Access, acceptance and adherence to cancer prehabilitation: a mixed‑methods systematic review

Purpose The purpose of this systematic review is to better understand access to, acceptance of and adherence to cancer prehabilitation. Methods MEDLINE, CINAHL, PsychINFO, Embase, Physiotherapy Evidence Database, ProQuest Medical Library, Cochrane Library, Web of Science and grey literature were systematically searched for quantitative, qualitative and mixed-methods studies published in English between January 2017 and June 2023. Screening, data extraction and critical appraisal were conducted by two reviewers independently using Covidence™ systematic review software. Data were analysed and synthesised thematically to address the question ‘What do we know about access, acceptance and adherence to cancer pre-habilitation, particularly among socially deprived and minority ethnic groups?’ The protocol is published on PROSPERO CRD42023403776 Results Searches identified 11,715 records, and 56 studies of variable methodological quality were included: 32 quantitative, 15 qualitative and nine mixed-methods. Analysis identified facilitators and barriers at individual and structural levels, and with interpersonal connections important for prehabilitation access, acceptance and adherence. No study reported analysis of facilitators and barriers to prehabilitation specific to people from ethnic minority communities. One study described health literacy as a barrier to access for people from socioeconomically deprived communities. Conclusions There is limited empirical research of barriers and facilitators to inform improvement in equity of access to cancer prehabilitation.


Introduction
Prehabilitation is a core component of supportive care for health and well-being during cancer survivorship.It aims to improve cancer treatment outcomes and longterm health by preparing people awaiting cancer treatments, not only surgery, through support for physical activity, nutrition and emotional well-being either alone or in combination, and from the point of diagnosis [1].Growing international evidence indicates that, in specific cancers, engagement with either uni or multimodal prehabilitation interventions can improve individuals' pre-treatment functional capacity [2,3], reduce treatment-related complications [4][5][6], ease anxiety [7] and enhance post-treatment recovery [8,9].As the evidence base develops and momentum for prehabilitation grows, the need to embed prehabilitation as the standard of care across different cancers has been recognised [10][11][12].In some regions, multimodal prehabilitation is now offered as the standard of care in certain cancers, particularly lung [13] and colorectal [14].
Internationally, there are persistent health disparities following cancer treatment.Treatment and survival outcomes are poor among people from socioeconomically deprived communities and some minority ethnic groups compared to socioeconomically advantaged and majority groups [15][16][17].To ease the overall social and economic impact of cancer on individuals and society, and to reduce the societal and healthcare costs of suboptimal treatment outcomes, it is important to identify the facilitators of and barriers to individuals' engagement with interventions.People from socioeconomically deprived communities and some minority ethnic groups are known to be underserved in prehabilitation interventions [1,18].Accordingly, to better understand reasons for informed action, this mixed-methods systematic review aims to identify, critically appraise and synthesise international empirical evidence of the facilitators of and barriers to access, acceptance and adherence of cancer prehabilitation.For this review, prehabilitation is defined as proactive and preventative for all cancer treatments (not only surgery and including neoadjuvant) and includes interventions to support physical activity, nutritional intake or psychological well-being, alone or together, carried out at any time before a course of treatment begins.

Database searches
In collaboration with a specialist health service systematic review librarian, the search strategy was developed using medical subject headings (MeSH) and keywords including and relating to cancer, prehabilitation, inequity, inequality, socioeconomic deprivation, ethnic groups and health services accessibility, and then tested and refined.The electronic databases Ovid SP MEDLINE, CINAHL via EBSCO host, PsycINFO, Ovid SP EMBASE, Ovid Emcare, Allied and Complementary Medicine (AMED), Physiotherapy Evidence Database (PEDRo) and Cochrane Central were systematically searched by EG for studies published in English between January 2017 and May 2023.The search strategy was tailored for each database and detailed in online resource (Supplementary information 1).Supplementary searches of grey literature using the Overton, Dimensions and Proquest dissertation and theses databases (PQDT), and relevant organisational websites were conducted.Reference lists of papers retrieved for full review were scrutinised for potentially useful papers not identified through the database searches.

Selection criteria
The PICO framework was used to guide inclusion criteria on population (P), Intervention (I), comparators (C) and outcomes (O) and context (Co).It enabled identification of primary qualitative, quantitative and mixed-methods research studies about prehabilitation, published in peer-reviewed journals.Eligibility criteria were used during study selection to screen this body of literature for empirical data about barriers and facilitators of prehabilitation.Non-empirical, opinion pieces, theoretical and methodological articles, reviews and editorials were excluded, as were studies involving children, adolescents and focusing on end-of-life care.

Study selection
All search results were stored in Endnote™.Following deduplication, results were imported into Covidence™ systematic review management software.For study selection, standardised systematic review methods [22] were used.All project team members were involved in study screening and selection.Firstly, two reviewers independently screened all returned titles and abstracts.Based on eligibility and relevance, these were sifted into 'yes', 'no' or 'maybe' categories.Disagreements were resolved by a third reviewer.Where a definite decision could not be made, full text was retrieved and assessed.Secondly, full text of all potentially relevant abstracts was retrieved and independently assessed for inclusion by two reviewers against the eligibility criteria.Arbitration by an independent reviewer in the event of disagreement was not required at this stage.Reasons for exclusion at full text review were recorded.

Quality assessment
Two reviewers independently assessed the quality of included studies via Covidence ™ using the Mixed Methods Appraisal Tool (MMAT) version 18 [23].The MMAT was constructed specifically for quality appraisal in mixed studies reviews and is widely used [23,24].Within a single tool, Version 18 of the MMAT can be used to appraise the methodological quality of five broad categories of study design, namely qualitative, randomised controlled trials, non-randomised, quantitative descriptive and mixed methods studies.The MMAT comprises two screening questions to establish whether or not the quality appraisal should proceed and 25 core questions: five criteria which mostly relate to the appropriateness of study design and approaches to sampling, data collection and analysis relevant to each of the five study designs [23].Each criterion is assessed as being met (Yes) or not (No).There is also scope to indicate uncertainty.A third reviewer independently moderated all quality assessments for accuracy.

Data extraction
Two reviewers independently extracted data systematically via Covidence™ using an adapted, piloted JBI mixed-methods data extraction form.Information extracted included study author, aim, year and country of publication, setting, intervention type, design, sample, data collection, analysis, data relating to prehabilitation facilitators and barriers and, as relevant, data on intervention for support of access, acceptance or adherence to prehabilitation.A third reviewer cross-checked the data extraction tables independently for accuracy and completeness.

Data synthesis and integration
All extracted findings were imported into Microsoft Excel.Quantitative data were 'qualitised' into textual descriptions of quantitative results to enable assimilation with qualitative data [25].To analyse and synthesise all findings, thematic synthesis [26,27] was used.Thematic analysis is an established process involving the identification and development of patterns and analytic themes in primary research data.Two reviewers coded the findings and then grouped related codes into preliminary descriptive themes which captured patterns across the data describing barriers to and facilitators of cancer prehabilitation [26].Preliminary themes were discussed with a third reviewer.Themes were then further combined and synthesised to generate three overarching analytical themes relative to the review question [26].

Results
Figure 1 shows the PRISMA flow chart of search results.Following the first and second round screening, 56 papers published between 2017 and 2023 were included: 33 quantitative; 14 qualitative and nine mixed methods.
A synopsis of study characteristics and the quality appraisal outcomes is found in Table 1.Brief narrative summaries of the included papers' findings of relevance to the review question, namely access, acceptance and adherence of prehabilitation interventions, are provided in the online supplementary information (supplementary information 2).

Study characteristics
Of the 32 quantitative studies reviewed, there were eight randomised controlled trials, two single-arm multi-centre trials, seven cohort studies and one cross-sectional survey.Others were pilot (n = 3), feasibility (n = 7), observational (n = 1) and prevalence (n = 1) studies, with one non-randomised trial and one audit.Qualitative studies (n = 15) mainly used a broad qualitative approach (n = 12), one used phenomenology, one participatory action research and one used a cross-sectional survey.Nine studies used mixed methods.

Methodological quality
There was considerable variation in the methodological quality of the 56 studies included.Twelve studies, 10 qualitative and two quantitative, satisfied all the MMAT criteria [23].Fourteen studies, nine mixed methods, two qualitative and three quantitative, satisfied just one or two criteria.Thus, data were extracted from a body of literature where one-fifth (21%) of publications were about research of the highest quality, defined as having met 100% of the MMAT criteria [23].Detailed results of the MMAT quality assessments are found in supplementary information (supplementary information 3).

Thematic synthesis
The thematic synthesis identified three cross-cutting analytic themes.As illustrated in Figure 2      structural for access to, acceptance of and adherence to prehabilitation.

Theme 1. The influence of individual drivers of cancer prehabilitation engagement
Factors at the level of the individual were found to shape prehabilitation access, acceptance and adherence.These included perceived need and benefits, motivations, health status and everyday practicalities.
The perceived need for and potential benefits of prehabilitation A key stimulus for accessing and adhering to cancer prehabilitation was a belief that engagement might confer benefit.Influences included clinicians' prehabilitation endorsement and encouragement [12,13,42,52,55,59,60,65,66,71], positive prior personal experiences of routine physical activities [60,69,70,77] and weight loss programmes [77], other patients' support [12,71] and the perceived need to improve personal fitness [60,63].Some participants in UK-based studies believed they had a social responsibility to engage in prehabilitation [63,64] as enhanced fitness would benefit healthcare services financially [12,64].
The money, the cost per night in the hospital, goodness knows how much that costs and the follow-up with all the doctors, the dieticians and everyone else behind (….).It's (prehabilitation) saving the NHS thousands and thousands of pounds of money ([64] p.4).
Several studies indicated some individuals perceived prehabilitation to be beneficial in that interventions provided a welcome distraction from their illness and situation [64,72,74].Benefit was understood in terms of being psychologically and physically prepared for cancer treatments, potentially enhancing post-treatment recovery and survival [12, 55, 60, 63, 64, 66-68, 70, 71, 74].
I benefited a lot from it because it caught me in that time just after diagnosis when things were pretty scary and pretty awful and I felt like it was one of the key pieces of my plan for positivity during this whole thing, because it was setting a tone for recovery ([74] p. 8) Yet, it was also clear that some individuals were disinterested in engaging with prehabilitation [56,58,66,74,80].Some studies suggested a connection between imminent surgery and patients' perceptions of little benefit of prehabilitation in the short timescales [47,54,63,69,77,79].Some individuals felt that making additional hospital visits for prehabilitation was onerous [54].Others were unaccustomed to or did not want to exercise [36,70] or perceived exercise as demanding [41], particularly when combined with cancer treatment [51].Some considered their existing fitness levels [61,63] and diet [61] sufficient.A sense of low perceived benefit of or need for prehabilitation meant it was considered a low priority [36].[71,77] conjoined with the desire to improve fitness [63,64,72], survive surgery [63,64] and to be present for and enjoy their families [64] were influential motivators for individuals' proactively effecting lifestyle change and thus engagement with prehabilitation.Having accessed prehabilitation, exercise logs and diaries [64,68,74], personal goal setting [61,64,71], progress self-monitoring [61, Fig. 2 Overarching themes 64,68,71,77], activity tracking and objective feedback [56,60] motivated individuals to maintain participation.They inspired them to remain on track, enabled them to realise their progress, build self-efficacy for prehabilitation adherence [60,70,73,76,77] and, through a process of cognitive reframing, regain a sense of control [71].Now I have a feeling of control over my body . . .I don't want cancer to define me.[71] Nonetheless, one study reported that motivation to access prehabilitation may be negatively affected by low levels of health literacy, which is associated with socioeconomic deprivation [46].Furthermore, sustaining motivation to continue prehabilitation could be challenging [43,45,58,64,70,74], especially when faced with unanticipated setbacks such as delayed surgery [57] or insufficient peer support [64].
Several studies reported that psychological distress had a negative effect on prehabilitation access and adherence [59,61,70,73].Described by a participant in one study [63] as 'dark moments', as anxiety and stress were often connected with attending hospitals [71].In addition, several studies reported that individuals felt overwhelmed, both generally [42,57,74] and emotionally [12,70], in advance of their treatments.Information overload [62] and competing personal matters which required their attention pre-treatment [70,80] contributed to the sense of feeling overwhelmed.

The value of home-based prehabilitation
Home-based prehabilitation interventions with remote professional supervision and support were accepted for their convenience [38,74], capacity to motivate [38,61,64,73] and build selfefficacy [40,61,64,73] and perceived benefit [40,69,74].Specifically, individuals reported that home-based prehabilitation enabled them to integrate interventions into their everyday lives [61,64].Exercising in the safe, private, space of home was enjoyable [36,66], could help with overcoming self-consciousness and engendered a sense of control [61,64].I couldn't go to the gym any longer.I can't very well be running out to the toilet the whole time.So, I had to find something else, so it was that [static bike at home].( [61] p. 206) …I don't want to do it [prehabilitation] in a hospital because I think it then becomes really competitive.And people are, like, if they can't do it, they feel….They would feel like, 'Oh, I'm not strong enough…' you know what I mean.It might depress them.Whereas if you do it in the house, you can do it at your own pace, there's nobody watching over you and everything.[64] Home-based prehabilitation interventions were important facilitators of access [48,66] and adherence [36,48,61].
The provision of portable exercise equipment such as resistance bands enabled sustained adherence, particularly when individuals were temporarily away from home [74].Some individuals welcomed the freedom and flexibility of homebased prehabilitation [72].Yet despite being provided with resources to monitor [34,42,52,64,66,76], supplement and continue physical activity at home [48,63,66,74,77], insufficient in-person healthcare professional engagement and encouragement could mean adherence was often difficult to monitor [69,81] and sustained intervention adherence could be challenging [28,63,64] and afforded a low priority by individuals [61,72,73].
There had to be real pressure, there really had!And then if suddenly they were not around (the health professionals), then I'm not sure I'd finish it.That's how I am.You have to keep an eye on me.[72] Navigating the technological space of tele-prehabilitation Sometimes referred to as 'tele' or 'digital'-prehabilitation, technology-based uni and multimodal home-based prehabilitation capitalised on internet and/or telephone communication services and was delivered using smartphones, videos, wearable technology, tablets, mobile applications, video platforms and secure video conferencing [34,36,42,45,56,70,71,76,80].In terms of acceptability, individuals perceived home-based, teleprehabilitation programmes as accessible, particularly during the SARS-CoV-2 pandemic [34,71,80]: Having prehabilitation outside of the hospital setting made things easier.I wasn't feeling good with the pain and couldn't travel too far.Could also do it in my own time ([71] p. 646) Home-based tele-rehabilitation was also perceived as motivating [36,45,56,76], conferred benefit [34,36,45,56,80], particularly when personalised [34,45,56,71] and reduced transport-associated costs [80].
Sustained tele-prehabilitation engagement was aided by the provision of smartphones [56,76], tablets with relevant applications and content downloaded [34], training watches [34,56,76], supplementary information and alternate web browser pathways for those without access to or with low digital literacy [42] and integrated digital training and support during the intervention's implementation [34,36,42].I would not have been able to endure the treatments and the surgery thereafter had it not been for the continuous support I was receiving through the digital platform.[34] Reported barriers were primarily intervention specific.They included technical [45,80] and device connectivity issues [34,76], broadband and website interface problems, particularly for individuals unaccustomed to using technology [45].Negative views of mobile mindfulness apps [56] and equipment aesthetics [76] were also described.
The active involvement of family during physical activities such as walking and exercise routines was reported to generate a sense of companionship, encouragement and motivational and psychological support [34,60,61,64,70,71,77].In these ways, prehabilitation interventions with embedded family support enhanced their acceptability [52].
My wife did the same ones with me so there were two of us doing the same stuff.We did the walks together.Then we would both do the exercises.So that was good company.[64] Findings reported in one study [31] indicated that living alone could have a negative effect on prehabilitation adherence.
The acceptability of prehabilitation interventions was enhanced by relevant healthcare professionals' supportive dialogue in the shape of information, personalised encouragement, validation and timely, constructive feedback on individuals' engagement, progress and performance [69,77], signposting to other support services [63] and broader emotional support [77].In addition to sustaining prehabilitation behaviours through collaboration, activation and motivational support [60,61,71,72,77,78], healthcare professionals' presence instilled a sense of trust [71], comfort [51] and safety [38,62,63] and reduced feelings of social isolation [71].The need for and importance of supportive dialogue with healthcare professionals during prehabilitation was identified by participants in one study investigating individuals' experiences of multimodal prehabilitation delivered via a leaflet and with no embedded healthcare professional support [73].
I have only been a number.Like I was a garden shovel with a barcode that you scanned at the cash register.There is no one who thinks about what this means for one's self-understanding--just to be regarded as a disease [...]There is no one asking about the human being behind it.It is insane [73] For some participants, peer support in the shape of information sharing was beneficial and enabled prehabilitation access [63,71].Integrated group or one to one peer support was reported to enhance an intervention's acceptability [12,63].In part, this was because individuals did not always want to engage their families, and peer support reduced their sense of isolation [71].Peer support was reported to be beneficial in terms of interaction with others in a similar situation, thereby lending individuals' social, emotional and motivational support, enabling them to remain on track with their prehabilitation programme [51,59,64,66,71].
Exercising in a group motivates.Let new patients exercise with other patients who are further along and have more experience exercising.They (experienced patients) can then tell them, Yes, you will get muscle aches, but they will subside too.[59] It was clear from some studies that the absence of peer support in prehabilitation interventions was lamented [64,71], with some participants exercising agency and accessing online patient forums to derive required support [71].

Discussion
This review reports findings from across the globe regarding facilitators of and barriers to access, acceptance and adherence of cancer prehabilitation.The findings draw attention to crosscutting themes at individual and structural levels and interpersonal factors that connect the levels.As illuminated in Fig. 2, the multifaceted facilitators and barriers underscore the complexity of cancer prehabilitation access, acceptance and adherence.
This review found interpersonal connections, support either directly obtained from peers, family, healthcare professionals or via digital connectivity, can facilitate a fit between the individual factors and structural factors that affect engagement with prehabilitation.Examples include encouragement from a spouse willing to engage in a recommended physical activity with the patient, practical help with digital technology, peer support during group prehabilitation and health professional supervision.Support through these interpersonal connections may be a core ingredient for successful access, acceptance and adherence.This proposition should now be explored and tested.There may be sub-groups with need or preference for certain sources of interpersonal support.Our review was designed to find out 'what is known about access, acceptance and adherence to cancer prehabilitation, particularly among socially deprived and minority ethnic groups' because of the known benefits from prehab for post treatment recovery [8,9].It found no empirically based analysis of prehabilitation access, acceptance or adherence by people from these groups.

The individual and structural context
This review revealed individual factors enabling or impeding prehabilitation access, acceptance and adherence include personal beliefs and understandings about potential harms or benefits; motivations, for example finding enjoyment in participation; health status and everyday practicalities such as time and transport availability.Structural factors identified included the availability of knowledgeable and supportive health professionals and/or people affected by cancer' service organisation, such as the availability of a prehabilitation multidisciplinary team and the place and space of service delivery, for example, if it was available in the community.
Individual and structural level factors affecting access to cancer treatment and care are widely reported [82][83][84][85].Some are proposed to be modifiable for improved health outcomes in groups at risk of poor health because of poverty and/or discrimination based on age, race, ethnicity or gender [84].The findings of the review are consistent with this wider literature on service access, acceptance and adherence.It is notable that although our search was designed to identify all literature about access, acceptance and adherence to cancer prehabilitation from 2017 to 2023, we found no analysis of structural differences.The differential experience of people from structurally vulnerable groups, for example, those who are socioeconomically deprived or from minority communities, had not been considered.Yet, evidence indicates that cancer rehabilitation services are underutilised by people from socioeconomically deprived communities [86,87] and ethnic minorities [88].We also know patient engagement with prehabilitation is variable [89], and third sector organisations claim people from socioeconomically deprived communities, which include people from some ethnic minorities, are underserved by prehabilitation services [1].Exploration and understanding of difference in prehabilitation experiences across social groups is needed if support for access, acceptance and adherence is to achieve equity in health outcomes.

Interpersonal connections linking individual experience and structural context
This review identified that it was people, namely peers, family members and friends, who, through their support, influenced the extent to which individual and structural level factors were obstacles or enablers of prehabilitation.In the relational space between individual experience and the infrastructure in place to enable prehabilitation, these people were supportive actors, influencing individuals' access to, acceptance of and adherence to prehabilitation.
International studies have revealed that interpersonal support is related to mental and physical health.Low perceived social support has been shown to be associated with mental and physical health problems [90].In the USA, a high level of perceived social support was found more likely in women and young people and low level of perceived social support more likely for those living in poverty [90].Loneliness has been proposed the mediating factor between socioeconomic status and health in a Norwegian population-based study of people aged over 40 years [91].Two explanations were suggested.Firstly, people with few social contacts have low levels of physical activity.Secondly, people with poor physical or emotional health are more likely to have low self-esteem and self-efficacy in self-care, which is associated with less successful occupational career and low socioeconomic status and thus fewer social contact resources to manage health [91].
This review supports an argument that interpersonal connections can be important for prehabilitation access, acceptance and adherence.It found evidence of relationships with family, peers and cancer care staff influencing access to, acceptance of, and adherence to prehabilitation.Perceived social support may have a key role in successful prehabilitation.This proposition should be further explored, paying attention to the known relationship between social support and socioeconomic status in other contexts and the potential for this to be an explanation of any observed difference in access across socioeconomic groups.

Technology as interpersonal connection?
An interesting finding is of data showing some people find web-based resources and/or online help to satisfy their prehabilitation information and support needs.These people experienced interpersonal connection through technology.An online survey among 1037 adults (18+) in the UK found that 80% of those with a long-term condition used technology for managing their health, a majority for seeking information whilst a third used wearable technology or apps.Those most likely to use technologies were younger and/or of high socioeconomic status, leading the authors to caution completely digital approaches because of the potential to exclude some groups from the care they need [92].Arguably, technology may provide a partial solution to enabling successful prehabilitation.

What this review adds
Our finding of structural and individual level factors affecting access to, acceptance of and adherence to prehabilitation is consistent with Levesque et al.'s [93] socioecological model of access to health services.Levesque et al.'s [93] model sets out access as a process with five dimensions of accessibility (approachability; acceptability; availability and accommodation; affordability; appropriateness) and five corresponding abilities of populations (ability to perceive; ability to seek; ability to reach; ability to pay; ability to engage).The model enables attention to social, service organisation and person-centred factors that influence access.However, the model does not address the relational dimensions derived from our data analysis, i.e. how personcentred and structural factors interrelate for better or poorer service access.Based on our findings, an important ingredient for improving access to prehabilitation may be attention to what happens in the relational space connecting these factors.Voorhees et al. [94] interpreted findings of participatory research about access to general practice and claimed it is the human abilities of workforce and clients that are an important yet absent consideration in Levesque's model.They argued that staff training and support for human interaction were needed.We agree.In addition, and based on our analysis, we also consider important the network of interactions between patient and others.Understanding the nature and mechanisms of these interactions may be important for health equity in prehabilitation.

Strengths and limitations
A strength of this review is that established, rigorous systematic review processes were followed to identify and select relevant peer-reviewed literature.Methods and thematic synthesis procedures were reported explicitly, providing an audit trail for dependability.To maximise study identification, the detailed and comprehensive search strategy was developed with the assistance of an expert information specialist, and the review was conducted by a multidisciplinary team with a minimum of two reviewers engaged in the screening and extracting process.Searches were limited from 2017 to 2023 and published in the English language.By limiting the search dates in this way, we have ensured that the evidence assessed has context and relevance to current policy and practices.This systematic review, as a result, provides an overarching picture and holistic understanding of access, acceptance and adherence to cancer prehabilitation.However, this review is not without its limitations.It is possible that some potentially useful studies, notably those not published in the English language have been omitted.Furthermore, we did not take account of study quality in our analysis.To reduce the risk of selection bias, studies were included irrespective of their methodological quality assessment.However, this means that some low quality evidence has been included, and this is a limitation to the credibility of the analysis.Nevertheless, there is some consistency between studies and across international healthcare settings.This does indicate a level of trustworthiness in the review findings.The review was of mixed cancer sites.Cancer site along with its symptoms and treatment-related problems may affect access, acceptance and adherence to prehabilitation.As the body of literature about engagement with prehabilitation grows, further work will be warranted to investigate cancer site-specific factors affecting inclusion in prehabilitation.

Conclusion
ThQueryere is limited empirical study of barriers and facilitators to inform improvement in equity of access to cancer prehabilitation.To enhance the inclusivity of cancer prehabilitation, adjustments may be needed to accommodate individual preferences and characteristics, such as comorbidity, and attention given to structural factors, such as staff training.Based on our findings, we propose interpersonal connections as a fundamental core ingredient for facilitation of prehabilitation access, acceptance and adherence.

Systematic review registration
This systematic review was registered in PROSPERO (CRD42023403776) Fig.1PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources.*Consider, if feasible to do so, reporting the number of records identified from each database or register searched (rather than the total number across all databases/registers). **If automation tools were used, indicate how many records were excluded by a human and how identify factors influencing uptake, engagement and adherence to the Chem-oFit intervention and to establish whether it was acceptable and feasible to use.

Table 1 (
1 PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources.