Abstract
Background:
There is a growing recognition of the importance of adolescent health and well-being. Yet, little attention has been paid to adolescent nutrition, and few policies and programs are targeting to improve adolescent nutrition in Indonesia.
Objective:
This analysis aimed to identify (1) the extent to which adolescents are considered in nutrition policy in Indonesia and (2) opportunities to improve nutrition policy content to effectively target adolescents.
Methods:
We collected data on policy content through a desk review of national and subnational level nutrition-specific strategic plans, laws, regulations, and program guidelines. We then conducted 74 key informant interviews with policy makers and program experts in health, education, and related sectors using semistructured interview guides based on policy theory to examine policy context and implementation. The policy content and interview data were analyzed using thematic synthesis and narrative analysis.
Results:
Currently, 2 nutrition-specific policies and programs are designed to improve adolescent nutrition in Indonesia, one focusing on iron–folic acid supplementation for adolescent girls and another on obesity prevention and management in schools. These programs are yet to be implemented at scale. Overall, adolescent nutrition is not yet considered a priority in the national development agenda. An opportunity exists to improve action on adolescent nutrition in Indonesia through scaling up of district-level policies and through improving coordination mechanisms across sectors.
Conclusions:
Few policies and programs exist to support adolescent nutrition in Indonesia. Coordinated efforts across relevant sectors and levels of government should be made to mainstream adolescent nutrition into relevant policies.
Introduction
An estimated 1.2 billion adolescents aged 10 to 19 years make up 16% of the global population. Indonesia alone is home to approximately 45 million adolescent boys and girls, comprising 18% of the total population. 1 Adolescence is a period of rapid growth and development and of nutritional vulnerability due to the increased requirements for energy and nutrients. Hence, a large number of Indonesian adolescents suffer from undernutrition, 2 which has major implications for the country’s economic growth and progress toward the sustainable development goals (SDGs), 3 among others through its consequences for maternal and child health.
The rising problem of double burden of malnutrition in Indonesia, the coexistence of undernutrition, including micronutrient deficiencies such as iron deficiency, and overnutrition, requires urgent attention. According to the 2013 National Basic Health Research Survey, 2 9.4% of Indonesian adolescents aged 16 to 18 years and 11.1% of those aged 13 to 15 years were thin (defined as body mass index (BMI) for age Z score <−2 SD 4 ), while 7.3% and 10.8%, respectively, were overweight (BMI for age Z score >+1 SD 4 ), showing a classic example of double burden of malnutrition. Notably, the prevalence of overweight and obesity among adolescents had increased 2- to 3-fold between 2000 and 2014. Importantly, both adolescent girls and boys have various nutritional challenges, including stunting, wasting, overweight, and anemia.
Second only to early childhood, adolescence represents a window of opportunity to address the double burden of malnutrition. Overweight/obese adolescents are likely to remain overweight/obese as adults, whereas stunted adolescents are also more likely to become overweight later in life. 5,6 Adolescents are increasingly recognized as potential agents of change, and nutritional intervention during adolescence positively disrupts the intergenerational cycle of malnutrition and poverty. 7
However, adolescent nutrition has received little attention worldwide. A recent review of policies on adolescent nutrition in the Scaling-Up Nutrition countries found that only 10 of 22 available national nutrition plans mentioned adolescents, and few programmatic actions were being taken to improve adolescent nutrition. 8 This review found Indonesia among the countries with the fewest policies targeting adolescent nutrition. This cannot continue if Indonesia is to achieve both the SDGs and its own vision of accelerated nutrition improvement for all.
Experts agree that adolescent nutrition requires a comprehensive approach and that policy action should include nutrition-specific policies, led by the health sector and implemented across sectors including health, education, and social welfare. 9 Although nutrition-specific policies and programs have typically been under the purview of the health sector, cross-sectoral coordination is therefore essential for their effective implementation.
The research question for this study was: How is adolescent nutrition supported at the policy level in Indonesia? Therefore, our analysis aimed to identify (1) the extent to which adolescents are considered in nutrition policy in the Indonesian context and (2) the opportunities to improve nutrition policy content to effectively target adolescents.
Methods
In this study, we consider nutrition policy as “courses of action (and inaction) that affect the set of institutions, organizations, services and funding arrangements” related to nutrition. 10 We defined nutrition-specific policy documents as those with a stated focus on nutrition, addressing the immediate determinants of malnutrition, namely, inadequate dietary intake and ill health as well as excess intake and insufficient physical activity, 11 including strategic plans, laws, regulations, and guidelines for implementation at national and subnational levels. 12 Nutrition-sensitive policies are policies from other sectors that include nutrition objectives.
Study Framework
The study design was guided by the policy analysis triangle 13 and the policy space analysis framework, 14 which have been used previously for nutrition policy analysis. These frameworks identify key factors that shape policy-making, such as content, processes, context, and actors as well as political considerations, framing, and characteristics and perceptions of the policy issue (in this case, nutrition). 13 -16 While these are simplified models of complex processes of decision-making, they enable consideration of the interactions between key influences on decision-making. Actors include individuals and institutions, and context considers the political, ideological, population, and historical influences on policy-making processes (how issues get on to the policy agenda, and how decision-making and implementation proceeds)—all of which shape policy content. 13
Drawing on these frameworks, our study was designed to identify opportunities to improve nutrition policy for adolescents in Indonesia. In particular, we considered policy context within the Indonesian setting of decentralization, different frames for adolescent nutrition (problem definition and solutions identified), and policy circumstances (awareness and prioritization, funding, and coordination). We also examined implementation-related issues.
Policy Mapping
The research team systematically mapped policies at national and subnational levels (from 2 selected districts: Klaten in Central Java Province and West Lombok in Nusa Tenggara Barat Province) in 2017. These 2 districts were purposively selected as the modeling area to represent western and eastern Indonesia from social, cultural, infrastructural, and adolescent nutrition perspectives. Klaten represents the culture and condition in the western part of Indonesia, which is more urban and developed, while Lombok represents the eastern part, which is more rural and less developed in terms of infrastructure. Klaten has higher population density and Human Development Index compared to West Lombok. While in both districts there is evidence of the double burden of nutrition (the coexistence of under- and overnutrition), Klaten shows an increasing rate of overnutrition and Lombok Barat represents an area with a high percentage of undernutrition among adolescents. In addition, both districts have shown strong commitment to reduce the burden of maternal and child undernutrition by breaking the intergenerational cycle of malnutrition, which is essential to modeling interventions.
We first developed a matrix for identifying relevant nutrition-specific policies across sectors that were relevant to adolescents and the double burden of malnutrition 11,17 and for extracting data based on the study frameworks. The policy documents were collected (1) from government websites using the key words child, health, nutrition, adolescent, food, health, school, supplement, obesity, malnutrition, stunting, wasting, anemia and (2) through direct requests to the Ministry of Health and other related ministries, government departments, and stakeholders in sectors such as education, religious affairs, social affairs, and food. Policies that are not relevant to adolescents such as those on infant formula and mandatory nutrition labeling, which only apply to infant foods, were excluded. In addition, we did not include policies related to food fortification and food security in this search because the focus of the study was on nutrition-specific policies that directly target adolescents. In addition, as it turned out, physical activity was included only in nutrition-sensitive policies, and therefore this topic is also not covered in this article.
Policy data were extracted into the matrix, according to predetermined themes. Data collected included the name of policy, type of policy, year of release, objectives, targeting of adolescents, type of nutrition issue(s) being addressed such as anemia, obesity, double burden of malnutrition, as well as the inclusion of details on implementation, coordination, budgeting, and monitoring and evaluation (M&E). The extraction grouped policies into the following key domains: (1) policy support for adolescent nutrition in strategic whole of government and other national policies with regulatory strength (eg, laws and presidential regulations); (2) translation of high-level policy statements into implementation-relevant documents; (3) translation of national policy to subnational policy; (4) cross-sectoral coordination; and (5) implementation of nutrition-specific programs.
The desk review was supplemented by in-depth interviews with key stakeholders, including government officials at national, provincial, and district levels. Relevant government agency officials were identified through the policy content analysis. We contacted heads of these agencies by mail to request the interviews, and the most relevant informants were selected by the agencies. A total of 74 informants participated in the study.
The in-depth interviews utilized semistructured interview guidelines based on our study frameworks. They were designed to gather additional information on how national policies are translated into programmatic actions and the extent to which these were implemented and to identify opportunities and challenges associated with adolescent nutrition as described in the objectives.
The in-depth interview discussion guides were pretested prior to the data collection. All interviews were held in Indonesian, digitally recorded, and transcribed semiverbatim. Information from the interviews were collated in a similar way as the policy content, using a separate matrix. Ethical clearance for this study was obtained from Gadjah Mada University in Yogyakarta and informed consent was obtained from all informants.
Data Analysis
Data were analyzed in an iterative process, integrating the findings from the desk review and the in-depth interviews. Data were analyzed using qualitative approaches, based on thematic synthesis and descriptive analysis, 18 to answer the overarching research question: How is adolescent nutrition supported at the policy level in Indonesia? Desk review findings were analyzed to identify subthemes within each of the predetermined themes, regarding how support for adolescent nutrition is operationalized. These themes included (1) availability of technical and implementation guidelines, (2) targeting of adolescents, (3) focus on overweight/obesity, (4) cross-sectoral coordination and coordination between government levels, (5) M&E, including the use of SMART (Specific, Measurable, Achievable, Realistic and Timebound) outcomes, budgeting, and gender sensitivity. Table 1 provides the summary of policy support as Strong (high-level policy providing full details), Emerging (available but lacking details), or Opportunity to Strengthen, based on the content of the policies and their translation into program implementation documents.
Summary of Strengths of Nutrition-Specific Policies by Theme.a
Abbreviations: M&E, monitoring and evaluation; MoH, Ministry of Health; NA, not applicable; NCD, noncommunicable diseases.
a Strong indicates high-level policy, providing full details; Emerging indicates lower level policy, provides limited details; and Opportunity for Strengthening indicates guidelines only, no details given.
Semiverbatim transcription notes from the interviews were grouped using the same themes from the desk review. As the purpose of the in-depth interviews included exploring local initiatives as well as implementation of national polices, additional categories were added during the process.
Content of implementation manuals and policies were crosschecked with information obtained from the interviews. Data were triangulated between in-depth interviews at all levels and policy content.
Results
Political Context and Policy Environment in Indonesia
Indonesian policies follow a strict hierarchy in which higher level policies such as Laws and Government or Presidential Regulations have more regulatory strength and a broader scope, covering multiple sectors (Law 12/2011; Table 2). Technical policies and guidelines published by the ministries are not considered in this hierarchy, and therefore lack “strength”, are binding within one sector only, and do not provide guidance on inter-sectoral cooperation.
Hierarchy of Indonesian Policies.
Since 1999, the government in Indonesia is decentralized to varying degrees. While some sectors, including security, foreign affairs, and religious affairs, remain under central control, the health and education sectors are among those decentralized to the district level. However, a recent law (No 23/2014, which came into force in 2017) has moved the management of senior high schools (catering to 15- to 19-year olds) under provincial, rather than district-level authority (Annex 1A of Law no 23/2014), further complicating the coordination between the health and education sectors. 19
Overarching vision and direction to all policies at national and subnational levels is provided by whole-of-government planning documents and strategic plans (Figure 2). None of these include adolescent health and nutrition as a development target, and nutrition is broadly framed as part of the efforts to develop high-quality human capital. In the absence of a national target for adolescent nutrition, it is not possible for subnational governments to prioritize adolescent nutrition independently. As a result, we found only a small number of policies that specifically aim to improve adolescent health and nutrition. Interestingly, obesity management and prevention of noncommunicable diseases (NCDs) are an emerging development priority in the national development plan. 20 However, due to discrepancies in planning periods between the different government levels, this has not yet been adopted in the development plans of the 2 districts in this study.
PRISMA Flowchart nutrition policy mapping.
Overarching policies and development planning.
Awareness of Adolescent Nutrition Among Policymakers and Program Experts
In general, the awareness on adolescent nutrition among policymakers and program experts was low, except among those from the health sector and planning agency (Bappeda). Notably, adolescents were perceived to be healthy and well nourished, with anemia being recognized as a concern only for some adolescents.
Policy Content
Of the 104 nutrition-related policies identified, only 8 were considered nutrition specific, whereas the remainders were classified as nutrition sensitive. Surprisingly, this includes the overarching policies on NCD as these lack focus on obesity. Two of the nutrition-specific policies specifically targeted adolescents, while the others included adolescents as part of a larger target group such as the entire population or those aged 15 years and older (Figure 1). The results of the in-depth interviews showed policy and programs in the health sectors were designed based on the life cycle, and most policymakers mentioned that there is no specific policy on adolescent nutrition.
Both the “adolescent-specific” policies were health sector guidelines, which have limited regulatory strength and are only binding within the health sector. The Guideline for Prevention and Management of Overweight and Obesity among School Children aged 6 to 19 years, issued in 2012, highlights the importance of health promotion and early case detection and referral. The Guideline for the Prevention and Management of Anemia among Adolescent Girls and Women of Reproductive Age (2016) targets adolescent girls aged 12 to 18 years and promotes iron–folic acid (IFA) supplementation and balanced diet, taking into account the increased nutritional needs during adolescence and greater significance of body image and physical appearance.
Other nutrition-specific policies that include adolescents among a broader target group are the Guideline for a Balanced Diet (2014) and the Guideline for Integrated Counseling Posts on NCD (2012). The former provides detailed recommendations on dietary intake tailored to different population groups based on age, gender, and physiological status. The latter refers to a community-based program for early detection and prevention of NCDs among the general population aged 15 to 59 years. Like other NCD policies, some of which don’t mention overweight or obesity, it focuses on smoking, diabetes, and hypertension. Our policy mapping did not identify any policies related to food marketing and labeling, subsidization of healthy diets, and taxes on unhealthy foods, all of which would be relevant to adolescents. In addition, no subnational nutrition policies targeting adolescents were found. This was not surprising, given the absence of high-level national policies targeting to improve adolescent nutrition.
The 2 national guidelines on anemia prevention and obesity management framed adolescent nutrition in the context of reproductive health and prevention of maternal anemia. While the 2 adolescent-specific guidelines lack regulatory strength, they provide details on implementation (Table 1). While anemia and overweight are addressed by the guidelines on IFA supplementation, early detection and management of obesity in school children, and balanced nutrition, the nutritional determinants of NCD, should be highlighted in relevant policies, as overweight and obesity were not explicitly mentioned in the overarching policies.
The importance of vertical and horizontal coordination within the government system is not mentioned in the obesity guideline for schoolchildren. On the other hand, the IFA guideline and NCD policies do mention the need for strong coordination. While M&E is included as an essential component in all policies (except those on balanced diet), the related operational guidance is missing, and respective indicators need to be more specific and measurable. The same holds true for budgeting, which is mentioned (but not detailed) in the IFA supplementation guideline.
Program Implementation
Although, strictly speaking, the “adolescent-specific” guidelines are health sector documents, their implementation however requires intersectoral coordination. In-depth interviews with subnational government officials revealed that for national policies to be implemented in Indonesia, corresponding subnational policies at the province and district levels are required, and technical guidelines from the central level need to be put in place to support program implementation, coordination, monitoring, and budget allocation.
The 2 nutrition-specific guidelines targeting adolescents have been translated into some programmatic actions. Since 2016, the guideline on anemia prevention has been implemented as IFA supplementation program among school-going adolescent girls while not yet reaching out of school girls and adolescent boys. The program components include weekly IFA supplementation combined with nutrition education on anemia and healthy eating behaviors. However, the program is still at a nascent stage, and coverage remains low. Currently, the national government supplies only 15% to 30% of IFA tablets required, while the remainder is expected to be procured locally using subnational budget. However, in-depth interviews with implementers revealed a lack of clarity on coordination and funding mechanisms, not only at the government level but also at schools.
This indicates there is an opportunity for increasing awareness of the importance of adolescent nutrition and strengthening the coordination between health and education sectors, to build a sense of shared ownership of the program among the education sector. In addition, the program would benefit from more stringent compliance reporting among the girls, and by targeting adolescent boys if not with the supplementation then with the related health education.
The policies and guidelines on obesity prevention in both school- and community-based settings focus on health promotion and screening. However, these programs are yet to be implemented at scale with quality. One of the reasons is likely poor coordination as illustrated by the fact that none of the informants outside the health sector were aware of the health-sector–specific guideline on obesity prevention and management in schools.
FGDs with adolescents in the 2 study areas confirmed the programs are not yet implemented to scale. On the other hand, 1 village had taken the initiative to provide weekly supplements for all adolescent girls, using village funds to procure the tablets. Some of the girls admitted to suboptimal compliance, largely related to the bad taste of the tablets. While the program only covers IFA distribution among girls, the opportunity to include boys in the nutrition and health education related to anemia is missed.
“If they only give it to girls, it must have something to do with menstruation. The boys are curious what it is and what it is for. But they never tell us”. (An adolescent boy, grade 12, West Lombok)
Discussion
The present landscape review of nutrition policy found that adolescent nutrition is an emerging priority in the national development agenda in Indonesia. Our review identified 2 nutrition-specific guidelines directly relevant to adolescents. Overall, the awareness of adolescent nutrition and its importance was low, especially among policy makers outside the health sector. This is not surprising, however, considering that adolescent nutrition has only recently begun to gain global attention. 9,11,21
A review of national health policy from 109 countries revealed that the majority of policies somewhat mention adolescents but rarely in the context of nutrition. 22 Similarly, among the national plans of 22 SUN Movement countries, 10 mentioned adolescent nutrition, but only 7 included policy and/or program support for adolescent nutrition. 8 Like in Indonesia, direct interventions were targeted at adolescent girls as part of the efforts to reduce birth complications and break the intergenerational cycle of malnutrition. In India, adolescent girls were identified as an important target group in the national nutrition policy as early as 1993, which may explain the country’s strong programming on adolescent nutrition. 23 Notably, only 1 country national plan included adolescent boys in the context of nutrition (as a target group for deworming). 8
The 2 single-sector, nutrition-specific policies specific to adolescents released by the health sector lack regulatory strength, being single-sector guidelines. This is considered a major challenge for adolescent nutrition programs, which usually require strong cross-sectoral coordination for effective implementation. In general, to facilitate cross-sectoral coordination, a high-level policy such as a Presidential or Government Regulation is needed, along with local regulations issued by the subnational government and district heads and technical guidelines to support program implementation.
India, which faces 55% anemia prevalence among its adolescents, has the largest scale direct intervention on adolescent nutrition, 8 a review of which 24 revealed the critical elements of a successful program that are relevant for other countries, including Indonesia: (1) the use of global and national evidence as the foundation for advocacy, particularly data on effectiveness and cost of the intervention; (2) use of existing delivery platforms such as schools; (3) clear definition of roles and responsibilities among the different government sectors at national and state levels; (4) involving all stakeholders, including girls and their parents, to ensure uptake, adherence, and coverage; (5) involving girls as peer counselors is an effective way to reach out-of-school girls; (6) quality communication with girls, families, and communities about the consequences of anemia and the benefits and side effects of supplementation, particularly linking the intervention with improved health and school performance; (7) adequate supply chain management including supplements, communication, and monitoring tools; (8) a fixed day for supplement distribution 25 ; (9) simple (self-)monitoring tools and aids; (10) integrated services package is more motivating for adolescent girls; and (11) use of unit cost data to inform program scale-up. This review also found that the biggest challenges lie in nutrition education and reaching out of school girls. 23
Notably, our landscape review identified a major policy and programmatic gap for adolescent boys and the most vulnerable groups of teenagers, such as those who are out of school, working, married, and pregnant. While this is not unique for Indonesia, 26 and marginalized groups are very difficult to reach, developing health policies that reach all individuals is the responsibility of the health sector. 22 These should specifically include reaching vulnerable girls before they leave the school system, providing active outreach of health services, as well as engaging adolescent girls as agents of change and involving boys and young men to support the health and nutrition of vulnerable girls. 26 While this may seem a dilution of limited resources, the cost of a 1-year supply of 52 IFA tablets for 1 student is only IDR 21,000 (approximately USD 1.50).
The policies related to adolescent nutrition have been translated into some programmatic actions, specifically to address anemia, obesity, and NCDs prevention. However, these programs are yet to be implemented at scale with quality. Lack of awareness among key decision makers with associated low priority in development agenda and budgetary planning led to a weak policy basis for multisectoral coordination, budgeting, and strong monitoring, which contribute to poor program coverage and implementation quality.
In addition, the different levels of decentralization in each sector are a challenge for coordination of nutrition programs. This is supported by Veetil who demonstrated that coordination in a decentralized system is more complicated and time consuming compared to a centralized system. 27 A similar example in Nepal showed that coordination between national and subnational governments was found to be a major challenge in the decentralization of the health system. 28
To our knowledge, this is the first attempt to conduct a comprehensive policy landscape analysis on adolescent nutrition in Indonesia. Our analysis included both national and subnational policies, including guidelines and strategic plans, which were supplemented by a series of in-depth interviews with key stakeholders and focus group discussions.
However, a few limitations need to be considered. The scope of the analysis was limited to policies specific to adolescents with less attention paid to those policies and programs that include adolescents within a larger target group. The desk review was only conducted based on limited key words, and many of the policies are not available online. However, the interviews have supported the effort of ensuring that all policies are included in the review. Finally, the findings at the subnational level are specific to the 2 study districts, and caution is needed with regard to the transferability of the results.
Conclusions and Recommendations
Adolescent nutrition is an emerging priority in Indonesian policy. Except for IFA supplementation (and obesity guidelines currently not implemented), there is no nutrition-specific policy targeting adolescents. While nutrition policies are the purview of the Ministry of Health (MoH), the implementation of nutrition programs requires cross-sectoral coordination. Currently, program implementation is hindered by a lack of high-level umbrella policies, subnational policies, and detailed technical guidelines on implementation, budget allocation, and M&E.
Advocacy is needed to increase awareness of the importance of adolescent nutrition among policymakers in nutrition-sensitive sectors, such as education. To strengthen coordination, the National Action Plan for School Age Children and Adolescent Health was recently adopted. This document aims to increase understanding and awareness of the importance of child and adolescent health, including nutrition, and forms the basis of coordinated policy across government sectors. Ideally, these policies should be in the form of a Presidential Regulation or Government Regulation. In addition, they should clearly identify the leading sector, roles, and responsibilities of related sectors and detail the coordination and funding mechanisms. At the subnational level, Governors and Heads of District Regulations are needed to ensure implementation is prioritized and detailed implementation, M&E, and budgeting guidelines should be formulated and distributed to the implementers. Nutrition messages, including those related to IFA tablets, should be simple and easy to implement, and should ideally be provided to both girls and boys. Including boys does not require substantial additional input, and it is likely to improve not only the boys’ nutritional status but also their understanding of nutrition, in particular anemia and menstruation-related issues, which are currently only discussed with the girls. Special attention is needed for vulnerable teenagers.
Footnotes
Authors’ Note
D.D.S. led the research and drafted the manuscript; A.M.T. and M.L. led development of the study protocol, provided input in tools, and reviewed the manuscript; A.R. contributed to the initial concept and protocol of the study, and together with J.H.R. provided input in tools and analysis and contributed to the manuscript.
Acknowledgments
This research was funded by The Canadian UNICEF Committee for the project “Addressing MNCH gaps to create scalable investments for the future” implemented by UNICEF Indonesia Country Office. The authors gratefully acknowledge Harriet Torlesse for initiating and conceptualizing the concept note of the study, and Ade Novita for providing the framework of Indonesian policy and reviewing the manuscript. We would like to express our appreciation to the informants for their willingness to participate, to the data collection team for their hard work: Aji Dwi Prasetyo, Dina Apriana, Hafizah Jusril, Dessy Susanty, and to the Savica team for their practical support.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was funded by The Government of Canada, Canadian UNICEF Committee and the 25th Team for the project “Addressing MNCH gaps to create scalable investments for the future” implemented by UNICEF Indonesia Country Office.
