Abstract

Introduction: Given the growing concern surrounding risk behaviors in adolescence and the limited exploration of self-care from a multidimensional perspective, this study is justified by the need to analyze this phenomenon in a comprehensive manner.

Objectives. The overall objective was to assess the level of self-care among young people in Andalusia and analyze its variations following the COVID-19 pandemic. Specifically, we sought to examine the relationship between self-care and the risk of eating disorders (EDs) and negative exercise addiction (NEA).

Methodology. A mixed research design was used. The quantitative phase consisted of a cross-sectional study with a sample of 1,018 adolescents to validate the Youth Self-Care Practice and Management questionnaire. The qualitative phase was based on interviews with teachers to gain insight into the social and educational context.

Results. The findings revealed a strong interrelationship between the self-care dimensions, confirming family support as a significant protective factor. Regression analysis identified that greater frequency of physical activity and self-care management were significant predictors of increased ED risk. For NEA risk, only physical activity was found to be a significant predictor.

Discussion and Conclusion. The study validates the PGJ questionnaire as an effective tool for early risk detection. The findings conclude that it is essential to implement a comprehensive approach that actively involves families and educational centers to effectively promote healthy habits and well-being among adolescents.

Keywords: Adolescent Health; Adolescents; Compulsive Exercise; Family Relations; Feeding and Eating Disorders; Health Risk Behaviors; Mental Health; Self Care; Social Support.

Resumen

Introducción: Ante la creciente preocupación por las conductas de riesgo en la adolescencia y la limitada exploración del autocuidado desde una perspectiva multidimensional, este estudio se justifica por la necesidad de analizar este fenómeno de forma integral.

Objetivos. El objetivo general fue evaluar el nivel de autocuidado en jóvenes andaluces y analizar sus variaciones tras la pandemia de COVID-19. Específicamente, se buscó examinar su relación con el riesgo de Trastornos de la Conducta Alimentaria (TCA) y Adicción Negativa al Ejercicio (ANE).

Metodología. Se empleó un diseño de investigación mixto. La fase cuantitativa consistió en un estudio transversal con una muestra de 1.018 adolescentes para la validación del cuestionario de Práctica y Gestión del Autocuidado Juvenil (PGJ). La fase cualitativa se basó en entrevistas con docentes para profundizar en el contexto social y educativo.

Resultados. Los hallazgos revelaron una fuerte interrelación entre las dimensiones del autocuidado, confirmándose el apoyo familiar como un factor protector significativo. El análisis de regresión identificó que una mayor frecuencia en la práctica física y la gestión del autocuidado eran predictores significativos de un mayor riesgo de TCA. Para el riesgo de ANE, únicamente la práctica física resultó ser un predictor significativo.

Discusión y Conclusión. El estudio valida el cuestionario PGJ como una herramienta eficaz para la detección precoz de riesgos. Se concluye que es fundamental implementar un enfoque integral que involucre activamente a las familias y los centros educativos para promover eficazmente hábitos saludables y el bienestar en la población adolescente.

Palabras clave: Adolescentes; Apoyo Social; Autocuidado; Conductas de Riesgo para la Salud; Ejercicio Compulsivo; Relaciones Familiares; Salud del Adolescente; Salud Mental; Trastornos de la Conducta Alimentaria.

Introduction

Self-care is defined as the set of intentional actions that individuals undertake to control internal and external factors that may affect their life and development^1,2. This concept is crucial during adolescence, a vital stage for the consolidation of habits that will continue into adulthood. Despite its strategic importance, self-care has been underexplored in the social sciences and had been predominantly addressed by health disciplines such as medicine or nursing, which focus on the prevention and treatment of diseases^3,7.

Although awareness campaigns target young people, rates of overweight, eating disorders (EDs), substance use, and sexual risk behavior have steadily increased. There is a notable discrepancy between adolescents' optimistic perception of their habits and the reality observed by health professionals, highlighting a gap in self-awareness and self-health management⁸.

Current research on youth self-care has significant limitations. Most studies focus on descriptive profiles of what young people do to take care of themselves, without delving into the factors that influence these behaviors^9-12. In addition, interventions and management models have focused almost exclusively on medical contexts and populations with existing pathologies, using a variety of specific questionnaires for each dimension or disease rather than a unified instrument that offers a comprehensive view^13-21.

This study is justified by the need to overcome these limitations through the creation and validation of a multidimensional instrument, the Youth Self-Care Practice and Management Questionnaire (PGJ), adapted to the adolescent population from a social sciences approach. From a nursing practice perspective, Orem's self-care deficit model¹ stands out as a particularly relevant theoretical framework, positing that the need for intervention arises when individuals are unable to meet their own self-care requirements. In the context of adolescence, this framework is particularly relevant as it allows for the analysis not only of self-care practices but also of the capabilities and limitations (deficits) that prevent young people from developing effective health agency, thus justifying the need for an instrument that measures both facets.

Objetives

This study aims to provide a holistic view of self-care among Andalusian youth, laying the foundations for the design of more effective and comprehensive preventive interventions. Therefore, the general and specific objectives are as follows:

The general objectives of this study are to obtain information on the level of self-care among Andalusian youth aged 12 to 16 and to analyze whether these practices have changed as a result of the COVID-19 pandemic.

The specific objectives are:

1. To examine the possible relationship between the risk of developing unhealthy behaviors related to diet and physical exercise, in particular EDs and negative exercise addiction (NEA).
2. To identify the behaviors and needs of young people in Andalusia in relation to self-care, considering the influence of the commitments and dynamics established with the adults with whom they live.

Method

Study design

A mixed-methods study was used. The quantitative phase was based on a cross-sectional, observational, and descriptive-correlational design, aimed at analyzing self-care practices and the relationships between their dimensions. The qualitative phase was exploratory in nature, using interviews to delve deeper into the perceptions of teachers and specialists on the phenomenon studied.

Population and sample

The target population of the study was young people in the autonomous community of Andalusia. The final sample for the quantitative phase consisted of N=1,018 young people with a mean age of 14.61 years (SD=2.157). A total of 59.6% of participants identified as female and 39.6% as male. The sample included representation from all Andalusian provinces (see Table 1).

Table 1. Age group and gender by province.

Convenience sampling was used. The principal investigator contacted school nurses at various educational centers, who subsequently informed families about the study through parent-teacher associations. Participation was voluntary. No specific rationale was given for the specific selection of educational centers, which may limit the representativeness of the sample.

Inclusion and exclusion criteria

• Inclusion criteria: enrolled as a student at the selected Andalusian schools; age between 12 and 16 years; submission of informed consent signed by legal guardians and assent from the minor.
• Exclusion criteria: Failure to meet the inclusion criteria.

Instruments

The following instruments were used for data collection:

• Sociodemographic characteristics: Information was collected on gender, age, weight, height, parents' occupation and educational level, place of residence, and subjective social class.
• Youth Self-Care Practice and Management Questionnaire (PGJ): An instrument created ad hoc for this project, consisting of 60 items distributed across four dimensions (physical, psychological, social, and self-care management). Responses were collected on a 5-point Likert scale (0: never to 4: always). The questionnaire demonstrated adequate reliability, with a Cronbach's alpha of α=0.84 and a McDonald's omega of ** ώ=0.72**.
• Multidimensional Scale of Perceived Social Support (MSPSS): Only the family support subscale was used, consisting of 4 items with a 7-point response scale. The subscale showed excellent internal consistency (α=0.893) (22,23,24).
• SCOFF Index: Screening questionnaire for EDs, consisting of 5 dichotomous response items (yes/no). A cut-off point of 2 or more affirmative responses suggests a risk of ED (25).
• Exercise Addiction Inventory (EAI): 6-item scale designed to identify signs of NEA, with responses on a 5-point Likert scale (26).
• Perception of self-care before/after COVID-19: Set of questions designed to assess the changes perceived by young people in their self-care practices (diet, relationships, sleep, etc.) before and after the pandemic, with three response options (worse, the same, better).

Procedure

To collect quantitative data, we first contacted the schools. Then, we sent the study information to the families and asked for the legal guardians' informed consent and the minors' assent. The questionnaires were given out at the schools.

For the qualitative phase, interviews were conducted with 12 teachers and specialists in the field to gather their perceptions of adolescent self-care (6 women and 6 men) aged between 35 and 50 years.

Data analysis

The analytical plan was adapted to the nature of the data and the objectives of the study.

SPSS software was used for quantitative analysis. The following analyses were performed:

• Descriptive analyses (frequencies, means, standard deviations) to characterize the sample and the scores on the different instruments.
• Cross-tabulation and the Chi-square (χ²) test to analyze the relationship between the level of family support (categorical variable) and the dimensions of self-care.
• One-way analysis of variance (ANOVA) to examine the existence of significant differences in self-care practices according to age and gender.
• Multiple linear regression analysis to determine the predictive capacity of self-care dimensions on the risk of EDs (SCOFF score) and NEA (EAI score).

For the qualitative analysis, a thematic content analysis of the interview transcripts was conducted. ATLAS.ti software (version 22) was used to facilitate data coding and the identification of emerging categories and patterns.

Ethical considerations

The study was approved by the Bioethics Committee of the University of Almería (ref: UALBIO2022/038). The principles of the Declaration of Helsinki were followed. Informed consent was obtained from legal guardians and assent from minors prior to participation. Anonymity and confidentiality of data were guaranteed, ensuring their exclusive use for research purposes.

Results

Quantitative results

Overall results of the PGJ questionnaire

The mean scores obtained in the population analyzed were considered average for the physical and psychological practice dimensions. In contrast, the mean scores were high for the social practice and self-care management dimensions.

Analysis by self-care dimension

Physical Practice: Data on risk behaviors (Table 1) showed that alcohol consumption was the most widespread behavior.

Table 2. Risk behaviors (%).

• Psychological Practice: In this dimension, spirituality (meditation or prayer) was found to be a relatively uncommon practice. Self-esteem and life satisfaction showed moderately positive trends, with 44.4% of respondents stating that they were “always” satisfied with their lives. Emotional management was identified as the weakest aspect.
• Social Practice: The results showed that relationships with family and friends were mostly positive. In contrast, romantic relationships were described in a more mixed manner, and emotional bonds with professionals (teachers, healthcare workers) were clearly weaker.
• Self-Care Management: This dimension, which assesses skills such as seeking information and making decisions about health, showed a markedly positive trend in most of the items evaluated.

Differences by age and gender

The ANOVA analysis revealed significant differences based on age and gender:

• In physical practice, significant differences were found by age, with younger participants (12-13 years) obtaining higher scores. Unlike the regression analysis, the ANOVA analysis did reveal significant differences by gender in physical practice, with higher scores among males.
• In psychological practice, no significant differences were found by age or gender.
• In social practice, no significant differences were found by gender or age independently; however, significant differences were found when the interaction between both variables was analyzed.
• In self-care management, significant differences were found by age, with higher scores in the younger age groups.

Influence of family support

The results of the cross-tabulation showed a statistically significant relationship between the perception of family support and the four dimensions of self-care: physical practice, social practice, psychological practice, and self-care management.

• Statistical analysis confirmed a highly significant relationship between family support and physical self-care practice (χ² test, p < 0.001).
• Similarly, a statistically significant correlation was found between family support and self-care in the social sphere (χ² test, p < 0.001). This data show that young people who feel more supported by their family environment also exhibit higher scores in their social practices.
• The relationship between family support and psychological well-being was also statistically significant (χ² test, p = 0.002). The data indicate that adolescents who perceive greater family support report higher levels of positive psychological practices. This result is particularly important because, as the study shows, poor psychological practices are directly correlated with a higher risk of developing EDs and NEA.
• Finally, the results reveal a positive, strong, and statistically significant relationship between the perception of family support and self-care management skills (χ² test, p < 0.001). Adolescents who feel they can count on their family are also more competent at proactively managing their health. This ranges from seeking information and professional help when they need it to the ability to change habits to improve their overall well-being.

While these statistical patterns are unambiguous, their true magnitude and underlying dynamics can only be fully understood through the experiences of professionals who interact with young people on a daily basis.

Risk of EDs and NEA

• Regression analysis showed that self-care dimensions significantly predicted ED risk (SCOFF), explaining 20% of the variance, and analysis of variance confirmed that at least one predictor had a significant effect.
• Regression analysis to predict NEA risk (EAI) was also significant, explaining 18.7% of the variance. However, social, psychological, and management practices dimensions were not significant predictors of NEA risk.

Impact of COVID-19

Analysis of the perceived changes after the pandemic showed a mixed impact. Improvements were reported in areas such as physical activity and social relationships, but more moderate changes or stagnation were observed in indicators such as sleep quality and relationship with oneself.

Qualitative Results

Thematic content analysis of the teacher interviews, conducted with ATLAS.ti, identified four central categories: self-harm and dangerous behaviors, emotion management, healthy habits, and healthy social relationships.

The teachers interviewed placed these categories within three main frameworks that influence adolescent behavior: family, peers, and school.

The key finding of the qualitative analysis was the constant interrelation among all categories and subcategories. The interviewees described these phenomena in a dynamic and connected way, highlighting the need for a comprehensive approach to promoting self-care, considering the simultaneous influence of the different frames of reference and the various dimensions of youth well-being.

Discussion

This section interprets the results presented, contextualizes them within the framework of existing scientific literature, acknowledges the methodological limitations of the study, and proposes future lines of research to advance the understanding of adolescent self-care.

The study findings indicate that self-care among Andalusian youth is a multidimensional phenomenon with a heterogeneous profile. The physical dimension, with average levels, reflects a worrying pattern previously identified in national studies: low adherence to recommended physical activity, especially among female adolescents, and sleep quality compromised by the use of electronic devices (27). A gender difference in physical activity was observed, in line with prior studies (27,28), which could reflect different socialization patterns where males are more involved in physical exercise and females are more inclined towards hygiene and nutrition. The negative influence of age on physical activity suggests that the transition to later stages of adolescence coincides with a decline in active habits.

On a psychological level, the coexistence of acceptable self-esteem with poor emotional management is a notable finding. This finding underscores the need for interventions that not only reinforce self-esteem, but also equip young people with tools for emotional regulation. Concerning the social dimension, the findings reaffirm the central role of the family as a pillar of emotional support, followed by peers. This is consistent with the literature that highlights the importance of emotional bonds as a protective factor during adolescence.

A central finding of this study is the confirmation of the significant influence of family support in all dimensions of self-care. This result reinforces the idea that a cohesive and communicative family environment acts as a key facilitator for the development of healthy habits. Likewise, the association found between low psychological self-care and an increased risk of EDs and NEA provides valuable empirical evidence. This association suggests that risk behaviors such as EDs and NEA may not be isolated issues of body image or exercise, but rather manifestations of underlying deficits in emotional management skills. Extreme control over food or exercise may function as a maladaptive coping strategy to compensate for an inability to regulate internal emotional states, a hypothesis that reinforces the need for interventions focused on emotional competence as primary prevention.

Limitations of the study

It is important to acknowledge certain limitations that may affect the interpretation and generalization of the results:

• The use of non-probability (convenience) sampling limits the possibility of generalizing the findings to the entire youth population of Andalusia. The sample may not be representative of the diversity of socioeconomic and cultural contexts in the region.
• The cross-sectional nature of the quantitative design prevents the establishment of causal relationships between variables. For example, although an association between family support and self-care was observed, the directionality of this relationship cannot be determined.
• The use of self-reported data may be subject to biases, such as social desirability, where participants may respond in a manner they consider socially acceptable rather than reflecting their true behaviors.

Future lines of research

Based on the findings and limitations of this study, the following future lines of research are proposed:

• Conduct longitudinal studies to observe the evolution of self-care practices over time and establish with greater certainty the causal relationships between variables such as family support, emotional management, and risk behaviors.
• Include additional contextual variables, such as the socioeconomic environment of the neighborhood or the specific characteristics of the educational center, to better understand how environmental factors modulate self-care practices.
• Design and evaluate the effectiveness of intervention programs based on a comprehensive approach that involves families, teachers, and young people in promoting self-care.

In short, this study provides a valuable snapshot of youth self-care and highlights the interconnection between its different dimensions, serving as a starting point for future research and preventive interventions.

Conclusions

This section presents the conclusions drawn directly from the results and discussion of the study. It summarizes the most relevant findings and their practical implications for health promotion among adolescents.

1. Gender-differentiated patterns of self-care are identified among Andalusian adolescents. While female adolescents show greater attention to rest and nutrition, men are more involved in physical activity, reflecting possible differences in the socialization of gender roles.
2. Young people's psychological self-care is characterized by a tension between generally positive self-esteem and poor emotional management. The effects of the COVID-19 lockdown appear to have exacerbated anxiety and sadness, especially among female adolescents, underscoring the urgency of prioritizing youth mental health.
3. Family and friendship relationships are fundamental pillars of self-care. The family is consolidated as the main source of emotional support, a role that is complemented by the growing importance of peers as adolescence progresses.
4. Self-care management reveals a proactive attitude toward health, although difficulties in establishing stable routines persist. It has been observed that concern for physical health increases with age, but emotional management skills decline.
5. Family support is confirmed as a key protective factor. A cohesive family network is directly associated with better self-care practices in all its dimensions, acting as a catalyst for the development of healthy habits.
6. Lack of self-care in the psychological and emotional spheres is associated with an increased risk of developing eating disorders and negative exercise addiction. The promotion of emotional skills is therefore a fundamental preventive tool.

In this context, the validated PGJ questionnaire is presented as a promising tool for the early detection of these vulnerabilities in the educational setting. Ultimately, there is a clear need to adopt a comprehensive and coordinated approach that actively involves families and educational institutions in order to effectively promote healthy lifestyle habits and strengthen young people's skills.

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