The results suggest that this sample of adolescents presents a healthy Lifestyle, assessed by the Lifestyle Questionnaire. Although higher than 50%, the Monitored Safety and Nutrition subscales were the subscales with a lower average score. With regard to Social Skills, half of the sample has a highly elaborate repertoire and, as the literature indicates and was expected, the adolescents with the healthiest Lifestyle are those with improved Social Skills resources . In addition, a solution of three clusters was found where cluster 3, the “Healthy”, was the biggest one and cluster 2, the “Sociable” was the most in need of skills-based health education programs.
Regarding the Monitored Safety subscale, the item that assesses if adolescents travel with someone who drank too much was the one that presented lower values (M=3.43, SD=1.91, ranging between 1 to 5). This result may be related to the mean age of the present sample and not a risk behaviour. However, it is worth mentioning that, in Portugal, the greatest occurrence of road accidents in motorized two-wheeled vehicles occurs mainly in male adolescents [32, 33] and, in the European Union, the highest prevalence of deaths has been observed in male adolescents between the ages of 15 and 29 years . In addition, one of the main causes of death and disability is alcohol consumption , and the injuries related to accidents or violent behaviors frequently associated with alcohol consumption are indicated as the major cause of death in childhood and adolescence (from 5 to 19 years) . Although recent data suggests a decreasing trend in the prevalence of alcohol consumption in both sexes at age 15, it suggest an increase in 16-year-old female adolescents , emphasizing the urgent to need to address this major cause of death and disability in adolescents, especially if associated with driving behaviors. Fortunately, according to the most recent results of the Health Behaviour in School-aged Children study in Portugal , from 6742 adolescents, most of them have never tried tobacco (93,7%), rarely use alcohol (90%), or drugs (96.1%), and 88.2% have reported never getting drunk.
Concerning the Nutrition subscale, the item that evaluates the consumption of foods with sugar had the lowest average score, highlighting that a high proportion of adolescents do not avoid foods with sugar. These results are in line with the national scenario that, as demonstrated in the Health Behavior in School-aged Children study, more than half of the Portuguese adolescents who participated in the study, reported consuming sweets and soft drinks at least once a week and more than two-thirds said that they sometimes ate unhealthy foods [36-39]. Despite the encouraging results of the present study, which highlight a healthy Lifestyle in a representative sample of adolescents in the Tâmega and Sousa region, nutrition / food and monitored safety require greater investment in implementing skills-based health education programs given the association of Social Skills with Lifestyle (ranging between r=.07 and r=.25 with p<.01 and p<.05).
Regarding the second objective of this study, the cluster analysis allowed the identification of three groups of adolescents with different behavior profiles. One of the clusters identified was named “Adjusted” because the adolescents in it showed less elaborate repertoire of Social Skills but good Lifestyle indicators. This group seems to have sufficient Social Skills to adopt good and healthy behaviors. The second cluster was named “Sociable” because this group of adolescents showed high social abilities but some difficulties in adopting healthy and adequate Lifestyles especially regarding Nutrition and Monitored Safety, suggesting a protective effect of Social Skills . The third cluster was called “Healthy” because it was the group of adolescents with highly elaborate repertoire of Social Skills, and with the healthier Lifestyle.
In addition, results showed that the Nutrition subscale was related to Civility skills, suggesting that the promotion of this social competence can, in turn, increase health awareness and health behaviors, especially with regard to diet and nutrient planning. Interestingly though, no significant relationships were found between the Monitored Safety subscale and Social Skills. This result may be related with the age range of the sample and with the fact that these adolescents did not have the legal age to drive yet (>18 years old). However, among the Monitored Safety behaviors evaluated in the questionnaire used in the study (“When I travel by car, I put my seat belt; I did not travel with a driver who drank too much; When I travel with someone, I like to maintain speed limits”), not travelling with a driver who drank too much, was the behavior reported with less frequency. It is also noteworthy that this group of adolescents, designated as “Sociable”, was older than the group of adolescents in the “Adjusted” and “Healthy” clusters, but even so, ages ranged from 12 and 14 years old. Probably, the adolescents in this group are still too young to drive with friends. We also found that girls in this cluster do less exercise compared to boys, as the literature indicates . Knowing that levels of physical activity are below those recommended by WHO , this result emphasizes the need to promote the involvement of girls in physical activity. However, we did not find differences in Lifestyle according to age, which may be related to the homogeneity of the sample (70% of the sample of this cluster consists of adolescents between 12 and 14 years of age).
Limitations and directions for future research
This study has some limitations that should be pointed out. The instruments used were self-reported and anthropometric data of adolescents, while demographic data of parents (such as age, socioeconomic status and household composition) were not collected. The study included only adolescents from the Tâmega and Sousa region, requiring a careful generalization of the findings. However, it is important to highlight that this region is characterized by a high prevalence of Tuberculosis  which, in addition to other factors, is also related to an unhealthy Lifestyle .
For future studies, we suggest an assessment of adolescents and their parents given the direct influence of parents’ Lifestyle on their children's Lifestyle [42, 43]. Moreover, White and Halliwell  found that adolescents’ perception of the mealtime environment contributes to the protective effect of family meals i.e. family meals were significantly associated with a lower likelihood of alcohol and tobacco use. In addition, parental styles should be evaluated; especially the parental style of the mother, since literature has been suggesting that it influences the children's adoption of high-risk behaviors . Screen time consumption is also a concern given the association with a reduced level of physical activity  and future studies should control this variable. Several studies have shown an advantage in the use of text messages, internet programs and chats, apps (e.g. whats`app), as effective tools to instigate behavior changes in adolescents [47, 48]. This is, in fact, a controversial topic that needs further research.
Implications for practice
This study reveals some implications for practice. In relation to the sample under study, we suggest regular health education sessions focused mainly on sugar intake behaviors, meal planning and travel safety with a driver who drinks too much (i.e. Social Skills training), as well as promoting the involvement of girls in the practice of physical activity. Given that previous behavior is the best predictor of the intentions to adopt healthy behaviors, namely, having a balanced diet, practicing sports, not drinking alcohol and not smoking or taking drugs  we suggest that health education sessions should be implemented in the school context [50, 51]. However, there are several activities that could be included in the physical activity curriculum that would be more attractive for girls than football or volleyball. Thus, the promotion of a healthy Lifestyle should be included in the school curriculum and be transversal to all academic disciplines.
In general, health education sessions should include factors that protect the adoption of risk behaviors, engage the main contexts of adolescent life, and address various health behaviors and target risks [36, 52]. The school context is in fact, privileged to carry out actions of this nature, but the inclusion and involvement of both adolescents and parents becomes fundamental. The promotion of an available repertoire of Social Skills that educates adolescents to a competent social style in Lifestyle choices is essential [53, 54]. Moreover, promoting emotional regulation as well as adaptive coping strategies is crucial for health promotion, especially in this population . For example, self-regulation cognitions are positively related to healthy eating in adolescents . Managing emotional regulation during class, conflict resolution, decision making, and choice may help adolescents in the adoption of health and protection behaviors. The most recent report of the Health Behaviour in School-aged Children study in Portugal , recommends the continuation of adolescent health programs, including sex education in schools, higher age limits for alcohol consumption and obligatory use of seat belts and helmets, in order to promote healthier lifestyles in adolescents, prevent deaths and disability.