Effectiveness of a multi-session positive self, appearance, and functionality program on women’s body satisfaction and response to media

Body Image 31 (2019) 102–111

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Body Image journal homepage: www.elsevier.com/locate/bodyimage

Effectiveness of a multi-session positive self, appearance, and functionality program on women’s body satisfaction and response to media Kate E. Mulgrew a,∗ , Ivanka Prichard b , Nicole Stalley a , Megan S.C. Lim c,d,e a

University of the Sunshine Coast School of Social Sciences, University of the Sunshine Coast, Maroochydore DC, Queensland, Australia College of Nursing and Health Sciences, Flinders University, South Australia, Australia c Centre for Population Health, Burnet Institute, Melbourne, Australia d School of Population Health and Preventive Medicine, Monash University, Melbourne, Australia e Melbourne School of Population and Global Health, University of Melbourne, Parkville, Australia b

a r t i c l e

i n f o

Article history: Received 30 November 2018 Received in revised form 28 August 2019 Accepted 28 August 2019 Keywords: Body functionality Positive appearance Media Body appreciation Intervention

a b s t r a c t Women’s relationship with their bodies may be improved through activities which encourage them to focus on the positive elements of their appearance, the functional qualities of their body, and positive aspects of themselves in general. This study examined the effectiveness a multi-session program addressing these elements. Across two online sessions, 117 Australian women (Mage = 23.48) completed writing tasks about the positive elements of their appearance, body functionality, and who they are as a person, as well as engaging with functionality-focused public health campaigns. A control group completed matched tasks on stress management. Results showed that both groups had improvements across trait body appreciation, self-objectification, and weight concern across the program. Within-session state improvements were found across stress, body appreciation, appearance and functionality satisfaction for both groups. An online media exposure task was used one week post-program completion (n = 81). Idealised media exposure reduced functionality satisfaction in both groups but did not impact any other outcome measure. Findings suggest that tasks encouraging positive reflections on appearance, functionality, and self are useful in improving women’s body satisfaction. Issues around choice of control group are discussed. Crown Copyright © 2019 Published by Elsevier Ltd. All rights reserved.

1. Introduction The positive body image movement has resulted in an increased understanding and recognition of the ways in which women positively inhabit their bodies. In their seminal paper, Tylka and Wood-Barcalow (2015a) point to the holistic, multidimensional nature of positive body image. Key features include body appreciation, acceptance, love, and respect towards one’s body, an adaptive investment in appearance, and an ability to filter cultural messages in a protective way. A further component is the value and appreciation of the various things that one’s body can do; that is, a focus on body functionality. In the present study, we examine the effectiveness of a multi-session positive body image program incorporating the aforementioned elements in improving state and trait

∗ Corresponding author at: School of Social Sciences, University of the Sunshine Coast, Locked Bag 4, Maroochydore DC, Queensland, 4558, Australia. E-mail address: [email protected] (K.E. Mulgrew). https://doi.org/10.1016/j.bodyim.2019.08.012 1740-1445/Crown Copyright © 2019 Published by Elsevier Ltd. All rights reserved.

outcomes and responses to thin-ideal media in a group of young adult women. Corresponding to the rise in interest in positive body image is an increased focus on body functionality. This construct refers broadly to everything that the body can do, and appears in various theoretical approaches such as Franzoi’s (1995) Body Conceptualisation theory, Piran’s (2015) Developmental Theory of Embodiment, and Fredrickson and Roberts’ (1997) Objectification Theory, and in scales such as the Body Esteem Scale (Franzoi & Shields, 1984; Frost, Franzoi, Oswald, & Shields, 2018), the Embodied Image Scale (Abbott & Barber, 2010), and the recent Functionality Appreciation Scale (Alleva, Tylka, & Kroon Van Diest, 2017). Franzoi (1995) proposed that the body may be viewed, by self or others, in either a holistic manner with a focus on the instrumental and functional qualities (i.e., Body-as-Process), or with a focus on the appearance of individual body parts (i.e., Body-As-Object). Likewise, Fredrickson and Roberts (1997) proposed that the body can be objectified and viewed as an object for the use and desire or others, or it can be viewed for what it can functionally do. These

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theories share at their core a recognition that focusing on the functional elements of the body can improve women’s connection with their bodies and can help to reduce self-objectification. A functional approach may be seen as part of a broader focus on embodiment, which can be related to less self-objectification, greater well-being, and a greater love and respect for one’s body (Menzel & Levine, 2011). Several interventions and public health campaigns have recently been developed to encourage women to reflect positively on the appearance and functionality of their body. Of relevance to the current study, these interventions include writing and reflecting tasks and functionality-focused videos and images. Findings generally show that women experience state-level and some traitlevel improvements after completion of these tasks. 1.1. Public health campaigns The first set of tasks relevant to the current study stem from recent public health campaigns that encourage women to engage in physical activity, and by doing so, model positive ways of inhabiting the body. Two such campaigns are This Girl Can from Sport England (2015) and the Start Playing, Stay Playing campaign, including the video #jointhemovement, from the Queensland Government (2016). Both campaigns share similar features: they showcase a diverse range of women of various age, ethnicity, and ability; with diverse body shapes and sizes, engaging in exercise. There is a focus on how the body realistically looks while exercising, e.g., red faces, hair plastered to the face with sweat, and body fat jiggling. Women are shown enjoying and challenging themselves across a range of individual and group exercises. The videos belonging to the campaigns are set to up-beat music. These depictions are in stark contrast to the range of “fitspiration” imagery prolific on social media, which ostensibly are designed to achieve a similar motivational purpose. However, experimental research shows that exposure to fitspiration-style images can result in body dissatisfaction (Prichard, McLachlan, Lavis, & Tiggemann, 2018; Robinson et al., 2017; Tiggemann & Zaccardo, 2015). Thus, imagery and videos which model non-objectified women exercising may allow women to reflect more positively upon their own functionality (Daniels, 2009, 2012). In support of this notion, Mulgrew, McCulloch, Farren, Prichard, and Lim (2018) demonstrated that young adult women who viewed the This Girl Can video (Study 1) or #jointhemovment video (Study 2) had higher state appearance satisfaction and intention to exercise compared to women who viewed a neutral control video. However, no effects were found for functionality satisfaction. The researchers suggested that women may need help to engage with the functionality depictions and reflect upon their own functionality. Thus, a multi-session approach which incorporated reflection and engagement-based writing tasks with these campaigns may provide women with realistic modelling of body functionality as well as the ability to reflect positively upon their own. 1.2. Writing tasks The second set of tasks to consider are single and multi-session writing tasks which encourage women to reflect on their body’s appearance or functionality. Findings from single-session writing tasks are mixed. Early work by Alleva, Martijn, Jansen, and Nederkoorn (2014) found no improvements to functionality satisfaction after a single-session writing task focusing on either appearance or the body’s functionality. In fact, women who wrote about appearance actually reported a decrease in functionality satisfaction. In contrast, some improvements were found by Mulgrew, Stalley, and Tiggemann (2017), who asked young adult women to write either about the positive elements of their appearance or the

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functionality of their body. State improvements were found across both appearance and functionality satisfaction, regardless of writing task. More consistent results have been found in studies using multi-session programs. In the 3-session Expand Your Horizon program (Alleva, Martijn, Van Breukelen, Jansen, & Karos, 2015), women with high body concern completed three writing tasks where they discussed the meaningfulness of a broad array of body functions. A range of positive outcomes were noted across trait levels of appearance and functionality satisfaction, body appreciation, and self-objectification. Benefits across trait body appreciation, and appearance and functionality satisfaction were also found in another multi-session study, with effects still seen at 1-week and 1-month follow-up points (Alleva et al., 2018). Thus, these findings generally suggest benefits from encouraging women to reflect upon and write about the various positive elements of how their body looks and functions. Interventions involving writing about one’s personal qualities have also been shown to be effective (e.g., Homan, Sedlak, & Boyd, 2014; Lew, Mann, Myers, Taylor, & Bower, 2007).For example, Homan et al. (2014) asked women to write about things for which they were grateful for five minutes. The women were encouraged to reflect broadly on various aspects of their life such as health, leisure activities, relationships, experiences, and so on. This reflection helped to buffer effects of subsequent idealised media exposure compared to women who wrote about daily hassles. Positive self-reflections are also found in several eating disorder prevention programs. For example, the Everybody’s Different program teaches adolescents to develop a positive sense of self by identifying and valuing one’s unique features (O’Dea & Abraham, 2000). Completion of this intervention led to improvements across a range of outcomes including increased body satisfaction and adolescents reporting less importance placed on popularity and physical appearance. In the present study, we took inspiration from a task by Lew et al. (2007), who encouraged women to write about the non-appearance aspects of their life of which they were proud and valued. They demonstrated that women who completed this task while viewing and comparing themselves to images of idealised models fared better than women who did a control writing task in which they described the attractive models. Thus, reflecting positively and holistically upon varied elements on who one is as a person complements existing appearance and functionality writing tasks as a healthy self-image is multifaceted, which includes, but is not limited to, body image (Tylka & Wood-Barcalow, 2015a). This is in line with the concept of inner positivity, which refers to the interrelationship between positive body image, positive feelings, and care for self and others (Tylka & Wood-Barcalow, 2015a). To this end, we incorporated both functionality-based campaigns and a series of writing tasks in the current study. 1.3. Media response The effectiveness of any program must be considered across a range of outcomes for it to be practically useful. Idealised imagery as presented in mass media is a potent sociocultural pressure for women. Models are commonly presented in an idealised and objectified manner, which has consistently been shown to negatively affect the body image and mood of female viewers, although there are a range of moderating factors (Grabe, Ward, & Hyde, 2008; Groesz, Levine, & Murnen, 2002). An important component of positive body image is the ability to reject these standards (Tylka & Wood-Barcalow, 2015a). For example, body appreciation, an important component of positive body image, has been shown to help protect women against negative effects of idealised media exposure (Halliwell, 2013). Thus, developing a positive body image may help women to reject rigid cultural messages about beauty. We therefore included a media exposure task to examine if the

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anticipated improvements from the program would buffer the traditionally observed negative effects. Buffering effects have been found after completion of a singlesession of gratitude-based writing task (Homan et al., 2014). However, single-session programs targeting positive appearance and/or functionality have generally not found that benefits extend to idealised media exposure. Despite gains in state appearance and functionality satisfaction after completing written reflection tasks, the women in Mulgrew et al.’s (2017) study still experienced reductions after exposure to images of the thin or fit ideal. That is, no buffering effects were found. Similarly, a single-session exposure to the #jointhemovment or This Girl Can functionality-focused videos did not protect women from lower satisfaction with physical functionality and/or appearance after viewing idealised images of posed or active models (Mulgrew et al., 2018). As noted by these authors, additional engagement and exposure to the positive messages are likely to be needed. However, even after three sessions of a functionality-focused writing task, Alleva et al. (2018) found that women still experienced reductions in state body satisfaction after viewing idealised imagery. Therefore, within-session improvements do not appear to offer a buffer to media exposure. One study, however, does suggest that change is possible. Alleva, Veldhuis, and Martijn (2016) found that women who completed a single-session of a functionality-focused writing task, compared to women who wrote about their travel routes, did have better state functionality satisfaction and trait body appreciation after viewing thin-ideal images. However, no differences were found across other state and trait measures, and no post-writing measures were taken, so it is difficult to track the changes to measures over time. Based on these studies, we included a media exposure task to examine whether cumulative benefits gained across multiple sessions of positive body image-related tasks would produce a buffer effect. 1.4. Current study In the current study, we build upon previous research examining single- and multiple-sessions of tasks which focus on encouraging women to positively reflect upon their appearance, body functionality, and unique sense of self. Instead of single-sessions (2018, Lew et al., 2007; Mulgrew et al., 2017) or multiple sessions on the one topic (2018, Alleva, Martijn et al., 2015), we included two sessions with a diverse range of tasks relating to positive ways of viewing the self. This study is the first to consider the cumulative benefit of these tasks together. A multi-session format was used as research has found that effects are generally enhanced compared to single session formats, likely because respondents have time to reflect upon and integrate the material into their daily lives (Lew et al., 2007; Stice & Shaw, 2004). Over the space of a week, women completed two online intervention sessions. Women were randomly allocated to receive either a Body Image or a Stress Management intervention. Stress management tasks were chosen for the control group as they still had the potential to benefit women but were not directly related to body image. In Session 1, both groups viewed videos and imagery, read stories, and provided short written reflections on the material. The Body Image group engaged with resources from two functionality-based public health campaigns. The Stress Management group engaged with resources from national mental health support groups about stress. Session 2 contained a series of writing tasks. The Body Image group completed three writing tasks reflecting upon positive elements of their body functionality, appearance, and who they were as a person. The Stress Management group completed three writing tasks about triggers of stress, strategies to manage stress, and relaxation techniques. Within all sessions, women completed pre- and post-test state measures to assess intra-session changes. One week after the second intervention ses-

sion they also completed a post-program assessment and media exposure task. Compared to women in the Stress Management program, we expected that women who completed the Body Image program would (a) have improvements to trait measures of selfobjectification, body appreciation, and body esteem from Session 1 to Post-Program; (b) have improvements to state measures of appearance satisfaction, body functionality, and body appreciation within each session; and (c) experience no change to the aforementioned state measures after a media exposure task at Post-Program. 2. Method 2.1. Participants The participants across Session 1 and Session 2 were 117 women aged between 17–35 years (M = 23.48, SD = 5.46) with an average body mass index (BMI) of 24.04 (SD = 5.29). Participants were predominantly Caucasian (91%) and currently studying at a university (80%). Of the 117 women who completed Sessions 1 and 2, n = 81 also completed the Post-Program assessment (Mage = 23.30, SD = 5.34; MBMI = 23.56, SD = 4.92). The sample was recruited from a regional Australian university via announcements in lectures, course sites, and a first-year psychology credit program. Social media announcements were placed on various health and well-being pages and the individual pages of the researchers and colleagues. 2.2. Materials 2.2.1. Demographic information Participant’s self-reported their age, height and weight (to calculate BMI), ethnicity, and whether they attended a university. 2.2.2. State appearance and functionality satisfaction Sixteen Visual Analogue Scales (VAS) were used to assess state satisfaction. Four items measured satisfaction with appearance (dimensions of overall appearance, weight and shape, fat, and attractiveness; Mulgrew & Tiggemann, 2018) and four items assessed functionality satisfaction (physical strength, how my body can move, what my body can do, and fit and healthy; Mulgrew et al., 2017). A further four items were used to assess dimensions of stress specifically (stressed, overwhelmed, calm, and relaxed) while four other mood items were used as filler distractor items (angry, sad, confident, and happy). For each item, women used a slider to rate how they felt “right now” from 1 to 100 (e.g., right now I feel calm). Only the end points of not at all and very much were given to reduce memory for previous answers across multiple testing sessions. Scores within each set of VAS were averaged to create one overall score of appearance satisfaction, functionality satisfaction, and stress; with higher scores indicating greater levels of the construct. Cronbach’s alpha scores were high (> .90) for each VAS across the multiple administrations. 2.2.3. State and trait body appreciation Trait body appreciation was measured using the 10-item Body Appreciation Scale-2 (BAS-2; Tylka & Wood-Barcalow, 2015b). This scale measures feelings of love, acceptance, and respect towards the body. Items are responded to on a 1 (never) to 5 (always) scale, with scores averaged, and higher scores indicating greater body appreciation. Previous research has demonstrated good psychometric properties for the scale including a Cronbach’s alpha score of .97 for women (Tylka & Wood-Barcalow, 2015b). The Cronbach’s alpha in our sample was similarly high across Session 1 (␣ = .94) and Post-Program (␣ = .96).

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The state adaptation of the BAS-2 (Homan, 2016) was used to assess contextual fluctuations in body appreciation. The original trait-based items were modified to assess how women feel “right now,” with the same 1–5 scale and scoring instructions used as the trait-based scale. Sound psychometric properties are reported with a Cronbach’s alpha of .97 for women (Homan, 2016), which was similarly high in our sample with scores ranging from .95 to .97 across administrations. 2.2.4. Body esteem The Revised Body Esteem Scale (BES; Frost et al., 2018) was used to assess feelings of satisfaction with areas of the body associated with sexual attractiveness (8 items), weight concern (8 items), and satisfaction with physical condition (6 items). Women rated each item along a 1 (have strong negative feelings) to 5 (have strong positive feelings) scale, with sub-scale scores calculated by summing the responses. Higher scores indicate greater body esteem. The scale has good psychometric properties (Frost et al., 2018) with high Cronbach’s alpha scores across all subscales at Session 1 (␣ = .76–.82) and Post-Program (␣ = .78–.86). 2.2.5. Self-objectification The Self-Objectification Questionnaire (Noll & Fredrickson, 1998) is a 10- item scale that measures the extent to which women view their bodies in appearance-based, objectified ways versus non-appearance competence-based ways. Women rank ten body attributes from most to least important to the physical self-concept. Scores given to the appearance dimensions and competence dimensions are summed, and then the sum of the competence items are subtracted from the sum of the appearance items. Scores range from -25 to + 25. Higher scores indicate more appearance focus which is interpreted as greater self-objectification. Construct validity is evidenced via correlations between self-objectification scores and related measures (Noll & Fredrickson, 1998). Cronbach alpha scores are not calculated as the scores are rank orders of attributes. 2.2.6. Resources, session 1 In Session 1, women engaged with videos, images, stories, and writing tasks relating to functionality or managing stress. The functionality material was taken from the 2015 Sport England campaign This Girl Can and the #jointhemovment Start Playing Stay Playing campaign from the Queensland Government (2016). Women were invited to watch two, 1.5-minute videos from both campaigns which display a diverse range of women engaging in exercise in a realistic manner. For example, women of various body shapes and abilities are shown engaging in activities such as swimming, running, and soccer. The depictions are non-objectified with a focus on the women engaging in activity and having fun. There appears to be a rejection of the typical idealised depictions with imagery of red and sweaty faces, cellulite, and body fat movement. The clips are set to upbeat music and appear to be fun and motivational. The campaigns also contain still images from the videos with motivational slogans across them such as, “I’m slow but I’m lapping everyone on the couch” and “#labelsareforclothing.” Women were shown four of the images from each campaign. Six stories from women describing their favourite physical activity were also used. After viewing each video and image set, women were asked which element they liked the best and how it made them feel. Women completed six short writing / engagement tasks in total. Research from the public health literature suggests that engagement with resources is important (Randolph & Viswanath, 2004). Links were provided to each campaign so that women could further explore the resources if they desired. Women in the Stress Management condition viewed two brief videos (1:42 & 2 min), pictorial material, and were asked the same

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engagement and reflection questions. The material was taken from the Australian Psychological Society and Headspace and contained information about understanding and managing stress and maintaining a healthy headspace. One of the videos contained footage of puppies with instructions to enjoy a cute video which may help to reduce stress. 2.2.7. Resources, session 2 Women completed three writing tasks in Session 2 which can be found in the Supplementary file. The first task invited women to reflect positively and write about the way in which their body functions. The second task asked women to write about the positive elements of their appearance. These two tasks were taken from Mulgrew et al. (2017). The third task was modelled from Lew et al. (2007) and asked women to write about the unique things that made them who they are. Across each of these three tasks, women were asked to consider how the positive elements of their functionality, appearance, and self contributed to their well-being. Within each writing task, examples and prompts were provided as a starting point. Some of the prompts were: energy, coordination, or running (functionality reflection); lips, waist, and hips (appearance reflection); and kind, honest, and confident (self-reflection). An example response provided was: “I am very sociable, so I have formed a lot of great friendships over the years.” Participants typed their responses into the online survey. They were encouraged to transfer and save their responses into a Word document so they could use it as a reminder of how amazing and unique they are. No explicit writing time frames were given but women were asked to generate 7–10 responses for each writing task. Responses were discarded if a minimum of six responses per writing task were not recorded. Only one participant was excluded as they did not provide any responses to the reflections despite continuing with the study. Within the Stress Management condition, women also completed three writing tasks which were framed in the same way and of similar length. The topics were triggers of stress, strategies to manage stress, and relaxation techniques to continue with stress management. The focus on the latter two topics was healthy ways in which to manage stress. Prompts were given for each task so that participants had a starting point, for example, work stress (triggers reflection), maintaining a healthy lifestyle (managing stress reflection), and writing in a journal (relaxation reflection). 2.2.8. Idealised images, Post-Program Ten images representing the Western female body ideal were used in the media exposure task. These images were a sub-set of those used by Mulgrew and Tiggemann (2018) with five posed and five active images chosen. We used both styles of images as they have been shown to trigger negative outcomes in viewers and reflect the traditional (e.g., thin and posed) and newer (e.g., thin and active) ideals of attractiveness. All images depicted young, attractive, thin, and toned models in revealing swimwear or work-out wear. Two strategies were used to ensure that participants did not skim through the images. First, women were asked to consider each image and answer two questions that followed. These questions were about the overall appeal of the image and its’ effectiveness in advertising lifestyle products. Second, a number was presented towards the end of the image set with an instruction to remember it. None of the women incorrectly answered the memory check question at the completion of the image set. 2.3. Procedure Ethical approval was provided by the first author’s institution. Women were invited to participate in a study entitled “Body Image and Stress.” No effort was made to conceal the nature of the study,

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Fig. 1. Flow chart of program.

although women were not informed of the multiple conditions or the hypotheses. Women aged 18–35 years, or 17 years if they were at university, were eligible to participate. As part of our recruitment blurb, we encouraged women of all shapes and sizes with various relationships with their body to participate. The online survey was hosted through SurveyMonkey. Fig. 1 shows the progression of participants through the study. In Session 1, women completed the demographic questions and baseline trait measures of body appreciation, self-objectification, and body esteem. They then completed a short distractor task involving reading an article from the university newsletter and answering some brief questions. Women then completed the pretest VAS and were randomly allocated to engage in either the Body Image or Stress Management Session 1 materials. Finally, women

completed the post-test VAS and were then invited to provide feedback on the task and to leave their details for participation in Session 2. An invitation was sent to complete Session 2 within three days of completing Session 1. Reminder emails were sent for participants who did not complete Session 2 within a week. In Session 2, women again completed pre-test VAS before the three writing tasks relating to either body image or stress management. Post-test VAS were then completed followed by an invitation for feedback and participation in the final session. An invitation to complete the post-program assessment was sent approximately one week after completing Session 2. At the Post-Program assessment, participants completed the post-test trait measures of body appreciation, self-objectification, and body esteem. They then completed a short distractor task

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Table 1 Descriptive (Mean and Standard Deviation) and Inferential Statistics Across Trait Outcome Measures as a Function of Program. Trait Outcome

Body appreciation Self-objectification Weight concern Physical condition Sexual attractiveness

Body Image Program

Stress Management Program

Results

Session 1

Post-Program

Session 1

Post-Program

Inferential statistics

n = 54

n = 35

n = 63

n = 46

Main effect Program

Main effect Time

Program × Time Interaction

3.13 (0.87) −0.58 (13.25) 21.70 (6.69) 18.91 (4.24) 31.05 (6.36)

3.19 (0.83) −3.35 (14.97) 22.14 (7.02) 18.97 (4.39) 30.20 (6.08)

3.04 (0.89) 0.55 (14.41) 19.09 (8.11) 17.09 (5.27) 28.50 (5.81)

3.16 (0.98) −1.30 (15.71) 20.34 (8.10) 17.44 (5.59) 28.50 (5.88)

F(1, 79) = 0.09, p = .76, f = .03 F(1, 72) = 0.25, p = .61, f = .06 F(1, 76) = 1.76, p = .18, f = .15 F(1, 75) = 2.35, p = .13, f = .17 F(1, 76) = 2.64, p = .10, f = .18

F(1, 79) = 4.41, p = .039, f = .24 F(1, 72) = 3.16, p = .08, f = .21 F(1, 76) = 3.11, p = .08, f = .20 F(1, 75) = 0.36, p = .55, f = .07 F(1, 76) = 1.09, p = .30, f = .12

F(1, 79) = 0.39, p = .53, f = .07 F(1, 72) = 0.12, p = .72, f = .04 F(1, 76) = 0.71, p = .40, f = .10 F(1, 75) = 0.18, p = .37, f = .04 F(1, 76) = 1.09, p = .30, f = .12

where they read a story from the university newsletter and answered brief questions about the content. Finally, participants completed the body image challenge wherein they reported preand post-test levels of state appearance and functionality satisfaction in response to the media exposure task. Within this task women were exposed to 10 idealised images and answered two questions about each image. Finally, participants were thanked for their time, debriefed, and invited to enter a prize draw in recognition of their time investment. Participants were also provided with a link to the resources provided in the other condition, if they wished to access them. Data from all sessions were matched by a code that participants generated in each session. Thus, women completed three sessions over approximately two weeks, with each session taking 30–40 min.

version 3.1 (Faul et al., 2007) showed that the achieved sample size was sufficient to detect a small effect (.25) with power of .80 and an alpha of .05. There were no significant baseline differences between the women in the two programs on age, BMI, pre-test VAS, or baseline trait measures (all ps > .05), suggesting random allocation was successful. There were also no significant differences between the programs on number of days between each session (all ps >.05). The median time spent in Session 1 was similar across Body Image (Mdn =28.50 min) and Stress Management (Mdn = 29.00) programs. Session 2 median times were also similar (Body Image Mdn = 25.50; Stress Management Mdn = 25.00).

3. Results

To test the first hypothesis that trait scores would improve over time, we conducted a series of Program (Body Image vs. Stress Management) by Time (Session 1 to Post-Program) ANOVAs, with each trait measure as a Dependent Variable. Significant interactions were followed up by examining changes over time within each program condition. These analyses were only conducted on women who completed all sessions. Descriptive and inferential statistics are shown in Table 1. There was no Program by Time interaction or main effect of Program for any of the trait outcome measures of body esteem, body appreciation, or self-objectification. However, a main effect of Time emerged for body appreciation (p = .03, f = .24) and a trend for self-objectification (p = .08, f = .21) and weight concern (p = .08, f = .20). Improvements were noted in these measures: a small increase in body appreciation from Session 1 (M = 3.08, SE = 0.10) to Post-Program (M = 3.18. SE = 0.10), a small shift towards lower self-objectification from Session 1 (M = -0.19, SE = 1.62) to PostProgram (M = -2.23, SE = 1.79), and a small increase in satisfaction

3.1. Preliminary analyses No major deviations from normality were noted and all statistical assumptions were met. Participants were retained if they provided data for both Session 1 and Session 2. An item-mean replacement was used across trait measures in cases of a small amount of missing data (n = 8 on BAS-2; n = 9 on BES). This allowed us to maximally retain data. The approach was chosen as item-mean and person-mean approaches yield similar results in situations with a small amount of missing data (Downey & King, 1998). No mean replacement was used on the Self-Objectification Questionnaire given it required rank-ordering. Mean VAS scores were calculated if at least 3 out of the 4 items were answered. Trend effects were considered when accompanied by a reasonable effect size. Effect size, f, can be interpreted as a small (.10), medium (.25), or large (.40; Faul, Erdfelder, Lang, & Buchner, 2007) effect. G*Power

3.2. Changes to trait measures across time

Table 2 Mean (Standard Deviation) for State Changes Within Each Session as a Function of Program. State Variables

Body Image Program Session 1

Appearance satisfaction Functionality Satisfaction Body appreciation Stress

Stress Management Program Session 2

Post-Program

Session 1

Session 2

Post-Program

Pre

Post

Pre

Post

Pre

Post

Pre

Post

Pre

Post

Pre

Post

38.03 (25.98) 49.19 (22.92) 3.05 (0.96) 47.06 (27.60)

46.94 (27.98) 53.11 (26.32) 3.28 (0.99) 39.02 (23.58)

43.52 (24.33) 49.73 (21.06) 3.21 (0.89) 46.18 (25.18)

46.89 (25.79) 55.19 (22.30) 3.47 (0.86) 38.42 (23.70)

46.15 (25.11) 51.24 (20.83) 3.25 (0.89) 45.59 (26.05)

43.13 (25.39) 46.44 (23.85) 3.27 (0.90) 46.42 (26.79)

37.52 (24.45) 46.06 (23.71) 3.18 (1.10) 48.10 (25.42)

41.80 (25.65) 50.13 (23.90) 3.29 (1.03) 37.86 (22.09)

40.27 (24.50) 46.10 (23.83) 3.22 (0.99) 45.42 (24.64)

41.77 (25.81) 49.33 (24.28) 3.30 (0.97) 41.42 (21.79)

39.04 (27.21) 45.84 (25.79) 3.20 (1.14) 45.64 (24.77)

38.98 (28.00) 43.36 (27.94) 3.09 (1.21) 46.81 (28.48)

Note: All changes from pre- to post-test were significant for Session 1 and Session 2 across both programs. At Post-Program, only functionality satisfaction significantly reduced from pre- to post-test.

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with areas of the body relating to weight concern (BES) from Session 1 (M = 20.40, SE = 0.85) to Post-Program (M = 21.24, SE = 0.87). 3.3. Within-session changes To test the second hypothesis that improvements would be found across the state outcome measures within each session, we conducted a series of Time (pre- to post-test within session) by Program ANOVAs. Significant interactions were followed up by examining changes over time within each program condition. Descriptive statistics are shown in Table 2. 3.3.1. Session 1 For state appearance satisfaction, there was a significant Time by Program interaction, F(1, 110) = 4.20, p = .043, f = .19. Although the increase over time was significant across both the Stress Management, F(1, 61) = 9.75, p = .003, f = .40, and Body Image program, F(1, 49) = 23.15, p < .001, f = .69, it was larger in the latter condition. There was no main effect of Program, F(1, 110) = 0.34, p = .55, f = .05, but a main effect of Time, F(1, 110) = 34.15, p < .001, f = .56, showing a significant increase from pre- to post-test. For state functionality satisfaction, there was no interaction, F(1, 107) = 0.08, p = .92, f = .03, nor an effect of Program, F(1, 107) = 0.45, p = .50, f = .06. However, there was a significant effect of Time, F(1, 107) = 22.88, p < .001, f = .45, showing an increase from pre(M = 47.63, SE = 2.24) to post-test (M = 51.62, SE = 2.40). For state body appreciation, there was a trend interaction, F(1, 110) = 3.39, p = .06, f = .17, which we interpret with caution. Although a small increase was found in both the Stress Management, F(1, 57) = 7.06, p = .01, f = .35, and the Body Image conditions, F(1, 53) = 18.16, p < .001, f = .58, the effect was larger in the latter condition. There was no effect of Program, F(1, 110) = 0.14 p = .70, f = .03, but a significant effect of Time, F(1, 110) = 25.50, p < .001, f = .48, showing a small increase from pre- (M = 3.12, SE = 0.98) to post-test (M = 3.29, SE = .096). Finally, for state stress, there was no interaction, F(1, 104) = 0.51, p = .47, f = .07, nor a main effect of Program, F(1, 104) = 0.01, p = .98, f = .01. However, there was a main effect of Time, F(1, 104) = 35.59, p < .001, f = .58, indicating a reduction in stress from pre- (M = 47.58, SE = 2.57) to post-test (M = 38.44, SE = 2.23). To summarise the results from Session 1, women in both programs experienced significant improvements in state levels of appearance satisfaction, functionality satisfaction, stress, and body appreciation (trend). Women in the Body Image program experienced a larger increase in body appreciation and appearance satisfaction than women in the Stress Management program. 3.3.2. Session 2 For state appearance satisfaction, there was no interaction, F(1, 111) = 1.06, p = .30, f = .09, no main effect of Program, F(1, 111) = 0.81, p = .37, f = .08, but a main effect of Time, F(1, 111) = 7.17, f = .25, showing an increase from pre- (M = 41.89, SE = 2.30) to posttest (M = 44.33, SE = 2.43). For state functionality satisfaction, there was no interaction, F(1, 107) = 1.80, p = .18, f = .13, no main effect of Program, F(1, 107) = 1.20, p = .27, f = .10, but a main effect of Time, F(1, 107) = 27.63, p < .001, f = .50, showing an increase from pre(M = 47.92, SE = 2.16) to post-test (M = 52.26, SE = 2.37). For state body appreciation, there was a significant interaction, F(1, 112) = 7.82, p = .006, f = .26. Although there was a significant increase across time for both the Stress Management, F(1, 60) = 4.96, p = .03, f = .28, and the Body Image program, F(1, 52) = 21.45, p < .001, f = .64, the effect was larger for the latter program. For main effects, there was no effect of Program, F(1, 112) = 0.22, p = .63, f = .04, but a main effect of Time, F(1, 112) = 27.47, p < .001, f = .49,

showing a small increase from pre- (M = 3.21, SE = 0.09) to post-test (M = 3.39, SE = 0.08). Finally, for state stress, there was no interaction, F(1, 108) = 1.77, p = .18, f = .12, no effect of Program, F(1, 108) = 0.06, p = .79, f = .03, but an effect of Time, F(1, 108) = 17.33, p < .001, f = .40. Participant’s stress levels significant reduced from pre- (M = 45.80, SE = 2.38) to post-test (M = 39.92, SE = 2.17). To summarise the results from Session 2, in response to both programs, participants experienced significant improvements in state appearance satisfaction, functionality satisfaction, body appreciation, and stress. Women in the Body Image program experienced a larger increase in body appreciation than women in the Stress Management program. 3.4. Media exposure challenge In the third hypothesis, we tested whether women who had completed the Body Image program would experience less negative effects after a media exposure challenge compared to women who completed the Stress Management program. A series of Time (Post-Program pre- vs. post scores) by Program ANOVAs were run with each state outcome variable as the dependent variable. Interactions were followed by looking at changes over time within each program. For state appearance satisfaction, there was no significant interaction, F(1, 71) = 1.78, p = .18, f = .16, no main effect of Program, F(1, 71) = 0.84, p = .36, f = .11, and no main effect of Time, F(1, 71) = .93, p = .17, f = .16. For state functionality satisfaction, there was no interaction, F(1, 69) = 0.55, p = .46, f = .09, no main effect of Program, F(1, 69) = 0.55, p = .46, f = .09, but a main effect of Time, F(1, 69) = 5.48, p = .02, f = .28, whereby all women decreased in functionality satisfaction from pre- (M = 48.54, SE = 2.81) to post-images (M = 44.90, SE = 3.10). For state body appreciation, there was no interaction, F(1, 72) = 2.14, p = .14, f = .17, no main effect of Program, F(1, 72) = 2.14, p = .14, f = .05, and no effect of Time, F(1, 72) = 1.10, p = .30, f = .12. For stress, there was no interaction, F(1, 69) = 0.01, p = .90, f = .01, no effect of Program, F(1, 69) = 0.01, p = .97, f = .01, and no effect of Time, F(1, 1, 69) = 0.49, p = .48, f = .08. To summarise findings from the media exposure analyses, women did not show the traditionally reported drop in satisfaction across appearance satisfaction or state body appreciation. However, functionality satisfaction decreased after viewing the idealised images. These results did not vary by program. 4. Discussion In this study, we examined the effectiveness of a short, multisession online intervention to improve the way women viewed themselves and their bodies. Although each component was based on previous research, this is the first time that the components have been packaged together and evaluated. Collectively, our results suggest that engagement with a set of resources which allow women to reflect positively on their appearance, body functionality, and unique elements of themselves, can improve some state and trait body image measures. Women across both programs experienced small improvements in trait body appreciation and satisfaction with weight, and less self-objectification. Although these changes were small, we think they are promising given the relatively short intervention period, the 1-week delay between program completion and the trait measures, and the difficulty in modifying ingrained, trait-level attitudes. State-level improvements were also noted within each intervention session across both programs. However, women in the Body Image program had significantly larger improvements to appearance satisfaction (Ses-

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sion 1) and body appreciation (Sessions 1 and 2) than women who completed the Stress Management program. Although promising, body image improvements were also noted in our Stress Management group. For many outcome variables, there were no significant differences between the benefits of the Stress Management and Body Image programs, although effect sizes were larger for the Body Image program. We propose two explanations for this lack of difference between programs. First, it may be that our Body Image program was effective, but the Stress Management program also had positive, yet unintended, flow-on effects to our body image variables. Within intervention studies, many control groups are non-active (e.g., waitlist control) or complete activities unrelated to psychological well-being. For example, the studies on which we based the current program used control groups that completed tasks such as a creative writing program (Alleva, Martijn et al., 2015), describing travel routes (Alleva et al., 2016), watching advertisements about dogs or cars (Mulgrew et al., 2018), or had no control group (Mulgrew et al., 2017). More broadly, research shows that when interventions are tested against an active control, they show significantly smaller improvements compared to those tested against a passive control group (Alleva, Sheeran et al., 2015). Thus, our active control with a focus on psychological well-being may have also improved body image outcomes. This is an important and novel finding as it helps researchers to establish whether interventions focused on positive appearance, functionality, and the self are better than other psychological well-being interventions, rather than general control groups. The improvements to state stress found within the sessions may stem from generalised improvements in psychological well-being from the programs. Research also suggests a link between stress and various body image measures. For example, the experience of a stressful event can result in increased weight dissatisfaction (Murray, Rieger, & Byrne, 2013, 2015), body dissatisfaction and drive for thinness (Ruggiero et al., 2008), and disordered eating attitudes and lower self-esteem (Costarelli & Patsai, 2012) in young adult women. Ruggiero et al. (2008) propose that stressful situations may elicit feelings of lack of control which may then trigger maladaptive attitudes and behaviours around eating, weight, and shape designed to regain a sense of control. This relationship may also occur in the opposite direction, that is, stress management strategies may assist with positive feelings about one’s appearance and functionality. Indeed, both programs had cross-over benefits. Therefore, general stress management strategies may be useful to include in future body image programs, particularly for women who are reluctant to discuss body image issues. The second possible explanation is that the improvements noted in both the Body Image and Stress Management programs may have naturally occurred regardless of the program. That is, the simple effect of being in a study produced change. Demand characteristics may have also produced the observed changes. The inclusion of a non-active control group would have allowed for causation to be more firmly established. There are, however, a few arguments against the idea of natural fluctuations. Each individual element of the program has separately been shown to have positive benefits, either as used in the exact or a similar format as here (Alleva et al., 2014, 2016, 2018; Lew et al., 2007; Mulgrew et al., 2017). As previously noted, none of the control groups in these studies completed activities related to psychological well-being. Further, although natural fluctuations occur in state measures throughout the day, it is unlikely that all our measures would have improved. Improvements may have been driven by demand effects; however, it is unlikely that women would recall their responses across all items, especially VAS which do not contain markers. The pattern of improvement is also broadly consistent with past research, as noted previously. Therefore, while we cannot rule out demand effects, we think they are unlikely to fully capture our findings.

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The improvements to trait body appreciation and trend-levels improvements to self-objectification and weight concern across the program are promising. Although the magnitude of the change was small, it is probably a realistic depiction of women’s capacity to change on trait-level constructs over the short time-course. Further, the Post-Program trait measures were taken one week after program completion, meaning that any benefits had to be maintained for at least that period. Benefits across trait measures have also been found from the multi-session functionality writing tasks used by Alleva et al. (2015, 2018)Alleva et al. (2015, 2018). For example, they found that the functionality writing group reported better body appreciation and self-objectification than the control writing group at 1-week follow-up (Alleva, Martijn et al., 2015). Collectively, these findings support the utility of this style of intervention. Further, the consistent improvements across state body appreciation, appearance satisfaction, and functionality satisfaction within each session show that these tasks are a useful way of providing immediate benefits to women’s body image. Our findings suggest that women are responsive and able to view their bodies in a positive light, when given appropriate cues. There is not clear evidence as to whether any benefits from the program extended to the media exposure task at Post-Program. On the one hand, we did not see the typically-reported negative effects after viewing idealised media. Women in our study reported no changes on state body appreciation or appearance satisfaction, although their levels of functionality satisfaction did decrease. Thus, the programs may have benefited women via an absence of the traditionally seen drop in body satisfaction after exposure. If so, this suggests that women’s experience in valuing and appreciating the diverse elements of their bodies, and ability to manage stress, offered some protective advantage when they were exposed to imagery of the thin and fit ideal. On the other hand, it may be that the media exposure task did not elicit the typical decreases in body satisfaction on this occasion. That is, women may not have been affected by the images, regardless of whether they had previously undertaken the programs. This is indeed a possibility, as media exposure does not always translate into negative outcomes in all viewers (e.g., Ferguson, 2013; Levine & Murnen, 2009). Although these two explanations are possibilities, we cautiously favour the buffering interpretation. Research generally suggests that women experience deceases in body satisfaction after exposure to idealised imagery (Grabe et al., 2008; Groesz et al., 2002). Perhaps most critically, the specific images we used here were taken from past research which has shown detrimental effects compared to scenery control conditions (e.g., Mulgrew et al., 2017, 2018). A novel component of our findings is that our Stress Management program also offered the same (potential) buffering effect. As noted previously, the cross-over benefits between the two programs may have offered improvements to general psychological well-being, which may have assisted with responses to the idealised media exposure. Although state body appreciation and appearance satisfaction were not affected by media exposure, a decrease was still found in state body functionality satisfaction. This reduction occurred despite women previously undertaking activities encouraging them to identify and value the various ways in which their body functions. An understanding of the different ways in which women view the appearance and functional elements of their bodies is important given the contemporary focus on the fit-ideal as the body of choice (Rodgers et al., 2018). Media depictions of women in action are now common (e.g., fitspiration), although they are still presented in an idealised manner (Carrotte, Prichard, & Lim, 2017). This, “blend between function and form” (Abbott & Barber, 2011, p. 334), can create additional pressure on women to not only look thin but also toned and fit (Mask, Blanchard, & Baker, 2014).

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Women have been traditionally socialised to view their own and other women’s bodies through an objectified lens (Fredrickson & Roberts, 1997). It is promising that beneficial state-level changes were achieved to functionality satisfaction within the individual program sessions. Women may need additional help to maintain a positive functionality focus when presented with body image threats in daily life, as in the media exposure task in our study. 4.1. Limitations and future research Some limitations of the study should be noted. First, we did not include a measure of social comparison to the media imagery and therefore cannot ascertain whether the tasks helped to disrupt social comparison processes. Upward social comparison is a key process through which women experience media-induced body dissatisfaction (Tiggemann & Polivy, 2010). However, these processes can be difficult to disrupt. Mulgrew et al. (2017) noted that over 70% of women in their sample still engaged in upward social comparison to idealised imagery even after completing a single session positive appearance and functionality reflection task. Previous research has pointed to the inter-relationships between social comparison, self-objectification, and body appreciation both at a trait (Andrew, Tiggemann, & Clark, 2015) and state level (Andrew, Tiggemann, & Clark, 2015). Therefore, future replications of this program could usefully incorporate strategies to reduce social comparisons. Second, as previously discussed, further consideration of the control group is needed. We opted for an active control group that would still offer some value to participants given the time commitment of the study. The improvements seen in our Stress Management control group, although beneficial to those women, do present challenges when trying to establish the benefits of the Body Image program. However, the implications are that future body image programs may wish to include materials on understanding and managing stress. Other researchers have also suggested that mindfulness techniques would be useful (Halliwell, 2013). Thus, future research could replicate this program with a broader range of topics. Finally, online intervention delivery has both benefits and limitations. Although checks were incorporated into the program, it is still impossible to fully monitor responses (Alleva et al., 2018). Online delivery does, however, allow for women to complete the program in the privacy of their homes at a convenient time, which is likely to improve engagement. Future research could include additional follow-up points to examine if the small trait-level changes observed in the current study are maintained. Additionally, it would be useful to know if women engaged further with the resources outside of the context of the study. Longer-term interventions (and follow-up) are of course preferable and generally produce stronger findings (Watson & Vaughn, 2006) but are not always practical. Another suggestion might be the inclusion of ‘booster’ sessions which may help to reinforce key messages and allow women to integrate the material into their daily lives. These additional sessions need to be balanced with considerations of the impact of priming effects which may stem from multiple administrations of measures. Although we used distractor tasks to break up the repetition of measures in our study, participants will still be sensitised to the topic of body image through the completion of measures. Future research could also examine the transferability of improvements in state and trait measures across other measures, such as cognitive ones. Interesting work by Glashouwer, Jonker, Thomassen, and de Jong (2016) has shown that although body dissatisfied women improved on shape concern and eating disorder symptoms after a positive mirror exposure task, their attention biases towards body parts identified as “ugly” or “beautiful” did not

change. Thus, additional work is needed to understand whether positive changes to self-reported measures also extend to automatic processes such as allocation of attention. In sum, we found evidence that encouraging women to reflect upon the positive elements of themselves, their appearance, body functionality, and ways to manage stress can lead to improvements across state and trait levels of body appreciation, appearance and functionality satisfaction. These benefits may have helped to buffer negative effects traditionally seen after idealised media exposure. The resources used are currently or readily available and can be used to improve women’s relationship with their body. Funding We gratefully acknowledge funding from University of the Sunshine Coast for the conduct of this study. Acknowledgement We would like to acknowledge the contribution of Rebecca Belte who contributed to the preparation of the paper. Appendix A. Supplementary data Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.bodyim.2019. 08.012. References Abbott, B. D., & Barber, B. L. (2010). Embodied image: Gender differences in functional and aesthetic body image among Australian adolescents. Body Image, 7, 22–31. http://dx.doi.org/10.1016/j.bodyim.2009.10.004 Abbott, B. D., & Barber, B. L. (2011). Differences in functional and aesthetic body image between sedentary girls and girls involved in sports and physical activity: Does sport type make a difference? Psychology of Sport and Exercise, 12, 333–342. http://dx.doi.org/10.1016/j.psychsport.2010.10.005 Alleva, J. M., Diedrichs, P. C., Halliwell, E., Martijn, C., Stuijfzand, B. G., Treneman-Evans, G., . . . & Rumsey, N. (2018). A randomised-controlled trial investigating potential underlying mechanisms of a functionality-based approach to improving women’s body image. Body Image, 25, 85–96. http://dx. doi.org/10.1016/j.bodyim.2018.02.009 Alleva, J. M., Martijn, C., Jansen, A., & Nederkoorn, C. (2014). Body language: Affecting body satisfaction by describing the body in functionality terms. Psychology of Women Quarterly, 38, 181–196. http://dx.doi.org/10.1177/ 0361684313507897 Alleva, J. M., Martijn, C., Van Breukelen, G. J., Jansen, A., & Karos, K. (2015). Expand your Horizon: A programme that improves body image and reduces self-objectification by training women to focus on body functionality. Body Image, 15, 81–89. http://dx.doi.org/10.1016/j.bodyim.2015.07.001 Alleva, J. M., Sheeran, P., Webb, T. L., Martijn, C., & Miles, E. (2015). A meta-analytic review of stand-alone interventions to improve body image. PloS One, 10(9), e0139177 http://dx.doi.org/10.1371/journal.pone.0139177 Alleva, J. M., Tylka, T. L., & Kroon Van Diest, A. M. K. (2017). The Functionality Appreciation Scale (FAS): Development and psychometric evaluation in US community women and men. Body Image, 23, 28–44. http://dx.doi.org/10. 1016/j.bodyim.2017.07.008 Alleva, J. M., Veldhuis, J., & Martijn, C. (2016). A pilot study investigating whether focusing on body functionality can protect women from the potential negative effects of viewing thin-ideal media images. Body Image, 17, 10–13. http://dx. doi.org/10.1016/j.bodyim.2016.01.007 Andrew, R., Tiggemann, M., & Clark, L. (2015a). Predictors of intuitive eating in adolescent girls. Journal of Adolescent Health, 56, 209–214. http://dx.doi.org/10. 1016/j.jadohealth.2014.09.005 Andrew, R., Tiggemann, M., & Clark, L. (2015b). The protective role of body appreciation against media-induced body dissatisfaction. Body Image, 15, 98–104. http://dx.doi.org/10.1016/j.bodyim.2015.07.005 Carrotte, E. R., Prichard, I., & Lim, M. (2017). ‘Fitspiration’ on social media: A content analysis of gendered images. Journal of Medical Internet Research, 19, e95. http://dx.doi.org/10.2196/jmir.6368 Costarelli, V., & Patsai, A. (2012). Academic examination stress increases disordered eating symptomatology in female university students. Eating and Weight Disorders, 17, 164–169. http://dx.doi.org/10.1007/BF03325343 Daniels, E. A. (2009). Sex objects, athletes, and sexy athletes: How media representations of women athletes can impact adolescent girls and college women. Journal of Adolescent Research, 24, 399–422. http://dx.doi.org/10.1177/ 0743558409336748

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