This study was conducted in Jakarta, the most populated city and the current capital city of Indonesia. Our study represented a large-scale study on body image among adolescents in a developing country and reflected the scale of the BID. However, this study was conducted during the mass social restriction, school closures, and implementation of online learning due to the COVID-19 pandemic. Therefore, despite performing direct observation, anthropometric measurement and questionnaire filling to each subject, we conducted a data collection procedure using an internet-based questionnaire. The subjects’ responses in our study were high, reaching about 82% of the recruited and 79% of them filled in completely. This result suggested that internet-based questionnaires may assure subjects’ convenience in answering quite sensitive questions such as their perspective on their body image as well as privacy and confidentiality. Previous internet-based studies on adolescents obtained only 28–47% of emails back and they could increase to 90% when the questionnaires were finalized at schools.24−5 The factors on assurance of privacy and confidentiality from internet-based research were also shown by another study.26 To anticipate high incomplete data, the questions in this internet-based study were issued sequentially and preferred the Likert scale more, as other studies in the adolescent group have been done.24,27 Nevertheless, previous internet-based studies showed a comparable internal consistency, validity, reliability, confidentiality, and experienced autonomy by the teenagers, to the paper-based studies.24,28−9
A higher percentage of hyperactivity problems in this study was also shown in several similar school-based studies using SDQ self-report in Indonesia.30−1 Other studies mostly showed more emotional difficulties in teenagers compared to other scales of SDQ.32−3 However, our study also showed higher percentages of the emotional problem as one of the commonest difficulties. Those studies using SDQ showed that psychosocial and mental health difficulties faced by teenagers are affected very much by their environment (peers and parents), residence areas, and socio-economic status.
Many studies indicated BID during the adolescence period was a risk factor for mental health problems, especially depression and anxiety.12,34−8 In this study, the overall psychosocial-mental health score was not statistically higher in the BID group, but the emotional symptom score differed statistically between the two groups. The emotional symptom scale in SDQ correlated highly with depression and anxiety symptoms.39 BID could induce this emotional symptom through the lack of confidence mediation, in which BID lowers self-confidence and then initiates depression and anxiety. Besides, the huge amount of pressure to have an ideal appearance from surroundings could potentially influence a teenager to feel unattractive and unaccepted by the group, then leading to depressive affect and diminished self-confidence.37 Moreover, the older adolescent also experienced other triggers such as unsuccessful diet, criticisms towards him/herself, and interpersonal problems, which aggravated the BID to induce emotional symptoms.34
The pressures to have an ideal appearance, which stimulate BID, originated from friends, parents, and media.40 In this study, the influence from parents was significantly associated with BID while the influence from friends and SM followers was not. The previous study also showed this occurrence and the impact of parental influence on BID was not only generated from verbal expression but also from the non-verbal expression of the parents who expected their children to achieve the ideal appearance standard and from their practice as adults to acquire the ideal appearance seen by their children.41 With no intention of teasing, parents’ encouraging comments on the teenagers’ appearance could promote dissatisfaction with body image.42 This might be due to their lower intolerance of their parents’ inputs than of their peers. Hence, more research is needed that explores this special kind of parental pressure.
The higher stress level was also significantly associated with BID in this study. Murray et al43 studied the relationship between psychological stress and BID using the Adolescent Stress Questionnaire. As the questionnaire was too long and should be internet-based, this study used Kessler-10 instead to determine a similar relationship. Apart from psychological stress screening, Kessler-10 was also known to correlate with depression and anxiety in adolescents.19 This might explain the association between stress as a risk factor for BID as it was also correlated with mental health in teenagers. Nevertheless, many issues that happened to teenagers could potentially trigger their stress levels and should be further studied.