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Research | Open | Published:

Adolescents, parents and teachers’ perceptions of risk and protective factors of substance use in Moroccan adolescents: a qualitative study

Abstract

Background

Substance use in adolescents is a global public health concern that continues to draw attention from academics, policy experts, and government officials. In Morocco, few studies have investigated the influencing factors of substance use in adolescents. Here, we aimed to fill this gap and to better understand factors that protect or influence substance use in adolescents.

Methods

We conducted a qualitative study using focus group discussions. The semi-structured interview guides were based on the socio-ecological model as a theoretical framework to explore perceptions of students, parents, and teachers regarding substance use risks and protective factors in adolescents. Data from each group were audio-recorded, transcribed, and analyzed using thematic analysis.

Results

From May to July 2016, 17 focus group discussions were conducted at two middle schools in Taza city, Morocco, which included 8 groups of 7 adolescents (28 boys and 28 girls) aged 14 to 16 years, 5 groups of parents (5 females and 21 males), and 4 groups of teachers (13 males and 5 females). Thematic analysis resulted in six common themes that represented the most salient perceived risk and protective factors regarding substance use among adolescents: perceived benefits of substance use, awareness and beliefs, family influence, peer influence, easy accessibility of substances, and social norms.

Conclusions

Our results demonstrate that multilevel prevention programs in adolescents should address influencing factors from the individual to the societal level, including social norms and the government’s policy toward substance use. Health education programs included as part of the school curriculum can contribute to promoting awareness and reducing risky behaviors of Moroccan adolescents.

Background

Adolescence is a time of physical, psychological, and social and emotional changes. At this stage of life, adolescents adopt behaviors that can lead to various health risks, including substance use [1]. For adolescents, substance use tends to be acquired through experimentation and curiosity, particularly through peers [2].

Alcohol, tobacco, and illicit drugs are the most used substances by adolescents worldwide, and these substances share similar patterns of use [3, 4]. Substance use is a leading cause of preventable morbidity and mortality among youth; indeed, more cases of death, disease, and disability are caused by substance use than by any other preventable health condition [5]. In addition, substance use is associated with many psychological, social, and economic complications, including depression, suicidal behavior, crime, and the global financial burden of drug abuse [6, 7].

Early involvement of substances increases the possibility that addiction will develop [8]. Substance use in adolescents is common in both low- and high-income countries [9, 10], and Morocco has shown both increased prevalence and early initiation of substance use in adolescents [11, 12].

Risk factors that potentially influence adolescents to use substances include experimentation, lack of awareness, poor parental monitoring, peer and family influences, gang affiliation, psychological problems, absenteeism, and below-average grades [13, 14]. Having a family member who uses substances can also be a risk factor; however, enjoyment and curiosity are cited as major influences in decisions by adolescents to use substances [15].

Protective factors against substance use have also been identified. These include prosocial peers, home support, school support, self-awareness, peer caring relationships, and community support [16]. In school settings, school attendance, parental or guardian connectedness, peer support at school, and parental supervision have been shown to be protective factors for adolescent health [17]. Religiosity can also keep teenagers from taking substances, even when they are experiencing difficult situations [18, 19].

An effective substance prevention program in adolescents requires clear identification of contextual risks and protective factors. Thus, the socio-ecological model has long been recommended to guide public health intervention research [20]. The principle of this theoretical framework is that the contextual environment (e.g., home, school, community) interacts with the individual to promote healthy behaviors or to create unhealthy ones, such as the use of substances [20]. This model allows exploration of complex interactions between multiple factors that influence risky behaviors in adolescents, thus presenting ways to promote healthy behaviors [21]. In the socio-ecological model [21], factors influencing the use of substances among adolescents have been categorized into four levels: individual, relationship, community, and societal.

In Morocco, the Mediterranean School Survey Project on Alcohol and Other Drugs, conducted in 2009 and 2013 among 15- to 17-year-olds, revealed that substances were used and started at an early age [12]. Similarly, results from the 2010 and 2016 Global School Health Surveys demonstrated an increasing prevalence of substance use among adolescents aged 13 to 15 years, especially regarding use of tobacco and cannabis [11, 22]. Another study conducted in the North Central Region of Morocco among 11- to 23-year-old school students reported a 16.1% lifetime prevalence of smoking and a 9.3% prevalence of using psychoactive substances. Specifically, cannabis was the most used substance (8.1%) followed by alcohol (4.3%) [23]. These studies show that tobacco and cannabis are the most used substances in adolescents compared to alcohol and other illicit drugs. This can be explained by the prohibition and disapproval of alcohol and illicit drug use by the religious, social and sometimes legal systems of our country. On the other hand, Morocco, it is one of the largest producers of cannabis resin in the world [24], making cannabis easy and inexpensive to obtain by teenagers.

Studies of factors that influence substance use in Moroccan adolescents are scarce, with most focusing on only individual and/or family factors [12, 13, 23]. This study seeks to fill this gap and this lack of data on contextual risk and protective factors of substance use (especially regarding use of tobacco and cannabis) in Moroccan adolescent. Here, we used a socio-ecological approach and focus group discussions (FGDs) with multiple-category design to obtain accurate descriptions of perceived risks and protective factors of substance use in Moroccan adolescents. Having a multiple-category design allows views of different groups to be explored in a similar category or in different categories [25]. For this study, we examined views of three different groups (adolescents, parents, and teachers) [26]. These results may aid in the development of more effective interventions.

Methods

Study participants and procedures

To explore perceived contextual risks and protective factors of substance use, we conducted 17 FGDs with 100 participants in Taza city, Morocco, from May to July 2016. We had 8 groups of adolescents (28 males and 28 females, 14–16 years old) who were recruited from two middle schools (disadvantaged and advantaged according to socio-economic level). From each school, adolescents from the last year of middle school were selected based on purposive sampling to obtain groups balanced across age, sex, and substance use behaviors. This age was selected because their educational programs include studies related to health risk behaviors. In addition, we had 5 groups of parents of adolescents (5 females and 21 males) who were included based on their voluntary participation. Teachers of disciplines concerned with health risk behaviors were randomly selected from included schools and grouped into 4 FGDs (13 male and 5 female teachers). Participant characteristics are shown in Table 1. We arranged participants into single-sex focus groups to respect the sociocultural norms of Morocco. Sampling continued until data saturation was reached.

Table 1 Participant characteristics

Privacy and confidentiality were maintained during interviews, which were conducted by two researchers. A moderator gave appropriate information about the study aims before the interview, and participants were informed about the tape-recording procedure and confidentiality. A silent observer made notes on non-verbal behaviors of individuals and group interactions. Before the FGDs were closed, participants were invited to add to or clarify their opinions. Each FGD lasted approximately 45 to 60 min.

Data collection instruments

Participants completed a brief, structured one-page questionnaire to record demographic characteristics. Qualitative data were gathered through FGDs using semi-structured interview guides. Three different sets of open-ended questions (adapted for adolescents, parents, and teachers) were used to explore the perceived risks and protective factors for substance use in adolescents at the individual, relationship, community, and societal levels (Table 2). Our interview guides were developed by the research team based on the socio-ecological model as a theoretical framework [21]. Interview questions were tested on small groups of each category of participants to identify wording issues.

Table 2 Sample of open-ended questions in focus group discussion guides

Ethical approval and consent to participate

The study was approved by the Faculty of Medicine and Pharmacy of Casablanca Research Ethics Committee and the National Control Commission for the Protection of Personal Data (A-RS-193-2015). Written informed consent was obtained from all participants before study enrollment. For adolescent participants, written informed consent was obtained from their parents or legal guardians, with verbal consent from each adolescent participant. Participants were informed that they could withhold information. The names of participants were separated from the transcripts and field notes and kept in a private place where only the leading author had access. Only the principal investigators had access to the full tapes.

Data analyses

All sessions were audiotaped, transcribed verbatim, and translated into English. All transcripts were checked for accuracy through listening to recordings when reading transcripts. Data sets based on adolescent, parent, and teacher discussions underwent thematic analysis [27], which allows repeating themes to be recognized across a data set. The inductive thematic analysis technique was used to explore accounts among participants without trying to fit these into a preexisting coding frame [27]. In addition, a semantic level of thematic analysis was used [27].

Data were analyzed using six phases of thematic analysis as recommended by Braun and Clarke [27] The coding process was iterative; to ensure transparency and reliability, and all transcripts were coded independently by the two researchers. Differences were then discussed and resolved to refine codes and identify key themes emerging from the data. The overreaching themes were then categorized according to the socio-ecological model [21], allowing us to explore several contextual factors influencing attitudes, beliefs, and practices associated with substance use in adolescents.

Results

Participant statements mainly focused on factors influencing tobacco use (including cigarette smoking, water pipes, and smokeless tobacco) and cannabis use (sepsi pipe and edible and smoked cannabis products). Some participants also commented on use of alcohol and other drugs.

Our analyses identified six common themes regarding substance use among the four categorical levels (individual, relationship, community, and societal): perceived benefits of substance use, awareness and beliefs, family influence, peer influence, easy accessibility of substances, and social norms. Table 3 shows illustrative quotes from different focus groups in support of each theme and sub-theme. In addition, Fig. 1 illustrates how the themes (factors influencing substance use in adolescents) fit within the socio-ecological model levels.

Table 3 Themes and examples of statements
Fig. 1
figure1

Diagram showing emerging themes and factors influencing substance use in Moroccan adolescents within the socio-ecological model

Perceived benefits of substance use (individual level)

This individual-level theme explains personal factors that cause substance use in adolescents because of perceived beneficial effects. In this theme, we found two sub-themes (personal positive appeal and escape negative state).

Personal positive appeal reflects personal motivations for substance use. Participants in all three FGD categories perceived that a self-image of maturity and looking dangerous were motives for substance use by teens (Ex. 1, Table 3). Others claimed that gaining attention and appreciation from friends were motivating factors (Ex. 2, Table 3), and several stated that having fun and getting high were motivators for substance use (Ex. 3, Table 3). Participants agreed that vulnerability and curiosity during adolescence, a time of increased physical, emotional, social, and behavioral changes, had major roles in substance use initiation among adolescents (Ex. 4 and Ex. 5, Table 3).

Some adolescents leaned on substances to enhance concentration in school. A father stated, “Some people think that using cigarettes help them to focus on their studies, which means they smoke to do well at mathematics for example.” Other adolescents earned money by selling drugs to their peers, as observed by one teacher: “Some adolescents gain money from selling drugs. At the beginning, they offer these drugs to their peers at no cost, until they become addicted.”

Escape negative states reflects the use of substances as a way to manage and forget psychological, personal, and family problems. Use of substances to self-treat depression, stress, anxiety, and lack of self-esteem was reported by several participants, including parents and teachers (Ex. 6 and Ex. 7, Table 3). Many participants viewed that adolescents used substances to forget and bring relief from problems like poverty, divorce, domestic violence, and social conflict. Some participants stated that academic failure was a trigger for teenagers to use substances (Ex. 8, Table 3).

Awareness and beliefs (individual level)

This theme reflects the protective factor of awareness about the harmful effects of substance use, which can lead to improved resilience and promote positive beliefs against their use. Adolescents and parents stated that awareness gained through personal interactions with family members, schools, and media served as a protective factor against substance use (Ex. 9, Table 3). Teachers agreed that the school setting is important for raising awareness and resistance to drugs but is still insufficient because of the lack of interest for this issue in the school curriculum and the lack of security in the school environment (Ex. 9, Table 3).

The negative influences of media and the lack of awareness about the severity of substance use-related harms, whether in family or in school, were regarded by many participants as important risk factors that increase adolescent substance use (Ex. 10, Table 3). In addition, participants noted the lack of specialists in schools to increase awareness and provide counseling for adolescents. One teacher expressed, “Some addicted adolescents cannot give up. There is also a lack of specialized human resources, such as a psychiatrist or social assistant, at school to follow a smoker or a drug user.”

Some adolescents, through vivid examples of drug-related harms or their desire to maintain their health, shared strong internal beliefs that these substances are not useful as they do not solve problems but destroy health. Parents and teachers also supported that a strong conviction against substance use and a desire to maintain health are protective factor (Ex. 11, Table 3). For example, adolescents who can organize their free time by filling it with beneficial activities such as sports are protected from being involved in substance use (Ex. 12, Table 3).

Family influence (relationship level)

This theme reflects influences of family, which may be either a protective or a risk factor for substance use in adolescents. In all three FGDs, most participants emphasized that adolescents who used substances had poor parenting, especially when their parents or siblings were substance users, thus implicitly influencing decisions to use drugs through observation or modeling. Adolescents agreed that, if parents used substances, their children will be much more likely to be involved in the same behavior (Ex. 13, Table 3).

Lack of parental supervision, lack of affection, and neglect within the family were expressed by some participants as risk factors for substance use (Ex. 14, Table 3). Participants believed that parents must be more supportive and embracing and less neglectful of their children’s behaviors.

In contrast, other adolescents stated that restriction and control from parents can lead to a lack of self-esteem, prompting use of drugs as self-protective or an act of rebellion against this control. Because teenagers often crave independence, they believed that strict and severe parental rules could actually backfire against the prevention of substance use. As stated by a male adolescent, “In some cases, you find that parents over-control teenagers, so they do what they want, because more control gives the opposite result. Parental control must be carried out intelligently without abuse. For example, if my father treated me with extra-rigor, I wouldn’t do what he asked me, but if he joked with me and treated me kindly, I would listen.”

In the three FGDs, most participants agreed that excess or limited pocket money can influence risky behaviors, including substance use (Ex. 15, Table 3). In contrast, having shared culture and beliefs in families against controlling behaviors are effective in preventing substance use in adolescents, particularly if there is a high level of parental monitoring. However, adolescents agreed that parental control must be accompanied by mutual trust, which is gained through meaningful discussions to understand unhealthy behaviors of their children. Intimate discussions may cause teenagers to avoid disappointing their family members and losing their confidence. This idea was supported by many adolescents, parents, and teachers (Ex. 16, Table 3).

Having a father who smokes could lead to advice regarding the negative health effects of smoking. One male adolescent noted, “My father smokes; he is the one who told me not to accompany friends who smoke because he was a victim when he was young and wants me not to be like him.”

Peer influence (relationship level)

Substance use in friends was considered by adolescents to be an important risk factor for experimenting and using substances, a view supported by parents and teachers (Ex. 17, Table 3). The desire to fit in and be accepted into a particular peer group can lead to drug- taking behavior. One adolescent stated, “When you find yourself in a group of smoking friends. When I tried to smoke for the first time it was only in front of my friends, I wanted to tell them that I share the same activities with you.” This dominant factor of peer influence was mentioned in narratives of all participants.

Some adolescents said that lack of money was not a deterrent for substance use because they can obtain drugs from friends or make some drugs themselves (e.g., edible cannabis products). An adolescent stated, “Some drugs, like edible cannabis, students make it here in school, so they agree that each one comes with a certain ingredient and then make it themselves.” Adolescents and teachers also mentioned the role of emotional relationships between boys and girls, which can influence the use of drugs by adolescents, especially girls under the influence of their boyfriends (Ex. 18, Table 3).

In contrast, in all FGDs, most participants believed that having close friends who do not have such behaviors can protect adolescents from this risk (Ex. 19, Table 3).

Easy accessibility of substances (community level)

This theme was based on statements in which substances, despite being illegal, were widely available and easily accessible for adolescents. Drugs could be obtained free of charge from friends or with their pocket money. Places selling substances and places for users were stated to be abundant and found everywhere (Ex 20, Table 3).

Many adolescents, parents, and teachers expressed that there is a lack of laws that penalize drug dealers and users. In addition, schools do not provide adequate surveillance, and there are unguarded places near the school where adolescents meet to take substances (Ex. 21, Table 3).

Social norms (societal level)

This theme was based on the negative or positive influence of collective social norms, such as normalization and religious beliefs, on substance use in adolescents.

In terms of normalization, participants stated that substance use appears to be integrated into the daily lives of people and has become more accepted by society. This, coupled with the desire to be like others, could put adolescents at a high risk of engaging in this risky behavior (Ex. 22, Table 3). Many participants viewed strong religious beliefs as a crucial protective factor that can help adolescents to avoid substances (Ex. 23, Table 3).

Discussion

This study aimed to better understand factors influencing substance use behaviors in Moroccan adolescents using a qualitative approach and the socio-ecological model as a theoretical framework. In accordance with previous ecological theories of development [28, 29], our overarching themes highlight several contextual risk and protective factors that influence substance use in adolescents. These themes were within all four socio-ecological levels (individual, relationship, community, and societal).

At the individual level, the theme of perceived benefits of substance use (reflecting beliefs on the beneficial effects of substances, including cannabis, cigarettes, and edible cannabis products) was consistent with previous qualitative investigations [14, 30]. This theme comprised two sub-themes: personal positive appeals and escape negative states. The personal positive appeal sub-theme includes boosting self-image, having fun, experimentation, and other normal adolescent behaviors [2, 30]. Perceived benefits can also include financial ones. In agreement with a previous study, our study showed that many adolescents were motivated to get pocket money by dealing drugs [31]. The use of substances in adolescents due to perceived benefits can be explained by the core construct in Bandura’s social cognitive theory, which suggests that behavior is partly motivated by the anticipated consequences, or outcome expectations, of the behavior [32]. Thus, the greater the perceived benefit associated with a behavior, the more likely that the behavior will be adopted.

The second sub-theme, escape of negative states, reflects the use of drugs to flee undesirable situations, especially those caused by psychological and family problems [14, 30, 33]. Substance use can be coupled with psychological problems, including suicidal ideation in Moroccan adolescents [34]. Evidence points to significant associations between psychological problems and substance use in adolescents [1, 7, 10, 23]. Adolescents may use drugs to escape or find relief from troubles and stressful situations or as a way to manage their problems. This self-medication theory of the use of psychoactive substances to self-regulate or alleviate stress [35, 36] offers an understanding of this finding. Therefore, a psychoeducational prevention program should provide adolescents with effective ways to deal with stress and life problems during adolescence, which could perhaps decrease substance use in adolescents.

The theme of awareness and beliefs was both protective against and a risk for substance use. Similar to previous studies, we found that lack of awareness about substance use-related harms was an important risk factor for adolescent substance use [19, 37]. Lack of knowledge regarding substance use may be due to poor dissemination within families or within schools. This is heightened by influences from media, which often present favorable images of tobacco and alcohol through advertising or “normalize” its presentation [37, 38]. In contrast, strong positive beliefs against substances can be a protective factor [19]. Messages from schools and media, personal interactions with family members, and vivid examples showing the harmful effects of drugs can influence personal beliefs [19, 37]. Nevertheless, our surveyed teachers mentioned that messages and education from schools were not sufficiently addressing drug awareness or promoting positive beliefs; teachers mentioned lack of health education in the school’s curriculum and absence of extracurricular activities. Drug prevention in adolescents can greatly benefit from the incorporation of substance use education into school curriculum, specifically including the use of modern technology to improve student participation [33, 39]. In addition, having extracurricular activities in schools and encouraging the intense participation of adolescents in these activities have been shown to reduce substance use in adolescents [40].

From these observations, better-designed intervention program should both increase adolescents’ knowledge about substance use-related hazards and change adolescents’ misconceptions about the perceived benefits of substance use. In addition, programs should include ways to develop adolescent resiliency with regard to decision-making, positive thinking, and coping abilities.

At the relationship level, we found that family and peers play important influential roles in substance use in adolescents, which is consistent with previous social and environmental theories [29, 41]. Similar to other studies [19, 37, 42, 43], our participants identified poor family relationships, lack of control or over-control, lack of affection, unmonitored pocket money, and substance use behaviors of parents and siblings as potential risk factors in adolescents. In a study of parenting styles in several European countries, neglectful parenting (neither warmth nor strictness) and authoritarian parenting (strictness but not warmth) were associated with high levels of substance use in adolescents. However, when parenting styles included an environment of acceptance, dialogue, and affection, levels of substance use were lower [44]. Substance-using family members who are role models, especially parents and siblings, can negatively influence the use of substances in adolescents [15, 37, 43]. Children who grow up with parents or siblings who use drugs may model behaviors and attitudes regarding substance use; through social learning processes of parental acceptance, the likelihood of substance use initiation and continuation is increased [45]. In contrast, and similar to other studies [19, 30, 37, 42, 43], we found that family beliefs against drug use are effective in preventing substance use in adolescents. Such results support the strong association between parental bonding and substance use in Moroccan adolescents from quantitative findings (unpublished data). Establishing a healthy culture and environment for adolescents can help protect against substance use. Therefore, intervention strategies should also include information regarding positive parenting practices and should educate substance-using family members about the negative effects of substance use on adolescents and the family in general [43].

Participants in our study emphasized that peers can either increase or decrease substance use among adolescents. As already documented, student drug users generally seek to attract other people to use substances in schools; under this pressure, adolescents may use substances to fit in with peers [14, 19, 30, 46]. Furthermore, as reported in a previous quantitative study (unpublished data), there is a strong association between substance use in adolescents and substance use behaviors of their friends. This influence is particular important during the adolescent developmental stage, where teens begin the process of differentiating themselves from their parents and orienting toward their peers; during this period, they also tend to prioritize the values, attitudes, and behaviors of peers versus those of their own family [47]. The role of peers in inducing substance use by adolescents appears to be moderated by the poor role of parents [30, 46]. In our study, participants stated that peers were often the primary way to obtain drugs or make certain drugs with local ingredients (edible cannabis products), as reported elsewhere [19]. In addition, our participants suggested that emotional relationships between girls and boys can play a role in substance use initiation, especially for girls who receive pressure from boyfriends or as a coping mechanism during relationship disturbances [48]. In contrast, participants also believed that having close friends who make good choices and those not engaged in high-risk activities could act as a protective factor against substance use, as documented previously [19, 30, 39]. Peers who do not engage in drug use behaviors and have negative attitudes toward the use of substances are likely to influence similar behaviors and attitudes. Consequently, it is important to provide adolescents with ways to counteract negative peer influences, for example, by providing effective refusal skills to withstand peer pressure and using prosocial peers in the implementation of substance use prevention programs.

Accessibility and affordability of substances have been noted in several studies as risk factors for substance use in adolescents [14, 19, 30, 37]. Our participants reported that substances were widely available and easily accessible in their environment despite their illegality. In addition, most teens knew where to easily obtain substances at lower prices. It is rational to suggest that, when more drugs are available in a given society, there is more probability that adolescents engage in drug use and other risky behaviors. Thus, minimizing the availability of substances by strengthening the security in school environments and imposing tougher laws to restrict substance delivery, especially among adolescents, may contribute to decreasing risky behaviors of adolescents.

At the societal level, we found that normalization of substance use, that is, integration of drugs into daily lives and drugs becoming tolerated by society, negatively affected risky behavior in adolescents. This finding was in line with other studies [30, 49]. In a study on how social norms influence adolescent substance use, descriptive norms (perceptions of what others do) were significantly associated with substance use in adolescents [50]. Thus, the widespread use of substances in young people (i.e., descriptive norms) may send a subtle message that this behavior is accepted and already expected and encourage other adolescents to engage socially in substance use [50]. On the other hand, our participants regarded strong religious beliefs as a protective factor against substance use in adolescents, although some mentioned that poor religious beliefs could also be a risk factor for substance use. This protective relationship between religiosity and health behavior, especially substance use, among adolescents has been well established in the literature [19, 42, 51]. The implementation of social norm interventions that attempt to modify perceptions of what behavior is normative could be a way to influence actual behavior. In addition, health interventions for adolescents should consider including religion outlets as a way to raise awareness of the risks associated with substance use.

Strengths and limitations

This study was conducted in two middle schools in an urban area of Morocco. However, our aim was not to generalize the findings; rather, our objective was to obtain a greater understanding of contextual risks and protective factors of substance use in adolescents. In addition, this first qualitative study in Morocco allowed us to better understand the different influencing factors on substance use in these adolescents. The large number of participants, the triangulation of participants, the theoretical framework, and the rigorous methodology applied allowed a more comprehensive overview.

Conclusions

Participants in this study recognized a number of perceived risks of and protective factors against substance use in adolescents. These results emphasize that effective prevention programs need to address multiple levels, from the individual to the societal, and should address the social norms and the government policies toward adolescent substance use. Furthermore, inclusion of intrapersonal factors, such as raising awareness about the harmful effects of drugs and building coping abilities and refusal skills in adolescents against risky behaviors, can result in a more favorable school-based prevention strategy. Finally, introducing health education as a school subject in the Moroccan Education Curriculum is a need for adolescents, which can serve as a way to enhance healthy behaviors in adolescents.

Abbreviations

FGDs:

Focus group discussions

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Acknowledgements

We are very grateful to all students who participated in the study. We also thank teachers/headmasters/principals of the participating schools for their support in the implementation of this project. Special thanks are due to Rasa G. Hamilton for her generous assistance with this publication. Our thanks also go to Azzam H. and her team for the workshops organized in Morocco on capacity building where this project has matured. We would also like to thank El Rhazi K. for the coordination of these workshops.

Funding

This study is supported by Moffitt Cancer Center under the NIH International Fogarty Center for the award number 5D43TW009804 (PI Anna Giuliano).

Availability of data and materials

The datasets underlying the results are not accessible to the public since the participants did not give their consent for the public sharing of their information. However, a summary of transcribed interviews is available from the corresponding author upon reasonable request. Discussion guides used in this study are also available upon request.

Author information

HE: conducted the study and wrote all drafts supported by YE and SE. HE, AE, SB and YE: are responsible for data collection and data analysis. YE and SE supervised the study and coordinated the research group. All authors participated in developing the overall study design. All authors were involved in drafting and finalizing the paper. All authors read and approved the final manuscript.

Correspondence to Hicham El Kazdouh.

Ethics declarations

Ethics approval and consent to participate

The study was approved by the Faculty of Medicine and Pharmacy of Casablanca Research Ethics Committee and the National Control Commission for the Protection of Personal Data (A-RS-193-2015). Written informed consent was obtained from all participants before study enrollment. For adolescent participants, written informed consent was obtained from their parents or legal guardians, with verbal consent from each adolescent participant. Participants were informed that they could withhold information. The names of participants were separated from the transcripts and field notes and kept in a private place where only the leading author had access. Only the principal investigators had access to the full tapes.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Keywords

  • Adolescents
  • Morocco
  • Qualitative study
  • School
  • Socio-ecological model
  • Substance use