Internet-based third wave interventions that reduce stress in parents of children and adolescents with chronic conditions: systematic review and meta-analysis

Childhood chronic conditions have doubled in the past 20 years (Edwards and Goodman, 2022; Virella Pérez et al., 2019). These long-lasting conditions have persistent effects (Smith et al., 2022) and typically require complex care from parents (Ten Haken et al., 2018) within the home (Page et al., 2021). This daily caregiving exceeds what healthy children need and can be emotionally demanding (Spiers and Beresford, 2017). Research increasingly focuses on how these conditions affect family members, including parents (Eccleston et al., 2015), and how they increase family stress regardless of severity or duration (Cousino and Hazen, 2013).

Further to this, chronic and overwhelming parenting stress is characterized by intense exhaustion in the parental role (Mikolajczak et al., 2018; Roskam and Mikolajczak, 2020), and has been associated with challenges in psychological adjustment for the parent and the child (Flujas-Contreras et al., 2023; Helgeson et al., 2012), together with an increase in child mental health problems (Amrock and Weitzman, 2014). While avoidant coping strategies may offer parents temporary relief (Waugh et al., 2021), they can increase long-term distress in parents (Bardeen and Fergus, 2016; Steeger et al., 2013) and interfere with the child’s illness management (Pinquart, 2018).

Interventions for parents of children with chronic conditions have traditionally focused on education, effective strategies, parenting skills and promoting confidence in the parenting role (Begle and Dumas, 2011; Vance and Brandon, 2017). While parenting interventions can reduce stress (Golfenshtein et al., 2016), research suggests incorporating third wave approaches may enhance effectiveness (Cohen and Semple, 2010). Third-wave cognitive behavioural therapy (CBT) extends traditional CBT principles by emphasizing contextual and functional aspects of psychological experiences, aiming to foster adaptive behavioural flexibility and holistic well-being that goes beyond symptom reduction (Hayes and Hofmann, 2021). Unlike traditional approaches that focus on changing the content of thoughts, third wave interventions emphasize understanding the context, processes and functions of how individuals relate to their experiences (Kahl et al., 2012). This approach builds on traditional CBT, which aims to identify and change negative thought patterns and behaviours to reduce distress (Fenn and Byrne, 2013). In contrast, third wave approaches incorporate mindfulness and acceptance techniques to develop a more flexible relationship with thoughts and feelings, encouraging psychological well-being and supporting behaviour change (Hayes et al., 2012).

Acceptance and Commitment Therapy (ACT) is a primary third wave therapeutic approach emphasizing mindfulness, acceptance and contextual treatment methods. ACT uses experiential exercises and metaphors to enhance psychological flexibility, which reduces psychological distress and improves quality of life (Crego et al., 2024; Stoddard and Afari, 2014).

Psychological flexibility relates to an individual’s ability to adapt to various situations when doing so leads to pursuing a meaningful life, and serves as a key mechanism of change in third wave approaches (Wersebe et al., 2018). Research has found that it acts as a barrier between stress experienced and negative psychological outcomes (Gloster et al., 2017). Studies have shown that strengthening psychological flexibility is effective in reducing stress (Holmberg et al., 2020; Li et al., 2024; Wang et al., 2023; Yao et al., 2024). Parents who engage in avoidant coping strategies exhibit poor psychological flexibility and increased psychological symptoms (i.e. anxiety, depression, stress), while facing challenges adjusting to their child’s ongoing care needs (Chong et al., 2017).

Despite the potential benefits of parenting interventions, researchers have identified several barriers that may prevent parents from attending or completing face-to-face interventions. These barriers include contextual stressors together with parents’ lack of knowledge about where and how to find helpful resources (McGoron and Ondersma, 2015). Additional challenges may involve a shortage of local interventions, limited services due to high demand and potential stigma associated with attending parenting interventions (Hall and Bierman, 2015; McGoron and Ondersma, 2015).

To overcome the limitations of face-to-face interventions, online platforms (e.g. videoconferencing, apps and websites) have become the most commonly used approach for implementing parent-based interventions (Flujas-Contreras et al., 2019; Hansen et al., 2019). These interventions offer several benefits, such as providing immediate access, enabling content updates, allowing parents to receive support and ask questions, and facilitating the monitoring of parents’ progress (Enebrink et al., 2012; Wetterborg et al., 2019). Studies have indicated that these interventions can potentially lower dropout rates because of their easy accessibility, cost-effectiveness, reduced stigma compared to attending in-person parenting interventions and the perception that they are simpler and faster to complete (Jones et al., 2014; McGoron and Ondersma, 2015).

Internet-based parenting interventions offer greater reach and sustainability (Breitenstein et al., 2014; Hall and Bierman, 2015; Jones et al., 2014; McGoron and Ondersma, 2015) while effectively increasing positive parenting behaviours and decreasing parental stress (i.e. small effect; Spencer et al., 2019). A Cochrane review (Law et al., 2019) examined 44 randomized controlled trials of psychological interventions for parents of children with chronic illness, including eight internet-delivered studies. These studies included five CBT studies (Bonnert et al., 2017; Law et al., 2015; Palermo et al., 2009; Palermo et al., 2016; Wade et al., 2017), two problem-solving therapy studies (Wade et al., 2006; Wade et al., 2015) and one motivational interviewing study (Ellis et al., 2017).

While this review provides evidence-based methods for improving psychosocial adaptation, the effectiveness of internet-based third wave parent interventions remains unknown, despite their widespread use in technology-driven parenting interventions (Flujas-Contreras et al., 2019; Hansen et al., 2019). As there continues to be a constant increase in the availability of technology, internet-based parent interventions may appear to be even more promising.

To date, no systematic reviews have examined whether internet-based third wave parent interventions are effective in reducing stress for parents of children and adolescents with chronic conditions. A systematic review by Byrne et al. (2021), centred on ACT interventions, sought to gather and analyse all ACT interventions that incorporated therapeutic components for parents in the treatment of various child-presenting issues (i.e. developmental disorders, chronic pain, physical and mental health problems). This review reported that ACT interventions demonstrated a positive effect on parent distress status, parent psychological flexibility, emotional regulation and an improvement in children’s problems.

Further research is needed to explore the potential of internet-based third wave interventions for this population cohort, to develop evidence-based strategies to help them manage their parenting stress. According to the International Prospective Register of Systematic Reviews (PROSPERO), no systematic review or meta-analysis has been published that examines the effectiveness of internet-based third wave interventions for parents of children and adolescents with chronic conditions, nor their impact on reducing parenting stress. This significant gap may result in parents being poorly informed as they attempt to cope with the stress of caring for a child with a chronic condition.

The aim of this systematic review is to answer the following questions:

The methodology of this systematic review follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework. In addition, the review was informed by the guidelines provided by Cochrane (Higgins et al., 2023). The Protocol for this systematic review has been registered in PROSPERO (International Prospective Register for Systematic Review) with the following registration number: CRD42022337334.

All peer-reviewed studies that met the inclusion criteria were included in this review and meta-analysis:

• English publications.

• Published between January 1970 and July 2022.

• Experimental studies that were internet-based, or a combination of internet-based and other models of delivery.

• Experimental studies that used a “third wave” approach, or a combination of third wave and other therapies. Third wave approaches include: ACT (Hayes et al., 1999); Behavior Activation (BA) (Lewinsohn and Shaffer, 1971); Cognitive Behavioural Analysis System of Psychotherapy (CBASP) (McCullough, 2003); Compassion Focused Therapy/Compassionate Mind Training (CT/CMT) (Gilbert, 2009); Functional Analytic Psychotherapy (FAP) (Kohlenberg and Tsai, 1991); Mindfulness Based Cognitive Therapy/Mindfulness Based Stress Reduction (MBCT/MBSR) (Kabat-Zinn, 1990); and Dialectical Behaviour Therapy (DBT) (Linehan, 1993).

• Studies that included at least one psychometrically sound, standardized measure of stress or proxies for stress, that was completed pre- and post-intervention by a parent.

• Minimally, study must be quasi-experimental.

Studies were excluded if they met the following exclusion criterion:

• Non-English publications.

• Studies that did not report a standardized measure of stress.

The following electronic databases were systematically searched between June 2022 and July 2022 using the advanced search function where possible:

• CINAHL (Cumulative Index to Nursing and Allied Health Literature) via EBSCO.

• EMCARE via OVID.

• EXCERPTA MEDICA (EMBASE) a database via OVID.

• MEDLINE via OVID.

• PsycINFO via OVID.

Medical subject headings (MeSH) and keywords were adopted. These included “cognitive behavioural therapy”, “internet-based intervention” and “chronic disease”. Keywords “internet-based interventions”, “parents”, “third wave”, “child”, “adolescent” and “chronic conditions” were included in the search. The search terms, including the use of truncation and wildcards where applicable, are detailed in  Appendix.

The determination of the keyword and MeSH were informed by the PICOR mnemonic. The PICOR mnemonic is a search heuristic which allows systematic reviewers to understand the thematic components of the question they seek to answer (Schardt et al., 2007). The PICOR definition for this study is outlined in Table 1 as follows.

Study selection was independently performed by two study authors (MD, LF). Any disagreements were resolved by consensus and consultation with the last author (HJC). All studies identified from database searches were imported into a reference management software (EndNote). These studies were reviewed by Title/Abstract. Studies that did not meet inclusion criteria were removed. All remaining studies received full-text review to determine that they met inclusion criteria. Studies that were not eligible were removed and categorized according to exclusion reasons. A final search was conducted through exploring all references of included articles, together with conducting searches of the first two authors of each included article, and examining studies published by these authors to identify additional studies not previously identified through database searches. The titles, abstracts and full texts of all studies were examined to determine inclusion in this study.

A standardized form was used to extract relevant information from the included studies. The relevant information, for each included study, was extracted and recorded in a table, which included:

• article details (authors, countries, publication years, funding sources);

• study characteristics (objectives, design, duration, recruitment criteria, sampling method, unit of randomization);

• participant characteristics (age, gender, chronic condition of adolescent, etc.);

• intervention group specifics (mode of delivery, session topics, length, frequency, duration, etc., including those of the control group); and

• outcomes (stress levels, attrition rate, means, SD, effect sizes, etc.).

For each included study, the specific extracted information was noted in a table and included:

• article information (authors, countries, publication years, funding source);

• study characteristics (aims of study, study design, study duration, recruitment criteria, sampling technique, unit of randomization);

• participant’s characteristics (age gender, chronic condition of adolescent, etc.);

• intervention group details (mode of delivery, session topics, length, frequency and duration, including those of the comparable control group); and

• outcomes (stress, number lost to follow-up, means, SD and effect sizes).

The data from all selected studies were extracted by one independent reviewer (MD) and was verified by a second reviewer (HJC).

As for the summary statistics, all reported means (M), standard deviations (SD) and sample sizes of the intervention and control groups from the included studies were entered into RevMan 5.4 (Cochrane, 2024) for meta-analyses, and were pooled for the outcomes (meta-analysis evaluating the impact of internet-based third wave interventions on parent stress symptoms in families of children and adolescents with chronic conditions).

The quality of the ten included studies was independently evaluated by two authors (MD, LF), with a third reviewer (HJC) being responsible for resolving any discrepancies. The criteria for the quality of assessment were based on the Cochrane Collaboration’s updated tool for assessing risk of bias (Higgins et al., 2019). The revised tool was developed in response to advancements in comprehending bias in RCTs and input from researchers who used the initial version of the assessment. The criteria were based on five key domains:

1. bias from the randomization process;

2. bias resulting from deviations from the planned interventions;

3. bias caused by incomplete outcome data;

4. bias in measuring outcomes; and

5. bias in the reporting of selected outcomes.

For each domain, a risk of bias judgment was made, with an overall assessment categorized as low risk, some concerns or high risk of bias.

In the systematic review protocol by Davey et al. (2024), the following was reported: “The exclusion criteria are studies that reported outcomes immediately following the intervention without a follow-up at least four weeks post-intervention”. In this review, however, this exclusion criterion was relaxed due to the very limited number of studies in this field.

A total of 2,983 studies were originally identified, with 580 duplicate studies removed, leaving 2,403 studies. Following title and abstract screening a total of 2,352 studies were excluded leaving 51 studies to be assessed via full-text. Following screening of full-text studies, 44 studies were excluded due to various reasons as reported on the PRISMA diagram below. A final total of seven studies were identified as meeting the inclusion criteria for this review.

Upon conducting an updated search in early 2024, a further three studies were identified that met the inclusion criteria, increasing the total number of included studies to ten (Figure 1). Two further papers were identified (Lappalainen et al., 2024; Zetterqvist et al., 2020); however, they did not fully meet the inclusion criteria. Lappalainen et al. (2024) was a follow-up study of Lappalainen et al. (2021), which is included in this review, and the Zetterqvist et al. (2020) study was excluded due to 39% of its cohort not meeting the medical diagnosis of a chronic condition.

Table 2 shows the characteristics of the ten included studies. All ten studies included assessed the effect of ACT interventions for parents of children or adolescents with chronic conditions, with two studies (Douma et al., 2021; Joosten et al., 2024) also incorporating CBT as part of their intervention. Six studies also incorporated elements of self-compassion as part of their ACT intervention (Kohut et al., 2021; Lappalainen et al., 2021; McMillan et al., 2022; Muscara et al., 2020; Sairanen et al., 2019; Whittingham et al., 2022). The included articles examined various chronic conditions, including chronic physical illnesses and developmental conditions. The interventions in all included studies were facilitated by mental health clinicians/psychologists, apart from the Sairanen et al. (2019) study. In this study, the intervention was facilitated by personal coaches who were undergraduate psychology students that had received four hours of training in ACT. The personal coaches were provided with two hours of supervision during the intervention, with more supervision provided if required. In two studies (Lappalainen et al., 2021; Whittingham et al., 2022), the interventions were delivered via modules through video presentations, with parents engaging in three online meetings with a psychologist (Lappalainen et al., 2021), or with parents participating in a moderated discussion board (Whittingham et al., 2022).

A component of all ten studies was to evaluate the impact of the ACT intervention on mental health symptoms of parents. The studies were focused on using ACT with parents and they drew on the six hexaflex processes of ACT (acceptance, defusion, contact with the present moment, self as context, values and committed actions; Hahs et al., 2019; Marino et al., 2021; Wright et al., 2022).

All studies used various methods of assessing stress. Four studies in this review used independent measures of stress (Hospital, Anxiety and Depression Scale [HADS], Douma et al., 2021; Distress Thermometer for Parents [DT-P], Joosten et al., 2024; Shirom-Melamed Burnout Questionnaire [SMBQ], Lappalainen et al., 2021; Post Traumatic Symptom Checklist [PCL-5], McMillan et al., 2022). A standardized measure of stress used in six studies was the DASS21 (Jin et al., 2023; Kohut et al., 2021; Muscara et al., 2020; Rayner et al., 2016b; Sairanen et al., 2019; Whittingham et al., 2022). Five of these studies examined the DASS21 stress component only (Kohut et al., 2021; Muscara et al., 2020; Rayner et al., 2016b; Sairanen et al., 2019; Whittingham et al., 2022); however, Jin et al. (2023) examined the total score of the DASS21. Three of the studies used the DASS21 and another measure of stress (Muscara et al., 2020 – PCL-5; Rayner et al., 2016b – PCL-5; Sairanen et al., 2019 – SMBQ). It was decided that for this review if the DASS21 measure was used to assess stress in a study, then this measure would be assessed.

Of note, two studies in this review (Kohut et al., 2021; Rayner et al., 2016b) did not supply sufficient data to inform the meta-analysis. They nevertheless appear in the forest plot to demonstrate the missing data in this review.

Table 3 illustrates the risk of bias across the ten studies included in this review. Eight studies in this review were rated as low risk of bias while two studies were rated as moderate risk of bias. A conservative interrater reliability score was calculated following McHugh (2012). The interrater reliability score was 18.9%. Any differences across the raters were attributed to interpretive differences. As Cochrane’s risk of bias tool indicates, rating risk of bias involves a measure of subjectivity (Higgins et al., 2019).

Treatment efficacy was performed using between-group random effects meta-analysis. It has been shown that random effects models are better suited for meta-analysis in relation to heterogeneity (Field and Gillett, 2010). The first measurement following treatment was used in this meta-analysis and included a total of 619 participants. Meta-analysis of the ten studies revealed moderate heterogeneity (Chi² = 10.34; I² = 32%; Figure 2) and that the interventions on parents of children and adolescents with chronic conditions was effective in reducing parental stress (−0.33, 95% CI: −0.17, −0.50; p < 0.001).

A funnel plot was used to investigate the possibility of publication bias (Figure 3). The funnel plot showed asymmetry, indicating that bias in the pooled results could be influenced by Muscara et al.’s (2020) study. After removing this study, the nine studies revealed low heterogeneity (Chi² = 2.28; I² = 0%; Figure 4). Nevertheless, the interventions were found to be still significant in reducing parental stress (95% CI: −0.24, 95% CI: −0.06; −0.42: p-value < 0.01).

This review synthesized ten studies to assess the effectiveness of internet-based third wave interventions for parents of children and adolescents with chronic conditions. These ten studies confirm Cohn et al.’s (2020) observation that there is a paucity of literature on parenting interventions for this cohort of parents. Meta-analysis of the random effects model showed that these interventions are effective, compared to the control group, and the difference was statistically significant.

Our review specifically identified ACT as the internet-based third wave approach of choice for this population. Previous reviews assessing ACT with varied forms of delivery for this cohort of parents identified significant effects of ACT on mood, including stress and depression (Byrne et al., 2021; Han et al., 2021; Jin et al., 2021). ACT’s effectiveness in these studies likely stems from parents developing psychological flexibility, allowing parents to avoid entanglement with difficult thoughts and feelings while focusing on adaptive coping strategies that benefit both their own and their child’s well-being (Coyne et al., 2011). Although previous internet-based studies suggest ACT may improve psychological flexibility components, results have been inconsistent (Brown et al., 2016). Some researchers have suggested that acceptance-related concepts of ACT may be more of benefit when attending face-to-face, and that a considerable period of time may be required to improve the acceptance concepts (Sairanen et al., 2019). However, ACT’s emphasis on mindfulness and acceptance strategies has been shown to enhance emotional regulation (Flujas-Contreras et al., 2022) which reduces parental stress.

In this review, six studies reported incorporating elements of self-compassion (Kohut et al., 2021; Lappalainen et al., 2021; McMillan et al., 2022., Muscara et al., 2020; Sairanen et al., 2019; Whittingham et al., 2022). Self-compassion has been described as sensitivity to one’s personal suffering, and the motivation to act in a way that alleviates one’s suffering (Carvalho et al., 2022). Although ACT does not explicitly target self-compassion, the literature reports a bridge between ACT and compassion-based approaches (Neff and Tirch, 2013; Neff and Dahm, 2015). The research not only suggests that ACT promotes self-compassion (Yadavaia et al., 2014), but also that self-compassion overlaps with the psychological processes promoted through ACT (Vowles et al., 2014).

A final search was conducted in May 2025 which revealed only one study that would have met the inclusion criteria for this review (Tilson et al. (2025). This study was conducted in the peak of the COVID-19 pandemic, and comprised a small sample size (n = 9). Research indicates that the pandemic introduced unique and significant stressors, including health anxieties, economic instability and disruptions to daily life (Von Suchodoletz et al., 2023). Consequently, including this study could introduce bias, inflating stress measures beyond the normal baseline levels, thereby compromising generalizability of the findings. With the future proliferation of such studies, future meta-analyses will be able to provide a more definitive answer.

A methodological strength of this review is that it followed the strictest systematic review guidelines as articulated by the Cochrane collaboration. Furthermore, to ensure methodological rigour, a pre-determined protocol was made publicly available on PROSPERO and was also published before conducting the review. Finally, that collectively the studies represented a low risk of bias heightens the confidence that we may have in this review’s results.

This review identified some limitations that need to be addressed in future research. There was protocol variation in most studies in this review. Protocol variation across studies may compromise data quality, validity and reliability (Chodankar, 2023). While all studies used ACT, implementation varied across studies. ACT is a more recent therapy, so no standard procedure for delivering ACT has been established. Three studies used the “Take a Breath” Protocol (McMillan et al., 2022; Muscara et al., 2020; Rayner et al., 2016b), and two used the “Op Koers” Protocol (Douma et al., 2021; Joosten et al., 2024). Both protocols were initially face-to-face interventions later adapted for online delivery to improve accessibility (Burke et al., 2014; Rayner et al., 2016a).

A further limitation in this review was that physical illnesses and developmental conditions were combined which creates potential baseline imbalances (Park and Hahn, 2022). Two studies in this review focused specifically on cerebral palsy (McMillan et al., 2022; Whittingham et al., 2022), while two others (Lappalainen et al., 2021; Sairanen et al., 2019) grouped chronic illnesses with developmental conditions. Parents of children with chronic illnesses face different challenges (e.g. ongoing treatments, hospital visits, uncertain prognoses; Cousino and Hazen, 2013) compared to parents of children with developmental conditions (e.g. behavioural issues, social skills deficits, long term care needs; Woodman and Hauser‐Cram, 2013). Establishing condition-specific baselines is crucial for reliability, validity and statistical power (Johnson et al., 2017).

Age cohort differences were also a limitation in this review as there are complexities of including different age cohorts into a single synthesis. The parent–child relationship changes significantly during the adolescent period due to the adolescent striving for autonomy. Grouping parents of younger children and adolescents together may mask specific age-related findings that, not only impact parental stress (Neece et al., 2012; Östberg et al., 2007), but also parent coping mechanisms and family functioning (Calero Plaza et al., 2020). Establishing equal baseline age-cohorts can isolate the effects of variables of interest, without being influenced by age-related differences.

A further limitation is the inconsistent stress measures used. Research shows that stress is a complex phenomenon measured across social, psychological and physiological levels, with few universally accepted standard measures. Using inconsistent measures often leads to conflating different stress constructs (Epel et al., 2018). As the measures used across the included studies measured varying constructs related to stress, the findings need to consider the specific context of the parent’s experience. Parent stress typically increases with child symptom severity (Shepherd et al., 2018), creating possible baseline imbalances that can introduce confounding factors (Mansournia et al., 2017). In addition, the treatability of a child’s condition may significantly impact parent stress levels, highlighting the need for research comparing stress patterns across various chronic conditions (Golfenshtein et al., 2015). Parents’ psychological flexibility also appears to influence stress levels, as research indicates a relationship between high parental stress and psychological inflexibility (Flujas-Contreras et al., 2023).

One notable limitation of this systematic review is the relatively limited number of studies identified for the review, which comprised a total of 611 participants. This sample size may constrain the generalizability of the findings, given the estimated 43% of children and adolescents suffering from a chronic condition (AIHW, 2020).

Future research needs to consider fathers’ experiences of interventions for this parent cohort. While fathers face stressors from raising children with chronic conditions (Giallo, et al., 2015), in this review only five studies recruited between 15% and 25% fathers (Jin et al., 2023; Joosten et al., 2024; Kohut et al., 2021; McMillan et al., 2022; Muscara et al., 2020). Evidence shows that fathers involved in caring for children with chronic conditions experience quality of life impacts and need additional support (Spurr et al., 2023). Their involvement positively affects both child well-being and family functioning (Swallow et al., 2012). As shared caregiving becomes more common, future randomized controlled trials should use gender-stratified sampling techniques to recruit more fathers and reduce selection bias, creating more representative parent samples (Smith et al., 2015).

This review of ten high-quality studies helps address knowledge gaps by demonstrating that internet-based ACT effectively reduces stress among parents of children and adolescents with chronic conditions.

The findings align with previous research demonstrating ACT’s positive impact on parental psychological flexibility, emotional regulation and stress reduction. The methodological strengths of this review which include, adherence to Cochrane collaboration guidelines, pre-registration on PROSPERO and the overall low risk of bias across included studies, enhance the credibility of these findings.

Despite these strengths, several limitations warrant consideration: protocol variations across interventions, heterogeneity of chronic conditions, differences in child age cohorts and inconsistent stress measurement approaches. These limitations highlight important areas for future research.

Future studies should focus on implementing strategies to increase father participation, establishing condition-specific baselines and developing a better understanding of how different chronic conditions uniquely impact parental stress levels. In addition, researchers should examine how different versions of intervention protocols perform and clarify which specific intervention components influence particular psychological processes.

The integration of self-compassion elements in many of the reviewed interventions suggests a promising connection between ACT and compassion-based approaches that merits further exploration. Future well-designed randomized controlled trials addressing the identified limitations will be crucial to developing more targeted and effective interventions for this vulnerable parent population, ultimately enhancing both parent and child wellbeing.

Funding statement: No funding was received from any entity for the development of this manuscript.

Authorship contribution statement: All authors participated in the design of this manuscript. Maria Davey conducted the literature search, screening and evaluation, extracted the data, and wrote and revised the original manuscript, which was modified and added to by all authors. All authors have contributed to and have approved the manuscript.

Ethics approval: No ethics approval is required due to this manuscript being a systematic review of existing literature.

Data availability statement: Data will be made available upon request from the corresponding author.

Conflict of interest: The authors declare no conflict of interest.

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