Article Text

Antiracism in leading public health universities, journals and funders: commitments, accountability and the decision-makers
  1. Afifah Rahman-Shepherd1,2,3,
  2. Ngozi A Erondu4,5,
  3. Bakht Anwar2,
  4. Ezekiel Boro3,6,7,
  5. Thuy Duyen Chau6,7,
  6. Renzo R Guinto8,
  7. Lara Hollmann3,
  8. Jerome Alan Mejarito8,
  9. Muneera A Rasheed3,9,
  10. Mishal Khan2,3
  1. 1Saw Swee Hock School of Public Health, National University Singapore and National University Health System, Singapore
  2. 2Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
  3. 3Action to Decolonise Global Health, Virtual Network, Global
  4. 4Global Institute for Disease Elimination, Abu Dhabi, UAE
  5. 5O'Neill Institute for National and Global Health Law, Georgetown University, Washington, District of Columbia, USA
  6. 6Faculty of Medicine, Institute of Global Health, University of Geneva, Geneva, Switzerland
  7. 7Graduate Institute of International and Development Studies, Geneva, Switzerland
  8. 8Planetary and Global Health Program, St Luke's Medical Center College of Medicine-William H. Quasha Memorial, Quezon City, Philippines
  9. 9Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
  1. Correspondence to Dr Mishal Khan; mishal.khan{at}


Introduction Two years since the murder of George Floyd, there has been unprecedented attention to racial justice by global public health organisations. Still, there is scepticism that attention alone will lead to real change.

Methods We identified the highest-ranked 15 public health universities, academic journals and funding agencies, and used a standardised data extraction template to analyse the organisation’s governance structures, leadership dynamics and public statements on antiracism since 1 May 2020.

Results We found that the majority of organisations (26/45) have not made any public statements in response to calls for antiracism actions, and that decision-making bodies are still lacking diversity and representation from the majority of the world’s population. Of those organisations that have made public statements (19/45), we identified seven types of commitments including policy change, financial resources, education and training. Most commitments were not accompanied by accountability measures, such as setting goals or developing metrics of progress, which raises concerns about how antiracism commitments are being tracked, as well as how they can be translated into tangible action.

Conclusion The absence of any kind of public statement paired with the greater lack of commitments and accountability measures calls into question whether leading public health organisations are concretely committed to racial justice and antiracism reform.

  • public health

Data availability statement

Data are available on reasonable request. The data in this research were extracted from publicly available sources, namely organisational websites. The authors may provide the collation and analysis of the data upon reasonable request.

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

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  • The dual crises of a pandemic threat and endemic racism has pushed through a re-examining of global health’s complicity in injustice and inequity.

  • Statements and movements to advance racial justice are often led by students and staff of global public health institutions, but without institutional commitment, willingness and resources, the question of real change towards antiracism reform remains.


  • To understand the direction of change and the pace of progress towards human rights-centred equitable global public health, we can and must systematically track organisations’ commitments.

  • We undertook an analysis of 45 of the highest-ranking public health universities, academic journals and funding agencies, to establish a baseline of what has been committed in terms of antiracism reform, how these commitments are being monitored, and who are making these commitments.


  • With a core mission to achieve ‘health for all’ and reduce inequities globally, global public health organisations have an obligation to speak up in the face of social and health injustices whenever they arise and offer the global community measurable commitments towards antiracism reform.

  • This study provides a baseline view of global public health organisations’ commitments to racial justice and antiracism reform, and the extent to which commitments have been taken seriously over a 2-year period, as a means of holding these organisations accountable and tracking progress.


Public health is, in many respects, a field that centres human rights and justice for all. However, while these ethical values are embedded in the constitution of the WHO and enshrined in the mottos of many global public health organisations, in practice these decades-long commitments have sometimes been characterised as ‘lip service’,1 2 in the face of continued inequity—not only in health outcomes, but in how we get to those outcomes.3 In May 2020, as the world grappled with the first wave of the COVID-19 pandemic, the violent murder of George Floyd forced a greater reckoning with the systems and structures upholding racial oppression. The dual crisis of a pandemic threat and endemic racism pushed through a re-examining of global health’s complicity in injustice and inequity.4 5

Yet, the question of actual change remains. Statements and movements to advance racial justice are often galvanised by students and staff of global public health institutions that identify organisational practices and policies that contribute to structural racism and prejudice.6 7 The collective power of these groups has had an impact in many spaces. For example, in 2021, two of the oldest schools of global public health, London School of Hygiene and Tropical Medicine and Liverpool School of Tropical Medicine were pushed into commissioning external reviews of their institutional policies and practices, examining everything from the curricula to human resource and promotional processes to institutional culture and leadership. Both reviews, which have since been published, revealed evidence of racial discriminatory practices that have resulted in exclusion and harm.8 Nor are academic and research institutions the only type of global public health institution reckoning with this reality; such practices are increasingly being evidenced in leading global public health journals and funders.9–15 Though encouraging, even commissioning reviews or adopting author reflexivity statements—a step that very few global health organisations have in fact taken—can seem like a tick-box activity if institutional commitment, willingness and resources are not provided to do the hard work to overhaul longstanding systems that were designed to preserve European and North American dominance in global health.16

Without tangible action and institutional reform, as it has been highlighted before, statements and reviews are empty vows that shield individual and organisational reputations at the expense of people of colour, other minoritised and marginalised groups, countries that receive foreign aid, and non-western ‘partners’ in global health research.17–19

There is an opportunity to understand, from the vantage point of nearly two years after George Floyd’s murder when global health actors were forced to confront their role in perpetuating structural racism, to question who is responsible for commitments that are aimed at building better culture, systems, policies and practices, and how are they being held accountable. Indeed, it has been argued that people may not be able to reform systems that they have built themselves, either owing to lack of conviction, willingness or ability to think radically enough to break past the confinements of what they already know and practice.8 But it is also true that there are some decision-makers that have wanted to make these changes for years, even decades, but leadership within their organisations impeded progressive antiracism action.

To understand the direction of change and the pace of progress towards human rights-centred equitable global public health, we can and must systematically track organisations’ commitments. We therefore undertook an analysis to establish a baseline of what has been committed, how these commitments are being monitored and who are making these commitments.


Focusing on organisations active in research, knowledge dissemination and evidence to policy translation in global public health, we analysed the 15 highest-ranking organisations in each of the following three categories: global public health universities or departments, global public health journals, and public and philanthropic funders of biomedical and health research (see online supplemental materials for the list of organisations). The search strategy, selection criteria and approach to extracting data, including public statements made by the organisation’s leadership, are detailed in box 1.

Supplemental material

Box 1

Search strategy, selection criteria and analysis of public statements

We used publicly available rankings of public health universities, journals and funders, and relied on their ranking system to select the 15 highest ranked organisations in each of the following categories. The rankings we used are as follows:

  • Universities: We used the 2022 US News ranking ('social science and public health' category) cross-checked with the Times Higher Education ranking.

  • Journals: We used the 2020 Scimago ranking, filtering for journals in health policy, social sciences, public health, environmental and occupational health.

  • Funders: We used the 2020 World RePORT data to identify the largest public and philanthropic funders of biomedical and health research, and supplemented this list with Viergever and Hendriks’ research in 2016.24 25

The search strategy and final list of 45 organisations were agreed by four authors (AR-S, NAE, LH and MK) independently. We developed a template in Excel to standardise data extraction across organisations. Five researchers (AR-S, MAR, TDC, JAM and BA) were allocated nine organisations each and used the template to independently extract and chart information on the organisations’ geographic location, governance structures, leadership demographics and public statements on antiracism from 1 May 2020 to 31 March 2022. All data were collected using publicly available information, including gender and ethnicity, and compiled into one spreadsheet for all 45 organisations. The data extracted on all organisations were validated by one of the five researchers (AR-S). Ethnicity was validated using an online software, Namsor and then classified using Majority World and Minority World nomenclature (see box 2 for definitions of these terms).

Public statements were identified using five search terms: antiracism, decolonising (global health), diversity, equity and inclusion. Variations on terms, for example, ‘antiracism’ and ‘racism’, were also applied. Searches were conducted in English using the organisations’ official websites, and all search results were scanned for inclusion. Statements were included if they were made directly by a ‘primary’ decision-maker (which is defined in the section on governance structures and leadership dynamics), and referenced how the organisation was acknowledging and/or planning to address the specific search term(s). Statements were excluded if they were from the organisation’s ‘equity, diversity and inclusion’ webpage, or from a research project webpage on health equity, for example. If the organisation did not have a site-wide search bar, a Google search was conducted using the organisation’s name ‘AND’ one of the five search terms (including any variations). Statements were extracted verbatim and charted into the Excel template for analysis.

Three of the funding 'agencies' websites'—Inserm, the German Federal Ministry of Education and Research (BMBF), and the Japan Agency for Medical Research and Development (AMED)—had to be translated into English using the websites translate function, which may have been a barrier to finding relevant information (as no statements were identified for BMBF and AMED), such as statements made by the organisations leadership. For these three organisations, a Google search as described above was additionally conducted to check if statements were captured (in English) elsewhere.

Box 2

Working definitions of terms12–15


A movement and practice that seeks to dismantle white supremacy and all forms of racism.


According to the WHO, equity is the ‘absence of unfair, avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or geographically or by other dimensions of inequality (eg, sex, gender, ethnicity, disability or sexual orientation)’.


Actions that encompass ‘the setting of strategic direction and objectives; making policies, laws, rules, regulations or decisions; raising and deploying resources to accomplish the strategic goals and objectives; and ensuring that strategic goals and objectives are accomplished’.16

Majority/minority world

We use ‘majority world’ to describe individuals from countries in Africa, Asia, the Pacific Islands, South and Central America, and the Caribbean, where the majority of the world’s population reside. We then use ‘minority world’ to describe individuals from countries in Europe and North America, as well as Australia and New Zealand, where the minority of the world’s population reside.26


The ‘relegation of people of colour to inferior status and treatment based on unfounded beliefs about innate inferiority, as well as unjust treatment and oppression of people of colour, whether intended or not’.14

Structural racism

The ‘processes of racism that are embedded in laws, policies and practices of society and its institutions that provide advantages to racial groups deemed as superior, while differentially oppressing, disadvantaging or otherwise neglecting racial groups viewed as inferior’.14

Once data had been collected for each organisation, a content analysis analysis of public statements was conducted by two of the researchers (BA and AR-S) independently. Statements were coded in three ways. First, using one or more of the five search terms we used to originally identify statements as a way of broadly categorising them (see box 1 for search terms). Second, the same two researchers took an inductive approach to iteratively identify and code different types of commitments, which were discussed and agreed with a third researcher independent of the data collection and analysis. There were seven types of commitments identified: a pledge, policy or strategy, recruitment or admission changes, a new structure or programme, finances, anonymous reporting or strengthening of these processes, transparency of information and/or data, and education or training. Third, in a similarly inductive approach, we identified and coded accountability measures that organisations said they were adopting. There were five types of measures identified: goals, targets or milestones, dedicated accountability body, reporting (internal and/or external), data collection and progress metrics. Where statements hyperlinked or referred to a separate strategy or an action plan, the researchers reviewed documents for commitments and accountability measures. To illustrate our approach to coding, we provide an example using one of The Wellcome Trust’s public statements we identified from the 26 March 2021, which states, ‘We know that we have played our part in perpetuating and reinforcing these inequalities… That is why today we are sharing Wellcome’s diversity, equity and inclusion strategy. We have set ourselves three bold and ambitious targets to reach by 2031 at the latest…’. Following our three layers of coding, this statement was first coded under ‘diversity’, ‘equity/equality’ and ‘inclusion’; then as a ‘pledge, policy or strategy’ for the type of commitment, and finally as ‘goals, targets or milestones’ for the type of accountability measure. Data were aggregated across all public statements identified in the specified timeframe for analysis.

Patient and public involvement

Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.


Organisational statements, commitments and accountability: who’s done what?

Only 19 of the 45 organisations we analysed had issued any statement by their leadership since 1 May 2020 (table 1). We also noted variability in the number of statements issued by different organisations; only 2 of the 15 highest ranking journals made a statement in this period compared with 10 of the 15 highest ranking universities. In total, these 19 organisations made 70 statements. We found that the number of statements spiked in June 2020, immediately following George Floyd’s murder, and again to a lesser extent in January 2021 (figure 1). This may be because organisations, such as the National Institutes of Health (NIH) who issued a statement in this time period, reaffirm their commitments made in previous years at the start of each new year, or because they launched initiatives, such as the NIH’s UNITE Initiative in January 2021. Other statements made in January 2021 were by the US Agency for International Development (USAID), which marked the start of the new presidential administration. But since January 2021, there has been a steady decline in statements.

Figure 1

Timeline of statements made across all organisations from May 2020 to March 2022.

Table 1

Characteristics of organisation’s statements and leadership structures

Over the study period, some organisations and companies reaffirmed their position by providing follow-up statements. Concerningly, of the 15 organisations who issued a statement in 2020, only 4 have made (at least) 1 follow-up statement each year since 2020; 6 have made only 1 follow-up statement in either 2021 or 2022; and 5 organisations have not followed up their statement in 2020 at all. We have considered the possibility that the highest-ranking organisations in global health universities, journals and funding agencies might be the least likely to issue a statement or commit to an action, precisely because of the power and privilege protecting their reputation. There may not be a real or perceived need for these organisations to change, nor any incentive given they benefit from the status quo, and other organisations not included in our analysis might be making more progress. However, we also see the highest-ranking organisations as trend-setters—for both good and bad practices—and our analysis targets these key players where there might be more resistance, but where change might have a domino effect.

Organisations more frequently mentioned equity (18/19), diversity (17/19) and inclusion (16/19) in their statements, followed closely by antiracism (15/19) (figure 2). Of the 70 statements made in total by these organisations, 61 mentioned antiracism. However, almost half of these 61 statements also mentioned their organisation’s new or ongoing equity, diversity and inclusion (EDI) efforts, which suggest that some organisations are likely to use EDI as an umbrella term, conflating antiracism action with progress on EDI. Despite all organisations, except for three, locating their headquarters in countries steeped in colonial and imperial projects, only 5 organisations—two funders in Canada and the UK, and 3 universities in Canada, the UK and the USA—mentioned decolonising their organisation’s efforts.

Figure 2

Number of organisations with statements mentioning key terms. Organisation; blue bar: Journal; orange bar: Funder; grey bar: University.

We identified 7 categories of commitments within the statements that we analysed: a new organisational policy (eg, strategies, action plans); human resource changes or improvements in recruitment and/or admission processes; enhanced education and/or training; new dedicated structures and/or programmes within the organisation; allocation of financial resources; and new or improved channels for anonymous reporting by staff and students (figure 3). The majority of organisations (17/19) committed to a new policy, typically in the form of a strategy or an action plan. Organisations also favoured commitments to increasing human resources or improving their recruitment and/or admission processes for staff and students, as well as developing new education and/or training materials for staff and students. In contrast, only 11 out of 19 organisations committed financial resources and less than half of the organisations committed to increasing the transparency of information and/or data (7/19), or to strengthening channels for staff and students to anonymously report discrimination (5/19).

Figure 3

Number of organisations mentioning a commitment in their statements. Organisation; blue bar: Journal; orange bar: Funder; grey bar: University.

In terms of accountability measures mentioned in organisations’ commitments, 12 out of 19 organisations set goals, targets or milestones yet less than half of the organisations also developed metrics to measure progress, plans to collect organisational data, internal and external reporting on progress, or established a dedicated accountability body to oversee implementation of the stated commitments (figure 4).

Figure 4

Number of organisations mentioning an accountability measure in their statements. Organisation; blue bar: Journal; orange bar: Funder; grey bar: University.

Overall, looking across the full set of 45 organisations, there was a paucity in making commitments to allocate specific resources (24%), or to more transparent reporting (16%), or that established accountability mechanisms (31%).

Do governance structures and leadership demographics explain the gaps in commitments?

In examining the diversity of organisational governance and leadership, we sought to identify the ‘primary’ decision-making structure responsible for operational decisions and implementation strategy. We defined the ‘primary’ decision-maker as the entity ultimately responsible for the governance and strategic direction of the organisation (as declared by the organisation), be it an individual, such as the dean of a school or department, or a body, such as a council or board. This is distinct from other governance structures that might sit at the leadership level, and might even include the ‘primary’ decision-maker, but play an advisory role to inform and guide decision-making. For the majority of organisations (60%), the ‘primary’ decision-maker was a single individual; for example, in universities, this was a dean, director or head of the school or department; in journals, this was an editor-in-chief; and in funding agencies, this was a director, president or a government representative, for example, a federal minister, administrator or secretary.

Of the 27 organisations with a single ‘primary’ decision-maker, 22 decision-makers were minority world men or women, and only 5 were majority world men or women (see box 2 for definitions of majority / minority world). This is a particularly striking finding when considering whether a single decision-maker can appropriately address structural racism—and the actions required to steer an organisation towards meaningful reform—when the likelihood of this individual representing marginalised groups locally and abroad is so low. Indeed, among the 19 organisations who issued statements, the ratio of minority world to majority world decision-makers was higher in organisations with a single ‘primary’ decision-maker compared with organisations with more than one person occupying a ‘primary’ decision-making seat. Simply put, it is much easier to ensure equitable representation in decision-making spaces if there is more than one seat at the decision-making table. Even in terms of commitments and accountability measures, those organisations that were led by a single ‘primary’ decision-maker established, on average, fewer commitments and accountability measures than those organisations where the ‘primary’ decision-making structure involved multiple decision-makers, such as in a council or board. Essentially, ‘primary’ decision-making spaces are not occupied or represented nearly enough by the majority world, and our findings suggest that expanding and diversifying decision-making spaces can enable more equitable representation.

Across organisations, the decision-making positions were dominated by minority world men (41%) and women (31%). In fact, for approximately every one majority world decision-maker, man or woman, there were four minority world decision-makers. Additionally, our analysis revealed that the majority of organisations (62%) did not make their leadership terms and election processes publicly available information. All of these organisations, except for two funding agencies, were global health universities and journals. This lack of transparency underscores the importance of examining governance and leadership environments in greater depth.

We additionally looked at whether these 45 organisations sit within a broader organisational structure whereby their mandate and functioning might be directly, or indirectly, affected by decisions made by the so-called ‘parent’ structure. We found that 36 of the 45 organisations sit beneath a higher governance structure; 14 (93%) schools or departments were situated within a larger university structure (eg, the Mailman School of Public Health is a school within Columbia University); 12 (80%) journals belonged to a ‘parent’ journal or a journal ‘group’ (eg, The Lancet Planetary Health is a journal of The Lancet Group) and 10 (67%) funding agencies fall under the remit of a national government agency (eg, the US Agency for International Development is a US government agency). The relation between these organisations and their ‘parent’ organisation may play a role in determining whether they can, in fact, make a public statement or not. For example, of the 26 organisations who did not issue a single statement, the ‘parent’ organisation of 13 did issue one or more statements. Thus, these organisations might rely to a greater or lesser extent on parent structures to address issues of racial justice, or they might consider organisation-wide statements to sufficiently apply to them. While ‘parent’ organisations and their statements did not fall within our search parameters, we recognise how organisational hierarchy might affect substructures, such as an individual school or journal, issuing public statements and commitments on racial justice. The level of autonomy that the highest-ranking global public health universities, journals and funders have, is an important barometer to consider in terms of the legitimacy and institutional ability such organisations have to truly advance racial equity as a public health goal.


What more is needed to accelerate meaningful antiracism reforms?

While public statements and commitments do not equate to reform, they are an important initial step towards acknowledging the power dynamics, structural inequities and harm inherent in many global public health organisations. Yet, even in this era of antiracist outrage, not even half of the 45 universities, journals and funders that we analysed in global public health have taken this step forward. In the absence of any kind of public statement, one must question whether the majority of the highest-ranked global public health organisations are in fact committed to racial justice and antiracism reform.

Of the organisations that have issued one or more statements, there are further gaps in the types of commitments and accountability measures adopted. Too often, commitments to antiracism are conflated with new or ongoing EDI efforts, and there is a need for organisations to better understand and articulate the differences in goals and objectives, rather than assuming EDI structures and programmes can absorb an antiracism agenda. Important questions are rightly being asked about whether EDI plans are tick-box exercises for organisations, or whether they are a starting point for a comprehensive antiracist reform.20 Khan et al have emphasised the need to distinguish EDI strategies from antiracism, highlighting that EDI often fails to confront power and privilege at the root of structural racism, particularly in global health.21 While we document the lack of diversity of decision-makers, we appreciate that diversity alone does not necessarily result in more equitable policies; it is essential for those who are appointed to represent marginalised groups to have verifiable track-records in challenging unjust practices, rather than being tokenistic seat-fillers used by organisations to claim diversity.8 This should be considered a criterion for every decision-maker, whether they play a ‘primary’ or advisory role in organisational decision-making. The success of EDI or antiracist reforms is not a zero-sum game, and intersectionality must be at the core of both efforts to achieve their intended goals and objectives.

Our analysis indicates that while 2020 was a turning point on antiracism action for some global public health organisations, others have remained ‘business as usual’. If a global reckoning of racial equity and justice cannot motivate these organisations towards tangible action, then their legitimacy in global public health and health justice spaces should be questioned. It also begs the question of what will motivate organisations towards real change?

While continued grassroots mobilisation and antiracism advocacy is critical, there is a need to build an evidence base on what works to dismantle racist systems, and support the expansion and routine collection of antiracism policies and actions across global public health organisations, especially those that have an active role in international research and partnerships. For example, research to understand optimal governance and leadership arrangements—such as ensuring transparency of decision-making processes—and to analyse the influence of government-level antiracism policies on steps taken by academic organisations within the jurisdiction, would be valuable.

We acknowledge that our sample represents a subset of global public health organisations and that a broader sample of organisations might surface different patterns. We decided to examine public statements and commitments following the murder of George Floyd in May 2020, because of its global significance to social and health justice, but we recognise that these organisations may have embarked on antiracist efforts prior, which would not have been captured in our analyses. We also recognise that organisations whose websites were not designed to be in English may use different terms to describe their antiracism efforts, which did not directly translate to one of the five search terms we selected.


Being cognisant of the lack of evidence of impact, we put forward the following strategies for consideration: a transparent mechanism through which complaints about racist practices in organisations can be easily submitted for independent investigation22; systematic tracking of organisational statements and commitments on antiracism, and routine public reporting; the development of metrics that can capture progress;23 and an independent expert body (that includes a board with a track record in antiracism reform) to monitor progress across global public health organisations. While we recognise that some organisations have already dedicated financial resources to act on their commitments, sustainable allocation of funding to support organisational efforts will be required to implement the reforms needed. But resource availability should not be used as a barrier to prevent organisations from promoting the right values and initiating a culture of antiracism action.

With a core mission to achieve ‘health for all’ and reduce inequities globally, global public health organisations have an obligation to speak up in the face of social and health injustices whenever they arise, and offer the global community measurable commitments towards antiracism reform. Is it not time that we hold global public health organisations accountable to these standards?

Data availability statement

Data are available on reasonable request. The data in this research were extracted from publicly available sources, namely organisational websites. The authors may provide the collation and analysis of the data upon reasonable request.

Ethics statements

Patient consent for publication


Supplementary materials

  • Supplementary Data

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


  • Handling editor Seye Abimbola

  • Twitter @eazyBoro, @DrMishalK

  • Contributors AR-S, NAE, LH, MAR and MK conceptualised the research goals, objectives and study design. AR-S and MK developed the methodology. AR-S led on its execution and is responsible for the overall content, acting as guarantor for this study. AR-S, BA, EB, TDC, JAM and MAR were involved in data collection and curation, and AR-S and BA conducted the analysis, validation and synthesis of the final dataset. AR-S, NAE, and MK prepared the original draft of the manuscript, and BA, EB, TDC, RRG and MAR contributed equally to revisions and editing. All authors reviewed the final manuscript.

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

  • Competing interests None declared.

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

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

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