Scaling up evidence-based body-image interventions for adolescents: Studies from the UK, India, and Indonesia

The field of adolescent body image research is well established and has been burgeoning since the mid-1990s. Body image concerns are prevalent among adolescents globally, and the extensive psychological and physical health consequences are widely recognised, particularly in high-income, English-speaking contexts (Cash, 2017). Encouragingly, a number of modifiable risk and protective factors have been identified and targeted interventions have shown effectiveness. The majority of these interventions are delivered by health professionals or researchers and target high-risk individuals, typically young women (Becker, Perez, et al., 2017), across Europe, Australia, and the United States (Chua et al., 2020). Reliance on expert provision, usually through face-to-face contact, makes many interventions costly, unsustainable, and inaccessible for most. As demonstrated by Kazdin and Blaze (2011), even doubling professionally delivered evidence-based interventions would still only reach a small proportion of those in need. In low- and middle-income countries, these statistics are even more concerning with even fewer health professionals available (Patel et al., 2016). As such, there is an urgent need to develop interventions that move away from the traditional health professional led model, to ensure interventions are scalable, cost-effective, and most importantly, accessible to reach those in need. The eight publications presented in this thesis seek to improve the real-world impact of evidence-based body image interventions by evaluating the impact of low-cost, scalable body image interventions. Moreover, this thesis expands the regions where body image interventions are typically developed and evaluated (namely, in Europe, Australia, and the United States) to consider the efficacy of interventions in India and Indonesia. Lastly, this thesis explores the issue of measurement when working in new cultural contexts, specifically in the development and validation of a culturally adapted body image measure for use among Indian adolescents. Together, the findings of these publications advance the field of body image scholarship in relation to task-shifting intervention delivery, adaptation and development of cultural relevant evidence-based programmes, and validation of measures in new cultural contexts. To circumvent the barrier of health professional led provision in the dissemination of body image interventions for adolescents, Publication 1 and 2 report on the evaluation of an online intervention for mothers of UK adolescent girls. The randomised controlled trial reported in Publication 1 provided support that mothers can be effective facilitators in the delivery of body image interventions for their daughters. That said, it is widely recognised that mothers’ engagement in interventions to improve the body image of their daughters is often low (Hart et al., 2015), limiting dissemination potential. Publication 2 explores mother and daughter preferences for intervention content with the view to improve uptake, engagement with, and ultimately the dissemination of, these types of interventions.Publication 3 and 4 evaluate teacher-led interventions in UK schools. Prior to these studies, school-based body image programmes had almost exclusively been evaluated when delivered by external providers. Few teacher-led interventions had been evaluated, and none reported sustained improvements in adolescent body image (Yager et al., 2013). Publication 4 is the first study to show improvements in body image among adolescents following the delivery of a teacher-led classroom-based intervention up to six-months later. As well ensuring the accessibility and scalability through task-shifting intervention delivery to teachers, these studies provide useful insights to inform task-shifting of school-based interventions across the mental health field. These insights are presented in Publication 5, which reports on the extensive acceptability data collected during Publication 3 and 4. Building upon the above studies, Publication 7 examined the acceptability and preliminary efficacy of a school-based intervention once adapted for use in a new cultural context; namely, in urban India. This publication is an important and novel development in the field. There is high demand for school-based mental health interventions in countries such as India (Ministry of Health and Family Welfare, 2014; Parikh et al., 2019), yet research efforts remain sparse. To robustly measure intervention impact in India, this project was underpinned by the adaptation and validation of the Body Esteem Scale for Adults and Adolescents among Indian adolescents (Publication 6). The final publication presented combines my learnings from the previous publications to report on the development and evaluation of a novel, social-media based intervention for Indonesian adolescent girls (Publication 8). This publication presents the protocol for a randomised controlled trial currently underway in Indonesia to evaluate a six-part series, developed in collaboration with an Indonesian creative agency, a non-profit technology focused organisation, a local research agency, and industry. This publication demonstrates my leadership skills within academia, and ability to work across multiple, multicultural stakeholders to achieve scalable evidence-based interventions for adolescents. In conclusion, this thesis brings together a body of work that explores methods for scaling up and improving the reach of body image interventions for young people. The findings suggest task-shifting intervention delivery to community members, such as schoolteachers and parents, and employing online strategies, are scalable and sustainable options to disseminate evidence-based body image interventions to adolescents. Collectively, they demonstrate the need for a multi-level approach to tackling body image concerns, in that no one intervention will suit all those in need. Further, this thesis provides evidence that culturally adapted, evidence-based interventions can be efficacious in new cultural contexts. Issues regarding the validity of body image measures when working internationally are also considered

One size does not fit all: Trajectories of body image development and their predictors in early adolescence

Background: Negative body image predicts many adverse outcomes. The current study prospectively examined patterns of body esteem development in early adolescence and identified predictors of developmental subtypes. Methods: 328 girls and 429 boys reported annually across a 4-year period (Mage at baseline = 11.14, SD = 0.35) on body esteem, appearance ideal internalization, perceived sociocultural pressures, appearance comparisons, appearance-related teasing, self-esteem, positive and negative affect, and dietary restraint. We performed latent class growth analyses to identify the most common trajectories of body esteem development and examine risk and protective factors for body image development. Results: Three developmental subgroups were identified: (a) high body esteem (39.1%); (b) moderate body esteem (46.1%); and (c) low body esteem (14.8%). Body esteem was stable within the low trajectory and there were minor fluctuations in the high and moderate trajectories. Greater appearance-related teasing, lower self-esteem, less positive affect, and higher dietary restraint predicted the low trajectory, whereas higher self-esteem and lower dietary restraint best predicted the high trajectory. Conclusions: Low body esteem appears to be largely stable from age 11 years. Prevention programming may be enhanced by incorporating components to address transdiagnostic resilience factors such as self-esteem and positive affect

Using online blogs to explore positive outcomes after burn injuries

This study uses blog analysis, a new and novel technique, to explore the positive outcomes experienced by burn survivors. This study examined 10 burn survivor blogs to offer a unique, longitudinal insight into burn survivor recovery. Using thematic analysis, three themes emerged: shift in self-perception, enhanced relationships and a change in life outlook. Many of these themes contained stories and experiences unique to a traumatic burn injury, suggesting that standardised trauma scales are not effectively measuring the impact of a burn in this population. Reflections on blog analysis are discussed, along with a recommendation that health researchers utilise the vast amount of data available from online blogs

Evaluating the ‘Dove Confident Me’ 5-session body image intervention delivered by teachers in schools: A cluster randomised controlled effectiveness trial

© 2020 Society for Adolescent Health and Medicine Purpose: Body dissatisfaction is common during adolescence and predicts poor psychological and physical health. Interventions have traditionally overrelied on delivery by external providers (e.g., researchers and psychologists), preventing scalability. This study evaluated the acceptability and effectiveness of a school-based body image intervention delivered by schoolteachers. Methods: Six British schools participated in a pragmatic cluster randomized controlled trial. Girls and boys aged 11–13 years received the five-session intervention delivered by their teachers (n = 848) or lessons-as-usual control (n = 647) and were assessed at baseline, postintervention, and 2-, 6-, 12-, 24- and 36-month follow-up. The primary outcome was body image (body esteem), secondary outcomes included risk factors for body image (internalization of appearance ideals, sociocultural pressures, social comparisons, appearance-related teasing, and conversations), and tertiary outcomes included psychosocial well-being (negative affect, self-esteem, dietary restraint, and life engagement). Results: Compared with the control group, intervention students demonstrated improvements in the primary outcome of body esteem at postintervention (Cohen's d =.15), 2-month (d =.26), and 6-month follow-up (d =.15). For girls, there was also a significant reduction in experienced appearance-related teasing at 6-month (d =.24) and 12-month (d =.30) follow-up. No other significant intervention effects were observed. The intervention was acceptable to students. Conclusions: These findings present the longest sustained improvements in a cognitive-affective body image outcome observed among girls and boys during a teacher-led universal body image program to date. Intervention refinement and improved teacher training may further improve outcomes. Task-shifting intervention delivery to community providers to scale up interventions is a promising strategy

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 South East 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, Mage = 13.59 years) completed measures of body image, disordered eating behaviors, appearance-related life engagement, desire for cosmetic surgery, appearance ideal internalization, media literacy, appearance-related teasing, and self-esteem. Younger girls (10-13 years) responses were analyzed separately to older girls (14-17 years). Over half of girls did not have high body esteem. Approximately a quarter of girls across both age groups reported restricting food intake, emotionally eating, and/or engaging in excessive exercise, and over half desired cosmetic surgery. Disordered eating behaviors and cosmetic surgery desire 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. Prospective research to investigate these findings further would be beneficial for a deeper understanding of body image risk factors for girls across Indonesia

Effectiveness of a brief school-based body image intervention 'Dove Confident Me: Single Session' when delivered by teachers and researchers: Results from a cluster randomised controlled trial

a b s t r a c t This study evaluated a 90-min single session school-based body image intervention (Dove Confident Me: Single Session), and investigated if delivery could be task-shifted to teachers. British adolescents (N ¼ 1707; 11e13 years; 50.83% girls) participated in a cluster randomised controlled trial [lessons as usual control; intervention teacher-led (TL); intervention researcher-led (RL)]. Body image, risk factors, and psychosocial and disordered eating outcomes were assessed 1-week pre-intervention, immediate post-intervention, and 4e9.5 weeks follow-up. Multilevel mixed-models showed post-intervention improvements for intervention students relative to control in body esteem (TL; girls only), negative affect (TL), dietary restraint (TL; girls only), eating disorder symptoms (TL), and life engagement (TL; RL). Awareness of sociocultural pressures increased at post-intervention (TL). Effects were small-medium in size (ds 0.19e0.76) and were not maintained at follow-up. There were no significant differences between conditions at post or follow-up on body satisfaction, appearance comparisons, teasing, appearance conversations and self-esteem. The intervention had short-term benefits for girls' body image and dietary restraint, and for eating disorder symptoms and some psychosocial outcomes among girls and boys. A multi-session version of the intervention is likely to be necessary for sustained improvements. Teachers can deliver this intervention effectively with minimal training, indicating broader scale dissemination is feasible. Trial registration: ISRCTN16782819

‘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

Evaluating the efficacy of a social media-based intervention (Warna-Warni Waktu) to improve body image among young Indonesian women: Parallel randomized controlled trial

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 (F1,1758=40.56, P<.001, partial η2=0.022) and T3 (F1,1782=54.03, P<.001, partial η2=0.03) and reduced skin shade dissatisfaction at T2 (F1,1744=8.05, P=.005, partial η2=0.005). Trait body satisfaction improvements occurred in the intervention group at T3 (F1, 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

Adaptation and validation of the Child Eating Disorder Examination Questionnaire (ChEDE-Q) for use in English among adolescents in Urban India

Eating pathology is increasingly common among Indian adolescents. However, brief validated measures of disordered eating in Indian contexts are scarce. This study adapted and validated a culturally appropriate English language version of the Child Eating Disorder Examination Questionnaire (ChEDE-Q) among 385 adolescents (mean age = 13.42 years; 47.3% girls) in urban India. Confirmatory factor analysis indicated that a two-factor eight-item solution had an acceptable fit to the data across gender: an ‘Eating Concerns and Restraint’ subscale and a ‘Weight and Shape Concerns’ subscale. Further, the questionnaire can be utilised as both a unidimensional and multidimensional tool. This allows for the computation of a total score on the primary factor of ‘Child Eating Pathology’, as well as the two subscales. Internal consistency of the ‘Weight and Shape Concerns’ subscale (α = 0.825) and ‘Eating Concerns and Restraint’ subscale (α = 0.649) was satisfactory. Concurrent validity was established through medium significant correlations with measures of body image and broader mental health. The results support the use of the ChEDE-Q for assessing disordered eating among urban Indian adolescents, thus providing the research community and practitioners with a measure to investigate the nature and scale of disordered eating among adolescents in India