Barriers of Implementing a Nutrition Education Program for Adolescents in Rural Indonesian Schools

@#Introduction: Nutrition education (NE) is a promising intervention in promoting behavior change. However, in developing countries where it is not included in the national curriculum, many barriers arise. The study aimed to explore the teachers’ perceived barriers of implementing a nutrition education program for adolescents in rural Indonesian schools. Methods: A qualitative participatory action research approach was applied in three selected schools in Bogor, Indonesia. Focus group discussion was used as the main method of data collection, involving 12 teachers who have implemented the Health and Nutrition Program for Adolescents. Triangulation was conducted through observation and feedback questionnaire from students. Data from multiple sources were coded, categorized, and thematically analyzed. Results: Three themes and six subthemes emerged, these include 1) capacity of teachers (lack of training and lack of nutrition knowledge), 2) school support (time constraints and lack of funding), and 3) external environment (unhealthy street vendors and parent’s lack of nutrition awareness). These identified barriers could be minimized by establishing a strong commitment of school principals, the inclusion of street-food vendors and parents, and also ensuring sufficient training of teachers. Conclusion: This study highlights the need for schools and program implementers to identify potential barriers prior to commencing NE and also strengthen opportunities within it. The barriers found in this study emphasizes the need for advocacy, sufficient training of teachers, and consideration of the external food environment. Further studies are suggested to confirm these findings, involving more informants and different settings, such as in the urban population.

Early development process of drama and storytelling scripts as media for nutrition education on balanced diets among elementary school children

@# Introduction: The Indonesian Guide on Balanced Nutrition endorsed in 2014, needs to be more widely publicised. One way is to use fun learning methods such as drama and storytelling, especially in schools. This study aimed to develop drama and storytelling scripts for educating students on balanced nutrition. Methods: Sixteen focus group discussions (FDGs) with thematic activities were conducted among 96 mother-child pairs in four elementary schools. The mothers’ age ranged from 30-50 years and the children 9-13 years. In-depth interviews were conducted with eight teachers (two from each participating school). The FGDs and interviews were designed to elicit information on knowledge and implementation of balanced nutrition guidelines at three levels, namely intrapersonal (students), family (mother) and environment (school teacher). Content analysis was used to identify relevant themes, which were developed into scripts for drama and storytelling. Results: The students, mothers, and teachers were not familiar with the general guidelines for balanced nutrition. The lack of variety of the food provided at home was reported. The draft scripts were discussed and modified for accuracy of the nutrition messages that were applied in character dialogues, song lyrics, dramas and storytelling. Conclusion: Storytelling and drama are effective for use by teachers and mothers for delivering nutrition messages in schools and the home.

A qualitative study comparing the coping strategies between food secure and food insecure households of Kaluppini indigenous people in South Sulawesi

@# Introduction: Food insecurity remains a global challenge, especially among vulnerable indigenous populations. Coping strategies to maintain food security among indigenous groups can be unique and complex, being influenced by cultures. This study aimed to explore the coping strategies employed by food secure and food insecure households in times of food insufficiency, in the Kaluppini indigenous population of South Sulawesi, Indonesia. Methods: The study recruited mothers of children aged below 5 years, who agreed to participate in the study’s focus group discussions (FGDs) and in-depth interviews. All information was recorded, transcribed verbatim and analysed. Results: A total of 61 mothers participated in 22 in-depth interviews and six FGDs. Five coping strategies were used by the Kaluppini people i.e. additional income generation, dietary alteration, access to alternative food sources, access to alternative cash sources, and, traditional ways of coping. Both food insecure and secure households reported making dietary changes, such as reducing consumption or substituting foods, borrowing food or money, and practising traditional coping strategies, such as food sharing after performing rituals. In order to generate income, food insecure households reported seeking additional work in the neighbourhood areas, while food secure households migrated in search of work to the other islands or other countries. Conclusion: Food insecure and food secure households changed their diets, borrowed food or money from relatives and relied on traditional coping mechanisms such as food sharing. It is suggested that food insecure Kaluppini households be encouraged to grow essential foods in their gardens to enhance food security.

Eating behaviour of adolescent schoolgirls in Malang, East Java: a qualitative study

@# Introduction: Poor eating behaviour is known to lead to nutritional deficiency among adolescents. At the same time, poor eating behaviour characterised by dietary excesses could lead to overweight and obesity. The present study aimed to explore the eating behaviour of adolescent schoolgirls in Malang, East Java Province, Indonesia, and to determine the factors that influenced their eating behaviour. Methods: This was a qualitative study, guided by the Social Cognitive Theory (SCT), which focused on individual and environmental influences to better understand health-related behaviours, such as eating behaviour. Triangulation was applied to the study subjects (adolescent girls, their mothers, and school staff). The methods used included individual in-depth interviews and focus group discussions. Qualitative data analyses were performed using Atlas.ti 7. Results: Most participants showed poor eating behaviour that was characterised by skipping breakfast, frequent consumption of fast foods and the consumption of local food with low nutrient content. Their eating behaviour was influenced by individual factors including personal preferences, the price of the food, and by environmental factors, such as the family, school and neighbourhood. Conclusion: Our findings showed that adolescent girls in Malang appeared to be aware of healthy eating but they showed unsatisfactory eating practices. Interventions are suggested to improve the poor eating behaviour of the adolescents toward avoiding malnutrition consequences.

Eating behaviour of young female workers with low socioeconomic status in Malang City, East Java: a qualitative study

@# Introduction: Eating behaviour is one of the important factors affecting nutritional status that has been widely investigated. However, there are few studies on the eating behaviour of young female workers in Indonesia. This study aimed at investigating the factors affecting eating behaviour of young female workers of low socioeconomic status in Malang, East Java province, Indonesia. Methods: Participants were recruited using purposive sampling from low-income families living in Malang City. The eligibility criteria were based on demographic information, including monthly household income and expenses. The participants recruited comprised 21 women aged 18-22 years who were employed outside their homes, unmarried and living with their parents. A qualitative methodology was used to understand the meaning and context of the eating behaviour of these women. In-depth interviews and focus group discussions were used as the primary data collection methods. Results: Two primary themes emerged as the main influences of the participants’ eating behaviour: individual attributes (food preferences, healthy eating knowledge and self-efficacy), and socio-environmental factors (peer influence, mother’s role and food availability). In general, the participants had some knowledge about healthy eating behaviour; however, they lacked self-efficacy to practise such behaviour. Conclusion: Individual motivations and socio-environmental factors were found to mediate the eating behaviour of young working women from poor households. These factors should be considered when designing nutrition programmes for achieving healthier eating behaviour among young working women.

Association between food marketing exposure and consumption of confectioneries among pre-school children in Jakarta

@# Introduction: Prevalence of obesity among pre-school children in Indonesia is increasing. Since food advertisements reach all age groups, this study was conducted to assess the association between food marketing exposure and children’s consumption of confectioneries at home. Methods: Two hundred and forty caregivers of children aged 3-5 years attending 25 early childhood education centres in Central Jakarta, were interviewed in this cross-sectional study. A structured food frequency questionnaire was used to determine food marketing exposure and child dietary consumption. Chi-square tests compared consumption of confectioneries with different levels of marketing exposure. Results: Out of a total 240 caregivers, most were mothers of the study children (79.2%) and other family members (19.2%). The majority of the caregivers did not work (81.7%), and <15.0% had graduated from university, while 42.0% lived with extended family members. The top ten confectioneries consumed by the children included chocolate wafer crisp, chocolate stick and soft candy. Among the most common food marketing practices were as advertisements on public transport, print and electronic media. The significant associations between four food marketing practices and consumption of eight types of confectioneries were key findings of this study. Receiving food promotion through short message service (SMS) was not significantly associated with consumption of the top ten confectioneries. Conclusion: A positive association was found between food marketing practices and consumption of confectioneries by pre-school children in Central Jakarta. An appropriate policy on food advertisements that targets children combined with parental food education is recommended for improving food consumption habits of young children.

Exposure and approval of food marketing strategies: a mixed methods study among household food providers in Jakarta

@# Introduction: Food marketing influences consumers’ food choices leading to unplanned food purchasing. Methods: This study used a mixed methods approach to investigate the association between food marketing exposure and approval of food marketing strategies among household food providers in Jakarta. Responses from 279 survey participants to questions on exposure and their approval of marketing strategies were analysed. An additional 16 informants who fulfilled the inclusion criteria were recruited for the in-depth interview. Logistic regression was conducted to assess the relationship between the categorical predictor variable (“exposure to active or passive marketing”) and the categorical outcome variable (“approval response to food marketing strategies”). Results: Almost half of the respondents reported not having exposure to active marketing in the past month, whereas approximately one-third had experienced such exposure 1-2 times. Most of the respondents disapproved the marketing of fast foods and sugar-sweetened foods. The highest disapproval was for the placement of vending machines carrying such foods in schools (69.9%). Respondents who were exposed to active marketing at least once in the previous month were 1.99 times more likely (AOR; 95% CI: 1.07-3.73) to approve the marketing of unhealthy foods. Conclusion: Exposure to food marketing promotion appeared to influence approval of marketing strategies among household food providers in Jakarta. In-depth interviews provided supportive evidence for the quantitative results. A mixed methods approach is suggested for larger studies to confirm these findings.

Food purchasing behaviour among urban slum women in East Jakarta: a qualitative study

@# Introduction: Urbanisation in Indonesia has been associated with a transition in nutrition which has been, in part, marked by an increased purchasing of readyto-eat, energy-dense, nutrient-poor foods. Women are responsible for purchasing and preparing food for the family. Their purchasing behaviours differ in various environments and population groups. This qualitative study was undertaken to explore the food environmental factors that influenced food purchasing behaviour of women who were the household food gatekeepers. Methods: The study was conducted in a slum area in East Jakarta. Eighteen overweight-obese and nonobese women who fulfilled the study’s inclusion criteria were recruited for interviews that used a semi-structured questionnaire. Emic observations were conducted in order to identify typical food purchasing activities. The data were coded and categorised using qualitative data analysis and research software (Atlas.ti 7 for Windows). Results: Most of the women purchased ready-to-eat foods rather than cook at home, either for the family or their own consumption. Several food environmental factors influenced women’s purchasing behaviour, including time and cost efficiency, food availability, family, exposure to ready-to-eat foods and food store marketing strategies. These factors led to the consumption of unhealthy foods that were high in fat, carbohydrate, sugar and salt that some of which may cause obesity. Conclusion: Purchasing unhealthy food was observed to be strongly linked with food-related environmental factors. This study provides an understanding of women’s food purchasing behaviour and highlight potential ways to foster healthier purchasing behaviour among urban slum dwellers.

Dietary diversity beliefs and practices among working mothers in Jakarta: a qualitative study

@#Introduction: Dietary diversity is a global challenge in complementary feeding. Despite more women joining the workforce in developing countries, there are limited studies on the beliefs of working mothers and their experiences in relation to the provision of dietary diversity as recommended by the World Health Organization. Methods: This qualitative study explored the behavioural, normative and control beliefs of working mothers on dietary diversity practices, based on the Theory of Planned Behaviour (TPB). A total of 25 mothers of different occupational levels were recruited from workplaces in Jakarta. Results: Working mothers at the lower occupational levels showed a lack of understanding of the importance of dietary diversity and reported poor practices. These included the late introduction of animal protein as a food source, and few types of feeding instant foods. Due to their limited knowledge of nutrition, these working mothers tended to accept poor dietary diversity practices as normal. Conclusion: Working mothers at the lower occupational levels practised poor dietary diversity owing to work-related factors. Efforts should be undertaken to provide correct nutritional information related to complementary feeding at workplaces, especially to working mothers in the unskilled occupations.

Workplace support and exclusive breastfeeding practice: a qualitative study in Jakarta, Indonesia

@# Introduction: The primary reason that compels working mothers to decrease their ability to continue to breastfeeding successfully is their return to work. Attempts to continue breastfeeding at work encounters several difficulties. This study aims to provide an overview of the workplace environment and how facilities at the workplace affect breastfeeding in Indonesia. Methods: We used a qualitative approach to provide a detailed picture of the influence of workplace support for working mothers to perform breastfeeding. We enrolled working mothers (n=18) in Jakarta, as participants and obtained the following information from them: parity, type of family and type of work. Results: The findings provided the general overview of the workplace environment and identified three factors that affected breastfeeding: seeking information during pregnancy, expression of breast milk at office facilities and the problem faced by working mothers. Conclusion: Although the breastfeeding performance of most working mothers in this study comprised exclusive breastfeeding, some fed their infants with formula milk. This study suggests that working mothers who continue to breastfeed after returning to work need the support of their employers, co-workers and others in the workplace to ensure the provision of health facilities and the protection and dissemination the rights of breastfeeding working mothers that might lead them to discontinue their breastfeeding practice.

Assessment of Breastfeeding Problems Experienced by Mothers in the First Six Months Postpartum: A Process of Tool Development

Introduction: Studies have found that breastfeeding problems are associated with negative breastfeeding outcomes. Unfortunately, assessing breastfeeding problems can be quite difficult. The objective of the paper is to share the process of tool development for the assessment of breastfeeding problem in an Indonesian setting. Methods: The development of the tool was a two-stage process, consisting of understanding the range and pattern of breastfeeding problems (through literature review, discussions with lactation experts, and in-depth interviews with nursing mothers) and the production of the tool (through discussions with graphic designers and communication practitioners, pre-testing the tools, and finalising a workable, viable tool). The process led the authors to use flash cards for assessing the breastfeeding problems. Each card consisted of information about age, a code number, an image and a description of the breastfeeding problem. Each set of the flash cards represented an age period of 0-1, 1-3, and 3-6 months. The final flash cards were used in a cross-sectional study of 205 mothers of infants aged 6-12 months in Maros District, South Sulawesi. Results: The flash cards captured patterns of breastfeeding problems experienced by mothers within the first month, such as sore nipple, no milk production, fatigue, breast engorgement, and sleepy baby, or those problems that persisted throughout the six-month period such as infants' refusal to breastfeed and mothers feeling fatigued. The decreasing or increasing magnitude of a problem over time was also reflected in the flash cards. Conclusion: Identification of the dynamic patterns and magnitude of breastfeeding problems was successfully captured with the use of flash cards.