Healthcare Professionals' Perspectives on the Use of Standing Frames for Children Diagnosed With Cerebral Palsy: An Explanatory Mixed Methods Study

Background: Standing frames are commonly used by healthcare professionals in their practice with children with cerebral palsy (CP) who do not have an independent standing function. A better understanding of healthcare professionals' attitudes and experiences with standing frames may impact practice and rehabilitation. Therefore, this study aimed to investigate the standing frame practice among healthcare professionals and expand their attitude and experience with the use of standing frames for children with CP.

life and activities is perceived essential to children's health and should be a primary focus in paediatric rehabilitation (Palisano et al. 2012).Novak et al. (2013Novak et al. ( , 2020) ) published two systematic reviews mapping interventions for children with CP.Interventions such as weight-bearing exercises and postural management, including standing supports for children with Gross Motor Function Classification System (GMFCS) Levels IV and V (Gericke 2006), were rated as having an effect according to a GRADE system rating (Novak et al. 2020(Novak et al. , 2013)).A standing support or assistive device, often referred to as a standing frame, is a fixed frame with support at the trunk, hips, knees and feet.Some also have head and arm support or both according to the child's needs (see Figure 1).In accordance with the ICF and the revised definition of CP, the potential value of standing frames is seen not only regarding 'body structure and function' but also in relation to 'activities' and 'participation' as the standing frame enables children with CP to participate in meaningful activities and be at eye level with their peers, thereby increasing social interaction (Paleg, Williams, and Livingstone 2024).
However, there is an absence of unified guidelines for healthcare professionals regarding the use of standing frames for children with CP and, thus, a lack of consensus on the use.A scoping review by McLean, Paleg, and Livingstone (2022) identified six guidelines that supported the use or development of supportedstanding programmes (Gericke 2006;Paleg et al. 2019;Fehlings et al. 2016;NICE 2016;Arva et al. 2009;IPTG n.d.).But the clinical guidelines differed in purpose, scope and type, and four had no specified guidelines on supported-standing interventions (McLean, Paleg, and Livingstone 2022).
To initiate high-quality research leading to unified clinical guidelines, it is essential to understand how standing frames are currently used in clinical practice and to gather information about their effects and side effects as experienced by healthcare professionals.This knowledge will enable the planning of future studies and ensure the production of high-quality research.Despite the lack of undisputed evidence for the efficacy of using standing

Summary
• The healthcare professionals had a child-centred approach when using standing frames for children with CP, which were to specify the 'need' factor in question rather than using only the child's GMFCS level.
• The healthcare professionals saw the standing frame as having many potential benefits and based their practice and use of standing frames on many different indications depending on their clinical assessment of the child.
• It may be difficult to make unified descriptions for the use of standing frames for all children with CP due to the fact that the children have different needs and indications for using a standing frame.
frames and a lack of detailed guidelines, healthcare professionals widely accept standing frames as standard care for children with CP (primarily for children with GMFCS Levels III-V) (Goodwin et al. 2018a).To initiate high-quality research, it is necessary to gain knowledge about how standing frames are currently used in clinical practice, as well as gather information about the effects and side effects experienced by healthcare professionals.We aimed to investigate the practice of using standing frames among healthcare professionals and to expand their attitudes and experiences with using standing frames for children with CP.

| Study Design
The current study was a mixed methods study with an explanatory sequential design (see Figure 2) (Creswell and Plano Clark 2022a).The study was conducted in two distinct but interconnected phases, i.e., a quantitative phase and a qualitative phase.
Firstly, a cross-sectional survey was conducted, collecting quantitative questionnaire data from healthcare professionals.Subsequently, specific results from the quantitative analysis were connected with qualitative focus group interviews to explain the results.Afterwards, meta-inferences were conducted by merging the quantitative and qualitative findings.
The design was justified based on the rationale of significance enhancement where quantitative and qualitative data analysis maximises the interpretation of significant findings (Onwuegbuzie and Leech 2004).

| Ethical Considerations
In accordance with Danish laws on research ethics, the study was reviewed and approved by the Research and Innovation Organization (RIO) of the University of Southern Denmark.The participants signed a consent form, in which they were informed about their rights to withdraw their consent and the Danish rules regarding storage of personal data (GDPR).

| Study Context
The survey part of this study was conducted in Denmark, Norway and the United States/Canada where the funding of a standing frame depends on the purpose of use.However, there seems to be international differences in the funding of standing frames regarding who funds them and on what basis they are funded.In Denmark, the standing frames are funded by the municipality where the child with CP lives; in Norway, the standing frames are offered by the state; and in the United States/Canada, standing frames can be funded by the state or the insurance companies.Furthermore, in Denmark and Norway, the standing frames are funded with a compensatory aim, so children with functional impairments get the same conditions as other children but are rarely funded with a training or treatment aim.

| Settings and Sample
Eligible participants were healthcare professionals (paediatricians, orthopaedic surgeons, physiotherapists and occupational therapists) presently or previously working with children diagnosed with CP who currently used or previously had used standing frames in any setting, e.g., schools, kindergartens or residences for children with CP.
The questionnaire was distributed in Denmark, Norway and the United States/Canada.The healthcare professionals were recruited through professional societies, child therapies, commercial partner distributor networks and social media like Facebook and LinkedIn.
Danish healthcare professionals replying to the questionnaire in the quantitative phase were invited to participate in a subsequent focus group interview.By accepting participation and responding to a question in the questionnaire, they were invited via email to take part in the focus group interviews.The focus group interviews were grouped according to where the healthcare professionals lived in Denmark.In addition, at least three healthcare professionals from the same location had to have accepted the invitation to participate in the focus group interview for it to be carried out.Before the questionnaire was distributed, a pilot test was conducted with a sample of five physiotherapists to secure the questions' relevance and understanding.Subsequently, the questionnaire was translated into Norwegian and American English and then back to Danish.The questionnaire contained four overall domains, which were demographic and professional characteristics of the healthcare professionals, recommendations on the use of standing frames, the indications for using a standing frame and perspectives on the future use of standing frames.Sixteen of the questions asked had fixed-choice responses, and five out of these 16 also had the possibility for free-text answers.The questionnaire can be viewed in Supporting Information S1.

| Qualitative Phase
Focus group interviews were held in March and April 2023.Focus group interviews were chosen to see if the dynamic social interaction between the healthcare professionals could bring out different points of view or if they shared the same attitudes and experiences (Brinkmann 2014).The interviews were conducted physically face-to-face and lasted about 1.5-2 h.The interview began with an informal conversation to create a safe and casual atmosphere.
A semistructured interview guide was developed based on the survey findings.The main headlines from the quantitative questionnaire were included in the interview guide to get an explanation and a deeper understanding of the healthcare professionals' attitudes and experiences.Furthermore, unexpected results (e.g., deviating responses) were incorporated into the interview guide to explain the survey results.The interview guide can be viewed in Supporting Information S2.The first author coordinated the focus group interviews and also moderated the discussions.The first author was a female in her mid-30s with 8 years of clinical experience working as a physiotherapist with children with CP, ensuring understanding about the terminology being used and in-depth knowledge about the use of standing frames.
During the interviews, the first author prioritised listening and observing in order to let the participants talk and discuss, which is considered to have opened up the conversation and was part of avoiding bias.

| Quantitative Analysis
The quantitative data from the questionnaire consisted mainly of categorical data.Accordingly, the data analysis of the questionnaires was descriptively analysed, reporting numbers and percentages for each question.Statistical analyses were performed using Stata/BE 17.0.

| Qualitative Analysis
The focus group interviews were audio-recorded, transcribed verbatim and anonymised by the first author.For data analysis of the focus group interviews, inductive thematic analysis was used and guided by six phases as described by Braun and Clarke (2006).After the authors got familiarised with the data, quotes were initially coded with the aim of this study in mind.
Next, the codes were collected and sorted into potential themes, and the themes were reviewed to check if they worked with the coded extracts and the entire dataset, creating a thematic 'map'.Afterwards, each theme was refined and defined by giving each theme a name and a definition that captured the 'essence' of the theme.All the phases of the data analysis were primarily performed by the first author under supervision of the last author.Furthermore, in the refinement phase, the themes were presented, reviewed and discussed within the research team to improve trustworthiness (Nowell et al. 2017).

| Integration
The integration was carried out in a systematic back-and-forth process by the first and last authors.The quantitative and qualitative results were placed in a matrix that enabled a visual comparison.Lines were drawn to connect similarities across the results of the studies.This analysis led to two shared discoveries: (1) healthcare professionals' recommendations and use of standing frames and (2) indications for health professionals' use of standing frames.The two discoveries framed further integration, using joint displays and a narrative weaving approach (Guetterman, Fetters, and Creswell 2015).In addition, three possible outcomes (confirmation, expansion and discordance) were used to guide the integration process and interpret the healthcare professionals' attitudes and experiences from the quantitative results and the qualitative findings, respectively (Fetters, Curry, and Creswell 2013).

| Quantitative Phase
A total of 224 healthcare professionals completed the questionnaire, of which 210 were eligible for inclusion.Thirteen were excluded due to their profession; one was a parent to a child with CP, not working as a healthcare professional and, therefore, also excluded.The characteristics of the healthcare professionals are described in Table 1.One hundred four healthcare professionals were from Denmark, 75 from Norway and 31 from North America.Most participants were physiotherapists (n = 172) and currently working with children with CP (n = 190).The majority of the healthcare professionals had over 10 years of experience working with children with CP (n = 121).

| Qualitative Phase
Five focus group interviews were completed with a total of 14 healthcare professionals.All the healthcare professionals were physiotherapists and had between 6 months and 27 years of experience working with children with CP (Table 1).They had all learned using standing frames from colleagues, standing frame courses and/or internships at kindergartens or residences for disabled children.

| Discoveries
Two discoveries were made describing and explaining the healthcare professionals' attitudes and experiences with the use of standing frames for children with CP.These are presented below.The two discoveries are first presented via quantitative results, then the qualitative findings and finally the integration and meta-inferences.Furthermore, the two discoveries are summarised in joint displays (Tables 2 and 3).

| Discovery 1:
The Healthcare Professionals' Recommendations and Use of Standing Frames

| Quantitative
More than 90% of the healthcare professionals used standing frames for children with GMFCS Levels IV and V (see Most of the healthcare professionals explained that the dosage of a standing frame, i.e., how long and how often the child with CP must stand, was also based on an assessment of the child's individual functional level and needs.A child could stand for a longer or shorter period depending on the child's nervous system's registration of inputs and whether the child was active or passive during standing.Their recommendations for how often were based on the general opinion that it is a human right to stand every day, as well as the perspective that repetition is vital for this target group and that the children do not achieve any effect by standing only once a week.
The majority of the healthcare professionals elaborated that the child's cognitive level was an individual factor that could play a vital role in the child's use of standing frames.
Concerning which standing frame they would recommend, the advice for the actual use of the standing frame and which activities the child could do while standing in the standing frame.Thus, the overall analysis showed that the healthcare professionals' use of standing frames was based on the child's individual needs.

| Integration
The integration showed an expansion as the quantitative and qualitative data diverged and expanded the insights on the use of standing frames regarding functional level (see Table 2).The majority of the healthcare professionals did not only use standing frames for children with low functional levels (GMFCS Levels IV and V), as shown in the quantitative data.Their professional decision was instead based on an individual assessment, which considered many different factors such as the child's cognitive level.
Healthcare professionals who participated in the focus group interviews, N = 14 Focus group interview 5: (n = 4) • All women and physiotherapists • Working at a residence for disabled children, a kindergarten for disabled children and at the municipality • Between 7 and 30 years of experience working with children with CP  Children with a high level of function were also recommended to use a standing frame when it was meaningful for the individual child's development.However, the participants were not given the opportunity to link the functional and cognitive levels in the questionnaire, which may explain the diverging findings.
The integration also expanded the quantitative results about age, frequency and duration (see Table 2).Most of the healthcare professionals voiced that their use of standing frames was based on clinical arguments such as following normal motor development (standing around 1 year of age), active versus passive standing (stands longer when active) and repetitions tailored to the individual child rather than just using it because that is what they usually do with children with CP.
The integrative analysis revealed that the healthcare professionals' use of standing frames could be divided into four categories, primarily based on an individual assessment of the child, but differ in the purpose the child has for using a standing frame and therefore differ in, e.g., dosage and activities (see Figure 3).

| Quantitative
Table 3 presents the findings concerning the indications on which the healthcare professionals based their recommendations and use.When the healthcare professionals were presented with a list of indications for using standing frames, they responded 'yes' to almost all (see response options in the questionnaire in Supporting Information S1).However, the three most chosen indications, when they were asked to prioritise three, were as follows: 'to improve or facilitate the opportunity for the child to participate in activities' (43.8%), 'to reduce the risk of hip dislocation' (38.1%) and 'to give the child an opportunity to change position' (35.2%).

| Theme: Clinical
Assessment.Almost all of the healthcare professionals found it difficult to settle on three indications of why they used standing frames for children with CP.Nearly all of the healthcare professionals explained this with the fact that all children are different; therefore, there are as many different indications as there are different children.The majority of the healthcare professionals had the experience that the indications depended on the child's challenges and potential.As such, the indications would change according to the child's functional and cognitive levels.In addition, almost all of the healthcare professionals emphasised that the indications are based on a clinical assessment.Most of the healthcare professionals expressed that they thought the indications were connected and, therefore, had difficulty prioritising them.These difficulties were particularly evident in weight-bearing, where the healthcare professionals explained that 'improving bone density', 'reducing the risk of fractures', 'contracture prophylaxis' and 'reducing the risk of hip dislocation' correlated with 'ensuring weight-bearing' and thus was an Quantitative questions

Meta-inference
How often and for how long would you recommend/use standing frames for?

Frequency of use:
From   important reason for the use of standing frames.In addition, it was also the experience of nearly all of the healthcare professionals that weight-bearing affected proprioception and could affect the children's arousal.It was elaborated that weight-bearing could influence head control and arm/hand function, and therefore, the standing frame provided the children with other opportunities for activities than when seated.

| Integration
The integration expanded the quantitative data regarding the healthcare professionals' indications for their use of standing frames for children with CP.The majority of the healthcare professionals stated that all children with CP are different and have different needs; therefore, the indications would not be the same for every child.These differences expanded the quantitative results, showing that choosing an indication cannot be simplified and generalised to all children with CP and had to be individually assessed.Furthermore, almost all of the healthcare professionals specified that many of the indications were connected, which suggested that the healthcare professionals saw the standing frame as an opportunity for achieving multiple purposes for the child.In addition, it showed that the healthcare professionals believed that the standing frame had several potential benefits for children with CP.

| Discussion
This mixed methods study provides a deeper understanding of healthcare professionals' attitudes and experiences regarding their standing frame practice.The qualitative phase of the study explained the quantitative findings.It provided a deeper understanding of the healthcare professionals' practice and motives for standing frame usage for children diagnosed with CP.When quantitative and qualitative data are integrated, expansion between the two datasets occurred, showing that the GMFCS level was not the only consideration for using standing frames; the cognitive level was also a factor of consideration.Furthermore, the healthcare professionals expanded the quantitative data, showing that the healthcare professionals' considerations regarding age and dosage were based on clinical experience.Finally, the indications on which the healthcare professionals based their use could not be generalised to all children with CP, and the healthcare professionals saw the standing frame as having many benefits.

| Comparison to Other Studies
The majority of the healthcare professionals investigated in this study agreed on using standing frames for children with CP with GMFCS Levels IV and V (92.0% and 95.2%, respectively) and from the age of 1 at the earliest (67.6%).This is consistent with the consensus statement published by Gericke (2006) which recommended that children with GMFCS Levels IV and V start standing from the age of 12 months.However, a systematic review by Paleg from 2011 suggests that children with moderate to severe gross motor delay should start using a standing frame as early as 9-10 months old.Despite this recommendation, the study does not provide a rationale and/or evidence for why these specific ages are recommended.In addition, many of the healthcare professionals agreed on dosage for standing frame use as 7 days/week (71.4%) for 31-60 min (65.2%).This follows a cross-sectional study from the United Kingdom, where the majority of prescribing physiotherapists suggested that standing frames should be used daily and recommended that the duration of standing should be 30-60 min (Goodwin et al. 2018a).However, there is limited evidence  supporting the use of standing frames.One randomised control trial (RCT) found an increasing trend in body mineral density for children with CP standing five times per week, 2 h/day, compared to a decreasing trend when the children stood just 20 min two to three times per week.These results were not statistically significant, though, and highlight the need for further evidence for the use of standing frames (Han et al. 2017).A feasibility study for an RCT showed a more considerable increase in hip migration in the control group compared to the intervention group together with improvements in range of motion and reduction of spasticity in the intervention group (Paleg, Williams, and Livingstone 2024).The control group had a daily mean standing frame duration of 37 min compared to the intervention group, which had a daily mean of 49 min.However, the sample size was small, causing differences between the groups in terms of level of function (Rapson et al. 2022).The evidence on dosage is limited, combined with the fact that children with CP often participate in a range of different interventions as part of their rehabilitation.Therefore, it can be discussed whether it is feasible for children to stand up seven times a week.On the other hand, seven times a week could be necessary for goal attainment.Furthermore, parental collaboration is crucial for implementing healthcare professionals' recommendations to use a standing frame seven times a week.However, the healthcare professionals only briefly elaborated on parental collaboration during the interviews; thus, it was not included as a theme in this article.Nevertheless, this is an important aspect related to the use of standing frames and warrants further investigation.
The theme 'individual needs' showed that almost all of the healthcare professionals had the need of the individual child in the centre of their rehabilitation, which is in accordance with the general ideas behind the ICF (Gericke 2006).The approach encourages individual and personalised goals based on the child's needs and must be changed according to age, life context and environment.This way, the child is recognised as having a central role in the rehabilitation (Trabacca et al. 2016;Castelli and Fazzi 2016).Furthermore, the theme is vital for future research, where identification of patient factors important to predict responses to interventions is needed, to ensure input to determine the most optimal care of an individual child as suggested by Damiano (2014).
In this study, the healthcare professionals choose 'to improve or facilitate the opportunity for the child to participate in activities', 'to reduce the risk of hip dislocation' and 'to give the child an opportunity to change position' as the three most important indications for using a standing frame.This is partly in agreement with the cross-sectional study from the United Kingdom, where the prescribing physiotherapists and nonprescribing professionals saw 'an opportunity for a change of position', 'participation in activities' and 'interaction with peers' as the most important benefits (Goodwin et al. 2018a).Despite our study having a wider study population than the UK study, asking only about GMFCS Levels IV and V in three different age groups, the healthcare professional respondents reported almost similar indications for the use of standing frames.
Regarding the healthcare professionals' chosen indications, there seems to be limited evidence.Viewing the indicator 'to improve or facilitate the opportunity for the child to participate in activities', a small study suggested that activities with the upper limbs can be affected by positioning; e.g., self-feeding could be enhanced by standing (Noronha, Bundy, and Groll 1989).Otherwise, no literature has been found to support this indicator.In terms of reducing the risk of hip dislocation with the use of a standing frame, Rapson et al. (2022), as mentioned above, saw an effect on hip migration.Likewise, a retrospective cohort study showed an effect on hip migration, but the children with CP were restricted to GMFCS Level III and were standing with their legs in abduction (Macias-Merlo et al. 2016).
The theme 'clinical assessment' expanded the quantitative results.To our knowledge, there is no evidence supporting this theme when looking at it in the context of indications of using standing frames for children with CP.It could be argued that the clinical assessment is also based on a child-centred approach, as described above, where the indications are assessed according to the child's individual needs.Only one study showed healthcare professionals' perspectives on the benefits of using a standing frame.However, the healthcare professionals did not elaborate on their experience with different indications for different children.Instead, they elaborated on why they saw the indications as beneficial; e.g., they explained that 'a change in position' was seen as a possibility for participation and stretch of the muscles.Furthermore, the study found that healthcare professionals based their prescription of standing frames on clinical experience and pragmatism (Goodwin et al. 2018b).This was not further elaborated, but it could indicate that the healthcare professionals also made a clinical assessment using a standing frame for children with CP.

| Strengths and Limitations
A strength of this study was the mixed methods design, which made it possible to take advantage of the possibility that the strengths of one method offset the weaknesses of another method (Creswell and Plano Clark 2022b).In this case, a mixed methods design made it possible not only to explain but also expand the findings, supplying a deeper understanding of the healthcare professionals' attitudes and experiences based on the argument that mixed methods provide more knowledge than just the sum of the two individual designs (Creswell and Plano Clark 2022b).Other strengths of this study were that the questionnaire was pilot tested before forwarding it to the healthcare professionals and that the quantitative and qualitative findings and integration were interpreted in close collaboration with the co-authors, which contributed to the credibility and trustworthiness of the study (Nowell et al. 2017).
Regarding potential limitations of this study, it was not possible to calculate the response rate concerning the questionnaire since they were distributed widely via multiple channels, leaving no specific number of potential participants.Therefore, whether the questionnaire reached all the potential healthcare professionals cannot be determined.Also, the generalisability of study findings may be questioned, i.e., whether the demographic characteristics of the participants who answered the questionnaire were comparable to the demographic characteristics of the interviewed participants and whether this could have an influence on the discoveries.
In addition, it was uncertain whether the current case mix of healthcare professionals who answered the questionnaire represented the target group.Likewise, it was unclear whether the interviewed healthcare professionals were representative of the target group given the fact that they all were Danish physiotherapists, thereby possibly not providing in-depth knowledge about all healthcare professionals' experiences and attitudes, and thus, the external validity and generalisability can be questioned.Furthermore, the interviewed Danish physiotherapists were very much in agreement about their use of standing frames, which is a point of attention in relation to whether all the nuances of attitudes and experiences towards the use of standing stands have been expanded adequately.In addition, the healthcare professionals' perceived confidence in their clinical recommendations could have been explored more to gain a deeper understanding of their clinical reasoning for using a standing frame for children with CP.
Another limitation of this study was that it was not possible, due to the separation of questionnaire answers and personal information, to make a purposeful sampling between the quantitative phase and qualitative phase; thus, participants were not selected based on their answers, as described by Creswell and Plano Clark (2022c).Therefore, whether the quantitative results have been explained sufficiently is uncertain.

| Clinical Aspect and Future Research
This study provides a unique insight into healthcare professionals' attitudes and experiences regarding standing frames for children with CP.However, it is notable that the indications on which the healthcare professionals based their usage are supported by limited evidence.Therefore, there is a need for evidence-based guidelines, preferably including an overview of possible indications and the best available evidence for and against these indications, to ensure the optimised usage of standing frames for children diagnosed with CP.Also, keep in mind that the described individual approach for using a standing frame for children diagnosed with CP makes it difficult to choose one effect outcome, which could affect obtaining evidence of the highest quality.Another aspect for future research is the importance of including children with CP and their families to get their point of view on the use of standing frames, thereby making research and evidence-based guidelines incorporating the users' perspectives.Including the role of parents and children's preferences, goals and expectations on using standing frames is also essential to ensure a feasible and meaningful intervention with effect, which should be investigated in future studies.

| Conclusion
Based on the quantitative results from the survey, most healthcare professionals had a clear attitude towards their standing frame practice.However, compared to the findings from the qualitative analysis, a deeper understanding of the healthcare professionals' attitudes and experiences emerged.The healthcare professionals' usage was to a greater extent based on the child's needs and a clinical assessment of these needs, demonstrating a child-centred approach.
Overall, this mixed methods study suggests that creating unified guidelines for the use of standing frames for all children with CP may be challenging due to diverse needs and indications for their use.Furthermore, there is a need for more evidence supporting the potential benefits of using standing frames to establish a groundwork for healthcare professionals' recommendations and practice.

FIGURE 3 |
FIGURE 3 | Simplified illustration based on the healthcare professionals' experience regarding their use of standing frames for children with CP.

TABLE 1 |
Characteristics of the healthcare professionals.

Table 2
3.3.2.1| Theme: Individual Needs.Data revealed that the majority of healthcare professionals' use of standing frames for children with CP was based on an individual assessment.Almost all of the healthcare professionals expressed that the use had to make sense regarding the individual child's development potential and level of function.Further, the standing frame

TABLE 2 |
Recommendations and use of standing frames for children with CP showing how the qualitative findings explained the quantitative results and were merged in an integration.Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cch.13320by University Library Of Southern Denmark, Wiley Online Library on [15/08/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

TABLE 3 |
Indications for the healthcare professionals' use of a standing frame showing how the qualitative findings explain the quantitative results and are merged in an integration.Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cch.13320by University Library Of Southern Denmark, Wiley Online Library on [15/08/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License 13652214, 2024, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cch.13320by University Library Of Southern Denmark, Wiley Online Library on [15/08/2024].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License