Health-Related Quality of Life Among Jordanian Adolescents

Abstract

Adolescence is an unpredictable stage of life with varied and rapid changes. In Jordan, health-related quality of life (HRQoL) has been examined among diabetic and obese children and adolescents. The purpose of this study was to assess the HRQoL of Jordanian healthy adolescents. Three hundred fifty-four male and female adolescents whose ages ranged from 12 to 19 participated in the study. A descriptive comparative design was employed to investigate adolescents’ HRQoL. The results revealed statistically significant differences in physical well-being, psychosocial well-being, and autonomy in favor of male adolescents. In addition, statistically significant differences were observed in favor of nonsmoker adolescents in psychosocial well-being, self-perception, parent relations and home life, financial resources, social relations and peers and school environment. In conclusion, the creation of a school health nurse role in Jordanian schools is crucial for helping adolescents improve their health.

Keywords

adolescents health-related quality of life (HRQoL)schools nursing

Background

Adolescence is a significant, formative life stage in which a transition from childhood to adulthood takes place. This period can be classified into three stages, in which the early stage represents adolescents whose ages range from 10 to 13 years, the middle stage ages 14 to 16 years and the late stage ages 17 to 19 years (Karunan, 2006). During this period, cognitive, physical, psychosocial, and emotional changes occur and affect the health and well-being of the individual (Patton & Viner, 2007). Therefore, examination of adolescents’ perception of health becomes increasingly important. Health-related quality of life (HRQoL) is a concept that encompasses different dimensions of well-being and helps to examine an individual’s subjective perception of health. Ravens-Sieberer et al. (2005) have developed a well-validated tool to assess HRQoL through implementation of an international study (KIDSCREEN Questionnaire). The dimensions evaluated by KIDSCREEN are physical and psychological well-being, moods and emotions, self-perception, autonomy, parent relations, social support and peers, school environment, social acceptance, and financial resources (Ravens-Sieberer et al., 2005).

HRQoL has been studied in healthy adolescents, as well as ill adolescents. For instance, a high proportion of adolescents with asthma, diabetes mellitus, and epilepsy have reported a moderate to high level of HRQoL (Zashikhina, & Hagglof, 2014). A low score of HRQoL (physical and psychosocial dimensions) has been reported among children and adolescents with chronic kidney disease in comparison with healthy children and adolescents (Kul et al., 2013; Tong et al., 2013). Female adolescents with eating disorders, such as anorexia nervosa and bulimia, have shown poorer HRQoL in the mental health dimension compared with the physical health dimension In addition, poorer HRQoL in all dimensions was found among adolescents with obsessive compulsive disorder (Vivan, Rodrigues, Wendt, Bicca, & Cordioli, 2013). In a study of diabetic adolescents, quality of life was found to be poor and to decrease as the disease course continued, and female patients scored lower in HRQoL than did male patients (Kalyva, Malakonaki, Eiser & Mamoulakies, 2011).

Regarding body weights, some studies have found no relationship and no significant differences between HRQoL of adolescents in three categories of body mass index (BMI) (Haraldstad, Christophersen, Eide, Nativg, & Helseth, 2011; Petersen et al., 2013). However, other studies have found that obese adolescents scored lower in the physical and psychological dimensions of the HRQoL than normal weight adolescents (Asl, & Poursharifi, 2011; Tyler, Johnston, Fullerton, & Foreyt, 2007; Ul-Haq, Mackay, Fenwick, & Pell, 2013). In addition, female, obese adolescents have scored lower than their male counterparts in the mental dimensions of HRQoL (Bonsergent et al., 2012).

Adolescents face a series of age-related and gender-specific challenges that change their perception of HRQoL. For instance, a negative relationship was found between adolescents’ age and HRQoL (Al-Fayez & Ohaeri, 2011; Haraldstad, Christophersen, Eide, Nativg, & Helseth, 2011). In addition, HRQoL has been associated with adolescents’ age and gender, with younger and male adolescents scoring higher than female and older adolescents (Bolton et al., 2014; Jorngarden, Wettergen, & von Essen, 2006). Adolescents aged 12 to 14 years have scored higher on the HRQoL (physical and psychological well-being, moods and emotions, self-perception, school environment, and autonomy dimensions) than older groups (aged 15-18 years). Petersen et al. (2012) found that lower social and physical quality of life were reported among 12- to 14-year-old adolescents, while adolescents aged between 15 and 18 years reported lower quality of life in emotional and school functioning. Moreover, a decrease in HRQoL was reported among adolescents after 12 years of age, and female adolescents have complained of stronger declines in the physical, psychological, and mood and emotion dimensions (Bisegger, Cloetta, von Bisegger, Abel, & Ravens-Sieberer, 2005; Svedberg, Eriksson, & Boman, 2013). Older male adolescents have scored higher than female adolescents in the physical and psychological well-being, moods and emotions, self-perception, and autonomy dimensions of the HRQoL (Svedberg et al., 2013). In one study, male adolescents scored higher than female adolescents in the emotional dimensions, while female adolescents scored higher than male adolescents in regard to the school dimensions (Klatchoian, Len, Terreri, & Hilario 2010). Finally, female adolescents have been shown to score lower than male adolescents in all HRQoL dimensions (Al-Fayez & Ohaeri, 2011; Bolton et al., 2014; Haraldstad, et al., 2011; Petersen et al., 2012).

Smoking has been recognized as a health problem among adolescents. In the United States, 6.7% of middle school and 23.3% of high school students in 2012 reported currently using tobacco products (Centers for Disease Control and Prevention, 2013). In Jordan, the prevalence of smoking and use of tobacco ranges from 15% to 30% among students aged 13 to 15 years (Belbeisi, Al Nsour, Batieha, Brown, & Walke, 2009). The impact of smoking is apparent on the physical as well as psychological well-being dimensions. For instance, a strong association was found between smoking and HRQoL, and adolescents who smoke have reported poorer HRQoL than adolescents who have never smoked (Dube, Thompson, Homa, & Zack, 2013). In addition, Ravens-Sieberer et al. (2006) found that regularly smoking adolescents scored lower in HRQoL. In Jordan, quality of life was examined among adolescents with diabetes mellitus. The results revealed that poorer overall quality of life was associated with shorter diabetes duration, elevated HbA1c values, gender (female), and older age (Al-Akour, Khader, & Shatnawi, 2010). In addition, Al-Akour, Khader, Khassawneh, and Bawadi (2012) studied HRQoL among obese adolescents in northern Jordan. These researchers’ results revealed that obese adolescents scored lower in the physical and psychological domains, while female and older adolescents scored lower in all HRQoL dimensions. However, in the Al-Akour studies, the Pediatric Quality of Life Inventory was used, which covers only four dimensions: physical, emotional, social, and school functioning. In contrast, the KIDSCREEN questionnaire is more comprehensive and covers 10 dimensions.

Adolescence is a period of transitions with varied and rapid changes in physical, emotional, psychological, and school functioning. HRQoL has been examined among diabetic and obese children and adolescents in Jordan. Because there is a scarcity of research on the HRQoL of healthy Jordanian adolescents, the purpose of this study is to assess the differences in Jordanian healthy adolescents’ HRQoL in relation to their stage of development and their smoking status. This assessment will help monitor the health status of this vulnerable group, detect adolescents with poor HRQoL, and provide the groundwork for needed interventions. HRQoL as an outcome measure enables reporting of adolescent’s perceptions of health and thus offers information about the neglected sides of adolescent health and contributes to the implementation of innovations in the health care field. Furthermore, this approach will result in an overall understanding of a long-term population health issue. Accordingly, this study was conducted to assess Jordanian healthy adolescents’ HRQoL.

Research Questions

Research Question 1: What are the levels of HRQoL among Jordanian healthy adolescents at schools?

Research Question 2: Are there differences in HRQoL among male and female adolescents?

Research Question 3: Are there differences in HRQoL among smoker and nonsmoker adolescents?

Research Question 4: Are there differences in HRQoL among the three stages of adolescence?

Method

Study Design

A descriptive cross-sectional comparative design was used to examine the HRQoL among healthy Jordanian adolescents who were in school.

Settings

Stratification sampling was used to stratify Jordan into a northern, middle, and southern region, and then another stratum was established based on the school type (public, private, and United Nations Relief and Work Agency [UNRWA] schools). Two schools from each stratum were randomly selected. Classes from fifth grade to the high school classes were approached.

Population and Sampling

The target population was in-school adolescents aged 10 through 19 years in Jordan. The inclusion criteria were (a) in-school adolescents aged 10 through 19 years in Jordan, (b) adolescents who agreed to participate, and (c) a consent form signed by their parents. The exclusion criteria were (a) any student who was under 10 or above 19 years of age, (b) any adolescent who did not agree to participate, (c) any student whose parents did not sign the consent form, and (d) any student who had any chronic diseases.

Sample Size

According to G-Power 3.0.3, and using the analysis of variance (ANOVA) test with a medium effect size of 0.3, at a power of 0.80 and a two-tailed level of significance set at .05, a total sample of at least 282 participants was needed.

Ethical Consideration

Ethical approval (July 4, 2014) from the institutional review board (IRB) was obtained prior to data collection, and informed consent from the adolescents and their parents or legal guardians was obtained. Before signing the consent form, the parents and the adolescents were asked to read the cover letter that was attached to the consent form. The cover letter described the purpose of the study, the time needed for completing the questionnaire, the contact information of the principle investigator, and the benefits and risks and clearly informed them that the participation in the study was voluntary and that the student had the right to withdraw from the study any time. All of the adolescents whose parents approved their participation in the study signed consent forms indicating that they were interested in participating. The participants were informed that the study was anonymous, and thus no identification information was requested.

The data were saved on the researcher’s computer and secured with a password. The results in the final report were presented in a way that the anonymity of the participants was assured. The questionnaires and any other hard copies related to the study were secured in a locked cabinet. The questionnaires were coded by numbers, and no one except the researcher knew the coding system. Finally, permission was obtained from the authors of the measurement tool to use the scales and to adapt them to Jordanian culture.

Data Collection

Data were collected through self-reported questionnaires. The researcher and three nursing research assistants distributed the questionnaires to the participants after training sessions. At each institution, the researcher and data collectors explained the study purpose and the procedure of data collection to the managers.

Questionnaires were distributed in the school classroom, and participants were given appropriate verbal instructions by the data collector. In addition, a brief description of the study’s purpose was given to participants before distributing the questionnaire. After that, the participants returned the completed questionnaire in a sealed envelope directly to the data collector.

Instrument

The KIDSCREEN instrument was used to assess the subjective health and well-being of adolescents (HRQoL). The KIDSCREEN is a self-report measure that is applicable to healthy and chronically ill children and adolescents, from 8 to 18 years of age. The KIDSCREEN-52 instrument measures 10 HRQoL dimensions: physical well-being (five items), psychological well-being (six items), moods and emotions (seven items), self-perception (five items), autonomy (five items), parent relations and home life (six items), social support and peers (six items), school environment (six items), social acceptance (bullying) (three items), and financial resources (three items). The KIDSCREEN-52 is a reliable, sensitive, and valid measure in 38 languages (Ravens-Sieberer et al., 2014). The Cronbach’s alpha reliability coefficient for the 10 KIDSCREEN dimensions ranges from .76 (social acceptance) to .89 (financial support; Ravens-Sieberer et al., 2005). In this study, the Cronbach’s alpha for the 10 KIDSCREEN dimensions ranged from .70 (perception of self) to .88 (parent relation and home life). The time required to complete the tool ranged from 15 to 20 min. A separate score was obtained for each of the 10 dimensions as well as the HRQoL index. The tool was forward translated to Arabic and backward translated to English by experts in translation, and the Arabic version was used for data collection.

Rasch scores were calculated and transformed into T-values with a mean of 50 and a standard deviation (SD) of 10 with a range of 45 to 55 considered being a normal quality of life. Values less than 45 and above 55 were considered noticeable values. The values of KIDSCREEN-52 T-scores refer to the mean values and SD from a sample of the European general population. In addition to the dimension scores, the KIDSCREEN-10 index was calculated to achieve a global score for the HRQoL (The KIDSCREEN Group, 2006). Because the dimensions scales differ in the number of items, the sum scores for each subscale were transformed to a scale ranging from 0 to 100 with higher scores indicating better HRQoL.

Data Analysis

Data were analyzed using the Statistical Package for Social Science (SPSS) Version 17. The questionnaires were coded by the researcher. The principal investigator was responsible for data entry. Descriptive statistics (frequencies and central tendency) were computed to describe the socio-demographic variables and the 10 dimensions of the KIDSCREEN. Furthermore, inferential statistics, such as Student’s t test, were carried out to test the differences between male and female and smoker and nonsmoker adolescents. ANOVA was also performed to test the differences between the stages of adolescents, and Scheffé’s post hoc test was conducted to perform multiple group comparisons. The age variable was recoded into three groups (early, middle, and late stage of adolescence) based on the United Nations Children’s Fund (UNICEF) classification of adolescent stages (Karunan, 2006). According to this classification, early stage represented the adolescents whose ages ranged from 10 to 13 years, middle stage from 14 to 16 years, and late stage from 17 to 18 years.

Results

Description of the Study Participants

A total of 450 questionnaires were distributed, and 96 of them were discarded due to incompleteness of data, which led to 354 questionnaires entered into the SPSS program (response rate of 70%). The data were screened and cleaned; missing data were managed and replaced by the mode for categorical variables and the mean for the continuous variables. The distribution of the continuous variables was checked using Pearson’s coefficient of skewness, and the results revealed that these variables were normally distributed. Student’s t test and ANOVA were used to compare the differences between groups in relation to the HRQoL dimensions. As shown in Table 1, 54.8% (n = 194) of the participants were female, and the majority of them resided in the city (n = 248, 70.1%) and studied in governmental schools (n = 237, 66.9%). In addition, their mean age was 15.3 years (SD = 1.3), and 13.6% of them smoked cigarettes (n = 48).

Table 1.

Socio-Demographic Characteristic (N = 354).

Variable	n (%)
Gender
Male	160 (45.2)
Female	194 (54.8)
Place of residency
Camp	94 (26.6)
Village	11 (3.1)
City	248 (70.1)
Countryside	1 (0.3)
School classification
Governmental	237 (66.9)
Private	46 (13)
UNRWA	71 (20.1)
Smoker adolescents	48 (13.6)
Stages of adolescents
Early stage	26 (7.3)
Middle stage	260 (73.4)
Late stage	68 (19.2)
Variable	M (SD)
Age	15.2 (1.7)
Monthly family income	605 (481.316)

Note. UNRWA = United Nations Relief and Work Agency.

Description of the KIDSCREEN Dimensions

HRQoL subscales were totaled and transformed to a score out of 100, with higher scores representing higher quality of life in respect to the specific dimensions. After that, scores were transformed to a Rasch score and then to T-scores to facilitate comparison between different scales with different item numbers. As presented in Table 2, the lowest scores were for the psychosocial well-being, autonomy, parent relation and home life, and mood and emotion dimensions.

Table 2.

Description of the Health-Related Quality of Life Dimensions.

Variable	0-100 score	T-score^a			T-score^a
Variable	M (SD)	25th	50th	75th	M (SD)
HRQoL index	70.0 (13.2)	37.4	42.3	48.3	43.3 (8.2)
Physical well-being	71.3 (15.0)	40.5	44.7	52.4	45.9 (9.3)
Psychosocial well-being	69.2 (17.5)	35.5	41.5	49.3	42.5 (10.3)
Mood and emotion	65.5 (18.2)	34.6	38.8	45.4	39.9 (10.3)
Self-perception	73.4 (17.1)	40.5	44.6	52.2	47.3 (9.6)
Autonomy	67.7 (18.9)	39.0	43.6	48.7	44.1 (10.5)
Parent relation and home life	74.1 (20.2)	38.3	44.1	51.8	44.7 (11.7)
Financial resources	70.9 (22.3)	41.9	46.6	52.4	46.9 (10.1)
Social support and peers	71.7 (17.9)	39.5	45.1	52.4	45.8 (10.7)
School environment	68.5 (17.4)	40.9	46.9	54.2	47.2 (9.9)
Social acceptance (bullying)	85.3 (19.6)	35.4	58.8	58.8	47.4 (12.9)

Note. HRQoL = health-related quality of life.

international T values based on Rasch person parameter.

Differences in KIDSCREEN Dimensions Between Male and Female, Smoker and Nonsmoker Adolescents

Student’s t test was used to examine the differences between male and female adolescents, as well as adolescent smokers and nonsmokers, in regard to the KIDSCREEN dimensions. The results revealed statistically significant differences in physical well-being, t(352) = 3.80, p < .001, psychosocial well-being, t(352) = 2.30, p < .021, and autonomy, t(352) = 2.80, p = .006. Male adolescents scored higher than female adolescents in physical well-being (M = 74.6, SD = 14.6 vs. M = 68.6, SD = 14.8), psychosocial well-being (M = 71.5, SD = 16.2 vs. M = 67.2, SD = 18.4), and autonomy (M = 70.8, SD = 18.6 vs. M = 65.2, SD = 19.0). However, female adolescents scored statistically significantly higher, t(352) = 2.42, p = .016, in the social support and peer dimension (M = 73.8, SD = 17.5 vs. M = 69.1, SD = 18.2). In regard to the other dimensions, no statistically significant differences were found between male and female adolescents (Table 3). There was no statistically significant difference in the HRQoL index between male and female participants, t(352) = 1.2, p = .243.

Table 3.

Results of Students t Test on the KIDSCREEN Dimensions in Regard to Gender and Smoking Status.

KIDSCREEN dimension	Variable	p value	Test value	df
Physical well-being	Gender	<.001***	3.80	352
Physical well-being	Smoking status	.284	1.07	352
Psychosocial well-being	Gender	.021*	2.30	352
Psychosocial well-being	Smoking status	.004**	2.92	352
Mood and emotion	Gender	.054	1.90	352
Mood and emotion	Smoking status	.172	1.37	352
Self-perception	Gender	.43	.791	352
Self-perception	Smoking status	.004**	2.91	352
Autonomy	Gender	.006**	2.80	352
Autonomy	Smoking status	.086	1.72	352
Parent relation and home life	Gender	.62	.996	352
Parent relation and home life	Smoking status	.001**	3.40	352
Financial resources	Gender	.19	1.30	352
Financial resources	Smoking status	.004**	2.88	352
Social support and peers	Gender	.016*	2.42	352
Social support and peers	Smoking status	.013*	2.49	352
School environment	Gender	.26	1.10	352
School environment	Smoking status	.003**	3.01	352
Social acceptance (bullying)	Gender	.06	1.86	352
Social acceptance (bullying)	Smoking status	.124	1.54	352

p< .05, two-tailed. **p < .01, two-tailed. ***p < .001, two-tailed.

The comparisons between adolescent smokers and nonsmokers revealed statistically significant differences in favor of adolescent nonsmokers in psychosocial well-being, t(352) = 2.9, p = .004 (M = 70.2, SD = 17.3 vs. M = 62.4, SD = 17.9), self-perception, t(352) = 2.91, p = .004 (M = 74.4, SD = 17.1 vs. M = 66.8, SD = 16.2), and parent relation and home life, t(352) = 3.40, p = .001 (M = 75.6, SD = 19.8 vs. M = 65.1, SD = 20.2). In addition, nonsmoker adolescents statistically significantly scored higher in financial resources, t(352) = 2.88, p = .004 (M = 72.2, SD = 22.1 vs. M = 62.4, SD = 21.7), social relation and peers, t(352) = 2.49, p = .013 (M = 72.6, SD = 17.5 vs. M = 65.7, SD = 20.1), and school environment, t(352) = 3.01, p = .003 (M = 69.6 SD = 17.5 vs. M = 61.5, SD = 15.5) (Table 3). Nonsmoker adolescents scored statistically significantly higher in the HRQoL index, t(352) = 2.5, p = .012 (M = 70.7, SD = 13.1 vs. M = 65.6, SD = 13.2) compared with adolescent smokers.

Differences in HRQoL Between the Different Stages of Adolescence

The age variable was recoded into three groups according to the stages of adolescence (early, middle, and late stage). ANOVA was used to examine the differences between the three stages in relation to the KIDSCREEN dimensions. The results revealed a statistically significant difference in the mood and emotion dimension, F(2, 351) = 3.29, p = .038, between the three groups. Scheffé’s post hoc test was conducted to perform multiple group comparisons and revealed a statistically significant difference between the early stage group and middle stage group (p = .047). Early stage adolescents (M = 74.2, SD = 16.2) scored higher than middle stage adolescents (M = 64.9, SD = 18.3); the middle stage and late stage did not differ from each other (p = .96) as well as the early stage and late stage (p = .059). No statistically significant differences were found in the other dimensions. Regarding the HRQoL index, no statistically significant differences were found between the different stages of adolescence, F(2, 351) = 0.05, p = .95.

Discussion

This study examined the HRQoL of Jordanian adolescents. In addition, the study reported the level of each HRQoL dimension and the differences in HRQoL index and its dimensions in relation to gender, smoking status, and stage of adolescence (early, middle, late stage).

In this study, adolescents scored higher in social acceptance, parent relation and home life, self-perception, social support, and physical well-being than in the other dimensions. Although no significant differences were found between male and female adolescents in regard to the HRQoL index, male adolescents scored higher than female adolescents in physical and psychosocial well-being and autonomy, which is consistent with the literature (Guedes et al., 2014; Svedberg et al., 2013). However, Klatchoian et al. (2010) found that male adolescents scored higher than female adolescents in the emotional dimension, while female adolescents scored higher in the school dimension. In addition, Guedes et al. (2014) found that male adolescents scored higher in mood and emotion, self-perception, and parent relations. In this study, male adolescents perceived themselves to be more active, energetic, physically fit, satisfied with life and autonomous. One explanation of these findings is that physical changes and development during puberty can strongly affect, either positively or negatively, an adolescent’s psychological status. Sun et al. (2002) has reported that the mean age of onset of puberty is approximately 10.5 years of age in girls and 11.5 years in boys. This early development in girls and the resulting accumulation of adipose tissue moves girls away from the thin ideal body image, while the late development of boys moves them toward the muscular ideal body image. Studies have found that female adolescents are less satisfied with their body than male adolescents and that male adolescents have higher self-esteem than their female counterparts (Kling, Hyde, Showers, & Buswell, 1999; Makinen, Puukko-Viertomies, Lindberg, Siimes, & Aalberg, 2012). Thus, male adolescents tend to be more comfortable with the physical changes occurring in puberty than female adolescents. In regard to the findings in the autonomy dimension, Jordanian culture is a masculine society in which men are more dominant, are allowed to be outside of the home for a long period of time, and are free from the time restrictions placed on women and girls. These differences provide the opportunity for male adolescents to perceive themselves as more autonomous than female adolescents.

In this study, nonsmoker adolescents scored higher than smoker adolescents in the HRQoL index, as well as in the self-perception, psychosocial well-being, and parent relations and home life dimensions. This finding means that nonsmoker adolescents felt satisfied with their life and with themselves, had higher self-esteem, and were supported and loved by parents and families. This is in line with literature in which adolescent smokers reported poorer HRQoL than nonsmokers (Dube et al., 2013; Ravens-Sieberer et al., 2006). Smoking is considered to be a coping mechanism for individuals with emotional problems, low self-esteem, low body image and dissatisfaction with self. In addition, smoking is thought to create conflict between adolescents and their families, which may alter their relationship.

Although rapid pubertal changes take place at the early stage of adolescence, the analysis of differences due to stage of adolescence found that adolescents in the early stage surprisingly scored higher than adolescents in the middle stage in mood and emotion. No significant difference in the HRQoL index was found in the other dimensions. This result was not consistent with other studies, in which a negative relationship was found between adolescents’ age and HRQoL (Al-Fayez & Ohaeri, 2011; Haraldstad et al., 2011). However, Svedberg, Eriksson, and Boman (2013) found that younger adolescents scored higher than older adolescents in physical and psychological well-being, self-perception, autonomy, and the school environment. In the literature, violent and aggressive behaviors were found to be higher in the middle and late stages of puberty (Hemphill et al., 2010). This may impact the emotional and psychological aspects of this stage of adolescence. Moreover, it is believed that during the middle and late stages of adolescence, internal and external stressors are high due to factors such as striving for autonomy, forming relationships, forming an ideal self image, and matching the expectations of parents and significant others. In addition, educational achievement and thinking about the future may impact adolescents’ emotions.

In this study, the HRQoL index was 70.0, which is comparable to other studies (Haraldstad et al., 2011; Petersen et al., 2012). However, it contradicted the results of Svedberg et al. (2013), in which the HRQoL index was good. HRQoL impairments primarily occur in the psychological, mood and emotion, autonomy, school environment, and parent relations and home life dimensions. Physical changes, social demands, academic achievement, role expectations, and culture may impact these aspects of HRQoL. Other possible factors are family wealth and educational level; adolescents of families from a high socioeconomic level had higher HRQoL, particularly in the physical well-being, perceived financial resources, and parent and home life dimensions (Von Rueden, Gosch, Rajmil, Bisegger, & Ravens-Sieberer, 2006). In this study, the adolescents came from low-income families, which may have affected their perception of health.

Conclusions and Implications

The assessment of HRQoL among adolescents in school is crucial, especially because there is a multidimensional measure that assesses adolescents’ perception of health. In this study, the HRQoL index was low among Jordanian adolescents with no significant differences between male and female adolescents. There were significant differences between boys and girls in regard to autonomy and physical and psychosocial well-being, and younger adolescents scored higher in the mood and emotion dimension. These findings highlight the importance of placing adequate emphasis on the special needs of adolescents. Adolescence is a challenging period of life and is associated with physical, cognitive, social, and emotional development. In addition, it is a time of life that is associated with many risks and problem behaviors, but it also presents great opportunities for sustained health and well-being through appropriate preparations. These preparations must be gender and age specific to fulfill the objectives of disease prevention and health promotion. Another important finding from this study is that nonsmoker adolescents scored higher than adolescent smokers in HRQoL index as well as in the self-perception, psychosocial well-being, and parent relations and home life dimensions. In the health care system, adolescents are either treated the same as children or have to share facilities with older adults. In Jordan, there are no active school health nurses, despite the fact that school nurses have the qualifications that are necessary to handle adolescent problems such as smoking, low self-esteem, and decreased autonomy. Furthermore, school nurses can involve parents to improve the health of their adolescents and to teach them effective coping skills. Thus, the creation of a school health nurse role is highly recommended. Implementation of a school-based clinic is crucial to managing adolescents’ problems.

Study Limitations

This study used a self-administered questionnaire and a convenience sampling technique of students in data collection, which may lead to response bias. The findings cannot be generalized to all Jordanian adolescents because of the small sample size. Thus, it is highly recommended to replicate this study with a larger sample size that will improve generalizability to the entire population.

Footnotes

Acknowledgements

We are thankful to the adolescent students who participated in this study.

Declaration of Conflicting Interests

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

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported and funded by the Deanship of Academic Research at the University of Jordan.

Author Biographies

Eman Mohammad Hourani, BSc, MSc, RN, is a lecturer at the Community Health Nursing Department, Faculty of Nursing, The University of Jordan.

Sawsan Mohammad Hammad, BSc, MSc, RN, is a clinical instructor at the Community Health Nursing Department, Faculty of Nursing, The University of Jordan.

Abeer Shaheen, PhD, RN, is an assistant professor at the Community Health Nursing Department, Faculty of Nursing, The University of Jordan.

Huda Musa Amre, BSc, MSc, RN, is an assistant dean for student affair at the Community Health Nursing Department, Faculty of Nursing, The University of Jordan.

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