The experiences of people with liver disease of palliative and end‐of‐life care in the United Kingdom—A systematic literature review and metasynthesis

Abstract Background Liver disease is a growing health concern and a major cause of death. It causes multiple symptoms, including financial, psychological and social issues. To address these challenges, palliative care can support people alongside active treatment, and towards the end of life, but little is known about the care experiences of individuals with liver disease in the United Kingdom. This review aimed to explore the palliative and end‐of‐life care experiences of people with liver disease in the United Kingdom. Method A systematic review was conducted using a five‐stage process and following Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines. Searches were across Web of Science, Scopus, EBSCO and grey literature until 10 May 2023. The review was registered through International Prospective Register of Systematic Reviews (PROSPERO). NVivo 12.5 was used to facilitate data analysis (systematic review registration: PROSPERO CRD42022382649). Results Of 6035 papers (excluding duplicates) found from searches, five met the inclusion criteria of primary research related to adults with liver disease receiving palliative and/or end‐of‐life care in the United Kingdom, published in English. Reflexive thematic analysis of the data was conducted. The themes identified were the experiences of people with liver disease of relating to healthcare professionals, using services, receiving support, and experiences of information and communication. These were connected by an overarching concept of disempowerment versus empowerment, with the notion of person‐centred care as an important feature. Conclusion This review has found variations in the care experiences of people with advanced liver disease towards the end of life and an overall lack of access to specialist palliative care services. Where services are designed to be person‐centred, experiences are more empowering. Further research is needed but with recognition that it is often unclear when care for people with liver disease is palliative or end‐of‐life. Patient and Public Contribution An online public involvement workshop was held on 18 April 2023 through Voice (2023). This included four people with liver disease and four carers to discuss the review findings and to design a qualitative research study to further explore the topic.

experiences are more empowering.Further research is needed but with recognition that it is often unclear when care for people with liver disease is palliative or endof-life.
Patient and Public Contribution: An online public involvement workshop was held on 18 April 2023 through Voice (2023).This included four people with liver disease and four carers to discuss the review findings and to design a qualitative research study to further explore the topic.

| BACKGROUND
Liver disease is increasing in the United Kingdom, and it is a major cause of mortality worldwide, accounting for two million deaths annually. 1Data from the Office for National Statistics 2 shows a 63.6% increase in the number of premature deaths in England from liver disease in the past 20 years, and it was the third leading cause of death in 2021 for those aged between 35 and 49 years. 3Around 60% of individuals affected are male and approximately 40% are female. 2e disease trajectory can be unpredictable, 4 it is not always clear when someone is reaching the end of their life, and 20% of people on the liver transplant list die while they are waiting for transplantation. 5tive treatment may continue until shortly before a person dies because of uncertain prognosis, young age of individuals, and rapid decline in health. 6Advanced liver disease causes numerous symptoms and social and financial issues. 7,8lliative care is the supportive treatment that can be offered alongside active treatment to help with symptoms and the challenges of living with liver disease.The International Association for Hospice and Palliative Care 9 defines palliative care as 'the active holistic care of individuals across all ages with serious health-related suffering due to severe illness, and especially of those near the end of life.It aims to improve the quality of life of patients, their families, and their caregivers'.It is commonly perceived that palliative care is synonymous with end-of-life care, but increasingly it is recognised that palliative care can be offered at any stage to ease symptoms and psychosocial issues for people with liver disease. 8,10The concept of 'parallel planning' in liver care 8 is an approach that acknowledges the need to actively manage complications, whilst also preparing people with liver disease, and their families, for potential deterioration in their health.
There are guidelines to support clinicians caring for people with end-stage liver disease 11,12 and the American Association for the Study of Liver Diseases recently published a guidance document. 13wever, healthcare professionals (HCPs) may not know when to refer people for palliative care or be confident discussing it with individuals. 14People with liver disease can be unclear about what palliative care is, tending to associate it with end-of-life and the loss of active therapy. 15The benefits of palliative care are well documented, 15 but there is a lack of research focusing on the experiences of people with liver disease of palliative care.Similarly, a recent literature review found limited research about patient's perspectives on end-of-life care in liver disease and Das et al. 16 recommended future studies focusing on their perspectives.Socioeconomic factors significantly influence liver disease mortality and people living in the most deprived areas are more adversely affected, including higher rates of hospital admissions. 17tional Health Service NHS Long Term Plan 18 advocates stronger action for reducing health inequalities, including access to healthcare provision, and this review is being used to develop a research project that could help to improve the effective implementation of personcentred care for people with advanced liver disease.

| Aim
The aim of this systematic review was to understand more about the experiences of people with liver disease in palliative and/or end-oflife care.

| METHODS
The Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) checklist 19 guided this systematic review report.This review explored the subjective experiences of people with liver disease; therefore, qualitative data was appropriate to answer the review question.The reviewers did not set out to exclude quantitative data, but it was apparent early on that qualitative evidence was required, which included mixed-methods studies.A qualitative methodological approach was followed, including metasyntheses, which are systematic techniques to combine the in-depth, rich qualitative research findings, to provide insights into the research question. 20A five-stage method for rigorously reviewing the literature, as proposed by Wolfswinkel et al., 21  Public involvement (PI) was incorporated into this systematic review at Stage 5.The ACTIVE framework to describe stakeholder involvement in systematic reviews 22 is Supporting Information: Appendix S1.The protocol for the systematic review was registered with the International Prospective Register of Systematic Reviews in accordance with PRISMA-P guidelines (CRD42022382649).

| Developing the research question
An initial check of the literature found that internationally, researchers have explored the experiences of people with advanced liver disease 22 and transnational systematic reviews have revealed shortfalls in access to palliative care. 16,24,25wever, health systems vary across the world and the experiences of people with liver disease may also differ because of this.For example, in the US individuals may have financial concerns around paying for their treatment, which are different to the United Kingdom.This systematic review forms part of a PhD project and is helping to shape a UK study with people who have advanced liver disease.Therefore, it was decided to focus on the United Kingdom.After scanning the literature and discussing with HCPs and people with liver disease, the review question was formed using the PEO format 26 : What are the experiences of adults with liver disease of palliative and end-oflife care in the United Kingdom?Population-adults with liver disease.
Exposure-palliative and end-of-life care in the United Kingdom.Outcome-experiences.

| Stage 1: Define
The initial selection criteria were decided before the searches were conducted, and a logbook was kept recording any changes to the criteria that were made throughout the review process. 21For example, when assessing papers against the selection criteria, it became apparent that to understand the experiences of people with liver disease, papers that did not include the perspectives and experiences of people with liver disease from their point of view should be excluded because such papers did not answer the research question.This meant that studies without some qualitative data were not included.

| Inclusion criteria
Included papers were primary research related to adults with liver disease receiving palliative and/or end-of-life care in the United Kingdom, published in English.

| Exclusion criteria
Publications about people without liver disease as their primary diagnosis were excluded, as were systematic and other types of reviews.Other exclusion reasons were as follows: 1. Participants <18 years 2.Not specific to end of life or palliative care, for people with liver disease.
3. No reference to the perspectives and/or experiences of people with liver disease from their point of view-the papers had to include the voices of people with liver disease.It became apparent early in the review that this excluded research that was purely quantitative.
4. Research outside of the United Kingdom.Davis et al. 30 provided a sociological critique of healthcare encounters of people with cirrhosis, but the focus was not end-oflife or palliative care.Both Kimbell and Hudson had journal papers published as part of their PhD research. 6,31These were read by the review team, and it was agreed that for the systematic review, it would be more thorough to include the theses rather than the journal papers of these studies.Therefore, with careful consideration and discussion between the review team, the included papers were narrowed down to five.

| Data extraction
Using Excel, a data summary chart (see

| Quality assessment
Assessment of the strengths and weaknesses of the literature was important to understanding how it could answer the research question.Papers were read, reread, and critically appraised. 37The Critical Appraisal Skills Programme 36 checklist guided the quality assessment, with consideration of how the concepts of rigour, validity, and reliability in the research process were approached. 38alitative research is reflexive and subjective in nature, so these concepts are more suitable when assessing qualitative papers, as opposed to the idea of bias. 39The first reviewer (C.B.) undertook a quality assessment, with discussion and oversight from the rest of the review team.Four papers were assessed as high quality, [33][34][35]40 and one was medium quality. 32 n additional criterion was included in the quality assessment process: PI in the research.This was essential to ensure that the studies were meaningful to people with liver disease and conducted with them rather than just about them. 41 was not mentioned by Cooper et al, 40 Hudson 33 or Quinn et al. 32 In contrast, Kimbell 34 and Kimbell et al. 35 had a clear PI strategy evidenced at different stages of the research process.

| Stage 4: Analyse
Reflexive thematic analysis was applied to data analysis 42 and NVivo Pro 12.5 software was used to support this approach.Previous authors have found NVivo to be a rigorous way of organising the data to facilitate interpretation and to look for themes. 43,44This involved the following process: 1. Papers were imported into NVivo Pro 12.5 2. Open Coding: Line-by-line coding of the results sections that were specifically relevant to answering the systematic review question. 43sults that did not answer the review question were not coded line by line.For example, in Kimbell's 34 thesis, chapter seven was analysed in depth because it focused on individuals' experiences of care, whereas chapter five was not coded because it explored the onset, manifestation and understanding of the disease.
3. Words/phrases that reflected action were mainly used to create nodes in NVivo Pro 12.5 for example, accessing hospital care.This was to enable the author to keep an open mind, spark thinking, develop original ideas and avoid premature conceptualisation. 45 Axial coding: Categories were developed from the open codes by looking at the connections and main concepts.For example, information and communication.

Selective coding:
In this final stage, the overarching concepts were developed, specifically disempowerment versus empowerment, which are explored in the discussion section of this review.

| RESULTS
Table 3 gives a summary of the demographics of individuals from the five studies.Analysis led to four main themes of experiences related to the following: 1. HCPs 2. Services 3. Support

Information and communication
These themes incorporated aspects that were either disempowering or empowering to individuals with liver disease, and personcentred care was found to be an important aspect of positive experiences.

Theme 1. Experiences as related to HCPs
There were frequent references to interactions and relationships with a range of HCPs throughout the data, with particular emphasis on the role of general practitioners (GPs) and specialist nurses.Conflicting experiences and perspectives of HCPs were apparent, depending on service structures and HCPs' communication skills.Clinicians who were responsive, wellinformed and person-centred improved care experiences.

| Perceptions of GPs in liver disease care
GPs were commonly cited, except in Quinn et al. 32 People with liver disease expressed mixed experiences of their GP's involvement, ranging from supportive and actively interested, 34 to lacking confidence and knowledge about liver disease, tending to leave decision-making to specialists. 33,34GPs were sometimes the first port-of-call for a person with liver disease, for example, to access paracentesis, 40 for psychological issues, or when dying at home. 34ere was variation in how supportive GPs were perceived to be, with their contribution improved when they were more informed, supported, and care was co-ordinated, as illustrated by Kimbell et al.'s 35 study in which the specialist nurse engaged with GPs to arrange advanced care plans.

| Specialist nurses
The importance of specialist nurses was cited as facilitating a personcentred approach through care coordination, information, and support to people with liver disease, their carers, and other HCPs.
This was particularly evident in Kimbell et al.'s 35 feasibility trial of a supportive care liver nurse specialist for people with liver disease.
Empowering experiences were described: 'We felt we were getting more answers, whereas in the hospital you feel as if it is, 'We're too busy, we've got other patients, you're not the only patient, we've got this patient to see'.
[…] When [study nurse] was here we got a chance to speak.p.923 Similar accounts were evident regarding an alcohol liaison nurse 34 and collaboration between the hospital and hospice specialist nurses. 32In Hudson's 33 research, the essential role of hepatology specialist nurses for coordination of care and advice was described but with frustration if the nurse was unavailable.It was not only specialist nurses who were cited positively, in Cooper et al., 40 regular home visits from community nurses provided valuable emotional support.In Kimbell, 34 there were encouraging descriptions of hospital staff, but there were contrasting examples of people with liver disease feeling mistreated by HCPs.

Theme 2. Experiences of services
There was a theme of experiences of healthcare services being empowering or disempowering to individuals with liver disease depending on: 1.Where care took place-primarily within secondary care, with exceptions depending on the structure of local services.
2. Access to services.
3. Access to specialist and palliative and end-of-life care.

| Hospital
It was apparent that hospitals played a huge role in how liver disease was managed towards the end of life, with frequent admissions, prolonged stays, and regular appointments being described as part of people's experiences.Sometimes this was positive and empowering for people who were so familiar with the wards and staff that it was like coming home when they were admitted to hospital. 34There were many examples of satisfaction with the care and support people received, including the suggestion from carers of those who had died in the hospital that they did not regret this experience. 34However, overall people wanted to avoid it whenever possible: 'I did not like going into hospital', 40, p.319 and 'I hate being in hospital.Everyone uses all these long words and it is scary and I just want to get out'.

| Accessing services
Mixed experiences of accessing healthcare services for people with liver disease were apparent, impacting satisfaction, well-being, and sense of empowerment as illustrated in Table 4. Except in Kimbell et al., 35 an important part of care experiences for people with ascites was access to paracentesis, relating to the type of drain and where drainage occurred.Although paracentesis is a form of symptom relief, rather than active treatment, it was not always perceived this way by individuals with ascites who sometimes viewed it as prolonging life. 34,405 | Access to specialist palliative and end-oflife care A wider issue was the discrepancy in access to palliative care and services specifically for people towards the end of life.People with liver disease rarely accessed hospices, except in Quinn et al. 32 Despite long-term abdominal drains in Cooper et al.'s 40 study being described as palliative, it was unclear what other palliative services individuals had access to, and it was suggested that some did not recognise their care as palliative.There was little mention of allied health professionals in the papers, which is significant because the high physical and psychological symptom burden of advanced liver disease was clear.The limited reference to other professionals was indicative that individuals often did not receive appropriate palliative support.Exceptions to this included the hospice's coordinated approach to providing supportive services 32 and the supportive care liver nurse specialist. 35eme 3. Experiences of support for people with liver disease People with liver disease, and their carers, received support from a variety of sources, with barriers and facilitators apparent, as illustrated in Table 5.

| The role of carers
There was a reference to family and friends having a vital role as carers, including taking people to appointments, supporting them with care coordination and access, and liaising with HCPs.Sometimes this was challenging, causing stress and deteriorations in carers' own physical health and emotional wellbeing. 33eme 4. Information and communication The concepts of information and communication were interrelated in the papers.Information, or lack of it, emerged from the data, and how this information was communicated, or not communicated was relevant.For example, people with liver disease did not always know what questions to ask but having a specialist nurse who gave information and was available to answer their questions in an accessible way was empowering in Kimbell et al.'s 35 study.Sometimes, people were disempowered and dissatisfied with the information they received and/or the way it was communicated to them. 33,34Occasionally, there existed a mismatch between the information that HCPs provided and the information that people with liver disease wanted to receive: 'I told them that, I want you to tell me the truth, no holds barred like, but they couldn't answer it.Because they didn't know' 33, p.122 and 'I remember asking the London doctor if there was anything he could do about it (my fatigue and itch)-he just said yes there is but he just needed to get the tests done first.

| Prognosis
People with liver disease regularly lacked information and knowledge about their prognosis and what to expect for a range of reasons: 1. Uncertain disease trajectory-the unpredictable nature of liver disease.
2. HCPs not knowing/understanding the prognosis or having the confidence to have conversations with individuals about these issues.
T A B L E 4 Experiences of accessing services.
Negative experiences of accessing healthcare services Positive experiences of accessing healthcare services • Organisational challenges or indirect access for people trying to access paracentesis in a hospital. 40 The location of services, for example, being far from home.
• Having to travel to services.• Parking challenges.
• Financial issues (related to parking, travel costs, or relatives giving up work time to support). 33 The impact on friends/family supporting people with liver disease to get to appointments. 33,34Telephone access, for example, to advice/support, 35 or direct access to departments for paracentesis. 40 Services in a convenient location, for example, person's home 35,40 or their nearest hospital. 34 Preferred environment, for example, hospice. 32 Co-ordinated care, for example, the role of specialist nurses 35 and the hospice 32 facilitating access to services.
T A B L E 5 Experiences of barriers and facilitators to support.
Experiences of barriers to support Experiences of facilitators to support • The structure of services, for example, in Cooper et al.'s 40 study, people sometimes had challenges accessing paracentesis.• Not knowing how to access support, for example, how to contact consultants for advice. 34 Poor care/communication from HCPs. 34 Service constraints, for example, time-limited appointments. 33,34Regular contact, for example, visits from community nurses. 40 Easy access, for example, to telephone support. 35p.144 • Access to specialist nurses such as the supportive care liver nurse specialist, 35 and the alcohol liaison nurse. 34 Knowing where to go for support. 35 Co-ordinated care, for example, the role of the hospice. 32 Having supportive friends and family. 34breviations: GP, general practitioner; HCP, healthcare proffesional.4. People with liver disease not wanting to lose hope. 33,34w information was communicated was important.p.144 Empowering examples included: 'Although the hospice can't cure my illness, it has helped me to cope with it.I feel less stressed and more confident having learned how to manage my energy and being aware of my limitations.p.S20 This was not typical within the results and Hudson 33 found that individuals with liver disease were often unsure of the implications of their diagnosis, with persistent uncertainty disempowering them from making plans.

| DISCUSSION
In this review, only five studies (detailed in Table 2) met the inclusion criteria to explore the experiences of people with liver disease in palliative and end-of-life care in the United Kingdom, confirming that this is an under-researched area. 16There was a lack of ethnic diversity in the individuals included in the studies, with the majority being white.More males participated in the studies, but this reflects the higher number of men who have liver disease compared with women. 2 Experiences were found to depend on who provided care and the structure of local services.There were variations in what care and support were available and where these were provided in terms of the person's home, clinics, hospital, and hospice, with most care taking place in secondary care.There were examples of personcentred approaches, but overall, there was a lack of advanced care planning, accessible information, and early referral to palliative care services.Crucially, people with advanced liver disease were often unclear about their illness and prognosis, meaning that their experiences were not necessarily that of care, which they perceived as palliative or end-of-life.This is not unique to liver disease: Gurgenci and Good 46 found that internationally, people with endstage cardiac failure lacked information and advanced care planning, facing uncertainty and delayed access to palliative care.

| Disempowerment versus empowerment
In healthcare, empowerment has been described as 'a process through which people gain greater control over decisions and actions affecting their health'. 47In contrast, disempowerment is having a lack of control over one's life and no power to change things. 48Distinct features of empowerment have been found for people with advanced life-limiting illnesses, relating to physical and psychosocial challenges, and Wakefield et al. 49 argued for greater efforts to progress the empowerment of people approaching the end of their lives. 49 overarching feature of this review was the presence of disempowering versus empowering experiences for people with liver disease in palliative and end-of-life care.Disempowerment was apparent when 1. Relationships with HCPs were dissatisfactory.
2. Services were mismatched with the needs of people with liver disease.
3. There were challenges in accessing care/support.4. Information/communication for people with liver disease was inadequate.
Other researchers have illustrated disempowerment facing people with advanced liver disease, arguing that this is caused by a complex interaction of limited resources, lack of HCP training and confidence in raising issues regarding the end of life. 30HCPs may themselves be disempowered to appropriately support people with liver disease, due to lack of confidence, skills and knowledge about palliative care. 4Greater understanding of the emotional needs of people with advanced liver disease has been advocated as a means of empowering HCPs to provide good quality palliative care. 50 this review, empowering experiences were apparent when there were 1. Positive relationships with HCPs.

| Person-centred care and empowerment
Internationally, researchers have advocated for liver disease services to be more person-centred. 51Where services are specifically designed to be person-centred, there is an opportunity for individuals, carers, and HCPs to have more empowering experiences-being empowered to share knowledge, work collaboratively, and make decisions.In this review, there were examples of services designed to improve the palliative and end-of-life care experiences of people with advanced liver disease, and the people who support them. 32,35,40Similarly, in Chivinge et al.'s 27 service improvement project, a nurse-led paracentesis service improved patient satisfaction and reduced complaints and waiting times.The perspectives of carers supporting people with advanced liver disease are also important to understanding care experiences and facilitating person-centred palliative care. 52Experiences are improved when there is a collaboration between hepatology, community services, and specialist palliative care, and there is advanced care planning. 32,35,52Researchers of other specialisms have also advocated person-centred care as a means of empowering people with longterm health conditions.For example, a Finnish study with people who have type 2 diabetes found that person-centred care was associated with higher empowerment levels. 53ckling healthcare inequalities has been described as a prime focus for action 18 and person-centred care is a vital part of this.
Without consideration of the needs of individuals and communities, inequalities persist.Appropriate palliative and end-of-life care services for everyone with advanced liver disease are important to addressing healthcare inequalities and empowering people towards the end of their lives.

| Public involvement
It is significant that PI was missing from Quinn et al., 32 Hudson, 33 and Cooper et al., 40 because as illustrated by Kimbell 34 and Kimbell et al., 35 PI can facilitate empowerment by providing the opportunity to influence research that is relevant to people with liver disease. 54udies that embed PI in the research design are recommended to ensure they are meaningful, inclusive, and collaborative with people affected by liver disease. 55As part of the systematic review process, an online PI workshop organised through Voice 56 was held with four people who have liver disease and four people who are carers for people with liver disease.The lead reviewer (C.B.) presented the findings and discussed them with the group who offered their perspectives: There is a stigma attached to liver disease which causes problems in communication between patients, medical professionals, etc. Would fully endorse your findings.The information given is poor… The toll on carers is enormous but the quality of care is highly dependent on how well they are educated.
It is important for people near the end of life to not be isolated.They need to be brought into the community more but because of lack of funding currently, this is becoming more difficult.
The need for research to explore the perspectives of people from ethnically diverse backgrounds was also highlighted by the PI group, especially to understand the cultural needs of individuals with liver disease and their families towards the end of life.

| Strengths and limitations of the review
To the authors' knowledge, this is the first systematic review to focus on the care experiences of people with liver disease in palliative and end-of-life care in the United Kingdom.Wolfswinkel et al.'s 21 fivestep approach facilitated a rigorous method for the review process and theory development.Using NVivo 12.5 software was an efficient way of organising the data, supporting thorough analysis and theme development.The PI workshop was valuable, adding credibility to the findings and could have been beneficial at earlier stages of the review process. 57 conducting this review, it was challenging to differentiate between care experienced by people with liver disease as palliative and/or end-of-life, and care experienced as active treatment.This was for the following reasons: 1.The unpredictable trajectory of liver disease.
2. The language used to describe care by authors and people participating in the studies.

Uncertainty (in individuals and HCPs).
In the review papers, it was sometimes unclear when liver disease care was end-of-life.For example, in Kimbell's 34 research, nine of the 15 participants with advanced liver disease died by the end of the yearlong study.However, six did not die and two individuals had an improvement in their health.People with liver disease may themselves be unclear when the care they are experiencing is palliative and/or end-of-life, as illustrated by some individuals' perception of palliative long-term abdominal drains as prolonging life, 40 and prognoses being rarely discussed. 34Other researchers have commented that people with advanced liver disease may not discuss their illness as being palliative, even when their prognosis is poor. 29HCPs can be uncertain about this too. 4For these reasons, when exploring end of life and palliative care experiences, researchers must pay careful attention to the language used when conducting research with people who have advanced liver disease.

| CONCLUSION
This review has found that people with advanced liver disease have mixed experiences of palliative and end-of-life care, depending on the quality of relationships with HCPs, the structure of local services, support available to them, the provision of information and how this is communicated to them.These factors contribute to whether care experiences are empowering or disempowering to individuals, with the concept of person-centred care identified as an important consideration.There is a need for further research with a more diverse population beyond a sample of predominantly white people.
PI should be embedded into the design, to further explore the perspectives of individuals with advanced liver disease and their carers regarding palliative and end-of-life care specifically, but with recognition that people with liver disease and their supporters may sometimes be unclear when care is palliative or end-of-life.

ACKNOWLEDGEMENTS
This systematic literature review forms part of a PhD project match funded by Lewis-Manning Hospice Care.The authors thank the public involvement group who attended the Voice workshop to discuss the findings of this review and plan further research.| 13 of 15 enabled a systematic process of theory development, providing insight and understanding into the experiences of people with liver disease of palliative and end-of-life care.This consisted of the following steps: 1. Define (the suitable data set) 2. Search (for the studies) 3. Select (refine the sample of studies to be reviewed) 4. Analyse (including open coding, axial coding, and selective coding) 5. Present (to show findings and insights, alongside key decisions made throughout the review process).

BERESFORD
with liver disease not knowing what questions to ask.

2 .
Services designed to meet palliative and end-of-life care needs.3.Accessible treatment, support, and advice.4. Appropriate information communicated in a sensitive way to people with liver disease and their carers.
BERESFORD ET AL.

Table 2
1 PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources.From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al.The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.BMJ.2021;372:n71.doi: 10.1136/bmj.n71.For more information visit: http://www.prisma-statement.org/.PRISMA, Preferred Reporting Items for Systematic reviews and Meta Analyses.
Summary of demographics.
35Of the 47 people recruited for Kimbell et al.'s35study, a total of 34 individuals went on to receive the intervention.