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Abstract
Background Type 2 diabetes mellitus (T2DM) is a global public health crisis impacting low-income and middle-income countries such as Bangladesh. While self-management is encouraged for individuals with T2DM, there is a significant lack of knowledge regarding the factors of facilitators, barriers and expectations associated with T2DM self-management in Bangladesh. This research aims to investigate the potential elements that support, impede and are anticipated in the effective practice of self-management for T2DM in rural areas of Bangladesh.
Methods and analysis This study will use an exploratory qualitative approach. 16 focus group discussions, 13 in-depth interviews and 9 key informant interviews will be conducted among multilevel stakeholders, including people with T2DM, their caregivers, healthcare providers, health managers/administrators and policy planners. Interviews will be audio-recorded, transcribed, translated and analysed using thematic analysis.
Ethics and dissemination This research project has been approved by the Monash University Human Research Ethics Committee (project reference number: 39483) and the Ethical Review Committee of the Centre for Injury Prevention and Research, Bangladesh (Memo: CIPRB/ERC/2023/14). Research findings will be disseminated in peer-reviewed journals and conference presentations. Published reports will include group data. Individual data privacy will be strictly maintained.
- diabetes & endocrinology
- qualitative research
- public health
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STRENGTHS AND LIMITATIONS OF THIS STUDY
This research study will employ a multistage cluster sampling approach to select study sites, aiming to thoroughly understand the self-management practices of people with diabetes in rural Bangladesh.
This qualitative study’s inclusive design will collect data from participants with diverse roles and backgrounds and from diverse regions throughout the country, enhancing the validity and trustworthiness of the study’s findings.
This study will be conducted in Bangladesh, a country with a globally high prevalence of diabetes, where the majority of individuals with type 2 diabetes mellitus live in rural areas with limited resources.
Though the study’s participants come from diverse regions of the country, certain local factors may impact the results to limit their wider generalisability.
Background
Type 2 diabetes mellitus (T2DM) has a significant impact on affected individuals, with a detrimental impact on quality of life and a substantial healthcare burden. In addition, it carries significant risk of major microvascular and macrovascular complications, morbidity, mortality and even premature death.1 In recent decades, T2DM has become a worldwide epidemic, disproportionately affecting adults in low-income and middle-income countries (LMICs), which account for an estimated 79.4% of the global population with T2DM.2 Furthermore, compared with high-income countries, people living in LMICs have poor access to health insurance or publicly available medical services, with out-of-pocket health expenditures reflecting a greater proportion of income.3 In 2021, diabetes-related health expenditures were 966 billion US$ globally,4 imposing a significant health and economic burden on individuals, their families and healthcare systems.5–10
In response to the magnitude of the disease burden, the International Diabetes Federation (IDF) strongly advocates the importance of self-management in controlling diabetes.2 In the context of T2DM, self-management is defined as the ability of patients to collaborate with healthcare teams and social networks to cope with their health conditions.11 Studies have demonstrated that effective self-management is the cornerstone of T2DM control,11–17 necessitating that people with T2DM adhere daily to specific behavioural actions. These actions include regularly monitoring blood glucose levels, adhering to a prescribed dietary regimen, being physically active, taking medications (insulin or oral) as prescribed and practising proper foot care.18 19 However, research conducted on diabetes indicates that diabetes self-management is a challenging endeavour globally.20
Bangladesh is an LMIC and the eighth most prevalent for T2DM globally, which affects 13.1 million (12.5%) of its population. This number is projected to increase to 22.3 million by 2045.21 22 Despite the high prevalence, the country’s prevention, control and management awareness is suboptimal,23 24 owing partly to a healthcare service delivery system not well-equipped to meet the rising disease burden.3 25 Approximately 61.8% of the Bangladeshi population live in rural areas,26 which increases risk factors for T2DM and poorer health outcomes compared with those living in urban areas.27 For example, a recent hospital-based study in Bangladesh showed that glycosylated haemoglobin (HbA1c) control was poorer among rural residents (73.7%) than urban residents (57.3%).28 Further, among insulin-dependent patients (65%), 62% had poor HbA1c control (HbA1c >8%).3 Another study in rural Bangladesh showed that 75% of people with diabetes were neglectful in managing diabetes, and 78% had poor adherence to blood glucose monitoring.23 Thus, there is an urgent need to explore factors impacting diabetes self-management practices among people with T2DM in rural Bangladesh.
Previous qualitative investigations in various countries/regions, including the USA, Europe, the UK, Latin America, Africa and South Asia, have evaluated individual, environmental and systemic barriers to self-management practices of individuals with T2DM.29–38 Individual barriers to self-management practices pose significant challenges to adapt to a new lifestyle following the diagnosis of diabetes39 40 including, suboptimal health-related knowledge,41 cultural beliefs,42 a failure to grasp the significance of self-management practices,41 adherence to alternate medications,43 financial constraints44 and lack of social and familial support.45 46 Environmental factors such as disenfranchisement42; limited amenities and an unsafe environment47 and poor weather conditions such as rain, floods, humidity and landslides,48 which may deter physical activity contribute to poor diabetes self-management. In addition, limited access to medications due to transportation constraints during the monsoon season in remote areas has a further deleterious impact on diabetes management and self-management.48 Systemic factors include limited access to patient education resources,49 lack of understanding of the management care plan,50 irregular supply of medicine at health facilities,51 lack of continuity of healthcare and lack of supportive relationships between healthcare service providers and patients.50 On the other hand, family support, cooking healthy meals, encouraging exercise, assisting with medication purchases and facilitating attendance at healthcare appointments are factors that help people with T2DM self-manage their diabetes.52 53 Previous studies suggest that self-management practices are also greatly influenced by a patient’s perceived expectations54 55 of self-management education, social support, problem-solving skills and self-efficacy.56
Until recently, studies were limited in addressing the facilitators and barriers to diabetes self-management practices in the context of multilevel stakeholders (eg, people with T2DM, their family members/caregivers, healthcare service providers, health managers/administrators and policy planners) interacting with and supporting patients with T2DM. Multilevel stakeholders provide opportunities to explore diabetes self-management from various viewpoints and then develop programmes with specific recommendations for diabetes self-management. No study has evaluated the facilitators and barriers to T2DM self-management practices from a multi-stakeholder perspective in Bangladesh, a country with a globally high prevalence of diabetes, where the majority of people with T2DM reside in rural areas facing unique healthcare challenges and limited resources. Additionally, no study has applied a theoretical framework to guide a comprehensive analysis of self-management practice determinants in rural Bangladesh or similar settings elsewhere. Moreover, the literature has not addressed various stakeholders’ expectations for conducting an effective self-management intervention programme in rural Bangladesh.
To address these gaps, this qualitative study explores the potential facilitators, barriers and expectations of effective T2DM self-management practices in rural Bangladesh from a multilevel stakeholders’ perspective. The information will help develop need-oriented self-management intervention programmes for rural Bangladeshi people with T2DM.
Specific objectives
To explore facilitators and barriers to diabetes self-management practices from the perspective of patients and their caregivers in rural Bangladesh.
To assess the constraints and opportunities of diabetes self-management practices from the healthcare service provider’s perspective in rural Bangladesh.
To understand how diabetes self-management practices can be improved in rural Bangladesh (eg, culturally appropriate health information/programmes, the use of guidelines, the promotion of a healthy lifestyle, medical adherence improvements).
This study will explore facilitators and barriers to diabetes self-management practices in rural Bangladesh from a multilevel perspective. In addition, the expectation, implementation and adoption capacity of diabetes self-management programmes in a rural community will be assessed, which is expected to influence T2DM-related service provision in the country (table 1).
Overview of study objectives, discussion points, themes and data sources
Methods
Study settings and the health system in Bangladesh
The health system in Bangladesh is pluralistic–multiple bodies and providers in the government or public sectors, private operators for-profit, non-governmental organisations and charities (not-for-profit) or donor agencies (developing partners/aids). These entities play roles in applying a mixed system of medical practices under the Ministry of Health and Family Welfare and Ministry of Local Government Rural Development and Co-operatives57 (figure 1). In addition to the above-mentioned providers, informal healthcare providers such as traditional healers, faith healers, herbalists, unqualified practitioners, drug sellers and homeopaths play a significant role nationwide.26 The administrative structure in Bangladesh comprises 8 divisions, 4 metropolitan cities, 64 districts, 495 upazilas (sub-districts), 4571 union parishads, 40 977 wards and approximately 87 310 villages58 (described in online supplemental figure S1). Based on this, the governing authorities provide a wide range of facilities and services at the tertiary, secondary and primary levels. Tertiary facilities are located at national, divisional and some district levels, offering specialised and advanced care. In addition to divisional levels, the secondary facilities exist at all district levels and in many upazila levels, providing specialised care as well as primary healthcare. Finally, the primary care level exists at the upazila levels, offering basic healthcare services and limited secondary care through the upazila health complexes (the first-level public hospitals) and using promotive, preventive, curative and rehabilitative approaches. A community clinic, the lowest level of static healthcare facility located at the village/ward level, provides outpatient services with promotive and preventive care.
Supplemental material
Health service delivery organisational structure in Bangladesh. Adapted from Bangladesh Health System Review.57 NGO, non-government organisation.
Despite multiple facilities, public sector diabetes care quality is impaired by a lack of resources, staff and equipment, adversely affecting service provision.25 26 59 On the other hand, most private for-profit sector is poorly designed, and the informal sector mostly comprises unqualified, traditional and homeopathic practitioners.59 Diabetes care in Bangladesh is mainly provided by the Bangladesh Diabetic Association, with centres in every district serving as a not-for-profit sector.60 However, access to this care is impacted by individual and environmental barriers such as cost, time, transportation, crowded conditions and distance, particularly for those living in remote or rural areas. Therefore, self-management practices and family support are essential for people with T2DM in rural areas, which can help them use their skills to manage their diabetes effectively.60 61
Study site selection
Bangladesh is geographically divided into eight administrative regions, known as divisions (the first layer), which are further subdivided into districts (the second layer). Each district has several upazilas (the third layer), and each upazila comprises several union parishads (the lowest layer). Each union parishad is further divided into 15–20 villages (approximately).62 The sampling process to be used is presented in figure 2.
Sampling method for focus group discussions.
This study will use a multistage cluster sampling approach. The prevalence of T2DM in Bangladesh is highest in the Dhaka and Chittagong divisions. The remaining divisions (ie, Rajshahi, Khulna, Barishal, Sylhet, Rangpur and Mymensingh) have a similar prevalence.63 One of the two divisions with the highest prevalence and three of the remaining six divisions will be studied. From the four selected divisions, one district within each will be chosen (figure 3). Then, one upazila from each chosen district will be picked. A union parishad will then be selected from the previously identified upazilas. Finally, villages will be selected from each union parishad (figure 2). All of the above selections will be conducted randomly. Notably, the rural population across Bangladesh is typically characterised by similar educational attainment, unemployment, income, reliance on small-scale farming or daily labour and healthcare access.64 The commencement of this study programme is scheduled to begin in June 2023 and will conclude in May 2024. The detailed study timeline is illustrated in online supplemental figure S2.
Study site map.
Study design and population
An exploratory, qualitative approach will be used in this study (figure 4). Qualitative study design focuses on understanding the social world through listening to participants’ viewpoints65 and considering their experiential knowledge. This is useful for understanding unknown phenomena in a problem or generating new ideas for research, such as factors affecting health behaviours and health service utilisation relevant to healthcare practice and policy.66 67 The data collection methods used will be via focus group discussions (FGDs), in-depth interviews (IDIs) and key informant interviews (KIIs) to enable exploration of various aspects of T2DM self-management practices, particularly focusing on social context facilitators and barriers by gathering perspectives on viewpoints, thoughts, expectations and suggestions65 68 from multilevel stakeholders. Data will be collected by interviewers (eg, medical graduates and research assistants) who are experienced in conducting qualitative interviews at various stakeholder levels.
The overall research process through three distinct. CC, Community Clinic; FGDs, focus group discussions; IDIs, in-depth interviews; KIIs, key informant interviews; NGO, non-government organisation; T2DM, type 2 diabetes mellitus; UHC, Upazila Health Complex, CHCP, community health care provider, UH&FPO, upazila health and family planning officer.
The FGDs will be conducted among patients with T2DM and their caregivers.69 The FGDs will aim to define key themes and points of consensus or disagreement gathered through interactions70 and draw on the participants’ individual perceptions and choice of language.71
The aim of the IDIs will be to ensure a mix of staff roles with local-level healthcare service providers, both formal (eg, registered medical officers, facility managers, nurses, pharmacists, nutritionists/dieticians and community healthcare providers) and informal (eg, kabirajs, faith healers and unqualified allopathic doctors). These are rural Bangladesh’s major healthcare service providers.72
The KIIs will be conducted with tertiary-level endocrinologists and/or diabetologists, nutritionists, organisation heads, public health practitioners/experts and policy planners to understand and explore their views on perceived facilitators and barriers to T2DM self-management practices in rural Bangladesh.
Recruitment and sample size determination
Participants for the FGDs will be recruited from selected villages (figure 2). A list of patients with T2DM will be prepared by visiting households in these villages. An explanatory statement with a brief description of the study and its objective will be distributed among potential participants. On showing interest, a potential participant will undergo eligibility screening. Data will be collected from eligible participants on signing a consent form.
A purposive sampling method will be used to select IDI and KII participants. A student investigator will contact participants from healthcare facilities for IDIs/KIIs via telephone, face-to-face or email communications and an appointment for an interview at their office will be made.
The number of interviews (sample size) will be determined following the principle of data saturation, that is, the interviews will be completed when no further new information, dimensions or ideas emerge, as outlined by Guest et al.73 A stepwise technique will be followed to reach data saturation.74 We propose conducting 16 FGDs, 13 IDIs and 9 KIIs to achieve data saturation based on Guest et al’s recommended approach73 (figure 4). This number could vary depending on the observed data redundancy during collection. This will comprise multiple interviewers simultaneously conducting interviews and performing initial/axial coding.75 After two-thirds of the interviews, the research team will perform preliminary coding to determine whether new information, dimensions or themes emerge.
Inclusion/exclusion criteria
People with T2DM and their caregivers
People with T2DM in this study refer to those who are (1) living in a rural setting and aged ≥18 years, (2) diagnosed with T2DM at least 1 year prior and (3) currently under the care of a registered physician. Patients will be excluded based on the following criteria: patients with severe illnesses or those diagnosed with cognitive or mental impairments.
A caregiver refers to a spouse or immediate family member who (1) lives with an individual with T2DM, (2) provides at-home support to an individual with T2DM and (3) assists, as an immediate family member, an individual with T2DM for more than 1 year prior to data collection.48 76 77
Healthcare service providers to conduct IDIs and KIIs
The healthcare service providers to conduct the IDIs include those providing diabetes care in the selected (1) district hospital, (2) upazila health complex, (3) community clinic, (4) diabetes hospital and (5) informal setup at the local level of rural Bangladesh. Further, the healthcare service providers to conduct the KIIs include endocrinologists, diabetologists, dietitians from tertiary-level hospitals that specialise in diabetes, directors from the medical college hospital, public health practitioners/experts and policy planners from public and non-government organisations in Bangladesh. Additionally, IDI and KII participants will be selected based on criteria such as (1) people aged 18 and older, (2) time and availability and (3) volunteer participation.
A few basic norms for selecting the participants are as follows: (1) participants will be selected with diverse characteristics (age, sex, occupation, income) for comprehensive insight, (2) an iterative process will be used to combine data collection and coding and (3) interviewers will maintain reflexivity, acknowledging their roles and biases.26
Research implementation plan and data management
This study will adopt the following sequential tasks: develop interview topic guides, recruitment and training workshops of field personnel, data collection, data processing and analysis and dissemination.
Interview topic guides
Interview topic guides were developed following an extensive literature review and consultation with relevant experts in the area. All guides were translated into Bangla (the native language of interviewers and participants). Following this, a native speaker (student investigator or student supervisor) checked for language clarity. Interview topic guides contained 12–15 key questions with accompanying prompts to explore the in-depth understanding/experiences of self-management practices, accessibility, difficulties and expectations in rural Bangladesh. Detailed interview topic guides can be found in online supplemental table 1.
Further, the interview topic guides will be used to collect information on the existing conditions of health facility services, including infrastructures, challenges and suggestions to improve the situation by interviewing healthcare service providers through IDIs and KIIs. All interview topic guides will be piloted in a similar setting (outside the original field sites) to assess study participants’ and interviewers’ comprehensibility, appropriateness and conformability. Based on the pilot study’s findings, required changes will be made before finalising interview topic guides.
Recruitment and training workshop for field personnel
Two medical graduates and four research assistants with social science backgrounds will be hired ad hoc. A training workshop will be organised to familiarise them with this study’s objectives and the interview guides for conducting FGDs, IDIs and KIIs. An expert group will train the field personnel in qualitative research methods to ensure the field personnel can clearly present the study objectives and the interview guides’ contents. The training workshop will be conducted in person. If the research team’s physical presence is limited, alternative arrangements will be made to hold the training workshop using audio-visual means such as through Skype, Zoom or voice calls. Additionally, two support personnel will be recruited from the area local to the data collection site. They will help the team navigate the area and build rapport with local residents.
Data collection
Transcripts will be generated and audio-recorded to facilitate data analysis. The focus group will be held at a nearby location to the participant’s home. This will be arranged through negotiation between the student investigator and the participants. Further, IDIs and KIIs will be conducted at the participant’s workplace. Written and verbal informed consent will be obtained from each participant before participating. The student investigator will organise and schedule the FGDs, IDIs and KIIs sessions. Each FGD will take approximately 45–60 min, and each IDI or KII will take 30–45 min. However, this process will last for 1 hour for each participant. The student investigator will observe the interviews (IDIs and KIIs) and FGDs by physical participation. Furthermore, two local academic investigators (local student supervisor and local student project investigator) will observe the interviews independently.
Theoretical framework
The social ecological theory addresses the complexities and interdependencies among socioeconomic, cultural, political, environmental, organisational, psychological and biological determinants of health.78 This study will follow Bronfenbrenner’s ecological system theory79 and Whittemore et al’s80 conceptual framework based on the social-ecological model, which is used to explain diabetes prevention and management and has been widely used in health service research.48 This model suggests that, for long-term behaviour change and, therefore, a successful programme, multiple levels of influence must be targeted. Influence levels are categorised as intrapersonal factors, interpersonal factors, institutional factors, community factors and public policy levels.79–83 Intrapersonal factors assess an individual’s ability to change their behaviour to optimise health in diabetes self-management practices, which are influenced by knowledge, attitudes, self-efficacy and self-confidence.84 85 A patient’s interpersonal relationships within a societal context, such as family, caregivers, friends, neighbours, colleagues and healthcare service providers, positively influence their diabetes self-management practices.82 86–88 Social support consists of interpersonal transactions and includes companionship and emotional, tangible and informational care.89 Institutional influences on an individual include work, school or college and religious surroundings. Institutional influences can provide a structural framework to promote healthy behaviours and prevention activities for diabetes-related comorbidities to a large group, thus forming social supports that further facilitate healthy lifestyle adoption.82 Their prescribed geographical location determines an individual’s community factor. Evidence indicates that neighbourhood and communities characteristics affect an individual’s health behaviour.80 85 90 Moreover, public policy influences an individual’s health behaviours through law and policy execution by local and national authorities.
This model is considered an appropriate framework to explain the dynamic interplay of multiple factors that acknowledge influencing causes as either facilitators, barriers or expectations to T2DM self-management practices in rural Bangladesh. Online supplemental figure S3 illustrates how to frame the coding procedure, analyse data and interpret findings.
Data processing and analysis
It is anticipated that a wide range of facilitators, barriers and expectations for T2DM self-management practices will be explored in this study from the perspectives of people with T2DM, their caregivers, healthcare service providers, administrators and policy planners. Anonymity and confidentiality of the information will be maintained by removing personal identifiers from the data. The notes and audio tapes will be saved on secure faculty-allocated network storage Monash (S:) drive. The applications will be accessible only to the research team. Participants’ identifiers, such as names and designations, will be removed from the main database. They will be saved in a separate, secure, electronic folder and not used for data analysis. The research findings will be published in scientific public health journals. The published reports will include group data only, and no individual data or information will be shared.
Once the interviews are completed, triangulating data from FGDs, IDIs and KIIs and comparing and contrasting the viewpoints of different stakeholder groups will strengthen the results on facilitators, barriers and expectations of T2DM self-management practices.91 The participants’ demographic characteristics will be presented as numbers and percentages and mean (±SD) as appropriate. Further, the study’s findings will be reported based on themes according to the social-ecological model level. Based on Bronfenbrenner’s ecological system theory, the analysis will be structured according to intrapersonal, interpersonal, organisational and societal influences on T2DM self-management practices. Interviews will be audio-recorded, transcribed verbatim and then translated into English. The transcripts will first be read multiple times to familiarise with the data, and the student investigator on ATLAS.ti will code the data. Then, the data will be analysed using thematic inductive analysis according to Braun and Clarke’s ‘15-Point Checklist of Criteria for Good Thematic Analysis’,74 and all the patterns will be checked to ensure they are relevant to the research questions. Coded data with similar meanings will be grouped to form subthemes, which will be reviewed multiple times by the student investigator and the research team. Themes will then be finalised by merging common subthemes. Connections between different themes and subthemes will be displayed using thematic maps.74 Finally, these themes will be evaluated to ensure they address the research questions, and relevant quotations will be selected to illustrate the study’s findings.
Quality assurance and rigour
The four most common rigour procedures will be addressed: credibility, transferability, dependability and confirmability.92 Credibility refers to the trustworthiness and believability of the findings. Credibility pertains to the reliability and believability of the results. Member checks will be performed to enhance the credibility of the study’s findings. Participants will review data collection themes and interpretations to ensure they are consistent with the correct interpretation. This study will provide information on study settings and demographic characteristics of the participants to clarify the results’ transferability. Two independent researchers will analyse the data to enhance the reliability of data interpretation. Discrepancies between the two investigators will be resolved through research group discussions. Confirmability and an audit trail will be maintained to record the research process. A peer audit will be performed.
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.
Ethics and dissemination
This research project received ethical approval from the Ethical Review Committee of the Centre for Injury Prevention and Research, Bangladesh (Memo: CIPRB/ERC/2023/14) and the Monash University Human Research Ethics Committee (project number: 39483).
All participants will receive an explanatory statement and the chance to ask questions about the study. Informed consent will be obtained before their participation. Data will be anonymised by removing personal details from transcripts. Research findings will be disseminated in peer-reviewed academic journals and conference presentations. Further, a summary of the research findings will be disseminated through community meetings, news media and advocacy initiatives among policymakers or planners.
Discussion
To the best of our knowledge, this is the first comprehensive study that aims to capture multiple stakeholders’ perspectives on facilitators, barriers and expectations for T2DM self-management practices in rural Bangladesh, engaging those who are more or less vulnerable based on locality and socioeconomic status rather than urban context. The study’s findings will aid policy planners, programme implementers, healthcare professionals and caregivers in developing need-oriented, effective and patient-centred self-management knowledge, skills and practices for people with T2DM in rural Bangladesh. Multiple views will be triangulated to initiate strategies to overcome barriers, reinforce facilitators and align expectations. This will provide evidence for developing a community-based practice approach for diabetes self-management. Further research, focusing on testing and evaluating the pathways proposed by this study, will be conducted to assess effectiveness in improving cost efficacy, and glycaemic control, and enhancing health-related quality of life for those affected by T2DM in rural Bangladesh. Despite rigorous sampling to ensure diverse participant representation across regions of the country, certain local factors may influence the results, potentially limiting their wider generalisability. Further, the exclusive focus of this study on rural populations may limit its generalisability to urban settings. In addition, this study may be subject to biases, including social desirability bias, in which participants may exaggerate or conceal true responses due to embarrassment or privacy concerns.
Ethics statements
Patient consent for publication
References
Supplementary materials
Supplementary Data
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Footnotes
CLH and BB are joint senior authors.
Contributors HAC, CLH, AEJ, LA and BB conceived and designed the study. HAC drafted the manuscript. CLH, AEJ, AK, AKMFR, LA and BB revised the manuscript. CLH and BB provided equal stewardship. The final manuscript has been read and approved by all authors.
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.
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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.