Previous studies and national surveys have demonstrated high rates of iron deficiency anaemia (IDA) among Indonesian female adolescents. Strategies to prevent and control IDA are critical for this population group, both for their own health and wellbeing and because early pregnancy and childbirth is highly possible in this life stage. Iron supplementation and fortification have been recognised as successful approaches to control IDA for high-risk groups, however, there has been a lack of attention to determining effectiveness of dietary diversity and/or modification to control IDA. Moreover, research on adolescent eating behaviour is scarce, particularly from non-Western countries and emphasising behavioural changes relevant for IDA prevention. Research to date has identified potential personal and environmental influences on eating behaviour that may be important to enhance dietary behavioural changes in adolescents. The applicability of these findings to the Indonesian and other non-Western settings is unknown.
This thesis aimed to understand the eating behaviours of Indonesian female adolescents relevant to IDA prevention and to understand personal and environmental influences on the behaviour. This study adapted a conceptual framework developed by Klepp and co-workers (2005), modifying it to reflect the factors likely to be relevant to adolescents in Indonesia.
This formative research consisted of two phases. In Phase 1, participants were randomly recruited from urban and rural secondary schools in South Sulawesi, Indonesia. A total of 518 girls aged 12-14 years completed an eating behaviour survey and dietary assessments. A sub-sample of girls identified as having ‘unhealthy eating habits’ based on the review of their dietary assessments’ results was selected to participate in Phase 2, which comprised qualitative in-depth interviews. The interviews were also conducted among selected mothers of the participant girls and school personnel from the participating schools. Fifty-two participants completed Phase 2.
Analyses were performed separately for Phase 1 and Phase 2 data. Four stages were undertaken to analyse data from Phase 1, namely exploratory factor analysis, descriptive analysis, bivariate analysis, and multiple regression. Thematic content analysis was performed for the Phase 2 data to identify emerging themes from key elements of participants’ accounts.
The Phase 1 findings showed skipping meals and dieting were common among the girls. Most girls had relatively less than recommended consumption of good iron and vitamin C sources with 94% of girls at risk of inadequate iron and 70% at risk of inadequate vitamin C intake (<77% of Indonesian RDA). Differences were noted in nutrient intakes across location and socio-demographic characteristics. Certain personal and environmental influences on the nutrient intakes of the girls were identified. Nutrition knowledge and parent modelling predicted iron intake in a positive direction, family size predicted iron intake in a negative direction (p<0.05). Self-evaluation and location predicted vitamin C intake in a positive direction (p<0.05). Phytate intake was inversely associated with age and dieting, and was positively associated with preference & attitude on GLVB, and nutrition knowledge (p<0.05). MFP-iron intake was positively associated with age, parent modelling, and dieting (p<0.10) but negatively associated with barrier to consume foods important for iron stores (p<0.05)
Phase 2 revealed that the girls reported practising poor eating habits such as skipping meals, frequent snacking of low nutrient-foods, and low consumption of foods rich in iron and vitamin C. The girls’ food preferences indicated a dietary transition from local traditional foods to foreign/Western foods. Knowledge and awareness of anaemia as well as knowledge regarding nutritious foods appeared to be poor. Responses from the three groups of participants revealed many aspects that could influence adolescent girls’ eating habits including their food preferences, ranging from personal, social environmental, to physical environmental factors.
Findings from both phases of the study confirm that a large proportion of the South Sulawesi adolescent girls were at risk of unhealthy eating behaviours and inadequate intakes of nutrients relevant to iron deficiency. As portrayed in the conceptual framework, the adolescents’ eating behaviours were shaped with multilevel influences, with evidence of interactions between their behaviours, some individual characteristics and the environment. Therefore, the adapted conceptual framework from Western adolescents referring to overall perspectives of Social Cognitive Theory and Ecological models was largely applicable to this study population, with the following specific differences. First, this study did not confirm the influence of self-efficacy. Second, further investigations are required to include traditional food beliefs as well as attitudes and preferences toward traditional/Indonesian vs. Western foods as additional concepts to the framework.
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