Focusing on flu

Abstract

Introduction: To describe adolescents' perspectives regarding the use of school-located immunization programs (SLIP) for influenza vaccination. More importantly, adolescents were asked what factors would make them more or less likely to use a SLIP offering influenza vaccine.

Results: Participants were generally found to be knowledgeable about influenza and to have positive attitudes toward receiving the vaccine via SLIP. Students were more willing to participate in a SLIP if it were low cost or free, less time-consuming than going to a doctor, and if they felt they could trust vaccinators. Overall, high school and middle school students ranked the benefits of SLIP similarly to each other.

Methods: Focus groups using nominal group method were conducted with middle and high school students in a large, urban school district. Responses were recorded by each school, and then, responses were ranked across all participating schools for each question.

Conclusions: A wide range of issues are important to middle and high school students when considering participation in SLIPs including convenience, public health benefits, trust in the program, program safety, and sanitary issues. Further research will be needed regarding the generalizability of these findings to larger populations of students.

Introduction

As of the 2010–2011 influenza season, ACIP (Advisory Committee on Immunization Practices) recommends that all people six months of age and older receive influenza vaccine annually.¹ This recommendation represents a final expansion from earlier universal recommendations that had expanded the target population to include children six months of age through 18 years. These new recommendations include adolescents, a traditionally challenging population to vaccinate, since they have fewer visits to a primary care provider. Recent years have revealed low immunization rates, even among children at high-risk of experiencing flu complications, and therefore adolescents have been specifically targeted for immunization. The recommendations also were considered potentially difficult to achieve because most adolescents rarely seek preventive care through health care providers.²

In addition to the challenges of having access to adolescents, these recommendations have the potential to be overwhelming to primary care practices. More specifically, if parents follow the recommendations and start to get their adolescent vaccinated, the number of visits to primary care physicians will increase dramatically. This increase will be a burden on primary care practices, given the time and resources needed to vaccinate the majority of adolescents.³ Even though rates of influenza vaccinations are still low among adolescents, if they were to increase per current recommendations, the burden to primary health care providers could be significant. To address the need of patients to schedule travel to providers’ offices, and the concerns of offices having to create resources to supply a potentially overwhelming demand, alternative immunization sites will be needed to deliver influenza vaccines to adolescents each year. One possible alternative site for vaccination to the primary care providers’ office is school-located immunization programs (SLIPs). These programs hold the potential to vaccinate many adolescents, by reaching them in a location where they spend a significant amount of time. Further, SLIPs have been shown to be successful and cost-effective for immunizing adolescents against influenza. However, even though they are successful and low-cost, they often result in the need for more resources; thus, it may not be feasible in all schools.^4-8

A key step to achieving the full benefits of SLIPs is having both parents and adolescents agree to use these programs for vaccination. Overall, studies have shown that parents are willing and feel comfortable having their children immunized via SLIPs.^9-12 Further, research has shown that most adolescents’ decisions about vaccines are influenced by and similar to parents.^13,14 However, SLIP participation also uniquely relies on students’ willingness to get vaccinated using a SLIP; student cooperation is needed for the transport of consent forms and the receipt of vaccines without parents present. Therefore, it is critical to understand adolescents’ attitudes about receiving the influenza vaccine via a SLIP.

With regard to vaccination, little research has focused on the acceptability of vaccines to adolescents, with most of the acceptability research related to the HPV vaccine.^15-19 Few studies have examined adolescents’ attitudes toward the influenza vaccine.^20,21 Li found that less than half of adolescents receive the vaccine, and the most common reasons for not receiving the vaccine related to a lack of perceived susceptibility to influenza (adolescents did not think they needed vaccination).²⁰ Painter found that only a third of adolescents intended to get the influenza vaccine, and intention was related to perceived barriers and norms, as well as having received the vaccine in the past.²¹ With regards to SLIPs, no studies have examined adolescents’ beliefs about SLIPs. Even though this study focused on the influenza vaccines, many child and adolescent vaccines could be delivered via SLIP program. Thus, this study is an important first step in understanding adolescents’ view of and potential for participation in SLIPs. This study examined adolescents’ beliefs and attitudes toward receiving the influenza vaccine via SLIP. More specifically, adolescents were asked what factors associated with SLIPs would make them more or less likely to agree to participate in such a program.

Results

Focus group participant

Fifty-five students from 5 schools (2 high shools [HS] and 3 middle schools [MS]) participated in the six groups that were conducted. Of the schools that participated, none of them had a school-based health clinic, and all of them had a full-time nurse on staff. Of the students, 25 (45%) were female. With regard to race/ethnicity, 24 (43%; 16 MS, and 8 HS) were Hispanic, 18 (33%; 6 MS, and 12 HS) were black-not Hispanic, 11 (20%; 5 MS, and 6 HS) were white-not Hispanic, and the remaining two participants (1 MS and 1 HS) were Asian and Pacific Islander. Twenty-eight (51%) students were in MS and 27 (49%) were in HS.

Engagement questions

Eight (4 MS and 4 HS) students (15%) had not heard of the flu vaccine. Over half (53%) of the students (16 MS and 14 HS) reported not having received the vaccine in the past.

With regard to discussion pertaining to knowledge about the flu, several students (both MS and HS) did not know anything or could not say anything about the flu. Of those who were able to talk about the flu, most of the information provided by both HS and MS students was accurate and revolved around the consequences (“getting sick” and “sometimes it can kill you”), the symptoms, the spread (“contagious”) and the prevention of flu. Of the students who commented on prevention, most reported the need to wash hands and be cautious when sneezing and coughing; one HS student said, “Wash your hands after coughing or sneezing. Use Kleenex or tissue, and dispose of it properly.” A few students (both MS and HS) were knowledgeable about the fact that there are different strains of flu and that those strains “mutate.” Further, a few high school (not middle school) students addressed issues related to high risk groups (“babies,” “old people,” “senior citizens”). One male high school student said, “I know that there are different risk groups with the flu. There are the senior citizens and young kids who need to get vaccinated first and then healthy citizens.”

With regard to knowing about flu vaccines, several middle and high school students reported not knowing anything about the vaccines. Of those who knew something, most HS and MS students reported that flu vaccines prevent someone from getting the flu. However, a few HS and MS students were confused regarding prevention. These few students reported that flu vaccines help “cure the flu,” and one student was confused, saying “I don’t know. I have a question about it though. Do you take it before you get it or like after you get it. I don’t know. Does it help to prevent you from getting it or to get you to feel better?” Several middle and high school students also reported understanding the fact that they were getting “a small strain” of the flu virus in the vaccine. One student said, “They actually put the flu in you, and this helps the body actually fight it off to strengthen your immune system, so you’ll be healthier when you actually get the flu.” Finally, both middle and high school students commented about side effects (sickness, fever) of getting the vaccine.

Exploratory questions

As stated above, there were four exploratory questions, and all questions were conducted with the groups using nominal group methods.

Benefits of getting vaccinated at school

Groups described many benefits of getting vaccinated at school, and there were several benefits that were brought up in most of the groups (low cost or free vaccine, not giving influenza to others, not missing out on activities due to illness). Remarkably, the highest priority benefit noted by students overall pertains to the public health benefit of the program being “healthier for everyone.” Table 1 provides a list of benefits and the sum of their rankings by type of group (HS and MS) and by overall rankings. Overall, the top five items were the same, with some differences in specific ranking, across the HS students and the MS students. When examining these differences more closely, the high school students and middle school students ranked each of these 5 benefits very comparably with the exception of convenience. Convenience was ranked highest for the high school students, but lowest for the middle school students. However, it should be noted that HS students just stated “convenience” as a benefit. Middle school students did not use that word in any of the groups; however, they stated several reasons that fell under the “theme” of convenience, but it often was an individual response that was not ranked as important by the group.

Table 1. List of ranked responses to the question “What are the benefits to getting children vaccinated in the school?”.

Responses	MS groups’ rankings	HS groups’ rankings	All groups’ rankings
Healthier for everyone	2	2	1
Low cost/free	1	3	1
Convenience	5	1	3
More options for everyone (low income, those who do not normally get it)	2	4	4
Don’t have to go to the doctor’s office (saves on time, money)	4	4	5

Ties are indicated using the same rank number.

Not listed in Table 1 were those benefits that were brought up in only one group. Most themes for the HS students were captured in the five primary responses. One high school student noted the benefit of “schools having access to shot records without the student providing it.” When examining the MS students, several answers were mentioned that were not captured in the five top-ranked responses and were not mentioned by the HS students. These included answers related to being supported by friends, feeling less worried about getting the flu, and being more informed. Another benefit mentioned by MS students was related to having a choice, and this benefit seemed to relate to getting vaccinated at school without their parents. Overall, several students reported that if they got the vaccine at school, they would not feel like they were “forced” to get it. One student said, “At my doctor where I go to, you don’t get to choose. They just sit you in the chair and they strap you up and they give you a shot.”

Drawbacks of getting vaccinated at school

There were several drawbacks to the use of SLIPs that were brought up in most of both the HS and MS groups (school not being a good place for giving vaccines, not knowing/trusting the person giving the shot, personal or parental beliefs, and the program taking more time to immunize large volumes of students). When looking at the distinctions between HS and MS students, the top two reasons mentioned by middle school students were being scared or afraid and getting sick at school, but students from the high schools did not mention either of these concerns. Further, high school students, not MS students, mentioned the possibility of running out of vaccine. Table 2 provides a list of drawbacks and the sum of their rankings.

Table 2. List of ranked responses to the question “What are the drawbacks to getting children vaccinated in the school?”.

Responses	MS groups’ rankings	HS groups’ rankings	All groups’ rankings
School not the best place to give it (not sanitary, comfortable, clean, or supportive)		1	1
May not know, trust, or be comfortable with the person giving the shot	4	2	3
Personal or parental beliefs (parents do not like their child getting it at school, religion or you do not agree with it)	3	3	2
Make take longer (i.e., too many students, need to examine each students medical record)	4	4	4
Scared or afraid	1		4
Might get sick in school	2
Too many people may need it, so it may run out		3

Ties are indicated using the same rank number.

There were several drawbacks that were listed by only one group of students. High school students mentioned variables associated with confidentiality issues, cost to the system, and “strange people” being present during the vaccination process. These variables were not mentioned by MS students. However, MS students, unlike high school students, mentioned friends being present and embarrassing them and parents not being in support of the vaccination at school as potential drawback to SLIP participation.

What would make the student more likely to use a SLIPs

Groups were able to give several features of SLIPs that would make them more likely to use such a program for vaccination. Overall, most groups mentioned that they would be more likely to use a SLIP if it were low cost/free, faster than going to a doctor, allowed for more awareness of the vaccine, had the nasal vaccine, and enabled students to get vaccinated by someone they know. Again, as with the benefits of SLIPs, only students from middle schools, not high schools, mentioned having “encouragement and social support” as a factor in making them more likely to use a SLIP. The top-ranked reasons are listed in Table 3.

Table 3. List of ranked responses to the question “What would make you more likely to get vaccinated at school?”.

Responses	MS groups’ rankings	HS groups’ rankings	Total groups’ rankings
Faster/won’t waste time away from work or school	1	1	1
Decrease cost/free	3	2	2
More awareness of the virus and vaccine	3	5	3
Knowing a competent person (i.e., nurse, doctor) is administering the vaccine	4	4	4
Having a choice of administration (nasal)		3	4
Encouragement from others (teachers, parents, doctors)	2

Ties are indicated using the same rank number.

There were several answers that were reported by only a few students or by only one group. There were several reasons listed by only one group of HS students, including ensuring that the vaccine is safe and sanitary, having a rest period after vaccination and knowing the vaccine will not run out. There were also several reasons listed by only one group of MS students. Those included having a doctor recommend it, feeling safer and less scared at school, having multiple doctors present to make immunizing move more quickly, having participation be voluntary, and understanding what vaccines you are getting. Offering incentives (money, contest, prize, treat) for vaccination was mentioned by both HS and MS students as possibly increasing the likelihood of SLIP use, but it was not in the top five responses for either group.

What would make the student less likely to use a SLIP

All of the groups mentioned that using a SLIP would be less likely if they did not trust or know the person giving the vaccine. Further, all groups were worried about side effects in general, and they were also worried about how others would view them if they did have a reaction or had side effects. Most groups also worried about safety and sanitary issues related to getting the vaccine at school. Under this theme, response included general statements (i.e., more hygienic at school) and specific statements that address safety or sanitary issues (i.e., being assured that vaccine and needles are being handled properly). The top five responses did not differ between HS and MS groups and are listed in Table 4.

Table 4. List of ranked responses to the question “What would make you less likely to get vaccinated at school?”.

Responses	MS groups’ rankings	HS groups’ rankings	Total groups’ rankings
Not having qualified professionals giving the vaccine	1	1	1
Do not know the person giving it, resulting in discomfort, rudeness, impatience	3	1	2
Safety or sanitary issues	4	3	3
Side effects	4	4	4
Having other students around, so they will see you or you will hear them cry, have a reaction, or have side effects	2	5	5

Ties are indicated using the same rank number.

There were other reasons students gave for being less likely to participate in a SLIP that were not ranked with a high priority. Three of these reasons were given by both HS and MS students. Those reasons included having no incentives, high cost, and possible overcrowding in a school setting. Many groups also reported that the likelihood of participation was based on personal or parental choice. More specifically, both HS and MS students were less likely to get vaccinated using a SLIP if they were required/forced to get it or if their parents did not want them to get vaccinated at school.

With regard to reasons only mentioned by one group, there were several mentioned by only MS students, including not knowing about the vaccine, having to miss school, not getting encouragement to participate, and having to go before or after school. There were also several reasons reported by only one HS group, including peer pressure, fear of complications, waiting lists, and negative rumors.

Exit questions

When asked if the delivery method (injection vs. intranasal) might influence their decision to get the vaccine, 34 (62%) students (19 MS and 15 HS) indicated that it would. When asked if their decision would be different if the vaccine offered were any other vaccine and not the flu vaccine, 25 (45%) students (8 MS and 17 HS) indicated that their thinking about participation would be different.

When asked about measures to ensure that consent gets home and signed, both HS and MS students had several ideas. Most of these ideas centered around two main concepts, including improved communication with the parents and incentives for students (and parents) to return the consents. With regard to communication, students suggested various modes of communication including e-mail, calling, and using technology already in place (i.e., texting, school webpage, robo-calls). One MS student expanded on this concept saying, “I know my parents. They like to text, so maybe like sending a massive text to parents.” Another MS student felt that multiple modes of communication may be helpful, “I think they should email them and call them, and when parents come to school for open house, you could inform them then that they’ll be sending home a consent form.” Similar to the open house, one HS student stated, “Maybe if there were like—not like a parent night, but if they had a form available at any school event so while the parents are there, they could just sign it at the event—like a theater show or something.” In terms of incentives, both HS and MS students had a variety of ideas regarding incentives including money, free dress day, skip school day, or food.

Finally, in response to an open-ended request for any additional thoughts, most responses from both HS and MS students revolved around having the choice to get the vaccine and having incentives for getting the vaccine. For example, one HS student actually thought incentives would work to entice students to get the vaccine, “maybe give an incentive to those who are more likely to forget or probably who don’t care about the flu shot. They get to skip class or get some kind of prize or something for getting the shot. Not only it is beneficial to your health, but you know, you can gain something from it. Provide some kind of food or whatever in return for getting the vaccine.”

Discussion

Students in a large, urban school district revealed a broad range of ideas about influenza SLIPs including those pertaining to convenience, cost, and public health concepts of supply and herd immunity. However, it should be noted that even though students were knowledgeable and knew flu vaccines prevented illness both individually and universally, over half had never received the influenza vaccine.

Despite some issues of concern, students seem to appreciate a wide breadth of benefits associated with SLIPs. Overall, students’ responses regarding what would make them more or less willing to participate in such programs included those pertaining to personal benefit and convenience. For example, students felt that school-located vaccines could be of personal benefit to them by being low cost and by providing them incentives to be vaccinated, as well as convenient, resulting in the process being faster than going to a doctor’s office or other provider‘s office.

With regard to incentives, students mentioned the importance of incentives for both vaccination and consent return. Interestingly, some comments were made by students suggesting incentives for the parents, as well as for the children. Overall, this may be an important intervention strategy when developing influenza SLIPs in order to build trust with families; however, implementation and post-implementation surveys studies have found that individual incentives for either return of consent forms or vaccination do not affect MS students’ vaccination behaviors.^22-25 Because all groups noted the improved convenience of the SLIP, it will require further investigation to determine if this might serve as a more significant incentive for the parents to return the forms.

Another personal benefit of SLIPs reported by adolescents centered around students already being familiar with people at school. Many students felt that “knowing” the people at school would make them more likely to use SLIPs. More specifically, students reported that they would be more comfortable and trusting of the “professional” giving the vaccination. Trust concerns were expressed as “knowing or trusting the person administering the vaccine” and “knowing a competent person (i.e. nurse or doctor) is administering the vaccine.” Even though trusting and knowing the person was important to both middle and high school students, this may not be always feasible in a SLIP program. Schools that have school based health centers (SBHC) on site have the capacity to have familiar personnel administer vaccines to students. However, SLIPs implemented at most schools are unrelated to the school nurse or SBHC; thus, the personnel and vaccinator in a SLIP will likely be individuals that students do not know. Therefore, quick interventions (identifying vaccinating personnel and their credentials) could be used to develop initial rapport with adolescent students.

Also, younger students felt that having support (friends at school) would make them more likely to get the shot; however, this was not typically a benefit reported by older students. Given the influence of friends and professionals on students’ willingness to participate in SLIPs, interventions should work to systematically incorporate familiar individuals (school personnel, community leaders, visible parent leaders) in the programs.

Other issues related to trust were deemed important, including trust in the vaccine and the vaccination process. Safety and trust in the competency of the program were common themes in many of the groups. These same concerns have been shown to be important to parents.²⁶ Interestingly, a few items were associated with public health benefits of the SLIP itself. More specifically, students were supportive of the potential SLIP outcome of keeping everyone healthy and having the ability to offer more options for vaccination for everyone, regardless of income and situation.

The limitations of this research are the ones inherent in focus group research. It is not clear that the issues of concern to this population of urban, public school students are generalizable to the population in general. In addition, there may be selection bias in the group composition with students who feel more or less favorably about vaccines or SLIPs or have more time to attend being more likely to participate in focus group discussions. This may be especially problematic for those students that were invited by the nurse to be part of a focus group. These students may have been those who frequently sought services from the nurse, thus, they may feel more comfortable utilizing services at school, such as a SLIP. Because this was the first study examining how students felt about SLIPs, specifically, getting the flu vaccine in a SLIP, ranking across all adolescent groups was felt to provide a more powerful assessment of the data. Indeed, in many cases, HS and MS students responded similarly. Yet, there could be a loss of differentiation of data, or conversely, overstatements of word choice/thematic differences between HS and MS students. For example, convenience was a concept described by a lot of individuals, and it was a top ranked response in the HS student groups. However, the HS students often just used the work “convenient”; thus, coded as that theme. It may be that MS students felt convenience was important (less time away from school), but they do not use the word “convenient” in their vocabulary.

Even though there were several limitations to this study, this study increases our understanding of variables that might be important for getting adolescents to use SLIPs. Further, these focus groups discussions are revealing and the overall validity somewhat substantiated by the relatively rapid saturation of concerns achieved after six groups, indicating that the themes described are common among students within this school district. These initials results are important for several reasons. First, it allows future studies to focus on developing a more thoroughly understanding of these global issues (i.e., safety, trust, and convenience). Given both the similarities and differences between HS and MS students, continued research also will highlight the developmental and logistical needs of each of these populations. Last, using this study and future research, policy makers and program developers can use these key findings to optimize the utilization of SLIPs. Further, these findings can be used in conjunction with parental views²⁷ to further develop success SLIPs. For example, it may be necessary to develop programs where students can have their parents present (especially in younger children), can meet and interact with the vaccination personnel, receive incentives for participation in the program, and receive feedback about the success of the vaccination program (i.e., how many teachers and students have been vaccinated).

Overall, school-located immunization programs may be more successful if children feel comfortable and willing to participate in SLIP programs Therefore, it is critical to understand students’ perspectives regarding the factors that make them more or less likely to participate in SLIPs and get vaccinated. Those creating SLIPs will be able to capitalize on the aspects of SLIPs that students appreciate and address and correct issues that may give rise to student concerns. This study supports the broad range of concepts important to students when considering participation in a SLIP. Importantly, addressing concerns regarding safety, trust, and the presence of supportive personnel is important to students and will be an important part of student recruitment for participation in SLIPs. Further, given that younger children still worry about being afraid or scared and want social support, measures should be taken to allow parents, teachers, the school nurse, or other trusted adults to be available for children’s vaccination. Incorporating and emphasizing these program elements when offering a SLIP could potentially increase program participation. Further study among larger populations of students will further refine these ideas and aid in the development of successful influenza vaccine SLIPs that directly address the issues most important to the students being vaccinated.

Methods

Recruitment

Fliers for participation in focus groups were posted in 5 local public middle schools (MS) and high schools (HS) in a large urban school district in Houston, Texas. Schools were divided based on percentage of free lunch program participation. An equal number of schools were chosen from different socioeconomic levels, so a balance in diversity would be achieved. Specific schools were offered participation in this study, with the goal of achieving overall racial/ethnic and socioeconomic balance among eligible participants. Of those that were offered participation, most schools (5 of 7) were willing to allow us to recruit students.

Students interested in joining the focus groups called the research line for more information. If interested, the students were instructed to locate the school nurse to pick up an informed consent, which they were told to take home for their parents to sign. Signed consent forms were brought to the focus groups. Using this method, fewer than five students contacted the research line because of flyer recruitment. To increase participation, the school nurses identified and approached students who may be interested and willing to participate in a focus group. The nurse then provided an informed consent form in the event the student was willing to participate in a focus group. Thus, most students were recruited by the school nurse.

Focus groups

Six focus groups consisting of eight to ten students each were conducted at the students’ school. Focus groups were conducted in the afternoon after school dismissal. All students received $30 for their participation, and pizza and drinks were provided. Each group lasted for approximately 60 min and was facilitated by a Clinical Psychology Master’s student. All focus groups were conducted in English. The number of groups conducted was based on the point at which saturation (few to no unique responses) in group responses occurred.

All participants completed a brief demographic questionnaire prior to the start of the focus group. During the focus groups, two qualitative methods were used: open ended questions and nominal group methodology. All questions were developed by the authors and were based on existing literature. The open ended questions, along with yes/no queries, were used at the beginning of each session for group engagement and at the end of each session to elicit responses to exit questions (Table 5). After the engagement questions were asked, the facilitator gave a brief introduction that provided the participants with information about the recommendations from the Centers for Disease Control and Prevention (CDC) regarding the universal recommendation for influenza vaccination of all people six months of age and older and the two primary delivery modalities for the vaccine (intranasal and injection). The participants also received information about the nominal group process that would be used for the majority of the group time.

Table 5. Engagement, exploratory, and exit questions used for student focus groups.

	Questions	Response type
Engagement questions	Have you ever heard of influenza (flu)?	Yes/no
	Have you ever heard of influenza (flu) vaccine?	Yes/no
	Have you ever received the vaccine?	Yes/no
	Have you ever been part of a school-located health program before?	Yes/no
	What do you know about the flu?	Open-ended
	What do you know about the flu vaccine?	Open-ended
Exploratory questions	What are the benefits of getting vaccinated at school?	Nominal group method
	What are the drawbacks of getting vaccinated at school?	Nominal group method
	What would make you more likely to get vaccinated at school?	Nominal group method
	What would make you less likely to get vaccinated at school?	Nominal group method
Exit questions	Does vaccine delivery (intranasal vs. injection) influence your decision to be immunized at school?	Yes/no
	Since written permission is needed for vaccination, explain what you think is needed to ensure consents get taken home, signed and returned.	Open-ended
	Does your thinking about participation change if it is a vaccine other than the flu vaccine?	Yes/no
	Anything else you would like to add about receiving flu vaccine in a SLIP?	Open-ended

Using the nominal group method, four exploratory questions examining factors of importance in the SLIP decision-making process were presented to the group (Table 5). The nominal group method was chosen to help establish consensus among the groups; it is a method commonly used in health and medicine with the aim of rapidly producing and ranking decisions.²⁸

The four exploratory questions used in this study addressed attitudes and perceptions regarding what factors are important to students when they consider the use of a SLIP. For this portion of the study, the facilitator presented a question to the participants, and then participants were asked to list answers to each question on a piece of paper. When the participants completed their lists, the facilitator asked for one response per participant until all had provided their entire list of answers to the group. A research assistant wrote the responses on a computer screen projected for the group. After all responses were recorded, group discussion ensued to clarify each item, amalgamate responses, remove any duplicate items, and discuss the items in more detail. When the list was finalized, the participants were asked to rank their top five priority items from the list in order of perceived importance. These rankings were presented to the facilitator.

All recruitment and study procedures were approved by the Baylor College of Medicine. All groups were run during the last two weeks of the school year, and each group was audiotaped and transcribed. The nominal group responses were reviewed post-hoc the conclusion of the groups to assess for saturation. At that time, post-hoc analysis revealed that saturation was met across HS and MS students.

Analysis

The group transcripts were read by both authors and the two other investigators who were involved in data collection. For the yes/no questions, frequencies of each response were recorded. For the open-ended questions, framework analysis was used as the structure for analyzing the data.²⁹ Overall, the interviews were coded using these themes. The coding was done by one of the principal authors, but the coding was reviewed and agreed upon for accuracy by all four investigators. Discrepancies between the codes were discussed and resolved by consensus. New themes and coding were developed as the data were mapped to existing literature.

Each exploratory question was analyzed separately. Rankings for each question were developed using the lists of the top five priority items submitted by each group participant. These rankings were developed by assigning points to each item that each participant reported as being important. More specifically, the items ranked most important (the first item on the participant’s list) were assigned a point value of 5, the second was assigned a 4, the third a 3, the fourth a 2, and the fifth most important item on the participant’s list was assigned a value of 1. Once these rankings were assigned, a final list of rankings within each group was developed, listing the most important items (items that received the most points) to the least important (items that received the least points). To develop rankings across groups, the responses for each group (not individual) were reviewed across the groups. Response items from different groups were considered equivalent if all investigators agreed they conveyed the same meaning. The same process described above for ranking within groups was used to determine final rankings across groups. Data were ranked across all groups to give a more general and comprehensive understanding of adolescent concerns/perceptions, within specific schools. Data presented in Tables 2–5 include rankings among the middle school (MS) groups, the high school (HS) groups, and the rankings across all groups (total).

Further, outside of these rankings, transcripts were read for any additional information that was not captured by the ranked lists. Information that was not previously captured was then coded into themes and noted.

10.4161/hv.26332