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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

[email protected]

Tanja Holager, MSc (Pharm), Senior Advisor, Regional Medicines Information and

Pharmacovigilance Centre, The University Hospital Oslo, Norway

[email protected]

Sølvi Helseth, RN PhD, Professor. Department of Nursing, Faculty of Health Sciences,

Oslo and Akershus University College of Applied Sciences, Oslo, Norway

[email protected]

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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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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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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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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Journal: BMJ Open

Manuscript ID bmjopen-2015-010184.R1


Date Submitted by the Author: 07-Dec-2015










jopen.bmj.com

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MJ O


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1



counter analgesics






[email protected]



[email protected]



[email protected]



Telephone +47 22 85 06 60, Fax +47 22 85 06 50

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2

Keywords: Adolescents, Over-the-counter analgesics, Coping strategies, Attachment

theory, Stress management



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3

ABSTRACT






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.











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


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4

Coping strategies

Attachment theory

Stress management

Qualitative study



leisure activities.






may give different descriptions.

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5

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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6


















life.

Methods


We approached all adolescents in their final grade at six junior high schools by


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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7

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


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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8

Table 1



Sex

Male 11

Female 14





Living with



Mother only 4


Two 1

Three 6

Four 8

Five or more 8

Changing 2

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9

The interview guide


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










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





<Fig. 1 here>






management.






topics of Step 1.






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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.



Results

We were able to develop four groups of adolescence, illuminating different





over” (Table 2).

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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).



Pain is manageable





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(School A, boy 1).







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








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).



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



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











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




















Attachment

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and anxiety.24


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during pain.





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Implications



















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OTC analgesics.

Conclusions








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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


Funding





No additional data available.

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References






Pediatrics 2005; 115: e152-62.











2009; 129: 1447-50.






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Pain Res Manag 2011; 16: 192–196.






9: 11-9.












Psychol 2008; 33: 894-904.

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25









Coping 2008; 21: 3-14.



Rev 2008; 28: 407-29.


Science 1973; 182: 20–29.


10: 1020-8.









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26








(October 2015).





2003; 61: 160-4.








J Caring Sci 2014; 28: 49-56.


2001; 358, 483-8.

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The process of analyzing adolescents’ descriptions of pain in daily life 170x124mm (300 x 300 DPI)

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Domain 1:

Research team

and reflexivity

Personal

Characteristics




2. Credentials


MD MSc, MD, PhD

3. Occupation


Associate Professor


5.

Experience and

training





Relationship with

participants

6.

Relationship

established


commencement? No

7.


of the interviewer






8.

Interviewer

characteristics





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of use.

Domain 2: study

design

Theoretical

framework

9.

Methodological






Participant

selection

10. Sampling















out? Reasons? One

Setting

14.

Setting of data

collection





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Data collection

17. Interview guide






many? No




20. Field notes



21. Duration







Domain 3:

analysis and

findingsz

Data analysis



4


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coding tree Yes




27. Software




Reporting





30.

Data and findings

consistent



31.

Clarity of major

themes


Yes

32.

Clarity of minor

themes



1 of 4

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Journal: BMJ Open

Manuscript ID bmjopen-2015-010184.R2


Date Submitted by the Author: 11-Jan-2016










jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



1



counter analgesics






[email protected]



[email protected]



[email protected]



Telephone +47 22 85 06 60, Fax +47 22 85 06 50

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ABSTRACT






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.











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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Keywords:

Adolescents


Coping strategies

Attachment theory

Stress management

Qualitative study



leisure activities.






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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5


















life.

Methods


We approached all adolescents in their final grade at six junior high schools by


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


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



Sex

Male 11

Female 14





Living with



Mother only 4


Two 1

Three 6

Four 8

Five or more 8

Changing 2

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The interview guide


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










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





<Fig. 1 here>





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management.






topics of 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.



Results

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We were able to describe four groups of adolescents, illuminating different





over” (Table 3).

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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).



Pain is manageable





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(School A, boy 1).







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








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).



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



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











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




















Attachment

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19






















and anxiety.24


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during pain.





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Implications



















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OTC analgesics.

Conclusions








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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


Funding





No additional data available.

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References






Pediatrics 2005; 115: e152-62.











2009; 129: 1447-50.






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Pain Res Manag 2011; 16: 192–96.






9: 11-9.












Psychol 2008; 33: 894-904.

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Coping 2008; 21: 3-14.



Rev 2008; 28: 407-29.


Science 1973; 182: 20–9.


10: 1020-8.









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(October 2015).





2003; 61: 160-4.








J Caring Sci 2014; 28: 49-56.


2001; 358, 483-8.

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The process of analyzing adolescents’ descriptions of pain in daily life 170x124mm (300 x 300 DPI)

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Domain 1:

Research team

and reflexivity

Personal

Characteristics




2. Credentials


MD MSc, MD, PhD

3. Occupation


Associate Professor


5.

Experience and

training





Relationship with

participants

6.

Relationship

established


commencement? No

7.


of the interviewer






8.

Interviewer

characteristics





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of use.

Domain 2: study

design

Theoretical

framework

9.

Methodological






Participant

selection

10. Sampling















out? Reasons? One

Setting

14.

Setting of data

collection





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Data collection

17. Interview guide






many? No




20. Field notes



21. Duration







Domain 3:

analysis and

findingsz

Data analysis



4


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coding tree Yes




27. Software




Reporting





30.

Data and findings

consistent



31.

Clarity of major

themes


Yes

32.

Clarity of minor

themes



1 of 4

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