma.
  • Design: Any qualitative research design (e.g. interviews or ethnography), including qualitative results from mixed-methods studies.
  • Evaluation: Descriptions of the experience or impact of incontinence associated stigma.
  • Research Type: Primary qualitative research.

The exclusion criteria are:

  1. Studies that do not meet the inclusion criteria.
  2. Studies not published in English.
  3. Studies that do not include a qualitative element.
  4. Studies reporting the perspectives of people who are not the person living with incontinence or the unpaid carer of a person living with incontinence (e.g. healthcare professionals).
  5. Studies that include brief reference to stigma in passing rather than a major theme or topic.

Search strategy

The key information source will be a structured search of literature in electronic databases: Embase, PsychINFO, MEDLINE and CINAHL. Literature from inception onwards will be searched. A title only search will be undertaken on Google Scholar using guidance from Haddaway et al [36], with the first 1000 results screened for eligibility. Additionally, Proquest Dissertations & Theses Global will be searched. The reference lists of included articles will be hand-searched for potentially eligible studies. The list of search terms will be devised and finalised in collaboration with a health sciences librarian using a combination of controlled vocabulary and key terms for the concepts in the inclusion criteria.

Study selection and data management

Following the removal of all duplicates, the database search and hand-searching will be performed with all titles and abstracts screened to remove studies that are clearly not relevant, guided by the eligibility criteria. The full text of remaining studies will be retrieved and reviewed. Where there is any question on study eligibility, the review team will discuss the study to reach a decision. A reason for exclusion will be recorded on the PRISMA flow-chart for each non-eligible study. The articles assessed to meet the inclusion criteria will be retained and included in the synthesis. Articles will be managed using EndNote Web, with new databases used to manage each stage of the process.

Data extraction and synthesis approach

Using a custom designed Microsoft Excel form (adapted from the Joanna Briggs Institute data extraction form), data will be extracted from each article on author, year of publication, geographic location, method, setting, population (e.g. clinical group), participant demographics, relevant results and comments. All data describing experiences of stigma or the impact of stigma will be extracted, including verbatim participant quotes. The results section of the data extraction form will be developed to capture data using the domains of the Framework for Understanding Non-communicable Disease related stigma [29]. Synthesis of the data will be undertaken by tabulating individual study data by domain. Variation between different groups (e.g. by sex or incontinence type) will be actively sought by the reviewers and developed into sub-domains where appropriate. Data will be explored within and across domains (and sub-domains) and studies, and grouped by relevant characteristics, for example underlying condition (e.g. prostate cancer or fistula), age or sex where sufficient data allows.

Quality appraisal

All eligible articles will be appraised for their quality using the Joanna Briggs Institute’s Critical appraisal Checklist for Qualitative Research assessment tool [37] and the results summarised. This tool has been used extensively and judged to provide a coherent assessment [37]. The appraisal process will help to determine whether included studies meet accepted quality standards and identify any limitations.

Confidence in cumulative evidence

The GRADE-CERQual (“Confidence in the Evidence from Reviews of Qualitative research”) approach will be used to report the level of confidence in whether the review findings provide a reasonable representation of the phenomenon of interest [38]. The four areas of assessment are: 1) methodological limitations, 2) coherence, 3) adequacy of data and 4) relevance [38]. The ‘Applying GRADE-CERQual to qualitative evidence synthesis findings’ set of papers will be used to guide the process [39–42]. Any ambiguities will be discussed by the review team in order to reach a decision.

Ethics

Ethical review will not be sought for conducting this systematic review as individual level data will not be accessed.

Discussion

This systematic review will provide for the first time a comprehensive and nuanced understanding of people’s experiences of incontinence-associated stigma and the impact that it has on their lives (and those of their unpaid carers). It will identify broader influences of contextual variables such as age, sex, underlying cause and type of incontinence, socio-economic culture and geographical location. By synthesising literature from a range of populations, we will be able to identify similarities and variations between groups that will support a thorough and cohesive characterisation of the phenomenon.

It is expected that this work will support clinicians, policy-makers and researchers who are trying to improve the quality of life of people living with incontinence and their carers. In particular, it will aid the development of one or more Stigma Reduction Interventions for people living with incontinence. Better understanding the phenomenon of incontinence associated stigma, will improve the chances of developing a targeted and effective SRI. Additionally, it is likely that this review will contribute new knowledge to support existing conceptual frameworks for understanding the experience of living with and caring for incontinence, for example the Dignity in Continence Care Framework [43]. Such frameworks provide a holistic understanding of incontinence and caring for incontinence, thus playing an important role in attempts to improve care.

There are some potential limitations to this study. As with all reviews of qualitative research, the findings of this review will be dependent on the methodological quality and reporting standards of the original studies. It has been observed that quality appraisal of qualitative studies can be problematic, in part due to the lack of agreement between different communities of researchers on how the value of such work should be assessed [44]. The use of the Joanna Briggs Institute’s Critical appraisal Checklist for Qualitative Research assessment tool [37] will go some way to mitigating these issues. An additional potential limitation is the variation in the definition of stigma used in the studies. The concept of stigma has been criticised for being too vague [45] and lacking a theoretical perspective [46]. The use of Rai and colleagues’ [32] framework and the review’s broad definition of stigma will help to address this concern.

Supporting information

S1 Checklist. PRISMA-P 2015 checklist.

https://doi.org/10.1371/journal.pone.0270885.s001

(DOCX)

References

  1. 1. Minassian VA, Drutz HP, Al-Badr A. Urinary incontinence as a worldwide problem. Int J Gynaecol Obstet. 2003 Sep;82(3):327–38. pmid:14499979.
  2. 2. Pretlove SJ, Radley S, Toozs-Hobson PM, Thompson PJ, Coomarasamy A, Khan KS. Prevalence of anal incontinence according to age and gender: a systematic review and meta-regression analysis. Int Urogynecol J Pelvic Floor Dysfunct. 2006 Jun;17(4):407–17. Epub 2006 Mar 30. pmid:16572280.
  3. 3. Milsom I, Coyne KS, Nicholson S, Kvasz M, Chen CI, Wein AJ. Global prevalence and economic burden of urgency urinary incontinence: a systematic review. Eur Urol. 2014 Jan;65(1):79–95. Epub 2013 Aug 27. pmid:24007713.
  4. 4. Irwin DE, Kopp ZS, Agatep B, Milsom I, Abrams P. Worldwide prevalence estimates of lower urinary tract symptoms, overactive bladder, urinary incontinence and bladder outlet obstruction. BJU Int. 2011 Oct;108(7):1132–8. Epub 2011 Jan 13. pmid:21231991.
  5. 5. Kopp RP, Marshall LM, Wang PY, Bauer DC, Barrett-Connor E, Parsons JK; Osteoporotic Fractures in Men MrOS Research Group. The burden of urinary incontinence and urinary bother among elderly prostate cancer survivors. Eur Urol. 2013 Oct;64(4):672–9. Epub 2013 Apr 3. pmid:23587870; PMCID: PMC3938018.
  6. 6. Ramaseshan AS, Felton J, Roque D, Rao G, Shipper AG, Sanses TVD. Pelvic floor disorders in women with gynecologic malignancies: a systematic review. Int Urogynecol J. 2018 Apr;29(4):459–476. Epub 2017 Sep 19. pmid:28929201; PMCID: PMC7329191.
  7. 7. Tuong NE, Klausner AP, Hampton LJ. A review of post-stroke urinary incontinence. Can J Urol. 2016 Jun;23(3):8265–70. pmid:27347618.
  8. 8. Subak LL, Richter HE, Hunskaar S. Obesity and urinary incontinence: epidemiology and clinical research update. J Urol. 2009 Dec;182(6 Suppl):S2–7. pmid:19846133; PMCID: PMC2866035.
  9. 9. Grant RL, Drennan VM, Rait G, Petersen I, Iliffe S. First diagnosis and management of incontinence in older people with and without dementia in primary care: a cohort study using The Health Improvement Network primary care database. PLoS Med. 2013 Aug;10(8):e1001505. Epub 2013 Aug 27. pmid:24015113; PMCID: PMC3754889.
  10. 10. Gu P, Kuenzig ME, Kaplan GG, Pimentel M, Rezaie A. Fecal Incontinence in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis. Inflamm Bowel Dis. 2018 May 18;24(6):1280–1290. pmid:29617820.
  11. 11. Keag OE, Norman JE, Stock SJ. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. PLoS Med. 2018 Jan 23;15(1):e1002494. pmid:29360829; PMCID: PMC5779640.
  12. 12. Hakimi S, Aminian E, Mohammadi M, Mohammad Alizadeh S, Bastani P, Houshmandi S. Prevalence and Risk Factors of Urinary/Anal Incontinence and Pelvic Organ Prolapse in Healthy Middle-Aged Iranian Women. J Menopausal Med. 2020 Apr;26(1):24–28. pmid:32307947; PMCID: PMC7160590.
  13. 13. Riemsma R, Hagen S, Kirschner-Hermanns R, Norton C, Wijk H, Andersson KE, et al. Can incontinence be cured? A systematic review of cure rates. BMC Med. 2017 Mar 24;15(1):63. pmid:28335792; PMCID: PMC5364653.
  14. 14. Beeckman D. A decade of research on Incontinence-Associated Dermatitis (IAD): Evidence, knowledge gaps and next steps. J Tissue Viability. 2017 Feb;26(1):47–56. Epub 2016 Feb 21. pmid:26949126.
  15. 15. Gale CR, Westbury LD, Cooper C, Dennison EM. Risk factors for incident falls in older men and women: the English longitudinal study of ageing. BMC Geriatr. 2018 May 16;18(1):117. pmid:29769023; PMCID: PMC5956831.
  16. 16. Cheng S, Lin D, Hu T, Cao L, Liao H, Mou X, et al. Association of urinary incontinence and depression or anxiety: a meta-analysis. J Int Med Res. 2020 Jun;48(6):300060520931348. pmid:32552169; PMCID: PMC7303787.
  17. 17. Kuoch KL, Hebbard GS, O’Connell HE, Austin DW, Knowles SR. Urinary and faecal incontinence: psychological factors and management recommendations. N Z Med J. 2019 Oct 4;132(1503):25–33. pmid:31581179.
  18. 18. Goffman E. Stigma: Notes on the Management of Spoiled Identity. 1963 New York: Simon & Schuster.
    • 19. Stangl AL, Earnshaw VA, Logie CH, van Brakel W, C Simbayi L, Barré I, et al. The Health Stigma and Discrimination Framework: a global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas. BMC Med. 2019 Feb 15;17(1):31. pmid:30764826; PMCID: PMC6376797.
    • 20. Bos A, Pryor J, Reeder G & Stutterheim S. Stigma: Advances in Theory and Research, Basic and Applied Social Psychology. 2013 35:1, 1–9,
    • 21. Campbell DG, Bonner LM, Bolkan CR, Lanto AB, Zivin K, Waltz TJ, et al. Stigma Predicts Treatment Preferences and Care Engagement Among Veterans Affairs Primary Care Patients with Depression. Ann Behav Med. 2016 Aug;50(4):533–44. pmid:26935310; PMCID: PMC4935614.
    • 22. Sirey JA, Bruce ML, Alexopoulos GS, Perlick DA, Raue P, Friedman SJ, et al. Perceived stigma as a predictor of treatment discontinuation in young and older outpatients with depression. Am J Psychiatry. 2001 Mar;158(3):479–81. pmid:11229992.
    • 23. Wong CCY, Pan-Weisz BM, Pan-Weisz TM, Yeung NCY, Mak WWS, Lu Q. Self-stigma predicts lower quality of life in Chinese American breast cancer survivors: exploring the mediating role of intrusive thoughts and posttraumatic growth. Qual Life Res. 2019 Oct;28(10):2753–2760. Epub 2019 May 23. pmid:31123880.
    • 24. Chakraborty P, Sanchez NA, Kaddumukasa M, Kajumba M, Kakooza-Mwesige A, Van Noord M, et al. Stigma reduction interventions for epilepsy: A systematized literature review. Epilepsy Behav. 2021 Jan;114(Pt B):107381. pmid:32883610
    • 25. Andersson GZ, Reinius M, Eriksson LE, Svedhem V, Esfahani FM, Deuba K, et al. Stigma reduction interventions in people living with HIV to improve health-related quality of life. Lancet HIV. 2020 Feb;7(2):e129–e140. Epub 2019 Nov 24. pmid:31776098; PMCID: PMC7343253.
    • 26. González-Domínguez S, González-Sanguino C, Muñoz M. Efficacy of a combined intervention program for the reduction of internalized stigma in people with severe mental illness. Schizophr Res. 2019 Sep;211:56–62. Epub 2019 Jul 24. pmid:31351829.
    • 27. Elenskaia K, Haidvogel K, Heidinger C, Doerfler D, Umek W, Hanzal E. The greatest taboo: urinary incontinence as a source of shame and embarrassment. Wien Klin Wochenschr. 2011 Oct;123(19–20):607–10. Epub 2011 Sep 22. pmid:21935649.
    • 28. Drennan VM, Cole L, Iliffe S. A taboo within a stigma? a qualitative study of managing incontinence with people with dementia living at home. BMC Geriatr. 2011 Nov 14;11:75. pmid:22081876; PMCID: PMC3250935.
    • 29. Lagro-Janssen TA, Hilkens CJ, Klaasen RI, Teunissen D. Greater emotional and social effect of urinary incontinence in men than women. J Am Geriatr Soc. 2008 Sep;56(9):1779–81. pmid:19166466.
    • 30. Mendes A, Hoga L, Gonçalves B, Silva P, Pereira P. Adult women’s experiences of urinary incontinence: a systematic review of qualitative evidence. JBI Database System Rev Implement Rep. 2017 May;15(5):1350–1408. pmid:28498174.
    • 31. Fischer N, Church P, Lyons J, McPherson AC. A qualitative exploration of the experiences of children with spina bifida and their parents around incontinence and social participation. Child Care Health Dev. 2015 Nov;41(6):954–62. Epub 2015 May 23. pmid:26010416.
    • 32. Rai SS, Syurina EV, Peters RMH, Putri AI, Zweekhorst MBM. Non-Communicable Diseases-Related Stigma: A Mixed-Methods Systematic Review. Int J Environ Res Public Health. 2020 Sep 12;17(18):6657. pmid:32932667; PMCID: PMC7559120.
    • 33. Tong A, Flemming K, McInnes E, Oliver S, Craig J. Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC Med Res Methodol. 2012 Nov 27;12:181. pmid:23185978; PMCID: PMC3552766.
    • 34. Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. PRISMA-P Group. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ. 2015 Jan 2;350:g7647. Erratum in: BMJ. 2016 Jul 21;354:i4086. pmid:25555855.
    • 35. Cooke A, Smith D, Booth A. Beyond PICO: the SPIDER tool for qualitative evidence synthesis. Qual Health Res. 2012 Oct;22(10):1435–43. Epub 2012 Jul 24. pmid:22829486.
    • 36. Haddaway NR, Collins AM, Coughlin D, Kirk S. The Role of Google Scholar in Evidence Reviews and Its Applicability to Grey Literature Searching. PLoS One. 2015 Sep 17;10(9):e0138237. pmid:26379270; PMCID: PMC4574933.
    • 37. Hannes K. Chapter 4: Critical appraisal of qualitative research. In: Noyes J, Booth A, Hannes K, Harden A, Harris J, Lewin S, Lockwood C (editors), Supplementary Guidance for Inclusion of Qualitative Research in Cochrane Systematic Reviews of Interventions. Version 1 (updated August 2011). Cochrane Collaboration Qualitative Methods Group, 2011. Available from URL http://cqrmg.cochrane.org/supplemental-handbook-guidance
      • 38. Lewin S, Booth A, Glenton C, Munthe-Kaas H, Rashidian A, Wainwright M, et al. Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series. Implement Sci. 2018 Jan 25;13(Suppl 1):2. pmid:29384079; PMCID: PMC5791040.
      • 39. Munthe-Kaas H, Bohren MA, Glenton C, Lewin S, Noyes J, Tunçalp Ö, et al. Applying GRADE-CERQual to qualitative evidence synthesis findings-paper 3: how to assess methodological limitations. Implement Sci. 2018 Jan 25;13(Suppl 1):9. pmid:29384078; PMCID: PMC5791044.
      • 40. Colvin CJ, Garside R, Wainwright M, Munthe-Kaas H, Glenton C, Bohren MA, et al. Applying GRADE-CERQual to qualitative evidence synthesis findings-paper 4: how to assess coherence. Implement Sci. 2018 Jan 25;13(Suppl 1):13. pmid:29384081; PMCID: PMC5791039.
      • 41. Glenton C, Carlsen B, Lewin S, Munthe-Kaas H, Colvin CJ, Tunçalp Ö, et al. Applying GRADE-CERQual to qualitative evidence synthesis findings-paper 5: how to assess adequacy of data. Implement Sci. 2018 Jan 25;13(Suppl 1):14. pmid:29384077; PMCID: PMC5791045.
      • 42. Noyes J, Booth A, Lewin S, Carlsen B, Glenton C, Colvin CJ, et al. Applying GRADE-CERQual to qualitative evidence synthesis findings-paper 6: how to assess relevance of the data. Implement Sci. 2018 Jan 25;13(Suppl 1):4. pmid:29384080; PMCID: PMC5791042.
      • 43. Ostaszkiewicz J. Reframing continence care in care-dependence. Geriatr Nurs. 2017 Nov-Dec;38(6):520–526. Epub 2017 Apr 23. pmid:28442175.
      • 44. Sandelowski M, Barroso J. Finding the findings in qualitative studies. J Nurs Scholarsh. 2002;34(3):213–9. pmid:12237982.
      • 45. Link & Phelan (2001) Link BG, Phelan JC. Conceptualizing stigma. Annual Review of Sociology. 2001;27(1):363–385.
      • 46. Deacon H. (2006). Towards a sustainable theory of health-related stigma: Lessons from the HIV/AIDS literature. Journal of Community & Applied Social Psychology, 16(6), 418–425.