Factors Associated With Self-Ecacy Toward Healthy Eating and Physical Activity Among Kuwaiti Adolescent Girls

Background: The factors that may inuence adolescents’ health-related behaviors in Kuwait are unclear. We hypothesized that girls’ self-ecacy would be negatively associated with their weight statuses and positively associated with healthy eating-related behaviors. This study aimed to measure healthy eating-related parameters, including self-ecacy, dietary habits, dietary beliefs, nutrition knowledge, and physical activity, in a sample of Kuwaiti adolescent girls and assess the correlates of self-ecacy, including weight status and dietary and health behaviors. Methods: In this cross-sectional, self-administered survey at the school level, we evaluated students of three schools in different governorate locations in Kuwait. The participants were adolescent girls (n=301; mean age, 16.6±1.2 years) who attended secondary schools. The main outcome measures were self-ecacy, dietary habits, dietary beliefs, nutrition knowledge, physical activity, and weight status per body mass index (BMI) categories. Pearson’s correlation analysis was performed to determine the associations among the healthy behavior related parameter scores. The independent samples t-test was used to examine the differences in scores between participants’ characteristics and self-ecacy scores (SES). Multivariate regression analysis was used to determine the nal independent correlates of SES. Results: Only 19.9% of the participants had high self-ecacy toward healthy eating behaviors, 20.9% had “satisfactory eating habits,” 11.3% had a good comprehension of the meanings of healthy and unhealthy dietary habits and food, 16.3% had good nutrition knowledge, and 29.2% had an active lifestyle. SES was negatively correlated with BMI (r=-0.074, P=0.03) and positively correlated with all domains of healthy eating and physical activity. However, SES was not associated with nutritional knowledge. The independent correlates of SES in the multivariate regression analysis were governorate, eating beliefs, healthy eating score, and physical activity (R 2 =38.3%). Conclusions: Adolescent girls in Kuwait demonstrated a high level of self-ecacy toward healthy eating and behaviors and had rm nutritional beliefs; however, they failed to translate their beliefs into good nutritional habits. It is necessary to develop interventional nutrition programs at the

Background Adolescent obesity is a major health concern in Kuwait. According to the latest survey conducted by the 2018 Kuwait Nutrition Surveillance System [1], 21.5% of adolescents are overweight, and 27.5% had obesity. Overweight and obesity correlate with age in both sexes [2]. There is consensus among researchers that adolescence is a transition period when teenagers gradually become independent and responsible for their own eating behaviors and attitudes [3]. During adolescence, young people assume responsibility for their own eating habits, health-related attitudes and behaviors, and their growing independence is often associated with unconventional eating patterns. Any retained dietary habits and nutritional knowledge acquired in adolescence may persist in adulthood and would have important lifelong rami cations [4,5,6]. Unhealthy eating habits commonly reported among Kuwaiti adolescents include fast food consumption, skipping breakfast, consumption of high-calorie snacks, and low consumption of fruits and vegetables [7,8]. Fewer studies have reported on the factors that affect the eating habits of Kuwaiti adolescents. Musaiger et al. [9] found that the lack of information and motivation were the main barriers keeping adolescents from eating a healthy diet. It is unclear what factors may in uence adolescents' health-related behaviors in Kuwait, and more studies are needed to identify what motivates and helps adolescents adopt healthy eating habits.
According to the social cognitive theory, behaviors are mediated by variables such as self-e cacy, attitudes, and knowledge. The concept of self-e cacy was de ned by Albert Bandura as an individual's beliefs toward his/her own ability to do something or his/her con dence in doing so. Martens et al. [10] found that food choice decisions were affected mainly by attitudes toward health, with positive attitudes being associated with higher intake of fruits and breakfast and less intake of high-fat snacks. Fitzgerald et al. [11] found that higher self-e cacy toward making healthy food choices was associated with healthy food intake among adolescents in Ireland. Furthermore, knowledge about healthy food choices may help improve eating habits and thus facilitate the adoption of a healthy diet [12,13,14]. Such factors in uencing food choices and eating behaviors and their interrelations have never been investigated in Kuwaiti adolescents. This research is important to determine the intervention strategies needed to address adolescents' nutrition-related health problems and improve healthy eating behaviors among them.
The present study was conducted to measure psychosocial determinants of eating behaviors in a sample of Kuwaiti adolescents, focusing on self-e cacy as the major outcome measure and to investigate the relationship between self-e cacy and dietary beliefs, physical activity, nutritional knowledge, and weight status in a sample of Kuwaiti adolescent girls. We hypothesized that girls' self-e cacy would be associated negatively with their weight statuses and positively with healthy eating-related behaviors.

Study design
The present cross-sectional study was conducted between October 2014 and February 2015 among adolescent girls recruited at three different high schools in Kuwait. A self-administered survey questionnaire was used to collect data on sociodemographic characteristics, anthropometric variables, body weight, dietary behavior, and health-related lifestyle habits. The data were collected during regular school hours.

Recruitment and sampling
Three hundred and one participants (n = 301) were conveniently sampled at three different schools located in three different governorates: Asema and Al-Jahra (both public schools), and Hawally (a private school). Each school location is characterized by special demographic and socio-cultural features as per the residential governorate of the students. For example, the educational levels of the Kuwaiti residents in Al-Jahra had been noted to be lower than those of Kuwaiti residents in Asema and Hawally. Although intermediate or secondary education is the dominant education category in each governorate among the adult population, 28.7% of Al-Jahra residents received only primary education or lower, whereas more than 40% of residents of Asema and Hawally reported being educated to college level or higher [15]. Several schools were invited to participate in the study, and only those who showed a willingness to cooperate in the research were approached by the research team. Ethical approval was obtained from the Ministry of Health and the Ministry of Education (approval no. 34751, January 26, 2015). Participating classrooms were chosen by the school administration based on scheduling convenience, and students were selected from each classroom randomly. Parental written informed consent was obtained prior to collecting data. All students aged 13-19 years who were willing to participate were included in this study.

Survey questionnaire: construction and validation
The survey questionnaire was initially adopted from that formulated by Turconi et al. [16]; however, many of the items were modi ed to render the nal questions appropriate for Kuwaiti adolescents. The survey questionnaire included six main sections in addition to the rst section on demographic information. The questionnaire contained a total of 48 questions. The survey questionnaire included the following six scales. (1) Self-e cacy: measured the level at which participants can assume attitudes and behaviors that can improve health statuses related to nutrition, with the possible outcomes presented as the shortest form of the Likert scale that included "yes," "I do not know," and "no" and scored as 3, 2, and 1, respectively. This section consisted of seven questions. The maximum possible score was 21, and the scores were divided into three tertiles categories based on sample distribution: low self-e cacy (scored 0 to 16), moderate self-e cacy (scored 16 to 19), and high self-e cacy (scored 19 to 21). (2) Nutritional knowledge: assessed a few nutritional aspects. This section consisted of 7 items. The maximum possible score was 7, and the total scores were divided into three categories based on sample distribution: insu cient knowledge (scored 0-3), good knowledge (scored 3-4), and very good (scored 4-7). (3) Dietary beliefs: measured participants' understanding levels in identifying the concepts of a healthy diet, the healthiest foods, and the healthiest cooking methods. This section consisted of three items. The maximum possible score was 12, and the total scores were divided into three categories based on sample distribution: little comprehension of the meaning of healthy and unhealthy food and dietary habits (scored 0 to 9), su cient comprehension of the meaning of healthy and unhealthy food and dietary habits (scored 9 to 11), and good comprehension of the meaning of healthy and unhealthy food and dietary habits (scored 11 to 12). (4) The healthy eating score (HES) was determined from participants' food frequency consumption, which represented the adequacy of intake of major food groups, including the daily consumption of fruits and vegetables, dairy products, carbohydrates, and meat. Furthermore, the intake of sweets, fast food, high sugar drinks, and energy drinks were measured.
Frequency of intake was measured as daily intake or intake per week if the food was not consumed daily; the ideal answer had the highest value, while the worst answer had the lowest value, according to the USDA sex and age-speci c guidelines [17]. The serving sizes were explained verbally, and illustrative graphics were included in the questionnaire to ensure that the adolescents could estimate food intake more accurately [18]. This section consisted of 19 items. The maximum possible score was 94, which indicated the best possible food intake pattern. (5) Dietary habits: assessed breakfast habits, consumption of foods containing high sugar levels after meals, the number of main meals in the day, and the type of snacks consumed daily. This section consisted of four items. The maximum possible score was 16, and the scores were divided into tertiles based on sample distribution: "inadequate eating habits" (scored 0-9), "partially satisfactory eating habits" (scored 9-12), and "satisfactory eating habit" (scored 12-16). (6) Physical activity: assessed physical activity levels, types of activity, and the number of hours spent in physical education (PE) classes. This section consisted of seven items. The maximum possible score in this section was 18, and the scores were divided into three categories: sedentary physical activity level (scored 0-8), moderate physical activity level (scored 8-10), and an active physical activity level (scored 10-18). The possible choices from all scales were coded in descending order from the healthiest answer (best value) to the least healthy one (least value).
The adopted survey questionnaire was tested for validity and reliability through four stages. The survey questions were reviewed for face validity by two faculty members of the Department of Nutrition and were translated into Arabic and back translated to English by a professional translator. A student researcher also reviewed the Arabic version to ensure that the wording was appropriate for the Kuwaiti students and could be understood clearly. Inconsistencies between the two versions were discussed and revised by the researchers. The modi ed questionnaire was tested for content validity by ve local experts in nutrition using Lawshe's method. All items with content validity ratios below 0.78 were excluded, and adjustments were made until a consensus was reached on the nal version [19]. Comprehensiveness and clarity were assessed by conducting structured interviews with a sample of adolescents (n = 10) who were not included in the main survey sample to con rm comprehension and feasibility for this age group. The nal version of the questionnaire was assessed for reliability using an additional group of adolescents (n = 33). Scores of the same students (2 weeks between 2 sittings) were assessed for testretest reliability; however, these students were not included in the main study sample. Cronbach's α was calculated for total subscales and recalculated if an item was removed from a subscale to improve consistency. The good consistency of the scale was de ned for Cronbach's α values between 0.5 and 0.7 based on the dimensionality of the scale [20]. However, a lower Cronbach's α was considered su cient to indicate consistency for scales with less than ten items [20]. Cronbach's α values ranged from 0.43 to 0.76, demonstrating acceptable internal consistency, similar to that reported in a study conducted by Turconi et al. [16].

Anthropometric measurements
Students' weights and heights were measured using a beam balance scale (Detecto eye-level scale with height rod, model number 2391; Acculab Digital Scales, USA). Students were asked to take off their shoes prior to measurement. Weights were recorded to the nearest decimal fraction, while heights were recorded to the nearest whole digit. The body mass index (BMI) was calculated by dividing the weight in kilograms by the square of the height in meters. The weight status was assessed using the Centers for Disease Control and Prevention growth charts and classi cations such that underweight, normal weight, overweight, and obesity were de ned as a BMI < 25th percentile, 25th ≤ BMI < 85th percentile, 85th BMI < 95th percentile, and BMI 95th percentile, respectively [21].

Sociodemographic information
The questionnaire included questions on each student's governorate, student's nationality, father's and mother's nationalities, father's and mother's educational levels, mean family income, major (science or literature), birth date, in addition to two questions: "Are you interested in receiving nutrition information?" and "What is the preferred source of any received nutrition information?"

Statistical methods
All variables were assessed for normality. Descriptive statistics were provided using means and standard deviations for continuous variables, frequencies and proportions for categorical variables, and prevalence for weight status. Analysis of variance with Bonferroni's correction was used to study the associations between tertiles of self-e cacy scores and other health-related domains. Pearson's correlation coe cients were determined for the relationship between the scores of the six scales and BMI. All scores, except for the HES, were divided into tertiles based on the sample distribution. Analysis of variance was used to compare the differences in mean scores across tertiles. Multivariate regression was used to determine the nal independent correlates of self-e cacy scores (SES). The data were coded, entered, and analyzed using SPSS Statistics version 24 (SPSS Inc., Chicago, IL, USA). Analysis items with P < 0.05 were considered statistically signi cant.

Population characteristics
A total of 301 participants (mean age, 16.6 ± 1.2 years) completed the study. We obtained equal participation from all three locations: Asema (n = 100, 33.2%), Al-Jahra (n = 100, 33.2%), and Hawally governorate (n = 101, 33.6%) ( Table 1). Kuwaiti students constituted 73.5% of the sample, whereas 26.5% were of other nationalities. Most of the students' parents had educational levels of bachelor's degree and higher (78.5% and 74.9% for fathers and mothers, respectively). With regards to family income, 11.2% reported income levels less than 1500 Kuwaiti dinar (KWD) per month, 41.4% reported income levels between 1500 and 2000 KWD per month, and 47.4% reported income levels above 2000 KWD per month (Table 1). Sixty-six of the participants (66.2%) reported that they were interested in receiving information on nutrition, while 15.2% were not interested in receiving information on nutrition, and 18.6% were unsure. When asked about their preferred source of nutritional information, 43.6% reported having received information from social media. The majority of students reported that they were not getting any nutritional information from health professionals (73.5%) or their schools (89.9%) (data not shown in the tables). The mean BMI was 25.26 ± 5.61 kg/m 2 . We found that 2.4% of participants were underweight, 54.9% had normal weights, 24.1% had overweight, and 18.5% had obesity.    Table 2). Overall, 20.9% of participants had "satisfactory eating habits," 55.9% had "partially satisfactory eating habits," and 23.3% had "inadequate eating habits" ( Table 2). For dietary beliefs, the mean score was 9.51 ± 1.97 (at 79% of the total score; IQR 8-11). Twenty-nine percent (28.9%) of participants showed poor comprehension about healthy and unhealthy food and dietary habits, 59.8% showed su cient comprehension, and only 11.3% showed good comprehension ( Table 2). More than sixty percent (68.4%) of the students believed that "a healthy diet is varied and includes all food groups," 64.8% of the participants identi ed correctly "washed ready to eat vegetables" as the healthiest food item from a list; 65.1% identi ed "cooking on a grill/in boiled water" as the healthiest cooking method, but the best answer was "cooking in the oven without fats" answered correctly by 21.9% of the sample.  (16)(17)(18)(19), and high (19)(20)(21) b Dietary habits score tertiles: low (0-9), moderate (9-12), and high (12)(13)(14)(15)(16) c Dietary beliefs score tertiles: low (0-9), moderate (9-11), and high (11)(12) d Physical activity score tertiles: low (0-8), moderate (8)(9)(10), and high (10)(11)(12)(13)(14)(15)(16)(17)(18) e Nutrition knowledge score tertiles: low (0-3), moderate (3)(4), and high (4-7) For physical activity (Table 2), the mean score was 9.05 ± 2.72 (at 50% of the total score; IQR 7-11). Almost a third of the sample (30.9%) had sedentary physical activity levels, more than a third (39.8%) had moderate physical activity levels, and another third (29.2%) reported active physical activity levels. Only 9% reported that their physical activity levels were high during their free time with activities such as brisk walking, dancing, swimming, and biking. More than two-thirds of the students (75.4%) reported that they participated in school-based PE classes, and 41.9% spent one hour per week in PE. Students perceived PE classes as "boring" (48.2%), "tiring" (15.3%), "make me feel well, healthy, and happy" (23.9%), and only 8% found PE classes to "stimulate them away from routine classroom activities." With regard to sedentary behaviors, 79.7% reported that they preferred watching television, listening to music, using the computer, or reading a book during their free time. Moreover, 33.9% spent more than 6 hours per day engaging in sedentary activities such as watching television, sitting at the desk, and playing with electronic gadgets. The average score for nutrition knowledge was 3.44 ± 1.12 (at 49% of the total score; IQR 3-4) ( Table 2). Overall, the nutritional knowledge was insu cient in 19.6% of the sample, good in 64.1%, and very good at 16.3%. Students were able to identify sources of carbohydrates (76.3%) and proteins (78.7%), and less able to identify sources of ber (43%). The majority of participants failed to identify foods that were low in fat (73.9%) or calorie-dense (79.4%). Most of the students (85%) were familiar with the concept that a "balanced diet" contains all the nutrients in proper quantities.

Comparison among locations
Differences in the mean scores of the six survey domains among school locations were assessed (Additional Table 3). There were no signi cant differences in the mean scores of HES among locations. In terms of food habits score, the Al-Jahra governorate had signi cantly the lowest mean score (9.6 ± 2.4 vs. 10.5 ± 2.4 for Asema and 10.9 ± 2.4 for Hawally), and the Hawally governorate school had signi cantly the highest physical activity score (10.1 ± 3.1 vs. 9.0 ± 2.2 for Asema and 8.0 ± 2.4 for Al-Jahra), dietary beliefs (10.3 ± 1.6 vs. 9.4 ± 2.1 for Asema and 8.9 ± 2.0 for Al-Jahra), and nutritional knowledge (4.0 ± 1.2 vs. 3.3 ± 0.9 for Asema and 3.0 ± 1.0 for Al-Jahra). The Asema governorate had signi cantly the lowest mean self-e cacy score (15.7 ± 4.0 vs. 17.4 ± 2.8 for Al-Jahra, and 17.9 ± 2.5 for Hawally). There were no differences in BMI and BMI percentiles among locations (P > 0.05). Correlates of self-e cacy Students who were in the highest SES tertile had the highest HES (47.6 ± 7.9) and physical activity score (9.7 ± 2.8) (Table 3). Furthermore, those in the upper two tertiles for SES scored higher than the 1st tertile for dietary beliefs (9.7 ± 1.9) and dietary habits (9.9 ± 1.8), respectively. When analyzing food frequency components, we found a signi cant association between SES and intake of dairy products, fast food, and sugar-sweetened beverages (Additional Table 1). Students with higher SES consumed dairy products more frequently and consumed fast food and sugar-sweetened beverages less frequently compared to those with lower SES. Also, we found signi cant associations between SES and snacking habits; that is, those participants with high SES tended to snack more on fruits or fruit juices/ milk or laban/yogurt/ dried fruits/ dates and were less likely to snack on candies/ chocolates/ sweets and cakes/ ice cream (Additional Table 2).
SES was positively associated with HES, dietary habits, dietary beliefs, and physical activity, but not with nutrition knowledge. Both SES and physical activity were negatively associated with BMI (Additional Table 4). In the univariate analysis, the nal correlates of SES, which we included in our multilinear regression model, were the governorates, BMI, and the scores of the following domains: HES, dietary habits, physical activity, and dietary beliefs ( Table 4). In the multivariate linear regression analysis, SES remained signi cantly associated with the governorate (β = 0.813, P < 0.001), physical activity (β = 0.153, P = 0.038), dietary beliefs (β = 0.245, P = 0.026), and HES (β = 0.173, P = 0.023) ( Table 5).

Discussion
To our knowledge, the present study is the rst to attempt to assess self-e cacy in relation to healthpromoting behaviors, such as physical activity and healthy eating among adolescent girls in Kuwait. The sample of adolescent girls assessed in this study demonstrated a moderate level of self-e cacy. However, those with the highest level of self-e cacy had better health-related behaviors, including more engagement in physical activity and consistent healthier dietary habits and food choices. This is in accordance with the results of several studies among adolescents that showed correlations between selfe cacy and increasing physical activity [22], increasing intake of fruits and vegetables, and engagement and adherence to weight control behaviors [23]. Self-e cacy is gained through knowledge, understanding, and skill development, and it is an important component in effective health communication and disease prevention interventions [24]. Self-e cacious people tend to be optimistic about engaging in behaviors, rather than focusing on negative thoughts about their inability to achieve a goal, are more likely to take on challenges easily, have a greater sense of commitment, and cope better with unexpected events or disappointment [24]. Non-e cacious people avoid challenges and fail at tasks perceived to be beyond their abilities, and they have little incentive to act or persevere in the face of di culties [24]. Fitzgerald et al. [11] showed that higher self-e cacy was associated with 'healthy food intake' in adolescents aged 13-18 years. In addition, lower self-e cacy for healthy eating and higher peer support for unhealthy eating were associated with 'unhealthy food intake.' Nastaskin and Fiocco [25] found that high self-e cacy was associated with the lowest levels of fat and sodium intake.
We found that female students with the highest self-e cacy had higher scores on dietary beliefs; that is, they had a better comprehension of what constitutes healthy versus unhealthy dietary practices. Dietary beliefs can in uence motivation and behavior; thus, it can guide the individual's capacity to carry out actions and make decisions that are part of success in progressing to positive outcomes. This is consistent with the role of self-e cacy in decision making, outlined by Bandura's social cognitive theory.
Glasofer et al. [26] found that among adolescent girls (n = 110, mean age 14.5 ± 1.7 years; mean BMI 27.1 ± 2.6 kg/m 2 ), self-e cacy (both general and eating-related) was negatively associated with selfreports of disinhibited eating behaviors (i.e., less frequent loss of control while eating in the past month).
The researchers identi ed that those girls least likely to believe in their ability to in uence outcomes were most vulnerable when faced with a toxic food environment such as a buffet meal [26]. Further, higher self-e cacy correlated positively with weight-conscious behaviors, such as eating more proteins as promoted by diet culture [26]. Several studies showed that self-e cacy was positively associated with healthy eating behaviors and negatively with unhealthy eating behaviors. Among female adolescents in Minnesota, self-e cacy toward making healthy food choices was signi cantly positively related to calcium intake [27]. Moreover, another study showed that self-e cacy toward low-fat milk consumption was correlated positively with low-fat milk consumption and negatively with sweetened beverages consumption [28]. In this study, self-e cacy toward health and nutrition was positively correlated with healthy eating habits and physical activity, and negatively with BMI.
We found that students with su cient nutrition knowledge about healthy and unhealthy foods and dietary habits had better eating habits. Musaiger et al. [9] found that one of the main barriers to healthy eating among adolescents was not having enough information on what constitutes a healthy diet. Wardle et al. [14] reported that nutritional knowledge was associated with higher intakes of fruits and vegetables and less intake of fat. Grosso et al. [12] demonstrated that improving nutrition knowledge in children and adolescents may lead them to adopt healthier eating behaviors. Contrary to our expectation, we did not nd a relationship between nutrition knowledge and self-e cacy. Among the adolescent girls, we identi ed a gap in knowledge about dietary ber, protein, and energy contents of food, which may indicate that they face di culties in translating nutritional advice into food choices that improve their diet [29]. The overall nutrition knowledge in our sample was low, similar to that in previous reports among Kuwaiti adolescents and college students [30,31]. We also found that the father's educational level was positively associated with students' level of nutritional knowledge [31]. The education of the father may re ect his high awareness and acquaintance with healthy nutrition and its impact on family health, and thus, may in uence their children's knowledge. Nutritional knowledge may be a predisposing factor for eating behaviors; however, voluntary behavior improvement requires motivation, ability, and opportunity to improve one's behavior. For example, having more experience with meal preparation and kitchen experiences increase con dence and independence in dietary decisions [32]. Lack of nutritional knowledge may be due to the lack of knowledge on nutrition-speci c information related to dietary concepts more than those gained with a general understanding developed through the family environment or peer pressures [11]. In support of these concepts, students from the Hawally governorate showed better nutritional knowledge scores than those from the other two governorates in terms of nutritional knowledge and dietary beliefs. We speculate that this is because it was the only school that reported providing a nutrition class in their curriculum. The school environment can be an important setting for providing, promoting, and supporting healthy lifestyles among youth [33]. It was clear from the students' responses about their source of information that there was a lack of a reliable source for this age group, as the majority of the female students reported getting information on nutrition from social media (43.6%) and rarely getting any information on nutrition from schools (10.1%) or health professionals (26.5%).
In support of the above ndings, we found that self-e cacy differed signi cantly according to governorates, and the governorate was found to be a major correlate in the multivariate regression model. Students from Al-Jahra scored the lowest in dietary habits and belief scores, physical activity, and nutrition knowledge. Students from the Asema governorate scored the lowest in SES. These observations can be partly explained by the fact that each governorate in Kuwait is characterized by special demographic and socio-cultural features. Similar to the results of a prior national survey, we found that according to the variations in parental educational levels among governorates, 28.7% of the Kuwaiti residents in Al-Jahra had received only primary education or less, whereas intermediate or secondary education was the dominant education category in other governorates, and over 40% of respondents in Asema and Hawally reported having received college education or higher [15]. Much of the variations found in SES between governorates may be due to sociodemographic characteristics, family dynamics, and parenting style, which need further exploration in future studies [34,35].
The prevalence of overweight and obesity (42.6%) was high in our sample, similar to those reported at the national level [1]. This can be partly explained by the poor eating habits found among the adolescent girls, evidenced by very low consumption of fruits and vegetables and high frequency of fast food intake, snacking on sweets, and drinking sugary beverages. These ndings are similar to those reported in earlier surveys [8]. Many factors increase fast food consumption among adolescents in Kuwait, including the availability of fast food restaurants 24 hours per day and 7 days per week, accessibility by home delivery, and the low prices [36]. In our sample, snack components were mainly sweets such as candies, chocolate, and ice creams (41.5%). The preference for sweets may be related to sex; as adolescent girls, hormonal changes may affect food choices and desires. Similarly, a preference for sweets as a snack choice was reported in Bahrain, where female students consumed sweets and chocolates more than males, and the majority of the female students reported that they consumed sweets and chocolates daily [37]. Stress was also shown to affect adolescents' food choices, but self-e cacy may be the moderator between stress and food intake [25].
Notably, in our sample, BMI was negatively associated with self-e cacy as shown by other researchers [38,39]; however, this relationship did not remain after considering all the various covariates in the multivariate regression model. In fact, there was no difference in weight status among SES tertiles in our sample. Our data showed that the relationship between weight status and self-e cacy could be modulated by physical activity, dietary beliefs, HES, and interacting factors related to the variations in the governorate or school location. All these factors may individually or synergistically affect weight status and susceptibility to overweight or obesity. Therefore, it is di cult to tease out an independent relationship.
Overall, physical activity levels were moderate in our sample at a higher level in the private school.
Physical activity scores showed that a majority (81%) of participants spent their free time engaging in sedentary activities such as listening to music and using their tablets, laptops, and computers, and only 10% spent their free time engaging in high-level physical activities. In addition, more than a third of the sample spent more than six hours per day, engaging in sedentary activities. These observations are similar to those of previous studies conducted among adolescents [8,38], which showed that adolescents' lifestyle habits consisted of spending several hours engaging in sedentary activities. Women are faced with more barriers to physical activity than men in Arab countries [9]. Some of the main barriers that were perceived to be somewhat important or important among female adolescents in Kuwait were "not having the time to be physically active," "the climate is not suitable for exercising," the "lack of motivation for physical activity," "less support from teachers," and the "lack of time." Similarly, we noted that increasing engagement in physical activity and decreasing sedentary behaviors among female adolescents are areas that need attention to promote a healthier and happier school environment among them. Expressing boredom and tiredness in relation to their PE classes, demonstrated that the students lacked motivation and had low self-e cacy.
Self-e cacy could be a primary target area for interventions leading to healthier lifestyle habits among adolescents. Particularly, combating the growing problem of obesity in adolescents in Kuwait is a public health priority. However, Boodai et al. [40] found poor adherence to obesity interventions among adolescents with obesity and their families in Kuwait, and their engagement in the offered interventions was limited. Adolescents and their parents expressed a low degree of concern about obesity, especially with respect to the fact that health-related quality of life was not impaired compared to that of their peers with healthy weights [40]. Furthermore, Al-Isa et al. [41] found multiple cardiometabolic risk factors in adolescents with obesity in Kuwait. Therefore, to implement effective interventions among adolescents, researchers should begin with a period of e cacy building, followed by a period of behavior change to yield maximum results. Furthermore, programs with such a structure should be evaluated in a subsequent randomized controlled trial [42].
The strengths of this study are: we collected data from 3 different schools in the largest governorates in Kuwait and used locally validated scales to measure SES and health-related behaviors. The limitations were: the sample consisted of only adolescent girls aged 13-19 years old, and therefore, the results may not be generalizable to adolescent males or younger females. Due to the recruitment strategy, these results may not be representative of their schools or their governorates and can only be considered as results of a pilot study. Therefore, future larger studies are warranted to determine these relationships in a more randomized sample using a cluster sampling method. This would require national efforts from the Ministry of Education to facilitate research, as cooperation from the school administration was very limited. In addition, due to the cross-sectional nature of this analysis, we can only infer associations among these variables but not a causal relationship. Future research should use a larger sample size to test statistical assumptions and evaluate the generalizability of results. Finally, prospective interventional studies should assess whether a change in self-e cacy may increase participation and adherence to health-promoting interventions.

Conclusions
Identifying self-e cacy and the interacting factors related to adolescents' health-promoting behaviors, including engagement in physical activity and healthy eating, is needed to design effective interventions for adolescents. These domains are important, warrant inclusion as part of the main outcomes of interventions, and may be more informative than focusing on weight alone. Teachers and health professionals should put more effort into helping adolescents understand the importance of meeting their dietary recommendations, especially encouraging the consumption of fruits and vegetables.
Schools should promote physical activity and ensure that PE classes are encouraging, age-appropriate, and enjoyable by offering a variety of activities. Furthermore, programs that target self-e cacy for healthy eating could be bene cial in improving eating habits among adolescents in Kuwait.