Title: A mixed methods systematic literature review of barriers and facilitators to help-seeking
among women with stigmatised pelvic health symptoms
Version: 0 Date: 12 Feb 2024
Reviewer:  Lucy Dwyer
Reviewer's report:
Summary
This publication aims to systematically review and synthesise quantitative, qualitative and
mixed methods research exploring the barriers and facilitators to help seeking in women with
stigmatised pelvic symptoms. The findings demonstrate that stigma, a lack of knowledge
and feeling trivialised by healthcare professionals are barriers to helpseeking. Facilitators
to helpseeking were being bothered by symptoms, support from family and friends, having
knowledge of the condition and worrying symptoms were indicative of a serious disease. For
some women, the stigma that prevented others from helpseeking, motivated them, however for
the majority it was a barrier.
As stated in the introduction, while there have previously been similar reviews undertaken, these
have been condition specific, including a number of pelvic conditions allows for conclusions
to be made about barriers and facilitators to helpseeking in women specific conditions. As
highlighted this is particularly relevant in view of the Women’s health strategy and other high
profile campaigns in women’s health over recent years.
Strengths
o This systematic review aimed to identify the barriers and facilitators women in high income
countries face in seeking help for stigmatised pelvic symptoms.
o The population, intervention and outcome were clear and well justified.
o The authors have used an appropriate framework to define the review question for mixed
methods studies and justified this.
o The search terms are clearly defined e.g. high income countries (World bank definition)
o Studies were excluded if the data was not collected from women (e.g. from the perspective
of healthcare professionals)
o Included studies written in 5 languages.
o Included all study designs, quant, qual and MM
o Appropriate study designs to answer research question
o Appropriate databases were searched
o Additional searches were undertaken
o Used MMAT
o Used GRADE-CERQual
o Generalisability of findings is good due to use of studies from high income countries while
acknowledging that the NHS makes the UK unique
o Use of appropriate behaviour theory (CSM) to structure and understand findings
o Analysis of review findings clearly explained
o A good amount of primary data to demonstrate findings
o Contradictory data between studies and participants was highlighted e.g. stigma was a barrier
to some and facilitator to others
o Highlights clinical benefit
o Directs further research
o Discuss reflexivity
Limitations
o Only included published studies. No grey literature included
o Quite a lot of uncertainty when appraising quality using the MMAT- Please could more detail
be added explaining why so many question marks? Was that not available in the paper? Could
it have been clarified by contacting the authors?
o What does quality assessment suggest? It has just been reported rather than used to inform
the review e.g. prioritising themes by quality of paper or to highlight the need for higher quality
research in this area in future. Please could you comment on this in your paper?
Minor comments
Lines 144-145-reference where SPIDER is recommended, I have found conflicting evidence
about this. Please could you add more detail, references to this statement.
In table 1, it states the sample is women from high income countries with urogynaecological
symptoms, however the list of stigmatised conditions are not all urogynaecological e.g.
menopause, herpes etc, I suggest you change this to pelvic symptoms as used elsewhere
Conclusion
I believe this is a high-quality, well-conducted, systematic review of an important topic and the
question is novel. I therefore recommend this review for publication but would like the authors
to consider the points I have made above as I believe they may strengthen the review further.