Article Text

Original research
Lived experience codesign of self-harm interventions: a scoping review
  1. Lucy C Wright1,
  2. Natalia Lopez Chemas2,
  3. Claudia Cooper2
  1. 1Barts and the London School of Medicine, Queen Mary University of London, London, UK
  2. 2Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
  1. Correspondence to Lucy C Wright; l.c.wright{at}


Objectives This study aims to map existing literature describing how people with lived experience of self-harm have engaged in codesigning self-harm interventions, understand barriers and facilitators to this engagement, and how the meaningfulness of codesign has been evaluated.

Design Scoping review by Joanna Briggs Institute methodology. A protocol was published online (

Data sources PubMed, Embase, PsycINFO, Web of Science, Cochrane Library, PROSPERO, and relevant websites were searched on 24 December 2022 (repeated 4 November 2023).

Eligibility criteria We included studies where individuals with lived experience of self-harm (first-hand or caregiver) have codesigned self-harm interventions.

Data extraction and synthesis Results were screened at title and abstract level, then full-text level by two researchers independently. Prespecified data were extracted, charted and sorted into themes.

Results We included 22 codesigned interventions across mobile health, educational settings, prisons and emergency departments. Involvement varied from designing content to multistage involvement in planning, delivery and dissemination. Included papers described the contribution of 159 female, 39 male and 21 transgender or gender diverse codesigners. Few studies included contributors from a minoritised ethnic or LGBTQIA+ group. Six studies evaluated how meaningfully people with lived experience were engaged in codesign: by documenting the impact of contributions on intervention design or through postdesign reflections. Barriers included difficulties recruiting inclusively, making time for meaningful engagement in stretched services and safeguarding concerns for codesigners. Explicit processes for ensuring safety and well-being, flexible schedules, and adequate funding facilitated codesign.

Conclusions To realise the potential of codesign to improve self-harm interventions, people with lived experience must be representative of those who use services. This requires processes that reassure potential contributors and referrers that codesigners will be safeguarded, remunerated, and their contributions used and valued.

  • Suicide & self-harm
  • Patient Participation

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study. Scoping review protocol, full search strategy and example search strategy are available via the Open Science Framework (

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Comprehensive search strategy with no restriction on publication date to capture breadth of evidence.

  • All papers screened at title/abstract and full-text level by two researchers independently.

  • Protocol uploaded to the Open Science Framework prior to conducting scoping review.

  • Did not check all published self-harm intervention papers for evidence of codesign, so instances where codesign was not mentioned in the title or abstract could have been missed.

  • Only the development paper for each intervention was included— follow-up papers were excluded at full-text level, which may have overlooked additional codesign details.


As health services shift from paternalistic to person-centred care, there is an increasing focus on engaging patients and caregivers with lived experience in designing services.1 Codesigned services are more efficient and relevant for end-users, foster positive emotions and increase service-user knowledge.2 Gold standard codesign is both active and embedded, where those with lived experience are equal partners with a meaningful role incorporating creativity, problem-solving and decision-making.3 Coproduction comprises codesign alongside codelivery.4 5 Coproduction guidelines state experiential knowledge should be respected by sharing both decision-making and power, so research is jointly owned between researchers and those with lived experience. Building and maintaining relationships should be prioritised through continued dialogue and reflection. Establishing ground rules, valuing reciprocity and flexibility are crucial. Diverse perspectives should be sought, especially from under-represented groups.6

Involvement of experts by experience in mental healthcare design is widespread across early psychosis, eating disorders, adult psychological therapies and youth mental health.7 8 However, the state of the field of codesigned self-harm interventions has not to our knowledge been the topic of a published review.

Self-harm is defined as direct, deliberate harm to one’s own body in the absence of suicidal intent, for reasons not socially sanctioned.9 The most prevalent forms are cutting, burning, hitting and banging.10 Self-harm is common. A nationally representative estimate of self-harm in England revealed a lifetime prevalence of 6.4%, with especially high rates in women aged 16–24, a quarter of whom self-harmed.11

Self-harm is prevalent in patients with Complex Emotional Needs,12 with prevalence rates of 95% and 90% in adolescent and adult samples diagnosed with emotionally unstable personality disorder.13 Self-harm behaviour occurs across a wide range of psychiatric diagnoses. People with depression, substance use and anxiety disorders are at particularly high risk.14 Self-harm is also present in the absence of comorbidities,15 prompting the inclusion of non-suicidal self-injury disorder as a condition in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V).16 High-risk groups include the lesbian, gay, bisexual, transgender, queer, questioning, intersex, or asexual (LGBTQIA+) population17 and those with chronic physical illnesses.18 A previous systematic review reported significant differences in self-harm rates between ethnic groups, with Asian males being least likely to self-harm and black females being most likely to self-harm. Black and South Asian people were less likely to repeat self-harm relative to white people.19

Self-harm can serve to regulate distressing emotions and escape from negative internal states, communicate distress and self-punishment, and can serve an antisuicide function for some.20 21 However, self-harm is a strong risk factor for future non-suicidal self-harm and completed suicide, with suicide risk up to 49 times the general population.22 23

All patients presenting with self-harm should receive information, have family/caregivers involved, undergo psychosocial assessment and have a personalised care plan and risk assessment.24 A series of Cochrane reviews question the efficacy of existing psychological interventions. In children and adolescents, consistently positive outcomes were found for dialectical behaviour therapy only,25 and in adults only cognitive behavioural therapy-based psychotherapy and mentalisation-based therapy showed promise.26 27

Several streams of evidence suggest existing self-harm interventions are not fit for purpose. There are accounts of patients being refused pain relief in the emergency department due to the self-inflicted nature of their wounds—‘I thought you liked pain’,28 or denied medical treatment under assumptions they would re-engage in self-harm.29 Patients recount stigmatising attitudes from healthcare professionals, labelled ‘attention-seeking’ for seeking help.30 Given the rise in self-harm in young people, it is particularly concerning that this age group report feeling let down by clinical services and dropped on discharge.31

Patients’ perceptions are not unfounded. Clinical staff across emergency departments, general medical and psychiatric settings had feelings of irritation and anger towards those presenting with self-harm.32 Unfortunately, these experiences are not unique to healthcare settings. Prison officers, nurses and doctors reportedly exhibited hostility towards prisoners who engaged in self-harm.33

Collaboration with patients and caregivers to design and implement new approaches and interventions may improve their acceptability and efficacy and build relationships with staff. While one systematic review noted that service-user evaluation of predesigned psychosocial self-harm interventions was rare,34 there have been no attempts to synthesise research regarding whether and how people with lived experience have codesigned self-harm interventions. Given the stigma surrounding self-harm from medical professionals, as well as self-stigma and the high number of people who self-harm who are not in contact with services,35 engaging this lived experience group may be particularly challenging. A review in this area is important to identify how codesign has been conducted and unique requirements and challenges to lived experience involvement.


The primary objective of this scoping review was to map the extent of lived experience involvement in codesigning self-harm interventions. We also sought to describe how representative codesigners have been of intervention end-users and explore benefits, challenges, barriers and facilitators to codesign. Additionally, we aimed to examine how the meaningfulness of codesign has been evaluated. Given that codesign is an emerging field, we conducted a scoping review, as we considered it the method most suited to our aim of identifying and mapping the breadth of codesign evidence in the area of self-harm. Scoping afforded flexibility and the ability to identify gaps in the literature.36


This work followed the Joanna Briggs Institute methodology for scoping reviews.37 Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews Checklist.38 The protocol is published (, online supplemental material 1).

Eligibility criteria

We included studies where individuals with first-hand or caregiver experience of self-harm codesigned interventions, materials or guidelines for self-harm. There were no restrictions on age, gender, diagnosis or publication date. Primary studies, systematic reviews, meta-analyses and grey literature were included. Only English language studies were included. Various collaborative design concepts such as codesign, coproduction, cocreation and patient and public involvement were incorporated. Interventions solely for self-harm where the intention was to die were excluded. Involvement restricted to consultation or giving feedback on pre-existing interventions was excluded.

Information sources

On 24 December 2022, we searched the following databases using a comprehensive search strategy comprising three concepts (‘codesign’, ‘self-harm’ and ‘intervention’): PubMed, Embase, PsycINFO, Web of Science and Cochrane Library, as well as grey literature in PROSPERO, and Online supplemental materials 2 and 3 detail the complete search strategy and example search. Websites were also scoped for relevant content: Department of Health, National Institute for Health and Care Research (NIHR), National Institute for Health and Care Excellence, The McPin Foundation, Royal College of Psychiatrists, Harmless, YoungMinds, MQ Mental Health Research and Mind. The search was updated on 4 November 2023.

Procedures for analysis

Following deduplication, all records were screened for eligibility at title and abstract level, then at full-text level, by two researchers independently (LCW and NLC). Disagreements were resolved via discussion with a third person (CC). Decisions were recorded using Rayyan (

We conducted a qualitative content analysis.39 LCW extracted the following data from included articles: authors, year and publication type, country, setting, intervention, self-harm definition, aims, methods, population, extent of codesign involvement, benefits/challenges and facilitators/barriers. During extraction, we decided that remuneration and evaluation of codesign activities should also be extracted. Frequency counts were made of types of publication, country, definition of self-harm and demographics of codesigners. A deductive approach was used to map before, during and after codesign data against key principles in NIHR guidelines for coproduced work including sharing power, including all perspectives, valuing contributor knowledge, reciprocity, and building and maintaining relationships.6 Data were categorised into intended user group, intended setting, aims, methods, role of the codesigner and barriers/facilitators, for reporting.

Patient and public involvement

Patients or the public were not involved in conducting this review.


Database searching returned 2737 records. Following deduplication, 1814 titles and abstracts were screened for eligibility. 71 full texts were assessed, of which 17 were included. Two additional materials were identified through web searches and one through references. The updated search yielded 328 results. After deduplication, 210 titles and abstracts were screened and 4 papers were read at full text level, of which 2 were included. A final 22 studies were included. The PRISMA flow chart in figure 1 summarises the selection process.

Figure 1

PRISMA flow chart of the screening process. Search 1 conducted 24 December 2022. Search 2 conducted on 4 November 2023. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Details of codesigned interventions, materials and guidelines are outlined separately for young people40–51 (table 1) and adults52–61 (table 2). We included 14 qualitative studies, 2 quantitative, 1 mixed methods, 1 commentary, 2 protocols (for future codesign and evaluation of self-harm interventions) and 2 web pages outlining coproduced materials. Thirteen studies took place in the UK, the rest in Australia, India, the USA, New Zealand, Canada and Taiwan. All were published between 2005 and 2023.

Table 1

Description of included studies involving young people in codesign of self-harm interventions

Table 2

Description of included studies involving adults in codesign of self-harm interventions

Four interventions were for non-suicidal self-harm,40 47 54 61 while eight interventions did not discriminate based on suicidal intent.43–46 48 50 51 60 The remaining sources did not define self-harm or the definition did not reference intent.

What interventions have been codesigned?

Of the 12 interventions designed by and for children and young people, 4 were mobile health technologies.42–45 Four were resources to support care providers—primary care practitioners,40 general hospital children’s nurses,41 parents and teachers,49 and school staff.48 In educational settings, young people codesigned and co-ran a self-injury group47 and codesigned outcomes for self-harm interventions, which informed a Cochrane review.50 Youth in India codesigned a psychological intervention for use in low-income and middle-income countries.46 Young people also codesigned guidelines for safe online communication about self-harm.51

Mobile health interventions were also the focus of three interventions codesigned by adults with lived experience of self-harm,52–54 and one protocol for a planned brief contact intervention.55 Adults also codesigned materials to aid professionals and caregivers, including a handbook for mental health trusts61 and self-harm awareness training delivered by experts by experience.57 Women’s prisons were the focus of three interventions.58–60 Finally, adults codesigned an activity workbook for self-harm recovery.56

To what extent, and using which methods, were individuals with lived experience involved?

Before codesign

Three studies describe how people with lived experience were involved in planning how studies would be conducted or evaluated, or in securing funding. In one study, people with lived experience identified the need for a co-run self-injury group within their American college campus.47 Service-users were also involved in the grant phase and protocol development,52 and informed study outcomes.60

During codesign

One study engaged people in online workshops50 while the remaining codesign was face-to-face via workshops, focus groups and interviews. Using sticky notes, codesigners wrote and thematically sorted triggers, urge-reduction messages, and characteristics of groups who self-harm for Txt4shs, with further workshops to personalise and refine the intervention.53 Over four workshops young people sketched intervention features as individuals, obtained group feedback, then prioritised optimal features for the final group design.42 Young people and their families were involved in ‘sprints’ and ‘scrums’ to iteratively develop the Village app—working as a team to a deadline.45

Using information gleaned from other stakeholders or literature alongside service-user design was common.61 Themes emerging from statistical analysis of medical records and challenges identified by general practice staff guided focus groups to source and create self-help materials for self-harm consultations.40 Registered children’s nurses identified their training needs, on which workshops were held with children and young people who used storyboards to reflect on their experiences and decide what should be included.41

Voting was frequently used in decision-making. Designing a psychological intervention, youth added missing elements to those identified through interviews and a systematic review, voted on elements for inclusion and built elements into modules.46 Young people codesigned a review for self-harm interventions by anonymously suggesting review outcomes which were combined with typical outcomes recorded in trials and voted on for inclusion.50 Two studies employed the Delphi expert consensus method whereby stakeholders voted on items obtained from literature searches and interviews with professionals and experts by experience for inclusion in guidelines for school self-harm management48 and online communication about self-harm.51

The Self Harmony hackathon uniquely included people with lived experience as designers, as inspiration through sharing their experiences, and as mentors to ensure sensitive engagement with self-harm.54 No Harm Done materials were also unique since sharing self-harm stories on film was the cocreation contribution, using real-life experiences to dispel myths.49

Extent of codesign involvement was less clear when interventions were not afforded a separate development paper,52 involving creative workshops,43 creating, refining and evaluating an app,44 and collaborative development of a prison self-harm pathway59 and self-harm workbook.56 Service-users will be involved in developing the content, settings and outcomes of a brief contact intervention.55

Four studies involved codelivery. Students planned topics for and facilitated a college self-injury group alongside counsellors.47 People with lived experience also designed and codelivered self-harm awareness training.57 In prisons, women designed outcomes for an existing intervention60 and a staff training package,58 which will be delivered by other prisoners with self-harm experience.

All decisions regarding the co-run self-injury group were made between consumers and counsellors who were viewed as equals.47 However, elements of some interventions were determined prior to lived experience involvement—content type and web-based nature,55 mood monitoring features,42 and an existing intervention for redevelopment.43

After codesign

App design ideas,42 guidelines,51 handbook training61 and findings60 were (or planned to be) codisseminated. Only one paper explicitly stated those with lived experience were acknowledged as contributors on final guidelines.48 Continued dialogue was rare, though people with lived experience not only codesigned the BEACON intervention but were coinvestigators in a subsequent randomised controlled trial.52


This varied from a certificate48 to travel reimbursement and food provision,54 vouchers,41 48 50 hourly pay42 53 and unspecified payment for involvement.51 57 More attractive incentives were proposed to encourage recruitment.41 Prison settings did not detail reimbursement, but stated the intervention would not interfere with women’s income.60 Others offered training opportunities such as conference attendance.52 No papers outlined the rationale for their chosen reimbursement, nor the time commitment of contributors.

Who is involved in codesign?

Most work included individuals with personal self-harm experience recruited via services,41 46 existing team networks,42 48 53 young people’s organisations,49 50 advertisements,54 social media51 or college mental health organisations.47 Snowball sampling was common.40 42 52 To manage risk, some studies excluded individuals who self-harmed in the past 3 months42 or were receiving acute hospital care for their self-harm.41 There was some gatekeeping to involvement by healthcare professionals and prison staff who excluded people if they were not deemed suitable for workshops41 and selected prisoners who were most ’suitable’ for intervention delivery or already held positions of responsibility.58 60 Six studies also involved family or caregivers.45 46 48–50 53 In some studies, codesigners varied across the development process53 or new individuals were added to make final modifications.46

In studies reporting demographics of lived experience codesigners, 159 were female and 39 were male.40–42 48 50 51 53 58–60 In one study, 19 codesigners were trans or gender diverse—over a quarter of the sample.51 In other studies, only one non-binary person and one transwoman were included.48 50 Few studies reported ethnicity. Young people who codesigned materials for UK general practice were overwhelmingly white,40 while two New Zealand studies sought Māori and non-Māori representation and recruited a Rōpū Mātanga Māori (clinical cultural governance group) to ensure Māori-centred work, given higher self-harm rates among this population.48 50 A study based in India recruited from the local population to develop an intervention for low-income and middle-income countries.46 Only one study reported details of employment, educational level and sexual orientation—with over half of their codesigners identifying as LGBTQIA+.51 No studies presented information on self-harm frequency (besides meeting an inclusion cut-off) or comorbidities.

What were the barriers and facilitators to self-harm intervention codesign?

Barriers and facilitators fell broadly into the categories of recruitment, safeguarding, enabling collaborative involvement, time and funding, and placement within the wider mental health system (see table 3).

Table 3

Barriers and facilitators to codesign of self-harm interventions by people with lived experience

Was codesign meaningful?

Meaningfulness of lived experience involvement may be discerned from how codesign benefited the intervention or reports from codesigners on the impact of their involvement. Several papers outlined positive impacts of their codesign efforts but did not report how these were assessed, for example, enabling the lived experience voice to be heard41 42 47 50 and making interventions relevant to end-users.41 48 52 Codeliverers reportedly broke down barriers to professional-run groups, served as role models for attendees,47 developed transferable skills,57 provided meaningful work and addressed the inmate-officer divide of a prison setting.59 60 However, few studies quantified the degree or success of these activities.

Three studies explicitly documented how lived experience contributions impacted intervention design. Young people identified more asset-based outcomes for self-harm interventions (‘better coping’ and ‘safer environment to talk about self-harm’) than typical self-harm reduction/cessation, prompting researchers to transform their review.50 Researchers were challenged on their preconceived idea to subcategorise people who self-harm and send generic support messages at prespecified times. Highlighting the personal nature of self-harm and potentially detrimental effects of receiving blanket messages paved the way for the highly personalised Txt4shs app.53 The Self Harmony hackathon informed a platform where digital mental health tools will be open-sourced.54

Three studies involved reflections on the codesign process. Assessments conducted with Changing Minds cotrainers revealed involvement gave them a valued role, increased self-esteem and confidence to develop supportive social networks and challenge discrimination.57 One codeliverer of prison self-harm awareness training reflected how the experience increased their self-esteem, confidence and acceptance of their own self-harming frequency. Additionally, most staff recipients reflected that the lived experience perspective was the most useful element.58 Reflective focus groups with young people and clinicians highlighted short consultations as a limiting factor of their codesigned materials.40 Some studies conducted debriefing but did not include what was discussed.47 50


In this scoping review, we identified 22 codesigned interventions, approaches and materials for self-harm across settings. Though codesign arose in the 1970s,62 most studies were published in the 2010s, in the UK. This surge in codesign publications is perhaps unsurprising given increasing self-harm prevalence, particularly in young people and the recent push towards lived experience involvement.63 64 12 interventions were designed by and for children and young people and 10 by adults. Where characteristics were reported, codesigners were predominantly women and were in contact with mental health or prison services. Only those studies in which the impact of codesign on the end-product was clearly documented,50 53 and where codesigners were involved in all stages of the research,52 appear to closely align with gold-standard guidelines.6 However, inconsistent detail of reporting between studies makes this difficult to assess. This was the first review to explore depth of lived experience involvement in the self-harm field, factors that help and hinder codesign and meaningfulness of involvement. A robust search strategy across multiple databases enabled a thorough examination of the literature.

Our findings indicate lived experience codesign varied from designing aspects of interventions with considerable input from the literature and other stakeholders, through to multistage involvement in design, delivery and dissemination, with equal decision-making say. It may be misinformed to aim for equal involvement in all decisions—guidelines state there can still be a leader, whether they are a service-user or another stakeholder.6 Few studies fostered involvement beyond initial design activities which may be viewed as tokenistic if codesigners are unable to see the impact of their involvement, particularly having shared personal information.65 66

Many stated benefits of codesign such as making interventions relevant to end-users and breaking down the staff—service-user divide lacked tangible empirical or qualitative evidence. Barriers and facilitators of codesign fell into themes of recruitment, safeguarding, involvement methods, time and funding, and mental health services. Meaningful coproduction should be ‘equitably remunerated’67 and ‘commensurate with the nature and demands of the activity’68 though, where reported, remuneration varied from a certificate of participation to hourly pay and did not meet recommendations.69 70

Unrepresentative stakeholders or involvement activities that exclude the most vulnerable in society could perpetuate power imbalances in self-harm interventions. Codesigners were predominantly cisgender women, especially in prison systems where codesign only took place in women’s institutions. While this gender imbalance reflects self-harm prevalence, a significant number of men are affected.71 72 Ethnicity was infrequently reported. Higher-risk groups including those acutely unwell, those with physical or mental health comorbidities and the LGBTQIA+ population73 were under-represented, except in one study where over half of codesigners identified as LGBTQIA+, in line with their over-representation in self-harm statistics.51 Self-harm may present differently in the context of certain conditions and tailored interventions may be required. Additionally, since self-harm is a somewhat hidden phenomenon, interventions designed by those in contact with services may not represent the needs of the wider population who self-harm.64 While online workshops remove geographical constraints to participation, they may be prohibitive for those lacking technology access. Indeed, research suggests experts by experience should be provided with the necessary equipment to remove barriers to involvement.65

Strategies such as snowball sampling and recruitment via existing networks may explain the lack of diversity in these lived experience samples. There was an element of clinician gatekeeping such that only those deemed suitable to take part acted as codesigners, though the criteria for suitability were often not reported. It is conceivable that ethics committees may have prohibited the involvement of those at greatest risk to themselves, but greater transparency documenting the inclusion process is required to confirm this.

We see the crucial next step as breaking down barriers to inclusion of the most vulnerable groups with lived experience of self-harm to ensure a representative set of voices are heard. We suggest that future publications of codesigned self-harm interventions describe: how codesigners are recruited, their demographics, time commitment and the rationale behind remuneration decisions. More transparency is needed regarding any inclusion criteria employed when recruiting codesigners, their comorbidities, contact with services and frequency of self-harm, to assess inclusivity. Researchers should outline barriers and facilitators to codesigning their intervention to inform subsequent practice. Continued dialogue and reflection after the design phase enable evaluation of the impact of coproduction activities and prevent tokenism.


We recognise that the dichotomy between non-suicidal self-injury and self-harm with the intent to die is contentious, particularly given the increased risk of suicide following self-harm.74 For this reason, we included interventions for self-harm where the intent was not specified, however, we excluded interventions for self-harm where the intent was to die as we believe this speaks to a different literature on suicide, where there is a host of codesigned interventions beyond the scope of this review. Though our search strategy was comprehensive across multiple databases, papers where search terms were not referenced in the title or abstract may have been overlooked. Our exploration of the representativeness of codesigners was limited by several papers not describing characteristics of those involved. Given the imperative for codesign of services in many countries, the relative paucity of evidence found suggests many codesign activities may be unpublished.


Codesign of self-harm interventions is becoming more frequent, but work is required to improve representation, in particular from ethnically diverse, male and higher-risk individuals. Additional safeguarding measures and support from relevant mental health or LGBTQIA+ champions to ensure sensitive involvement could empower a wider group to have their voices heard. Addressing financial, technological and systemic barriers and raising awareness of codesign opportunities could increase accessibility, as could greater transparency in documenting codesign decisions.

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study. Scoping review protocol, full search strategy and example search strategy are available via the Open Science Framework (

Ethics statements

Patient consent for publication


This work was presented as a poster at the seventh Suicide and Self-harm Early and Mid-Career Researchers’ Forum (EMCRF).


Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


  • Contributors LCW and CC conceptualised the scoping review. LCW and NLC read papers at title/abstract and full text level and decided on inclusion. LCW wrote the manuscript. All authors contributed to interpretation of results and editing the manuscript. LCW is the guarantor for the work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

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

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

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