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Finnish physicians’stress related to
information systems keeps increasing: a
longitudinal three-wave survey study
, Hannele Hyppönen
, Tuulikki Vehko
, Sari Kujala
, Anna-Mari Aalto
, Jukka Vänskä
and Marko Elovainio
Background: Poorly functioning, time-consuming, and inadequate information systems are among the most
important work-related psychosocial factors causing stress in physicians. The present study examined the trend in
the perceived stress that was related to information systems (SRIS) among Finnish physicians during a nine-year
follow-up. In addition, we examined the associations of gender, age, employment sector, specialization status,
leadership position, on-call burden, and time pressure with SRIS change and levels.
Methods: A longitudinal design with three survey data collection waves (2006, 2010 and 2015) based on a random
sample of Finnish physicians in 2006 was used. The study sample included 1095 physicians (62.3% women, mean
age 54.4 years) who provided data on SRIS in every wave. GLM repeated measures analyses were used to examine
the associations between independent variables and the SRIS trend during the years 2006, 2010, and 2015.
Results: SRIS increased during the study period. The estimated marginal mean of SRIS in 2006 was 2.80 (95%
CI = 2.68–2.92) and the mean increase was 0.46 (95% CI = 0.30–0.61) points from 2006 to 2010 and 0.25 (95%
CI = 0.11–0.39) points from 2010 to 2015. Moreover, our results show that the increase was most pronounced in
primary care, whereas in hospitals SRIS did not increase between 2010 and 2015. SRIS increased more among those in
a leadership position. On-call duties and high time-pressures were associated with higher SRIS levels during all waves.
Conclusions: Changing, difficult, and poorly functioning information systems (IS) are a prominent source of stress
among Finnish physicians and this perceived stress continues to increase. Organizations should implement
arrangements to ease stress stemming from IS especially for those with a high workload and on-call or leadership
duties. To decrease IS-related stress, it would be important to study in more detail the main IS factors that contribute
to SRIS. Earlier studies indicate that the usability and stability of information systems as well as end-user involvement in
system development and work-procedure planning may be significant factors.
Keywords: Information systems, Physicians, Stress, Electronic health records, Longitudinal research
The most stressful work-related factors among physi-
cians have traditionally been time pressure, work load,
difficult patients, and problems in team work [1–3].
Recently, however, poorly functioning, time-consuming,
and inadequate information systems (IS) have emerged
as one of the most stressing factors in physicians’work
[4, 5]. Moreover, it has been shown that stress that is
related to information systems (SRIS) has increased in
the period 2006 to 2010 . The use of IS has been
found to increase physicians’workload  and cognitive
demands . The resulting information chaos may have
ramifications, for example, for physician performance
and patient safety .
The increased number of functions in electronic health
records (EHRs) has been associated with more stress
and less job satisfaction . In addition, time pressure
was more strongly related to negative outcomes such as
burnout, dissatisfaction, and intent to leave among those
* Correspondence: firstname.lastname@example.org
National Institute for Health and Welfare, P.O. Box 30, 00271 Helsinki, Finland
Full list of author information is available at the end of the article
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International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Heponiemi et al. BMC Medical Informatics and Decision Making (2017) 17:147
physicians who had to manage a high number of EHR
functions compared to those managing a low number of
functions . Poor EHR usability, time-consuming data
entry, interference with face-to-face patient care, inabil-
ity to exchange health information between health infor-
mation systems (HIS), and impairments in clinical
documentation have been found to be prominent
sources of physicians’professional dissatisfaction .
The traditional doctor–patient relationship has been
impacted by the use of HIS. Physicians have to turn to
the computer to complete electronic forms during the
encounter, and this can be time consuming, especially if
the physician suffers from limited computer skills. For
some physicians, aspects of EHRs represent a distraction
during visits . In a US study, the average screen gaze
time of physicians ranged from 25% to 55% of the con-
sultancy session, inevitably meaning less eye-contact and
less conversation with the patient . In the same
study, 92% of physicians felt that engagement with elec-
tronic medical records (EMR) disturbed communication
with their patients. Screen gaze has been found to be
particularly disruptive to psychosocial inquiry and emo-
tional responsiveness, indicating that visual attentiveness
to the monitor rather than eye contact with the patient
may inhibit sensitive or full patient disclosure . It
has been found that after implementation of an EHR,
the physician’s time in the clinical setting has transferred
from directly caring for patients to documenting in the
EHR . Physicians’have been rated as having less ef-
fective communication when they spent more time look-
ing at the computer and when there were more periods
of silence in the consultation .
EHRs may be challenging to use because of the
multiplicity of screens, options, and navigational aids
. However, the demands and pressures of care
may not allow physicians time to master all the com-
plex system functions . Physicians may also see it
as a burden if forced to learn how to use the EHR
system effectively and efficiently. It is also possible
that a lack of appropriate skills and time to learn
them lead physicians to regard the EHR system as ex-
In addition, the ever-changing new functionalities and
systems require constant development of physicians’
skills. In Finland in 2014, only 24% of physicians in
health centres and 37% in hospitals thought that HIS did
not require long orientation and only half of the physi-
cians knew where to give feedback about HIS problems
. These ratings worsened after the year 2010. Many
physicians complain about poor service from the infor-
mation system vendor, including a lack of training and
support for problems . However, IS changes may
also be a positive improvement, which might help to de-
crease stress levels related to IS.
The Finnish context
Finnish public health care is mainly financed through
taxation. All residents in Finland have a right to use
public health care services including primary health care
and specialized health care. Provision of health care ser-
vices is mainly in responsibility of municipalities. All
Finnish residents have a National Health Insurance
coverage partly reimbursing also the costs coming from
the use of private health services. The private sector
consists mainly on a) customers themselves paying and
purchasing their care or by using health insurances, and
b) occupational health services where employers pay ser-
vices for their employees. Private health care sector use
has increased from 2000 to 2009, though in the last few
years, the trend has been declining; in 2013, the private
sector constituted 5.9% of total health expenditure .
Some municipalities have outsourced parts or all of their
health centres through open tendering. However, most
of services are still provided by municipalities.
HIS have undergone notable recent reforms in
Finland, adding to the burden of dealing with novel
functionalities and systems. The public sector EHR
coverage in Finland reached 100% in 2010, while almost
every private sector provider also uses an EHR system
. The EHR infrastructure is not uniform, however,
though the number of trade names has decreased and
since 2014, there have been five different trade names
operating in public secondary care and six in public pri-
mary care . In a move towards integrated patient
data services, Finland has launched the national digital
repository for electronic patient data, Kanta, targeted to
health care service providers, pharmacies, and citizens,
which has been deployed in phases throughout Finland
during the period 2012–2017. Kanta services include
electronic prescription, My Kanta pages for citizens, a
patient data repository, and a pharmaceutical database.
Joining the Kanta services is mandatory for all public
health care providers, while private service providers
that use electronic documentation also have to join the
Kanta services. By the end of 2014, all pharmacies and
public service providers with the exception of one had
joined the national ePrescription service . At that
time, a large proportion of private sector providers had
also joined, and the national ePrescription system was
almost fully implemented. From the beginning of 2017,
ePrescribing was the only and obligatory means for pre-
scribing and dispensing medications.
Aims of the study
The present study aimed to examine the 9-year longitu-
dinal development of SRIS levels among Finnish
physicians. SRIS levels were examined in three waves in
the years 2006, 2010 and 2015. Thus, the present study
adds to the previous literature by giving valuable
Heponiemi et al. BMC Medical Informatics and Decision Making (2017) 17:147 Page 2 of 8
longitudinal information on how physicians experience
IS and how stressful experiences have developed both
recently and over the 9-year period.
Given that previous research has shown that age, gen-
der, employment sector, and specialty may have an effect
on EHR adoption and attitudes towards EHRs [22–25],
we also examined the effects of these factors on the
levels and development of SRIS over the study period.
Moreover, the use of IS may lead to information chaos,
which is known to be influenced by mental workload
and time available to cope with this information chaos
. Therefore, we also examined the effects of chal-
lenges at work, such as time pressures, on-call burden,
and leadership position, on levels and development of
SRIS over time. Thus, the present study also adds to pre-
vious research by examining possible work-related
correlates of SRIS.
The present study is a part of the Finnish Health Care
Professionals Study that started in 2006. The data were
gathered from a random sample of 5000 physicians in
Finland (30% of the physician population) based on the
database of physicians maintained by the Finnish Med-
ical Association. The register covered all licensed physi-
cians in Finland. In wave 1 (2006), data were gathered
via postal questionnaires. Non-respondents were sent a
reminder and a copy of the questionnaire up to two
times. Responses were received from 2841 physicians
(response rate 57%). The sample was representative of
the eligible population in terms of age, gender, and em-
ployment sector . Ethical approval for the study was
obtained from the Ethical Review Board of the National
Institute for Health and Welfare.
Four years later, in wave 2 (2010), data were gathered
via either a web-based or traditional postal survey. In
wave 1, respondents were asked for their consent to par-
ticipate in follow-up surveys, with 2206 agreeing to par-
ticipate in future surveys. Those who had died or had
incorrect address information were excluded (n= 37).
Thus, in wave 2, the follow-up survey was sent to 2169
physicians. First, an email invitation to participate in the
web-based survey was sent, which was followed by two
email reminders. For those who did not respond to
these, a postal questionnaire was sent once. Email and
postal addresses were obtained from the Finnish Medical
Association. The total number of respondents was 1705
(response rate 79%; 60% women).
In wave 3 (2015), data were gathered either via a web-
based or traditional postal survey. Questionnaires were
sent to those that gave consent for follow-up in the 2006
survey. Those who had died during the follow-up or
who had an unknown address in 2015 (n= 47) were
excluded, leaving 2159 physicians. Of these 1462 physi-
cians responded (response rate 68.3%). The present
study uses a subsample that includes 1095 physicians
(62.3% women, mean age 54.4, SD = 9.0, age range 34–
72) who had answered the SRIS survey items in every
wave. The present sample included more women (57.4%
in eligible population), slightly older respondents (mean
age 47.3 in eligible population), and more specialists
(66.8% in our sample vs. 61.6 in eligible population)
compared to the eligible population.
Stress related to information systems (SRIS) was mea-
sured with two items asking “How often have you been
distracted, worried, or stressed about (during the past
half-year period) a) constantly changing information sys-
tems and b) difficult, poorly performing IT equipment /
software.”The items were rated on a 5-point Likert-
scale ranging from 1 (never)to5(very often) with higher
scores indicating higher SRIS. A mean value for the two
items was calculated, with the reliability (Cronbach’s
alpha) of this composite scale in the present sample be-
ing 0.84 in 2006, 0.84 in 2010, and 0.85 in 2015.
Employment sector was categorized into four groups in
the analyses: a) those who worked in primary care in
every wave (n= 162), b) those who worked in hospitals
in every wave (n= 343), c) those who worked in the pri-
vate sector in every wave (n= 102), and d) others
(n= 466). Specialization status was used from the first
wave in 2006 and it was categorized as a) not special-
ized, b) specialization ongoing, and c) specialists.
Leadership position was categorized into three groups:
a) those who had a leadership position in every wave
(n= 166), b) those who were not in a leadership position
in any wave (n= 559), and c) others (n= 323).
On-call burden was categorized into three groups: a)
those who had on-call duties in every wave (n= 318), b)
those who were not on-call in any wave (n= 431), and
c) others (n= 334).
Time pressure was measured with three items that
were developed based on previous research among
nurses and health care staff and which have shown ad-
equate psychometric properties . The time-pressure
scale measures stress due to time shortages at work and
scheduling problems. An example item: “How often have
you been distracted from, worried about, or stressed
about (during the past half-year period) not being able
to do your work properly.”The items were rated on a 5-
point Likert-scale ranging from 1 (never)to5(very
often), with higher scores indicating higher time pres-
sure. A mean value of the three items was calculated
and the reliability of the composite scale in the present
sample was 0.84 in 2006, 0.87 in 2010, and 0.87 in 2015.
For the purpose of analyses, time pressure scores were
Heponiemi et al. BMC Medical Informatics and Decision Making (2017) 17:147 Page 3 of 8
categorized into three groups: a) those who had high
levels of time pressure in every wave (above the median
every time; n= 262), b) those who had low levels of time
pressure in every wave (below the median every time;
n= 296), and c) others (n= 534).
These above mentioned aggregated groups regarding
sector, leadership position, on-call duties and time pres-
sure were used for statistical analyses to get a measure
of cumulated exposure over time.
GLM repeated measures analysis was performed to exam-
ine the effects of independent variables (gender, age,
specialization status, employment sector, leadership pos-
ition, on-call burden, and time pressure) on the develop-
ment of SRIS over the study period. The associations of
Mauchly’s Test of Sphericity indicated that the assumption
of sphericity had been violated, (p< .001), and therefore, a
Greenhouse-Geisser correction was used. All analyses
were conducted using the SPSS statistical package 23.0.
The characteristics of the study sample are reported in
Table 1. The majority of respondents were specialized
already in 2006 and in 2015 the number of specialists
had further increased. The number of private physicians
had increased from 12% in 2006 to 22% in 2015, whereas
the numbers of primary care physicians and hospital
physicians had slightly decreased. The proportion of
those who had a leadership position had slightly in-
creased from 2006 to 2015. In contrast, the proportion
of those who had on-call duties had decreased from
2006 to 2015. Time pressure had decreased during the
study period (F = 54.1, p< 0.001).
The results of the GLM repeated measures analysis
showed that there was a significant effect of time on
SRIS (F =7.15,p= .001), indicating that SRIS had in-
creased during the study period. Post hoc tests using the
Bonferroni correction revealed that estimated marginal
means of SRIS starting from 2.80 (95% CI = 2.68–2.92)
in 2006 increased by an average of 0.46 (95% CI = 0.30–
0.61) points from year 2006 to 2010 (p< 0.001) and then
increased by an additional 0.25 (95% CI = 0.11–0.39)
points between years 2010 and 2015 (p < 0.001).
Working/health-care sector had a significant inter-
action with time in relation to SRIS (F = 3.74,
p= 0.001). Those who had worked in primary care at all
time points had the highest increase in SRIS from 2006
to 2015 (Fig. 1). Those who had worked in hospitals had
the highest levels of SRIS in the years 2006 and 2010,
but in 2015 the SRIS levels had not increased further.
Among private sector physicians, the SRIS levels had in-
creased over the waves, but were less pronounced than
in other sectors.
Table 1 Characteristics of the study sample
2006 2010 2015 Whole period
Not specialized 149 13.8 114 10.4 108 9.9
Specialization on-going 209 19.4 117 10.7 43 3.9
Specialists 721 66.8 862 78.9 934 85.6
Primary care 240 22.1 244 22.5 217 19.8 162 15.1
Hospital 482 44.5 479 44.2 443 40.5 343 32.0
Private 134 12.4 188 17.3 238 21.8 102 9.5
Other 228 21.0 173 16.0 196 17.9
Yes 305 28.5 345 31.6 343 32.0 166 15.2
No 767 71.5 746 68.4 728 68.0 559 51.1
Yes 586 53.7 471 43.1 389 35.7 318 29.0
No 505 46.3 622 56.9 700 64.3 431 39.4
Mean SD Mean SD Mean SD
SRIS 2.93 1.2 3.31 1.1 3.48 1.1
Time pressure 3.36 1.0 3.18 1.0 3.06 1.1
SRIS stress related to information systems
Aggregated frequencies showing those who were in the category in every measurement phase
Heponiemi et al. BMC Medical Informatics and Decision Making (2017) 17:147 Page 4 of 8
Leadership position had a significant interaction with
time in relation to SRIS (F = 2.80, p= 0.024). The high-
est increase of SRIS was among those who were in a
leadership position in every wave; in 2006 they had the
lowest levels of SRIS, but in 2015 the highest (Fig. 2).
Those who did not have a leadership position at all had
the highest levels in 2006, but their increase in SRIS was
not so pronounced as for others. The effect of on-call
burden did not vary across the different waves, but it
had a significant between-subjects effect (F = 4.86,
p= 0.008), indicating that those who had an on-call bur-
den in every wave had higher levels of SRIS in every
wave as well (Fig. 2). Similarly, the effect of time pres-
sure did not vary across the years, but it had a significant
between-subjects effect (F = 23.75, p< 0.001). Those
who had high levels of time pressure in every wave also
had high levels of SRIS in every wave (Fig. 2). Age was
not related to SRIS.
The present 9-year longitudinal study with three waves
shows that stress that was related to ever-changing, diffi-
cult, and poorly functioning information systems has in-
creased among Finnish physicians between 2006 and
2015. Moreover, our results show that this increase was
most pronounced in primary care, whereas in hospitals
this increase had stopped between 2010 and 2015. Those
who had a leadership position in every wave had a
higher increase of SRIS than those who did not have a
leadership position at all. The effects of burden coming
from on-call duties and high time pressures did not vary
across time: Those who had on-call duties or high time
pressures in every wave also had higher levels of SRIS
than their counterparts in every wave.
Our findings are in line with previous findings related
to HIS showing that physicians suffer from strain and
stress from poorly functioning and inadequate HIS [4–6,
19, 28]. Our results also show that IS-related stress
keeps increasing. According to other studies, physicians
complain about HIS that work too slowly and unreliably
and that poorly support physicians’daily work and mul-
tiprofessional co-operation [4, 28]. They also rate their
EHR systems very critically, reporting several usability
problems, system failures, and deficiencies as well as
poor support for the documentation and retrieval of pa-
tient data [25, 29]. Poor EHR usability, time-consuming
data entry, interference with face-to-face patient care,
and inability to exchange health information have been
associated with physicians’professional dissatisfaction
, while a higher number of EHR functions has been
associated with stress and job dissatisfaction [10, 11].
However, even though physicians experience stress
from problems associated with IS, previous studies have
shown that they also acknowledge their value. For
Fig. 1 The levels of stress related to information systems (SRIS)
according to employment sector
Fig. 2 The levels of stress related to information systems (SRIS) according
to leadership position, on-call burden and time pressure burden
Heponiemi et al. BMC Medical Informatics and Decision Making (2017) 17:147 Page 5 of 8
example, primary care physicians in Scotland considered
that EHRs are an essential part of their work during a
consultation and facilitate patient care and make infor-
mation more accessible . However, they pointed out
issues that needed improving, such as system failures,
information overload, difficulties in adjusting to new sys-
tems, interoperability problems, and poor usability.
Swedish physicians regarded their EHR system as easy
to use in general and for prescribing drugs, while be-
lieved ePrescriptions to be time saving and safer than
handwritten prescriptions .
We showed that primary care physicians had the high-
est increase of SRIS from 2006 to 2015 and their levels
of SRIS were highest in 2015. In contrast, hospital physi-
cians had the highest levels in 2006 and 2010, but in
2015 their levels had not increased further from 2010
levels. Thus, our results suggest that in hospitals, the
negative trend related to IS has levelled out. Previous
studies with another sample have shown that in 2010
and in 2014, hospital physicians were most critical of
HIS in Finland [4, 28]. Also results from the USA sug-
gest that hospital physicians have worse attitudes about
EMRs . One reason for the levelling out of SRIS
among Finnish hospital physicians might be that im-
provements in usability of the systems used in the hospi-
tals may have been implemented. Moreover, the national
information services platform (ePrescription and eArc-
hive) have been implemented between 2010 and 2015,
supporting medication management and summary views
of patient data. It may also be that changes in the con-
text of other than information technology (IT) have lev-
elled out the impact of poor usability of IS in Finnish
hospitals. The actual effect of IS on the levelling of SRIS
in hospitals requires further examination and it would
be important to obtain more information about which
changes in IS are stressful and which are helpful. This
seems to be a double-edged sword: On the one hand,
changing systems are a source of stress, but on the other
hand they may offer improvements and reduce strain.
Our finding that private physicians had the lowest levels
of SRIS throughout the study period is in accordance with
previous findings. A previous Finnish study found that pri-
vate physicians are more satisfied with their electronic pa-
tient records (EPR) than public sector physicians .
Especially private sector physicians were more satisfied
with the stability and speed of their EPRs, as well as ex-
periencing less often endangering of patient safety related
to EPRs. Compared to responses from the public sector
(primary care and hospitals), Finnish physicians working
in the private sector have been more satisfied with their
EHR systems, specifically the user interface characteristics
and support for routine tasks .
We found that constantly changing, poorly function-
ing, and difficult information systems are experienced as
the most stressful when facing more other work-related
challenges, such as high job-demands and a need to
hurry. High time pressures and on-call burden were
associated with high SRIS in all the study waves and
leadership position in the last wave. Thus, the
complexity, time-pressure, and distraction aspects of
EHRs [12, 13, 15, 17] seem to be most strenuous when
the work is already challenging and the physician has
difficulties in coping with the work.
The present study was a 9-year longitudinal study with
three measurement phases with an interval of 4–5 years.
The doings and working places of the respondents be-
tween the study measurements is not possible to know.
Thus, respondent may have held other positions be-
tween the measurements than during the measurement
phases. Moreover, we used self-reported measures, and
this may be associated with problems in inflation of the
strengths of relationships and with common-method
variance. Therefore, well-known validated measures
showing good reliability were used. Our key limitation is
that our main variable SRIS was a mean of only two
items rather than on many elements. However, this
variable showed good reliability (0.84–0.85) and has pre-
viously been widely used and associated, for example,
with employees’distress (General Health Questionnaire)
and higher levels of on-call duties [34, 35].
Moreover, although we controlled for factors such as
age, gender, and specialization, we cannot rule out the
possibility of residual confounding. In addition, our
sample is not completely representative of the present
physician population in Finland. Our sample included
more women, older physicians, and more specialists than
the eligible population in 2015. Our findings should
not be generalized to health care systems using differ-
ent kinds of IT-systems or dissimilar styles of organ-
izing health care.
The present study found that poorly functioning IS are a
prominent source of stress among Finnish physicians
and this stress continues to increase. This is alarming
particularly since SRIS has been associated with higher
levels of distress, lower self-rated health, and lower work
ability . Thus, health organizations and software pro-
viders should take more seriously the problems with IS
in health care.
It is alarming that stress levels due to IS continue to
increase among physicians. IS have become a part of
everyday life for physicians over a period of several years
and previous studies suggest that with time and practice,
the influence of poor usability will diminish . In par-
allel to learning, one would assume that stress levels
would also level out. The fact that stress levels still con-
tinue to rise implies that current information systems
Heponiemi et al. BMC Medical Informatics and Decision Making (2017) 17:147 Page 6 of 8
are too complicated, even after years of trying to learn,
especially in the context of high time pressures. In
Finland, several new systems have been adopted over the
study period and stress cumulates when physicians have
to get used to new systems before they have even
become accustomed to previous systems.
We found support for the suggestion that high mental
workload and lack of time to cope among physicians
may have an effect on the ramifications of information
chaos resulting from IS . Thus, organizations should
pay more attention to the overall strain that physicians
experience. In addition, organizations should implement
arrangements to ease the stress and extra duties coming
from IS for those with high job strain, such as high
workload and a lot of on-call or leadership duties.
However, the present study also found promising re-
sults, given that hospitals had been able to stem the in-
crease in SRIS. Future studies should try to find IS and
work-related factors that could help to ease the stress
coming from poorly functioning IS in health care. Of
course, it would be most important to improve the us-
ability and stability of the systems, as well as to involve
end-users in the development of HIS and in the plan-
ning of work procedures.
EHR: Electronic health record; EMR: Electronic medical record; EPR: Electronic
patient record; HIS: Health information systems; IS: Information systems;
IT: Information technology; SRIS: Stress related to information systems
This study was supported by the Finnish Work Environment Fund (project 116104),
the Strategic Research Council at the Academy of Finland (project 303607) and the
Ministry of Social Affairs and Health (project 112241). None of them had any role in
the design of the study and collection, analysis, and interpretation of data and in
Availability of data and materials
The datasets during and/or analyzed during the current study available from
the corresponding author on reasonable request.
TH performed the statistical analysis, participated in its design and drafted
the manuscript. HH, SK and TV were involved in drafting the manuscript and
in revising it critically for important intellectual content. JV and AA
participated in the design and coordination of the study and helped to draft
the manuscript. ME conceived of the study, and participated in its design
and coordination and helped to draft the manuscript. All authors read and
approved the final manuscript.
Ethics approval and consent to participate
Ethical approval for the study was obtained from National Institute for Health
and Welfare (former National Research and Development Centre for Welfare
and Health). The respondents were asked their consent in the first wave in
2006. The survey script also reminded the participants that they were under
no obligation to complete and/or submit the survey.
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
National Institute for Health and Welfare, P.O. Box 30, 00271 Helsinki,
Aalto university, Espoo, Finland.
Finnish Medical Association,
University of Helsinki, Helsinki, Finland.
Received: 20 April 2017 Accepted: 9 October 2017
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