Challenges and opportunities for competency-based health professional education in Bangladesh: an interview, observation and mapping study.

BACKGROUND: Bangladesh has a shortfall of health professionals. The World Health Organization states that improving education will increase recruitment and retention of health workers. Traditional learning approaches, in medical education particularly, focus on didactic teaching, teaching of subjects and knowledge testing. These approaches have been superseded in some programmes, with a greater focus on active learning, integrated teaching and learning of knowledge, application, skills and attitudes or values and associated testing of competencies as educational outcomes. In addition, some regions do not have continuous professional development or clinical placements for health worker students, contributing to difficulties in retention of health workers. This study aims to explore the experiences of health professional education in Bangladesh, focusing on what is through observation of health professional education sessions and experiences of educators. METHODS: This mixed method study included 22 observations of teaching sessions in clinical and educational settings, detailed analysis of 8 national curricula documents mapped to Global Competency and Outcomes Framework for Universal Health Coverage and 15 interviews of professionals responsible for health education. An observational checklist was created based on previous literature which assessed training of within dimensions of basic clinical skills; diagnosis and management; professionalism; professional development; and effective communication. Interviews explored current practices within health education in Bangladesh, as well as barriers and facilitators to incorporating different approaches to learning. RESULTS: Observations revealed a variety of approaches and frameworks followed across institutions. Only one observation included all sub-competencies of the checklist. National curricula documents varied in their coverage of the Global Competency and Outcomes Framework domains. Three key themes were generated from a thematic analysis of interview transcripts: (1) education across the career span; (2) challenges for health professional education; (3) contextual factors and health professional education. Opportunities for progression and development post qualification are limited and certain professions are favoured over others. CONCLUSION: Traditional approaches seem to predominate but there is some enthusiasm for a more clinical focus to education and for more competency based approaches to teaching, learning and assessment.

Sub-district level correlation between tuberculosis notifications and socio-demographic factors in Dhaka City corporation, Bangladesh.

We developed a novel method to align two data sources (TB notifications and the Demographic Health Survey, DHS) captured at different geographic scales. We used this method to identify sociodemographic indicators - specifically population density - that were ecologically correlated with elevated TB notification rates across wards (~100 000 people) in Dhaka, Bangladesh. We found population density was the variable most closely correlated with ward-level TB notification rates (Spearman's rank correlation 0.45). Our approach can be useful, as publicly available data (e.g. DHS data) could help identify factors that are ecologically associated with disease burden when more granular data (e.g. ward-level TB notifications) are not available. Use of this approach might help in designing spatially targeted interventions for TB and other diseases in settings of weak existing data on disease burden at the subdistrict level.

Quantifying geographic heterogeneity in TB incidence and the potential impact of geographically targeted interventions in South and North City Corporations of Dhaka, Bangladesh: a model-based study.

In rapidly growing and high-burden urban centres, identifying tuberculosis (TB) transmission hotspots and understanding the potential impact of interventions can inform future control and prevention strategies. Using data on local demography, TB reports and patient reporting patterns in Dhaka South City Corporation (DSCC) and Dhaka North City Corporation (DNCC), Bangladesh, between 2010 and 2017, we developed maps of TB reporting rates across wards in DSCC and DNCC and identified wards with high rates of reported TB (i.e. 'hotspots') in DSCC and DNCC. We developed ward-level transmission models and estimated the potential epidemiological impact of three TB interventions: active case finding (ACF), mass preventive therapy (PT) and a combination of ACF and PT, implemented either citywide or targeted to high-incidence hotspots. There was substantial geographic heterogeneity in the estimated TB incidence in both DSCC and DNCC: incidence in the highest-incidence wards was over ten times higher than in the lowest-incidence wards in each city corporation. ACF, PT and combined ACF plus PT delivered to 10% of the population reduced TB incidence by a projected 7%-9%, 13%-15% and 19%-23% over five years, respectively. Targeting TB hotspots increased the projected reduction in TB incidence achieved by each intervention 1.4- to 1.8-fold. The geographical pattern of TB notifications suggests high levels of ongoing TB transmission in DSCC and DNCC, with substantial heterogeneity at the ward level. Interventions that reduce transmission are likely to be highly effective and incorporating notification data at the local level can further improve intervention efficiency.

Eye diseases: the neglected health condition among urban slum population of Dhaka, Bangladesh.

INTRODUCTION: Globally, eye diseases are considered as one of the major contributors of nonfatal disabling conditions. In Bangladesh, 1.5% of adults are blind and 21.6% have low vision. Therefore, this paper aimed to identify the community-based prevalence and associated risk factors of eye diseases among slum dwellers of Dhaka city. METHODS: The study was carried out in two phases. In the first phase, a survey was conducted using multistage cluster sampling among 1320 households of three purposively selected slums in Dhaka city. From each household, one family member (≥ 18 years old) was randomly interviewed by trained data collectors using a structured questionnaire. After that, each of the participants was requested to take part in the second phase of the study. Following the request, 432 participants out of 1320 participants came into the tertiary care hospitals where they were clinically assessed by ophthalmologist for presence of eye diseases. A number of descriptive and inferential statistics were performed using Stata 13. RESULT: The majority of total 432 study participants were female (68.6%), married (82.6%) and Muslim (98.8%). Among them almost all (92.8%) were clinically diagnosed with eye disease. The most prevalent eye diseases were refractive error (63.2%), conjunctivitis (17.1%), visual impairment (16.4%) and cataract (7.2%). Refractive error was found significantly associated with older age, female gender and income generating work. Cataract was found negatively associated with the level of education, however, opposite relationship was found between cataract and visual impairment. CONCLUSION: Our study provides epidemiologic data on the prevalence of eye diseases among adult population in low-income urban community of Dhaka city. The high prevalence of refractive error, allergic conjunctivitis, visual impairment, and cataract among this group of people suggests the importance of increasing access to eye care services.

Cross-cultural adaptation of the short-form condom attitude scale: validity assessment in a sub-sample of rural-to-urban migrant workers in Bangladesh.

BACKGROUND: The reliable and valid measurement of attitudes towards condom use are essential to assist efforts to design population specific interventions aimed at promoting positive attitude towards, and increased use of condoms. Although several studies, mostly in English speaking western world, have demonstrated the utility of condom attitude scales, very limited culturally relevant condom attitude measures have been developed till to date. We have developed a scale and evaluated its psychometric properties in a sub-sample of rural-to-urban migrant workers in Bangladesh. METHODS: This paper reports mostly on cross-sectional survey components of a mixed methods sexual health research in Bangladesh. The survey sample (n = 878) comprised rural-to-urban migrant taxi drivers (n = 437) and restaurant workers (n = 441) in Dhaka (aged 18-35 years). The study also involved focus group sessions with same populations to establish the content validity and cultural equivalency of the scale. The current scale was administered with a large sexual health survey questionnaire and consisted of 10 items. Quantitative and qualitative data were assessed with statistical and thematic analysis, respectively, and then presented. RESULTS: The participants found the scale simple and easy to understand and use. The internal consistency (α) of the scale was 0.89 with high construct validity (the first component accounted for about 52% of variance and second component about 20% of the total variance with an Eigen-value for both factors greater than one). The test-retest reliability (repeatability) was also found satisfactory with high inter-item correlations (the majority of the intra-class correlation coefficient values was above 2 and was significant for all items on the scale, p < 0.001). The 2-week repeatability assessed by the Pearson product-moment correlation coefficient was 0.75. CONCLUSION: The results indicated that Bengali version of the scale have good metric properties for assessing attitudes toward condom use. Validated scale is a short, simple and reliable instrument for measuring attitudes towards condom use in vulnerable populations like current study sample. This culturally-customized scale can be used to monitor the progress of condom uptake and promotion activities in Bangladesh or similar settings.

Evaluation of a Mobile-Based Immunization Decision Support System for Scheduling Age-Appropriate Vaccine Schedules for Children Younger Than 2 Years in Pakistan and Bangladesh: Lessons From a Multisite, Mixed Methods Study.

BACKGROUND: Missed opportunities for vaccination (MOVs), that is, when children interact with the health system but fail to receive age-eligible vaccines, pose a crucial challenge for equitable and universal immunization coverage. Inaccurate interpretations of complex catch-up schedules by health workers contribute to MOVs. OBJECTIVE: We assessed the feasibility of a mobile-based immunization decision support system (iDSS) to automatically construct age-appropriate vaccination schedules for children and to prevent MOVs. METHODS: A sequential exploratory mixed methods study was conducted at 6 immunization centers in Pakistan and Bangladesh. An android-based iDSS that is packaged in the form of an application programming interface constructed age-appropriate immunization schedules for eligible children. The diagnostic accuracy of the iDSS was measured by comparing the schedules constructed by the iDSS with the gold standard of evaluation (World Health Organization-recommended Expanded Programme on Immunization schedule constructed by a vaccines expert). Preliminary estimates were collected on the number of MOVs among visiting children (caused by inaccurate vaccination scheduling by vaccinators) that could be reduced through iDSS by comparing the manual schedules constructed by vaccinators with the gold standard. Finally, the vaccinators' understanding, perceived usability, and acceptability of the iDSS were determined through interviews with key informants. RESULTS: From July 5, 2019, to April 11, 2020, a total of 6241 immunization visits were recorded from 4613 eligible children. Data were collected for 17,961 immunization doses for all antigens. The iDSS correctly scheduled 99.8% (17,932/17,961) of all age-appropriate immunization doses compared with the gold standard. In comparison, vaccinators correctly scheduled 96.8% (17,378/17,961) of all immunization doses. A total of 3.2% (583/17,961) of all due doses (across antigens) were missed in age-eligible children by the vaccinators across both countries. Vaccinators reported positively on the usefulness of iDSS, as well as the understanding and benefits of the technology. CONCLUSIONS: This study demonstrated the feasibility of a mobile-based iDSS to accurately construct age-appropriate vaccination schedules for children aged 0 to 23 months across multicountry and low- and middle-income country settings, and underscores its potential to increase immunization coverage and timeliness by eliminating MOVs.

Uptake and Completion of Tuberculosis Preventive Treatment Using 12-Dose, Weekly Isoniazid-Rifapentine Regimen in Bangladesh: A Community-Based Implementation Study.

BACKGROUND: The United Nations high-level meeting (UNHLM) pledged to enroll 30 million in tuberculosis preventive treatment (TPT) by 2022, necessitating TPT expansion to all at tuberculosis (TB) risk. We assessed the uptake and completion of a 12-dose, weekly isoniazid-rifapentine (3HP) TPT regimen. METHODS: Between February 2018 and March 2019 in Dhaka, community-based TPT using 3HP targeted household contacts of 883 confirmed drug-sensitive pulmonary TB patients. Adhering to World Health Organization guidelines, contacts underwent active TB screening before TPT initiation. RESULTS: Of 3193 contacts who were advised health facility visits for screening, 67% (n = 2149) complied. Among these, 1804 (84%) received chest X-rays. Active TB was diagnosed in 39 (2%) contacts; they commenced TB treatment. Over 97% of 1216 contacts began TPT, with completion rates higher among females, those with more education and income, non-slum residents, and those without 3HP-related adverse events. Adverse events, mainly mild, occurred in 5% of participants. CONCLUSIONS: The 3HP regimen, with its short duration, self-administered option, and minimal side effects, achieved satisfactory completion rates. A community-focused TPT approach is feasible, scalable nationally, and aligns with UNHLM targets.

Prevalence of co-morbid depression in out-patients with type 2 diabetes mellitus in Bangladesh.

BACKGROUND: Little is known about the prevalence of depression in people with diabetes in Bangladesh. This study examined the prevalence and factors associated with depression in out-patients with Type 2 diabetes in Bangladesh. METHODS: In this cross-sectional study a random sample of 483 diabetes out-patients from three diabetes clinics in Bangladesh was invited to participate. Of them 417 patients took part. Depressive symptoms were measured using previously developed and culturally standardized Bengali and Sylheti versions of the World HealthOrganization-5 Well Being Index (WHO-5) and the Patient Health Questionairre-9 (PHQ-9) with predefined cut-off scores. Data was collected using two different modes; e.g. standard assisted collection and audio questionnaire methods. Associations between depression and patient characteristics were explored using regression analysis. RESULTS: The prevalence of depressive symptoms was 34% (PHQ-9 score ≥ 5) and 36% (WHO-5 score < 52) with audio questionnaire delivery method. The prevalence rates were similar regardless of the type (PHQ-9 vs. WHO-5) and language (Sylheti vs. Bengali) of the questionnaires, and methods of delivery (standard assisted vs. audio methods). The significant predictors of depressive symptoms using either the PHQ-9 or WHO-5 questionnaires were; age, income, gender, treatment intensity, and co-morbid cardiovascular disease. Further, depression was strongly associated with poor glycaemic control and number of co-morbid conditions. CONCLUSIONS: This study demonstrated that depression prevalence is common in out-patients with type 2 diabetes in Bangladesh. In a setting where recognition, screening and treatment levels remain low, health care providers need to focus their efforts on diagnosing, referring and effectively treating this important disease in order to improve service delivery.

Holistic Approach to Tuberculosis Detection, Treatment and Prevention: Emerging Evidence and Strategies from the Field.

The global fight against tuberculosis (TB) has gained momentum since the adoption of the 'End TB Strategy' in 2014 [...].

A comprehensive situation assessment of injection practices in primary health care hospitals in Bangladesh.

BACKGROUND: Understanding injection practices is crucial for evidence-based development of intervention initiatives. This study explored the extent of injection use and injection safety practices in primary care hospitals in Bangladesh. METHODS: The study employed both quantitative and qualitative research methods. The methods used were--a retrospective audit of prescriptions (n = 4320), focus group discussions (six with 43 participants), in-depth interviews (n = 38) with a range service providers, and systematic observation of the activities of injection providers (n = 120), waste handlers (n = 48) and hospital facilities (n = 24). Quantitative and qualitative data were assessed with statistical and thematic analysis, respectively, and then combined. RESULTS: As many as 78% of our study sample (n = 4230) received an injection. The most commonly prescribed injections (n = 3354) including antibiotics (78.3%), IV fluids (38.6%), analgesics/pain killers (29.4%), vitamins (26.7%), and anti-histamines (18.5%). Further, 43.7% (n = 1145) of the prescribed antibiotics (n = 2626) were given to treat diarrhea and 42.3% (n = 600) of IV fluids (n = 1295) were used to manage general weakness conditions. Nearly one-third (29.8%; n = 36/120) of injection providers reported needle-stick injuries in the last 6 months with highest incidences in Rajshahi division followed by Dhaka division. Disposal of injection needles, syringes and other materials was not done properly in 83.5% (n = 20/24) of the facilities. Health providers' safety concerns were not addressed properly; only 23% (n = 28/120) of the health providers and 4.2% (n = 2/48) of the waste handlers were fully immunized against Hepatitis B virus. Moreover, 73% (n = 87/120) of the injection providers and 90% (n = 43/48) of the waste handlers were not trained in injection safety practices and infection prevention. Qualitative data further confirmed that both providers and patients preferred injections, believing that they provide quick relief. The doctors' perceived injection use as their prescribing norm that enabled them to prove their professional credibility and to remain popular in a competitive health care market. Additionally, persistent pressure from hospital administration to use up injections before their expiry dates also influenced doctors to prescribe injections regardless of actual indications. CONCLUSIONS: As far as the patients and providers' safety is concerned, this study demonstrated a need for further research exploring the dynamics of injection use and safety in Bangladesh. In a context where a high level of injection use and unsafe practices were reported, immediate prevention initiatives need to be operated through continued intervention efforts and health providers' training in primary care hospitals in Bangladesh.

Incorporating patient reporting patterns to evaluate spatially targeted TB interventions.

PURPOSE: Tuberculosis (TB) is geographically heterogeneous, and geographic targeting can improve the impact of TB interventions. However, standard TB notification data may not sufficiently capture this heterogeneity. Better understanding of patient reporting patterns (discrepancies between residence and place of presentation) may improve our ability to use notifications to appropriately target interventions. METHODS: Using demographic data and TB reports from Dhaka North City Corporation and Dhaka South City Corporation, we identified wards of high TB incidence and developed a TB transmission model. We calibrated the model to patient-level data from selected wards under four different reporting pattern assumptions and estimated the relative impact of targeted versus untargeted active case finding. RESULTS: The impact of geographically targeted interventions varied substantially depending on reporting pattern assumptions. The relative reduction in TB incidence, comparing targeted with untargeted active case finding in Dhaka North City Corporation, was 1.20, assuming weak correlation between reporting and residence, versus 2.45, assuming perfect correlation. Similar patterns were observed in Dhaka South City Corporation (1.03 vs. 2.08). CONCLUSIONS: Movement of individuals seeking TB diagnoses may substantially affect ward-level TB transmission. Better understanding of patient reporting patterns can improve estimates of the impact of targeted interventions in reducing TB incidence. Incorporating high-quality patient-level data is critical to optimizing TB interventions.

Securing recruitment and obtaining informed consent in minority ethnic groups in the UK.

BACKGROUND: Previous health research has often explicitly excluded individuals from minority ethnic backgrounds due to perceived cultural and communication difficulties, including studies where there might be language/literacy problems in obtaining informed consent. This study addressed these difficulties by developing audio-recorded methods of obtaining informed consent and recording data. This report outlines 1) our experiences with securing recruitment to a qualitative study investigating alternative methods of data collection, and 2) the development of a standardised process for obtaining informed consent from individuals from minority ethnic backgrounds whose main language does not have an agreed written form. METHODS: Two researchers from South Asian backgrounds recruited adults with Type 2 diabetes whose main language was spoken and not written, to attend a series of focus groups. A screening tool was used at recruitment in order to assess literacy skills in potential participants. Informed consent was obtained using audio-recordings of the patient information and recording patients' verbal consent. Participants' perceptions of this method of obtaining consent were recorded. RESULTS: Recruitment rates were improved by using telephone compared to face-to-face methods. The screening tool was found to be acceptable by all potential participants. Audio-recorded methods of obtaining informed consent were easy to implement and accepted by all participants. Attrition rates differed according to ethnic group. Snowballing techniques only partly improved participation rates. CONCLUSION: Audio-recorded methods of obtaining informed consent are an acceptable alternative to written consent in study populations where literacy skills are variable. Further exploration of issues relating to attrition is required, and a range of methods may be necessary in order to maximise response and participation rates.

Hygiene on maternity units: lessons from a needs assessment in Bangladesh and India.

BACKGROUND: As the proportion of deliveries in health institutions increases in low- and middle-income countries, so do the challenges of maintaining standards of hygiene and preventing healthcare-associated infections (HCAIs) in mothers and babies. Adequate water, sanitation, and hygiene (WASH) and infection prevention and control (IPC) in these settings should be seen as integral parts of the broader domain of quality care. Assessment approaches are needed which capture standards for both WASH and IPC, and so inform quality improvement processes. DESIGN: A needs assessment was conducted in seven maternity units in Gujarat, India, and eight in Dhaka Division, Bangladesh in 2014. The WASH & CLEAN study developed and applied a suite of tools - a 'walkthrough checklist' which included the collection of swab samples, a facility needs assessment tool and document review, and qualitative interviews with staff and recently delivered women - to establish the state of hygiene as measured by visual cleanliness and the presence of potential pathogens, and individual and contextual determinants or drivers. RESULTS: No clear relationship was found between visually assessed cleanliness and the presence of pathogens; findings from qualitative interviews and the facility questionnaire found inadequacies in IPC training for healthcare providers and no formal training at all for ward cleaners. Lack of written policies and protocols, and poor monitoring and supervision also contributed to suboptimal IPC standards. CONCLUSIONS: Visual assessment of cleanliness and hygiene is an inadequate marker for 'safety' in terms of the presence of potential pathogens and associated risk of infection. Routine environmental screening of high-risk touch sites using simple microbiology could improve detection and control of pathogens. IPC training for both healthcare providers and ward cleaners represents an important opportunity for quality improvement. This should occur in conjunction with broader systems changes, including the establishment of functioning IPC committees, implementing standard policies and protocols, and improving health management information systems to capture information on maternal and newborn HCAIs.

Patient experiences of taking antidepressants for depression: a secondary qualitative analysis.

BACKGROUND: Depression is one of the most commonly encountered mental health problems leading to significant morbidity and mortality and high medical and societal costs. Antidepressant prescribing in the UK has more than doubled in the last decade. There are a variety of factors that have been shown to affect a patient's experience of taking antidepressants The aim of this research was to explore patient narratives interviews about depression and its treatment in order to improve patient and health professional understanding of what it is like to use antidepressants. METHODS: This study involved a supplementary secondary qualitative analysis of 80 in-depth narrative interviews from Healthtalkonline. Patients' experiences of using medicines for depression were explored in the context of their social, occupational and emotional impact, to identify any additional issues and to clarify what type of information people want to find after being prescribed a medicine. The interviews were conducted by the University of Oxford and had received ethical approval and been consented and copyrighted for this purpose. Data were analyzed thematically. RESULTS: The most prominent theme was the coexistence of several conflicting issues around the use of medicines and participants were mostly influenced by the reality of their experiences, beliefs, attitudes and interaction with health care. Antidepressants appear to occupy a central place in many people' lives. Many people described how their medicines had helped them and how this served as a reinforcement to continue taking them in order to maintain a "normal life." Those who had stopped taking their antidepressants were likely to have experienced adverse reactions and had unsatisfactory interactions with health care professionals. A lack of information about antidepressants was a major cause of dissatisfaction often shaping attitudes to antidepressants'. CONCLUSIONS: People's experiences with antidepressant use have a major impact on treatment continuation and hence treatment outcomes. Further studies are needed on depressed patients' beliefs about their depression and treatment and how they relate to different stages of illness, their interactions with health care and their adherence to antidepressants.

Epidemiology of depression and diabetes: a systematic review.

BACKGROUND: Research suggests that co-morbid diabetes and depression is common; however, the implications for clinical practice remain unclear. This paper reviews the current epidemiological evidence on comorbid diabetes and depression, in order to identify the key publications which could both inform practice and identify gaps in knowledge and research. METHODS: A systematic review was conducted to identify published literature on the epidemiology of diabetes and depression. In order to review evidence on up-to-date knowledge of recent research and innovations in care literature searches for the last five years (August 2006-August 2011) were conducted. To identify relevant literature, electronic databases MEDLINE, Psych-INFO and EMBASE were searched for English language articles in peer-reviewed journals. RESULTS: High rates of co-morbidity of depression and diabetes have been reported. The prevalence rate of depression is more than three-times higher in people with type 1 diabetes (12%, range 5.8-43.3% vs. 3.2%, range 2.7-11.4%) and nearly twice as high in people with type 2 diabetes (19.1%, range 6.5-33% vs. 10.7%, range 3.8-19.4%) compared to those without. Women with diabetes and also women without diabetes experience a higher prevalence of depression than men. Reviewed studies provide support for a modest relationship between diabetes and depressive symptoms, but the exact direction of this relationship remains unclear. LIMITATIONS: Most studies reviewed were cross-sectional and this limits any conclusions about the causal nature and direction of the relationship between diabetes and depression. Variation in measurement methods, lack of longitudinal data and few studies outside Europe and America limit the generalizability of the findings of this review. CONCLUSIONS: Current research suggests that the risk of developing depression is increased in people with diabetes; however, further studies are required in order to establish the nature of the relationship between depression, glycaemic control and the development of diabetes complications, and make appropriate recommendations for treatment and to support self-management of diabetes.

Epidemiology of depression in diabetes: international and cross-cultural issues.

INTRODUCTION: This paper reviews the most up-to-date epidemiological evidence of the relationship between depression and diabetes, and considers the risk factors for the development of depression and the consequences of depression in diabetes with an emphasis on international and cross-cultural data. The difficulties that researchers face when epidemiological studies require assessment of psychological phenomena, such as depression, across different cultural settings are explored. METHODS: Relevant papers were sought on the epidemiology of diabetes and depression in people with diabetes by undertaking a literature search of electronic databases including MEDLINE, Psych-INFO, CINAHL and EMBASE. These papers were assessed by the authors and a narrative review of the relevant literature was composed. RESULTS: Systematic reviews of the prevalence of depression in people with diabetes have focused on studies conducted in English speaking countries and emerging data suggest that there may be international variations in prevalence and also in how symptoms of depression are reported. There appears to be a bi-directional relationship between depression and diabetes, with one influencing the other; however, research in this area is further complicated by the fact that potential risk factors for depression in people with diabetes often interact with each other and with other factors. Further research is needed to elucidate the causal mechanisms underlying these associations. LIMITATIONS: Data from non-English speaking countries remain scarce and so it is difficult to come to any firm conclusions as to the international variation in prevalence rates of co-morbid diabetes and depression in these countries until further research has been conducted. CONCLUSION: It is important to take a culture-centered approach to our understanding of mental health and illness and consider the key issues related to the development of culturally sensitive depression screening tools. In order to come to any firm conclusions about the international variation in prevalence of co-morbid diabetes and depression, issues of culture and diversity must be taken into account prior to conducting international epidemiological studies.