Agung 

et al. BMC Public Health (2022) 22:2348

https://doi.org/10.1186/s12889-022-14669-6

RESEARCH Open Access

The barriers of home environments

for obesity prevention in Indonesian
adolescents
Fransisca Handy Agung1,2*   , Rini Sekartini3   , Nani Cahyani Sudarsono4   , Aryono Hendarto3   ,
Meita Dhamayanti5   , Retno Asti Werdhani4    and Susan M. Sawyer6    

Abstract 
Background:  Obesity and its related cardiovascular-metabolic diseases are growing public health concerns. Despite
global attention to obesity, its prevalence is steeply increasing in developing countries, especially in children and ado-
lescents. Eating behaviours and physical activity are modifiable risk factors for obesity that can variably be shaped by
families. Eating behaviours and physical activity are especially important during adolescence, given its significance as
a foundational period for developing healthy lifestyles. This qualitative study aimed to explore barriers and opportuni-
ties around creating healthy lifestyles among adolescents in Indonesia, focussing on family environments from diverse
socio-demographic backgrounds.
Method:  In-depth interviews using a semi-structured guide were undertaken with consecutively recruited
10–18-year-old adolescents with overweight or obesity, and their parents, from three different sites: urban (Jakarta,
the capital city of Indonesia), peri-urban (West Java Province) and rural (Banten Province). Thematic analysis was used
to identify patterns of meaning.
Results:  Nineteen dyads were interviewed. Thematic analysis revealed four themes: limited knowledge of healthy
lifestyles; healthy lifestyles not a concern of daily life; limited parenting skills, including inequity around gender roles;
and aspects of availability and accessibility. These interconnected barriers influenced lifestyle practices at home within
the context of daily preferences and decisions around food and activities. Gender role inequity and healthy food
accessibility were more prominent in rural families than in those from urban or peri-urban settings.
Conclusions:  Healthy lifestyles in adolescence may be supported by strategies to enhance parenting skills, build
individual motivation, and support the development of more enabling environments.
Keywords:  Adolescent, Eating behaviours, Healthy lifestyles, Obesity, Parenting, Physical activity, Prevention

Introduction experienced an even more rapid increase [2]. In Indone-

Over the past four decades, there has been a ten fold sia, for example, a 2018 national health survey revealed
increase in the global prevalence of obesity in adoles- 19.8% of adolescents were overweight and obesity, a ten
cents [1]. Many low and middle-income countries have fold increase in the past decade [3, 4]. The COVID-19
pandemic is expected to amplify this trend due to many
life restrictions [5].
*Correspondence: [email protected] Overnutrition impacts adolescents’ health and
1
Present address: Doctoral Program Faculty of Medicine Universitas wellbeing. Adolescents with overweight or obesity
Indonesia, Jl. Salemba Raya No.6 Jakarta Pusat, Jakarta 10430, Indonesia have a five to eight times greater risk of developing
Full list of author information is available at the end of the article

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Agung et al. BMC Public Health (2022) 22:2348 Page 2 of 10

cardiovascular-metabolic problems in later adulthood [6, contexts. We focused on the home environment, as we
7]. In the past deacde, cardiovascular-metabolic diseases wished to explore how parents understand their roles
such as stroke, heart disease and diabetes have caused the and responsibilities around promoting healthy lifestyles
greatest morbidity and mortality in Indonesia than other in their children, and the practices they engage in within
disease groups, and contributing to rising health costs their daily lives. The wider objective of this study was to
and reduced productivity [8]. use these findings to inform the development of a train-
Healthy diet and physical activity are central to pre- ing module for primary healthcare professionals.
venting overweight and obesity [9]. A recent system-
atic review of fifteen studies of adolescents in Indonesia Method
highlighted the poor quality of their diet [10]. All of the This is a qualitative study using semi-structured in-dept
reviewed studies revealed inadequate fruit and vegeta- interviews to adolescents and their parents.
ble consumption, high consumption of sugary beverages,
and frequent skipping of breakfast and snacking among Development of the interview guide
10–17-year-olds [10]. Furthermore, the 2018 national A semi-structured interview guide was developed in the
survey in Indonesia showed that in terms of physical Indonesian language (Bahasa) by the lead researcher, in
activity, the proportion of the population over 10 years of consultation with the group. This was refined after pilot
age within the ‘less active’ category was 33.7% [4]. Higher interviews with two adolescents (a boy and a girl) and
than recorded in the same survey from only 5 years ear- two parents (a mother and a father). The interview ques-
lier [3], physical inactivity is expected to have increased tions focused on three key areas: knowledge of healthy
even further during the COVID-19 pandemic [11]. eating, physical activity, sedentary activity (screen time)
Parent capabilities to provide enabling environments and obesity; daily life-style practices at home; and the
for children to develop a healthy lifestyle will reflect a parent-adolescent relationship, especially around the
variety of barriers and facilitators in homes as well as in establishment of healthy lifestyles at home (see Table 1).
communities. While we know ‘what’ family factors affect
adolescent lifestyles, it is not entirely clear ‘how’ and Settings and participants
‘why’ these factors are, or are not, able to support adoles- Participants were adolescents and one of their parents
cents in adopting healthy lifestyle practices, especially in who were enrolled between December 2019–Febru-
Asia [12]. Certainly, there is scarce evidence about how ary 2020 from three different socio-demographic back-
Indonesian parents understand their role and what fac- grounds: an urban setting (Jakarta, the capital city of
tors influence them around shaping healthy behaviors in Indonesia), a peri-urban setting (Bogor, a district near
their children. For this reason, we aimed to explore the Jakarta in West Java Province), and a rural setting (Pan-
barriers and opportunities around healthy eating behav- deglang, a rural district in Banten Province). The inclu-
iors and physical activity among Indonesian adolescents sion criteria were that adolescents were aged 10–18 years
and their parents across various sociodemographic old, had a BMI percentile of 85 or above (WHO growth

Table 1  Interview guide

Area Examples of questions

1. Knowledge on obesity and healthy lifestyle - What do you know about obesity and its impacts?
- What is healthy eating? What is healthy snacking?
- What are the recommendations for physical activity and screen time for
adolescents?
2. Daily practices at home and the modifiable factors around these - What are your eating habits at home?
- What are your daily activities?
- How many hours screen time do you get each day?
- What are the factors that influence your eating habits / activities / screen
time habits?
3. Parent-adolescent relationship around healthy lifestyle establishment - Is there any discussion or talk on healthy lifestyles at home?
- What are the house rules about eating / physical activity / screen time?
- How are meals organised at home?
- How are daily household chores organised at home?
- How do you understand and apply your role as a parent?
 Agung et al. BMC Public Health (2022) 22:2348 Page 3 of 10

chart  2006), did not have any developmental concerns thematic categories emerged. Each analyst generated an
and lived with their parents. initial coding scheme that included a range of observable
categories, following which the themes were then dis-
Recruitment cussed among all the analysts. Once they were finalized,
For each location, a local research assistant experienced transcripts were imported into NVivo (Version 12.6.0,
in community-based research was recruited to iden- QSR International - UK) for electronic coding. Using
tify potentially eligible participants. Those from the the thematic coding frame, a chart of the data was cre-
peri-urban and rural settings were identified with com- ated with each participant represented across all themes.
munication with the local leader. In the urban setting, This enabled comparison to be made within and across
participants were also recruited using social media (Face- the interviews, allowed identification of deviant cases,
book, Whatsapp). The research assistant provided a thor- and highlighted the views that participants held towards
ough explanation of the study to potential participants by a particular issue [13].
phone or face-to-face. If the potential participants and
one of his/her parents expressed interest in participating
Results
in the study, an interview was arranged, prior to which
Nineteen adolescents and their parents participated in
a brief explanation was repeated in person by the inter-
the study, with an even balance across the urban (seven
viewer at the scheduled interview time before partici-
dyads), peri-urban (six dyads) and rural sites (six dyads).
pants were invited to provide signed, informed consent/
There were eight and eleven adolescents with overweight
assent. We hoped to recruit a gender balance of boys and
and obesity respectively. The group was evenly balanced
girls and to recruit at least one father from each loca-
between younger adolescents (nine adolescents were
tion (expecting that the majority of participating parents
aged between 10 and 14 years) and older adolescents (ten
would be mothers). A convenience sampling method was
were aged 15–19 years old). There were similar numbers
used, with recruitment continuing until no new codes
of male and female adolescents. On the parent side, there
were found in the data transcripts.
were significantly more mothers (fourteen) than fathers
(five). Parents from the rural area had all graduated from
Data collection
secondary school, those from the peri-urban area were
Three trained interviewers with experience communi-
a mix of secondary school and tertiary graduates, while
cating with adolescents used a semi-structured guide
those from the urban area all had tertiary qualifications.
to undertake the interviews at the study participants’
About half of the adolescents, mainly the younger ones,
homes. One interviewer was used for each of the three
wished their parents to be present throughout the inter-
population groups. In the peri-urban and rural popula-
view younger adolescents and parents from the rural area
tions, each interview also included the local research
provided simpler responses in comparison to older ado-
assistant to help translate local languages and local
lescents, and parents from the urban setting were gener-
customs. Each interview started with a brief explana-
ally more expansive.
tion of the study, following which written consent was
Four interdependent themes emerged from the analy-
obtained from the parent and assent from the adoles-
sis, as depicted in Fig.  1. Two themes (knowledge and
cent. Each adolescent and their parents then separately
personal concern) were considered to be individual fac-
completed a demographic questionnaire. After a state-
tors for both adolescents and parents. The third theme
ment that suggested they may be more comfortable being
(availability and accessibility) was considered to lie within
interviewed alone, they were offered the opportunity to
the physical environment, and was also relevant for both
be interviewed alone or together. Each interview took
adolescents and parents. The fourth theme (parenting
approximately 45 to 60  minutes. All interviews were
skills) was considered to reflect the social environment
audio-recorded and transcribed for analysis in Bahasa,
experienced by adolescents.
and also translated into English.

Data analysis Theme 1. Limited knowledge and understanding

The transcribed interviews were analysed by the lead Participants from all three sites had some appreciation
researcher and two independent analysts with differ- of the issues relating to healthy eating, with deeper, more
ent backgrounds: a health communication expert with explorative answers obtained from the urban population
expertise in adolescent health advocacy, and a gen- (see Table  2). Most study participants had some basic
eral practitioner with extensive counseling experience knowledge of healthy eating, such as the value of eating
around nutrition and family wellbeing in rural commu- a range of types of food and the importance of regular
nities. A line-by-line open coding process was used until mealtimes.
Agung et al. BMC Public Health (2022) 22:2348 Page 4 of 10

Fig. 1  Thematic map depicting individual, social environment and physical environment factors associated with dietary and physical activity
behaviours in adolescents

“Healthy eating means we eat regularly” (Mother, Most participants were able to identify various sources
peri-urban) of sugar and fat.
“Candy, chocolate, and coffee contain too much
“A healthy diet is a balanced diet, carbohydrates,
sugar” (Boy, urban area)
protein, vitamins, minerals, and fiber” (Mother,
urban)
“(Source of fat is) milk. But fatty meal is meat.
Chicken should not be eaten with the skin, only the
The concept of a healthy menu consisting of ‘healthy breast is healthy” (Mother, peri-urban)
four perfect five’ is an Indonesian concept of healthy
However, they had little understanding of recommen-
eating that, first adopted in 1952, refers to four healthy
dations around how much of these foods should (or
food types [A staple food, a side dish, vegetables and
shouldn’t) be eaten.
fruits] with milk as the fifth. This adage was more
prominently noted among participants than ideas “I’ve heard about the balanced diet, but (I) don’t
around the importance of a balanced diet, especially in understand about the portion of each food group”
the rural and peri-urban populations. (Father, peri-urban area)
“Healthy diet is ‘healthy four perfect five’” (Mother,
“I can eat two cupcakes a day, but I can only have
peri-urban)
one tablespoon of sugar a day” (Girl, urban area)
Most participants also understood the importance of
Most participants were aware that physical activity
fruit and vegetables and the hazard of too much fried
included various activities of daily living in addition to
food, although they could not always explain why fruits
sports or more intentional forms of physical activity.
and vegetables are important or why too much fried
food might be unhealthy. “Activities that are done at home such as sweeping,
washing, cooking … and also taking a walk as well as
“If you eat vegetables, sometimes it contains water,
exercising” (Mother, rural area)
so it is good for our body” (Father, rural area)
However, there was less certainty about the recom-
“Fried food is unhealthy because sometime the oil mended amount of physical activity. The tentativeness
has been used many times” (Girl, peri-urban) reflected in many remarks (indicated by much use of
 Agung et al. BMC Public Health (2022) 22:2348 Page 5 of 10

Table 2  Representative quotes of theme 1 (knowledge of healthy eating, physical activity, screen time, overweight and obesity)

Knowledge of healthy eating

  Balanced nutrition is ‘healthy four perfect five’ (Girl, rural)
  I’ve never heard of a balanced diet (Father, rural)
  Well, as a saying ‘healthy four perfect five’, there have to be vegetables, carbohydrates, fruits, and milk.” (Boy, peri-urban)
  (Healthy eating is) we eat regularly and not too much (Mother, peri-urban)
  If we eat food that is oily or fatty, we can eat fruits and vegetables as neutralizers. (Question) What is a neutralizer? (Answer) It Something that is
good for the body (Boy, peri-urban)
  Food that is balanced in nutrition, protein, carbohydrates, and vitamins. It does not mean there is no carbohydrate. Therefore, the food is balanced,
not too much (Boy, urban)
  A healthy diet is no carbohydrates or fewer carbohydrates. A balanced diet includes healthy four perfect five.” (Mother, urban)
  (Question) What is food that contains fat? What is the source of fat? (Answer) Something fried (Question) Besides that, is there anything else
(Answer) I do not know. (Boy, rural)
  Cola also contains a lot of sugar. Energy drinks and bottled drinks also contain a lot of sugar, especially for those who like snacks. Teh Sisri (a brand
of bottled tea) or something like that also contains a lot of sugar. (Mother, peri-urban)
  (Question) Why fruits and vegetables are healthy food? (Answer) Because fruit and vegetables contain vitamins. Vitamins are important for our bod-
ies.” (Girl, peri-urban)
  Fat comes from protein and also meat. Fish and chicken also contain fat. Moreover, there is also fat in plants. Healthy fat is said to be mostly in fish.”
(Mother, urban)
  (Question) How much is should a teenager eat? (Answer) Well, when she/he feels full. (Father, peri-urban)
Knowledge of Physical Activity and Screen time
  Physical activity is volleyball, swimming, jogging, and taking a walk and playing basketball. (Girl, rural area)
  Physical activity is active movements of our bodies. (Mother, suburban area)
  I think walking at the mall can be considered a physical activity as well (Father, urban)
  Physical activity that makes our bodies move more than the ordinary way and (we breath) more than normal breathing (Mother, urban area)
  Screen time, as far as I know, is 2 hours at most, isn’t it?. (Mother, rural area)
  (Question) How long should an adolescent sit in front of a TV or gadget? (Answer) Until I get tired of it (Boy, peri-urban)
Knowledge of overweight and obesity
  (Overweight is) when the weight is not ideal compared to the height (Mother, urban area)
  It causes diabetes, heart disease, stroke, and back pain (Girl, urban area)
  (Question) Anything else that might happen to adolescents due to obesity? (Answer) Decreased self-confidence (Father, urban area)
  (Question) How can people achieve a healthier body weight? (Answer) Limit the screen time, exercise a lot, and eat less (Boy, peri-urban area)
  My weight once fell from 116 (kg) to 100 (kg), but it went up again to 105 (kg). (Question) What were you doing at that time? (Answer) I went to the
fitness center regularly but it only lasted for 2 weeks (Boy, peri-urban area)
  At that time, it was only for a few months that I limited myself to not eating from morning till noon. At noon, I ate vegetables, stew, without rice. It
only lasted for 2–3 months. I couldn’t handle it. I ate rice again.” (Boy, peri-urban area)

expressions such as “maybe” or “isn’t it?”) suggested Most study participants had some knowledge of the
that many responses were largely guesses. health effects of overweight and obesity. However, there
were numerous misconceptions about this, including the
“Exercise for at least 60 minutes, isn’t it?” (Mother
best approaches to preventing obesity and weight man-
14, peri-urban area)
agement. For example, one peri-urban adolescent had
tried a very strict diet to lose weight without any appre-
“Maybe … it’s two or three times a week?” (Boy 13,
ciation that weight management is a long-term goal that
peri-urban areas)
requires the development of a healthy lifestyle, rather
There was little appreciation of any recommendations than a short-term ‘quick-fix’ of weight loss.
around screen time, with most participants unable to
“I limited myself to not eating from morning till
answer questions about this at all.
noon. At noon, I ate vegetables, stew, without rice. It
“I honestly don’t know how long the maximum only lasted for 2-3 months. I couldn’t handle it” (Boy,
screen time is” (Father, peri-urban area) peri-urban area)
Agung et al. BMC Public Health (2022) 22:2348 Page 6 of 10

For all areas of knowledge, parent and adolescent pairs (Question) “What might help you to eat healthier
appeared to have a similar level of understanding of the food containing fruit and vegetables? Was any
issues raised. effort made at home?” “Nothing [laughs]” (Boy,
rural area).
Theme 2. Not a prominent daily concern
There was little evidence from parents or adolescents
across the three sites that their knowledge influenced
day-to-day decisions around shopping, meal choices, and
Theme 3. Availability and accessibility
daily activities (see Table  3). The responses from both
Issues around the availability and accessibility of
adolescents and their parents showed that convenience
healthy meals were significantly revealed in the inter-
and preference led their daily lifestyle choices. There was
views (see Table 4). Ultra-processed high-energy foods,
little evidence of planning for daily activities and a lack
such as chicken nuggets, were the food that urban and
of motivation to practice according to their knowledge of
peri-urban parents reported always needing to have at
healthy lifestyle.
home due to their practicality and easy accessibility.
“Breakfast at home, usually just something practical
“We always have frozen food such as nuggets and
(such as) bread and milk” (Mother, urban area)
sausages because it is easy to prepare” (Mother,
urban area)
(Question) What is the hard part (about being phys-
ically active)? “I feel so lazy [laughs]” (Boy, rural
area).

Table 3  Representative quotes of theme 2 (healthy lifestyle is not a daily concern)

(Question) What might help you to eat healthier food containing fruit and vegetables? Was any effort made at home? (Answer) Nothing [laughs] (Boy,
rural)
(Question) Why don’t you do badminton anymore? (Answer) I am bored (Question) Why is that? (Answer) Well, it’s just me being bored (Boy, rural)
The thing is, now it is hard in terms of time. If I continue to do some physical activity, I cannot work as a motorbike taxi driver (Father, rural)
It is difficult to find the time (for sports) (Boy, peri-urban area)
I play with my cellphone all day whenever I have free time (Question) Apart from playing on your cellphone, are there any activities that you do?
(Answer) No. That’s it (Boy, peri-urban area)
(Question) Is it because you don’t think about it, or do you have a hard time eating fruit regularly? (Answer) I don’t think about it (Father, peri-urban)
I want to (have a healthy lifestyle), but I was just like ‘ah, maybe later’ (Mother, peri-urban)
The difficulty is that the children do not like doing physical activity. They are just not interested (Mother, urban)
(Question) So, mostly it is fried dishes by the sound of it. Why? (Answer) Well, it’s the easiest (Girl, urban area)
(Question) What are the challenges of preparing vegetables every day? (Answer) Well, I often forgot to buy. I have to frequently check the storage. The
hard thing is (we) do not really like vegetables and fruits (Mother, urban)
The challenge is that I am always tempted to order food through online services (Girl, urban)

Table 4  Representative quotes of theme 3 (availability and accessibility)

Adolescent
  Vegetables are rare. I eat kale if it is available. I eat cassava leaves if they are available at home.” (Girl, rural area)
  (Question) How can your parents help you to eat more vegetables? (Answer) Well it needs to be provided on the table (Boy, urban area)
  If I am hungry and do not know what to eat, I drink packaged apple juice which is always available (Girl, urban)
  I usually drink packaged sugary drinks. It is always available at home. I rarely eat something sweet like candy since it is not available. (Boy, urban
area)
Parents
  It (fruit) is a bit difficult. (Question) Why is it difficult, Sir? (Answer) We have to plan them. It is too far to buy them. It cost a lot. (Father, rural area)
  In the market, the choices are either banana or papaya. Sometimes we can get bored too. (Mother, rural)
  (Question) Why do you rarely play badminton? (Answer) Well now, there is no accessible field nearby anymore (Mother, peri-urban)
  The difficulty is the lack of space. Moreover, there are too many cars around here. Thus, it is difficult (to do physical activity).” (Mother, urban)
  Fruit is only available in the early days [after the monthly salary payment] (Mother, urban)
 Agung et al. BMC Public Health (2022) 22:2348 Page 7 of 10

Most adolescents said that they did not eat healthy Lack of availability of an enabling environment for a
meals because they simply ate what was provided for more active lifestyle was also commonly cited by both
them at home. adolescents and parents, across all participating sites, as a
barrier to greater participation in physical activity.
“Well, just whatever is available. If there is fish, I eat
fish. If there is egg, I eat egg” (Boy, rural area) “The environment also plays a role. For example, it
is dangerous to ride a bike because there are a lot of
In contrast, while at some level, many parents
motorbikes” (Mother, urban area)
expressed a desire to prepare healthier meals, because
healthier foods were not always eaten by their children,
“The badminton field is gone now. It was changed
many suggested that this lead over time to them becom-
into a building. We have no place to play badminton
ing dissuaded from preparing healthy food.
again” (Father, rural)
“When it is not fried, no one eats it, so it becomes
wasteful” (Mother, peri-urban area).
For parents, accessibility was also influenced by the Theme 4. Limitations in parenting skills
affordability of food, both in terms of its price and loca- From each region, participant responses showed limita-
tion (time, travel costs), especially for those in the rural tions in parents’ understanding of adolescent develop-
area. ment, especially around the development of autonomy
and independence (see Table 5). Parents were permissive
(Question) “Do you have vegetables every day “No, it
to a very high level around their children’s food choices
is hard. Only if there is someone who sells it around
and daily activities. There was no evidence that par-
here.” (Question) “Why don’t you buy them at the
ents tried to regulate their children’s behaviors through
market, Sir?” “It’s costly. The market is far from here,
interactive negotiation. Instead, parents swung from
near the port” (Father, rural area)
a highly permissive stance to one of prohibition when

Table 5  Representative quotes of theme 4 (limitation in parenting skills)

Lack of interactive discussion on healthy lifestyle

  (Question) What do you usually discuss with your son about food? (Answer) Sometimes I ask him to eat fresh fruit but otherwise, I suggest he eats
whatever is available (Father, rural area)
  We rarely discuss things (Father, peri-urban area)
  (Question) Do you ever discuss food or daily activity at home with your parents? (Answer) No. My mother only asks me what I want to eat tomor-
row (Boy, urban area)
Lack of structure and rules / expectation
  (Question) Is there any regulation on eating and drinking? For example, you cannot eat or drink certain things.” (Answer) There is no regulation for
food. (Mother, rural area)
  (Question) What are the rules (on screen time)? (Answer) Turn it off when it is midnight (Boy, rural)
  (Question) What are the regulations? (Answer) Well, do not play with your cellphone too much for it can disturb your study (Question) How much is
too much for you, Mam? (Answer) If I see him on his gadget continuously (Mother, rural)
  Sometimes, if it is too much, the (TV) remote control is taken. (Laughs) Then I turn it off (Father, peri-urban)
  (Question) Is there any method to restrict unhealthy food or drinks, Sir? (Answer) There is no specific method, at least we do not store any
(unhealthy food). (Father, urban)
Lack of parental modeling
  The father is still sleeping when the children ask for a morning run or bike (laughs). (Mother, peri-urban)
  My parents do not eat broccoli either. Thus, why I should like it? (Boy, urban)
  His father loves snacking so much, so they (father and son) both are fit each other, (Mother, urban)
  Daddy keeps on playing with his phone. Mom does it (physical exercise) sometimes (Girl, urban area)
Gender inequity in parenting
  (Question) Who cleans the house? (Answer) Mother (Question) Who does the dishes? (Answer) Mother (Question) What about your father?
(Answer) He works. (Boy, rural area)
  The mother does all the house chores (Father, rural)
  If I remind him, he does not listen. Yet, if the mother says it to him, he listens. Thus, his mom talks to him more often (Father, rural)
  The eating habit is always monitored by the mother (Father, peri-urban)
  I do not know about balanced diet. Maybe my wife (know), she is the one who usually learns about food and health from youtube. (Father, peri-
urban)
Agung et al. BMC Public Health (2022) 22:2348 Page 8 of 10

parents became more concerned about their adolescent’s foods [16]. One concern is whether such general informa-
behaviors. tion about a balanced diet is sufficiently granular or prac-
tical to help contemporary families make healthy choices
“There are none (rules). He can eat whatever he
in the context of current food availability and the rapidly
wants” (Father, rural area).
rising prevalence of overweight and obesity. Rather than
knowledge, consistent with a recent global qualitative
“I do not forbid it, yet when it is too much, for exam-
review [12], family dietary practices were highly influ-
ple drinking boxed tea or sweet things continuously, I
enced by preference, convenience, availability and price.
will stop them” (Mother, urban area).
There was little confidence about any recommenda-
tions or expectations of daily physical activity, with a high
Furthermore, several statements from parents indi- level of tentativeness of parent responses. These find-
cated that their daily practices around eating and physi- ings are similar to other qualitative studies, such as from
cal activity were primarily driven by their children’s Morocco which found that while parents and adolescents
preferences. generally understood the benefits of exercise, they had
little appreciation of the ideal frequency and duration of
“We mostly follow (what the children like to eat)” physical activity for adolescents [17]. While parents were
(Father, peri-urban area). also aware that their children had high levels of screen
Surprisingly (as this was not the focus of the inter- time, consistent with other recent studies from India and
views), the extent of gender imbalance around parenting Malaysia [14, 18], there was little evidence that parents
roles featured prominently in the interviews with parents tried to encourage or shape more active daily routines at
and adolescents from the rural and peri-urban regions. home.
Our study questions did not specifically address gender In this study, parents and adolescents largely under-
roles around meals and physical activities or the relative stood the causes of overweight and obesity, with some
balance of parenting responsibilities between parents. understanding that adolescents needed to change some
While this may also have been a feature in urban families, of their behaviors. However, there was little confidence
it did not arise in any of those interviews. Mothers played that this might occur. For example, these overweight
a dominant role in meal planning, ensuring that food adolescents wanted strategies to help them to imme-
was available at home including shopping and cooking, diately lose large amounts of weight, just like a study in
as well as monitoring their children’s eating and physi- East Java in which 78% of 206 female adolescents with an
cal activity when it was monitored. There was almost no unhealthy diet reported wanting to acutely lose weight
adolescent involvement in household chores, including [19]. While this can be appreciated to reflect adolescents’
grocery shopping and meal preparation. short-term reward-seeking behaviors [20], it also dem-
onstrates a striking lack of appreciation that the core aim
“I only have sons. Thus, I do all the household chores. of obesity management is shaping long-term healthy life-
No one helps me at home” (Mother, rural area). styles [9]. Our findings provide little confidence that par-
ents appreciate the importance of their role in helping to
“Well, the rules (around eating) are given and moni- influence their children’s behaviours around this. It also
tored by their mother” (Father, peri-urban). reinforces the importance of adolescents’ agency around
food choices and how parents engage with their adoles-
Discussion cents around this [21].
Parents and adolescents across three different sociode- Availability and accessibility are strong determinants
mographic backgrounds had basic knowledge about of eating behaviours and physical activity that reflect the
healthy lifestyles, albeit with some major knowledge gaps, influence of socio-economic conditions [22, 23]. Study
especially around the benefits of physical activity and the participants from the rural area were found to be most
downsides of sedentary activity. Consistent with studies affected by these factors, especially around limited acces-
from other countries in Asia [14, 15], the most common sibility to healthy food, as previously found [14, 24]. How-
understanding of a healthy diet related to the impor- ever, beyond these factors, “not having time” and “lazy”
tance of eating a range of foods rather than an apprecia- were also the common explanations used by parents for
tion of the value of different types of food or knowledge not preparing more healthy food and for their children
of recommended amounts. In Indonesia, the govern- having highly sedentary lifestyles. Aspects of conveni-
ment’s 1952 health promotion message about nutrition ence such as easy access, low price and practicality also
of ‘healthy four perfect five’ remains frequently used by drove parent choices, as did adolescent preferences, con-
families to justify the importance of eating a variety of sistent with other studies about food choices [25, 26].
 Agung et al. BMC Public Health (2022) 22:2348 Page 9 of 10

This finding emphasizes that developing enabling envi- the health care system. Consistent with the majority of
ronments, including access to affordable healthy food, is studies of adolescents and their health, more mothers
an important aspect of establishing healthy diets [23, 27]. than fathers participated in these interviews as mother
There are two elements to parenting. One is about the were more commonly present at the time of data col-
aspect of demand and structure, while the other is about lection. Nevertheless, we included father(s) from
responsiveness and support [28]. The findings from this each sociodemographic setting. These families were
study suggest poor parental ability to provide both struc- recruited from three different sociodemographic back-
ture and support for healthy lifestyles due to the absence grounds. While the small sample size and diversity of
of clear expectations and rules, the lack of parental ability the Indonesian population means that these results are
to make healthy food available, the lack of parental mod- not able to be used to describe lifestyle and parenting
eling, and the lack of communication skills that would challenges around raising adolescents across Indonesia,
enable them to negotiate with their children around an unexpected finding was that their lifestyle practices
aspects of healthy lifestyles. In the same way, the finding were not particularly different by setting.
that adolescent-parent dyads mostly had similar levels of
knowledge, rather than higher levels, reduces the ability
of parents to be a source of information for their chil- Conclusion and future implication
dren. These challanges suggest lack of information, skills This study found deficiencies in the knowledge, atti-
and support for parenting in Indonesia, especially sup- tudes and capabilities of Indonesian parents of adoles-
port for parenting contemporary adolescents, who face cents with overweight or obesity to implement healthy
a very different set of challenges than they faced when lifestyles, and also identified that the agency that ado-
young [29]. These findings also reveal a lack of environ- lescents have around lifestyle choices then influences
mental enabling factors that might otherwise empower family decisions. Barriers around the availability and
parents to develop a healthy lifestyle at home, supported accessibility of healthy food and physical activity facili-
by government policies or programs that influence social ties featured more in rurally based families than the
norms and the resources available for healthy lifestyles, urban families. Future obesity prevention program
as found in a study from China [30]. should consider providing more practical information
While not the primary focus of this study, we found about healthy lifestyles, and include interventions to
substantial gender inequalities between fathers and build motivation in parents and adolescents. Efforts
mothers around parenting within socioeconomically to provide families and communities with the nutri-
disadvantaged families. Consistent with other studies, tional, social and physical environments that support
[31] we found that fathers were largely absent from both sustained behavioral change in adolescents also appear
practical and emotional aspects of caregiving. Although indicated. This will equally require efforts to improve
a review showed that father and child physical activity parenting capabilities as parents remain the primary
are modestly associated [32], another recent systematic actors shaping enabling environments for adolescents.
review revealed that a father’s eating habits, weight sta-
tus, and parenting techniques influence dietary behaviors
Abbreviations
of their children [33]. BMI: Body Mass Index; WHO: World Health Organization.
This study has a number of limitations. We were
interested in understanding the modifiable behaviours Acknowledgements
The authors thank Neni Suhaerni Hardianti for assisting with enrolment from
of overweight and obesity within the home environ- the Pandeglang district, Loveria Sekarini and Siska Widawati for interviewing
ment with the objective of informing a future inter- adolescents and their parents, and Santi Wulandari and Rinaldi Ridwan for
vention in primary care. As such, our inclusion criteria assisting with data analysis.
was for adolescents with overweight or obesity. We do Authors’ contributions
not know to what extent the knowledge, attitudes and All authors substantially contributed to the conception of the work. FHA, RAW,
skills highlighted in these dyads are reflective of the RS and SS developed the study design. FHA carried out the data collection.
FHA led the data analysis supported by SS. FHA and SS wrote the initial draft.
attitudes of adolescents of more normal weight and All authors revised it critically and approved the final version to be published.
their parents. The consistency of our findings with
previous studies suggests they may be similar. We also Funding
This research was supported by Universitas Indonesia (Grant number NKB-5/
did not explore the extent to which these adolescents UN2.RST/ HKP.05. 00/2020) and Universitas Pelita Harapan (Grant number 037/
had engaged with primary care providers around their FK-UPH/XI/2019).
weight to know to what extent their knowledge, atti-
Availability of data and materials
tudes and skills may have reflected engagement with Data and materials used for this study are available from the corresponding
author upon request.
Agung et al. BMC Public Health (2022) 22:2348 Page 10 of 10

Declarations 13. Clarke V, Braun V, Hayfield N. Thematic analysis. Qual Psychol.

2015;222:248.
Ethics approval and consent to participate 14. Joshi-Reddy K, Kamble V, Kunte P, Hardy-Johnson P, Fall CH, Barker M, et al.
The study was performed in accordance with the relevant Declaration of Adolescent diet and physical activity in the context of economic, social
Helsinki and was approved by the ethic committee of The Faculty of Medicine, and nutrition transition in rural Maharashtra, India: a qualitative study.
University of Indonesia, with approval number 0024/UN2.F1/ETIK/2019. Public Health Nutr. 2021;24(16):5299–308.
A thorough explanation of the study and written informed consent was 15. Ishak SIZS, Chin YS, Taib MNM, Shariff ZM. Malaysian adolescents’
obtained from all study participant and their parents prior to the interviewing. perceptions of healthy eating: a qualitative study. Public Health Nutr.
2020;23(8):1440–9.
Consent for publication 16. Colozza D. Dietary health perceptions and sources of nutritional knowl-
Not applicable. edge in an urban food environment: a qualitative study from Indonesia.
Public Health Nutr. 2021;24(10):2848–58.
Competing interests 17. Abdelghaffar E-A, Siham B. Perspectives of adolescents, parents,
The authors declare that they have no competing interests. and teachers on barriers and facilitators of physical activity among
school-age adolescents: a qualitative analysis. Environ Health Prev Med.
Author details 2019;24(1):21.
1
 Present address: Doctoral Program Faculty of Medicine Universitas Indonesia, 18. Mohammadi S, Su TT, Papadaki A, Jalaludin MY, Dahlui M, Mohamed
Jl. Salemba Raya No.6 Jakarta Pusat, Jakarta 10430, Indonesia. 2 Faculty of Medi- MNA, et al. Perceptions of eating practices and physical activity among
cine, Universitas Pelita Harapan, Jl. Jend. Sudirman No.20, Bencongan, Kelapa Malaysian adolescents in secondary schools: a qualitative study with
Dua, Tangerang, Banten 15810, Indonesia. 3 Department of Child Health, multi-stakeholders. Public Health Nutr. 2021;24(8):2273–85.
Faculty of Medicine Universitas Indonesia, Jl. Salemba Raya No.6 Jakarta Pusat, 19. Sukamto ME, Fajrianthi F, Muttaqin D, Hamidah H. The effects of socio-
Jakarta 10430, Indonesia. 4 Department of Community Medicine, Faculty cultural pressures, BMI, weight perception and body dissatisfaction on
of Medicine Universitas Indonesia, Jl. Pegangsaan Timur no 16 Jakarta Pusat, unhealthy weight control behaviors among Indonesian adolescent girls;
Jakarta 10310, Indonesia. 5 Department of Child Health, Faculty of Medicine 2020.
Universitas Padjajaran, Jl. Professor Eyckman No.38, Pasteur, Bandung, West 20. Balvin N, Banati P. The adolescent brain: a second window of opportu-
Java, Indonesia. 6 Centre for Adolescent Health, Royal Children’s Hospital, nity–a compendium.: UNICEF Available at: https://​www.​unicef-​ircorg/​
Murdoch Children’s Research, Institute, Department of Paediatrics, University publi​catio​ns/​933-​the-​adole​scent-​brain-a-​second-​window-​of-​oppor​
of Melbourne, 50 Flemington Rd, Parkville, VIC 3052, Australia. tunity-​a-​compe​ndium.​html. Accessed 1 Feb 2017; 2020.
21. Patton GC, Neufeld LM, Dogra S, Frongillo EA, Hargreaves D, He S, et al.
Received: 27 July 2022 Accepted: 18 November 2022 Nourishing our future: the lancet series on adolescent nutrition. Lancet.
2022;399(10320):123–5.
22. Pitt E, Gallegos D, Comans T, Cameron C, Thornton L. Exploring the influ-
ence of local food environments on food behaviours: a systematic review
of qualitative literature. Public Health Nutr. 2017;20(13):2393–405.
References 23. Neufeld LM, Andrade EB, Ballonoff Suleiman A, Barker M, Beal T, Blum LS,
1. Organization WH. Tenfold increase in childhood and adolescent obesity et al. Food choice in transition: adolescent autonomy, agency, and the
in four decades: new study by Imperial College London and WHO; 2017. food environment. Lancet. 2022;399(10320):185–97.
p. 2020. 24. Wong J, de Bruyn J, Bagnol B, Grieve H, Li M, Pym R, et al. Small-scale
2. Dong Y, Jan C, Ma Y, Dong B, Zou Z, Yang Y, et al. Economic development poultry and food security in resource-poor settings: a review. Glob Food
and the nutritional status of Chinese school-aged children and adoles- Security. 2017;15:43–52.
cents from 1995 to 2014: an analysis of five successive national surveys. 25. Maulida R, Nanishi K, Green J, Shibanuma A, Jimba M. Food-choice
Lancet Diabetes Endocrinol. 2019;7(4):288–99. motives of adolescents in Jakarta, Indonesia: the roles of gender and fam-
3. Indonesia MoHRo. Basic health survey Jakarta: Health Research and ily income. Public Health Nutr. 2016;19(15):2760–8.
development department. Jakarta: Ministry of Health RI; 2013. 26. Blum LS, Mellisa A, Kurnia Sari E, Novitasari Yusadiredja I, van Liere M,
4. Indonesia MoHRo. Basic health survey. Jakarta: Ministry of Health RI; 2018. Shulman S, et al. In-depth assessment of snacking behaviour in unmar-
5. Clemmensen C, Petersen MB, Sorensen TIA. Will the COVID-19 pandemic ried adolescent girls 16-19 years of age living in urban centres of Java,
worsen the obesity epidemic? Nat Rev Endocrinol. 2020;16(9):469–70. Indonesia. Matern Child Nutr. 2019;15(4):e12833.
6. Kelsey MM, Zaepfel A, Bjornstad P, Nadeau KJ. Age-related consequences 27. Organization WH. Population-based approaches to childhood obesity
of childhood obesity. Gerontology. 2014;60(3):222–8. prevention. Geneva: World Health Organization; 2012.
7. Araujo J, Ramos E. Paediatric obesity and cardiovascular risk factors - a life 28. Baumrind D. The influence of parenting style on adolescent competence
course approach. Porto Biomed J. 2017;2(4):102–10. and substance use. J Early Adolesc. 1991;11(1):56–95.
8. Marthias T, Anindya K, Ng N, McPake B, Atun R, Arfyanto H, et al. Impact of 29. Tomlinson HB, Andina S. Parenting education in Indonesia: review and
non-communicable disease multimorbidity on health service use, cata- recommendations to strengthen programs and systems; 2015.
strophic health expenditure and productivity loss in Indonesia: a popula- 30. Wang Y, Yan AF, Shi X, Wang H, Wang Z, Gittelsohn J, et al. Child and
tion-based panel data analysis study. BMJ Open. 2021;11(2):e041870. parental perspectives on diet and physical activity decisions: implica-
9. Barlow SE. Expert committee recommendations regarding the preven- tions for childhood obesity prevention in China. Asia Pac J Clin Nutr.
tion, assessment, and treatment of child and adolescent overweight and 2017;26(5):888–98.
obesity: summary report. Pediatrics. 2007;120(Supplement 4):S164–S92. 31. Montgomery JE, Chaviano CL, Rayburn AD, McWey LM. Parents at-risk
10. Rachmi CN, Jusril H, Ariawan I, Beal T, Sutrisna A. Eating behaviour of and their children: intersections of gender role attitudes and parenting
Indonesian adolescents: a systematic review of the literature. Public practices. Child Fam Soc Work. 2017;22(3):1151–60.
Health Nutr. 2021;24(S2):s84–97. 32. Neshteruk CD, Nezami BT, Nino-Tapias G, Davison KK, Ward DS. The influ-
11. Andriyani FD, Biddle SJH, De Cocker K. Adolescents’ physical activity ence of fathers on children’s physical activity: a review of the literature
and sedentary behaviour in Indonesia during the COVID-19 pan- from 2009 to 2015. Prev Med. 2017;102:12–9.
demic: a qualitative study of mothers’ perspectives. BMC Public Health. 33. Litchford A, Roskos MRS, Wengreen H. Influence of fathers on the feed-
2021;21(1):1864. ing practices and behaviors of children: a systematic review. Appetite.
12. Liu KSN, Chen JY, Ng MYC, Yeung MHY, Bedford LE, Lam CLK. How does 2020;147:104558.
the family influence adolescent eating habits in terms of knowledge,
attitudes and practices? A global systematic review of qualitative studies.
Nutrients. 2021;13(11):288–99 .
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