Placeholder image for staff profiles

Dr Jose Marcano-Belisario


Research Fellow in Digital Health
PhD, MPH, BSc, MBBS

Biography

My qualifications

2019
PhD: use of mobile phone technology for the assessment of mood during pregnancy
Imperial College London
2011
Master of Public Health (MPH) with Distinction
Imperial College London
2010
BSc Psychology (First Class)
Goldsmiths College, University of London
2004
MBBS
Central University of Venezuela

Previous roles

01 June 2017 - 13 April 2018
Senior Systematic Reviewer working on the development of NICE clinical guidelines dealing with women's health, cancer and social care topics
National Guideline Alliance, Royal College of Obstetricians and Gynaecologists
04 October 2011 - 13 January 2017
Research assistant in Digital Health/eHealth
Imperial College London

Research

Research interests

My publications

Publications

Marcano-Belisario José S., Gupta Ajay, O?Donoghue John, Ramchandani Paul, Morrison Cecily, Car Josip (2017) Implementation of depression screening in antenatal clinics through tablet computers: results of a feasibility study,BMC Medical Informatics and Decision Making 17 (1) BioMed Central Ltd

Background:

Mobile devices may facilitate depression screening in the waiting area of antenatal clinics. This can
present implementation challenges, of which we focused on survey layout and technology deployment.

Methods:

We assessed the feasibility of using tablet computers to administer a socio-demographic survey, the
Whooley questions and the Edinburgh Postnatal Depression Scale (EPDS) to 530 pregnant women attending
National Health Service (NHS) antenatal clinics across England. We randomised participants to one of two layout
versions of these surveys: (i) a scrolling layout where each survey was presented on a single screen; or (ii) a paging layout where only one question appeared on the screen at any given time.

Results:

Overall, 85.10% of eligible pregnant women agreed to take part. Of these, 90.95% completed the study procedures. Approximately 23% of participants answered Yes to at least one Whooley question, and approximately 13% of them scored 10 points of more on the EPDS. We observed no association between survey layout and the responses given to the Whooley questions, the median EPDS scores, the number of participants at increased risk of
self-harm, and the number of participants asking for technical assistance. However, we observed a difference in the number of participants at each EPDS scoring interval (p = 0.008), which provide an indication of a woman?s risk of
depression. A scrolling layout resulted in faster completion times (median = 4 min 46 s) than a paging layout
(median = 5 min 33 s) (p = 0.024). However, the clinical significance of this difference (47.5 s) is yet to be
determined.

Conclusions:

Tablet computers can be used for depression screening in the waiting area of antenatal clinics. This requires the careful consideration of clinical workflows, and technology-related issues such as connectivity and security. An association between survey layout and EPDS scoring intervals needs to be explored further to determine if it corresponds to a survey layout effect. Future research needs to evaluate the effect of this type of antenatal depression screening on clinical outcomes and clinic workflows.

Doherty Kevin, Barry Marguerite, Marcano-Belisario Jose, Arnaud Bérenger, Morrison Cecily, Car Josip, Doherty Gavin (2018) A Mobile App for the Self-Report of Psychological Well-Being During Pregnancy (BrightSelf): Qualitative Design Study.,JMIR Mental Health 5 (4) JMIR Publications

Background:

Maternal mental health impacts both parental well-being and childhood development. In the United Kingdom, 15% of women are affected by depression during pregnancy or within 1 year of giving birth. Suicide is a leading cause of perinatal maternal mortality, and it is estimated that >50% of perinatal depression cases go undiagnosed. Mobile technologies are potentially valuable tools for the early recognition of depressive symptoms, but complex design challenges must be addressed to enable their use in public health screening.

Objective:

The aim of this study was to explore the issues and challenges surrounding the use of mobile phones for the self-report of psychological well-being during pregnancy.

Methods:

This paper presents design research carried out as part of the development of BrightSelf, a mobile app for the self-report of psychological well-being during pregnancy. Design sessions were carried out with 38 participants, including pregnant women, mothers, midwives, and other health professionals. Overall, 19 hours of audio were fully transcribed and used as the basis of thematic analysis.

Results:

The study highlighted anxieties concerning the pregnancy journey, challenges surrounding current approaches to the appraisal of well-being in perinatal care, and the midwife-patient relationship. Designers should consider the framing of perinatal mental health technologies, the experience of self-report, supporting self-awareness and disclosure, providing value to users through both self-report and supplementary features, and designing for longitudinal engagement.

Conclusions:

This study highlights the needs, motivations, and anxieties of women with respect to technology use in pregnancy and implications for the design of mobile health technologies.

Marcano-Belisario José S, Gupta Ajay K, O'Donoghue John, Morrison Cecily, Car Josip (2016) Tablet computers for implementing NICE antenatal mental health guidelines: protocol of a feasibility study,BMJ Open 6 (1) BMJ Publishing Group Limited

Introduction

Depression is one of the most common mental health disorders that may affect women during pregnancy. The prompt identification of this disorder, and the provision of treatment, may help to reduce the likelihood of post-partum depression, prevent severe forms of the disease, and reduce its intergenerational impact. Despite women's repeated encounters with health services throughout their antenatal care, depression often goes undiagnosed. This is one area where mobile health could prove useful. We will assess the feasibility of using tablets to incorporate depression screening into antenatal pathways. We will also assess if survey layout could affect the quality of the data collected through these devices.

Methods and analysis

We will test the feasibility of using iPad Airs for the administration of the Whooley questions and the Edinburgh Postnatal Depression Scale (EPDS) to pregnant women attending antenatal clinics in England. We will assess the impact of survey layout on the quality of the responses given to these screening scales using a parallel, randomised controlled study design. We will calculate the positive predictive value, the negative predictive value and the false omission rate of the Whooley questions in comparison with the EPDS. We will calculate differences in data equivalence, time needed to complete the surveys, break-off rates, data completeness and requests for help between the 2 experimental groups: using all questions in one screen and navigation by vertical scrolling, or a single question per screen and navigation by multiple pages.

Ethics and dissemination

This study has been approved by the National Research Ethics Service Committee South East Coast?Surrey. Our findings will be disseminated through academic peer-reviewed publications, conferences and discussion with peers.

Green S. A., Poots A. J., Marcano-Belisario J., Samarasundera E., Green J., Honeybourne E., Barnes R. (2013) Mapping mental health service access: achieving equity through quality improvement.,JOURNAL OF PUBLIC HEALTH 35 (2) pp. 286-292 OXFORD UNIVERSITY PRESS

Background

Improving access to psychological therapies (IAPTs) services deliver evidence-based care to people with depression and anxiety. A quality
improvement (QI) initiative was undertaken by an IAPT service to improve referrals providing an opportunity to evaluate equitable access.

Methods

QI methodologies were used by the clinical team to improve referrals to the service. The collection of geo-coded data allowed
referrals to be mapped to small geographical areas according to deprivation.

Results

A total of 6078 patients were referred to the IAPT service during the period of analysis and mapped to120 unique lower super output
areas (LSOAs). The average weekly referral rate rose from 17 during the baseline phase to 43 during the QI implementation phase. Spatial
analysis demonstrated all 15 of the high deprivation/low referral LSOAs were converted to high deprivation/high or medium referral LSOAs
following the QI initiative.

Conclusion

This work highlights the importance of QI in developing clinical services aligned to the needs of the population through the
analysis of routine data matched to health needs. Mapping can be utilized to communicate complex information to inform the planning and
organization of clinical service delivery and evaluate the progress and sustainability of QI initiatives.

Marcano Belisario Jose S, Bruggeling Michelle N, Gunn Laura H, Brusamento Serena, Car Josip (2012) Interventions for recruiting smokers into cessation programmes,The Cochrane Library Wiley
Background:

Tobacco control is a top public health priority around the globe due to the high prevalence of cigarette smoking and its associated morbidity and mortality. Much effort has been focused on establishing the effectiveness of different smoking cessation strategies. This review, however, aims to address the initial challenge faced by smoking cessation programmes: recruitment of smokers.

Objective:
The primary objective of this review was to determine the effectiveness of different strategies for recruiting smokers into cessation programmes. The secondary objective was to determine the impact that these strategies had on smoking cessation rates at least six months after enrolment into a cessation programme

Search methods:
We searched the specialised register of the Cochrane Tobacco Addiction Group using a search strategy which included the terms ?recruit$?, ?invit$?, ?enter?, ?entry?, ?enrolment?) combined with (?smok$?, ?cigarette?, ?smoking cessation?, ?tobacco?) in the title, abstract
or keyword fields. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and registers of current and ongoing trials. We also searched the reference lists of included studies.

Selection criteria
We included randomised controlled trials and cluster randomised controlled trials that compared at least two different methods of recruiting current smokers into a smoking cessation programme. We also included those studies which focused on the effectiveness of a smoking cessation programme as long as the study involved multiple recruitment methods and reported results of the recruitment
phase.

Data collection and analysis:
From each included study, we extracted data on the type of participants, type of recruitment strategies (i.e., setting, mode of communication used, intensity and duration) and comparisons, and on randomisation, allocation concealment, and blinding procedures. Our primary outcome was the proportion of smokers successfully recruited to each cessation programme compared to alternative
modalities of recruitment. Our secondary outcome was smoking cessation for at least six months. Given the substantial heterogeneity across recruitment interventions and participants, we adopted a narrative synthesis approach for summarising results.

Main results:
This review includes 19 studies with a total of 14,890 participants. We categorised the included studies according to the modes used to deliver the recruitment strategy: head to head comparison of individual recruitment strategies; comparison of the same delivery mode but with different content or intensity; and the addition of another mode to an existing recruitment method.

We identified three studies that made head-to-head comparisons of different types of recruitment strategies. Of these, only one study detected a significant effect, finding that a personal phone call was more effective than a generic invitation letter (RR 40.73, 95%
CI 2.53 to 654.74). Five studies compared interventions using the same delivery modes but different content. Results showed that tailored messages through an interactive voice response system resulted in a higher recruitment rate than assessment of smoking status
alone using the same system (RR 8.64, 95% CI 4.41 to 16.93), and that text messages indicating scarcity of places available were more effective than generic text message reminders (RR 1.45, 95% CI 1.07 to 1.96). One study compared interventions using the same delivery mode but different intensity and found that allowing for more phone call attempts to reach potential participants can result in
better recruitment (RR 1.87, 95% CI 1.61 to 2.18). Finally, 10 studies investigated the effect of adding a recruitment mode to existing recruitment strategies. Findings showed that: adding a text message reminder or real quotes from participants

Barry Marguerite, Doherty Kevin, Marcano Belisario Jose, Car Josip, Morrison Cecily, Doherty Gavin (2017) mHealth for Maternal Mental Health.,CHI '17 Proceedings of the 2017 CHI Conference on Human Factors in Computing Systems pp. 2708-2756 ACM Publications
Health and wellbeing applications increasingly raise ethical
issues for design. User-centred and participatory design
approaches, while grounded in everyday wisdom, cannot be
expected to address ethical reflection consistently, as
multiple value systems come into play. We explore the
potential of phronesis, a concept from Aristotelian virtue
ethics, for mHealth design. Phronesis describes wisdom and
judgment garnered from practical experience of specific
situations in context. Applied phronesis contributes
everyday wisdom to challenging issues for vulnerable target
users. Drawing on research into mHealth technologies for
psychological wellbeing, we explore how phronesis can
inform ethical design. Using a case study on an app for selfreporting symptoms of depression during pregnancy, we
present a framework for incorporating a phronetic approach
into design, involving: (a) a wide feedback net to capture
phronetic input early in design; (b) observing the order of
feedback, which directly affects value priorities in design;
(c) ethical pluralism recognising different coexisting value
systems; (d) acknowledging subjectivity in the disclosure
and recognition of individual researcher and participant
values. We offer insights into how a phronetic approach can
contribute everyday wisdom to designing mHealth technologies to help designers foster the values that
promote human flourishing.
Marcano Belisario José S, Huckvale Kit, Greenfield Geva, Car Josip, Gunn Laura H (2013) Smartphone and tablet self management apps for asthma,The Cochrane Library Wiley

Background

Asthma is one of the most common long-term conditions worldwide, which places considerable pressure on patients, communities
and health systems. The major international clinical guidelines now recommend the inclusion of self management programmes in
the routine management of patients with asthma. These programmes have been associated with improved outcomes in patients with
asthma. However, the implementation of self management programmes in clinical practice, and their uptake by patients, is still poor.
Recent developments in mobile technology, such as smartphone and tablet computer apps, could help develop a platform for the
delivery of self management interventions that are highly customisable, low-cost and easily accessible.

Objectives

To assess the effectiveness, cost-effectiveness and feasibility of using smartphone and tablet apps to facilitate the self management of
individuals with asthma.

Search methods

We searched the Cochrane Airways Group Register (CAGR), the Cochrane Central Register of Controlled Trials (CENTRAL),
MEDLINE, EMBASE, PsycINFO, CINAHL, GlobalHealth Library, Compendex/Inspec/Referex, IEEEXplore, ACMDigital Library,
CiteSeerx and CAB abstracts via Web of Knowledge. We also searched registers of current and ongoing trials and the grey literature.
We checked the reference lists of all primary studies and review articles for additional references. We searched for studies published
from 2000 onwards. The latest search was run in June 2013.

Selection criteria

We included parallel randomised controlled trials (RCTs) that compared self management interventions for patients with cliniciandiagnosed
asthma delivered via smartphone apps to self management interventions delivered via traditional methods (e.g. paper-based
asthma diaries).

Data collection and analysis

We used standard methods expected by the Cochrane Collaboration. Our primary outcomes were symptom scores; frequency of
healthcare visits due to asthma exacerbations or complications and health-related quality of life.

Main results

We included two RCTs with a total of 408 participants. We found no cluster RCTs, controlled before and after studies or interrupted
time series studies that met the inclusion criteria for this systematic review. Both RCTs evaluated the effect of a mobile phone-based
asthma self management intervention on asthma control by comparing it to traditional, paper-based asthma self management. One
study allowed participants to keep daily entries of their asthma symptoms, asthma medication usage, peak flow readings and peak flow
variability on their mobile phone, from which their level of asthma control was calculated remotely and displayed together with the
corresponding asthma self management recommendations. In the other study, participants recorded the same readings twice daily, and
they received immediate selfmanagement feedback in the form of a three-colour traffic light display on their phones. Participants falling
into the amber zone of their action plan twice, or into the red zone once, received a phone call from an asthma nurse who enquired
about the reasons for their uncontrolled asthma.
We did not conduct a meta-analysis of the data extracted due to the considerable degree of heterogeneity between these studies. Instead
we adopted a narrative synthesis approach. Overall, the results were inconclusive and we judged the evidence to have a GRADE rating
of low quality because further evidence is very likely to have an important impact on our confidence in the estimate of effect and is
likely to change the estimate. In addition, there was not enough information in one of the included studies to assess the risk of bias for
themajority of the domains. Although the other included study was methodologically rigorous, it was not possible to blind participants
or personnel in the study. Moreover, there are concerns in both studies in relation to

George Pradeep Paul, Papachristou Nikos, Belisario José Marcano, Wang Wei, Wark Petra A, Cotic Ziva, Rasmussen Kristine, Sluiter René, Riboli?Sasco Eva, Car Lorainne Tudor, Musulanov Eve Marie, Molina Joseph Antonio, Heng Bee Hoon, Zhang Yanfeng, Wheeler Erica Lynette, Al Shorbaji Najeeb, Majeed Azeem, Car Josip (2014) Online eLearning for undergraduates in health professions: A systematic review of the impact on knowledge, skills, attitudes and satisfaction.,Journal of Global Health 4 (1) Edinburgh University Global Health Society

Background

Health systems worldwide are facing shortages in health professional workforce. Several studies have demonstrated the direct correlation between the availability of health workers, coverage of health services, and population health outcomes. To address this shortage, online eLearning is increasingly being adopted in health professionals? education. To inform policy?making, in online eLearning, we need to determine its effectiveness.

Methods

We performed a systematic review of the effectiveness of online eLearning through a comprehensive search of the major databases for randomised controlled trials that compared online eLearning to traditional learning or alternative learning methods. The search period was from January 2000 to August 2013. We included articles which primarily focused on students' knowledge, skills, satisfaction and attitudes toward eLearning and cost-effectiveness and adverse effects as secondary outcomes. Two reviewers independently extracted data from the included studies. Due to significant heterogeneity among the included studies, we presented our results as a narrative synthesis.

Findings

Fifty?nine studies, including 6750 students enrolled in medicine, dentistry, nursing, physical therapy and pharmacy studies, met the inclusion criteria. Twelve of the 50 studies testing knowledge gains found significantly higher gains in the online eLearning intervention groups compared to traditional learning, whereas 27 did not detect significant differences or found mixed results. Eleven studies did not test for differences. Six studies detected significantly higher skill gains in the online eLearning intervention groups, whilst 3 other studies testing skill gains did not detect differences between groups and 1 study showed mixed results. Twelve studies tested students' attitudes, of which 8 studies showed no differences in attitudes or preferences for online eLearning. Students' satisfaction was measured in 29 studies, 4 studies showed higher satisfaction for online eLearning and 20 studies showed no difference in satisfaction between online eLearning and traditional learning. Risk of bias was high for several of the included studies.

Conclusion

The current evidence base suggests that online eLearning is equivalent, possibly superior to traditional learning. These findings present a potential incentive for policy makers to cautiously encourage its adoption, while respecting the heterogeneity among the studies.

Marcano Belisario Jose Salvador, Doherty Kevin, O'Donoghue John, Ramchandani Paul, Majeed Azeem, Doherty Gavin, Morrison Cecily, Car Josip (2017) A bespoke mobile application for the longitudinal assessment of depression and mood during pregnancy: protocol of a feasibility study,BMJ Open 7 (5) BMJ Publishing Group Ltd

Introduction

Depression is a common mental health disorder during pregnancy, with important consequences for mothers and their children. Despite this, it goes undiagnosed and untreated in many women attending antenatal care. Smartphones could help support the prompt identification of antenatal depression in this setting. In addition, these devices enable the implementation of ecological momentary assessment techniques, which could be used to assess how mood is experienced during pregnancy. With this study, we
will assess the feasibility of using a bespoke mobile
application (app) running on participants? own handsets for
the longitudinal (6 months) monitoring of antenatal mood
and screening of depression.

Methods and analysis

We will use a randomised controlled study design to compare two types of assessment strategies: retrospective + momentary (consisting of the Edinburgh Postnatal Depression Scale plus five momentary and two contextual questions),
and retrospective (consisting of the Edinburgh Postnatal
Depression Scale only). We will assess the impact that these strategies have on participant adherence to a prespecified sampling protocol, dropout rates and timeliness of data completion. We will evaluate differences in acceptance of the technology through a short quantitative survey and open-ended questions. We will also assess the potential effect that momentary assessments could have on retrospective data. We will attempt to identify any patterns in app usage through the analysis of log data.

Ethics and dissemination

This study has been reviewed and approved by the National Research Ethics Service Committee South East Coast?Surrey on 15 April 2016 as a notice of substantial amendment to the original submission (9 July 2015) under the Research Ethics Committee (REC) reference 15/LO/0977. This study is being sponsored by Imperial College London under the reference number 15IC2687 and has been included in
the UK Clinical Research Network Study Portfolio under
the Central Portfolio Management System number 19280.
The findings of this study will be disseminated through
academic peer-reviewed publications, poster presentations
and abstracts at academic and professional conferences,
discussion with peers, and social media. The findings of
this study will also inform the PhD theses of JSMB and KD.

Rasmussen Kristine, Belisario José Marcano, Wark Petra A, Molina Joseph Antonio, Loong Stewart Lee, Cotic Ziva, Papachristou Nikolaos, Riboli?Sasco Eva, Car Lorainne Tudor, Musulanov Eve Marie, Kunz Holger, Zhang Yanfeng, George Pradeep Paul, Heng Bee Hoon, Wheeler Erica Lynette, Al Shorbaji Najeeb, Svab Igor, Atun Rifat, Majeed Azeem, Car Josip (2014) Offline eLearning for undergraduates in health professions: A systematic review of the impact on knowledge, skills, attitudes and satisfaction.,Journal of Global Health 4 (1) Edinburgh University Global Health Society
Background:

The world is short of 7.2 million health?care workers and this figure is growing. The shortage of teachers is even greater, which limits traditional education modes. eLearning may help overcome this training need. Offline eLearning is useful in remote and resource?limited settings with poor internet access. To inform investments in offline eLearning, we need to establish its effectiveness in terms of gaining knowledge and skills, students? satisfaction and attitudes towards eLearning.

Methods:

We conducted a systematic review of offline eLearning for students enrolled in undergraduate, health?related university degrees. We included randomised controlled trials that compared offline eLearning to traditional learning or an alternative eLearning method. We searched the major bibliographic databases in August 2013 to identify articles that focused primarily on students? knowledge, skills, satisfaction and attitudes toward eLearning, and health economic information and adverse effects as secondary outcomes. We also searched reference lists of relevant studies. Two reviewers independently extracted data from the included studies. We synthesized the findings using a thematic summary approach.

Findings:

Forty?nine studies, including 4955 students enrolled in undergraduate medical, dentistry, nursing, psychology, or physical therapy studies, met the inclusion criteria. Eleven of the 33 studies testing knowledge gains found significantly higher gains in the eLearning intervention groups compared to traditional learning, whereas 21 did not detect significant differences or found mixed results. One study did not test for differences. Eight studies detected significantly higher skill gains in the eLearning intervention groups, whilst the other 5 testing skill gains did not detect differences between groups. No study found offline eLearning as inferior. Generally no differences in attitudes or preference of eLearning over traditional learning were observed. No clear trends were found in the comparison of different modes of eLearning. Most of the studies were small and subject to several biases.

Conclusions:

Our results suggest that offline eLearning is equivalent and possibly superior to traditional learning regarding knowledge, skills, attitudes and satisfaction. Although a robust conclusion cannot be drawn due to variable quality of the evidence, these results justify further investment into offline eLearning to address the global health care workforce shortage.

Marcano Belisario José S, Jamsek Jan, Huckvale Kit, O'Donoghue John, Morrison Cecily P, Car Josip (2015) Comparison of self-administered survey questionnaire responses collected using mobile apps versus other methods,The Cochrane Library Wiley
Background:
Self-administered survey questionnaires are an important data collection tool in clinical practice, public health research and epidemiology. They are ideal for achieving a wide geographic coverage of the target population, dealing with sensitive topics and are less resource intensive than other data collection methods. These survey questionnaires can be delivered electronically, which can maximise the scalability and speed of data collection while reducing cost. In recent years, the use of apps running on consumer smart devices (i.e., smartphones and tablets) for this purpose has received considerable attention. However, variation in the mode of delivering a survey questionnaire could affect the quality of the responses collected.

Objectives:
To assess the impact that smartphone and tablet apps as a delivery mode have on the quality of survey questionnaire responses compared to any other alternative delivery mode: paper, laptop computer, tablet computer (manufactured before 2007), short message service (SMS) and plastic objects.

Search methods:
We searched MEDLINE, EMBASE, PsycINFO, IEEEXplore, Web of Science, CABI: CAB Abstracts, Current Contents Connect,
ACM Digital, ERIC, Sociological Abstracts, Health Management Information Consortium, the Campbell Library and CENTRAL. We also searched registers of current and ongoing clinical trials such as ClinicalTrials.gov and the World Health Organization (WHO)International Clinical Trials Registry Platform. We also searched the grey literature in OpenGrey, Mobile Active and ProQuest Dissertation & Theses. Lastly, we searched Google Scholar and the reference lists of included studies and relevant systematic reviews. We
performed all searches up to 12 and 13 April 2015.

Selection criteria:
We included parallel randomised controlled trials (RCTs), crossover trials and paired repeated measures studies that compared the electronic delivery of self-administered survey questionnaires via a smartphone or tablet app with any other delivery mode. We included data obtained from participants completing health-related self-administered survey questionnaire, both validated and non-validated. We also included data offered by both healthy volunteers and by those with any clinical diagnosis. We included studies that reported any of the following outcomes: data equivalence; data accuracy; data completeness; response rates; differences in the time taken to complete a survey questionnaire; differences in respondent?s adherence to the original sampling protocol; and acceptability to respondents of the delivery mode. We included studies that were published in 2007 or after, as devices that became available during this time are compatible with the mobile operating system (OS) framework that focuses on apps.

Data collection and analysis:
Two review authors independently extracted data from the included studies using a standardised form created for this systematic review in REDCap. They then compared their forms to reach consensus. Through an initial systematic mapping on the included studies, we identified two settings in which survey completion took place: controlled and uncontrolled. These settings differed in terms of (i)
the location where surveys were completed, (ii) the frequency and intensity of sampling protocols, and (iii) the level of control over potential confounders (e.g., type of technology, level of help offered to respondents).We conducted a narrative synthesis of the evidence because a meta-analysis was not appropriate due to high levels of clinical and methodological diversity. We reported our findings for each outcome according to the setting in which the studies were conducted.

Main results:
We included 14 studies (15 records) with a total of 2275 participants; although we included only 2272 participants in the final analyses as there were missing data for three participants from one included study. Regarding data equivalence, in both controlled and u