Interacting factors associated with Low antibiotic prescribing for respiratory tract infections in primary health care – a mixed methods study in Sweden
Strandberg et al. BMC Family Practice
Interacting factors associated with Low antibiotic prescribing for respiratory tract infections in primary health care - a mixed methods study in Sweden
Eva Lena Strandberg 0 1 2 4
Annika Brorsson 0 2 3 4
Malin André 7 8
Hedvig Gröndal 6
Sigvard Mölstad 2 4
Katarina Hedin 0 2 4 5
0 Equal contributors
1 Blekinge Centre of Competence, Blekinge County Council , Karlskrona , Sweden
2 Department of Clinical Sciences , Malmö , Family Medicine, Lund University , Malmö , Sweden
3 Center for Primary Health Care Research , Malmö, Skåne Region , Sweden
4 Department of Clinical Sciences , Malmö , Family Medicine, Lund University , Malmö , Sweden
5 Department of Research and Development , Region Kronoberg, Växjö , Sweden
6 Department of Sociology Uppsala, Uppsala University , Uppsala , Sweden
7 Department of Public Health and Caring Sciences - Family Medicine and Preventive Medicine, Uppsala University , Uppsala , Sweden
8 Department of Medicine and Health Sciences, Family Medicine, Linköping University , Linköping , Sweden
Background: Prescribing of antibiotics for common infections varies widely, and there is no medical explanation. Systematic reviews have highlighted factors that may influence antibiotic prescribing and that this is a complex process. It is unclear how factors interact and how the primary care organization affects diagnostic procedures and antibiotic prescribing. Therefore, we sought to explore and understand interactions between factors influencing antibiotic prescribing for respiratory tract infections in primary care. Methods: Our mixed methods design was guided by the Triangulation Design Model according to Creswell. Quantitative and qualitative data were collected in parallel. Quantitative data were collected by prescription statistics, questionnaires to patients, and general practitioners' audit registrations. Qualitative data were collected through observations and semi-structured interviews. Results: From the analysis of the data from the different sources an overall theme emerged: A common practice in the primary health care centre is crucial for low antibiotic prescribing in line with guidelines. Several factors contribute to a common practice, such as promoting management and leadership, internalized guidelines including inter-professional discussions, the general practitioner's diagnostic process, nurse triage, and patient expectation. These factors were closely related and influenced each other. The results showed that knowledge must be internalized and guidelines need to be normative for the group as well as for every individual. Conclusions: Low prescribing is associated with adapted and transformed guidelines within all staff, not only general practitioners. Nurses' triage and self-care advice played an important role. Encouragement from the management level stimulated inter-professional discussions about antibiotic prescribing. Informal opinion moulders talking about antibiotic prescribing was supported by the managers. Finally, continuous professional development activities were encouraged for up-to-date knowledge.
Mixed methods design; Antibiotic prescribing; Guidelines; Implementation; Primary care
Prescribing of antibiotics for common infections varies
widely between different countries in Europe, and Sweden
is one of the countries where antibiotic prescribing is
lowest measured as prescriptions/1000 inhabitants per
In Sweden the prescribing, especially for respiratory
tract infections (RTIs), varies among counties [
between different primary health care centres (PHCCs) [
and between individual doctors [
], but there is no
medical explanation for the variation [
]. The wide variation
in prescribing of antibiotics suggests that guidelines for
treatment of common infections are not implemented
Strama (the Swedish strategic programme against
antibiotic resistance) has worked for a more rational use of
antibiotics in Sweden during the last 20 years and through
local Strama groups have reduced prescribing of
antibiotics both nationally and regionally. Different professions
have cooperated in the matter and the prescribing of
antibiotics has declined sharply in ambulatory care [
Since the year 2000, Strama together with the Medical
Product Agency (MPA) have developed guidelines for the
diagnosis and treatment of common infections. The
guidelines have been disseminated through mailings to
the health centres, articles in the Swedish Medical Journal,
presentations at national and local meetings and through
out-reach visits to the health centres by members of the
local Strama groups in each of the 21 counties.
The availability of established guidelines for diagnosis
and treatment is seen as a prerequisite for reducing
variation in medical practice, especially in modern health
]. Modern health care is a complex system, where
several factors of importance for the dissemination of
knowledge have been identified: the individual
professional caregiver, the patient, the professional interaction
and organization, including leadership and support
], and it is in the daily conversations that learning
and practices develop [
In an international perspective, Swedish primary
health care has unique features. PHCCs are often
organized as group clinics with a limited budget for salaries
for all staff, general practitioners (GPs) included, samples
and medications. Significant is the close collaboration
between nurses and GPs. Telephone counselling is often
the first step when the patient needs medical advice or a
Systematic reviews have highlighted factors that may
influence the prescribing of antibiotics, for example
socio-demographic factors of the doctors, their attitudes,
patient characteristics and factors related to health care
organization, and they conclude that antibiotic prescribing
is a complex process [
]. Near-patient testing has been
discussed as a way to reduce uncertainty and improve the
physician’s diagnosis in respiratory tract infections in
ambulatory care. Near-patient tests are extensively used in
Sweden  but there are divergent results from studies
of their effect on antibiotic prescribing [
]. It is
unclear how factors interact and how the organization and
collaboration within the PHCC affect diagnostic
procedures and the prescribing of antibiotics. There are no
empirical studies of the interaction between these factors.
The aim of this study was to explore and understand
interactions between factors influencing antibiotic
prescribing for RTIs in primary care, with special focus on
PHCCs with low antibiotic prescribing.
During January and February 2014 we studied six
PHCCs in three different regions in Sweden. From each
region we chose one PHCC with low and one with high
prescribing levels compared to the average in the county
in the first half of 2013. By studying both types of
PHCCs, we expected to gain an understanding of
conditions and factors influencing antibiotic prescribing for
RTIs, even though the focus of the study was on health
centres with low prescribing.
To arrive at an understanding of how these factors
interact, we chose a mixed methods design. Our mixed
methods design was guided by the Triangulation Design
Model according to Creswell both in the design and the
analysis of the study [
]. The collection of the
quantitative and qualitative data was simultaneous and the
presentation of the findings from the different sources was
integrated in the results and discussion sections.
Quantitative data were collected through prescription statistics,
questionnaires to patients, and GPs’ audit registrations
according to the Audit Project Odense (APO) method [
Qualitative data were collected through observations and
semi-structured interviews. Observations contribute to
visualizing the gap between people’s attitudes and their
]. Observations and interviews were conducted
by the same researchers.
Antibiotic prescription statistics were provided by
Apotekens Service AB (Concise) from 2013 and from
two weeks before and after the data collection period.
The variables studied were antibiotics prescribed by the
GPs at the PHCC/1000 listed patients at the PHCC and
antibiotics prescribed by physicians from other
departments/1000 listed patients at the PHCC (Fig. 1).
A questionnaire survey was performed during the
study period. All patients (or legal guardians for children
younger than 15 years) with symptoms of RTIs were
asked to answer the questionnaire before their
consultation with the doctor. Those who had difficulties
understanding Swedish were excluded. Questions were asked
about age, sex, other diseases, expectations and other
questions related to the visit.
Audit registrations were performed by the GPs for each
visit for RTIs. Symptoms, sampling, diagnoses and
antibiotic treatment as well as the clinical assessment of the
severity of the RTI were noted prospectively and
consecutively, in accordance with the APO method, which can
neither be defined as strictly quantitative nor qualitative.
The APO method is a voluntary process with the aim to
audit GPs’ own clinical work proceeding from the
question, ‘are we doing the right thing in the right way?’.
Observations were performed by six researchers, one
GP and one social scientist in each region. During the
study period we performed direct observations of the
patient’s way through the PHCC. We observed the
interaction between patients and employees, the routines of
the PHCC concerning RTIs at different work units:
telephone counselling, in the reception, the doctor’s surgery,
nurse reception, and at different workplace meetings.
We also observed the clinical treatment of three different
RTI cases: sore throat, pain in the ear and patients with
cough where an infection was suspected. All observations
were documented as reflective field notes directly after the
In the six PHCCs a reasonable proportion of the nurses
and GPs and all managers were interviewed. The
distribution is shown in Table 1. In all, 53 people were interviewed.
Concerning the educational background of the managers,
only two were physicians (one operational manager and
one senior manager) and the rest were either nurses or
had another educational background. Semi-structured
interview guides with open-ended questions were used
to ensure that all subjects were covered and to stimulate
the interviewees’ own narratives. The interviews
comprised questions about guidelines, collaboration,
education, clinical behaviour including diagnostic procedures,
and patient-centred consultation. The predefined
categories were derived from the researchers’ preconceptions of
the research field. Four researchers were GPs and two
were social scientists, five women and one man. The
interviews were audio recorded and transcribed verbatim by a
The different data were compiled and analysed for each
participating PHCC. The quantitative data were analysed
by descriptive statistics and the categorical variables
were presented as proportions. In comparisons Chi-square
test or Fisher’s exact test were used.
For the qualitative data we used qualitative content
analysis, an editing analysis style according to Crabtree
and Miller [
]. We analysed both the transcribed
interviews and the field notes from each observation. The data
were organized in categories and themes, predefined as
well as newly emerging from the data.
In the next steps, we identified the common traits
for the three low-prescribing PHCCs and for the three
high-prescribing PHCCs and compared those with each
other. This paper presents the characteristics of the
When comparing the PHCCs, the research group used a
mixed inductive and deductive approach that built on
knowledge gained from the literature on high-performing
]. The qualitative analysis was performed
manually. The results were discussed in the research group
until consensus was achieved.
The research team visited each PHCC with feedback
on the results of the specific PHCC, which gave all GPs
and nurses an opportunity to reflect on the findings,
thereby enhancing the validity of our findings.
The PHCCs selected as low- or high-prescribing PHCCs
for the study remained low and high during the course
of the study. Figure 1 shows the level of antibiotic
prescribing during 2013. Background characteristics of the
participating PHCCs are shown in Table 2.
The overall theme that characterized PHCCs with low
prescribing of antibiotics was A common practice in line
with guidelines (Fig. 2). We identified five main factors
of importance for antibiotic prescribing for RTIs in
primary health care: Promoting management and leadership
– facilitating structure, Local processing –
Internalization of guidelines, GP’s diagnostic process, Standardized
Nurse Triage, and Patient expectation (Table 3).
A common practice in line with guidelines
Each main factor was of great importance in the process
of achieving a common practice in line with guidelines
for RTIs and antibiotic prescribing. The factors could be
viewed as cogwheels that lock together in a constant
process where internal discussions and continuous
professional development activities are 'lubricants' to keep it
going. The whole process was supported – and to some
extent also controlled – by the manager.
In the three PHCCs with a high prescribing rate and
low adherence to guidelines for RTIs, the conditions
were reversed. They lacked several of the components
demonstrated in Fig. 2, which led to a diverse practice.
Promoting management and leadership – facilitating
A dedicated leadership played an important role for the
PHCC’s ability to achieve and maintain adherence to
guidelines for RTIs and antibiotic prescribing. The
managers of the low-prescribing PHCCs enabled GPs, nurses
and laboratory staff to meet regularly. Professional
discussions contributed to integrating new knowledge into
practice and also maintaining current knowledge. Both
formal and informal leaders took an active part in this
process. New colleagues were educated into the culture
of the PHCC. Continuous follow-up of prescribing
habits was initiated by the operational manager.
“Really important that I am engaged in how we work
and that we have good routines and a good structure,
so I feel that that is valuable. And I.. what I.. the
signals I give to the staff show that I care too about
how they prescribe and how they work with
Several GPs expressed a desire to be able to collect data
on prescribing themselves. (Observations, interviews)
From the observations and interviews we also noted that
access to, and encouragement of, regular and planned
education was typical for the low-prescribing PHCCs but
not for the high-prescribing ones.
Local processing – Internalization of guidelines
In PHCCs with low prescribing the guidelines were
internalized through an ongoing professional discussion about
their content. The process was promoted by formal and
informal opinion moulders. As a result all GPs and nurses
knew and trusted the guidelines. (Observations, interviews)
“But he is after all the one with the knowledge and
the authority that he has, and the wisdom too. So it’s
like this … everyone listens to what he says, mostly,
because he has wise things to say.” (Manager)
Individual feedback on prescribing behaviour, together
with professional discussions, was essential both for
maintaining and developing a low prescribing of
antibiotics for RTIs (Prescribing statistics, interviews, audit).
Patients sometimes said one thing to the nurse on the
phone and another in the personal meeting with the GP.
Feedback between GPs and nurses on the severity of the
infection seemed more frequent in the low-prescribing
PHCCs (Observations, interviews).
GP’s diagnostic process
In low-prescribing PHCCs the GP decided whether tests
should be taken or not. When the GP considers
antibiotic treatment for e.g. sore throat the guidelines
stipulate a confirmation by taking near-patient rapid antigen
detection test (RADT). The GPs said that they were
aware of that particular guideline.
“Well, it has been said … if we are to consider treatment,
you must have a positive RADT too.” (Doctor)
Near-patient tests, in particular C-reactive protein
(CRP), were used less frequently by the GPs at the
lowprescribing PHCCs. GPs at low-prescribing PHCCs
clearly expressed that clinical criteria need to be present
e.g. to take RADT. (Observations, interviews, audit)
“I never take a RADT without having set up these
criteria first, you know, because taking a RADT with
no grounds, that’s totally crazy.” (Doctor)
According to the audit registration, GPs at
lowprescribing PHCCs prescribed fewer antibiotics also
during the study period and GPs in high-prescribing PHCCs
used near-patient tests more frequently. The latter also
reported more frequent use of clinical assessment alone,
without acknowledged diagnostic criteria. Almost every
infection was classified as mild or moderate by the GP,
but more were classified as mild among the
lowprescribing and more were classified as moderate among
the high-prescribing PHCCs. A larger proportion of the
infections were diagnosed as upper respiratory tract
infection at the low-prescribing and as pneumonia at the
high-prescribing PHCCs (Table 4) (Audit).
Standardized nurse triage
Telephone triage by a nurse or sometimes also by a
doctor was a prioritized task at PHCCs where prescribing of
antibiotics was low. Characteristic for such PHCCs was
that there were special routines for nurse triage. Patients
were passed through after a first contact with a nurse,
often by telephone. When a patient or a parent called the
PHCC for an RTI, the nurse had an important role
assessing whether the patient could manage with self-care
advice or if a GP consultation was necessary. If the nurse
believed that self-care advice was not enough, the nurse
gave the patient a consultation with one of the permanent
doctors and not the locums. (Observations, interviews)
Where the guidelines were clear and implemented
and internalized, the nurse had a relatively easy task to
decide whether a GP consultation was necessary, even if
there always was a certain uncertainty and sometimes
even fear of making mistakes:
“our role is rather important, precisely to inform
about self-care in situations where self-care is the
thing to do and there both the triage handbook and
the Strama guidelines are fairly clear and easy to
follow, but of course there are exceptions where you
… and then I think that children are the most difficult
and elderly people with multiple diseases of course
Routines and procedures must be clear enough for the
nurse or the GP to make the right decisions about which
patient needs an appointment:
“But there the nurse has an important role in being
able, well, at least making sure that only those come
… that it’s the right patients who come, that those
who don’t need to come don’t come.” (Manager)
Patients who were examined at the high-prescribing
PHCCs reported to a greater extent that it was easy to
get an appointment with the GP (Table 5).
In PHCCs where prescribing of antibiotics was low, nurses
and GPs expressed that patients do not want unnecessary
Table 5 Patients’ reports of knowledge, duration of symptoms
Low antibiotic High antibiotic
n = 71 (%) n = 120 (%)
19 (30.2) 39 (35.5)
It was easy to get an
appointment with the GP?
I know if I need an antibiotic
Have confidence in your doctor’s 42 (62.7)
decision not to prescribe
Antibiotics help against bacteria
Antibiotics help against virus
antibiotic treatments but rather good advice about how to
treat the infection. Of all patients, 24% were expecting to
receive an antibiotic prescription. Significantly more of
these were visiting the low-prescribing PHCCs. Most of
the patients answering the questionnaire knew that
antibiotics were effective against bacteria and almost half of
them thought they were effective against viruses (Table 5).
(Prescribing statistics, interviews, audit, patient survey)
The GPs at the low-prescribing PHCCs started the
consultations in a more patient-centred way with
openended questions in order to get a picture of the patients’
expectations. They only introduced antibiotics when they
had clinically assessed all circumstances and had come to
the conclusion that an antibiotic treatment was needed
according to the guidelines. Nurses also said that they
had observed a change in patients’ expectations in this
direction over the past five years or so. (Observations,
“people are so aware today that you shouldn’t take it
[antibiotics] unnecessarily and the development of
resistance and so on, so I don’t think so. We don’t
have that type of patients here who demand
antibiotics, I don’t think so.” (Nurse)
From the analysis of the data from the different sources
an overall theme emerged: A common practice in the
PHCC is crucial for low antibiotic prescribing in line
with guidelines. Several factors contribute such as
promoting management and leadership, internalized guidelines,
the GP’s diagnostic process, nurse triage, and patient
expectation. These factors were closely related and
influenced each other.
The results also showed that new knowledge was
internalized both in the PHCC as a whole and in all
members of the staff. The guidelines were normative for the
group as well as for every individual in the group.
The mixed methods design enabled us to get as complete
a picture as possible of the studied PHCCs. Six PHCCs
might seem too few, but with the mixed methods design
we have obtained abundant data. One difficulty was to get
an overview of all research data. A remedy was separate
steps of the analysis and the fact that the researchers had
different research experience. The analysis with both
inductive and deductive elements as well as the descriptive
statistics from the patient survey and the audit increased
the validity of the results.
The observations gave an idea of the local culture at
the PHCC as well as relations and interaction between
the employees. Through the observations we reached an
understanding of what actually happened between the
patients and the staff on their way through the PHCC,
although compared to ethnographic research the study
period was relatively short. We believe this was
outweighed by the presence of more than one observer.
The study period would normally have been a high
season for respiratory tract infections, but during 2014
the infection season appeared later than usual and
therefore there were fewer patients with RTIs than expected.
Additionally, there were sometimes difficulties
convincing the patients about the importance of answering the
questionnaire and sometimes the receptionists forgot or
did not have the time to hand them out. Due to the low
numbers in both the patient survey and the audit, the
data must be interpreted with caution when standing
alone, but when aggregated with data from the
interviews and observations the findings were strengthened.
We focused specifically on what happened at the
lowprescribing PHCCs, even though we also collected data
from high-prescribing PHCCs. Those were collected in
order to mirror the low-prescribing PHCCs and to achieve
a better understanding of factors influencing antibiotic
prescribing for RTIs in primary health care.
The organization of Swedish PHCCs as group clinics
implies that the findings of this study must be
interpreted with reservations in an international perspective
where group clinics are less common.
Comparison with existing literature
A common practice
Previous studies have shown that new knowledge will be
used in clinical practice, when transformed through
continuous discussions among staff. New knowledge must be
applicable and meaningful in the local context and its
credibility is tested in a learning process [
]. Such a process
requires forums and opportunities for discussions.
Lowprescribing PHCCs had set aside time for regular meetings
for medical issues and prioritized training, within and
between professions, which enabled this process.
This study identified the leadership as a crucial factor
for low antibiotic prescribing. The leadership must
provide structural conditions and encouragement for
interprofessional collaboration in order to achieve a common
practice in keeping with guidelines. This is in line with the
conclusions of two recent studies [
]. In the present
study the management strove for a common goal using
feedback and active discussion regarding antibiotic
prescribing. At low-prescribing PHCCs, GPs were also acting
as explicit local opinion moulders, an important function
for knowledge translation . Organizational readiness
for change is also of importance. Unfortunately according
to a systematic review from 2014 [
], practically no
instruments have been developed for assessing organizational
readiness for knowledge translation in health care.
Developing such instruments might be a subject for future
research. Our findings strengthen that the Strama model
is a successful way of working. Strama contributes to
enhanced discussions among different professions about
antibiotic use for RTIs and supports the importance of
feedback. Feedback helps to show that you do not always
do what you think and therefore can stimulate behaviour
In our study, all PHCCs were given feedback on the
health centre’s prescribed antibiotics every three months.
At the low-prescribing PHCCs these data were discussed
at staff meetings. According to the interviews, GPs
would need easier access to a relevant presentation of
their own prescribing data.
Several reviews have stressed well-functioning
interprofessional collaboration as an important condition for
knowledge dissemination and evidence-based practice
]. In this study the collaboration between nurses
and GPs appeared particularly important. The nurses’
triage to either self-care or appointment to the GP was
decisive for which patients were offered an appointment.
Some studies have shown that fruitful collaboration
between GPs and nurses is based on professional respect
and confidence in each other’s professional competence
]. These conditions were present in the
lowprescribing PHCCs. There was also a consensus that most
infections are self-limiting and for those patients self-care
was the first choice. Consequently these patients, not in
need of an appointment, escape unnecessary testing and
antibiotic treatment. Thus, correct triage is an important
factor behind low antibiotic prescribing.
The patients had generally good knowledge of
antibiotics. Most of the patients answering the questionnaire
knew that antibiotics were effective against bacteria and
less than half of them thought they were effective against
viruses. This proportion is in line with an earlier Swedish
study and better than in a Spanish study [
More patients in the low-prescribing PHCCs expected
antibiotics compared to patients in the high-prescribing
PHCCs. A probable explanation might be that the nurses
at the low-prescribing PHCCs had selected patients with
respiratory infections who might benefit from antibiotic
treatment according to guidelines. However, the GPs at
low-prescribing PHCCs rated most infections as mild
while GPs at high-prescribing PHCCs more often
classified the respiratory tract infection as moderate. The
more common use of bacterial diagnoses among the
high prescribers compared to low prescribers has been
shown earlier [
]. The different assessment of the
severity of the infection in our study, together with the
different proportions of diagnoses requiring antibiotic
treatment, may thus be seen as a way to retrospectively
legitimize prescribing of antibiotics. The individual
prescribing patterns may have greater significance than the
clinical picture for treatment decisions, consistent with
previous studies . In our study, one third of the
patients were treated with antibiotics, which is lower than
in most international studies [
There has been a paradigm shift regarding the
management of infections over the past 20 years, from an
earlier approach according to which all infections of
probable bacterial aetiology had to be treated with
antibiotics, to a more modern policy of treating with
antibiotics only if there is evidence for benefit [
earlier approach reappeared in several interviews,
especially in the high-prescribing PHCCs. Moreover, our
study showed that high-prescribing PHCCs also used
near-patient tests (both RADT and CRP) to a higher
degree than low-prescribing PHCCs. Thus, high use of
rapid near-patient tests may be associated with high
prescribing of antibiotics. This result differs from previous
studies where the use of antibiotics decreased after these
tests were introduced . The differences may be due
to a different prescribing pattern than in Sweden, or that
the tests were introduced with clear and specific
guidelines for their use. The result in our study is in line with
others indicating that the use of RADT and CRP not
according to guidelines increases the risk of overtreatment
with antibiotics [
In PHCC with low antibiotic prescribing some important
factors were observed. Guidelines were adapted and
transformed into a common practice within the staff at
the PHCC, not only the GPs. Nurses’ triage in the
telephone played an important role in daily practice.
Encouragement from the manager stimulated inter-professional
discussions concerning antibiotic prescribing and informal
opinion moulders talking about antibiotic prescribing
were supported by the managers. Near-patient tests were
used in accordance with the guidelines. Moreover,
routines and IT systems were adapted in a way that enabled
GPs themselves to access prescribing data easily from
registers as a basis for professional discussions. Finally,
continuous professional development activities were
encouraged for everyone to be able to have up-to-date
knowledge. All these factors were interacting in the
PHCC with low antibiotic prescribing and the managers
need to facilitate them. The factors also have to be taken
into account when making interventions to rational
APO, Audit Project Odense; CRP, C-Reactive Protein; GP, General Practitioner;
MPA, Medical Product Agency; PHCC, Primary Health Care Centre; RADT,
Rapid Antigen Detection Test; RTI, Respiratory Tract Infection; Strama,
Swedish strategic programme against antibiotic resistance
Special thanks to Ingvar Ovhed for his help with the audit and Lena
Lennartsson for her excellent transcribing of the interviews.
The project was funded by grants from the Public Health Agency of Sweden.
The funding body had no role in the design and implementation of the
study, nor in writing the manuscript.
Availability of data and materials
Since sharing of data was not included in the approval from the ethics
committee or the informed consent from participants, data will not be made
Conceived and designed the study: ELS, AB, MA, HG, SM, KH. Performed the
interviews and observations: ELS, AB, MA, HG, KH. Data analysis: ELS, AB, MA,
HG, KH. Wrote the paper: ELS, AB, KH. Commented and contributed to the
final manuscript: ELS, AB, MA, HG, SM, KH. All authors have read and
approved the final version of the manuscript.
The authors declare that they have no competing interests.
Consent for publication
Not applicable. The manuscript does not contain any individual person’s data.
Ethics approval and consent to participate
The study conforms to the principles outlined in the Declaration of Helsinki
and was approved by the Regional Ethical Review Board in Lund, Sweden
(2013/679). Participation was voluntary. All participants in the different data
sources gave their written informed consent to participate by replying to a
written invitation. All data were treated confidentially and could not be
traced to any named person. Since sharing of data was not included in the
approval from the ethics committee or the informed consent from
participants, data will not be made public.
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