What works in secondary schools? A systematic review of classroom-based body image programs

A Pilot Evaluation of the Respect You Curriculum

BACKGROUND

The objective of this study is to evaluate the Respect YOU program's impact on students' eating expectancies, body image satisfaction levels, self-efficacy, and knowledge. A total of 444 (intervention cohort n = 348, control cohort n = 96) underclassmen enrolled in health or physical education courses from 7 high schools in the Midwest participated in the study.

METHODS

A repeated measure research design was utilized to assess students' eating expectancies, body image satisfaction levels, self-efficacy, and knowledge. More specifically, paired t-tests were conducted to compare outcome measurements to evaluate the efficacy of the intervention.

RESULTS

Among the students who received the intervention (n = 348), there was a statistically significant change in scores for eating expectancies (Z = -14.403, p < .001), body image satisfaction levels (Z = -14.114, p < .001), social media self-efficacy (Z = 14.868, p < .001), and knowledge scales (Z = -16.100, p < .001) at post-intervention and compared to the control group.

CONCLUSIONS

Results indicate that the Respect YOU program was effective in improving body image scores, eating expectancies, self-esteem, and knowledge-related outcomes among students post-intervention. These results can be used to further develop educational programming to address body image concerns and disordered eating among adolescents.

Making it relevant: A codesign and cultural acceptability study of Be Real's BodyKind Ireland body image programme for older adolescents

Body image is an established public health concern and there is a pressing need for evidence-informed universal programmes for older adolescents. To ensure high standard, quality programmes, there have been calls to adapt existing programmes to different contexts in ways that ensure materials are relevant, but still aligned with their theoretical foundations. This study outlines the cultural adaptation of the BodyKind programme in Ireland, which was initially developed in the USA, to address an unmet need to provide an inclusive, strengths-focused, school-based body image intervention for older adolescents. After receiving BodyKind, codesign workshops were conducted with 12 adolescents aged 15-16 years, who provided feedback and designed content (examples/scenarios) to increase the programme's relevance for adolescents. Feedback on cultural appropriateness of programme materials were obtained via interviews with six female post-primary teachers and one mental health clinician. Qualitative data were analysed using thematic analysis. BodyKind was perceived as highly acceptable by stakeholders who offered suggestions for programme refinement. Themes included 1.) Programme acceptability, 2.) Implementation considerations, 3.) Programme refinement. This study used multi-stakeholder feedback to engage in cultural adaptation of BodyKind prior to further evaluation, thereby informing efforts to implement sustainable and scalable programmes in schools.

A pre-post evaluation of the impact of the Embrace Kids film on children's and adults' body image and self-compassion

Given the prevalence of body dissatisfaction among young people, which tends to persist into adulthood, a need exists for large-scale interventions that address this problem. Film has been identified as a resource that is well-suited to large-scale dissemination, which can achieve broad impact and reach. Embrace Kids, a film aimed at improving young people's body image, is one such resource. To evaluate the film's impact on body image, 55 children (M = 10.59, SD = 1.49) and 47 adults (M = 43.75, SD = 8.54) were recruited from the Australian general public to complete a brief survey before and after viewing the film. After viewing the film, significant increases in state body appreciation, state functionality appreciation and state self-compassion were reported for children (d = 0.46 - 0.61) and adults (d = 0.88 - 1.08). They supported the safety of the film by indicating that it did not make them more concerned about their appearance. Findings provide initial support for the film as a scalable intervention that can be safely task-shifted to non-professional audiences. Future research directions include comparing the effect of Embrace Kids against a control film, and testing the longitudinal impact of the film on trait body image.

Exploration of parental consent for adolescent involvement in genital body image education research

Genital body image is a highly understudied concept but is important for sexual health and broader body image satisfaction. Effective genital body image interventions for adolescents have been developed, however, parental consent can be a barrier to adolescent participation. The aim of this study was to conduct a novel exploration of parental consent for genital body image education research and factors related to this consent. Participants were 125 parents of adolescents in Australia who completed an online questionnaire including measures of demographic characteristics, personality traits and attitudes, and likelihood of consent for an adolescent son and daughter participating in hypothetical genital body image education research. The vast majority of parents indicated that they definitely would consent to their adolescent sons' and daughters' involvement in this hypothetical research. There was no significant difference in likelihood of consent based on the gender of the adolescent. Parents having more conservative attitudes towards sex was the only factor tested that reduced the likelihood of providing consent. Overall, our results suggest parents are generally supportive of adolescent involvement in genital body image education research. This concept should be included in broader body image educational programs so adolescents gain exposure to this important but neglected topic.

Enhancing understanding of social media literacy to better inform prevention of body image and eating disorders

Research has revealed an important role for appearance-focused, and in particular photo-based, social media in the development of body image and eating pathology. Social media literacy is a multifaceted construct involving purposeful selection and exposure to social media content and use of protective filtering (deliberately screening and interpreting information in a protective manner), as well as implementing critical skills related to understanding the unrealistic nature of social media content, limiting appearance comparisons with images, and contributing to social media (comments and images) in ways that limit the pursuit of appearance ideals. Previous work has provided partial support for these facets as related to lower levels of body image and eating concerns. However, additional conceptual and measurement work is needed to advance understanding of this protective role and how to foster social media literacy. Although data are scarce, targeting social media literacy in prevention and intervention programs may also be valuable. In this perspective piece, key features that we identify as priorities for future prevention and intervention efforts include developing interventions that target the implementation of social media skills beyond their acquisition. In addition, leveraging social media user generated content for prevention purposes would likely be useful, as would embedding micro-skill delivery within platforms.

Examining Teacher Concerns and Anxiety on the Implementation of a Universal Body Image Program

In the past 30 years, there have been numerous positive body image and eating disorder prevention programs targeting youth developed for school-based settings. Frequently, teachers are used as interventionists to increase dissemination, decrease costs relative to researchers, and increase scalability. However, little is known about teacher concerns and barriers that may hinder successful uptake and implementation. The current study recruited a total of 269 teachers who consented to implement a universal body image and appearance-related bullying and teasing prevention program in their classrooms as part of a randomized controlled trial. Teachers expressed some worry that they may say the wrong thing, and concern about feeling uncomfortable teaching the program due to their own body dissatisfaction. Teacher's ethnicity, gender, years teaching, dieting behaviors and other weight control behaviors, and self-efficacy were not associated with concerns related to teaching the curriculum. Teachers with lower body esteem reported higher concerns and anxiety related to teaching a body image curriculum. In free response items, teachers worried about handling student comments that were beyond the scope of the curriculum. Teacher self-efficacy was the only variable associated with the number of program sessions implemented. Findings suggest avenues to increase implementation.

Evaluating a school-based body image lesson in Indonesia: A randomised controlled trial

Negative body image is a common public health concern among adolescents, globally. The aim of the current study was to evaluate the effectiveness, implementation fidelity, and acceptability of a single session, school-based universal body image intervention in Indonesia. A total of 1926 adolescents (59.4 % girls) and 12 school guidance counsellors (lesson facilitators) from nine state junior secondary schools in Surabaya, East Java took part in a two-arm open parallel cluster randomised controlled trial. In response to the changing circumstances due to the COVID-19 pandemic, half of the lessons were conducted in person and half were delivered online. Results showed that the lesson did not significantly improve adolescent body image or secondary outcomes relative to the control, though there was no evidence of harm. There were no substantive findings regarding intervention effectiveness by gender. The mode of intervention delivery (online vs. in-person) did not significantly influence the main findings. Implementation fidelity varied widely, and the lesson content and pedagogy were largely acceptable, though there was a strong preference for in-person lesson delivery. Findings have implications for researchers aiming to improve adolescent body image in low- and middle-income countries. Lessons learned can inform future school-based efforts to support adolescent body image.

A cognitive dissonance body image intervention 'Free Being Me' delivered by guide leaders to adolescent girl guides in India: A pilot and acceptability trial

This pilot study assessed the acceptability and pre-post intervention effects of a cognitive dissonance-based body image intervention, Free Being Me, delivered by Guide leaders to adolescent girls in India. Girls aged 11-14 years (Mage = 12.6, N = 117), who were members of the national scouting and guiding association of India, received the intervention across five weekly 1-hour group sessions. The primary outcome (body esteem) and secondary outcomes (self-esteem, internalisation of appearance ideals, negative and positive affect, and life disengagement) were measured pre-intervention and immediately post-intervention. The intervention was acceptable. Adolescent girls reported high levels of comfort (89%), enjoyment (90%), and perceived importance (92%) with suggestions for improvement including more interactive activities. Facilitator adherence and competence delivering Free Being Me was rated good. Significant within-groups pre-post intervention improvements in body esteem (Cohen's d = 0.28) and reductions in internalisation of appearance ideals (Cohen's d = 0.49) were identified. No changes to self-esteem, negative or positive affect, or life disengagement were observed. This study suggests that Free Being Me is acceptable for community-based delivery and Guide leader format with promising pre-post intervention effects. Going forward, a randomised controlled trial is necessary to make confident interpretations on the effectiveness of Free Being Me.

Task shifting eating disorders prevention: A pilot study of selective interventions adapted for teacher-led universal delivery in secondary schools

OBJECTIVE

Increasing effectiveness and sustainability of universal school-based eating disorder prevention is needed. This study adapted two existing selective prevention programmes for universal delivery, investigating feasibility, acceptability, and preliminary effects when delivered by trained teachers to classes of mixed-gender adolescents.

METHOD

A three-arm controlled pilot study with Year 9 students (N = 288; Mage  = 13.61 SDage  = .50). Three schools in south Wales and south-west England were allocated to mindfulness-based intervention (MBI), dissonance-based intervention (DBI), or classes-as-usual (CAU) control. Self-reported eating disorder risk factors were collected at baseline, 6-week post-intervention, and 2-month follow-up. Focus groups were conducted post-intervention.

RESULTS

Delivery and evaluation were feasible, allowing for flexibility in scheduling, with good retention. Student and teacher ratings indicated moderate acceptability of both interventions, with recommendations for refinement. Mixed model analyses, controlling for baseline, showed significant effects of condition across post-intervention and follow-up for body esteem (DBI > CAU; Cohen's d = .34) and positive affect (MBI > CAU, d = .58). For girls only, both MBI and DBI improved body satisfaction and internalization, and the MBI additionally resulted in improved weight and shape concerns, negative affect, and life disengagement (d's = .39-1.12), across post-intervention and follow-up.

DISCUSSION

Selective eating disorder prevention programmes based on cognitive dissonance and mindfulness can be delivered universally in schools, by teachers, allowing for appropriate flexibility necessary for real world implementation. Moderate acceptability indicates areas for improving content and delivery; positive effects on key outcomes are encouraging. These findings provide support for further robust evaluation.

PUBLIC SIGNIFICANCE

Existing universal eating disorder prevention is limited by small effects and reliance on highly trained facilitators. This study is the first to adapt mindfulness- and dissonance-based interventions for delivery by teachers, to adolescents of all genders in a classroom setting. Delivery was largely feasible and acceptable, and both interventions showed significant effects across key risk factors for eating disorders, with larger effect sizes than found previously. This underpins further robust evaluation.

Longitudinal pathways between childhood BMI, body dissatisfaction, and adolescent depression: an observational study using the UK Millenium Cohort Study

BACKGROUND

Globally, more adolescents are having depressive symptoms than in the past. High BMI is a risk factor for depressive symptoms, potentially acting via increased body dissatisfaction. Robust longitudinal evidence of these associations could help to inform preventive interventions, but such evidence remains scarce. We investigated the longitudinal associations between BMI at age 7 years and depressive symptoms at age 14 years (objective 1), BMI at age 7 years and body dissatisfaction at age 11 years (objective 2), and body dissatisfaction at age 11 years and depression at age 14 years (objective 3). We also investigated the extent to which body dissatisfaction mediated the association between BMI and depressive symptoms (objective 4).

METHODS

This study used data from the Millennium Cohort Study, a representative longitudinal general population cohort of UK children born between Sept 1, 2000, and Jan 11, 2002. We used univariable and multivariable linear regression models to investigate the associations in objectives 1-3 adjusting for a range of child-level and family-level confounders. For mediation analyses we used non-parametric g-formula (objective 4). We reported stratified results in presence of sex differences. All analyses were based on participants with complete BMI data and imputed confounders and outcomes.

FINDINGS

Our sample included 13 135 participants. Of these, 6624 (50·4%) were male participants and 6511 (49·6%) were female participants; 11 096 (84·4%) were of White ethnicity and 2039 (15·6%) were from a minority ethnic background. At baseline, mean age was 7·2 years (SD 0·25, range 6·3-8·3). In multivariable models, an SD increase in BMI at age 7 years was associated with greater depressive symptoms at age 14 years (estimated regression coefficient [coeff]: 0·30, 95% CI 0·17-0·43) and greater body dissatisfaction at age 11 years (coeff 0·15, 0·12-0·18). Greater body dissatisfaction at age 11 years was associated with higher depressive symptoms at age 14 years (coeff 0·60, 0·52-0·68). All these associations were twice as large in girls as in boys. Body dissatisfaction explained 43% of the association between BMI and depression in girls.

INTERPRETATION

Our findings bear relevance for interventions aimed at reducing weight in childhood and reducing body dissatisfaction. Implementation of evidence-based body image interventions and identification of drivers of weight stigma should be key public health priorities. Interventions aiming to reduce weight in childhood need to avoid increasing body dissatisfaction and should target environmental drivers of weight rather than individuals.

FUNDING

Wellcome Trust; The Royal Society; Economic and Social Research Council; and the National Institute for Health and Care Research.

A short-form drama series created for the digital media environment: A randomised controlled trial exploring effects on girls' body satisfaction, acceptance of appearance diversity, and appearance-related internalised racism

'Edutainment' micro-interventions are a scalable public health strategy that can challenge media-related body image pressures and race- and weight- based stigma. This study evaluated the impact of viewing a brief, theoretically-informed, short-form drama episode on Black and non-Black adolescent girls' body image, acceptance of diversity of appearance (assessed by acceptance of an individual in a larger body and a Black individual), and appearance-related internalised racism (among Black girls only). The fictional drama depicted characters of diverse body sizes and race/ethnicities, with each episode focusing on a risk or protective factor for body image concerns among adolescent girls (e.g., appearance-related teasing and conversations). Participants (N = 686; 50.4 % Black, 49.6 % non-Black) aged 13-18 (Mage = 15.72 years) were randomly allocated to view either the first episode of this series (focused on social media's unrealistic appearance ideals and strategies to resist pressures) or a non-body-image-related control video. Findings revealed no significant differences in body satisfaction between conditions but significant improvements in the acceptance of appearance diversity among all girls who viewed the body image episode. Black girls who viewed this episode experienced significant improvements to appearance-related internalised racism. Edutainment micro-interventions constitute a promising avenue for promoting acceptance of appearance diversity and reducing appearance-related internalised racism.

Pilot feasibility and acceptability trial of BE REAL's BodyKind: A universal school-based body image intervention for adolescents

Body dissatisfaction is prevalent among adolescents and a primary risk factor for eating disorders, yet there are few body image interventions for older adolescents that support development of positive body image. Therefore, we assessed the feasibility, acceptability and preliminary effectiveness of BodyKind, a four-lesson, mixed gender, teacher-led, school-based curriculum for older adolescents, that combines principles of self-compassion, compassion for others, cognitive dissonance, and social activism to address contemporary adolescent body image concerns (i.e., appearance bias, comparisons on social media) and strengthen positive body image development. The sample contained 147 adolescents, predominantly racial/ethnic minorities (>95%), 54.8% male, 41.5% female and 4.1% gender-minority students aged 15-18 years (M=16.24, SD=.96) from a low-income, inner-city high school in the Midwestern US. Two teachers received training and delivered the curriculum to students. This single arm, mixed methods trial assessed student and teacher acceptability, teacher fidelity and student intervention outcomes. Despite reasonable teacher fidelity, recruitment/attendance rates, post-intervention data loss (35% attrition) limited evaluations of program effectiveness and study feasibility. Important learnings regarding study feasibility will inform optimisation for future school-based trials. Findings demonstrate high acceptability of BodyKind among teachers and adolescents in a lower socioeconomic school setting, and further randomized controlled effectiveness trials are required.

Protocol of a cluster randomised trial of BodyKind: a school-based body image programme for adolescents

BACKGROUND

Poor body image is prevalent among adolescents and associated with several negative outcomes for their physical and psychological health. There is a pressing need to address this growing public health concern, yet there are few evidence-informed universal programmes for older adolescents that address contemporary body image concerns (i.e., social media). BodyKind is a four lesson, school-based, teacher led, universal body image programme that incorporates empirically supported principles of cognitive dissonance, self-compassion, compassion for others and social activism, to support positive body image development. Building on previous pilot trials in the USA, this paper outlines the protocol for a cluster randomised control trial (cRCT) and implementation evaluation of the BodyKind programme which was culturally adapted for the Irish cultural context.

METHODS

We aim to recruit 600 students aged 15-17 years in Transition Year (4th year) across 26 second-level schools in Ireland. Using minimisation, schools will be randomly assigned to receive BodyKind (intervention condition, n=300) or classes as usual (waitlist control, n=300). Teachers in intervention groups will receive training and deliver the programme to students over four weeks, at a rate of one lesson per week. Primary outcomes of body appreciation, body dissatisfaction and psychological wellbeing and secondary outcomes of self-compassion, compassion for others, body ideal internalisation, social justice motives and appearance-based social media use will be assessed at pre-, post- and 2 month follow up. Mediation and moderation analyses will be conducted to identify how and for whom the intervention works best. An implementation evaluation will assess the quality of programme implementation across schools and how this may influence intervention outcomes. Waitlist control schools will receive the programme after the 2-month follow up.

CONCLUSION

This study will be the first to implement a cRCT and an implementation evaluation to assess the impact of this multicomponent school-based body image programme designed to support healthy body image development. If shown to be effective, BodyKind will have the potential to improve adolescent body image and wellbeing and inform efforts to implement sustainable and scalable programmes in schools.

TRIAL REGISTRATION

The trial was retrospectively registered on 10/10/2023 on ClinicalTrials.gov NCT06076993 .

Effectiveness of interventional package on body image perception and self-esteem among adolescents - A pilot study

Background of the Study

In adolescence various physical and psychological changes, impact their overall perception that leads to either satisfaction or dissatisfaction with body image. Adolescents can suffer from body image dissatisfaction. Counselling sessions, video and documentaries can be used to improve the body image concerns. So, this study aims to evaluate the impact of interventional package on the body image perception and self-esteem among adolescents.

Materials and Methods

The sampling technique used to enrol 65 adolescents was simple random. Body image was assessed in the form of affective and behavioural body image perception. Two different structured scales were used to assess affective and behavioural body image perception. Pre-test was conducted to assess the body image perception among adolescents; then, documentary was shown in the form of intervention 1 and the post-test 1 was taken, again booklet was distributed as intervention 2 and post-test -2 was taken.

Results

A statistically significant improvement in the satisfaction with weight, height, complexion, hair, teeth, buttocks, thigh and moustache, after the use of interventional package. In behavioural perception of body image, no significant association was found in pre-test, post-test 1 and 2, there is statistically significant improvement in self-esteem of adolescents, as P = 0.03.

Conclusion

Interventional package in the form of documentary and booklet is useful in improving body image perception among adolescents. Significant improvement was seen in perception related to certain body parts.

How can we help you? A global investigation into girls' body image experiences in sport and intervention preferences

Existing interventions that target the intersection of girls' body image and sports participation are marginally effective, which is, in part, due to methodological limitations pertaining to intervention development (i.e., not theoretically or stakeholder informed). In this research, girls were consulted on their positive and negative body image experiences in sport and their preferences for fostering and remedying these experiences, respectively, in a new intervention. One-hundred and two girls (11-17-years; n = 91) and youth advisory board members (18-35-years; n = 15) from 13 countries participated in semi-structured focus groups and/or surveys. Template analysis of focus group and survey data resulted in 10 first-level themes and three integrative themes, which highlighted factors that both hinder and help girls' body image while playing sport, as well as girls' intervention preferences and cross-national considerations that will eventually impact the adaptation, localisation, and scaling of the intervention. Overall, girls favoured a girl and woman-only, multimodal intervention that upskilled them in appreciating their bodies, while challenging others' harmful behaviours. Stakeholder insights are crucial in creating acceptable, effective, and scalable interventions. Insights from this consultation phase will inform the development of a new scalable, evidence- and stakeholder-informed intervention that aims to foster girls' positive body image and sports enjoyment.

Effects of online self-compassionate writing on stigmatizing and affirming self-perceptions: Potential boundary conditions in undergraduate women

This study investigated the effects of an online self-compassionate writing intervention on stigmatizing and affirming self-views toward the body in a sample of college women (N = 254). Participants were randomly assigned to a self-compassionate writing, attentional-control writing, or wait-list control condition for one week, and completed measures of self-compassion, affirming self-perceptions, and stigmatizing self-perceptions at baseline, one-week post intervention, and one-month post intervention. A series of mixed AN(C)OVAs revealed no significant effects by condition or time on stigmatizing or affirming self-views toward the body when controlling for self-esteem, internalized weight stigma, and eating disorder symptomatology. Follow-up exploratory analyses demonstrated no significant effects by condition on the six facets of self-compassion. Notably, participants were significantly more likely to drop out from the study over time if they were lower in self-compassion and self-esteem, and higher in internalized weight stigma at baseline. These results suggest that online self-compassion writing interventions may need to be longer and more potent, especially for women with more entrenched and stigmatized views about their bodies, as well as potential boundary conditions of cultivating self-compassion in a short-term online intervention.

Independent pragmatic replication of the Dove Confident Me body image program in an Australian Girls Independent Secondary School

Following calls for the independent replication of universal body image programs under diverse conditions, this research aimed to investigate whether the universal co-educational prevention program developed for audiences in the United Kingdom (Dove Confident Me, DCM), was an acceptable and effective intervention when delivered by teachers to adolescent girls attending a single-sex Australian school. Comprising two studies, Study 1, evaluated DCM among Grade 8 students (N = 198) at a single-sex private school, and compared the results with students (N = 208) s from a matched comparison group. No improvements were observed on outcome measures between the comparison and intervention girls over the three time points. Study 2 involved minor modifications to the aesthetics and content of the program, as well as the logistics of delivery. Delivered by teachers to Grade 8 students (N = 242 intervention and N = 354 comparison), there were significant improvements in acceptability of the modified DCM program, yet no interaction effects observed on outcome measures. While the program did no harm, it is possible that there are adjustments to the methods utilized and content of programs that are trialed in efforts to prevent body image concerns and eating disorders in the school setting.

A randomized controlled trial to evaluate the acceptability and effectiveness of two eating disorders prevention interventions: the HEIDI BP-HW project

BACKGROUND

Eating disorders (ED) are common in Switzerland, as in other Western countries, with a prevalence of any ED of 3.5%. However, no specific prevention intervention has been evaluated in the French-speaking part of the country. In this study, we assessed the acceptability and effectiveness of two well-validated eating disorders prevention interventions: the Body Project intervention (BP), based on cognitive dissonance techniques, and the Healthy Weight intervention (HW), based on the implementation of a healthy lifestyle.

METHODS

Forty female students, aged 18-28, with body dissatisfaction, were randomized into three arms: a BP group, an HW group, and a waiting-list control group (WLCG). The primary outcome measure was body dissatisfaction. Secondary outcomes were thin-ideal internalization, dietary restraint, negative affect, and ED psychopathology. Thirty-three participants completed the assessments before and after the one-month interventions or waiting period. A follow-up measurement was conducted one month after the interventions to assess the stability of the results.

RESULTS

Both interventions, delivered via a virtual web platform, were considered acceptable. The reduction in body dissatisfaction was greater in the BP group (r = 0.7; p < 0.01) or the HW group (r = 0.6; p < 0.01) than in the WLCG, with large effect sizes. Dietary restraint and shape concern were also significantly reduced in the BP group (r = 0.6 and r = 0.7, respectively; p < 0.01) and HW group (r = 0.5 and r = 0.5, respectively; p < 0.05) compared to the WLCG, with moderate to large effect sizes. The results obtained in each intervention group were stable at the one-month follow-up.

CONCLUSIONS

This study showed encouraging results in young women with body dissatisfaction, arguing in favor of the French adaptations of the BP and HW interventions. However, the feasibility of recruitment was difficult, partly due to the pandemic situation at the time of the study, and should be further considered to improve dissemination.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04558073, 22/09/2020 and Swiss National Clinical Trial Portal (SNCTP000003978).

A meta-analytic review of impact of measurement choice on RCTs to reduce appearance internalization

OBJECTIVE

Prior reviews have shown that interventions targeting internalization of appearance standards are generally efficacious, though there is considerable heterogeneity in estimates across studies. This updated review of the literature evaluates whether efficacy estimates from RCTs systematically vary as a function of three related outcome measures (internalization, awareness, and perceived pressure regarding appearance standards).

METHODS

Seven electronic databases were systematically searched from inception to February 8, 2023. The Cochrane Risk of Bias tool assessed each study's risk of bias. Studies included were randomized-controlled trials evaluating body image/eating disorder prevention or intervention programs targeting internalization as a focal point of treatment. Effect sizes were meta-analyzed and meta-regression analyses were conducted investigating the impact of outcome measure choice on study effect size at post-intervention and follow-up.

RESULTS

Thirty-seven studies (N = 4809 participants) were included. The meta-analytic findings as expected found interventions efficacious at reducing internalization post-intervention (d = -0.47, 95% CI [-0.60 to -0.34], k = 44), and at follow-up (d = -0.28, 95% CI [-0.39 to -0.17], k = 43), but also highly heterogenous (I2  = 52-67%). Operationalization of internalization moderated results at follow-up but not post-intervention timepoints, with awareness measures (compared with internalization measures) producing weaker effect sizes. Exploratory analyses found bigger effects when internalization was compared with all other measurement categories combined, suggesting possible issues with statistical power in main analyses.

DISCUSSION

Mixed present findings suggest need for further evaluation of measurement effects on efficacy, and possible caution in choice of outcome measure for internalization-based interventions.

PUBLIC SIGNIFICANCE STATEMENT

This review provides some preliminary evidence that choice of survey measures used in randomized controlled trials can impact our judgments about whether a trial reduces the extent to which participants endorse unrealistic appearance standards. Accuracy in measurement of this efficacy of trials is crucial, given the role that internalized appearance standards play in onset and maintenance of eating disorders.

The co-creation, initial piloting, and protocol for a cluster randomised controlled trial of a coach-led positive body image intervention for girls in sport

BACKGROUND

Globally, girls disengage from sports at an earlier age and higher rate than boys. This is, in part, due to the unique body image challenges that girls face, relative to their male peers. Existing intervention efforts that aim to reduce girls' negative body image and movement experiences have proven marginally effective, if not ineffective. This paper outlines the co-creation, initial piloting and protocol for a cluster randomised controlled trial of Body Confident Athletes (BCA); an in-person, coach-led intervention that aims to foster positive body image and sports enjoyment among girls.

METHODS

Following co-creation and an initial pilot, a two-armed cluster randomised controlled trial will assess the immediate (post-intervention) and short-term (1-month and 3-month follow-up) impact of BCA on girls' (N = 1,036; 11-17 years old) body image, sports enjoyment, and affect. Sport organisations will be randomly allocated (1:1) into either an intervention or waitlist control condition. Girls and coaches in the intervention condition will complete three 60-minute sessions over three consecutive weeks. The primary outcome will be the immediate change in girls' body esteem, with secondary outcomes assessing the immediate and short-term changes in girls' body appreciation, self-objectification, attuned self-care, sports enjoyment, and affect.

DISCUSSION

This research is the first to utilise an international multi-stakeholder partnership to co-create and evaluate an intervention that addresses the intersection of girls' body image and sport experiences. The theoretical and methodological considerations of this research have led to a feasible intervention and trial protocol, and if proven effective, BCA may assist in reducing the global gender disparity in sports participation.

TRIAL REGISTRATION NUMBER

NCT05594524 , registered 25^th October 2022.

Body Image among Girls in Indonesia: Associations with Disordered Eating Behaviors, Life Engagement, Desire for Cosmetic Surgery and Psychosocial Influences

Body image is an important risk factor for mental and physical health during adolescence. Nonetheless, few studies have empirically investigated body image among girls in Southeast Asia. This cross-sectional study examined the prevalence of body esteem (a holistic measure of body image assessing the degree of satisfaction with one's appearance, weight, and shape), associated behavioral outcomes, and potential psychosocial influences on body image among Indonesian girls to inform future intervention efforts. Girls across Indonesia with internet access (N = 318, M_age = 13.59 years) completed a questionnaire that assessed body image, disordered eating behaviors, appearance-related life engagement, desire for cosmetic surgery, appearance ideal internalization, media literacy, appearance-related teasing, and self-esteem. The younger girls' (10-13 years) responses were analyzed separately from those of the older girls (14-17 years). Over half of the girls did not have high body esteem. Approximately a quarter of the girls across both age groups reported restricting their food intake, emotionally eating, and/or engaging in excessive exercise, and over half desired cosmetic surgery. Disordered eating behaviors and a desire for cosmetic surgery were negatively correlated with body esteem. Hierarchical regression analyses found BMI, internalization, appearance-related teasing, and self-esteem were uniquely associated with body esteem among younger girls. Appearance-related teasing and self-esteem were positively associated with body esteem among older girls. These findings suggest body image interventions may be important for this population, with appearance-related teasing and self-esteem potentially useful targets for intervention efforts. Further prospective research to investigate these findings would be beneficial for a deeper understanding of body image risk factors for girls across Indonesia.

Evaluating a body image school-based intervention in India: A randomized controlled trial

Body dissatisfaction is highly prevalent among adolescents in low- and middle- income countries, including in India. However, evidence-based interventions are lacking. This study evaluated the efficacy of a school-based mixed-gender body image intervention among adolescents in India. A randomized controlled trial was conducted among 568 (43 % girls) Year 7 students (aged 11-14; 94 % aged 12-13) in six schools in Delhi. Each school was randomly allocated to receive five 45-minute intervention sessions delivered by trained psychologists or a wait-list control condition. The primary outcome of body image and related secondary outcomes were assessed at pre-intervention, post-intervention, and 3-month follow-up. Intention-to-treat linear mixed models analyses showed improvements in body image relative to the control group at post-intervention and 3-month follow-up. Significant improvements were identified at post-intervention for internalization, life disengagement, disordered eating, self-esteem, and negative affect, with effects maintained in nearly all outcomes (girls only - internalization, boys only - life disengagement) at 3-month follow-up. This study presents the first mixed-gender school-based body image intervention in India, which was efficacious in improving urban adolescents' body image, disordered eating, and related outcomes.

Examination of bidirectional relationships between fear of negative evaluation and weight/shape concerns over 3 years: A longitudinal cohort study of Australian adolescents

OBJECTIVE

Adolescents commonly experience both fear of negative evaluation and weight/shape concerns. However, evidence concerning the prospective associations between these constructs during adolescence is limited. The current study examined the bidirectional relationships between fear of negative evaluation and weight/shape concerns over a 3-year period in adolescents.

METHOD

Australian high school students (n = 2073; 55% girls) completed self-report measures at three timepoints, each 1 year apart.

RESULTS

Findings showed a bidirectional relationship, whereby increases in fear of negative evaluation predicted exacerbated weight/shape concerns, and vice versa. Results point towards a vicious maintenance cycle between fear of negative evaluation and weight/shape concerns.

DISCUSSION

Findings from the current study highlight the importance of considering both fear of negative evaluation and weight/shape concerns in the development of health promotion and prevention programs designed to reduce the occurrence and adverse effects of body dissatisfaction or improve general mental health.

PUBLIC SIGNIFICANCE

Many adolescents experience some level of fear of negative evaluation (i.e., worry about being judged by others) and worry about their weight and/or shape. This study examined the prospective relationship between both constructs. Findings showed a bidirectional relationship, whereby higher fear of negative evaluation predicted increased weight/shape concerns, and vice versa. Programs designed to reduce body dissatisfaction might be improved by targeting both fear of negative evaluation and weight/shape concerns.

Goodform: A cluster randomised controlled trial of a school-based program to prevent body dissatisfaction and muscle building supplement use among adolescent boys

Although body dissatisfaction is common among adolescent boys, few intervention programs specifically developed for boys have been shown to be effective for reducing body dissatisfaction. Our study aim was to evaluate Goodform, a 4-session, teacher delivered intervention program specifically developed for boys to reduce body dissatisfaction and muscle building supplement use. The Goodform program was based on cognitive dissonance, social learning theory, and a social norms approach, and drew from two existing body image intervention programs that have shown promise among males: The Body Project- More than Muscles, and the Athletes Training and Learning to Avoid Steroids Program (ATLAS). A sample of 488 boys in grades 9 and 10 (M_age = 14.81, SD_age = 0.51) at nine secondary schools in Australia were randomly assigned to Goodform (n = 244) or control (n = 244) at the school level. Self-reported body image, supplement use, anabolic androgenic steroid (AAS) use, and attitudes around using AAS and muscle building supplements were measured at baseline, post-intervention, and eight-week follow-up. Analyses with multi-level, mixed-effect regression models revealed no changes over time attributable to the intervention. Our results have implications for researchers in the body image and eating disorder prevention fields. Lessons learned in this study can inform future school-based efforts for reducing muscle building supplement use.

The Needs of School Professionals for Eating Disorder Prevention in Australian Schools: A Mixed-Methods Survey

(1) Background: School professionals such as teachers and counsellors are uniquely positioned to facilitate discussion around disordered eating and body image; however, little is known about the needs of school professionals with respect to eating disorder prevention. This study aimed to explore the needs and perceptions of Australian school professionals regarding eating disorder prevention. (2) Methods: School professionals were recruited to a mixed-methods online cross-sectional survey. The survey assessed demographics and perceived needs and attitudes to eating disorder prevention. (3) Results: Most participants (92%) were willing to participate in eating disorder prevention; however, only 61% reported good knowledge and 41% reported feeling confident in implementing eating disorder prevention. Those who had received training in eating disorders (24%) reported higher confidence (p = 0.02) and knowledge (p = 0.04). Only 66% of respondents reported that all teachers should be involved in eating disorder prevention while barriers including workload, knowledge, and resources were commonly highlighted. Fewer respondents working in primary school settings reported the need for prevention approaches (p = 0.046). (4) Conclusions: Despite a willingness to be involved in the prevention of eating disorders, there are inconsistencies in attitudes regarding the role of school professionals in eating disorder prevention. The findings of this study reinforce that understanding professional roles, school settings, and personal attitudes is critical in the development of more efficacious school professional training and prevention interventions.

“Why don’t I look like her?” How adolescent girls view social media and its connection to body image

Background

Adolescent girls appear more vulnerable to experiencing mental health difficulties from social media use than boys. The presence of sexualized images online is thought to contribute, through increasing body dissatisfaction among adolescent girls. Sexual objectification through images may reinforce to adolescent girls that their value is based on their appearance. This study explored how sexualized images typically found on social media might influence adolescent girls’ mental health, in positive and/or negative ways.

Methods

In-depth interviews were conducted with girls aged 14–17 years (n = 24) in Perth, Western Australia. Data were analyzed using thematic analysis.

Results

Participants identified body image as a major concern, reporting negative appearance comparisons when viewing images on social media. Appearance comparisons were perceived to exacerbate adolescent girls’ appearance-based concerns. Comparisons also influenced adolescent girls’ efforts to change their appearance and seek validation on social media. The importance of awareness and education from a younger age about social media and its influence on body image was emphasized, as was the need for strategies to promote positive body image and counteract negative body image.

Conclusion

The findings of this study have important implications for professionals working with adolescent girls and for the development of health promotion programs addressing social media use and body image concerns.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01845-4.

Feasibility and acceptability of video-based microinterventions for eating disorder prevention among adolescents in secondary schools

OBJECTIVE

Eating disorders (EDs) often emerge in late adolescence. Schools are ideal settings for prevention programs; however, cost and time limit implementation. Microinterventions may overcome these challenges. This study adapted two microinterventions (cognitive dissonance, self-compassion) and assessed feasibility and acceptability among mid-adolescents to provide proof-of-concept for further investigation.

METHOD

Feedback from staff (n = 5) and student (n = 15) focus groups contributed iteratively to the adaptation of intervention materials. Students in Grade 10 and 11 (N = 101, M_age  = 15.80, SD = 0.68) were then randomly allocated by class to a 20-min video-based cognitive-dissonance or self-compassion intervention, accessed on their school devices. ED risk and protective factors were assessed at baseline, immediate postintervention (state outcomes), and 1-week follow-up (trait outcomes). Acceptability items were included at both timepoints.

RESULTS

Implementation was deemed feasible. Girls generally reported greater acceptability than boys. Among girls, the self-compassion intervention demonstrated greater acceptability. Among boys, some aspects of acceptability (e.g., lesson endorsement, utilization of techniques) were rated higher in the cognitive dissonance group whereas other aspects (e.g., understanding, interest) were greater in the self-compassion group. All groups exhibited favorable changes in most state outcomes, however trait outcome change was varied.

DISCUSSION

Microinterventions provide a feasible way of implementing prevention strategies in a time-poor educational context. Future large-scale evaluation is warranted to determine efficacy, following modifications based on current findings.

PUBLIC SIGNIFICANCE

This study shows promising feasibility and acceptability of two brief, self-guided video-based lessons (microinterventions) for adolescents in school classrooms, that use psychological techniques to target appearance pressures as a key risk factor for eating disorders. Such interventions are easier to implement in school settings than longer, facilitator-led interventions, to encourage greater uptake and ongoing use. Findings support further research to evaluate effectiveness, to ultimately provide accessible and gender-inclusive tools for busy schools.

Weight misperception and substance use: Brazilian Study of Cardiovascular Risks in Adolescents (ERICA)

BACKGROUND

Adolescence is a crucial period for body image formation. Weight misperception is the discrepancy between individuals' body weight perception and their actual nutritional status. Both weight concerns and substance use are common among adolescents, and there is evidence of an associations between these two variables. Thus, the aim of this study was to assess the association between weight misperception and substance use (smoking and alcohol) in a national sample of normal weight Brazilian adolescents.

METHODS

Data were obtained from the Brazilian Study of Cardiovascular Risks in Adolescents (ERICA), a cross-sectional, multicenter, national, school-based survey, carried out in 124 municipalities with more than 100,000 inhabitants from Brazil. The sample included adolescents aged 12-17 years, classified as normal weight by nutritional status evaluation. The following measures were collected: weight underestimation and overestimation (exposure); having tried cigarette smoking, current smoking, current alcohol consumption, binge drinking and current smoking and alcohol consumption(outcomes); macro-region, sex, type of school, and excessive screen time (confounders). The frequency of variables was calculated with 95% confidence intervals (CI). Poisson regression models were used to estimate prevalence ratios (PR).

RESULTS

In total, data from 53,447 adolescents were analyzed. Weight misperception was present in a third of the adolescents, with similar prevalence of weight underestimation and overestimation. In adolescents aged 12-14 years, weight underestimation and overestimation were associated with having tried cigarette smoking (PR: 1.18 and 1.43, respectively), current alcohol consumption (PR: 1.33 for both weight misperception categories), and binge drinking (PR: 1.96 and 2.01, respectively). Weight underestimation was associated with both having tried cigarette smoking and current alcohol consumption in boys (PR: 1.14 and 1.16, respectively) and girls (PR: 1.32 and 1.15, respectively). In girls, weight overestimation was associated with all substance use variables (PR between 1.19 and 1.41).

CONCLUSIONS

Our results showed an association between weight misperception and having tried cigarette smoking, alcohol consumption, and binge drinking in younger adolescents. In addition, weight overestimation was associated with all substance use indicators in girls. Based on our findings, interventions aimed to improve weight perception in normal weight adolescents may contribute to the reduction of substance use in this population.

Evaluating the Efficacy of a Social Media-Based Intervention (Warna-Warni Waktu) to Improve Body Image Among Young Indonesian Women: Parallel Randomized Controlled Trial (Preprint)

BACKGROUND

Body dissatisfaction is a global issue, particularly among adolescent girls and young women. Effective body image interventions exist but face barriers to scaling up, particularly in lower- and middle-income countries, such as Indonesia, where a need exists.

OBJECTIVE

We aimed to evaluate the acceptability and efficacy of Warna-Warni Waktu, a social media-based, fictional 6-episode video series with self-guided web-based activities for improving body image among young Indonesian adolescent girls and young women. We hypothesized that Warna-Warni Waktu would increase trait body satisfaction and mood and decrease internalization of appearance ideals and skin shade dissatisfaction relative to the waitlist control condition. We also anticipated improvements in state body satisfaction and mood immediately following each video.

METHODS

We conducted a web-based, 2-arm randomized controlled trial among 2000 adolescent girls and young women, aged 15 to 19 years, recruited via telephone by an Indonesian research agency. Block randomization (1:1 allocation) was performed. Participants and researchers were not concealed from the randomized arm. Participants completed self-report assessments of trait body satisfaction (primary outcome) and the internalization of appearance ideals, mood, and skin shade dissatisfaction at baseline (before randomization), time 2 (1 day after the intervention [T2]), and time 3 (1 month after the intervention [T3]). Participants also completed state body satisfaction and mood measures immediately before and after each video. Data were evaluated using linear mixed models with an intent-to-treat analysis. Intervention adherence was tracked. Acceptability data were collected.

RESULTS

There were 1847 participants. Relative to the control condition (n=923), the intervention group (n=924) showed reduced internalization of appearance ideals at T2 (F_1,1758=40.56, P<.001, partial η²=0.022) and T3 (F_1,1782=54.03, P<.001, partial η²=0.03) and reduced skin shade dissatisfaction at T2 (F_1,1744=8.05, P=.005, partial η²=0.005). Trait body satisfaction improvements occurred in the intervention group at T3 (F_{1, 1781}=9.02, P=.005, partial η²=0.005), which was completely mediated by the internalization change scores between baseline and T2 (indirect effect: β=.03, 95% CI 0.017-0.041; direct effect: β=.03, P=.13), consistent with the Tripartite Influence Model of body dissatisfaction. Trait mood showed no significant effects. Dependent sample t tests (2-tailed) found each video improved state body satisfaction and mood. Cumulative analyses found significant and progressive improvements in pre- and poststate body satisfaction and mood. Intervention adherence was good; participants watched an average of 5.2 (SD 1.66) videos. Acceptability scores were high for understandability, enjoyment, age appropriateness, usefulness, and likelihood to recommend.

CONCLUSIONS

Warna-Warni Waktu is an effective eHealth intervention to reduce body dissatisfaction among Indonesian adolescent girls and young women. Although the effects were small, Warna-Warni Waktu is a scalable, cost-effective alternative to more intense interventions. Initially, dissemination through paid social media advertising will reach thousands of young Indonesian women.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05383807, https://clinicaltrials.gov/ct2/show/NCT05383807 ; ISRCTN Registry ISRCTN35483207, https://www.isrctn.com/ISRCTN35483207.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/33596.

A comic-based body image intervention for adolescents in semi-rural Indian schools: Study protocol for a randomized controlled trial

Adolescents in India experience body dissatisfaction, however, empirically supported interventions are lacking. This paper describes the protocol for the development, acceptability testing, and cluster randomized controlled trial (RCT) of a six-session comic-based intervention, which aims to improve body image and related outcomes among adolescents in semi-rural Indian schools. If found to be acceptable and effective, UNICEF will disseminate the intervention across schools in eight states of India. The acceptability study will be conducted with 24 students in Classes 6-8 (age 11-14) and nine teachers from Hindi-medium government schools using interviews and focus groups. The subsequent RCT will be conducted with 2400 students, with schools randomized to either the comic-based intervention or lessons-as-usual (control) groups. The primary outcome is body esteem, and secondary outcomes are disordered eating, appearance ideal internalization, body-image-related life disengagement, self-esteem, negative affect, and positive affect. Additional exploratory outcome measures are skin colour dissatisfaction, body hair dissatisfaction, appearance-based teasing, and endorsement of traditional gender roles. These outcomes will be examined at three timepoints: baseline (T1), 1 week-post-intervention (T2), and 12-weeks follow-up (T3). Analyses will compare outcomes in the intervention with the control group. This will be the first study to evaluate a body image intervention for adolescents in semi-rural Indian schools.

A systematic review of interventions aiming to promote positive body image in children and adolescents

Evidence shows interventions can improve positive body image in adult women. This systematic review examined the evidence of efficacy of interventions that aimed to increase positive body image in children and young people aged under 18 years. The authors followed PRISMA guidelines for the review. Searches of CINAHL Plus, Medline, PsychINFO, Wiley Online Library, SCOPUS and grey literature were conducted up to February 2021 and identified 4171 papers. Thirteen studies evaluating 12 interventions, designed for children/adolescents aged 9-18 years, were eligible and evaluated using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool. The studies evaluated body appreciation, body-esteem, and embodiment. Studies using cognitive dissonance, peer support, and psychoeducation had evidence of improving body appreciation and body-esteem in adolescent girls. However, evidence of efficacy for younger children and boys was lacking and the studies ranged in methodological quality. Further research should rigorously evaluate positive body image interventions using second-generation measures that assess specific components of positive body image and consider how to promote positive body image in young children and boys.

From Self-Doubt to Pride: Understanding the Empowering Effects of Delivering School-Based Wellness Programmes for Emerging Adult Facilitators-A Qualitative Study

Ample literature exists on the impact of prevention programmes on their target audience, while much less is known about how delivering such programmes influences their facilitators. Even less literature exists on the emotional and social processes that form this potential impact on facilitators. The current study analysed qualitative in-depth, non-structured interviews, as well as written essays provided by 33 student-facilitators who delivered the "Favoring Myself" programme in Israel during 2019-2021. This school-based wellness programme comprised 10 weekly, 90 min sessions on self-care behaviours, media literacy, self-esteem, and positive body image, which are well-known protective factors against risky behaviours. A thematic analysis was applied to explore the main themes in the collected data. An interesting affective transformation from self-doubt to pride in themselves emerged as a shared experience of these young facilitators. Facilitators related their ability to facilitate the programme, as well as to undergo an individual maturation and empowerment experience, to certain components of the programme itself, such as the preparatory course, individual supervision, and the peer-group experience. This shift from doubt to pride is discussed using two frameworks-a theoretical discourse of emerging adulthood as a developmental stage, and the self-determination theory.

The Healthy Body Image Intervention and Reduction in Eating Disorder Symptomatology and Muscle Building Supplement Use in High School Students: A Study of Mediating Factors

Background

Mediation analysis is important to test the theoretical framework underpinning an intervention. We therefore aimed to investigate if the healthy body image (HBI) intervention's effect on eating disorder (ED) symptomatology and use of muscle building supplements was mediated by the change in risk and protective factors for ED development and muscle building supplement use.

Methods

This study used data from the HBI intervention: a cluster randomized controlled universal intervention aiming to promote positive body image and embodiment and reduce the risk for ED development including 30 schools in Norway. A total of 1,713 (37% boys) participants were included in the analyses. Conditional latent growth curve analyses were performed to test for indirect effects on ED symptomatology and weekly frequency of protein and creatine supplement use measured at the 12-month follow-up via change in the proposed mediators.

Results

In girls, the reduction in ED symptomatology was mediated by positive changes in protective factors (self-esteem and body image flexibility) and reductions in risk factor scores (perceived media pressure and thin appearance internalization). Comparable changes in protective and risk factors among boys played no mediating role.

Conclusion

Interventions aiming to reduce the risk of ED development in girls may benefit from aiming to enhance self-esteem and body image flexibility and reduce perceived media pressure and thin appearance internalization. Future studies should investigate the casual relationship between muscle building supplement use and risk and protective factors for ED development in both girls and boys.

What about being a feminist is protective? An examination of constructs related to feminist beliefs as moderators of the relationship between media awareness and thin-ideal internalization

Feminist beliefs have been identified as a potential protective factor in the relationship between media awareness and thin-ideal internalization; however, the precise reason why feminist beliefs serve this role is unclear. A series of three studies examined the reasons why feminist beliefs may be protective in non-student samples, considering as possible explanations open-minded thinking, critical thinking, and media attitudes and literacy. Study 1 showed that the moderating role of feminist beliefs on the relationship between media awareness and thin-ideal internalization held in a non-undergraduate sample. Study 2 found that feminist beliefs and self-identifying as a feminist were related to open-minded thinking, critical thinking, and media attitudes and literacy. Study 3 found that most of these constructs did not serve the same moderating role as feminist beliefs. However, a complex relationship emerged when both feminist self-identification and media attitudes and literacy were considered simultaneously as moderators, adding to the literature emphasizing that self-identifying as a feminist has a protective role over and above that of merely holding feminist beliefs. These results suggest that feminist beliefs may be a unique combination of these constructs or that there may be yet a different reason why feminist beliefs are protective against thin-ideal internalization.

Systematic Review of Digital Interventions for Adolescent and Young Adult Women's Body Image

Background

A growing number of digital interventions have been developed to address a range of mental health issues including body image. Identifying effective interventions for body image is important given the prevalence of body image concerns and their associated negative outcomes among young women. This review aimed to critically evaluate current evidence on the use of digital interventions for adolescent and young adult women's body image.

Methods

A literature search was performed in November 2021 across three databases, PsychINFO, Web of Science and Pubmed to identify studies published with keywords and synonyms of "body image" and "digital interventions" that have been conducted with girls/women aged 10-25 years. Studies were included if they assessed a universal body image intervention delivered through a digital platform (e.g., web-based, mobile phone) and if they reported body image outcomes using validated measures. Two authors independently screened studies extracted data and assessed the quality of studies.

Results

Eight of 15 interventions were effective in improving at least one body image outcome from pre-post intervention; however, effect sizes were mostly small-medium, and few effects were maintained at follow-up. Studies were heterogeneous in terms of delivery format, duration, sample characteristics, quality, and outcomes.

Discussion

Findings suggest that digitally delivered interventions can effectively improve some body image outcomes in young women. Characteristics of effective studies are discussed and suggestions for future work on intervention development in this field are provided.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021281435, identifier CRD42021281435.

"My critical filter buffers your app filter": Social media literacy as a protective factor for body image

Exposure to idealized appearance images on social media is recognized as having a damaging effect on body image. Identifying and harnessing protective factors are, therefore, important research foci. Building on traditional media literacy concepts, one proposed protective factor is social media literacy, that is, the application of a critical analysis of motivations behind social media posts and the constructed, generally unrealistic nature of images, when viewing appearance-focused images on social media. This article describes theoretical models of social media literacy and current measurement approaches. In addition, it examines empirical support for a protective role for social media literacy, before considering directions for future research. It was concluded that, although there is still much that needs to be understood, there is modest preliminary support for a protective role for social media literacy, especially in girls and young women.

Can more people be "Happy Being Me"? Testing the delivery of a universal body satisfaction program by clinicians and school staff

The research presented here evaluates the delivery of Happy Being Me (HBM; Dunstan, Paxton & McLean, 2017) with boys and girls in their first year of secondary school in the UK (Year 7 and after comparisons aged 11-12). HBM is a manualised universal prevention programme which aims to improve body dissatisfaction and associated risk factors. Risk factors studied here were internalization of the thin ideal, physical appearance comparisons, appearance conversations. Secondary outcomes measured were self-esteem and eating disorder symptomsStudy 1 tested the effectiveness of HBM (n = 172) compared to a control group (n = 197) who received curriculum as usual. HBM resulted in significantly improved body satisfaction post-intervention which was maintained at follow up. There were no significant changes in risk factors.Study 2 compared clinician (n = 172) and teacher (n = 174) delivery. Students who received clinician-led, but not teacher-led, HBM had improved body satisfaction and this was maintained at follow up. Internalization of the thin ideal and self-esteem, improved in both clinician and teacher-led groups with small to medium sized effects. HBM can be delivered by clinicians independent of programme developers in a heterogeneous sample with positive effects on body satisfaction. Issues arising for wider delivery are discussed.

A Novel, Scalable Social Media-Based Intervention ("Warna-Warni Waktu") to Reduce Body Dissatisfaction Among Young Indonesian Women: Protocol for a Parallel Randomized Controlled Trial

Background

Despite the prevalence of body dissatisfaction among young Indonesian women and its consequential negative impacts, there are currently no evidence-based, culturally appropriate interventions to tackle this issue. Therefore, there is a need to develop scalable, cost-effective, and accessible interventions to improve body image among this population.

Objective

This paper describes the study protocol of a parallel randomized controlled trial to evaluate the effectiveness of Warna-Warni Waktu, a social media–based intervention that aims to reduce state and trait body dissatisfaction and improve mood among young Indonesian women aged 15-19 years.

Methods

The trial will take place online. Approximately 1800 young women from 10 cities in Indonesia, evenly split across the ages of 15-19 years, will be recruited via a local research agency’s established research panel. Participants will be randomly allocated to the intervention condition or a waitlist control condition. The intervention consists of six 5-minute videos, with each video supplemented with up to five brief interactive activities. The videos (and associated activities) will be delivered at a rate of one per day across 6 days. All participants will complete three self-report assessments: at baseline (Day 1), 1 day following the intervention (Day 9), and 1 month following the intervention (Day 36). The primary outcome will be change in trait body dissatisfaction. Secondary outcomes include change in internalization of appearance ideals, trait mood, and skin shade satisfaction. Intervention effectiveness on these outcomes will be analyzed using linear mixed models by a statistician blinded to the randomized condition. Intervention participants will also complete state measures of body satisfaction and mood before and after watching each video to assess the immediate impact of each video. This secondary analysis of state measures will be conducted at the within-group level.

Results

Recruitment began in October 2021, with baseline assessments underway shortly thereafter. The results of the study will be submitted for publication in 2022.

Conclusions

This is the first study to evaluate an eHealth intervention aimed at reducing body dissatisfaction among young Indonesian women. If effective, the intervention will be disseminated to over half a million young women in Indonesia via Facebook, Instagram, and YouTube.

Trial Registration

ClinicalTrials.gov NCT05023213; https://clinicaltrials.gov/ct2/show/NCT05023213

International Registered Report Identifier (IRRID)

PRR1-10.2196/33596

Comics as a body image intervention among adolescents in Indian Hindi medium schools: insights from an acceptability study

BACKGROUND

Indian adolescents experience body dissatisfaction. However, empirically supported interventions are lacking, particularly in lower socio-economic regions of India. This paper describes the acceptability testing of a six-session teacher-led comics-based intervention, aiming to improve body image and related outcomes among adolescents in Indian Hindi medium schools.

METHODS

Thirty-five students (50% girls; M _{age, girls} = 12.3 years; M _{age, boys} = 13 years) and nine teachers (11% women) from Hindi medium schools in Rajasthan, India, completed a quantitative acceptability questionnaire regarding comics that target body dissatisfaction and associated risk factors. They also participated in online or telephone semi-structured interviews to share in-depth feedback, with teachers providing additional feedback on an accompanying teacher guide. The quantitative data were analysed descriptively, with the interviews analysed using qualitative codebook thematic analysis.

RESULTS

Quantitative analyses revealed that 73% of students felt the comics made them feel good about themselves. Qualitative analyses revealed four themes: (1) body dissatisfaction is a concern; (2) the comics are powerful; (3) increasing ease of understanding; (4) a teacher guide to aid delivery.

CONCLUSION

This study demonstrates acceptability of a novel teacher-led comics-based body image intervention for adolescents in Indian Hindi medium schools from lower socio-economic settings. These findings are currently informing intervention optimizations, which will be evaluated in a randomized controlled effectiveness trial. If found to be effective, this intervention will be disseminated across eight Indian states by UNICEF. Trial registration. This trial has been registered with ClinicalTrials.gov; a database of privately and publicly funded studies conducted around the world. Registration date: 2nd May 2020; Registration ID: (NCT04317755). https://clinicaltrials.gov/ct2/show/NCT04317755?term=NCT04317755&draw=2&rank=1.

'Dove Confident Me Indonesia: Single Session': study protocol for a randomised controlled trial to evaluate a school-based body image intervention among Indonesian adolescents

Background

Due to the prevalence and associated adverse health consequences of negative body image among adolescents globally, there is a need to develop acceptable, effective, and scalable interventions. School-based body image interventions delivered by trained teachers show promise in reducing negative body image in adolescents. However, there is currently a lack of evidenced-based body image interventions for use in low- and middle-income countries (LMICs). This paper outlines a protocol for the development and evaluation of Dove Confident Me Indonesia: Single Session, a single-session, teacher-led body image intervention for Indonesian adolescents.

Method

The effectiveness of the intervention will be evaluated using a cluster randomised controlled trial design. Due to the COVID-19 pandemic, the trial will be conducted online. Trained teachers or school guidance counsellors will deliver the intervention. Self-report questionnaires will be collected at three time points: baseline, post-intervention, and two-month follow-up. The primary outcome is body esteem. Secondary outcomes are internalisation of appearance ideals, mood, engagement in life activities, tendency to engage in appearance comparisons, and skin shade satisfaction. A minimum of 1000 participants will provide 95% power to detect small-to-medium intervention effects. To account for attrition and potential internet issues, the sample will comprise of 2000 Indonesian adolescents in grades 7–9, attending state junior high schools in Surabaya, East Java. Quantitative and qualitative data on acceptability of the intervention will also be collected from teachers and students. Additionally, fidelity of lesson implementation will be assessed. This project received ethical approval from the Universitas Indonesia and the University of the West of England. The intervention will be disseminated in junior high schools throughout Indonesia via UNICEF’s Life Skills Education (LSE) programme, which will be freely available for teachers to download.

Discussion

This paper presents Dove Confident Me Indonesia: Single Session, a culturally adapted school-based intervention designed to improve Indonesian adolescents’ body image. It details the plan for evaluation, highlighting the strengths and limitations of the proposed study design. It will be informative for others aiming to adapt evidence-based school curricula to promote well-being among adolescents in LMICs.

Trial registration

NCT04665557. Registered 11th December 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11770-0.

[The Effects of Programs on Body-Image Improvement in Adolescents: A Systematic Review and Meta-Analysis]

PURPOSE

This study's objective was to investigate the effects of programs that improve adolescents' body image, using a systematic review and meta-analysis.

METHODS

A literature search was performed in eleven electronic databases, using preferred reporting items for systematic reviews and meta-analysis guidelines. Population characteristics, contents of the programs, and measured outcomes were systematically reviewed from 21 selected studies. To estimate the size of the effects, meta-analysis was conducted using Comprehensive Meta-Analysis software.

RESULTS

The contents of the programs that aimed to improve body image included physical, psychological, interpersonal, and sociocultural interventions. Sixteen studies were meta-analyzed to estimate the effect size of body-image improvement programs. Results showed that the program for body-image improvement had significant effects on body satisfaction (effect size [ES] = 0.56, 95% confidence interval [CI] = 0.23 to 0.89), and body dissatisfaction (ES = - 0.15, 95% CI = - 0.23 to - 0.08).

CONCLUSION

The program for body image improvement in adolescents includes a combination of physical, psychological, interpersonal relationship, and socio-cultural dimensions. The program that seeks to improve body image appears to be effective at increasing body satisfaction, and at reducing body dissatisfaction in adolescents. Thus, it is necessary to develop and apply multidimensional programs for adolescents to have a positive body image.

Outcomes of a Cluster Randomized Controlled Trial of the SoMe Social Media Literacy Program for Improving Body Image-Related Outcomes in Adolescent Boys and Girls

Although the negative effect of social media use among youth on body image and eating concerns has been established, few classroom-based resources that can decrease these effects through targeting social media literacy skills have been developed. This study aimed to test the efficacy of SoMe, a social media literacy body image, dieting, and wellbeing program for adolescents, through a cluster randomized controlled trial. Participants (n = 892; M_age = 12.77, SD = 0.74; range 11–15; 49.5% male) were randomized by school (n = 8) to receive either weekly SoMe (n = 483) or control sessions (lessons as usual; n = 409) over 4 weeks in their classroom. Participants completed surveys at four timepoints (baseline, 1-week post-intervention, and 6- and 12-month follow-up) assessing body dissatisfaction, dietary restraint, strategies to increase muscles (primary outcomes), self-esteem and depressive symptoms (secondary outcomes), and internalization of appearance ideals and appearance comparison (exploratory outcomes). Modest positive intervention effects were found in dietary restraint and depressive symptoms at 6-month follow-up in girls but few positive effects emerged for boys. The findings provide only preliminary support for a social media literacy intervention, but suggest the usefulness of both identifying those who benefit most from a universally delivered intervention and the need to refine the intervention to maximize intervention effects.

Disordered eating, body image concerns, and weight control behaviors in primary school aged children: A systematic review and meta-analysis of universal-selective prevention interventions

OBJECTIVE

Body image concerns and extreme weight control behaviors frequently develop in childhood indicating an important age group for the implementation of universal-selective prevention approaches. This systematic review aimed to evaluate the effect of universal-selective prevention interventions addressing disordered eating, body image concerns, and/or extreme weight control behaviors in children aged 6-12 years.

METHOD

Nine databases were searched up to April 2021. Studies were included if they delivered a universal-selective prevention intervention to children aged 6-12 years and reported outcomes relating to body image, disordered eating, or weight control behaviors. The review was conducted in line with the PRISMA Guidelines.

RESULTS

A total of 42 articles describing 39 studies included in the review, with most (n = 24; 57%) classified as neutral quality. Thirty studies implemented an eating disorder specific universal-selective program and nine implemented lifestyle interventions plus content to address disordered eating risk factors. Meta-analysis (n = 16 studies) revealed an improvement in body image-related outcomes across all studies (standardized mean difference [SMD] 0.26 [95%CI 0.01, 0.51]); with a high level of heterogeneity (Î2 = 89.9%; p < .01). Meta-analysis according to gender revealed a general improvement in body image-related outcomes for girls (SMD 0.40 [95%CI 0.07, 0.73]), but not boys (SMD 0.23 [95%CI -0.24, 0.70]).

DISCUSSION

By investigating child, parental and teaching interventions and including outcomes such as weight control and disordered eating behaviors, a trend toward a reduction in eating disorder risk factors was observed, particularly body image-related outomes in girls. Future directions include embedded disordered eating prevention materials within existing lifestyle interventions and inclusion of more diverse samples.

Association between body weight misperception and dietary patterns in Brazilian adolescents: Cross-sectional study using ERICA data

The association between body image and eating behaviors or weight control strategies has been demonstrated in the scientific literature, but there is a lack of evidence on the association between weight misperception and food consumption indicators in adolescents. This study aimed to evaluate the association between weight misperception and dietary patterns (DPs) in the Brazilian Study of Cardiovascular Risks in Adolescents (ERICA). It was a national school-based cross-sectional study conducted among students aged 12–17 years. Data were collected in the form of anthropometric measurements, responses in self-answered questionnaires, and 24-h dietary recall. The following variables were assessed: weight underestimation and overestimation (independent variables), which were defined as the presence of a disagreement between nutritional status and self-perceived weight; dietary patterns (dependent variables), defined by a posteriori method using principal component factor analysis; and individual and demographic variables (covariates). Data analysis was performed using the Poisson regression models method, stratified by sex. A total of 52,038 adolescents with normal weights were evaluated. The weight misperception prevalence was 34.0% (95% confidence interval [CI]: 33.0, 35.0). Three DPs were identified: “Traditional Brazilian,” “Processed meat sandwiches and coffee,” and “Ultra-processed and sweet foods.” In girls, weight underestimation was directly associated with the “Traditional Brazilian” (1.24; 95% CI: 1.08, 1.43) and “Ultra-processed and sweet foods” DPs (1.29; 95% CI: 1.09, 1.54), and overestimation was inversely associated with all the DPs. In boys, a direct association between underestimation and the “Ultra-processed and sweet foods” DP (1.29; 95% CI: 1.10, 1.51) was found. Overestimation was inversely associated with the “Traditional Brazilian” DP (0.79; 95% CI: 0.63, 0.99). The inverse association between overestimation and the “Traditional Brazilian” DP, and the direct association between underestimation and the “Ultra-processed and sweet foods” DP indicated that weight misperception was related to unhealthy eating habits in Brazilian adolescents.

Young adult mental health sequelae of eating and body image disturbances in adolescence

OBJECTIVE

There has been interest in the antecedents and mental health impacts of eating and body image disturbances in adolescence. Less is known about longer-term mental health impacts into young adulthood, as longitudinal studies with data spanning this developmental period are rare. We capitalize on mental health data collected across adolescence and young adulthood from a population-based cohort study that has been following >2000 Australian children and their families from infancy to young adulthood.

METHOD

This sample comprised 1,568 participants who completed the Eating Disorder Inventory drive for thinness and bulimic behavior (the severity of binge-purge patterns) subscales, and a modified version of the body dissatisfaction subscale in mid-adolescence (15-16 years), or the Depression Anxiety Stress Scales in young adulthood (19-20, 23-24, and 27-28 years).

RESULTS

After adjusting for baseline demographic and prior mental health factors (<13 years of age), all three indices of eating and body image disturbances in adolescence predicted each mental health outcome in young adulthood. Mental health risks associated with adolescent body dissatisfaction and bulimic behavior scores remained stable across young adulthood, with men having more pronounced problems associated with bulimic behavior scores than women. In contrast, mental health risks associated with adolescent drive for thinness scores diminished across this period similarly for men and women.

DISCUSSION

Findings suggest that adolescent eating and body image disturbances may have long-term mental health impacts that extend into young adulthood. This underscores the need for early preventative intervention, and longer-term monitoring and support for body image and eating disturbances.

"I didn't want to say something and them to go outside and tell everyone": The acceptability of a dissonance-based body image intervention among adolescent girls in the UK

Cognitive dissonance-based interventions (CDIs) have been well established as effective programs for the prevention of eating disorders. However, limited research has qualitatively explored adolescent girls experience of such interventions. The present study examined the acceptability of a cognitive dissonance-based body image intervention among adolescent girls in UK secondary schools. Adolescent girls aged 14-18 years (N = 99; M_age = 14.87, SD = 0.97) who opted to participate in the intervention were invited to provide intervention feedback via open-ended questions and small focus groups. The findings suggest that the intervention was largely acceptable among adolescent girls. Peers played an important role. Despite initial concerns about sharing within the group, the groups provided a sense of belonging and participants no longer felt alone in their experience of body dissatisfaction. Participants discussed a transition from negative to positive body image following the intervention. Although acceptability was generally high, the data provides some interesting insights into potential considerations and modifications which may be advantageous in future CDIs. These include enhancing authenticity through reduced reliance on the script, inclusion of more personal content from the peer-leaders, and more interactive activities and physical movement.