Online Brazilian Journal of Nursing | ISSN: 1676-4285

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REVIEW PROTOCOL

Women's experiences of self-management in gynecological health: a systematic review of qualitative evidence protocol

Isabela Cristina Nogueira1, Raquel Santa Bregalda1, Flávia de Oliveira Motta Maia1, Dalvani Marques1, Maria Helena Baena de Moraes Lopes1

1 School of Nursing, University of Campinas (UNICAMP), Campinas, SP, Brazil.

ABSTRACT

Objective: To understand women's experiences of self-management in gynecological health, considering 'experience' as knowledge or learning gained through practice. Method: A systematic review of qualitative evidence will be conducted in accordance with the Joanna Briggs Institute methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols. A three-stage search strategy will be conducted by two independent reviewers to explore the gynecologic health experiences of cisgender women aged 18 years and older who have already experienced menarche, excluding those who are experiencing the pregnancy-puerperium cycle. The review will consider interpretive and critical articles such as grounded theory, phenomenology, action research, feminist research, and ethnography. Databases including MEDLINE (Pubmed), Pubmed (NLM), Embase, BVS (Bireme), Scopus, Web of Science, Cochrane, and Cinahl (EBSCO) will be searched. Unpublished studies will be searched in ProQuest, Base Acervus and BDTD databases.

Descriptors: Culture; Gynecology; Health Behavior; Self-Management; Women’s Health.

INTRODUCTION

Beliefs, knowledge, and practices related to women's health have changed over the centuries according to the sociocultural context of each period. The ancestral practices that permeated the life and health cycles of women in the Middle Ages were replaced by medicalized practices that sought to break with the concept of nature that had been produced by the Renaissance. This new configuration of society is consolidated by the criminalization of reproduction and expropriates women from the popular knowledge that had been transmitted from generation to generation, building a wall of scientific and medicalized knowledge(1-2).

This medicalization, as a medical intervention in society, was called by Foucault a social policy that has health as an ideal and a responsibility of all, and had a focus, especially in England, on "controlling the health and bodies of the poorer classes to make them more fit for work and less dangerous to the richer classes"(3). In this context, hygiene and the functioning of medicine are at the same time instances of social and moral control, the by-product of which is the classification of those who conform to this ideal and those who do not.

The medicalization of life cycles also focuses on power and control over women's health, bodies, and reproductive processes(4). The medical power over the female body as an object of medicine has been gradually constructed throughout history through the medical discourse that takes hold of certain elements of this body and reduces them to their biological condition, justifying them according to its interests. Between the 19th and 20th centuries, medicine became particularly interested in defining the social roles of men and women, problematizing women's lives on the basis of their reproductive capacity or lack thereof(5).

The health paradigm shift of the twentieth century, built on the scientific revolution and based on the potential for social control and power over the body and health centered on the physician, remains constructed in this way to this day. The medicalization of the female body can be observed in various practices that aim to control, silence, and/or alter the natural female cycles and reinforce the dispossession of women over their bodies, gynecological health, and reproductive cycles.

Bekar et al.(6) surveyed 313 Turkish women to analyze attitudes toward gynecological health, addressing issues related to perineal hygiene, gynecological problems, and solutions to such problems. The results showed that women's knowledge about their gynecological health is insufficient and it is essential to increase this knowledge to avoid health complications.

Another study by Ali et al.(7) with 353 participants compared the perceptions, practices and challenges of Pakistani women regarding menstrual hygiene. The study revealed inadequate knowledge about menstruation and consequently incorrect practices in maintaining menstrual hygiene, exemplified by the fact that 77.8% of women in the general population and 66.1% of health professionals surveyed reported avoiding bathing during menstruation because it causes "irregular flow". Most of the women interviewed reported feeling anxious at the time of menarche. The authors defend in the article the importance of filling the knowledge gaps about reproductive cycles and destigmatizing menstruation to ensure the correct management of menstrual cycles, considering aspects such as adequate personal hygiene during menstruation, access to products, management of physical symptoms and emotional, community participation, among others.

Despite the intense medicalization of the female body, there is a growing number of women who, collectively or individually, problematize the medical-scientific hegemony because they perceive the power relations involved in the production of this knowledge and claim the role of autonomy for the intrinsic knowledge of their own body(8). Movements in this direction, which strengthen the incentive for a more autonomous gynecological practice, can be seen in recent years, especially with the growth and greater visibility of feminist movements around the world.

The search for a more autonomous gynecological practice gave rise in 1960 to the self-help movement, which encouraged women to know their own bodies and sexuality, using the exercise of self-knowledge as a form of liberation, introducing the concept of self-management gynecology or autonomous gynecology(9). Self-management gynecology is a practice that seeks to encourage women to get to know their bodies so that they can take care of their health, without necessarily breaking completely with conventional gynecology, but using it to their advantage, rescuing the intrinsic wisdom of each body and valuing the popular knowledge that has been neglected by allopathic medicine(8).

Some studies are carried out with the aim of broadening the perspectives and forms of women's health care(10–12). However, no studies have been found that aim to synthesize women's experiences regarding the relationship between self-knowledge and gynecological health in order to provide effective and empowering support and to develop evidence-based public policies for women.

In order to achieve this objective and to follow the high methodological rigor and quality expected for the conduct of systematic reviews(13), this protocol was prepared with information on the main objectives, characteristics of the review project and the planned analyses, as well as to ensure that the review methods are transparent and reproducible to avoid the risk of bias.

METHOD

The protocol has been registered on the PROSPERO platform under the registration number CRD42023391428.

Aims

To understand women's experiences of self-management of gynecological health, defining 'experience' as knowledge or learning gained through practice, and to identify and synthesize qualitative evidence on women's experiences of self-management of gynecological health.

Design

The proposed systematic review will follow the JBI methodology for systematic reviews of qualitative evidence(14), taking into account the interpretive and critical philosophical perspectives. The interpretive perspective seeks to synthesize evidence related to interactions that occur in the health care setting or to provide insight into social, emotional, or experimental phenomena, whereas critical research seeks to explore issues such as power and change(15).

Participants

This review will consider studies that include the experiences of cisgender women over the age of 18 who have already experienced menarche, excluding those who are experiencing the pregnancy-puerperium cycle. Cisgender women are defined as people who were born with female genitalia and identify with the female gender.

Phenomena of interest

This review will consider studies that explore women's experiences of self-management of gynecological care at different points in their reproductive cycle.

Context

This review will consider studies that include women from a variety of geographic locations and cultural backgrounds to provide a broad perspective on the selected phenomena.  

Study designs

This review will consider interpretive and critical articles including, but not limited to, phenomenology, grounded theory, ethnography, action research, and feminist research that draw on women's experiences of self-management of gynecological health.

Search strategy

The search strategy aims to identify both published and unpublished studies. Guided by the JBI methodology, a limited search of MEDLINE (PubMed) and CINAHL (EBSCO) was conducted to identify relevant productions on the topic. Based on the results of these articles, a comprehensive search strategy for MEDLINE (Pubmed) was developed, taking into account keywords in the titles, abstracts and main text, as detailed in Figure 1. During the analysis process, the references of the selected articles will be evaluated and, if they are consistent with the research objective, they will be included in the full analysis.

The studies included will not have a specific language or date range to ensure inclusion of research that reflects the evolving landscape of women's health and to include a broader range of scientific contributions given the limited scientific output on this topic.  

Databases to be searched include MEDLINE (PubMed), PubMed PMC, Embase, BVS (Bireme), Scopus, Web of Science, Cochrane, and CINAHL (EBSCO). Sources of unpublished studies and grey literature to be searched include Proquest, BDTD and Base Acervus.

Figure 1 – Search strategy for MEDLINE (PubMed), Campinas, SP, Brazil, 2023

Study selection

Search results will be collected, imported and de-duplicated in EndNote Web/2022 (Clarivate Analytics, PA, USA). Titles and abstracts will be evaluated by two independent reviewers after a pilot test, and relevant studies will be retrieved in full and imported into the JBI system for unified management, evaluation, and review of information. The full text of the articles will be evaluated by the reviewers according to the inclusion criteria. The selected articles will be categorized and reported in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flowchart(15). Articles that do not meet the inclusion criteria will be excluded from the analysis, and the reasons for exclusion will be recorded for each article. In case of disagreement between the reviewers on any study, at any stage of the process, a third reviewer will be involved in the discussion to resolve disagreements.

Assessment of methodological quality

The standard JBI Critical Appraisal Checklist for Qualitative Research(16) will be used by two independent reviewers to critically appraise eligible articles for methodological quality. Authors will be contacted as necessary to obtain missing information or to provide additional information for clarity. The results of the critical appraisal will be presented in a table and as a narrative.

All studies will be subjected to data extraction and synthesis whenever possible, regardless of the results of the methodological quality of the studies.

Data extraction

Two independent reviewers will use the standardized JBI data extraction tool(14) to extract data from the studies included in the review. The data extraction process will include several aspects, including population characteristics, contextual information, cultural factors, geographic location, study methods, and pertinent findings related to the objective of the review. The level of credibility of the retrieved findings will be determined, along with any associated visuals. Disagreements among reviewers will be resolved through discussion or with the assistance of a third reviewer. If further information is needed, the authors of the publications will be contacted.

Data synthesis

Whenever possible, qualitative findings will be grouped using JBI SUMARI and following the meta-aggregation method outlined by Munn et al.(17) This approach involves aggregating or synthesizing the findings to develop a collection of statements that represent the amalgamation of the findings. This synthesis process involves collecting the findings and classifying and categorizing them according to their similarity into qualitative findings, with the aim of generating a comprehensive set of qualitative evidence to serve as a basis for evidence-based practice. Where textual pooling is not possible, a narrative structure will be used to communicate the findings. Only conclusive and reliable findings are included in the synthesis.

Assessing confidence in the results

The ConQual approach to building confidence in the results of qualitative research synthesis will be used to assess and grade the final synthesized findings. The recommended format for presenting findings in the JBI Evidence Synthesis Manual will be followed to present these findings in a summary of findings(14). Key elements of the review will be included in the Summary of Findings, which will also explain how the ConQual score is determined. It will include the title of the review, its target population, its phenomena of interest, and its unique contextual aspects. Based on the structure developed by Munn et al.(17), each summarized finding generated by the review will be reported along with information about the type of study, scores for dependability and trustworthiness, and an overall ConQual score.

ACKNOWLEDGEMENTS

It is essential to acknowledge the librarian APMO's substantial participation in the search strategy's definition process.

CONFLICT OF INTERESTS

The authors have declared that there is no conflict of interests.

REFERENCES

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Submission: 31-Jul-2023

Approved: 20-May-2024

Editors:

Ana Carla Dantas Cavalcanti (ORCID: 0000-0003-3531-4694)

Paula Vanessa Peclat Flores (ORCID: 0000-0002-9726-5229)

Cláudia Maria Messias (ORCID: 0000-0002-1323-0214)

Corresponding author: Isabela Cristina Nogueira (Email: n.isabela07@gmail.com)