ANTHROPOLOGICAL RESEARCHES AND STUDIES
No: 16

EVALUATION OF ADHERENCE TO THE MEDITERRANEAN DIET USING THE KIDMED INDEX IN ADOLESCENTS FROM MOULAY ABDELLAH COMMUNE, MOROCCO

Ghizlane BENADDI (1), Halima DAIF (1), Imane HADDOU (1), Sanaa EL-JAMAL (1, 2), Halima BELAOUFI (1), Mohammed ELAYACHI (1), Omar EL HIBA (1) and Rekia BELAHSEN (1)
Keywords: Mediterranean diet; KIDMED score; weight status; health status; adolescents

DOI: https://doi.org/10.26758/16.1.33

1Laboratory of Anthropogenetics, Biotechnology and Health, Department of Biology, Faculty of Sciences, Chouaib Doukkali University – El Jadida 24 000, Morocco

2 Higher Institute of Professions Nurses and Health Techniques of Casablanca, Morocco

Emails and ORCID IDs:

Address correspondence to: Rekia BELAHSEN, Faculty of Sciences, Chouaib Doukkali University, Training and Research Unit on Nutrition & Food Sciences, LABS, El Jadida 24000, Morocco. Phone : 212 523 34 2325/212 664 97 16 16 Fax : 212 523 34 21 87/449 Email : rekiabelahsen@gmail.com/ rbelahsen@yahoo.com

Abstract

Objectives. The Mediterranean diet (MD), considered healthy, is increasingly abandoned by adolescents. This cross-sectional study aimed to assess adherence to the MD and its associated factors among adolescents in a predominantly rural area of Morocco.

Material and methods. A total of 211 adolescents aged 14–18 years were included. Socio-demographic and socioeconomic data were collected using a structured questionnaire, anthropometric measurements were performed, and MD adherence was assessed using the KIDMED index.

Results. Higher adherence to the MD was observed among boys, adolescents living in rural areas, and those from higher-income households or whose fathers were engaged in agricultural or intellectual professions. Conversely, lower adherence was more frequent among girls, adolescents living in precarious housing, and those from low-income families. An inverse association was observed between MD adherence and excess weight, with lower BMI, BMI z-score, and WHtR among adolescents with higher adherence.

Conclusions. These findings highlight the influence of individual, familial, and environmental factors on adolescent dietary behaviors and support a socio-ecological perspective on adherence to the Mediterranean diet. Given the cross-sectional design of the study, the observed associations should be interpreted with caution.

Keywords: Mediterranean diet; KIDMED score; weight status; health status; adolescents

Suggested citation (APA):

Benaddi, G., Daif, H., Haddou, I., El-Jamal, S., Belaoufi, H., Elayachi, M., El Hiba, O., & Belahsen, R. (2026). Evaluation of Adherence to the Mediterranean Diet Using the KIDMED Index in Adolescents from Moulay Abdellah Commune, Morocco, Anthropological Researches and Studies, 16, 512-525. https://doi.org/10.26758/16.1.33

Introduction

Adolescence is a critical phase of human development, during which dietary habits are established that can influence health throughout life (Sawyer et al., 2012). Among its recognized nutritional benefits, the Mediterranean diet (MD) is considered by many organizations, including the WHO, as a healthy diet, rich in fruits, vegetables, whole grains, olive oil, fish, and legumes, and widely associated with a reduced risk of chronic diseases such as obesity, type 2 diabetes, and cardiovascular disease (Galbete et al., 2018; Kahleova et al., 2017).

Nevertheless, adolescence is marked by a progressive deterioration in diet quality globally. Indeed, the World Health Organization (WHO) estimates that more than 80% of adolescents do not consume the recommended intakes of fruits and vegetables, with a rapid increase in consumption of ultra-processed foods high in sugars, saturated fats, and salt, including in low- and middle-income countries. Observing this development contributes to the worrying increase in overweight and obesity among adolescents, the global prevalence of which has more than quadrupled over the last four decades, making diet a major determinant of future health (Popkin et al., 2020; World Health Organization [WHO], 2024).

Despite its mentioned benefits, adherence to the Mediterranean diet (MD) has declined in recent decades, particularly among young people, and remains insufficient in several contexts, particularly those in rural areas of Morocco, where socioeconomic insecurity and low parental education constitute major obstacles to a balanced diet (Belaoufi et al., 2024; El Mokhtari et al., 2024).

MD is appreciated for its composition, which is plant-based in nature, and its richness in many components beneficial to health, including nutrients and bioactive substances.  This diet (MD) presents protective effects on several complementary biological mechanisms. These mechanisms include better metabolic regulation, reduction of low-grade inflammation, and improvement in insulin sensitivity. In addition, the richness of this diet in dietary fiber, antioxidants, polyphenols, and monounsaturated fatty acids also promotes satiety, glycemic stability, and limits the accumulation of visceral fat mass, thus contributing to the prevention of cardiometabolic diseases that can set in during adolescence (Serra-Majem et al., 2019; Sofi et al., 2008).

The increase in consumption of processed foods high in sugars and saturated fats, which increasingly affects young people, is associated with the ongoing nutritional transition in the country and increasing rates of overweight and obesity (WHO, 2024).

In Morocco, this nutritional transition takes place in a context of rapid socio-economic transformations, marked by urbanization, the globalization of the food supply, and the evolution of lifestyles. All these changes favor easy accessibility to ultra-processed foods to the detriment of traditional foods, particularly among adolescents, a population particularly vulnerable to social and commercial influences (Popkin et al.,2020). Moreover, several studies have highlighted significant gender differences, with a higher prevalence of abdominal obesity, with a higher cardiometabolic risk in adolescent girls than in boys, suggesting the combined influence of biological, behavioral, and socioeconomic factors (El Kabbaoui et al., 2018; Sahel et al., 2022).

Family structure is also an important determinant of eating habits in adolescence, as this study illustrates. Large or single-parent families, often facing economic and organizational constraints, present less favorable conditions for meal planning. Nuclear families, on the other hand, are generally associated with greater meal regularity and better nutritional advice. However, nuclear, large, or single-parent families do not allow for contact and exchanges between grandparents and young people, and hinder the transmission of traditional balanced eating practices and behaviours, and the traditional Mediterranean model from one generation to the next (Darmon & Drewnowski, 2015; Desbouys et al., 2020).

Furthermore, other factors recognized as determinants of adolescent eating behavior include family structure, socioeconomic status, parental education level, and place of residence (rural or urban) (Belaoufi et al., 2024; Cherkaoui et al., 2013). However, few studies have analyzed these factors together in rural areas of Morocco, where specific living conditions can influence eating habits and associated risks.

From this perspective, the present study adopts the socio-ecological model of health, which considers eating behaviors as the result of complex interactions between individual factors (sex, age, weight), family factors (socioeconomic status, household structure, parents’ occupation and education level), and contextual factors (residential environment, food accessibility). This conceptual framework allows for an integrated understanding of the determinants of adherence to the Mediterranean diet among adolescents, thus moving beyond a strictly individual approach.

A better understanding of the local context is essential for designing targeted nutritional interventions adapted to the socio-economic and cultural realities of these populations. Therefore, this study aims to analyze the social and anthropometric factors associated with adherence to the Mediterranean diet among adolescents in a predominantly rural commune of Moulay Abdellah, Morocco. The ultimate goal is to identify the main determinants likely to influence eating behaviors and the level of adherence to the Mediterranean diet, in order to guide public health policies and nutritional prevention programs tailored to adolescents in rural areas.

Materials and methods

Study Population

This cross-sectional study was conducted during the 2024–2025 school year in a public secondary school located in the coastal municipality of Moulay Abdellah, in the province of El Jadida, Morocco. The school population was composed of adolescents aged 14 to 18 enrolled in the school during the academic year, from the surrounding rural areas (Sidi Abed, Ouled Issa, and Moulay Abdellah) and to a lesser extent, from the city of El Jadida, thus providing a mixed rural-urban context. The relevant administrative data was unavailable during the data collection period, and the exact total number of students could not be precisely determined at the time of the survey, which prevented the calculation of the exact participation rate. However, of the students present on the data collection days and who had obtained parental informed consent, a total of 211 adolescents were included in the study.

Inclusion criteria: Adolescents enrolled in the selected school, aged 14 to 18 years, and providing informed consent were included in the present survey. Adolescents with a physical disability, absent during anthropometric measurements, those on a special diet, or those who did not complete the questionnaire were excluded from the study.

Data Collection

The research tools used in this study to collect the study data have been used in many previous studies conducted by our research team. In summary, data were collected using a structured questionnaire, translated into dialectal Arabic and adapted to the local Moroccan sociocultural context, tested and validated with a small group of adolescents before the main surveys to ensure the clarity, understanding and cultural appropriateness of the questionnaire items (Barakat et al., 2022; Belaoufi et al., 2024; Sahel et al., 2022). Minor adjustments were made accordingly before the final administration.

The survey collected the following information:

Sociodemographic and Socioeconomic Characteristics. The sociodemographic variables collected were gender, age, parents’ education level (illiterate, primary, secondary, university), place of residence (urban or rural), household size, family structure (nuclear or composite), and parents’ marital status (married, divorced, widowed).

The socio-professional category (SPC) was assessed based on the parents’ profession type and used as an indicator of adolescents’ socio-economic status. The socioeconomic characteristics collected included the parents’ socio-professional category (SPC), according to the classification of Orban-Seghebarth et al. (1982). Five occupational categories were selected: SPC1, professionals and large business owners; SPC2, managers and civil servants; SPC3a, farmers and fishermen; SPC3b, manual workers, craftspeople, employees, drivers, and salespeople; and SPC4, people without paid employment. For the mother’s occupation, SPC3 was presented as a single category due to the very homogeneous distribution of this variable in the study sample, while for the father’s occupation, SPC3 was subdivided into two subcategories, SPC3a and SPC3b, this distinction being more informative in interpreting the observed differences in adherence to the Mediterranean diet. Monthly household income was classified into three categories : low (<3000 MAD), medium (3000–5000 MAD) and high (>5000 MAD) and Housing tenure status as owner or renter.

Anthropometric Data. Anthropometric measurements were carried out according to World Health Organization (WHO) standards (Barakat et al., 2022). Weight was measured using an electronic bathroom scale QR-130 (150 ± 0.05 kg), with participants wearing light clothing and barefoot. Height was measured to the nearest 0.1 cm, using a wall-mounted measuring rod, in a standing position with heels together, arms at the sides of the body, and head in the Frankfurt position. Waist circumference (WC) was measured using a non-stretch tape, without compression, at the midpoint of the distance between the last rib and the anterior superior iliac crest, at the end of expiration. The waist-to-height ratio (WHtR) was calculated by dividing the waist circumference by the height. A threshold of 0.5 was used to identify abdominal obesity. If WHtR < 0.5, there is no abdominal obesity, and when the WHtR ≥ 0.5, it means the subject presents abdominal obesity. BMI z-scores for age were obtained using WHO AnthroPlus software (version 1.0.4, 2010), with reference to the 2007 WHO standards. The following categories were used to categorize BMI in classes of underweight if z-score ≤ -2 SD, normal weight if -2 SD < z-score < +1 SD, overweight when z-score ≥ +1 SD, and obesity for z-score ≥ +2 SD.

Assessment of Mediterranean Diet Adherence. Adherence to the MD was assessed using the KIDMED index, developed by Serra-Majem et al. in 2004 (Sofi et al., 2008). This tool is widely used to assess the quality of dietary habits of children and adolescents in the Mediterranean region and elsewhere, and has demonstrated good psychometric validity (Desbouys et al., 2020; Serra-Majem et al., 2019). The KIDMED questionnaire consists of 16 dichotomous (yes/no) items. Each positive response to a question favorable to the Mediterranean diet (e.g., daily consumption of fruits, vegetables, dairy products, breakfast intake, use of olive oil, etc.) is scored +1 point, while positive responses to questions indicating unfavorable dietary habits (e.g., regular consumption of fast food, industrial pastries, or sweets, skipping breakfast) are scored -1 point. The total KIDMED index score ranges from -4 to +12, allowing for a classification of adherence to the Mediterranean diet into three levels. Good (optimal) adherence is defined as a score ≥ 8, reflecting dietary habits consistent with the Mediterranean diet. Average adherence is defined as a score between 4 and 7, indicating acceptable dietary habits but with room for improvement. Finally, a score ≤ 3 indicates poor adherence (very low quality diet), requiring special attention.

Statistical Data Analysis

The collected data were entered, coded, and analyzed using IBM SPSS Statistics version 26.0 software. Descriptive statistics were used to summarize qualitative variables as frequencies and percentages, and quantitative variables (such as age, BMI, etc.) as means ± standard deviation. The normality of the distribution of quantitative variables (described by their mean ± standard deviation) was verified using the Shapiro-Wilk test. Between-group comparisons were performed based on the nature of the variables: the chi-square (χ²) test was used for qualitative variables, the Student t-test for comparisons of means between two groups, and one-way ANOVA for comparisons of means between multiple groups. Binary logistic regression analyses were performed to identify factors associated with overweight and adherence to the MD. Incomplete questionnaires were excluded from the analysis. The remaining missing data, in small proportions, were processed by complete case analysis (listwise deletion). These results are expressed as odds ratios (OR) with their 95% confidence intervals (95% CI) and the corresponding p-value.

To avoid model instability due to overparameterization, the multinomial logistic regression model was constructed using a parsimonious approach. Only variables with theoretical relevance, a significant association in bivariate analysis, and sufficient frequencies in each category were retained. Variables with rare categories were grouped or excluded to respect the assumption of a minimum number of events per variable and to ensure the stability of the estimates. The statistical significance threshold was set at p ≤ .05.

Results

Sociodemographic and Socioeconomic Characteristics of the Study Population

The sociodemographic and socioeconomic characteristics of adolescents by sex are presented in Table 1. The sample comprised 211 adolescents aged 14 to 18 years, with a slight male predominance.

Significant differences according to sex were observed for several socioeconomic indicators. Housing conditions differed significantly between girls and boys, with a higher proportion of boys living in peri-urban areas or precarious housing (p = .013). Marked disparities in monthly household income were also shown by sex, with more girls coming from low-income households and none belonging to the highest income category (p < .001).

Regarding parental characteristics, no significant sex-related differences were observed for family type or parental marital status. Fathers’ educational level was comparable in both boys and girls, while that of the mothers was significantly different, being lower among the mothers of girls (p = .002). The mothers’ occupations were very homogeneous in the study sample and were therefore presented as the overall category SPC3. For the fathers’ occupations, SPC3 was subdivided into SPC3a, corresponding to farmers and fishermen, and SPC3b, corresponding to manual workers, craftspeople, office workers, drivers, and salespeople. However, the fathers’ socio-professional category showed no significant differences between the sexes.

Table 1  

Sociodemographic and socioeconomic characteristics of adolescents according to sex (to see Table 1, please click here)

Anthropometric Characteristics and Weight Status According to Sex

Table 2 presents a comparison of anthropometric characteristics and weight status according to sex. Boys had significantly higher mean weight and height than girls (p < .001), reflecting expected biological differences related to growth and pubertal development. In contrast, mean BMI and BMI z-score did not differ significantly between the two sexes. However, analysis by weight status category showed a significantly higher prevalence of overweight in girls compared to boys (p = .006).

Abdominal obesity, assessed by the waist-to-height ratio (WHtR), was also significantly more frequent in girls than in boys (p = .004), indicating a less favorable distribution of fat mass in adolescent girls.

Table 2

Comparison of adolescents´ anthropometric characteristics and weight status according to sex (to see Table 2, please click here)

Adherence to the Mediterranean Diet According to Sociodemographic and Socioeconomic Characteristics

The distribution of adherence to the Mediterranean diet (MD) according to sociodemographic and socioeconomic characteristics is presented in Table 3. A significant association was observed between sex and adherence to the MD (p < .001), with a higher proportion of good adherence among boys, whereas poor adherence was more frequent among girls.

Adherence to the MD was also significantly associated with the residential environment. Adolescents living in rural housing had higher rates of good adherence than those residing in peri-urban areas or precarious housing (p < .001). Family structure was also significantly associated with adherence, with adolescents from nuclear families showing higher levels of adherence than those living in composite families (p = .004).

Household income was strongly associated with adherence to MD (p < .001), with good adherence concentrated among adolescents from high-income households, whereas poor adherence was predominantly found in low-income households.

In contrast, parental marital status and parental education level were not significantly associated with adherence to MD. Mothers’ occupation showed low variability and was not associated with adherence to MD, whereas fathers’ socio-professional category was significantly associated with adherence to the MD (p < .001).

Association between adherence to the Mediterranean diet and anthropometric indicators

The associations between adherence to the MD and anthropometric characteristics are presented in Table 4. Although no significant difference in age was observed according to adherence levels, clear trends were observed for several anthropometric indicators.

Adolescents with good adherence to the Mediterranean diet had significantly lower BMI, BMI z-score, and WHtR values ​​compared to those with average or poor adherence (p<.001), indicating an inverse association between diet quality and excess weight.

Analysis by weight category confirmed this trend, with a higher proportion of normal-weight adolescents with good adherence, whereas overweight and abdominal obesity were more frequent among adolescents with average or poor adherence to the Mediterranean diet.

Multivariate Analysis of Factors Associated with Adherence to the Mediterranean Diet

Table 5 presents the results of the multinomial logistic regression analysis. After adjusting for potential confounding factors, several variables remained independently associated with adherence to the Mediterranean diet. Female sex was associated with a significantly lower probability of average or good adherence compared to male sex (p < .001). Low household income was also a factor negatively associated with adherence (p < .001). Nutritionally, overweight, as assessed by the BMI z-score, was independently associated with poor adherence to the Mediterranean diet, with a high odds ratio. Furthermore, adolescents living in peri-urban areas and those from composite families had a significantly lower probability of adhering to the Mediterranean diet than their peers living in rural areas and from nuclear families.

Table 3

Adherence to MD according to the sociodemographic, socioeconomic and anthropometric profile of adolescents (to see Table 3, please click here)

Table 4

Association between anthropometric characteristics and adherence to the Mediterranean diet (to see Table 4, please click here)

Table 5

Multinomial logistic regression analysis of factors associated with average or poor adherence to the Mediterranean diet (reference category: good adherence) (to see Table 5, please click here)

Discussions

These study results shed light on the determinants of adherence to the Mediterranean diet among adolescents attending school in a predominantly rural area of ​​Morocco, within the context of an ongoing nutritional transition and in light of the socio-ecological model, integrating the individual, familial, and environmental dimensions that shape eating behaviors during adolescence.

Gender Differences in Adherence to the Mediterranean Diet

Gender appears to be a major determinant of adherence to the Mediterranean diet. Higher levels of adherence to the Mediterranean diet were generally observed among the boys, while these levels were lower among girls. These differences are likely linked to social norms associated with different gender roles and sociocultural constraints that can influence eating behaviors from adolescence onward (Sawyer et al., 2018; WHO, 2024). In Mediterranean and North African contexts, differing expectations regarding parental control, mobility, eating practices, and body image can expose adolescent girls to specific forms of nutritional vulnerability. Several studies have, in fact, shown that girls, although often more closely monitored in terms of their diet, may adopt unbalanced practices related to weight concerns or inappropriate dietary restrictions (Desbouys et al., 2020; Serra-Majem et al., 2019).

Socioeconomic and Family Determinants

Although socioeconomic status is a central factor in adherence to the Mediterranean diet, the data from this study revealed that greater adherence is independently associated with higher monthly household income and a more favorable paternal socioeconomic status among the adolescents studied. This observation confirms the existence of a link between social status and diet quality. These results are consistent with those in the literature showing that economic constraints often limit access to foods characteristic of the Mediterranean diet (fruits, vegetables, fish, olive oil), particularly in low-income households (Desbouys et al., 2020; Sawyer et al., 2018).

Another relevant determinant of adherence to the Mediterranean diet identified in this study is family structure, with greater adherence observed among adolescents from nuclear families than among those living in extended families. This association appears to be more closely linked to meal organization, the regularity of eating habits, and the transmission of nutritional norms than to parental marital status, the latter not being significantly associated with adherence in this study (Carpenter et al.,2016).

Furthermore, while there is no statistically significant association between parental education level and adherence to the Mediterranean diet, a trend toward greater adherence is observed among adolescents whose parents have a higher level of education. The lack of significance could be explained by the overall homogeneity of educational level in the sample, preventing the detection of a statistical effect, as has been reported in other studies conducted in similar contexts (Cherkaoui et al., 2013).

Residential Environment and Dietary Context

An important determinant of adherence to the dietary regime studied in this work concerns the residential environment. Indeed, the data obtained show that adolescents living in rural areas had better adherence to the dietary regime than those residing in peri-urban areas or precarious housing. This result can be explained by the stability of these rural adolescents and the maintenance of traditional dietary practices in their households, with a greater frequency of home-prepared meals and easier access to local products, particularly in families involved in agriculture or fishing (Da Silva et al., 2009; Dernini & Berry, 2015).

Conversely, peri-urban environments are often characterized by instability and less favorable food systems, marked by a greater availability of ultra-processed foods, less access to fresh produce, and reduced time spent on food preparation, which may contribute to the decline in the quality of adolescents’ diets (Garnett et al., 2015; Popkin et al., 2020).

Anthropometric Status and Adherence to the Mediterranean Diet

Data from this study reveal a clear inverse association between adherence to the Mediterranean diet and anthropometric indicators of excess weight. Good adherence to this diet was observed among adolescents with lower BMI, BMI z-score, and waist-to-height ratio. Conversely, overweight and abdominal obesity were more frequent among those with poor adherence to the Mediterranean diet.

Consistent with these results, an association between a Mediterranean-style diet and a more favorable body composition has already been established in children and adolescents by numerous studies (Manzano-Carrasco et al., 2020; Tosti, 2018). However, the present study, being cross-sectional in nature, did not allow for the inference of causal associations. This made it impossible to establish whether poor adherence to the diet promotes excess weight, whether excess weight influences food choices, or whether these two dimensions result from the combined effect of social and environmental determinants.

Multivariate Determinants and the Socio-Ecological Framework

The multivariate analysis conducted in this study confirms that sex, household income, family structure, type of housing, and weight status independently contribute to adherence to the Mediterranean diet. By including all these variables in the analysis, these results support the socio-ecological approach, according to which adolescent eating behaviors result from complex interactions between individual (sex, weight status), family (socioeconomic level, household structure, parental occupation), and contextual (residential and food environment) factors (WHO, 2024). This integrated perspective underscores that adherence to a healthy eating pattern cannot be reduced to a simple individual responsibility but is strongly influenced by structural constraints, particularly in middle-income countries facing a rapid nutritional transition (Popkin et al., 2020).

Implications for Public Health and Nutritional Interventions

These results highlight the need to develop targeted nutritional interventions that take into account social inequalities and environmental constraints. Promoting the Mediterranean diet among adolescents should be tailored to the multidimensional local socio-economic reality, with particular attention to girls, low-income households, extended families, and adolescents living in peri-urban areas.

Strategies combining nutrition education, family-based approaches, and actions aimed at improving economic and geographic access to healthy foods could help reduce food inequalities and promote adherence to the Mediterranean diet and the sustainable adoption of protective eating behaviors from adolescence onward (Desbouys et al., 2020; Rosi et al., 2024).

Conclusion

This study highlights a marked heterogeneity in adherence to the Mediterranean diet among school-aged adolescents in a predominantly rural municipality in Morocco, reflecting the combined influence of individual, family, and contextual factors. The results show that sex, household socioeconomic status, family structure, type of housing, and weight status are associated with variations in adherence to this dietary model, illustrating the complexity of the determinants of eating behaviors in adolescence.

These observations fall within the framework of the socioecological model of health, according to which adolescent diets result from interactions between individual, family, and environmental factors, rather than strictly individual choices.

Overall, the findings highlight the importance of integrating social, familial, and environmental determinants into strategies for promoting healthy eating in adolescence. They underscore the need for targeted nutritional interventions, adapted to local socioeconomic realities, particularly for adolescents living in vulnerable situations.

Longitudinal studies conducted on larger samples would be necessary to better understand the temporal relationships between diet quality and weight status and to strengthen the scientific basis of public health initiatives targeting adolescents.

Limitations and future directions

While this study has the strength of shedding light on the determinants of dietary behavior and adherence to the Mediterranean diet among school adolescents from rural areas, it has certain methodological limitations that should be considered when interpreting the results.

Because this research is cross-sectional, it only identifies associations between the variables studied and does not establish causal relationships.

The relatively modest sample size and the use of convenience sampling, based on student attendance on data collection days and parental consent, may introduce selection bias, limit the generalizability of the results, and contribute to the potential instability of certain estimates in the multivariate model.

An additional limitation of the study is the lack of precise information on the total size of the eligible population at the time of the survey, which prevented the calculation of the exact participation rate.

Finally, dietary and behavioral data were based on self-administered questionnaires, which may be affected by recall bias and social desirability bias. However, standardized administration of the questionnaires in a school setting and ensuring anonymity of responses were implemented to minimize these biases.

Competing interests

The authors declare no competing interests.

Ethics Committee Approval

The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Before data collection, the necessary authorizations were obtained from the local educational authorities in El Jadida province, Morocco (representative of the Ministry of Education and school administration) under reference [#0483/2022 and #2015/2023], in accordance with national regulations governing non-interventional research involving minors.

Consent to participate

Written informed consent from parents or legal guardians, as well as the assent of the adolescents, was obtained after a full explanation of the study’s objectives. Participation was voluntary, and adolescents could withdraw from the study at any time without consequence. The anonymity and confidentiality of the collected data were strictly maintained throughout the research.

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