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Ment Health Fam Med. 2009 September; 6(3): 163–172.
PMCID: PMC2838649

A qualitative study on adolescence, health and family

Abstract

Family is important to both health and adolescence. Adolescence is a time of peak health, but there are some important family based risk factors. The aim of this study was to explore the perspective of adolescent Iranians on issues of family and their health. We used descriptive, qualitative methodology and purposeful sampling and interviews for collecting the data. Forty‐one participants explained their perspectives on health and family. Data were analysed using qualitative content analysis. Analysis revealed three categories of risk factors: a widening generation gap, effective parenting and family financial situation. To have healthy adolescents, both children and parents need more knowledge and better skills about adolescent health and development and about social trends. To understand adolescents in a more realistic way, parents should develop healthy communication to avoid family health problems.

Keywords: adolescent, family, family role, generation gap, health, parenting, qualitative approach

Introduction

The family is a heavenly or basic unit which has deep roots in both Iranian national culture and religious belief. It has the meaning of loving, belonging, training and coexisting as well as safety, security and unity. As written in the Holy Quran, Sura Rome verse 21: ‘Amongst God's signs for you is this, that He created mates for you from among yourselves for you to dwell with in tranquility. It is He who put love and compassion between you. Verily in these are signs for those who reflect.’ Prophet Mohammad said: ‘Best amongst you is he who treats his family well: and I am kindest of all to my own family’.1

Family can be a place where both potential resources for health or possible threats to wellbeing may arise. The core functions of family are the exchange of love, affection, comprehension, nurturing and care, economic security, a sense of identity and belonging, raising children and guidance on social values2 and there are some important interactional effects between family and its members at different developmental stages.

Adolescence is a crucial period of human life and adolescents may encounter problems that may affect them for the rest of their lives. Family has a fundamental role in different aspects of the health of adolescents and examples of this are available from around the world. Seventeen percent of Finnish teenagers frequently reported tiredness and 10% did not experience the joy of life.3 The protective function of family has been showed to be an important factor in the prevention of risk behaviours in Chilean adolescents4 and family religiosity was negatively associated with adolescent sexual activity in a US national longitudinal study by Manlove et al.5 Poor children's health status, parental marital status and family rearing patterns were shown as risk factors for adolescent emotional abuse in a study from China.6 The overall effect of family interventions in reducing adolescent drinking has been shown in a meta‐analysis.7

The Iranian context and related studies

Iran, with 15 million adolescents accounting for almost 25% of the total Iranian population, is one of the youngest countries in the world, a situation which can pose many challenges to family co‐hesion.8 Compared with their western counterparts, Iranian adolescents are less delinquent. Iranian culture expects that adolescents should respect and obey their parents and children usually live with their parents until marriage, no matter how old they are. Even after marriage, they may continue living with their parents independently in the family home. Segregation of the sexes is respected in public places such as schools and the university environment and/or workplace is the first opportunity for the sexes to communicate. Out of wedlock sexual relationships are prohibited by Iranian religion, culture and law. Over the last decade, as a result of the influence of western culture via satellite media, adolescents and their families are experiencing an increase in rates of aggression, parents being insulted, opposite sex relationships, western hair styles, fast food, individualisation and smoking, and this cultural colonisation is in many cases unwelcome.

The Iran National Youth Organization (INYO) is the main formal organisation responsible for adolescent and youth programming and welfare in Iran. This high‐level, well‐organised body plans to develop evidence‐based programmes to improve adolescents' quality of life.

According to INYO research, 66% of adolescents believed that the influence of satellite media will foster western culture and a developing consumerism which are crucial challenging agents for the deep and rich Iranian culture. Adolescents stated that their main needs were to have useful and safe pastimes during adolescence and a future career.9

Emami et al investigated mental health in Iranian adolescents and found that a considerable proportion of adolescents experienced mental disorders, with girls experiencing such disorders more frequently than boys.10 Salimi et al studied high school students to assess the effects of parental expectations on students' anxiety about education and career. Analysis yielded a negative correlation between parental self‐esteem and expectations and students' anxiety about education and career.11 A qualitative content analysis on addiction in Iranian adolescents revealed themes of the causes and prevalence of addiction, unhealthy friendship and communication, increased rates of cigarette smoking, alcohol and drugs, barriers to and factors in addiction and health and family and addiction.12 A cross‐sectional study carried out on smoking in Iranian adolescents found that the most common reasons youths cited for initiating cigarette smoking were to attract attention from friends, due to family inattention and due to poverty.13 A cross‐sectional survey to evaluate the extent and potential correlates of sexual risk taking behaviours among adolescent boys in metropolitan Tehran found two factors to be considered as sexual risk taking behaviour: ‘not using condom or, inconsistent condom use in sexual contacts’ and ‘multiple sexual partners in lifetime’.14 A grounded theory study to develop an identity‐based model for adolescent health in Iran found identity as a core variable and the concepts of friendship and relationships, education, family, lack of limitation and community as main categories.8

The health status of Iranian adolescents, specifically their psychological profiles combined with evolving social trends, create a unique challenge for them as they struggle to grow up. It is important to understand their health concerns and needs in relation to their families, as this will promote a pathway to a healthier future for adolescents.

This article explores the perspective of Iranian adolescents on issues of family and their health. Knowledge of these perspectives will help both families and health providers to better understand the health of adolescents, and will help with future planning and provide ideas for more helpful future involvement. These data will be of use to parents, advocates and adolescent health activists to enable them to realise the scope of the challenges confronting them and guide them to focus on their potential resources. The purpose of this study was to explore the perspectives of Iranian adolescents on family factors that may facilitate or inhibit health. The main research question was: ‘Which family factors were health bridges and barriers, and what extreme experiences had adolescents had regarding their health and family?’.

Methodology

Research method

A descriptive, qualitative approach was used to enable the researchers to learn about the perspective of adolescents on health. According to Boswell and Cannon, a qualitative method is suitable for uncovering the complex human issues and what lies behind them.15 The method used is the analysis of the content of narrative data to identify prominent themes and patterns among the themes16 and is a method that is useful for studying phenomena about which little is known.

Sample and data collection method

Purposeful sampling was used. Participants were recruited from schools, their homes, parks and cultural houses in Tehran, the capital of Iran. The criterion for participation in this study was simply being an adolescent (between 11 and 19 years old). After the purpose of the study and the research questions had been explained an appointment was made with those adolescents who consented to participate in the study.

At the beginning of each open‐ended, semi‐structured interview, participants were asked to explain their feelings about their health: which factors they considered to be their health bridges and barriers, and what extreme experiences they had encountered regarding their health.

During the first interview, participants indicated what they understood by adolescent health as a general concept. These responses were used by researchers to develop the interview process overtime, focusing on the main factors identified by participants as affecting adolescent health. Interviews were audiotaped, took place over one to three sessions and lasted between 30 minutes and three hours with an average length of 70 minutes.

Each transcribed interview was initially analysed as a unit; subsequently, all interview themes were analysed together, as a whole. The interaction between data collection and data analysis is clear, each providing the direction for the other. Interviews were conducted until data saturation occurred. According to Polit and Beck, data are considered saturated ‘when themes and categories in the data become repetitive and redundant, and when no new data can be gleaned by further data collection’.16

Ethical considerations

The Nursing Faculty of Tehran University of Medical Sciences (TUMS) gave ethical approval for the research. Adolescents were verbally informed about the aim of the study and were asked to participate voluntarily. Participants were informed that they could refuse to answer a question or withdraw from the study at any time and if a participant asked for his/her tape, it was given to him/her without making use of the data. Consent was also obtained from all principals of the schools which participating adolescents attended. To protect their privacy and confidentiality, interviews were conducted with the participation of only the interviewer and the interviewee and participants were identified by an identification code. Emphasis was placed on creating a relaxed atmosphere during interview through the use of good communication skills. Interviews were continued with those adolescents who were willing to discuss with the researcher their experiences and deep emotions about adolescent health and family. Three adolescents who ceased participation in the study (with a transcript recheck) were permitted to do so.

Data analysis

The interviews were analysed using the qualitative content analysis method. Content analysis has an important place in the wide range of investigative tools valuable to investigators of themes17 and was therefore selected as an appropriate method for the analysis of the study data.

A theme or code is a single assertion about a subject and it is the most useful unit of content analysis. The unit of analysis for this study was a meaningful statement, ranging in length from a word to one or two complete sentences. The first phase of the analysis was line by line coding; key phrases of the transcripts, in participants' own words, were identified and underlined. The underlined codes were rephrased into a shorter code phrase in the second phase of the analysis. Subsequently, those phrases with similar meanings were brought together and subcategories generated. In the final stage of analysis named categories were generated through further abstraction and grouping of subcategory themes.17,18 The data analysis process is shown in Box 1.

Box 1 Data analysis process

First phase. Line by line coding

‘Parents should teach us how to live; they should help us to understand the meaning of life, but every morning they take us to school; they register our names in extra classes. They will do many things for us, but at last we don't learn how to live, in our future real life’.

Second phase. Phrasing shorter codes

Parental responsibility in learning how to live

Parental responsibility to explain the meaning of the life

Doing lots of non‐essential daily activities for children

Negligence from the main parental responsibilities

Learning how to live

A sense of not to be healthy regarding communication with parents

Third phase. Generation of sub‐themes

Necessity of being ready for future real life

Fourth phase. Making and naming

Effective parenting

Data credibility

Credibility of data was established through member (participant) rechecking, peer checking and prolonged engagement with participants and data. The maximum variation of sampling was also used to confirm reliability and credibility of the data themes.19 Five participants were contacted after analysis for member rechecking, and were given a full transcript of their coded interviews with a summary of the themes that had emerged to see whether these reflected their perspective. The researcher's explanations were also added, if needed. Inter‐transcript reliability was established by completing a second review and peer checking, carried out by a number of colleagues who were briefed by the researchers. Transcript and theme rechecking showed acceptable agreement between, and among, different peers and the research team. The results were also checked with five adolescents who had not participated in this research to confirm result ‘fit’. Prolonged engagement with participants and data helped the researcher to obtain the adolescents' trust and to get a better understanding of the research environment. The sampling strategies enabled a maximum variation of sampling to occur and, as a result, a vast range of views and experiences was obtained.

Findings

Participant characteristics

Participants consisted of 41 adolescents aged between 11 and 19 years old, 22 of them female and 19 male. The remaining demographic characteristics of the participants are shown in Table 1.

Table 1
Demographic characteristics of participants

Themes and sub‐themes

Content analysis of the transcripts revealed the following three main themes, each of which embraces two to three sub‐themes. The participants identified family adolescent health factors as consisting of:

  • a widening generation gap
  • effective parenting in adolescent health promotion
  • the family financial situation and health (see Box 2).

    Box 2 Emerged themes and sub‐themes

    A widening generation gap

    • Parental knowledge deficit about adolescents' health risk factors and characteristics
    • Non‐friendly and humiliating parental relationship with their children
    • Traditional parents

    Effective parenting

    • Parental responsibility in adolescents' health promotion
    • Abstinence from drinks and cigarettes in their parents' presence
    • Parental conflicts as an inhibiting factor of adolescents' health

    Family financial situation

    • Parents' joblessness
    • Parents' overload

Theme1: The widening generation gap

The first main theme was the widening generation gap, with three sub‐themes: parental lack of knowledge about adolescent health risk factors and characteristics; an unfriendly and humiliating parental relationship with their children; and traditional parents.

PARENTAL LACK OF KNOWLEDGE ABOUT ADOLESCENT HEALTH RISK FACTORS AND CHARACTERISTICS

A parental lack of knowledge about adolescent health risk factors and characteristics was emphasised by most participants. Adolescents mentioned that this could create communication problems with their parents and this was caused by the widening gap between the two generations.

Participants stated that adolescent developmental changes were usually ignored and normal adolescent changes were interpreted as deviation or stubbornness by parents because of their lack of knowledge about adolescent health risk factors and characteristics. Becoming independent is one of the developmental changes in adolescence and an inappropriate environment to enable this change could be a barrier for adolescent development. Adolescents hoped that parents would learn to appreciate how important it is to have a deeper understanding of them and their changing situation. As one 19‐year‐old female described: ‘We are very different from our parents; there is a wide gap between us. In the past, the girls were similar to their moms and the boys to their dads, but now we can't understand mutual needs and expectations’.

AN UNFRIENDLY AND HUMILIATING PARENTAL RELATIONSHIP WITH THEIR CHILDREN

An unfriendly and humiliating parental relationship with their children was a special issue for adolescents and it formed the second theme. Participants explained that this kind of relationship caused a sense of loneliness, of not being understood, of not having been guided by parents and resulted in decreased participation in family activities. ‘Becoming depressed’ and ‘feeling unhealthy’ were revealed as consequences of an unfriendly and humiliating relationship. As one of the participants, a 14‐year‐old male described: ‘I feel that I am collapsed and crushed when they [my parents] punish me, I'm completely unhealthy when they yell at me.’

TRADITIONAL PARENTS

Some of the participants complained about parents who held traditional values. Participants revealed that they experienced more change, sometimes unwanted change related to use of the internet and satellite media. Adolescents explained that the more they used the internet, the more their pseudo‐needs developed, the more their interest in fashion grew, the more challenges evolved and the wider the gap between adolescents and their parents became.

Adolescents believed that traditional parents could not understand social changes and modernity, which was important from the adolescent perspective. As one 19‐year‐old female described: ‘parents don't understand changes; they should know that everything is changing, so we shouldn't be like them; we shouldn't do the same things they did’.

Theme 2: Effective parenting

Effective parenting was the second main category with three sub‐categories: parental responsibility in adolescent health promotion; abstinence from alcohol and smoking in parents' presence; and parental conflict as an inhibiting factor of adolescent health.

PARENTAL RESPONSIBILITY IN ADOLESCENT HEALTH PROMOTION

Parental responsibility in adolescent health promotion was described as an important factor in adolescent health according to all participants. Participants believed that parents are responsible for the protection and promotion of their children's health. Adolescents stated that they expected the following from their parents: good communication; teaching life skills; identity development; nurturing of self‐esteem and provision of comfort and peace. These themes are clearly revealed in the following quotations: ‘parents should help us to understand the meaning of life, but every morning they take us to school; they register our names in extra classes. They do many things for us, but ultimately we don't know how to live.’ An 18‐year‐old male participant stated ‘If I had a daughter, I would never push her to do this or that; I would teach her how to live; I would make her free to make decisions – even wrong ones – these would be useful for her development’.

Our participants pointed out that parents are responsible for making a safe, warm environment for their children so that they would prefer being at home to being elsewhere. Adolescents complained about their parents repetitious dos and don'ts; as one 19‐year‐old female described: ‘We are fed up with our parents telling us to study, to think of university entrance exams; we never played or watched cartoons. They think that our school status is all our future’.

ABSTINENCE FROM ALCOHOL AND CIGARETTES IN THEIR PARENTS' PRESENCE

Abstinence from alcohol and cigarettes in their parents' presence, because of a sense of shame and out of respect for their parents, has been revealed as an imposed health promotion factor. Although adolescents often complain about limitations imposed by their families, some have had good experiences of such family limitations. Many adolescents speak of travelling and picnicking with their family as a turning point in their teenage life, due to self‐limitation out of respect for their family. As one 18‐year‐old male stated: ‘The time when I was completely healthy was when travelling, because I was with my family, and I couldn't smoke or drink in their presence’.

PARENTAL CONFLICT AS A NEGATIVE FACTOR IN ADOLESCENT HEALTH

The adolescents studied held the views that family has a fundamental supportive role in the psychological aspect of adolescent health and that parental conflict was a negative factor in adolescent health. Participants believed that children are usually the ‘blameless victims’ of parental conflict, which may create many difficulties in adulthood. As one 14‐year‐old male said: ‘My mother and father are fighting with each other so they cannot be kind to me. I failed school last year because of their constant conflicts at home. But they don't see their own problems, only mine’.

Theme 3: The family financial situation

The last category was the family financial situation, which contains the two sub‐categories of parental overload and parental unemployment.

PARENTAL OVERLOAD

Parental overload as a consequence of their financial situation was an important factor in adolescent health as parental stress was generated by overwork. According to the participants, the financial situation as well as the inflation rate, which forced parents to have several jobs, had major implications for both adolescent and family health. Challenges presented themselves as families experienced an ‘imposed modernity’ as mothers changed their role and entered into paid employment. This change in role meant that they could not integrate the family in the same way as they could when they were solely in the homemaker role, nor could they answer the emotional needs of their adolescent children as effectively. These challenges regarding the strong supportive and caring role of the family are, and will be, more important in an oriental culture such as that of Iran.

Participants perceived that fatigued parents, who had several jobs, did not know about their teenagers' developmental needs and were completely out of reach, could limit the potential for adolescent health, and this could also be the case for unemployed parents. Adolescents expected emotional and psychological support more than a nurturing and physiological role from their parents and participants believed that the more parents worked the less the emotional attention they would pay to their children. ‘Now both of our parents have to work; there won't be anyone to talk to, even a short chat; they have no more time and energy to pay attention to their children’. An 18‐year‐old male and 16‐year‐old girl added: ‘they don't know that we need their individual affection and care more than the money they give us’.

Parental unemployment and inflation was another aspect of financial problems identified as important to both adolescent and family health. As one 15‐year‐old male participant put it: ‘I think poverty and a bad financial family situation will cause family problems’.

The main themes and some of the sub‐themes will be developed further in the discussion.

Discussion

In general, qualitative research methods search for answers from the broader social context. The closer we get to the natural state in which health research data are collected, the fewer the limitations that will exist in translating the findings into real‐life applications. According to the participants in this study, the family has a vital role to play in adolescent health.

Methodological considerations

While this study was conducted in a qualitative manner, potential limitations still exist. The naturalistic paradigm of the study and the deeper meaning of health can limit the generation of the findings. The researchers in this study asked about the health of the participants without considering which of the three stages of adolescence – early, middle or late – participants were negotiating. In order to gain a clearer and deeper understanding of adolescent health beliefs, participants' developmental stage could have been considered.

The study also has the limitation that the same female researcher (SP) interviewed both male and female adolescents. Although there were rich data extracted from male participants, in a traditional and religious culture such as that in Iran, males might have had fewer cultural inhibitions and less sense of shyness with a same‐sex interviewer, especially regarding the topics of health and sexual behaviour.

No data were collected for those adolescents who declined to participate, or who asked for their tapes or their transcripts, because of the informed consent process.

Strengths of the study design were that transcripts and codes were reviewed by a variety of people including participants, non‐participant adolescents, colleagues and researchers. As a result of this thorough process the results may be transferable to groups and contexts similar to those represented by the adolescents in this study. Prolonged engagement with participants, maximum variation of sampling and good communication skills have contributed to the deep and rich data gathered in this research.

Theme 1: The widening generation gap

As our participants stated, the widening generation gap can affect both family and adolescent health. The widening gap between generations, social trends, modernity and more virtual communication along with socialisation will increasingly aggravate the problems of the adolescents' traditional families. Our female participants disagreed more with the family's functions and the traditional role of their parents because of the greater limitations and narrower restrictions which they have experienced. Adolescent–parent challenges have also been emphasised in other studies. Independence is important to adolescents, but it is family consistency that matters to parents. The challenges are in these areas: housing, rules and regulations, nutrition and sleep patterns, as well as same‐sex and opposite sex friendships.20 Moreover, troubled relationship with parents and siblings were significant predictors of smoking in Iranian adolescents, notably in girls.13

Parents can have an influence on promoting beneficial adolescent health behaviours and reducing risky behaviours.2 Open and responsive communication, the provision of an appropriate level of supervision and keeping involved in children's lives are associated with better adolescent outcomes in identity formation.20,21 Participants revealed that both they and their parents need more knowledge and better practices to pass through this unstable stormy developmental period. From the adolescents' point of view, schools and media should teach them, though this is already happening. Health care activists, family and school health nurses can be effective in these areas. Community health nurses should have a better understanding of the family changes as they are familiar with the transactions between adolescents and families. According to Allender and Spradley this understanding can help them to develop more appropriate models and thus to solve family problems.22

Unfriendly communication is a challenging issue for both children and parents. The less the parents know about the characteristics of adolescence, the more communication conflicts they will experience. This may be because of the traditional supervisory role of the parents on the one hand, and adolescents' need for independence and for a supportive and informative parental relationship on the other hand.

Changing social norms affects adolescent health in different ways. Traditional parents were targets of complaint because of the limitations that they imposed on adolescents. Because of the sense of limitation, these challenges between adolescents and parents are common in research literature on adolescents.20,21

According to Tsai and Wong, in their qualitative study on adolescent pregnancy in Taiwan, weakening family bonds, cultural changes and a widening generation gap could increase the risk of adolescent pregnancy.23

With regard to education, the imposition of study and majors was another specific issue mentioned by a number of adolescents. Participants claimed that parents tried to enact their own unachieved desires through their children and failed to respect their children's inclinations and talents. The imposed study and majors could also worsen the communication challenges between the two generations. As a result of worry about drug availability, parents push their children to study in order for them to remain protected; a fact which, in turn, creates additional tensions in the families. In one qualitative study, a specific concern mentioned by a number of parents was that of their children's education.24

Theme 2: Effective parenting

The importance of an effective parental role and a warm home environment were emphasised by the participants. The findings of Mollahasani's research on Iranian adolescents showed that adolescents needed their parents to play an active parental role or else they would search for this support outside their home.25 This would indirectly increase the probability of drug addiction. This is an important point as Iran is a high‐risk country for illicit substance misuse as it is a transit path for drug traffickers because of its geographical location. So an effective family and conscientious parents will both be important in preventing adolescent addiction. The mentioned study supports our participants' claims that parents care for adolescents' physical needs, but that psychological needs are more important from the adolescent perspective.25 As our participants said, parents were responsible for ‘preparing a secure, free, warm and relaxed atmosphere at home’, ‘avoiding family conflicts’ and ‘being kind to their children’. Community health nurses can help both adolescents and their parents by teaching them communication skills.26

According to another study, respondents who perceived the parental relationship in the family to be moderate or poor felt lower satisfaction as well as a more negative attitude towards life; they had lower self‐esteem, and experienced a more depressed mood than those who reported a good parental relationship.27 Adolescents who have maternal warmth and attachment, who have caring parents and who are expected by their parents to have high academic achievement are at a lower risk of becoming addicted to drugs. Having appropriate familial relationships and living in an effective family could also decrease the risk of adolescent addiction problems. Parental availability during special times when family members assemble together, for example at dinner time, will help to protect adolescents from addiction28,29 and better family support is associated with lower levels of risk behaviour in adolescents.30

Theme 3: The family financial situation

The importance of the family's financial situation was emphasised by the participants. We make the supposition that the consequences of financial problems, which resulted in parents caring more for the physiological rather than the emotional needs of children, received more criticism from adolescents than the economic problems themselves. Participants perceived that both unemployed parents and fatigued parents who had several jobs frequently did not know about their teenagers' developmental needs, and were completely out of reach of their adolescents so could negatively impact upon their children's health. Some of our participants talked about ‘adolescent health’ and ‘economic justice’ as being inextricably linked. Adolescents' social sensitivity, idealism and comparison with peers contributes to a sense that their health is dictated by divisions in society. Social welfare and adolescents' participation in part‐time jobs can increase their income, enhance their self‐esteem and improve their health perception.

Families change in response to economic conditions.31 Many studies have recognised the central role of socioeconomic factors in determining both adolescent and family health. The physical and mental health of adolescents is related to the structure of their families, their educational attainment, current economic conditions and personal allowances.27,32 Furthermore, perceived family functioning was concurrently related to measures of adolescent psychological wellbeing (existential wellbeing, mastery, life satisfaction, self‐esteem and general psychiatric morbidity) and problem behaviour (substance abuse and delinquency) in Shek's longitudinal study.33

Conclusion

Nurse educators, especially in developing countries that are experiencing a transitional trend, could incorporate the findings of this study into family health nursing education programmes for both public health nurses and students in order to help families develop a better understanding of adolescent health needs. Community and public health nurses should be encouraged to periodically orientate others about adolescent interaction with peers, family and health and the interaction with social factors. Family and school health services should be encouraged to improve both parental and adolescent health by enhancing parental and adolescent communication skills and by keeping parents informed about adolescent changes related to emerging social trends.

Further research is necessary to test which of these interventions is more effective. Other research questions that might be helpful include the following:

  • What are the effective factors in attaining optimal adolescent health?
  • Which familial and sociocultural changes might be helpful in enhancing adolescent health outcomes?
  • What are the experiences and the processes of being and remaining healthy in different adolescent groups?

The family has a fundamental role to play in adolescent health. The participants of this study emphasised three main categories associated with health outcomes: a widening generation gap, effective parenting and family financial situation.

Both adolescents and parents need to know more about how to participate in a healthy family that will train healthy adolescents with more effective social responsibility based on their own realistic plans for their future lives.

ACKNOWLEDGEMENTS

We gratefully acknowledge the very helpful participation of adolescents as well as school staff without whose contribution this study would not have been completed.

The authors also gratefully acknowledge Professor Helena Leino‐Kilpi (Nursing Department, Turku University, Finland) for her very helpful comments.

Our special thanks are dedicated to Mr Ahmadreza Farzaneh Nejad (TUMS) and Mr Damon Tringham (Turku University, Finland) who proofread the earlier manuscript and edited the English version of the article.

This article is written based on the investigator's PhD dissertation at the faculty of Nursing and Midwifery, TUMS; therefore, the official support of TUMS is also acknowledged.

Contributor Information

Soroor Parvizy, Assistant Professor, Nursing and Midwifery Faculty, Iran University of Medical Sciences, Tehran, Iran.

Fazlollah Ahmadi, Associate Professor, Nursing Department, Faculty of Medicine, Tarbiat Modarres University, Tehran, Iran.

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