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Vol. 24 - Num. 94

Original Papers

Scientific publications of primary care paediatricians in Spain the last six years (2015-2020)

Paloma Comino Vázqueza, Josep Vicent Balaguer Martínezb, Marta Carballal Mariñoc, Ramona Mínguez Verdejod, Ernestina Azor Martíneze, Ana Gallego Iborraf

aPediatra. CS de Utrera Norte. Utrera. Sevilla. España.
bPediatra. CAP Sant Ildefons. Cornellà de Llobregat. Barcelona. España.
cPediatra. CS Cercera-Culleredo. A Coruña. España.
dPediatra. CS de Algemesí. Algemesí. Valencia. España.
ePediatra. UGC Virgen del Mar. Almería. España.
fPediatra. Unidad de Atención Infantil Temprana. Distrito Sanitario Málaga-Guadalhorce. Málaga. España.

Correspondence: P Comino. E-mail: palomacomino@gmail.com

Reference of this article: Comino Vázquez P, Balaguer Martínez JV, Carballal Mariño M, Mínguez Verdejo R, Azor Martínez E, Gallego Iborra A. Scientific publications of primary care paediatricians in Spain the last six years (2015-2020). Rev Pediatr Aten Primaria. 2022;24:149-58.

Published in Internet: 16-06-2022 - Visits: 2431

Abstract

Introduction: health care delivery should always be associated with quality research, as the scientific method is used to assess and investigate problems to identify their causes or solutions as part of an ongoing health care quality improvement process. The objective of our study was to determine the frequency with which primary care paediatricians (PCPs) in Spain contribute as authors of publications in the main national and international paediatric journals.

Material and methods: descriptive cross-sectional study. We reviewed the authorship of the articles published in every Spanish national and regional paediatric journal and in the 3 most relevant international paediatric journals in the period ranging from January 1, 2015 to June 30, 2020.

Results: the review included a total of 6398 articles, 2030 from national journals and 4368 articles from international journals. In the group of articles published in Spanish journals, we found authors that were PCPs in 410 (20.2%), with exclusive participation of PCPs in 117 (5.8%) and a PCP listed as the first author in 258 (12.7%). In articles published in international journals, 31 (0.71%) had a Spanish author in the list, and only 5 listed at least one Spanish PCP.

Conclusions: involvement in research and contribution to national scientific journals is low among PCPs. At the international level, there are few publications by Spanish paediatricians in the main paediatric journals, with an extremely low number of contributions by PCPs in these journals.

Keywords

Bibliometrics Paediatrics Primary health care Research Scholarly communication

INTRODUCTION

It is now 35 years since the figure of the primary care paediatrician (PCP) was established in Spain.1 They are the ideal specialists for paediatric clinical care2 and have been consolidated as a service highly valued by the public.3 However, the threefold task that should be intrinsic to any healthcare group, care, teaching and research, has developed unequally.

Although it is well known that healthcare activity should always be linked to quality research, facilitating a process of continuous improvement in clinical care through analysis and study of the causes and solutions of problems in daily practice,4 the research work conducted by PCPs seems quantitatively sparse, fragmentary and little recognised.1

As a previous publication has noted,5 the advantages of research in primary care (PC) include its comprehensive view of health (which lends itself to the study of both acute and chronic processes), in real settings (with access to records of real, well-defined populations and therefore with less participant bias), taking account of other areas of research commonly ignored in hospital or academic settings (such as longitudinal follow-up of the natural history of disease, preventive activities or health promotion), working with healthy as well as sick populations and focusing on the dissemination of practical results, applicable to everyday clinical work.

However, as has been pointed out in bibliometric reviews of PC research in Spain,6,7 the productivity and impact of research in primary care remain low. Among the causes that may explain this situation are the high pressure of care, which has become more acute in recent years, the widely scattered geographic locations of paediatricians and their limited training in research methodology or lack of experience in applying it. Deficiencies can still be observed in organisation, training and provision of resources by managements to foster research by PCPs.

Moreover, the possibilities of conducting clinical trials in the child population are few, owing to methodological, ethical and legal problems when it comes to complying with quality standards. A further added difficulty is that paediatric diseases tend to be rare, with very few patients, making it essential to form a network and conduct multicentre studies to bring together a sufficient number of cases.8

Only by creating favourable conditions for collaboration and exchange of resources between academics, health professionals, regulatory bodies and industry, at both national and international level, and giving impetus to training specialists in research methodology will we succeed in promoting participation in designing and carrying out paediatric clinical studies.

To address the scientific output of this group we have analysed the publications of PCPs in biomedical journals. The objective of this study is to find out how frequently PCPs participate as authors in national and international paediatric journals.

MATERIALS AND METHODS

Design and scope

This is a cross-sectional descriptive study of the participation of PCPs as authors of publications in national paediatric journals and in the leading international paediatric journals.

Study period

The information was collected between 1 July and 31 December 2020.

Population selection and data collection

We conducted an exhaustive review (article by article) of the authorship of articles published in the selected journals from 1 January 2015 to 30 June 2020. We reviewed the authors of articles classified as editorials, originals/brief originals, reviews (including systematic reviews and meta-analyses), case reports and letters to the editor. Articles of any other type were not reviewed.

For authors to be considered as PCPs, they had to identify themselves as such or indicate a health centre as their place of work.

The selected journals were generalist paediatric journals that accepted original articles for publication. Journals intended for ongoing training of professionals and secondary journals were disregarded. In the category of Spanish journals, we took into account both journals of national scope and regional journals or bulletins. We therefore reviewed authorship in the following journals: Acta Pediátrica Española (up to April 2020, the last existing issue), Anales de Pediatría, Revista de Pediatría de Atención Primaria, Revista Española de Pediatría (up to October 2018, the last existing issue), Boletín de la Sociedad de Aragón, la Rioja y Soria, Boletín de la Sociedad Vasco-Navarra, Boletín de Pediatría, Canarias Pediátrica, Pediatría Catalana and VOX Pediátrica.

As for international journals, we reviewed authorship in the three generalist paediatric journals with the highest ratings according to SCImago Journal Rank. These journals were JAMA Pediatrics, The Lancet Child and Adolescent Health and Pediatrics.

Variables

For each of the articles from national journals included in the study the following variables were obtained:

  • Type of article: editorial, original, review, case report or letter to the editor.
  • Total number of authors of the article.
  • Number of Spanish PCPs among the authors of the article.
  • Is the first author a Spanish PCP? Yes or no.
  • Subject-matter of the article:
    • Clinical subjects: adolescence, allergy, asthma, breastfeeding, cardiology, dermatology, emergency medicine/toxicology, endocrinology, environmental health, gastroenterology, genetics/dysmorphology, gynaecology, haematology/oncology, infectious diseases, neonatology, nephrology/urology, neurodevelopment/learning, neurology, nutrition, odontology, ophthalmology, orthopaedics/trauma, otorhinolaryngology, palliative care, pulmonology, psychiatry/psychology, rheumatology, social paediatrics, surgery, vaccination and routine preventive care.
    • Non-clinical subjects: diagnostics, ethics, evidence-based medicine, healthcare quality and management, health education, information systems, lifestyle, natural history/risk factors, new technologies, clinic organisation and scheduling, prevalence, preventive activities, health care professions, protocols and standardization, quality of life, training and treatment/management.
  • In the case of original articles, we also obtained the following information:
    • Type of study: observational, experimental/interventional, diagnostic/prognostic, or other?
    • Is it a funded project? Yes, no or could not be determined.

With international journals, we carried out the analysis issue by issue, so that the following information was collected in each issue of the journal studied: number of editorials, number of original articles, number of reviews, number of case reports, number of letters to the editor. If any article(s) with a Spanish author were detected in that issue of the journal, the following variables were compiled: type of article, total number of Spanish paediatricians, number of PCPs among the authors, number of times a PCP appears as first author and subject-matter of the article.

Ethical considerations

Since the study analysed public information, it was exempt from the need of evaluation by an ethics committee.

RESULTS

We reviewed 6398 articles, 2030 in national journals and 4368 in international journals.

Results of the review of national journals

Of the 2030 articles in national journals, a PCP participated in 410 (20.2%), the participants were exclusively PCPs in 117 (5.8%) and the first author was a PCP in 258 (12.7%). Table 1 shows the distribution of PCPs according to the type of article (Fig. 1).

Table 1. Distribution of primary care paediatrician (PCP) authors by type of article in national journals
Type of article Articles with participation of at least 1 PCP n (%) Articles authored exclusively by PCPs n (%) Articles with a PCP as first author n (%)
Editorial (n = 120) 28 (23.3) 27 (22.5) 23 (19.2)
Original (n = 797) 152 (19.1) 29 (3.6) 88 (11.0)
Review (n = 162) 48 (29.6) 17 (10.5) 31 (19.1)
Case report (n = 620) 152 (24.5) 39 (6.3) 96 (15.5)
Letter to the editor (n = 331) 30 (9.1) 5 (1.5) 20 (6.0)
Total (n = 2030) 410 (20.2) 117 (5.8) 258 (12.7)
n: number of articles.
Figure 1. Distribution of primary care paediatrician (PCP) authors by type of article in national journals
Figure 1. Distribution of primary care paediatrician (PCP) authors by type of article in national journals.

Table 2 gives details of the distribution of PCPs for each journal. The journal of national scope with most publications in which PCPs participated was the Revista de Pediatría de Atención Primaria, followed by Anales de Pediatría and Acta Pediátrica Española.

Table 2. Distribution of primary care paediatrician (PCP) authors by national journal
Journal Articles with participation of at least 1 PCP n (%) Articles authored exclusively by PCPs n (%) Articles with a PCP as first author n (%)
Anales de Pediatría (n = 1003) 85 (8.5) 19 (1.9) 48 (4.8)
Acta Pediátrica Española (n = 349) 35 (10.0) 12 (3.4) 24 (6.9)
Revista Española de Pediatría (n = 124) 6 (4.8) 0 (0.0) 2 (1.6)
Revista de Pediatría de Atención Primaria (n = 349) 172 (49.3) 41 (11.7) 117 (33.5)
Boletín de la Sociedad de Aragón, La Rioja y Soria (n = 15) 15 (100) 8 (53.3) 11 (73.3)
Boletín de Pediatría (n = 15) 15 (100) 2 (13.3) 9 (60.0)
Boletín de la Sociedad Vasco-Navarra (n = 17) 17 (100) 6 (35.3) 10 (58.8)
Canarias Pediátrica (n = 14) 14 (100) 8 (57.1) 13 (92.9)
Pediatría Catalana (n = 124) 31 (25.0) 14 (11.3) 13 (10.5)
VOX Pediátrica (n = 20) 20 (100) 7 (35.0) 11 (55.0)
Total (n = 2030) 410 (20.2) 117 (5.8) 258 (12.7)
n: number of articles.

The proportional participation of PCPs in regional journals was significantly higher than in national ones. The odds ratio for articles in which a PCP appears as first author was 4.15 (95% CI: 2.99-5.77) in regional journals compared to journals of national scope. For articles in which the authors included a PCP it was 6.17 (95% CI: 4.56-8.34) and for those authored exclusively by PCPs it was 6.85 (95% CI: 4.56-10.28).

Most of the original articles in which a PCP participated were of an observational type (133). We found only 9 experimental or interventional studies and 4 diagnostic or prognostic ones. Table 3 shows details of the distribution of PCPs by type of study (original articles).

Table 3. Distribution of primary care paediatrician (PCP) authors by type of study (original articles)
Type of study Articles with participation of at least 1 PCP n (%) Articles authored exclusively by PCPs n (%) Articles with a PCP as first author n (%)
Observational (n = 731) 133 (18.2) 22 (3.0) 76 (10.4)
Experimental/interventional (n = 35) 9 (25.7) 3 (8.6) 4 (11.4)
Diagnostic/prognostic (n = 16) 4 (25.0) 2 (12.5) 3 (18.8)
Other (n = 15) 6 (40.0) 2 (13.3) 5 (33.3)
Total (n = 797) 152 (19.1) 29 (3.6) 88 (11.0)
n: number of articles.

Of the 797 original articles published, 90 (11.3%) received some funding. A PCP participated in 27 of these (30%), 4 were exclusively authored by PCPs (4.4%) and in 13 (14.4%) a PCP was the first author.

The trend over time in the number of publications during these six years remained stable. The number of articles in which at least one paediatrician participated ranged between 84 in 2015 and 62 in 2018. As for articles authored exclusively by PCPs, we found 27 in 2015 and 17 in 2018. There were 60 articles in which the first author was a PCP in 2015 and 39 in 2018.

The subjects addressed in the publications corresponding to the highest proportions of PCP participation were routine preventive paediatric care (at least one PCP was listed in 90% of the articles on this subject), vaccination (62%) and breastfeeding (59%), followed by neurodevelopment (47.8%), adolescence (42.9%), environmental health (41.6%) and social paediatrics (39.4%). However, the clinical subjects that most often appeared in national journals in absolute terms were infectious diseases (250 articles), neonatology (158) and dermatology (120); the proportion of articles on each of these subjects in which at least one PCP participated was 26.4%, 6.3% and 36.7% respectively, as shown in Table 4.

Table 4. Distribution of primary care paediatrician (PCP) authors by clinical subjects of articles
  Articles with participation of at least 1 PCP n (%) Articles authored exclusively by PCPs n (%) Articles with a PCP as first author n (%) Total no. of times the subject appears n (%)
Adolescence 9 (42.9) 2 (9.5) 5 (23.8) 21 (100)
Allergy 1 (8.3) 0 (0.0) 0 (0.0) 12 (100)
Asthma 4 (36.4) 1 (9.1) 2 (18.2) 11 (100)
Breastfeeding 13 (59.1) 4 (18.2) 7 (31.8) 22 (100)
Cardiology 5 (5.2) 1 (1.0) 1 (1.0) 96 (100)
Dermatology 44 (36.7) 15 (12.5) 28 (23.3) 120 (100)
Emergency medicine/toxicology 13 (13.7) 3 (3.2) 10 (10.5) 95 (100)
Endocrinology 19 (16.7) 4 (3.5) 13 (11.4) 114 (100)
Environmental health 5 (41.6) 2 (16.7) 4 (33.3) 12 (100)
Gastroenterology 18 (17.3) 7 (6.7) 14 (13.5) 104 (100)
Genetics/dysmorphology 3 (3.7) 0 (0.0) 1 (1.2) 81 (100)
Gynaecology 8 (26.7) 2 (6.7) 7 (23.3) 30 (100)
Haematology/oncology 9 (9.6) 0 (0.0) 7 (7.4) 94 (100)
Infectious diseases 66 (26.4) 21 (8.4) 48 (19.2) 250 (100)
Neonatology 10 (6.3) 3 (1.9) 5 (3.2) 158 (100)
Nephrology/urology 10 (14.3) 3 (4.3) 6 (8.6) 70 (100)
Neurodevelopment/learning 11 (47.8) 2 (8.7) 8 (34.8) 23 (100)
Neurology 7 (8.0) 0 (0.0) 2 (2.3) 87 (100)
Nutrition 25 (27.5) 6 (6.6) 16 (17.6) 91 (100)
Odontology 3 (23.1) 1 (7.7) 2 (15.4) 13 (100)
Ophthalmology 2 (10.0) 1 (5.0) 1 (5.0) 20 (100)
Orthopaedics/traumatology 14 (33.3) 4 (9.5) 8 (19.0) 42 (100)
Otorhinolaryngology 6 (27.3) 4 (18.2) 6 (27.3) 22 (100)
Palliative care 1 (9.1) 0 (0.0) 0 (0.0) 11 (100)
Pulmonology 5 (10.0) 1 (2.0) 3 (6.0) 50 (100)
Psychiatry/psychology 11 (29.7) 2 (5.4) 5 (13.5) 37 (100)
Rheumatology 5 (18.5) 0 (0.0) 3 (11.1) 27 (100)
Social paediatrics 13 (39.4) 5 (15.2) 10 (30.3) 33 (100)
Surgery 11 (9.6) 3 (2.6) 6 (5.3) 114 (100)
Vaccination 17 (62.3) 7 (25.9) 8 (29.6) 27 (100)
Routine paediatric preventive care 9 (90.0) 2 (20.0) 5 (50.0) 10 (100)
Total       1897
n: number of articles.

Among non-clinical subjects, represented in Table 5, the most common in general was healthcare quality and management, which accounted for 24.0%, followed by training, at 11.5%. The total number of subjects of the articles reviewed (2280) was higher than the number of articles reviewed (2030), since up to three subjects could be chosen for each article.

Table 5. Distribution of primary care paediatrician (PCP) authors for non-clinical subjects of articles
  Articles with participation of at least 1 PCP n (%) Articles authored exclusively by PCPs n (%) Articles with a PCP as first author n (%) Total no. of times the subject appears n (%)
Diagnostics 6 (18.2) 0 (0.0) 5 (5.2) 33 (100)
Ethics 4 (40.0) 1 (10.0) 2 (20.0) 10 (100)
Evidence-based medicine 1 (100) 1 (100) 1 (100) 1 (100)
Healthcare quality and management 11 (12.0) 4 (4.3) 10 (10.9) 92 (100)
Health education 7 (53.8) 2 (15.4) 6 (46.2) 13 (100)
Information systems 8 (61.5) 3 (23.1) 5 (38.5) 13 (100)
Lifestyle 16 (47.1) 5 (14.7) 11 (32.4) 34 (100)
Natural history/risk factors 2 (66.6) 0 (0.0) 0 (0.0) 3 (100)
New technologies 4 (25.9) 1 (6.3) 2 (12.6) 16 (100)
Organization/scheduling 3 (60.0) 1 (20.0) 3 (60.0) 5 (100)
Prevalence 3 (100) 0 (0.0) 0 (0.0) 3 (100)
Preventive activities 12 (46.2) 1 (3.8) 9 (34.6) 26 (100)
Health professions 13 (39.4) 7 (21.2) 7 (21.2) 33 (100)
Protocols/standardization 2 (28.6) 0 (0.0) 0 (0.0) 7 (100)
Quality of life 8 (53.3) 2 (13.3) 4 (26.6) 15 (100)
Training 3 (6.8) 1 (2.3) 2 (4.5) 44 (100)
Management/treatment 11 (31.4) 4 (11.4) 10 (28.6) 35 (100)
Total       383
n: number of articles.

Results of the review of international journals

We reviewed a total of 4368 articles. In only 31 cases (0.71%) was one or more of the authors Spanish, and in 5 of these at least one PCP participated. In 4 of them, the first author was a PCP. Two were original articles, two more were letters to the editor and the other was a case report. Table 6 shows the detailed distribution of Spanish authors and PCPs by journal, and in Table 7 we can see the distribution of Spanish authors according to the type of articles in which they participated.

Table 6. Distribution of Spanish and primary care paediatrician (PCP) authors for international journals
Journal Article
All Spanish authors n (%) Participation of at least 1 PCP n (%) PCP as first author n (%)
JAMA Pediatrics (n = 10) 2 (20.0) 2 (20.0) 2 (20.0)
Pediatrics (n = 17) 8 (47.1) 2 (11.8) 2 (11.8)
The Lancet Child and Adolescent Health (n = 4) 0 (0.0) 1 (25.0) 0 (0.0)
Total (n = 31) 10 (32.3) 5 (16.1) 4 (12.9)
n: number of articles.
Table 7. Distribution of primary care paediatrician (PCP) authors, by type of article, among publications in international journals with at least one Spanish author
Type of article All Spanish authors n (%) Participation of at least 1 PCP n (%) PCP as first author n (%)
Editorial (n = 1) 0 (0.0) 0 (0.0) 0 (0.0)
Original (n = 13) 4 (30.8) 2 (15.4) 1 (7.7)
Review (n = 5) 0 (0.0) 0 (0.0) 0 (0.0)
Case report (n = 7) 4 (57.1) 1 (14.3) 1 (14.3)
Letter to the editor (n = 5) 2 (40.0) 2 (40.0) 2 (40.0)
Total (n = 31) 10 (32.3) 5 (16.1) 4 (12.9)
n: number of articles.

Of the 13 original articles in which Spanish authors participated, there were 11 (84.6%) that had received some funding. Of these, 4 (36.4%) had exclusively Spanish authors, a PCP had participated in 2 (18.2%) and there was 1 (9.1%) that had a PCP as first author. In terms of the type of study, 6 were experimental or interventional studies and 6 were observational studies.

The subjects of publications by Spanish paediatricians in international journals were neonatology (3 articles), endocrinology (2 articles) and dermatology, genetics/metabolism/dysmorphology, infectious diseases and psychiatry/psychology, with one article on each.

The subjects of the publications in which a PCP appeared among the authors in international journals were infectious diseases (2), neonatology (1), endocrinology (1) and vaccination (1).

DISCUSSION

This study shows the limited amount of research produced by PCPs at both national and international level. In articles in national journals the authors included a PCP in 20.2% of cases; in international journals the proportion did not reach 1%. The object of primary care paediatrics is to give children the best possible healthcare.5 To provide optimal paediatric care, we need to ask ourselves questions and try to resolve them with the best scientific evidence, and this is the object of clinical research in PC.9 Publications by PCPs in the last six years have been analysed to evaluate the current state of research in PC paediatrics and compare it with previous publications. We have reviewed periodicals that accept originals, which provide better evidence of research work, to avoid the bias towards reviews, and the different types of article have been separated because the publication requirements for each are understood to be different.

Díaz-Vázquez et al.1 reviewed 6425 articles in the period 1999-2005, identifying 565 in which at least one PCP participated (8.9%). In our review of the period 2015-2020 we can see that the research and publication activity of PCPs remains low: of 6398 articles reviewed, there was a PCP among the authors in 415 (6.5%). In journals oriented to their own subspeciality, such as the Revista de Pediatría de Atención Primaria, only 33.5% of the articles in our review had a PCP as first author, an almost identical percentage to that of the previous review (33.6%). The great majority of studies were observational in both periods. In the international sphere, PCPs maintained a merely token presence, with 24 articles published by PCPs in the period 1995-2005 compared to 31 in 2015-2020. In 2018, according to the statistical portal of the Ministry of Health, there were 4464 hospital paediatricians and 5418 PCPs; however, the number of publications by PCPs is much lower than for hospital paediatricians.5

Since the closure of the Revista Española de Pediatría in 2018 and of Acta Pediátrica Española in 2020, there are only two generalist paediatric journals of national scope that accept original articles: Anales de Pediatría and Revista de Pediatría de Atención Primaria. The weight of paediatric publication is relatively low in the scientific world,8 and this, added to the scarcity of Spanish paediatric journals that accept original articles, means that PCPs, especially those who are starting out in the research world, face serious difficulties in publishing their results.10 Perhaps this is one of the reasons why proportional participation in regional journals (with lower impact and distribution) is significantly higher than in national journals: the odds ratio for articles in which a PCP appears as first author is 4.15 (95% CI: 2.99-5.77). 

At international level, as we have noted, there are few publications by Spanish paediatricians in the main paediatric journals, and a merely token presence of publications by PCPs in these journals. Of the 4368 articles that we reviewed in international journals, 31 (0.71%) included a Spanish author and there were only 5 in which at least one PCP participated. An indicator of the quality requirement for studies is having received some funding, as is the case in the great majority (84.6%) of the original articles published by Spanish authors in international journals. This serves to reinforce the importance of increasing the resources that facilitate research so as to be able to obtain publications in journals with a high impact factor.9

To overcome the lack of training in research methodology, the AEPap Research Group organises courses every two years. In addition, a Research Network in Primary Care Paediatrics, PAPenRED, was created in 2013.11 This network of professionals makes it possible to obtain representative information on the Spanish population, motivates paediatricians in studying and carrying out their healthcare tasks and creates a knowledge network in PC paediatrics.

A possible limitation of this study may be the fact that the search was conducted only in the journals indicated, omitting other international journals of lower impact in which it may be easier to publish. Even so, it is not to be expected that the number of publications by PCPs will be high in these journals and for this reason we considered it more relevant to analyse only the most important journals. Another limitation may be not having directly taken account of the quality of the material published, although it can be deduced indirectly from publication in international journals with a high impact factor, as well as from articles that obtained funding. For this reason, we analysed original studies in greater detail, since they are the ones that correspond directly to studies with a methodological design that meets minimum quality standards. For future reviews it would be interesting to take the authors’ sex into account, as has recently been done in a publication on primary care.12

In view of all this, we conclude that research in Spain in paediatrics, and more specifically in primary care paediatrics, is at unacceptably low levels and an effort is required from both PCPs and the health system to promote and encourage this activity.

CONFLICTS OF INTEREST

The authors have no conflicts of interest to declare in relation to the preparation and publication of this article.

ABBREVIATIONS

PC: primary care · AEPap: Asociación Española de Pediatría de Atención Primaria (Spanish Association of Primary Care Paediatrics) · PCP: primary care paediatrician · PAPenRED: Red de Investigación en Pediatría de Atención Primaria (Research Network in Primary Care Paediatrics).

ACKNOWLEDGEMENTS

To the other members of the AEPap Research Group, for their collaboration: Cristina Cañavate González, Edurne Ciriza Barea, Guadalupe del Castillo Aguas, María Rodríguez Rodríguez, Juana María Ledesma Albarrán, Trinidad Álvarez de Laviada and María Dolores Cantarero Vallejo.

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