DOI: 10.31038/EDMJ.2025911

Abstract

Objective: To conduct a systematic review of the experiences of patients with Sjögren’s syndrome.

Methods: We performed a computerized search across PubMed, Web of Science, Embase, Cochrane Library, CINAHL, PsychINFO, Proquest, CNKI, CBM, Wanfang Data, and VIP databases to identify qualitative studies on the illness experiences of Sjögren’s syndrome patients from the inception of the libraries to September 2023. The JBI Critical Appraisal Tool for qualitative research in Australia was utilized to assess the quality of the included studies, and synthesis methods were employed to integrate the findings.

Results: Nine studies were included, yielding 32 findings that were categorized into 10 themes, culminating in 4 overarching outcomes: (1) prolonged and challenging diagnostic and treatment journeys; (2) significant daily life disruptions; (3) diverse coping styles and illness attitudes; (4) a pronounced need for, yet scarcity of, social support.

Conclusions: Sjögren’s syndrome patients endure profound physical and mental disturbances, leading to a markedly diminished quality of life. It is imperative for healthcare professionals to enhance symptom management and intervention, focus on assessing patients’ psychological well-being and coping mechanisms, and develop a comprehensive medical and social support system to ameliorate patients’ quality of life.

Keywords

Sjögren’s syndrome, Illness experience, Qualitative research, Meta-synthesis

Introduction

Sjögren’s syndrome (SS) is a chronic autoimmune disease hallmarked by dry mouth and eyes due to lymphocytic infiltration of the salivary and lacrimal glands, with primary clinical manifestations including xerostomia, fatigue, and musculoskeletal pain [1]. Predominantly affecting middle-aged and elderly women, the global incidence rate ranges from 0.04% to 4.80% [2]. SS is a protracted and relapsing condition; as it advances, symptoms can impact multiple bodily systems, severely compromising patients’ physical and mental health [3,4]. Amid the evolution of the bio-psycho-social medical model, the psychological well-being of patients with SS has become a focal point for researchers. Existing studies, while exploring the experiences and sentiments of SS patients, exhibit variations in racial, contextual, and methodological aspects, preventing a comprehensive understanding from a single study. This investigation employs a meta-integration approach to compile a more exhaustive qualitative evidence base reflecting the experiences of SS patients, aiming to inform clinical healthcare professionals and bolster the development of targeted interventions and measures.

Methods

The protocol was registered a priori with the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42023472699.

Search Strategy

PubMed, Web of Science, Embase, Cochrane Library, CINAHL, PsychINFO, Proquest, CNKI, CBM, Wanfang Data and VIP was searched for qualitative studies on the experience of SS from its inception to 30 September 2024, and the references of the included studies were searched manually. Search terms such as ‘Sjogren’s Syndrome/primary Sjogren’s syndrome/Sjogren’s syndrome/ Sicca Syndrome/Sicca exocrinopathy/SS/pSS; illness experience/ experience/feel*; qualitative research/qualitative research/qualitative study/participant observation/phenomenology/action research’ etc. The search strategy is illustrated with a PubMed example, see Figure 1.

Figure 1: Pubmed search strategy

Literature Inclusion and Exclusion Criteria

The inclusion criteria referred to the PICoS model [5,6]. (1) Population (P): patients diagnosed with SS (including primary Sjögren’s syndrome and Sjögren’s syndrome), age≥18 years old, gender is not limited; (2)Interest phenomenon (I): patients with SS since the disease since the real experience of the disease and feelings; (3) Context (Co): the life experiences of patients with SS during or after the diagnosis and treatment process; (4)Study design (S): qualitative research, including phenomenology, Grounded theory, ethnography and action research. Exclusion criteria: (1)duplicated published literature; (3)non-Chinese and English literature; (2)literature with no access to full text.

Literature Screening and Data Extraction

Literature screening and data extraction were carried out independently by 2 researchers (1st and 2nd authors), with a 3rd researcher (4th author) assisting in judgement when differences of opinion were encountered. The retrieved literature was imported into Endnote21, duplicates were eliminated, titles and abstracts were read for initial screening, and the full text was further read for re-screening to make a final decision on whether to include the literature. The information extracted mainly included the author, year of publication, country, subject of study, research method, phenomenon of interest and findings.

Evaluation of Literature Quality

The included literature was evaluated by 2 researchers using the JBI qualitative research quality assessment tool [7]. The tool consists of 10 items designed to assess the quality of qualitative research literature with different methods, including research methodology and conceptual depth of information. 2 researchers were assessed with ‘yes’, ‘no’, ‘not clear’were used to assess the quality of the literature, which was classified into 3 grades, A, B, and C. All criteria were assessed as grade A if they were met, grade B if they were partially met, and grade C if none of them were met. Only studies with grades A and B were included in this study and studies with grade C were excluded. Disagreements, if any, were resolved through independent judgement by a 3rd researcher.

Meta Integration Methodology

The pooled integration method from the Australian JBI Centre for Evidence-Based Healthcare was employed to synthesize the qualitative research literature under review [7,8]. Researchers, well-versed in evidence-based nursing and experienced with qualitative methodologies, meticulously examined the included literature. This process aimed to comprehend and elucidate the significance of each finding, consolidate them into categories, and ultimately amalgamate these into novel insights by dissecting the interconnections between categories.

Results

Literature Search Results

The results of the initial literature search were 588 articles, and 9 articles were included after screening and quality evaluation. The time range was from 2001 to 2020, including 1 article in Chinese and 8 articles in English. Research methods phenomenology 6 articles, descriptive research 2 articles, grounded theory 1 article. The literature screening process is shown in Figure 2.

Figure 2: Flow chart of literature screening

Basic Characteristics and Quality Evaluation of the Included Literature

The basic characteristics of the literature are shown in Table 1 and the quality evaluation is shown in Table 2.

Table 1: The basic characteristics of the included literature(n=9).

Author	Year	Country	Participants	Study design	Location	Aim	Themes
Nancy et al. [9]	2001	America	10 patients	Descriptive Research	telephone interview	To explore the lived experiences of people with SS and to uncover the coping strategies and attitudes of actual patients with SS	Four themes: helping hindering hoping hurting
Rebecca J et al. [10]	2017	The United Kingdom	20 patients	Phenomenological Research	Hospital outpatient departments or research institutes	To investigate the experience of fatigue and related symptoms in patients with pSS	Three themes: the physical experience of fatigue; ocular fatigue and fatigue related to ocular complaints; cognitive aspects of fatigue
Jemma L et al. [11]	2023	The United Kingdom	not mentioned	Phenomenological Research	Online Sites	To qualitatively explore the conversations about sexual functioning that females with SS had on internet forums	Four themes: the symptoms of SS and their impact on the sexual environment; the emotional responses that are commonly evoked in response to sexual difficulties; the strategies that users have implemented to manage sexual problems; and the impact that a partner’s behavior may have on the sexual environment.
Di Ying J et al. [12]	2016	Singapore	10 patients	Phenomenological Research	Dental school conference room	To provide clinicians with insight into how dry mouth can impact on the daily lives of Sjögren’s Syndrome patients	Four themes: the journey to diagnosis; disease impact spectrum (of dry mouth amid other symptoms); interactions with healthcare professionals; and the positive coping process.
Angelika et al. [13]	2017	Austria	20 patients	Phenomenological Research	Outpatient quiet room	To explore perspectives and needs of patients with PSS that influence health related quality of life (HRQL)	Three themes: Physical dimension; psychological & emotional challenges; social life & daily living
Gonzalo et al. [14]	2016	Chile	12 patients	Grounded Theory	Hospital lighting and soundproofed private rooms	To give an encompassing in-depth account of the life experiences of women with pSS and health-related behaviours, and to summarize these experiences in an integrated model.	Three themes: illness experience, social interaction and psychological response
Peng et al. [15]	2023	Taiwan, Province of China	14 patients	Phenomenological Research	Patient’s neighborhood fast food restaurant or hospital	To explore the experiences of SS patients seeking care	Four themes: annoying symptoms; difficulty in confirming a diagnosis; fear of medication side effects; confronting the disease
Anne et al. [16]	2014	Norway	9 patients	Phenomenological Research	not mentioned	To examine how fatigue may differ from ordinary tiredness in patients with primary Sjögren’s syndrome (SS)	Two themes: a heavy, resistant body and ever- present lack of vitality; unpredictable and uncontrollable fluctuations in fatigue
Kerry et al. [17]	2020	The United Kingdom	48 patients	Descriptive Research	Online Forum	To explore the disease and treatment experiences of patients with pSS	Three themes: Symptoms; Symptom Impacts; Patient Experiences with pSS Management

Note: 1 Was there a clear statement of the aims of the research? 2 Is a qualitative methodology appropriate? 3 Was the research design appropriate to address the aims of the research? 4 Was the recruitment strategy appropriate to the aims of the research? 5 Was the data collected in a way that addressed the research issue? 6 Has the relationship between researcher and participants been adequately considered? 7 Have ethical issues been taken into consideration? 8 Was the data analysis sufficiently rigorous? 9Is there a clear statement of findings? 10 How valuable is the research?

Table 2: Methodological quality evaluation of the included literature (n=9).

Publication	1	2	3	4	5	6	7	8	9	10
Nancy et al. [9]	Yes	Yes	No	No	Yes	No	Yes	Yes	Yes	Yes
Rebecca J et al. [10]	Yes	Yes	Yes	Unclear	Yes	No	Yes	Yes	Yes	Yes
Jemma L et al. [11]	Yes	Yes	Yes	Unclear	Yes	No	No	Yes	Yes	Yes
Di Ying J et al. [12]	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes
Angelika et al. [13]	Yes	Yes	Yes	No	Yes	No	Yes	Yes	Yes	Yes
Gonzalo et al. [14]	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes
Peng et al. [15]	Yes	Yes	Yes	No	Yes	No	Yes	Yes	Yes	Yes
Anne et al. [16]	Yes	Yes	Yes	Unclear	Yes	No	No	Yes	Yes	Yes
Kerry et al. [17]	Unclear	Yes	Yes	Unclear	Yes	No	No	Yes	Yes	Yes

Results of Meta-integration

The researcher distilled a total of 32 findings by iteratively reading and analyzing the nine pieces of literature included, organizing and generalizing the similar findings into 10 new categories, and obtaining four integrative findings.

Integrating Outcome 1: A Long and Difficult Consultation Experience

Category 1: Long Time to Diagnosis of Disease

Patients often experience multiple visits to the doctor due to disease symptoms involving multiple systems throughout the body (‘These searches were complicated by the need for multiple diagnoses including fibromyalgia, Raynaud’s, RA, lupus, and chronic fatigue syndrome’[9] ‘Many respondents discussed their histories of multiple doctor visits both to general practitioners and to specialists’[9]), in which most patients received only specialist symptomatic management (‘the focus of the physician’s visit was on prescribing medication to bring symptomatic relief ’[15]), and the time to confirmation of the diagnosis was continually prolonged (‘after 5 years of symptoms and unsatisfying visits at different doctors, one doctor was on the right way’[13]) they questioned the professionalism of the doctors (‘the thing is do the general practitioners know about it ?’[12] ‘Every practitioner speaks differently, three speak three ways and no one can tell me what it really is’[15] ‘My doctor doesn’t believe I have SS’[9])

Category 2: Difficult Treatment Process

Due to a lack of knowledge about the disease, patients often felt overwhelmed (‘she didn’t always know what was enough importance to alert her doctor’[9], ‘I don’t know that I actually really need to know all just at this point in time’[12]), and showed concern about medications that bring about side effects and effectiveness (‘worried about the side effects from western medication’[15], ‘the various medications do not help much’[9]), and financial burdens that grew as the disease progressed (‘every year thousands of dollars to the dentist’[12], ‘my retirement and savings have been depleted’[16])

Integration Outcome 2: Severe Daily Life Distress

Category 3: Physical Symptoms Throughout the Body

The most common discomfort experienced by patients is dry mouth and eyes (‘my lips stick together and I can’t separate them’[14], ‘my eyes are dry it feels like sandpaper has been rubbed over them’[16] ‘a feeling of choking’[13]), limited dietary choices (‘I can’t eat dry food, I can’t swallow it’[13]) Some patients experience a gradual loss of their sense of taste (‘sometimes I can’t taste food, I also find myself losing my sense of taste and smell’[14]); pain accompanies the patient (‘limbs, everything hurts’[13]), and constant fatigue fills the daily routine (‘just peeling potatoes is exhausting!’[15], ‘I don’t even have the energy to talk’[16], ‘I can sleep for days at a time when the fatigue comes’[10]), and sleep is affected (‘When I sit up in bed, I can only sleep’[13], ‘When I turn around, I have a feeling of suffocation’[13])

Category 4: Intimate Relationships in Trouble

Disease manifestations of oral dryness and female vaginal dryness (‘I don’t realise that I’m only comfortable with kisses on the mouth’[11], ‘My vaginal dryness has gotten worse’[11]) affect the patient’s intimate relationship harmony(‘My husband and I have not had sex for over a year’[11] ‘My husband does not tolerate changes in our sex life’)[14]), patients’ libido declines, intimacy decreases, and they feel guilt and pain (‘It’s too painful’[11] ‘The guilt overwhelms me’[11])

Category 5: Negative Psychological Experiences

Patients often feel helpless and sad in the face of the disease (‘especially when you are tired, you feel low’ [9] ‘one time I broke down and burst into tears, which stressed me out a lot’ [9]) SS is a chronic disease for which there is no cure for it, and a variety of symptomatic medications such as immunological agents and other drugs are mostly used in the clinic. While taking medications, patients are concerned about their potential range of side effects (‘anti-inflammatories, paracetamol, codeine, you end up with more tablets’ [11] ‘too many side effects of western medication’ [15]), and some patients are annoyed with the status (‘a few people questioned what they were doing to deserve SS’ [11], ‘I’m getting very, very annoyed’ [10] ‘I’m getting very, very bad’ [10]). During the course of the disease, the functioning of multiple organ organs throughout the patient’s body is progressively affected, and the patient expresses his or her fears about the uncertainty of the future progression of the disease (‘The worst thing is not knowing what is going to happen’ [8] ‘Fear of organ failure and dialysis’ [8] ‘fear of incapacitation’ [8]) In understanding the incurable nature of the disease, coupled with the constant physical and mental distress, patients develop self-loathing (‘I hate myself, I hate this woman in pain’ [10]), they chose to reject the sympathy of others and tried to hide the condition (‘don’t want people to look at me differently or say ‘poor me’’ [8] ‘I don’t let anyone see it…I cover everything up’ [9])

Category 6: Social and Work Disorders

SS symptoms affect all systems throughout the body and cause many inconveniences to the patient during daily life and social interaction (‘I can’t read at night because my eyes are too sore and tired’ [9] ‘Driving is often limited due to fatigue and dry eyes’ [8] ‘My tongue gets stuck and I can’t express myself clearly’ [13] ‘I have a very limited life of shutting myself away and going to the hospital’ [13]), and was unable to perform previous work (‘I have noticed that I get tired faster in conversations’ [9] ‘Especially with computer work, patients find it challenging to have long conversations with clients’ [12] ‘My dryness is greatly affected my life, causing me to stop working and retire early’ [16])

Integrating Outcome 3: Very Different Coping Styles and Attitudes Towards Illness

Category 7: Positive Attitude and Coping

Patient maintains a positive outlook throughout the disease diagnosis and treatment process, believing that he or she will ultimately overcome the disease (‘I’ll be lucky if that’s all that’s knocked out of me’ [8] ‘I think in time I’ll get back to where I was before’ [13] ‘There are a lot of people who lie down and die, they sink because of health problems – not me!’ [13] ‘I’m trying to say come across it and accept it’ [15]) They actively use multiple resources around them to seek help to learn about the disease (‘learning how to understand and help themselves from multiple sources such as other patients, support groups, literature and computer searches’ [8]) while attempting to make lifestyle adjustments to accommodate the disease (‘Many respondents drank water more frequently and changed their eating patterns. Keeping their hands and feet as warm as possible and pacing themselves according to their activity and rest needs’[8] ‘Made a lateral move to work’ [8] ‘We tried all the backwash.’[10] ‘My water bottle is my best friend’ [10] ‘Making vaginal uterine trays, moisturisers or soaps to alleviate the dryness associated with dry syndrome’ [10]), and some patients try alternative medicine treatments (‘Started actively exploring complementary and alternative medicine and started seeing a nutritionist’ [11]) Some patients comfort their souls by being religious and helping each other (‘I also attend spiritual events and worship God, all we do is ask for human nature’ [13] ‘We would go to church, and when we were sick we would ask our brothers and sisters in the group to pray for me, and then there would be an outlet for our moods’[15] ‘Doing small feats of charity myself, exhorting people to be good, teaching while doing so, and contributing my skills during my lifetime’[15]), and in doing so, patients experienced positive physical and mental positive feedback (‘personal growth and development can be facilitated’ [8] ‘the research process itself is an altruistic act that positively affects their self-esteem’ [11])

Category 8: Negative Attitudes and Coping Styles

Conversely some patients maintained negative attitudes and chose to delay seeking treatment (‘She tried to deny her symptoms and sometimes let the bad signs and symptoms go on for too long before seeking help’ [8] ‘She tried not to think about anything and took it day by day. I didn’t cope with it properly and that was my way’ [8]).

Integration Outcome 4: Thirst for and Lack of Social Support

Category 9: Lack of Social Support

SS patients do not receive sufficient support from family (especially spouses) and friends (‘My husband is the worst problem because he doesn’t understand’ [8] ‘My husband is not supportive or helpful, and doesn’t tolerate changes in our sex life’ ‘There are no friends to talk to about dry syndrome’ [8]) and on the other hand, the help received by patients in peer support groups is not sufficiently represented (‘There is a marked negativity in the support group and a lack of shared responsibility for managing the group’ [8] ‘The support group did not support her as a leader and she found herself dragged down by the others’ [8])

Category 10: Desire for Social Support

Adequate support from close relationships brought great help to the patient (‘More than one person said that her best support came from her spouse’ [8] ‘My whole family knows about this and they all try to help me not to talk too much and to keep me calm’[13]) Meanwhile, during the visit, patients were eager to be able to communicate effectively with each other and with healthcare professionals to give them psychological support and comfort (‘It’s very important to be able to talk to the healthcare professionals, I know that at the moment they can’t do anything about it, it’s okay, but you’re listening to it, you’re not just folding it’ [11] ‘An understanding healthcare practitioner made a big impact’ [8])

Discussion

Focus on the Impact of SS Symptoms on Patients and Actively Take Appropriate Measures to Alleviate Them

Integration results reveal that Sjögren’s syndrome (SS) patients endure a spectrum of symptoms, including dry mouth and eyes, fatigue, and generalized pain, significantly impairing their quality of life. As dry eyes can progress to keratitis, patients may experience blurred vision, redness, and ocular discomfort. Reduced salivary gland secretion not only affects eating and swallowing but also speech and taste perception, potentially leading to halitosis, oral ulcers, and rampant caries, which disrupt daily eating and social interactions [17- 18]. Healthcare professionals should advise patients on maintaining oral and ocular hygiene, facilitate early screening and diagnosis, and intervene to enhance glandular secretion, thereby mitigating the symptoms’ impact on physical and mental well-being. Sleep quality is closely linked to quality of life; sleep disorders can affect daily life and may trigger immune and inflammatory responses, increasing the risk of autoimmune diseases [19]. Professionals should assess and address patients’ sleep issues promptly, employing personalized treatments. Cognitive-behavioral therapy has been shown to improve sleep quality in SS patients, and both exercise therapy and traditional Chinese medicine (TCM) offer safe and effective interventions for sleep disorders [20,21]. Sexual dysfunction, a significant aspect of physical and mental health, is prevalent among female SS patients, threatening intimacy and potentially inducing negative emotions such as embarrassment and helplessness. Studies indicate that the prevalence of sexual dysfunction in SS patients is twice that of the general population, with vaginal dryness, pain, and fatigue influencing sexual behavior [22]. Given the sensitive nature of this issue, few patients are willing to discuss it openly. Healthcare professionals should delve into patients’ experiences, bolster nurse-patient trust, and provide empathetic listening, respect, and support. Collaborating with gynecologists and psychologists can offer patients comprehensive professional and psychological assistance.

There is no cure for SS, hence treatment focuses on symptom relief, mitigating local and systemic damage, and enhancing quality of life [23]. The emphasis should be on early screening and diagnosis through collaborative efforts with multidisciplinary teams. In recent years, traditional Chinese medicine (TCM) and its techniques have gained traction in SS treatment, attributed to their efficacy in symptom improvement and lower incidence of toxic side effects [24,25]. Future clinical outcomes may be enhanced by integrating TCM with other therapeutic approaches. Additionally, patients can be empowered to adopt healthier lifestyles, thereby improving their quality of life, through comprehensive and personalized health education initiatives.

Focusing on Negative Emotions in SS Patients and Fostering Positive Coping Strategies

Integrative findings reveal that SS patients experience a spectrum of negative emotions, impacting their quality of life due to enduring clinical symptoms, daily life limitations, and compromised social functioning [27]. Research indicates that the prevalence of anxiety and depression among SS patients is markedly higher than in the general population, with rates of 33.8% and 36.9%, respectively [26]. Healthcare professionals must prioritize the emotional well-being of SS patients, delve into the origins of their negative emotions, and guide them towards effective emotional expression and coping mechanisms. Encouraging a realistic understanding of disease symptoms and bolstering confidence in treatment outcomes is crucial. Evidence supports the efficacy of positive thinking training therapy and narrative care in alleviating anxiety and depression, thereby enhancing life quality [28-30]. Tailored interventions for SS patients can strengthen nurse-patient rapport, mitigate negative emotional impacts, and promote a positive and stable mental state.

The study’s findings highlight the diverse coping strategies employed by SS patients, which are their cognitive and behavioral responses to the disease and its associated disruptions [31]. Effective coping strategies are crucial for alleviating symptoms, enhancing functional status, and improving quality of life [32,33]. Healthcare professionals should promptly assess these strategies and provide ongoing support to patients who utilize positive approaches. Additionally, professionals must delve into the challenges faced by patients with negative or avoidant coping mechanisms to foster better disease acceptance and develop constructive cognitive coping strategies. Family support is pivotal in bolstering patients’ confidence in treatment and in converting negative emotions and coping behaviors [34]. Engaging patients and their caregivers in treatment decisions is essential for increasing their investment in therapy. Continuity of care, including regular professional guidance, is vital for encouraging patients to actively engage in their disease management and to confront their condition with a positive attitude.

Constructing an Optimal Medical and Social Support System

The integration findings indicate that Sjögren’s syndrome (SS) can affect multiple bodily systems, prompting patients to seek treatment for their presenting symptoms. Without adequate disease knowledge and interdisciplinary collaboration in diagnosis and treatment, healthcare providers may fail to make accurate assessments, leading to delayed SS diagnoses. During consultations, patients often receive only symptomatic treatment, which falls short of addressing their comprehensive needs. Thus, medical staff must enhance their expertise and foster interdisciplinary collaboration to develop personalized diagnostic and treatment plans, as well as offer patients thorough, evidence-based education and guidance on SS [23]. Patient care continuity should also be a priority, leveraging ‘Internet + nursing services’, interdisciplinary nursing teams, and hospital-community- family collaborative frameworks to ensure precise and efficient patient management [35]. Additionally, family, peer, and social support are crucial for SS treatment. Patients require ample emotional support from families, and peer support groups should be professionalized and made more effective. Group composition should be carefully selected to foster constructive communication and sharing among patients, with ongoing monitoring to address their emotional and informational needs, and to implement timely adjustments and management strategies.

Conclusion

Using meta-integration methodology, this study thoroughly examined the illness experiences of patients with SS, revealing four key themes: the complexity and duration of diagnostic and treatment processes, substantial disruptions to daily life, a variety of coping styles and illness attitudes, and an evident gap in social support despite a high demand. Healthcare professionals are advised to implement personalized care strategies to mitigate patients’ distressing symptoms, address psychological well-being to foster positive outlooks, and engage in interdisciplinary collaboration to enhance diagnostic and therapeutic approaches.

Limitation

This study has certain limitations: it did not include studies that have not yet been published, introducing a degree of selective bias; and some of the included literature is relatively old, which may limit the applicability of the meta-integrated results and may not fully reflect the experiences of SS patients. This indirectly suggests that there is a current lack of attention to the psychological experiences of SS patients, which warrants further in-depth exploration in the future.

Acknowledgements

We would like to express our sincere gratitude to all those who contributed to this work. Your support and assistance have been invaluable throughout the research process.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

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