Each of the discussions was conducted in the primary language of the host country and audio recorded. Discussions were conducted with the aid of the topic guide for which facilitators in each country had received briefing via a teleconference. We used open ended questions intending the discussions to be participant led (examples given in appendix 1). The recordings were transcribed verbatim and back-translated into English by an external company. The transcripts were coded and analysed by two independent authors, AA and GE. Analytic themes were developed inductively in consultation with all authors and used to organise the data. A constant comparative method was used to consecutively inform sampling, topic guide development and analyses [13] . As the study sample is based on purely qualitative research methods, aiming solely to identify possible themes, we did not measure the frequency of responses or attempt to weight them. Finally, all recordings were destroyed after the transcripts and analyses were verified for accuracy.