Self-esteem, body esteem and body image: Exploring effective solutions for ‘at risk’ young women
Low self-esteem and dissatisfaction with weight and looks is common amongst young people. Particularly for girls, low self-esteem and poor body image have been identified to be risk factors for development of eating disorders. This thesis sought to answer two broad aims. The first aim was to explore if a specific group based intervention (“Girls on the Go!” program), led by health professionals and delivered from a community setting increased self-esteem and related self-perceptions and behaviours in ‘at risk’ school age girls compared to no intervention. The second aim was to identify if interventions designed to improve self-esteem of girls improve their self-esteem compared to no interventions. Five key studies comprised this project.
Study 1 was a retrospective investigation of an existing pre- program/ post-program evaluation dataset of the “Girls on the Go!” program collected over the first 8 years of program provision at Greater Dandenong Community Health Services. Participants were 176 girls (age range 10-17) from 15 programs (each comprising 7-11 girls).The program was successful in improving self-esteem (p<0.001), self-confidence (p<0.001) and satisfaction with body image (p<0.001). This retrospective audit did not encompass comparison against a randomly selected control group. A randomised control trial methodology allowed for such comparison and this constituted the aim of Study 2 and Study 3.
For Study 2 and Study 3 participants were girls between 10 and 17 years of age from 12 schools, either high school participants for Study 2 or primary school participants for Study 3. Eligibility criteria for girls to be referred to the “Girls on the Go!” program and also to be included in the study were: poor or negative body image, low self-esteem, inactivity in sports and exercise, poor diet, or being overweight or underweight. Both Study 2 and Study 3 were stepped-wedge cluster randomised controlled trial of the “Girls on the Go!” program intervention that used the waiting list for the program to generate the control condition. Measurements were made using Rosenberg Self-Esteem Scale, Clinical Interview Assessment, Self-Efficacy Scale (included: Mental Health and Physical Health Self-Efficacy Scales), Body Esteem Scale, and the Dutch Eating Behaviour Questionnaire for Children. Outcomes were compared between groups using linear mixed models, suitable for analyzing longitudinal data where there is likelihood of missing data or loss to follow-up. Data was clustered by school to account for dependency between observations from students from the same school. The intervention led to a significant increase (p < .05) in self-esteem and self-efficacy (mental and physical health self-efficacy subscales), for both primary and secondary school-aged participants and reduced dieting behaviours (secondary school participants). These gains were retained after 6 months of follow-up.
The aim of Study 4 was to explore whether the effect of “Girls on the Go!” intervention was consistent across high school and primary school participant girls from Study 2 and Study 3. A participant-level meta-analysis was conducted. Participant level meta-analysis allowed for a more powerful and reliable examination of treatment effects across high school and primary school participants from the two studies. Pooled data analysis findings indicate that exposure to the intervention had a positive and equal impact on participants’ self-esteem and self-efficacy including mental health self-efficacy and physical health self-efficacy. Interaction effects revealed self-esteem, physical health self-efficacy and mental health self-efficacy scores did not change from the time they completed the program to the subsequent follow up assessments, which indicated medium to long term stability of these measures as a result of the intervention.
The objectives of Study 5 were to systematically identify and synthesise evidence of effectiveness from randomised trials of interventions aimed at improving self-esteem and related outcomes (body satisfaction, dieting, physical activity self-efficacy) amongst girls, and to identify characteristics of programs that are more effective. A literature search was conducted up to November 2015. Six papers were eligible for inclusion. Most interventions (except Tirlea et al., 2016) were implemented in the school environment and adopted either a direct or indirect self-esteem component to enhance self-esteem and prevent disordered eating. Most studies’ interventions were mainly facilitated by trained teachers, (except Tirlea et al., 2016) targeted at universal audiences of mixed genders and ranging in age between 13.06 to 15.84 years old. The pooled effect size, using the lower and upper ICC, for self-esteem were 0.27 (95% Confidence Intervals [CI], 0.16, 0.38), and at short term follow up for self-esteem were 0.21 (95% CI, 0.06, 0.37) for body satisfaction were 0.22 (95% CI, 0.11, 0.34) and physical health self-efficacy was 0.29 (95% CI, 0.14, 0.44) respectively. These results support the implementation of interventions aimed at increasing levels of self-esteem.
The clinical implications of studies 1-4 are that providing preventive health services to young women at risk of disordered eating and other health concerns can potentially be achieved using a holistic program such as “Girls on the Go!” that focuses on promoting self-esteem, health and well-being. The results of study 5 (systematic review and meta-analyses) demonstrated there is support for the implementation of interventions aimed at increasing levels of self-esteem in girls. There was a trend for interventions that have a self-esteem component to also improve body satisfaction.
Little research has investigated the role of self-esteem and self-esteem interventions effectiveness to prevent negative consequences associated with poor self-esteem. This thesis provided a summary of existing literature of self-esteem risk factors and self-esteem interventions effectiveness. The present evaluation results provide evidence base for the “Girls on the Go!” program effectiveness and suggests that a health education program that promotes positive change in how one thinks about the self and their body may achieve the healthy lifestyle changes needed to maintain a long and happy life free of eating disorders.