The CERQual Approach assesses the extent to which a review finding is a reasonable representation of the phenomenon of interest (the focus of the review question). Each review finding was assessed for each of the 4 quality elements listed and defined below in Table 6. Table 6: Description of quality elements in GRADE-CERQual for qualitative studies Quality element Description Methodological limitations The extent of problems in the design or conduct of the included studies that could decrease the confidence that the review finding is a reasonable representation of the phenomenon of interest. Assessed at the study level using an NGC checklist. Coherence The extent to which the reviewer is able to identify a clear pattern across the studies included in the review. Relevance The extent to which the body of evidence from the included studies is applicable to the context (study population, phenomenon of interest, setting) specified in the protocol. Adequacy The degree of the confidence that the review finding is being supported by sufficient data. This is an overall determination of the richness (depth of analysis) and quantity of the evidence supporting a review finding or theme. Details of how the 4 quality elements (methodological limitations, coherence, relevance and adequacy) were appraised for each review finding are given below. 4.3.4.4.1 Methodological limitations Each review finding had its methodological limitations assessed within each study first using an NGC checklist. Based on the degree of methodological limitations studies were evaluated as having minor, moderate or severe limitations. The questions to be answered in the checklist below included: Was qualitative design an appropriate approach? Was the study approved by an ethics committee? Was the study clear in what it sought to do? Is the context clearly described? Is the role of the researcher clearly described? Are the research design and methods rigorous? 