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Introduction
Adolescence is a phase characterized by physical, psychological, and social changes from 10 to 19 years old people. This phase is considered to be essential because adolescents are expected to acquire appropriate behaviors to be healthy in adulthood1,2.
As adolescence is a stage of constant change, adolescents develop a greater awareness of their body image; however, not all adolescents manage to adapt themselves and maintain a favorable attitude towards their body, making adolescence a stage of high vulnerability3,4.
Body image is an essential component of health, so we can define it as a multifaceted construct that refers to the mental representation of the body, which includes perceptual, cognitive-affective, and behavioral aspects5,6.
According to Hernandez et al.7 and Smolak8 there are differences between men and women regarding their body image, which has been supported by some research indicating that women are more dissatisfied with their bodies than men9,10,11. Nevertheless, it does not indicate that the study of body image in men is not critical. Due to this matter, there is great interest in researching body image during adolescence, especially because of the impact, it has on health12.
Salazar-Mora2 indicates that body image should be analyzed from a sociocultural approach because having body acceptance or not is influenced by society, parents, and peers. Likewise, Raich13 states that the imposition of unattainable body aesthetic ideals causes adolescents to develop a conflict between the body they have and the one they would like to have. This conflict may develop body dissatisfaction, which is expressed as a negative appraisal of the size and shape of the body (or parts of it) as well as weight5,14,15.
Body dissatisfaction is a predictor of the triggering of eating disorders (ED), body dysmorphia, and steroid use12, in addition, it is a risk factor for the promotion of emotional distress16, depression, low self-esteem, drive for muscularity and thinness17, and suicidal ideation3 as well.
Some researchers agree that further research is needed to understand the differences between women and men regarding their body image7,8, besides identifying those protective and risk factors which affect this construct18.
However, Jones and Smolak12 express that one cannot wait for complete crystal clear on the factors that impact adolescent body image. From this perspective, it is important for researchers to start designing, implementing, and evaluating programs. Researchers such as Ordónez-Azuara et al.19, Presnell et al.16 and Vaquero-Cristóbal et al.20 agree that the implementation of promotion and prevention programs should be privileged because benefits for adolescent health would be greater. Moreover, it is considered necessary that those in charge of delivering the programs be highly trained. Therefore, this review is aimed at examining the intervention programs that have been conducted to improve body image in adolescents. Elements that were analyzed included: sample, program approach, theoretical model, content, teaching and learning tools, and post-intervention and follow-up outcomes.
Materials and methods
The PRISMA statement was used in this systematic review (Preferred Reporting Items for Systematic Reviews)21. The search for studies was carried out in the databases PubMed, Web of Science, MEDLINE- ProQuest, and EBSCO, using the search strategy: (body image OR body dissatisfaction OR body satisfaction OR body image disturbance) AND (intervention OR program OR treatment OR prevention) AND (adolescents OR teenagers OR high school students OR youth). The search period was from January 1st, 2017, to January 25th, 2022.
For the selection of the studies, the following criteria were considered: a) empirical studies, b) body image interventions aimed at adolescents, c) quasi-experimental or experimental design, and d) written in English. Likewise, the exclusion criteria were: a) studies that do not correspond to the topic, b) literature reviews or meta-analysis, c) conferences, dissertations, or books, d) non-experimental or preexperimental design, and 4) intervention protocols.
After searching the studies in the four databases, 70 articles were obtained from which 51.4% were eliminated because they were duplicates. Subsequently, the titles and abstracts were examined, and when necessary, the full text was reviewed. Of the 34 articles, 37.1% were eliminated because they did not meet the inclusion criteria, leaving a total of eight (11.4%) articles (Figure 1).
In addition to considering the inclusion criteria, the first two authors of this study assessed the methodological quality of the eight studies using the Quality Assessment Tool for Quantitative Studies, elaborated by the Effective Public Health Practice Project (EPHPP)22. This tool allows the evaluation of various quantitative study designs (e.g, randomized controlled trials [RCT], quasi-experimental studies, uncontrolled studies), in addition, it has been shown to have construct and content validity. It contains six domains: a) selection bias, b) study design, c) confounders, d) blinding, e) data collection methods, and f) withdrawals and dropouts. According to the dictionary attached to this tool, each domain is rated as strong (3 points), moderate (2 points), or weak (1 point). When the domain scores are obtained, they are averaged to obtain the overall rating (maximum 3 points), whereby each study is assigned a rating of weak (1.00-1.50), moderate (1.51-2.51), or strong (2.513.00) quality. Only studies assessed as strong and moderate are included in the review (Table 1).
Table 1 Methodological quality of studies included in the review
| Studies | Domains | Rating | Global quality | |||||
|---|---|---|---|---|---|---|---|---|
| 1. Selection | 2. Study design | 3. Confounders | 4. Blinding | 5. Data collection methods | 6. Withdrawals and dropouts | |||
| Bell et al.23 | 3 | 2 | 3 | 2 | 3 | 3 | 2.66 | Strong |
| Gordon et al.24 | 3 | 3 | 3 | 2 | 3 | 3 | 2.83 | Strong |
| Ovejero et al.25 | 3 | 2 | 2 | 2 | 3 | 2 | 2.33 | Moderate |
| Regehr et al.26 | 3 | 2 | 3 | 2 | 3 | 3 | 2.66 | Strong |
| Ghahremani et al.27 | 3 | 2 | 3 | 2 | 3 | 3 | 2.66 | Strong |
| Rodgers et al.28 | 3 | 2 | 3 | 2 | 3 | 3 | 2.66 | Strong |
| Dunstan et al.29 | 3 | 2 | 3 | 2 | 3 | 3 | 2.66 | Strong |
| Dhillon and Deepak30 | 3 | 2 | 3 | 2 | 3 | 3 | 2.66 | Strong |
Note. Quality ratings. 3 = strong; 2 = moderate; 1 = weak Source: own elaboration
From the eight articles included in the review, the following data were extracted independently by two authors of this study: reference, sample, program approach and name, theoretical model, sessions, duration, and frequency, content, didactic strategies, and main results (Table 2).
Table 2 Content of body image programs included in the review
| Reference | Sample | Program approach and name | Theoretical model | Sessions, duration, and frequency | Content | Teaching and learning tools | Results | |
|---|---|---|---|---|---|---|---|---|
| Post-intervention | Follow-up | |||||||
| Bell et al.23 England | n = 268 H and M 12 to 13 years C = 134 I = 134 | o g n i t i v e dissonance i g i t a l Bodies | NE | Single session 60 minutes | Body ideals across time and culture, with a specific focus on social media spaces. D e c o n s t r u c t the myths surrounding the perfect body. The role of adolescents in the creation, perpetuation, and reinforcement of body ideals using digital technologies. | Self-affirmations. Discussion. Group assignments. Workbook. Implementation of intentions. | Body satisfaction was improved. Only women reduced internalization of the thinness ideal, but not internalization of the athleticism ideal or self-objectification. | After eight weeks, the improvement in body satisfaction w a s maintained. |
| Gordon et al.24 Australia | n = 892 H and M 11 to 15 years C = 409 I = 483 | M e d i a literacy SoMe | Constructivist theory | 4 sessions 50 minutes Weekly | Criticism of advertising in social networks. Social networks: Are they real? Interaction with friends in social networks. Create positive social networks. | Slides. Brochures. Examples of social networks. | In girls, dietary restriction and depressive symptoms were reduced. In boys, self-esteem and drive for muscle building were increased (being an adverse effect). | The changes obtained in the girls were m a i n t a i n e d for up to six months. In the case of children, the changes were preserved until 12 months of age. |
| Ovejero et al.25 Spain | n = 214 H and M 14 years C = 115 I = 99 | NE ECOPREV | Cognitive-social theory | 8 sessions 50 minutes Weekly | Media literacy. Healthy eating habits. Physical activity. E m o t i o n a l intelligence. Activism. | Historical analysis. Use of advertising messages. Food pyramid. Film clips. Videos. | Body satisfaction, self-esteem, repair, and emotional clarity were improved. S e l f - o r i e n t e d perfectionism and internalization of the body ideal of muscularity and thinness decreased. | The results were main tained after six months and one year |
| Regehr et al.26 Canada | n = 119 H and M 12 years C = 43 I = 76 | Interactive Free To Be | P o s i t i v e psychology | 6 sessions 55 minutes NE | p p e a r a n c e pressures and media messages. Awareness of how the media is manipulated and the impact this has on the viewer. o d y appreciation. Stereotypes of appearance and behavior. Positive body image. Self-identification. | Activity notebook. | Positive body image enhancement was not achieved. There was an increase in body image coping strategies and media literacy. Body dissatisfaction was reduced. It should be noted that men were the main beneficiaries of the program. | NA |
| Ghahremani et al.27 Iran | n = 150 M 14 years C = 78 I = 72 | NE | Self-efficacy theory | 6 sessions 45 minutes NE | Body image and goal setting. The ability to feel cognition or selfsurveillance. Critical thinking. P r a c t i c e appreciation. Mind and body preparation. | Self-tests. Conferences. Reflection in the mirror. ABC learning (activation, belief, consequence). C o r r e c t i v e thinking. Gratitude practice. Body image ladder. | Body image concerns were significantly decreased, and selfesteem was increased. | NA |
| Rodgers et al.28 United States | n = 274 H and M 18 years | NE BodiMojo | NE | 6 weeks NE Daily | Mood and e m o t i o n a l regulation. Gratitude. Self-compassion (e.g., mindfulness, k i n d n e s s , humanity). Body image (e.g., media literacy, peer influences, a p p e a r a n c e comparison). Healthy lifestyle (e.g., mindful eating, sleep hygiene, physical activity). | Questionnaires. Audio meditation. Journaling. Record of feelings. | Esteem about appearance, selfcompassion, and body image increased. No significant effects were found on body image flexibility or comparison by appearance and no significant effects were found on mood. | The changes w e r e maintained at 12 weeks. |
| Dunstan et al.29 Australia | n = 200 M 11 to 14 years C = 53 I1 = 74 I2 = 73 | Interactive Happy Being Me | NE | 6 sessions NE | Body image. Pressure and prejudice. Fat talk. Media. | Discussion. Posters. | Body dissatisfaction decreased, as well as the internalization of the thinness ideal and the comparison of appearance. In addition, there was an increase in selfesteem. | The reduction in the internalization of the thin ideal and the increase in self- esteem were maintained at six months. |
| Dhillon and Deepak30 India | n = 49 M 12 to 14 years C = 25 I = 24 | M e d i a literacy NE | NE | Single session 55 minutes | Media literacy. Use of technology to create beauty. Hidden media agendas in the promotion of beauty ideals. | Images of actresses and models from India and the West. Videos. Advertisements. Discussion. | Body satisfaction increased, as did awareness of the artificiality of media images. | NA |
Note. n = sample size; H = men; M = women; C = control group; I = intervention group; NE = not specified; NA = not applicable Source: own elaboration
Results
Methodological quality
Eight studies were included in this review and span from 2017 to 2022. Eighty-seven-point five percent of the studies had a strong methodological quality23,24,26,27,28,29,30. Only one study showed moderate methodological quality25.
Country
Body image programs for adolescents aged 11 to 18 years old were conducted in Australia (n = 2)24,29, United States28, England23, Iran27, Spain25, Canada26 and India30.
Purpose
Programs aimed at improving body image (n = 3) and body satisfaction (n = 5). In addition, the authors of these programs expected that they would also address issues such as internalization of the body ideal of muscularity/thinness, appearance comparison and psychological risk factors, mood, self-esteem, and body change strategies and wellbeing.
Methodology
Thirty-seven-point five percent of the studies included only women and 62.5% were mixed. Regarding the design of the studies, 87.5% were quasi-experimental and only one was an RCT. The sample size for the control group ranged from 25 to 409 participants (M = 127.71; SD = 132.62) and for the intervention group ranged from 24 to 483 participants (M = 156.00; SD = 151.86).
The studies assessed body image or body satisfaction/ dissatisfaction using as instruments: Body Image State Scale (BISS)31, Body Image Questionnaire (QÜIC)32, Body Image Acceptance and Action Questionnaire (BIAAQ)33, Body Image Concern Inventory (BICI)34, Body Satisfaction Scale (BSS)35, Body Appreciation Scale (BAS)36, Eating Disorder Inventory-Body Dissatisfaction Subscale (EDI-BD)37 and the Eating Disorder Examination Questionnaire (EDEQ)38. Furthermore, other instruments aimed at evaluating social appearance standards were used, such as the Sociocultural Attitudes Towards Appearance Questionnaire (SATAQ-3-4; n = 5)39,40 and the Physical Appearance Comparison Scale (PACS; n = 3)41, for self-esteem the Rosenberg Self-Esteem Scale (RSES; n = 4)42, for feeding behavior was used Dutch Eating Behaviour Questionnaire (DEBQ; n = 2)43 and for body esteem the Body Esteem Scale for Adults and Adolescents (BESAA; n = 2)44. Only the study by Regehr et al.26 used an additional scale to assess satisfaction with their program.
For the intervention, only half of the studies reported the type of program they implemented, highlighting media literacy (n = 2), cognitive dissonance (n = 1), and interactive (n = 2). Four studies stated that their program had a theoretical foundation24,26,27. The programs were also implemented by research assistants or researchers in psychology, doctoral students, or professionals with doctoral degrees25,29and facilitators24,26. In some studies, single sessions were conducted (n = 2), while in others there were four (n = 1), six (n = 3), or even eight sessions (n = 1), the average was 4.57 sessions (SD = 2.70), however, the Rodgers et al.28 study did not mention how many sessions they conducted. The duration of each session was 45 to 60 minutes, and concerning the periodicity, three studies did not specify it26,27,29. The main topics addressed in the program sessions were: body aesthetic ideals, appearance pressure and prejudices, media literacy, body image, body appreciation, positive social networks, mood and emotional regulation, gratitude and self-compassion, and healthy lifestyles.
Teaching and learning tools used vary from one intervention program to another, however, it should be noted that the tools have been more interactive than didactic.
All studies applied a pre-test and a post-test. More than half were followed up (n = 5) with a time interval of eight weeks to 12 months.
Effects on post-intervention and follow-up
The results achieved after the implementation of the programs reflected favorable changes in body satisfaction23,25,30, the body image27,28 and the reduction of body dissatisfaction29. On the other hand, no changes were obtained in positive body image26 or body dissatisfaction24.
Some programs also had significant changes in decreasing the internalization of the thin/muscle ideal23,25,29, in increasing self-esteem24,25,27,29and body image coping strategies26. Likewise, Rodgers et al.28 indicated that they did not have the expected results in terms of body image flexibility or comparison by appearance and mood.
Specifically, the Gordon et al.24 program was able to reduce food restriction and depressive symptoms, but they reported that it harmed men as they increased the drive for muscularity, which according to the authors was due to the content of the program.
Concerning follow-up, the most of the programs maintained the same changes over the years23,24,25,28,29.
Discussion
The goal of this review was to examine the intervention programs that have been conducted to improve on body image in adolescents. Therefore, after identifying and selecting the studies through the databases, an evaluation of the methodological quality was carried out to ensure that the studies were prepared with high scientific rigor, which in turn allowed confidence in their results and conclusions. In the present review, we used the tool developed by the EPHPP22, which has been found to have excellent inter-rater reliability45. As a result of this evaluation, seven studies had strong methodological quality, and only one had moderate methodological quality.
Over the years, the use of various approaches in body image intervention programs has been identified. In this review, the focus of two studies24,30 was media literacy. From this approach, participants play an active role as they are taught to analyze, understand, evaluate, and even critically transform the messages they receive from the media regarding unrealistic stereotypes of perfection of men and women. Programs under this approach involve increasing participants’ awareness and developing strategies to defend themselves against the persuasive influence of the media46,47. Similarly, two studies26,29 provided information on positive body image, appearance pressure and media, body appreciation, among others, used interactive techniques, used the interactive approach which allows participants to engage deeply with the program so that they can gain and employ the skills learned in their daily lives, enabling change that goes beyond simply increasing the knowledge48. Only one study23 used the cognitive dissonance approach which allows participants to modify inconsistencies arising from thoughts, emotions, beliefs, attitudes, and behaviors that cause psychological distress49. This discomfort motivates participants to voluntarily change their behavior until they restore their consistency50. It should be noted that each of these approaches has both empirical and scientific support, which allows us to know their effectiveness over the years and whether their use will benefit the health of participants. Three studies25,26,27,28 did not specify which approach they used so we suggest not omitting important information about the intervention program even if it is thought it can be inferred.
Importantly, some studies24,25,26,27 stated the theoretical foundation of their program (e.g., constructivist theory, socialcognitive, self-efficacy, positive psychology). However, there is still no agreement as to which theory and approach would be the most appropriate to ensure the success of the program51. In the same sense, there is a lack of evidence that would allow us to determine with certainty who or whose programs are the most appropriate to implement intervention programs51. In this case, some programs24,25,26,29 were run by research assistants or researchers in psychology, doctoral students or professionals with doctorates, in conjunction with facilitators who were trained by the principal investigators and although the results were relevant, it is necessary to keep in mind that training must be provided correctly to avoid generating negative effects on participants.
Sixty-two-point five percent of the intervention programs conducted four to eight sessions obtaining favorable postintervention results26,27, and in some cases their effects were also reflected in the follow-up24,25,29. It has been established that interventions that include a one-session hour per week during three weeks at least, generate more significant changes because participants have more opportunities to reflect on the content and materials of the program, as well as to apply what they have learned48,52. However, it has been noted that participant attrition in multisession interventions is a problem. Therefore, they are suggested to be brief53. Stice and Shaw48 recognize that one-session interventions are easier to disseminate, have greater acceptability, and are lower cost, but might be less effective compared to long-term interventions. On the contrary, the intervention programs of Bell et al.23 and Dhillon and Deepak30 had positive post-intervention results, although not all changes were maintained at follow-up23. Given this discrepancy between single-session and multi-session interventions, more research is needed to understand what would be most appropriate according to the needs and accessibility of the participants.
As shown in Table 2, the contents of the intervention programs and the teaching and learning tools are not the same, since it depends to a great extent on the focus of the program. However, when designing an intervention program, it is necessary to carry out an exhaustive review of the literature to obtain the best scientific evidence on what and how it has been done and who has done it. An important aspect to consider is to know the limitations that the researchers have had at the time of implementing the program, since this information will help us to reduce risks during the intervention.
According to O´Dea46, one of the basic principles to be considered by responsible researchers in the development of intervention programs is first, do no harm. Concerning this, one study reported that the intervention was counterproductive for men as the drive for muscularity increased postintervention and was maintained at follow-up. This result was due to the content of the program; however, the authors did not mention if they implemented any measures to reduce the harm caused by the intervention24. Therefore, future research should have clear ethical principles for research involving human subjects to safeguard the health of the participants. Finally, the time interval of the five studies that conducted a follow-up was from eight weeks to 12 months, which complicates making a concrete conclusion on the scope since some maintained the same changes and others did not, so Yager et al.54 suggest that intervention programs consider conducting a minimum follow-up of three months if the necessary conditions exist to do so.
Conclusions
The findings of this review allow us to conclude that intervention programs are a safe and effective way to improve body image in adolescents aged 11 to 18 years old if the design, implementation, and evaluation are carried out correctly. Therefore, it is necessary to analyze and evaluate the existing scientific evidence on body image programs to ensure that methodologically it is a quality program and that everything that has been detrimental to the health of adolescents has been discarded. It is important to recognize that there is still much to be done in terms of health promotion and prevention. Therefore, for future research it is recommended the following: 1) it is necessary to have instruments with adequate psychometric properties and specifically designed for the target population, 2) intervention programs should include both men and women, as both are vulnerable to body image problems, 3) likewise, it must be guaranteed that all those who participate in the intervention complete it, so it will be the task of the researcher to develop strategies to prevent desertion, 4) although followup is sometimes not possible, it should be considered when designing the intervention program, because this way we can ensure that what was implemented is meaningful for the participants, 5) finally, in the Piran55 study it is pointed out that new intervention programs should be oriented towards positive body image, as well as the inclusion of positive psychology and embodiment. In this sense, Hernández Cruz et al.56 reviewed the literature on positive body image interventions in children and adolescents and found favorable results after the intervention, but the effects were not maintained at follow-up, and there was no homogeneity in the methodological aspects, which represents a great area of opportunity for researchers.
