https://orcid.org/0000-0002-2668-7360
Figures
Abstract
Numerous intervention studies have attempted to increase cervical screening uptake among immigrant women, nonetheless their screening participation remains low. This systematic review and meta-analysis aimed to summarise the evidence on interventions to improve cervical screening among immigrant women globally and identify their effectiveness. Databases PubMed, EMBASE, Scopus, PsycINFO, ERIC, CINAHL and CENTRAL were systematically searched from inception to October 12, 2021, for intervention studies, including randomised and clinical controlled trials (RCT, CCT) and one and two group pre-post studies. Peer-reviewed studies involving immigrant and refugee women, in community and clinical settings, were eligible. Comparator interventions were usual or minimal care or attention control. Data extraction, quality appraisal and risk of bias were assessed by two authors independently using COVIDENCE software. Narrative synthesis of findings was carried out, with the main outcome measure defined as the cervical screening uptake rate difference pre- and post-intervention followed by random effects meta-analysis of trials and two group pre-post studies, using Comprehensive Meta-Analysis software, to calculate pooled rate ratios and adjustment for publication bias, where found. The protocol followed PRISMA guidelines and was registered prospectively with PROSPERO (CRD42020192341). 1,900 studies were identified, of which 42 (21 RCTS, 4 CCTs, and 16 pre-post studies) with 44,224 participants, were included in the systematic review, and 28 with 35,495 participants in the meta-analysis. Overall, the uptake difference rate for interventions ranged from -6.7 to 96%. Meta-analysis demonstrated a pooled rate ratio of 1.15 (95% CI 1.03–1.29), with high heterogeneity. Culturally sensitive, multicomponent interventions, using different modes of information delivery and self-sampling modality were most promising. Interventions led to at least 15% increase in cervical screening participation among immigrant women. Interventions designed to overcome logistical barriers and use multiple channels to communicate culturally appropriate health promotion messages are most effective at achieving cervical screening uptake among immigrant women.
Citation: Alam Z, Cairns JM, Scott M, Dean JA, Janda M (2023) Interventions to increase cervical screening uptake among immigrant women: A systematic review and meta-analysis. PLoS ONE 18(6): e0281976. https://doi.org/10.1371/journal.pone.0281976
Editor: Gulzhanat Aimagambetova, Nazarbayev University School of Medicine, KAZAKHSTAN
Received: August 9, 2022; Accepted: February 5, 2023; Published: June 2, 2023
Copyright: © 2023 Alam et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: The study was supported by Australian Government Research Training Program scholarship granted to ZA. JM is funded by Yorkshire Cancer research (Award reference number HEND405). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Cervical cancer, despite being preventable, is a leading cause of cancer diagnosis and death among women worldwide, with 342,000 women dying in 2020 [1] Women in low and lower-middle income countries are most affected [2, 3]. Advances in biomedical research has led to the introduction of novel surgical, radiotherapeutic and systemic options for the treatment of cervical cancer [4]. Research evidence clearly shows that secondary prevention in terms of screening can effectively reduce cervical cancer mortality [5]. Screening options now being employed worldwide include Pap and HPV test [6]. Although many high-income countries have successful screening programs, disparities remain among certain population subgroups [7]. Immigrants have been identified as a subgroup with lower cervical screening uptake [8]. Therefore, multiple studies have delivered interventions to bring about better screening uptake among immigrant women globally.
Three systematic reviews have summarised studies involving health promotion interventions to increase cervical screening uptake among at-risk population subgroups. Of those, two focused on specific migrant groups i.e., Asian and Hispanic immigrant populations and indicated the role of sociocultural factors and population characteristics in intervention effectiveness [9, 10]. Whereas the third review on studies conducted between 2006–16 focused on activities for increasing cervical screening uptake among low socioeconomic groups, indicating effectiveness of HPV self-sampling [9]. Reviews have been carried out to summarise the evidence on interventions that used specific strategies such as education provision, Human Papilloma Virus (HPV) self-sampling or health care provider (HCP) counselling among the Indigenous/native women [11–14]. However, none of these previous reviews addressed the overall diverse immigrant populations in different parts of the world, nor summarised various intervention strategies for increasing cervical screening in immigrants. Given the recent launch of global initiative to eliminate cervical cancer as a public health problem by WHO [15], it is critical to systematically review the evidence on effectiveness of interventions, among under reached groups such as immigrants.
Thus, the objective of this study was to obtain the systematic evidence, expanding on immigrant population subgroups from various backgrounds, not limited to intervention strategies of specific type, as opposed to previous reviews and to compare the effect of intervention between intervention and control groups through meta-analysis. This review aimed to systematically summarise the global and up to date evidence on interventions aiming to increase cervical screening uptake among immigrant and refugee women, and quantify their effectiveness via providing a pooled estimate of the effect, through a meta-analysis. A further aim was to extract the characteristics of interventions most effective for increasing cervical screening uptake, in order to inform researchers and policy makers of the most promising intervention components to include in future interventions and to identify find any remaining knowledge gaps.
Methods
This systematic review followed PRISMA 2020 guidelines [16] (checklist included in S1 Table). The protocol was registered with International Prospective Register of Systematic reviews (PROSPERO) Registration number: CRD42020192341. Refer to S1 File for published protocol.
Study search
Pubmed, Scopus, EMBASE, CINAHL, PsycINFO, CENTRAL and ERIC were searched from inception to 12th October 2021. The search strategy was developed with guidance by a professional librarian and combined the most appropriate keywords, MESH terms and Boolean operators, such as ((cervical cancer OR cancer of the cervix OR cervical neoplasm)) OR cervical cancer, uterine)) AND (((screening OR detection OR Pap test OR Pap smear)) OR cervical smear))) AND (((immigrant* OR migrant* OR refugee* OR emigrant*)) OR (emigrants and immigrants)))). S2 Table (a-h) provide the full electronic search strategy for each database. Additionally, bibliographies of included articles were hand-searched to identify other potentially relevant studies (S2 Table (i)). Titles and abstracts of studies were screened to identify interventions or health promotion activities aimed to increase cervical screening uptake among immigrant or refugee women. The database search was repeated in June 2022 to include any recently published studies.
Study eligibility and selection
Original, peer-reviewed studies of any design ((randomised controlled trials (RCT), clinical controlled trials (CCT), cohort analytic pre-post (Quasi experimental) studies), with both simple and complex interventions were included, without restriction of language. Studies with interventions focusing only on increasing cervical cancer and screening knowledge, but not behaviour, and descriptive studies exploring patterns of cervical screening uptake among immigrant groups were excluded. Studies without complete outcome data were also excluded, after attempting to contact the authors for details. Studies involving immigrant and refugee women from any background were included. Conference proceedings and theses were excluded. Studies were independently retrieved and screened against inclusion criteria by at least two reviewers (ZA, JC, MS) via COVIDENCE, with resolution of any difference through mutual discussion.
Data extraction
Fields predesignated by the authors were used to extract study data, including publication details (author, year), population characteristics (sample size, age, ethnicity, baseline screening status), study setting and location, recruitment method, intervention characteristics (type of intervention, control and intervention group, follow up period), and outcome measure(s). The outcome measure of primary interest for the systematic review was difference in cervical screening uptake from pre- to post-intervention in the intervention group, expressed as percentage. When the study reported more than one outcome measure, or calculations for different time intervals, the one with higher value was used. According to PRISMA guidelines, data were also extracted independently by at least two authors (ZA, MS, JC).
Synthesis of extracted data and meta-analysis
Extracted data were then synthesised and reported narratively, arranging studies based on intervention type (simple/multifaceted), study setting (urban, rural community/clinical), source of outcome data measurement (self-reported/record based), screening method offered (self-sampling/pap test/ combined), mode of delivery (in person/via use of mail/telephone/media), intervention format (brochures/video/combined), guidance by a theoretical or behaviour change model (theoretically guided) and involvement of personnel (HCPs/Promotoras). Outcome data was reported with ranges across studies with similar characteristics.
The review was followed by meta-analysis of RCTs, CCTs and two-group pre-post studies. Meta-analysis was performed using Comprehensive Meta-Analysis (CMA) software Version 3 [17]. Due to wide variety of interventions used and populations addressed, random effects model was selected. The pooled effect size (ES) was calculated from the proportion of women screened post intervention in the intervention and control groups, respectively, and was reported with 95% confidence intervals along with p values (p<0.05 considered as threshold for statistical significance). Q statistics and I2 values were reported to inform about heterogeneity. A statistically significant Q value is indicative of heterogenous distribution of ES, whereas the I2 statistic describes ES heterogeneity contributed by non-sampling error. Additionally, a prediction interval with 95% confidence interval was calculated, which is an accurate measurement of heterogeneity and variance of the ES, and gives more information on the distribution of effect than I2 analysis alone [18]. To explore heterogeneity further, studies were then stratified into subgroups based on explanatory variables such as study type. Analysis was only performed when there were three or more studies available in a stratification group.
Publication bias was assessed by visual funnel plots inspection, assessment of symmetry via Egger’s test and Begg–Mazumdar Kendall’s Tau test. When bias was found, it was adjusted using trim and fill method introduced by Duval and Tweedie [19]. Sensitivity analysis was also conducted by removing studies with low quality (that scored weak on EPHPP scale), as well as an evident outlier with the highest effect size.
Critical synthesis and quality appraisal of the studies
The quality of included studies was appraised using the Effective Public Health Care Practice Project (EPHPP) quantitative study quality assessment tool. This tool was first published in 1998 and effectively measures quality of intervention studies, especially in public health [20, 21]. It assesses six criteria: selection bias (representation by target population), study design and randomisation, confounders and their adjustment, blinding of participants and assessors, validity and reliability of data collection methods, and withdrawals and dropouts. The scores were determined by two independent reviewers (ZA, JC) and inter-rater reliability using Cohen’s kappa calculated.
Results
In total, 1,900 articles were retrieved from databases including Pubmed (392), Scopus (459), EMBASE (480), CINAHL (356), PsycINFO (140), CENTRAL (53) and ERIC (3) and bibliographies of the included articles (17) (Fig 1). After removal of 1,151 duplicates, 749 studies remained. Their titles and abstracts were searched to include relevant interventions, yielding 103 studies. Of these, 42 articles were chosen after a full text review, with 28/42 included in the meta-analysis. Remaining studies (61) were excluded as they lacked full text (10), had irrelevant outcomes/inadequate information on outcome measures (23), focused on increasing knowledge only (3), focused on intervention design (9) or included generalised information summary (7) only, addressed irrelevant populations (8), or consisted of review (1).
Characteristics of the included studies
Of the 42 studies in total, 21 were RCTs, four CCTs, 12 (single group pre-post) and four (two group pre-post) cohort analytic studies. Table 1 provides the characteristics of overall studies included in the systematic review. The majority of studies (23) were conducted between 2011–2021. The number of participants ranged from 42–10,810, age ranged from 18–72 years, with similar participant characteristics in the controlled trials as in overall studies, while the cohort analytic studies had a smaller maximal number of participants (65–1,732).
Baseline screening status of participants in most of the studies (34/42) was under- or never- screened, however nine studies included participants who were up to date with screening as well. The majority of studies (36/42) were conducted in community settings (residences, churches, community centres, consulates); 31 in metropolitan and five in rural areas, whereas the rest (5/42) were conducted in healthcare settings (refugee/immigrant clinics). The majority of studies were conducted in the US (31), with relatively few in other countries: Canada (3), Hong Kong (3), UK (2), and Norway (2). Nearly one third (14) of the studies targeted multiethnic participants, whereas the rest involved immigrants from specific backgrounds only, including Latinas (4), Vietnamese (5), Hispanic (5), South Asian (4), Filipino (1), Chinese (2), Mexican (2), Korean (2), Cambodian (1), Somali (1) and Pacific Islander (1).
Most of the studies involved immigrant women from the community not belonging to any specific profession, while six studies focused on specific subgroups i.e., nail salon workers, farmworkers, and female sex workers (Table 2). The follow-up time after intervention ranged between two months to four years, with the majority having six months follow-up. Based on the EPHPP tool, most studies were weak in quality (21), followed by moderate (15) and strong (5).
Intervention characteristics
Difference in cervical screening uptake ranged from 20–96% in the pre-post studies and -6.7 to 81% in controlled studies, for an overall range difference of -6.7 to 96% (Table 2). Almost all intervention studies focused on increasing cervical screening uptake through education, with eight using brochures or flip charts, 13 using audio-visual tools, and 10 using a combination of both. The screening uptake difference ranged from 16.7–81% for interventions using brochures, 2.4–87% for those using videos and -6.7 to 70% using a combination of both. The majority of the interventions (34/42) were delivered in person via Promotoras or health care workers, with three combining these with mailed materials [20, 28, 50], and one with media delivered education [31], whereas three solely used telephone, mail and media each [24, 29, 34]. Of the reviewed studies, 15 used behavioural intervention techniques beyond education such as motivation, persuasion and role modelling via survivors, celebrities, and narrative videos (screening uptake difference -6.7 to 77%). Three studies used specialised immigrant clinics to reach the target population (screening uptake difference 51−96%) [32, 55, 56].
Although most interventions promoted Pap test only, three focused on increasing HPV self-sampling in combination with Pap test, and resulted in increased cervical screening by 66−77%, compared to 11−48% increase in Pap test arms [42, 43, 47]. Another RCT offered self-sampling option only in person or by mail resulting increasing cervical screening by 81 and 72%, respectively [50]. Relatively few studies (3) involved health care practitioners in intervention delivery, of which one RCT, conducted in family doctor practices, yielded screening uptake increase by 2.6% [58] and two single group pre-post studies by 52−87% [40, 55]. Moreover, navigation, reminders and financial incentives as additional components of intervention were used in 26 studies, reporting screening uptake increases by 8−96%. Most studies (25) assessed screening uptake through self-reported uptake of -6.7 to81%, whereas 17 used objective measures such as medical record extraction reporting an increase of 2.6−96%. Not all controlled trials used completely unexposed control arms, seven studies used minimal intervention groups [33, 36, 41, 45, 47, 54, 61], three used intensive intervention groups as control arms [44, 52, 59], whereas four used attention control interventions such as physical activity or diabetes education [30, 41, 46, 48]. When grouped based on type of control group, participants in the intervention group had a change in cervical screening of -6.6 to 24.8% in studies with non-exposed control groups, 8−77% with a minimally exposed control groups, 38−81% in intensive interventions control groups, and 3−19% in control groups offered attention control interventions.
Results from meta-analysis
The 28 studies included in the meta-analysis had 35 intervention arms. They included 35,495 participants overall, 20,685 in the control arms and 14,810 in the intervention arms, respectively. Pooled ES of cervical screening yielded a rate ratio of 1.49 (95% confidence interval (CI): 1.36–1.65), (Fig 2) with a Q value of 402.2 and I2 value of 93%, indicating high heterogeneity. Prediction interval calculation indicated that the true ES in 95% of the comparable populations would fall between 0.95–2.34, thus concluding that cervical screening intervention would likely, but not always, be effective in immigrant populations. However, funnel plot inspection (Fig 3), Begg–Mazumdar Kendall’s Tau (–0.43, p = 0.001) and Egger tests (intercept = 3.66, p = 0.0001) indicated publication bias. Therefore, the ES was recalculated using Duval and Tweedie’s trim and fill method, with 10 studies being adjusted, resulting in an ES of 1.15 (95% CI 1.03−1.29, p < 0.001) (Table 3). Substantial heterogeneity remained in almost all subgroups that were formed based on explanatory variables, indicating differences in intervention design, methodology and populations. Publication bias was also evident for most subgroups and adjusted accordingly (Table 3).
Subgroup meta-analysis indicated that when information and education was delivered using multiple modalities such as brochures and visual media strategies, ES (1.29 (95% CI: 0.83–2.00)) were higher, compared to using each modality alone (Refer to S1 Fig (a-k) for the subgroup forest plots). Results also suggested that multifaceted interventions had higher likelihood of increasing screening (ES 1.19 95% CI: (1.04–1.36)) compared to provision of education alone (ES 1.10 (95% CI: 0.97–1.24)). Studies with interventions delivered in person had a higher ES of 1.18 (95% CI: 1.04–1.35) compared to the ones that were not (ES 1.13 (95% CI 0.98–1.30)). It was observed that interventions with attention control arms such as exercise and diabetes education had lower effect (ES 1.04 (95% CI: 1.00–1.09)), compared to those with non-exposed control groups (ES 1.23 (95% CI: 1.04–1.44)) or minimal intervention groups (ES 1.15 (95% CI: 0.88–1.51)).
Interventions with under- or never-screened participants had considerably higher ES of 1.34 (95% CI: 1.00–1.81)), compared to those that also included participants up to date (ES 1.10 (95% CI: 1.06–1.14). Theoretically guided intervention studies had higher ES as did the ones involving community health workers and those conducted at broader level involving multiple locations within the country. No statistically significant difference in ES was seen in groups based on length of follow up, outcome source or study quality. When sensitivity analysis was conducted by removing studies with low quality [28, 63], or those evident as outliers in the funnel plot [47], heterogeneity indices remained the same and no effect was observed on the effect size.
Quality appraisal and risk of bias
Quality appraisal results suggested that the majority of the cohort pre-post studies were weak (13) due to lack of randomisation and participant blinding, contributing towards low overall quality scores. Common reasons for the controlled trials to be weak included selection bias due to lack of representative population when participants were conveniently sampled, or lack of details on confounder adjustment. Refer to S3 Table for description of individual quality criteria for all studies included in meta-analysis. Inter-rater reliability testing between the two quality raters (ZA, JC) yielded Cohen’s Kappa of 0.4. The reason for low kappa score was differences in perception of rating criteria (selection bias, confounding) between the reviewers.
Discussion
This study critically reviewed and meta-analysed interventions to increase cervical screening uptake among immigrant women globally. The review found that culturally appropriate interventions such as those providing HPV self-sampling methodology and targeted clinics for immigrants are most effective. Meta-analysis found that multicomponent interventions were more beneficial than single component ones, as were those theoretically guided, delivered in-person and using multiple formats of information delivery. Participant characteristics, such as baseline screening status also influenced the success of the interventions, as did the type of intervention selected for the control group.
To our knowledge this is the first systematic review and meta-analysis to comprehensively map the global evidence on the effectiveness of interventions to increase cervical screening in immigrant women. It compared the intervention effect sizes based on characteristics such as delivery format, involvement of HCPs, modes of educative material, screening status of participants and type of control group. The strengths of this study include following a prospectively registered protocol, clearly and transparently outlining our search strategy and methods of analysis, having multiple reviewers independently working on each review stage, and investigating novel methods of encouraging screening i.e., self-sampling, not included in previous intervention reviews on immigrants. However, this review also has certain limitations. First, although we conducted a comprehensive search of multiple databases, some studies might not have been located. We tried to overcome this through hand citation searches. Second, we found the EPHPP tool was more favorable towards experimental studies compared to non-controlled studies resulting in most studies being scored of weak quality. We also found significant heterogeneity in the studies limiting the number we could include in the sub-group meta-analyses.
The meta-analysis results suggested a low overall ES of 1.15 (95% CI 1.03–1.29) across all intervention studies after adjustment for publication bias. Although the results suggest a positive effect of interventions for cervical screening uptake, the results need to be interpreted with caution, in light of high heterogeneity (I2 = 93%, Q = 402.2). However, heterogeneity often cannot be prevented in behaviour change studies, especially when dealing with diverse populations that require interventions adapted to their special needs. Similar heterogeneity has been observed in studies reporting meta-analysis of intervention studies for screening for other cancers [64]. Publication bias encountered in this review suggests that studies with less positive outcomes may exist but are difficult to trace [65]. Despite our efforts to find these unpublished studies, none could be discovered. Additionally, low Kappa score as evaluated in our study indicates weak interrater reliability on the quality appraisal of the studies. However, the literature suggests that the Kappa index may amplify disagreement estimate among the raters [66]. A low Kappa index is more of a concern when dealing with diagnostic tests in clinical studies [67] compared to quality appraisal, as in the current study.
The interventions included in the systematic review ranged from simple approaches such as mere provision of information, to those incorporating multiple components such as support of women using behaviour change techniques, patient navigation and practical help (provision of clinics for immigrants, childcare and transport). It was evident that the complex multifaceted interventional options, addressing broad areas of behavioural change and helping overcome the logistic constraints, were more effective at improving cervical screening uptake. It is similar to what has been reported for screening uptake for other cancers [64, 68], and for cervical screening among women generally [9]. In contrast to the systematic review findings, meta-analysis suggested that combined modes of information provision such as brochures, visual media as well as written information are more effective than using each of these strategies alone, similar to previous findings [69]. The difference between systematic review and meta-analysis findings could reflect that the meta-analysis mainly included higher quality studies and trials. Interventions that were guided by theoretical behaviour change models also had statistically significant stronger ES compared to the studies which were not. The advantages offered by interventional designs based on theoretical models have been summarised previously [70].
Interventions in broad populations, including both under- and well-screened women, compared to those including under- or never-screened women only, were less effective. Previous research also reported better effectiveness of risk-targeted rather than population-based interventions [71]. Thus, choosing the population on which to intervene is important, although it might be less convenient to reach a specific proportion rather than an entire immigrant population subgroup.
One of the intervention methods that recently became available and seems promising is HPV self-sampling. Although meta-analysis could not be performed due to the limited number of self-sampling studies available, the systematic review reported it resulted in higher screening compared to other interventions. A previous systematic review and meta-analysis reported self-sampling is more effective in increasing screening participation than traditional Pap testing in women generally [14]. Various barriers to screening common among immigrant women, such as modesty, religious reasons, and female HCP preference favour usage of HPV self-sampling in this population [72]. Similarly, HCP involvement significantly improved screening uptake, although few studies of interventions targeting HCP behaviours have been carried out. Interventions aimed at HCPs alongside the women could be important in enhancing screening uptake as suggested for other cancers [73]. The systematic review also reported the advantage of use of specialised clinics to reach immigrant women and enhance their screening uptake. Although meta-analysis could not be performed due to lack of eligible studies, a previous meta-analysis indicated specialised clinics to be strongly effective in increasing immunisation and cancer screening uptake among adults [74]. Likewise, cultural appropriateness is important when dealing with individuals of immigrant background, with availability of materials in the women’s native language being critical. All studies in this review used the same languages as that of the participants and often involved lay community health workers, such as Promotoras; this personalised approach was effective in the meta-analysis. Therefore, policies designed to address cervical screening services and interventions for migrants should take into consideration relevance of cultural responsiveness when including components such as information provision, navigation as well as financial incentives.
Another interesting finding from the systematic review was higher screening uptake rates when outcomes were assessed objectively rather than through self-report, although meta-analysis did not report statistically significant difference among the two groups, A possible explanation could be greater reliability of clinical records which can be obtained without the need of follow-up of each individual participant, reducing the non-response bias.
None of the included study reported cost-effectiveness of the intervention used, it is recommended to include this outcome in future studies. This would be of high practical value, allowing the policymakers to understand the choice of intervention, including of HPV self-sampling method. A recent systematic review of studies assessing cost of HPV self-sampling compared to standard screening strategies, reported it to be highly cost-effective for under screened women in high income countries, either when offered alone or in combination with other strategies [75]. Furthermore, effect of certain variable of interest, age and such as length of stay of participants in the country, could be explored through meta-regression in future studies.
In conclusion, this review identified a large number of studies, that have evaluated interventions to increase uptake of cervical screening amongst immigrant women. The findings suggest that interventions with multifaceted, culturally sensitive components, addressing practical challenges and including HPV self-sampling modality, could lead to significant increase in cervical screening participation among immigrant women. Review findings also suggest that using multiple channels to communicate with the target audience is the next most important feature of a likely successful intervention strategy. However, due to substantial heterogeneity observed in the meta-analysis results, intervention effects need to be interpreted cautiously. There is opportunity to study interventions that involve trusted HCPs [76, 77]. We recommend future research on this topic adopts robust study designs to improve the quality of the studies and avoid potential contamination. Theoretically guided interventions, targeted in their approach to ensure recruitment of women who could benefit most from an intervention, are recommended.
Supporting information
S1 File. Published PROSPERO protocol for the systematic review and meta-analysis.
https://doi.org/10.1371/journal.pone.0281976.s001
(PDF)
S1 Fig. Forest plots showing sub-group analysis for cervical screening intervention studies included in the meta-analysis.
https://doi.org/10.1371/journal.pone.0281976.s002
(DOCX)
S1 Table. PRISMA 2020 checklist as used in the review process.
https://doi.org/10.1371/journal.pone.0281976.s003
(DOCX)
S2 Table. Search strategy as used in different databases.
https://doi.org/10.1371/journal.pone.0281976.s004
(DOCX)
S3 Table. Quality appraisal of studies included in the systematic review.
https://doi.org/10.1371/journal.pone.0281976.s005
(DOCX)
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