Nineteen adolescents and their parents participated in the study, with an even balance across the urban (seven dyads), peri-urban (six dyads) and rural sites (six dyads). There were eight and eleven adolescents with overweight and obesity respectively. The group was evenly balanced between younger adolescents (nine adolescents were aged between 10 and 14 years) and older adolescents (ten were aged 15–19 years old). There were similar numbers of male and female adolescents. On the parent side, there were significantly more mothers (fourteen) than fathers (five). Parents from the rural area had all graduated from secondary school, those from the peri-urban area were a mix of secondary school and tertiary graduates, while those from the urban area all had tertiary qualifications. About half of the adolescents, mainly the younger ones, wished their parents to be present throughout the interview younger adolescents and parents from the rural area provided simpler responses in comparison to older adolescents, and parents from the urban setting were generally more expansive.
Four interdependent themes emerged from the analysis, as depicted in Fig. 1. Two themes (knowledge and personal concern) were considered to be individual factors for both adolescents and parents. The third theme (availability and accessibility) was considered to lie within the physical environment, and was also relevant for both adolescents and parents. The fourth theme (parenting skills) was considered to reflect the social environment experienced by adolescents.
Thematic map depicting individual, social environment and physical environment factors associated with dietary and physical activity behaviours in adolescents
Theme 1. Limited knowledge and understanding
Participants from all three sites had some appreciation of the issues relating to healthy eating, with deeper, more explorative answers obtained from the urban population (see Table 2). Most study participants had some basic knowledge of healthy eating, such as the value of eating a range of types of food and the importance of regular mealtimes.
“Healthy eating means we eat regularly” (Mother, peri-urban)
“A healthy diet is a balanced diet, carbohydrates, protein, vitamins, minerals, and fiber” (Mother, urban)
The concept of a healthy menu consisting of ‘healthy four perfect five’ is an Indonesian concept of healthy eating that, first adopted in 1952, refers to four healthy food types [A staple food, a side dish, vegetables and fruits] with milk as the fifth. This adage was more prominently noted among participants than ideas around the importance of a balanced diet, especially in the rural and peri-urban populations.
“Healthy diet is ‘healthy four perfect five’” (Mother, peri-urban)
Most participants also understood the importance of fruit and vegetables and the hazard of too much fried food, although they could not always explain why fruits and vegetables are 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 sometime the oil has been used many times” (Girl, peri-urban)
Most participants were able to identify various sources of sugar and fat.
“Candy, chocolate, and coffee contain too much sugar” (Boy, urban area)
“(Source of fat is) milk. But fatty meal is meat. Chicken should not be eaten with the skin, only the breast is healthy” (Mother, peri-urban)
However, they had little understanding of recommendations around how much of these foods should (or shouldn’t) be eaten.
“I’ve heard about the balanced diet, but (I) don’t understand about the portion of each food group” (Father, peri-urban area)
“I can eat two cupcakes a day, but I can only have one tablespoon of sugar a day” (Girl, urban area)
Most participants were aware that physical activity included various activities of daily living in addition to sports or more intentional forms of physical activity.
“Activities that are done at home such as sweeping, washing, cooking … and also taking a walk as well as exercising” (Mother, rural area)
However, there was less certainty about the recommended amount of physical activity. The tentativeness reflected in many remarks (indicated by much use of expressions such as “maybe” or “isn’t it?”) suggested that many responses were largely guesses.
“Exercise for at least 60 minutes, isn’t it?” (Mother 14, peri-urban area)
“Maybe … it’s two or three times a week?” (Boy 13, peri-urban areas)
There was little appreciation of any recommendations around screen time, with most participants unable to answer questions about this at all.
“I honestly don’t know how long the maximum screen time is” (Father, peri-urban area)
Most study participants had some knowledge of the health effects of overweight and obesity. However, there were numerous misconceptions about this, including the best approaches to preventing obesity and weight management. For example, one peri-urban adolescent had tried a very strict diet to lose weight without any appreciation that weight management is a long-term goal that requires the development of a healthy lifestyle, rather than a short-term ‘quick-fix’ of weight loss.
“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” (Boy, peri-urban area)
For all areas of knowledge, parent and adolescent pairs appeared to have a similar level of understanding of the issues raised.
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 daily activities (see Table 3). The responses from both adolescents and their parents showed that convenience and preference led their daily lifestyle choices. There was little evidence of planning for daily activities and a lack of motivation to practice according to their knowledge of healthy lifestyle.
“Breakfast at home, usually just something practical (such as) bread and milk” (Mother, urban area)
(Question) What is the hard part (about being physically active)? “I feel so lazy [laughs]” (Boy, rural area).
(Question) “What might help you to eat healthier food containing fruit and vegetables? Was any effort made at home?” “Nothing [laughs]” (Boy, rural area).
Theme 3. Availability and accessibility
Issues around 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, were the food that urban and peri-urban parents reported always needing to have at home due to their practicality and easy accessibility.
“We always have frozen food such as nuggets and sausages because it is easy to prepare” (Mother, urban area)
Most adolescents said that they did not eat healthy meals because they simply ate what was provided for them at home.
“Well, just whatever is available. If there is fish, I eat fish. If there is egg, I eat 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 this lead over time to them becoming dissuaded from preparing healthy food.
“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 affordability of food, both in terms of its price and location (time, travel costs), especially for those in the rural area.
(Question) “Do you have vegetables every day “No, it is hard. Only if there is someone who sells it around here.” (Question) “Why don’t you buy them at the market, Sir?” “It’s costly. The market is far from here, near the port” (Father, rural area)
Lack of availability of an enabling environment for a more active lifestyle was also commonly cited by both 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 a lot of motorbikes” (Mother, urban area)
“The badminton field is gone now. It was changed into a building. We have no place to play badminton again” (Father, rural)
Theme 4. Limitations in parenting skills
From each region, participant responses showed limitations in parents’ understanding of adolescent development, especially around the development of autonomy and independence (see Table 5). Parents were permissive to a very high level around their children’s food choices and daily activities. There was no evidence that parents tried to regulate their children’s behaviors through interactive negotiation. Instead, parents swung from a highly permissive stance to one of prohibition when parents became more concerned about their adolescent’s behaviors.
“There are none (rules). He can eat whatever he wants” (Father, rural area).
“I do not forbid it, yet when it is too much, for example drinking boxed tea or sweet things continuously, I will stop them” (Mother, urban area).
Furthermore, several statements from parents indicated that their daily practices around eating and physical activity were primarily driven by their children’s preferences.
“We mostly follow (what the children like to eat)” (Father, peri-urban area).
Surprisingly (as this was not the focus of the interviews), the extent of gender imbalance around parenting roles featured prominently in the interviews with parents and adolescents from the rural and peri-urban regions. Our study questions did not specifically address gender roles around meals and physical activities or the relative balance of parenting responsibilities between parents. While this may also have been a feature in urban families, it did not arise in any of those interviews. Mothers played a dominant role in meal planning, ensuring that food was available at home including shopping and cooking, as well as monitoring their children’s eating and physical activity when it was monitored. There was almost no adolescent involvement in household chores, including grocery shopping and meal preparation.
“I only have sons. Thus, I do all the household chores. No one helps me at home” (Mother, rural area).
“Well, the rules (around eating) are given and monitored by their mother” (Father, peri-urban).
