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How adolescents experience and cope with pain in daily life: A qualitative study on ways to cope, and the use of over-
the-counter analgesics
Journal: BMJ Open
Manuscript ID bmjopen-2015-010184
Article Type: Research
Date Submitted by the Author: 06-Oct-2015
Complete List of Authors: Lagerløv, Per; University of Oslo, Institute of health and society, Department of general practice Rosvold, Elin; Institute of Health and Society, Department of General
Practice Holager, Tanja; Regional Medicines Information and Pharmacovigilance Centre Helseth, Sølvi; Oslo and Akershus University College of Applied Sciences,
<b>Primary Subject Heading</b>:
Qualitative research
Secondary Subject Heading: General practice / Family practice
Keywords: Adolescents, Over-the-counter analgesics, Coping strategies, Attachment theory, Stress management, Qualitative study
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How adolescents experience and cope with pain in daily life:
A qualitative study on ways to cope and the use of over-the-
counter analgesics
Per Lagerløv, MSc (Pharm), MD PhD, Associate Professor, Department of General
Practice, Institute of Health and Society, The Medical Faculty, University of Oslo,
Norway. [email protected]
Elin Olaug Rosvold, MD PhD, Professor, Department of General Practice, Institute of
Health and Society, The Medical Faculty, University of Oslo, Norway
Tanja Holager, MSc (Pharm), Senior Advisor, Regional Medicines Information and
Pharmacovigilance Centre, The University Hospital Oslo, Norway
Sølvi Helseth, RN PhD, Professor. Department of Nursing, Faculty of Health Sciences,
Oslo and Akershus University College of Applied Sciences, Oslo, Norway
Corresponding author: Per Lagerløv, Department of General Practice, Institute of Health
and Society, University of Oslo, Pb 1130 Blindern, N-0318 Oslo, Norway
Telephone +47 22 85 06 60, Fax +47 22 85 06 50
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Keywords: Adolescents, Over-the-counter analgesics, Coping strategies, Attachment
theory, Stress management
Word count: abstract: 201
Word count: manuscript: 3954
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ABSTRACT
Objective: The aim of this study was to describe how different adolescents experience
and manage pain in their daily life, with a focus on their use of over-the counter
analgesics. More specifically, the aim was to explore different patterns among the
adolescents in pain descriptions, in the management of pain, in relationships with
others, and in their daily life.
Design: Qualitative in depth interviews on experiences with pain, pain management and
involvement of family and friends during pain.
Participants and setting: Twenty five 15-16 year olds from six different junior high
schools, both genders, with and without immigrant background were interviewed at
their local schools in Norway.
Results: We identified four groups of adolescents with similarities in attitudes and
management strategies to pain: “pain is manageable”, “pain is communicable”, “pain is
inevitable”, and “pain is all over”. The subjects within each group differed in how they
engaged their parents in pain; how they perceived, communicated and managed pain;
and how they involved emotions and used over-the-counter analgesics.
Conclusions: The adolescents’ different involvement with the family during pain related
to their pain perception and management. Knowledge of the different ways of
approaching pain is important when supporting adolescents and when tailoring
interventions.
Keywords:
Adolescents
Over-the-counter analgesics
Coping strategies
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Attachment theory
Stress management
Qualitative study
Strength and limitations of this study
• This study integrates experience of pain with descriptions of family, friends and
leisure activities. Four groups of adolescents with similarities in attitudes and
management strategies to pain are identified. Our study visualizes that patterns
of strategies and attitudes to pain are associated with their daily life.
• The knowledge of interconnection between pain, management and daily life may
make it easier to identify adolescents at risk for inappropriate use of over-the-
counter analgesics and better tailor interventions.
• A limitation might be a possibility for oversimplification. Our descriptions are
given with a perspective on attachment and management theories. Other theories
may give different descriptions. We do not intend to infer anything about cause
and effects between the described topics for each adolescent although some
speculations are given.
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Introduction
Pain in daily life is a normal experience for adolescents, and headache, abdominal,
and musculoskeletal types of pain are the most common. Such pain frequently affects
their daily life and might result in absence from school, sleep problems, poor school
performance, and problems with social activities.1,2 Over-the-counter (OTC) analgesics
are helpful tools in managing pain, and self-medication with these medicines—such as
paracetamol or ibuprofen—is common during the early teens.3 During the last decade
there has been a marked increase in the use of OTC analgesics among adolescents.4-6 It
is known that adolescents differ in their attitudes to using OTC analgesics during pain
episodes: some are liberal and some are more restrictive.7 Pain is not always treated
with medication. However, there is limited knowledge on the connection between the
ways of managing pain and the use of OTC analgesics. Differences in pain management
and attitudes toward medication might relate to each adolescent’s personality and
coping style.8 How children and adolescents cope with pain can influence their
emotional and physical functioning, as well as any pain-related disability.9,10 ‘Coping’ is
defined as the combination of cognitive and behavioral efforts to manage demands
appraised as taxing or exceeding the resources of the person.11 In simple words, coping
is what people do—consciously or otherwise—to manage the challenges of pain in
everyday life. Following the theory of stress management, it is relevant to assume that
different coping strategies, such as problem-oriented and emotionally oriented
approaches, are used to manage stressful experiences such as pain.11 It has been shown
that how children and adolescents experience and conquer pain will affect the severity
of pain-related disability.10 However, there is still a lack of studies focusing on the
experiences of pain and pain coping in adolescence.
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Most adolescents have access to OTC analgesics at home and can easily get hold
of them without asking their parents.7, 12 Parents are considered to play an important
part in modeling the perception and expression of pain, and coping strategies for their
children.13-15 Thus, it is reasonable to assume that adolescents’ use of OTC analgesics is
influenced by their parents’ use and attitudes.16 Parents do not always know to what
extent their children suffer from pain,1 and neither might the parents be aware of their
child’s self-medication with OTC analgesics. How pain and pain coping are
communicated between parents and adolescents might be a crucial factor to consider in
research. Simons, Claar & Logan found that parents’ protective responses to
adolescents’ complaints about pain seemed to promote greater disability and more
complaints.15 Attachment theory, which describes the importance of the relationships to
significant others in modeling the perception of pain, can be used as a framework to
understand these processes.13
The aim of this study was to describe how different adolescents experience and
manage pain in their daily life, with a focus on their use of OTC analgesics. More
specifically, the aim was to explore different patterns among the adolescents in pain
descriptions, in the management of pain, in relationships with others, and in their daily
life.
Methods
Recruitment of informants
We approached all adolescents in their finale grade at six junior high schools by
visiting the school classes and invite for participation in our interview study – of 626
students approached 117 volunteered. It was a requirement that participants’ informed
consent forms were signed by their parents. Those wishing to participate in the
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interview study submitted a cell phone number enabling an appointment to be made for
an interview. They also responded to questions about sex and whether both, one or
neither of their parents spoke Norwegian as their mother tongue. The last question was
intended to identify subjects with different cultural backgrounds. No selections were
done based on consumption of OTC analgesics. A strategic sample of adolescents was
contacted to attain an equal number of informants from each school and sex, and to
include those whose parents were either bilingual or only spoke Norwegian. In total 26
adolescents were contacted by phone according to the sampling strategy. Only two of
those approached refused participation. When completing the sampling, one subject
changed her mind and wanted to participate, giving 25 informants. A description of the
recruited subjects is given in Table 1.
<Table 1 here>
The interview guide
The interview technique was open-ended semi structured interviews based on a
guide developed in consultation with teachers, school health nurses, leaders of youth
clubs, and child welfare authorities, and tested in a pilot study. The main topics were
their descriptions on interactions with family and friends, leisure activities, and pain
descriptions (location, and intensities) and pain management.
The interviews
One of the authors (PL) performed all the interviews, which were taped. The
interviews lasted 20–45 minutes and were conducted at each school during ordinary
school hours. The conversation was private and in a separate room away from the
classroom. One secretary transcribed all interviews. The verbatim account was reviewed
by the interviewer, and the soundtracks were available to all researchers.
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Ethical issues
The study was approved by The Regional Committee on Medical Research Ethics
in Norway (registration ID number S-06286a) and registered at the Norwegian Data
Inspectorate. The school health nurse and school counselor at each school were
informed about the study. When the interviewer found it appropriate because of topics
raised during the interview, they recommended that the subject should consult the
school health nurse later. Two participants were given such advice.
Analytical procedure
The analytical process is described in five steps (Fig. 1). The thematic analysis
followed Kvale & Brinchman and our preconception was the theory of stress and
coping, and attachment theory.17, 11, 13 By making ourselves acquainted with these
theories the observations derived from the transcripts were formulated in language
compatible with the theories. The last analytical step was grouping the adolescent
according to the descriptions on each topic into an overall experience and approach to
pain, and design different groups encompassing all participating adolescents, in
accordance with the Norwegian sociologist Karen Widerberg.18
<Fig. 1 here>
Description of the five analytical steps
Step 1. Each member of the research team listened to the soundtracks
individually, read the transcriptions, and condensed all the interviews, staying close to
the adolescents’ own descriptions (self-understanding), within the frame of four broad
categories or topics: family and friends; leisure activity; pain descriptions; pain
management.
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Step 2. The researchers asked questions such as: “What does this tell us about the
adolescent’s daily life?” and “What does this tell us about how he/she experiences and
manages pain?” These questions were discussed in the light of common sense, using
our experience in different professions (medical doctors, pharmacist, and nurse). The
results of this step of analysis were described for each adolescent within the four broad
topics of Step 1.
Step 3. Putting the results of Step 2 into a spreadsheet, we were able to perform
the analysis across the individuals, looking for similarities and differences in the
descriptions. During this process, patterns emerged across the subjects, indicating that
similarities within one topic (e.g., family relations) were followed by similarities in the
other topics (e.g., pain coping behavior).
Step 4. Subjects with similar descriptions on all topics were then grouped. The
groups were not preformed but emerged as an outcome in the work of describing the
individual adolescent as a person according to description on the topics given in step 1.
Four groups emerged, sharing characteristics on how they lived and managed their
everyday lives and on how they experienced and managed pain. During each of Steps
1–4, the transcripts and soundtracks were frequently consulted to ensure comparability.
Step 5. This step involved discussing the results in the light of earlier research,
and constructing a statement describing the characteristics of each group of adolescence.
Results
We were able to develop four groups of adolescence, illuminating different
experiences and approaches on how to handle pain. Within each group the adolescents
expressed similarities on the topics "family and friends, leisure activity, pain
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descriptions, and pain management". These groups were described with statements:
“pain is manageable”, “pain is communicable”, “pain is inevitable”, and “pain is all
over” (Table 2). The four groups varied in their ways of coping with pain, but
seemingly there was also a pattern that connected relationships with family and friends
and how they lived their lives with their pain-coping behavior and use of OTC
analgesics. There were some differences between the four groups in their use of OTC
analgesics; however, the groups also shared some common attitudes to the medicines.
Particular views on the low risks of using OTC analgesics could not be ascribed to any
specific group. The only concern presented by a few subjects was that frequent use of
analgesics might cause the painkilling effects to wear off: “I am sure I will have more
pain in the future. I am worried that the painkillers will have no effect then.” (School A,
girl 2). Subjects also shared the view that information should not be forced upon them,
and it should be adapted to their age: “The information might better fit adolescents if it
could be incorporated into a vivid story from real life.” (School F, girl 4). They also
appreciated the information leaflet in the package. They felt that some form of warning
on the package would be useful: “On a package of cigarettes is a warning that they
might cause cancer. If needed, similar warnings could be given for OTC analgesics,
however this might be printed with small letters.” (School F, boy 2).
<Table 2 here>
Below we describe for each group the emerging themes on the topics pain descriptions
and management, and family and friends.
Pain is manageable
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Interviewees in this group (four boys and five girls) described pain as a nuisance
that hindered them in sports and other activities, although it was mostly manageable.
Pain was often attributed to sports activities and frequently appeared in the extremities:
“It’s the knee (that hurts). I don’t believe it’s serious; it is only that I should not do
things that give pain. Might be the meniscus, I don’t think that anything has broken.”
(School A, boy 1).
Because these subjects invested much effort in competitive sports, pain was
mostly not to be bothered about and seemed not to be of central importance. They
experienced good control of their lives and dealt with challenges in a systematic
stepwise manner as they appeared: “If my back hurts, then I have learned some
exercises I can do, and, for instance, if I am to lie flat on the floor, I put a pillow under
here…”(School B, girl 2). They experienced few conflicts in life and had good
relationships with family and friends. However, they did not involve their parents in
pain management. Their parents trusted them to manage large parts of their own lives,
including pain. If necessary, OTC analgesics were accessible at home and were used as
part of a logical approach, but not as the first tool when in pain: “If I really was in pain,
and I felt I had to take a painkiller, then I would have decided to do so myself, because
in a way it is my choice. Mum can’t feel how much my head hurts.” (School A, girl 2). If
they needed information, they would ask their parents. Overall, pain or pain
management was not a topic much discussed with parents or friends in this group of
adolescents: “I cannot remember that we ever have talked about painkillers at school.”
(School B, boy 1). “We (my friends and I) usually don’t talk about painkillers; it is not a
very interesting topic.” (School E, boy 2).
Pain is communicable
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Pain was typically described as headache and muscle pain among the five boys
and three girls in this group. The symptoms often arose from tension, stress, or the
pressure of their own expectations. The subjects were bothered by pain and in several
ways felt emotionally affected by it. They used energy to adjust to the environment. To
do so, they had to be open to inputs from other people, receiving both help and
hindrances, through communication. Pain was mostly managed in a structured way: one
remedy at a time. If OTC analgesics were the remedies most easily accessed, they were
the first to be tried: “I tell myself when in pain: Yes, now I can take a painkiller and it
will become better.” (School E, boy 3).
This group described pain to be a topic for discussion with friends but not so often with
parents. They had frequent social interactions with friends, but also joined in on
activities with the family. However, the parents in most cases in this group restricted the
access to medication: “My parents have come to an agreement about where to put the
boundaries (when it comes to the use of painkillers)”. (School F, boy 2).
Pain is inevitable
In this group, two boys and three girls, tension headache was the most prominent
pain, frequently described with emotional involvement. They participated in life with
family and friends as it unfolded and described pain as inevitable. At the same time it
was something to worry about: “…this (my headache) happens when there has been a
very hectic day at school, and there have been too many things like shouting and
screaming…” (School D, girl 2). When in pain, the goal was to deal with the pain using
the remedies offered to them, often resulting in a trial-and-error approach. These
subjects would involve their parents during pain, but it was seldom a topic among peers:
“I will seek a doctor if those around me notice that I have frequent headaches.” (School
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C, boy 1). OTC analgesics were used in combination with other remedies, but were not
part of a strategic plan. They described OTC analgesics as easily accessible at home:
“…taking analgesics makes me feel more safe and secure, and I get rid of the pain.”
(School D, girl 4). If information about analgesics was needed, they expressed a
preference for oral information since they found this more easily accessible. They also
suggested consulting the school nurse or their general practitioner.
Pain is all over
The group labeled “Pain is all over”, consisted of three girls who were heavily
affected by pain in everyday life. The pain appeared as headaches, abdominal, and
muscle pain. They could not describe any distinct causes of pain and no treatment really
worked. “I don’t trust that Ibux ® (ibuprofen) and similar medicines work, I think that
you just imagine that it makes you better…it is the imagination that works.” (School B,
girl 4). Typically, they were all deeply involved in the fate of the family, who had more
than an average number of difficulties. These girls were, in a way, locked up in pain at
home with many duties and few out-of-home activities: “…[the pain] may be because
you are thinking a lot…about lots of things in life…and it is no good…especially when
[I’m] alone.” (School A, girl 3). Their mothers were their “partners in pain” and were
involved in pain management. OTC analgesics were used casually to try to find a way
out of pain: “I have never figured pain killers to be dangerous, and I take only one or
perhaps two.” (School B, girl 2). They often felt tired and had limited physical ability:
“I often take a nap when I come home from school…and I sleep through the night…but
it happens that I am more tired in the morning than when I went to bed…I am not
happy. There are lots of difficulties for us. …” (School B, girl 4). Their goal was to
sustain everyday life and hope for the future. Now, they had resigned to the pain and felt
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depressed. These girls had no systematic strategy for pain management, but they would
have liked to have some information about what worked best.
Discussion
Four major attitudes to pain were identified among our adolescents: Pain is
manageable, pain is communicable, pain is inevitable, and pain is all over.
Pain management strategies
The strategies applied in pain managements were a purely problem-oriented
approach, a mixed problem- and emotion-oriented approach, a purely emotional
approach and, finally, no approach or a passive approach (i.e., helplessness).11 The pain
is manageable group seemed to succeed in a problem-oriented approach to pain. The
pain is communicable group had a stepwise approach, and adjusted to using the
remedies at hand. They were more open to discuss emotions, and thus had an emotional
focus in resolving their pain. The pain is inevitable and the pain is all over groups did
not seem to apply a stepwise strategy. Emotion-focused and less problem-oriented
solutions tend to be used by people with insecure attachments. 19, 20 Folkman
emphasized the importance of emotion-focused solutions to give meaning to what was
happening, and as a tool to evaluate when to give in.19 The pain is inevitable group
might have asked for help when it was time to give in, but the pain is all over group had
given up. According to Walker, Smith, Garber & Claar the way of coping used by the
pain is all over group refers to a type of emotion-focused coping that has been termed
passive coping.8 They described a depressed mood, and their helplessness might have
resembled learned helplessness, which is known to go hand in hand with depression.21
Attachment
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Different attachment relationships shape pain-signaling behavior.22 It is
anticipated that children’s attachment to their caregivers will shape how they react to
pain. It is through an environmental mirror that children learn to regulate their feelings,
emotions, and physiological responses. According to Crittenden & Dallos one type of
reaction is the inhibition of pain signals.23 In this case, the caregivers do not manage to
respond adequately to the child’s negative emotion. The caregivers turn away, and
somehow reject the child.
Among the subjects in the pain is manageable group, some suppression and
detachment from pain stimuli might have been present; perhaps they were silencing
their bodies. Their description of pain was sparse and without emotional involvement.
Subjects in the pain is communicable group, who were more involved in the family,
stated that emotions bothered them and affected them physically. Members of the pain
is inevitable group described the presence of pain as a part of destiny that could affect
them as well as other family members.
The pain experiences among the first three groups might perhaps be ascribed to
secure attachment forms according to Crittenden & Dallos 23, but the members of the
pain is all over group were different. They were heavily involved in difficult family
situations, and it is reasonable to assume that their more general perception of pain
could be a way to communicate a wish to be comforted. An expression of pain might
also be more acceptable than expressions of anxiety and anger.23 Their general
perception of pain could have mirrored pain catastrophizing, increased pain perception,
and anxiety.24
Autonomy from family care
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Subjects in the pain is manageable group seemed to be more emancipated and
detached from their families, unlike those in the pain is all over group who were heavily
involved in family problems. Perhaps some liberation from the family is needed for a
successful approach to pain. The use of OTC analgesics seems to be learned from the
parents, especially from the mother.16 Parental protective responses to pain might
inadvertently promote disability and symptom.15 To live in a strenuous family climate
raises the levels of cytokines and creates resistance to steroids in a dose–response
fashion, reflecting allostatic overload and predisposes to pain.25, 26 In Norway, the health
of adolescents is evaluated regularly.27 The main impression from these surveys is that
today’s adolescents fare better than earlier, they are less in opposition to schools and
teachers, are happier with their parents, and stay more frequently at home connected
with people on the internet. However, adolescents, especially girls, report more
frequently that they are anxious and depressed; their mental health has deteriorated.27
Similar trends are reported from Denmark28 and Sweden29 which like Norway have had
stable economic development. Thus, there might be an association between pain
experience and management, and the degree of autonomy in family life. The subjects in
the groups pain is manageable and pain is communicable did not usually involve their
parents during pain. They used problem-oriented management strategies in contrast to
those from the pain is inevitable and pain is all over groups who involved their parents
during pain.
OTC analgesics and information
The only concern raised about OTC analgesics was that they might lose their
efficacy, and that an important tool to manage everyday pain would then be gone. To
our knowledge, OTC analgesics do not produce tachyphylaxis.30 The development of
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medication-induced headaches, which are well known to be initiated by the frequent use
of OTC analgesics, might constitute an explanation of a lost effect. 31Perhaps the use of
OTC analgesics is not as unproblematic as was stated by our subjects.
There is evidence that different coping styles and attachment forms should be
considered in tailoring information.32, 8 Our findings support these studies.
Implications
This study might signify that regulations hampering access to OTC analgesics
could have a counterproductive effect because it might disempower adolescents and tie
them closer to family care. This may not necessarily improve their management
strategy. Brief advice session from professionals in primary care—such as school nurses
or general practitioners—might be sufficient to guide the majority of adolescents. 33
However, the excessive and regular use of OTC analgesics might reflect a difficult life
and such adolescents could be in need of more extensive help.34
Study strengths and weaknesses
We aimed for patterns of behaviour, and not isolated attitudes and strategies. We
believe this gave a wider perspective because descriptions on single topics are
interconnected. However, such a procedure might force an oversimplification. Another
challenge is to ensure transparency because it is not easy to verify group descriptions
based on extracts of statements concerning the specific topics.
Management and attachment theories affected our precognition. Other angles
might have given different descriptions. The interview guide was designed for practical
purposes. The strength was that it enabled easy communication. A theory-focused
interview guide might have enabled deeper penetration into theoretical perspectives, but
this was not the intent at the outset. However, our data are compatible with the
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theoretical perspective discussed. With regard to reflexivity35 the interviewer is a
medical doctor, and the interviews took place at school during ordinary school hours.
Strength of this study was that a medical doctor promises confidentiality. Its weakness
might be the perception of some authority that might hamper openness, for instance on
the excessive use of OTC analgesics.
The sample size was predetermined based on the selection criteria to ensure
recruitment of informants from all schools in the chosen district, both genders, and with
both native and foreign backgrounds. We cannot totally exclude the possibility of richer
descriptions if more adolescents were included. However, because we were able to sort
more than one adolescent into each group, it gives confidence that we have attained
saturation for our descriptions. The impressions gained in our interviews should be
transferable to the adolescents in Norway, independent of differences in consume of
OTC analgesics.
Conclusions
Pain experiences and management strategies are affected by daily life with family
and friends. We describe four groups of adolescents whose experiences could be termed
pain is manageable, pain is communicable, pain is inevitable, and pain is all over.
These groups differed in pain perception, management strategies, and the use of OTC
analgesics. When advising adolescents or making interventions to improve on the use of
OTC analgesics, one should acknowledge the importance of the wider community,
especially the family.
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Contributorship statement
All authors have contributed fully to this study and share the responsibility for
what is published. The first author performed all interviews, all authors contributed
equally to the design, analysis and writing of this paper.
Competing interests
There are no competing interests.
Funding
This study has been funded by a small grant from The Foundation for the
Advancement of Norwegian Apothecary Pharmacy but this foundation has been
involved in neither the design of the study nor in how it was conducted.
Data sharing statement
This is a qualitative study. The interviews were taped and transcribed verbatim.
Both the taped interviews and transcribed verbatim were available to all the authors but
has not been shared with other scientists.
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Fig. 1. The process of analyzing adolescents’ descriptions of pain in daily life.
The main arrows symbolize the stepwise process of analysis, and the double arrows indicate that
throughout the analysis the transcript and sound tracks were consulted to ensure congruence between
derivatives and data.
Condensation
of
information
Step 1
Consensus
on
descriptions
Step 2
Comparison
of
descriptions
Step 3
Grouping of
informants
Step 4
Labeling
groups
Step 5
Transcript and sound tracks
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Table 1
Information on the 25 adolescents taking part in interviews, describing their cultural background
reflected by the language used at home, and their family characteristics
Sex
Male 11
Female 14
Language used as mother tongue
Norwegian used by both parents 17
Norwegian used by one parent 4
Foreign language used by both parents 4
Living with
Mother and father together 19
Mother and father separately 2
Mother only 4
Total number in the household (siblings, parents, grandparents)
Two 1
Three 6
Four 8
Five or more 8
Changing 2
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Table 2. Descriptions of four ways of experiencing and approaching pain among adolescents
Themes Experiences and approaches to pain
Pain is manageable Pain is communicable Pain is inevitable Pain is all over
Family and friends
Duties, involvement of family
and friends
- Have few or no duties at home
and dine infrequently together
with the family.
- Do not involve parents during
pain.
- Have full access to OTC
analgesics.
- Pain is an uninteresting topic
not to be discussed with friends.
- Have duties at home and often
dine together with the family.
- Usually do not involve parents
during pain.
- Have limitations in access to
OTC analgesics.
- Pain is a topic to be discussed
with friend.
-Have few duties at home but
often dine together with the
family.
- Involve parents during pain.
- Have full access to OTC
analgesics.
- Pain is a personal experience,
rarely discussed with friends
- Have many duties at home,
dine together with the family
and are heavily involved in
family difficulties.
- Mothers are involved during
pain and the use of OTC
analgesics.
-Pain experience stays within
the family and is not discussed
with friends.
Leisure activity
With family or friends
- Interact with friends through
competitive sport activities.
- Have frequent social
interactions with friends.
- Have equal interactions with
family and friends.
- Have few out-of-home
activities.
Pain description Location, causes, and
emotionality
- Pain frequently appears in
extremities.
- Pain is attributed to specific
situations, e.g., a sports injury.
- Are not emotionally affected
by pain.
- Pain located in head and
muscles.
- Pain arises from tension and
stress or the pressure of own
expectations.
- Are emotionally affected by
pain.
- Mainly headache without
specific causes.
- Pain is a part of destiny.
- Are emotionally affected by
pain and worrying.
- Pain is global.
- Pain affects the head, stomach,
or the muscles without evident
external causes.
- Are emotionally affected,
often feel tired, and have
depressed moods.
Pain management
Strategy
- Have a stepwise approach to
pain management.
- Have a variety of strategies
used in a systematic way.
- OTC analgesics are a late
choice.
- Have a stepwise approach to
pain management.
- Choice of strategy depends on
what is at hand.
- Trial-and-error approach.
- OTC analgesics are one of
several approaches.
- No strategy for pain
management.
- OTC analgesics are used
occasionally.
- Resignation.
Number and gender Four boys and five girls Five boys and three girls Two boys and three girls Three girls
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Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist
No Item Guide questions/description
Domain 1:
Research team
and reflexivity
Personal
Characteristics
1. Interviewer/facilitator
Which author/s conducted the interview or focus
group? Per Lagerløv
2. Credentials
What were the researcher's credentials? E.g. PhD,
MD MSc, MD, PhD
3. Occupation
What was their occupation at the time of the study?
Associate Professor
4. Gender Was the researcher male or female? Male
5.
Experience and
training
What experience or training did the researcher have?
Courses on qualitative study, published
internationally 2 studies as first author and 2
studies as last author.
Relationship with
participants
6.
Relationship
established
Was a relationship established prior to study
commencement? No
7.
Participant knowledge
of the interviewer
What did the participants know about the researcher?
e.g. personal goals, reasons for doing the research
They know that the interviewer was a GP and
participated in a quantitative study examining the
use of OTC analgesics among adolescents
8.
Interviewer
characteristics
What characteristics were reported about the
interviewer/facilitator? e.g. Bias, assumptions,
reasons and interests in the research topic: That a
GP might promise confidentiality but also that it
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No Item Guide questions/description
might somewhat hamper openness on the amount
of use.
Domain 2: study
design
Theoretical
framework
9.
Methodological
orientation and Theory
What methodological orientation was stated to
underpin the study? e.g. grounded theory, discourse
analysis, ethnography, phenomenology, content
analysis: Content analyses
Participant
selection
10. Sampling
How were participants selected? e.g. purposive,
convenience, consecutive, snowball. Inviting all
adolescents at final grade at six junior high
schools, and stratified selection on gender,
school, and language used at home.
11. Method of approach
How were participants approached? e.g. face-to-face,
telephone, mail, email. Visit in the classrooms
informing about the study, written invitations
were distributed, agreements to participate with
consents from parents collected by the teacher.
12. Sample size How many participants were in the study? 25
13. Non-participation
How many people refused to participate or dropped
out? Reasons? One
Setting
14.
Setting of data
collection
Where was the data collected? e.g. home, clinic,
workplace The interviews were conducted at the
local schools – six junior high schools.
15. Presence of non- Was anyone else present besides the
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No Item Guide questions/description
participants participants.and researchers? No
16. Description of sample
What are the important characteristics of the sample?
e.g. demographic data, date. It aimed to get
information from different adolescents sampled
from different schools (in different
socioeconomically regions), genders and cultural
background (language used at home).
Data collection
17. Interview guide
Were questions, prompts, guides provided by the
authors? Was it pilot tested? An interview guide
was developed and piloted.
18. Repeat interviews
Were repeat interviews carried out? If yes, how
many? No
19. Audio/visual recording
Did the research use audio or visual recording to
collect the data? Used audio recording
20. Field notes
Were field notes made during and/or after the
interview or focus group? No
21. Duration
What was the duration of the interviews or focus
group? The interviews lasted about 45 minutes
22. Data saturation Was data saturation discussed? Yes
23. Transcripts returned
Were transcripts returned to participants for comment
and/or correction? No
Domain 3:
analysis and
findingsz
Data analysis
24. Number of data coders
How many data coders coded the data? All authors;
4
25. Description of the Did authors provide a description of the coding tree?
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No Item Guide questions/description
coding tree Yes
26. Derivation of themes
Were themes identified in advance or derived from
the data? Derived from the data
27. Software
What software, if applicable, was used to manage the
data? Software not used
28. Participant checking Did participants provide feedback on the findings? No
Reporting
29. Quotations presented
Were participant quotations presented to illustrate the
themes / findings? Yes Was each quotation
identified? e.g. participant number Yes
30.
Data and findings
consistent
Was there consistency between the data presented
and the findings? Yes
31.
Clarity of major
themes
Were major themes clearly presented in the findings?
Yes
32.
Clarity of minor
themes
Is there a description of diverse cases or discussion
of minor themes? Yes
1 of 4
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How adolescents experience and cope with pain in daily life: A qualitative study on ways to cope, and the use of over-
the-counter analgesics
Journal: BMJ Open
Manuscript ID bmjopen-2015-010184.R1
Article Type: Research
Date Submitted by the Author: 07-Dec-2015
Complete List of Authors: Lagerløv, Per; University of Oslo, Institute of health and society, Department of general practice Rosvold, Elin; Institute of Health and Society, Department of General
Practice Holager, Tanja; Regional Medicines Information and Pharmacovigilance Centre Helseth, Sølvi; Oslo and Akershus University College of Applied Sciences,
<b>Primary Subject Heading</b>:
Qualitative research
Secondary Subject Heading: General practice / Family practice
Keywords: Adolescents, Over-the-counter analgesics, Coping strategies, Attachment theory, Stress management, Qualitative study
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How adolescents experience and cope with pain in daily life:
A qualitative study on ways to cope and the use of over-the-
counter analgesics
Per Lagerløv, MSc (Pharm), MD PhD, Associate Professor, Department of General
Practice, Institute of Health and Society, The Medical Faculty, University of Oslo,
Norway. [email protected]
Elin Olaug Rosvold, MD PhD, Professor, Department of General Practice, Institute of
Health and Society, The Medical Faculty, University of Oslo, Norway
Tanja Holager, MSc (Pharm), Senior Advisor, Regional Medicines Information and
Pharmacovigilance Centre, The University Hospital Oslo, Norway
Sølvi Helseth, RN PhD, Professor. Department of Nursing, Faculty of Health Sciences,
Oslo and Akershus University College of Applied Sciences, Oslo, Norway
Corresponding author: Per Lagerløv, Department of General Practice, Institute of Health
and Society, University of Oslo, Pb 1130 Blindern, N-0318 Oslo, Norway
Telephone +47 22 85 06 60, Fax +47 22 85 06 50
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Keywords: Adolescents, Over-the-counter analgesics, Coping strategies, Attachment
theory, Stress management
Word count: abstract: 229
Word count: manuscript: 4055
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ABSTRACT
Objective: The aim of this study was to describe how different adolescents experience
and manage pain in their daily life, with a focus on their use of over-the counter
analgesics. More specifically, the aim was to explore different patterns among the
adolescents in pain descriptions, in the management of pain, in relationships with
others, and in their daily life.
Design: Qualitative in depth interviews on experiences with pain, pain management and
involvement of family and friends during pain. Pain and stress management strategies
and attachment theory will be in focus for interpretations.
Participants and setting: Twenty five 15-16 year olds from six different junior high
schools, both genders, with and without immigrant background were interviewed at
their local schools in Norway.
Results: We identified four groups of adolescents with similarities in attitudes and
management strategies to pain: “pain is manageable”, “pain is communicable”, “pain is
inevitable”, and “pain is all over”. The subjects within each group differed in how they
engaged their parents in pain; how they perceived, communicated and managed pain;
and how they involved emotions and used over-the-counter analgesics.
Conclusions: The adolescents’ different involvement with the family during pain related
to their pain perception and management. Knowledge of the different ways of
approaching pain is important when supporting adolescents and may be a subject for
further research on the use of over-the- counter analgesics in the family.
Keywords:
Adolescents
Over-the-counter analgesics
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Coping strategies
Attachment theory
Stress management
Qualitative study
Strength and limitations of this study
• This study integrates experience of pain with descriptions of family, friends and
leisure activities.
• The knowledge of interconnection between pain, management and daily life may
make it easier to identify adolescents at risk for inappropriate use of over-the-
counter analgesics and better tailor interventions.
• A limitation might be a possibility for oversimplification. Our descriptions are
given with a perspective on attachment and management theories. Other theories
may give different descriptions.
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Introduction
Pain in daily life is a common experience for adolescents, and headache,
abdominal, and musculoskeletal types of pain are the most common. Such pain
frequently affects their daily life and might result in absence from school, sleep
problems, poor school performance, and problems with social activities.1,2 Over-the-
counter (OTC) analgesics are helpful tools in managing pain, and self-medication with
these medicines—such as paracetamol or ibuprofen—is common during the early
teens.3 During the last decade there has been a marked increase in the use of OTC
analgesics among adolescents.4-6 It is known that adolescents differ in their attitudes to
using OTC analgesics during pain episodes: some are liberal and some are more
restrictive.7 Pain is not always treated with medication. However, there is limited
knowledge on the connection between the ways of managing pain and the use of OTC
analgesics. Differences in pain management and attitudes toward medication might
relate to each adolescent’s personality and coping style.8 How children and adolescents
cope with pain can influence their emotional and physical functioning, as well as any
pain-related disability.9,10 ‘Coping’ is defined as the combination of cognitive and
behavioral efforts to manage demands appraised as taxing or exceeding the resources of
the person.11 In simple words, coping is what people do—consciously or otherwise—to
manage the challenges of pain in everyday life. Following the theory of stress
management, it is relevant to assume that different coping strategies, such as problem-
oriented and emotionally oriented approaches, are used to manage stressful experiences
such as pain.11 It has been shown that how children and adolescents experience and
conquer pain will affect the severity of pain-related disability.10 However, there is still a
lack of studies focusing on the experiences of pain and pain coping in adolescence.
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Most adolescents have access to OTC analgesics at home and can easily get hold
of them without asking their parents.7, 12 Parents are considered to play an important
part in modeling the perception and expression of pain, and coping strategies for their
children.13-15 Thus, it is reasonable to assume that adolescents’ use of OTC analgesics is
influenced by their parents’ use and attitudes.16 Parents do not always know to what
extent their children suffer from pain,1 and neither might the parents be aware of their
child’s self-medication with OTC analgesics. How pain and pain coping are
communicated between parents and adolescents might be a crucial factor to consider in
research. Simons, Claar & Logan found that parents’ protective responses to
adolescents’ complaints about pain seemed to promote greater disability and more
complaints.15 Attachment theory, which describes the importance of the relationships to
significant others in modeling the perception of pain, can be used as a framework to
understand these processes.13
The aim of this study was to describe how different adolescents experience and
manage pain in their daily life, with a focus on their use of OTC analgesics. More
specifically, the aim was to explore different patterns among the adolescents in pain
descriptions, in the management of pain, in relationships with others, and in their daily
life.
Methods
Recruitment of informants
We approached all adolescents in their final grade at six junior high schools by
visiting the school classes and invite for participation in our interview study – of 626
students approached 117 volunteered. It was a requirement that the adolescents
volunteered with consent at the level of parents. Adolescents interested in participating
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received an invitation letter to be signed by the student and the parents at home. These
signed consents were collected by the teachers. Those wishing to participate in the
interview study submitted a cell phone number enabling an appointment to be made for
an interview on the consent letter attached to the invitation letter. They also responded
to questions about sex and whether both, one or neither of their parents spoke
Norwegian as their mother tongue. The last question was intended to identify subjects
with different cultural backgrounds. No selections were done based on consumption of
OTC analgesics or pain experience. A strategic sample of adolescents was contacted to
attain an equal number of informants from each school and sex, and to include those
whose parents were either bilingual or only spoke Norwegian. In total 26 adolescents
were contacted by phone according to the sampling strategy. Only two of those
approached refused participation. When completing the sampling, one subject changed
her mind and wanted to participate, giving 25 informants. A description of the recruited
subjects is given in Table 1.
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Table 1
Information on the 25 adolescents taking part in interviews, describing their cultural background
reflected by the language used at home, and their family characteristics
Sex
Male 11
Female 14
Language used as mother tongue
Norwegian used by both parents 17
Norwegian used by one parent 4
Foreign language used by both parents 4
Living with
Mother and father together 19
Mother and father separately 2
Mother only 4
Total number in the household (siblings, parents, grandparents)
Two 1
Three 6
Four 8
Five or more 8
Changing 2
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The interview guide
The interview technique was open-ended semi structured interviews based on a
guide developed in consultation with teachers, school health nurses, leaders of youth
clubs, and child welfare authorities, and tested in a pilot study. The main topics were
their descriptions on interactions with family and friends, leisure activities, pain
descriptions (location, and intensities), pain management, and their own use and
attitudes to OTC-analgesics and information.
The interviews
One of the authors (PL, a male doctor) performed all the interviews, which were
taped. The interviews lasted 20–45 minutes and were conducted at each school during
ordinary school hours. The conversation was private and in a separate room away from
the classroom. One secretary transcribed all interviews. The verbatim account was
reviewed by the interviewer, and the soundtracks were available to all researchers.
Ethical issues
The study was approved by The Regional Committee on Medical Research Ethics
in Norway (registration ID number S-06286a) and registered at the Norwegian Data
Inspectorate. The school health nurse and school counselor at each school were
informed about the study. When the interviewer found it appropriate because of topics
raised during the interview, they recommended that the subject should consult the
school health nurse later. Two participants were given such advice.
Analytical procedure
The analytical process is described in five steps (Fig. 1). The thematic analysis
followed Kvale & Brinchman and our preconception was the theory of stress and
coping, and attachment theory.17, 11, 13 The first step was to be acquainted with the data
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without a theoretical perspective. By making ourselves acquainted with these theories
the observations derived from the transcripts were then formulated in language
compatible with the theories. The last analytical step was grouping the adolescent
according to the descriptions on each topic into an overall experience and approach to
pain, and design different groups encompassing all participating adolescents, in
accordance with the Norwegian sociologist Karen Widerberg.18
<Fig. 1 here>
Description of the five analytical steps
Step 1. Each member of the research team listened to the soundtracks
individually, read the transcriptions, and condensed all the interviews, staying close to
the adolescents’ own descriptions (self-understanding), within the frame of four broad
categories or topics: family and friends; leisure activity; pain descriptions; pain
management.
Step 2. The researchers asked questions such as: “What does this tell us about the
adolescent’s daily life?” and “What does this tell us about how he/she experiences and
manages pain?” These questions were discussed in the light of common sense, using
our experience in different professions (medical doctors, pharmacist, and nurse). The
results of this step of analysis were described for each adolescent within the four broad
topics of Step 1.
Step 3. Putting the results of Step 2 into a spreadsheet, we were able to perform
the analysis across the individuals, looking for similarities and differences in the
descriptions. During this process, patterns emerged across the subjects, indicating that
similarities within one topic (e.g., family relations) were followed by similarities in the
other topics (e.g., pain coping behavior).
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Step 4. Subjects with similar descriptions on all topics were then grouped. The
groups were not preformed but emerged as an outcome in the work of describing the
individual adolescent as a person according to description on the topics given in step 1.
This work took place during several meetings with all four authors. Four groups
emerged, sharing characteristics on how they lived and managed their everyday lives
and on how they experienced and managed pain. During each of Steps 1–4, the
transcripts and soundtracks were frequently consulted to ensure comparability.
Step 5. This step involved discussing the results in the light of earlier research,
and constructing a statement describing the characteristics of each group of adolescence.
Results
We were able to develop four groups of adolescence, illuminating different
experiences and approaches on how to handle pain. Within each group the adolescents
expressed similarities on the topics "family and friends, leisure activity, pain
descriptions, and pain management". These groups were described with statements:
“pain is manageable”, “pain is communicable”, “pain is inevitable”, and “pain is all
over” (Table 2).
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Table 2. Descriptions of four ways of experiencing and approaching pain among adolescents
Themes Experiences and approaches to pain
Pain is
manageable
Pain is
communicable
Pain is
inevitable
Pain is all over
Family and
friends
Duties,
involvement of
family and friends
- Have few or no duties at home and dine infrequently together with the family. - Do not involve parents during pain. - Have full access to OTC analgesics. - Pain is an uninteresting topic not to be discussed with friends.
- Have duties at home and often dine together with the family. - Usually do not involve parents during pain. - Have limitations in access to OTC analgesics. - Pain is a topic to be discussed with friend.
-Have few duties at home but often dine together with the family. - Involve parents during pain. - Have full access to OTC analgesics. - Pain is a personal experience, rarely discussed with friends
- Have many duties at home, dine together with the family and are heavily involved in family difficulties. - Mothers are involved during pain and the use of OTC analgesics. -Pain experience stays within the family and is not discussed with friends.
Leisure activity With family or
friends
- Interact with friends through competitive sport activities.
- Have frequent social interactions with friends.
- Have equal interactions with family and friends.
- Have few out-of-home activities.
Pain description
Location, causes,
and emotionality
- Pain frequently appears in extremities. - Pain is attributed to specific situations, e.g., a sports injury. - Are not emotionally affected by pain.
- Pain located in head and muscles. - Pain arises from tension and stress or the pressure of own expectations. - Are emotionally affected by pain.
- Mainly headache without specific causes. - Pain is a part of destiny. - Are emotionally affected by pain and worrying.
- Pain is global. - Pain affects the head, stomach, or the muscles without evident external causes. - Are emotionally affected, often feel tired, and have depressed moods.
Pain
management
Strategy
- Have a stepwise approach to pain management. - Have a variety of strategies used in a systematic way. - OTC analgesics are a late choice.
- Have a stepwise approach to pain management. - Choice of strategy depends on what is at hand.
- Trial-and-error approach. - OTC analgesics are one of several approaches.
- No strategy for pain management. - OTC analgesics are used occasionally. - Resignation.
Number and
gender Four boys and five girls
Five boys and three girls
Two boys and three girls
Three girls
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The four groups varied in their ways of coping with pain, but seemingly there was
also a pattern that connected relationships with family and friends and how they lived
their lives with their pain-coping behavior and use of OTC analgesics. There were some
differences between the four groups in their use of OTC analgesics; however, the groups
also shared some common attitudes to the medicines. Particular views on the low risks
of using OTC analgesics could not be ascribed to any specific group. The only concern
presented by a few subjects was that frequent use of analgesics might cause the
painkilling effects to wear off: “I am sure I will have more pain in the future. I am
worried that the painkillers will have no effect then.” (School A, girl 2). Subjects also
shared the view that information should not be forced upon them, and it should be
adapted to their age: “The information might better fit adolescents if it could be
incorporated into a vivid story from real life.” (School F, girl 4). They also appreciated
the information leaflet in the package. They felt that some form of warning on the
package would be useful: “On a package of cigarettes is a warning that they might
cause cancer. If needed, similar warnings could be given for OTC analgesics, however
this might be printed with small letters.” (School F, boy 2).
Below we describe for each group the emerging themes on the topics pain descriptions
and management, and family and friends.
Pain is manageable
Interviewees in this group (four boys and five girls) described pain as a nuisance
that hindered them in sports and other activities, although it was mostly manageable.
Pain was often attributed to sports activities and frequently appeared in the extremities:
“It’s the knee (that hurts). I don’t believe it’s serious; it is only that I should not do
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things that give pain. Might be the meniscus, I don’t think that anything has broken.”
(School A, boy 1).
Because these subjects invested much effort in competitive sports, pain was
mostly not to be bothered about and seemed not to be of central importance. They
experienced good control of their lives and dealt with challenges in a systematic
stepwise manner as they appeared: “If my back hurts, then I have learned some
exercises I can do, and, for instance, if I am to lie flat on the floor, I put a pillow under
here…”(School B, girl 2). They experienced few conflicts in life and had good
relationships with family and friends. However, they did not involve their parents in
pain management. Their parents trusted them to manage large parts of their own lives,
including pain. If necessary, OTC analgesics were accessible at home and were used as
part of a logical approach, but not as the first tool when in pain: “If I really was in pain,
and I felt I had to take a painkiller, then I would have decided to do so myself, because
in a way it is my choice. Mum can’t feel how much my head hurts.” (School A, girl 2). If
they needed information, they would ask their parents. Overall, pain or pain
management was not a topic much discussed with parents or friends in this group of
adolescents: “I cannot remember that we ever have talked about painkillers at school.”
(School B, boy 1). “We (my friends and I) usually don’t talk about painkillers; it is not a
very interesting topic.” (School E, boy 2).
Pain is communicable
Pain was typically described as headache and muscle pain among the five boys
and three girls in this group. The symptoms often arose from tension, stress, or the
pressure of their own expectations. "It is much homework in the final grade, the time for
exams are approaching. I turn very tense and tired. I am working till late hours" (School
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C, girl 3). The subjects were bothered by pain and in several ways felt emotionally
affected by it. They used energy to adjust to the environment. To do so, they had to be
open to inputs from other people, receiving both help and hindrances, through
communication. Pain was mostly managed in a structured way: one remedy at a time. If
OTC analgesics were the remedies most easily accessed, they were the first to be tried:
“I tell myself when in pain: Yes, now I can take a painkiller and it will become better.”
(School E, boy 3).
This group described pain to be a topic for discussion with friends but not so often with
parents. They had frequent social interactions with friends, but also joined in on
activities with the family. “Some of my girlfriends use painkillers all the time since they
cannot await recovery” (School C, girl 3). However, the parents in most cases in this
group restricted the access to medication: “My parents have come to an agreement
about where to put the boundaries (when it comes to the use of painkillers)”. (School F,
boy 2).
Pain is inevitable
In this group, two boys and three girls, tension headache was the most prominent
pain, frequently described with emotional involvement. They participated in life with
family and friends as it unfolded and described pain as inevitable. “…this (my
headache) happens when there has been a very hectic day at school, and there have
been too many things like shouting and screaming…” (School D, girl 2). When in pain,
the goal was to deal with the pain using the remedies offered to them, often resulting in
a trial-and-error approach. These subjects would involve their parents during pain, but it
was seldom a topic among peers: “I will seek a doctor if those around me (family)
notice that I have frequent headaches.” (School C, boy 1). OTC analgesics were used in
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combination with other remedies, but were not part of a strategic plan. They described
OTC analgesics as easily accessible at home: “…taking analgesics makes me feel more
safe and secure, and I get rid of the pain.” (School D, girl 4). If information about
analgesics was needed, they expressed a preference for verbal information since they
found this more easily accessible. They also suggested consulting the school nurse or
their general practitioner.
Pain is all over
The group labeled “Pain is all over”, consisted of three girls who were heavily
affected by pain in everyday life. The pain appeared as headaches, abdominal, and
muscle pain. They could not describe any distinct causes of pain and no treatment really
worked. “I don’t trust that Ibux ® (ibuprofen) and similar medicines work, I think that
you just imagine that it makes you better…it is the imagination that works.” (School B,
girl 4). Typically, they were all deeply involved in the fate of the family, who had more
than an average number of difficulties. These girls were, in a way, locked up in pain at
home with many duties and few out-of-home activities: “…[the pain] may be because
you are thinking a lot…about lots of things in life…and it is no good…especially when
[I’m] alone.” (School A, girl 3). Their mothers were their “partners in pain” and were
involved in pain management. “My mom thinks in a way it’s straightforward to take an
Ibux (ibuporphene) and the like” (School B, girl 4). They often felt tired and had limited
physical ability: “I often take a nap when I come home from school…and I sleep
through the night…but it happens that I am more tired in the morning than when I went
to bed…I am not happy. There are lots of difficulties for us. …” (School B, girl 4). Their
goal was to sustain everyday life and hope for the future. Now, they had resigned to the
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pain and felt depressed. These girls had no systematic strategy for pain management,
but they would have liked to have some information about what worked best.
Discussion
Four major attitudes to pain were identified among our adolescents: Pain is
manageable, pain is communicable, pain is inevitable, and pain is all over.
Pain management strategies
The strategies applied in pain managements were a purely problem-oriented
approach, a mixed problem- and emotion-oriented approach, a purely emotional
approach and, finally, no approach or a passive approach (i.e., helplessness).11 The pain
is manageable group seemed to succeed in a problem-oriented approach to pain. The
pain is communicable group had a stepwise approach, and adjusted to using the
remedies at hand. They were more open to discuss emotions, and thus had an emotional
focus in resolving their pain. The pain is inevitable and the pain is all over groups did
not seem to apply a stepwise strategy. Emotion-focused and less problem-oriented
solutions tend to be used by people with insecure attachments. 19, 20 Folkman
emphasized the importance of emotion-focused solutions to give meaning to what was
happening, and as a tool to evaluate when to give in.19 The pain is inevitable group
might have asked for help when it was time to give in, but the pain is all over group had
given up. According to Walker, Smith, Garber & Claar the way of coping used by the
pain is all over group refers to a type of emotion-focused coping that has been termed
passive coping.8 They described a depressed mood, and their helplessness might have
resembled learned helplessness, which is known to go hand in hand with depression.21
Attachment
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Different attachment relationships shape pain-signaling behavior.22 It is
anticipated that children’s attachment to their caregivers will shape how they react to
pain. It is through an environmental mirror that children learn to regulate their feelings,
emotions, and physiological responses. According to Crittenden & Dallos one type of
reaction is the inhibition of pain signals.23 In this case, the caregivers do not manage to
respond adequately to the child’s negative emotion. The caregivers turn away, and
somehow reject the child.
Among the subjects in the pain is manageable group, some suppression and
detachment from pain stimuli might have been present; perhaps they were silencing
their bodies. Their description of pain was sparse and without emotional involvement.
Subjects in the pain is communicable group, who were more involved in the family,
stated that emotions bothered them and affected them physically. Members of the pain
is inevitable group described the presence of pain as a part of destiny that could affect
them as well as other family members.
The pain experiences among the first three groups might perhaps be ascribed to
secure attachment forms according to Crittenden & Dallos 23, but the members of the
pain is all over group were different. They were heavily involved in difficult family
situations, and it is reasonable to assume that their more general perception of pain
could be a way to communicate a wish to be comforted. An expression of pain might
also be more acceptable than expressions of anxiety and anger.23 Their general
perception of pain could have mirrored pain catastrophizing, increased pain perception,
and anxiety.24
Autonomy from family care
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Subjects in the pain is manageable group seemed to be more emancipated and
detached from their families, unlike those in the pain is all over group who were heavily
involved in family problems. Perhaps some liberation from the family is needed for a
successful approach to pain. The use of OTC analgesics seems to be learned from the
parents, especially from the mother.16 Parental protective responses to pain might
inadvertently promote disability and symptom.15 To live in a strenuous family climate
raises the levels of cytokines and creates resistance to steroids in a dose–response
fashion, reflecting allostatic overload and predisposes to pain.25, 26 In Norway, the health
of adolescents is evaluated regularly.27 The main impression from these surveys is that
today’s adolescents fare better than earlier, they are less in opposition to schools and
teachers, are happier with their parents, and stay more frequently at home connected
with people on the internet. However, adolescents, especially girls, report more
frequently that they are anxious and depressed; their mental health has deteriorated.27
Similar trends are reported from Denmark28 and Sweden29 which like Norway have had
stable economic development. Thus, there might be an association between pain
experience and management, and the degree of autonomy in family life. The subjects in
the groups pain is manageable and pain is communicable did not usually involve their
parents during pain. They used problem-oriented management strategies in contrast to
those from the pain is inevitable and pain is all over groups who involved their parents
during pain.
OTC analgesics and information
The only concern raised about OTC analgesics was that they might lose their
efficacy, and that an important tool to manage everyday pain would then be gone. To
our knowledge, OTC analgesics do not produce tachyphylaxis.30 The development of
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medication-induced headaches, which are well known to be initiated by the frequent use
of OTC analgesics, might constitute an explanation of a lost effect. 31Perhaps the use of
OTC analgesics is not as unproblematic as was stated by our subjects.
There is evidence that different coping styles and attachment forms should be
considered in tailoring information.32, 8 Our findings support these studies.
Implications
This study might signify that regulations hampering access to OTC analgesics
could have a counterproductive effect because it might disempower adolescents and tie
them closer to family care. This may not necessarily improve their management
strategy. Brief advice session from professionals in primary care—such as school nurses
or general practitioners—might be sufficient to guide the majority of adolescents. 33
However, the excessive and regular use of OTC analgesics might reflect a difficult life
and such adolescents could be in need of more extensive help.34
Study strengths and weaknesses
We aimed for patterns of behaviour, and not isolated attitudes and strategies. We
believe this gave a wider perspective because descriptions on single topics are
interconnected. However, such a procedure might force an oversimplification. Another
challenge is to ensure transparency because it is not easy to verify group descriptions
based on extracts of statements concerning the specific topics.
Management and attachment theories affected our precognition. Other angles
might have given different descriptions. The interview guide was designed for practical
purposes. The strength was that it enabled easy communication. A theory-focused
interview guide might have enabled deeper penetration into theoretical perspectives, but
this was not the intent at the outset. However, our data are compatible with the
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theoretical perspective discussed. With regard to reflexivity35 the interviewer is a
medical doctor, and the interviews took place at school during ordinary school hours.
Strength of this study was that a medical doctor promises confidentiality. Its weakness
might be the perception of some authority that might hamper openness, for instance on
the excessive use of OTC analgesics.
The sample size was predetermined based on the selection criteria to ensure
recruitment of informants from all schools in the chosen district, both genders, and with
both native and foreign backgrounds. We cannot totally exclude the possibility of richer
descriptions if more adolescents were included. However, because we were able to sort
more than one adolescent into each group, it gives confidence that we have attained
saturation for our descriptions. The impressions gained in our interviews should be
transferable to the adolescents in Norway, independent of differences in consume of
OTC analgesics.
Conclusions
Pain experiences and management strategies are affected by daily life with family
and friends. We describe four groups of adolescents whose experiences could be termed
pain is manageable, pain is communicable, pain is inevitable, and pain is all over.
These groups differed in pain perception, management strategies, and the use of OTC
analgesics. When advising adolescents or making interventions to improve on the use of
OTC analgesics, one should acknowledge the importance of the wider community,
especially the family.
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Contributorship statement
PL, EOR, TH and SH planned and prepared the study. PL and TH visited all
junior high schools, and informed and invited the participants. PL conducted the
interviews. PL, EOR, TH and SH all participated equally in the analysis of transcripts.
PL and SH prepared the initial draft of the paper which was worked out in collaboration
with all authors. All authors share the responsibility for what is published. None of us
has any conflicts of interest in the publication.
Competing interests
There are no competing interests.
Funding
This study has been funded by a small grant from The Foundation for the
Advancement of Norwegian Apothecary Pharmacy but this foundation has been
involved in neither the design of the study nor in how it was conducted.
Data sharing statement
No additional data available.
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27. Bakken A (ed). NOVA. Ungdata. Nasjonale resultater 2013. NOVA Rapport 10/14
2014 Oslo: NOVA, www.ungdata.no (October 2015).
28. Ottosen M, Andersen D, Hansen AT, Lauritsen M, Østergaard SV: Børn og unge i
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29. Ung i dag 2013, Sammanfattning, Myndigheten för ungdoms- och
civilsamhällesfrågor, www.mucf.se/publikationer/ung-i-dag-2013-sammanfattning
(October 2015).
30. Aronson, J. K. (Ed.). Meyler’s side effects of drugs. The international encyclopedia
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34. Skarstein S, Rosvold EO, Helseth S, Kvarme LG, Holager T, Småstuen MC,
Lagerløv P. High-frequency use of over-the-counter analgesics among
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The process of analyzing adolescents’ descriptions of pain in daily life 170x124mm (300 x 300 DPI)
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Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist
No Item Guide questions/description
Domain 1:
Research team
and reflexivity
Personal
Characteristics
1. Interviewer/facilitator
Which author/s conducted the interview or focus
group? Per Lagerløv
2. Credentials
What were the researcher's credentials? E.g. PhD,
MD MSc, MD, PhD
3. Occupation
What was their occupation at the time of the study?
Associate Professor
4. Gender Was the researcher male or female? Male
5.
Experience and
training
What experience or training did the researcher have?
Courses on qualitative study, published
internationally 2 studies as first author and 2
studies as last author.
Relationship with
participants
6.
Relationship
established
Was a relationship established prior to study
commencement? No
7.
Participant knowledge
of the interviewer
What did the participants know about the researcher?
e.g. personal goals, reasons for doing the research
They know that the interviewer was a GP and
participated in a quantitative study examining the
use of OTC analgesics among adolescents
8.
Interviewer
characteristics
What characteristics were reported about the
interviewer/facilitator? e.g. Bias, assumptions,
reasons and interests in the research topic: That a
GP might promise confidentiality but also that it
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No Item Guide questions/description
might somewhat hamper openness on the amount
of use.
Domain 2: study
design
Theoretical
framework
9.
Methodological
orientation and Theory
What methodological orientation was stated to
underpin the study? e.g. grounded theory, discourse
analysis, ethnography, phenomenology, content
analysis: Content analyses
Participant
selection
10. Sampling
How were participants selected? e.g. purposive,
convenience, consecutive, snowball. Inviting all
adolescents at final grade at six junior high
schools, and stratified selection on gender,
school, and language used at home.
11. Method of approach
How were participants approached? e.g. face-to-face,
telephone, mail, email. Visit in the classrooms
informing about the study, written invitations
were distributed, agreements to participate with
consents from parents collected by the teacher.
12. Sample size How many participants were in the study? 25
13. Non-participation
How many people refused to participate or dropped
out? Reasons? One
Setting
14.
Setting of data
collection
Where was the data collected? e.g. home, clinic,
workplace The interviews were conducted at the
local schools – six junior high schools.
15. Presence of non- Was anyone else present besides the
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No Item Guide questions/description
participants participants.and researchers? No
16. Description of sample
What are the important characteristics of the sample?
e.g. demographic data, date. It aimed to get
information from different adolescents sampled
from different schools (in different
socioeconomically regions), genders and cultural
background (language used at home).
Data collection
17. Interview guide
Were questions, prompts, guides provided by the
authors? Was it pilot tested? An interview guide
was developed and piloted.
18. Repeat interviews
Were repeat interviews carried out? If yes, how
many? No
19. Audio/visual recording
Did the research use audio or visual recording to
collect the data? Used audio recording
20. Field notes
Were field notes made during and/or after the
interview or focus group? No
21. Duration
What was the duration of the interviews or focus
group? The interviews lasted about 45 minutes
22. Data saturation Was data saturation discussed? Yes
23. Transcripts returned
Were transcripts returned to participants for comment
and/or correction? No
Domain 3:
analysis and
findingsz
Data analysis
24. Number of data coders
How many data coders coded the data? All authors;
4
25. Description of the Did authors provide a description of the coding tree?
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No Item Guide questions/description
coding tree Yes
26. Derivation of themes
Were themes identified in advance or derived from
the data? Derived from the data
27. Software
What software, if applicable, was used to manage the
data? Software not used
28. Participant checking Did participants provide feedback on the findings? No
Reporting
29. Quotations presented
Were participant quotations presented to illustrate the
themes / findings? Yes Was each quotation
identified? e.g. participant number Yes
30.
Data and findings
consistent
Was there consistency between the data presented
and the findings? Yes
31.
Clarity of major
themes
Were major themes clearly presented in the findings?
Yes
32.
Clarity of minor
themes
Is there a description of diverse cases or discussion
of minor themes? Yes
1 of 4
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How adolescents experience and cope with pain in daily life: A qualitative study on ways to cope, and the use of over-
the-counter analgesics
Journal: BMJ Open
Manuscript ID bmjopen-2015-010184.R2
Article Type: Research
Date Submitted by the Author: 11-Jan-2016
Complete List of Authors: Lagerløv, Per; University of Oslo, Institute of health and society, Department of general practice Rosvold, Elin; Institute of Health and Society, Department of General
Practice Holager, Tanja; Regional Medicines Information and Pharmacovigilance Centre Helseth, Sølvi; Oslo and Akershus University College of Applied Sciences,
<b>Primary Subject Heading</b>:
Qualitative research
Secondary Subject Heading: General practice / Family practice
Keywords: Adolescents, Over-the-counter analgesics, Coping strategies, Attachment theory, Stress management, Qualitative study
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1
How adolescents experience and cope with pain in daily life:
A qualitative study on ways to cope and the use of over-the-
counter analgesics
Per Lagerløv, MSc (Pharm), MD PhD, Associate Professor, Department of General
Practice, Institute of Health and Society, The Medical Faculty, University of Oslo,
Norway. [email protected]
Elin Olaug Rosvold, MD PhD, Professor, Department of General Practice, Institute of
Health and Society, The Medical Faculty, University of Oslo, Norway
Tanja Holager, MSc (Pharm), Senior Advisor, Regional Medicines Information and
Pharmacovigilance Centre, The University Hospital Oslo, Norway
Sølvi Helseth, RN PhD, Professor. Department of Nursing, Faculty of Health Sciences,
Oslo and Akershus University College of Applied Sciences, Oslo, Norway
Corresponding author: Per Lagerløv, Department of General Practice, Institute of Health
and Society, University of Oslo, Pb 1130 Blindern, N-0318 Oslo, Norway
Telephone +47 22 85 06 60, Fax +47 22 85 06 50
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ABSTRACT
Objective: The aim of this study was to describe how different adolescents experience
and manage pain in their daily life, with a focus on their use of over-the counter
analgesics. More specifically, the aim was to explore different patterns among the
adolescents in pain descriptions, in the management of pain, in relationships with
others, and in their daily life.
Design: Qualitative semi-structured interviews on experiences with pain, pain
management and involvement of family and friends during pain. Pain and stress
management strategies and attachment theory will be in focus for interpretations.
Participants and setting: Twenty five 15-16 year olds from six different junior high
schools, both genders, with and without immigrant background were interviewed at
their local schools in Norway.
Results: We identified four groups of adolescents with similarities in attitudes and
management strategies to pain: “pain is manageable”, “pain is communicable”, “pain is
inevitable”, and “pain is all over”. The subjects within each group differed in how they
engaged their parents in pain; how they perceived, communicated and managed pain;
and how they involved emotions and used over-the-counter analgesics.
Conclusions: The adolescents’ different involvement with the family during pain related
to their pain perception and management. Knowledge of the different ways of
approaching pain is important when supporting adolescents and may be a subject for
further research on the use of over-the- counter analgesics in the family.
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Word count: abstract: 228
Word count: manuscript: 4052
Keywords:
Adolescents
Over-the-counter analgesics
Coping strategies
Attachment theory
Stress management
Qualitative study
Strength and limitations of this study
• This study integrates experience of pain with descriptions of family, friends and
leisure activities.
• The knowledge of interconnection between pain, management and daily life may
make it easier to identify adolescents at risk for inappropriate use of over-the-
counter analgesics and better tailor interventions.
• A limitation might be a possibility for oversimplification. Our descriptions are
given with a perspective on attachment and management theories. Other theories
may give different descriptions.
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Introduction
Pain in daily life is a common experience for adolescents, and headache,
abdominal, and musculoskeletal types of pain are the most common. Such pain
frequently affects their daily life and might result in absence from school, sleep
problems, poor school performance, and problems with social activities.1,2 Over-the-
counter (OTC) analgesics are helpful tools in managing pain, and self-medication with
these medicines—such as paracetamol or ibuprofen—is common during the early
teens.3 During the last decade there has been a marked increase in the use of OTC
analgesics among adolescents.4-6 It is known that adolescents differ in their attitudes to
using OTC analgesics during pain episodes: some are liberal and some are more
restrictive.7 Pain is not always treated with medication. However, there is limited
knowledge on the connection between the ways of managing pain and the use of OTC
analgesics. Differences in pain management and attitudes toward medication might
relate to each adolescent’s personality and coping style.8 How children and adolescents
cope with pain can influence their emotional and physical functioning, as well as any
pain-related disability.9,10 ‘Coping’ is defined as the combination of cognitive and
behavioral efforts to manage demands appraised as taxing or exceeding the resources of
the person.11 In simple words, coping is what people do—consciously or otherwise—to
manage the challenges of pain in everyday life. Following the theory of stress
management, it is relevant to assume that different coping strategies, such as problem-
oriented and emotionally oriented approaches, are used to manage stressful experiences
such as pain.11 It has been shown that how children and adolescents experience and
conquer pain will affect the severity of pain-related disability.10 However, there is still a
lack of studies focusing on the experiences of pain and pain coping in adolescence.
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Most adolescents have access to OTC analgesics at home and can easily get hold
of them without asking their parents.7, 12 Parents are considered to play an important
part in modeling the perception and expression of pain, and coping strategies for their
children.13-15 Thus, it is reasonable to assume that adolescents’ use of OTC analgesics is
influenced by their parents’ use and attitudes.16 Parents do not always know to what
extent their children suffer from pain,1 and neither might the parents be aware of their
child’s self-medication with OTC analgesics. How pain and pain coping are
communicated between parents and adolescents might be a crucial factor to consider in
research. Simons, Claar & Logan found that parents’ protective responses to
adolescents’ complaints about pain seemed to promote greater disability and more
complaints.15 Attachment theory, which describes the importance of the relationships to
significant others in modeling the perception of pain, can be used as a framework to
understand these processes.13
The aim of this study was to describe how different adolescents experience and
manage pain in their daily life, with a focus on their use of OTC analgesics. More
specifically, the aim was to explore different patterns among the adolescents in pain
descriptions, in the management of pain, in relationships with others, and in their daily
life.
Methods
Recruitment of informants
We approached all adolescents in their final grade at six junior high schools by
visiting the school classes and invite for participation in our interview study – of 626
students approached 117 volunteered. It was a requirement that the adolescents
volunteered with consent at the level of parents. Adolescents interested in participating
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received an invitation letter to be signed by the student and the parents at home. These
signed consents were collected by the teachers. Those wishing to participate in the
interview study submitted a cell phone number enabling an appointment to be made for
an interview on the consent letter attached to the invitation letter. They also responded
to questions about sex and whether both, one or neither of their parents spoke
Norwegian as their mother tongue. The last question was intended to identify subjects
with different cultural backgrounds. No selections were done based on consumption of
OTC analgesics or pain experience. A strategic sample of adolescents was contacted to
attain an equal number of informants from each school and sex, and to include those
whose parents were either bilingual or only spoke Norwegian. In total 26 adolescents
were contacted by phone according to the sampling strategy. One refused participation
giving 25 informants. A description of the recruited subjects is given in Table 1.
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Table 1
Information on the 25 adolescents taking part in interviews, describing their cultural background
reflected by the language used at home, and their family characteristics
Sex
Male 11
Female 14
Language used as mother tongue
Norwegian used by both parents 17
Norwegian used by one parent 4
Foreign language used by both parents 4
Living with
Mother and father together 19
Mother and father separately 2
Mother only 4
Total number in the household (siblings, parents, grandparents)
Two 1
Three 6
Four 8
Five or more 8
Changing 2
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The interview guide
The interview technique was open-ended semi structured interviews based on a
guide (Table 2) developed in consultation with teachers, school health nurses, leaders of
youth clubs, and child welfare authorities, and tested in a pilot study. The main topics
were their descriptions on interactions with family and friends, leisure activities, pain
descriptions (location, and intensities), pain management, and their own use and
attitudes to OTC-analgesics and information.
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Table 2. Interview guide: Pain, Adolescence and Self-medication
About you
1. Who do you live together with? 2. Please tell me about an ordinary weekday, from the time you get out of bed until bedtime. Is there anything in your everyday routine you would like to change? 3. Please tell me about a day off.
Attitude to pain and behavior when in pain
4. Please tell me about the last time you experienced pain. 5. What do you think was the cause of that pain? 6. What did you do to get rid of the pain? 7. Please tell me about a period where you experienced much pain or frequent use of painkillers. 8. What happens when you take painkillers? 9. What kind of thoughts do you have when you are using OTC analgesics? 10. What kind of feelings, if any, do you have when you are using OTC analgesics? 11. In which cases would you seek a doctor’s advice for your ailments? About other afflictions and delimitation to pain
12. Please tell me about the last time you were feeling very tired and worn-down. 13. Please tell me about the last time you experienced sleeplessness or muscle tension? 14. What do you think may be the causes (for 12 and 13)? Was it related to a special situation? 15. How did you manage to change the situation? 16. What are your considerations for using OTC analgesics in these circumstances?
Culture and knowledge about using medication 17. How did you first learn about the use of painkillers? 18. How do your family (father and mother) look upon the use of painkillers? 19. What do you know about the use of painkillers among your friends? 20. Please describe the information or advertisements about OTC that you have seen or received on. 21. In which way do you wish to be informed about OTC analgesics in the future?
At the end of the interview
- Is there anything you would like to add, for instance something I have not asked about? - How did you experience this interview?
The interviews
One of the authors (PL, a male doctor) performed all the interviews, which were
taped. The interviews lasted 20–45 minutes and were conducted at each school during
ordinary school hours. The conversation was private and in a separate room away from
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the classroom. One secretary transcribed all interviews. The verbatim account was
reviewed by the interviewer, and the soundtracks were available to all researchers.
Ethical issues
The study was approved by The Regional Committee on Medical Research Ethics
in Norway (registration ID number S-06286a) and registered at the Norwegian Data
Inspectorate. The school health nurse and school counselor at each school were
informed about the study. When the interviewer found it appropriate because of topics
raised during the interview, they recommended that the subject should consult the
school health nurse later. Two participants were given such advice.
Analytical procedure
The analytical process is described in five steps (Fig. 1). The thematic analysis
followed Kvale & Brinchman and our preconception was the theory of stress and
coping, and attachment theory.17, 11, 13 The first step was to be acquainted with the data
without a theoretical perspective. By making ourselves acquainted with these theories
the observations derived from the transcripts were then formulated in language
compatible with the theories. The last analytical step was grouping the adolescent
according to the descriptions on each topic into an overall experience and approach to
pain, and design different groups encompassing all participating adolescents, in
accordance with the Norwegian sociologist Karen Widerberg.18
<Fig. 1 here>
Description of the five analytical steps
Step 1. Each member of the research team listened to the soundtracks
individually, read the transcriptions, and condensed all the interviews, staying close to
the adolescents’ own descriptions (self-understanding), within the frame of four broad
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categories or topics: family and friends; leisure activity; pain descriptions; pain
management.
Step 2. The researchers asked questions such as: “What does this tell us about the
adolescent’s daily life?” and “What does this tell us about how he/she experiences and
manages pain?” These questions were discussed in the light of common sense, using
our experience in different professions (medical doctors, pharmacist, and nurse). The
results of this step of analysis were described for each adolescent within the four broad
topics of Step 1.
Step 3. Putting the results of Step 2 into a spreadsheet, we were able to perform
the analysis across the individuals, looking for similarities and differences in the
descriptions. During this process, patterns emerged across the subjects, indicating that
similarities within one topic (e.g., family relations) were followed by similarities in the
other topics (e.g., pain coping behavior).
Step 4. Subjects with similar descriptions on all topics were then grouped. The
groups were not preformed but emerged as an outcome in the work of describing the
individual adolescent as a person according to description on the topics given in step 1.
This work took place during several meetings with all four authors. Four groups
emerged, sharing characteristics on how they lived and managed their everyday lives
and on how they experienced and managed pain. During each of Steps 1–4, the
transcripts and soundtracks were frequently consulted to ensure comparability.
Step 5. This step involved discussing the results in the light of earlier research,
and constructing a statement describing the characteristics of each group of adolescence.
Results
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We were able to describe four groups of adolescents, illuminating different
experiences and approaches on how to handle pain. Within each group the adolescents
expressed similarities on the topics "family and friends, leisure activity, pain
descriptions, and pain management". These groups were described with statements:
“pain is manageable”, “pain is communicable”, “pain is inevitable”, and “pain is all
over” (Table 3).
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Table 3. Descriptions of four ways of experiencing and approaching pain among adolescents
Themes Experiences and approaches to pain
Pain is
manageable
Pain is
communicable
Pain is
inevitable
Pain is all over
Family and
friends
Duties,
involvement of
family and friends
- Have few or no duties at home and dine infrequently together with the family. - Do not involve parents during pain. - Have full access to OTC analgesics. - Pain is an uninteresting topic not to be discussed with friends.
- Have duties at home and often dine together with the family. - Usually do not involve parents during pain. - Have limitations in access to OTC analgesics. - Pain is a topic to be discussed with friend.
-Have few duties at home but often dine together with the family. - Involve parents during pain. - Have full access to OTC analgesics. - Pain is a personal experience, rarely discussed with friends
- Have many duties at home, dine together with the family and are heavily involved in family difficulties. - Mothers are involved during pain and the use of OTC analgesics. -Pain experience stays within the family and is not discussed with friends.
Leisure activity With family or
friends
- Interact with friends through competitive sport activities.
- Have frequent social interactions with friends.
- Have equal interactions with family and friends.
- Have few out-of-home activities.
Pain description
Location, causes,
and emotionality
- Pain frequently appears in extremities. - Pain is attributed to specific situations, e.g., a sports injury. - Are not emotionally affected by pain.
- Pain located in head and muscles. - Pain arises from tension and stress or the pressure of own expectations. - Are emotionally affected by pain.
- Mainly headache without specific causes. - Pain is a part of destiny. - Are emotionally affected by pain and worrying.
- Pain is global. - Pain affects the head, stomach, or the muscles without evident external causes. - Are emotionally affected, often feel tired, and have depressed moods.
Pain
management
Strategy
- Have a stepwise approach to pain management. - Have a variety of strategies used in a systematic way. - OTC analgesics are a late choice.
- Have a stepwise approach to pain management. - Choice of strategy depends on what is at hand.
- Trial-and-error approach. - OTC analgesics are one of several approaches.
- No strategy for pain management. - OTC analgesics are used occasionally. - Resignation.
Number and
gender Four boys and five girls
Five boys and three girls
Two boys and three girls
Three girls
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The four groups varied in their ways of coping with pain, but seemingly there was
also a pattern that connected relationships with family and friends and how they lived
their lives with their pain-coping behavior and use of OTC analgesics. There were some
differences between the four groups in their use of OTC analgesics; however, the groups
also shared some common attitudes to the medicines. Particular views on the low risks
of using OTC analgesics could not be ascribed to any specific group. The only concern
presented by a few subjects was that frequent use of analgesics might cause the
painkilling effects to wear off: “I am sure I will have more pain in the future. I am
worried that the painkillers will have no effect then.” (School A, girl 2). Subjects also
shared the view that information should not be forced upon them, and it should be
adapted to their age: “The information might better fit adolescents if it could be
incorporated into a vivid story from real life.” (School F, girl 4). They also appreciated
the information leaflet in the package. They felt that some form of warning on the
package would be useful: “On a package of cigarettes is a warning that they might
cause cancer. If needed, similar warnings could be given for OTC analgesics, however
this might be printed with small letters.” (School F, boy 2).
Below we describe for each group the emerging themes on the topics pain descriptions
and management, and family and friends.
Pain is manageable
Interviewees in this group (four boys and five girls) described pain as a nuisance
that hindered them in sports and other activities, although it was mostly manageable.
Pain was often attributed to sports activities and frequently appeared in the extremities:
“It’s the knee (that hurts). I don’t believe it’s serious; it is only that I should not do
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things that give pain. Might be the meniscus, I don’t think that anything has broken.”
(School A, boy 1).
Because these subjects invested much effort in competitive sports, pain was
mostly not to be bothered about and seemed not to be of central importance. They
experienced good control of their lives and dealt with challenges in a systematic
stepwise manner as they appeared: “If my back hurts, then I have learned some
exercises I can do, and, for instance, if I am to lie flat on the floor, I put a pillow under
here…”(School B, girl 2). They experienced few conflicts in life and had good
relationships with family and friends. They had a busy life with leisure activates and
often did not eat dinner with the family. Their parents trusted them to manage large
parts of their own lives, including pain, and the adolescents did not involve their parents
in pain management. If necessary, OTC analgesics were accessible at home and were
used as part of a logical approach, but not as the first tool when in pain: “If I really was
in pain, and I felt I had to take a painkiller, then I would have decided to do so myself,
because in a way it is my choice. Mum can’t feel how much my head hurts.” (School A,
girl 2). If they needed information, they would ask their parents. Overall, pain or pain
management was not a topic much discussed with parents or friends in this group of
adolescents: “I cannot remember that we ever have talked about painkillers at school.”
(School B, boy 1). “We (my friends and I) usually don’t talk about painkillers; it is not a
very interesting topic.” (School E, boy 2).
Pain is communicable
Pain was typically described as headache and muscle pain among the five boys
and three girls in this group. The symptoms often arose from tension, stress, or the
pressure of their own expectations. "It is much homework in the final grade, the time for
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exams are approaching. I turn very tense and tired. I am working till late hours" (School
C, girl 3). The subjects were bothered by pain and in several ways felt emotionally
affected by it. They used energy to adjust to the environment. To do so, they had to be
open to inputs from other people, receiving both help and hindrances, through
communication. Pain was mostly managed in a structured way: one remedy at a time. If
OTC analgesics were the remedies most easily accessed, they were the first to be tried:
“I tell myself when in pain: Yes, now I can take a painkiller and it will become better.”
(School E, boy 3).
This group described pain to be a topic for discussion with friends but not so often with
parents. They had frequent social interactions with friends, but also joined in on
activities with the family. “Some of my girlfriends use painkillers all the time since they
cannot await recovery” (School C, girl 3). However, the parents in most cases in this
group restricted the access to medication: “My parents have come to an agreement
about where to put the boundaries (when it comes to the use of painkillers)”. (School F,
boy 2).
Pain is inevitable
In this group, two boys and three girls, tension headache was the most prominent
pain, frequently described with emotional involvement. They participated in life with
family and friends as it unfolded and described pain as inevitable. “…this (my
headache) happens when there has been a very hectic day at school, and there have
been too many things like shouting and screaming…” (School D, girl 2). When in pain,
the goal was to deal with the pain using the remedies offered to them, often resulting in
a trial-and-error approach. These subjects would involve their parents during pain, but it
was seldom a topic among peers: “I will seek a doctor if those around me (family)
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notice that I have frequent headaches.” (School C, boy 1). OTC analgesics were used in
combination with other remedies, but were not part of a strategic plan. They described
OTC analgesics as easily accessible at home: “…taking analgesics makes me feel more
safe and secure, and I get rid of the pain.” (School D, girl 4). If information about
analgesics was needed, they expressed a preference for verbal information since they
found this more easily accessible. They also suggested consulting the school nurse or
their general practitioner.
Pain is all over
The group labeled “Pain is all over”, consisted of three girls who were heavily
affected by pain in everyday life. The pain appeared as headaches, abdominal, and
muscle pain. They could not describe any distinct causes of pain and no treatment really
worked. “I don’t trust that Ibux ® (ibuprofen) and similar medicines work, I think that
you just imagine that it makes you better…it is the imagination that works.” (School B,
girl 4). Typically, they were all deeply involved in the fate of the family, who had more
than an average number of difficulties. These girls were, in a way, locked up in pain at
home with many duties and few out-of-home activities: “…[the pain] may be because
you are thinking a lot…about lots of things in life…and it is no good…especially when
[I’m] alone.” (School A, girl 3). Their mothers were their “partners in pain” and were
involved in pain management. “My mom thinks in a way it’s straightforward to take an
Ibux (ibuporphene) and the like” (School B, girl 4). They often felt tired and had
limited physical ability: “I often take a nap when I come home from school…and I sleep
through the night…but it happens that I am more tired in the morning than when I went
to bed…I am not happy. There are lots of difficulties for us. …” (School B, girl 4). Their
goal was to sustain everyday life and hope for the future. Now, they had resigned to the
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pain and felt depressed. These girls had no systematic strategy for pain management,
but they would have liked to have some information about what worked best.
Discussion
Four major attitudes to pain were identified among our adolescents: Pain is
manageable, pain is communicable, pain is inevitable, and pain is all over.
Pain management strategies
The strategies applied in pain managements were a purely problem-oriented
approach, a mixed problem- and emotion-oriented approach, a purely emotional
approach and, finally, no approach or a passive approach (i.e., helplessness).11 The pain
is manageable group seemed to succeed in a problem-oriented approach to pain. The
pain is communicable group had a stepwise approach, and adjusted to using the
remedies at hand. They were more open to discuss emotions, and thus had an emotional
focus in resolving their pain. The pain is inevitable and the pain is all over groups did
not seem to apply a stepwise strategy. Emotion-focused and less problem-oriented
solutions tend to be used by people with insecure attachments. 19, 20 Folkman
emphasized the importance of emotion-focused solutions to give meaning to what was
happening, and as a tool to evaluate when to give in.19 The pain is inevitable group
might have asked for help when it was time to give in, but the pain is all over group had
given up. According to Walker, Smith, Garber & Claar the way of coping used by the
pain is all over group refers to a type of emotion-focused coping that has been termed
passive coping.8 They described a depressed mood, and their helplessness might have
resembled learned helplessness, which is known to go hand in hand with depression.21
Attachment
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Different attachment relationships shape pain-signaling behavior.22 It is
anticipated that children’s attachment to their caregivers will shape how they react to
pain. It is through an environmental mirror that children learn to regulate their feelings,
emotions, and physiological responses. According to Crittenden & Dallos one type of
reaction is the inhibition of pain signals.23 In this case, the caregivers do not manage to
respond adequately to the child’s negative emotion. The caregivers turn away, and
somehow reject the child.
Among the subjects in the pain is manageable group, some suppression and
detachment from pain stimuli might have been present; perhaps they were silencing
their bodies. Their description of pain was sparse and without emotional involvement.
Subjects in the pain is communicable group, who were more involved in the family,
stated that emotions bothered them and affected them physically. Members of the pain
is inevitable group described the presence of pain as a part of destiny that could affect
them as well as other family members.
The pain experiences among the first three groups might perhaps be ascribed to
secure attachment forms according to Crittenden & Dallos 23, but the members of the
pain is all over group were different. They were heavily involved in difficult family
situations, and it is reasonable to assume that their more general perception of pain
could be a way to communicate a wish to be comforted. An expression of pain might
also be more acceptable than expressions of anxiety and anger.23 Their general
perception of pain could have mirrored pain catastrophizing, increased pain perception,
and anxiety.24
Autonomy from family care
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Subjects in the pain is manageable group seemed to be more emancipated and
detached from their families, unlike those in the pain is all over group who were heavily
involved in family problems. Perhaps some liberation from the family is needed for a
successful approach to pain. The use of OTC analgesics seems to be learned from the
parents, especially from the mother.16 Parental protective responses to pain might
inadvertently promote disability and symptom.15 To live in a strenuous family climate
raises the levels of cytokines and creates resistance to steroids in a dose–response
fashion, reflecting allostatic overload and predisposes to pain.25, 26 In Norway, the health
of adolescents is evaluated regularly.27 The main impression from these surveys is that
today’s adolescents fare better than earlier, they are less in opposition to schools and
teachers, are happier with their parents, and stay more frequently at home connected
with people on the internet. However, adolescents, especially girls, report more
frequently that they are anxious and depressed; their mental health has deteriorated.27
Similar trends are reported from Denmark28 and Sweden29 which like Norway have had
stable economic development. Thus, there might be an association between pain
experience and management, and the degree of autonomy in family life. The subjects in
the groups pain is manageable and pain is communicable did not usually involve their
parents during pain. They used problem-oriented management strategies in contrast to
those from the pain is inevitable and pain is all over groups who involved their parents
during pain.
OTC analgesics and information
The only concern raised about OTC analgesics was that they might lose their
efficacy, and that an important tool to manage everyday pain would then be gone. To
our knowledge, OTC analgesics do not produce tachyphylaxis.30 The development of
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medication-induced headaches, which are well known to be initiated by the frequent use
of OTC analgesics, might constitute an explanation of a lost effect. 31Perhaps the use of
OTC analgesics is not as unproblematic as was stated by our subjects.
There is evidence that different coping styles and attachment forms should be
considered in tailoring information.32, 8 Our findings support these studies.
Implications
This study might signify that regulations hampering access to OTC analgesics
could have a counterproductive effect because it might disempower adolescents and tie
them closer to family care. This may not necessarily improve their management
strategy. Brief advice session from professionals in primary care—such as school nurses
or general practitioners—might be sufficient to guide the majority of adolescents. 33
However, the excessive and regular use of OTC analgesics might reflect a difficult life
and such adolescents could be in need of more extensive help.34
Study strengths and weaknesses
We aimed for patterns of behaviour, and not isolated attitudes and strategies. We
believe this gave a wider perspective because descriptions on single topics are
interconnected. However, such a procedure might force an oversimplification. Another
challenge is to ensure transparency because it is not easy to verify group descriptions
based on extracts of statements concerning the specific topics.
Management and attachment theories affected our precognition. Other angles
might have given different descriptions. The interview guide was designed for practical
purposes. The strength was that it enabled easy communication. A theory-focused
interview guide might have enabled deeper penetration into theoretical perspectives, but
this was not the intent at the outset. However, our data are compatible with the
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theoretical perspective discussed. With regard to reflexivity35 the interviewer is a
medical doctor, and the interviews took place at school during ordinary school hours.
Strength of this study was that a medical doctor promises confidentiality. Its weakness
might be the perception of some authority that might hamper openness, for instance on
the excessive use of OTC analgesics.
The sample size was predetermined based on the selection criteria to ensure
recruitment of informants from all schools in the chosen district, both genders, and with
both native and foreign backgrounds. We cannot totally exclude the possibility of richer
descriptions if more adolescents were included. However, because we were able to sort
more than one adolescent into each group, it gives confidence that we have attained
saturation for our descriptions. The impressions gained in our interviews should be
transferable to the adolescents in Norway, independent of differences in consume of
OTC analgesics.
Conclusions
Pain experiences and management strategies are affected by daily life with family
and friends. We describe four groups of adolescents whose experiences could be termed
pain is manageable, pain is communicable, pain is inevitable, and pain is all over.
These groups differed in pain perception, management strategies, and the use of OTC
analgesics. When advising adolescents or making interventions to improve on the use of
OTC analgesics, one should acknowledge the importance of the wider community,
especially the family.
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Contributorship statement
PL, EOR, TH and SH planned and prepared the study. PL and TH visited all
junior high schools, and informed and invited the participants. PL conducted the
interviews. PL, EOR, TH and SH all participated equally in the analysis of transcripts.
PL and SH prepared the initial draft of the paper which was worked out in collaboration
with all authors. All authors share the responsibility for what is published. None of us
has any conflicts of interest in the publication.
Competing interests
There are no competing interests.
Funding
This study has been funded by a small grant from The Foundation for the
Advancement of Norwegian Apothecary Pharmacy but this foundation has been
involved in neither the design of the study nor in how it was conducted.
Data sharing statement
No additional data available.
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27. Bakken A (ed). NOVA. Ungdata. Nasjonale resultater 2013. NOVA Rapport 10/14
2014 Oslo: NOVA, www.ungdata.no (October 2015).
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29. Ung i dag 2013, Sammanfattning, Myndigheten för ungdoms- och
civilsamhällesfrågor, www.mucf.se/publikationer/ung-i-dag-2013-sammanfattning
(October 2015).
30. Aronson, J. K. (Ed.). Meyler’s side effects of drugs. The international encyclopedia
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34. Skarstein S, Rosvold EO, Helseth S, Kvarme LG, Holager T, Småstuen MC,
Lagerløv P. High-frequency use of over-the-counter analgesics among
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The process of analyzing adolescents’ descriptions of pain in daily life 170x124mm (300 x 300 DPI)
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Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist
No Item Guide questions/description
Domain 1:
Research team
and reflexivity
Personal
Characteristics
1. Interviewer/facilitator
Which author/s conducted the interview or focus
group? Per Lagerløv
2. Credentials
What were the researcher's credentials? E.g. PhD,
MD MSc, MD, PhD
3. Occupation
What was their occupation at the time of the study?
Associate Professor
4. Gender Was the researcher male or female? Male
5.
Experience and
training
What experience or training did the researcher have?
Courses on qualitative study, published
internationally 2 studies as first author and 2
studies as last author.
Relationship with
participants
6.
Relationship
established
Was a relationship established prior to study
commencement? No
7.
Participant knowledge
of the interviewer
What did the participants know about the researcher?
e.g. personal goals, reasons for doing the research
They know that the interviewer was a GP and
participated in a quantitative study examining the
use of OTC analgesics among adolescents
8.
Interviewer
characteristics
What characteristics were reported about the
interviewer/facilitator? e.g. Bias, assumptions,
reasons and interests in the research topic: That a
GP might promise confidentiality but also that it
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No Item Guide questions/description
might somewhat hamper openness on the amount
of use.
Domain 2: study
design
Theoretical
framework
9.
Methodological
orientation and Theory
What methodological orientation was stated to
underpin the study? e.g. grounded theory, discourse
analysis, ethnography, phenomenology, content
analysis: Content analyses
Participant
selection
10. Sampling
How were participants selected? e.g. purposive,
convenience, consecutive, snowball. Inviting all
adolescents at final grade at six junior high
schools, and stratified selection on gender,
school, and language used at home.
11. Method of approach
How were participants approached? e.g. face-to-face,
telephone, mail, email. Visit in the classrooms
informing about the study, written invitations
were distributed, agreements to participate with
consents from parents collected by the teacher.
12. Sample size How many participants were in the study? 25
13. Non-participation
How many people refused to participate or dropped
out? Reasons? One
Setting
14.
Setting of data
collection
Where was the data collected? e.g. home, clinic,
workplace The interviews were conducted at the
local schools – six junior high schools.
15. Presence of non- Was anyone else present besides the
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No Item Guide questions/description
participants participants.and researchers? No
16. Description of sample
What are the important characteristics of the sample?
e.g. demographic data, date. It aimed to get
information from different adolescents sampled
from different schools (in different
socioeconomically regions), genders and cultural
background (language used at home).
Data collection
17. Interview guide
Were questions, prompts, guides provided by the
authors? Was it pilot tested? An interview guide
was developed and piloted.
18. Repeat interviews
Were repeat interviews carried out? If yes, how
many? No
19. Audio/visual recording
Did the research use audio or visual recording to
collect the data? Used audio recording
20. Field notes
Were field notes made during and/or after the
interview or focus group? No
21. Duration
What was the duration of the interviews or focus
group? The interviews lasted about 45 minutes
22. Data saturation Was data saturation discussed? Yes
23. Transcripts returned
Were transcripts returned to participants for comment
and/or correction? No
Domain 3:
analysis and
findingsz
Data analysis
24. Number of data coders
How many data coders coded the data? All authors;
4
25. Description of the Did authors provide a description of the coding tree?
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No Item Guide questions/description
coding tree Yes
26. Derivation of themes
Were themes identified in advance or derived from
the data? Derived from the data
27. Software
What software, if applicable, was used to manage the
data? Software not used
28. Participant checking Did participants provide feedback on the findings? No
Reporting
29. Quotations presented
Were participant quotations presented to illustrate the
themes / findings? Yes Was each quotation
identified? e.g. participant number Yes
30.
Data and findings
consistent
Was there consistency between the data presented
and the findings? Yes
31.
Clarity of major
themes
Were major themes clearly presented in the findings?
Yes
32.
Clarity of minor
themes
Is there a description of diverse cases or discussion
of minor themes? Yes
1 of 4
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