1 Introduction

The public health emergency that accompanied the COVID-19 pandemic highlighted the value of infectious disease prevention in public health. The collective ability to promote and protect this value has clearly become a decisive factor in societal safety, economic well-being and development. The introduction of screening tests for Sars-CoV-2 has been an extraordinary prevention and infection control tool during the most difficult phases of the emergency [1]. However, health policy decisions implemented for pandemic control, including bans and mandates, inevitably induced negative reactions towards health authorities, such as feelings of distrust of vaccines and negative attitudes towards screening tests [2]. Yet, little information is available on how such issues were elaborated and affected the adolescent population in school settings. Despite the common agreement on the benefits of COVID-19 screening as a tool to increase school attendance during the pandemic, adherence to school-based screening programmes has often been suboptimal [3, 4]. The reasons behind the lack of compliance with such an important preventive measure may be complex. They can simply lie in fear for the discomfort the test may provoke or go deeply into personal beliefs and trust in health authorities [5].

To know attitudes, opinions and emotions of the population, during the last decades, there has been a growing interest in research techniques that exploit group interactions as a primary cognitive resource [6]. In this setting, social actors are not regarded as simple sources of information but as main actors of research capable of jointly elaborating a view of the phenomenon under investigation.

It is exactly within the theoretical context of Participatory Research (PR) that qualitative analysis becomes an effective tool for the transmission of information and, at the same time, an opportunity for the cultural growth of the participants. Qualitative research methods are used to explore and understand complex and contextual phenomena in the social sciences and also in the medical field. The aim of these analyses is to obtain an in-depth understanding of the views, experiences and meanings attributed by the participants involved [7]. Based on these considerations, the World Café method (WC) was adopted and used in the present study as a qualitative research approach in school settings to carry out participatory work sessions based on participants' social interaction, a vehicle and resource for information transmission, role awareness and cultural growth.

Developed in America in the 1990s by J. Brown and D. Isaacs, WC is based on the concepts of collective intelligence and Bohmian Dialogue, that is, the realization that thinking is a collective process achievable only by the exchange of culture and communication and that intelligence emerges through common purposeful engagement among individuals in a group setting [8].

The scientific literature describes how the World Café method has been successfully applied to different contexts to promote collaboration and creation of projects aimed at improving living and working conditions. Within each discussion group, in fact, personal opinions are not only the result of individual reflections but come from collective discussion and confrontation with other participants [9]. This crucial aspect of the WC represents the first important aspect of the method and, for this reason, differs from traditional group interviews, where interaction takes place from time to time between the participants and the researcher.

As part of the project ‘Innovative systems for the early detection of COVID-19 outbreaks in school settings in Italy’, work package ‘Determinants of Refusal of SARS-CoV-2 Screening in School Settings’, funded by the Italian Ministry of Health – CCM 2020 (National Centre for disease prevention and control), a conceptual model was developed to be used to set up standard tools for assessing individual barriers in adherence to preventive programmes such as screening tests for SARS-CoV-2. In developing the model, special emphasis was placed on factors that may be predominant in the school setting. The aim of this study was to analyse students' attitudes and to elicit their views on the topic based on their own experiences during the COVID-19 pandemic.

2 Materials and Methods

Between March and May 2023, three World Café sessions were organized in three schools adhering to the Ministry of Health – CCM project in Puglia region, Italy, enrolling 70 high school students on a voluntary basis. Before each session, all participants signed an informed consent form containing a description of the method and details on the use of personal data.

A conceptual model based on five domains was developed for guiding the conversation sessions: swab taking, perception of disease risk, consequences of positivity, attitude towards authorities, information and communication.

The WC sessions carried out according to the guidelines of the World Café Community Foundation [10], involved 4 classes with a mean of 17.5 students per class distributed to 5 tables; each table had a moderator who was fixed at the established location whose task was asking questions, facilitating dialogue and noting emerging reflections. The discussion sessions included the use of some equipment, such as small tables and chairs distributed in the classroom (5–6 seats per table), placemats, sheets of paper and pencils to jot down thoughts, considerations and ideas. Each group of students rounded through all 5 tables at each turn change (every 20 min), thus providing their input to all discussion domains. The total duration of the sessions was, therefore, 1 h and 40 min (5 rounds, 20 min each), during which students addressed all the topics related to the domains of the conceptual model. The questions and topics addressed at the tables used as guide during the discussion sessions are summarized in Table 1.

All World Café sessions were recorded and transcribed in full, indicating the discussion domain and marking each participant's intervention with an identifying number from 1 to 6.

Data were analysed using inductive thematic analysis [11], which benefits from theoretical flexibility and the ability to categorize, organize and describe students' experiences through the identification of key themes and subthemes. The transcribed texts were imported into ATLAS.ti software, which, also takes advantage of artificial intelligence (AI), performed qualitative content analysis. In ATLAS. ti, categories can be renamed, deleted, grouped and merged by the researchers [12]. Two researchers independently examined the coding of the texts, refining it further after discussion and consensus. Codes and subcodes were grouped into themes, ensuring that these were consistent, clear and distinct.

The study was conducted after receiving ethics approval from the ethical committee of the University Hospital of Foggia number 62/CE/2023 on 29 March 2023. The study was conducted with the financial support of the Italian Ministry of Health – CCM 2020. The funder had no role in study design, data collection and interpretation, or decision to submit the work for publication.

3 Results

The arguments discussed by the 70 high school students included in the study, divided by the 5 thematic domains, listed in a matrix of favoring and hindering factors, are shown in Table 2.

The details of the thematic map illustrating the relationships between the key themes and coded terms are provided in Table 3.

4 Discussion

Our study investigated the experiences, attitudes and beliefs of a group of high school students regarding the recent pandemic, with a focus on the impact of the screening methods for COVID-19 offered for free in the schools as part of the Ministry of Health – CCM project ‘Determinants of Non-Adherence to Screening for SARS-CoV-2 in School Settings’. The qualitative analysis revealed singular insights, and the World Café method enabled the creation of spontaneous and stimulating conversations, highlighting the young participants' keen critical sense and lively interest in the topics under discussion. The theme group ‘Emotions/thoughts’ turns out to be the most discussed by students within all 5 domains explored, confirming the centrality of the emotional sphere on adolescents' personal experience during the pandemic. Students reported some initial difficulties in adapting to the restrictions imposed by lockdown and distance learning, and this generated heterogeneous emotional responses with respect to isolation. Indeed, the emotional impact was multifaceted and diversified: some students reacted to the restrictions with proactive and supportive attitudes, while others experienced deleterious effects on their psyche, with anxiety, frustration, inadequacy and loneliness prevailing. In line with the results illustrated, recent scientific literature confirms that social isolation is a significant predictor of vulnerability to psychological distress in students [13], resulting in increased stress, anxiety and self-reported depressive symptoms [14].

Many students have also expressed concern about the consequences of distance education on overall academic performance, claiming, in line with the literature, a decrease in the quality of achievement in terms of academic performance and interest in studying [15, 16].

‘Public Health Policies’ also constitutes a predominant theme in the dialogues among participants. Students' critical attitudes towards political governance evidently led to a significant reduction in trust towards institutions, which were accused of lack of transparency towards the population. Government management of the pandemic, restrictive measures, monitoring systems and ministerial decrees were contested in part by participants and often deemed excessive and negatively impacting individual stress levels. During the discussion sessions, preventive measures taken by schools during the high viral circulation phase were also examined, with largely favourable opinions from students regarding the desirability of being part of a free, noninvasive monitoring programme for SARS-CoV-2 in the school setting. Most participants firmly supported the great advantages of salivary swabbing, performed in the classroom, compared to nasopharyngeal swabbing, in terms of minimal invasiveness, convenience and speed of (self-)execution, supporting its usefulness and effectiveness in the school setting. However, the aspects that emerged as major determinants of non-adherence to screening for COVID-19 are firmly related, once again, to the emotional sphere and personal experience of each participant. Continuing the analysis, the topic of communication sparked a lively debate, being the fourth most discussed topic in the various World Cafés. Pandemic information sources, often cited by students, embody the emblem of effective, correct and usable communication, as does the concept of misinformation, which has its roots in vaccine hesitancy. Indeed, students stated that confusing, often conflicting messages and misinformation about health risks can have a negative impact on personal attitudes, behaviours towards vaccines and adherence to screening campaigns. The scientific literature shows that a large proportion of young people get information about their health from social platforms [17, 18]; considering what has just been stated, the concern about the consequences to which the spread of misinformation among young people through social media can lead takes on unquestionable meaning. Indeed, this dangerous mechanism, if entrenched, would reinforce general distrust in institutional sources of communication, encouraging the establishment of attitudes of conspiracy, scepticism and vaccine hesitancy [19]. On the other hand, the position of students who stated that they use institutional sources as the exclusive channel from which to draw information regarding COVID-19 is worth noting. This highlights a mature attitude and underscores how developing from a young age a good level of health literacy can guide towards conscious, knowledgeable choices that protect health even in situations of high psycho-social impact, such as a pandemic. Finally, the opportunity for the participants to freely express their thoughts in the discussion sessions, by carrying personal experiences, underscored a sense of strong participation and emotional involvement towards all the issues addressed in the World Cafés.

This study has several strengths and limitations. The interest and participation in World Café by students show that it is an effective and appropriate approach to exploring students' experiences during the pandemic. However, data must be considered in terms of the context in which it was collected; the WC collected retrospective information on a small sample of participants coming from the same region of Southern Italy, although from different cities. Consequently, the present findings cannot be inferred to the entire adolescent population. Future research should therefore continue to implement in-depth qualitative surveys of youth to document a variety of perspectives on their attitudes and beliefs. The interaction between the factors that have influenced adolescents' emotions and attitudes regarding the recent pandemic is complex and dynamic, and we do not claim to have been able to fully grasp it, as this would require a multifactorial approach. However, the results of this study could be used as a basis to further explore adherence to screening tests in the adolescent population during and after pandemics. In this respect, quantitative analysis may complement our findings by the means of robust statistically sound surveys.

5 Conclusions

The many insights gained from the WC analysis, if appropriately reframed, bring out useful elements for taking actions aimed at reducing young people's distrust and mistrust of vaccination and screening campaigns. Personal experience, whether positive or negative, was confirmed in the WC as a key determinant in guiding the health-related choices of the students interviewed. Participants' partial criticism of government actions taken during the pandemic and little trust placed in institutions are fuelled by the lack of effective media communication, which left room for the spread of personal beliefs that turned out to be often wrong. Institutions and schools should therefore focus on disseminating clear and targeted messages to help fight misinformation and noncompliant behaviour. In the wake of the interest expressed by students regarding the preventive measures taken to respond to SARS-CoV-2 pandemic, it would be desirable to reintroduce similar initiatives aimed at educating and raising awareness among adolescents in the school setting. Pro-social initiatives can, in fact, concretely strengthen the key factors of young people's adherence to screening campaigns [20].

In view of these considerations, a multifactorial approach and the cooperation of various stakeholders become necessary to discard generalized attitudes of scepticism and conspiracy and to facilitate the population's adherence to screening procedures. Finally, the results of the present study suggest that, in the context of qualitative analysis, the World Café method proves to be a useful and effective instrument for scrutinizing the emotional sphere of adolescents and analysing their thoughts, attitudes and knowledge, in the construction of a clear, spontaneous and unbiased dialogue in which everyone's opinion makes an exclusive and indispensable contribution.

Author Contributions

Valeria Gabellone: investigation, formal analysis, data curation, writing–original draft, writing–review and editing, project administration, methodology. Fabiana Nuccetelli: methodology, data curation, investigation, formal analysis, writing–review and editing, project administration. Elisa Gabrielli: validation, project administration, writing–review and editing. Leonardo Ascatigno: investigation, validation, writing–review and editing. Pier Luigi Lopalco: conceptualization, methodology, writing–review and editing, validation, supervision. Rosa Prato: conceptualization, methodology, writing–review and editing, funding acquisition, validation, supervision.

Conflicts of Interest

The authors declare no conflicts of interest.