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Systematic review
Health systems research in burn care: an evidence gap map
  1. Vikash Ranjan Keshri1,2,
  2. Margaret Peden1,3,
  3. Pratishtha Singh2,
  4. Robyn Norton1,3,
  5. Seye Abimbola4,
  6. Jagnoor Jagnoor1,2
  1. 1 The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
  2. 2 Injury Division, The George Institute for Global Health India, New Delhi, Delhi, India
  3. 3 The George Institute for Global Health UK, Imperial College London, London, UK
  4. 4 School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Dr Vikash Ranjan Keshri, The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales 2052, Australia; vrkeshri{at}gmail.com

Abstract

Background Burn injury is associated with significant mortality and disability. Resilient and responsive health systems are needed for optimal response and care for people who sustain burn injuries. However, the extent of health systems research (HSR) in burn care is unknown. This review aimed to systematically map the global HSR related to burn care.

Methods An evidence gap map (EGM) was developed based on the World Health Organization health systems framework. All major medical, health and injury databases were searched. A standard method was used to develop the EGM.

Results A total of 6586 articles were screened, and the full text of 206 articles was reviewed, of which 106 met the inclusion criteria. Most included studies were cross-sectional (61%) and were conducted in hospitals (71%) with patients (48%) or healthcare providers (29%) as participants. Most studies were conducted in high-income countries, while only 13% were conducted in low-and middle-income countries, accounting for 60% of burns mortality burden globally. The most common health systems areas of focus were service delivery (53%), health workforce (33%) and technology (19%). Studies on health policy, governance and leadership were absent, and there were only 14 qualitative studies.

Conclusions Major evidence gaps exist for an integrated health systems response to burns care. There is an inequity between the burden of burn injuries and HSR. Strengthening research capacity will facilitate evidence-informed health systems and policy reforms to sustainably improve access to affordable, equitable and optimal burn care and outcomes.

  • Burn
  • Systematic Review
  • Global
  • Public Health
  • Health Services
  • Policy

Data availability statement

All data relevant to the study are included in the article.

https://doi.org/10.1136/ip-2023-044963

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Advancements in clinical methods and research have improved outcomes in burn injuries, but numerous health system-related challenges remain. The extent of research on health systems related to burns is not well understood.

    WHAT THIS STUDY ADDS

    • We conducted a systematic search of all health systems research (HSR) in burns globally and developed an evidence gap map. Overall, research outputs were very limited. Among the existing HSR, there is little focus on policy, governance, leadership and financing research. There is high inequality in research output among different income groups of countries and regions in comparison to the magnitude of burdens.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • This study documents the current state of HSR in burns care systems, using an evidence gap map approach. It highlights the need for building capacity for health policy and systems research (HPSR), pertinent for improving burns care and outcomes. This is critical as burns remain a public health challenge in resource-poor settings, among socioeconomically disadvantaged populations and health systems with competing priorities.

    Background

    Burns are one of the major injuries with significant mortality and disability burdens globally. In 2019, an estimated 111 292 deaths and 7 460 448 disability-adjusted life-years were attributed to fire, heat and hot substances.1 2 Low-income countries (LICs) and lower-middle-income countries (LMICs) combined account for 63% of all mortality due to burn injuries as compared with 37% in upper-middle-income countries and high-income countries (HIC) combined.2 The African (AFR) and South-East Asian Regions (SEAR) of the World Health Organization (WHO) account for more than 53% of total deaths due to fire, heat and hot substances.2 Patients with major burn injuries require timely and specialist care to protect life, heal wounds, and optimise physical and psychological functions, and then long-term and community-based rehabilitation for optimal recovery and social reintegration.3 Therefore, a resilient and responsive health system is a critical prerequisite for an adequate response to people who sustain burn injury.4 Health systems are defined as ‘all organisations, people and actions whose primary intent is to promote, restore or maintain health’.5 Health systems must be responsive, efficient, of good quality and accessible with adequate financial and social risk protection.5

    The advancements in clinical methods, approaches for care, technology and rehabilitation practices have significantly improved major burn injury outcomes in recent times.6 Research and evidence on clinical care and rehabilitation have contributed to this development.7 However, the benefit of clinical advancement is limited to care in specialised burn care settings, while the issues of equitable access and continuum of care continue to be a challenge globally.8 9 In LICs and LMICs, the limited network of burns centres and multiple health systems challenges affect access and outcomes.10 Health systems research (HSR) in burns can support the generation of evidence on systems issues and guide systems strengthening. The research should address relevant issues for burns at all three levels of systems architecture: addressing clinical and individual patients or burn unit issues (microlevel), systems issues at institutions or in regional areas (mesolevel) and relevant subnational or national-level policies (macrolevel).11

    The intersection between existing health systems and research systems is termed ‘health research systems’ (HRS).12 HRS is broadly defined as ‘the people, institutions and activities whose primary purpose in relation to research is to generate high-quality knowledge that can be used to promote, restore and/or maintain the health status of populations; it should include the mechanisms adopted to encourage the utilisation of research’.12 A review of research on burn injuries suggests rapid growth in output in the last two decades,13 though the extent of research at the intersection of burn care and health systems is not well identified. Therefore, searching and mapping the current level of evidence in HSR related to burn injuries and responses is essential to identify the evidence gaps and support future research priorities.

    In this paper, we aim to systematically map the existing HSR related to burns care globally.

    Methods

    The overall approach used for developing this evidence gap map (EGM) is based on the methodology developed by Snilstveit et al 14 and contextually modified by other researchers.15 16 EGM is an approach used to visually show the extent of available research in any field.14 It is essentially designed to be used as a policy advocacy tool based on the identified gap in the evidence on a particular topic.14 There are three main steps in the development of an EGM:

    • Identifying the conceptual framework and developing the intervention and outcome matrix.

    • Systematically searching the literature and data extraction.

    • Presenting the findings in an EGM.

    Conceptual framework and intervention and outcome matrix

    We selected the existing WHO health systems framework as our conceptual framework due to its simplicity and ubiquitous acceptance.17 The framework consists of six building blocks: governance and leadership, financing, medical products and technology, information, health workforce, and service delivery.5 These building blocks constitute our primary interventions, in the column in the EGM matrix, and we are terming this as ‘area of focus’ to signify health systems issues and inclusion of observational studies. The outcome indicators in the matrix are guided by the health systems outcome goals and termed as ‘health systems outcome’, which include improved health, access and coverage, responsiveness, quality of care, efficiency, and social and financial risk protection. Further, we divided the area of focus into subdomains according to major themes included in health systems literature on burns (see online supplemental file 1). We developed standard operational definitions of all areas of focus and health systems outcome terms (see online supplemental file 1).

    Supplemental material

    Systematic literature search and study selection

    ‘Burn’ and its related Medical Subject Heading (MeSH) terms, such as burns, burn unit, inhalational burn, chemical burn and electrical burn, were our first key concept. The six building blocks of health systems formed our second key concept. We removed medical products and vaccines while retaining technology in the fourth building block to filter studies on drugs and drug and vaccine trials. We expanded each building block term as per MeSH terminologies. The final search strategy included a combination of the first (burns) and second (health systems) concepts. Then we systematically searched all relevant medical and public health databases, including Medline via PubMed, Scopus, CINAHL via Ovid, Embase via Ovid and Safetylit- an injury-specific literature database. These databases cover a comprehensive range of literature for the topic of our focus. We used the inclusion and exclusion criteria mentioned in box 1 to filter search results. Details of search strategies and terms are given in online supplemental file 2.

    Supplemental material

    Box 1

    Inclusion and exclusion criteria

    Inclusion criteria

    • Population/problem: all age groups and genders.

    • Geographical area: all.

    • Intervention and outcomes: at least one health systems building block and burns.

    • Study period: published between 1 January 2000 and 30 June 2022.

    • Language and publication status: journal articles with full text in English.

    • Study designs:

      Original articles: study describing findings of primary data/information or secondary analysis of the primary dataset.

      Observation studies: included.

      Qualitative studies: included.

      Interventional studies: Details of study design to be included are:

      • Randomised controlled trials—with intervention either at individual or cluster level.

      • Non-randomised studies: Regression discontinuity design, controlled before and after studies with an intervention and comparison group using methods to match individuals and groups statistically, panel data study and cross-sectional studies using methods to control for selection bias and confounding, and interrupted-time series studies which use observation at multiple time points before and after the intervention.

      • Systematic reviews and literature reviews: studies fulfilling the criteria of a systematic review or systematically conducted literature review, which describe methods used for search strategy, data collection and synthesis.

    Exclusion criteria

    • Theoretical studies, modelling studies, efficacy trials or systematic reviews of efficacy trials or laboratory studies.

    • Any study not based on primary data or secondary analysis of primarily collected data.

    • Non-systematic literature reviews.

    • Studies related to COVID-19.

    Screening and data extraction

    We screened potential studies in two phases. In phase I, abstracts were reviewed using defined inclusion and exclusion criteria (box 1), followed by the full text in phase II. Two reviewers (VRK and PS) independently screened the abstracts in Rayyan web-based application.18 Reviewers held regular discussions to resolve conflicting decisions, and consultation with senior authors (MP and JJ) helped resolve any remaining conflicts. We used a predefined tool to extract data from included studies. The data extraction tool includes information on study citation, year, author affiliations and discipline, study design, methods, settings, participants, objective, and health systems block and subdomains. The Research Data Capture (REDCap) electronic data capture tool was used for data extraction.19 The first author (VRK) extracted data, and all entries were cross-checked by the other author (PS) for any discrepancies. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) chart with details of study screening is shown in figure 1.

    Figure 1
    Figure 1

    PRISMA flow chart. (PRISMA, Preferred Reporting Items for Systematic reviewsand Meta-Analyses.)* Other sources: Reference scanning.

    Analysis and development of the EGM matrix

    An EGM is usually developed for impact evaluations and interventional studies. But considering the limitations of interventional studies in understanding health systems, we also included observational and qualitative studies in the results. First, we analysed basic descriptive characteristics of included studies and relevance to health systems building blocks. We then reviewed all studies to assign subdomains and health systems outcomes as per the operational definitions. A study dealing with more than one building block or addressing more than one outcome was assigned to all relevant fields. After coding all studies to their relevant area of focus and health systems outcome fields, a visual EGM map was generated in MS Excel. We also conducted separate analyses for interventional studies and mapped them distinctly in the EGM.

    Patient and public involvement

    This manuscript is a systematic review of existing literature, and it was not feasible to engage patients or the public in its design, or conduct, or reporting.

    Results

    We identified 7060 citations after searching databases, and an additional 48 citations were identified by reference scanning. Of these, 522 were duplicates. So, 6586 abstracts were screened for possible inclusion, of which 6380 were excluded as they did not meet our inclusion criteria. Finally, we reviewed the full text of 206 articles. Based on this screening, another 100 articles were excluded (online supplemental file 3). The most common reasons for excluding studies were: not directly related to any health systems building block, addressing clinical aspects only and not specific to burns. Other reasons for exclusion were if the study was on prevention of burn, patient’s clinical prognosis, without primary data or an analysis of the primary database, related to COVID-19 and reports of study protocols without results. The full text in English was not available for seven papers, so these were also excluded. The final analysis was done for 106 citations (figure 1).

    Supplemental material

    Study characteristics

    Most included studies were cross-sectional (61%), followed by qualitative (13%), systematic literature reviews (10%) and others (7%). There were only 13 interventional studies, including 4 randomised controlled trials (RCT), 4 non-RCT and 5 pre–post evaluations. Hospital was the most common study setting (71%), and only a small proportion of studies were conducted in peripheral health systems (12%), community or population (4%) settings. Hospital patients (48%) and healthcare providers (29%) were the two most common sources of data. The most common health systems building block addressed was service delivery (53%), followed by health workforce (33%), technology (19%), financing (18%) and information (11%). No included study reported on leadership or governance in burns (table 1).

    View this table:
    Table 1

    Characteristics of included studies

    Researchers’/authors’ profile

    Medical doctors (mostly plastic surgeons) were the lead authors for the majority (60%) of the papers. Researchers with background in nursing and allied health (rehabilitation and others) were lead authors for 26% of the included papers. Authors from public health and other backgrounds led 13% of included papers. Around 90% of the authors were affiliated with a medical institution, university or hospital, while 8% were affiliated with non-medical institutions or universities, and 2% with other institutions (table 1).

    Study location and distribution by country income categories and WHO regions

    We categorised the country focus of the studies according to the World Bank income groups and compared it with the burden of burn injuries in these groups, as per the Global Burden of Disease estimates.20 Most of the studies (64%) were based in HICs, which has the lowest burden for burns mortality (11%). On the contrary, LMICs with 46% of burns mortality burden were the focus for only 12% of the included studies. LICs with 13% burns mortality contributed to less than 1% of included studies (figure 2). Among WHO regions, the SEAR, with 28% of the mortality burden contributed to less than 2% of publications and the AFR with a 21% burden contributed only 6% of publications. Conversely, the region of the Americas contributed to around 36% of research output, with 9% of the mortality burden (figure 2).

    Figure 2
    Figure 2

    Study location and burns mortality burden by the World Bank country income group and WHO regions.

    Description of EGM and key features of included studies

    The included studies were categorised into one or more area of focus and health systems outcome categories according to the issues addressed in the results of the study. The snapshot of the visual presentation of the EGM visual is available in Figure 3, while the live map can be accessed here. We also developed separate maps for all included studies (n=106) and interventional studies (n=13). In figure 3, the blue bubbles in the EGM indicate all studies, while the green bubbles indicate interventional studies. The bubble sizes correspond to the number of available studies in the domain. The EGM with bubbles linked with all included study citations in each box is available as online supplemental file 4. Here, we describe the key features of included studies.

    Supplemental material

    Figure 3
    Figure 3

    Evidence and gap map for health systems research in burn care.

    1. Service delivery: 56 studies addressed service delivery issues, out of which 13 dealt with the availability and distribution of health facilities, 31 with organisation, coordination and management of services and care, and 17 with the place, mode of service delivery and facility preparedness. The most common health systems outcome was access and coverage (n=29), improved health (n=20), efficiency (n=18), responsiveness (n=16) and quality of care (n=9). In addition, there were 11 interventional studies on service delivery. The themes identified among the included studies under this domain were: referral transport, linkage and referral management, service provision for burn care and rehabilitation, infrastructure availability, organisation of care, prehospital care, access to service and use of telemedicine to improve access.

    2. Health workforce: 35 studies addressed the health workforce, most commonly the availability and distribution (n=12) and incentive and motivation (n=12), followed by education and training (n=11) and human resource management (n=9). Among these, common health systems outcomes addressed were responsiveness (n=18), quality of care (n=11), access and coverage (n=11), improved health (n=9) and efficiency (n=5). Included studies on the health workforce mostly centred on the health workers’ availability and linkage with service provision, rehabilitation workers, and training of health workers, especially nurses and paramedics. Qualitative studies discussed team dynamics, work satisfaction and emotional resilience among health workers, especially nurses. Six studies on the health workforce were interventional studies.

    3. Information and research: studies in this domain most dealt with health education and communications (n=7), data and research (n=4) and health information systems (n=3). ‘Improved health’ was the most common health systems outcome indicator for studies on the information. Sources of information, health education methods and interventions were the most frequent themes of included studies under this building block. Four studies on information and research related to burns were interventional studies.

    4. Technology: studies in this domain most commonly discussed telemedicine (n=14), followed by technology-enabled healthcare delivery (n=5). Seven studies on technology were interventional, four dealt with telemedicine and three with technology and healthcare delivery. Studies on technology mostly described the use of telemedicine for improving access, triaging and referral, and the feasibility of service delivery via telemedicine. A few studies also focused on using innovative technology for health education and improving health intervention for improved outcomes.

    5. Health financing: studies on health financing concentrated on costing and economic evaluation (n=14), followed by social and financial risk protection (n=11) and efficiency (n=8). A few papers reported financial benefits and access to healthcare (n=5). Only one included study on health financing in burn care was interventional.

    Key features from qualitative research in health systems and burns

    Among all included studies (n=106), there were 14 qualitative studies, all published in the last 10 years. These studies were based in six countries: Iran (n=6), Australia (n=3), Brazil (n=2), Belgium (n=1) Ghana (n=1) and South Korea (n=1). Out of the 14 qualitative studies, 12 were led by the first author with background in nursing, while one each was led by public health and social and rehabilitation researchers. Ten qualitative studies discussed health workforce issues, three discussed burn survivors in the community, and one discussed both patients, and health workforce. The most common themes of qualitative analysis were exploring the experience and challenges of health workforces, especially nurses and nursing students, followed by patients’ experience with postdischarge care.

    Discussion

    In this EGM, we mapped the existing peer-reviewed journal publications dealing with health systems issues for burn care globally. The EGM shows limited research output on burns addressing systems’ building blocks. The available studies were mainly clustered around three building blocks: service delivery, health workforce and technology, especially telemedicine. Published studies on leadership and governance were absent, and studies on health financing, information and research were limited. Most studies addressed health facility issues (microlevel), while a limited number of studies explored issues beyond the health facility at the geo-administrative level (mesolevel) and subnational or national level (macrolevel) issues. We also observed skewed distribution of study locations vis-a-vis the magnitude of the burn injury burden. Most research outputs were generated from HICs, while most of the mortality and disability burden were in LICs and LMICs, especially in AFR and SEAR. Research on burns was commonly conducted by clinical practitioners and only a few studies were led by public health researchers, indicating low public health research priorities for burn injury. Findings also indicate methodological limitations as most included studies were quantitative and cross-sectional in nature. Overall, the EGM highlights a need to expand the horizon and develop a roadmap to strengthen HSR in burn care.

    Service delivery was the most common area of focus among included studies, however, those were mainly clustered around issues, such as referral, service access and service provisions.21–24 The higher number of studies in service delivery also reflects the methodological and disciplinary orientation of researchers, the nature of research projects and study settings. Most of these studies were led by clinicians in tertiary burn care settings with either patients or healthcare providers as subjects. Very few studies addressed service delivery beyond tertiary burns care centres, thus, continuing gaps in understanding the patients’ longer-term needs and challenges, care pathways, integration of burn care into health systems and postdischarge continuum of care. Studies analysing macrolevel health systems issues for burn care were missing, thus limiting the scope for generating policy recommendations. Experts have previously called for addressing systems and macrolevel research questions in burn care.25

    Studies on the health workforce explored a wide range of issues and were methodologically more diverse. Here, the most common themes were availability, education and training and the challenge of working in burn units, and the challenges of rehabilitation.26–29 However, some qualitative studies also explored team dynamics, emotional challenges, incentives and motivation among nurses.30 31 Studies on health workforce issues such as mapping, planning, policies, training needs and designs, and interest of health workers in burn care were limited. There were limited studies on the health workforce from LICs and LMICs where multifaceted health workforce challenges are common.

    Telemedicine was the main theme for a large number of health systems studies on burn care and response. Available evidence highlights the use of telemedicine for diagnosis, triage and referral, service provision for minor burn injuries and postdischarge rehabilitation.32–35 The use of telemedicine also increased during the COVID-19 pandemic.36 Timely access to burn care is a frequent challenge in all contexts, and the high number of studies on telemedicine reflects the need to address the time-sensitive access gap. However, few studies explored the implementation challenges for telemedicine in resource-constrained settings. Studies on information and research building blocks dealt with health education and sources of information, such as web-based information.37–39 A few studies also discussed information and data systems related to burn injuries and responses40 41 However, studies addressing health information systems and data-driven policy and planning for burn care were limited.

    Included studies in health financing focused on cost analysis and economic evaluation of delivering burn care services at health facilities.42–44 Health financing issues from patients’ perspectives, such as financial barriers to access, sources of expenditure and level of financial risk protection, were not adequately explored. Systems level health financing issues, such as financing policies, national and subnational budget allocation, health insurance coverage, and source of health expenditure by patients were also not adequately addressed in the available literature.

    Our analysis points towards limitations in the methodological orientations on research in burns. Most of the included studies were quantitative and cross-sectional, however a few researchers with nursing backgrounds used qualitative approaches to examine the health workforce challenges in a burn unit. Methodological limitations and quality concerns in survey and research in burns were highlighted earlier too.45 46 The EGM findings suggest the need to build capacity for burns researchers in health policy and systems research (HPSR). A recent WHO multistakeholder consultation also outlined the need for more HPSR for strengthening rehabilitation care.47 Public health institutions and researchers must also explore population-based and health systems approaches to research on burn injuries and response. The EGM also calls for funding agencies to prioritise research gap areas and geographical locations with high burns burden.

    There is vast inequity in mortality burden and research output, based on the World Bank category and WHO regions. LMICs and LICs have the majority of burns burden but contribute to a small fraction of total research output. Similarly, research output from SEAR and AFR regions is minimal compared with the magnitude of burn injuries in these regions. The inequality in research output have been documented for burns research.48 49 The WHO global observatory on health research and development noted wide inequalities across countries and health issues. According to their latest report, injury research is just 5% of the grants awarded by leading funding institutions.50 The regions of AFR and SEAR are a tiny fraction of the overall amount of research funding.50 The challenges of research capacity and limited institutional support to undertake research are frequently recognised.51 In addition, the publication bias in global health limits opportunities for LMICs researchers.52 53 The English language barrier and lack of support for availing translation assistance or lack of funding for high open access fees push them to publish in local journals that are not indexed in major literature databases, such as PubMed or Scopus.53

    A comprehensive approach to align and strengthen HRS in burns should be prioritised to facilitate scalability and increase impact. Using the HRS framework, we identified the existing gaps in the current research ecosystem and health systems’ response to burn injuries, and suggested action for aligning the interaction of health and research systems.12 A comprehensive HRS in burns will have an expanded research focus from microlevel to mesolevel and macrolevel issues. In addition, there is a need for interdisciplinary collaboration and diversifying methodological approaches by capacity building of researchers working in the field of burn injuries. More importantly, there is an urgent need to prioritise research on burns in countries and populations with research paucity and high burden. Funding agencies, professional societies and institutions must use similar evidence-mapping exercises to align existing research priorities in burn injuries and care to improve outcomes (figure 4).

    Figure 4
    Figure 4

    A proposed framework of action to strengthen health research systems in burns.

    This novel EGM highlights the availability and gaps in HSR for burn care, with the aim to support future research priority settings. The International Society for Burns Injuries (ISBI), a global network of burn care practitioners and researchers, has identified priority research topics that include organisation and delivery of burn care, quality improvements and ethical issues, besides core clinical areas.54 However, there is a need to expand this list to include more health systems building blocks, such as addressing the health workforce challenges, financing options, leadership and governance, policies, and information systems. Research priorities should also be aligned to include issues at the mesolevels and microlevels through collaboration with public health and HPSR researchers. In addition, there is a need to support burn care systems research in LICs and LMICs, particularly in SEAR and AFR regions of the WHO. An equitable distribution in research output from these regions is critical to ensure the ISBI motto of ‘one world, one standard of burns care’.54 A more collaborative and systems-focused research can support higher prioritisation of burns in subnational, national and global health policy priorities.

    To our knowledge, this is the first EGM on HSR related to burns care. However, the study also has a few limitations. EGMs usually include non-peer-reviewed publications, however, we have included only peer-reviewed published literature and extensively searched multiple databases to capture all published research papers. The intervention and outcome matrix for the EGM is ideally designed for interventional studies. However, we also included observational studies in the list due to limited number of interventional studies. Categorising health systems’ area of focus subcategories was complex due to the wide scope of each building block. We used standard references for this exercise, yet a few observational studies were not specific in health systems outcomes, so we had to categorise them to the closest outcome category. To mitigate investigator bias, two researchers independently categorised area of focus and health systems outcomes. Only English language papers were included; thus, we may have missed literature in other languages.

    Conclusion

    In conclusion, the EGM shows a significant paucity of HSR in burn care. Available research are clustered around service delivery, health workforce and telemedicine, and addressed microlevel or mesolevel issues. Research on macrolevel issues, such as leadership and governance, and health policies, are very scarce. There is a need to deliberate, discuss and build burn specific HPSR capacity, including collaborative research between clinical and public health researchers to support robust and sustainable HRS for responding to burn injuries globally. The funding bodies, professional associations, institutions, international organisations, global researchers and clinicians should prioritise and promote research leadership and projects in LMICs and regions with the highest gaps in research and injury burden.

    Data availability statement

    All data relevant to the study are included in the article.

    Ethics statements

    Patient consent for publication

    Acknowledgments

    Authors would like to acknowledge Dr. Soumyadeep Bhaumik for his comments during analysis and Dr. Sandeep Moola for reviewing search strategies.

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    Supplementary materials

    Footnotes

    • Twitter @docVRK, @margiepeden

    • Contributors VRK conceptualised the study with inputs from MP and JJ. VRK did the literature search. VRK and PS screened the literature, with support from JJ and MP. VRK did data extraction, and PS verified the data. VRK conducted the analysis and PS, JJ, MP and SA provided inputs. VRK wrote the manuscript. MP, JJ, RN and SA provided critical comments to revise the manuscript. All authors reviewed and approved the final manuscript. VRK has access to all data and act as guarantor.

    • Funding VRK is supported by Tuition Fees Scholarship from the University of New South Wales (UNSW), Sydney, Australia. JJ is supported by Emerging Leadership level-2 fellowship by the National Health and Medical Research Council, Australia.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.