The scoping review methodology will be conducted in accordance with the JBI guidelines for scoping reviews  and Arksey and O’Malley’s  five-step process for scoping reviews. The PRISMA-P 2015 checklist (Additional file 1) will ensure adherence to rigorous standards are met .
Identifying the research question
The primary research question for this scoping review is as follows:
How does structural stigma associated with a diagnosis of BPD impact on access to health services and care for people with BPD, their carers/families, and clinicians?
Additional sub-questions will be explored to facilitate a deeper understanding of the key factors, barriers, and mechanisms contributing to the maintenance of structural stigma in health systems experienced by this population, as follows:
- What are the perspectives and experiences of structural stigma among consumers with BPD, their carers/families, and clinicians?
- What are the specific drivers and facilitators influencing the manifestation and maintenance of structural stigma in health systems towards consumers diagnosed with BPD, and the implications for research, policy and practice?
This review will be founded on the Population, Concept and Context framework , as follows:
Studies focusing on stigma in health systems will be included in this review if consumers are aged 12 years or older and have a diagnosis of BPD; carers/families of people with BPD; or clinicians working in clinical outpatients, inpatients, or community-based services.
This review will focus on structural stigma; this will subsume stigma maintained by some clinicians in relation to consumers with BPD and their carers/families within the context of crisis care. These studies must include stigma as an outcome to enable the current review to identify and map the key outcomes of structural stigma relevant to a diagnosis of BPD in health systems. Included studies will also be BPD-specific, examining:
- Participants perspectives and experiences of stigma in healthcare
- Impact of stigma on access to health services and quality of care
- Identification of contributing factors associated with the creation and maintenance of structural stigma in health systems
- Policy and funding allocation associated with BPD-related services in healthcare settings.
Studies included in this review must examine structural stigma associated with BPD in healthcare settings such as outpatients, inpatients, primary health care, or community-based facilities.
Identify relevant studies
The search strategy will identify published and unpublished studies relating to stigma experienced by consumers with BPD, carers/families, and/or clinicians in healthcare systems. Study designs consisting of mixed methods, qualitative, and quantitative approaches will be included in this review. Preliminary searches were executed in PsycINFO to test the search text word terms and subject heading combinations (Additional file 2). The search strategy was further refined following analysis of relevant articles key words, resulting in a comprehensive search strategy to identify all existing peer-reviewed articles relating to the topic of interest. The search was further tested to ensure that at least 10% of the citations were relevant to the topic and that the 10 test articles used to ensure that the search was sensitive enough to locate key citations were, in fact, located in the final search. The following database sources will be searched: PsycINFO (Ovid), MEDLINE (Ovid), and Scopus (Elsevier), CINAHL (EBSCO Connect), ProQuest, Cochrane library (Wiley), and JBI Evidence-Based Database (Ovid). A research librarian with expertize in sourcing literature guided the design of the search strategies. A grey literature search (Additional file 3) using Google search engine will then be conducted to identify other relevant citations such as, clinical practice guidelines, and other government reports.
Rationale justifying the inclusion and exclusion criteria will be articulated in the final scoping review paper.
Studies included will meet the following criteria:
- Written in English language only
- Peer-reviewed journal articles and reviews
- Non peer-reviewed literature including clinical practice guidelines and other government reports relating to the treatment of consumers with BPD in healthcare services
- No limitations to the publication date will be imposed.
We will exclude publications reporting the following:
- editorials, commentaries, books, theses, conference abstracts, abstracts without full-text available, and presentations
- Studies with a focus on mental illnesses that do not include BPD
- Studies on brain abnormalities relating to BPD
- Studies on structural stigma in non-clinical settings
All citations identified from the search will be collated and uploaded into EndNote v.9. Citations will be uploaded into Covidence and deduplicated. Two independent reviewers (PK and AKFS) will screen the titles and abstracts against the defined selection criteria to identify relevant studies. Full text articles of selected studies will be retrieved via Covidence and assessed against the inclusion criteria. Full text articles that are deemed ineligible will be excluded in accordance with the exclusion criteria and reported in the final scoping review paper. Any discrepancies in decisions regarding the inclusion of studies will be accessed and resolved by a third reviewer (SL) with clinical expertize in the field of mental health. Results of the search will be presented in a PRISMA Flow Diagram  generated by Covidence and reported in full in the final scoping review paper.
Assessment of methodological quality
Separate reviewers (PK and AKFS) will assess the full text studies for methodological validity prior to conducting the inclusion process of the review, using the MMAT v.2018 . Discrepancies in decisions regarding methodological quality will be discussed by the research team and resolved by a third reviewer (SL). All studies, including those of lower methodological quality, will be included in this review.
Charting the data
Separate reviewers (PK and AKFS) will extract the data from the included studies to populate the summary table. A data extraction tool will be used to capture key information in tabular form that is relevant to the objectives and questions of the review (Additional file 4). This will include information on the population groups, concept, and context. The following key headings, for example, will be included to structure the extraction of relevant data: author, year, country; population type/sample size; clinical area/setting; study design; data collection/methods; and main findings.
Collating, summarizing and reporting results
Results of the extracted quantitative and qualitative data will be presented in tabular form, accompanied by a narrative summary of key findings relating to the scoping review objective and questions. Descriptive statistics will be used to describe and summarize key characteristics of the studies, present percentages, frequencies and any patterns emerging from the data in relation to, for example, professional type/clinical area/healthcare setting, BPD, and structural stigma. Implications for future research, policy and practice in addressing structural stigma towards consumers diagnosed with BPD, and their carers/family in health systems will also be discussed.