Parental and Familial Factors Influencing Physical Activity Levels in Early Adolescence: A Prospective Study

Abstract

Parental/familial factors are important determinants of the physical activity level (PAL) in children and adolescents, but studies rarely prospectively evaluate their relationships. This study aimed to evaluate the changes in physical activity levels among adolescents from Bosnia and Herzegovina over a two-year period and to determine parental/familial predictors of PAL in early adolescence. A total of 651 participants (50.3% females) were tested at baseline (beginning of high school education; 14 years old on average) and at follow-up (approximately 20 months later). The predictors included sociodemographic characteristics (age, gender) and parental/familial factors (socioeconomic status of the family, maternal and paternal education, conflict with parents, parental absence from home, parental questioning, and parental monitoring). Physical activity levels were evidenced by the Physical Activity Questionnaire for Adolescents (PAQ-A; criterion). Boys were more active than girls, both at baseline (t-test = 3.09, p < 0.001) and at follow-up (t-test = 3.4, p < 0.001). Physical activity level decreased over the observed two-year period (t-test = 16.89, p < 0.001), especially in boys, which is probably a consequence of drop-out from the sport in this period. Logistic regression evidenced parental education as a positive predictor of physical activity level at baseline (OR [95% CI]; 1.38 [1.15-170], 1.35 [1.10-1.65]), and at follow-up (1.35 [1.11-1.69], 1.29 [1.09-1.59], for maternal and paternal education, respectively). Parents with a higher level of education are probably more informed about the importance of physical activity on health status, and thus transfer this information to their children as well. The age from 14 to 16 years is likely a critical period for maintaining physical activity levels in boys, while further studies of a younger age are necessary to evaluate the dynamics of changes in physical activity levels for girls. For maintaining physical activity levels in adolescence, special attention should be paid to children whose parents are less educated, and to inform them of the benefits of an appropriate physical activity level and its necessity for maintaining proper health and growth.

Full text

healthcare
Article
Parental and Familial Factors Influencing
Physical Activity Levels in Early Adolescence:
A Prospective Study
Dora Maric 1, Ivan Kvesic 2, Ivana Kujundzic Lujan 2, Antonino Bianco 1, Natasa Zenic 3,
Vlatko Separovic 4, Admir Terzic 4, Sime Versic 3and Damir Sekulic 3, *
1
PhD Program in Health Promotion and Cognitive Sciences, Department of Psychology Educational Science
and Human Movement, Sport and Exercise Sciences Research Unit, University of Palermo,
90100 Palermo, Italy; dora.maric@unipa.it (D.M.); antonino.bianco@community.unipa.it (A.B.)
2Faculty of Science and Education, University of Mostar, 88000 Mostar, Bosnia and Herzegovina;
ivan.kvesic@fpmoz.sum.ba (I.K.); ivana.kujundzic.lujan@fpmoz.sum.ba (I.K.L.)
3Faculty of Kinesiology, University of Split, 21000 Split, Croatia; natasazenic@gmail.com (N.Z.);
sime.versic@gmail.com (S.V.)
4Faculty of Sport Faculty of Physical Education and Sports, University of Tuzla,
Tuzla 75000, Bosnia and Herzegovina; vlatko.separovic@untz.ba (V.S.); admir.terza@bih.net.ba (A.T.)
*Correspondence: dado@kifst.hr
Received: 4 November 2020; Accepted: 1 December 2020; Published: 2 December 2020


Abstract:
Parental/familial factors are important determinants of the physical activity level (PAL) in
children and adolescents, but studies rarely prospectively evaluate their relationships. This study
aimed to evaluate the changes in physical activity levels among adolescents from Bosnia and
Herzegovina over a two-year period and to determine parental/familial predictors of PAL in early
adolescence. A total of 651 participants (50.3% females) were tested at baseline (beginning of
high school education; 14 years old on average) and at follow-up (approximately 20 months later).
The predictors included sociodemographic characteristics (age, gender) and parental/familial factors
(socioeconomic status of the family, maternal and paternal education, conflict with parents, parental
absence from home, parental questioning, and parental monitoring). Physical activity levels were
evidenced by the Physical Activity Questionnaire for Adolescents (PAQ-A; criterion). Boys were more
active than girls, both at baseline (t-test =3.09, p<0.001) and at follow-up (t-test =3.4,
p<0.001
).
Physical activity level decreased over the observed two-year period (t-test =16.89, p<0.001), especially
in boys, which is probably a consequence of drop-out from the sport in this period. Logistic regression
evidenced parental education as a positive predictor of physical activity level at baseline (
OR [95% CI];
1.38 [1.15–170], 1.35 [1.10–1.65]), and at follow-up (1.35 [1.11–1.69], 1.29 [1.09–1.59], for maternal
and paternal education, respectively). Parents with a higher level of education are probably more
informed about the importance of physical activity on health status, and thus transfer this information
to their children as well. The age from 14 to 16 years is likely a critical period for maintaining physical
activity levels in boys, while further studies of a younger age are necessary to evaluate the dynamics
of changes in physical activity levels for girls. For maintaining physical activity levels in adolescence,
special attention should be paid to children whose parents are less educated, and to inform them of
the benefits of an appropriate physical activity level and its necessity for maintaining proper health
and growth.
Keywords: physical activity; parental factor; adolescents; gender differences
Healthcare 2020,8, 532; doi:10.3390/healthcare8040532 www.mdpi.com/journal/healthcare

Healthcare 2020,8, 532 2 of 17
1. Introduction
Physical activity (PA) represents an important segment of physical and mental health status [
1
–
3
].
Irrespective of the importance of PA in all periods of life, reaching the appropriate PA level (PAL) is
particularly important in childhood and adolescence, since regular PA is essential for healthy growth
and development during this life period for a number of reasons. Young people with high PALs
are less prone to cardiovascular diseases and type 2 diabetes, control their weight better, maintain
a healthy musculoskeletal system and respiratory capacities, and experience mental health benefits
(i.e., self-confidence and reduced likelihood of depression) and also have a higher level of self-perceived
health status [
4
–
11
]. Moreover, a decreased PAL in adolescence can cause chronic health problems
(e.g., cancer and cardiovascular and respiratory diseases) and obesity at a later age [12,13].
Although debates over the amount and type of PA needed for health benefits continue, the World
Health Organization (WHO) recommends at least 60 min a day of moderate-to-vigorous PA for children
and adolescents aged 5–17 years [
14
]. However, most children and adolescents worldwide do not
meet the recommended PAL requirements [
15
–
18
]. Specifically, a global study found that only 20%
of children between the ages of 13 and 15 exercise within the WHO recommendation levels [
15
].
These results differ among the studied populations; for example, only 15.9% of Americans between 14
and 17 years, 7% of Canadians between 6 and 19 years, and 5.6% of Chinese between 9 and 17 years
engage in at least 60 min of moderate activity six times a week [16–18].
Adolescence is a critical period in an individual’s development, in which young people form
attitudes about many important life issues, including health and educational habits, and the habits and
attitudes that young people gain during this period will likely continue into the adult phase of their
lives [
1
,
19
]. Despite the clearly emphasized and well-known importance of achieving appropriate
PALs in young people, studies have shown that PALs significantly decline in adolescence [20].
In cross-sectional studies on youths in North America and Europe, research has indicated a clear
decline of PA in adolescence [21,22]. Longitudinal studies have also noted a trend of decreased PALs
in adolescents [
4
]. In a five-year longitudinal study, the authors tracked changes in habits from early to
late adolescence and noticed a significant decline in weekly hours spent by young people engaged
in PA; in contrast, they observed an increase in computer time, especially in boys [
23
]. Research on
young Norwegians, conducted over a period of eight years (13–21 years of age), reported a decrease in
PA between 13 and 19 years [
24
]. A recent study on older adolescents from Bosnia and Herzegovina
detected a significant decrease in PALs between 16 and 18 years of age, irrespective of gender [
25
].
Obviously, there is a global trend of decreasing PALs; therefore, factors associated with such negative
changes need to be elucidated.
Indeed, in order to solve this burning issue, a wide range of interventions have been developed with
the aim of promoting the greater involvement of children and adolescents in some form of PA [
9
,
20
,
26
].
One of the most important preconditions for creating successful and targeted interventions is the
identification of factors that affect PAL [
27
]. As a result, in recent years, a large number of studies have
dealt with the analysis of the predictors of PALs in adolescents [
20
,
28
–
31
]. In general, PAL predictors
can be divided into five groups: Demographic (biological) factors, psychological (cognitive) factors,
behavioral characteristics, sociocultural factors, and the physical environment [32].
Globally, there are relatively consistent findings: (i) Boys are more active than girls, and (ii)
PALs decrease during adolescence [
33
]. Furthermore, decreased PALs have been noticed in children
from families with poorer socioeconomic status, simply because of the limited choice of physical
activities/sports [
34
]. When it comes to psychological factors, studies have confirmed self-efficacy and
motivation (which is primarily caused by perceived (sporting) competence and goal orientation) as
the most important psychological predictors that positively affect PALs in young people [
33
]. Of the
sociological factors, parental support stands out most consistently as a factor that positively influences
PALs due to its positive influence on the involvement of youths in PA [
28
,
35
,
36
]. In this context,
parents prove to be more important than other agents of socialization (colleagues, school, etc.) because,

Healthcare 2020,8, 532 3 of 17
in addition to influencing young people as role models, they also serve as a kind of “gate keeper” by
enrolling children in sports clubs, driving them to training, and so on [20].
Studiesexaminingparentalinfluenceonchildren’sPALhaveidentifieda numberof predictors, including
parental support, family connectedness, parental expectations, and parental monitoring
[29,30,37–39]
.
Children of active mothers and fathers are proven to be multiple times more active than children of
inactive parents [
30
]. Parental support was consistently positively and significantly associated with child
PA in numerous studies examining these factors [
29
,
39
]. Among theoverweight children and adolescents,
higher levels of family connectedness, parental expectations and moderate levels of parental monitoring
were associated with the lower level of PA [
37
]. Additionally, familial environmental and genetic factors
showed to have a significant influence on the familial resemblance in PAL [38].
Despite all efforts, there is still no clear and definitive evaluation of the determinants of the PALs
in adolescents [
28
]. On the one hand, this can be explained by the various measuring instruments used
to estimate PA [
28
]. In brief, some authors used objective measurement techniques such as heart rate
monitors, pedometers and accelerometers [
40
–
43
]. Meanwhile, most of the studies which analyzed PALs
in children and adolescents used subjective technique methods including self-report questionnaires,
interviewer-administered questionnaires, proxy-report questionnaires and diaries [
44
–
50
]. Self-report
and interviewer-administered questionnaires rely on children’s self-reported activity in the past period,
which can vary from the past three days to the whole year [
44
–
47
]. In proxy reports, parents and
teachers provide information regarding children’s PAL [
48
,
49
]. Finally, diaries were used in only a few
studies because it is very demanding for children to take regular notes about their PAL [50].
The results of previous studies were undoubtedly determined by oftentimes homogenous samples
of participants, so the same factors need to be investigated in subgroups of different ethnicities,
socioeconomic statuses, and environmental characteristics [
28
]. Moreover, the researchers that have
studied this topic have highlighted regularly in their conclusions the need for a systematic and
longitudinal analysis of a number of factors that, due to their complexity, should be observed together,
analyzing cause–effect relationships between them, in order to obtain a more realistic picture of
the determinants of PA during adolescence [
36
,
51
]. Although studies performed so far provided
evidence on a decrease in PAL during the period of adolescence on the territory of southeastern Europe,
there is a limited body of prospective evidence about: (i) changes in PAL which occur in younger
adolescents, and (ii) factors which may influence such changes in this territory. Specifically, to the best
of our knowledge no study so far prospectively examined the changes in PAL, while examining the
socio-economic, socio-educational, and factors of parent–child relationship as covariates of changes in
PAL in younger adolescents from the territory of former Yugoslavia.
For these reasons, the main aim of this study was to prospectively evaluate the changes in PALs
among adolescents from Bosnia and Herzegovina over the 2-years period, between 14 and 16 years of age.
Further, we evaluated the influence of socio-economic, socio-educational, and parent–child relationship
factors on PALs at the beginning of the 1st year of high school (approximately 14 years of age), and at
the end of the 2nd year of high-school (approximately 16 years of age). The authors hypothesized that
a decline of PAL will occur during the course of the study. Additionally, we hypothesized that studied
factors would influence PALs in both boys and girls.
2. Materials and Methods
2.1. Design and Participants
The participants in this prospective cohort study were adolescents from Bosnia and Hercegovina,
more precisely, from Tuzla county, Herzegovina–Neretva county, and Western Herzegovina county.
The sampling was based on a multi-stage cluster sampling method including (i) clustering of all
schools from selected counties into two cluster (based on school-size), (ii) random sampling of 50%
of high schools from each cluster, and (iii) random sampling of 50% of 1st grades from each of the
selected schools. During the baseline testing, a total of 701 participants were examined. Therefore,

Healthcare 2020,8, 532 4 of 17
the inclusion criteria for this study were: (i) regular participation in the high-school education in
selected high-schools, and (ii) participation in testing at both testing waves (please see later for details
on testing). No specific exclusion criteria were specified. At baseline (September 2017), the participants
were at the beginning of the first grade of high school and were 14.3
±
1.01 years old on average.
The follow-up testing occurred 20 months later, in spring 2019, including 691 participants at the end of
the second grade of high school. In this study, we included only those participants who were tested at
both baseline and follow-up (n=651; 50.3% females). Finally, the dropout rate was 12%. Included
participants met the sample size criteria, since the required sample size for the observed population,
and a level of significance of p<0.05 was 398. The sampling procedure, drop-out rates and locations of
the study are presented in Figure 1.
Figure 1. Study location, number of tested participants over testing waves, and drop-out rates.
2.2. Instruments
The variables in this study included: (i) Participants’ sociodemographic characteristics, (ii) parental/
familial factors, and (iii) PALs. Sociodemographic characteristics and parental/familial factors were
evaluated by structured questionnaires which were previously confirmed to be valid and reliable in similar
samples of participants, and results are presented in detail elsewhere [
52
–
54
]. The sociodemographic
variables included age (in years), and gender (male and female). The parental/familial factors observed in
the study consisted of socioeconomic status of the family (responded on a three-point scale: below average,
average, and above average), paternal and maternal education level (elementary school, high school,

Healthcare 2020,8, 532 5 of 17
and college/university degree), conflict with parents (almost never, rarely, periodically, and often), parental
absence from home (always at home, rarely absent, occasionally absent, and often absent), self-perceived
parental care (parents do not care at all, do not care enough, good care, and very much care), and parental
questioning about friends, school grades, problems, etc. (mostly never, rarely, from time to time, and often).
PALs were estimated with the Physical Activity Questionnaire for Adolescents (PAQ-A), which was
previously validated and used in numerous studies [
24
]. The PAQ-A is a questionnaire form for which
participants provide their self-reported PALs during the last seven days. The first eight questions
contribute to the final score on a scale from 0 (minimum) to 5 (maximum PAL) refer to different forms
of PA (e.g., sports, free play, and physical education in school). The last question was used only for
the detection of injuries and/or illness that could have possibly prevented participants from PA in
the last seven days. Finally, the difference between the PAQ-A results at baseline and those at the
follow-up for each participant was calculated as a measure of changes in PALs. For the purpose of
this study participants were grouped according to their PAQ-A results into two groups; those with
sufficient/appropriate PAL (PAQ-A score of 2.73 and above), and those with insufficient/inappropriate
PAL (PAQ-A score <2.73) [26].
2.3. Procedures
All high schools in the selected counties were divided into two groups according to the number of
children, and one-half of the first age classes were randomly selected from each of the groups. During
the first school week (early September 2017), the examiners visited the schools and informed the
children about the testing, as well as shared consent forms to participate in the research. The testing
itself was conducted two weeks after, including only those students who brought a signed form by their
parents. The study purposes and aims were explained to the students and their parents (in written
form), and it was clearly indicated to them that the survey was strictly anonymous and that they could
refuse to participate and/or not respond to any of the questions or to the whole questioning. Due to the
specificity of testing at two-time points and for the purpose of pairing the results, children were asked
to choose a personal anonymous code to use for both testing waves (i.e., the last three digits of their
e-mail password). The survey lasted approximately 15 min, and was performed on an online internet
platform, using the school equipment and resources or private mobile phones. Second testing was
performed over the last two weeks of the school year 2018/19 (late May, early June 2019) using the
same protocol. The entire testing procedure was performed in accordance with ethical guidelines and
was approved by the Ethical Committee of the University of Split, Faculty of Kinesiology (approval
number: 2181-205-05-02-05-14-005).
After conducting both baseline- and follow-up tests, analysis of the attrition bias was calculated
No significant differences were evidenced in PAL between the children tested at both waves and the
ones who dropped out. However, the drop-out rate was higher in males than in females. By calculating
intracluster correlation (with schools as clusters), we evidence the relatedness of responses within
each cluster (school) [
55
]. Specifically, the intracluster coefficient (IC) for the baseline PAL showed
appropriate within-school variance (IC =0.06).
2.4. Data Analysis
Descriptive statistics included calculation of means and standard deviations for PAQ-A,
and frequencies and percentages for remaining variables.
The second phase of statistical processing included calculation of the differences between groups
(boys vs. girls; sufficient PAL vs. insufficient PAL), and within groups (PAL at baseline vs. PAL at
follow-up). Namely, t-test for dependent samples was used to evaluate the differences for PAL obtained
at baseline and follow-up for the total sample, and stratified for gender. Differences between groups
in raw PAL scores were evidenced by t-test for independent samples. Additionally, dichotomized
PAL-values (insufficient-/sufficient-PAL) were compared between groups and this was completed by

Healthcare 2020,8, 532 6 of 17
Chi-square (
χ
2) calculation. Mann–Whitney test (MW) was used to compare ordinal variables between
groups, while χ2 was used to evidence the differences between groups in categorical variables.
To define the influence of studied predictors on PAL at baseline and follow-up the logistic
regression was applied. First, each predictor was correlated with dichotomized PAQ-A values
(insufficient PAL was coded as “1”, and sufficient PAL was coded as “2”). In order to further evaluate
the eventual co-variability of the predictors, and to identify/eliminate any possible causal relationship
between predictors, in the last phase of the statistical analyses the multivariate logistic regressions
were calculated for dichotomized criteria (PAL at baseline, and PAL at follow-up). For such purpose,
all predictors found to be significantly correlated to PAL were included in the multivariate logistic
regression model. The final model was checked by the Hosmer–Lemeshow test of model fit (with
significant
χ
2 indicating inappropriate model fit). Negelkerke R square, p-values, Odds Ratio (OR) and
corresponding 95% Confidence Interval (95% CI) were reported as indicators of association between
predictors and criteria.
3. Results
PALs decreased significantly during the course of the study in total sample (from 2.26
±
1.13 to 2.13
±
1.06; t-test =16.89, p<0.001), and when observed separately for boys (from 2.42
±
1.19 to
2.28 ±1.01
,
t-test =10.41, p<0.001), and for girls (from 2.14
±
1.07 to 2.01
±
0.99, t-test =13.42,
p<0.001
). The PAL
was higher in boys than in girls at baseline (t-test =3.09, p<0.001), and at follow-up (t-test =3.4,
p<0.001).
The 31% of adolescents reached appropriate/sufficient PAL at baseline (38% boys and 26% girls),
while only 26% of them had appropriate PAL at follow-up (31% girls and 22% girls) (Figure 2).
When observed at categorical scale (sufficient/insufficient PAL) the differences between genders were
significant at baseline (
χ
2=9.54, p<0.001), and at follow-up measurement (
χ
2=7.08, p<0.01), with a
higher prevalence of sufficient PAL among boys.
Figure 2.
Prevalence of insufficient/sufficient physical activity level (PAL) in adolescents from Bosnia
and Herzegovina at baseline (beginning of high school education) and follow-up (end of 2nd year of
high-school).

Healthcare 2020,8, 532 7 of 17
The differences between adolescents who achieved and those who did not achieve sufficient PAL
are presented in Table 1. Parental monitoring was lower in adolescents with insufficient PAL at baseline
(MW Mann Whintey test =2.12, p=0.03). A sufficient PAL at baseline was found in children whose
fathers and mothers were better educated (MW =2.74, p<0.01 and MW =3.3, p<0.001 for paternal
and maternal education, respectively).
Table 1.
Differences between adolescents grouped according to sufficiency/insufficiency of physical
activity level (PAL) at baseline.
Variables Baseline PAL Mann–Whitney
Sufficient Insufficient MW p
F%F%
Socioeconomic status 1.09 0.27
Below average 2 0.9 8 1.8
Average 188 87.9 372 81.8
Above average 17 7.9 55 12.1
Paternal education 2.74 0.01
Elementary school 2 0.9 11 2.4
High school 110 51.4 264 58.0
College level 48 22.4 96 21.1
University level 47 22.0 63 13.8
Maternal education 3.3 0.001
Elementary school 3 1.4 14 3.1
High school 103 48.1 265 58.2
College level 51 23.8 91 20.0
University level 50 23.4 68 14.9
Parental/familial conflict 1.06 0.28
No. never 157 34.5 66 30.8
Rarely 188 41.3 91 42.5
From time to time 72 15.8 42 19.6
Often 24 5.3 10 4.7
Parental absence 1.42 0.15
Always at home 40 18.7 103 22.6
Rarely absent 72 33.6 156 34.3
Occasionally absent 76 35.5 136 29.9
Frequently absent 21 9.8 42 9.2
Parental care 0.61 0.53
Do not care at all 0 0.0 3 0.7
Do not care enough 3 1.4 15 3.3
Good care 43 20.1 85 18.7
Very much care 163 76.2 333 73.2
Parental questioning 2.12 0.03
Mostly never 4 1.9 12 2.6
Rarely 18 8.4 41 9.0
From time to time 102 47.7 158 34.7
Often 84 39.3 228 50.1
Legend: Note that participants were not obligated to respond to all questions and therefore for some variables all
responses summarized does not equal the total sample of participants (n=651).
The higher maternal- (MW =2.72, p<0.01), and paternal-education (MW =2.13, p<0.05) was
found in adolescents who had appropriate PAL at follow-up. No significant differences between
groups based on PAL were evidenced for other predictors (Table 2).

Healthcare 2020,8, 532 8 of 17
Table 2.
Differences between adolescents grouped according to sufficiency/insufficiency of physical
activity level (PAL) at follow-up.
Variables Follow-Up PAL Mann–Whitney
Sufficient Insufficient MW p
F%F%
Socioeconomic status 0.24 0.8
Below average 1 0.6 9 1.8
Average 154 86.5 406 82.7
Above average 16 9.0 56 11.4
Paternal education 2.13 0.03
Elementary school 1 0.6 12 2.4
High school 94 52.8 280 57.0
College level 37 20.8 107 21.8
University level 39 21.9 71 14.5
Maternal education 2.72 0.01
Elementary school 2 1.1 15 3.1
High school 89 50.0 279 56.8
College level 35 19.7 107 21.8
University level 45 25.3 73 14.9
Parental/familial conflict 1.47 0.14
No. never 51 28.7 172 35.0
Rarely 78 43.8 201 40.9
From time to time 36 20.2 78 15.9
Often 8 4.5 26 5.3
Parental absence 1.24 0.21
Always at home 31 17.4 112 22.8
Rarely absent 62 34.8 166 33.8
Occasionally absent 65 36.5 147 29.9
Frequently absent 15 8.4 48 9.8
Parental care 0.32 0.75
Do not care at all 0 0.0 3 0.6
Do not care enough 3 1.7 15 3.1
Good care 36 20.2 92 18.7
Very much care 134 75.3 362 73.7
Parental questioning 1.44 0.15
Mostly never 3 1.7 13 2.6
Rarely 16 9.0 43 8.8
From time to time 81 45.5 179 36.5
Often 73 41.0 239 48.7
Legend: Note that participants were not obligated to respond to all questions and therefore for some variables all
responses summarized does not equal the total sample of participants (n=651).
Figures 3and 4present univariate relationships between baseline sociodemographic and
parental/familial factor, and dichotomized PAL criteria at baseline (Figure 3) and at follow-up (Figure 4).
At baseline, the higher likelihood for appropriate PAL was found in males (Negelkerke R square: 0.02;
OR: 1.68, 95% CI: 1.21–2.34; p<0.001), for those adolescents whose mothers (Negelkerke R square:
0.02; OR: 1.38, 95% CI: 1.15–1.70; p<0.001), and whose fathers were better educated (Negelkerke
R square: 0.02; baseline: OR: 1.35, 95% CI: 1.10–1.65, p<0.01). At follow-up higher likelihood for
appropriate PAL was found for boys (Negelkerke R square: 0.02; OR: 1.54, 95% CI: 1.11–2.03, p<0.001),
adolescents who reported better maternal (Negelkerke R square: 0.02; OR: 1.35, 95% CI: 1.11–1.69,
p<0.05)
, and those who reported better paternal-education (Negelkerke R square: 0.015; OR: 1.29,
95% CI: 1.09–1.59, p<0.05).

Healthcare 2020,8, 532 9 of 17
Figure 3.
Correlates of sufficient physical activity level at baseline (results are presented as Odds Ratio
[OR]
±
95% Cofidence Interval [CI]; dotted line presents OR of 1 Odds Ratio and statistical significance
of p<0.005 if not crossed by 95% CI bar).
Figure 4.
Correlates of sufficient physical activity level at follow-up (results are presented as Odds Ratio
[OR]
±
95% Cofidence Interval [CI]; dotted line presents OR of 1 Odds Ratio and statistical significance
of p<0.005 if not crossed by 95% CI bar).
Multivariate logistic were calculated while simultaneously including all variables evidenced as
being significant univariate predictors of PAL at baseline and follow-up. Male gender (OR: 1.55, 95% CI:
1.11–1.91, p<0.001), higher paternal education (OR: 1.35, 95% CI: 1.05–1.67, p<0.05), and higher
maternal education (OR: 1.34, 95% CI: 1.06–1.71, p<0.05) were all significantly related to PAL-baseline
(Negelkerke R square: 0.04). In total 67% of the participants were correctly classified according to
specified regression function. A similar multivariate relationship was found when PAL at follow-up
was observed as a criterion. Namely, higher paternal education (OR: 1.21, 95% CI: 1.01–1.44, p<0.05),
and higher maternal education (OR: 1.30, 95% CI: 1.05–1.57, p<0.01), together with male gender
(OR: 1.50, 95% CI: 1.05–2.15, p<0.01) were positively correlated with appropriate/sufficient PAL at
follow-up (Negelkerke R square: 0.05), with 71% participants being correctly classified. Results of the
multivariate logistic regressions actually evidence the independent influence of paternal education and
gender on PAL (Figure 5). A Hosmer–Lemeshov test evidenced appropriate model fit for multivariate
logistic regression models calculated for PAL at baseline (
χ
2=7.37 p=0.39), and for PAL at follow-up
(χ2=8.01, p=0.31).

Healthcare 2020,8, 532 10 of 17
Figure 5.
Multivariate logistic regression correlates of sufficient physical activity level (PAL) at baseline
and at follow-up measurement (results are presented as Odds Ratio [OR]
±
95% Cofidence Interval
[CI]; dotted line presents OR of 1 Odds Ratio and statistical significance of p<0.005 if not crossed by
95% CI bar).
4. Discussion
There are several important findings of this study. First, boys were more active than girls,
PALs decreased over the study course, and the decrease was more evident in boys. As a result,
we may support our initial study hypothesis. Second, parental education was evidenced as a positive
influencing factor of PALs in both testing waves. Finally, no significant influences of socioeconomic
status, parental/familial conflict, parental absence from home, parental care, and parental questioning
on PALs were found. Therefore, our second hypothesis may be partially accepted.
4.1. Changes and Differences in PALs
Our results evidenced higher PALs in boys than in girls in early adolescence (between 14 and
16 years of age). Such findings are in line with previous research, which, almost without exception,
reported higher PALs in boys [
4
,
21
,
22
,
28
]. Specifically, an epidemiological review article that analyzed
PALs and fitness levels in children and adolescents concluded that boys are approximately 14% and
25% more active than their female peers, respectively, and that over the school years, PALs decrease by
3–7% [
56
]. Previous studies have highlighted three of the most common perspectives for explaining
the important determinants of gender-differences in PALs: (i) Socialization, (ii) attitudinal factors,
and (iii) organized sports [30,57–60].
In the context of socialization, research has highlighted the significant impact of the environment
(i.e., parents, peers, and teachers) on PALs in adolescents [
30
,
58
]. This impact differs between genders,
which is explained by an interaction between gender and parental or teacher involvement [
57
].
Additionally, a larger proportion of girls have negative experiences with practicing some form
of physical activity and sports (e.g., feeling stupid or incompetent, being negatively evaluated,
not having enough choice, and using inadequate facilities), which consequently reduces the level of
their involvement in physical activity and sports [60].
An attitudinal explanation of the gender differences in physical activity and sports involvement
assumes that gender roles foster differences in attitudes that contribute to differences in practicing sports
and in physical activity in general [
57
]. Among other things, a greater association has been noticed
between masculine identities and sports. In other words, boys are more competitive and generally
more interested in sports than girls, which consequently contributes to their higher PALs [61,62].

Healthcare 2020,8, 532 11 of 17
Irrespective of previous explanations, research has highlighted organized sports as a key factor in
explaining gender differences in PALs [
57
]. This perspective is based on the fact that a large proportion
of the PALs among young people refers to organized sports in sports clubs, where have much greater
gender differences in inclusion compared to the overall gender difference in physical activity [
59
].
In short, the organized sports system favors men through organizational specifics, more competition,
and more accessible sports facilities, and also the dropout rate for girls is much higher, especially
taking into account girls’ menstrual cycle and more frequent absence from sports training in girls
due to menstrual pain and/or hygienic reasons [
63
,
64
]. Put together, the higher PALs among boys
is understandable.
The decrease in PALs in our sample is in accordance with previous studies, where authors have
regularly confirmed a decrease in PALs during adolescence [
20
,
56
]. More specifically, a decline in PALs
from the beginning of the first grade of high school to the end of the second grade was approximately
7%, and this was more emphasized in boys (8%) than in girls (5%). Several studies have analyzed
longitudinal PAL changes during adolescence, and have evidenced various causes for the decrease in
PALs [
23
,
65
]. Collectively, authors most often point out the increase in school obligations, weight gain,
and increased screen time, as well as a decline in active transport.
Although not entirely consistent, previous research has more often identified a higher rate of
PAL decline in boys during younger adolescence [
66
,
67
]. However, it must be observed in light of
the higher PALs in boys than in girls at the beginning of the observed period [
57
,
68
]. The reason for
this stands in the fact that girls drop out of sports earlier (between 9 and 12 years). Therefore, during
younger adolescence, girls generally have a lower baseline level of PA and thus less of a chance of an
additional decline in PALs than boys, who, during this period (13–16 years), start to drop out from
organized sports [67].
4.2. Parental Education and Physical Activity during Adolescence
Thus far, much research has analyzed the influence of parental and familial factors on PALs in
children and adolescents [
35
,
36
,
69
]. Above all, family support has been consistently shown to be a
positive predictor of PALs in adolescents [
35
]. Specifically, parents have been proven to be one of the
most important predictors of PALs, because they serve as role models and they finance and actively
participate in the organization of sports activities for their children [
20
]. However, previous studies
have not consistently highlighted parental education as a predictor of PALs in adolescence.
Some studies have shown that there is no significant influence [
35
,
69
], while others have indicated
a positive influence of a higher educational level of parents on their children’s PALs [
70
,
71
]. In studies
that have confirmed a positive influence, this fact was primarily explained by the relationship between
the level of education and familial socioeconomic status and income [
70
]. For example, a longitudinal
study on 1213 African-American and 1166 Caucasian girls found a significant impact of parental
education on PALs, which was explained by the negative impact of low socioeconomic status and
a potentially stressful home environment on PALs in children, highlighting the need to solve social
disparities that potentiate health disparities [70].
In contrast, although parental education was positively correlated with PALs in children, we found
no significant effect of socioeconomic status on PALs, and therefore our results are not absolutely
consistent with previous findings [
36
,
72
]. Before discussing it must be noted that data on socio-economic
status for adolescents observed herein could be observed as plausible since results are comparable
to data reported in previous studies where somewhat older adolescents from the same country were
included [
53
,
73
]. Most likely, in the region where the study was conducted, the financial status of
the family does not have a strong influence on sports involvement as in some other regions of the
world. Specifically, in studied counties, as well as on the whole territory of Bosnia and Herzegovina,
the majority of sports are available to all children (i.e., participation is mostly free), the distances between
home and sports facilities are relatively short (i.e., children do not depend on parental transport),
and most popular sports do not require specific and expensive sports equipment, and are practiced in

Healthcare 2020,8, 532 12 of 17
school facilities and gyms (i.e., team sports like football, handball, basketball) [
52
]. Taken together,
even the influence of socioeconomic status on participation in sports and PA in the studied adolescents
was reduced. Therefore, the cause of the connection between parental education and the children’s
PALs in our study should be found in something else.
Mainly, it is reasonable to assume that parents with a higher level of education are generally
better informed and are more aware of the importance of PA on the health status of their children [
27
].
Therefore, better-educated parents more likely to encourage their children to engage in some form
of PA or sports. This explanation is in accordance with a recent discussion offered in a study where
maternal education was positively correlated with PALs in somewhat older adolescents, and where the
authors highlighted mothers as being more involved in their children’s life in later adolescence, even in
the domain of physical activity, irrespective of the known influence of fathers on sports participation,
which is more evident in earlier adolescence [
27
]. Interestingly, even in our study the effect size
(based on R square from univariate logistic regressions) for PAL at follow-up was higher for maternal
education, than for paternal education (Nagelkerke R square =0.02 and 0.015, for maternal- and
paternal-education, respectively) which indicate the stronger influence of maternal education on PAL
of the children at the age of 16. Meanwhile, based on the same statistical parameter, maternal- and
paternal-education are equally important predictors of PAL at baseline (i.e., 14 years of age).
4.3. Familial Variables and Physical Activity in Adolescence
Parental and familial factors are known to be important determinants of various health-related
behaviors in adolescents, and previous studies have regularly confirmed the direct influence of
family cohesion, parent–child relationships, and parental involvement in children’s daily activities on
PALs [
74
,
75
]. These dimensions of parental influence may be a reflection of an authoritative parenting
style, which generally includes reaction, in the form of providing emotional support and involvement,
but also demanding in terms of providing an appropriate level of parental control [
75
]. Studies find
that authoritative parenting styles are often associated with higher levels of student achievement [
76
].
Furthermore, a study examining PALs and sedentary lifestyles in girls identified an authoritative
parenting style as a significant positive predictor of PALs [77].
Similar findings have been found in studies of some other issues, such as smoking [
78
]. Specifically,
it has been shown that parents with an authoritative parenting style who have anti-smoking household
rules and who do not smoke themselves are more likely to have adolescents who do not consume
cigarettes [
78
]. Additionally, in the study examining optimal parent–child relationships, parental
warmth and strictness were highly associated with a child’s well-being [
79
]. However, in our study,
the variables examining parent–child relationships, familial conflict, parental absence from the home,
parental care, and parental questioning were not significant predictors of PALs.
The most likely reason for such relative inconsistency in our results (i.e., non-significant influence
of parental control and monitoring variables on the PALs of their children) compared to those reported
previously, where the authors regularly confirmed significant correlations between similar sets of
variables that could be found in the differences between the established “magnitude” of parental
control/monitoring. Namely, in our study, a minority of the children reported “low levels of parental
control/monitoring” (see Results for details). Meanwhile, when using an identical measurement tool
and studying somewhat older adolescents, previous reports from the same region (i.e., southeastern
Europe) have shown a considerably larger variance in their results [
54
]. It could simply mathematically
result in a higher possibility of reaching a statistically significant association between variables [80].
4.4. Limitations and Strengths
The first limitation of the study is the subjective nature of the measurement tool, since data were
collected by a questionnaire. Therefore, there is a possibility that the participants did not answer
honestly and/or tended to provide socially desirable answers. However, the authors strongly believe
this possibility was reduced due to the testing protocol, the experience of the researchers, and the strict

Healthcare 2020,8, 532 13 of 17
anonymity of the testing. Moreover, PALs were evidenced by questionnaire and were not objectively
measured. However, the use of objective measures of PALs (e.g., accelerometers, pedometers) was
limited because of the large sample size and the prospective nature of the study. Next, the observed
sample did not represent the whole country, so the results should be generalized only for specific
regions. Finally, this study did not take into account biological maturity, but only chronological
maturity of the adolescents. Considering the well-known influence of maturity on multiple factors,
future investigations should pay attention to it, and include the biological age in analyses of such kind.
This is one of the first studies that systematically examined the parental/familial predictors of
PALs in adolescents from southeastern Europe. Additionally, this is probably the first prospective
study of PAL changes and the predictors of PALs in young adolescents in this region. One of the
strengths of this study is the fact that the tested sample was twice as large as that theoretically required
for high statistical power, with a minor dropout rate. Finally, given that decreased PALs are highlighted
globally as a major public health concern because of their association with the leading causes of death,
illness, and disability, the authors believe that the findings of this research can be used in the global
fight against the pandemic of physical inactivity, and that they will initiate further research. Findings
of this study suggest practical interventions on children with parents of a lower educational level and
the need to further examine the decline in PAL for girls at an earlier age than analyzed here. Moreover,
additional factors related to decreased PAL in boys between 14 and 16 years of age should be evaluated.
5. Conclusions
The results of this study showed that boys are generally more active than girls in the period of
younger adolescence (14–16 years). With a prospective follow-up over a two-year period, a declining
trend in PALs was observed, and this negative trend was larger in boys. Given that previous researchers
have found an earlier dropout from organized sports in girls (between 9 and 12 years old), it is obvious
that the period between 14 and 16 years of age is particularly important for boys. Future studies should
certainly investigate all of the factors that lead to dropouts from sports in younger male adolescents
and the predictors of PAL decline in girls should be studied in younger years.
This study analyzed parental factors as possible indicators of PALs in younger adolescents,
and especially emphasized the education of parents in both testing waves as a positive predictor.
Therefore, in order to prevent a decrease in PALs in early adolescence, there is an evident need to
specifically focus on children whose parents are of a lower educational level. This will hopefully
improve their awareness of the importance of PA in this period of life. Such efforts will consequently
have an important positive impact on the overall health status both in adolescence and later life.
Additionally, the established influence of parental education on the PAL of their children should
be observed out of the context of the relationship. Namely, we can anticipate that specific education of
the parents about the benefits and importance of physical activity would be directly translated to PAL
of their children. Therefore, we may encourage studies that will investigate the effects of education of
the parents (i.e., responsible adults) on their children’s PAL. In doing so special attention should be
placed on parents of lower educational status and health-related topics of physical activity.
Parental/familial variables explaining socioeconomic status, as well as parental/familial control
and monitoring, were not shown to be important predictors of PALs in the studied period (between
14 and 16 years of age). Most likely, the fact that the studied adolescents evidenced low levels of
parental conflict and high parental control reduced the possibility that these variables significantly
influenced PALs. Moreover, in the studied region, sports activities are relatively available to all children,
which reduced the possibility that the socioeconomic status of the studied adolescents significantly
contributed to PALs.
Author Contributions:
Data curation, I.K., I.K.L., A.T. and S.V.; Formal analysis, D.M., I.K., I.K.L., A.B. and V.S.;
Funding acquisition, A.B.; Investigation, A.T. and D.S.; Methodology, D.M., N.Z. and V.S.; Project administration,
N.Z.; Software, N.Z. and S.V.; Writing—original draft, D.M., S.V. and D.S. All authors have read and agreed to the
published version of the manuscript.

Healthcare 2020,8, 532 14 of 17
Funding:
This research received no external funding. The APC was funded by the PhD Program in Health
Promotion and Cognitive Sciences, University of Palermo.
Acknowledgments:
Authors are particularly grateful to all children who voluntary participated in the research.
Special thanks goes to school authorities for their help and support.
Conflicts of Interest: The authors declare no conflict of interest.
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