Leone Dissertation Defensedraft

James E.
Leone Defense 10/29/07
PREDICTORS OF BODY IMAGE DISSATISFACTION AMONG SELECTED ADOLESCENT MALES
by James Edward Leone B.S., Bridgewater State College, 2001 M.S., Indiana State University, 2002
A Dissertation Submitted in Partial Fulfillment of the Requirements for the Doctor of Philosophy Degree
Department of Health Education in the Graduate School Southern Illinois University Carbondale
October 29, 2007
James E. Leone Defense 10/29/07
Copyright by James Edward Leone 2007 All Rights Reserved
DISSERTATION APPROVAL FORMS
AN ABSTRACT OF THE DISSERTATION OF JAMES E. LEONE, for the Doctor of Philosophy degree in HEALTH EDUCATION, presented on October 29, 2007 at Southern Illinois University Carbondale. TITLE: Predictors of body image dissatisfaction among selected adolescent males MAJOR PROFESSOR: Dr. Joyce V. Fetro The purpose of this research study was twofold: 1. to examine the phenomenon of body image satisfaction based on intrapersonal, interpersonal, and social factors identified in current empirical and theoretical literature, and 2. to identify the strongest predictive interpersonal and social factors of body image dissatisfaction among selected adolescent males. Part One included a content analysis of 293 (244 empirical and 49 theoretical) studies concerning body image. The content analysis sample was determined by related literature obtained through online database searches in behavioral, social, psychological, and medical science periodicals from years 1990 to 2005. Identification of the most frequently occurring intrapersonal, interpersonal, and social factors yielded 112 factors including 17 other factors. Following identification of the most frequently occurring and statistically significant intrapersonal, interpersonal, and social factors, an instrument (the Adolescent Body Image Satisfaction Scale (ABISS)) was developed and pilot tested to measure selected independent variables in an adolescent male population. Part Two was comprised of a sample of 330 adolescent males in grades nine through twelve from the New England region. Sample size was determined by power analyses. Twenty-eight factors (independent variables) identified from Part One were correlated to the dependent variable (adolescent male body image dissatisfaction) and was measured by the Adolescent Body Image Satisfaction Scale (ABISS).
Correlational analyses were computed to measure strengths of association between interpersonal and social factors. Stepwise and ordinal multiple regressions were used to identify the strongest predictors of adolescent male body image dissatisfaction. The strongest relationships concerning adolescent male body image dissatisfaction were having the desire for the body of another person, teasing, being more satisfied with ones body when they were younger, and having difficulty coping with criticism. Predictive models were computed using total ABISS score and body image dissatisfaction classification. Age and sports participation accounted for 6.3% of variance in the first model. That is, participants who were older and who did not participate in organized sports tended to be more dissatisfied with body image. Stepwise regressions predicted dissatisfaction by total ABISS scores, which included eight independent variables: having the desire for the body of another, having been teased, being more satisfied with the body when a person was younger, having very few friends, having difficulty coping with various forms of criticism, reporting instances of having been bullied, use of recreational drugs (e.g., alcohol or tobacco), and guardian criticism. This model accounted for 54% of model variance. A third model using an ordinal regression was computed to predict dissatisfaction by body image dissatisfaction classification. This model included all factors of the previous model with the exception of guardian criticism and accounted for 56.7% of model variance.
DEDICATION
Start by doing what is necessary, then do what is possible, and suddenly you are doing the impossible. ~Saint Francis of Assisi
The writing of this dissertation would not have been possible without the guidance from my family, friends and teachers throughout the years. Through their encouragement and at times, unrelenting support, I have develop a true sense for what defines a scholar. Therefore, this dissertation is dedicated to those who have helped me in the process of physical, emotional and spiritual growth past, present and future. Thank you!
ACKNOWLEDGMENTS
Life without thankfulness is devoid of love and passion. Hope without thankfulness is lacking in fine perception. Faith without thankfulness lacks strength and fortitude. Every virtue divorced from thankfulness is maimed and limps along the spiritual road. ~John Henry Jowett
Never did I realize how hard writing the acknowledgment sections would be until I sat down and attempted it. In such a short section of this overall magnum opus, I am troubled to think that I have to capture the kindness, direction, and generosity in a few brief paragraphs. Completing a doctoral program and dissertation is not unlike climbing Everest; you may be the only one who reaches the summit, but it is those who help you along the way that makes it a successful experience. For those who helped me along the way, you know who you are and what your help has meant to me over the past few years and throughout my lifetime: past, present, and future! To the good Lord for providing me with the spiritual belief in myself and in the greater cause. To my loving wife Logan. Without your love, continual praise and support, this would have been a futile endeavor. You taught me how to believe in Every Moment. To my parents for their gracious support of me through the years, and no the education will NEVER stop! To the teachings of the Dalai Lama and Paramhansa Yogananda for the way to the enlightened path. To Ruby for teaching me the survivor spirit, the joy of simply being there, and a sense of undying loyalty.
To my family, Jen, Sean, Samantha, Baby Mac, Jane, Alan, Kendra, and Willow for helping me to develop my sense of self, and to appreciate the diverse pleasures of life. To my SIUC friends, Barb, Teufel, Bigogno, Deb, Mark, Panton, Tony, John, Elaine, and Mike for helping me along the way, whether it be by social support or academic consultation. To my committee Drs. Fetro, Welshimer, Kittleson, Hammig, Partridge, and Robertson for all of your work and insightful comments. To my friends in Waltham for leaving me alone to do my work. Allowing me to be a weekend recluse was more helpful than you will ever know. To my good friends Kim and Doug for the discussions, statistics help, photocopying, spur of the moment trips to Hucks Now, and shared discussions on insanity. To my colleagues at Northeastern University; Kimberly, Suanne, Jamie, and Ms. Sylvia, for your help in the last minute details of the process. To my new colleagues at The George Washington University; Wayne, Bev, Amanda, Ivan, Alex, Pat, Larry, Todd, Jerry, Mirha, Debbie, and Kendra, for believing in my success through patience and good faith. To those who helped me with the sampling process; Leigh Perkins, Siri Akal Singh Khalsa, Andrea Fleming, Christina Roache, Earlene Avalon, George Alvarez, Glen Hopkins, Helen Malone, Brian Lewton, Bryan V., Dr. James, Jane McDonald, Chad Kelly, Robert Colandreo, and Maria Kuschel.
To the students and administrators who were gracious enough to allow me to pitch my gimmick. To Dr. Mark Kittleson, Dr. Mary Watson, and Jennifer Rossi for your comments and constructive criticism of my survey development and validation process. To Drs. Harrison G. Pope, Jr. and Roberto Olivardia for their assistance with conceptualizing my topic. Lastly, to all those who came before me; with your foundation. I have been truly able to stand on the shoulders of giants, Thank you!
TABLE OF CONTENTS Section Page ABSTRACT...................................................................................................................iv DEDICATION...............................................................................................................vi ACKNOWLEDGMENTS............................................................................................vii LIST OF TABLES.......................................................................................................xiii LIST OF FIGURES......................................................................................................xv LIST OF APPENDICES..............................................................................................xvi PREFACE.....................................................................................................................17 CHAPTERS CHAPTER 1 Introduction..........................................................................................19 Introduction to the study...................................................................................19 Need for the study.............................................................................................22 Significance of the study...................................................................................24 Purposes of the study........................................................................................26 Research questions............................................................................................26 Research design.................................................................................................26 Data collection..................................................................................................27 Sample selection...............................................................................................28 Data analysis.....................................................................................................28 Assumptions......................................................................................................29 Limitations........................................................................................................29 Delimitations.....................................................................................................31 Operational definitions......................................................................................31 Summary...........................................................................................................38 CHAPTER 2 Review of the literature........................................................................40 Purpose of the study..........................................................................................40 Background.......................................................................................................40 Conceptual foundations.....................................................................................40 Adolescent drug use and body image................................................................47
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Research on body image...................................................................................56 Research with men............................................................................................58 Research on boys and adolescent males............................................................61 Body image dissatisfaction and psychosocial disease models..........................63 Body image and public health concerns............................................................71 Theoretical framework......................................................................................72 Intrapersonal factors..........................................................................................73 Interpersonal factors..........................................................................................83 Social factors.....................................................................................................89 Summary.........................................................................................................100 CHAPTER 3 Methods.............................................................................................101 Part One research design.................................................................................101 Research question...........................................................................................102 Sample.............................................................................................................102 Data collection................................................................................................103 Data analysis...................................................................................................107 Part Two research design................................................................................111 Research questions..........................................................................................112 Instrument development..................................................................................113 Human Subjects Committee review................................................................116 Pilot testing.....................................................................................................117 Sample.............................................................................................................121 Data collection................................................................................................121 Data analysis...................................................................................................123 Summary.........................................................................................................126 CHAPTER 4 Results................................................................................................127 Descriptive study of body image satisfaction (Part One)................................127 Pre-testing of coding procedures.....................................................................128 Selection and description of sample................................................................129 Findings of the content analysis......................................................................133 Intra-rater and Inter-rater reliability................................................................147 Adolescent Body Image Satisfaction Scale validation and pilot study..........149 Summary of key findings in Part One.............................................................150 Correlational cross-sectional study of adolescent male body image dissatisfaction (Part Two)...............................................................................153 Description of sample.....................................................................................156 Findings from Part Two..................................................................................159 Summary of key findings in Part Two............................................................175 CHAPTER 5 Summary, Discussion, Conclusions, and Recommendations............178
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Summary of the study.....................................................................................178 Conclusions....................................................................................................182 Discussion.......................................................................................................183 Recommendations for future research............................................................203 REFERENCES............................................................................................................206 APPENDICES Appendix A SIUC Human Subjects Committee Forms & Approval......................226 Appendix B Content Analysis Categories & Guidelines.........................................228 Appendix C Contact Letters & Correspondence......................................................248 Appendix D The Adolescent Body Image Satisfaction Scale (ABISS)...................252 Appendix E Pilot Study Procedures & Forms.........................................................267 Appendix F Full Sample Procedures & Forms........................................................273 Appendix G Parental Informed Consent Forms & Minor Assent Forms................284 CURRICULUM VITA...............................................................................................289
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LIST OF TABLES TABLE PAGE
Table 1: Diagnostic Criteria for Body Dysmorphic Disorder.......................................33 Table 2: Proposed Diagnostic Criteria for Muscle Dysmorphia...................................36 Table 3: Diagnostic Criteria for Obsessive Compulsive Disorder................................37 Table 4: Diagnostic Criteria for Anorexia Nervosa......................................................79 Table 5: Diagnostic Criteria for Bulimia Nervosa........................................................79 Table 6: Diagnostic Criteria for Binge Eating Disorder...............................................80 Table 7: Data Analysis Methods for Part One and Part Two......................................125 Table 8: Database Sources of Publication Included in the Content Analysis.............131 Table 9: Academic and Professional Journals Included in the Content Analysis.......132 Table 10: Type of Journal Publication........................................................................132 Table 11: Years of Publication for Academic and Professional Journals...................133 Table 12: Operational Definitions of Body Image......................................................134 Table 13: Research Designs Used in Empirical Studies.............................................136 Table 14: Sample Size Indicated in Empirical Studies...............................................137 Table 15: Sample Composition Used in Empirical Studies........................................138 Table 16: Geographic Location of Sample Used in Empirical Studies......................140 Table 17: Instrument(s) Used to Assess Body Image.................................................141 Table 18: Statistics Used in Empirical Studies...........................................................143 Table 19: Frequencies and Percentages of Intrapersonal Factors...............................144 Table 20: Frequencies and Percentages of Interpersonal Factors...............................145 Table 21: Frequencies and Percentages of Social Factors..........................................146
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Table 22: Pilot Study Reliability Statistics and Adjustments.....................................154 Table 23: Pilot Study Item Analysis for the ABISS...................................................156 Table 24: Composition of Student Sample by Grade.................................................157 Table 25: Composition of Student Sample by Age.....................................................157 Table 26: Composition of Student Sample by Race/Ethnicity....................................158 Table 27: Composition of Student Sample by Sexual Orientation.............................159 Table 28 Descriptive Statistics for Responses to the ABISS......................................161 Table 29 Descriptive Statistics for Social and Interpersonal Independent Variables. 163 Table 30: Results from Body Image Classification Categories..................................165 Table 31: Pearson Correlations on Total ABISS with Interpersonal, Social, and Demographic Variables...............................................................................................167 Table 32: Pearson Correlations on BID Classification with Interpersonal, Social, and Demographic Variables...............................................................................................169 Table 33: Stepwise Regression on Total ABISS by Demographics...........................171 Table 34: Stepwise Regression on Total ABISS by Interpersonal and Social Variables. .....................................................................................................................................172 Table 35: Ordinal Regression on Classification Using Interpersonal and Social Variables. .....................................................................................................................................173 Table 36: Ordinal Regression on Classification Using Interpersonal and Social Variables. .....................................................................................................................................174
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LIST OF FIGURES FIGURE PAGE
Figure 1: Global Components of Body Image..............................................................41 Figure 2: Proposed Obsessive-Compulsive Spectrum Disorders and ..........................68 Their Relationship to One Another Figure 3: Etiologic Pathway to Eating Disturbances....................................................78 Figure 4: Continuum of Interpersonal Influences.........................................................88 Figure 5: Map of United States Geographic Divisions...............................................139
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LIST OF APPENDICES APPENDIX A : APPENDIX B : APPENDIX C : Southern Illinois University Carbondale Human Subjects Committee Application and Approval Forms Content Analysis Categories and Guidelines Content Analysis Data Collection Sheets Contact Letters and Correspondence Pilot Study Administrator Letter Pilot Study Cover Letter Full Sample Participant Cover Letter The Adolescent Body Image Satisfaction Scale (ABISS) Adolescent Body Image Satisfaction Scale Expert Panel Evaluation Form Pilot Study Procedures and Forms Pilot Study Instruction Script Full Sample Procedures Participant Recruitment Sheets (Phone Script) Recruitment Tally Sheets Address Tracking Recruitment Forms Survey Completion Instructions Consent Forms Parental Informed Consent Minor Assent
APPENDIX D :
APPENDIX E : APPENDIX F :
APPENDIX G :
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PREFACE Body image is a phenomenon all people experience each day they awaken. The pervasive nature of both a positive and negative body image has profound effects on quality of life. Body image research is quite expansive, yet there remains a fragmented approach in classifying what causes people to become so dissatisfied with their bodies. For centuries, man has struggled with which form governs which; the mind or the body. Today, we see and hear of clear examples of the mind-body connection and the significant impact each has on overall holistic health and well-being. Children and young adolescents are particularly vulnerable to developing negative body images. Perhaps the most notorious examples of why people, particularly adolescents, seem to be more focused than ever on how they look, is the result of social forces, namely, media influences. Media is an omnipresent and omnipotent factor in daily life. People often do not realize how extensive their daily actions are governed not by free-will, but rather, the subliminal messages fed to them each day they interact in society. Media can be viewed as positive or negative; its use is the primary determinant of this outcome. For many, media convinces them that they are simply not good enough and that they can always improve on what they have. Considering the period of adolescence inherently holds questioning of personal values and exploring new attitudes, it is not to anyones surprise adolescents are the most aggressively marketed to group in the world. The question remainsat what costs?
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Industries, such as supplement companies, thrive making people feel insecure with their bodies. Rather than celebrating the endless variations in the human form, unscrupulous companies aim at capitalizing on peoples insecurities in the name of profit. Adolescents are simply not ready from a maturational standpoint to make prudent decisions regarding what is good and what is bad. It is critical that adults understand why young adults make the decisions they do, ranging from the types of clothes they wear to what they aim to put into their developing bodies. As health educators strive to provide a comprehensive model of health starting from kindergarten and beyond, issues regarding how to deconstruct media ploys and enhancing resiliency factors to develop a strong and positive body image, remain a challenge, particularly for males. Hope exists in developing a comprehensive and predictive model of adolescent body image dissatisfaction. Fear-based approaches are minimally effective, thus, it is time to unite existing theory and empirical research, so as to promote healthier adolescent mental health states in the future. The goal of this dissertation is to provide that link and to advance body image theory in the process.
~James E. Leone
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CHAPTER 1
A sound mind in a sound body is a short but full description of a happy state in this world. ~John Locke (1632 - 1704)
INTRODUCTION TO THE STUDY Body image is an umbrella term encompassing many areas. It may be defined as, the internal, subjective representations of physical appearance and bodily experience.1, p.199 Body image also has been defined as, a multidimensional construct embedded in the larger, integrative construct of identity.2 Body image is a multidimensional phenomenon that plays a vital role in dramatically influencing quality of life.3,4 Developing throughout the lifecycle, body image is greatly impacted during adolescence.5 As people grow and develop in a physiological sense, so too does selfperception. Personal identity is fashioned during this time, which makes adolescents vulnerable to the reactions of others as they strive to define who they are.1,6 Several factors influence adolescent development including: biology, sociocultural influences, and the physical environment. The dynamic relationship among these and other variables provides lasting effects on adolescent body image as youth progress to adulthood and beyond.7 Idealized images of male and female physiques are presented in the media every day. Images, portrayed in magazines, television advertisements and billboards, television shows and movies, and music videos have a strong impact on how adolescents relate to their physical and psychosocial environments.8-11A variety of maladaptive behaviors have been associated with disturbances in body image.12,13 Psychological distress (e.g., low 19
self-esteem and poor body image) predisposes adolescents to chronic depression, disordered eating, substance use and abuse, and several affective (i.e., emotional) spectrum and somatic (i.e., body) disorders.3,7 A sense of need to conform to socially idealized standards of beauty often drives adolescents to alter their physical appearance through a variety of means, some with long-term consequences.14,15 Behaviors, such as excessive supplement use, cosmetic surgery (e.g., breast augmentation, liposuction), use of body image drugs (e.g., androgenic-anabolic steroids, ephedrine), and unhealthful dieting practices carry with them a life-time of psychological and physiological sequelae.1,10 Those who resist sociocultural influences may find themselves isolated from peer groups, which may result in feelings of estrangement and adolescent alienation.16 Although it is a common phenomenon for adolescents to associate with peer groups of similar interests and norms, it has become an increasing trend for negative health behaviors, such as tobacco use and promiscuous sexual practices, to impact all involved in peer groups.17 Waugh and Bulik18 and Presnell, Bearman and Stice19 noted the influence of group dynamics on female adolescent peer groups and eating disorder prevalence and practices, and how these trends contribute to similar issues in their offspring. Similarly, Pope and colleagues10,20,21 noted trends in adolescent male peer groups and prevalence of androgenic-anabolic steroid (AAS) use and other body morphing (i.e., changing) substances. Boys have continued to be an understudied group when compared with research concerning girls, particularly in the realm of eating disorders and body image dissatisfaction.10,22-26 Trend analysis as to what predisposes adolescents to body image disturbances that may precede negative health practices have eluded researchers. Specific personality attributes, such as self-esteem and confidence,
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have been postulated to influence body image.27 Specific environmental influences on body image (e.g., geographical location or urban/rural) and circumstances in which adolescents live have yet to be addressed in the literature. Changes in adolescent social groups may play a stronger role in the development of a negative body image than once thought. Group interactions once considered normative, such as social gatherings and group activities, have notably declined over the past thirty years.28,29 Robert Putnam, author of Bowling Alone, noted participation in activities, such as Four H, Girls Scouts, Boy Scouts, and several other adolescent activities has markedly declined.30 Greater emphases on impersonal communication, such as cellular telephones, electronic mail, and instant messaging have further isolated the adolescent. Electronic media, such as the Internet, have provided unprecedented gateways to sociocultural influences.31,32 This latter point illustrates social isolation, which has been postulated to play a role in negative body affect.3 Researchers have identified several intrapersonal predisposing factors (e.g., selfesteem, internalization of teasing) affecting body image dissatisfaction and subsequent negative health behaviors (e.g., drug use, early onset of sexual activity). A holistic model, however, appears to be lacking.19 Many independent risk factors have been presented and discussed in the literature; however, the strength of relationships and associations among these factors has yet to be established. Factors, such as resiliency, have been identified as protective factors, yet again, how resiliency relates to other variables is unknown at present. Therefore, it is critical that health educators and other professionals identify intrapersonal, interpersonal, and social factors that place boys and adolescent males at
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risk for body image dissatisfaction as well as factors that offset risks and serve as protective factors.15
Need for the Study Body image is a multidimensional phenomenon (e.g., interpersonal, intrapersonal, social factors), which plays a vital role in influencing quality of life.3,4 Many research studies7,13,15,27 have attempted to elucidate predictive factors of dissatisfaction with body image in groups ranging from children to older adults. Measuring body image dissatisfaction presents a particular challenge due to its changing constructs and associated meanings throughout various stages of life.3 For example, how a person views him/herself as an adolescent (e.g., body weight, facial features) is markedly different than that of an elderly person (e.g., health status, quality of life).14,15 Many constructs have been studied in detail as they relate to body image dissatisfaction including; gender,4,10,29,33-35 developmental influences (e.g., psychoneuroendocrinology),29,36-39 family influences (e.g., number of siblings and parental connectedness),40-46 interpersonal influences (e.g., friends and peer groups),47-49 cultural and ethnic determinants,50-54 social norms of women (e.g., expecting to behave a certain way based on gender),55,56 and physical attributes.3,57-59 Specifically, males have only recently become a particular interest in the research. Studies clearly are skewed toward females when body image is the topic of study.10,22-26 Dissatisfaction with body image has been linked to higher incidence of chronic depression, disordered eating and eating disorders, lower self-esteem and confidence.60,61
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Other research has explored the association between negative body affect and unhealthy behaviors and decisions (e.g., substance use, multiple sexual partners).62,63 Intrapersonal factors, such as self-esteem, self-efficacy, and body competence can have a profound impact on a persons body image perception.64 This latter point is particularly true during adolescence. Having a valid and reliable measure predictive of dissatisfaction with intrapersonal factors (i.e., body image) is needed.3 Various interpersonal factors, such as parental criticism, peer and sibling teasing, as well as bullying have been shown to strongly correlate with body image dissatisfaction in both males and females.65 Lack of father-son connectedness also may predict a negative body affect in adolescent males.66 Adolescent male body image has not received the same attention as female body image concerns as with anorexia nervosa and bulimia nervosa. Pope and colleagues10 have called for a time when the other 50% of the population receives equal concern for an important topic, such as body image dissatisfaction due to the propensity for affecting overall quality of life. Social factors mediating body image dissatisfaction have been identified in the literature.9 Examples of social factors influencing adolescent male body image include: television programming and advertisements,9 magazines geared toward male fitness models,67 and unrealistic marketing ploys to convince boys and adolescent males that they are not good enough.10 Social factors combined with interpersonal factors may heavily contribute to intrapersonal dissatisfaction with ones body and his image of it. Therefore, a need exists in terms of how to best isolate contributing interpersonal and social factors affecting negative adolescent male body image, so as to develop specific curriculum and programming to protect developing adolescent male body image.
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Ultimately, the focus of this research was aimed at identifying and working with intrapersonal, interpersonal, and social factors that are modifiable through programming for boys and adolescent males. Resiliency training will hopefully address the myriad of negative affects resulting from intrapersonal dissatisfaction with ones body image. Existing research studies have attempted to identify one or more influencing factors related to body image dissatisfaction. Predictive models have been developed looking at a limited number of variables, such as teasing, gender, and self-esteem.7,27 While it is important to understand what predisposes adolescents to body image dissatisfaction, based on an extensive review of related literature, the interaction of intrapersonal, interpersonal, and social factors in a holistic model has yet to be explored. Greater efforts need to be undertaken to link empirical and theoretical literature within an integrated and holistic body image dissatisfaction theory with adolescent males.10,22-26 An appropriate predictive measure is warranted. Emphasis in this study focused on intrapersonal, interpersonal, and social factors associated with adolescent male body image dissatisfaction. Before acting on a particular issue (i.e., body image dissatisfaction), a thorough understanding of the phenomenon should be initiated so as to prevent misguided interventions and unnecessary planning.68 Understanding what factors precipitate adolescent males to become estranged with a healthy body image and act on negative health behaviors, such as body image drug use, was the impetus for this studys approach. Significance of the Study Robert Blum described some unprecedented challenges facing young people at the start of the 21st century: they are the first generation to grow up in a world
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characterized by instantaneous global communication and the threat of both AIDS and the widespread use of terrorism as a political weapon. They will be the first generation to fully compete in a global economy and the first generation of whom the majority will spend at least part of childhood in a single-parent household.69, p.43 Professionals working with young people in this fast-changing environment need a clear understanding of the processes of adolescence. Models for understanding this phase of life, however, are rapidly changing in ways that significantly can influence practice, such as the advent of newer technology and instant communication devices (e.g., text messaging). Body image is a phenomenon affecting everyone (positively and negatively) from birth until death, but is particularly impressionable in adolescence.1,3 Recognizing that significant changes are occurring in social contexts in which adolescents live, there is a need to identify significant influences on critical developmental aspects of body image.70 Preventing negative affect associated with body image dissatisfaction and related social comorbidities (e.g., substance use, unsafe health practices) can have a significant impact on improving adolescent health. Validating association among variables can help satisfy the need for accurate predicting of body image dissatisfaction and related disorders, avoiding unnecessary interventions, furthering understanding of individual predictor variables, and enhancing networking among health educators, parents, and other professionals who interact with adolescent populations.16,71 Health educators are ideally positioned to address many of these aforementioned issues. Being that health education is one of the most borrowing of health care professions,68 influence may be exercised in a multitude of areas as with adolescent health and body image. As health care providers, health educators provide services
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ranging from mental and school health to social work and counseling.68 Pooling knowledge and theoretical applications from the behavioral sciences can be effectively used to influence positive body images, particularly in traditionally under-served groups, such as adolescent males.10,38,65 The day where issues once thought to affect mostly girls has come full circle affecting boys on an equal to near-equal basis.10 Purpose of the Study The purpose of this research study was twofold: 1. to examine the phenomenon of body image satisfaction based on intrapersonal, interpersonal, and social factors identified in current empirical and theoretical literature, and 2. to identify the strongest predictive interpersonal and social factors of body image dissatisfaction among selected adolescent males. Research Questions Research questions addressed in this study were: 1. What are intrapersonal, interpersonal, and social factors associated with body image dissatisfaction based on a systematic review of existing theoretical and empirical literature? 2. Which interpersonal and social factors are the strongest predictors of body image dissatisfaction among selected adolescent males? Research Design This study contained a descriptive component in Part One as well as a correlational cross-sectional design in Part Two. Through a systematic review of existing theoretical and empirical literature, Part One examined frequencies of intrapersonal,
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interpersonal, and social factors as they relate to body image dissatisfaction. Frequency of occurrence of each factor determined significance and inclusion in the survey. Part Two used a cross-sectional correlational design. Correlational analysis and multiple regression were used to determine the strength(s) of association among factors and the strongest predictors of adolescent male body image dissatisfaction. A valid and reliable survey, the Adolescent Body Image Satisfaction Scale (ABISS) was developed from the content analysis in Part One as well as from existing instruments measuring body image satisfaction. The ABISS measures significant intrapersonal factors relating to adolescent male body image dissatisfaction. Additional items were included to measure contributing interpersonal and social factors based on the content analysis. Data Collection Part One of the research used content analysis to examine existing literature on body image dissatisfaction. Use of the term dissatisfaction represents a general range on the continuum of body image satisfaction; therefore, studies using body satisfaction criteria were included in the content analysis. Data collection forms were developed to assure accurate and organized documentation of the analysis of empirical studies as well as theoretical literature (see Appendix B). Part Two used the Adolescent Body Image Satisfaction Scale (ABISS) to determine intrapersonal feelings of body image dissatisfaction among selected male adolescents in grades 9-12. The ABISS is a 32-item survey that was developed from review of the literature and previously well-established instruments3,72 on body image satisfaction and dissatisfaction. Additionally, relevant interpersonal, social, and demographic factors identified via the content analysis from
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Part One were included as survey items to identify correlations and predictors of body image dissatisfaction. Sample Selection Related literature for Part One was obtained through comprehensive online database searches in health behavior (Health Source Nursing/Academic Edition, ERIC), social science (SocINDEX), psychology (PsychINFO), and medical science periodicals (CINAHL, MEDLINE, Nursing and Allied Health Collection, SPORTDiscus, PubMed) from years 1990-2005. Part Two was comprised of selected adolescent males in grades nine through twelve from the New England region. Student sample size was determined by power analyses. Data Analysis For Part One, data were systematically collected and coded from existing empirical and theoretical studies identified from professional research databases. Frequencies were calculated for each coded category (see Appendix B). Groupings of possible intrapersonal, interpersonal, and social factors were summarized and discussed. Items measuring relevant and significant intrapersonal factors were included in the ABISS to measure adolescent male body image dissatisfaction. Additional interpersonal and social factors were added as survey items to measure correlations and predictors of adolescent male body image dissatisfaction. Part Two used correlational analysis to determine associations among variables under study. Multiple regression was used to determine predictive factors of adolescent male body image dissatisfaction.
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Assumptions The following assumptions were made concerning this study: 1. Resources were adequate to perform a thorough content analysis of empirical and theoretical studies. 2. Intrapersonal, interpersonal, and social factors were identifiable in the literature. 3. Selected identified factors/variables were accurately measured in an adolescent sample. 4. The adolescent sample was honest when answering survey items in the Adolescent Body Image Satisfaction Scale (ABISS). 5. Adolescent participants voluntarily participated in this study. 6. The Adolescent Body Image Satisfaction Scale (ABISS) accurately measured adolescent male body image dissatisfaction and its relevant constructs. 7. Readability of the Adolescent Body Image Satisfaction Scale (ABISS) was age/grade-appropriate and understood by participants. 8. Factors identified in previous literature pertinent to body image dissatisfaction were identified and reported accurately. Limitations Factors beyond control are inherent in all research designs. According to Isaac and Michael,73 these limitations beyond the control of the researchers may impact the studys internal and external validity. In this study, the following were taken into account when interpreting the results:
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1. Content analysis will merely identify frequency of appearance of factors in the literature. 2. All intrapersonal, interpersonal, and social factors may not be identified through content analysis due to the use of a pre-determined limited number (9) of academic databases. 3. A limited number of empirical and theoretical studies with sophisticated designs will be available to use in this research including unpublished works. 4. Some variables identified in Part Ones content analysis may not be measurable through quantitative methods. 5. Certain variables identified in the content analysis may not be appropriate for an adolescent sample. 6. Results may not be representative of all adolescent males. 7. Adolescents not receiving positive parental/guardian consent to participate will be excluded from the study. 8. Timing of survey administration may play a role in the accuracy and comparability of the adolescent sample (e.g., days of inclement weather or time of day). 9. Sensitive items in the survey may not fully measure the concept of body image due to each persons varied experiences and perceptions. 10. Forms of response bias may be unavoidable due to the potentially sensitive nature of the questions (i.e., socially desirable answers).
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Delimitations Delimitations are specific criteria established at the beginning of a study to define limits and narrow the scope applicable for use with a particular population and describe which generalizations may be made.73 Delimitations are those factors which make a research study workable.74 In this study, the following delimitations included: 1. Studies included in the content analysis were written in the English language. 2. Research on body image is relatively new; therefore, only documents from 1990 to 2005 were included in the content analysis. 3. Although there are many sources for identifying factors related to body image, the content analysis was performed with only selective available resources (e.g., online databases and published hard copy articles and manuscripts) available through SIUCs Morris Library system and interlibrary loan services. 4. All adolescent participants were in grades 9-12 at the time of the survey administration. 5. Data were gathered from the New England region. 6. Participation included individuals who were able to understand the instrument items. 7. The survey was administered one time only. Operational Definitions The following definitions were used in this study: Adolescence: the period of transition in which an individual changes from a child to an adult.75, p.408-409 Both biological and physiological changes occur as an individual
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becomes an adult. Other factors include a period of transition where increased peer relations, social responsibility, sexual maturity and other sociocultural components mark when one has grown up.75 For purposes of this study, the term adolescent referred to individuals in grades 9 through 12. Body Image: An umbrella term for a large number of concepts as they relate to the human perception of the body.1 Body image consists of the internal, subjective representations of physical appearance and bodily experience.3, p.7 It has also been classically defined as the picture of our own body which we form in our mind; that is to say, the way in which the body appears to ourselves.3, p.7 Simply, body image is our internal self-portrait.6 In this research, body image included all constructs related to how a person feel about and perceives themselves as influenced by social, interpersonal, and intrapersonal relationships. a. Body Esteem: A measure of overall body image often referred to as appearance esteem; it includes specific components, such as facial features, hair, and general appearance as well as ideal image perception.29 b. Body Attitude: A general affective attribute of ones body status.76 c. Body Awareness: Attentional amplification of somatosensory signals. Often part of autonomic influences, body awareness occurs when automatic processes cease and direction shifts to perceptual awareness. This phenomenon is very distinct in infants and gradually disengages as the mind and body integrate into one unit as individuals become adults.77 d. Body Shame: A feeling of self-worthlessness when comparing the self to others or other sociocultural norms. Shame regarding the body results when
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normative expectations of the self are not met by the individual.78 e. Body Surveillance: Watching oneself as though one were the observer. The act of surveying ones body is associated with control more so than for self-love or appreciative purposes.79 Body Dysmorphic Disorder (BDD): A preoccupation with an idea that some aspect of appearance is unattractive, deformed, or not right in some way, when in reality the perceived flaw is minimal or non-existent.1, p.3 Ranging in severity, BDD is categorized as a somatoform disorder which also satisfies criteria for delusional disorder.80 (see Table 1) Table 1. Diagnostic Criteria for Body Dysmorphic Disorder A. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the persons concern is markedly excessive. B. The preoccupation causes clinically significant distress or impairment in social, occupational or other important areas of functioning. C. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa).
(Adapted from the DSM-IV TR, American Psychiatric Association, 2000)
Body Image Disturbance: A feeling of unacceptable body features. Normative components (i.e., attitudes) are skewed negatively resulting in sensory and perceptual distortions.81 Body Image Dissatisfaction: A negative affective response to ones perception of physical appearance. Factors attributable to dissatisfaction are culturally, developmentally, familial, and personality based.1,82 Body Image Drugs: Categories of drugs used to gain muscle, lose fat, or otherwise improve body appearance or athletic performance. Sometimes called ergogenic aids,
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they are equally termed body image drugs because many individuals take them to improve personal appearance rather than to improve performance in sport. Examples include: androgenic-anabolic steroids, hormones, - agonists, stimulants, drugs used to purge fluid or calories, and anticatabolic agents.21 Body Mass Index (BMI): A calculation using height and weight to measure ones level of fatness. It is agreed that BMI has utility for large-scale research applications; however, it is less useful when measuring one specific individual at one given time. The accepted international standards in the United States and the World Health Organization (WHO) are the following; <18.5 = under-weight, 18.5 24.9 = healthy weight, 25-29.9 = overweight, and >30 = obese. BMI may be calculated dividing a persons weight in kilograms by height in meters squared.83 Content Analysis: A research technique for making replicable and valid inferences from data to their context. Methodology is detail-oriented, but unlike strictly qualitative designs, content analysis has external validity as a goal.84 Correlational Designs: Research in which an attempt is made to discover or clarify relationships through the use of correlation coefficients.85 Delusional Disorder: Non-bizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by spouse or lover, or having a disease) of at least 1 month's duration. The disorder includes delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior.80 Ergogenic Aids: Nutritional products or drugs, that are additive to a persons performance or appearance.10
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Ethnicity: Having many meanings, ethnicity can be studied as nationalities, cultures, or linguistic groupings. Sometimes, it is a religiously-based cultural form or all groups that have some sense of common history and common fate, recognizing the common history may be at least in part mythical.86 Internalization: A progressive process whereby interactions between the person and the outer world are replaced by inner representations of the self and body.45,87 Interpersonal Factors: Social interchanges occurring between or among people. Factors may include communication, criticism, teasing, and bullying among others.68 Intrapersonal Factors: Thoughts, beliefs, and values held true by the individual concerning oneself in relation to society. For example, ability to perform a task would characterize the intrapersonal belief of self-efficacy. Related to body image, how a person conceives his physical attractiveness would be another example.10,68 Multiple Regression: A statistical method used for predicting a criterion. Two of more variables are used to achieve this outcome. The general purpose of multiple regression (the term was first used by Pearson, 1908) is to learn more about the relationship between several independent or predictor variables and a dependent or criterion variable.88 Muscle Dysmorphia: A subtype of Body Dysmorphic Disorder, characterized by a preoccupation with body build or musculature.10 Originally proposed as a somatoform disorder in 1993 by Pope and colleagues,89 muscle dysmorphia has recently been redefined as part of the spectrum psychological disorders stemming from Obsessive Compulsive Disorder.90 (see Table 2)
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Table 2. Proposed Diagnostic Criteria for Muscle Dysmorphia A. Preoccupation with the idea that ones body is not sufficiently lean and muscular. Characteristic associated behaviors include long hours of lifting weights and excessive attention to diet. _______________________________________________________________________ _ B. The preoccupation is manifested by at least two of the following four criteria: 1. The individual frequently gives up important, social, occupational or recreational activities because of a compulsive need to maintain his or her workout and diet schedule. 2. The individual avoids situations where his or her body is exposed to others, or endures such situations only with marked distress or intense anxiety. 3. The preoccupation about the inadequacy of body size or musculature causes clinically significant distress or impairment in social, occupational or other important areas of functioning. 4. The individual continues to workout, diet, or use ergogenic (performanceenhancing) substances despite knowledge of adverse physical or psychological consequences. _______________________________________________________________________ _ C. The primary focus of the preoccupation and behaviors is on being too small or inadequately muscular, as distinguished from fear of being fat as in Anorexia Nervosa or primary preoccupation only with other aspects of appearance as in other forms of Body Dysmorphic Disorder.
(Adapted from The Adonis Complex: The secret crisis of male body obsession by Pope, Phillips and Olivardia, 2000. Note: These are proposed diagnostic criteria and not formally recognized in the DSM IV -TR)
Normative Discontent: The pervasive negative feelings that girls and women experience toward their bodies as part of Western cultural ideals.91 Obsessive Compulsive Disorder (OCD): A psychological spectrum disorder in which people develop obsessions (recurrent thoughts that do not resolve) and compulsions (unresolved repetitive behaviors).10,80 (see Table 3)
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Table 3. Diagnostic Criteria for Obsessive Compulsive Disorder A. Either Obsessions or compulsions: Obsessions as defined by (1), (2), (3), and (4): 2. recurrent and persistent thoughts, impulses or images that are experienced at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress 3. the thoughts, impulses or images are not simply excessive worries about reallife problems 4. the person attempts to ignore or suppress such thoughts, impulses or images, or to neutralize them with some other thought or action 5. the person recognizes that the obsessive thoughts, impulses or images are a product of his or her own mind (not imposed from without as in thought insertion) Compulsions as defined by (1) and (2): 1. repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly 2. the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children. C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the persons normal routine, occupational (or academic) functioning, or usual social activities or relationships. D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an Eating Disorder; hair pulling in the presence of Trichotillomania; concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder). E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
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Health-Related Quality of Life (HRQoL): The concept of health-related quality of life refers to a person or group's perceived physical and mental health over time.92 Self-Esteem: A feeling of pride in oneself as it relates to global image as well as the congruence with a desired image of oneself.93 Self-Schema: Cognitive generalizations about the self, derived from past experience, which organize and guide the processing of self-related information contained in an individuals social experience.94 Social Factors: External influences impacting ones behaviors or belief systems. For example, attractive body ideals in various media can negatively affect ones body image. Other examples include: television, advertisements, magazines, and tailored messages.65,68 Somatoform Disorder: Physical symptoms that seem as if they are part of a general medical condition, however no general medical condition, other mental disorder, or substance is present. Psychological conflicts may becoming translated into physical problems or complaints.1,80 Summary This chapter has presented an overview of a study to identify and test predictive factors of body image dissatisfaction among selected adolescent males. A valid and reliable survey based on empirical and theoretical research was developed. Intrapersonal, interpersonal, and social factors were used to predict adolescent male body image dissatisfaction. Additionally, this study sought to examine what are the strongest predictors of adolescent male body image dissatisfaction.
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A non-experimental, descriptive research design as well as a correlational crosssectional design was employed using content analysis, multiple regression, and correlational statistical analysis. The Adolescent Body Image Satisfaction Scale (ABISS) was created from existing instruments and literature pertaining to body image as well as intrapersonal factors identified in Part Ones content analysis. The ABISS allowed for measurement of variables and constructs identified in Part One. Survey validity and reliability were established through a pilot test. Chapter Two provides a comprehensive review of the related literature to body image, body image satisfaction and its constructs, and relevant discussion of intrapersonal, interpersonal, and social factors. Chapter Three details the research design, instrument design and development, and data analysis.
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CHAPTER 2 REVIEW OF THE LITERATURE

I keep six honest serving men, (they taught me all I knew). Their names are what, why and when and how and where and who. ~Rudyard Kipling (1865-1936)
Purpose of Study The purpose of this research study was twofold: 1. to examine the phenomenon of body image satisfaction based on intrapersonal, interpersonal, and social factors identified in current empirical and theoretical literature, and 2. to identify the strongest predictive interpersonal and social factors of body image dissatisfaction among selected adolescent males. Review of the literature is comprised of three major sections: 1. Background of Body Image, 2. Research on Body Image, and 3. Theoretical Framework. Background of Body Image The term body image carries with it several connotations, denotations, and practical definitions. An internet search for body image resulted in 301,000,000 hits (July 26, 2006). The following section discusses the formal term body image and other related terms and concepts as to the background of body image. Conceptual Foundations Body image may be defined as, the internal, subjective representations of physical appearance and bodily experience.1, p.199 Body image also has been defined as, a multidimensional construct embedded in the larger, integrative construct of identity.2 Being something all individuals experience, body image is a complex and elusive construct.1 Body image is also a multidimensional phenomenon which plays a
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vital role in dramatically influencing quality of life.3,4 Many researchers have attempted to formalize a definition due to an ever-growing body of literature of both epistemological as well as sociologic evidence; however, capturing this human phenomenon is difficult. Overall, body image may be considered an umbrella term for many concepts and constructs.1 When viewed by its parts, body represents the somatic component of ones physical self, whereas image is best defined as a perceptual phenomenon based on views of oneself and the reactions of others.93 As people grow and develop in a physiological sense, so too does their perception of themselves. Reactions of others help to define who one is in a perceptual sense and, ultimately, allows for development of an internal portrait of the self.1,6 Rooted in cognitive, emotional, behavioral, and perceptual dimensions, body image is a core aspect of identity.1,3 Figure 1 depicts a broad scheme of global components of body image. Body schema is the conceptualization of ones body and its processes, whereas body ego is how one feels about his/her body and feeds into the self-concept or what one believes to be true of their physical self.3,6 A combination of three factors helps define the body image in a broad sense. _______________________________________________________________________ _ Body Schema
Body Ego Self-Concept (Self-esteem) _______________________________________________________________________ _
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Figure 1. Global components of body image Evolution of Body Image Body image has been studied by foremost psychological researchers, such as Schilder, Freud, Head, and Fisher.1,3 Due to the multifaceted nature of body image, several disciplines have contributed to the body of knowledge, including neurology, psychology, sociology, philosophy, and psychoanalysis.1 In addition to these primary fields of scientific inquiry, new domains have been formed to better study and further an understanding of body image, such as psychoneurobiology.3 Much early research included distinguishing the self from the non-self (e.g., the physical environment from psychological processes),77 how neglect impacts development,95 and abnormal body image experiences, such as phantom limb pain.96 The concept of studying body image began around the turn of the 20th century to better understand how it [body image] could impact a persons quality of life.3 Early studies of body image emphasized body schema whereby bodily movements, such as posture, were guided by a central neural mechanism.97 Paul Schilder advanced the study of body image solely as a neuropathological model to an integrated biopsychosocial model.3 Fisher and Cleveland98 published works in the 1950s and 1960s about psychodynamic aspects of body image; that is, how its constructs interact with the self and the environment, ultimately impacting behavior. Similarly, during this time, behavioral theorist Albert Bandura began synthesizing his work on Social Learning Theory (later to become Social Cognitive Theory). This dynamic interaction between the person, the environment, and resultant behaviors came to be called reciprocal determinism of the triadic relationship.68 A popular model of barrier and
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penetration gained credence during this period. The theory stated body image may be protected or damaged based on specific barriers contrived by the individual either on a conscious or subconscious level. Environmental factors (e.g., media) are able to function reciprocally with the individual either penetrating or being redirected.98 Sociocultural factors as with Tom Wolfes satire on the developing Me philosophy became prevalent in the 1960s. People were encouraged to get in touch with themselves leading to, the new alchemical dream [of] remaking, remodeling, elevating and polishing ones very Self, and observing, studying, and doting onMe! Later, in the 1970s, an explosion of body awareness became apparent with adult magazines, provocative styles of dress, and an emerging pornography industry.99, p.79 In opposition to the work of Fisher in the 1950s, Shontz100 argued for a reintegration of the body into body image research. Shontz remarked, the shift from neurological to psychodynamic conceptions has removed body from body image.100, p.37 This movement led to a greater research emphasis on the physiologic processes that govern bodily experiences, including somatic and neurological components. Much of this paradigm shift led to research in the areas of physical disability and neurological and psychiatric consequences. The 1990s ushered-in a strong emphasis on clinical manifestations of body image disturbances, such as anorexia nervosa and similar eating disorder patterns. Assessment and treatment became a prime area of research.3 Work in cognitive-behavioral therapy began to show results with clinical populations affected by body image disturbances.82 Simply stated, the 1990s produced a profound knowledge of cognitive, psychometric, and psychotherapeutic developments.3 The establishment of a multidisciplinary approach in
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treating body image disturbances has led to both a systematic means of studying it, but also fragmenting its core elements into many scientific fields of study.101 Healthy People 2010 and Body Image Initiated in 1979 by the United States Surgeon General, Healthy People set health objectives for the nation encompassing one decade to meet or exceed its goals and objectives. Healthy People 2010 (HP 2010) has established two overarching goals which are; 1. to increase quality and years of healthy life and, 2. to eliminate health disparities. In addition to these two goals, HP 2010 has set ten Leading Health Indicators (LHI) Items as they relate to body image including: overweight and obesity, substance abuse, and mental health.102 Each LHI is used to measure the status of the Nations health until the year 2010. Specific process goals are included in each of these broad categories. Each health indicator was selected on the basis to motivate action, ability to collect measurement data, and their importance as public health issues.102 In the context of HP 2010, this research study focused on LHI #4 (Substance Abuse) and LHI #6 (Mental Health). Although, it may be argued that body image (e.g., a persons global self-esteem) encompasses all ten LHIs in HP 2010. Mental Health. The state of a persons mental health strongly guides the health behaviors they choose.80 A strong sense of self and identity is often predictive of healthy life choices.68 Conversely, a weakness in the integrity of a persons self-esteem and body image often leads to poor lifestyle choices negatively impacting health.3 Adolescent mental health is a critical area to explore due to the propensity for behaviors developed during this phase of life to carry-on throughout the lifespan.2 Models allowing for a
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greater depth of understanding of what impacts and leads to negative health behaviors (e.g., sexual promiscuity and drug use), are needed to appropriately design and implement prevention measures in curricula. Feelings of dissatisfaction with ones body due to weight, shape, or other physical features is particularly concerning during a volatile period as with adolescence,1 but has also been noted in pre-adolescent populations.103 Capitalizing on positive mental health of adolescents in a comprehensive and holistic model has yet to be devised and implemented. A paucity in the scientific literature exists exploring this latter concept. Substance Abuse. HP 2010 aims to decrease the incidence of substance abuse in all populations.104 Substance use between the ages of 13-21 appears to be most predictive of lifetime abuse of drugs.103 Similarly, each year of delayed use resulted in a predictive model of 4 % to 5 % less of a likelihood of using drugs.105 Oftentimes, initiatives focus on illicit drugs, such as marijuana, cocaine, heroin, and methamphetamine while ignoring over-the-counter drug use.21 Products sold without a prescription may be equally as dangerous and abused as prescription drugs. A meta-analysis of ergogenic supplement use found that sports supplements and over-the-counter drugs are more commonly abused (i.e., taken in excess of the recommended dosage) when compared to prescription and controlled drugs.105 Another study106 found the co-occurrence of poly-drug use with body image drugs (i.e., androgenic-anabolic steroids). Nalbuphine hydrochloride, a nonscheduled opioid agonist/antagonist analgesic was found to be commonly used and abused by AAS users. Dependence created by a drug, such as Nalbuphine, suggests a gateway mechanism to drug abuse rooted in body image drug use.106 This latter point is interesting; however, there remains unsubstantiated conclusive data.
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This silent epidemic may lead to more health consequences and hospitalizations than known due to secrecy of use and lack of federal regulations governing ergogenic aids.21,106 Prevalence and trend data of sports supplements, ergogenic aids and performance-enhancers, and body image drugs usage is warranted.21 Adolescents participating in high school athletics reportedly use AAS and other body image drugs (e.g., amphetamines, hGH) less often than non-athletes.107 Trends suggest the possibility of physical appearance taking greater precedence in an adolescents life than focus on ones sport. Put in perspective with overall substance abuse models, the widespread use and availability of these categories of drugs and products necessitates formulation of clear models of usage patterns and predictive factors leading to use (e.g., body image dissatisfaction). Future Directions Relating to body image, there is general agreement by most disciplines that future directions for research and systematic evaluation is housed within three core areas; 1. body image plays an integral role in understanding the human experience, 2. body image is a complex human construct, and 3. there is a dearth of empirical and theoretical integration within and across disciplines.3 Body image effects emotions, thoughts, and behaviors of everyday life thereby affecting quality of life. Fisher108, p.18 asserts, Human identity cannot be separated from its somatic headquarters in the world. As body image research progresses, so does the vast array of terminology to describe it. Terms, such as body esteem, body satisfaction, and body perception have led to a common vernacular usage of the term body images.101 Fisher contended that there is no one body image, but only an umbrella term to conceptualize the complexity of what it represents.108 Therefore,
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the term body images attempts to integrate the multilevel phenomenon experienced by all.101 For purposes of this research, the common term of body image was used. Adolescent Drug Use and Body Image
Reality is a crutch for people who cannot cope with drugs ~Lily Tomlin
It has been said that drugs are a symptom of something greater. This section explores drug use among adolescents. While drug use encompasses both licit and illicit products, the majority of literature as it pertains to this research study focuses on body image drugs, which vary in legal permissibility. Drugs and Societal Costs Drug use has been a concern in nearly every culture at any given point in time. Body image drug use presents a unique problem. In the United States, President Richard Nixon initiated the War on Drugs campaign (1971), which has carried-over from one presidential term to another. President Nixon termed illicit drug use as, Americas public enemy number one.109 In response to this drug epidemic, the Office of National Drug Control Policy (ONDCP) was created during the Reagan administration in 1988. A national drug czar was appointed to direct this organization.109 Although body image drugs do not fall into the traditional model of drugs of abuse, there remains a social impact as well as a personal one. Thirty-one percent of hospital visits involving minors (age 13-18) involve some form of drug.109 Without having exact data available, it is difficult to determine what percentage of accidents, violent episodes, and health-related issues result from body image drugs alone. In a 1996 retrospective study by Pope et al,110 133 prisoners were interviewed to establish the nature
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and pathology of their crime warranting incarceration. It was concluded that steroid use played a significant role in violent crime and criminal behavior as suggested by this sample. Other drugs, such as amphetamines (meth), MDMA (X or ecstasy), caffeine, and ephedrine, also may prompt bouts of mania in some individuals.21,71,106 As one law enforcement and forensic investigator put it, we can attempt to enforce drivers under the influence of alcohol and similar drugs, the question becomes how do we enforce the law when a person has roid rage in a domestic dispute?110, p.265 Youth Risk Behavior Surveillance The Youth Risk Behavior Surveillance Survey (YRBSS) was initiated in 1990 as part of national effort to track health risk behaviors that markedly contribute to the leading causes of death, disability, and social problems among youth and adolescents in the United States. The system tracks the following areas as they relate to adolescents: tobacco use, unhealthy dietary behaviors, inadequate physical activity, alcohol and other drug use, sexual behaviors contributing to HIV/AIDS and other sexually transmitted infections, and behaviors that lead to unintentional injuries.111 Overall, intent of the YRBSS serves to: determine the prevalence of health risk behaviors, assess whether health risk behaviors increase, decrease, or stay the same over time, examine the co-occurrence of health risk behaviors, provide comparable national, state, and local data, provide comparable data among subpopulations of youth, and monitor progress toward achieving Healthy People 2010 objectives and other program indicators.111 Specific content areas of YRBSS data as they pertain to this study are alcohol and other drug use patterns. The next section details drugs of concern for adolescent populations as they relate to adolescent body image.
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Body Image Drugs Data support growing numbers of men, women, and adolescents take products to improve body appearance or athletic performance.10 Grouping of products often termed ergogenic aids, typically are touted to promote muscle gain, fat loss, or otherwise improve physical appearance.21 Taking products to improve physical performance, specifically athletic performance, is a growing trend; however, the focus of this section is to explore how products termed body image drugs are used not for performanceenhancement but, rather, for enhancement of physical appearance. There are several categories of drugs with a select few detailed below. Anabolic Steroids. Androgenic-anabolic steroids (AAS) are similar in structure and effect to that of the naturally occurring hormone testosterone.10,112,113 Although naturally occurring, AAS are commonly used by persons seeking performanceenhancement or gains in lean muscle for enhancing physical appearance.113 A question often asked is, do AAS pose a threat to citizens or are they a consequence of an overly narcissistic society? The next section presents data illustrating adolescent usage. It is important to note that the effects of AAS hold greater risks in adolescent populations than in adults.113,114 Data from the YRBSS 2005 report 4% of students have taken steroid pills or injections without a doctors prescription one or more times during their life. Overall, prevalence showed use was higher in males (4.8%) than females (3.2%). Hispanic males showed the highest prevalence of use at 5.6%. Males in 10th grade reported heaviest use at 5.2% with students in 9th grade at 4.8%, when compared to other grade categories. Data revealed high rates at 6.5% - 7.7% of lifetime use among high school students.115
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Limitations of these data are self-report bias and especially understanding of the term anabolic steroid on the survey. The Monitoring the Future Survey (MTF) has also provided substantial data looking at adolescent drug use prevalence, perceptions of use, accessibility of drugs, and specific drug use trends.116 Students in grades 8, 10, and 12 were surveyed concerning the previously mentioned factors. Regarding AAS use, overall prevalence of lifetime use corroborated previous findings at 3% to 7 % use.115 In 2005, rates actually declined by 1.1%; however, 2006 findings negated the previous years decline.116 Similar to other national surveys of adolescent behaviors, mainstream and illicit drugs, such as tobacco and methamphetamine are tracked. Data concerning the prevalence, perceptions, and usage patterns of body image drugs such as human Growth Hormone (hGH) and AAS have yet to be systematically tracked. Internationally, it has been reported that 83,000 11-18 year old Canadian adolescents have taken AAS. Additionally, drug use among those in health and fitness industries in Europe is perceived to be a Europe-wide public health issue.113,117 For example, Korkia and Stimson118 report AAS use in London gymnasiums to be a high as 50%. It has been challenging to put a number on the percentage of adolescent users of AAS. The first large-scale study on AAS use in adolescent populations was conducted in 1987 and suggested that 3% to 12% of high school males use AAS.119 Kanayama et al.,21 expressed concern for AAS use as representing a major public health problem in the United States with estimates of one million users. Data on females remained unchanged for decades (roughly 1% or less); however, recent data suggest increasing usage trends.117
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From a public health perspective, several studies detail the negative consequences of adolescent AAS use. Prevalence studies suggested users tend to be males and are more apt to use illicit drugs, and alcohol and tobacco products.115 A better understanding of personal and sociocultural risk factors and the processes leading to AAS use is needed for comprehensive intervention and prevention strategies. Various risk factors have been identified including, gender, grade and age, race and ethnicity, socioeconomic status, parental characteristics, geographical location, school size, city size, participation in athletics, and personality attributes.115 Of particular interest is body image and perceived physical health. Several research investigations10,113,119 have found AAS use to be strongly correlated with poor body image. With most attention on AAS use and athletic populations, concern for non-athletes remains an understudied problem. Enhancing physical appearance was only second in reasons why adolescents use AAS to that of athletic performance-enhancement.115 Knowing other AAS users (i.e., peers/friends) also appears to be correlated with adolescent use.120 High-risk behaviors are strongly correlated with AAS use in adolescents including; driving after drinking, carrying a gun, number of sexual partners in last three months, not using a condom, history of sexually transmitted infections, injury sustained in physical fighting requiring medical attention, not wearing a helmet on a motorcycle, not wearing a seatbelt, and suicide attempts requiring medical attention.121,122 Physical risk factors are of particular concern for short-term and long-term consequences. Short-term health issues, such as facial and systemic acne, excessive hair growth, elevation in lipoprotein levels (i.e., high cholesterol), and aggressive behavior are some of the immediate effects of AAS use.113 Longer-term consequences include:
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atherosclerosis due to changes in lipoprotein levels,123 negative affect, depressive episodes and aggression,124,125 violent crime,110 concomitant drug abuse,71,126 as well as systemic and musculoskeletal disorders.114,127 A problem when presenting the issue of AAS and long-term consequences with adolescents is limited capacity to view the future. Research is needed to expand understanding sociocultural causal effects of AAS use as they relate to adolescent body image, particularly in males. Stimulants. Stimulants cover a wide variety of supplements, herbals, and substances ranging from ephedrine to caffeine.21 Most drugs possessing a stimulant or stimulant-like effect are termed amphetamines. Essentially, amphetamines are sympathomimetic amines because they stimulate the sympathetic nervous system.128 Many of these drugs or supplements containing amphetamine derivatives can pose a variety of health risks including: panic, heart palpitations, stroke, psychosis, and liver toxicity.128 In the context of being a body image drug, stimulants provide a person with the potential desirable benefits of weight-loss and leaning-up of muscle.21 Sympathomimetic effects enhance metabolism resulting in more calories burned and also suppressed appetite.21,128 While these effects may seem beneficial, when taken in excess or in combination with other drugs and unhealthful dietary practices, stimulants can lead to severe consequences.128 Even caffeine, one of the most widely used stimulants with an estimated 165 million Americans using, can be harmful to ones health. Caffeine possesses addictive qualities and subsequent withdrawal symptoms when a person becomes habituated.112 In summary, stimulants present a quick-fix solution to adolescents concerned with body weight and leanness. The undeniable results produced by this category of drugs
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make it difficult to intervene and design effective measures of control and education. Federal attempts to ban the sale of ephedra over-the-counter have only curbed licit use of ephedra-containing products.129 Many supplement manufacturers simply add comparable ingredients (e.g., caffeine, bitter orange, and guarana), which still produce stimulant-like effects.128 Ultimately, the question is not how can stimulants be better controlled by federal agencies, but rather, how can a better understanding concerning the psyche of use as it relates to body image enhance prevention and intervention strategies.21 To date, there are no prevalence statistics available concerning use of these an like substances. Growth Hormone and Derivatives. Human Growth Hormone (hGH) is produced naturally in the body, particularly during adolescence. Affecting nearly every tissue in the body, hGH has wide-ranging effects from bone and muscle growth to liver and brain function.112,128 Muscle growth is enhanced due to a nitrogen-sparing and retaining effect making hGH an anabolic/anticatabolic product.112 This attribute makes hGH enticing for those who seek lean muscle mass, particularly young adult and adolescent males.10 Much interest also has been generated by hGH due to its permanent effects on muscle mass and lean tissue growth.21 Human Growth Hormone comes with both a commercial as well as a health-related cost. Users can pay upwards of $30,000 per year for supplies and therapy.112 From a health standpoint, hGH and similar products produce uncontrolled tissue growth which may lead to specific cancers, liver hypertrophy and dysfunction, acromegaly (thickening of cartilaginous tissues), and even gigantism.21,112 Many other substances, such as animal hormones, human chorionic gonadotrophin (hcg), thyroid hormones, insulin-like growth factors (IGF-1), insulin, adrenal hormones, and androstenedione also have been purported to enhance hGH-like
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effects.21 The commonality of these substances are their potential, whether substantiated or not, to impact the body so as to improve ones image of it.21 The ultimate price may come with either adverse health consequences or financial burden. Human Growth Hormone does hold promise for clinical populations (e.g., HIV/AIDS patients, elderly populations);112 however, when used for enhancing ones body image, results may adversely affect a persons health and well-being.
- Agonists. Perhaps one of the most widely used - Agonists is clenbuterol.21

Drugs like clenbuterol are similar to that of amphetamines. - Agonists however, are specific to muscle tissue.112 Traditionally used for treating asthma,112 drugs like clenbuterol have been widely used in bodybuilding communities and for performanceenhancement in athletics.128 Little to no evidence exists to support any anabolic effect. Sanctions however, were imposed on Olympic weightlifters during the 1992 games due to positive tests.128 Clenbuterol also has been proposed to promote lipolysis (fat breakdown) similar in function to stimulants.112 This latter point makes - Agonists popular in managing ones weight or leanness thus, perpetuating it as a body image drug.21 In terms of adverse effects, - Agonists present similar side-effects as with stimulants (i.e., anxiety, heart palpitations, and psychosis),128 making it a potentially hazardous drug when taken improperly.
Further Issues Body image drugs present a growing problem due to their inherent risk factors. Widespread use and availability of many of these drugs makes tracking patterns of usage
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difficult.21 Additionally, motivation regarding usage presents even more of a problem when establishing causal relationships among variables. Most research has primarily focused on androgenic-anabolic steroids. There are virtually no data examining other categories of these drugs.130 Secrecy of use is another problem when examining body image drug use. People who tend to use these drugs often do so because of insecurities with their physical appearance.21 A particular challenge is presented when attempting to understand adolescent use. Gateway theory131 of drug use also applies to body image drugs. People often seek more results when body image drugs fail them or provide diminishing returns. Progression from supplements, such as creatine to adrenal hormones to AAS, often describes typical patterns.10,21 Poly drug use is another commonly occurring phenomenon with body image drug use, which may lead to dependence syndromes.21,132 In isolation, each drug may present minimal side effects. In combination however, the psychological and physiological consequences can be severe. Unlike other drugs of abuse (e.g., cocaine, heroine), body image drugs often do not fit into typical classic drug abuse models.21 A drug, such as cocaine, stimulates reward centers in the brain creating feelings of euphoria. Growth hormone, anabolic steroids, and others do not appear to fit this paradigm. Ultimately, the reward appears to be generated in the form of elevated self-esteem.21,75 Users of body image drugs often view their use as a positive [and needed] part of a healthy training routine.21 When viewed from this perspective, classic drug user profiles become invalid.130 Kanayama et al,21, p.62 called for, more epidemiological data to espouse how, when, and why these drugs are taken. In contrast to the previous classic drug use model,
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research on body image can play a key role in determining usage patterns. Kanayama and others21, p.63 noted, A growing literature suggests that modern society places increasing pressures on both women and men to achieve an ideal body appearance. Taking the impressionable nature of adolescence, this latter point is concerning. Trends are backed by several well-designed research inquiries on Barbie dolls and G.I. action figures,23,133,134 Miss America pageants,135 and male centerfold models.11,24,59 More evidence is needed to understand prevalence and use patterns both in the United States and abroad, morbidity (and mortality) rates associated with abuse, risk factors associated with abuse, and sociocultural factors underlying the issue.21 With a better understanding of these issues, a better and more holistic approach may be possible in addressing this issue from a public health perspective. Confronting societal roots of body image drug use continues to remain an important but understudied area of drug use. Research on Body Image
"The images are impossible for most females to achieve, but they sell products and make girls feel negatively about their own looksMales are impacted through action figures present subtle messages of unrealistic role models of well-sculpted, heavily muscled, perfect bodies that little boys see as their role models. ~Sondra Kronberg (Media Literacy, 2006)
A wealth of empirical and theoretical research has been produced over the past fifty years.3 Citations related to body image and body satisfaction have shown positive growth trends in psychological and medical databases since the 1950s. Initially, much research appeared in PsychINFO databases; however, in the 1970s, a shift occurred toward public medicine reference databases (e.g., PubMed).3 Several distinct areas of study emerged over the past several decades including: conceptual foundations,
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developmental perspectives, methods of assessment, cultural differences, dysfunction and disorder models, medical research, surgeries and interventions, and psychosocial models and interventions.3 A consistent challenge has been integrating these distinct fields of research. Theoretical positions and lines of research are seldom integrated failing to capture the rich diversity of body images.3 Fisher and Shontz noted, what particularly impresses me about the multiple branches of the current work dealing with body attitudes and feelings is how disconnected they are. These branches often thrive in splendid isolation, as if others did not exist. Cross-references by researchers in the different areas are, at best, sparse.108, p.3 From the time we are born, until the time we pass on, body image continues to develop and evolve. Development occurs through a variety of inherent biological and sociocultural influences.29 By the time children reach adolescence, negative body image helps to predict the development of disorders, such as chronic depression and eating disorders. Limitations when looking at developmental body image include a lack of longitudinal and prospective research designs. Research with infants suggests touch plays a critical role in body image development. Parents who touch their infants and children help develop the psyche with somatic experiences.31 This factor, in turn, helps the child conceptualize his or her role in the environment. Infants have limited means by which to distinguish themselves from the environment. The reliance on kinesthetic, visceral, and motor sensation plays a crucial role in the development of the body and the image of it. The need for adequate somaticsensory stimulation has been well-studied and is a necessary component for the development of healthy body images.31 Therefore, based on these findings, an integrative
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model of body image research is needed including predictors of body image dissatisfaction, particularly in adolescent males. Research with Men For years, the onus of concern for body image rested with females. Concern for body image was never absent in males, but rather, not brought to the surface of the public consciousness. Male body image concerns have only recently surfaced in the past decade, particularly through the work of Pope and colleagues.10 The following section will detail the recent trend of male preoccupation with physical appearance and the impact on body image and cognitive affect. Historically, shame and fear of public humiliation drove men with body image dissatisfaction and eating disorders underground.10,136 Paradigm shifts in cultural standards of beauty and functionality have become paramount in contemporary society.22 As with females, variations among cultures have been studied in men as well. Trends indicate body image dissatisfaction occurs in countries with similar socioeconomic status as the United States (e.g., Israel, Austria, Australia and Samoa).33,34,35 Variations of physical attractiveness through cultures likely have origins in early childhood through adolescence with sociocultural ideals being the major factors.22 Similar to television consumption detailed by Tiggeman,9,137 Pope et al.,23 asserted modeling through toy action figures, such as G.I. Joe, may contribute to body dissatisfaction or distortion in boys and men. In this research, action figures were found to have become more muscular over time (1960s to the 1990s) far exceeding the muscularity of even the largest bodybuilders.23 A similar trend also was noted in Playgirl male centerfold models from the 1970s through the 1990s as well as other womens magazines.24 These factors may
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play a contributing role to the development of spectrum and somatoform disorders, such as body dysmorphia or muscle dysmorphia, to be discussed in following sections. These trends contribute to a contemporary paradox of males wanting to be heavier, but perceive themselves as lighter, whereas females wish to be lighter, but perceive themselves as almost 10-15 pounds heavier than they are in actuality. Suggested motivating factors point toward concern with physical appearance, popularity, and attractiveness to the opposite sex.138,139 Male body image is typically assessed through ideals, such as power and dominance. The notion of the pack leader, has been present throughout history.139 It also has been asserted that success rather than physical attractiveness defines the male ideal and his position within the male hierarchy.138 The evolving roles of males in a Post-Industrial era has led to parity with females.10 No longer do males command industry governed by muscle and sweat; but rather, todays workforce stresses ingenuity and skill of which females are aptly capable. As a result, males may react by seizing control of the one element that remains distinct to them, the ability to overpower others through muscle.140 Evolution of the supermale, a mediaendorsed conception, may be viewed as a contributing factor to male body image dissatisfaction with unattainable physical ideals.22 It has been suggested that men are susceptible to a greater variety of weight concerns than females. Concern is generated due to the nature of the complexity of weight gain and physical appearance and strength of which females are less likely to be involved.22 Men, like women, often want to change their weight, but often are more preoccupied with body shape and muscularity.10 Appearance often is equated with success and with newer vernacular terms such as, metrosexual, todays man often finds
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a need to react to these pressures. Reactions vary but may include: obsessive exercise, dieting, use of body image drugs,21 and even cosmetic surgery.22 These and other like disorders will be presented and discussed in the following sections of this review. Recognition and diagnosis of body image issues in males is different and more difficult than that of females for a variety of reasons. Westmoreland-Corson and Anderson22 noted mens reluctance to admit having a female issue as one factor, a bias in the Diagnostic and Statistical Manual for Psychological Disorders (DSM-TR IV) geared toward females as the second, and male binge eating behaviors being considered as healthy and normal guy behavior. Male concern for these behaviors is less overt than females, making the task of predicting and intervening on behalf of body image concerns and related consequences a clinical challenge. Follow-up studies169 using male samples could provide telling evidence when tracking male body image satisfaction over time. Males are more likely to respond to body image dissatisfaction preempting co-morbid conditions, such as chronic depression and alcoholism.25 Treatment aspects, such as antidepressant medications and cognitive behavioral therapy (CBT), are only as beneficial as luring out mens hidden obsessions with their bodies and resultant body image dissatisfaction.10 Contemporary society plays a pivotal role in setting men up for failure.22 The ideal of the supermale is a reality in society, but unrealistic in terms of coming to fruition for most men. Unrealistic expectations lead to a pattern of unattainable ideals most boys and men face in their everyday lives. Mark Twain noted, The worst loneliness is to not be comfortable with yourself.22 This quote may play true for most males in the 21st century. Research on Boys and Adolescent Males
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Body image is the most important component of an adolescents global selfesteem.2 Similarly, concern for body image appears to be a strong factor in developed societies, whereas underdeveloped and developing nations report lesser concern.2 This point dates back to Abraham Maslows hierarchy of needs. Masculine beauty is defined less easily, although trends toward a more muscular physique are preferred by males.10 As boys and girls mature (roughly to age 11), both typically show comparable levels of overall body esteem through childhood.37 Several studies9,22,29,37 indicate trends of dissatisfaction with body shape and weight in elementary school children. Forty percent of elementary school girls and 25% of boys expressed discontent when measured with a modified body image satisfaction instrument.37 Children as young as six years of age have been found to express concern with their bodies.29 Internalization of negative affect at a young age appears to be a strong predictor of body image disturbance in adolescence and into adulthood. Boys who are underweight are most likely to be dissatisfied with their weight and many with normal weight wish to weigh more.141 Approximately one-third of boys are dissatisfied with their body shape, desiring larger upper arms, chest and shoulders.141 Dieting and purging are less likely than exercise to be chosen by boys as methods of weight control.23,24,141 Dieting among boys is more likely to be associated with increased body weight and some sports, such as wrestling. Body consciousness and altered body image are widespread among adolescents, and may be associated with potentially harmful eating practices in both sexes.141 Body satisfaction in boys decreases from elementary school years through adolescence.38 Often, this trend reverses as males progress through puberty due to gains
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in muscle mass. Weight gain associated with lean mass is perceived as positive for adolescent males, whereas as females report a negative affect.38 Younger males often report wanting to be bigger with respect to muscle mass. Gruber and Pope39 presented a computer-based body image program to younger males. Results showed males preferred a heavier physique when compared to what they believe to be an ideal physique. When males were asked to select from a group of silhouettes, they tended to select a heavierthan-average silhouette. This perception has been seen in repeated studies2,17,28,35,58,142 and it is hypothesized that it is because they equate heavier with more muscular in the absence of a silhouette that clearly represents muscular. When compared to female perspectives of ideal male physiques, results consistently demonstrated a much higher body weight ideal from the male perspective.39 This research suggests body image in boys appears to be approaching dissatisfaction when compared to normative components and that of female perceptions. On a positive note, boys are typically more satisfied (overall) with their weight and shape than females.37 It is difficult however, to draw definitive conclusions about the development of body esteem and image because of the paucity of research. Adolescence is a period of emotional, social, psychological, and physical change. Feelings of discontent may result in negative health behaviors, ranging from dieting and cosmetic surgeries to other compensatory behaviors.5 Males typically gain upwards of 75 to 100 pounds with lean muscle mass as the majority, but for those who do not, or do not meet sociocultural standards may become dissatisfied.2,10,141 This model sets up a paradigm for potential female body image dissatisfaction due to weight gain and male dissatisfaction because of a lack of adequate gain. Puberty does not consistently correlate
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to body image dissatisfaction; however, it does accentuate previous existing vulnerabilities and problems, such as low self-esteem and feelings of shame. Timing may play a major role with early development as a negative factor for females and a positive factor for males and late development as a negative factor for males.2 Body Image Dissatisfaction and Psychosocial Disease Models In the United States and abroad, a trend toward negative body image exists. This section explores how negative body image manifests itself both in a psychological and physiological sense. Psychosocial Disease Model Body image dissatisfaction manifests itself in several ways, ranging from impaired psychological functioning to actual somatic disorders. Additionally, the term psychosocial implies disease characteristics are in some ways, as much a social consequence as they are rooted in the individual. An individual cannot escape the reality that s/he is a social creature.6 Each component is presented and discussed in terms of its etiology and how it presents with body image dissatisfaction. Obsessive Compulsive Disorder Housed within the broad psychiatric category of spectrum disorders, obsessive compulsive disorder (OCD) is defined as, obsessions or compulsions (usually both) that cause marked distress, are time-consuming (take more than one hour per day), or significantly interfere with functioning. Obsessions are characterized by recurrent, persistent and intrusive thoughts, impulses or images; whereas, compulsions are repetitive behaviors or mental acts that are performed in response to an obsession and are
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aimed at preventing or reducing distress or a dreaded event.1, p.318, 80 For full diagnostic criteria refer to Table 3. Obsessive thoughts range the gamut as do their behaviors. Behaviors affecting body image may include excessive mirror checking, exercise, cosmetic surgeries, and many others. Being the parent disorder of several others, OCD presents a general range of disorders that are specifically addressed in the following sections. Body Dysmorphic Disorder Phillips1 defines Body Dysmorphic Disorder (BDD) as having three qualities: 1. preoccupation with some imagined defect in appearance; if a slight physical anomaly is present, the persons concern is markedly excessive; 2. preoccupation causes clinically significant distress or impairment in social, occupational or other important areas of functioning; and, 3. the preoccupation is not better accounted for by another mental disorder. Additionally, BDD is a subcategory of OCD and part of the general spectrum disorders classification system.80 Often emerging in adolescence, the defining factor of BDD versus simply being dissatisfied with a part of ones body is the preoccupying and obsessive nature of it. Regardless of whether there is even a defect at all, it becomes real for the person experiencing symptoms of BDD.1 Each person formally diagnosed with BDD must meet previous criteria (see Table 1). Each person however, will experience BDD differently. Severity, body areas, and behaviors are all unique to the individual, although similarities and behavioral patterns are possible.1 This phenomenon is not a new concept. Descriptive accounts of BDD can be traced back to the late 1890s.1 Stekel commented, a peculiar group of people who preoccupy themselves continuously with a specific part of the body. In one case, it is the
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nose; in another it is the bald head; in a third case the ear, the eyes, (or) in women the bosom, the genitalia, etc. These obsessive thoughts are very tormenting.1, p.19 Freud studied the Wolf Man through psychoanalysis. Later, it was discovered by his second psychotherapist, Ruth Brunswick, that, His life was centered on the little mirror in his pocket, and his fate depended on what it revealed or was about to reveal.1, p.19 Phillips1 presented data on the prevalence and potential consequences of BDD in her work, The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. She wrote BDD affects 1-2% of the general United States population which equates to roughly 5.8 million people; 4-5% of people in outpatient treatment have BDD; 8% of people with chronic depression have BDD; and up to 12% of people seeking psychiatric treatment in outpatient settings satisfy BDD criteria. Several clues may alert a person to signs and symptoms of BDD including; excessive checking of appearance, avoidance behaviors (such as mirrors), frequently comparing oneself to others, seeking reassurance regarding appearance from people, excessive time grooming, hiding parts of the body, picking at ones skin with hopes of improving appearance, use of cosmetic surgery, and many others.1 Body image has been researched as a key component in social anxiety disorders and lower levels of social self-esteem.3 Phillips1 discussed BDD as a consequence of a distorted body image. Given such a long history of body image research, body image disturbance in BDD is understudied and warrants further research on its impact on global self-esteem and body image in general.1 The next section briefly outlines muscle dysmorphia, a sub-clinical category of body dysmorphia. Muscle Dysmorphia
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Muscle dysmorphia (MD) was originally described by Pope and colleagues.89 The disorder also has been referred to as reverse anorexia and bigorexia. Pope and colleagues10, p.87 stated, Muscle dysmorphia is a specific type of BDDthe general category of BDD refers to all types of serious unfounded body image concerns. Muscle dysmorphia is simply the form of BDD in which muscularity, as opposed to some other aspect of the body, becomes the focus. Causes of MD most likely include a variety of factors ranging from sociocultural influences to genetic factors.89 Body esteem is a key measure and component of muscle dysmorphia.143 Unlike other disorders, such as anorexia nervosa (AN) and bulimia nervosa (BN), identification, diagnosis and treatment of muscle dysmorphia presents a challenge to the practitioner. This latter point may be due to the fact that people with MD often are perceived and perceive themselves to be healthy. Behaviors and attitudes often become overt to family and friends but the person experiencing MD remains oblivious. There is extensive research on AN and BN; however, it is not the goal to discuss each in this section. It is acknowledged, however, that AN and BN are greatly influenced by body image perception. Although not formally categorized as a DSM IV TR disorder, several researchers have proposed diagnostic criteria for MD.10,26,90,144 These criteria can be found in Table 2. As with other body image disorders, people experience MD differently. Muscle dysmorphia has been studied from various angles since it was proposed as a category of body dissatisfaction in 1993. Leone et al.,145 reviewed current trends and how the disorder can be recognized and managed in competitive athletics. Recently (2005), it was proposed that MD should be redefined as a spectrum disorder rather than a somatoform
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disorder based on empirical evidence over the past decade.90 This means MD may need to be re-conceptualized as a psychological issue versus a body concern issue. When viewed as a body image disorder rather than a collection of psychiatric and behavioral oddities, MD becomes a window by which todays evolving ideals of beauty, particularly of the male body, can be seen. Although females also are susceptible to the disorder, data suggest males are more commonly affected.10 From a traditional perspective, masculinity and muscle has defined the measure of a man.146 Muscle has come to symbolize health, dominance, power, strength, sexual virility, and threat.147 When there is an actual or perceived flaw with ones muscularity, obsessive thoughts, and ultimately, a concern for the body may result.146 Insecurity may be a cause for development of a hypermasculine persona or even insecurity with shifting gender roles.147 Society is likely to play a major role in the etiology of MD and similar body image disorders, particularly in males. Messages broadcast that real men have big muscles and that a lack thereof reflects an unmasculine ideal.89,145 De-masculinization often leads to a reactive approach, which may include using body-enhancing substances, such as androgenic-anabolic steroids (AAS). Many males and a few females disclosed they use AAS purely for body appearance ideals rather than for athletic ideals or goals.20,148,149 A schematic of MDs relationship to other spectrum disorders is presented in Figure 2.
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_______________________________________________________________________ _
Eating Disorder Symptoms Obsessive Compulsive Symptoms Body Dysmorphic Symptoms _______________________________________________________________________ _ Figure 2. Proposed obsessive-compulsive spectrum disorders and their relationship among each other. Muscle dysmorphia among other body image disorders, likely will continue to increase in prevalence due to media and societal influences.38,150,151 Until a fundamental shift in the ideals and pressure placed upon both males and females to look a certain way diminishes, the incidence of affective body image spectrum disorders is likely to increase. The following section outlines somatic disorders contributing to body image disturbance. Somatic Disorders Soma refers to the body. Opposite the previous section detailing spectrum disorders, this section explores specific causes of body image dissatisfaction from a body-based perspective. Specific content includes issues concerning: dermatology, oral Muscle Dysmorphia Symptoms
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health, urology, weight loss, cosmetic surgery, and disfigurement (both congenital and acquired). Skin is the largest organ of the human body. It is an active and dynamic structure playing many roles. Serving as a barrier to the external world, skin is also the most visible of structures.151 The cutaneous surface is what society initially perceives. For that reason, having healthy, unblemished skin enhances self-esteem and identity. Additionally, those with visible deformities are more apt to be stigmatized and teased than those who appear normal. Having a presentable skin surface is usually a prerequisite for maintaining optimal body image.152 Research has shown people with skin disorders often have severe psychological reactions. Patients with psoriasis (25%) indicated they wish they were dead at some point in their lives because of it.153 Other factors impacting skin and body image include: age of onset of disorders, gender, anatomical location, nature of the skin disorder, pre-morbid personality issues, and family and social support networks.154 Oral health and dental medicine present unique considerations regarding body image. Deviation from the norm with respect to dental and facial features is often cause for body image dissatisfaction, particularly in childhood.155 Facial attractiveness has been studied as a social asset resulting in greater acceptance by others, including peers, teachers, and employers. Feingold156 however, found that objective and subjective measures of attractiveness are not always correlated. One of the first facial features to be noticed are the teeth and oral cavity. Defects affecting this area correlate directly to lower levels of self-esteem and self worth. Reflective appraisal is one of the first developmental aspects of body image in infancy. Infants react to how they see others (adults) react.
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Deficiencies related to facial or dental features often lead to a lifetime of self and body image insecurities.157,158 Urological disorders present a sensitive topic for both men and women.159 Consisting of the kidneys and the organs of excretion, the urological systems primary purpose is to eliminate waste and also serves a reproductive function.151 Incontinence is an issue afflicting an estimated 13 million people in the United States, mostly women. Continence generally implies a level of self-control and with that self-confidence. A lack of these factors may lead to lower self-esteem, self-doubt, humiliation, and concern for body image.160 Sexual and body image affects of these conditions may be influenced by the visibility or extent of the physical problem.161 Reactions to Body Image Dissatisfaction Other issues concerning body image include weight loss, cosmetic procedures, and disfigurement. Negative body image most often is related to body weight and weightsensitive parts and often is higher in overweight than non-overweight people. Variability in body image among overweight persons is not related to the degree of overweight. Similarly, a negative body image (or concern about appearance) is an important factor in deciding to lose weight and in selecting how much weight to lose.3,162 The nature of cosmetic surgery itself is to change the body. Rates of surgery have increase considerably in the past 15 years.163 With the five most common procedures being liposuction, breast augmentation, eyelid surgery, Botox injections, and facelifts, one does not have to search very hard to make a connection between cosmetic surgery and body image concern.163 Procedures are no longer reserved for the wealthy and elite; women and men across age, racial, and socioeconomic groups now seek cosmetic surgery to improve their
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appearance and, ultimately, their perceived body image.163 Rumsey164, p.431 noted, A visibly disfiguring condition poses considerable challenges to the process of building and maintaining a positive body image and self-esteem. The pressures that lead affected individuals to seek surgical, medical, and/or psychosocial interventions come from a variety of possible sources: social context, peers and/or family, and personal beliefs. Certainly, this society has well-entrenched standards regarding physical appearance, and media and advertising exert persistent pressures to correct any and all flaws. As technology advances, it is expected that people will change their appearance whether congenital or acquired in nature.165 Body Image and Public Health Concerns A simplistic definition of public health is, an effort organized by society to protect, promote, and restore the peoples health.166 The use of drugs as a result of concern for ones body image is of particular interest encompassing many dimensions of health. A more unified model of what constitutes body image dissatisfaction in adolescent populations will help design intervention and prevention programming. Kanayama et al.,21, p.64 stated, With a better understanding of these issues [prevalence and usage patterns of body image drugs], we may be better able to calculate the public health consequences of body image drug abuse, devise appropriate therapeutic approaches, and confront the societal roots of this phenomenon. Specific examples of body image drugs, such as androgenic-anabolic steroids (AAS), were discussed at length in previous sections; however, aside from drug use, understanding predictive factors of body image dissatisfaction in male adolescents will allow for a greater understanding of the phenomenon as a whole. Research has been limited in this area; however, Leone and
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Fetro167 have explored protective or preclusionary factors to AAS use, which suggest a generational or sociocultural mitigator is at work concerning this phenomenon. Theoretical Framework A thorough understanding of the phenomenon should be initiated so as to prevent misguided interventions and unnecessary planning.68 Understanding what intrapersonal, interpersonal, and social factors precipitate adolescent males to become estranged with a healthy body image and act on negative health behaviors such as body image drug use is focus of this section. Intrapersonal factors include a wide array of affective beliefs and values.68 Ranging from self-esteem and self-efficacy to physical competence, intrapersonal affect has been discussed as a primary factor impacting body image satisfaction.3 Intrapersonal affect develops from the interaction among interpersonal and social influences.68 A person interacts with these influences, reflects on their meanings, internalizes meaning based-on previous experiences, and ultimately, acts on influences resulting in behaviors.68,168 Objective measures devised to assess global body image are lacking.3 Few specified instruments address specific adolescent male population body image factors, let alone overall body image satisfaction. Interpersonal factors are forms of communication occurring between or among people.75 Unlike intrapersonal factors where communications with others lead to reflective appraisals and internalization of affects, interpersonal communication and behaviors require a common exchange, such as criticism or teasing.68,168 Bullying behaviors have been studied in terms of its influence on self-esteem and possibly body image. Studies such as this examining bullying (an interpersonal communication), have
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been directly correlated to negatively affecting self-esteem and self-efficacy.65 Within the context of adolescent male body image, a greater need exists to identify how interaction among various interpersonal communications affects global self-esteem and global body image. Social factors encompass several direct and indirect forms of communication, such as media advertisements, television programming, and written media (e.g., magazines).9,67 These social factors, oftentimes referred to as environmental determinants, have a strong propensity to affect ones body image.3,64,68,168 Normative beliefs have been shown to be directly influenced by social factors.64,168 Examples include ideal body types for females, detailing very thin models. For years, females have attempted to live-up to this ideal with disappointment resulting. Eating disorders and other negative behaviors can result from social factors coupled with the interaction between interpersonal and intrapersonal beliefs.65 Less has been focused on concerning how social factors, traditionally thought to greatly impact females, also affects males. Pope and colleagues10,23 discuss how simple action figure toys may negatively impact a boys selfesteem and ultimately, his body image. A greater understanding examining how social factors impact adolescent male body image dissatisfaction is warranted. The following sections detail specific categories within the broad context of intrapersonal, interpersonal, and social factors. Intrapersonal Factors Gender
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Differences in gender related to body image are readily apparent. Traditionally, females have been concerned with body image leading to the contemporary concept of normative discontent.91 This concept describes the pervasive negative feelings that some girls and women feel about their bodies. Once thought to be a phenomenon of adolescence, body image concerns and disturbances continue to plague some women throughout their lifespans.137 Females are more likely than males to experience body image concerns regardless of age.4 Much research has focused solely on how body image concerns may negatively impact females and their quality of life. As outlined in a previous section, all people have and experience body image.3 The connection between body image concern and discontent has been causally linked to disordered eating and eating disorders.14,15 Recently, a similar line of research has sought to consider the male body image disposition discussed in the following section. Physical Attributes One of the most encompassing aspects of what constitutes a negative body image, is how a person perceives themselves physically. Preoccupation with physical appearance can lead to negative behaviors and psychiatric issues, such as body dysmorphia, which was previously discussed. Cash and Pruzinsky3 noted no one acceptable definition of negative body image exists. This assertion makes amassing epidemiological evidence a challenge. According to a 1996 U.S. survey on body satisfaction in Psychology Today, men were most concerned with their mid-torso region (63%) and body weight (53%).59 This finding represents a significant shift from the initial survey conducted in 1972 where men were
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concerned with the same features, but at nearly half the rate as in 1996.3,58,59 Cash and colleagues3 expressed caution when interpreting these findings as the survey samples were self-selected and wording changed from 1972 to 1996. Regardless, survey results offered compelling evidence toward a trend in negative body image in the United States. A validated survey by Cash and Henry57 offered similar results in an anonymous and more scientifically and methodologically sound study. Since 1972, discussion of the Psychology Today surveys identified specific areas of body image concern (i.e., weight and torso), but does little to capture body image research. Some, if not most people, have discontent with some aspect of their bodies.3 This latter point does not correspond with global body image discontent or more formally negative body image. A paucity of literature exists correlating single physical attributes of discontent with global body discontent and other areas of body image research. Previous surveys have suggested body image has deteriorated over the past few decades.3,58,59 Concern for this deterioration calls into question whether negative body image is becoming more pervasive or whether a heightened concern and resultant reactions to ones physical appearance exists. Certainly, advances in health from the 1970s fitness craze prompted many to get active to reduce the risk of hypokinetic diseases, such as coronary artery disease (CAD).83 Feingold and Mazzella5 concluded that both men and women experienced a decline in body image satisfaction with women declining at a more significant rate. Both sexes appear more dissatisfied with physical attributes suggesting negative body image. Heatherton et al.,169 discussed a decrease in weight concern, anorexic and bulimic symptoms. This latter point may be best explained by a heightened awareness of these and like psychosomatic disorders by healthcare
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professionals and the ability to provide screening and interventions at earlier ages. Whether body image is improving or declining remains a matter of debate due to methodological issues or philosophical contrasts. Trend data, coupled with anecdotal evidence, suggest people are less satisfied with their bodies; however, this does not provide a satisfactory answer to the question concerning whether negative body image is becoming more pervasive, especially among boys and men.3 Discontent does not necessarily impact emotional well-being. Cash and Pruzinsky3, p.274 discussed, most attempts to quantify the prevalence of negative body image neglect to assess, 1. the psychological importance that people place in their evaluation of their appearance and, 2. the related impact of the evaluations vis--vis personal distress and adaptive functioning. This point prompted creation of the Body Image Questionnaire (BIQ),3 which takes discrepancies into account when evaluating negative body image. Higher perceived scores versus actual scores indicate a more negative conceptualization of body image.3 In summary, the answers found are only as good as the questions posed. There is a need for large-scale, representative studies examining this area of focus due to its impact on quality of life. Body Mass With body mass (weight) being the most commonly studied component of body image concern, it is not surprising that stigmatization of overweight children is readily apparent in three year olds.4 In one study,29 fifty percent of females aged 6-8 years old wanted to be thinner. Although less of a concern for males, data suggest a developing affect in males as well.29 Concern at this age is disturbing due to the impending weight gain associated with puberty. This phenomenon continues after adolescence and into
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college-aged populations. Negative body image associated with weight gain is pervasive in college populations.29 Concern may be explained by fear of gaining weight in the first year of college commonly referred to as the freshman fifteen.137 As high as 82% of college women reported wanting to lose weight, even though only 1.4% were statistically overweight, with 57% of males surveyed desiring the same.137 In a study by Heatherton et al,169 68% of the same cohort still desired to lose weight after ten years. These findings suggest weight loss and body image concerns continue throughout the lifespan in females, but may lessen with age. Data on males continues unexplored. Other areas leading to discontent include: stigma and prejudice associated with obesity, challenges to male and female ideals (i.e., thinness), social expectations, and objectification.4 Body Mass Index (BMI) is a relative measure of a persons health status.83 Using height in meters squared and body mass in kilograms, a calculation can be performed yielding an overall number. The BMI has become controversial because many people, including physicians, have come to rely on it for medical diagnosis even though that has never been BMIs purpose. It is meant to be used as a simple means of classifying sedentary (physically inactive) individuals with an average body composition. For these individuals, the current values are as follows: a BMI of 18.5 to 25 may indicate optimal weight; a BMI lower than 18.5 suggests the person is underweight while a number above 25 may indicate the person is overweight; a BMI below 15 may indicate the person has an eating disorder; a number above 30 suggests the person is obese (over 40, morbidly obese). For a given body shape and density, the BMI will be proportional to height (e.g.,
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if all body dimensions increase by 50%, the BMI increases by 50%).83 Discerning ones BMI may also be useful when investigating factors associated with body image.3
Self-Esteem Dissatisfaction in body image has been linked to lower levels of self-esteem.3 An etiological pathway leads to eating disturbances and, potentially, eating disorders, such as anorexia nervosa and bulimia nervosa.4 Figure 3 conceptualizes this pathway. _______________________________________________________________________ _ Ideal Self Negative Behaviors & Eating Disorders
Internalization of thinness as beauty Actual Self
Body Dissatisfaction
_______________________________________________________________________ _ Figure 3. Etiologic pathway to eating disturbances Diagnostic criteria for anorexia nervosa may be found in Table 4, bulimia nervosa in Table 5, and binge eating disorder in Table 6. Co-morbid conditions associated with body image disturbances have been well-studied. However, Heinberg et al.,170 have proposed a controversial notion that a certain degree of body image concern and dissatisfaction may actually be beneficial. The premise of this argument is that some level of dissatisfaction
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with ones body may provide motivation to engage in healthy dieting and exercise behaviors.170 This theory seems plausible as a self-regulatory behavior. The authors however, neglect to appropriately define some levels of body dissatisfaction. The male body often is viewed in terms of its functionality.4 Loss of functionality or perceptions of diminished functionality may negatively impact self-esteem and subsequently body image. Table 4. Diagnostic Criteria for Anorexia Nervosa A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected). B. Intense fear of gaining weight or becoming fat, even though underweight. C. Disturbance in the way in which ones body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight. D. For women, amenorrhea is also a necessary requirement although this does not hold true for men.
Table 5. Diagnostic Criteria for Bulimia Nervosa
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A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances 2. a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa.
Table 6. Diagnostic Criteria for Binge-Eating Disorder A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances. 2. a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) B. The binge-eating episodes are associated with three (or more) of the following: 1. eating more rapidly than normal 2. eating until feeling uncomfortably full 3. eating large amounts of food when not feeling physically hungry 4. eating alone because of being embarrassed by how much one is eating 5. feeling disgusted with oneself, depressed, or very guilty after overeating C. Marked distress regarding binge eating is present. D. The binge eating occurs, on average, at least 2 days a week for 6 months. E. The binge eating is not associated with the regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa.
Body Mass Index, Overweight, and Intrapersonal Social Comparison (Reflective Appraisals)
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Several contributing factors researched have been suggested to affect adolescent body image. Body Mass Index (BMI) is an indirect biological factor contributing to negative body image. Negative body image is most likely due to the fact that biases against obese persons are present by the age of six.29 Overweight and obese people are more prone to psychopathology and poor mental health.29,37 Another contributing developmental factor is temperament. Although everyone makes social comparisons, emotionally resilient people typically make comparisons that enhance their view of body image. Predisposition to chronic depression and anxiety disorders may result in social comparison tendencies. Comparing oneself may lead to negative conclusions about ones body (e.g., shame); however, this is most likely due to ones emotional status versus the actual act of comparing. Most research however, has been conducted only with females.171 Sociocultural influences include parents, siblings, and peers. Each influences development of body image in different ways. Each factor is discussed in the following section. Psychiatric Concerns Several comorbidities associated with body image dissatisfaction have been noted in the literature. These include: mood disorders, anxiety disorders, substance-related disorders, eating disorders, somatoform disorders, and psychotic disorders.1 Each category has specific disorders within it. Each disorder is briefly discussed as it relates to body image dissatisfaction. There are four major types of mood disorders; major depression, atypical subtype, bipolar (manic-depressive) disorder, and dysthymic disorder.1,80 A major concern related to depression is lowered self-esteem and feelings of worthlessness.1 It is difficult to parse
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out whether body image dissatisfaction precedes depression or if the opposite is true. Atypical subtype involves a reactive mood.1 Significant weight gain as well as sensitivity to others reactions may contribute to body image concern.80 Bipolar disorder, also known as manic-depressive disorder, involves two distinct phases; excessive elation and happiness and irritability and depressive episodes. Initially, feelings of enhanced selfesteem and grandiose thoughts often revert back to feelings of worthlessness and apathy when the hypomania stage resumes.80 Lastly, dysthymic disorder involves a less severe form of depression. However, appetite issues along with low self-esteem and feelings of hopelessness may contribute to body image concern.1, p.316-320,79 Anxiety disorders contributing to body image concern include: panic disorder, agoraphobia, social phobia (social anxiety disorder), specific phobias, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and general anxiety disorder. In a greater sense, panic disorder contributes to social phobia and various forms of it, including agoraphobia. Physiologic and psychological reactions are possible, which impair social functioning. When a person experiences one of these disorders in terms of his/her body, concern regarding the body often results. Substance-related disorders have been discussed in-depth in previous sections on drug abuse; however, it is important to note it is a contributory as well as a reactive factor related to body image dissatisfaction.
1, p.316-320,80
Somatoform disorders were previously discussed. Eating disorders, including anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder entail disturbances in global self-esteem, locus of control, and the reactions to re-establish them. Anorexia nervosa involves severe, self-imposed weight-loss whereas BN is
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characterized by recurrent episodes of binge eating followed by compensatory purging activities such as vomiting or laxative usage. Binge eating disorder involves eating more rapidly than normal resulting in an uncomfortably full sensation. People become very distressed about their behavior and often have concerns for body image and body shape. The two other categories include psychotic disorders and other. These may not formally contribute to body image dissatisfaction; however, many of the associated symptoms with each add to negative body image. 1, p.316-320,80
Interpersonal Factors Influences When answering the question, what makes people dissatisfied with their appearance? one needs to look toward interpersonal relationships, among other factors. Social comparison and interpersonal feedback received from others, contribute heavily to self concept and self-esteem.47,48,64 The power of suggestion and comments have been shown to be powerful influences over how people perceive themselves. Interpersonal processes, such as a passing comment or criticism, can elevate or dampen mood and selfconfidence. Research confirms the psychosocial impact of others comments on selfesteem and body image.47 Essentially, research has suggested people do care what is said about them, refuting the popular childhood mantra of sticks and stones. According to Murray, Touyz and Beumont,49 three primary interpersonal processes play significant roles in body image development: reflective appraisals, feedback (on physical appearance), and social comparison. Although these factors were
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described in a previous section, they are pervasive in terms of the level of sociocultural influence. Essentially, reflective appraisals are personal perceptions of how others perceive us. Feedback helps develop the perception of how people view each other. Perceptions are garnered through comments, opinions, and other forms of non-verbal feedback. Social comparison is a process of self-appraisal.47,64 Research indicated those who compare themselves with people to whom they view as physically attractive rate their own attractiveness lower than people who compare themselves to others viewed as unattractive. Additionally, correlational studies have found consistent levels of comparison to be related to higher levels of body dissatisfaction. Interestingly, research has suggested it is not whom people compare themselves to more than the act itself.165
Familial Influences Family often plays a significant role in not only helping to shape a persons values and beliefs, but also to reinforce their own family traditions.40 A common profile for body image distortion, such as eating disorders and compulsive exercising, include: perfectionism, success-driven, low self-esteem, upper-middle class upbringing, and coming from families with a high degree of unexpressed emotion.40 As noted, perception of body image is a developmental process. During this developmental process, a person develops a body schema, helping to define himself/herself as he/she interacts with his/her world. Body schema may be best described as unconscious body awareness.41 A negative body schema influences what people notice, attend to, and recall related to their physical experiences.41 The main process is internalization of experiences, which may lead to both positive and negative outcomes as they relate to body image.
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Contributing factors to internalization include: projection from others (e.g., parents and siblings), identification, and overall culture.41 Social Cognitive [Learning] Theory proposes that parents are critical agents of socialization.168 Parents roles affecting how children perceive themselves and their subsequent effect on self-image are important to consider. Parental praise or degradation has been studied with findings suggesting a strong link between degrading comments and the development of body image concerns.42 MacGregor and others,172 asserted that children will see their defects, whether real or imagined, as their parents see them. Concern generated from parental comments may contribute to the progression of negative body schema as the internalization of criticism occurs.172 Positive parental comments tend to hold the opposite effect in enhancing self-esteem and resiliency.173 Identification is an important process as a child attempts to model after a samesexed parent or guardian.87 Formally defined as, a process of becoming like someone in one or several aspects of thought and behavior, children incorporate and identify with their parents body image as part of their own.41, p.117 For example, when mothers openly criticize their own bodies, their daughters become more critical of their own bodies as well. Conversely, when fathers comment on their daughters physical appearance, critique impacts her body schema in either positive or negative ways.43,44,45 Little to no research has explored this phenomenon between fathers and sons.66 With much of the research concerning mother and father interactions, other factors, such a sibling interactions, also play a role in the development of body schema and body image, however, research has yet to provide substantial findings.
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Teasing One of the most influential precipitators of body image dissatisfaction is teasing. At the interpersonal level, research has identified teasing as a consistent predictor of body image concern and dissatisfaction.174 The role of teasing has been causally linked to negative body affect and problematic behaviors, such as eating disorders and alcohol consumption.46 Parental teasing followed by siblings and peers were found to negatively impact ones body image satisfaction.46 Specific comments concerning ones body appearance can greatly affect behaviors. In males, for example, Pope et al.,10 noted boys were more likely to react to teasing and criticism with hostility, teasing others, body image drug use, and forms of violent behavior. Being that body image develops throughout the lifespan, significant interpersonal relationships play a vital role influencing how people perceive themselves.47 Three major interpersonal relationships impacting views of body satisfaction are: peers, romantic partners, and strangers.175 Peer groups have been shown to be particularly influential in adolescence, while continuing throughout a lifetime.47,175 As mentioned previously, teasing is a strong predictor of discontent, peers and friends are among the most frequent and worst perpetrators of teasing, second only to brothers.175, p.48 The role of peer acceptance also has been studied extensively in girls; however, boys reported receiving more negative commentary from peers about weight and shape than girls.46,173 These points call into question whether members in peer groups influence each other directly (i.e., social
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contagion theory), or whether peer affiliation reflects pre-existing body image attitudes and eating behaviors.176 Romantic relationships play an important role in the acceptance of the self and others.177 Lower relationship satisfaction has been associated with lower levels of selfesteem and body image satisfaction.175,177 Because a great deal of time is spent together in a relationship, people often are vulnerable when entrusting others with personal issues, such as body acceptance. Also, it has been noted in research literature that men and women have inaccurate perceptions of gender expectations with regard to ideal bodies with males expecting females to want more muscular physiques on males and females expecting males to desire thinner physiques on females.177,178 Similar perceptions also were found to be true with adolescents by Gruber and colleagues.39 Relationship dynamics are complex in and of themselves, but when framed in the context of adolescence, dynamics become all-the-more intricate as adolescents attempt to define themselves in relationships. Individuals may knowingly or inadvertently encourage negative body image in their partners to maintain power, enhance self-image, provide encouragement, or foster feelings of dependency.165 Lastly, body image disturbance may negatively impact sexual relations. Avoidance may become a reaction to negative body image, leading to a cyclical pattern of perceived unattractiveness or undesirability in both partners.165 As the former statement suggests, much of the research has focused solely on adult relationships with little exploring adolescent romances. The third area of interpersonal relationships is strangers. Oftentimes people do not express concern of, what others think of them. Research, however, suggests otherwise. Sociocultural messages and the vast influence of media play key roles in shaping
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peoples body image. Murray and colleagues49 found men were more likely to indicate the desire to look attractive to the opposite sex. Strangers may directly influence body image because of the lack of restraint in providing feedback, whether positive or negative in content. The result can lead to impaired social functioning based on what many people claim does not affect perceptions of themselves. A need for better and more comprehensive predictors of body image disturbance is needed.49 When summarized on an interpersonal continuum, the interrelatedness of all factors becomes readily apparent (see Figure 4). ___________________________________________________________________
Period of Influence Major Source of Body Image Reinforcement
Childhood
Parents
Adolescence
Peers
Adulthood
Romantic Partners
______________________________________________________________________
Figure 4. Continuum of interpersonal influences Noted previously, teasing has been found to significantly affect body image perception.46 When viewed as an interpersonal factor, those with low self-esteem may be profoundly affected by teasing. The source of the teasing is an important factor to consider, such as parent, relative, peer, or stranger.27,29,37,38,39 Self doubt has been discussed as a normative part of puberty and adolescence. Factors, such as teasing can add to self doubt, thereby reinforcing the affect.2,5 88
Body Modifications through Exercise Exercise is an important factor to minimize aging and maintain a competent body or internal body image.179 Gender differences become less pronounced as aging occurs.180 Normal loss of muscle mass and strength appears to lead to negative self-esteem, particularly in men. Middle age appears to be a crucial time for both genders as fears of aging are readily apparent. Baby boomers are reaching middle age at a time when physical beauty and aesthetics are revered more than ever. Social trends and expectations may be setting the stage for an entire generation of people with body image concerns and dissatisfaction.181 Social Factors Social Comparison Social comparison is more common in females than males; however, this fact may be due to the lack of research with males. Magazines presenting beauty and weight advice contribute to internalization of ideals of beauty, thus reinforcing or enabling future behaviors to occur.168 When ideals are not met or present with a discrepancy (see Figure 3), body image dissatisfaction may result.4
Familial Influences As discussed in the previous section, familial influences can weigh heavily on the positive (healthy) or negative (unhealthy) development of body image in adolescents. In some instances, parents may promote a negative body image by enabling unhealthy
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dietary and exercise practices, such as providing money for performance-enhancing supplements or promoting excessive exercise for sport success. In one study, fathers were found to greatly influence their adolescent sons perception of their physical and athletic abilities by the comments made to them.182 Parental criticism, particularly from a parent of the same sex, has been identified as an enabling and reinforcing factor to provoke a child to take action when addressing an aspect related to body image.3 In extreme instances, some parents (usually fathers) have purchased androgenic-anabolic steroids to aid in their sons athletic endeavors.10 To lesser extent, some parents may be enough to provoke action such as dieting practices or drug use.3 Although culture, ethnicity, and social norms could fit into any category among intrapersonal, interpersonal, and social factors, each will be discussed as a social factor to body image dissatisfaction. To properly discuss how body image is impacted by culture, ethnicity, and social norms, these terms must first be systematically defined. Culture may be viewed as, the totality of socially transmitted behavior patterns, arts, beliefs, institution, and all other products of human work and thought.93 Resnicow and Ross,50, p.243 define ethnic identity as, the extent to which individuals identify with and gravitate toward their racial or ethnic group. These factors include racial and ethnic pride, affinity for group culture, attitudes toward majority culture, involvement with group members, attitudes concerning racism and intermarriage issues, and the importance of preservation of ones culture and background.50 Social norms often fall within two categories; descriptive and injunctive. Descriptive social norms indicate the way or manner in which most people act. Injunctive social norms indicate what types of behavior(s) of which
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others approve or disapprove in any given situation.68 The following sections discuss research as it relates to sociocultural perspectives of body image.
Sociocultural Perspectives Caucasian Perspective. Much research with body image has been conducted with Caucasian samples. Results often reflect a bias toward the Caucasian experience, at the expense of understanding others.3 The review of literature up to this point likewise emphasized the Caucasian experience with body image and its constructs. Therefore, little attention in this section will be given to examining the Caucasian perspective with a heavier emphasis being place on others. African American Perspective. There appears to be more flexibility with standards of attractiveness in African Americans than in Caucasians.51 Additionally, African Americans also have greater levels of comfort with body weight and body shape.51,52,53 Having a more tolerant and, oftentimes appreciative perspective of the body suggests lower rates of body dissatisfaction in African Americans.51 This pathway often leads to higher levels of global self-esteem in African Americans than other ethnic groups.51,52,53,183 Research has suggested African American males have higher levels of self-esteem than Caucasian males. Factors directly attributable to body image, however, are not identified.51,52,53 Smith and colleagues183 also found African American males reported more cognitive-behavioral investment (e.g., grooming practices and adornment of jewelry) in their physical appearance than Caucasian males. This process may indicate African American males actively seek to change their appearance for social and self acceptance when compared to Caucasian males.
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Asian American Perspective. Traditional Asian values are commonly referenced as important and influential factors when exploring body image.3 Often described as collectivist, modest, and restrained, these factors play key roles in how Asians perceive their bodies both interpersonally and socioculturally.183,184 Pressure to represent ones family or culture often leads to shame if not achieved.184 Physical appearance is another form of representation Asians ascribe to the collectivist tradition. Perfectionist traits have also been explored in the research literature as a contributing factor to body image pressure and disturbance.184,185 Asian culture also promotes restraint and modesty of emotions to preserve cultural ideals.184 It is insulting to point-out inferiorities of others to promote oneself. These behaviors may appear to be self-effacement in non-Asian society; however, when viewed as modesty, it becomes socially acceptable.184 A problematic issue with modesty likens itself to males not openly disclosing body image concerns.10 Asian culture may preclude people from openly discussing body image concerns and from seeking counseling for such issues. A need for social approval has also predicted eating disturbances in Asians.185 From antiquity, Asian culture often ascribed good health and beauty to corpulence, such as with Buddha and other prominent figures. In contemporary Asian culture, this latter point is no longer applicable. Lee and others186,187 found thinness to be an ideal of both men and women. Asian experiences with body dissatisfaction are less than that of Caucasians, which may be mitigated by cultural differences in food consumption or metabolic differences. Research is lacking exploring body image concern for the Asian male perspective.187
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Research suggests Asians are more apt to seek cosmetic procedures (e.g., eyes) than other ethnic groups.188 Seeking cosmetic interventions may be reflective of Westernization influences on a global economy or simply a sociocultural shift. Racism and stereotyping also predict body image disturbance. Lee and Zahn189 found when compared to other ethnic minority groups, Asian American youth were more inclined to choose to be more Caucasian-like. Pressure to acculturate may lead to disturbances prompting unnecessary cosmetic procedures.188 Hispanic Latino Perspective. With Hispanic/Latino populations growing in the United States,102 it is important to review factors impacting views of body image. The role of family and food are important components defining Hispanic/Latino culture. A strong sense of family and family identification, particularly with maternal identification, pervades Hispanic/Latino culture.190 As with Asian culture, traditional values are strong within Hispanic/Latino communities. Traditional values also incorporate patriarchal dominance, submissive female roles, self-sacrifice, and restraint.191,192 If patriarchal dominance is questioned or threatened, males may react by attempting to re-establish control through a variety of means ranging from violence to body image dissatisfaction. Use of androgenic-anabolic steroids may help to establish a macho image, thereby reinforcing male dominance through muscle.10,191,192 Cultural fatalism is strongly associated with traditional Hispanic Catholic values.191 According to traditional Hispanic/Latino sociocultural views, life is hard and people should accept their fate to achieve their reward in heaven.191 Acculturation also threatens traditional Hispanic/Latino values. Research has explored some Hispanic/Latino males attempts to mirror Western societal values at the expense of their
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own. Acculturation and adolescence increase the likelihood for developing body image disturbances especially in early adolescence.193,194 One hypothesis related to acculturation is that Hispanic/Latino culture is changing with regard to body image. This change may be due to U.S. culture being heavily exported to Latin American countries.191,192 With the adoption of Western ideals related to thinness and muscularity, body image disturbances, as measured in a Brazilian sample regarding eating disorders, has been reported.195 A few points can be taken from research concerning Hispanic/Latino culture; 1. body image has its own cultural components in Hispanic/Latino cultures, 2. acculturation may explain some of the reasons why Hispanic/Latino culture is demonstrating a heavier emphasis on body ideals and, 3. the pervasive media and exportation of Westernized ideals to Latin American countries has led to sociocultural changes in beliefs regarding beauty.191 Homosexuality and Body Image. Men and women in Western society are bombarded with ideals of beauty and how men and women should look to represent this ideal. Lahti196 discussed the disproportionate emphasis on muscularity in gay male communities. Gay males also have been reported to have a disproportionate experience with eating disorders compared to other populations.10,197 Research with male eating disorders suggests, among other factors, that gay males are less satisfied with their bodies than heterosexual males.197 Gay males often go through a preparatory phase (physically) for gay-oriented events, such as rave parties, parades, and other events where exposing body is common.198 Body concern is not surprising considering gay male media and erotica highlight and exaggerate gay mens physical proportions, especially muscles and
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genitals.196 Male fitness models dating back to the 1950s typically show disproportionate muscularity and genitals than average men.196 Magazines, such as The Male Ideal, Physique, and Modern Men are good examples. Data are lacking concerning bisexual orientations. Because bisexuals are attracted to both sexes, pressure to value physical attractiveness at opposite ends of the spectrum may lead to body image concern for both men and women.199,200 Gay males have been touted as looking more feminine than heterosexual men although, there is less of a demarcation between feminine features and attractiveness.201,202 The majority of these studies were conducted in the 1970s and 1980s using collegiate samples thereby limiting generalizability of the results. Females were more likely to rate unattractive males as gay versus others.201,202 These and like stereotypes may contribute to body image and weight concern in these populations. It was found that gay men weigh less than heterosexual men.10,56 When evaluating designs of these studies, it is critical to examine sample selection for weight comparisons. For example, in several studies, older males were recruited and compared to a male collegiate sample. It is well-known that weight gain positively correlates with age, thus, results are not conclusive.83 Well-controlled studies are needed along with longitudinal research designs for both males and females regarding this question.56 Lesbians appear to be less concerned with physical attractiveness than gay males.56 Gay men also show a wider gap between ideal and actual body types, more social pressure to diet, and more public self-consciousness than heterosexual men.10,197,199 To corroborate these findings, Siever200 found heterosexual men versus homosexual men
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had the highest levels of body satisfaction and the lowest levels of body dissatisfaction and concerns about body shape. Overall, inconsistencies in recruiting representative samples and methodological issues, concerning gay and lesbian research issues related to body image have to be carefully evaluated. Sweeping generalizations often promote stereotypic conclusions, which may not be representative of the true underlying concepts. Gay men appear to be more critical of physical appearance and seek-out means to address these concerns through excessive dieting, anabolic steroids, and cosmetic procedures.10,198,199,200 Body dissatisfaction continues to be a probable cause for many body image issues in gay men and less in lesbian women. Moreover, little to no research has explored bisexual male body image concerns.
Media Media and toys present a complex and confusing issue. Research only recently has factored in media influences and toys with their impact on body image and body esteem.9,11,23,24 Media has a significant influence on body image perceptions. Tiggeman and colleagues137 hypothesized body image concerns are predicted by prolonged television exposure. It was concluded that television watching does have an impact on young peoples sense of body image, but the critical aspects are the type of material and motivations for watching, not the total amount of television watched.137 Media pervades the everyday lives of people living in Western society. Whether it is in the form of magazines, newspapers, television, or the Internet, some form of media presents itself on a daily basis. Studies1,3,8 reported that up to 83% of women and girls read womens
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fashion magazines with unknown statistics for men. Television consumption may play an extensive role in developing and, in some cases, maintaining and changing, body images. Tiggeman9 noted, Virtually every home has a television set, switched-on for an average of seven hours per day, with individuals watching three or four hours. Many avenues of influence with respect to media and body image exist. Media content are powerful indicators and conveyors of the sociocultural ideal. Men have been selectively targeted by magazines and advertisements encouraging limitless muscularity and leanness.11 Trends suggest men and boys are gaining on women with respect to body image dissatisfaction. The medias omnipresent depiction of body ideals for both men and women may lead to internalization of such ideals and, ultimately, these ideals of thinness and muscularity become standards to which people judge themselves to be acceptable or not. Appearance has become a core basis of self-evaluation, with self-worth contingent on meeting societal ideals. Studies confirm that social comparison, internalization of body ideals, and investment in appearance are related to body dissatisfaction.3,101 Empirical evidence, such as anecdotal reports, correlational studies of media exposure, and experimental studies of the immediate impact of idealized images exist, suggesting strong effects of media on body image.59 A 1997 survey showed 50% of females and 33% of males reported that very thin or muscular magazine models made them feel insecure and want to lose weight or gain lean muscle mass.59 In various clinical interviews with women (and some men) diagnosed with eating disorders, most made some reference to the impact of fashion models and the magazines in which they appear as a trigger for their eating disorder.203
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Field and colleagues204 conducted a large prospective study (n = 12,000) with 914 year old boys and girls. Results reported media involvement preceded the development of weight concerns. Girls and boys reported making considerable efforts to look like same-sex figures in the media and were more likely to become concerned about their weight and body shape than those who reported less media exposure. These factors also were shown to be predictive in girls for purging on a monthly basis and boys wanting bigger muscles. There are conflicting findings when specific predictor variables are examined. For example, Stice and colleagues205 found a direct link between media exposure and eating disorders, whereas Tiggeman and others206 found less of a direct relationship. Magazine reading, but not television exposure, was related to eating disorder symptomatology, with an opposite pattern for body dissatisfaction.205 Other studies9 have found the content of television watched, not the quantity, was predictive of eating disorders and body image dissatisfaction. Music videos, in particular, may be the most potent sources of negative modeling with high levels of eroticism and sex-role stereotyping of women being excessively thin and males excessively muscular.9,207 Another point of view is that people who are predisposed to body image concerns may seek-out particular media versus the opposite holding true.8 Lastly, the major emphasis on research and media has sought reasons for causation. Controlled experimental designs, where images are presented at timed intervals, have been associated with immediate negative effects as they relate to body image concern. This finding has held true for both adult men and women, although more notably in women. Long-term exposures are difficult to measure and often present with
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small effect sizes. It can be concluded however, that brief exposure to idealized media images does have deleterious short-term effects on mood and body satisfaction.9,76 Exposure may not be a cause itself, but may present enough pressure for an individual already experiencing some level of concern about body weight and shape to be impacted (i.e., triggers). Data on men and boys continues to be less clear-cut.11 Further research is needed to help identify variables that mediate and moderate potentially adverse effects of exposure to idealized media images and to capitalize on these protective factors. It is unlikely, given economic pressures to sell, that media tactics will change. Therefore, alternative strategies to equip children and adolescents with media literacy skills (e.g., product deconstruction) to resist pressures become important.9,10 Younger people need to be able to deconstruct and critically think about what images and messages promote, specifically those glorifying ideals and harmful dietary practices.9
Toys With respect to toys, research suggests 90% of girls aged 3-11 own a Barbie doll. Proportionally, only 1 in 100,000 women measure up to Barbie.142,209 Girls appear to receive stronger, more consistent messages about the need to have an ideal body than males. Limitations of current research include use of predominantly Caucasian female samples. Pope et al.,23 conducted a similar research study using G.I. Joe action figures given that most boys own some form of action figure. Results indicated similar trends in increasing unattainable muscularity in the dolls. Past research has demonstrated a clear link between Barbie dolls and body image issues, and perhaps, future research will show a similar trend in action figures as well. Overall, media and toys play an important role in
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developing body images in boys and girls.23 Further research in this area is warranted to complete the picture as to what degree of influence common childrens toys play in body image satisfaction.
Summary This literature review was divided into three sections. Concepts as they relate to body image and health-related consequences (e.g., body image drug use) were explored in detail. A historical and contemporary overview of each concept was provided. Potential causal factors for adolescent body image dissatisfaction as suggested by current literature were discussed. The role of body image drugs, was explored in terms of how they may relate to poor body image. Theory of intrapersonal, interpersonal, and social factors was presented as they relate to adolescent body image dissatisfaction. Chapter Three presents methods used in the study including research design, instrumentation, data collection, and data analysis techniques.
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CHAPTER 3
Health is not success, but that which permits it ~Author Unknown
Methods The purpose of this research study was twofold: 1. to examine the phenomenon of body image satisfaction based on intrapersonal, interpersonal, and social factors identified in current empirical and theoretical literature, and 2. to identify the strongest predictive interpersonal and social factors of body image dissatisfaction among selected adolescent males. Chapter 3 describes methods used in this study. Each section (Part One and Part Two) are discussed. Part One includes a descriptive component exploring body image satisfaction via systematic content analysis of existing theoretical and empirical literature; Part Two includes a correlational cross-sectional component to identify predictors and associated strength of each predictor with adolescent male body image dissatisfaction. Research design, sample selection, instrument development, data collection, and data analysis are discussed independently for each part. Part One: A Descriptive Study of Body Image Satisfaction Research Design The phenomenon of body image satisfaction exists throughout the lifespan; it is particularly vulnerable, however, during adolescence.5 Literature suggests a direct relationship exists among individual factors (e.g., intrapersonal factors) affecting body image as well as environmental factors (e.g., interpersonal and social factors).3,101 A
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descriptive research design, using content analysis, can be useful in identifying most, if not all, factors associated with a given phenomenon.82 Research Question The following research question was addressed in Part One of this study: What are intrapersonal, interpersonal, and social factors associated with body image dissatisfaction based on a systematic review of existing theoretical and empirical literature? Sample Measuring an entire population is not always possible for a variety of reasons (e.g., time and money). Drawing from a select population to make observations and inferring meaning about the populations characteristics is the ultimate goal of sampling.209 Using theoretical and empirical literature related to adolescent body image encompasses a large number of sources. Providing systematic structure to the review process is essential to construct a valid and reliable understanding of the phenomenon. Body image research encompasses many fields of study.3 Therefore, a purposeful sample of theoretical and empirical literature was chosen from relevant medical, psychological, behavioral, sociological, and health resources. A search for primary literature (years 1990 to 2005), both published and unpublished, was conducted. Considering much of the relevant body image research has been empirically studied since 1990, searches from these years were deemed most appropriate so as to exclude dated work.
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Data Collection Content analysis procedures of existing theoretical and empirical literature were used to determine possible intrapersonal, interpersonal, social factors of body image dissatisfaction. Krippendorff84 advocated for a systems approach when attempting to describe trends, patterns, and differences in research studies. Content of each theoretical and empirical study were classified according to meaning(s) and a count of frequencies in which concepts or groups identified in the text will be generated.84,210 In this study, text was coded, or broken down, into manageable categories on a variety of levels, such as words, word sense, phrase, sentence, or theme, and examined using one of content analysis' basic methods: conceptual analysis.84,211 Accordingly, a defined set of rules and limits (see Appendix B) have been developed to maintain objectivity in the coding of literature. References to body image dissatisfaction and adolescent body image, were entered into the following databases: Health Source Nursing/Academic Edition, SocINDEX (Index of Sociology), PsychINFO (Psychology Information), CINAHL (Cumulative Index of Nursing and Allied Health Literature), MEDLINE, Nursing and Allied Health Collection, SPORTDiscus, PubMed, and ERIC (Education Resources Information Center). The following section discusses how coding procedures were implemented in this study. a. The Coding Unit: Frequencies were examined and organized into a single recording unit. For theoretical studies, each intrapersonal, interpersonal, and social factor associated with body image dissatisfaction were weighed equally. For empirical research, each
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intrapersonal, interpersonal, and social factor reported as statistically significant (p <.05) was counted and weighed equally. b. Code Categories: Categories generated should reflect the purposes of the study as well as the research question(s). Focus should be geared toward looking at the occurrence of selected terms within a text or texts, such as body image, body image dissatisfaction, and body dysmorphia. Terms may be implicit as well as explicit. Explicit terms are easily identifiable (e.g., self-esteem), whereas coding for implicit terms and deciding their level of implication is complicated by the need to base judgments on a somewhat subjective system (e.g., body satisfaction based on a continuum). Attempts to limit subjectivity, and keeping to within limits of reliable and valid measures, involves using either a specialized dictionary or contextual translation rules.211 Although various categories can be generated, three primary categories were used for this content analysis focusing on intrapersonal, interpersonal, and social factors. Other categories, such as research design and methods were tracked to account for any trends in the literature. Operational definitions for each category have been outlined and may be found in Appendix B. c. Design of Data Collection Forms: Data collection forms (see Appendix B) were developed to facilitate a valid and reliable content analysis of the literature. Forms contain all relevant information related to the phenomenon of study. Data collection sheets provide space to record coding information for categories 1 19. Although a hard copy of this
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form was generated, all data from each content analysis were entered in a computer-based file (i.e., Microsoft Excel, Microsoft Corporation, 2007) for ease of retrieval. d. Microsoft Excel Files: (Microsoft Corporation, 2007) Database files were created from the content analysis using Microsoft Excel on a PC-based platform. Database files were identical to hard copy forms found in Appendix B. Files were entered and stored using this program for ease of retrieval, storage, and modification. Each study in Part One was identified as theoretically or empirically-based. An identification tag designated as T# and E#, was used to track each study. e. Testing of Coding Process: To assure reliability of content analysis coding procedures, an analysis of 2% of randomly selected studies using the data collection forms detailed previously, was conducted by the researcher (intra-rater reliability) as well as another health education professional familiar with content analysis (inter-rater reliability). The researcher re-coded each study and examined the percent agreement to establish reliability. f. Theoretical and Empirical Research Content Analysis: Content analysis was performed on theoretical and empirical studies identified in a database search through Southern Illinois Universitys Morris Library database system. A category was chosen (e.g., health behavioral sciences) and the relevant database(s) were selected for review. Upon selection of categories, the following search entries, adolescent body
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image, and body image dissatisfaction, were entered into the database search fields. All related search results were identified, marked, and saved electronically either as a Microsoft Word or Adobe Acrobat (PDF) (Adobe Systems, Inc., 2007) file. Each subsequent file was downloaded and printed as a hard copy. All nonelectronic files were physically sought-out at Morris Library, photocopied, and included in the content analysis. Articles not directly accessible were obtained through interlibrary loan. g. Revisions to the Coding Process: Revisions to the coding process were warranted as determined by the dissertation committee Chairperson, other committee members, and the researcher. h. Coding of Text: All written works in library and database searches were assigned identification numbers. Title and year of the work as well as source and document type were recorded for the entire sample. A decision regarding usefulness of the study was made prior to progressing to further coding. Purpose and results of each study (if applicable) were recorded for each piece of work. If a study was excluded from the sample, a brief description of this decision was recorded on the data collection form (see Appendix B). Intrapersonal, interpersonal, and social factors related to adolescent male body image were identified and numerically coded for both theoretical and empirical studies. For example, a theoretical study identifying intrapersonal factors would be noted as, TINTRA1TINTRA2TINTRA3,
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whereas an empirical study found to identify interpersonal factors was coded as, EINTER1EINTER2EINTER3. Research design, sample size, sample age, sample characteristics, geographic location, body image instrument(s) used, and statistical method(s) were numerically coded for empirical studies only. Each factor was assigned a code number. Additional codes were assigned to unforeseen categories as needed. Coding was not weighted. Coding guidelines and each numerical code are found in Appendix B. Data Analysis In this study, conceptual content analysis was deemed most appropriate. A concept (or theme) was chosen for examination and was quantified and tallied for its presence.84 Use of content analysis allows for more stringent guidelines when evaluating various written works. Content analysis ultimately allows for greater validity and reliability of results when conducted within a systematic process.84 Content analysis is the study of recorded human communications.85,212 Additionally, content analysis is characterized as a research technique for making replicable and valid inferences from data to their context.84 Content analysis is a process of organizing and integrating narrative qualitative information according to themes and concepts.213 Many topics are well-suited when answering classic questions such as, Who says what, to whom, why, how, and with what effect?212, p.305 Being that adolescent body image is a multidimensional phenomenon; researchers often search for answers to these aforementioned questions.4
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It would be impractical to identify all parts of a communication; therefore, units of analysis (e.g., specific parts of the text or manuscript) are preferred when conducting a content analysis.85,212 When themes or concepts are to be identified, all possible (and reasonable) sources may be considered, such as books, articles, pages, paragraphs, or even simple lines of text.212 Extensive or simple data recording sheets (see Appendix B) often are employed to simplify the task of systematically reviewing and recording relevant information.212 Common units of analyses are the size of an article, individual words or themes, and sometimes items. Space and time measures may also be included in the unit of analysis. Additionally, content analysis methods can be applied to nearly every piece of written work.85,212 Methodology is detail-oriented, but unlike strictly qualitative designs, content analysis has external validity as a goal.210 This section presents a brief overview of content analysis, types, applications, and concerns for internal and external validity. Babbie212, p.309 describes content analysis as a coding operation. Raw data is transformed into a standardized form. For example, there are several constructs consistent with body image (self-esteem, satisfaction, and body awareness); therefore, coding helps identify frequencies and commonalities of category tags.85,212 Two basic forms of coding are manifest and latent. Manifest content is superficial or visible surface content, which is how often something appears or is discussed. Latent content conveys an underlying meaning.212 This study primarily focused on manifest content of communications concerning body image. A detailed description of coding processes, category, category tags, and other record tasks are presented and discussed in detail in Appendix B.
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The strongest advantage of content analysis is the ability to merge both quantitative and qualitative data into meaningful formats.213 Krippendorff84 noted basic advantages to content analysis including: its unobtrusive technique, its acceptance of unstructured material, its context sensitivity, and its ability to deal with large volumes of data. Content analysis is economical in terms of time and money. Access to the material is the primary consideration when approaching this method of inquiry.212 Additionally, if an area of the analysis is performed incorrectly, it can be redone with re-coding and with minimal cost or loss of data as with other methods of study (e.g., true experimental or field research).212 With the strengths of content analysis also come the weaknesses. Weaknesses include: examination of only recorded information, validity may be limited (as with any research); however, reliability is generally well-established.212 Subjectivity is always a potential issue regarding this method of analysis.213 To establish reliability in the coding process, agreement must be reached by different coders or through multiple re-coding by the primary researcher (i.e., inter-rater and intra-rater reliability). For each coded category, descriptive statistics, frequencies, and percentages of specific factors associated with body image (e.g., self-esteem), and body image dissatisfaction were calculated. Selected studies concerning body image, adolescent body image, and body image dissatisfaction were examined. Data from Part One was used to develop items to measure relevant and applicable intrapersonal, interpersonal, and social factors for inclusion in the Adolescent Body Image Satisfaction Scale (ABISS). The intent of the descriptive section of this study was to identify significant intrapersonal, interpersonal, and social factors as they relate to body image
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dissatisfaction. Significance was classified as appearing multiple times in theoretical literature and/or empirical studies having statistical significance. Understanding and identifying factors that: 1. contribute to body image development within the individual (i.e., intrapersonal factors), 2. are influenced by relationships (i.e., interpersonal factors), and 3. environmentally reinforce and allow for behaviors to persist (i.e., social factors), establishes the need for performing a content analysis of body image dissatisfaction. Relevant and measurable factors were included in the Adolescent Body Image Satisfaction Scale (ABISS). Items pertaining to these factors (i.e., intrapersonal, interpersonal, social factor) also were developed from previous well-established instruments. Results from the content analysis answered the research question posed for Part One of this study, What are intrapersonal, interpersonal, and social factors associated with body image dissatisfaction based on a systematic review of existing theoretical and empirical literature?
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Part Two: A Correlational Cross-sectional Study of Adolescent Male Body Image Dissatisfaction Research Design Cross-sectional Designs A correlational cross-sectional design was used for Part Two of this study. Correlational methods can be used to identify strengths of relationships among identified factors.73,214 Research questions can be verified or refuted through these measures.209 Additionally, multiple regression allows for predictive factors of a phenomenon to be espoused.73,214 One or more dependent variables may be selected as possible predictors and existing data are examined to determine possible strengths of relationships among all possible factors under study in an ex post facto design.73 Cross-sectional research allows for participants to be assessed during a single period in their lives.73 Cross-sectional research designs are effective means to gather a snap shot of a participants affect; however, stronger designs (e.g., longitudinal or prospective) are desirable when attempting to track effects over time.73 Arnold et al.,215, p.17 note, At one point in time the subjects are assessed to determine whether they were exposed to the relevant agent and whether they have the outcome of interest. Some of the subjects will not have been exposed nor have the outcome of interest. This clearly distinguishes this type of study from other observational studies (cohort and case controlled) where reference to either exposure and/or outcome is made. A crosssectional approach is an efficient (i.e., time and cost) method by which to study
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adolescent male body image dissatisfaction. Assuming all sampling criteria are met as previously discussed, valid and reliable results can be attained.
Correlational Design Based on several factors measured, strength of various predictors were determined. Due to the complex nature of factors affecting body image satisfaction, correlational designs allow for stronger measures of association than other methods, such as experimental designs.73 Correlational designs are limited in that they lack establishing cause-effect relationships; however, they aim to determine measures of association (e.g., what goes with what).73 With such a large number of independent variables potentially affecting adolescent body image dissatisfaction, this method allowed for the most efficient assessment of adolescent body image dissatisfaction. Ultimately, this research design sought to identify modifiable body image factors (interpersonal and social) for future curriculum planning and interventions.
Research Question The following research question were addressed in Part Two of this study: Which interpersonal and social factors are the strongest predictors of selected adolescent male body image dissatisfaction?
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Instrument Development Draft of the Adolescent body Image Satisfaction Scale Many instruments have been developed to measure body image in a variety of populations. For instance, Cash3 developed multiple surveys addressing body image satisfaction, such as the Body Image Ideals Questionnaire (BIQ), Body Image Disturbance Questionnaire (BIDQ), and the Body Image States Scale (BISS). Others have addressed body image concerning disfigurement,154,165,172 dermatology,152,153 and, aging.179,180,216,217 Available instruments have been scrutinized as they pertain to adolescent body image attitudes and resultant behaviors. However, no one instrument captures adolescent male body image dissatisfaction. To date, an instrument measuring adolescent male body image dissatisfaction in high school age ranges does not exist. Sections and specific items in various surveys relate to measures of adolescent body image; however, no full-scale survey exists. Modifications of original surveys would dramatically alter validity and reliability scores. Therefore, there is a need to develop an age-appropriate survey to measure male adolescent body image dissatisfaction. A draft of the ABISS was developed from existing literature and previous instruments measuring body image satisfaction. Items were added to this draft based on results from the content analysis in Part One of this study. Added items are discussed in the following section.
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The Adolescent Body Image Satisfaction Scale with Added Items The Adolescent Body Image Satisfaction Scale (ABISS) is an instrument developed from well-established body image surveys and questionnaires (e.g., Body Image Disturbance Questionnaire,3 Body Image Questionnaire,82,101 Multidimensional Body Self-Relations Questionnaire3,101), as well as from recent work by Leone and Partridge.218 Included in the ABISS are three primary sections focused on assessing adolescent body image. Intrapersonal, interpersonal, and social factors concerning male adolescent body image dissatisfaction were ascertained from in Part Ones content analysis. Finally, a section to elicit participant demographic information was included. Section I, the ABISS (see Appendix E) consists of 50-items measuring various aspects of body image dissatisfaction (adjusted to 32 items following pilot testing). The scale examines intrapersonal factors potentially impacting body image for the positive or negative. A series of four options using a Likert-type scale, (i.e., strongly agree to strongly disagree) is presented. Because body image exists on a continuum (i.e., positive and healthy to negative and unhealthy), a range of responses are possible for each section and for the overall instrument. For instance, each question is assigned an inherent value of positivity or negativity. Example: I am satisfied with my body weight. SD 4 D 3 A 2 SA 1 [Likert scale options] [inherent values]
In this case, if the participant responds with disagree or strongly disagree, a value of 3 or 4 will correspond to a pre-determined rating of dissatisfaction, whereas agree or strongly agree corresponds with a value of satisfaction. Questions were
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worded both positively and negatively so as to establish split-half reliability of the instrument. Selected items were re-coded (i.e., reverse coded), based on wording. For example, I am satisfied with my body, on a Likert scale of agree, somewhat agree, somewhat disagree, and disagree would range from 1 through 4. A score of 3 or 4 would likely indicate dissatisfaction, with 1 or 2 representing satisfaction. The same question worded oppositely, I am dissatisfied with my body, was reverse coded with agree being scored as 4 and disagree being scored as 1. The ABISS is summed and a total dissatisfaction score is determined. Body image dissatisfaction scores can range from 65 to 128. Scores below 65 indicate a relatively positive body image. Scores of 65-86 indicate mild body image dissatisfaction, 87-108 moderate body image dissatisfaction, and 109-128 indicate strong body image dissatisfaction. Section two presents questions concerning interpersonal and social factors potentially contributing to a negative body image. Items were added based on results from the content analysis in Part One of this study. Section three assesses demographic and background items as they relate to adolescent male body image dissatisfaction scores. Sections two and three use the same Likert scale scoring system as section one, however, scores were summed as in section one. Results from sections two and three were correlated to body image dissatisfaction scores in section one (i.e., the ABISS). Multiple regressions were run on each factor in sections two and three to determine the strongest predictors of adolescent male body image dissatisfaction. Ultimately, the ABISS provides an instrument geared toward measuring adolescent male global body image.
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A valid and reliable measure of adolescent body image satisfaction and related behaviors (i.e., the ABISS) provides health educators, psychologists, social workers, and school administrators with a standard by which to measure and evaluate student needs and program policies.
Expert Panel Review The ABISS was reviewed by an expert panel. The panel included two health educators with backgrounds in instrument psychometrics, two clinical psychologists with backgrounds in clinical survey administration, and one health educator with a background in adolescent health. Comments as well as question agreement (i.e., to keep or omit items) factors were solicited from this panel. The ABISS evaluation form (see Appendix E) was provided to expedite the panel review process. The evaluation form lists the section and question number, options to retain, retain with revisions, and omit various survey items, and a section for open-ended comments. Comments were evaluated by the researcher and adjustments to the ABISS were made as needed. In terms of retaining or omitting of items, agreement of four out of the five panel experts (80%) must have been met. Human Subjects Review According to the U.S. Department of Health and Human Services, all studies using human subjects must be reviewed and approved by a Human Subjects Review Board before testing. Prior to administration of any surveys or meetings, appropriate human subjects approval was granted by Southern Illinois University Carbondales Institutional Review Boards Human Subjects Review Committee.
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Pilot Testing Following SIUC Human Subjects Committee approval, and prior to administration of the ABISS, a pilot test was conducted to identify and address potential problems with the survey, data collection procedures, and/or data analyses. Pilot testing is valuable in determining issues with language, readability, and the approximate time to complete the survey.219 Some items included in the survey address potentially sensitive topics about ones body; therefore, potential existed for some participants to be offended, which may lead to unanswered items. To account for this possibility and to minimize omission of questions due to content, feedback from the pilot study helped adjust, reword, or omit any items deemed inappropriate. Students included in the pilot study were afforded the opportunity to critically examine each item and provide subjective feedback about the survey. After administration of the survey, the researcher was available for student questions and open discussion regarding the survey. The instrument was pilot tested with a sample (n = 27) of 9th through 12th graders from a local area high school within the New England region. Initial contact with the high school administrator was made through telephone calls and followed-up with a confirmation letter. Following approval from the school administrator, a date and time were established when the survey could be administered. Administration took place on one day; therefore, students not present during the day of the survey, were excluded from the pilot test. Additionally, prior to administration of the survey, a cover letter, parental informed consent form, and student/minor assent form to participate were made available and sent home with the student (see Appendix G for samples of these forms). Only students providing informed consent and minor assent forms were permitted to take the
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survey, all others were temporarily excused from the classroom along with female students for a scheduled activity period. Students aged 18 and older filled-out and returned an informed consent form to the researcher. Surveys were administered by the researcher on a pre-determined date and time (see pilot study procedures in Appendix F). This strategy of administration assured consistency in following procedures. A brief script (see Appendix F) was read to the participants followed by collection of the consent forms and lastly, administration of the survey. Time was allotted for qualitative verbal feedback. Surveys were collected in an unmarked envelope. To help assure honest responses, all forms and surveys were anonymous. Students were provided a blank sheet to cover their answers during survey administration. Data were tabulated and examined for content errors, wording, readability and language, and any other comments to enhance instrument validity. Appropriate modifications were made to the survey prior to re-administration. Upon approval from the dissertation committee, the main study was conducted using a randomized sample of 9th through 12th graders using a standardized database listing (for study procedures, see Appendix G). Readability The Adolescent Body Image Satisfaction Scale (ABISS) was designed to be completed by students who are literate in the English language. Careful planning and attention to the reading level was assessed using the Fleisch Reading Ease scale and the Fleisch-Kincaid Grade Level formula. The Fleisch Reading Ease score rates text on a 100-point scale; the higher the score, the easier it is to understand the document. Most documents aim to score in the range of 60 to 70. The draft ABISS scored a 70.4 using the
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Fleisch Reading Ease score, with the overall instrument scoring 62.7. The FleischKincaid Grade Level score rates text according to school grade levels (in the United States). For example, a score of 6.0 would indicate that a sixth grader could read and understand the text. For purposes of this study, a reading level of 7th grade will be most appropriate. Most documents aim to score between a 7.0 to 8.0 level.220 The score of the ABISS was determined to be acceptable at a 6.6 level. Readability statistics are used to assist the researcher in determining the ageappropriateness of the document. Surveys and other documents should be as close to the intended sample reading level to assure reliable and valid responses.219,220 In addition to readability statistics, participants also had the ability to qualitatively comment on the ABISS during pilot testing. Modifications were made on an as-needed basis. Reliability Reliability measures consistency, dependability, reproducibility, or repeatability of tests scores of data.88,215,221 Any measure is comprised of a true score and its error according to classical measurement theory.221 A reliable survey holds these factors true. When close agreement of the same phenomenon exists among several measurements, reliability of the procedures, instrument, or research will be high.215 High levels of reliability are critically important in research due to the nature of the dependability of data results. With these points in mind, the Adolescent Body Image Satisfaction Scale (ABISS) satisfied these aforementioned criteria. Reliability of the instrument was established via pilot testing and internal consistency measures (e.g., Cronbachs alpha coefficient) for specific subscales and the survey as a whole.
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Various measures of reliability are available including: stability, equivalence, and internal consistency.222 The focus of the ABISS was internal consistency of sections as well as overall instrument reliability. Internal consistency calculates the average correlation among items in an instrument, seeing how well they hang together in showing relationships with one another.222, p.139 For measures of internal consistency, Cronbachs alpha () coefficient is an appropriate estimate of reliability. Total instrument test-item correlations and Cronbachs alpha scores were calculated for both the pilot test and the actual study sample and are presented in Chapter 4. Validity Validity indicates how well an instrument measures what is intended to be measured.72,88 To establish validity of the ABISS, face and content validity were assessed. Face validity assesses whether an instruments characteristics appear to measure the intended constructs and appear to be appropriate for the intended audience/sample. Comments and feedback from the pilot study sample as well as panel experts helped to establish face validity for the ABISS. Content validity is the degree to which a survey covers the range of responses related to a concept or phenomenon which was accounted for via Part Ones content analysis as well as feedback from the expert panel holding the aforementioned criteria constant.88 Main Study The main study used a random sample of (n = 330) adolescent males in grades 9 through 12. Participants were recruited from lists generated from an independent market research firm located in the New England region. The ABISS and related forms were
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mailed to the participants along with a return postage-paid envelope. Surveys were processed anonymously by the market research firm and forwarded to the researcher for coding and data analysis. Sample A sample (n = 330) of adolescent males in grades 9 through 12 were invited to participate in this research study. Power analyses concerning the database sample were used to determine overall acceptable sample size. Random database lists were generated by a market research firm in the New England region. Parents of males in grades 9 through 12 were contacted via telephone. Study procedures first were explained to the parent and then the child. Upon verbal consent from the parent and child, the ABISS survey, consent forms, and instructions were mailed to the specified address of the participant. For detailed procedures, refer to Appendix G. Sampling continued until the appropriate sample size had been met.
Data Collection The dependent variable in Part Two was adolescent male body image dissatisfaction. This variable was measured using the Adolescent Body Image Satisfaction Scale (ABISS). A random sample (n = 330) of adolescent males in grades 9 through 12 was solicited from a database through a market research firm in the New England region. A recruiter contacted households from lists indicating a male child in 9th through 12th grade. A structured script (see Appendix I) was first read to the parent and then to the child, describing details of the study. After obtaining verbal parental and minor assent, an accurate mailing address was confirmed with the participant. The market
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research firm mailed the following; (1) parental consent form, (1) minor assent form, (1) set of instructions, and (1) ABISS survey in addition to a self-addressed stamped envelope to return the survey. Quota sheets helped to assure reasonable sampling of the region. Tally sheets also were used to track results of the recruiting process (see Appendix I). Participants were asked to mail their survey and consent and assent forms directly to the market research firm for processing in the provided self-addressed stamped envelope. Upon receipt of the return envelope, a market research firm employee removed the unique tracking code from the ABISS survey, so as to maintain participant anonymity. Parental consent and minor assent forms were separated from the surveys as well. Once all forms and surveys were received, the market research firm mailed a $5 honorarium to the participant along with a letter of thanks. Copies of all letters and communications may be found in Appendix C. In addition to the $5 honorarium participants were informed of a chance to win one of five $50 gift certificates to Best Buy at the conclusion of the study. Completed surveys were forwarded to the researcher for coding and data analysis. All surveys had to be accompanied by the appropriate consent forms (i.e., parental consent and minor assent if under 18 years old or informed consent if 18 years old or older) and not have any identifiable markings on them. Honoraria were not processed for any survey not meeting these guidelines, which was also indicated in the instructions to the participants. Missing data was handled on a case-by-case basis. Surveys deemed unusable were excluded from the sample; however, surveys missing some items (three or
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less) included in the overall sample at the discretion of the researcher using appropriate statistical substitution techniques. Data Analysis Correlational Analysis Investigation into the extent to which variations in one factor correspond with variations in one or more factors is the primary goal of correlational analysis.73 Correspondence between one factor and another is determined by correlation coefficients, which in turn indicate a certain weight associated with them.73,88 The correlation coefficient (r), which is commonly referred to Pearsons r, summarizes both magnitude and direction of the linear relationship between two variables. According to Isaac and Michael,73 designs using correlational analysis bear certain characteristics unique to other research designs. This research design is appropriate where variables are complex and may not lend themselves to experimental or controlled manipulation of the variables (e.g., global body image). Measurement of several variables and their interrelationships simultaneously in a realistic setting is another attribute of correlational designs and analysis.73 Research concerning body image often uses correlational designs to explain the interrelationships among a host of factors. For instance, Tiggeman et al.,9 sought to determine the relationship between television consumption and level of body image dissatisfaction. In this example, correlational methods are most appropriate when trying to parse out extraneous factors not related to the phenomenon of study. In another example, Kostanski et al.,223 used correlational methods to identify male and female child
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and adolescent dissatisfaction with body image holding independent variables, such as Body Mass Index, as a predictor. In this research, specific factors (e.g., interpersonal and social factors), were tested for correlations concerning body image dissatisfaction assessed via intrapersonal factors. For instance, an interpersonal factor, such as teasing was analyzed for correlation to other factors, such as bullying to be better able to predict body image dissatisfaction. Among some limitations of correlational research are: lack of establishing cause and effect, less rigor than true experimental designs due to less control over variables, predisposition to identify spurious or random relation patterns, which have little to no reliability and validity, relational patterns that can be arbitrary or ambiguous, and lastly, correlational designs have been term shot-gun approaches which may limit meaningful or useful interpretation of data when careful planning is not undertaken.73
Multiple Regression In the context of body image research, several factors (or predictors) are involved in a persons perception of their body image at any given point in time. To more clearly identify relationships between multiple predictors and the criterion (i.e., body image dissatisfaction), multiple regression is used instead of simple regression.88 Utility of using multiple regression is when research attempts to find the best predictors of a variable. Data from the ABISS were coded and analyzed using the Statistical Package for the Social Sciences software, (SPSS version 14.0, SPSS Inc., Chicago, IL). Descriptive statistics, including frequencies, percentages, and measures of central tendency and dispersion were calculated for each independent variable, body image dissatisfaction
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scale score, and for combined interpersonal and social scores. Pearson r coefficients were calculated among subscale scores and combined body image dissatisfaction scores. Multiple regression was used to test for predictors of adolescent male body image dissatisfaction. The strongest predictors were determined by correlation coefficients for each independent variable. Independent variables were dummy-coded prior to running analyses to simplify the process and to allow for ease of interpretation of results. All levels of significance were set a priori at <.05. Results were able to address the research questions posed previously in this section (see Table 7). Table 7. Data Analysis Methods for Parts One and Two
Research Question Part One What are intrapersonal, Factor (Variable) Analysis Method(s)
interpersonal, and social factors associated with body

image dissatisfaction based on a systematic review of existing theoretical and empirical literature? Part Two
Body Image Dissatisfaction (D) Intrapersonal Factors (I) Interpersonal Factors (I) Social Factors (I)
Content Analysis
Which interpersonal and social factors are the strongest predictors of selected male adolescent body image dissatisfaction?
(I)= Independent Variable (D)= Dependent Variable
Adolescent male body image dissatisfaction (D) Interpersonal Factors (I) Social Factors (I)
Multiple Regression Correlation Analysis
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Summary Chapter 3 provided an explanation of the methods and procedures used in this study. A descriptive as well as a correlational cross-sectional research design was used to predict interpersonal and social factors attributable to adolescent male body image dissatisfaction. Part One used content analysis to identify pertinent variables of body image dissatisfaction and was used to develop the Adolescent Body Image Satisfaction Scale (ABISS). Part Two tested the strongest predictors of this phenomenon using the ABISS. The sample included male students in grades 9 through 12 from the New England region. Survey questions were pilot tested for measures of reliability, validity, procedural errors, content errors, and readability prior to administration. Data were compiled and analyzed using correlational and multiple regression statistical techniques. Chapter 4 presents the results of this study. Chapter 5 will discuss the results and conclusions, and present recommendation for future research based on the study.
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CHAPTER 4 RESULTS OF THE STUDY

Never regard study as a duty, but as the enviable opportunity to learn to know the liberating influence of beauty in the realm of the spirit for your own personal joy and to the profit of the community to which your later work belongs. ~Albert Einstein
The purposes of this research study were twofold: 1. to examine the phenomenon of body image satisfaction based on intrapersonal, interpersonal, and social factors identified in current empirical and theoretical literature, and 2. to identify the strongest predictive interpersonal and social factors of body image dissatisfaction among selected adolescent males. The findings presented in this chapter are divided into two parts. Part One includes results of the descriptive study of body image satisfaction based on intrapersonal, interpersonal, and social factors identified in current empirical and theoretical literature. Part Two presents results of the correlational cross-sectional study of adolescent male body image dissatisfaction.
Part One: A Descriptive Study of Body Image Satisfaction Part One of this study was designed to answer the research question: what comprises the phenomenon of body image satisfaction based on an exploration of intrapersonal, interpersonal, and social factors identified in current empirical and theoretical literature? Results have been divided into four sections. The first section discusses changes in coding procedures after pre-testing. The second section discusses the selection and description of the sample. The third section describes the sample of written works included in the content analysis and presents findings of the overall content
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analysis concerning body image satisfaction. The final section presents and discusses intra-rater and inter-rater reliability of the content analysis.
Pre-testing of Coding Procedures A selection of first ten works from a variety of journals was chosen to pre-test coding categories and procedures using Microsoft Excel. Attention was paid to appropriateness of categories, methods in identifying themes from operational definitions, order of categories, and additional coding processes for statistical analysis. The following changes were adopted for the content analysis data collection procedures: 1. In addition to the letter codes used to identify the type or category of study (i.e., theoretical, empirical, unknown, etc.), a numerical code was added to expedite coding for analysis of frequencies. For example, a theoretical study would be labeled as T with the associated number (e.g., T34). To identify this theoretical work for analysis, a code of 2 was added and so forth for other categories. 2. Seven of the ten works selected for pre-testing included a non-specific sample description in terms of gender breakdown. Based on this finding, all subsequent sample sizes were recorded as an overall sample versus a breakdown of gender. 3. In addition to the previously identified geographic categories, three of the ten works selected for pre-testing indicated an international sample. Based on this
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finding, an additional category labeled, international sample was included in the coding procedures. 4. Operational definitions of body image in all coded studies had to include a statement that the classification of a definition of this term was in fact a definition from a referenced source. 5. Classification of intrapersonal, interpersonal, and social factors was established to encompass one term or concept per category. For example, support may be identified as an intrapersonal experience, interpersonal factor, or as a social construct. For purposes of this research, once a factor was identified, it was placed in one category only at the discretion of the researcher. This was established to avoid overlap of information among categories. 6. It was decided that the Other Factors category would only be recorded and not numerically coded. Following pre-test coding of categories and procedures, ten selected works were re-coded according to the new changes and included in the total sample. Categories, category classifications, and coding guidelines adjusted to reflect pre-testing changes, are found in Appendix B. Selection and Description of the Sample An online and manual search of academic databases was conducted. Nine academic databases including: Health Source Nursing/Academic Edition, SocINDEX (Index of Sociology), PsychINFO (Psychology Information), CINAHL (Cumulative Index of Nursing and Allied Health Literature), MEDLINE, Nursing and Allied Health
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Collection, SPORTDiscus, PubMed, and ERIC (Education Resources Information Center) were searched using the following identifiers, body image dissatisfaction, and adolescent body image dissatisfaction. Additional limiters were set for the years 1990 through 2005. These years were deemed most appropriate because of the wealth of developmental research on body image during this period. A total of 938 works were identified from all nine academic databases. The majority (26.8%) of studies were identified in PubMed followed by, MEDLINE (19.0%), PsychINFO (13.5%), CINAHL (11.0%), Nursing and Allied Health Collection (7.5%), SocINDEX (7.2%), ERIC (6.5%), SPORTDiscus (4.6%), and Health Source Nursing/Academic Edition (3.9%). Following the primary search, all files were copied into a Microsoft Excel database and a search for duplicate studies was conducted using the memory function. Two-hundred thirty-one studies were found to be duplicates resulting in a new sample size of (n = 707). Works were then analyzed for relevance to the research and research questions resulting in the exclusion of 401 studies and a new sample size of (n = 306). Lastly, 13 studies were excluded due to other reasons, such as book reviews or reviews of literature. Therefore, (n = 293) studies were included in the final sample. Empirical studies comprised 83.3% (n = 244) of the sample with 16.7% (n = 49) originating from theoretical sources. The majority of studies (n = 140) or 47.8% originated from psychological sources. Medical sources comprised 22.2% (n = 65) followed by health sources 16.7% (n = 49), social sciences 12.3% (n = 36), and 1.0% (n = 3) were unknown. Number and percentages of all publication sources in the coded sample are found in Table 8.
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Table 8. Frequencies and Percentages of Different Journals in Each Field of Research in the Coded Sample. Field of Research Number and Percentage of Journals in Coded Sample (n = 293) Psychology 140 (47.8) Medicine 65 (22.2) Health 49 (16.7) Social Science 36 (12.3) Unknown 3 (1.0) Totals 293 (100.0)
A total of 121 academic journals were represented in this sample. All works were available via online academic databases in a downloadable form, as a hardcopy located in Southern Illinois University Carbondales Morris Library, or through Interlibrary Loan services. The International Journal of Eating Disorders was the source of the majority of coded studies at 19.5% (n = 57) followed by the Journal of Adolescent Health 4.8% (n = 14). Table 9 presents journals comprising 1% or more of the overall sample. The type of document (DOC) from each journal was coded resulting in the majority 90.8% (n = 266) representing journal articles. Other types of documents are presented in Table 10. Reasons for exclusion of documents (n = 13) of the coded sample included other (38.4%), duplicate work 23.1%, review of the literature 23.1%, and irrelevant to the content of the research 15.4%.
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Table 9. Frequencies and Percentages of Journal Sources Included in the Overall Sample Journal Source of Publication* Number and Percentage of Journals in Coded Sample (n = 293) International Journal of Eating Disorders 57 (19.5) Perceptual and Motor Skills 16 (5.5) Journal of Adolescent Health 14 (4.8) Adolescence 9 (3.1) Journal of Youth and Adolescence 7 (2.4) Journal of Psychosomatic Research 7 (2.4) Eating and Weight Disorders 6 (2.0) Obesity Research 5 (1.7) Sex Roles 5 (1.7) Eating Behaviors 4 (1.4) Journal of Personality Assessment 4 (1.4) Journal of Psychology 4 (1.4) Journal of Psychology and Child Psychiatry 4 (1.4) Developmental Psychology 4 (1.4) Australian Journal of Psychology 4 (1.4) Journal of Nutrition Education and Behavior 3 (1.0) Body Image 3 (1.0) Pediatrics 3 (1.0) Clinical Child Psychology and Psychiatry 3 (1.0) Psychotherapy and Psychosomatics 3 (1.0) Social Behavior and Personality: An 3 (1.0) International Journal * Table includes those journals comprising 1% or more of the coded sample. Table 10. Frequencies and Percentages of Document Type in Coded Sample Document Type Frequency of Written Works and Percent of Coded Sample (n = 293) Journal Article 266 (90.8) Research Report 15 (5.1) Meeting Abstract or Conference Proceedings 4 (1.4) Critique of Previous Research 2 (0.7) Dissertation or Thesis 2 (0.7) Edited Book 1 (0.3) Letter 1 (0.3) Editorial 1 (0.3) Unpublished Paper 1 (0.3.) Total Sample 293 (100.0)
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Theoretical and empirical studies identified in the database and library search were published between 1990 and 2005. In the coded sample, 25.9% (n = 76) were written or published in 2005 followed by 17.7% (n = 52) in 2004, 11.6% (n = 34) in 2001, and 11.3% (n = 33) in 2002. Years of publication are found in Table 11. Table 11. Frequency and Percent of Year of Publication in Coded Sample Year of Publication* Number Coded (Percent of Coded Sample) (n = 293) 2005 76 (25.9) 2004 52 (17.7) 2003 27 (9.2) 2002 33 (11.3) 2001 34 (11.6) 2000 24 (8.2) 1999 10 (3.4) 1998 8 (2.7) 1997 6 (2.0) 1996 6 (2.0) 1995 5 (1.7) 1993 6 (2.0) 1992 2 (0.7) 1991 2 (0.7) 1990 2 (0.7) * Year 1990 did not include any coded works in the sample. Content Analysis Findings Operational Definition of Body Image Operational definitions of body image used by author(s) of theoretical and empirical studies were coded. Definition of the term body image had to meet pre-existing criteria of being a referenced definition prior to inclusion for coding. Reviews of literature prompted creation of ten distinct operational definitions of body image. Work
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without a referenced definition of body image or where body image was not identified was coded as E0 or T0. Ten operational definitions of body image were identified and coded. Body image was discussed as, sociocultural and intrapersonal factors impacting ones view of the body, in 16.7% (n = 49) of the studies. In 47 studies (16.0%), body image was discussed as, an affective consequence of body-esteem and sociocultural influences. Forty studies (13.7%) operationalized body image as, consisting of global components including selfesteem and body-esteem. A full presentation of frequencies and percentages of operational definitions of body image used in the coded sample are presented in Table 12. Additionally, a complete list of operational definitions used, frequencies, and percentages are found in Appendix B. Table 12. Frequencies and Percentages of Operational Definitions of Body Image in Coded Sample Operational Definition of Body Image* Frequency and Percentage of Coded Sample (n = 293) Sociocultural and interpersonal factors 49 (16.7) impacting ones body view body capabilities. An affective consequence of body-esteem and 47 (16.0) sociocultural influences. Comprised of global components including 40 (13.7) global self-esteem and body-esteem. A psychiatric affect influenced by societal and 29 (9.9) personal factors. Empirical work without a clear operational 23 (7.8) definition of body image Reflective appraisal of ones perceived physical 22 (7.5) appearance. Attitudinal and perceptual dimension of ones 18 (6.1) overall view of the self. Perception of ones appearance and body affect 18 (6.1) based-on past developmental experiences as well as interpersonal and social determinants. Perceptual affect, influencing and ultimately 16 (5.5) impacting, ones behaviors. 134
Table 12 (Continued) A persons mental image and evaluation of appearance and the influence of these perceptions and attitudes on behavior. Theoretical work without a clear operational definition of body image An experiential perspective that is multidimensional including mental representations as well as sensory and somatic components. Totals
14 10 7
(4.8) (3.4) (2.4)
293
(100.0)
* Definitions based on referenced sources in both theoretical and empirical sources. Research Design Nine categories of research designs as delineated by Isaac and Michael73 were coded. In the case of multiple designs used, an a priori decision to code the primary design to answer the majority of the research questions or hypotheses was made, although this did not prove to be an issue in this sample. Theoretical content was coded as T0 and empirical work without a clear research design were coded as E0. Correlational and causal-comparative designs were used most often in the coded empirical sample. Correlational designs were used in 94 studies (38.5%) and causalcomparative designs comprised 18.0% (n = 44) of the coded empirical sample. Thirtyfour studies (13.9%) employed designs to develop and/or validate an instrument measuring various constructs of body image. Descriptive designs were used in 11.5% (n = 28) of the studies with all other designs used in less than 5% of the studies. Additionally, 16.7% (n = 49) studies were not coded for research design because of theoretical content and one (0.4%) empirical study presented with an unclear research design. Frequencies and percentages of research designs are found in Table 13.
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Table 13. Frequencies and Percentages of Research Designs Used in Coded Empirical Studies Research Design* Frequencies and Percentages of Coded Empirical Studies (n = 244) Correlational 94 (38.5) Causal-Comparative (Ex Post Facto) 44 (18.0) Instrument Developmental or Validation 34 (13.9) Descriptive 28 (11.5) Developmental 11 (4.5) Quasi-Experimental 11 (4.5) Case and Field Studies 6 (2.5) Qualitative 6 (2.5) True Experimental 5 (2.0) Historical 3 (1.2) Action Research 1 (0.4) Empirical Research with an Unclear Design 1 (0.4) Total (Frequency and Percentage) 244 (99.9)** * Definitions of research designs based on Isaac and Michael.73 ** Due to rounding. Sample Size Sample size was reported in 221 of the 244 (90.6%) coded empirical studies. Forty-nine works were coded as theoretical content; therefore, a sample was not indicated. The smallest reported sample included five participants used in qualitative interviews, whereas the largest sample was comprised of national sample of 36,320 participants. The majority of studies (69.2%; n = 153), included samples ranging from 1500 participants. Table 14 presents frequencies and percentages of sample size intervals.
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Table 14. Frequencies and Percentages of Sample Size Intervals in Coded Empirical Studies Sample Size Interval* Frequencies and Percentages of Coded Empirical Sample (n = 221) 1 500 153 (69.2) 501 1000 30 (13.6) 1001 1500 15 (6.8) 1501 2000 3 (1.4) 2001 2500 3 (1.4) 3001 3500 1 (0.5) 3501 4000 1 (0.5) 4001 4500 1 (0.5) 4501 5000 2 (0.9) 5001 5500 2 (0.9) 5501 6000 1 (0.5) 8501 9000 1 (0.5) > 10,000 8 (3.6) Totals 221 (100.3)** * Sample size not indicated in 23 (9.4%) of coded empirical studies. ** Due to rounding. Composition of the Sample Composition of samples used in empirical studies was recorded and coded in 233 studies. Mixed samples of adolescent males and females comprised 42.1% (n = 98) of studies. Thirty-seven studies (15.9%) included a mixed sample of adults, with 12.0% (n = 28) indicating samples of adolescent females and 12.0% (n = 28) adult females. Adolescent males comprised 7.7% (n = 18) of sample participants and 6.0% (n = 14) of samples included adult males. Forty-nine studies (16.7%) were coded as theoretical, therefore no sample was recorded. Additionally, 3.8% (n = 11) of studies did not clearly indicate the composition of participants included in the sample. Frequencies and percentages of sample composition are presented in Table 15.
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Table 15. Frequencies and Percentages of Sample Composition in Coded Empirical Studies Type of Sample* Frequency and Percent of Coded Empirical Studies (n = 233) Adolescents: Mixed Sample of Males and 98 (42.1) Females Adults: Mixed Sample of Males and Females 37 (15.9) Adult Females 28 (12.0) Adolescent Females 28 (12.0) Adolescent Males 18 (7.7) Adult Males 14 (6.0) Females: Mixed Sample of Adult and 4 (1.7) Adolescents Adult Females and Mixed Sample of 3 (1.3) Adolescent Males and Females Adolescents Mixed and Adults Mixed 2 (0.9) (Males and Females) Adult Females and Adolescent Females 1 (0.4) Adults: Mixed Males and Females and 1 (0.4) Adolescent Females Pre-Adolescents (Males and Females) 1 (0.4) Totals 233 (100.7)** * Sample size not indicated in 11 (4.5%) of coded empirical studies. ** Due to rounding. Geographic Location Nine geographic locations as defined by the 2000 United States Census Bureau were used to code areas of sampling (see Figure 5). An additional geographic category (International) was added due to a large number of studies using samples outside of the United States or its territories. A large number of studies (51.3%; n = 120) were conducted outside of the United States and territories as an international sample with the remainder originating in the United States. Forty-nine studies (16.7%) were theoretical in nature; therefore, no sample geographic location was indicated. Moreover, 3.4% (n = 10) of empirical studies did not indicate the geographic location of their sample. Other
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geographic locations of the sample are presented in Table 16 along with frequencies and percentages. _______________________________________________________________________ _
1 4 8 3 5 9 7 6 2
Legend: 1 = New England 2 = Middle Atlantic 3 = East North Central 4 = West North Central 5 = South Atlantic
6 = East South Central 7 = West South Central 8 = Mountain 9 = Pacific
Figure 5. Map of the United States divided into nine geographic areas according to the 2000 United States Census Bureau.
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Table 16. Frequencies and Percentages of Geographic Locations in Coded Empirical Studies Geographic Location* Frequency and Percent of Coded Empirical Studies (n = 234) International Sample 120 (51.3) South Atlantic 22 (9.4) New England 16 (6.8) Middle Atlantic 16 (6.8) East North Central 12 (5.1) West South Central 12 (5.1) National Sample 10 (4.3) West North Central 9 (3.8) Mountain Division 8 (3.4) Pacific Division 6 (2.6) East South Central 4 (1.7) Totals 234 (100.3)** * Geographic location not indicated in 10 (4.1%) of coded empirical studies. United States Territories were not indicated in the coded sample. ** Due to rounding. Body Image Instrument A variety of instruments measuring body image and its related constructs were coded for each empirical study and included in the content analysis. Overall, 115 individual instruments were identified in empirical studies included in the content analysis. Fifty-nine empirical studies (20.1%) did not indicate the instrument(s) used to measure body image. The most commonly used instrument was the Eating Disorders Inventory (EDI) by Garner and colleagues. This instrument was used in 40 studies or 21.6% of the overall sample. The Body Image Satisfaction Scale (BISS) was used in 18.9% of studies (n = 35) and measures relative satisfaction with ones body or specific parts of ones body. The Eating Attitudes Test (EAT) by Leichner et. al, which measures a persons feelings toward food and control factors, was used in 13.0% of studies (n = 24) followed by the Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965). The RSES was
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used in 10.8% of studies (n = 20) included in the sample, which measures self-esteem and affect toward factors impacting ones view or perceived view, of themselves. Frequencies and percentages of body image instruments or instruments used to assess constructs of body image identified in 5 or more empirical studies are presented in Table 17. Appendix B contains a listing of all (n = 115) instruments identified in the content analysis. Table 17. Frequencies and Percentages of Body Image and Related Instruments Used in Coded Empirical Studies Body Image Instrument Used Frequency and Percent of Coded Empirical Studies (n = 185) Eating Disorders Inventory (Garner et al.) 40 (21.6) Body Image Satisfaction Scale 35 (18.9) Eating Attitudes Test (Leichner et al.) 24 (13.0) Rosenberg Self-Esteem Scale (Rosenberg) 20 (10.8) Body Esteem Scale (Beaudoin et al.) 19 (10.3) Beck Depression Inventory (Beck) 15 (8.1) Body Esteem Scale for Adolescents and 13 (7.0) Adults (Mendelson et al., 1997) Social Physique Anxiety Scale 12 (6.5) Body Shape Questionnaire (Cooper, Taylor, 10 (5.4) Cooper & Fairburn, 1987) Structured Clinical Interview Dimensions 10 (5.4) Body Figure Rating Scale 9 (4.9) Body Image Assessment for Obesity 7 (3.8) Body Attitudes Questionnaire (Ben-Tovim & 7 (3.8) Walker) Digital Image Manipulation 6 (3.2) Sociocultural Influences on Body Image and 6 (3.2) Body Change (McCabe & Ricciardelli) Silhouette Survey (Stunkard et al., 1983) 5 (2.7) General Health Questionnaire 5 (2.7) Body Image Satisfaction Questionnaire 5 (2.7) Instrument used not specified 59 (25.3)* Instrument used less than 5 times** 167 (90.3) *Of overall coded empirical sample (n = 233). ** Complete list of instruments used, frequencies, and percentages is found in Appendix B.
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In 76.5% (n = 88) of the 115 instruments, reliability and validity statistics were presented and discussed. As previously mentioned, 11.6% (n = 34) studies were conducted to establish instrument psychometrics and development. Various measures of reliability were presented and discussed, such as test-retest reliability, internal consistency, and split-half reliability; however, no formal statistics as to the number of instruments assessing these measures were recorded. Validity was discussed in various developmental studies for body image instruments. Face, construct, and concurrent validity were frequently assessed; however, factor analysis was used in 13.0% of studies (n = 38) to establish construct validity.
Statistics Used A variety of statistical and data analysis methods were identified and coded. Both parametric and non-parametric statistics were identified in coded empirical work. Multiple statistics for each study were coded. Twelve different statistics were used in 239 coded empirical studies. Statistics were not specified in 2.1% (n = 5) empirical studies. Correlation was the most frequently used statistic, used in 161 (67.4%) of studies followed by analysis of variance (ANOVA) techniques, including multiple analysis of variance (MANOVA) and analysis of covariance (ANCOVA), (49.8%; n = 119). The remaining statistical techniques accounted for less than 5% of techniques used in the empirical studies. Table 18 presents frequencies and percentages of statistics used in all coded empirical studies.
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Table 18. Frequencies and Percentages of Statistics Used in Coded Empirical Studies Statistics Used Frequency and Percent of Coded Empirical Studies (n = 239) Correlation 161 (67.4) Analysis of Variance 119 (49.8) (ANOVA, MANOVA, ANCOVA, MANCOVA) Descriptive Statistics 90 (37.7) t-test (independent, dependent) 86 (36.0) Regression (multiple, linear, logistic) 80 (33.5) Chi Square 66 (27.6) Factor Analysis 38 (15.9) Thematic Analysis (qualitative) 7 (2.9) Structural Equation Modeling (SEM) 6 (2.5) Open Coding (qualitative) 6 (2.5) Statistics used unspecified 5 (2.1)* Path Analysis 4 (1.7) Content Analysis 1 (0.4) * Of overall coded empirical sample (n = 244). Intrapersonal Factors Intrapersonal factors encompass thoughts, beliefs, and values held true by the individual concerning oneself in relation to society. Intrapersonal factors hypothesized by authors of theoretical studies were included in the sample for coding. In empirical studies, only factors which were found to have statistical significance at the <.05 level were included. Content analysis of 293 theoretical and empirical studies resulted in identification of 57 intrapersonal factors; some of which were identified for inclusion in the development of the Adolescent Body Image Satisfaction Scale (ABISS). The most frequently occurring intrapersonal factor was body/self-esteem, which was noted in 137 studies (46.8%). Body dissatisfaction was identified in 126 studies (43%) followed by
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self-concept (32.4%; n = 95), body satisfaction (32.1%; n = 94), and ideal body size (31.7%; n = 93). A listing of intrapersonal factor frequencies and percentages found in 20% or more studies are found in Table 19. Comprehensive listings of all 57 identified intrapersonal factors are found in Appendix B. Table 19. Frequencies and Percentages of Intrapersonal Factors Identified in all Coded Work Intrapersonal Factors* Frequency and Percent of Coded Theoretical and Empirical Studies (n = 293) Body and Self-Esteem 137 (46.8) Body Dissatisfaction 126 (43.0) Self-Concept 95 (32.4) Body Satisfaction 94 (32.1) Ideal Body Size 93 (31.7) Internalization 87 (30.0) Self Image 81 (27.6) Physique Anxiety 74 (25.3) Negative Affect 73 (24.9) Self-Perception 73 (24.9) Depression 59 (20.1) * Intrapersonal factors with frequencies occurring in 20% or more of coded studies; a full presentation of intrapersonal factors may be found in Appendix B. Interpersonal Factors Interpersonal factors include social interchanges occurring between or among people, such as communication, criticism, teasing, and bullying among others. Eighteen interpersonal factors were identified in theoretical and empirical studies. Table 20 presents interpersonal factors indicated in 20% or more of the sample studies. Comprehensive frequencies and percentages of interpersonal factors are found in Appendix B. The greatest percentage of interpersonal factors (68.8%) was related to comparison tendencies of individuals (both self and peers). Thirteen (4.4%) empirical
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studies did not classify a significant interpersonal construct and one (0.3%) theoretical study failed to present a hypothesis of an interpersonal factor affecting body image satisfaction. Table 20. Frequencies and Percentages of Interpersonal Factors Identified in all Coded Work Interpersonal Factors* Frequency and Percent of Coded Theoretical and Empirical Studies (n = 279) Comparison 192 (68.8) Gender Factors 121 (43.4) Appearance Conversations 111 (39.8) Peer Pressure 90 (32.3) Role Modeling 78 (28.0) Peer Appearance Conversations 72 (25.8) Teasing (parental, sibling, peer, 65 (23.3) stranger) Family Influences 60 (21.5) Perceived Feedback 56 (20.1) Empirical studies with unspecified 13 (4.4)** interpersonal factors Theoretical studies with unspecified 1 (0.3)** interpersonal factors * Interpersonal factors with frequencies occurring in 20% or more of coded studies; a full presentation of interpersonal factors may be found in Appendix B. ** Based on full coded sample (n = 293). Social Factors Social factors may be conceptualized as, external influences impacting ones behaviors or belief systems. For example, attractive body ideals in various media can negatively affect ones body image. Other examples include: television, advertisements, magazines, and tailored messages. Thirty-seven social factors affecting body image satisfaction were identified in coded theoretical and empirical studies. The predominant social factor of social norms was identified in 173 studies (59.0%). The period of adolescence was a significant factor
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in 143 studies (48.8%) and cultural body ideals was identified in 133 studies (45.4%). Social factors were not identified or were not statistically significant factors in seven (2.4%) of all coded empirical studies. Two theoretical studies (0.7%) did not hypothesize or discuss relevant social factors related to body image satisfaction. Table 21 summarizes relevant social factor frequencies and percentages. Other social factors identified in less than 10% of all coded theoretical and empirical studies are presented in Appendix B. Table 21. Frequencies and Percentages of Social Factors Identified in all Coded Work Social Factors* Frequency and Percent of Coded Theoretical and Empirical Studies (n = 284) Norms 173 (60.9) Period of Adolescence 143 (50.4) Cultural Body Ideal 133 (46.8) Social Physique Anxiety 109 (38.4) Referent Values 92 (32.4) Peer Acceptance 83 (29.2) Masculine Ideals 81 (28.5) Social Anxiety (general) 80 (27.3) Social Desirability 68 (23.9) Media Influences 63 (22.2) Stigmatization 58 (20.4) Ethnicity/Cultural Factors 52 (18.3) Popularity 52 (18.3) Discrimination 46 (16.2) Bullying 45 (15.8) Social Influence 43 (15.1) Pubertal Development (timing) 42 (14.8) Acculturation 41 (14.4) Empirical studies with unspecified 7 (2.4)** interpersonal factors Theoretical studies with unspecified 2 (0.7)** interpersonal factors * Social factors with frequencies occurring in 10% or more of coded studies; a full presentation of social factors may be found in Appendix B. ** Based on full coded sample (n = 293).
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Other Factors In both coded theoretical and empirical studies, other factors not unique to intrapersonal, interpersonal, or social influences were identified and recorded. Some factors were not reported as statistically significant; therefore, they were recorded for completeness of the content analysis. Seventeen factors were identified in the content analysis including; body mass index (BMI), discrepancy, dieting practices, severity of asthma, anhedonia, physical disability, overestimation, body importance, perceived pressure (various sources), disordered eating, panel rating, developmental influences, health outcomes, health resources, good health (defined as a value), genetic factors, and perceived fraudulence.
Intra-rater and Inter-rater Reliability Two percent of coded theoretical and empirical studies were randomized and stratified for recoding purposes. The overall coded sample included 293 studies; therefore, six studies were chosen at random for recoding. To allow for even distribution of studies used for recoding, selection of the number of recoded studies was based on the percentages of theoretical (16.7%) and empirical (83.3%) works. One theoretical study and five empirical studies were chosen at random for recoding. The following theoretical study (T14) was chosen for recoding. Random selections of (E73, E113, E187, E192, and E211) were identified for recoding of empirical studies.
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Intra-rater Reliability Following coding of all written works (n = 293), one theoretical study and five empirical studies were recoded by the researcher. Content from the original Microsoft Excel database file was recoded in a separate Microsoft Excel database file. There were no differences noted from the first coding and the recoding in the single theoretical study reviewed indicating 100% intra-rater reliability. Three out of five (60%) of the empirical studies were recoded as they were in the original coding. In the remaining two empirical studies, there were minor differences noted in the recoding of the purpose and results of the study. Overall intent of each section was noted to be consistent in overall meaning, although wording and order were different. Type of research design was a noted discrepancy in one study (E187) compared to the initial coding. Recoding of all other categories was the same as the original.
Inter-rater Reliability A second person was asked to recode the six studies chosen at random. This person was oriented to the overall process and time was allotted to answer any questions. Consistent with intra-rater results, discrepancies were noted in the purpose of the study and results of the study in all six works. Inherent meaning appeared to be consistent across all studies that were evaluated. The second person coded one study (E187) as correlational, which was consistent with the second coding by the researcher; however, this was different from the original coding as a descriptive research design. In the theoretical study (T14), three intrapersonal factors (two less and one added) and one social factor (added) were coded differently than the original. Discrepancies were noted
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in three empirical studies (E113, E187, and E211) in terms of intrapersonal factors. Two additional factors were identified in E113 by the second coder, one less in E187, and three less in E211. All other categories demonstrated consistent coding compared to the original. Findings suggest acceptable intra-rater and inter-rater reliability of content analysis coding procedures.84 Adolescent Body Image Satisfaction Scale Validation and Pilot Study A pilot study was conducted to validate and adjust the Adolescent Body Image Satisfaction Scale as needed. A sample of 27 male high school students in grades 9 through 12 participated. Verbal and written consent from the school administrator was granted prior to communication with teachers and students. Upon approval, a cover letter, parental and minor consent forms, and a copy of the survey were sent to a contact person at the participating school for review and dissemination. After review of the forms, the school contact person sent parental letters of consent and cover letters (see Appendix G) to the parents of prospective participants. A date and time was set-up for collection of forms and administration of surveys. On the day of the pilot survey administration, the researcher delivered detailed instructions for completion of the survey. Time was allotted for questions from the participants. Students were asked to place their signed parental informed consent forms and their signed minor assent forms in a designated envelope. Students age 18 or older were only asked to sign and date the informed consent form. Surveys were administered to the sample, which included six freshmen, five sophomores, nine juniors, and seven seniors (n = 27). The average time for completion of the survey was 13 minutes.
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Following completion of the survey, students were asked to provide feedback in a brief 10 minute discussion group with the researcher. Comments were presented, discussed, and recorded for adjustments to be made at a later time. Written comments also were recorded and used to make adjustments to the final version of the survey. Sections detailing findings for instrument validity, reliability, and adjustments made to the survey based on the pilot study are found in Part Two results.
Summary of Part One The purpose of Part One was to examine the phenomenon of body image satisfaction based on intrapersonal, interpersonal, and social factors identified in current empirical and theoretical literature. Through a comprehensive search in nine academic databases as well as Interlibrary Loan Services, 938 theoretical and empirical studies concerning adolescent body image and body image dissatisfaction were identified. Following examination of these 938 studies, 231 were found to be duplicate citations resulting in 707 studies. Further examination for relevance to the purpose of the study resulted in exclusion of 401 studies leaving 306 studies for review. Thirteen studies were excluded, resulting in 293 studies (83.3% empirical and 16.7% theoretical) coded in the content analysis. After coding, frequencies and percentages were calculated for: number of theoretical and empirical studies, research design, year of publication, source and journal of publication, document type, sample size, geographic location, sample composition, operational definition of body image, instruments used, statistics used, and intrapersonal, interpersonal, and social factors.
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Forty-nine (16.7%) theoretical studies and 244 (83.3%) empirical studies were identified for content analysis coding. Eleven research designs were used to classify empirical research. A majority (32.1%) of empirical studies used a correlational research design followed by causal-comparative approaches (15.0%). Most studies (83.9%) were published between the years 2000 2005. Nearly half (47.8%), of studies came from psychological sources with the International Journal of Eating Disorders comprising the most frequently (19.5%) occurring journal. Two-hundred sixty-six studies (90.8%) were identified as journal articles and 69.2% of empirical studies used sample sizes between 1 to 500 participants. The composition of the sample was identified as a mixed sample of adolescent boys and girls in 42.1% of studies. One-hundred twenty studies (41.0%) originated outside of the United States as an international sample. Authors provided general operational definitions of body image, yielding an even spread of distributions among ten categories. Similarity of themes from each of the ten definitions included: body-esteem, self-esteem, perceptions, the interplay of intrapersonal factors, interpersonal relationships, and social forces impacting ones image, and multidimensional constructs impacting ones global body image. A variety of instruments (n = 121) used to measure body image and its constructs were identified. The most frequently cited instruments were the Eating Disorders Inventory (13.7%), the Body Image Satisfaction Scale (11.9%), and the Eating Attitudes Test (8.2%). Although many different statistical methods were used, correlation was used most frequently. Descriptive statistics were identified in 30.7% of studies and t-tests accounted for 29.4%, which is a consistent finding concerning the number of correlational,
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descriptive, and causal-comparative research designs. Lastly, 57 intrapersonal factors, 18 interpersonal factors, and 37 social factors were identified through the content analysis. The most frequently occurring intrapersonal factors were body and self-esteem, body dissatisfaction, self-concept, body satisfaction, and ideal body size. Comparison, gender, appearance conversations, peer pressure, and role modeling were the most frequently occurring interpersonal factors identified. Social factors most commonly cited were norms, period of adolescence, cultural body ideals, physique anxiety, referent values, peer acceptance, masculine ideals, and social anxiety. Seventeen additional other factors were identified. Intrapersonal, interpersonal, and social factors identified in this content analysis were used in the development of the Adolescent Body Image Satisfaction Scale (ABISS) used in Part Two of this study.
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Part Two:A Correlational Cross-sectional Study of Adolescent Male Body Image Dissatisfaction
Part Two of this study answered the following research question: Which interpersonal and social factors are the strongest predictors of selected adolescent male body image dissatisfaction? Results of Part Two are presented in four sections. The first section presents pilot study findings for the validation of the Adolescent Body Image Satisfaction Scale (ABISS). Section two describes the sample included in both the pilot and main study. Section three presents findings from the main sample. A summary of key findings from Part Two is presented in the final section. Instrument Validity Feedback from the pilot sample was used to adjust and modify content of the ABISS. Additionally, previous feedback on instrument validity was garnered from expert panel review. The most frequently occurring and statistically significant intrapersonal, interpersonal, and social variables found in the content analysis were included in the ABISS or used to modify original questions prior to the pilot study. Comments and feedback from the pilot study sample as well as panel experts helped to establish face validity for the ABISS. Content validity was determined assuring the survey covered a range of responses related to the concept of body image. Comments from the pilot sample were taken into consideration and are discussed in the following section on adjustments made to the survey.
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Instrument Reliability Initial reliability statistics were generated for the following sections; the Adolescent Body Image Satisfaction Scale (ABISS first half), the entire Adolescent Body Image Satisfaction Scale, Interpersonal and Social Factors (Section II), and the entire instrument (sections I and II). Reliability statistics were deemed to be moderate to low for each section using Cronbachs alpha coefficient and split-half reliability measures. The next section will present adjustments made to the instrument addressing issues of reliability. Original and post-adjustment reliability statistics are found in Table 22. Table 22. Pilot Study Reliability Statistics and Adjustments (n = 27).* Survey Section Original Cronbach alpha score and (# of items included in analysis) .250 (25) .058 (50) .658 (28) .472 (53) Adjusted Cronbach alpha score and (# of items included in analysis)** .793 (16) .651 (32) .652 (28) .676 (44)
Adolescent Body Image Satisfaction Scale Adolescent Body Image Satisfaction Scale Split-Half Interpersonal and Social Factors (Section II) Entire Survey Form
* Values are Cronbachs alpha coefficient with sample size used in the analysis. ** Post-item analysis using Cronbachs alpha coefficient. Adjustments to the Adolescent Body Image Satisfaction Scale Item analysis and subsequent adjustments are presented in Table 23. Overall, open-ended comments solicited from the pilot study student sample were positively worded. Written and verbal comments reflecting, a good survey was a
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common theme. Students mentioned the code column was somewhat confusing; therefore, a note was added under the column code heading asking participants to leave the column blank. Item #6 in Section II was mis-worded. The word day was identified as missing from the statement and was added to assure question clarity. As previously mentioned, initial reliability of the instrument was moderate to low. An item analysis was initiated to examine questions that displayed skewness in responses. Each item in the ABISS was analyzed in terms of its impact on overall reliability of the instrument. Nine of the original 25 items in the ABISS were removed, which positively enhanced the instruments overall reliability. The ABISS attempted to capture constructs of body image satisfaction, which are not homogeneous; therefore, removal of items demonstrating unreliable scores did not detract from the instruments overall mission in terms of establishing an adolescents level of body image (dis)satisfaction. Reverse-worded, corresponding items in the second half (items 26-50) of the survey were also removed to assure acceptable split-half reliability. In total, 18 items were removed from the original 50-item instrument. Each item was considered in terms of the value added to the survey. It was determined that the resulting 16 ABISS items and their corresponding 16 reverse coded items were appropriate for assessing body image satisfaction by the expert panel. The scale to measure body image satisfaction was also adjusted accordingly. The maximum value of each question was 4, with minimum values of 1. The maximum body image score for the 32-item scale is 128 with minimum scores of 32. Scores ranging from 32-64 are indicative of a positive body image, 65-86 mild body image dissatisfaction, 87-108 moderate body image dissatisfaction, and 109-128 strong body image dissatisfaction.
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Table 23. Pilot Study Item Analysis for the Adolescent Body Image Satisfaction Scale. Deleted Survey Item Original ABISS* .250 (25)** Adjusted ABISS*** (n = 27) .392 .480 .501 .556 .611 .677 .739 .806 .816
I have been rejected by girlfriends/boyfriends because of my body. I dislike my present percentage of body fat. I often feel small compared to others. I have low self-esteem about my looks. I avoid social gatherings because of the way I look. My body is awkward. I am ashamed of my body. I get anxious/upset when others might see my body partially or fully unclothed. I like to look different/unique than my peers.
* Original ABISS values using a participant sample of (n = 27). ** Indicates number of questions included in the ABISS, not including reverse-worded questions. *** Lists reliability scores of the ABISS as each item was removed. Note: each corresponding oppositely worded items also were removed from the instrument. Description of the Main Sample This section describes a demographic profile of the participants used in this sample. The adjusted Adolescent Body Image Satisfaction Scale (ABISS) was distributed to 330 adolescent males in the New England region. Eight surveys were not included in the analysis due to excessive missing data. Composition varied by grade (see Table 24).
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Table 24. Composition of Student Sample by Grade Grade Level Grade 9 (Freshman) Grade 10 (Sophomore) Grade 11 (Junior) Grade 12 (Senior) Other (College Preparatory) Total Number and (Percent of Sample) (N= 330) 68 (20.6) 126 80 55 1 330 (38.2) (24.2) (16.7) (0.3) (100.0)
Participants ranged in age from 14 to 19 years old. Participants had a minimum age of 14 years and a maximum age of 19 years. The mean age was 16.36 years with a median age of 16 years. Table 25 presents frequencies and percentages of participant age. Table 25. Composition of Sample by Age. Participant Age 14 15 16 17 18 19 Total Number and (Percent of Sample) (N = 330) 14 (4.2) 62 110 87 49 8 330 (18.8) (33.3) (26.4) (14.8) (2.4) (100.0)
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A majority of the sample were White/Caucasian (non-Hispanic) (n = 232; 70.3%) followed by Black/African-American (non-Hispanic) (n = 33; 10.0%). Further demographic data concerning race and ethnicity are presented in Table 26. Table 26. Composition of Student Sample by Race/Ethnicity Race/Ethnicity White/Caucasian (non-Hispanic) Black or African-American (non-Hispanic) Asian White/Hispanic Origin Multiracial Black/Hispanic Origin American Indian or Alaska Native Other Total Number of Students (Percent of Sample) (N = 330) 232 (70.3) 33 24 16 12 11 1 1 330 (10.0) (7.3) (4.8) (3.6) (3.3) (0.3) (0.3) (100.0)
The minimum height was 61 inches and the maximum height was 78 inches. Average height for participants was 69.80 inches (2.90). The minimum weight of participants was 105 pounds with a maximum weight of 303 pounds. The mean weight was 166.60 pounds (32.2). The average body mass index (BMI) was determined to be 24.0, indicating a healthy range.
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A majority (n = 294; 89.1%) of participants reported their sexual orientation as heterosexual. Table 27 presents a full description of participant data concerning sexual orientation. Table 27. Composition of Student Sample by Sexual Orientation Sexual Orientation Heterosexual No Response Bisexual Homosexual Transgendered Total Number of Students (Percent of Sample) (N = 330) 294 17 11 7 1 330 (89.1) (5.2) (3.3) (2.1) (0.3) (100.0)
Lastly, 85.5% (n = 282) of participants reported playing an organized sport at their high school with 14.5% (n = 48) not playing a sport.
Findings from Part Two Responses for the Adolescent Body Image Satisfaction Scale are presented in Table 28 and responses for section two (social and interpersonal independent variables) of the survey are presented in Table 29. Responses indicated that adolescent males in this sample expressed a stronger desire for muscularity (3.10) and often sought reassurance concerning their appearance (3.09). Desire for body perfection was also expressed by 68.2% of the sample. Sixty-one
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and a half percent of the sample indicated that they are critical of their body. Overall sample scores were slightly skewed towards dissatisfaction with body image. In terms of being dissatisfied with their body, 71.4% indicated they were alright with their body and over half (55.9%) of participants indicated they gain satisfaction by being physically dominant over others. Participants indicated a higher sense of self-esteem concerning their physical appearance with 72.8% (2.68) believing they were physically attractive people. This finding was also supported by more than half of the participants agreeing that they gain positive attention from others due to their looks. Responses to section two of the survey presented 28 interpersonal and social variables. Seventy-five percent indicated they were sexually confident. Approximately half of the sample reported introverted type of behaviors and excessive (greater than 3 hours per day) personal computer and television usage were found to be similar (38.3% and 32.5%) respectively. In terms of bullying behaviors, 44% reported having been bullied during some period of their lives and 33.1% reported having difficulty coping with criticism. In terms of behaviors, 42.8% reported frequently or always checking their appearance in mirrors or reflective surfaces. Nearly two-thirds (64.2%) indicated the desire to always be in control of things and 63.3% strive for perfection frequently to always in their lives. Additionally, 67.5% reported having worn certain types of clothing with the purpose of hiding parts of their bodies sometimes to always. Findings are presented in Table 29 concerning these behaviors.
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Table 28. Descriptive Statistics of Survey Responses for the Adolescent body Image Satisfaction Scale (N = 330).
Survey Item
I wish I were more muscular. I feel good when others reassure me that I look alright. I want the perfect body. I get satisfaction physically dominating others. (n = 329) I am dissatisfied with my body. (n = 328) I am a physically attractive person.* (n = 328) Seeing other males that are more muscular than me does not affect the way I view my body.* (n = 329) I am critical of my body. I am satisfied with my bodys muscle tone.* I gain positive attention because of my looks.* There is no perfect body.* I do not need other people to tell me that I look alright.* My body makes me feel confident.* My body is strong.*
Strongly Disagree ** 7(2.1) 5(1.5)
Disagree** Agree** 42(12.7) 34(10.3) 191(57.9) 216(65.5)
Strongly Agree** 90(27.3) 75(22.7)
Sample Mean 3.10 3.09
Standard Deviation 0.69 0.62
20(6.1) 39(11.9)
85(25.8) 106(32.2)
125(37.9) 126(38.3)
100(30.3) 58(17.6)
2.92 2.91
0.89 5.38
76(23.2) 8(2.4)
158(48.2) 81(24.7)
82(25.0) 173(52.7)
12(3.6) 66(20.1)
2.68 2.68
7.57 7.57
23(7.0)
127(38.6)
127(38.6)
52(15.8)
2.66
5.38
28(8.5) 27(8.2) 9(2.7)
99(30.0) 129(39.1) 142(43.0)
169(51.2) 150(45.5) 149(45.2)
34(10.3) 24(7.3) 30(9.1)
2.63 2.52 2.39
0.78 0.75 0.69
41(12.4) 12(3.6)
101(30.6) 102(30.9)
117(35.5) 174(52.7)
71(21.5) 42(12.7)
2.34 2.25
0.95 0.72
13(3.9) 54(16.4)
99(30.0) 173(52.4)
172(52.1) 85(25.8)
46(13.9) 18(5.5)
2.24 2.20
0.74 0.78
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People find me physically attractive.* I feel connected with my body.* Seeing other males that are more muscular than me makes me upset.
11(3.3) 13(3.9) 65(19.7)
89(27.0) 77(23.3) 172(52.1)
182(55.2) 189(57.3) 79(23.9)
48(14.5) 51(15.5) 14(4.2)
2.19 2.16 2.13
0.72 0.72 0.77
Table 28 (Continued)
I am satisfied with my body.* I am comfortable with my body.* I respect my body (eat healthy, exercise, etc.).* My body is weak. I am athletic.* My body makes me feel insecure. I am physically intimidated by others. People find me physically unattractive. I do things that disrespect my body (i.e., drugs, over-eat). I am in control of my body.* I feel disconnected with my body. I am unattractive. (n = 329) I am not athletic. I feel people ignore me because of my
12(3.6) 16(4.8) 18(5.5)
76(23.0) 63(19.1) 62(18.8)
176(53.3) 168(50.9) 163(49.4)
66(20.0) 83(25.2) 87(26.4)
2.10 2.04 2.03
0.75 0.80 0.82
100(30.3) 20(6.1) 105(31.8) 97(29.4) 88(26.7)
162(49.1) 56(17.0) 157(47.6) 170(51.5) 189(57.3)
56(17.0) 137(41.5) 58(17.6) 57(17.3) 45(13.6)
12(3.6) 117(35.5) 10(3.0) 6(1.8) 8(2.4)
1.94 1.94 1.92 1.92 1.92
0.79 0.88 0.78 0.73 0.70
147(44.5)
89(27.0)
74(22.4)
20(6.1)
1.90
0.95
16(4.8) 117(35.5) 111(33.7) 154(46.7) 133(40.3)
38(11.5) 151(45.8) 168(51.1) 125(37.9) 159(48.2)
166(50.3) 55(16.7) 43(13.1) 36(10.9) 35(10.6)
110(33.3) 7(2.1) 7(2.1) 15(4.5) 3(0.9)
1.88 1.85 1.84 1.73 1.72
0.79 0.77 0.73 0.83 0.69
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looks. My body is out of control.
145(43.9) Mean Score 68.96 1.72
150(45.5) Standard Deviation 12.20 0.60
28(8.5)
7(2.1)
1.69
0.72
Section Totals
ABISS Score Body Image Dissatisfaction Classification Score
* Indicates reverse coded items ** Indicates frequency (n) and percentage (%) Where scores ranging from 32-64 equal positive body image, 65-86 mild body image dissatisfaction, 87-108 moderate body image dissatisfaction, and 109-128 strong body image dissatisfaction Where values of 1 indicate positive body image, 2 slightly negative, 3 negative, and 4 strong body image dissatisfaction
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Table 29. Descriptive Statistics of Survey Responses for Social and Interpersonal Independent Variables (N = 330).
Survey Item
I am sexually confident. (n = 329) I like to keep to myself. (n = 329) I use a computer more than 3 hours per unrelated to schoolwork. (n = 329) I watch more than 3 hours of television per day. (n = 329) I have been discriminated against because of the way I look. (n = 329) My height makes me upset. (n = 329) I have been bullied by others. I wish I had the body of someone else. I find it difficult to cope with criticism. Physically, I am developing more slowly compared to others my age. I was more satisfied with my body when I was younger than I am now. I come from a low income family background.
Strongly Disagree * 18(5.5)
Disagree* 64(19.4)
Agree* 154(46.8)
Strongly Agree* 93(28.3)
Sample Mean 3.27
Standard Deviation 5.35
55(45.1)
122(37.1)
137(41.5)
15(4.5)
2.63
5.38
62(18.8)
141(42.8)
81(24.6)
45(13.7)
2.62
5.40
89(27.1)
133(40.4)
79(24.0)
28(8.5)
2.43
5.41
87(26.4)
153(46.5)
77(23.4)
12(3.6)
2.34
5.40
91(27.7)
156(47.4)
67(20.4)
15(4.5)
2.31
5.40
74(22.4) 70(21.2) 59(17.9) 90(27.3)
111(33.6) 136(41.2) 162(49.1) 135(40.9)
121(36.7) 91(27.6) 90(27.3) 88(26.7)
24(7.3) 33(10.0) 19(5.8) 17(5.2)
2.29 2.26 2.21 2.10
0.90 0.91 0.80 0.86
108(32.7)
128(38.8)
78(23.6)
16(4.8)
2.01
0.87
118(35.8)
147(44.5)
41(12.4)
24(7.3)
1.91
0.88
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I have very few friends.
157(47.6)
136(41.2)
28(8.5)
9(2.7)
1.66
0.75
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Table 29 (Continued)
Survey Item
I frequently look in mirrors to make sure that I look alright. (n = 327) I like to always be in control. I like to be perfect in most things I do. I wear clothing that hides my body. (n = 329) My sibling(s) (brother/sister) tease/criticize my body. (n = 328) I have been teased about my body. Other family members (e.g., uncles, aunts, cousins, etc.) criticize me about my body. (n = 328) I take sports supplements (i.e., protein, creatine, nitric oxide, etc.). I use recreational drugs, such as alcohol or tobacco more than 1 time per month. My father criticizes me about my body. (n = 329) I read bodybuilding and fitness magazines. I use illegal drugs, such as marijuana, ecstasy, and/or meth more than 1
Never* 59(18.0)
Sometimes * 128(39.1)
Frequently * 92(28.1)
Always* 48(14.7)
Sample Mean 3.27
Standard Deviation 9.23
15(4.5) 15(4.5) 107(32.5) 199(60.7)
103(31.2) 106(32.1) 154(46.8) 94(28.7)
110(33.3) 130(39.4) 51(15.5) 29(8.8)
102(30.9) 79(23.9) 17(5.2) 6(1.8)
2.91 2.83 2.23 2.11
0.89 0.85 5.41 7.61
98(29.7) 253(77.1)
186(56.4) 66(20.1)
33(10.0) 6(1.8)
13(3.9) 3(0.1)
1.88 1.86
0.74 7.62
181(54.8)
72(21.8)
67(14.2)
30(9.1)
1.78
1.00
187(56.7)
69(20.9)
40(12.1)
34(10.3)
1.76
1.02
237(72.0)
63(19.1)
21(6.4)
8(2.4)
1.69
5.42
218(66.1)
76(23.0)
23(7.0)
13(3.9)
1.49
0.79
244(74.1)
49(14.9)
16(4.9)
20(6.1)
1.43
0.84
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time per month. (n = 329) I think about using anabolic steroids (i.e., roids, juice, test). My guardians criticize me about my body. My mother criticizes me about my body.
251(76.1)
52(15.8)
16(4.8)
11(3.3)
1.35
0.73
246(74.5) 255(77.3)
69(20.9) 56(17.0)
12(3.6) 15(4.5)
3(0.9) 4(1.2)
1.31 1.30
0.59 0.61
* Indicates frequency (n) and percentage (%)
Participants were classified into one of four body image categories based on their responses and summed scores on the ABISS. Scores on the ABISS could range from 32 128, where scores ranging from 32-64 indicated positive body image, 65-86 mild body image dissatisfaction, 87-108 moderate body image dissatisfaction, and 109-128 strong body image dissatisfaction. The overall samples mean score on the ABISS was (68.96 12.02) and yielded classification categories in the mild/slightly negative body image dissatisfaction category (1.72 0.60). Findings indicate this cross-sectional sample experience slight negative body image concerns, see Table 30. Table 30. Results of Body Image Classification Categories. Body Image Classification Category Positive Body Image Mild/Slight Body Image Dissatisfaction Moderate Body Image Dissatisfaction Strong Body Image Dissatisfaction Total Number of Students (Percent of Sample) (N = 330) 115 (34.8) 194 19 2 330 (58.8) (5.8) (0.6) (100.0)
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The following section presents findings from: correlations for the total Adolescent Body Image Satisfaction Scale (ABISS) between Interpersonal and Social independent variables 1-28 and demographics variables, correlations for Body Image Dissatisfaction (BID) classification scores versus Interpersonal and Social independent variables 1-28 and demographic variables, a between-subjects analysis of variance (ANOVA) for ethnicity, a Chi-Square statistic for BID classification by ethnicity, and regressions for analysis of predictive factors for the ABISS and BID classifications. Correlations for Total ABISS Scores between Factors 1-28 and Demographic Variables To investigate if there were statistically significant associations between total ABISS (Adolescent Body Image Satisfaction Scale) scores and interpersonal and social variables, correlational analyses were conducted. Statistically significant positive relationships were found between total ABISS scores and 15 individual variables. The following independent variables were found to be statistically significant at the p < .001 level: desire for the body of another (r = .571); having been teased about the body (r = . 490); being more satisfied with their body when they were younger (r = .450); difficulty coping with criticism (r = .443); having fewer friends (r = .390); bullying (r = .363); think about using AAS (r = .303); slower physical development (r = .289); use of recreational drugs (r = .221); maternal criticism (r = .199); guardian criticism (r = .191); and reading fitness magazines (r = .182). The following variables were found to be statistically significant at the p < .05 level: sport participation (r = .159); use of illicit drugs (r = .130); and higher academic grade level (r = .113). For a complete presentation of results, see Table 31.
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Table 31. Pearson Correlations on Total ABISS with Interpersonal, Social, and Demographic Variables Independent Variable discrimination for looks height discontent introversion bullying television viewing personal computer usage fewer friends sexual confidence cannot cope with criticism desire body of another slower physical development body satisfaction when younger low family SES perfectionist teased about body think about AAS use guardian criticism maternal criticism paternal criticism sibling criticism other family criticism read fitness magazines consume sports supplements frequent mirror checking use recreational drugs use illicit drugs like to be in control wear clothing that hides body participant age academic grade level sports participation participant height participant weight Note. *p< .05, **p< .01, ***p< .001. Total ABISS Correlations .071 -.028 .060 .363*** -.015 .073 .390*** -.043 .443*** .571*** .289*** .450*** .091 -.044 .490*** .303*** .191*** .199*** .047 .042 .007 .182** .009 -.049 .221*** .130* .027 .058 .106 .113* .087 -.057 .079
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Correlations between BID Classification Scores and Interpersonal, Social Variables and Demographic Variables To investigate if there were statistically significant associations between Body Image Dissatisfaction (BID) classification scores and interpersonal and social variables, correlational analyses were conducted. Statistically significant positive relationships were found between BID classification and 23 individual variables. The following independent variables were found to be statistically significant at the p < .001 level: desire for the body of another (r = .507); sexual confidence (r = -.443); having fewer friends (r = .411); having been teased about the body (r = .407); the inability to cope well with criticism (r = .404); being discriminated against because of looks or physical appearance (r = .397); having been bullied (r = .367); being more satisfied with their body when they were younger (r = .351); wearing clothing that hides the body (r = .318); think about using AAS (r = .270); slower physical development (r = .266); use of recreational drugs (r = . 238); being discontent with height (r = .223); sibling criticism (r = .220); and paternal criticism (r = .197). The following variables were found to be statistically significant at the p < .05 level: maternal criticism (r = .161); guardian criticism (r = .156); higher academic grade level (r = .152); age (older) (r = .141); use of illicit drugs (r = .130); personal computer and Internet usage (r = .123); introverted personality type (r = .122); and other family criticism (r = .122). For a complete presentation of results, see Table 32.
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Table 32. Pearson Correlations on BID Classification Scores with Interpersonal, Social, and Demographic Variables Independent Variable discrimination for looks height discontent introversion bullying television viewing personal computer usage fewer friends sexual confidence cannot cope with criticism desire body of another slower physical development body satisfaction when younger low family SES perfectionist teased about body think about AAS use guardian criticism maternal criticism paternal criticism sibling criticism other family criticism read fitness magazines consume sports supplements frequent mirror checking use recreational drugs use illicit drugs like to be in control wear clothing that hides body participant age academic grade level sports participation participant height participant weight BID Classification Scores .397*** .223*** .122* .367*** .070 .123* .411*** -.443(**) .404*** .507*** .266*** .351*** .097 -.041 .407*** .270*** .156** .161*** .197*** .220*** .0065 .097 -.012 .059 .238*** .130* .028 .318*** .141* .152** .084 .004 .058
Note. *p< .05, **p< .01, ***p< .001, (**) negative correlation
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In efforts to fully explore contributing factors to adolescent male body image dissatisfaction, analysis of variance (ANOVA) and Chi-Square analyses were conducted for total ABISS scores and BID classification score by ethnicity, respectively. Results are presented in the next section.
ANOVA on Total ABISS Scores by Ethnicity and Chi-Square on BID Classification by Ethnicity A between-subjects analysis of variance (ANOVA) was performed on total ABISS (Adolescent Body Image Satisfaction Scale) scores by ethnicity (White vs. NonWhite). There was no mean statistically significant difference found in total ABISS scores between Whites (M = 69.35, SD = 12.28) and Non-Whites (M = 68.02, SD = 12.03), F (1,328) = .822, ns. To investigate whether participants differed in BID classification by ethnicity, a Chi-Square statistic was used. The Pearson chi-square results and indicated that BID classification scores were not statistically significantly different by ethnicity (White vs. Non-White), (2 = 7.09, df = 3, N = 330, ns). Regression statistics were calculated to determine strengths of relationships between the independent variables (interpersonal and social factors) and the dependent variable (body image satisfaction scores), to answer the research question, Which interpersonal and social factors are the strongest predictors of body image dissatisfaction among selected adolescent males? Results are presented in the following section.
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Regression Analysis A stepwise, linear regression was conducted on total ABISS (Adolescent Body Image Satisfaction Scale) scores using demographic information as predictors. Model 2 using sports participation and age together as predictors was statistically significant, F (2, 310) = 10.34, p < .001, and accounted for 6.3% of the variability in total ABISS scores; meaning that 6.3% of the variance in total ABISS scores can be predicted from sports participation and age together. The t-value assessing the significance of these predictors together indicates that sports participation and age together are significantly contributing to the equation for predicting total ABISS scores, Table 33. Table 33. Stepwise Regression on Total ABISS by Demographics Predictor Variable Sports Participation Participant Age B 6.714 1.710 SE 1.885 .597 .196 .157 t 3.562 2.863 Sig. .0001 .004
Note: Significant at the p< .05 level. Another stepwise, linear regression was conducted on total ABISS scores using interpersonal and social variables 1-28 as predictors. Model 8 included the following independent variables: desire for the body of another, having been teased, more satisfied with body when younger, having very few friends, difficulty coping with criticism, having been bullied, use of recreational drugs, and guardian criticism. Together as predictors, these eight variables were statistically significant, F (8, 320) = 47.05, p < . 001, and accounted for 54% of the variability in total ABISS scores, meaning that 54% of the variance in total ABISS scores can be predicted from these interpersonal and social
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independent variables. The t-value assessing the significance of these predictors together indicates that these independent variables together are significantly contributing to the equation for predicting total ABISS scores, Table 34. Table 34. Stepwise Regression on Total ABISS by Interpersonal and Social Independent Variables 1-28 Independent Predictor Variables desire body of another teased about body body satisfaction when younger fewer friends cannot cope with criticism bullying use of recreational drugs guardian criticism Note: Significant at the p< .05 level. An ordinal regression was conducted on BID classification scores using interpersonal and social variables as predictors. The model was statistically significant, (X (28) = 207.68, p < .001) and accounted for 56.7% of the variance in scores. Having been bullied, having very few friends, difficulty coping with criticism, desire for the body of another, more satisfied with body when younger, having been teased, and use of recreational drugs were statistically significant predictors, Table 35. B 4.183 3.740 2.899 2.315 1.933 1.559 1.260 1.721 SE . 616 . 751 . 594 . 682 . 675 . 578 . 468 . 858 .311 .225 .207 .142 .127 .114 .106 -.08 3 t 6.791 4.977 4.884 3.396 2.864 2.696 2.693 2.005 Sig. .0001 .0001 .0001 .001 .004 .007 .007 .046
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Table 35. Ordinal Regression on Classification Using Interpersonal and Social Independent Variables.
Independent Variable discrimination for looks height discontent introversion bullying televisions viewing personal computer usage fewer friends sexual confidence cannot cope with criticism desire body of another slower physical development more satisfied with body when younger low family SES Perfectionist tendencies teased about body think about AAS use guardian criticism maternal criticism Estimat e .002 -.007 .007 .485 -.068 -.025 .844 -.024 .460 1.111 .124 .360 -.099 -.206 .689 .246 -.246 -.190 Std. Error .029 .044 .034 .179 .054 .032 .215 .025 .214 .201 .182 .178 .168 .192 .233 .252 .356 .328 Wald .006 .022 .050 7.320 1.613 .588 15.39 6 .981 4.632 30.54 9 .467 4.084 .352 1.159 8.738 .949 .478 .334 df Sig. 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 . 939 . 881 . 823 . 007 . 204 . 443 . 001 . 322 . 031 . 001 . 494 . 043 . 553 . 282 . 003 . 330 . 489 .
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paternal criticism sibling criticism other family criticism read fitness magazines consume sports supplements frequent mirror checking use recreational drugs use illicit drugs like to be in control wear clothing that hides body
.016 -.022 .050 -.013 -.101 .004 .463 -.198 -.030 .014
.031 .020 .030 .222 .183 .018 .217 .250 .182 .026
.248 1.247 2.654 .003 .306 .038 4.582 .630 .027 .268
1 1 1 1 1 1 1 1 1 1
563 . 618 . 264 . 103 . 954 . 580 . 845 . 032 . 428 . 868 . 605
Note: Significant at the p< .05 level. These estimate coefficients were positive, indicating that as these independent variable factors scores increased, classification scores (i.e., higher body dissatisfaction) scores increased. Lastly, an ordinal regression was conducted on BID classification scores using Demographics 1-7 as predictors. The model was statistically significant, (X (7) = 22.88, p < .01) and accounted for 8.6% of the variance in BID classification scores. Sport participation was the only statistically significant predictor, Table 36. This estimate coefficient was positive, indicating that participants involved in sports, had lower body image dissatisfaction scores.
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Table 36. Ordinal Regression on Body Image Dissatisfaction Classification Using Interpersonal and Social Variables. Independent Variables Age Grade Race/Ethnicity Sexual Orientation Sports Participation Height Weight Note: Significant at the p< .05 level. Estimate .239 .127 -.464 -.846 .849 -.029 .006 SE .183 .206 .264 .514 .357 .046 .004 Wald 1.715 .380 3.083 2.713 5.656 .389 2.293 df 1 1 1 1 1 1 1 Sig. .190 .537 .079 .100 .017 .533 .130
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Summary of Key Findings from Part Two Part two of this study sought to answer the question, Which interpersonal and social factors are the strongest predictors of body image dissatisfaction among selected adolescent males? A cross-sectional correlational approach was used to address the aforementioned question. The student sample was comprised of 330 adolescent males in grades nine through twelve. The range in student ages was 14 to 19 years old, with a mean age of 16.36 years. The sample was predominantly White/Caucasian (70.3%), with 38.2% (n = 126) in their sophomore level of secondary school. A majority (89.1%) indicated a heterosexual orientation. Pilot sample data indicated acceptable reliability scores for the Adolescent Body Image Satisfaction Scale (ABISS), with a Cronbachs alpha coefficient of = .816. Face and content validity were assured through pilot testing measures and evaluation by an expert panel. Based on correlational computations, a number of relationships were found between body image dissatisfaction and interpersonal and social factors. Analyses were conducted measuring the total (raw) score for the Adolescent Body Image Satisfaction Scale (ABISS) and the resulting body image satisfaction classification. Total ABISS scores could range between 32 128 and resulting classification were determined to be body image satisfaction, mild body image dissatisfaction, moderate body image dissatisfaction, and strong body image dissatisfaction. A range of scores were noted,
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with a majority (58.8%) of participants classified as having mild, slightly negative body image dissatisfaction.. The strongest contributing interpersonal and social factors were having the desire for the body of another person (r = .571, p <.001), teasing (r = .490, p <.001), being more satisfied with their body when they were younger (r = .450, p <.001), and experiencing difficulty coping with criticism (r = 443, p <.001), respectively. Other statistically significant interpersonal and social factors also were found, but with weaker correlational associations. An overall summary of contributory factors for both total ABISS score and classification of body image dissatisfaction are presented in Table 28. An analysis of variance (ANOVA) was performed to investigate differences in total ABISS score by race/ethnicity. Findings suggested no statistically significant difference among total ABISS scores and racial/ethnic background (p <.822). Additionally, a Chi-square statistic was used to investigate statistically significant differences between level of body image dissatisfaction classification and race/ethnicity. Again, no statistically significant differences were found between Whites and NonWhites (2 = 7.09). Sport participation (i.e., non-participation) and age accounted for 6.3% of total model variability for body image dissatisfaction scores. Individually, those who participated in organized athletics were less likely to be dissatisfied with their body, accounting for 8.6% of variability in the model. Based on total ABISS scores, Model 8 identified eight predictive factors contributing to body image dissatisfaction including; having the desire for the body of another, having been teased, being more satisfied with their body when they were
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younger, having very few friends, expressing difficulty coping with criticism, having been bullied, use of recreational drugs, and guardian criticism. These predictors were statistically significant, F (8, 320) = 47.05, p < .001, and accounted for 54% of the variability in total ABISS scores. Similarly, a step-wise linear regression was conducted for predictors of body image dissatisfaction classifications. Seven interpersonal and social factors were identified in the predictive model. Significant factors included in the model were; having been bullied, having very few friends, expressing difficulty coping with criticism, having the desire for the body of another, being more satisfied with their body when they were younger, having been teased, and use of recreational drugs, were statistically significant accounting for 56.7% of total variability in the model. Chapter 5 will present a summary of the study, conclusions, a discussion of the findings, and recommendations for future research.
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CHAPTER 5 SUMMARY, CONCLUSIONS, DISCUSSION, AND RECOMMENDATIONS

To make of human affairs a coherent, precise, predictable whole, one must ignore or suppress man as he really is. It is by eliminating man from their equation that the makers of history can predict the future, and the writers of history can give a pattern to the past. ~Eric Hoffer
The purposes of this research study were twofold: 1. to examine the phenomenon of body image satisfaction based on intrapersonal, interpersonal, and social factors identified in current empirical and theoretical literature, and 2. to identify the strongest predictive interpersonal and social factors of body image dissatisfaction among selected adolescent males. This chapter presents a summary of the study, conclusions, a discussion of the results, and recommendations for future research.
Summary of the Study Researchers have identified several intrapersonal predisposing factors (e.g., selfesteem, internalization of teasing) affecting body image dissatisfaction and subsequent negative health behaviors (e.g., drug use, early onset of sexual activity). A predictive model for adolescent males appears to be lacking. Many independent risk factors have been presented and discussed in the literature; however, the strength of relationships and associations among these factors has yet to be established. Factors, such as resiliency, have been identified as protective factors, yet again, how resiliency relates to other variables is unknown at present. Therefore, it is critical that health educators and other professionals identify intrapersonal, interpersonal, and social factors that place boys and adolescent males at risk for body image dissatisfaction as well as factors that offset risks
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and serve as protective factors. A valid and reliable means by which to examine predictive factors associated with adolescent male body image dissatisfaction is needed. Part One of this study systematically analyzed existing theoretical and empirical literature on adolescent body image dissatisfaction. A content analysis of 293 theoretical and empirical studies was conducted through a library and academic database search of periodicals. Medical, behavioral, psychological, and social science databases were used in the content analysis. A total of 121 academic journals were represented in this sample. Nearly half (47.8%) of the journals were retrieved from the field of psychology and 90.8% were journal articles versus other publication types (i.e., books, letters, etc.). Categories used in the content analysis included: year and source of publication, type of document, definition(s) of body image, research design, sample size, sample composition, geographic location of the research, type of body image instrument(s) used, statistics used, interpersonal, intrapersonal, and social factors identified, and any other relevant factors. Studies included in the content analysis were published between the years 1990 2005, with most (83.9%) published from 2000 to 2005. The sample had 25.9% published in 2005 alone, representing the most common year in this study. Twelve operational definitions of body image were specified. Additionally, most discussions concerning body image were of a general nature. Body image as an affective consequence of body-esteem and sociocultural influences and sociocultural and interpersonal factors impacting ones view of the body, were the two most commonly cited operational definitions.
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Many identified studies were either correlational (38.5%) or causal-comparative (18.0%) in terms of research design. Correlational statistics were the most commonly used method of data analysis, indicated in 67.4% of empirical studies. Most studies (69.2%) included samples of less than 500 subjects. A mixed sample of both male and female adolescents was used in 42.1% of empirical studies followed by a mix of adult males and females ranging in ages. Over half (51.3%) of the studies were conducted internationally (i.e., outside of the United States of America). One quarter (25.3%) of empirical studies did not formally specify the type of instrument used to assess body image followed by the Eating Disorders Inventory by Garner and others indicated in 21.6% of empirical studies. A total of 111 instruments were identified, developed in a range of years. Fifty-seven intrapersonal factors were identified with body and self-esteem as well as body dissatisfaction identified in nearly half of the studies. Eighteen interpersonal factors were identified with comparison and gender-based factors being the most commonly cited examples. A total of 37 social factors were identified with normative values, the period of adolescence, and cultural body ideals serving as the most commonly referenced factors. Lastly, 17 other factors were noted in the literature, which can be found in Appendix B. The content analysis in Part One served as a conceptual base for the development of the Adolescent Body Image Satisfaction Scale (ABISS) used in Part Two of this study. Part one of the ABISS used intrapersonal factors impacting body image satisfaction as noted in empirical and theoretical studies. Part two of the ABISS included questions
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formulated from statistically significant interpersonal and social factors identified in the content analysis. Based on statistically significant intrapersonal factors, a 50-item scale containing reverse coded questions was developed to measure individual perception of body image satisfaction. Following pilot testing, the ABISS was adjusted to a 32-item reverse coded scale based on reliability statistics for internal consistency among questions. Selected statistically significant interpersonal, social, and demographic factors identified in Part Ones content analysis were included and measured as independent predictor variables of body image dissatisfaction. Data were collected from 330 adolescent male students in grades 9 through 12 in the New England region of the United States. Data were coded and analyzed using the Statistical Packages for the Social Sciences (SPSS version 14.0, Chicago, IL) software. Descriptive statistics were calculated for the overall sample including, grade level, age, height, weight, sport participation, sexual orientation, and racial/ethnic category. Pearson correlations (r) were calculated for each independent variable and their relationship to body image dissatisfaction as measured by the total Adolescent Body Image Satisfaction Scale (ABISS) and body image dissatisfaction (BID) classification. A between-subjects analysis of variance (ANOVA) was performed on total ABISS (Adolescent Body Image Satisfaction Scale) scores by ethnicity (White vs. Non-White). To investigate whether participants differed in BID classification by ethnicity, a chisquare statistic was used. Lastly, stepwise and ordinal regressions were computed to predict the strongest predictor(s) of adolescent male body image dissatisfaction.
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Pearson correlations showed moderately strong relationships among four independent variables and body image dissatisfaction including: having the desire for the body of another, teasing, having been more satisfied with ones body when they were younger, and reporting difficulty coping with criticism. Eight factors in the stepwise regression model (desire for the body of another, having been teased, more satisfied with body when younger, having very few friends, difficulty coping with criticism, having been bullied, use of recreational drugs, and guardian criticism) were identified as they contributed to the total ABISS score. These eight factors explained 54% of the model variance. Seven factors in the ordinal regression model (having been bullied, having very few friends, difficulty coping with criticism, desire for the body of another, more satisfied with body when younger, having been teased, and use of recreational drugs) were identified as they contributed to the body image dissatisfaction classification score. These seven factors explained 56.7% of the model variance. Individually, sport participation predicted being less dissatisfied with ones body by explaining 8.6% of the models variance.
Conclusions Several main points can be taken from this preliminary investigation in adolescent male body image dissatisfaction. Development of a reliable and valid age-appropriate gender-specific instrument geared at measuring the phenomenon of adolescent male body image was undertaken. The Adolescent Body Image Satisfaction Scale (ABISS) was designed based on findings from Part Ones content analysis of related theoretical and
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empirical body image literature. Specific items included in the ABISS demonstrated good internal consistency and face validity after pilot testing amendments. It can be concluded that the identification of the most theoretically and empirically relevant intrapersonal, interpersonal, and social factors associated with body image dissatisfaction based on a systematic review of existing literature was achieve through the development of the ABISS. Part Two sought to identify the strongest predictive interpersonal and social factors of body image dissatisfaction among selected adolescent males. The strongest predictive factors of adolescent male body image dissatisfaction included: having the desire for the body of another, having been teased, being more satisfied with the body when a person was younger, having very few friends, having difficulty coping with various forms of criticism, reporting instances of having been bullied, use of recreational drugs (e.g., alcohol or tobacco), and guardian criticism. These models confirm that adolescent male body image dissatisfaction results from a confluence of a variety of interpersonal and social influences.
Discussion of the Results Part One This study sought to address the need for a unified approach to understanding factors that predict and predispose adolescent males to body image dissatisfaction as previously discussed in the literature.7,10,16,22-27,70,71 Review of the literature and content analysis from Part One of this study, confirmed that instruments geared toward measuring body image dissatisfaction in adolescent males are nearly non-existent.3,7,10
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Cash and colleagues3 noted that instruments and other scales often approach measuring adolescent male (or female) body affect through the use of previously developed instruments used in clinical populations and adults. While these instruments may assess some aspects of body image dissatisfaction, a non-specific approach has its shortcomings. Results from Part One of this study confirmed the need for the development of an age and gender-appropriate scale for measuring adolescent male body image dissatisfaction. This study attempted to identify what predisposes adolescent males to body image dissatisfaction. Findings from this research may have profound effects when attempting to address gender disparities and resultant negative behaviors (e.g., use of illicit drugs, lower graduation rates, higher rates of suicide and suicide attempts).10,224 Pope and colleagues10 called for action, describing a time when the other 50% of the population (i.e., males) received the same attention and empathy for body image disturbances traditionally associated with females. Boys have continued to be an understudied group when compared with research concerning girls, particularly in the realm of eating disorders and body image concern;10,22-26 therefore, this study focused on adding to the limited research on boys in this area. Part One of this study attempted to identify the most relevant intrapersonal, interpersonal, and social factors affecting adolescent males as noted in theoretical and empirical literature. Data collected in the content analysis supported Shontzs100 assertion that body image research exists in splendid isolation, and a reintegration of theory with empirical support is needed. Review of 293 empirical and theoretical studies in four primary fields of research confirmed a fragmented approach to identifying body image dissatisfaction. Objectives,
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methods, and operational definitions encompassing the phenomenon of body image dissatisfaction were quite varied, as results confirmed in Table 12. Twelve operational definitions identified various pathways by which researchers study body image. Multiple approaches are often needed, but in this process, connections between the psychological affect and the body are often lost. Again, Shontz remarked, the shift from neurological to psychodynamic conceptions has removed body from body image.100, p.37 A full appreciation capturing the extent of body image research was made possible in this study, by examining both published and unpublished theoretical and empirical research. Factors (intrapersonal, interpersonal, and social) were identified via content analysis and tracked according to statistical significance where applicable. Each factor was evaluated against existing literature, which determined the inclusion criteria in the Adolescent Body Image Satisfaction Scale (ABISS). Independent variables also were treated in a similar manner to identify strengths of relationships with the dependent variable assessed by the ABISS. Intrapersonal Factors Several intrapersonal factors included in the Adolescent Body Image Satisfaction Scale (ABISS) were found to be consistent with previous literature. Factors affecting individual self-esteem and self-concept were included in this category. Specific factors noted in the content analysis, such as body esteem,3, 7 confidence,225 perfection,3,7,10,26 and shame91 were consistent examples discussed in previous literature.
Interpersonal Factors
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Also consistent with the literature, were various interpersonal factors affecting body image satisfaction. These interpersonal factors were included as independent variables in Section II of the ABISS, and were used to test correlational relationships with overall body image satisfaction measured by the ABISS. Murray, Touyz and Beumont,49 identified three primary interpersonal processes that play significant roles in body image development: reflective appraisals, feedback (on physical appearance), and social comparison. Factors, such as teasing,174,175 peer criticism,65 familial criticism,7,40,46,66 and bullying226 were included in Section II of the survey based on support from the literature and results from the content analysis. Social Factors Relevant social factors also were included in Section II of the ABISS. Literature and results from the content analysis supported inclusion of social concepts, such as comparison tendencies168, parental criticism182, racial/ethnic factors,50 sexual orientation,10,197 media influences,9,11,23,24 toys,23,142,209 among others. Availability of hardcopy journal articles was a limitation of this studys approach using content analysis. Additionally, specific journals discussing adolescent body image were virtually non-existent. Extrapolating data and inferring meaning from studies that used adult populations was another limiting factor of this study. Many instruments indicated in the research were limiting in that most were not specific to adolescents, more notably adolescent males. The most common instrument used was the Eating Disorders Inventory (EDI), which was developed in the 1980s. Some themes may not relate well to todays social norms concerning eating behaviors. Another limitation of this and like instruments is that body image disorders are commonly associated with eating disorders,
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such as anorexia nervosa and bulimia nervosa.202,203 Research indicates adolescent males are far less likely than females to battle eating disorders; however, adolescent males are equally as likely to experience body image dissatisfaction.10,206 Another potentially limiting factor in research identified in the content analysis is that approximately half of all research was conducted with international samples. While this approach allows for a diverse view of the phenomenon of body image dissatisfaction, culturally-bound factors make interpretation of the results a challenge when generalizing to all adolescent populations. Using content analysis methods, Part One of this research answered the research question, What are intrapersonal, interpersonal, and social factors associated with body image dissatisfaction based on a systematic review of existing theoretical and empirical literature? These results allowed for the construction, revision, and validation of an age and gender-appropriate instrument used to measure body image dissatisfaction in adolescent males (i.e., the Adolescent Body Image Satisfaction Scale). Part Two A correlational, cross-sectional design was used in Part Two of this study to answer the following research question, Which interpersonal and social factors are the strongest predictors of body image dissatisfaction among selected adolescent males? Correlational methods were used to identify strengths of relationships among identified factors.73,214 According to Isaac and Michael73, cross-sectional research allows for participants to be assessed during a single period in their lives and is an effective means to gather a snap shot of a participants affect during any given period of time.
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The overall sample was fairly evenly distributed among grades 9 through 12, Table 24. Distribution of grade level was important so as to minimize effects of social and peer influence as well as age on overall correlations (i.e., skewness of results). Additionally, the sample size of 330 participants was deemed appropriate by power analyses (CI 95%) for statistical analyses to be accurate and meaningful. Overall demographic data were acceptable representations of high school populations in the New England region.107,111,115,181 Other demographics were less representative of national data trends. For instance, data from the 2005 Youth Risk Behavior Survey (YRBS)115, indicated male youth sports participation with a mean of 62% whereas this study had a relatively high rate of participation organized sports at 85.5%. Being that national data include younger participants, results may have been bolstered in this study due to the nature of a highly specific sample in one region of the country. National data from the YRBS did range in sport participation from 51% to as high as 71%. Had a larger, more representative sample been recruited for this study, demographic results may have more closely paralleled national results as with the YRBS. Bullying was found to have a weak to moderate relationship (r = .363 and .367) with total Adolescent Body Image Satisfaction Scale (ABISS) scores and body image dissatisfaction (BID) classification, respectively. Spriggs et al.226 noted bullying behaviors have notable relationships with social maladjustment and negative health behaviors, both as the person being bullied and the bully himself. Family, peer, and school factors were reported to have strong relationships with bullying behaviors. This study sought to investigate if bullying confirmed or refuted previous research in terms of body image satisfaction. Janssen and others227 found strong relationships with adolescents
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who were reportedly obese or reported a negative affect and the likelihood of being a bully. Similarly, negative correlations were found among those who were more likely to be victims of bullying; that is, victims were more likely to be less overweight, although other reports have verified overweight as a significant contributing factor to both types of behaviors.228 Body image dissatisfaction appears to contribute to bullying behaviors in adolescents, although specific causes were not ascertained in this study. Having fewer friends was moderately correlated to body image dissatisfaction as noted on scores from the ABISS (r = .390) and BID classification (r = .411). Introversion is often a preceding factor to having fewer social networks.75 Feelings of adolescent alienation have been explored previously by Fetro16 and were shown to correlate to negative health practices, such as drug use and lack of social participation and involvement in peer-based activities. Social experiences have been found to correlate to body image satisfaction,139,229,230 but as Cash and Pruzinsky3, p.283 note, body image and social functioning are intertwined conceptually, empirically, and experientially; we urge more scientific inquiry into how body image attitudes shape and are shaped by social relations and interpersonal experiences. Having fewer social relationships (in this instance, friends) related to less satisfaction with ones body image according to this research. If asked as a general assessment question, such as, I have few social relationships, and by providing specific examples (e.g., friends, family issues, work, sports), a stronger relationship may have been found as advocated in Cash and Flemings229 research. Inability to cope with various sources of criticism (peer, parental, sibling), also correlated to higher scores for body image dissatisfaction. These moderate relationships
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reflect the interaction of negative intrapersonal coping skills with social and interpersonal factors as discussed in Palladino-Green and Pritchards7 research. Further exploration into specific relationships between criticism and body image dissatisfaction were found. Interestingly, the strongest relationship with source of criticism and body image dissatisfaction was found with sibling criticism. This finding is in contrast to studies where stronger relationships were found in parental and familial criticism7 and peers.19,41,65 Vincent and McCabe46 found siblings played a small yet significant role in cognitive restraint among girls, but results were not significant for boys. Criticism from paternal sources was more strongly correlated to body image dissatisfaction (r = .197) in adolescent males than from maternal sources (r = .161) or other family members. Cash and Pruzinsky3 cited research where maternal criticism predicted body image dissatisfaction and eating disorder symptoms in their daughters;41,45,46,48 however, research along these lines for fathers and sons is lacking. This research confirms that there is a stronger relationship between a fathers criticism and his sons body image satisfaction.66 Greater research efforts need to be undertaken to further explore to what extent father-son relationships impact adolescent body image satisfaction and resultant health behaviors. Perhaps closely related to source of criticism, the reaction of desiring to have the body of another person may be an outcome of this affect. A moderate relationship (r = . 571) was found between being dissatisfied with ones body and desiring a different body. Other influences, such as teasing and reading fitness magazines also were found to contribute to body image dissatisfaction. Objectification theory (watching oneself as if they were the observer) as proposed by Fredrickson and Roberts78, discusses this phenomenon in the context of females and eating disturbances. The effects of popular
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media, such as fitness magazines aimed at male body perfection10 coupled with parental, peer, and sibling teasing suggests a propensity for objectified body surveillance and higher body image dissatisfaction. Body surveillance, as discussed by Fredrickson and Roberts,78 has been noted as a consistent predictor of negative body image experience, but mainly in female populations. Other work by Pope and colleagues,10,23,24 suggested that men are as susceptible to objectification and body surveillance as women. Reading fitness magazines may be a reaction to body image dissatisfaction with hopes of achieving an ideal body. Conversely, reading fitness magazines may also predispose adolescent males who have a vulnerable body image to become more dissatisfied with their present body. This form of body shame may parallel findings discussed in Rodin and others91 work on females and the concept of normative discontent. Directionality of these relationships was not established in this study. With respect to teasing (a form of criticism), a moderately strong correlation was found (r = .490) with the overall ABISS score. Reactions to teasing often vary by gender and age.3 For example, Steiner-Adair and colleagues231, discussed how typical parental and administrator reactions in school settings often promote ignoring the negative behaviors of teasing. It is acknowledge that ignoring something often averts immediate confrontation, but often manifests as an internalized negative affect. Boys are less likely to ignore teasing, are less likely to report teasing incidences,3 and often react with violent behaviors (e.g., physical fighting) or may adopt bullying behaviors.3,10,65 Rieves and Cash232, found peers and friends to be among the worst perpetrators of teasing, second to only brothers. The present study did not assess the source of teasing, which may have provoked a similar finding in this cohort of adolescent males. Regardless, research has
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acknowledged that teasing and harassment by peers in particular, but also from adults, contribute to negative body image.3,231 Perhaps a reaction in adolescent males to teasing and also from possible sources of social influence, such as reading fitness magazines (previously discussed), is the ideation of using ergogenic aids or body image drugs,10,21-26 such as androgenicanabolic steroids (AAS). A positive and significant correlation was found in this study concerning ideation of using AAS. Previous research has confirmed poly-drug use patterns in people who have a negative body image.7,10-12,14,19-22 Furham and Calnan14, discussed their findings of eating disturbance, lower self-esteem, obsessive reasons for exercising, and body weight dissatisfaction in adolescent males. The commercialization of the male body also has been presented as a plausible factor in boys and adolescent males seeking to morph their bodies in terms of leanness and muscularity.11,24 Results from this research confirm previous findings of men with lower body satisfaction and AAS use; however, this research presents an understudied area of adolescent male ideation of AAS use. Only one study107 has investigated AAS use patterns and body satisfaction in this population. Precipitators of body image dissatisfaction are multifaceted as are the resultant negative health behaviors (AAS ideation and use). The correlation in this sample was lower (r = .303). Relationships may have been limited by self-report bias or simply providing socially desirable responses regardless of efforts to assure participant anonymity. Further research should address this finding and attempt to link possible causal factors or precipitators (i.e., media, teasing, criticism, etc.). Two findings, being more satisfied with ones body when they were younger and instances of perceived slower physical development were positively correlated to body
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image dissatisfaction classification scores. Adolescents who reported greater instances of teasing and bullying were also more likely to report being dissatisfied with there physical development progress.17 An often under-studied area of body image research relates to endocrinology.3 Studies have shown that social perception, especially among peers, predicts satisfaction with ones own self-perception.233 A limitation of this line of research is that studies often investigate short stature in boys and precocious puberty in girls (e.g., Turners syndrome).233,234 Height discontent was evaluated in this study, which found a weak correlation (r = .223) to body image dissatisfaction; however, the nature of discontent was not established (i.e., too tall or too short). This research presented a general question, which was left up to the participant to interpret for himself. Findings suggest that slower physical development in adolescent males lead to feelings of inadequacy, body image dissatisfaction, and having greater satisfaction with their body when they were younger. As predicted, ideation of using androgenic-anabolic steroids was found to have a stronger positive correlation to body image dissatisfaction than use of recreational or illicit drugs (r = .303, r = .238, r = .130) respectively. Kanayama, Pope, and Hudson21 discussed the phenomenon of growing body image dissatisfaction in men due to societal factors. The expected reaction would be for men and boys to turn to drugs and other substances that change the body in terms of promoting leanness or enhancing ones level of muscularity. Findings from the 2005 YRBS115 and other studies,107,109,110,112,121 suggest adolescents with greater instances of maladaptive behaviors (e.g., truancy, violent behavior, bullying, etc.) were more likely to use both recreational drugs (e.g., alcohol and tobacco) and illicit drugs (e.g., marijuana). As previously discussed in this research,
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violent behaviors, such as bullying were correlated to body image dissatisfaction. Adolescents who have been bullied often become perpetrators themselves.226 Golub and Johnson131 presented findings of body image satisfaction correlating to less instances of both licit and illicit drug use. Similarly, Naylor et al121 discussed drug use patterns in a cohort of adolescents in Massachusetts and instances of high-risk behaviors, such as driving while intoxicated and risky sexual practices. This research supports previous findings from Naylor121 and a reverse (but consistent) relationship with findings from Golub and Johnson.131 Recreational drug use presented a stronger correlational relationship in this cohort of adolescents, which is also consistent with data from the 2005 YRBS.115 Again, accuracy of responses to these factors in survey research is often limited to self-report bias and issues with confidentiality/anonymity of answers. Handling of the survey responses and coding by an independent third party was used to minimize this effect. Grade level was weakly correlated to body image dissatisfaction. Adolescents were more likely to be dissatisfied with their bodies as they progressed in grade level. Research with female cohorts is well-established in terms of identifying maturational and growth patterns.2 Females tend to become less satisfied with their bodies as they enter puberty. Discontent is likely due to increases in body weight, additional adipose tissue, and other developmental factors.2 Research with boys and adolescent males is less wellestablished.2,3,10 Graber et al.2, p.76 noted, There is far less research on the development of body image in adolescent boys, and this research is inconsistent as to the impact of pubertal timing. Overall, it appears that the timing of puberty does not have a strong or lasting impact on boys body image. Previous research has found that boys are often
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more dissatisfied with their bodies when they are pre-pubescent (approximately 11-13 years old) and often report becoming more satisfied as they approach puberty due to positive growth patterns (e.g., increases in muscle mass, lean body tissue, height, and strength).2,3,10 Findings from this research revealed that adolescent males became more dissatisfied with their bodies and perceptions of it as they progressed in age and grade level, which is in contrast to findings from Graber et al.2 An interesting corollary to this finding has been suggested by Pope and others,10,24 where the societal commercialization of the male body has likely taken a former protective factor of physiologic male development and tuned it into a social expectation in terms of perfection. Boys who are subjected to media messages detailing the perfect male body may grow to seek this ideal versus appreciating the normal maturation they are experiencing.10 Limitations of these findings include the effects of maturation and cross-sectional research approaches making assessment of this phenomenon a challenge. The impression we hold of our body is usually the complex outcome of factors that foster satisfaction, offset by those that create dissatisfaction.235, p.219 One such factor found in this study that fosters positive body image satisfaction is sports participation. Over 85% of this sample reported participation in organized sports. Research has presented conflicting results correlating body image satisfaction and sport participation. Findings suggest that type of sport predicts satisfaction or dissatisfaction with ones body image.3 For example, Huddy and Cash236 presented findings from their study comparing body image satisfaction between male marathon runners and controls. Results indicated that marathoners were more satisfied with their bodies than the controls. Other research has found less satisfaction in males who participated in sports stressing lower body mass,
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such a distance running, crew, and equestrian.237 Body image satisfaction was found to be higher among American football players and bodybuilders than those participating in cross-country running and cycling where upper body mass may be viewed as a disadvantage.237 This study was limited in that it did not seek to establish relationships between type of sport and body image satisfaction. Interpretation of this studys results should be weighed in the context of previous findings concerning sport participation and body image affect.2,235-237 Participants who reported discrimination because of how they look were more likely to experience body image dissatisfaction. Social and interpersonal factors influencing body image perception (i.e., discrimination) play an important role in helping to shape adolescent affect.3,6,168 Type of discrimination was not established in this study possibly limiting interpretation of the results. Discrimination for ones physical appearance would be consistent with findings from this study in terms of teasing, criticism, slower physical development, and bullying. Further research should be conducted to establish what types of discrimination negatively impact body image. Television viewing was not correlated with body image dissatisfaction and was actually slightly negatively correlated (r = -.015), meaning that those who watched television were likely to be more satisfied with their body. Results of this finding were not significant, but stand in stark contrast to the research of Tiggeman.9 Of note is that Tiggemans research9 explored the content of television programming versus simply time of viewing. Computer (PC) usage was found to have a slight correlation (r = .123) with body image dissatisfaction in this sample. Computer usage of more than three hours per day,
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unrelated to schoolwork or academic activities was found to negatively impact body image. Various forms of media (e.g., print, television, radio, Internet, etc.) have been studied to measure their impact on body image satisfaction. Palladino-Green and Pritchard7 found that media influences predicted body image dissatisfaction in adult men and women. Mass media are powerful conveyors of sociocultural ideals.9 For example, Pope, Phillips, and Olivardia10 discussed their findings of social trends and cultural norms impacting the ideal male form. It is clear from the research that men and boys are increasingly subject to idealistic media images about their bodies.3,10-12 Content of computer usage was not established in this research; therefore results should be interpreted in the context of other research findings. Considering many computer uses extend beyond standard applications (word processing, spreadsheets, etc.), findings may correlate to the content of what is being viewed, such as music, music videos, streaming videos, among others. The portability of computer capabilities (e.g., iPods, cellular telephones, Blackberries, etc.) also should be factored into overall exposure times. As a whole, research supports a link between media exposure and body image; however, direction and causality of these relationships have yet to have been addressed.3,9 Sexual confidence was found to have a negative directional relationship with body image satisfaction, meaning that participants who reported higher levels of sexual confidence were less dissatisfied with their body. Grogan and Richards225 qualitatively investigated body satisfaction and other thematic factors, such a sexual confidence. Their findings support this research in that men and boys who were more satisfied with their level of muscularity and physical development were more likely to report being satisfied with their bodies and perceptions of it. A discussion of power and physical competence
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was also presented in their findings from focus groups. Socially acceptable responses or perhaps embarrassment answering this question may have presented a limitation in this study. Giving examples of what sexual confidence means may have provided stronger conclusive results. Future adjustments to the Adolescent Body Image Satisfaction Scale concerning this item are warranted. Wearing clothing that hides the body (e.g., baggy or darker colors) was found to positively correlate to body image dissatisfaction (r = .318). Typically, this behavior is found in people (mainly women and girls) who have an eating disorder, such as anorexia nervosa or bulimia nervosa.238 Other research1,10,26,89,144,145 has found that males with specific types of body image dissatisfaction, such as body dysmorphia or muscle dysmorphia also use such practices. Hiding the body is often viewed as a form of shame for either being too large (overweight) or too small (thin).78 This studys findings did not establish a causal directional relationship as to whether those reporting higher level of body image dissatisfaction and wore clothing to hide their body, were more likely to be overweight, underweight, or normal weight. Other findings were found to have little to no relationship with body image dissatisfaction in adolescent males. Symptomatology surrounding body image disturbances, such as eating disorders often describe a patient profile. According to the Diagnostic and Statistical Manual for Mental Disorders80, persons with anorexia nervosa often have perfectionist qualities, come from middle to higher socioeconomic backgrounds, and seek control in their lives, Tables 3-6. Findings from this research showed no substantial correlation or statistical significance for socioeconomic status (r = .097), perfectionism (r = -.044), and liking to be in control (r = .028). These findings
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are somewhat surprising in that they do not support a model for viewing male body image dissatisfaction in the same light as with female body image. It is common to find instruments used to measure body image to be non-gender specific.3 Additionally, modifications to body image assessments meant for females and used with males, may not provide accurate results.3 The way in which we view male body image dissatisfaction has its own unique factors. Pope, Katz, and Hudson89 for example, presented their initial findings of muscle dysmorphia as reverse anorexia. Later, this phenomenon was later more appropriately term muscle dysmorphia, a subtype of obsessive compulsive disorder and body dysmorphic disorder, Tables 1-3. Further research should focus on genderspecific models for body image dissatisfaction, particularly in male populations (i.e., boys, adolescents, and men). Another interesting finding was the lack of correlation between ideation of androgenic-anabolic steroid (AAS) use and consumption of sports supplements. Use of sports supplements, such as creatine, protein powders and other amino acids, and metabolic optimizers have been studied as precursors for some people that go on to use AAS.21,61,107,112,114,120,122,127,130,131,148,149 Kanayama et al.61 explored the incidence and availability of over-the-counter drug use in men in U.S. gymnasiums. Participants who used AAS were more likely to have reported previous or con-current heavy use of sports supplements. This study did not support Kanayama et als61 correlative findings. Lack of corroboration among studies may be accounted for by differences in sample composition. Kanayama et al.61 used adult men from U.S. gymnasiums, whereas this study used a cross-sectional randomized sample of adolescent males. Research should
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focus not only on AAS use and sports supplements, but also the role body image satisfaction plays in this process. Mirror checking is commonly associated with body image dissatisfaction.1 The obsession that some aspect of the body is not acceptable often provokes the compulsion to check ones appearance in a mirror several times per day.1 In this study, mirror checking was not correlated to body image dissatisfaction. This may be due to a variety of factors, but the main likelihood is vanity. Pope and colleagues10 discussed men and boys are often preoccupied with appearance, but it is traditionally considered to be unmasculine to worry about ones looks. Luciano99, p.4 commented on male vanity in the United States in her book, Looking Good: Male Body Image in Modern America stating, We are clearly witnessing the evolution of an obsession with body image, especially among middle-class men, and a corresponding male appropriation of, status-seeking activities once seen as feminine. Self-report bias may have limited results of this factor. Recall bias may have also limited findings, in that participants may not have remembered or recognized a ubiquitous daily activity, as with checking a mirror. Research has explored the relationship between sexual orientation and body image satisfaction in men. Gay and bisexual men were found to be more likely to report instances of body image dissatisfaction than heterosexual comparison cohorts.56,239 Herzog and colleagues found gay men were more likely to have an ideal weight below normative values whereas heterosexual men desired a higher ideal body weight.56 Silberstein and others239 found gay men were more likely to exercise to improve physical appearance whereas heterosexual men exercised more for health benefits and enjoyment. Findings from this study did not find any relationship between sexual orientation and
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body image satisfaction. Self-report bias could have been a strong limiting factor as many adolescent males may fear the stigma associated with being gay, bisexual, or transgendered.202 Another potentially limiting factor could have been the lack of a strong sample of adolescents reporting a sexual orientation other than heterosexual (n = 19; 5.7%). With respect to race/ethnic factors, no statistically significant differences were found between Whites and Non-Whites. This is a consistent finding with previous research where less is known about body image satisfaction based on racial/ethnic background in males.3,51,240 In other gender-based research, White women were more likely to be dissatisfied with their bodies than Black women. Hispanic/Latino and Asian women fell in the middle.51-54 Findings in men are less conclusive and warrant further exploration. For example, Smith and colleagues183 found that Black men reported more cognitive-behavioral investment in physical appearance compared to White men. This research did not distinguished Non-White groupings, which should be investigated in future studies. Two regression models were used to predict body image dissatisfaction in adolescent males. In the first model, Demographic1 (age) and Demographic 5 (sport participation) accounted for 6.3% of the variability in total ABISS scores. As discussed previously, participation in sports appears to be a protective factor for body image in adolescent males whereas as age likely contributes to higher dissatisfaction scores. Sport type is a predictive factor that needs further exploration. Type of sport should be brokendown to investigate which sport(s) contribute to positive and negative body image in adolescent males.3,236,237 Age factors are most likely a reflection of the growing
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commercial value of the male body as suggested by Pope et al.24 With only 6.3% of the models variance accounted for, further exploration needs to be undertaken to examine other contributing factors. A step-wise linear regression on total ABISS score found Factors 10 (desire for the body of another), 15 (having been teased), 12 (more satisfied with body when younger), 7 (having very few friends), 9 (difficulty coping with criticism), 4 (having been bullied), 25 (use of recreational drugs), and 17 (guardian criticism) as significant predictors of adolescent male body image dissatisfaction accounting for 54% of total model variance. An ordinal regression on body image dissatisfaction (BID) classification scores found Factors 4 (having been bullied), 7 (having very few friends), 9 (difficulty coping with criticism), 10 (desire for the body of another), 12 (more satisfied with body when younger), 15 (having been teased), and 25 (use of recreational drugs) as significant predictors of adolescent male body image dissatisfaction accounting for 56.7% of total model variance. Common factors identified in these two models were nearly identical showing good correlation between total ABISS scores and BID classifications. Only Factor 17 (guardian criticism) was not accounted for in both models. Being that the nature of body image is a multifaceted construct2, which greatly impacts quality of life,3,4 a comprehensive understanding of what contributes to this process is essential. Luciano99 noted male body image is undergoing a confluence of social, economic, and cultural changes that will continue to be instrumental in shaping how adolescent male body image is viewed in the U.S. and abroad. Knowledge of the strongest predictors as identified in this research, will allow for evidence-based health education programming aimed at
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improving body image in adolescent males. Further knowledge of factors contributing to negative body image affect in adolescent males can be analyzed an inferences concerning protective qualities can be further studied.
Recommendations for Future Research Future research on adolescent male body image dissatisfaction is warranted based on results from this study. The following recommendations for health education practice, professional preparation, and future research are presented based on findings from both parts of this study. 1. Use of a systematic review or content analysis of the literature on body image should be advocated when developing age-appropriate and gender-specific instruments. 2. Health educators need to be aware of the impact of adolescent male body image dissatisfaction, so as to develop relevant programming to enhance body image and self-esteem and off-set risk factors as previously discussed. 3. Continue to review and revise items included in the Adolescent Body Image Satisfaction Scale (ABISS) using larger samples and individual item factor analyses. 4. Give more specific examples in question wording for the ABISS. For example, define sexual confidence, or height discontent. 5. Using constructs and items in the ABISS, develop an open-ended version of the instrument to better ascribe meaning to responses garnered in the ABISS. 6. Using the strongest predictive factors for adolescent male body image dissatisfaction, develop item subscales to better understand overall meaning of each construct of body image.
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7. Body image is often only addressed in health education courses, such as human sexuality or sexuality education. This research was an attempt to further demonstrate the need for an understanding of the role(s) body image plays in the development of positive or negative health practices in adolescent males. Further exploration in expanding body image content in other health education courses (e.g., drug education, theory and practice) is strongly recommended. 8. Conduct the same research in other geographic regions of the United States. 9. This research was conducting during the winter and spring seasons of the school year. Conduct research during other seasons (i.e., fall and summer) to note any similarities or differences in findings. 10. Examine possible differences comparing private (independent) school settings with public schools. 11. Use a prospective research design to track and account for changes due to maturation in samples. 12. Compare results from the ABISS in adolescent males with adult men, noting for any similarities or differences as factors influencing development occur. 13. Verify the strongest predictors of this research using a conceptual model through path analysis testing. 14. Extrapolating meaning and making inferences from studies using female and adult populations presents issues with accuracy of defining the phenomenon of body image. Use body image literature limited to that of adolescent males. 15. Identify specific types of bullying behaviors and sources of teasing so as to establish causality and directionality.
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16. Conduct more in-depth research with father-son interactions and body image satisfaction, particularly the role of paternal criticism and the impact on a boys selfesteem and body image perception. 17. Ascertain directionality of relationships concerning drug and supplement use, reading fitness magazines, and teasing. 18. Incorporate alternative means to administer the ABISS, such online passwordprotected secure systems, or through iPodcasts. 19. Expand research looking at sport participation factors contributing to adolescent male body image. Compute analyses related to type of sport versus simply sport participation. 20. Study the content of television and computer usage and its role in adolescent male body image versus time of use. 21. With respect to wearing clothing that hides the body, conduct further research investigating the physical stature of those that identify these behaviors. Identifying factors, such as overweight, underweight, or normative weight could provide greater insight into this behavior. 22. Conduct further analyses on the role of racial background and ethnicity in adolescent males as opposed to classifying participants as either White or Non-White.
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APPENDICES
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APPENDICES
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APPENDIX A HUMAN SUBJECTS APPROVAL AND FORMS
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[HSC Forms Forthcoming]
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APPENDIX B CONTENT ANALYSIS CATEGORIES, CLASSIFICATIONS, AND CODING GUIDELINES
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Data Collection Sheets ID: TLE: PURP: RES: CODE: DES: YR: SRC: DOC: N: NCOMP: GEO: BI: INST: STAT: INTRA: INTER: SOC: OTHR:
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DESCRIPTION OF CATEGORIES AND CODING GUIDELINES FOR CONTENT ANALYSIS The following details how each category was coded using empirical and theoretical research studies. _______________________________________________________________________ _ Identification Number (ID): Each piece of work was identified through a systematic identification number. The type of study and the order in which it was reviewed constituted the ID number. Categories are as follows: (1) E: Empirical work (2) T: Theoretical work (3) U: Unknown category of work (4) D: Duplicate citation Each piece of work reviewed was coded according to the sequence of review. An example would be: E125 or empirical study and the 125th one reviewed overall. Numerical coding was used for data analysis methods. _______________________________________________________________________ _ Title (TLE): The exact title of the written work was used; no numerical coding was used. _______________________________________________________________________ _ Purpose (PURP): A brief summary of the intent of the research study was recorded for both theoretical and empirical research. _______________________________________________________________________ _ Results of Study (RES): Applicable in only empirical research designs; only statistically significant results of the study were summarized.
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_______________________________________________________________________ _
Coding Decision (CODE): A decision to include or exclude written work in the sample was coded as: (1)Y = included in sample (2)N = excluded from sample The following numerical codes were used to indicate reason(s) why a written work was excluded from the sample: 3. Work was not available in a printable form at Southern Illinois University Carbondale nor available through Interlibrary Loan services 4. Not written in the English language 5. Irrelevant to content of the research 6. Book review 7. Not original research or critique of previous work 8. Duplicate citation 9. Review of the literature 10. Other _______________________________________________________________________ _ Research Design (DES): Categorization of various research design employed in each study was applicable only to empirical studies. Each study details its method by which to evaluate and obtain answers to research questions and to control variance. In the event a written work did not meet formal inclusion criteria or exhibited deficiencies in the design of the research, it was coded accordingly: 0. Work was not coded T0: Theoretical work therefore no research design E0: Empirical research with an unclear design The following eleven categories are research designs as defined by Isaac and Michael.73 1. Action Research Involves developing new skills or new approaches to solve problems with direct application(s) to the classroom or another applied setting.
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2. Case and Field Studies Involves intensively studying the background, current status, and environmental interactions of a given social unit: an individual, group, institution, or community.
Research Design (DES Continued): 3. Causal Comparative (Ex Post Facto) Involves investigating the possible cause-and-effect relationships by observing some existing consequence and searching back through the data for plausible causal factors. 4. Correlational Involves investigating the extent to which variations in one factor correspond with variations in one or more other factors based on correlation coefficients. 5. Descriptive Involves systematically describing a situation or area of interest factually and accurately. 6. Developmental Involves investigating patterns and sequences of growth and/or change as a function of time. 7. Historical Involves reconstructing the past objectively and accurately, often in relation to the tenability of a hypothesis. 8. Qualitative Also called Naturalistic Research, involves processes of inquiry not overtly measurable via quantitative methods. Designs include phenomenology, case studies, grounded theory, ethnography, and biography. 9. Quasi-Experimental Involves approximating the conditions of a true experiment in a setting which does not allow the control and/or manipulation of all relevant variables. The researcher must clearly understand what compromises exist in the internal and external validity of their design and proceed with these limitations. 10. True Experimental Involves investigating possible cause-and-effect relationships by exposing one or more experimental groups to one or more treatment conditions and comparing the results to one or more control groups not receiving the treatment. Random assignment of subjects is a critical component in assuring validity. 11. Instrument development/evaluation Involves establishing the reliability and validity of existing or older instruments. _______________________________________________________________________ _
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Year of Publication (YR): Refers to the year of the publication; numerical coding per year was used for data analysis. _______________________________________________________________________ _ Source of Publication (SRC): This category was split-coded. Letter codes indicate the field of research/academic discipline the written work originated from. Numerical coding refers to the specific title of the journal/publication. PSY: SSC: HLT: MED: UNK: Psychology Social Science (includes Sociology) Health Medicine (includes Nursing and Allied Health) Unknown Source
1. Addictive Behaviors 2. Adolescence 3. Adolescent Medicine 4. Adolescent Medicine: State of the Art Reviews 5. American Journal of Drug and Alcohol Abuse 6. American Journal of Health Behaviors 7. American Journal of Psychiatry 8. American Psychological Association 9. American Sociological Association 10. Annals of Nutrition and Metabolism 11. Appetite 12. Assessment 13. Australian Journal of Psychology 14. Behavior Research and Therapy 15. Best Practice and Research in Clinical Endocrinology and Metabolism 16. Body Image 17. Bosnian Journal of Basic Medical Sciences 18. British Journal of Health Psychology 19. Canadian Journal of Psychiatry Clinical Child Psychology and Psychiatry 20. Canadian Medical Association Journal 21. Child and Adolescent Psychiatric Clinics of North America 22. Child Development 23. Child Study Journal 24. Childrens Voice 25. Clinical Psychology Review
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26. Communications: The European Journal of Communication Research 27. Community Dentistry and Oral Epidemiology 28. Culture in Psychology 29. Developmental Psychology 30. Drug and Alcohol Dependence 31. Eating Behaviors 32. Eating Disorders 33. Eating and Weight Disorders 34. Ethnicity and Disease Source of Publication (SRC Continued): This category was split-coded. Letter codes indicate the field of research/academic discipline the written work originated from. Numerical coding refers to the specific title of the journal/publication. PSY: SSC: HLT: MED: UNK: Psychology Social Science (includes Sociology) Health Medicine (includes Nursing and Allied Health) Unknown Source
35. European Eating Disorders Review 36. European Journal of Clinical Nutrition 37. European Journal of Endocrinology 38. European Journal of Public Health 39. Harvard Review of Psychiatry 40. Health Education Research 41. Health Promotion International 42. Health Psychology 43. Healthy Weight Journal 44. International Journal of Behavioral Medicine 45. International Journal of Eating Disorders 46. International Journal of Mens Health 47. International Journal of Obesity and Related Metabolic Disorders 48. Issues in Comprehensive Pediatric Nursing 49. Journal of Abnormal Psychology 50. Journal of Adolescent Health 51. Journal of Adolescent Research 52. Journal of Advanced Nursing 53. Journal of Affective Disorders 54. Journal of the American Academy of Child and Adolescent Psychiatry 55. Journal of American College Health 56. Journal of Applied Measurement 57. Journal of Athletic Training 58. Journal of Child and Adolescent Substance Abuse 59. Journal of Child and Family Studies
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60. Journal of Consulting and Clinical Psychology 61. Journal of Cultural Diversity 62. Journal of Drug Education 63. Journal of Early Adolescence 64. Journal of Epidemiology and Community Health 65. Journal of Ethnic and Cultural Diversity in Social work 66. Journal of Family Issues 67. Journal of Genetic Psychology 68. Journal of Health Psychology Source of Publication (SRC Continued): This category was split-coded. Letter codes indicate the field of research/academic discipline the written work originated from. Numerical coding refers to the specific title of the journal/publication. PSY: SSC: HLT: MED: UNK: Psychology Social Science (includes Sociology) Health Medicine (includes Nursing and Allied Health) Unknown Source
69. Journal of Human Nutrition and Dietetics 70. Journal of Nervous and Mental Disease 71. Journal of Nutrition Education and Behavior 72. Journal of Pediatric Nursing 73. Journal of Pediatric Psychology 74. Journal of Personality Assessment 75. Journal of Personality and Social Psychology 76. Journal of Psychology 77. Journal of Psychology and Child Psychiatry 78. Journal of Psychosomatic Research 79. Journal of Reproductive and Infant Psychology 80. Journal of Research on Adolescence 81. Journal of School Health 82. Journal of School Nursing 83. Journal of Science and Medicine in Sport 84. Journal of Sex Research 85. Journal of Social and Clinical Psychology 86. Journal of Social Psychology 87. Journal of Strength and Conditioning Research 88. Journal of Studies on Alcohol 89. Journal of Youth and Adolescence 90. Leisure Studies 91. Medicine and Science in Sports and Exercise 92. Minerva Pediatrica 93. Monographs of Society for Research in Child Development
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94. Obesity Research 95. Pediatrics 96. Pediatric Exercise Science 97. Perceptual and Motor Skills 98. Personality and Social Psychology Bulletin 99. Psychiatry and Clinical Neurosciences 100. Psychological Medicine 101. Psychopathology 102. Psychopharmacology Source of Publication (SRC Continued): This category was split-coded. Letter codes indicate the field of research/academic discipline the written work originated from. Numerical coding refers to the specific title of the journal/publication. PSY: SSC: HLT: MED: UNK: Psychology Social Science (includes Sociology) Health Medicine (includes Nursing and Allied Health) Unknown Source
103. Psychosomatics 104. Psychotherapy and Psychosomatics 105. Research Quarterly for Exercise and Sport 106. Scandinavian Journal of Primary Healthcare 107. Scandinavian Journal of Psychology 108. School Nurse News 109. Scientific American 110. Sex Roles 111. Social Behavior and Personality: An International Journal 112. Social Science and Medicine 113. Sports Medicine 114. Substance Use and Misuse 115. Suicide and Life-Threatening Behavior 116. The British Journal of Clinical Psychology 117. The Scientific World Journal 118. Total Health 119. Twin Research: The Official Journal for International Society of Twin Studies _______________________________________________________________________ _ Document Type (DOC): Refers to the specific type of document reviewed for the content analysis (e.g., book, journal article, dissertations).
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1. Journal article 2. Book 3. Book (edited) 4. Book review 5. Letter 6. Critique of previous research 7. Editorial 8. Meeting abstract (conference proceedings) 9. Dissertation 10. Unpublished paper Document Type (DOC Continued): 11. Presentation 12. Personal communication 13. Government document 14. Research report _______________________________________________________________________ _ Sample Size (n): Empirical studies involving subjects were tracked according to the overall sample (i.e. N). The following codes were used when a sample size could not be determined: 1. Work was not coded T0: Theoretical work therefore no sample size was indicated E0: Empirical research with an unspecified sample size _______________________________________________________________________ _ Composition of Sample (NCOMP): Sample composition will not be numerically coded due the various categories. A descriptive label will be assessed for the sample to better indicate subjects this category. For example, a label may be high school students, college students, adolescents, etc. The following codes will be used when composition cannot be determined: NC: Work was not coded T0: Theoretical work therefore no sample size was indicated E0: Empirical research with an unspecified sample composition 1. 2. 3. 4. 5. Adolescents: mixed sample Adolescent males Adult females Adolescent females Adult males
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6. Adults: mixed sample 7. Females: mixed sample of adults and adolescents 8. Adult females and Adolescent mixed sample 9. Adolescent mixed sample and Adult mixed sample 10. Adult females and adolescent females 11. Adult mixed sample and Adolescent females 12. Pre-Adolescent sample _______________________________________________________________________ _
Geographic Location (GEO): Studies conducted in the United States were numerically coded according to the geographic region in which the research took place. United States Census Bureau (2000) data divides each region of the country into divisions. Studies conducted outside of the United States were numerically coded as well as studies involving a national sample of subjects. 0. Work was not coded T0: Theoretical work therefore no sample was used E0: Empirical research with an unspecified location 2. New England (Maine, Massachusetts, Vermont, New Hampshire) 3. Middle Atlantic (Connecticut, New Jersey, New York, Pennsylvania, Rhode Island) 4. East North Central (Illinois, Indiana, Michigan, Ohio, Wisconsin) 5. West North Central (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota) 6. South Atlantic (Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia) 7. East South Central (Alabama, Kentucky, Mississippi, Tennessee) 8. West South Central (Arkansas, Louisiana, Oklahoma, Texas) 9. Mountain (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming) 10. Pacific (Alaska, California, Hawaii, Oregon, Washington)
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11. United States Territories (Puerto Rico, U.S. Virgin Islands, Guam) 12. National sample 13. International sample a. Austria b. Italy c. Samoa d. India e. China f. Japan Geographic Location (GEO Continued): g. Canada h. Mexico i. Sweden j. United Kingdom k. Spain l. France m. Turkey n. Bosnia o. South Africa p. Israel q. Finland r. Germany _______________________________________________________________________ _ Operational Definition of Body Image (BI): Author(s) definition or use of body image. Subscales or components are also included. 0. Work was not coded T0: Theoretical work with operational definition not specified E0: Empirical research with operational definition not specified 1. Attitudinal and perceptual dimension of ones overall view of the self. 2. An affective consequence of body-esteem and sociocultural influences. 3. Comprised of global components including global self-esteem and bodyesteem. 4. Perceptual affect, influencing and ultimately impacting, ones behaviors. 5. A psychiatric affect influenced by societal and personal factors. 6. Sociocultural and interpersonal factors impacting ones view of the body and its capabilities.
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7. Reflective appraisal of ones perceived physical appearance. 8. A persons mental image and evaluation of appearance and the influence of these perceptions and attitudes on behavior. 9. Perception of ones appearance and body affect based-on past developmental experiences as well as interpersonal and social determinants. 10. An experiential perspective that is multidimensional including mental representations as well as sensory and somatic components. _______________________________________________________________________ _
Instrument Used (INST): Inclusion of an instrument designed to measure body image (if any). 0. Work was not coded T0: Theoretical work therefore no instrument was used E0: Empirical research with an unspecified instrument 1. Silhouette Survey (Stunkard et al., 1983) 2. Body Esteem Scale (BESS) (Beaudoin et al.) 3. Eating Attitudes Test (EAT) (Leichner et al.) 4. Eating Disorders Inventory (EDI) (Garner et al., 1984) 5. Body Image Satisfaction Scale (BISS) 6. Revised Body Image Scale (Secourd & Jourard, 1994) 7. Body Image Assessment for Obesity 8. Children Eating Attitudes Test (ChEAT) 9. Anorexia Inventory for Self-Rating (Anis et al.) 10. General Health Questionnaire (GHQ-28) 11. Structured Interview for Anorexic and Bulimic Syndromes 12. Schedule for Affective Disorder and Schizophrenia (SIAB-EX) 13. Beck Depression Inventory (BDI) (Beck, et al.) 14. Digital Image Manipulation (DIM) 15. Contour Drawing Rating Scale (Thompson & Gray, 1995) 16. Social Physique Anxiety Scale (SPAS) 17. Body Esteem Scale for Adolescents and Adults (Mendelson et al., 1997) 18. Center for Epidemiologic Studies Depression Scale (CES-D) 19. Body Attitudes Questionnaire (Ben-Tovim & Walker) 20. Dutch Eating Behaviors Questionnaire 21. Extreme Weight-Loss Behaviors Scale 22. Physical Appearance Comparison Scale 23. Self-Concept Clarity Scale
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24. Rosenberg Self-Esteem Scale (RSES) (Rosenberg, 1965) 25. Drive for Muscularity Scale (DMS) (McCreary & Sasse, 2000) 26. Drive for Muscularity Attitudes Questionnaire (DMAQ) 27. The Weight and its Relationship to Adolescents Perceptions of Their Providers Scale (WRAP) 28. The Greek Physical Self-Description Questionnaire 29. Body Image Affect Scale (Campbell & Chow) 30. Global Self-Esteem (Bachman & OMalley) 31. Three-Factor Eating Questionnaire Revised-18 32. Childrens Depression Inventory (CDI) 33. Multidimensional Self-Concept Scale (MSCS) 34. Body Image and Body Change Inventory (Ricciardelli & McCabe) 35. Sociocultural Influences on Body Image and Body Change (McCabe & Ricciardelli) Instrument Used (INST Continued): Inclusion of an instrument designed to measure body image (if any). 0. Work was not coded T0: Theoretical work therefore no instrument was used E0: Empirical research with an unspecified instrument 36. The Internalization Scale of the Sociocultural Attitudes Toward Apperance Questionnaire (Heinberg, Thompson & Stormer, 1995) 37. Body Area Satisfaction Scale (BASS) (Brown et al.) 38. Self Perception Profile for Adolescents (SPPA) 39. Body Image Satisfaction Questionnaire (BISQ) 40. Dieting Status Measure (DiSM) 41. Subjective Body Dimensions Apparatus 42. Body Shape Questionnaire (BSQ) (Cooper, Taylor, Cooper & Fairburn, 1987) 43. Impact of Event Scale (IES) 44. Body Figure Rating Scale 45. Body Image Coping Strategies Inventory (BICSI) 46. Perceived Sociocultural Pressure Scale 47. Ideal Body Stereotype Scale Revised (Stice & Bearman) 48. General Temperament Survey (Watson & Clark) 49. Appearance Self-Esteem Scale (Pliner, Chaiken, Flett, 1990) 50. Body Figure Perception Questionnaire (Stunkard, Sorenson, Schulsinger, 1983) 51. Self-Esteem Questionnaire (SEQ) (Dubois, Felner, Brand, Phillips & Lease, 1996) 52. The Childrens Figure Rating Scale (Collins, 1991) 53. Satisfaction and Dissatisfaction with Body Parts Scale (Berscheid et al.) 54. Eating Disorders Examination (EDE) (Cooper & Fairburn)
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55. Harter Self-Perception Profile for Children (Harter) 56. Somatomorphic Matrix 57. Childrens Physical Self-Perception Profile 58. Youth Risk Behavior Survey (YRBS 2003) 59. Sociocultural Attitudes Towards Appearance Questionnaire (SATAQ) 60. Sociocultural Internalization of Appearance Questionnaire (SIAQ-A) 61. Adolescent Coping Scale (ACS) 62. Restraint Scale-Revised 63. Mizes Anoretic Cognitions Questionnaire (MAC) (Mize) 64. Body Attitudes Test (BAT) (Probst et al., 1995) 65. Eating Disorder Examination-12 (EDE-12) 66. Body Uneasiness Test 67. State-Trait Anxiety Test 68. BMI Silhouette Matching Test (BMI-SMT) 69. Severity of Dependence Scale (SDS) Instrument Used (INST Continued): Inclusion of an instrument designed to measure body image (if any). 0. Work was not coded T0: Theoretical work therefore no instrument was used E0: Empirical research with an unspecified instrument 70. Physical Appearance-Related Teasing Scale- Revised (PARTS-R) 71. Muscle Appearance Satisfaction Scale (MASS) (Mayville et al., 2002) 72. Body Image Questionnaire (BIQ) (Cash) 73. Body Modification Scale (BMS) 74. Excessive Exercise Scale (EES) 75. Body Checking Questionnaire 76. The Family Behavior Checklist 77. Diabetes Knowledge Scale 78. Structured Clinical Interview Dimensions (SCID) 79. Bem Sex Role Inventory (BSRI) (Bem, 1974) 80. Perceived Sociocultural Influences on Body Image and Body Change Questionnaire 81. Body Image Perception and Attitude Scale for Children (BIPAS-C) 82. Peabody Picture Vocabulary test-Revised (PPVT-R) (Dunn & Dunn) 83. Alternate Uses Test of Divergent Thinking 84. Social Phobia Scale 85. Multidimensional Body Self-Relations Questionnaire (MBSRQ) (Cash) 86. Demographic and Dieting Questionnaire (Maloney et al.) 87. Drive for Thinness (Garner, 1984) 88. Perception of Teasing Scale (POTS) (Thompson et al.) 89. Zungs Self-Rating Depression Scale (Zung) 90. Parental Bonding Instrument (PBI) (Parker, 1983)
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91. Structured Inventory for Anorexic and Bulimic Syndromes (SIAB-EX) (Fichter, et al., 1991) 92. Index of Self-Esteem 93. Bulimia Test-Revised (BULIT-R) (Thalen, et al., 1991) 94. Body Satisfaction Scale (BSS) (Slade, et al., 1990) 95. Dual Dimension Figure Rating Scale (Stunkard, 1983) 96. Revised Restraint Scale (Polivy et al.) 97. Risk Index Scale (Leon et al.) 98. Pubertal Development Scale (PDS) (Pterson et al.) 99. Negative Emotionality Scale (NE) 100. Positive Emotionality Scale (PE) 101. Constraint Scale (CON) (Wallen) 102. General Behavior Inventory (GBI) (Ellis) 103. Self-Perception Profile for Adolescents (SPPA) (Harter) 104. My Sexual Feelings Scale (Leon et al.) 105. Physical Activity Participation Questionnaire (PAR-Q) Instrument Used (INST Continued): Inclusion of an instrument designed to measure body image (if any). 0. Work was not coded T0: Theoretical work therefore no instrument was used E0: Empirical research with an unspecified instrument Self-Esteem Questionnaire 106. Body Image Scale 107. Eating and Me 108. Strengths and Difficulties Questionnaire (SDQ) 109. Positive and Negative Affect Scale for Children (PANAS-C) 110. Sociocultural Attitudes Towards Appearance Questionnaire-Revised (SATAQ-R) (Cusumano & Thompson, 1997) 111. Millon Adolescent Clinical Inventory (MACI) (Millon, Millon & Davis, 1993) _______________________________________________________________________ _ Statistics Used (STAT): Includes parametric and nonparametric statistics used in data analysis. Studies using multiple statistical methods used multiple codes. Only statistics specified in the research article were numerically coded. No assumptions regarding statistics used were made. 0. Work was not coded T0: Theoretical work therefore no statistics were used E0: Empirical research with an unspecified statistical method(s)
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1. Descriptive (including measures of central tendency, dispersion, variability, frequencies, and percentages) 2. Correlation 3. Regression (including linear, multiple, and logistic) 4. Analysis of variance (ANOVA) (including multiple analysis of variance, analysis of covariance, and multiple analysis of covariance) 5. t-tests (including independent and dependent and one and two-tailed tests) 6. Factor analysis 7. Structural Equation Modeling (SEM) 8. Chi square 9. Thematic analysis (qualitative) 10. Path analysis 11. Open coding (qualitative) 12. Content analysis _______________________________________________________________________ _
Intrapersonal Factors Identified (INTRA): Variables used to describe individuals body image satisfaction such as self-concept, acceptance, and body attitude. 0. Work was not coded T0: Theoretical work with intrapersonal factors not specified E0: Empirical research with intrapersonal factors not specified 1. Body satisfaction 2. Body attitude 3. Drive for thinness 4. Body (Self) Esteem 5. High Expectations 6. Perfectionism 7. Self-concept 8. Drive for muscularity 9. Body image disturbance 10. Negative affect 11. Eating restraint 12. Appearance anxiety 13. Body dissatisfaction 14. Psychiatric morbidity 15. Ideal body size 16. Depression 17. Failure 18. Guilt
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19. Shame 20. Homosexuality 21. Leanness 22. Physique anxiety 23. Body build 24. Self-worth 25. Self-confidence 26. Narcissism 27. Self-image 28. Self-objectification 29. Self-surveillance 30. Internalization 31. Self-identity 32. Self-perception 33. Coping skills 34. Loneliness 35. Attractiveness 36. Fear of fat or feeling fat 37. Locus of control Intrapersonal Factors Identified (INTRA Continued): 38. Physical (Body) competence or athleticism 39. Emotional eating 40. Stress 41. Threats 42. Protection 43. Fulfillment 44. Self-efficacy 45. Self-acceptance 46. Mood (affect) 47. Self-blame 48. Suicidality 49. Avoidance 50. Obsessive compulsive tendencies 51. Body checking 52. Emotional expression 53. Alienation 54. Aggression 55. Body awareness 56. Eating attitude 57. Self-appraisal _______________________________________________________________________ _ Interpersonal Factors Identified (INTER):
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Variables concerning relationship factors that interact with and affect body image satisfaction. Interpersonal factors identified in theoretical studies were coded with a T preceding the category; interpersonal factors identified in empirical studies were coded with an E preceding the category. 0. Work was not coded T0: Theoretical place factors not specified E0: Empirical research place factors not specified 1. Comparison 2. Teamwork 3. Muscle conversations 4. Appearance conversations 5. Peer dieting practices 6. Teasing (parental, sibling, stranger) 7. Family influences 8. Role modeling 9. Harrassment (sexual) 10. Relationship status (single, married, etc.) 11. Healthcare provider relationship Interpersonal Factors Identified (INTER Continued): 12. Parental connectedness 13. Peer appearance conversations 14. Peer pressure 15. Gender 16. Abuse 17. Encouragement 18. Perceived feedback _______________________________________________________________________ _ Social Factors Identified (SOC): Variables describing sociocultural influences affecting personal satisfaction or dissatisfaction with body image. 0. Work was not coded T0: Theoretical work where no social factors were identified E0: Empirical research where time social were not identified 1. 2. 3. 4. 5. Socio-economic status (SES) Media (television, internet, radio, etc.) Peer acceptance Eating location Social anxiety
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6. School factors 7. Ethnicity and cultural values 8. Public school 9. Minority stress 10. Masculine ideals 11. Athletics and sports participation 12. Norms 13. Acculturation 14. Stigmatization 15. Discrimination 16. Social health status 17. Period of adolescence 18. Pubertal development and timing 19. Time 20. Popularity 21. Bullying 22. GLBT association 23. Cultural body ideal 24. Sexual practices, values, and roles 25. Westernization influences 26. Physique uneasiness Social Factors Identified (SOC Continued): 27. Social exposure 28. Companionship (or lack of) 29. Social desirability 30. Social isolation 31. Fashion 32. Urban, Suburban, and Rural settings 33. Social support 34. Referent values 35. Social influence 36. Social mobility 37. Social class _______________________________________________________________________ _ Other Factors (OTHR): Categories generated from other comparable categories worthy of note. 1. 2. 3. 4. 5. Body Mass Index (BMI) Discrepancy Dieting (various) Severity of asthma Anhedonia
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6. Physical disability 7. Overestimation 8. Body importance 9. Perceived pressure 10. Disordered eating practices 11. Panel rating (subjective) 12. Developmental influences 13. Health outcomes 14. Health resources 15. Good health (global) 16. Genetic factors 17. Perceived fraudulence _______________________________________________________________________ _
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APPENDIX C CONTACT LETTERS AND CORRESPONDENCE
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Pilot Study Administrator Letter

May 10, 2007 Lawrence W. Becker Headmaster The Brooks School 1160 Great Pond Road North Andover, MA 01845 Dear Mr. Becker, I appreciate you taking the time and effort to assist me with my dissertation entitled, Predictors of body image dissatisfaction among selected adolescent males. The goal of this phase of the project is to conduct a pilot study to assure a valid and reliable instrument. This is where your school plays a vital role in assuring success of this process. I am asking that you allow me to survey forty (40) of your male students in grades 9 through 12. I am looking for an even distribution of ten (10) students per grade level. The survey, called the Adolescent Body Image Satisfaction Scale or ABISS, should not take more than thirty (30) minutes to administer. Prior to administration, I will go through detailed instructions with the students. Following administration, I would also like to discuss the instrument with the students for improvement purposes. Pilot data will remain anonymous and will only be used to assess the instrument. Results will be made available to you and the school at your request. Parental consent (if under age 18) and minor assent forms will be distributed prior to the date of administration. Students selected to participate in this process will be required to return parental consent and minor assent forms prior to participating. There are minimal foreseeable risks associated with this project, which has been approved by the Southern Illinois University Carbondale Human Subjects Committee. I have enclosed the relevant forms for your review. Again, I sincerely thank you and your students for assisting me in this important process. Should any questions arise, please do not hesitate to contact me at your earliest convenience. Regards,
James E. Leone, MS, ATC, CSCS Doctoral Candidate in Health Education Southern Illinois University Carbondale Carbondale, IL 62901 781-608-2044 (hm) 617-373-5536 (wk) jleoneatc@yahoo.com (e-mail)
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Pilot Study Cover Letter May 2007 Dear Participant, I am a doctoral candidate in the Department of Health Education at Southern Illinois University Carbondale. The purpose of the enclosed survey is to assess adolescent attitudes and perceptions concerning body image dissatisfaction and possible influential factors. In addition, there are a few questions that ask demographic (background) questions. The intent of this research is to understand characteristics of body image dissatisfaction as they relate to various risk factors among adolescents and young adults. You and your school/class were selected to participate in this research because of the relevance of age categories represented in your school/classes. The survey will take 15 20 minutes to complete. All responses will be kept anonymous. Only people directly involved with this project will have access to the surveys. You were chosen for this study because you meet the likely criteria for inclusion in this research. Completion and return of this survey indicate voluntary consent to participate in this study. Please return all parental consent (if under 18 years old) and minor assent forms to the researcher prior to taking the survey. Questions about this study can be directed to me or my dissertation advisor, Dr. Joyce V. Fetro, Department of Health Education, SIUC, Carbondale, IL 62901-4310*. Phone (618) 453-2777. (* 4-digit SIU mailcode) Thank you for taking the time to assist me in this research. James E. Leone, M.S., LAT, ATC, CSCS Doctoral Candidate in Health Education Southern Illinois University Carbondale 617-373-5536 (work) E-mail: jleoneatc@yahoo.com
This project has been reviewed and approved by the SIUC Human Subjects Committee. Questions concerning your rights as a participant in this research may be addressed to the Committee Chairperson, Office of Research Development and Administration, SIUC, Carbondale, IL 62901-4709. Phone (618) 453-4533. E-mail: siuhsc@siu.edu
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Full Study Participant Cover Letter May 2007 Dear Participant, Thank you for agreeing to participant in my doctoral research study! The purpose of the enclosed survey is to assess adolescent attitudes and perceptions concerning body image dissatisfaction. In addition, there are a few questions that ask demographic (background) questions. The intent of this research is to understand characteristics of body image dissatisfaction as they relate to various risk factors among adolescents and young adults. You were selected to participate in this research because of the relevance of your age category. The survey will take 15 20 minutes to complete. All responses will be kept anonymous. Only people directly involved with this project will have access to the surveys. You were chosen for this study because you meet the likely criteria for inclusion in this research. Completion and return of this survey indicate voluntary consent to participate. Please use the return envelope provided. You will not incur any costs during this process. Your honorarium will be processed upon receipt of the parental consent form (if under age 18), minor assent form, and survey. The identification on your survey will be removed by a third party prior to processing so as to track your participation, but will in no way connect your survey responses back to you. Additionally, your identification number will be automatically entered into a drawing to win one of five $50 gift certificates to Best Buy stores. Questions about this study can be directed to me or my dissertation advisor, Dr. Joyce V. Fetro, Department of Health Education, SIUC, Carbondale, IL 62901-4310*. Phone (618) 453-2777. (* 4-digit SIU mailcode) Thank you for taking the time to assist me in this research. James E. Leone, M.S., LAT, ATC, CSCS Doctoral Candidate in Health Education Southern Illinois University Carbondale Carbondale, IL 62901 617-373-5536 (wk) E-mail: jleoneatc@yahoo.com
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APPENDIX D THE ADOLESCENT BODY IMAGE SATISFACTION SCALE AND RELATED FORMS
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Adolescent Body Image Satisfaction Scale Overview: This survey will look at factors that may affect adolescent body image satisfaction. There are three main purposes/sections of this survey: 1. measurement of Intrapersonal factors as they relate to body image dissatisfaction, 2. questions about Interpersonal and Social factors, and 3. Background questions. Instructions: Please be as accurate and honest as possible when answering ALL of the following questions. The survey contains three sections as described above. Be reminded that all of your answers will remain strictly anonymous. You will not be identified through any part of the survey process. Also, please do not make any marks on the survey that might reveal your identity. If you have any questions while taking the survey, please alert the survey administrator. Once you have completed the survey, place it inside the unmarked manila envelop at the front of the room. Thank You for Participating! James E. Leone, M.S., LAT, ATC, CSCS Doctoral Candidate, Health Education Southern Illinois University Carbondale Carbondale, IL 62901 617-373-5536 (wk) jleoneatc@yahoo.com (e-mail)
This project has been reviewed and approved by the SIUC Human Subjects Committee. Questions concerning your rights as a participant in this research may be addressed to the Committee Chairperson, Office of Research Development and Administration, SIUC, Carbondale, IL 629014709. Phone (618) 453-4533. E-mail: siuhsc@siu.edu
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SECTION I THE ADOLESCENT BODY IMAGE SATISFACTION SCALE Revised (Circle ONE response for each question)
ITEM # 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. ITEM I am satisfied with my body.* I am a physically attractive person.* I dislike my present percentage of body fat. I am satisfied with my bodys muscle tone.* My body is strong.* I often feel small compared to others. I feel people ignore me because of my looks. I feel good when others reassure me that I look alright. I am in control of my body.* I get satisfaction physically dominating others. People find me physically attractive.* I have low self-esteem about my looks. I avoid social gatherings because of the way I look. I like to look different/unique than my peers.* STRONGLY DISAGREE 1 1 1 1 1 1 1 1 1 1 1 1 1 1 DISAGREE 2 2 2 2 2 2 2 2 2 2 2 2 2 2 AGREE 3 3 3 3 3 3 3 3 3 3 3 3 3 3 STRONGLY AGREE 4 4 4 4 4 4 4 4 4 4 4 4 4 4 CODE
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15. ITEM # 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29.
I am critical of my body. QUESTION I respect my body (eat healthy, exercise, etc.).* My body makes me feel confident.* I am athletic.* My body is awkward. I want the perfect body. Seeing other males that are more muscular than me makes me upset. I am ashamed of my body. I get anxious/upset when others might see my body partially or fully unclothed. I have been rejected by girlfriends/boyfriends because of my body. I feel connected with my body.* I am dissatisfied with my body. I am unattractive. I am happy with my body fat.* I wish I were more muscular.
1 STRONGLY DISAGREE 1 1 1 1 1 1 1 1 1 1 1 1 1 1
2 DISAGREE 2 2 2 2 2 2 2 2 2 2 2 2 2 2
3 AGREE 3 3 3 3 3 3 3 3 3 3 3 3 3 3
4 STRONGLY AGREE 4 4 4 4 4 4 4 4 4 4 4 4 4 4 CODE
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30. 31.
My body is weak. I feel bigger than others.*
1 1
2 2
3 3
4 4
ITEM # 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44.
QUESTION I gain positive attention because of my looks.* I do not need other people to tell me that I look alright.* My body is out of control. I am physically intimidated by others. People find me physically unattractive. I have high self-esteem concerning my looks.* My looks allow me to freely socialize with friends and peers.* I like for my looks to fit-in with others. I am comfortable with my body.* I do things that disrespect my body (i.e., drugs, over-eat, cut, etc.). My body makes me feel insecure. I am not athletic. My body is graceful.*
STRONGLY DISAGREE 1 1 1 1 1 1 1 1 1 1 1 1 1
DISAGREE 2 2 2 2 2 2 2 2 2 2 2 2 2
AGREE 3 3 3 3 3 3 3 3 3 3 3 3 3
STRONGLY AGREE 4 4 4 4 4 4 4 4 4 4 4 4 4
CODE
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45. 46.
There is no perfect body.* Seeing other males that are more muscular than me does not affect the way I view my body.* I am proud of my body.* QUESTION I am comfortable when others might see my body fully or partially unclothed.* My girlfriends/boyfriends accept my body.* I feel disconnected with my body.
1 1
2 2
3 3
4 4
47. ITEM # 48. 49. 50.
1 STRONGLY DISAGREE 1 1 1
2 DISAGREE 2 2 2
3 AGREE 3 3 3
4 STRONGLY AGREE 4 4 4 CODE
ABISS Score
__________
* Indicates reverse coded items Shaded area includes items that were omitted based on the pilot study findings
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SECTION II INTERPERSONAL AND SOCIAL FACTORS (Circle ONE response for each question)
ITEM # 1. 2. 3. 4. 5. 6. 7. 8. 9. 1 0. 1 1. 1 2. QUESTION I have been discriminated against because of the way I look. My height makes me upset. I like to keep to myself. I have been bullied by others. I watch more than 3 hours of television per day. I use a computer more than 3 hours per unrelated to schoolwork. I have very few friends. I am sexually confident. I find it difficult to cope with criticism. I wish I had the body of someone else. Physically, I am developing more slowly compared to others my age. I was more satisfied with my body when I was STRONGLY DISAGREE 1 1 1 1 1 1 1 1 1 1 1 DISAGREE 2 2 2 2 2 2 2 2 2 2 2 AGREE 3 3 3 3 3 3 3 3 3 3 3 STRONGLY AGREE 4 4 4 4 4 4 4 4 4 4 4 CODE
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younger than I am now. 1 3. 1 4. ITEM # 1 5. 1 6. 1 7. 1 8. 1 9. 2 0. 2 1. 2 2. I come from a low income family background. I like to be perfect in most things I do. QUESTION I have been teased about my body. I think about using anabolic steroids (i.e., roids, juice, test). My guardians criticize me about my body. My mother criticizes me about my body. My father criticizes me about my body. My sibling(s) (brother/sister) tease/criticize me about my body. Other family members (e.g., uncles, aunts, cousins, etc.) criticize me about my body. I read bodybuilding and fitness magazines. 1 1 STRONGLY DISAGREE 1 1 1 1 1 1 2 2 DISAGREE 2 2 2 2 2 2 3 3 AGREE 3 3 3 3 3 3 4 4 STRONGLY AGREE 4 4 4 4 4 4 CODE
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2 3. 2 4. 2 5. 2 6. 2 7. 2 8.
I take sports supplements (i.e., protein, creatine, nitric oxide, etc.). I frequently look in mirrors to make sure that I look alright. I use recreational drugs, such as alcohol or tobacco more than 1 time per month. I use illegal drugs, such as marijuana, ecstasy, and/or meth more than 1 time per month. I like to always be in control. I wear clothing that hides my body.
1 1 1
2 2 2
3 3 3
4 4 4
1 1
2 2
3 3
4 4
SECTION III BACKGROUND QUESTIONS (Circle ONE response for each question)
ITEM # 1. QUESTION What is your age? RESPONSE CODE
__________ (write in years) 1 Grade 9 (freshman) 2 Grade 10 (sophomore)
2.
What grade level are you in school? (circle one only)
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3 Grade 11 (junior) 4 Grade 12 (senior) 5 Other (college preparatory) 3. How would you describe yourself? (circle one only) 1 White/Caucasian (non-Hispanic) (persons having origins in any of the original peoples of Europe, the Middle East, or North Africa) 2 Black or African American (non-Hispanic) (persons having origins in any of the black racial groups of Africa) 3 White/Hispanic origin (persons having geographical or cultural origins in traditional Latin culture) 4 Black/Hispanic origin (persons having geographical or cultural origins in traditional Latin culture) 5 Asian (persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, Cambodia, China, India, Japan, Korea, Malaysia, the Philippine Islands, Thailand, and Vietnam) 6 Native Hawaiian or other Pacific Islander (persons having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands) 7 American Indian or Alaska Native (persons having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment) 8 Multiracial (persons who are not easily classified into a single race) 9 Other (please specify) ___________________________________ 4. What is your sexual orientation? 0 no response
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(circle one only)
1 heterosexual (i.e., straight) 2 homosexual (i.e., gay) 3 bisexual (i.e., bi) 4 transgendered
5.
Do you participate in organized (interscholastic) high school athletics? (circle one only)
1 Yes 2 No If yes, indicate all of your sports. _______________________________
6. 7.
What is your approximate height in feet and inches (i.e., 5 feet 10 inches)? What is your approximate body weight in pounds (i.e., 170 lbs.)?
__________ (write in) __________ (write in)
THANK YOU FOR PARTICIPATING IN THIS SURVEY!
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THE ADOLESCENT BODY IMAGE SATISFACTION SCALE ITEM CRITERIA EVALUATION FORM
Dear Evaluator, Thank you for agreeing to evaluate this instrument. Your input and feedback will prove instrumental in making this a valid and reliable tool to measure adolescent male body image dissatisfaction. The following describes the overall instrument, the item selection process, and scoring procedures. Additionally, following the description section, an item evaluation form is provided to make review of the instrument easy. I anticipate this process will take no more 30 45 minutes of your time. Instrument Goal The goals of the ABISS are threefold in purpose: 1. to measure adolescent male body image dissatisfaction via satisfaction scales, 2. to measure correlations between various interpersonal and social factors and body image dissatisfaction, and 3. to collect background/demographic information. Item Selection Items were selected based on applicability to various concepts and constructs related to body image. Items included in the ABISS were based on their ability to ascertain global body image, specifically in adolescent males. Interpersonal and social factors were included in section two based on a systematic content analysis of relevant literature. Each factor was based on frequency of occurrence and relevance in both theoretical and empirical literature. Lastly, demographic and background questions were developed to further establish direct relationships among personal factors and body image dissatisfaction. Instrument Scoring The ABISS (section one) measures adolescent male body image dissatisfaction. Each item is scored on a Likert scale system from 1 4. The higher rating (e.g., 3 or 4) indicates a higher level of body image dissatisfaction. Items indicated by an asterisk (*), will be reverse coded. The instrument presents a variety of positively and negatively worded items in the first section of the ABISS (i.e., items 1 25). Items 25 50 are oppositely worded from the first section so as to establish split-half reliability. Section two seeks to establish adolescent perceptions of various interpersonal and social factors impacting their body image. Each item presents an interpersonal or social factor identified in the literature as it relates to a negative body image. The respondent is presented with another Likert scale option of 1 4 (strongly disagree through strongly agree). Factors in section two will be assessed for strength of correlation to identified body image dissatisfaction garnered in part one. Additionally, using multiple regression analysis, the strongest predictive factors will be determined as well. Section three presents the respondent with background/demographic questions. Correlations among background/demographic data will also be established using the ABISS.
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I am including an item analysis sheet in efforts to expedite your review process of the instrument. Please try to have your evaluation complete and returned to me (electronically) by no later than Wednesday, April 11, 2007. I greatly appreciate your time and expertise!
Sincerely, James E. Leone, MS, ATC, CSCS Doctoral Candidate in Health Education Southern Illinois University Carbondale
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THE ADOLESCENT BODY IMAGE SATISFACTION SCALE

Instrument Revision Form Please use the following form to evaluate all three sections of the ABISS. Note: Items are indicated for each section by the following: A-1, A-2, A-3 represents the ABISS, IS-1, IS-2, IS3, represents Interpersonal and Social factors, and B-1, B-2, B-3, represents Background questions. Please X ONE box only. Type your comments directly into the comments box section. ITEM RETA RETAIN OMIT COMMENTS # IN W/ REVISI ONS A-1 A-2 A-3 A-4 A-5 A-6 A-7 A-8 A-9 A-10 A-11 A-12 A-13 A-14 A-15 A-16 A-17 A-18 A-19 A-20 A-21 A-22 A-23 A-24 A-25 A-26 A-27 A-28 A-29 A-30 A-31
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A-32
Item #
A-33 A-34 A-35 A-36 A-37 A-38 A-39 A-40 A-41 A-42 A-43 A-44 A-45 A-46 A-47 A-48 A-49 A-50 IS-1 IS-2 IS-3 IS-4 IS-5 IS-6 IS-7 IS-8 IS-9 IS-10 IS-11 IS-12 IS-13 IS-14 IS-15 IS-16 IS-17 IS-18 IS-19 IS-20 IS-21 IS-22
Retain
Retain w/ revisions
Omit

Comments
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IS-23 IS-24 IS-25 IS-26 IS-27 B-1 B-2 B-3 B-4 B-5 B-6 B-7
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APPENDIX E PILOT STUDY PROCEDURES AND FORMS
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Pilot Study Procedures _______________________________________________________________________ _ 1. Contact initiated with school administrator(s) for approval to use their school for the pilot study. Contact will be made via telephone and/or email and followed-up with a hardcopy letter. 2. Appropriate consent forms and survey drafts will be sent to the school administrator for review. 3. School administrator provides a signed letter indicating approval to conduct the pilot study at their school. 4. Upon approval from the school administrator, parental and minor assent forms will be sent home with the students. 5. Dates and times will be scheduled for survey administration. 6. The researcher will arrive at the high school at a pre-determined date and time, and will introduce himself and the study to each grade level (i.e., grades 9 through 12).* 7. Time will be allotted for any questions or concerns the students may have concerning the study or its procedures. 8. The researcher will collect parental consent and minor assent forms from all participating students. 9. Instructions will be handed out to the students. 10. Surveys will be handed-out to the students face down along with a pen (standard ink color) and a sheet of paper to cover responses to the questions. 11. Instructions will be read with the students. 12. Answer any additional questions from the students. 13. Students will turn over their survey and begin.** 14. When all students are finished with the survey, they will be asked to write any comments regarding wording, meaning, points of confusion, etc. on the survey. 15. The researcher will then ask questions of the students and take notes regarding the survey and the survey process.
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16. Students will return the surveys in the provided manila envelope. 17. The last student will seal the envelope and return it to the researcher, thus concluding the pilot study process. * ** Sample size will include (n = 10) male students from grades 9 through 10. Surveys will be timed and proctored by the researcher.
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INTRODUCTION SCRIPT Pilot Study Phase * My name is James E. Leone. I am presently completing my doctoral dissertation in health education at Southern Illinois University Carbondale in Illinois. The purpose of my doctoral dissertation is to identify predictors of adolescent male body image dissatisfaction using a novel survey. My target group is male high school students in grades 9 through 12. I developed this topic because of gaps in the research literature and personal interest. * A survey will help assess current adolescent male attitudes concerning body image dissatisfaction. Having a valid and reliable instrument will allow health educators, school administrators, professionals who work with adolescents, mental health personnel, and others to better meet social and psychological needs of adolescent males. I have received Human Subjects Committee approval from Southern Illinois University Carbondale as well as permission from the Brooks School to conduct this research. * I would appreciate your assistance in helping me. This is part of a pilot study in order to improve the instrument.
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PILOT STUDY INSTRUCTIONS Survey Script (to be read to students) Please follow along as I read you the instructions for this survey. Follow along with the paper in front of you on your desk. This survey has three parts: two sections where you are going to read some statements about your feelings and opinions and, a section on your demographics (personal background).
In sections one and two you will be asked to respond to questions with the following options: Strongly Disagree Disagree Agree Strongly Agree
Please choose the option that best represents your feelings and opinions concerning each question. Section three includes background questions, that is, questions that help indicate your background in a general sense. Please be aware these questions are very general and will not be used to identify you or your responses in any way. Some examples of background questions are: Your grade level (9th, 10th, 11th, 12th) Your age Your height
I have provided you with the following materials: Pen/pencil Survey (white)
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Instruction sheet (orange) Privacy sheet (blue)
Before we proceed, please return your parental consent (if under 18 years old) and minor assent form to me. I will seal these in a separate envelope from your surveys. You may not take a survey until I have these forms. Once again, this is not a test. There are no right or wrong answers. Please do your best to answer each question completely and honestly. If you have any questions about the survey or directions, please ask now before you start (allow for time for questions). When you are finished with the survey, please place it in the manila envelope at the front desk and return to your seat. When the last person has completed the survey, the envelope will be sealed and return to the researcher (James E. Leone). All responses will remain anonymous. Lastly, I would like to get your feedback and opinions on the survey. Following the survey, I will meet with you as a group to briefly discuss the survey and get any feedback you would like to offer to make it a better, more understandable survey. Thank you for your participation in this important research! You may begin the survey.
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APPENDIX F MAIN STUDY PROCEDURES AND FORMS
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Fieldwork Boston, Inc. Main Study Procedures Recruitment and Mailing Process: _______________________________________________________________________ _ 1. Fieldwork Boston, Inc. will generate a random database list of parents of 9th through 12th grade males from the New England area. 2. A recruiter from fieldwork Boston, Inc. will call parents of 9th through 12th grade males from the database list. Tallies will be kept concerning the results of each phone call. 3. The recruiter will read from a script introducing the studys purpose, methods, and incentives for participation. 4. The recruiter will attempt to gain parental consent (over the telephone), and will then ask to speak with the child to re-introduce the study and to gain minor assent (over the telephone). 5. An accurate mailing address will be confirmed and recorded. 6. Quota sheets will be adjusted after each recruit. 7. Recruited names and addresses will be forwarded to the fieldwork Boston, Inc. mail processing center. 8. fieldwork Boston, Inc. sends out: (1) set of instructions including how to complete the survey, due dates, and incentives, (1) parental informed consent, (1) minor assent form, (1) Adolescent Body Image Satisfaction Scale (ABISS) survey, and (1) selfaddressed stamped envelope. Completed and Returned Survey Process: _______________________________________________________________________ _ 1. Fieldwork Boston, Inc. receives completed surveys. 2. Fieldwork Boston, Inc. separates the code sheet from each survey and places it in a separate file. 3. Fieldwork Boston, Inc. separates the informed consent and minor assent forms from each survey and places them in separate files. 4. Fieldwork Boston, Inc. places the ABISS survey in a separate file. 5. Tally and quota sheets will be adjusted based on completed surveys.
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6. Fieldwork Boston, Inc. will forward the completed surveys to the researcher for coding and analysis.* 7. Codes from the completed surveys will be matched to respondent addresses and a $5 cash honorarium will be mailed to the respondent along with a letter of thanks. 8. At the conclusion of the study, all completed survey codes will be randomized and five (5) will be selected for an additional $50 Best Buy gift card. 9. Five (5) $50 Best Buy gift cards will be sent out by fieldwork Boston, Inc. to qualifying respondents. _______________________________________________________________________ _ * Incomplete surveys will result in a forfeiture of incentive. Surveys will any Identifying marks will be treated as an incomplete survey with the same forfeiture of incentives holding true. Surveys not accompanied by the required Parental consent and minor assent will also be considered incomplete.
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PHONE RECRUITMENT SCRIPT (to be read to the participant) Hello, my name is James Leone and I am a doctoral candidate at Southern Illinois University Carbondale. Your name was obtained through a listing with Fieldwork Boston, Inc., a market research company in Waltham, MA. May I speak with [name of parent on database list]? (If parent is unavailable, ask to schedule a more appropriate time to call back and tally). [If parent/guardian is available continue with introduction] I am conducting a doctoral dissertation research study with adolescent males. The emphasis of the study is to identify factors affecting body image and body image satisfaction. Our records indicate you have a son in high school [verify], is that correct? (if records are accurate, continue; if not, terminate and tally). I would like to invite your son to participate in this study, which involves the completion of a 15-20 minute survey. Upon completion of the survey and relevant forms, he will be mailed five dollars and will be eligible to win an additional $50 gift certificate to Best Buy stores. Three forms will be sent; 1. a survey, 2. a parental consent form (if under age 18), and 3. a minor assent form as well as a set of instructions. The parental consent and minor assent form needs to be read and signed by you and your son and returned along with the completed survey. This will be reiterated in the instructions sent to you. All forms and the survey should be sent back using the pre-paid postage envelope provided. Does this sound like something your son would be willing to do? [If yes, continue; if no, thank them for their time and terminate phone call and tally]. Some questions ask for honest responses concerning sexual orientation and illicit activities (e.g., drug use). Additionally, some questions assess self-image and self-worth of the individual. There is a chance the individual may be upset from these questions and may want to consult a school counselor or discontinue participation in the research. Fieldwork, Boston, Inc., will retain your survey data only for processing purposes (i.e., sorting of forms and identification numbers or approximately 1-3 days). Immediately following processing, all data will be forwarded to the researcher (James E. Leone) for management of data and contact information. May I speak with your son? [when on the phone] I was explaining this research study to your mom/dad and they said you may be interested in participating. Let me briefly tell you what it is about. [redefine the study purpose]. Does this sound like something you would be willing to do? [If yes, confirm the mailing address]. Thanks! I will be sending you a packet of forms and the survey. Please be sure to have all of the forms signed and answer ALL questions on the survey. Remember that your
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responses will be anonymous, that is, no one will be able to track your responses because a unique identification number will be used to mail your honorarium and not your name. [Stress the date of completion with the participant] Do you have any questions for me at this time? [If no questions, thank and terminate the phone call; adjust quota sheets]
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RECRUITMENT TALLY SHEET (Mark an X through each number for each recruit) 1 11 21 31 41 51 61 71 81 91 101 111 121 131 141 151 161 171 181 191 201 2 12 22 32 42 52 62 72 82 92 102 112 122 132 142 152 162 172 182 192 202 3 13 23 33 43 53 63 73 83 93 103 113 123 133 143 153 163 173 183 193 203 4 14 24 34 44 54 64 74 84 94 104 114 124 134 144 154 164 174 184 194 204 5 15 25 35 45 55 65 75 85 95 105 115 125 135 145 155 165 175 185 195 205 6 16 26 36 46 56 66 76 86 96 106 116 126 136 146 156 166 176 186 196 206 7 17 27 37 47 57 67 77 87 97 107 117 127 137 147 157 167 177 187 197 207 8 18 28 38 48 58 68 78 88 98 108 118 128 138 148 158 168 178 188 198 208 9 19 29 39 49 59 69 79 89 99 109 119 129 139 149 159 169 179 189 199 209 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 210
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211 221 231 241 251 261 271 281 291 301 311 321 331 341
212 222 232 242 252 262 272 282 292 302 312 322 332 342
213 223 233 243 253 263 273 283 293 303 313 323 333 343
214 224 234 244 254 264 274 284 294 304 314 324 334 344
215 225 235 245 255 265 275 285 295 305 315 325 335 345
216 226 236 246 256 266 276 286 296 306 316 326 336 346
217 227 237 247 257 267 277 287 297 307 317 327 337 347
218 228 238 248 258 268 278 288 298 308 318 328 338 348
219 229 239 249 259 269 279 289 299 309 319 329 339 349
220 230 240 250 260 270 (min) 280 290 300 310 320 330 340 350 (max)
Grade Level (Mark an X through each number for each participant) 9th Grade (freshman) 1 11 21 31 41 51 61 2 12 22 32 42 52 62 3 13 23 33 43 53 63 4 14 24 34 44 54 64 5 15 25 35 45 55 65 6 16 26 36 46 56 66 7 17 27 37 47 57 67 8 18 28 38 48 58 68 9 19 29 39 49 59 69 10 20 30 40 50 60 70
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71 81
72 82
73 83
74 84
75 85
76 86
77 87
78
79
80
88 (max)
10th Grade (sophomore) 1 11 21 31 41 51 61 71 81 2 12 22 32 42 52 62 72 82 3 13 23 33 43 53 63 73 83 4 14 24 34 44 54 64 74 84 5 15 25 35 45 55 65 75 85 6 16 26 36 46 56 66 76 86 7 17 27 37 47 57 67 77 87 8 18 28 38 48 58 68 78 9 19 29 39 49 59 69 79 10 20 30 40 50 60 70 80
88 (max)
11th Grade (junior) 1 11 21 31 41 51 61 71 81 2 12 22 32 42 52 62 72 82 3 13 23 33 43 53 63 73 83 4 14 24 34 44 54 64 74 84 5 15 25 35 45 55 65 75 85 6 16 26 36 46 56 66 76 86 7 17 27 37 47 57 67 77 87 8 18 28 38 48 58 68 78 9 19 29 39 49 59 69 79 10 20 30 40 50 60 70 80
88 (max)
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12th Grade (senior) 1 11 21 31 41 51 61 71 81 2 12 22 32 42 52 62 72 82 3 13 23 33 43 53 63 73 83 4 14 24 34 44 54 64 74 84 5 15 25 35 45 55 65 75 85 6 16 26 36 46 56 66 76 86 7 17 27 37 47 57 67 77 87 8 18 28 38 48 58 68 78 9 19 29 39 49 59 69 79 10 20 30 40 50 60 70 80
88 (max)
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PARTICIPANT IDENTIFICATION CODES Survey ID Code Participant Name Mailing Address Complete Honorarium Sent Survey ID Code Participant Name Mailing Address Complete Honorarium Sent Survey ID Code Participant Name Mailing Address Complete Honorarium Sent Survey ID Code Participant Name Mailing Address Complete Honorarium Sent Survey ID Code Participant Name Mailing Address Complete Honorarium Sent Survey ID Code Participant Name Mailing Address Complete Honorarium Sent Survey ID Code Participant Name Mailing Address Complete Honorarium Sent
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SURVEY COMPLETION INSTRUCTIONS Hello! Thank you for agreeing to participate in this important research study! First, please make sure you have the following forms (in addition to this instruction sheet): Adolescent Body Image Satisfaction Survey (ABISS) (white) Parental Consent Form (yellow) Minor Assent Form (green)
You should also have a postage-paid envelope to send the forms back to the specified address. If you are missing any forms, please contact me as soon as possible so I can get the missing form(s) to you. Instructions: 1. Select a quiet time for you to read through the forms. 2. Make sure your parent signs the parental informed consent form if you are less than 18 years old. If you are 18 years old or older, you must sign the informed consent form where your parent would. 3. Make sure you sign the minor assent form. 4. Take the Adolescent Body Image Satisfaction Survey (ABISS). Be reminded that in order to make this a successful process you must answer ALL survey questions as honestly as possible. Circle your responses directly on the survey form. 5. Once you complete the survey, re-check all pages to make sure you answered all questions. Also, be sure you have not made any marks that might identify who you are. 6. Place the survey, parental consent, and minor assent form in the postage-paid envelope and place it in the mail. PLEASE RETURN THE SURVEYS AND FORMS BY NO LATER THAN May 30, 2007 Your responses will not be able to be tracked back to you. Your honorarium will be sent once all forms and the survey are received. Additionally, your name will be eligible for a $50 Best Buy gift card. If you have any questions or concerns, please do not hesitate to contact me. I thank you in advance for your time and help on this important research study! James E. Leone, MS, LAT, ATC, CSCS Doctoral Candidate in Health Education 617-373-5536 (work) jleoneatc@yahoo.com (e-mail)
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APPENDIX G PARTICIPANT CONSENT FORMS
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Cover Letter Pilot Study May 2007 Dear Participant, I am a doctoral candidate in the Department of Health Education at Southern Illinois University Carbondale. The purpose of this survey is to assess adolescent attitudes and perceptions concerning body image dissatisfaction. In addition, there are a few questions that ask demographic (background) questions. This is a pilot study to assure an accurate instrument that measures what it is supposed to measure (i.e., validity). The intent of this research is to understand characteristics of body image dissatisfaction as they relate to various risk factors among adolescents and young adults. You and your school/class were selected to participate in this research because of the relevance of age categories represented in your classes. The survey will take 10 15 minutes to complete. All responses will be kept anonymous. Only people directly involved with this project will have access to the surveys. You will also be asked to comment and provide feedback on the survey in a group discussion format lasting no more than 10-15 minutes. You may choose not to participate in this process without penalty. Please be advised that the purpose of the discussion is to assist with research development and design and responses will not be recorded for research purposes. You were chosen for this study because you meet the likely criteria for inclusion in this research. Participation in this pilot study is completely voluntary and you may withdraw at any time without penalty. Questions about this study can be directed to me or my dissertation advisor, Dr. Joyce V. Fetro, Department of Health Education, SIUC, Carbondale, IL 62901-4310*. Phone (618) 453-2777. (* 4-digit SIU mailcode) Thank you for taking the time to assist us in this research. James E. Leone, M.S., LAT, ATC, CSCS 617-373-5536 E-mail: jleoneatc@yahoo.com
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Cover Letter Full Sample May 2007 Dear Participant, I am a doctoral candidate in the Department of Health Education at Southern Illinois University Carbondale. The purpose of the enclosed survey is to assess adolescent attitudes and perceptions concerning body image dissatisfaction. In addition, there are a few questions that ask demographic (background) questions. The intent of this research is to understand characteristics of body image dissatisfaction as they relate to various risk factors among adolescents and young adults. You were selected to participate in this research because of the relevance of your age category and level in high school (i.e., grades 9 through 12). The survey will take 10 15 minutes to complete. All responses will be kept anonymous. Only people directly involved with this project will have access to the surveys. You were chosen for this study because you meet the likely criteria for inclusion in this research. Completion and return of this survey indicate voluntary consent to participate in this study. You may choose to withdraw your participation at any point during this process without penalty. Please use the return envelope provided. Questions about this study can be directed to me or my dissertation advisor, Dr. Joyce V. Fetro, Department of Health Education, SIUC, Carbondale, IL 62901-4310*. Phone (618) 453-2777. (* 4-digit SIU mailcode) Thank you for taking the time to assist us in this research. James E. Leone, M.S.,LAT, ATC, CSCS 617-373-5536 E-mail: jleoneatc@yahoo.com
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SOUTHERN ILLINOIS UNIVERSITY CARBONDALE Parental Informed Consent Form My name is James E. Leone. I am a doctoral candidate at Southern Illinois University Carbondale in the Department of Health Education. I am asking your child to participate in my doctoral research. The purpose of my study is to assess adolescent attitudes and perceptions concerning body image dissatisfaction. Participation is voluntary. If you choose to allow your child to participate in the study, it will take approximately 10 15 minutes of their time. He will be asked to answer a survey on adolescent body image and demographic/background questions. Some questions ask for honest responses concerning sexual orientation and illicit activities (e.g., drug use). Additionally, some questions assess self-image and self-worth of the individual. There is a chance the individual may be upset from these questions and may want to consult a school counselor or discontinue participation in the research. You will also be asked to comment and provide feedback on the survey in a group discussion format lasting no more than 10-15 minutes. You may choose not to participate in this process without penalty. Please be advised that the purpose of the discussion is to assist with research development and design and responses will not be recorded for research purposes. All responses will be anonymous and will not be tracked according to your child. Only those directly involved with this project will have access to the data. Additionally, you (your child) may withdraw from this study at any time without penalty. If you have any questions about the study, please contact me or my doctoral research advisor Dr. Joyce V. Fetro. By signing here, I attest to the fact I am willing to allow my child to participate in this research recognizing the fact I have the right to withdraw my participation at any point. _______________________________________ __________________ Signature of Parent Thank you for taking the time to assist us in this research!
James E. Leone, M.S., LAT, ATC, CSCS Doctoral Candidate Department of Health Education 617-373-5536 Email: jleoneatc@yahoo.com Joyce V. Fetro, Ph.D., CHES, FASHA Professor, Health Education Department of Health Education 618-453-2777 Email: jvf8088@aol.com
Date
This project has been reviewed and approved by the SIUC Human Subjects Committee. Questions concerning your rights as a participant in this research may be addressed to the Committee Chairperson,
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Office of Research Development and Administration, SIUC, Carbondale, IL 62901-4709. Phone (618) 453-4533. E-mail: siuhsc@siu.edu
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SOUTHERN ILLINOIS UNIVERSITY CARBONDALE Minor Assent Form My name is James E. Leone. I am a doctoral candidate at Southern Illinois UniversityCarbondale in Health Education. I am asking you to participate in my doctoral research study. The purpose of my study is to assess adolescent attitudes and perceptions concerning body image dissatisfaction. Participation is voluntary. Additionally, you may withdraw from this study at any time without penalty. If you choose to participate in the study, it will take approximately 10 15 minutes of your time. You will be asked to answer a survey on adolescent body image and related background questions. Some questions ask for honest responses concerning sexual orientation and illicit activities (e.g., drug use). Additionally, some questions assess self-image and self-worth of the individual. There is a chance the individual may be upset from these questions and may want to consult a school counselor or discontinue participation in the research. All of your responses will be anonymous. Only those directly involved with this project will have access to the data. Your responses will not be able to be tracked to you at any point in the research process. Additionally, if you are under the age of 18, we will need a signature of parental consent as well. If you have any questions about the study, please contact me or my research colleague Dr. Joyce V. Fetro. By signing here, I attest to the fact I am willing to participate in this research recognizing the fact I have the right to withdraw my participation at any point. _______________________________________ __________________ Signature of Participant Thank you for taking the time to assist us in this research!
Date
James E. Leone, M.S., LAT, ATC, CSCS Doctoral Candidate Department of Health Education 617-373-5536 Email: jleoneatc@yahoo.com
Joyce V. Fetro, Ph.D., CHES, FASHA Professor, Health Education Department of Health Education 618-453-2777 Email: jvf8088@aol.com
This project has been reviewed and approved by the SIUC Human Subjects Committee. Questions concerning your rights as a participant in this research may be addressed to the Committee Chairperson,
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Office of Research Development and Administration, SIUC, Carbondale, IL 62901-4709. Phone (618) 453-4533. E-mail: siuhsc@siu.edu
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VITA Graduate School Southern Illinois University James Edward Leone Date of Birth: March 17, 1976
11995 Coverstone Hill Circle, Manassas, Virginia 20109 Bridgewater State College Bachelor of Science, Physical Education, January 2001 Indiana State University Master of Science, Athletic Training, May 2002 Special Honors and Awards: Whos Who among Teachers and Educators Recognition, June 2007 Great Lakes Athletic Trainers Association (GLATA) Doctoral Scholarship Award, March 2007 Whos Who in Education, Academic Keys Association, June 2003 Indiana State University, Athletic Training Department, Outstanding Graduate Student Award, May 2002 Bridgewater State College, Department of Movement Arts, Physical Education, and Leisure Studies, Athletic Trainer of the Year Award, May 2000 Whos Who Among Colleges and Universities Recognition, April 2000 All-American Collegiate Scholar Distinction by the United States Achievement Academy, Spring 2000 Dissertation Title: Predictors of Body Image Dissatisfaction Among Selected Adolescent Males Major Professor: Joyce V. Fetro, Ph.D.
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Publications: Leone JE, Maurer-Starks S. Innovative teaching strategies in research methods for health professions. Calif J Health Promo. 2007;5(3):62-69. Leone JE, Fetro JV. Perceptions and attitudes toward androgenic-anabolic steroid usage among two age categories : A qualitative inquiry. J Strength Condit Res. 2007, 21(2) :532-537. Leone JE, Gray KA. Strategies for highly effective athletic training education Program Directors: A practical approach to interdependence. Athletic Training Education Journal. 2007;2(1):21-25. Leone JE, Gray KA. Keep your eyes open: Four new supplements on the horizon. NATA News. 2007;(February):40-42. Leone JE, Sedory EJ, Gray KA. Recognition and treatment of muscle dysmorphia and related body image disturbances. J Athl Train. 2005;40(4) :352-359. Leone JE, Gray KA, Rossi JM, Massie JE. Celiac disease symptoms in a female collegiate tennis player : A case report. J Athl Train. 2005;40(4) :365-369. Leone JE, Garbo CM, Gray KA. A unique skin lesion in a male collegiate tennis player: A case report. J Athl Train. 2005;40(2): S-83. Leone JE. Research: A Key Issue. NATA News. 2004;(January):50. Leone JE. Be forthright with athletes about supplements. NATA News. 2003; (December):26-28. Leone JE. Celiac disease symptoms in a female collegiate tennis player: A case report [abstract]. J Athl Train. 2003;38(2): S-61 S-62. Gray KA, Leone JE. Insidious gynecomastia in a collegiate baseball player: A case report. J Athl Train. 2003;38(2): S-56.
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James E.

Leone Defense 10/29/07

PREDICTORS OF BODY IMAGE DISSATISFACTION AMONG SELECTED ADOLESCENT MALES

October 29, 2007

James E. Leone Defense 10/29/07

Copyright by James Edward Leone 2007 All Rights Reserved

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DISSERTATION APPROVAL FORMS

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LIST OF TABLES TABLE PAGE

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LIST OF FIGURES FIGURE PAGE

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CHAPTER 2 REVIEW OF THE LITERATURE

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Body Ego Self-Concept (Self-esteem) _______________________________________________________________________ _

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