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The prevalence of childhood overweight has increased in the past two decades in Indonesia. Even though prevalence is escalating, there is a lack of qualitative evidence to assist in the design and implementation of strategies to tackle this issue. This study aimed to explore the view of primary carers mothers and grandmothers from different socio-economic-status groups, on childhood overweight in the Greater Bandung Area, Indonesia.
We used the grounded theory approach in our analysis. Three main categories emerged: the concept of overweight, factors contributing to overweight, and awareness and feelings towards overweight children. Most carers from all SES groups defined overweight subjectively, while a few from the low SES group defined it objectively. All carers had some knowledge of the main factors that contribute to childhood overweight: dietary factors, activity levels and sedentary behavior, and hereditary factors.
Carers from all SES groups described similar characteristics of overweight; carers from low and intermediate SES groups had mixed feelings while all high SES carers have negative feelings about overweight children, mostly related to stigma. However, carers who identified their own children as being overweight expressed sensitivity about this weight status, especially their physical abilities.
There are several policy implications. Firstly, health-related knowledge of the primary carers is of great importance and needs augmenting. Secondly, simpler and more effective ways to disseminate healthy lifestyle messages to carers is required. Fourthly, the Department of Education may need to improve the quality and quantity of physical activity in schools.
The online version of this article doi Overweight, on the other hand, has only been recognised as an Indonesian health problem for little more than a decade [ 2 , 3 ].
The prevalence of childhood overweight in Indonesia has significantly increased in the last 20 years, with higher prevalence rates found among boys in general and boys and girls living in urban areas [ 2 ]. To our knowledge, qualitative evidence about overweight in Indonesia is scarce, with the available evidence mainly focused on mothers with overweight children, [ 4 ] and none considering the views of people from different socio-economic groups.
Parents, particularly mothers, hold an important role in child feeding, role modelling for healthy eating and active living, and the prevention of overweight [ 5 — 11 ]. Many potential strategies in tackling overweight will involve working with families, especially the primary carers of young children. These strategies will benefit from an understanding of the knowledge, attitudes, and behaviours of the primary carers. We undertook a qualitative study in Bandung, West Java, Indonesia.
These three areas have different Human Development Index scores high, medium, and low ; these were used as a measure of different levels of socioeconomic status [ 12 ]. The locations of the selected areas Cisarua, Margahayu, and Sukasari districts represent the low, intermediate, and high socio-economic status areas, respectively.
Inclusion criteria were carers of children who hold or share the primary role in decision-making for the care of the child or were responsible, in part or in whole, for child feeding and eating, including food shopping and budgeting. Numbers and participants of focus group discussions in Bandung, Indonesia. To recruit participants from low and intermediate SES areas, we contacted Community Health Centres Puskesmas in the chosen areas to reach carers of under five children.
We collaborated with local midwives and health kader mothers who are trained and work for the Puskesmas and Community Health Posts [ Posyandu ] for a small incentive.
These kader have knowledge of the people living in the communities [ 13 ]. We provided a verbal explanation of the project, and disseminated the participant information statement to invite participation.
In Indonesia, children from socially advantaged families do not go to Puskesmas , but to private medical practices or specialists, and they attend private schools. We used the same approach in each school i. Interested carers then directly contacted the research team who gave further explanation about the discussion process and took details. Carers who gave verbal consent to participate were later approached to set the date and time for the FGD. Question guidelines were developed in English and finalised during the training.
This process included a discussion of potential issues and possible resolutions that might be encountered during the FGDs. Prior to each FGD, the study team explained the FGD process to the participants and asked them to fill in the basic demographic information form and provide written informed consent.
Participants were offered the language of their choice to be used during the FGDs, either Indonesian or Sundanese the language of West Java , in which all three moderators were fluent. Each FGD began with a min ice-breaker, to build rapport between participants and researchers. Similarly, and to ensure confidentiality, we did not videotape the discussion. To ensure consistency of the discussion the moderator used the same guideline, including a set of prompt questions.
Group size ranged from 6 to 9 people. Participants each received 11 USD for participation. Transcription and translation started immediately after the first FGD, giving the team some time to reflect on the discussion results. The research assistants then translated the transcripts into English; both Indonesian and English transcripts were checked by CLH and CNR to ensure the quality of the translation.
Sundanese or Indonesian terms that have no exact English translation were kept and explained in English inside parentheses next to those terms. We used the grounded theory approach in our analysis [ 14 — 16 ].
All transcripts were analysed using NVivo for Mac version The research assistants were not involved in the analysis phase. The analysis was conducted following the steps: 1 CNR and CLH read all transcripts several times to familiarise themselves with the data. As part of the analysis, CNR quantified comments throughout the transcripts looking at responses from individual carers. LAB and ML, experts in childhood obesity and childhood nutrition, were significantly involved in the design phase of the research and writing up of the manuscript.
Credibility and trustworthiness were addressed in several ways. One researcher CNR was the moderator of all 12 FGDs and could, therefore, describe the situation and convey the opinions stated directly words or indirectly intonation of voice or facial expressions consistently. We reduced interpretive bias by involving another analyst CLH who was not present during the data collection. CNR also conducted triangulation with the two research assistants and used the notes made during the FGDs to ensure the nuances captured during the discussions were agreed upon by three facilitators.
A total of 94 carers gave their consent and participated in the FGDs. We had similar numbers of carers in the under 5 years and elementary groups. Most carers from the low and intermediate SES groups had graduated either from elementary or middle and high school, but none from university.
In contrast, most carers from the high SES groups were university graduates with only a few having middle and high school qualifications alone. We had carers from 11 different ethnicities; however, we did not find that ethnicity played a part in the differences in the discussions. Characteristics of participants from 12 focus group discussions in Greater Bandung Area, Indonesia.
There were several marked differences between the three SES groups involved. Category and subcategories on the perception of overweight in carers in Greater Bandung Area, Indonesia. Most 23 out of 27 carers in the high SES category defined overweight subjectively, for example through visual interpretation of body size. The researchers did not provide any particular definition of overweight nor differentiate between overweight and obesity at the beginning of our discussions, since most Indonesians use the same word, kegemukan.
One carer stated that in her opinion the two terms are the same. KMS is a card used since the s in Indonesia Additional file 1. In , the Indonesian Ministry of Health released a regulation to use this card for children aged under 5. They specifically differentiated between cuteness and health status in overweight children. However, they also included the concept of healthy overweight.
Carers from all three SES groups referred to Indonesian media celebrities they considered had ideal bodies. The ideal body was described as tall, slim, skinny, or model-like in women and a well-muscled body in men. However, it was difficult to name child celebrities they felt had an ideal body. Intermediate and high SES groups commented upon vitamin supplements, milk, cooking oil, and mealtimes especially dinner.
Diets high in carbohydrate rice or noodles were also a factor. One mother high SES group admitted that it is part of their identity as an Indonesian. Low and intermediate SES carers in particular mentioned that the ideal menu should consist of empat sehat lima sempurna Four Healthy, Five Perfect — an Indonesian ideal meal incorporating carbohydrates, proteins, vegetables, fruits, and milk.
This concept, introduced by the Indonesian government in , is now considered dated because it only gives information about variety of food without considering quantity [ 19 ]. In the government introduced new guidelines Pedoman Umum Gizi Seimbang PUGS - Balanced Nutrition Guidelines that contain information on both food variety and portion size along with the importance of exercise and water consumption [ 19 , 20 ].
None of the carers mentioned PUGS. This was considered not enough by all low and intermediate SES carers, who said children should engage in more physical activity. Carers stated that boys spent their time in PE class by playing soccer and girls by having aerobic activities.
All children in the low SES groups went to public schools free of any charge , while children in intermediate SES groups went to public schools or Islamic schools madrasah; some fee payment required but not as expensive as private schools.
Public kindergartens start at 7. Children from low and intermediate SES groups spent their time after school playing outside although they also had screen time watching TV at night. In contrast, children from high SES groups spent most of their after school time indoors at home.
In addition to the school physical education class, there were extracurricular activities such as dancing, martial arts, and soccer. All children in these groups went to private schools. Most children had other extracurricular activities e. Carers from low and intermediate SES groups had a similar understanding of heredity i. Quotes on awareness and feelings towards overweight in children according to carers from Bandung, Indonesia. Intermediate and high SES carers added that overweight children get sick more often compared to their healthy weight counterparts.
All carers stated that overweight children eat bigger portions compared to healthy weight children, admitting that sometimes their children eat the same portion of food as their parents. Carers from the low SES groups were aware that their overweight children eat more than three times a day. One carer stated that her obese child eats regularly three times a day at home, but every time he visits a relative or a neighbour, he accepts their invitation to eat.
It is customary in Indonesia to offer people children or adults food whenever they visit. It is considered polite and respectful for the host to do so, and the guest should accept, in order to show respect. Carers in the intermediate and high SES groups also raised the issue of snacks, as their children would eat three or four times a day and snack in between.
Pinching children on their cheeks to express their feelings is common in Indonesia, for example when people think the child is cute.
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