Home environment barriers to obesity prevention in Indonesian adolescents | BMC Public Health

Nineteen adolescents and their parents participated in the study with an even balance of urban (seven dyads), suburban (six dyads), and rural (six dyads) locations. There were eight and eleven adolescents who were overweight and obese, respectively. The group was evenly balanced between younger adolescents (nine adolescents were aged 10–14 years) and older adolescents (ten were aged 15–19 years). There were similar numbers of adolescent males and females. On the parents’ side, there were significantly more mothers (fourteen) than fathers (five). All parents from rural areas had secondary education, those from suburban areas were a mixture of secondary and tertiary education, while those from urban areas had tertiary education. About half of the adolescents, mostly the younger ones, wanted their parents to be present during the interview. Younger adolescents and rural parents gave simpler responses than older adolescents, and urban parents were generally more expansive.

Four interdependent themes emerged from the analysis, as shown in Fig. 1. Two themes (knowledge and personal concern) were considered individual factors for both adolescents and parents. The third theme (availability and accessibility) is considered to be located in the physical environment and is also relevant to both adolescents and parents. The fourth theme (parenting skills) is considered to reflect the social environment in which adolescents find themselves.

Topic 1. Limited knowledge and understanding

Participants from all three sites rated healthy eating issues to some extent, with deeper, more exploratory responses received from the urban population (see Table 2). Most study participants had some basic knowledge about healthy eating, such as the value of eating a variety of foods and the importance of eating regularly.

“Healthy eating means eating regularly“ (Mother, suburban)

“A healthy diet is a balanced diet, carbohydrates, proteins, vitamins, minerals and fiber” (Mother, urban)

The healthy menu concept consisting of “healthy four perfect five” is an Indonesian healthy eating concept that was first adopted in 1952 and refers to four types of healthy foods [A staple food, a side dish, vegetables and fruits] with milk as a heel. This saying was more prominent among participants than ideas about the importance of a balanced diet, especially in rural and suburban populations.

“A healthy diet is a “healthy four perfect five”“ (Mother, suburban)

Most participants also understood the importance of fruits and vegetables and the dangers of too much fried food, although they could not always explain why fruits and vegetables were important or why too much fried food might be unhealthy.

“If you eat vegetables, sometimes it contains water, so it is good for our body“ (Father, rural area)

“Fried food is unhealthy because sometimes the oil has been used many times“ (Girl, suburban)

Most participants were able to identify different sources of sugar and fat.

“Candy, chocolate and coffee contain too much sugar“ (Boy, Urban Area)

“(A source of fat is) milk. But a greasy dish is meat. The chicken should not be eaten with the skin, only the breast is healthy“ (Mother, suburban)

However, they didn’t have much understanding of recommendations about how much of these foods they should (or shouldn’t) eat.

“I’ve heard of a balanced diet, but (I) don’t understand the portion of each food group“ (Father, suburban area)

“I can eat two cupcakes a day, but I can only eat one tablespoon of sugar a day“ (Girl, Urban Area)

Most participants were aware that physical activity included a variety of activities of daily living in addition to sport or more intentional forms of physical activity.

“Activities that are done at home, such as sweeping, washing, cooking … and also walking, as well as exercise“ (Mother, rural area)

However, there was less certainty about the recommended amount of physical activity. The uncertainty reflected in many remarks (indicated by the frequent use of expressions such as “maybe” or “isn’t it?”) suggests that many answers are largely guesswork.

“Do sports for at least 60 minutes, right?” (Mother 14, suburban area)

“Maybe… it’s two or three times a week?” (Boy 13, suburban areas)

There was little appreciation of any recommendations around screen time, with most participants unable to answer questions about it at all.

“To be honest, I don’t know what the maximum time in front of the screen is” (Father, suburban area)

Most study participants had some knowledge of the health effects of being overweight and obese. However, there were many misconceptions about it, including the best approaches to obesity prevention and weight management. For example, a suburban teenager tried a very strict diet to lose weight, not realizing that weight management is a long-term goal that requires developing a healthy lifestyle, not a short-term “quick fix” to lose weight.

“I limited myself to not eating from morning to noon. For lunch I ate vegetables, stew, no rice. Lasts only 2-3 months. I couldn’t cope” (Boy, suburban area)

For all domains of knowledge, parent-adolescent pairs appeared to have a similar level of understanding of the issues raised.

Topic 2. Daily care is not important

There was little evidence from parents or adolescents in the three sites that their knowledge influenced everyday decisions about shopping, food choices and daily activities (see Table 3). Responses from both teenagers and their parents show that convenience and preference drive their daily lifestyle choices. There was little evidence of planning daily activities and lack of motivation to practice according to their knowledge of a healthy lifestyle.

“Breakfast at home, usually just something practical (like) bread and milk” (Mother, urban area)

(Question) What is the hard part (about physical activity)? “I feel so lazy [laughs]” (Boy, rural area).

(Question) “What can help you eat a healthier diet containing fruits and vegetables? Have any efforts been made at home?” “Nothing [laughs]” (Boy, rural area).

Topic 3. Availability and accessibility

Issues surrounding the availability and accessibility of healthy meals were significantly revealed in the interviews (see Table 4). Ultra-processed high-energy foods, such as chicken nuggets, are the food that urban and suburban parents report that they should always have at home because of their convenience and ease of access.

“We always have frozen foods like bites and sausages because they are easy to prepare” (Mother, urban area)

Most teenagers say they don’t eat healthy because they just eat what’s available at home.

“Well, whatever is available. If there is fish, I eat fish. If there is an egg, I eat an egg” (Boy, rural area)

In contrast, while at some level many parents expressed a desire to prepare healthier meals because healthier foods were not always eaten by their children, many suggested that over time this led to dissuading them from preparing healthy meals. food.

“When it’s not fried, nobody eats it, so it’s a waste” (Mother, suburban).

For parents, affordability was also influenced by the availability of food, both in terms of its cost and location (time, travel costs), especially for those in rural areas.

(Question) “Do they eat vegetables every day “No, it’s hard. Only if there’s someone here to sell it.” (Q) “Why don’t you buy them at the market, sir?” “This is expensive. The market is far from here, near the harbor“ (Father, rural area)

Lack of a supportive environment for a more active lifestyle was also frequently cited by adolescents and parents across all participating sites as a barrier to greater participation in physical activity.

“The environment also plays a role. For example, it is dangerous to ride a bike because there are many bikes“ (Mother, Urban Area)

“The badminton court is gone. It has been converted into a building. Again, no place to play badminton“ (Father, rural)

Topic 4. Limitations in parenting skills

From each region, participant responses indicated limitations in parents’ understanding of adolescent development, particularly around the development of autonomy and independence (see Table 5). Parents were tolerant to a very high level regarding their children’s food choices and daily activities. There is no evidence that parents attempted to regulate their children’s behavior through interactive negotiation. Instead, parents shifted from a highly permissive to a prohibitive stance as parents became more concerned about their adolescent’s behavior.

“There are no (rules). He can eat whatever he wants“ (Father, rural area).

“I don’t forbid it, but when they overdo it, like drinking tea all the time or sweets, I’ll stop them“ (Mother, urban area).

In addition, several parent statements indicated that their daily practices regarding nutrition and physical activity were primarily driven by their children’s preferences.

“Mostly we follow (what the children like to eat)” (Father, suburban).

Surprisingly (as this was not the focus of the interviews), the degree of gender imbalance in parenting roles featured prominently in the interviews with parents and adolescents from rural and suburban regions. Our survey questions did not specifically address gender roles around nutrition and physical activity or the relative balance of parenting responsibilities between parents. Although this may have been characteristic of urban families as well, it did not arise in any of these interviews. Mothers play a dominant role in meal planning, ensuring that food is available at home, including shopping and cooking, and monitoring their children’s eating and physical activity when they are observed. There was almost no adolescent involvement in household chores, including grocery shopping and food preparation.

“I have only sons. This is how I do all the household chores. Nobody helps me at home“ (Mother, rural area).

“Well, the rules (about feeding) are given and monitored by their mother“ (Father, suburban).