The analysis resulted in five themes that represent 16 categories, which in turn include a subset of the 81 identified subcategories. The themes are linked, and they influence how the difficult situations causing moral stress were managed and how moral stress affected wellbeing among the participants both during and after the response. The five themes were “type of difficult situation”, “managing difficult situations”, “tools and support”, “engagement as a protective factor” and “work environment stressors as a risk factor”. An overview of the themes, categories and subcategories is displayed in Table 2.

Table 2 Result of content analysis from FGD with disaster healthcare responders about moral challenges

Theme 1, type of difficult situation: duration, frequency, and intensity

This theme comprises three categories that represent the different types of difficult situations that responders face.

Participants discussed the difficult situations with descriptions of frustration, powerlessness, helplessness, anxiety, anger, and sadness when being hindered or unable to appropriately address recognized needs. Some situations were described as resulting in imposed harm or created false hope among patients instead of helping as intended.

Not being able to act and being hindered by external obstacles

This category represents eight subcategories that characterize situations in which obstacles hindered participants from acting upon their moral values or acting according to what they perceived was right.

The external circumstances included a lack of resources and enormous needs, political and cultural aspects, organizational decisions, and the need to prioritize one’s own security. Participants expressed frustration and powerlessness when faced with situations in which they could not address needs for different reasons. Being forced to make difficult prioritization decisions leaving individual patients behind or being prevented from providing needed care or comfort were examples of these situations. All participants noted that it was frustrating to be prevented from acting when facing a moral challenge.

FGD 1: Yes, as some kind of … justification for these types of decisions was like … which I thought you got … We talked a lot about (it) and so …. the hard fact was that we were actually there more to fight an epidemic than to help individuals actually.

FGD 2: And it was full … it was full war … there were … so very badly sick people and injured…multi-traumas…there were horrible orthopaedic things because they were, eh. … But … It became so much so I didn’t know what… I had to do something, I couldn’t really do anything…or really should not. We should only evacuate; we should only be there.

Actions perceived as insufficient

This category represents eight subcategories that describe situations in which participants tried their best but nonetheless felt that their actions were not good enough or not consistent with their moral standards.

When participants or their organization could not adhere to important values or needed to prioritize differently than they were used to or when they lacked sufficient means or capacities to act according to necessity, feelings of insufficiency and frustration ensued. The difficulties related to balancing collaboration with authorities and other organizations as well as trying to build trust with authorities and the community were a source of frustration when they led to delays in the response. However, participants stated that functional collaboration was necessary. A lack of coordination and lack of clear leadership communication among organizations within the response and in their own organization made the response ineffective and was a source of frustration for all participants. Further, noticing inequities between themselves and the population they were there to assist or between themselves and local colleagues created feelings of sadness, anger and frustration among several participants.

FGD 1: P2. But I was thinking that when I was there … my role as a doctor and (to) do exactly the right treatments and things like that got a pretty serious setback so to say…

FGD 3: Because you put higher demands on those that you work with, of course. It is us, or like, we must, someone must … stand up for what we do. And that I often think makes it more frustrating than the work in itself – if the organization does not support you in what you do or, yes. And not only, not just, like having opinions but also, sort of simply facilitate the work.

FGD 1: …But you are still not prepared anyway, because of the heat and… and to manage like … // So in a short time, you want to do so much more … I was a supervisor nurse then … had 60 patients … in high risk and … and had four tents.

Imposing harm instead of helping

This category represents seven subcategories concerning situations where participants felt that their actions resulted in harm instead of help.

Several participants expressed that they were very displeased when the response had harmful rather than helpful results. Some participants described situations in which they felt that the response created false hope among the population that they sought to help. Certain participants reported frustration when they realized that decisions or actions taken contributed to increasing inequalities, particularly related to increased disparities between population groups.

Some participants described situations in which motivational conflicts among colleagues became contagious within the team. This was described as diverging motivations or attitudes among colleagues that became apparent in encounters with patients and/or within the team. All participants argued that being part of a bad decision created a feeling of complicity. This feeling extended to situations in which participants felt they were associated with other colleagues’ misbehaviour or intentions. Several participants reported situations in which their colleagues acted against the protocols or acted immorally against patients and local colleagues. Colleagues’ misconduct was reported as especially frustrating by participants because it was an unforeseen challenge. Another unexpected challenge was being accused by colleagues of making a poor decision that had to be made due to the acute situation and therefore it was difficult to manage the colleagues’ reaction in the disaster setting.

FGD 3: And it was a nurse who worked with him who said that yes, unless he leaves, then I leave. And which she later did, she left because she couldn’t work with him. She had written down every day what he had done (wrong): He told the patients this, he prescribed this antibiotic, he did this, and, like, she had documented … for a month, wrong, wrong, wrong. But, in the end, she gave up, like no, this doesn’t go, I can’t.

FGD 3: And then I experienced, huge ethical dilemmas, when I saw that those who worked there (with us), not at all were humanitarian. It was really hard for me, and I still have a hard time with this… When I work for (organization x) we gave food to all refugees, in a dose that is, a normal food-dose as well … But there they would receive half an apple and a half sandwich, per day.

FGD1: But we work in healthcare as well, we are used to that kind of people … like you are unable to manage certain patients within surgical care also … // … like here at home … // … But it is this thing that you can stand there by yourself, like this decision, like, I … the example I had. //…That you stand alone with the decision yourself and that you then, by a colleague, can be (accused) like this.

Theme 2, managing difficult situations

This theme includes three categories about how difficult situations were managed and the consequences of resolved and unresolved situations.

Resolving the situation

This category comprises eight subcategories that represent how participants managed and resolved difficult situations. The descriptions of managing difficult situations were mostly focused on constructive, individual solutions. Several participants declared that they tried to focus on solutions rather than problems and that it was necessary to adapt to the current context to better understand the environment and the underlying causes of problems. Some participants expressed that they sometimes had to act, even when they knew it was not the best solution, as a way to manage the situation—to feel that they had at least done something.

All participants believed that creative collaboration with national and international staff was a method to resolve issues, as well as asking for help and support in the situation. Some participants described that they contacted different people outside the response team for advice when confronted with a situation in which they could not find an acceptable solution or act according to their moral values. Doing so was a way for participants to resolve problems when they did not receive adequate support within the team or from the organization. All participants considered collaboration with colleagues to be a useful method to resolve difficult situations and common problems. Resolving issues together resulted in a positive sense of teambuilding. Some participants expressed that they used their earlier experiences as a guide, which was seen as helpful: this strategy made it easier to find constructive solutions.

Many participants mentioned that they sometimes had to be courageous in order to fight and be a voice for the good and to resolve issues. They did so despite feeling a risk of being viewed as naïve and uncomfortable when raising their voice. Some participants described situations in which they felt that they themselves or the organization were not true to their values, and they therefore chose to state that they did not agree with the decision made by the organization and discontinued their mission as a way to resolve the situation.

FGD 3: We were able to help many, so then you have to see it as that at least, that we could still help some and then, it was so that we, we tried to do most things, even if we were too few really to do all that, but it’s better to work a lot when we were there and try, as little as possible, to get angry. To get angry every day in trying to get others to do things they do not want to, then it is almost better to work more and then ignore, in becoming, having conflicts with the staff as well. So, it felt like that, so we decided we would do that anyway.

FGD 1: But there…we did not have a lot (of resources), like morphine you could not bring that in…//into the country and things like that so, we often had a lack of…and we were out of sterile gauze. Yes, but then we had to cut and sterilize ourselves and boiled over fire and all sorts of things because it was really hard with the logistics to get in (medical materials)…

FGD 1: That is … a conflict that I recognize also, that it (is) as well as two sides and one wants to work … impartial.// … It was mostly a rebel-controlled area… and we would work impartially but … then we thought we got too few patients from the actual (x) … area … I noticed this more and more that it didn’t fit into (the organization’s) … rules … that you just take someone from one side, so this became a … great conflict for me actually … so I chose to cancel my mission …

Consequences of unresolved situations: moral distress

This category comprises 14 subcategories that represent the consequences of not being able to resolve difficult situations.

Participants reported that the consequences depended on the severity of the situation, whether the situation was repeated, and the duration of the response. Several participants expressed realizing unforeseen consequences as an additional frustration. Feelings of helplessness, a surreal feeling, feelings of isolation and rumination were reactions reported as consequences by all participants. Several participants described feeling increased helplessness and isolation if it was impossible to resolve the situation or if support was lacking. Many participants noted that difficult situations stayed in their memory for a long time after the response. They were still thinking at the time of the interview of what happened and expressed that it had left them scarred. Some participants described that the difficult experiences “hit” them a long time after being home. They tried to forget and continue their normal work and daily life, but at some point, the experiences still affected them.

Some participants reported feeling exhaustion that led them to discontinue the response prematurely, while some reported that they discontinued in order to spare themselves before becoming too exhausted. Depending on their time in the field and their experience during the response, participants felt that their perceptions of coming home were affected in different ways. Some participants experienced coming home as more problematic than being in the field: some described that their feelings became obvious only after some time had passed and they allowed themselves to reflect. Some participants found that they had to adjust and find a new normal in their everyday life. Feeling alienated after repatriation was common among many participants, both at work and privately. Some participants described taking a break before they returned to their normal work. Another common reflection among participants concerned feelings of loneliness after the response, when no one was interested in listening to their stories, at either a professional or private level or both. Some participants described having lost a sense of naivety due to their experiences.

FGD 1: //…I think I was pretty … I was pretty exhausted, or I needed to get home and somehow digest everything. And then … I felt the risk was that if I were to stay … then I would be burned out, and then maybe I wouldn’t want to go again … while if I then stopped when I was still feeling okay… so … I haven’t regretted that … decision…

FGD 4: …This UFO feeling when you get home… and encounter Swedish healthcare. It… is there always… the longer the mission, the longer you feel like a UFO… And what people are talking about and what… the patients are talking about… You come from another planet, what is this? … But then it goes pretty quick… it goes faster for every mission, and the shorter the mission is… it is easier to just fall back into the… rhythm here at home…in some way.

FGD 3: It was really so difficult. And you, like, lose some kind of naivety. Or, and somehow, I feel that this … // Yes, the world wasn’t as good. Or I do not know how to say … But somehow … // You lose something in that. Something you believed in or what it was now. And that, maybe you should have been warned about that before, that … it won’t be so good afterwards, even if I don’t regret that I did it either, but maybe you would have been warned of how hard it was…

Consequences of managing difficult situations: positive consequences

This category includes six subcategories that describe experiences of resolving and/or managing difficult situations.

Many participants described the results of managing difficult situations as opportunities for personal and professional growth. Some participants stated that they could contribute to improvements due to their learned experiences; indeed, some expressed pride that their creative solutions and functional teamwork contributed to resolving issues. Several participants described that, in the end, managing difficult situations and learning from mistakes resulted in making a difference and achieving good for others. All participants claimed that when arriving home, they reflected on their experiences and learned things about themselves, which in turn gave them self-confidence.

All participants stated that they experienced positive consequences, such as a changed world view with increased awareness of inequalities among all participants, where they could be a spokesperson. The newfound awareness of inequalities was sometimes linked to a sense of guilt and sometimes to a sense of increasing gratitude. Many participants described, when returning to their work, increased reflection on the capacity of Swedish healthcare.

FGD 1: … Or that it was like this, but you whine about the delayed bus or something like that … // … So, I think that somewhere, something happened in me as well or that I maybe got a slightly different outlook on the way in which I learned a lot when I was there but…

FGD 3: Mostly, you are very grateful to live here as a woman really. When you are exposed and when you see many other countries and how much you can decide over your own life, that is probably what you are most grateful for, I think when I return …

FGD 3: … //…I have to say that I am grateful every time I put on gloves. I try not to forget that we have so much (of) here. We have plastic aprons and gloves and disinfectants all the time and can wash our hands.

Theme 3, tools and support

This theme comprises four categories concerning the support and tools available to manage morally challenging situations and other ways to find support when it was lacking.

Informal support

This category represents five subcategories that describe access to informal support during and after the response.

Many participants described that it was mostly their own responsibility to take care of themselves during the response and upon their return home. When neither tools nor functional support were available to them, they had to find constructive solutions and support. Support during the response was described by almost all participants as coming from colleagues, with whom informal talks and relationships were seen as invaluable. Participants further reported that informal support was centred on having meetups in the evening or sharing everyday thoughts with a roommate. Several participants mentioned that it was invaluable to have someone who could understand and make them feel that they were not alone with their emotions. However, many participants described that this was dependent on the context, and if there was no one they could talk to, they would feel even more isolated. Another taxing circumstance described by many participants was the awareness of being unable to use their normal support network.

After the response, many participants described that it was difficult to share their experiences with family and friends. Three participants described that it would be unthinkable to talk about particular experiences with their partners, family members and friends. They therefore kept parts of their experiences and feelings to themselves. Several participants described that they chose to share their stories with a selected group of people whom they trusted or with persons who had undergone similar experiences. These persons could be individuals whom the participants had met in preparatory courses within their organizations. Several participants reported feeling relieved when they talked about their experiences with other people, realizing that they were not alone in their feelings of frustration and powerlessness during the response.

FGD 2: I did not tell everything (to my family)… not into the smallest detail … because some things can be too extreme. //…Yes, just with security means and such things … so like when you are in war and such things … then it can be extreme around you, so … like … so everything in the smallest little detail, I don’t tell.

FGD 2: So, I’ll probably say that, or to my rescue…// it was my local colleagues, that is, those who saw exactly the same thing as me. So, they were in it, and they were closer to it than I. They lived in the village, it was their neighbours, it was theirs…

FGD 4: You had so that … then in the evening when you kind of switched off the lamp and would go to sleep then … you could … // … because we shared rooms and came close to each other …. That was when you had … that opportunity as well.

FGD 3: … And it becomes also, you also get debriefing during long time and, so that I think have been very important like keeping in touch with them (colleagues), because you have experienced a little, kind of similar things, yes. And it’s often easier to talk through (when coming home), with those who have worked with similar organizations and so … //

Formal support

This category represents three subcategories that describe access to formal support during and after the response.

Many participants claimed that appropriate and available formal support and tools during the mission were lacking. Leadership support within the team that was not functioning well added to the sense of frustration and loneliness. Participants contended that tools for ethical analysis were not used or that to their knowledge such tools did not exist, in their organizations.

Tools available during the response were described by several participants as being dependent on an individual’s own resourcefulness. They took their own initiative to find support during difficult situations; however, being provided with contact information for psychological support was described by two participants as giving them a sense of safety. Psychological support was used by only one participant, and this kind of support during the response was not provided by all three organizations. Some participants were able to meet with a psychologist at the expense of the organization after repatriation. One organization had a counsellor available when needed, whereas two organizations offered sessions with a psychologist after repatriation. Additional sessions could then be provided by a referral for psychological services within the regular health-care services. However, this was described by some participants as inappropriate due to the psychologist not seeming to understand what they had been through, or having no experience from the field. When the psychologist was unable to relate to the difficulties that participants had faced, this resulted in increased feelings of loneliness. However, they described it as helpful when a psychologist could relate to and confront participants’ stories about their experiences. After the response, debriefing sessions were mandatory within two organizations, and home-coming seminars were opportunities for reflections and sharing experiences. Home-coming seminars, which were provided by two organizations, were described as useful but difficult to attend because they were offered only a few times each year.

FGD 2: P2. … I really think, I am completely pro all kinds of psychologists, but I still think that it is a triumph to meet other (colleagues) who have been in the same situation or in similar or completely different situations (to talk to)…P1: Like, you two ..? P2: Yeah exactly, it would have been great to meet some of you …

FGD3: In (organization x) they have homecoming seminars, and so, then you can talk to others who have been in different places; you meet, and it is great because you … it is like, here that you exchange, like, experiences from different places and then relate to it. A bit like that, so I still think that. Talking about it makes, after all, makes you see that it is not just you who has felt this way. Well, it’s more that thing that… helps in different situations so…

Preparatory support

This category represents three subcategories that describe the support given by the organization before the actual response which was helpful when facing difficult situations.

Preparation such as courses and trainings were described by all participants as useful to both their professional development and social networking. Participants argued that the social network developed from the courses was especially important. The network comprised a contact group with whom some participants had regular contact during their missions despite being in different places around the world. Briefings provided by the organization before the response were perceived by all participants as necessary but also sometimes as inefficiently designed or structured. Further, some participants reported frustration stemming from a lack of, or an ineffective, hand-over of information when arriving at the response site.

FGD 2: …we had a lot of group work and then, like one is supposed to struggle and do group work with someone who lives in another country and this, and everyone had different ideas about everything and everyone had different experiences. But after that, then we had each other. And then we have met a lot.

FGD 2: It was my first assignment. So … you try to … read in somewhat. But then it was not really what was in this description that I actually was doing at the time. Then, what I needed to know it didn’t say. Thus, such concrete details. If I’m going to write a referral on someone, how do I do it? Where should I make copies? Who will sign? Very handy stuff.

FGD 3: Neah, I think I looked them up (the hand-over reports) myself somewhere. No, that has been extremely bad. Extremely bad with those parts. These project-specific hand-overs…

Other tools

This category represents three subcategories that describe other tools and idiosyncratic methods used to manage and resolve difficult situations during and after the response.

Participants who used stress-management tools such as yoga or other group activities described these activities as meaningful tools to relieve stress. Further, group activities provided opportunities to get to know each other in the team.

Some participants described that they started to work immediately after coming home; however, this was sometimes experienced as very demanding. A few participants took some time off before returning to their regular workplace even though the hiatus was not arranged for by the organization. Several participants reported that if they started to work too early after repatriation, they became more frustrated in their regular work. However, some participants noted that professional colleagues were a source for support. Two participants described having colleagues who knew them well and who could recognize that they did not feel well and dared to ask about their wellness. Certain participants gave lectures and presentations about their experiences in the field when coming home. This was seen as a meaningful way to process their experiences. Participants who joined “post-project groups” with individuals who were participating in a specific response such as the Ebola outbreak considered the activity to be very useful: it provided an overview and understanding of what happened during the time, and participants could understand their own place in a larger whole. Several participants argued about the importance of keeping in contact with colleagues who had similar experiences, especially when, or if, there was little or no formal support.

FGD 2: It was: -Now, we will talk about all the investigations we’re going to do and //, so. And I worked on it, and then finally came, one afternoon the janitor came in (saying) like this: How are things really with you? How are you? Then it was the janitor, not a close colleague. – You’re not quite normal, are you all right? Here, it was so nice when someone just said that …

FGD 1: What has been good for me, it has been to … lecture. // Like in networks and like … interest organizations and … and schools and so. // … So that … it helped me through that in some way … I think.

Theme 4, engagement as a protective factor

This theme consists of four categories that cover participants’ perceptions of their professional role and motivation within their occupation which over all served as a protective factor despite the difficult situations they faced.

Altruistic motivation

This category represents two subcategories that describe an altruistic motivation to participate in disaster response. This motivation was stated by several participants to be the desire to achieve good for others, inform their community about the reality in the world, combined with an urge to make a difference.

FGD 2: … what really … happens because there were so many television pictures and … that … there was so much inaccuracy (through media) I also thought … about these things, that it was …then I felt a bit more that I //it was a bit my duty to tell as well, about these fates and a little about how it really is //…

FGD 1: But then there is something that you can think that it is exciting and that you think it is … is fun but somewhere you will still do your best or do what you think or somehow,that is what makes the difference.

Professional and personal motivation

This category represents two subcategories that describe the professional and personal motivation to participate in disaster response and reflections on this type of work.

Many participants stated that their motivation to engage in this type of work was to get learning and experience. All participants suggested that their experiences gave them opportunities for growth. Gaining experiences as opportunities for growth outweighed the negative impact of difficult situations. Several participants described trying to remind themselves that regardless of the outcome, they had done the best they could with what they had. This was considered by many participants to be a way to cope and live with their experiences. However, this growth and confidence was something that they learned themselves and increased with the experiences from the assignments.

FGD 1: Seems to be like … almost all people who go away … That there is more than one assignment … So, it points towards that … there is something … in it for … // something in it for personal development.

FGD 3: But I can agree with that, despite being very unprepared, but I also felt that I was very ready with: ‘You can do this’. It is not your fault that things are not in place (when working in a disaster setting), that no one has checked, really, it is not your fault. You do what you can, and… And that I think you get with age, like that security…

Framed by the professional role

This category represents two subcategories that describe participants’ reasoning about their professional role within an organization.

Many participants described their awareness of their role within a larger structure: within this structure, they must follow rules and guidelines. This awareness resulted in the participants arguing that individuals cannot do what they choose at any moment. Several participants argued that the rules and guidelines are important and are there to protect the patients. However, the guidelines also serve to protect the local staff, since they should not be exposed to changing working conditions every time a new team member joins the response.

FGD 3. After all, it has to do with structures, cultures, more than the care itself. Because I buy that… the first paper I signed was that I would follow the organization’s guidelines and… I have accepted that. That I can’t do what I do here at home, there. But, on the other hand, one can have a humanistic attitude about what one does. That it is not a yes or a no, but one can always give good care and see that this is a human being, like…

FGD 1: According to the principles as well … guidelines and … there are often guidelines … // if you talk about surgery or what you are talking about, antibiotics or whatever it is. // … So that … all employees then follow those. // … That there is some structure with leadership and such, which gives some kind of control.

Challenges are part of the work

This category represents three subcategories that relate to the reasoning about facing difficulties and challenges as part of one’s occupation.

When discussing the overall experiences, participants expressed a common perception that there are problems everywhere and that the world is not perfect. Many participants related to challenges within their usual work in Swedish healthcare and perceived challenges to be a part of daily life. Another way of thinking reported by some participants was that they had agreed on the conditions of this kind of work and that this made them prepared to face difficulties.

FGD3: Yes, it is dilemmas, hospital beds and everyone who quits and how people leave for staffing agencies, and that costs us a lot of money instead of investing in those who are there and invest in nurses, in a just and decent working environment. It is horrible, it is really obnoxious when you work such shifts, I cannot cope with that …

FGD 3: It’s like you go out and accept the medical … part, that I cannot save a premature baby in (country x) even though she breathes, looks rosy and is alert. But I can give dignified care, worthy care.

Theme 5, the work environment as a risk factor

This theme consists of two categories that cover participants’ perception of other sources of stress within their work environment. These stressors put additional strain to the participants when facing specific difficult situations which becomes a risk factor when dealing with moral stress.

Work environment

This category represents three subcategories describing risk taking and traumatic events in participants’ work.

All participants mentioned that they were aware of taking both safety and financial risks when signing up for this type of work. Being willing to take these risks was discussed as a factor that separated them from those who did not continue with this work. Some participants reported that they also took a personal health risk, since they understood that their experiences could affect their daily functioning when returning home. Some participants reported experiencing traumatic events, such as robbery and shootings, as additional sources of stress. These events, however, led to increased attention from the existing support structures: Participants reported that special support structures with evacuation possibilities and psychosocial support were quickly in place for those who had experienced such an event.

FGD 2: But that is a frustration that is quite common. In our assignments, people are hindered from travel because it is so difficult… so special … those who go to Syria now and away to Iraq … // So maybe you end up outside (the country) and are in some hotel … at some strange place nearby … and people tend to feel quite bad about that…

FGD 2: P1. It can be beautiful. When I see the pictures now, I see it, but didn’t I see how beautiful it was? But I don’t think I did. Because it was so difficult. P2: It was so, it was really tough. But it was because when I was there, it was so unsettled too, so you felt that … everywhere it was turbulent, and you dared not go outside …

FGD 2: Nah, but, but I think it was so much more concrete. // I mean a robbery and weapon, this all can be understood, and then they certainly have some PM then, because it has certainly happened, eh… But like this other, with which you go in this, uh, this reality every single day…

Stress and exhaustion

This category represents three subcategories describing additional sources of stress within their work.

All participants described facing difficulties within the team, especially when colleagues and individuals in leadership positions did not fulfil their managerial duties, as a factor leading them to feel drained. This resulted in further difficulties in obtaining support or raising issues within the team.

Many participants described their occupational context with its constant overwhelming needs and human suffering as being draining. This was especially a challenge as they lived within the context and did not have a chance to take a break from their working environment. Some participants also described having an issue with being in a role with responsibility within this context, in which they were supposed to function as a responsible team leader for their team.

FGD 4: … That’s what has been the most difficult… it was so difficult there and then, because there was no time to… reflect… //… like… we had… it was an emergency assignment where you were out… on the boat like fifteen hours a day and then go home and prepare for the next day… // and then up and go to the next and… there was someone… new as well… similar story that you met… so it was like…//… It was not so easy to handle it there and then you only got to … // … push forward

FGD 2: Pregnant women … with small children and rubber boats and … only that, you get so influenced by how miserable…how horrible people have it and that they still have the power to … take this journey … So yeah … it is also that you are weakened by…just by the situation … Emotionally within the situation, in many situations…//…you see so much suffering…which might weaken you…already before a specific event happens… I can think …

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