Life satisfaction, physical activity and quality of life associated with the health of school-age adolescents

sus ainabili y A icle Li e Sa is ac ion, Physical Ac i i y and Quali y o Li e Associa ed wi h he Heal h o School-Age Adolescen s JoséD. U chaga 1, Raquel M. Gue a a 2,* , An onio S. Cabaco 3and JoséE. Mo al-Ga cía2 1Facul y o Communica ion, Pon i ical Uni e si y o Salamanca, C/Compañía,5, 37002 Salamanca, Spain; [email p o ec ed] 2Facul y o Educa ion, Pon i ical Uni e si y o Salamanca, C/Compañía,5, 37002 Salamanca, Spain; [email p o ec ed] 3Facul y o Psychology, Pon i ical Uni e si y o Salamanca, C/Compañía,5, 37002 Salamanca, Spain; [email p o ec ed] *Co espondence: [email p o ec ed] Recei ed: 1 Sep embe 2020; Accep ed: 11 No embe 2020; Published: 14 No embe 2020   Abs ac : The main pu pose o his s udy is o unde s and he Quali y o Li e Associa ed wi h Heal h (QLAH) o a sample o school-age adolescen s, and he exis ing associa ions be ween he la e and o he a iables, such as amily li e sa is ac ion, pe sonal li e sa is ac ion (LS), iendships sa is ac ion, physical ac i i y wi h amily, iends and pe sonal physical ac i i y. The sample consis ed o 1226 Spanish school-age adolescen s (50.9% boys and 40.1% gi ls) wi h ages be ween 12 and 16 yea s old. Se e al scales ha we e ex ac ed om he in e na ional Heal h Beha iou in School-aged Child en (HBSC) 2016 s udy, sponso ed by he Wo ld Heal h O ganiza ion (WHO), we e used as wo king ins umen s in his piece o esea ch. SPSS (24.0) was he so wa e package used o pe o m he analyses o desc ip i e s a is ics, co ela ion and mul iple eg ession, whe eas AMOS (24.0) was used o s uc u al equa ions. The esul s e eal a s ong associa ion be ween he physical ac i i y (PA) s uden s unde ake (pe sonal, wi h hei amilies and iends) and li e sa is ac ion, amily li e sa is ac ion and sa is ac ion wi h he ela ionships wi h iends. Addi ionally, bo h cons uc s (physical ac i i y and sa is ac ion, unde s ood as an indica o o good heal h) can p edic he esponden s’ Quali y o Li e Associa ed wi h Heal h. The a iables (QLAH, LS and PA) a e in e ela ed, hus esul ing in majo p ac ical implica ions. Keywo ds: adolescence; li e sa is ac ion; heal hy habi s; amily; pee ela ionships; school 1. In oduc ion Adolescence is a pa icula ly ele an s age in he de elopmen o indi iduals, as i is du ing his ime ha iden i y is o med, he indi idual’s socialisa ion p ocess e ol es, wi h many o he habi s ha will accompany hem h oughou hei adul age also being acqui ed a his s age. In ecen decades, nume ous esea ch s udies ha e ocused on his s age as a majo de elopmen s age [ 1 – 5 ] and ha e highligh ed i as a key ime o he adop ion o heal hy li es yles, poin ing ou i s impo ance o building posi i e amily and social ela ionships ha ensu e he wellbeing o he indi idual [ 6 – 11 ]. Addi ionally, his is a key s age in he sense ha i is he ime when he li es yle o indi iduals begins o o m, po en ially a ec ing hei heal h du ing adul hood [12,13]. Heal h is b oadly unde s ood—in eg a ing he physical, men al and social dimensions o he adolescen — o depend on di e se ac o s, such as he en i onmen , human biology o he heal h sys em [ 1 – 5 ] de e mining hei u u e physical, men al and social wellbeing [ 14 ]. Compa a i e s udies unde aken in a ious coun ies main ain his iew [ 15 ] and allow o he design o p e en a i e policies, which ake in o accoun he ole o con ex ual (coun y) o pe sonal (age o gende ) a iables [16]. Sus ainabili y 2020,12, 9486; doi:10.3390/su12229486 www.mdpi.com/jou nal/sus ainabili y Sus ainabili y 2020,12, 9486 2 o 13 One o he g ea es bene i s o he adop ion and consolida ion o heal hy habi s as a mechanism o imp o e people’s heal h is he p ac ice o physical ac i i y (PA), which has a posi i e impac on he physical, physiological, psychological and social sphe es o li e [ 17 , 18 ]. Regula p ac ice o PA posi i ely con ibu es o he imp o emen o he physical condi ion (bo h he ca dio espi a o y unc ions and muscle s eng h). Vigo ous exe cise, o example, has been associa ed wi h a heal hy le el o ca dio espi a o y i ness [ 19 ]. Resea ch indica es ha PA is bene icial in educing he isk o ca dio ascula and me abolic disease, educing body a , imp o ing bone heal h and educing he symp oms o dep ession [ 18 , 19 ]. I also posi i ely a ec s men al heal h, as egula p ac ice o PA inc eases sel -es eem, c ea ing posi i i y in he indi idual who exe cises, whe eas a seden a y li es yle causes dep essi e moods and heal h issues [20]. The consolida ion o heal hy habi s, such as he habi ual p ac ice o PA is essen ial a all s ages o li e as i b ings people nume ous bene i s in he p e en ion o disease, he adop ion o o he heal hy habi s and as a ac o p o ec ing agains beha iou s ha pose a isk o heal h [ 21 , 22 ]. A ecen esea ch s udy [ 23 ] disco e ed ha he p ac ice o PA has associa ions wi h o he pa ame e s, such as he educ ion o oxic subs ance consump ion o he imp o emen o nu i ion [24]. In Spain, he da a ex ac ed om he Heal h Beha iou in School-aged Child en (HBSC) 2016 [ 25 ] s udy e eal ha 48.4% o adolescen s akes PA acco ding o he ecommenda ions o he Wo ld Heal h O ganiza ion (WHO) [ 26 ]. Addi ionally, he same s udy shows ha boys end o p ac ice mo e PA han gi ls and ha hei p ac ice dec eases wi h age in bo h cases [ 25 ]. Despi e he posi i e e ec s o an ac i e li e and he impo ance o p ac ising PA in childhood and adolescence being known o e e yone, only a mino i y o young people comply wi h he daily ecommenda ions o p ac icing mode a e o igo ous PA o 60 min [27–35]. School is no ed as being a undamen al en i y in he p omo ion o physical/spo s ac i i ies [ 36 ] and i is conside ed as a majo pilla in he es ablishmen o heal hy li e habi s in adolescence [ 37 , 38 ]. I is impo an o ake in o accoun he a io be ween physical educa ion lessons and ou -o -school ec ea ional ac i i ies [ 39 , 40 ] and he need o inc ease he p ac ice o physical/spo s ac i i ies ou side school du ing his pe iod o ime, as he amoun o PA aken in school does no seem o be su icien [ 41 ]. The amily can play a complemen a y ole o ha o school, as he simul aneous wo k in bo h en i onmen s makes i easie o p omo e ac i e and heal hy li e habi s and o c ea e a good mo i a ional g ound om he ea ly s ages o li e ha p o ides bene i s o adolescen s [ 42 , 43 ]. The in luence ha hose close o he adolescen can ha e is an impo an ac o in inc easing hei mo i a ion and hei in e es owa ds physically ac i e ac i i ies [ 43 ]. In line wi h his, ecen esea ch e eals ha he p ac ice o PA wi hin he amily p omo es PA in adolescence [ 44 – 51 ]. The p ac ice o PA by iends also seems o impac on he pe sonal p ac ice o PA [50–53]. In e ms o men al heal h, li e a u e shows ha he li e sa is ac ion (LS) adolescen s epo o ha e is closely linked o hei wellbeing, wi h his being a subjec i e indica o [ 54 ] a ising om he compa ison be ween hei pe sonal ci cums ances and wha hey belie e o be an adequa e li e s anda d [ 55 ], which also has majo implica ions in he psychological, social and educa ional unc ioning o hese indi iduals [56–60]. Nume ous esea ch s udies p o e ha adolescen s’ sa is ac ion wi h li e is especially ela ed o he expe iences he indi iduals ha e wi h hei amilies [ 8 , 61 ], which is he main sou ce o suppo p o iding wellbeing o he indi iduals, oge he wi h hei iends [ 62 – 65 ]. O he au ho s [ 10 ], con i m a high le el o amily ha mony as being c ucial o he de elopmen o an adolescen . Aspec s such as school sa is ac ion, heal h, money and wo k a e also ela ed o he le el o li e sa is ac ion in adolescen s, whe e hei ela ionships wi h iends a e an impo an ac o o hei psychological de elopmen [66,67]. Addi ionally, se e al pape s ake bo h aspec s in o accoun , i.e., PA and LS, and s a e ha he e is a close associa ion be ween hem. These s udies ha e ound ha people whose li e habi s include PA ha e a be e pe cep ion o hei heal h and LS le els [ 68 – 71 ]. Since he 80s, he assessmen o Quali y o Li e Associa ed wi h Heal h (QLAH) has acqui ed ce ain impo ance in esea ch as a Sus ainabili y 2020,12, 9486 3 o 13 measu emen o heal h, being unde s ood as a alid cons uc o he assessmen o adolescen s’ heal h [ 72 ]. This mul idimensional cons uc includes he subjec i e assessmen o social, physical and cogni i e unc ioning, mobili y, pe sonal ca e and emo ional wellbeing [ 73 ]. In he same way, physical condi ion associa ed wi h heal h (PFH) is deemed o be one o he ac o s de e mining Quali y o Li e Associa ed wi h Heal h (QLAH) [74,75]. Ano he impo an ac o o ake in o accoun is he measu ing ins umen s employed in his esea ch, as a a ie y o scales ha e been used o assess he cons uc “quali y o li e in adolescen s”. In he las i y yea s, he mos commonly used ins umen o da a aken om o e hal a million adolescen s in e iewed in Ame ica and Eu ope, was PedsQl [ 76 ], in si ua ions associa ed wi h pa hologies, whe eas KIDSCREEN [ 77 ] was used o heal hy adolescen s. The e a e also ques ionnai es on he quali y o li e o adolescen s [ 78 ], which a e speci ic o s udies associa ed wi h hei ca e s o o help assess he e iciency o s uden p og ams such as CHQ [79]. Al hough quali y o li e, heal h and p ac ice o PA ha e been analysed in p e ious s udies, he e a e no enough s udies dealing wi h he connec ion be ween all hese a iables in school-age adolescen s. The e is a need o analyse he ela ionships be ween he physical, men al and social heal h o adolescen s in o de o ind ou he deg ee o which he ac o s unde s udy in hese h ee dimensions can p edic he heal h s a us o he adolescen (acco ding o hei Quali y o Li e Associa ed wi h Heal h). This esea ch in ends o unde s and he Quali y o Li e Associa ed wi h Heal h (QLAH) and he ela ionship exis ing be ween his and o he a iables, such as amily li e sa is ac ion, li e sa is ac ion, sa is ac ion wi h he ela ionships wi h iends, amily physical ac i i ies, iends’ physical ac i i ies and pe sonal physical ac i i y. The inno a i e aspec ha he in es iga ion con ibu es is he s udy o he a o emen ioned concep s as a whole, agains he o he mo e agmen ed o bila e al iews con ibu ed by p e ious esea ch s udies. 2. Ma e ials and Me hods 2.1. Design and Pa icipan s The sample was aken in he ci y o Salamanca, in Spain. A desc ip i e c oss-sec ional s udy was designed wi h he pa icipa ion o 16 schools selec ed by conglome a e s a i ied andom mul is age sampling, which p o ided a ep esen a ion o he 4 a eas o social ac ion o he ci y and he ypes o schools (s a e o semi-s a e). The o al sample consis ed o 1226 Spanish school-aged adolescen s (50.9% boys and 49.1% gi ls), en olled in he 2017/2018 school yea and dis ibu ed in o 2 academic le els: 1s yea o Obliga o y Seconda y Educa ion wi h 602 pa icipan s (331 boys and 271 gi ls; age: 12.9 ± 0.57 yea s old) and 4 h yea o Obliga o y Seconda y Educa ion wi h 624 pa icipan s (281 boys and 343 gi ls; age: 16.09 ±0.73 yea s old). The sample had a ma gin e o o 2% (p=q=0.5; con idence le el =95%). 2.2. Ins umen s A sociodemog aphic ques ionnai e and a ious speci ic scales, which we e alida ed o he s udy o he a ious cons uc s, we e used. All o hem a e also p esen in he HBSC s udy [ 25 ]. The ollowing a e he ins umen s employed: (a) Sociodemog aphic ques ionnai e in o de o de e mine sex (male and emale) and age in yea s. (b) In o de o measu e he le el o pe sonal li e sa is ac ion (PLS), Can il’s scale [ 80 ] was used, consis ing o only one-i em ques ion: “Gene ally speaking, wha do you eel you li e is like a p esen ?”. A scale o 0 o 10 was used o he answe op ions, whe e 0 means “The wo s li e possible” and 10 means “The bes li e possible”. (c) Family li e sa is ac ion (FLS) was measu ed by adap ing he Can il [ 80 ] scale and i consis ed o only one-i em ques ion: “Gene ally speaking, how sa is ied a e you wi h you amily ela ionships?”. A scale o 0 o 10 was used o he answe op ions, whe e 0 means “My amily does no ge on a all” and 10 means “My amily ge s on eally well”. Sus ainabili y 2020,12, 9486 4 o 13 (d) Sa is ac ion wi h he ela ionships wi h iends (SF) was measu ed using he ollowing ques ion: “I you we e o a e he ela ionship you ha e wi h you iends in gene al, wha sco e would you gi e i ?” A scale o 0 o 10 was used o he answe op ions, whe e 0 means “I ha e he wo s ela ionship possible wi h my iends” and 10 means “I ha e he bes ela ionship possible wi h my iends”. (e) PA was assessed by means o h ee speci ic i ems ex ac ed om he HBSC (2014) s udy ques ionnai e [ 81 ]: wo ques ions ela ing o amily, one ela ed wi h pe sonal physical ac i i y and one wi h he spo s ac i i ies unde aken by iends: Family: “How equen ly do you and you amily usually do one o he ollowing hings oge he ? Go ou o walks oge he (FPA-W); P ac ice spo s oge he ” (FPA-S). Bo h ques ions had 5 answe op ions: e e y day (5), mos days (4), app oxima ely once a week (3), less o en han once a week (2), ne e (1). Pe sonal physical ac i i y (PPA): “In he las 7 days, how many days we e you physically ac i e o a o al o a leas 60 min pe day? The answe op ions o e ed we e om 0 o 7 days. Spo s physical ac i i y unde aken by iends (PAF-S): “Mos people wi hin my g oups o iends p ac ice some spo s ac i i y wi h o he people”. Fou po en ial answe op ions we e p o ided (ne e , a ely, occasionally, o en). ( ) The QLAH was assessed using he Kidsc een-10 [ 77 ] package, which is a ool ha can alloca e a global index o emo ional wellbeing h ough 10 i ems which comp ise physical, psychological and social aspec s. The s uden s we e equi ed o answe whe he “in he las week” hey el well and i , ull o ene gy, sad, lonely, whe he hey had enough ime o hemsel es, managed o do he hings hey wan ed o do in hei leisu e ime, we e ea ed ai ly by hei pa en s, had a good ime wi h hei iends, hings wen well in school o high school, and whe he hey we e able o concen a e o pay a en ion. The sco e o each o he i ems wen om 1 o 5 (ne e , a ely, occasionally, almos always and always). 2.3. P ocedu e This esea ch s udy was de eloped in compliance wi h he e hical code o he Decla a ion o Helsinki, e ised in 2013, applicable o hese ypes o esea ch s udies, bu also adap ed o he Da a P o ec ion Ac (O ganic Law 15/1999) and unde he p emises o he Spanish cu en ly e ec i e laws on esea ch wi h human subjec s (Royal Dec ee 561/1993). The s udy p o ocol was app o ed by he E hics Commi ee o Resea ch wi h Human Subjec s o he Pon i ical Uni e si y o Salamanca. Be o e he da a we e collec ed, he school cen es we e app oached in o de o ob ain p io pe mission o he esponden s o pa icipa e in he s udy. Pa en al consen was also sough so ha hey could be pa o he esea ch by explaining o he adolescen s ha he da a would be p ocessed anonymously and olun a ily. Pa icipan s did no ob ain compensa ion o hei con ibu ions. In o de o p e en he esponden s’ answe s om being biased, a coding sys em was used o gua an ee anonymi y and con iden iali y o he esponden s a all imes. Ques ionnai es we e comple ed wi hin he no mal school hou s a he ime alloca ed o pe sonal u o ing suppo , by ained in e iewe s unde he supe ision o he main esea che . The s uden s answe ed he ques ionnai e in app oxima ely en minu es. The p ocedu e (Figu e 1) complied wi h he h ee basic equi emen s o he In e na ional Coo dina ing Cen e o he HBSC s udy: he s uden s answe ed he ques ionnai e by hemsel es; anonymi y o he answe s was assu ed and gua an eed and he ques ionnai es we e adminis e ed wi hin he school cen e. The inclusion c i e ia we e: olun a y s uden pa icipa ion and p o ision o pa en al o legal cus odian au ho isa ion. The exclusion c i e ia o his piece o esea ch we e: he p o ision o inapp op ia e o incomple e answe s o any o he i ems in he ques ionnai es, ailu e o p o ide pa en al o legal cus odian au ho isa ion, e idence o a pa hology ha could p e en he child om egula ly p ac icing PA du ing he ime o he s udy o in he 6 p e ious mon hs. Sus ainabili y 2020,12, 9486 5 o 13 Sus ainabili y 2020, 12, x FOR PEER REVIEW 5 o 14 Da a analysis was pe o med using he SPSS 24.0. and AMOS 24.0 so wa e packages. Desc ip i e s a is ics we e used in o de o unde s and he dis ibu ion; he Pea son co ela ion index was employed o he s udy o he bi a ia e ela ionships; and mul iple eg ession was used o he p edic ion o a iables QLAH, pe sonal li e sa is ac ion (PLS) and pe sonal physical ac i i y (PPA). The AMOS 24.0 so wa e package allowed o he s udy o he s uc u al equa ion modelling adjus men s using he Maximum Likelihood me hod. Figu e 1. Cha on he s ep-by-s ep p ocedu e o he su ey. 3. Resul s Ini ially, he p edic ed co ela ions we e p esen ed in he i e esea ch-speci ic objec i es and, subsequen ly, he esul o a model o s uc u al equa ions. 3.1. Co ela ion Analysis The co ela ions ob ained amongs he a iables being he objec o he s udy (Table 1) p o e o all be signi ican (p < 0.01), and o ollow he p edic ed pa e n. Table 1. Summa y o he in e -co ela ions and desc ip o s o sco es in QLAH, FLS, PLS, FS, FPA-W, FPA-S, PPA and PAF-S. QLAH FLS PLS FS FPA-S FPA-W PPA PAF-S FLS 0.496 *** PLS 0.585 *** 0.528 *** FS 0.322 *** 0.227 *** 0.329 *** FPA-S 0.267 *** 0.287 *** 0.257 *** 0.165 *** FPA-W 0.314 *** 0.361 *** 0.295 *** 0.086 ** 0.456 *** PPA 0.299 *** 0.136 *** 0.169 *** 0.182 *** 0.229 *** 0.090 ** PAF-S 0.209 *** 0.167 *** 0.108 *** 0.089 ** 0.160 *** 0.104 *** 0.211 *** M 37.9 8.30 7.79 8.83 2.10 2.62 4.38 2.60 SD 6.07 1.89 1.65 1.28 1.197 1.14 1.96 0.592 Skewness −0.48 −1.49 −0.92 −1.87 0.82 0.20 −0.22 −1.19 Ku osis 0.21 2.67 1.29 5.70 −0.37 −0.69 −0.89 0.41 No e: QLAH: Quali y o Li e Associa ed wi h Heal h; FLS: Family Li e Sa is ac ion; PLS: Pe sonal Li e Sa is ac ion; FS: F iendships Sa is ac ion; FPA-S: Family Physical Ac i i y: Spo s; FPA-W: Family Physical Figu e 1. Cha on he s ep-by-s ep p ocedu e o he su ey. 2.4. Da a Analysis Da a analysis was pe o med using he SPSS 24.0. and AMOS 24.0 so wa e packages. Desc ip i e s a is ics we e used in o de o unde s and he dis ibu ion; he Pea son co ela ion index was employed o he s udy o he bi a ia e ela ionships; and mul iple eg ession was used o he p edic ion o a iables QLAH, pe sonal li e sa is ac ion (PLS) and pe sonal physical ac i i y (PPA). The AMOS 24.0 so wa e package allowed o he s udy o he s uc u al equa ion modelling adjus men s using he Maximum Likelihood me hod. 3. Resul s Ini ially, he p edic ed co ela ions we e p esen ed in he i e esea ch-speci ic objec i es and, subsequen ly, he esul o a model o s uc u al equa ions. 3.1. Co ela ion Analysis The co ela ions ob ained amongs he a iables being he objec o he s udy (Table 1) p o e o all be signi ican (p<0.01), and o ollow he p edic ed pa e n. In he i s place, posi i e co ela ions ha e been iden i ied be ween he PA p ac iced wi h he amily, he PA p ac iced by he adolescen and he PA p ac iced by hei iends. The e a e e y signi ican co ela ions (p<0.001) be ween he pe sonal physical ac i i y (PPA) unde aken and bo h he spo s/physical ac i i y p ac iced wi h he amily (FPA-S) (0.229) and he spo s/physical ac i i y p ac iced by iends (PAF-S) (0.211). In line wi h expec a ions, in second place he e we e posi i e co ela ions be ween pe sonal li e sa is ac ion and amily li e sa is ac ion (0.528) as well as iendships sa is ac ion (0.329). The e is also a posi i e co ela ion be ween amily li e sa is ac ion (FLS) and iendships sa is ac ion (FS) (0.227). Family li e sa is ac ion (FLS) is posi i ely co ela ed wi h he p ac ice o amily physical ac i i y, whe he i is a spo s ac i i y (FPA-S) (0.287) o walks (FPA-W) (0.361). In ou h place, QLAH is con i med o be co ela ed wi h he a ious ypes o PA ( amily, pe sonal and iends’ ac i i ies), as well as LS (wi h he amily, wi h onesel and wi h iends). The closes co ela ions be ween QLAH and he le el o sa is ac ion a e ob ained wi h pe sonal li e sa is ac ion (PLS) (0.585) and amily li e sa is ac ion (FLS) (0.496). The closes co ela ions be ween QLAH and PA a e ob ained wi h amily spo s/physical ac i i y (FPA-S) (0.314) and pe sonal physical ac i i y (PPA) (0.299). Sus ainabili y 2020,12, 9486 6 o 13 Table 1. Summa y o he in e -co ela ions and desc ip o s o sco es in QLAH, FLS, PLS, FS, FPA-W, FPA-S, PPA and PAF-S. QLAH FLS PLS FS FPA-S FPA-W PPA PAF-S FLS 0.496 *** PLS 0.585 *** 0.528 *** FS 0.322 *** 0.227 *** 0.329 *** FPA-S 0.267 *** 0.287 *** 0.257 *** 0.165 *** FPA-W 0.314 *** 0.361 *** 0.295 *** 0.086 ** 0.456 *** PPA 0.299 *** 0.136 *** 0.169 *** 0.182 *** 0.229 *** 0.090 ** PAF-S 0.209 *** 0.167 *** 0.108 *** 0.089 ** 0.160 *** 0.104 *** 0.211 *** M 37.9 8.30 7.79 8.83 2.10 2.62 4.38 2.60 SD 6.07 1.89 1.65 1.28 1.197 1.14 1.96 0.592 Skewness −0.48 −1.49 −0.92 −1.87 0.82 0.20 −0.22 −1.19 Ku osis 0.21 2.67 1.29 5.70 −0.37 −0.69 −0.89 0.41 No e: QLAH: Quali y o Li e Associa ed wi h Heal h; FLS: Family Li e Sa is ac ion; PLS: Pe sonal Li e Sa is ac ion; FS: F iendships Sa is ac ion; FPA-S: Family Physical Ac i i y: Spo s; FPA-W: Family Physical Ac i i y: Walks; PPA: Pe sonal Physical Ac i i y (las week, 60 min./day); PAF-S: Spo s/Physical Ac i i y P ac iced by F iends); M: mean; SD: s anda d de ia ion. ** p<0.01; *** p<0.001. Mul iple eg ession. The ele an mul iple eg ession analysis was pe o med ia he “s ep by s ep” p ocedu e o he p edic ion o he QLAH, PLS and PPA a iables, wi h a 0.05 p obabili y en y c i e ion and 0.10 p obabili y emo al c i e ion. The esul s (Table 2) e eal ha QLAH is he mos p edic able a iable (R 2 =0.451), wi h he sa is ac ion pa ame e s unde conside a ion being e y ele an ( amily, iendships and pe sonal li e sa is ac ion), as well as a ious aspec s o physical ac i i y (pe sonal, iends and amily walks). PLS is he second mos p edic able a iable (R 2 =0.436) and o his p edic ion QLAH, FLS, FS and FPA-W a e ele an . And las ly, he p edic ion o PPA is e y low (R 2 =0.142), which includes QLAH, he h ee PA a iables (FPA-S, FPA-W and PAF) and FS. Table 2. Mul iple eg ession models o QLAH, PLS and PPA: las s ep. Dependen Va iable Coe icien s Co ela ions Collinea i y S ep Model BdSEdBe p Ze o-O de Pa ial Tole anceVIF QLAH a6 (Cons an ) 11.47 1.080 10.61 <0.001 PLS 1.40 0.096 0.379 14.51 <0.001 0.585 0.384 0.659 1.52 FLS 0.648 0.084 0.201 7.73 <0.001 0.496 0.216 0.663 1.51 PPA 0.504 0.069 0.163 7.34 <0.001 0.299 0.206 0.917 1.09 FS 0.508 0.108 0.107 4.71 <0.001 0.322 0.134 0.871 1.15 FPA-W 0.518 0.122 0.097 4.23 <0.001 0.314 0.120 0.851 1.18 PAF-S 0.831 0.225 0.081 3.70 <0.001 0.209 0.105 0.934 1.07 Model Summa y: R=0.672; R2=0.451; adj R2=0.449; SEE g=4.50 ANOVA: F=167.7.; p<0.001 PLS b4 (Cons an ) 0.012 0.292 0.04 0.968 QLAH 0.103 0.007 0.380 14.65 <0.001 0.585 0.387 0.687 1.46 FLS 0.251 0.022 0.287 11.20 <0.001 0.528 0.305 0.701 1.43 FS 0.175 0.029 0.136 5.97 <0.001 0.329 0.168 0.889 1.13 FPA-W 0.088 0.034 0.061 2.60 0.010 0.295 0.074 0.844 1.18 Model Summa y: R=0.661; R2=0.436; adj R2=0.435; SEE g=1.24 ANOVA: F=236.6.; p<0.001 Sus ainabili y 2020,12, 9486 7 o 13 Table 2. Con . Dependen Va iable Coe icien s Co ela ions Collinea i y S ep Model BdSEdBe p Ze o-O de Pa ial Tole anceVIF PPA c5 (Cons an ) − 0.812 0.455 −1.79 0.074 QLAH 0.073 0.010 0.225 7.51 <0.001 0.299 0.210 0.783 1.28 FPA-S 0.279 0.050 0.171 5.62 <0.001 0.229 0.159 0.759 1.32 PAF-S 0.457 0.090 0.138 5.07 <0.001 0.211 0.144 0.944 1.06 FS 0.117 0.043 0.076 2.70 0.007 0.182 0.077 0.886 1.13 FPA-W − 0.137 0.053 − 0.079 −2.60 0.010 0.090 − 0.074 0.750 1.33 Model Summa y: R=0.377; R2=0.142; adj R2=0.139; SEE g=1.82 ANOVA: F=40.56.; p<0.001 a. Excluded a iable: FPA-S; b. Excluded a iables: FPA-S, PAF-S and PPA; c. Excluded a iables: FLS and PLS; d. Uns anda dized; e. S anda dized; . VIF =Va iance in la ion ac o ; g. SEE =S anda d e o o es ima e. 3.2. S uc u al Equa ion Model Based on he abo e esul s, a model o associa ion amongs he a iables was sough , aking QLAH as a dependen a iable and o include in he model bo h sa is ac ion a iables and physical ac i i y a iables. P io o he Pa hAnalysis, mul i a ia e no mali y was checked [ 82 ] which can be admi ed o la ge samples i he a iables ake asymme y alues below 3 and ku osis alues o 10 (Table 2). The wo king me hodology consis ed o adding a iables and hei associa ions o he pu poses o p edic ing QLAH, in a way ha a heo e ically in e p e able model could be ob ained and he adjus men indexes could be accep able. The model ob ained (Figu e 2) e ealed an RMSEA (Roo Mean Squa e E o o App oxima ion) o 0.06 (CI 90% =0.019, 0.113) wi h a PClose o 0.282, which indica es an adequa e model adjus men . The inc emen al adjus men indexes e eal op imal adjus men (NFI, no mal i index =0.996; FRI, lexibili y- igidi y index =0.959; IFI, inc emen al i index =0.997; TLI, Tucke Lewis index =0.966; CFI, Ben le compa a i e i index =0.997) [82,83]. Sus ainabili y 2020, 12, x FOR PEER REVIEW 8 o 14 3.2. S uc u al Equa ion Model Based on he abo e esul s, a model o associa ion amongs he a iables was sough , aking QLAH as a dependen a iable and o include in he model bo h sa is ac ion a iables and physical ac i i y a iables. P io o he Pa hAnalysis, mul i a ia e no mali y was checked [82] which can be admi ed o la ge samples i he a iables ake asymme y alues below 3 and ku osis alues o 10 (Table 2). The wo king me hodology consis ed o adding a iables and hei associa ions o he pu poses o p edic ing QLAH, in a way ha a heo e ically in e p e able model could be ob ained and he adjus men indexes could be accep able. The model ob ained (Figu e 2) e ealed an RMSEA (Roo Mean Squa e E o o App oxima ion) o 0.06 (CI 90% = 0.019, 0.113) wi h a PClose o 0.282, which indica es an adequa e model adjus men . The inc emen al adjus men indexes e eal op imal adjus men (NFI, no mal i index = 0.996; FRI, lexibili y- igidi y index = 0.959; IFI, inc emen al i index = 0.997; TLI, Tucke Lewis index = 0.966; CFI, Ben le compa a i e i index = 0.997) [82,83]. The model explains 38.4% o he a iance o QLAH. Va iables PLS (0.519) and PPA (0.191) a e he ones con ibu ing mos o explain QLAH di ec ly, ollowed by FS (.104). Addi ionally, he indi ec e ec o PLS (0.034) on QLAH h ough FS should be aken in o accoun . Figu e 2. S uc u al equa ion modelling o he p edic ion o QLAH based on FLS, PLS, FS and PPA. Es ima es o he s anda dised maximum likelihood pa ame e s. All he coe icien s a e signi ican o p < 0.001. The model es ablishes ha he e a e co ela ions be ween PPA and he a ious LS dimensions unde assessmen (pe sonal, amily and iends), as well as be ween PLS and FLS and FS and he las wo wi h QLAH. 4. Discussion The esul s o his esea ch s udy a e in line wi h o he Spanish esea ch on physical ac i i y, wi h pe sonal physical ac i i y being associa ed wi h amily physical ac i i y [44,45]. Thus, adolescen s who s a e hey walk in he company o hei pa en s and ha hey p ac ice physical ac i i y wi h hem on a egula basis e eal be e le els o physical ac i i y and, in u n, acco ding o he da a ob ained, be e amily li e sa is ac ion. I is he e o e essen ial o he amily o suppo child en in he p ac ice o PA and e en o hem o p ac ice i oge he [46–48], since such suppo can be de e mining in he consolida ion o heal hy habi s, e en in adul hood [49]. Va ious esea ch s udies ha e con i med ha adolescence is a key s age o he consolida ion o li es yle and p ac ice o PA on a egula basis [11,18]. Figu e 2. S uc u al equa ion modelling o he p edic ion o QLAH based on FLS, PLS, FS and PPA. Es ima es o he s anda dised maximum likelihood pa ame e s. All he coe icien s a e signi ican o p<0.001. The model explains 38.4% o he a iance o QLAH. Va iables PLS (0.519) and PPA (0.191) a e he ones con ibu ing mos o explain QLAH di ec ly, ollowed by FS (.104). Addi ionally, he indi ec e ec o PLS (0.034) on QLAH h ough FS should be aken in o accoun . Sus ainabili y 2020,12, 9486 8 o 13 The model es ablishes ha he e a e co ela ions be ween PPA and he a ious LS dimensions unde assessmen (pe sonal, amily and iends), as well as be ween PLS and FLS and FS and he las wo wi h QLAH. 4. Discussion The esul s o his esea ch s udy a e in line wi h o he Spanish esea ch on physical ac i i y, wi h pe sonal physical ac i i y being associa ed wi h amily physical ac i i y [ 44 , 45 ]. Thus, adolescen s who s a e hey walk in he company o hei pa en s and ha hey p ac ice physical ac i i y wi h hem on a egula basis e eal be e le els o physical ac i i y and, in u n, acco ding o he da a ob ained, be e amily li e sa is ac ion. I is he e o e essen ial o he amily o suppo child en in he p ac ice o PA and e en o hem o p ac ice i oge he [ 46 – 48 ], since such suppo can be de e mining in he consolida ion o heal hy habi s, e en in adul hood [ 49 ]. Va ious esea ch s udies ha e con i med ha adolescence is a key s age o he consolida ion o li es yle and p ac ice o PA on a egula basis [ 11 , 18 ]. The esul s a e also in line wi h o he s udies which p o e an associa ion be ween he pe sonal physical ac i i y and he ac ha iends p ac ice physical ac i i y oo [ 62 – 66 ]. In ac , he iendships social en i onmen has an impac on he p ac ice o PA; hus, adolescen s who a e iendly wi h physically ac i e indi iduals a e mo e likely o mo e away om seden a y habi s and o emain mo e physically ac i e [ 51 ]. This in luence o iends on he p omo ion o heal hy li es yles can exis om childhood o la e adolescence [63]. On he o he hand, he LS o he adolescen s being in e iewed was closely associa ed wi h hei amily li e sa is ac ion and hei iendships sa is ac ion [ 8 , 10 , 61 ]. A close bond wi h hei amilies and posi i e social ela ionships undoub edly ha e an impac on he heal h o adolescen s; and he e o e i is p o en as essen ial o p omo e measu es o gua an ee such heal hy ela ionships, as hey help imp o e LS, PA and QLAH a his s age o de elopmen . In his sense, li e sa is ac ion is also ein o ced when adolescen s sha e hei p oblems o conce ns wi h hei pa en s and iends [ 63 ]. The e o e, subjec i e wellbeing is posi i ely associa ed wi h he in e ac ions be ween amily membe s and iends, o example, when hey sha e daily li e ac i i ies [64]. Adolescen s who enjoy a be e QLAH e eal g ea e pe cei ed suppo in he adop ion o heal hy habi s, such as he p ac ice o PA, by hei pa en s and iends [ 65 ]. The abo e-men ioned empi ic e idence has an impac on he imp o emen o he physical condi ion and on he p e en ion o ca dio ascula disease [ 11 ], con ibu ing o imp o ed psychosocial heal h s a us [ 67 ], socialisa ion and e en academic pe o mance [58–60]. In oday’s socie y, and mo e pa icula ly du ing a heal h pandemic (COVID-19), i is especially ele an o p omo e he wellbeing o people o all ages, ensu ing hey enjoy a heal hy li es yle and en i onmen as he means o sus ainable de elopmen . The ac o s de e mining and in luencing he heal h o people a e nume ous and hese ha e an impac on hei de elopmen . Amongs hem, physical condi ion plays a pa icula ly ele an ole [ 24 , 74 ]. Fo example, p omo ing he egula p ac ice o physical exe cise is essen ial o help adop an ac i e and heal hy li es yle a ce ain s ages o li e [ 31 ]. In his sense, child en and adolescen s a e ecommended o p ac ice mode a e o igo ous physical ac i i y o o e 60 min e e y day [ 32 ] in o de o ensu e ein o ced wellbeing om an ea ly s age o li e [ 33 , 34 ], as his habi can be ex ended o adul hood [ 24 ]. In spi e o his, he p ac ice o physical ac i i y emains below he ecommended le els [ 35 ]. In ligh o his, i becomes necessa y o c ea e an en i onmen ha p omo es heal hy li es yles, whe e he s uc u e and design o he ci ies allow o he sus ainable de elopmen [ 16 ] o hei inhabi an s, as well as o he educa ional ins i u ions and he local communi ies o make an e o o p omo e he adop ion o habi s ha con ibu e o good physical, men al and social heal h. A limi a ion o his piece o esea ch is ha wi h he pu pose o compa ing i s indings agains he HBSC in e na ional s udy, his s udy used single-i em ins umen s (such as he Can il Scale) in o de o measu e he le el o pe sonal li e sa is ac ion (PLS), amily li e sa is ac ion (FLS) and sa is ac ion Sus ainabili y 2020,12, 9486 9 o 13 wi h he ela ionships wi h iends (SF). We belie e o u he esea ch wo k i is impo an o use ins umen s wi h mo e i ems. 5. Conclusions This s udy e eals ha LS in he adolescen and PA a e di ec ly connec ed wi h posi i e ela ionships wi h hei amilies and iends, as well as he physical ac i i y he amily and iends p ac ice. QLAH can be p edic ed o a g ea ex en om he sa is ac ion o he adolescen (wi h li e, wi h hei amily li e and wi h hei iendships) and om hei p ac ice o PA (as well as ha o he amily and iends). The e o e, he s udy e eals he e is an in e ela ionship be ween LS, QLAH and PA, which a e he h ee dimensions o an in eg al concep o heal h. Howe e , he esul s o his s udy ha e limi a ions, including he use o a c oss-sec ional design, as well as he c i ical conside a ions ha hese ypes o s udies ecei e, as hey ollow sel - epo ing me hods and he e o e do no conside subjec i e ac o s [ 84 ]. On he o he hand, one s eng h ha mus be highligh ed is he sample olume and ype, as well as he inclusion o a iables ela ing o amily and iends. F om an applied poin o iew, he e idence o an exis ing associa ion amongs LS, QLAH and he p ac ice o PA o adolescen s’ heal h and hei heal hy habi s implies ha i is impo an o p omo e posi i e ela ionships in he amily and wi h iends [ 58 , 65 , 67 ]. I is he e o e essen ial o de elop s a egies o p omo e heal hy li es yles, in ol ing a ious sec o s, such as he educa ional, social, amily and he media sec o s. This is a s a egy ha p e en s he issues iden i ied in la e s ages o de elopmen such as, o example, in uni e si y s uden s, whe e he ime spen using social media has been ound o ha e, amongs o he e ec s, a educ ion in he p ac ice o physical ac i i y and a poo e quali y o li e [ 75 ]. The e o e, he s udy o g oups o popula ions pe o med by li e s ages, in spi e o being c oss-sec ional, as is he case wi h his s udy, p o ides he possibili y o es ablishing p ospec i e iews ha can be he g ounds o disease p e en ion and heal h-p omo ion p og ams. Au ho Con ibu ions: Concep ualisa ion, R.M.G., A.S.C. and J.E.M.-G.; me hodology J.D.U. and J.E.M.-G.; o mal analysis, J.D.U.; in es iga ion, R.M.G.; da a cu a ion, J.D.U.; w i ing—o iginal d a p epa a ion, J.D.U., R.M.G., A.S.C. and J.E.M.-G.; w i ing— e iew and edi ing, R.M.G. and J.E.M.-G.; isualisa ion, J.D.U. and A.S.C.; supe ision, J.D.U. and R.M.G.; p ojec adminis a ion, R.M.G.; unding acquisi ion, J.D.U., R.M.G., A.S.C. and J.E.M.-G. All au ho s ha e ead and ag eed o he published e sion o he manusc ip . Funding: This esea ch ecei ed no ex e nal unding. Con lic s o In e es : The au ho s decla e no con lic o in e es . Re e ences 1. E ikson, E.H. Sociedad y Adolescencia; Siglo XXI Edi o es: Mexico Ci y, Mexico, 1972. 2. Se apio, A. Realidad psicosocial: La adolescencia ac ual y su emp ano comienzo. Re . Es ud. Ju . 2006 ,73, 11–23. 3. Oli a, A.; Pe egal, M.A. Desa ollo posi i o adolescen e. In El Desa ollo Posi i o Adolescen e. Un Nue o Pa adigma Pa a la In es igación y la In e ención; Edi o ial Sín esis: Mad id, Spain, 2015; pp. 19–40. 4. Oli a, A.; R í os, M.; An ol í n-Su á ez, L.; Pa a, A.; He nando, A.; Pe egal, A. M á s all á del d é ici : Cons uyendo un modelo de desa ollo posi i o adolescen e. In ancia y Ap endizaje. In anc. Ap endiz. 2010 ,33, 223–234. [C ossRe ] 5. B ink, A.J.; Wissing, M.P. A model o a posi i e you h de elopmen in e en ion. J. Child Adolesc. Men . Heal h 2012,24, 1–13. 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