Jordanian adolescents’ health behaviour and school climate

Abstract

Aim

This study was conducted to assess the occurrence of physical activity, nutritional habits, tooth brushing and seat belt use behaviour among adolescent school students in Jordan, and to examine the effect of psychosocial aspects of school on these behaviours.

Method

A cross-sectional descriptive correlational design was used to draw a sample of in-school adolescents aged between 11 and 15 years. The final sample included 1166 adolescents from five public and two private schools. Study participants filled in a translated version of the health behaviour in school aged children questionnaire. Descriptive statistics, correlational (point biserial), and bivariate analyses (chi-square tests) were used to analyse the data.

Results

Among the study sample 34.5% of the adolescents practised exercise outside school hours once a week or less frequently, and only 53.1% of them brushed their teeth more than once a day. Regarding seat belt use, 44.7% of the adolescents used them rarely or never. Concerning carbonated sugary drinks and sweets consumption, about 64% and 83.3% of the adolescents, respectively, consumed them once a day or more often. The percentages of adolescents who never drank low fat or whole fat milk were 43.1% and 38.2%, respectively.

Conclusions

The study concluded that school adolescents do engage in unhealthy behaviour. Psychosocial aspect of schools were associated with students’ physical activity, nutritional habits, tooth brushing and seat belt use behaviours.

Introduction

Adolescents (aged 10–19 years) constitute 1.2 billion of the world's population; about 90% of those adolescents live in low and middle-income countries. Promoting healthy practices during adolescence is considered an investment in countries’ future health and social infrastructure. Many risk or protective factors for future adult disease either start or are reinforced during this critical period of life (World Health Organization, 2015a).

Insufficient physical activity is one of the 10 leading risk factors for death worldwide and a key risk factor for non-communicable diseases such as cardiovascular diseases and diabetes. More than 80% of the world’s adolescent population is insufficiently physically active (World Health Organization, 2015b). The recommended physical activity guidelines for adolescents are 60 minutes of moderate to vigorous physical activity daily. According to World Health Organization (WHO) survey data, less than one in every four adolescents meets these recommendations (World Health Organization, 2016a). According to the Centers for Disease Control and Prevention (CDC) Youth Risk Behavior Surveillance (YRBS) (2013) that was conducted in United States, only 27.1% of surveyed high school students had participated in at least 60 minutes per day of physical activity on all 7 days before the survey, and 15.2% of high school students had not participated in 60 or more minutes of any kind of physical activity on any day during the 7 days before the survey. In the same survey, participation in physical activity was determined by age. Also, there was a gender difference as girls participated in physical activity 24% less than boys 34.9% (Kann et al., 2014). In a report that described physical activity levels worldwide with data for adolescents (13–15 years old) from 105 countries, the proportion of adolescents doing fewer than 60 minutes of physical activity of moderate to vigorous intensity per day is 80.3%; boys were more active than girls (Hallal et al., 2012). A study conducted in Saudi Arabia revealed that almost half of the boys (1401) and three-quarters of the girls (1507) who participated in this study did not meet daily physical activity guidelines (Al-Hazzaa et al., 2011). A Jordanian study that investigated factors contributing to adolescents’ obesity revealed that decreased physical activity, increased intake of high caloric food, alongside a school and a home environment that discourages a healthy lifestyle were factors contributing to obesity among adolescents in Jordan (Al-Kloub and Froelicher, 2009). Other Jordanian studies that included university students showed that among those students physical activity has the lowest frequency among the measured health promoting behaviour (Nassar and Shaheen, 2014; Shaheen et al., 2015). Another study that included school adolescents in the north of Jordan revealed that 52.5% of adolescents did exercise three to six times weekly, while 24.7% exercised once a week or less, and 48.5% reported that they were physically active. The same study showed that boys were more active than girls in the amount of weekly exercise (Haddad et al., 2009). In the same way, a Jordanian study which investigated health risk behaviour in Jordanian adolescents aged 15–19 years also found that one-fifth of students had been physically active at least 60 minutes daily (Malak, 2015).

Healthy eating habits during adolescence are essential for good health. However, many adolescents in developing countries are undernourished. Moreover, adolescents who are obese or overweight are increasing in both low and high-income countries (World Health Organization, 2016a). Also, unhealthy eating habits in adolescents is associated with iron deficiency anaemia, which is considered the third cause of death and disability for this group (Washi and Ageib, 2010; World Health Organization, 2016a). Fruit and vegetables are a very important aspect of adolescents’ diet because they are considered a source of dietary fibre, vitamins, minerals and phytochemicals. Fibre intake is linked to a lower incidence of cardiovascular disease and obesity, and phytochemicals function as antioxidants, phytoestrogens, anti-inflammatory agents and other protective mechanisms. According to current recommendations, at least five daily servings of fruit and vegetables are recommended (Slavin and Lloyd, 2012). On the other hand, the consumption of sweets regularly is responsible for a high prevalence of obesity and its related problems in the population (Hu, 2013).

Previous Jordanian studies that examined the nutritional habits of Jordanian adolescents revealed that they consumed less than the daily requirements of fruits, vegetables, milk and meat, while the intake of fast food, carbonated sugary drinks and sweets were higher than recommended (Haddad et al., 2009; Malak, 2015). In a cross-sectional study that aimed to estimate the frequency of being overweight and obesity in Jordanian adolescents aged 15 or 16 years and the effect of eating habits and physical activity on obesity, 17.5% of study adolescents were overweight and 9.6% were obese. In addition, eating a low quality diet (i.e. chips and sweets) was a significant dietary predictor of excess weight (Manal Ibrahim et al., 2010).

In a different scenario, road traffic injuries are the leading cause of death among the young population aged 15–29 years. The majority of those deaths occur in low and middle-income countries. Road traffic accidents could result in non-fatal injuries which may end with disability. According to 2010 statistics, road traffic accidents cost countries about 3% of their gross national product. Young people and men are more prone to road accidents than their older and female counterparts. It was reported that seat belt use reduces the risk of fatality by 40–50% among front seat passengers and by 25–75% among rear seat passengers (World Health Organization, 2016b). Jordan is one of the top countries in the world in terms of having higher numbers of road traffic accidents which lead to a relatively high number of injuries and fatalities (Al-Khateeb, 2010).

Tooth brushing is considered an important behaviour for maintaining oral health (Wiegand and Schlueter, 2014). Frequent tooth brushing is associated with a lower incidence of dental caries, teeth missing and filled teeth (Pakpour et al., 2011). Studies that examined adolescents’ tooth brushing behaviour revealed that they have poor oral hygiene (Pakpour et al., 2011). A cross-sectional study was conducted among adolescents aged less than 15 years in Jordan and revealed that among male and female respondents 23.1% and 11.7%, respectively, did not brush their teeth in the past month (Emmanuel Rudatsikira and Muula, 2011).

Schools are the place where adolescents spend a substantial part of their lives. While schools are responsible for direct teaching of academic skills, they also provide opportunities for relational, emotional and behavioural development. Schools can play an important role in enhancing the health status of adolescents, because many personality characteristics and aspects of health and risk behaviours are formulated during these years (Faour, 2012; Gautam and Punia, 2012; Hockenberry et al., 2012; Kumari, 2012).

The psychosocial climate at school is an important protective factor against many health risk behaviours. Students who feel connected to their schools are more prone to engage in healthy behaviour and to succeed academically (Ahmad, 2012; Dehuff, 2013; Voight et al., 2011; Wang and Dishion, 2012). Teacher support and peer relationships are part of the psychosocial climate at school. Teacher support at school through showing interest, attention and emotional support increases students’ feelings of connectedness. Being a part of a positive peer group encourages students to be involved in school activities, increases their sense of connectedness to school, achievement levels and engagement in health behaviours (Dehuff, 2013; Wang and Dishion, 2012). The psychosocial environment at school is also influenced by policies related to discipline, opportunities for meaningful student participation and teachers’ classroom management practices. A positive school environment is characterised as one that prevents a punitive discipline climate, provides caring and supportive interpersonal relationships, provides opportunities to participate in school activities and decision making, and has shared positive norms, goals and values (Ashley et al., 2012).

Schools play a crucial role in improving the dietary, tooth brushing, seat belt use and physical activity behaviours by creating a supportive environment for students through implementing policies that support healthy eating, regular tooth brushing, seat belt use and physical activity behaviours. Schools can provide opportunities for adolescents to learn about and practice these behaviours (Al-Kloub and Froelicher, 2009; Centers for Disease Control and Prevention, 2015; Morton et al., 2016; Shenoy and Sequeira, 2010).

Little research has been conducted on adolescent health behaviour in Jordan. Therefore, and based on the previous discussed literature, we selected physical activity, nutritional intake, tooth brushing and seat belt use, as they have high impact on adolescent health. Furthermore, this study will investigate the utilisation of these behaviours among adolescent populations and the influence of the school environment on these behaviours. This may increase our knowledge about adolescent health behaviour and the role of schools in enhancing healthy behaviour of this population. Identifying the occurrence of adolescent health behaviours and their relationship with the school environment will provide vital information for healthcare professionals to develop school-based health behaviour intervention programmes, evaluate the effectiveness of health education in the school curriculum, and identify areas that need further attention.

Methods

Sample and sampling

The target population for the study included in-school adolescents aged between 11 and 15 years. A multi-stage cluster sampling design was used to draw the study sample. In Jordan, schools have two major sectors, private and public (Ministry of Education, 2010b). At the first level, the researchers randomly selected directorates that represent private and public education sectors. At the second level, researchers randomly selected schools from the list of schools that are available online from the Ministry of Education (Ministry of Education, 2010a). Finally, within each selected school the researcher chose a class from each of the 6th to 10th grades randomly. The inclusion criteria were: in-school adolescents aged 11–15 years, adolescents who agreed to participate and had their parents’ consent to their participation. The exclusion criteria were: any adolescent who was under 11 or above 15 years of age, who refused to participate or his parents did not consent, and who was absent on the survey day. The sample size was calculated based on the target population using confidence intervals of plus or minus three, a confidence level of 95%, the resulting sample size was 1052 students. An additional 10% were added to the sample for any possible missing data (Polit and Beck, 2010).

Ethical considerations

Ethical approval was obtained from the ethics committee at the university where the researcher works and the Ministry of Education Ethical Committee. The informed consent of the parents or legal guardians was obtained prior to data collection. This form stated the purpose of the study, clearly identified that participation in the study was voluntary and that students had the right to withdraw from the study at any time. Also, because students in this study were mature enough to understand basic information, a written consent was obtained from the students as well.

Procedure

Researchers obtained individual school consent for each selected school from the school principal and teachers to ensure their willingness to participate in the study. Data were collected through a self-administered questionnaire. Administration of the questionnaire took place in the school classroom and was filled in within the class period for all selected classes on the same day. Students returned the filled in questionnaires in a sealed envelope.

Measures

The international standard version of the Health Behavior in School Aged Children (HBSC) questionnaire was used in this study. Several research studies were conducted to test the reliability and validity of the HBSC questionnaire, and this tool was found to be reliable and valid (Currie et al., 2008; Liu et al., 2010).

A committee of experts in community and child health nursing translated the questionnaire into Arabic, performed back translation and validated its content, and checked its appropriateness to Jordanian culture. The questions were restricted to the selected variables in the study. The questionnaire was piloted for format, procedure and time using 100 students who were excluded from the final analysis of this study.

Demographic data

Sample characteristics including adolescents’ gender, age and school type were collected using the HBSC demographic data sheet.

Perceived school climate

Adolescents’ perception of the school climate was measured using the Perceived School Climate subscale of the HBSC questionnaire. This subscale is a Likert-type scale from strongly agree to strongly disagree that is composed of five items including ‘in our school the students take part in making rules’, ‘the rules in this school are fair’, ‘our school is a nice place to be’, ‘I belong to this school’ and ‘I feel safe at this school’. Scores on this scale range from 5 to 25. Higher scores indicated a more positive perception of the school climate.

Teacher support

Adolescents’ perception of teacher support was measured by the Teacher Support subscale of the HSBC questionnaire. This subscale is a Likert-type scale from strongly agree to strongly disagree that is composed of four items including ‘I am encouraged to express my own views in my class’, ‘our teachers treat us fairly’, ‘when I need extra help I can get it’ and ‘my teachers are interested in me as a person’. Scores of this subscale range from 4 to 20.

Peer support

Adolescents’ perception of peer support was measured by the Peer Support subscale of the HSBC questionnaire. This subscale is a Likert-type scale from strongly agree to strongly disagree composed of three items including ‘the students at my class enjoy being together’, ‘most of the students in my class are kind and helpful’ and ‘the students accepted me as I am’, and the scores range from 3 to 15.

In the current study, Cronbach alpha reliability for the school climate subscale, peer support subscale and teacher support subscale was 0.69, 0.80 and 0.73, respectively.

Physical activity

The frequency of physical activity was measured using the question: outside school hours how often do you usually exercise in your free time so much that you get out of breath or sweat? Responses were: 1 = every day, 2 = 4 to 6 times a week, 3 = 2 to 3 times a week, 4 = once a week, 5 = once a month, 6 = less than once a month, 7 = never. Physical activity duration was measured using the question: outside school hours how many hours a week do you usually exercise in your free time so much that you get out of breath or sweat? Responses were: 1 = none, 2 = about half an hour, 3 = about 1 hour, 4 = about 2 to 3 hours, 5 = about 4 to 6 hours, 6 = 7 hours or more. Physical activity was dichotomised as those who outside of school hours usually exercised in their free time so much that they got out of breath or sweated for one hour or less per week or those who exercised more frequently.

Tooth brushing

Tooth brushing behaviour was measured using a single question: how often do you brush your teeth? Responses were: 1 = more than once a day, 2 = once a day, 3 = at least once a week but not daily, 4 = less than once a week, 5 = never. Tooth brushing was dichotomised as those who brush their teeth less than daily or those who brush their teeth once a day or more often.

Nutritional intake

Nutritional intake was measured using the question: how often do you drink or eat any of the following? Fruit, raw vegetables, cooked vegetables, brown bread, whole milk, and skimmed and semi-skimmed milk, carbonated sugary drinks, sweets, potato crisps, chips, hamburgers or hot dogs, and coffee. Responses were: never, rarely, at least once a week, but not every day, once a day, more than once a day. The healthy food intake was measured through the question: how often do you drink or eat any of the following? Fruit, raw vegetables, cooked vegetables, brown bread, whole milk, and skimmed and semi-skimmed milk. Responses were: never = 1, rarely = 2, at least once a week, but not every day = 3, once a day = 4, more than once a day = 5. The junk food intake was measured through the question: how often do you drink or eat any of the following? Carbonated sugary drinks, sweets, potato crisps, chips, hamburgers or hot dogs, and coffee. Responses were: 5 = never, 4 = rarely, 3 = at least once a week, but not every day, 2 = once a day, 1 = more than once a day. A total score was calculated for the healthy and junk intake ranging from 12 to 60, with a cut point of 26 based on the 60th percentile. Students who scored above 26 were considered part of the healthy food intake group, while students who scored below 26 were considered part of the unhealthy food intake group.

Seat belt use

Seat belt use was measured using the question: how often do you use a seat belt when you sit in a car? Responses were: always, often, sometimes, rarely or never, usually there is no seat belt where I sit, never travel by car. Car seat belt use was dichotomised as those who do not always use a seat belt when seated in a car or those who always do so.

Data analysis

Data were analysed using IBM SPSS version 17. Frequencies and percentages were calculated to describe sample characteristics including gender and educational sector and to describe adolescents’ behaviour, including physical activity frequency and duration, tooth brushing, seat belt use and nutritional habits. Mean and standard deviations were used to describe adolescents’ age. Correlational analysis (point biserial) was used to explore the relationships between psychosocial school climate and adolescents’ behaviour. Bivariate analyses were conducted using chi-square tests of significance to detect differences in the occurrence of behaviours in relation to selected variables including age and gender. Differences were considered statistically significant if the P value was less than 0.05.

Results

Sample characteristics

The final sample included 1166 adolescents. The study sample included 614 girls (52.7%) and 552 boys (47.3%). The majority of adolescents were from the public education sector (60.7%). Twenty questionnaires (1.7%) were incomplete and were excluded from the final analysis. The mean age of the sample was 13.0 years (SD 1.2).

The frequency of selected behaviour among participating adolescents

Table 1 describes the frequencies and percentages of physical activity, tooth brushing, seat belt use and nutritional behaviour. Among the study sample, 34.5% of adolescents practised exercise outside school hours once a week or less frequently. The duration of exercise was less than one hour for 64.2% of adolescents. Only 53.1% of the adolescents brushed their teeth more than once a day, while almost 10% brushed their teeth once a week or less and 5.1% never brushed their teeth. Regarding seat belt use, 44.7% of the adolescents used a seat belt rarely or never. About 64% of the adolescents drank cola or other carbonated sugary drinks once a day or more often. The majority of them (83.3%) consumed sweets once a day or more often. The percentages of adolescents who never drank low fat or whole fat milk was 43.1% and 38.2%, respectively.

Table 1.

Frequencies and percentages of selected behaviours among participating adolescents (N = 1166).

Adolescents’ behaviours
Physical activity (frequency)	Every day	4 to 6 Times a week	2 to 3 Times a week	Once a week	Once a month	Less than once a month	Never
	370 (31.7%)	145 (12.4%)	249 (21.4%)	204 (17.5%)	65 (5.6%)	57 (4.9%)	76 (6.5%)
Physical activity (duration)	None	About half an hour	About 1 hour	About 2 to 3 hours	About 4 to 6 hours	7 Hours or more
	139 (11.9%)	298 (25.6%)	311 (26.7%)	246 (21.1%)	84 (7.2%)	88 (7.5%)
Tooth brushing	More than once a day	Once a day	At least once a week but not daily	Less than once a week	Never
	619 (53.1%)	373 (32%)	75 (6.4%)	39 (3.3%)	60 (5.1%)
Seat belt use	Always	Often	Sometimes	Rarely or never	Usually there is no seat belt where I sit	Never travel by car
	165 (14.2%)	166 (14.2%)	218 (18.7%)	521 (44.7%)	53 (4.5%)	43 (3.7%)
Nutritional habits	More than once a day	Once a day	Once a week	Rarely	Never
Eat fruit	379 (32.5%)	601 (51.5%)	106 (9.1%)	51 (4.4%)	29 (2.5%)
Eat raw vegetables	317 (27.2%)	647 955.5%)	101 (8.7%)	66 (5.7%)	35 (3%)
Eat cooked vegetables	162 (13.9%)	601 (51.5%)	172 (14.8%)	111 (9.5%)	120 (10.3%)
Drink coke or other carbonated sugary drinks	287 (26.6%)	463 (39.7%)	161 (13.8%)	163 (14%)	92 (7.9%)
Eat sweets (candy or chocolate)	408 (35%)	563 (48.3%)	105 99%)	70 (6%)	20 (1.7%)
Eat cakes or pastries	268 (23%)	596 (51.1%)	172 (14.8%)	106 (9.1%)	24 (2.1%)
Eat potato crisps	248 (21.3%)	584 (50.1%)	209 (17.9%)	100 (8.6%)	25 (2.1%)
Eat chips/fried potatoes	357 (30.6%)	582 (49.9%)	88 (7.5%)	95 (8.1%)	44 (3.8%)
Eat hamburgers, hot dogs, sausages	102 (8.7%)	305 (26.2%)	347 (29.8%)	326 (28%)	86 (7.4%)
Eat whole wheat or rye bread	591 (50.7%)	409 (35.1%)	52 (4.5%)	56 (4.8%)	58 (5%)
Drink low fat milk	120 (10.3%)	273 (23.4%)	108 (9.3%)	162 (13.9%)	503 (43.1%)
Drink whole  fat milk	155 (13.3%)	299 (25.6%)	103 (8.8%)	164 (14.1%)	445 (38.5%)
Drink coffee	84 (7.25)	144 (12.3%)	87 (7.5%)	100 (8.6%)	751 (64.4%)

Psychosocial school climate subscales and adolescent health behaviour

The correlation between school climate subscale and tooth brushing behaviour was statistically significant (rpb (1164) = 0.08, P = 0.006). A negative perception of school climate was associated with unhealthy tooth brushing behaviour (see Table 2). School climate subscale correlations with physical activity, seat belt use and nutritional intake behaviours were statistically not significant. The teacher support subscale was significantly correlated with physical activity (rpb (1164) = 0.08, P = 0.004) and tooth brushing behaviour (rpb (1164) = 0.077, P = 0.008). A lower perception of teacher support was associated with unhealthy physical activity and tooth brushing behaviour. The peer support subscale was significantly associated with tooth brushing behavior (rpb (1164) = 0.08, P = 0.006). A lower perception of peer support was associated with unhealthy tooth brushing. The correlations between the peer support subscale and nutritional intake, physical activity and seat belt use behaviours were statistically not significant.

Table 2.

Correlations between psychosocial school climate subscales and adolescents’ health behaviour (N = 1166).

Scale		Physical activity	Seat belt use	Tooth brushing	Nutritional intake
School climate subscale	r	0.005	0.044	0.08	0.026
	P	0.855	0.136	0.006*	0.377
Teacher support subscale	r	0.08	0.045	0.077	0.029
	P	0.004*	0.122	0.008*	0.315
Peer support subscale	r	0.021	–0.023	0.08	0.039
	P	0.476	0.393	0.006*	0.188

^*Significant correlation P < 0.05.

Differences in adolescents’ behaviour in relation to selected factors

A chi-square test of goodness of fit was performed to determine whether the healthy and unhealthy groups of adolescents’ behaviours were equal by gender (see Table 3). A higher proportion of girls consumed an unhealthy nutritional intake (73.6%) and practised exercise less frequently than boys (79%). However, a higher proportion of girls practised tooth brushing more frequently than boys (59.3%). Differences in seat belt use behaviour in relation to gender were not statistically significant.

Table 4.

Results of chi-square test and descriptive statistics for selected adolescents’ behaviours by age.

Adolescents’ behaviour groups	11 Years	12 Years	13 Years	14 Years	15 Years	χ2 (df)
Healthy seat belt use group	48 (28.4%)	24 (11.2%)	39 (13.1%)	42 (11.5%)	12 (9.9%)	33.9 (4)
Unhealthy seat belt use group	121 (71.6%)	190 (88.8%)	258 (86.9%)	323 (88.5 %)	109 (90.1%)
Healthy tooth brushing group	106 (62.7%)	111 (51.9%)	161 (54.2%)	194 (953.2%)	47 (38.8%)	16.4(4)
Unhealthy tooth brushing group	63 (37.3%)	103 (48.1%)	136 (45.8%)	171 (46.8%)	74 (61.2%)

Numbers in parentheses indicate column percentages for behaviour groups.

^*P < 0.001.

Table 3.

Results of chi-square test and descriptive statistics for selected adolescents’ behaviours by gender.

Adolescents’ behaviour groups	Boys	Girls	χ2 (df)
Healthy physical activity group	289 (52.4%)	129 (21%)	1.24 (1)
Unhealthy physical activity group	263 (47.6%)	485 (79%)
Healthy tooth brushing group	255 (46.2%)	364 (59.3%)	19.9 (1)
Unhealthy tooth brushing group	297 (53.8%)	250 (40.7%)
Healthy nutritional intake group	223 (40.4%)	162 (26.4%)	25.8 (1)
Unhealthy nutritional intake group	329 (59.9%)	452 (73.6%)

Numbers in parentheses indicate column percentages for behaviour groups.

^*P < 0.001.

The chi-square test results indicate that seat belt use and tooth brushing behaviours appear to be statistically associated with adolescents’ age; older adolescents tend to brush their teeth and use seat belts less frequently than younger adolescents. The results show no statistically significant difference in physical activity and nutritional intake behaviours by age.

Discussion

This study investigated the frequency of physical activity, nutritional habits, tooth brushing and seat belt use behaviours among adolescent school students, and examined the association of the psychosocial school climate on these behaviours.

The current study revealed that approximately half of the adolescents brushed their teeth more than once daily. This finding is consistent with previous national data, in which Haddad et al. (2009) reported that 52.8% of the adolescents in their study brushed their teeth once a day. Comparatively lower rates of tooth brushing were reported by a study by Emmanuel Rudatsikira and Muula (2011).

As the current study showed that the majority of adolescents had high consumption rates of cola, carbonated sugary drinks and sweets, this means that the frequency of tooth brushing behaviour is not enough to maintain their oral health (Ayo-Yusuf and Booyens, 2011). This calls for more emphasis on encouraging students to brush their teeth more frequently.

In the current study, girls tended to brush their teeth more than boys and this was consistent with previous findings by Emmanuel Rudatsikira and Muula (2011) and Dorri et al. (2010). The high proportion of girls who brushed their teeth compared to boys can be explained by the fact that girls consider teeth as part of their aesthetic appearance. Girls may be more concerned about their beauty than boys and this reason may motivate them to engage in this behaviour. Girls think that they could benefit from engagement in healthy tooth brushing behaviour by maintaining their beautiful looks (Ayo-Yusuf and Booyens, 2011).

The current study also found that there is a decrease in tooth brushing behaviour by age. Parental influence decreases as adolescents move towards adulthood, and this may explain why the frequency of tooth brushing decreases with age (Machida et al., 2008).

A positive perception of the school climate was associated with healthy tooth brushing behaviour. A positive perception of the psychosocial school climate indicates that students are connected and belong to their schools, and this motivates them to participate in school activities and programmes and to engage in healthy behaviour (Ahmad, 2012; Dehuff, 2013; Voight et al., 2011; Wang and Dishion, 2012). Health education about tooth brushing at schools is effective in improving oral health knowledge, practices and oral hygiene status. School policies and education could enhance learning about and practising tooth brushing (Shenoy and Sequeira, 2010). Peer support at school was also associated with healthy tooth brushing. In the same way, it was reported previously that peers’ engagement in healthy tooth brushing behaviour could encourage the adolescent to be engaged in this behaviour too (Dorri et al., 2010). Furthermore, the adolescent could exhibit this behaviour out of competition with his peers. Interpersonal influences by peers through modeling the behaviour will increase the probability of adolescent engagement in the behaviour. Teacher support at school was also associated with healthy tooth brushing behaviour. Teachers could enhance students’ tooth brushing behaviour by modeling it and providing the students with positive reinforcement when they perform it (Ramroop et al., 2011).

In general, two thirds of adolescents in the current study reported that they exercised one hour or less per week outside school hours. This means that the majority of adolescents in this study reported insufficient physical activity. This result is consistent with previous Jordanian studies. For example, Haddad et al. (2009) reported that 66.4% of their sample did not meet the criteria of a minimum of 20 minutes of exercise six or more times a week. Also, one study that was conducted in Saudi Arabia revealed that almost half of the boys and three quarters of the girls did not meet daily physical activity guidelines (Al-Hazzaa et al., 2011). Similarly, the findings of the YRBS of the CDC showed that only 72.9% of high school students surveyed had participated in at least 60 minutes per day of physical activity (Kann et al., 2014).

The insufficient physical activity can be explained by the lack of facilities to exercise outside schools (El-Gilany et al., 2011). Although many public centres and schools provide playgrounds for the public, they only provide a space without equipment or organisation of the activities. Jordan, as with many of the developing countries, cannot allocate enough money to build public facilities (Bauman et al., 2012). This highlights the role of civic organisations in providing financial support for the initiation of such facilities that provides opportunities for adolescents to enjoy their time and promote their health.

Boys in the current study exercised outside school hours more frequently than girls. This result is consistent with previous research findings, which revealed that boys are more physically active than girls (Al-Hazzaa et al., 2011; Hallal et al., 2012; Kann et al., 2014). The lack of girls’ physical activity could be a cultural issue, because the playing of sports by girls is not as culturally acceptable as their male counterparts. Girls have more family responsibilities and do not have as much time to participate in sports as boys. Moreover, boys’ willingness to be strong to satisfy their masculine body image and to protect themselves could be another reason that motivates boys to be physically more active (Slater and Tiggemann, 2010).

Adolescents who perceive their teachers as supportive were more likely to engage in healthy physical activity. A good student–teacher relationship could lead to students’ involvement in healthy behaviours by teachers’ encouragement and positive reinforcement of student engagement in the healthy behaviour (Eather et al., 2013).

Despite the rules and regulations of seat belt use and its known benefits, only one third of the current study sample used seat belts always and often when traveling by car. The lower rates of seat belt use may be because adolescents are not convinced of the safety benefits of seat belt use or are not concerned with avoiding risk. Parents and peers could provide another explanation for these results. Those adolescents may lack the role-models of regular seat belt use or lack the social pressure to use seat belts. Parents play an influential role in enhancing this behaviour, starting from infancy through childhood and adolescence (Ginsburg et al., 2009). There was a statistically significant difference in seat belt use behaviour in relation to age. Adolescents at a higher age tended not to use seat belts when travelling when compared with adolescents in lower age groups. Similar results were found in an earlier study (Briggs et al., 2008).

Insufficient consumption of fruits, vegetables and milk was noticed among this study sample, while the intake of fast food, carbonated sugary drinks and sweets was higher than recommended. The results were comparable to previous research about the nutritional habits of Jordanian adolescents (Haddad et al., 2009). Another Saudian study indicated that the majority of adolescents did not have a daily intake of fruits, vegetables and milk (Al-Hazzaa et al., 2011). One study conducted among 239 adolescents (13–18 years old) in Jeddah revealed that 44.6% of the adolescents were overweight, and 56.6%, 30.5% and 13.0% of energy was derived from carbohydrates, fats and proteins, respectively (Washi and Ageib, 2010).

Among the study sample, there was a high consumption of carbonated sugary drinks and sweets and a low consumption of milk. This could be explained by the availability and accessibility of carbonated sugary drinks and sweets at schools, homes, shops and restaurants (Vereecken et al., 2010). Television commercials are another aspect that increases adolescents’ consumption of sweets and carbonated sugary drinks (Koordeman et al., 2010). The high consumption of carbonated sugary drinks accompanied by a low consumption of milk seriously affects the bone structure of adolescents and increases the risk of bone fractures (Nieves et al., 2010; Seifert et al., 2011). Also, the high consumption of sweets and carbonated sugary drinks along with insufficient physical activity increases the risk of obesity, which is considered a risk factor for many non-communicable diseases (Bray, 2010; Maersk et al., 2012). Moreover, a higher percentage of adolescents in the current study consumed whole fat milk more than low fat milk. Adolescents usually do not need the extra kilojoules they get if they carry on drinking full fat milk. This may increase the risk of obesity (Reedy and Krebs-Smith, 2010).

The Jordanian government started a school nutritional project in 1999 in an effort to provide a healthy breakfast for students at schools. However, the project includes only some schools in some areas of the kingdom, and the expansion in this project depends on financial support that is not available (Social and Industrial Food Service Institute, 2014). However, this project did not include all schools in the kingdom so raising awareness of students and their families through a supportive school environment that implements health education programmes might facilitate promoting healthy nutritional habits among students.

In the current study girls were more likely to consume an unhealthy intake of nutrition than boys. In the same way, the results of a study conducted in Saudi Arabia found that girls’ intake of French fries and potato chips, cakes and donuts and sweets and chocolate was also significantly higher than that of boys (Al-Hazzaa et al., 2011).

Conclusions

School adolescents reported attending insufficient levels of physical activity, insufficient consumption of fruits, vegetables, milk, and a high consumption of fast foods, carbonated sugary drinks and sweets, less than recommended tooth brushing frequency, and lower rates of using seat belts when traveling by car.

The psychosocial climate at school facilitated positive behaviours among adolescents. In addition, teacher support enhanced physical activities and tooth brushing among adolescents, and a positive perception of the school climate was associated with healthy tooth brushing behaviour. Also, peer support is another facilitating factor that enhanced tooth brushing among adolescents.

Study limitations

The limitation of this study is that data were collected through a self-administered questionnaire thus there is a risk of response biases. However, this was probably minimised by the fact that study participants completed the questionnaires anonymously.

Key points for policy, practice and/or research

• This study provides evidence about adolescents’ health behaviours. These results can be used to produce recommendations to policy makers, healthcare providers, particularly school nurses, teachers and parents to collaborate to enhance healthy behaviours among adolescents.

• The efforts from all these parties should be implemented via means of different approaches such as health education programmes, curricular integration at schools, and counselling/behavioural modification programmes.

• Strategies to reduce the marketing of unhealthy food products, to provide access to healthy foods, and to encourage physical activity at schools and in the community are important for all, but are especially recommended for adolescents.

• Modification of the school climate should be implemented in order to influence adolescents’ behaviour. Peer support could be utilised to improve healthy behaviours among adolescents through conducting joint health education and trainee programmes that are guided by school nurses and include both teachers and students to educate adolescents about healthy behaviours and their importance for their health.

• Finally, raising awareness about the importance of using seat belts among adolescents is warranted by school nurses, and parents of children and other adults should be role models for their children.

Biography

Omayyah Nassar obtained her undergraduate, master's and doctoral degrees from the School of Nursing at the University of Jordan. Currently, she is an assistant professor there and head of the child health nursing clinical section. She teaches on child and adolescent health on undergraduate and postgraduate programmes and has research interests in child and adolescent development, children's health and wellbeing, and health promotion.

Abeer Mohammed Shaheen is assistant professor at the University of Jordan. She has undergraduate, master's and doctoral degrees from the University of Jordan. She had several publications in the fields of health promotion, school health, adolescents' health. She is a member of the Sigma Theta Tau International organization for Nursing/Jordanian Chapter.

Samiha Jarrah is Vice President and Dean of the Faculty of Nursing at the Applied Science Private University in Jordan. Professor Jarrah is responsible for curriculum development and quality improvement projects. She has extensive consulting experiences with different national, regional and international organizations and NGOs. In 2015 she was given the award of distinguished Professor in Nursing, from the Scientific Society of Arab Nursing Faculties.

Mary Norton, a Kearny native, Felician College Associate Dean and Professor of Global Academic Initiatives, recently was named the recipient of the Nell J Watts Lifetime Achievement in Nursing Award by Sigma Theta Tau International (STTI), Honor Society of Nursing.

Inaam A Khalaf, PhD, RN, is a professor of nursing at the University of Jordan – where she teaches nursing research, nursing theory, nursing education and child health nursing in graduate and undergraduate programmes. Her research activity focusses on increasing understanding of nursing education, maternal health among families, and grief. She has published internationally from research funded through national and international grants.

Khaldoun Mohammad Hamdan is assistant professor at Al Ahliyya Amman University. He completed his doctoral and master's degrees at the University of Jordan and his undergraduate degree at Jordan University of Science and Technology. His main research interests are directed towards adult health, critical care, pain, and end-of-life care.

Authorship

We confirm that all listed authors meet the authorship criteria and that all authors are in agreement with the content of the manuscript.

Declaration of conflicting interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics

Ethical approval was obtained from the ethics committee at the university where the researcher works and the Ministry of Education Ethical Committee.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.