Prevalence and factors associated with loneliness among Indonesian adolescent girls: a cross-sectional study | BMC Women’s Health
This study examines the prevalence and associated factors of loneliness among school-going adolescent girls in Indonesia. A 6.5% prevalence of often or always feeling lonely was found in this study population. This result is lower than that reported among adolescent girls in ASEAN countries at 7.8%.  and is even significantly lower than that of some African countries, such as Morocco (25.1%)  and Tanzania (17.4%) . It is also significantly lower than that of Latin American and Caribbean countries (14.6%) as well as the USA (14.4%) and Russia (14.7%) . Although this prevalence is concerning, the lower rate in Southeast Asia compared to other regions can be explained by social ties and high income.
In a recent meta-analysis, Eccles and Qualter  show that social cohesion is a powerful factor in reducing loneliness. Unlike Western cultures, which emphasize independence and individualism, Asian societies, including Indonesia, have evolved towards a more sociocentric, collectivist and interdependent culture. . This could explain the lower prevalence of loneliness among Indonesian teenage girls and is reflected in the even lower rates found among teenage girls with supportive parents and close, kind friends. The significant contribution of positive social relationships has also been consistently reported elsewhere [5, 6, 11]and our study shows that teenage girls without close friends are 3.8 times more likely to experience loneliness.
Our study further shows the association between loneliness and several health risk behaviors such as substance use (psychostimulants, drug use), psychosocial distress (being bullied, suicidal planning and ideation , sleep disturbances, lack of close friends) and a sedentary lifestyle. According to Peltzer and Pengpid , substance abuse is a way to cope with loneliness, and loneliness is a predictor of depression and suicide. Additionally, being bullied is linked to the inability to form friendships [2, 29, 30]. Shaheen et al.  show that Jordanian teenagers who reported having less support from family or friends experienced more bullying. Kendrick et al. , on the other hand, found that friendliness is protective against bullying. We found that teenage girls who were bullied in the past month were 1.6 times more likely to experience loneliness than those who were never bullied. Although our study did not measure the association between social connections and bullying, the results of the association between social disconnection, bullying and the experience of loneliness indicate that this relationship may exist in our study sample. Nevertheless, loneliness is both a cause and a consequence of bullying [29, 30] or suicidal behavior [31,32,33]. The direction of the association for either variable is unclear and would warrant further investigation.
We also found associations between loneliness, as well as social and environmental factors such as hunger and passive smoking. The experience of hunger in this study is an indicator of the food insecurity situation and an approximation of the socio-economic status of the population studied. The finding that food insecurity can cause loneliness was also seen among Tanzanian teenagers [7, 34]. These authors link lower-class socioeconomic status and limited family support to the likelihood of being hungry and also point to the negative effect of hunger on mental health. A different study, albeit in an older US population, shows that loneliness increases the likelihood of being hungry and recommends strengthening the social support system for this group . On the other hand, passive smoking is common and smoking regulations in Indonesia are generally poor. Smokers, mostly men or fathers, smoke inside the house  and expose their lonely teenage girls who mostly stay at home. The increased risks of loneliness from passive smoking found in our study are also consistent with previous reports, particularly those using WHO-GSHS data. [6, 11]. However, the cause and effect of hunger, passive smoking, and loneliness in adolescents are not well understood and require further research.
The prevalence of loneliness among teenage girls may be lower in Indonesia, but should still be of concern. Peltzer and Pengpid , in their study of loneliness in the general population of Indonesia, show that adolescents and the elderly population have the highest prevalence in the country. Given the possible heightened risk faced by adolescent girls, efforts at the national level must be age and gender specific.
Limitations of this study include that it focused on adolescent girls in schools because the GSHS is only conducted in these settings and as such the results do not represent all adolescent girls nationwide. . The inclusion of out-of-school adolescent girls may yield different results. Additionally, the lack of covariates or the use of loneliness as a single-item measure has previously been reported as limiting as a qualitative indicator. The cross-sectional design also makes it difficult to measure causality. Future studies on loneliness might consider collecting primary data through longitudinal studies instead of using GSHS data.