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This study investigates the prevalence and associated factors of loneliness among adolescent girls attending school in Indonesia. In this study population, a 6.5% prevalence of feeling mostly or always alone was found. This finding is lower than that reported among adolescent girls in ASEAN countries at 7.8%  and it is even significantly lower than in some African countries, such as Morocco (25.1%)  and Tanzania (17.4%) . It is also significantly lower than in the countries of Latin America and the Caribbean (14.6%) as well as the USA (14.4%) and Russia (14.7%) . While this prevalence should be cause for concern, the lower rate in Southeast Asia compared to other regions may be explained by social connectedness and high income.
In a recent meta-analysis, Eccles and Qualter  show that social cohesion is an important factor in alleviating loneliness. Unlike Western cultures, which emphasize independence and individualism, Asian societies, including Indonesia, have evolved into a more sociocentric, collectivist, and interdependent culture. . This could explain the lower prevalence of loneliness among Indonesian adolescents and is reflected in the even lower rates found among adolescents 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 adolescent girls without close friends are 3.8 times more likely to experience loneliness.
Our study also shows the association between loneliness and various health risk behaviors, such as substance use (psychostimulants, drug use), psychosocial distress (being bullied, suicidal ideation and planning, sleep disorders, lack of close friends ) and a sedentary lifestyle. According to Peltzer and Pengpid , substance abuse is a way of coping with loneliness, and loneliness is a predictor of depression and suicide. Also, being bullied is related to the inability to form friendships. [2, 29, 30]. Shaheen et al.  show that Jordanian adolescents who reported reduced support from family or friends experienced more bullying. Kendrick et al. , on the other hand, found that the quality of friends protects against bullying. We found that teenage girls who were bullied in the past month are 1.6 times more likely to experience loneliness than those who have never been bullied. Although our study did not measure the association between social connectedness and bullying, the findings of the association between social disconnection, bullying, and experience of loneliness indicate that this relationship might exist in our study sample. However, loneliness is reported to be both a cause and a consequence of being bullied. [29, 30] or suicidal behavior [31,32,33]. The direction of the association for any of the variables 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 situation of food insecurity and a proxy for the socioeconomic level of the study population. The finding that food insecurity can cause loneliness has also been found among adolescents in Tanzania. [7, 34]. These authors link lower-class socioeconomic status and limited family support with the likelihood of being hungry and also highlight the negative effect that hunger has on mental health. Another study, albeit in an older US population, shows that loneliness increases the likelihood of hunger and recommends strengthening the social support system for this group . On the other hand, passive smoking is common and the regulation of smoking in Indonesia is generally poor. Smokers, mostly men or fathers, smoke indoors.  and expose their lonely teenagers who stay mostly at home. The increased odds of loneliness from passive smoking found in our study have also been consistent with previous reports, especially those using WHO-GSHS data. [6, 11]. However, the cause and effect of hunger, passive smoking, and loneliness in adolescent populations is not well understood and requires more research.
The prevalence of loneliness among adolescent girls may be lower in Indonesia, but it should still be a cause for concern. Peltzer and Pengpid , in their study on loneliness in the general population of Indonesia, show that adolescents and the elderly population have the highest prevalence in the country. Considering the potential increased risk faced by adolescent girls, efforts at the national level must be age and gender sensitive.
Limitations of this study include that it focused on adolescent females in schools because the GSHS is only conducted in those settings, and as such the findings do not represent all adolescent females in the country. The inclusion of adolescents who do not attend school may generate different results. Furthermore, the absence of covariates or the use of loneliness as a single-item measure was previously reported to be limiting as a qualitative indicator. The cross-sectional design also makes it difficult to measure causality. Future studies on loneliness may consider collecting primary data through longitudinal studies rather than using GSHS data.