Understanding collaboration in a multi-national research capacity-building partnership: a qualitative study
Varshney et al. Health Research Policy and Systems
Understanding collaboration in a multi- national research capacity-building partnership: a qualitative study
Dinansha Varshney 1
Salla Atkins 0
Arindam Das 2
Vishal Diwan 0 1 3
0 Department of Public Health Sciences, Karolinska Institutet , Stockholm , Sweden
1 Department of Public Health and Environment, RD Gardi Medical College , Ujjain , India
2 Institute of Health Management Research University , Jaipur , India
3 International Centre for Health Research, RD Gardi Medical College , Ujjain , India
Background: Research capacity building and its impact on policy and international research partnership is increasingly seen as important. High income and low- and middle-income countries frequently engage in research collaborations. These can have a positive impact on research capacity building, provided such partnerships are long-term collaborations with a unified aim, but they can also have challenges. What are these challenges, which often result in a short term/ non viable collaboration? Does such collaboration results in capacity building? What are the requirements to make any collaboration sustainable? This study aimed to answer these and other research questions through examining an international collaboration in one multi-country research capacity building project ARCADE RSDH (Asian Regional Capacity Development for Research on Social Determinants of Health). Method: A qualitative study was conducted that focused on the reasons for the collaboration, collaboration patterns involved, processes of exchanging information, barriers faced and perceived growth in research capacity. In-depth interviews were conducted with the principal investigators (n = 12), research assistants (n = 2) and a scientific coordinator (n = 1) of the collaborating institutes. Data were analysed using thematic framework analysis. Results: The initial contact between institutes was through previous collaborations. The collaboration was affected by the organisational structure of the partner institutes, political influences and the collaboration design. Communication was usually conducted online, which was affected by differences in time and language and inefficient infrastructure. Limited funding resulted in restricted engagement by some partners. Conclusion: This study explored work in a large, North-South collaboration project focusing on building research capacity in partner institutes. The project helped strengthen research capacity, though differences in organization types, existing research capacity, culture, time, and language acted as obstacles to the success of the project. Managing these differences requires preplanned strategies to develop functional communication channels among the partners, maintaining transparency, and sharing the rewards and benefits at all stages of collaboration.
International collaboration; Research capacity building; Social determinants of health
Health research capacity can contribute to overall health
system development of any country, particularly in
lowand middle-income countries (LMICs), where there is
less capacity in research [
]. The reasons for low
research output from LMICs can be shortages of local
qualified researchers, limited funding, poor
infrastructure, and lack of expertise in academic writing [
Building and sustaining research capacity within
developing countries is a complex [
], but essential and
effective means of accelerating research contributions to
health and development [
]. However, researchers
have noted that 90% of global research investments
addresses the needs of only 10% of the world’s
population . Most research output is also from
highincome countries [
Facilitating collaboration between developed and
developing counterparts [
] could result in higher
research outputs from LMICs [
]. To this end,
organisations, such as the Council on Health Research
for Development (COHRED) in 2003, were created at
the global level to work directly with governments in
LMICs to promote national and international
collaborations . Research collaboration in general has
grown in importance for scientists, research
organisations and policymakers [
]. However, in spite of
many initiatives, generally originating from
highincome countries, collaborations are often criticised
for failing to strengthen, incorporate, and involve
lowincome partners in priority setting and publications,
and research collaboration does not always result in
increased outputs [
]. An international,
cross-disciplinary, project faces many challenges, such as
communication and coordination problems, misunderstandings, and
mismatched expectations. Participants in such projects
come from different fields of work and work for a unified
goal, and are usually dependent on each other [
Therefore, the responsibility for making such collaboration
successful falls onto the lead researchers, leading others
at partner universities and institutes. This management
of multiple stakeholders with different resources and
expectations is also a challenge [
]. It is suggested
that successful research collaborations need exploration
and identification of areas of interventions, effective
dissemination strategies, uptake of results and, most
importantly, the commitment of the partner countries
]. Barriers to successful collaboration include,
amongst others, aims that are not shared, unequal
distribution of power, lack of trust, ineffective
membership structures and poor leadership .
Despite these challenges, international collaborations
are often presented as a panacea for particularly
complex issues and problems that exist within the fields
of policy and politics in a wide range of international
]. Many benefits and requirements of
such interventions are documented in the past, but
the actual process of the collaboration has been
studied infrequently. Given the challenges in
transdisciplinary and international collaborative research,
and the possible barriers to success, it is important to
learn from existing collaborations to give
recommendations for countering challenges. Therefore, we aimed to
understand (1) What are these challenges, which
often result in a short-term/non-viable collaboration?
(2) Does such collaboration result in capacity
building? and (3) What are the requirements to make
collaborations sustainable? in one multi-country
research collaboration, ARCADE RSDH (Asian Regional
Capacity Development Research on Social
Determinants of Health).
ARCADE RSDH Project
ARCADE RSDH (www.arcade-project.org) was
developed in response to inequities in health in the Asian
context, coinciding with weak local health research
capacity, especially in the social determinants of
health (SDH) research [
]. The project originated as
an adaptation of its sister project ARCADE HSSR.
The project developed and progressed through funds
from the European Union. The purpose of this
collaboration was to add new research training capacity by
training a new generation of researchers. The focus
was on postgraduate, doctoral and postdoctoral
training in LMICs in Asia, and on the promotion of
research on the SDH [
]. Under this collaboration,
many courses were developed and delivered across
institutions, and institutional capacity in grants
management and communications was built [
Various innovative technologies were used by the
project to produce world class online learning modules.
Through innovative technology, courses were made
available to researchers in LMICs that may not
otherwise have had access to such material. The list
of ARCADE partners is shown in Table 1.
The ARCADE Consortia
ARCADE RSDH operated through 12 universities
operating within a network with expertise in research
in social determinants of health or related areas.
Karolinska Institutet (KI), based in Sweden,
coordinated the project activities. At each partner
institution, Principal Investigators (PI) were mostly senior
staff, supported by junior staff (postdoctoral fellows,
researchers or PhD students) in running the project.
Activities were developed collaboratively within the
consortium. The consortium had two regional training
centres (hubs; TJMC and SJNANHS, at the time of this
study), each training doctoral and postdoctoral
students, from their own countries, from the other Asian
partners and from the European partners, as well as
open to international student applications. The
European partners and their networks supported the two
regional training centres through staff visits and
exchanges. The two regional training centres supported
each other through exchange of course materials,
experience, skills and staff, joint training programmes
for their students, and joint applications for research
and research training grants in cooperation with
We conducted a qualitative interview study online in R
D Gardi Medical College, Ujjain, India with 12 partner
universities, from India, China, Oman, Vietnam, UK,
Sweden, Finland and South Africa, between March 2014
to June 2014. The study was conducted in the middle
phase of this project.
Email invitations were sent to all the PIs and project staff
of the partner organizations for in-depth interviews,
stating the purpose and objectives of the study. In total, 16
participants from 12 institutions (12 PIs, two research
assistants, one project manager and one scientific
coordinator) participated in the study. Half of the interviewees
were key people involved in formulation and execution of
the project, and the rest played a less central role.
Individual interviews at a time and place convenient to the
participants were conducted in English through Skype in
March and April 2014. The interviews followed a set of
topic guides, which were designed for the following
categories of participants: coordinating organisation partners
with large funding including the hub and partners with
little funding. The topic guide addressed (1) the reasons
for collaboration, (2) how the information was exchanged
and the challenges faced while carrying out project’s
activities, and (3) whether capacity growth has occurred in
the developing country over the course of the
collaboration (Additional file 1). Each interview lasted
approximately 40 to 45 minutes. The interviews were recorded
electronically using a tape recorder. The first author then
transcribed them and this was cross-checked by the last
author (VD). In order to protect anonymity, each
transcript was marked with a unique case identification
number and all names were removed.
The data collected were analyzed using thematic
framework analysis. The transcripts were read and reread and
initial codes were enlisted by research team. Each code
was described briefly. From these codes, a list of
categories were developed which were tabulated using
Microsoft Excel 2010. This framework was applied again on
the transcripts, charting the data onto excel, modifying
categories where necessary. The final framework,
consisting of 52 codes and 16 subcategories was analysed
further to develop seven categories and three themes.
To increase the reliability, the complete thematic
framework was read by the last author independently and
updated. Analyses were discussed repeatedly among the
Three themes emerged from the analysis, namely (1)
collaboration process: perception, phases and patterns;
(2) communication and outputs hampered by Internet
infrastructure and consortium size; and (3) outcomes of
the collaboration: what was actually achieved (Table 2).
but joined the collaboration to extend its
Theme 1: Collaboration process: perception, phases and pattern
The collaboration process theme emerged from the
following categories: (1) perception about the project –
unequal participation depending on available funding;
(2) collaboration process – importance of the network;
and (3) collaboration pattern – challenges between
Category 1: Perception about the project – unequal
participation depending on available funding
A clear understanding about the project aim and goal is
important in an international collaborative project. It
seemed that ARCADE RSDH partners shared an
understanding of the project. Many interviewees saw
ARCADE RSDH as a great way of extending collaboration
and adding research capacity to their own institutes.
“Our institute needs to work with other international
institutes, to enhance our network” – Interviewee,
small partner organisation.
“The peculiarity of this project is that the big partners
have a bigger involvement, stronger roles and they
tend to participate more. The involvement of smaller
partners seems to be a little less involved, but there
are some exceptions in our case” – Interviewee,
Participants regarded the project as a way to
improve both the collaboration capacity at the
organisations as well as the educational capacity of the
Category 2: The collaboration process – importance
The consortium was developed based on previous
working experience. Initially, partners were selected based on
previous working relationships with KIs and knowledge
and interest in the subject area.
“We knew that they were excellent from previous
experience and we wanted to bring the collaboration
to the new project to continue working with them” –
Interviewee, coordinating organisation.
Partner organisations were not just selected because
they were known to the coordinator, they also had to
have expertise and resources to implement the study.
For example, one of the small partners did not have
any previous relation with the coordinating institute,
“No, this is the first time we are working with KI, we
don’t have any previous collaboration with any of the
institute. Our institute is very much aligned to the aim
of the project and we need to enhance our network” –
Interviewee, small partner.
Similar interests with the project’s objectives acted
as a motivation to join the project, though
motivations differed between ‘smaller’ and ‘larger’ partners.
Partners with less funding were motivated to
participate by access to resources and opportunity to
communicate with international experts, which would
ultimately enhance their institute’s scientific/research
carrying capacity. On the other hand, ‘larger’ partners
wished to share their resources and skilful expertise
with the developing institutes in order to help them
gain technical capacity. This kind of mutual interest
aided the collaboration:
“KI approached us to give training to the less
resourced research organisation and we have resources
to help them, so we joined the project” –Interviewee,
“By this kind of collaboration, we could increase
educational resource and communicate with
international experts” – Interviewee, small partner
Category 3: Collaboration pattern – challenges between
The organisational culture and its structure influence
any collaboration to a great extent. In this project,
the preference for collaboration was with universities
due to their flexible working style, though not all the
partners were universities. According to one
interviewee, the bureaucratic structure and other political
issues often made collaboration difficult with some
government run organizations because of their rigid
“The role of politicians is very much higher so it is
much more difficult to work with government institute
especially in India. However, I am working with other
institution in other countries, their political
involvement is not there and it’s easy to work with
them in comparison to India” – Interviewee,
While analysing the pattern of collaboration among
ARCADE RSDH partners, collaboration was seen (1)
between organisations in European countries; (2)
between organisations in European and Asian countries;
(3) between organisations in Asian countries; and (4)
between organisations within the same country.
Active collaboration was seen between the European
partners. One of the European partners is the
coordinating organisation, which receives help from another
European organisation in developing online courses.
The collaboration among Asian and European partners
was seen as good, though there seemed to be less
involvement of smaller Asian partners than the ‘larger’ Asian
“We have this kind of activity of mentorship. We have
expert faculties from Chinese university and IDS [United
Kingdom] ” – Interviewee, small partner organisation.
However, the links between the Asian partners were found
to be weak. Only one or two institutes from Asian countries
collaborated with each other as opposed to collaborating
with European institutes. Some of the reasons mentioned
for this included little interaction and previous experience of
working together between partners. The differences in goals
and administrative structures of the partners (medical
colleges, management and research institutes, universities)
also influenced the collaboration practice negatively.
“We came to know our partner after the consortium
was formed; most of the institutes are universities
different from us so we don’t have much scope to
learn from them” – Interviewee, small partner.
Participants observed that ‘smaller’ partners
collaborated with the hub institutes and other ‘larger’ partner
organisations, but there was no or little interaction
between them. The participants suspected this was caused
by a lack of resources at ‘smaller’ partners, limited
funding and differences in the educational system, language
and culture of the institutes.
“I think, as project needs more communication, many
times we couldn’t get some difference in culture and
language and we have different educational systems
which poses challenges. Yes language is a big problem”
– Interviewee, small partner.
Missing common goals among the partner institutes
may hinder the process of international collaboration.
To some extent, this was the case in ARCADE RSDH –
according to one of the small partner PIs, the
programme intends to build the research capacity of
the institutes by giving training to the PhD students
and not the staff. Therefore, as these institutes did not
have PhD students, they were not active participants.
Theme 2: Communication and outputs hampered by
Internet infrastructure and consortium size
This theme emerged from the following categories: (1)
email facilitating communication in a large consortium,
and (2) the size of the consortium and diverse partners
as a challenge to communication and activity.
Category 1: Email facilitating communication in a large consortium
Technology plays an important role in building
international collaboration. It helps to bridge the cultural
diversity and differences in an international
collaboration such as ARCADE RSDH. Expectations of the
collaboration can be quite different, and therefore good
communication channels between the partners are
important, which is usually facilitated by technology. The
most common and convenient method used in
communicating daily activities was email. Technology such as Skype
and GoToMeeting (www.gotomeeting.com) were used to
arrange online meetings. While reports gave partners an
idea of ongoing activities, the most interaction and sharing
of work occurred at annual meetings:
“This is a huge project so many people have joined
and working in the same year, the best way to get
more response is by email” – Interviewee, small
As the coordinating institute preferred to work via email,
all partners also found that response from the coordinator
“We get loads of emails they are good at providing
emails. They immediately reply. We come to know about
all the activities” – Interviewee, small partner, Asia.
Partners communicated in the consortium to different
degrees – responses to the coordinator varied from
partner to partner. Similarly, the hub institutes reported
getting mixed responses from ‘smaller’ partners, as some
replied promptly and others were more reluctant:
“The main challenge is people don’t respond to
emails so that’s the problem” – Interviewee,
hub institute, Asia.
Category 2: Size of the consortium and diverse partners as a challenge to communication and activity
The size of the consortium, and the diversity of partners,
was one of the challenges in ARCADE RSDH. One of
the main challenges is keeping track of all the ongoing
activities, as ARCADE RSDH had 13 partners:
“Since it is a big workload for the coordinator to keep
track of all the activities of the partners, sometimes
some of the activities go under the radar” –
Interviewee, coordinating institute.
Lack of in-depth knowledge of ongoing activities was
also seen as a barrier to activity by small partners; as
some partners were ignorant about the project activities
they lost interest in the project and became passive:
“We need effective communication we have so many
partners. For example, I don’t know the recent
development of this project and activities done” –
Interviewee, small partner organisation.
As some of the staff contributed to the project
parttime, they were seen as overburdened. They could
contribute only limited hours to the project, some due
to limited budget. According to an interviewee,
parttime involvement also affected the project outputs.
One's entire attention is needed on the project to make
the project successful. Inability to motivate the partners
was also stated as a shortcoming.
“If we want ARCADE to happen really the interest
should be solely focused on ARCADE activities.
Motivation shall be as such that one really pays
attention to this. Now the communication between
the organisations is also must, the annual meeting
is also a problem as not all are able to participate
because of the time difference or the difficulty to
reach the place. Having a conference on Skype is also
difficult” – Interviewee, big partner organisation.
The basic structure of the consortium, in which the
hub institutes communicated with smaller partners and
coordinating institutes, was seen as one of the challenges
in communication. This specific structure sometimes
resulted in turbulent flows of information as the exchange
of information mostly occurred among the coordinating
institute and larger partners and less between small
partners. Smaller partners were mostly dependent on the
hub institute for communication:
“Another problem is the structure of ARCADE is based
on hub working/communicating with small institutes
in some way that has not been working and this is
creating a problem” – Interviewee, coordinating
According to the participants, new ways should have
been explored to engage all the partners in the project.
To increase their involvement, they should be told about
the benefits of engaging themselves in grant writing and
grant management workshops, which will later help
them build their research capacity. The diversity of
partners meant that there were several challenges to address
in communication, including lack of infrastructure for
communication and time differences.
Lack of infrastructure as barrier to collaboration
Within the large consortium, lacking infrastructure,
including internet facilities in ‘small’ partner organisations,
affected the planned ongoing activities of the project.
Even if Internet was available, the bandwidth may not
have been sufficient, which was one of the most
important prerequisites for conducting online courses and
other online activities for a project like ARCADE RSDH.
All this resulted in a weak collaboration, especially among
the small partners and between small and big partners.
“If you want to give good video or audio, bandwidth
shall be good, but the institute is not able to give its
entire bandwidth to this education” – Interviewee,
As can be expected, no technical issues were reported
in European partners.
As many of the partners were from different countries,
time differences also hampered the collaboration and
resulted in increased dependency on the use of email.
Arranging online meetings with all the partners was
difficult as any time decided was odd for one or
“Setting up of some meeting, which would engage
one person from Canada and other partners based
in China and Vietnam, bringing up everyone in the
same meeting is challenging” – Interviewee,
The small partners, who were less active, did not find
timing as a major issue in collaboration.
“Until now, we have not arranged any such meetings
so I don’t see any challenge, it’s just a management
issue” – Interviewee, small institute.
Theme 3: Outcomes of the collaboration: what was actually achieved?
This theme emerged from the following categories: (1)
limited effects on research training capacity and (2)
infrastructure development as an additional outcome.
Category 1: Limited effects on research training capacity
Participants felt that building research capacity for any
institute is a gradual process and takes time, though
enhancement in the research capacity was certainly
“Increase in research carrying capacity, specifically
in SDH [social determinants of health] is not that
significant, if judged by the no of proposals submitted
for funding. But it will soon become better. I cannot
score it high” – Interviewee, small partner
Hub institutes felt that their capacity had increased,
with mentoring activities, development and networks
“There are courses which are not developed in our
institute but are developed by other partner
organisations, so our students get the benefit of those
courses. Other than that it’s an internal learning too,
how to work in collaboration with other organisations”
– Interviewee, big partner organisation, European
According to participants, mapping the impact of
research capacity building activities was essential to an
international collaborative project. For this, certain
indicators were to be developed. ARCADE RSDH had some
process indicators to assess the ongoing activities in the
project, but those were not sufficient to map the gain in
the research carrying capacity of the partner institute.
“This is something we haven’t really captured with
indicators as to how our project is progressing and
this is very much qualitative and depends on the
level of satisfaction, etc.” – Interviewee, coordinating
Category 2: Infrastructure development as an additional outcome
Some participants reported that they had developed in
terms of infrastructure, which they were lacking earlier,
and had become increasingly aware about grant
management and implementation of online activities such
as meetings and courses. An increase in human
resource capacity was also observed in partner
organisations. Specific platforms for online learning, such as
Moodle (www.moodle.org) were adopted and developed
by the hub institutes to conduct online courses. Many
blended courses had been conducted across the partner
institutes and a good enrolment of students for these
courses was seen.
“Staff has increased so small partner organisation’s
capacity has also grown. I think last time, when
online activities were conducted, they were not that
good as of now. Things are better technically
[Internet connectivity]” – Interviewee, hub institute.
This study explored the process of collaboration in an
international collaborative project, ARCADE RSDH,
which focused on building research capacity of young
postgraduate, doctoral and postdoctoral researchers.
The project activities were carried out in a collaborative
environment, with different collaborative partners and
a unified goal [
]. The project partners were assigned
different roles that ranged from providing the resources
to being the end-users of materials developed within
the project. The study highlighted how a collaboration
begins and develops, and the challenges and solutions
for communication and achieving the set goals.
Collaborative projects are often seen challenging, as
the project managers come from different organisations
and backgrounds to work together. The diversity in
cultural and national backgrounds, skill sets and expertise,
and managerial roles, results in different expectations,
which may be difficult to meet [
ARCADE RSDH had 12 partners with diverse cultural
and organisational backgrounds, which were brought
together mainly due to previous working relationships. It is
often seen that human, linguistic or social ties form as a
result of historical interactions and support present-day
]. The partners involved in ARCADE
were known to each other through previous work relations,
though not all of them were familiar with each other. These
working relationships were not necessarily long term.
Other studies have suggested that spatial proximity
encourages collaboration [
]. ARCADE RSDH did not
seem to be influenced by spatial proximity as much as
previous working ties. However, the geographic spread
also created challenges in collaboration, including time
zones, organisational cultures and distance to meetings
despite an active use of online resources. In order to
counter the effects of distance, emails were used as the
main mode of communication. However, email is usually
overloaded and often missed by project staff [
and thus may not be the most effective mode of
communication . Project-related communication was
enhanced by quarterly and annual meetings, but not all
partners attended these. In order to overcome these
communication challenges a robust communication
strategy should be planned, which should encourage
face-to-face interaction among all the project partners,
taking into account the time and cultural differences in
the beginning phase of the project [
One of the barriers found in this project, both with
regards to communication and achieving outcomes, was
understanding each other’s infrastructures and
administrative organisations. In this collaboration, some partners
who initially committed to the project later became
passive. This could have been due to incentives not
aligning with the demand for achievements, recognition
and rewards [
]. Lack of a clear understanding
about other partners’ organizational structure and
working style is also one of the reason behind them becoming
passive. Successful collaborations require an
understanding of each other’s working environment from the
project planning stage of the partnership in order to get a
clear insight about each other’s working methods. This
alignment can be achieved by openly discussing the
differences and processing them at the beginning of the
project, enhancing a focus driven collaboration .
Paradoxically to the aim of collaborations to enhance
research capacity, existing research capacity in an
institute also attracted collaboration with international
partners in our study. Research indicates that scientific
research requires a ‘baseline’ level of scientific
infrastructure to make collaboration effective in capacity
]. Therefore, institutions that do not have
capacity at that critical level may not attract further
capacity building, an issue that deserves attention and
One reason for “smaller” partners becoming passive
could be the funding structure and management
structure that operated through hubs [
]. In another
collaboration, African partners could not contact each other
directly and were obliged to direct their communication
through United Kingdom-based researchers [
6, 34, 35
This kind of structure can decrease communication
among the partners, and thus result in passivity.
Attention should also be paid to funding structure in projects.
‘Small’ partners with limited resources cannot commit
resources, including staff, to projects fully. Paying
attention to ‘smaller’ partners’ needs is important in planning
activities. This helps enhance their research capacity,
and in ensuring an equitable approach to capacity
Long and sustained collaboration is key to a project’s
positive outcome. Sustained, systematic effort is
particularly needed in collaborations aiming to build
research capacity [
]. Short-term collaborations often
lead to loss of existing achievements, especially in
LMICs, with capacities left unused and researchers
migrating away in search of other job opportunities
]. Research projects receive funding for a short
period, which allows the creation of the project, but
sustaining it longer when timelines are strict and
further financing limited is challenging [
RSDH was a 4-year span project, which received its
funding from the European Union Seventh Framework
Programme. These activities came to an end after
4 years, though relationships were developed with
project partners. Our participants felt that collaboration
in ARCADE RSDH had indeed helped to develop
research carrying capacity of partner organisations in
various ways, though the activities initiated should
have been carried on further as research capacity
building takes many years and systematic effort and is
not built in a short time frame.
This study explored international collaboration using a
cross-sectional, qualitative study. As the study was
conducted at a particular point of time during the middle
phase of the project, it cannot represent the working of
the collaboration during the entire project. Following
the implementation from the beginning to the end may
have yielded more substantial results. This study did not
assesses the process indicators and outcomes of activities
planned during the project. Evaluation of such indicators
in future will give more insight of research collaboration
in such a large consortium.
This study explored work in a large, North–South
collaboration project focusing on building research capacity
in partner institutes. Collaborative partners emphasised
the need to set up clear targets, communication
strategies and align research interests at the start of
collaboration. Managing these challenges requires
preplanned strategies to develop proper communication
channels among the partners, maintaining
transparency, and sharing the rewards and benefits at all stages
of collaboration. North–South collaborations should
ensure that funding is equitable to ensure active
participation. Collaborations such as ARCADE RSDH have
potential to build research capacity in all partners, but
such activity needs sustained and systematic effort.
Additional file 1: Topic Guide – Understanding collaboration in a
multi-national research capacity-building partnership. (DOCX 18 kb)
ARCADE RSDH, Asian Regional Capacity Development Research on Social
Determinants of Health; LMIC, low- and middle-income countries
We acknowledge all our respondents for their participation in this study.
The research received funding from the European Union’s Seventh Framework
Programme (FP7/2007-2013) under grant agreement number 281930, ARCADE
RSDH. The funders had no role in study design, data collection and analysis,
decision to publish, or preparation of the manuscript.
Availability of data and materials
Due to ethical and legal restrictions, all inquiries should be made to The
Chairman, Ethics Committee, RD Gardi Medical College, Agar Road, Ujjain,
India 456006 (Emails: , ), giving all
details of the publication. Upon verification of genuineness of the inquiry,
the data will be made available. For reference, please quote ethical
permission no. 414 dated 20/5/2014.
DV, SA, AD and VD conceived and designed the study; DV collected and
analyzed the data and wrote the first draft. SA and VD contributed in further
analysis and refining of the results and provided intellectual content in the
writing of the manuscript. All authors approved the final version.
The authors declare that they have no competing interests.
Ethics approval and consent to participate
The study was approved by ethics committee of RD Gardi Medical College,
Ujjain (no 414 dated 20/5/2014). Informed consent was obtained from all the
participants for the interview and recording and the information collected
from all the respondents was kept confidential and anonymous.
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