The meaning of ethically charged encounters and their possible influence on professional identity in Norwegian public health nursing: a phenomenological hermeneutic study


  • Berit Misund Dahl PHN,

    Doctoral Student, Corresponding author
    1. Nordic School of Public Health, Gothenburg, Sweden
    2. Department of Health Sciences, Aalesund University College, Ålesund, Norway
    • Correspondence to:

      Berit Misund Dahl, Department of Health Sciences, Aalesund University College, PO Box 1517, NO-6025 Ålesund, Norway.


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  • Anne Clancy PHN, DrPH,

    Associate Professor
    1. School of Nursing, Department of Health and Social Work, Harstad University College, Harstad, Norway
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  • Therese Andrews Dr.polit.

    Senior Researcher
    1. Nordland Research Institute, University of Nordland, Bodø, Norway
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  • The copyright line for this article was changed on September 30, 2014 after original online publication.



In today's health care, new health reforms focus on market values and demands of efficiency influence health workers' professional practice. Norwegian public health nurses work mainly with healthy populations, but the children, families and young people they meet can be in vulnerable and even dependent situations. Strategies in coping with ethically challenging encounters can be important for the identity of the profession.


The aim of the study was to illuminate public health nurses' experiences of being in ethically charged encounters and to reflect upon how these experiences can influence their professional identity.


A purposive sample of 23 Norwegian public health nurses with experience ranging from 0.5 to 25 years narrated about their work-related experiences. The interviews were interpreted with a phenomenological hermeneutic method inspired by the philosophy of Paul Ricoeur.


Four themes were identified: feeling responsible, being committed, feeling confident and feeling inadequate. These experiences were related to both work and private life and involved an emotional commitment to the well-being of children, young people and families.


On the basis of the findings, it can be estimated that PHNs are committed to their work, and defending children's rights is a strong driving force. Responsibility for service users is a deciding factor that can overshadow institutional demands. It seems as if value conflicts mobilised courage which is essential in maintaining moral strength. This is in turn important for a strong professional identity and can have positive implications for the quality of public health nursing work.


This paper is part of a larger study on professional identity in Norwegian public health nursing practice. The purpose of this article is to elucidate public health nurses' (PHNs) experiences of being in ethically charged encounters and to reflect upon how the PHNs' experiences can influence their professional identity.

Challenges related to professionalisation, academic demands and today's focus on market values have raised questions concerning professional identity in health professions [1], as practitioners have adopted new demanding roles and changed practices over time [2]. Developing a strong professional identity contributes to the profession's prominence and effectiveness, whereas weakened professional identity leads to low commitment and decreased public confidence [3]. Studies have called for a reframing of nurses' professional identity [4-6].

All aspects of public health nursing have ethical components [7], and the values of practitioners can affect what they perceive as relevant problems, goals and approaches in practice [8]. Elucidating values in public health nursing practice can thus create a deeper understanding of their professional identity and be instrumental in developing a practice that can benefit both individuals and populations.

Norwegian PHNs work mainly at child and youth health clinics and school health services. Their focus is on promoting the health and well-being of children, young people and families. More than 90% of Norwegian families participate in the public health nursing programme. The professional values of PHNs are related not only to their core competencies in health promotion and disease prevention but also to their nursing care relationship-centred value base [9]. Although Norwegian public health nurses work mainly with the healthy population, the parents and young people they meet in their work can be in vulnerable and even dependent situations. Contemporary Norwegian public debate is questioning today's management ideology in health care [10]. Public health nurses can experience dilemmas created by institutional loyalties on the one hand and being true to values of the profession on the other. This can influence PHNs' relationship with their service users, and their choice of strategies in coping with these challenges can become important for the identity of the profession.


Various explanations of the concept of professional identity exist in the literature [11] – or it simply goes unexplained [12]. Mead [13] asserts an individual builds identity through interaction with others; both significant others and generalised others. Ricoeur [14] advocates that when we narrate about our experiences, a personal identity is constructed. He assumes the narratives have an ethical basis (in the good life) that helps us understand. Professional identity is understood as the profession's collective self-understanding in relation to the institutional macrolevel and the individual professional's microlevel [15, 16]. Wenger [17] maintains that professional identity develops in interaction among professionals in a shared community of practice. Fagermoen [8] restricts professional identity to be related to fundamental values (in nursing); however, in this study, it is understood that both the values and competence [16] of a practitioner contribute to constituting their professional identity.

A profession is founded on specific values related to an ideological basis which is more engaged in quality than efficiency [18]. The word value indicates something important, worthwhile, and worth striving for [19], and the individual values of a practitioner are understood as a synthesis of personal and professional values related to prevailing professional standards [20]. Individual values are related to one's action competence or practical knowledge, similar to what Schön [21] described as ‘knowledge-in action’. When PHNs narrate their practice experiences, the meaning of their values can be revealed. The guidelines for values in practice are codes of ethics, conduct and practice [22]. Guidelines state the professional, ethical and personal responsibilities of the nurse [23]. Ethical theories relevant to health professions are duty ethics, virtue ethics and ethics of proximity [20]. Duty ethics focuses on performing the appropriate actions. Virtue ethics is concerned with the ethical character of the professional and is similar to what Aristotle [24] referred to as having sound personal qualities and performing ‘good actions’. These are based on the practical wisdom of the practitioner, described in Aristotelian terms as the intellectual virtue of phronesis [25]. Ethics of proximity refers to the ethical relationship, care, trust and responsibility [26]. Through sincere involvement, engagement and mutual dialogue with other people, individuals act virtuously [25, 27]. Martinsen asserts that caring in nursing is moral practice [28, 29]. Practitioners bring their personal values into the professional field and develop ethical practice through reflection and responsiveness to the population they serve [20]. However, in practice, values are taken for granted and are seldom discussed [16].

While there is a lack of research studies describing challenges in public health nursing practice, studies on values suggest an interrelation between personal and professional values, such as trust, respect and responsibility [30] and that values are influenced by the primary force of relationships [31]. Nursing studies reveal the primacy of the following values: trust, responsibility, dignity, autonomy and altruism [8, 32]. A review of the literature on public sector professional identities [3] has shown a relationship between personal and professional identity and that government and institutions disclaim core values, creating resistance discourses among professionals (3, p. 36). Lowe et al. [33] asserted that clarity on professional identity is needed to strengthen the nursing role.



The article adopted an inductive qualitative approach. Narrative interviews and a phenomenological hermeneutic method were carried out, inspired by Ricoeur [34] and Lindseth and Norberg [35]. The phenomenological hermeneutical method is suitable for revealing the meaning of lived experience and was found appropriate when elucidating the nature of ethically charged encounters, as narrated by Norwegian PHNs.


The sample consisted of 23 female PHNs from small, middle and large communities in two counties in Norway. They worked in health clinics for children and young people and school health services. Their practice experience ranged from 0.5 to 25 years (Table 1). There were no obvious patterns between answers and length of work, and they were treated as one sample.

Table 1. Characteristics of the sample
Number of informants23
Length of service0.5–25 years, with a mean of 11.2 years
<1 years length of service2 (PHN 1 and 2)
1–5 years length of service5 (PHN 3–7)
10–15 years length of service9 (PHN 8–16)
15–25 years length of service7 (PHN 17–23)
Number working at child health clinic (H)6
Number working in school health service (S)7
Both health clinic and school health service (HS)10
Size of municipalities4500–625 000 inhabitants
Number of municipalities/districts12
Distribution of informants1–4 in each municipality/district

Data collection

Individual interviews were conducted by the first author during autumn 2009 and in 2010. Access to the research field was established through oral and written inquiries to public health nursing supervisors. These supervisors then informed the PHNs, who established direct contact with the researcher. All interviews were conducted at the workplace of the interviewee, except for one interview that was performed in a café. The interviews lasted from 60 to 80 minutes and were tape-recorded and transcribed verbatim.

The interviewer asked the PHNs what it meant to them to be a PHN and to describe experiences in which they felt that they had done a good job and those in which they felt challenged. The role of the interviewer was to allow the interviewees to narrate without interruption – even in those cases when the development of the story did not seem relevant [36]. According to Lindseth and Norberg [35], the main focus is not on what each nurse conveys in the interview but rather on the possibilities to live and act as a nurse that the transcribed text reveals.

Ethical considerations

Research ethical guidelines were followed. All interviews were tape-recorded. Before beginning the study, participants signed consent forms and were informed that they could withdraw at any time.

Data analysis

The phenomenological hermeneutic analysis included three methodological steps [35]. The first step was a naïve reading to formulate a naïve understanding of the whole text. The focus was on openness towards the essential meaning of the text.

The second step was a structural analysis. The text was divided into meaning units, which were condensed and abstracted to form subthemes and themes. The themes were reflected upon and compared to the naïve understanding. The process of condensation and validation was repeated until the naïve understanding was validated by the structural analysis [35, 37].

In the third step, the whole text was reread with an open approach. Comprehensive understanding and reflection were formulated based on the naïve understanding, the validated themes, the authors' preunderstanding and relevant literature. The method allows a dialectic movement between understanding the whole text and explaining parts of the text [34, 38].


Naïve understanding

The PHNs are proud of their work and are engaged and interested in their service users. Their lived experience of ethically charged encounters is related to feelings of being valuable, appreciated and needed by the families. However, PHNs also experience challenging situations, which leave them feeling inadequate. Dealing with conflicts is considered a valuable skill. The PHNs feel that they are also expected to live up to their public health nursing role in private settings, this can create challenges for them. The naïve understanding of the text shows that PHNs lived experience of interacting with children, families and young people is mainly good but also challenging.

Themes and subthemes

A structural analysis was conducted, resulting in four themes and nine subthemes (see Table 2).

Table 2. Themes and subthemes formulated from the structural analysis of the interviews with public health nurses (n = 23)
Feeling responsibleBeing engaged in the well-being of children, families and young people
Blurred boundaries between work and private life
Being committedBeing concerned
‘Standing up to fight’
Feeling confidentDealing with conflicting loyalties
Being courageous
Gaining trust
Feeling inadequateFailing to meet expectations
Feeling unimportant

Feeling responsible

The theme feeling responsible involved two subthemes: being engaged in the well-being of children, families and young people, and blurred boundaries between work and private life.

Being engaged in the well-being of children, families and young people

Public health nurses revealed a genuine interest in the well-being of their service users. Being engaged meant interacting with service users, showing empathy and guiding them. Although PHNs were very aware of their duty to empower parents regarding health issues, they felt that doing so could be a challenge. A PHN (8 HS) described a situation involving a young mother with serious postnatal depression. The biggest challenge was getting the young father to realise that he now had a very important role in the family.

Engagement could also be related to cultural diversity. A PHN (9 HS) narrated about a female refugee who was a single mother to two boys. She came from a country where men have a very important role, and her boys felt that they could decide themselves how to spend their money and when they should come home at night. The mother needed knowledge and guidance about common parenting practices in Norway.

Blurred boundaries between work and private life

Public health nurses felt responsible and were often so morally engaged that they brought their work home. The PHNs generally worked alone and often had to deal with tough cases. They found it difficult to leave challenging situations at work, and this affected their lives in a negative way. Interrupted sleep patterns were a common topic during the interviews. Several PHNs spoke about this. As one nurse (20 S) said,

I have office hours at the school on Fridays, and there was one boy who had cut himself on a Friday afternoon when I was down there [at school]. I remember thinking: ‘Will you live until Monday?’ I was sure he was so badly cut that he had killed himself.

This moral engagement could also entail giving a young person or parent the PHN's personal phone number. A PHN (16 S) recalled that a mother told her that her daughter had carried the PHN's phone number in her handbag for years. It gave the girl a sense of security knowing that she could call the PHN.

Blurred boundaries between work and private life resulted in an unclear distinction between the professional and private role of the PHN. One nurse (19 HS) wondered whether it was only the PHN role the service users saw, not the person.

In private settings, blurred boundaries lead to PHNs being ascribed qualities that were consistent with their professional role. Parents regarded their local PHN as ‘a mini doctor’ and contacted her in private. PHNs were expected to be role models for good parenting, and they sometimes felt that they were under surveillance in public spaces. One PHN (15 H) described this situation as follows,

If I am out and about, amongst people, I don't always say that I am a PHN in case people want to share all their personal stories with me, stories that I am not interested in hearing outside of work.… Because I cannot ask questions that I would normally ask at work, and, thus, cannot give the advice that I would normally give either.

However, some PHNs felt that this had never been a burden. A PHN (8 HS) made the following comment,

Oh, so you are a PHN'. They have some kind of an idea that I am such and such a type.… I have never thought about being regarded as a role model in private.…What I have heard is actually that ‘Oh, how lovely to see that a PHN is not perfect.

The findings show that PHNs in this study had a strong sense of moral responsibility that remained with them on their time off.

Being committed

The theme being committed included being concerned and ‘standing up to fight’.

Being concerned

Being concerned was related to situations where PHNs experienced children and young people being in troubled relationships. One PHN (13 S) spoke about preventing abuse and improving the situation for vulnerable children in order to prevent parents from becoming angrier – and hitting more.

‘Standing up to fight’

In many of the narrations, commitment was related to being advocates for children. According to the PHNs, they fulfilled an important role in being there for parents and for children who would otherwise neither be seen nor heard. Being an advocate was seen as part of their preventative role.

Public health nurses had to stand up and fight in certain cases. One PHN (7 S) commented that it was so important that PHNs cared, and remarked that they must get involved even though it might be easier to back out when the pressure became too heavy. The PHNs were committed, showed emotional involvement and were willing to fight for the rights of their service users.

Feeling confident

Another theme in the interviews was feeling confident, which entailed dealing with conflicting loyalties, being courageous and gaining trust.

Dealing with conflicting loyalties

Dealing with conflicting loyalties meant having to cope with ethical dilemmas. The study shows that external factors, like prioritising certain duties, could contribute to morally difficult choices, such as deciding whether to be flexible and open or to adhere strictly to the regular programme. The findings show that PHNs were proud of their work. One nurse (5 H) spoke about the lack of resources, yet high expectations regarding the quality of their services. She felt a strong loyalty conflict because she could not offer more. The PHNs experienced ethical dilemmas when they had to choose between alternative courses of action when none seemed ideal.

Being courageous

In challenging situations, PHNs needed courage to cope and to be visible. Managing conflicts were regarded a necessity. Nurses became involved in conflicts, where the trust of the parents could be at stake. One PHN (13 S) said,

I felt a little bit pressed into a corner. It would have been better to let it go rather than get involved in the conflict, but you do not have the opportunity to opt out, really.

Some PHNs expressed being prejudiced and regarding the service users with suspicion. In these situations, the PHNs had to mobilise their moral strength in order to perform their professional duties. Being courageous could also entail enduring abusive comments, which meant that PHNs sometimes got feedback that provoked them. One PHN (3 HS) described the following situation,

I said the wrong thing and that I had to check the guidelines. I was a bit uncertain. They were outraged. I've never been abused so much in my entire life. This was a family with an ill sibling, and the parents wanted me to say that everything is just fine with this child; that was difficult.

The PHNs expressed that they had to be professional, no matter what. When faced with a challenging situation, the PHNs mobilised their courage. One PHN (23 S) described a particular challenging situation,

There was a girl who came and knocked on my door once or twice a week. And you are doing your best to help, having ‘a good dialogue’, and yet you know she is not looking for change. I felt like no matter what I said, she just was not interested because she did not wish for change.

The PHN was humble and had the courage to admit her inadequacy. She contacted a school counsellor to talk to the girl.

Gaining trust

The PHNs felt trusted and appreciated and were aware that they, at times, could make a difference in the lives of parents and young people. One nurse (2 H) said that she had received a lot of positive feedback from families. Another nurse (8 HS) said that at times the service users could probably manage fine without the PHN. However, there were also consultations where the PHNs made important discoveries and saw the vital importance of their work. PHNs related trust to their action competence and power aspects of their role. A PHN (16 S) commented that one has to be careful with that trust and have respect for it. She saw the power aspect of her role. The PHNs were aware that they occupied a position of power and that they should not abuse their power.

Feeling inadequate

Feeling inadequate meant failing to meet expectations and feeling unimportant.

Failing to meet expectations

Failing to meet their own expectations, or those of their service users, made the PHNs feel inadequate. One PHN (16 S) described a situation in which a mother accused her of not doing enough for her daughter who had a serious eating disorder. She felt inadequate because she could not meet the expectations of the mother. The PHN had believed what the girl said and felt slightly manipulated by her. The mother had a different view of her daughter's situation. The PHN remarked that it was not easy trying to please everybody. Another PHN (1 HS) spoke about not meeting a young girl's expectations and leaving her in the lurch. The girl felt that the PHN had let her down, and this was difficult for the nurse, because she felt she had let the girl down too.

Feeling unimportant

The PHNs also felt inadequate when they were not considered important to the young people or parents they were trying to help. One PHN (5H) described how she lacked the skills to interact with the service user:

I couldn't connect, or I didn't have the necessary tools…Then I felt [that] I wasn't important and [that] the child health clinic didn't mean anything.

When the PHNs narrated about challenging meetings, they showed emotional involvement and spoke of the importance of maintaining self-control, also when they felt they did not meet the needs of the service users.

Comprehensive understanding

Public health nurses in this study were a heterogeneous group, being at different places and different stages in their careers. Despite the differences, we have found some interesting common characteristics even if some variation is identified.

The findings indicate that ethically charged encounters were part of the PHNs' experiences as pointed out in the structural analysis, that is, feeling responsible, being committed, feeling confident and feeling inadequate. The ethical challenges were related to PHNs' feelings of responsibility for the service users. Feelings that could overshadow institutional demands and the power position of their role. Defending children's rights was prioritised at the expense of maintaining a pleasant relationship with parents. This, and a strong commitment to work, could cause blurred boundaries between work and private life. Ricoeur [14] maintains the ethical dimensions of personal identity imply continuity, as opposed to Giddens [39] claiming identity is reflexively constructed and embedded with little stability.

The value of responsibility is related both to PHNs' professional and personal identity, since challenging situations could lead to ethical dilemmas at work and in private settings. In accordance with Andrews [40], PHNs in this study experienced that some parents expected them to be available on their time off. Although the PHNs did not want to disappoint the parents, most of them did not want to be disturbed in private. Benner [41] maintained that to do a good job from an ethical perspective, individuals must separate their personal feelings from their professional responsibility. However, this study showed that feelings of responsibility do not always cease when the workday ends, as Clancy and Svensson ([31], p. 165) pointed out ‘the door to the other is always ajar’.

The findings indicate that the personal and professional values of PHNs are so tightly woven together that it is impossible to divide them into separate entities. This is in line with Heggen [42], who noted that based on fundamental self-identity, practitioners support some collective professional symbols, but can practice the role in different ways.

The PHNs showed responsibility by adopting a dialectic approach to their service users. This approach entails establishing a relationship between the interlocutors and the topic of conversation and having a firm belief that the other party always has something of interest to share [25]. Being respected and showing respect were important to the PHNs, this is confirmed by former studies on values in public health nursing [30, 43].

The PHNs showed a social commitment regarding children's rights and felt a moral responsibility to enter into conflicts if necessary. As professionals PHNs have a mandate to protect children, however, by taking the child's side, they risk losing the parents' trust. Taking sides could be experienced as a value conflict in that not only parents but also PHNs felt vulnerable. Having a good relationships with parents was important for PHNs, and parental conflicts could have a negative effect on the PHN's self-identity. On the other hand, defending children's rights was a strong driving force. This finding is in contrast to studies where PHNs have been portrayed as reticent and cautious professionals whose main focus is on maintaining a good relationship with parents and avoiding conflicts [44, 45]. The finding supports Clancy [43] who has shown that PHNs are not afraid to speak their minds if necessary. Dealing with conflicts requires courage. This study also indicates that feeling courageous and confident can be an inner strength or virtue that PHNs have.

Public health nurses recognised their influential position. There is great power in a supporting role [46], and the moral responsibility of nurses demands that they use their power responsibly [47]. Public health nurses were concerned with those most in need of their services. The majority of service users did not have special needs, but PHNs took responsibility for those who deviated from the norm even though these situations could, at times, be emotionally challenging.

Public health nurses felt unimportant and inadequate when they failed to meet expectations from parents and young people. Identity development is closely connected to practice experiences and a relational perspective, which can be divided into a subjective and an objective part [13, 14]. The subject position can be both about their own experiences of being a PHN and doing public health nursing work. The objective part is other peoples' image of the PHN. It can thus be interpreted that lack of parental respect for PHNs competence and conflicts can influence the nurses' self-identity and hence the identity of the profession. Maintaining self-control was important when the PHNs felt criticised and abused. The nurses felt that not intervening showed a lack of respect for the integrity of the family. One can argue that feeling ashamed and inadequate can weaken self-identity. Martinsen ([46], p. 161), however, describes both positive and negative aspects of shame. When shame is understood as a positive phenomenon, it is derived from personal ethical values of acting with good intentions and enables ethical readiness. This study indicates that feelings of inadequacy as well as confidence and courage comprise ethical awareness in public health nursing.

The narratives are told in a context that has a historical dimension and a current situational context. Public health nurses are often pulled in different directions – that is, they are expected to adhere to professional institutional requirements (macrolevel) for being effective and show understanding, flexibility and respect at a relational level (microlevel) [48]. Public health nurses might not be fully prepared for a consultation due to time pressures. This could be due to New Public Management (NPM) ideologies in today's healthcare services, too many tasks and too few resources. Being effective can be seen as a positive side of NPM ideology, but this can cause PHNs to compromise on value work and prioritise in a way that they can come to regret. The moral standards of a practitioner can be challenged by time pressures [15, 32]. Market values can also overshadow the values of professions [20]. PHNs saw the importance of following the regular programme; however, a sense of responsibility for their service users could, at times, overshadow institutional demands and give PHNs the courage to prioritise the time needed in a given situation. Individualised care focusing on a family's specific needs can be more time-consuming and expensive than routine care [49]. By being courageous, nurses can generate strength and help patients to argue for professional care [50]. The institutional level can influence the PHNs' identity, and a relevant question is whether professional identity is strengthened by following the institutional requirements or by following the profession's values of individualised care?

The PHNs moral strength to perform according to service users' individual needs can indicate responsibility and courage, and a commitment to the underlying humanistic values and the ethical guidelines of the profession.

Methodological considerations

Qualitative studies require trustworthiness, authenticity, a critical approach and honourable intentions [51]. In this study, trustworthiness was secured by describing the context and interpretation process thoroughly. According to Ricoeur [34], phenomenological hermeneutic is an argumentative discipline, and the results can be arguments in ongoing discourses and be appropriated, mediating possibilities and new meanings in practice. Ricoeur [34] asserted that a text can always be understood differently but that some interpretations may be more probable than others. Rich descriptions and variations in the interview text required a strict interpretation process, where internal consistency and possible other interpretations were taken into consideration [35]. The first author collected and transcribed the data, the first and second author read and developed the transcribed text, and all authors contributed in the analysis. Understanding the text depends on preunderstanding, of which individuals are only partly aware [37, 52]. In qualitative studies, authors' preunderstanding affects the interpretative process [53]. As public health nursing researchers and PHNs, the first and second author of the present study have a preunderstanding. The preunderstanding of the field was carefully taken into consideration through critical reflection and discussion to avoid a biased interpretative process.


From the findings it may be estimated that public health nurses' experiences of being in ethically charged encounters are related to responsibility, confidence and trust, and the commitment to engage in difficult situations. The study indicates that these experiences can influence their professional identity in different ways. The PHNs in the study face ethical dilemmas in practice. They have to live up to institutional expectations and remain loyal to their service users, encountering difficult practice situations that can lead to value conflicts, leaving PHNs feeling confident and at times inadequate. The study shows that PHNs had the courage to deal with value conflicts and difficult situations. This, in turn, can work to strengthen their professional identity. Elucidating underlying factors in professional identity can contribute to creating awareness of public health nursing legitimacy and authenticity. Further research should focus more on challenges concerning PHNs' competence and how it influences professional identity.

Implications for public health nursing practice

  • Public health nurses need to be aware that ethically charged encounters can lead to value conflicts and feelings of both inadequacy and confidence. Being courageous and dealing with difficult situations can strengthen professional identity.
  • To have responsibility for service users is a deciding factor that can overshadow institutional demands which can be a challenge to professional identity.
  • Public health nurses must recognise they have an influential position and be aware not to misuse the power of the role.
  • Defending children's rights can course tensions in relationships with parents.
  • Having a strong commitment to work can cause blurred boundaries between work and private life.
  • Reflecting on ethical dilemmas in education and practice can help map alternative courses of action and contribute to sound professional practice.


The authors would like to thank the participants of the study for sharing their experiences with us. The authors would also like to thank Professor Mads Hermansen for constructive comments on the manuscript.

Author contributions

Berit Misund Dahl designed the study and collected the data. The analysis and interpretation was carried out by Berit Misund Dahl and supervised by Anne Clancy and Therese Andrews. The drafting of manuscript was made by all authors, and all authors have approved the final article.

Ethical approval

The study was approved by the Norwegian Social Science Data Services (NSD) No. 22315.


We thank Aalesund University College, Norway, and Nordic School of Public Health, Gothenburg, Sweden for their support.