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Body image concerns are prevalent among young adults, who may be vulnerable to developing body image concerns because of particular risk factors associated with this life period. With technological advancements, digital mobile health (mHealth) apps are cost-effective and scalable interventions. Thus, mHealth apps can be explored as a form of prevention effort to alleviate body image concerns in young adults.
In this randomized controlled trial, we examined the effectiveness of a self-guided mHealth app in improving body image and self-compassion in a sample of university students.
Participants (N=310) were randomized to a 9-day self-guided body image and self-compassion mHealth app (n=149) and to an active waitlist control group (n=161), where they completed a similarly structured 9-day program on cooperation. Both programs consisted of content learning and activities such as quizzes, with the number and length of activities matched for both programs. Measures were obtained at baseline, upon completion of the programs (after the intervention), and at 4-week follow-up.
The intervention group for female participants reported significant reduction in body dissatisfaction (
This study provides preliminary evidence for a self-guided mHealth app in improving body image concerns and self-compassion in young adult university students. Future studies should include longer follow-ups, and examine its effects with the wider populations of young adults.
ClinicalTrials.gov NCT04977973; https://clinicaltrials.gov/ct2/show/NCT04977973
Body image problems are highly prevalent among adolescents and young adults and have been frequently implicated in the development and maintenance of problematic eating behaviors [
Individuals tend to engage in upward appearance comparison, whereby they compare their appearance to others whom they perceive to be more attractive [
Exposure to media contributes to appearance-ideal internalization and appearance comparison. Media and social networking platforms are filled with ideal-looking images of the self and others which are often skewed representations of reality [
Among peers, appearance-focused comparison and appearance-related conversations and activities may also increase body dissatisfaction as they increase individuals’ awareness of their bodies, strengthen the internalization of appearance ideals, and negatively alter personal attitudes and beliefs in relation to beauty standards [
Apart from sociocultural influences, ruminative cognitive styles have been associated with greater body dissatisfaction [
Positive body image is characterized as being accepting, appreciating, and respecting of our bodies through attending to the body’s needs, protecting ourselves against unrealistic body ideals, having broader conceptualizations of beauty, and filtering information in a body-protective manner [
Intervention programs targeting body image risk and protective factors have been developed in the last 2 decades. Psychoeducational and cognitive behavioral programs have been effective in improving body image concerns, reducing disordered eating behaviors and attitudes, thin-ideal internalization, and dieting in adolescents and young adults [
The direct challenging of the thin-ideal within dissonance-based interventions differs somewhat from a self-compassion approach, which aims to promote greater awareness of adverse outcomes created by the thin-ideal. In response to this awareness, self-compassion interventions engender a mindset that promotes self-kindness and connection with others in the face of body image concerns. In other words, self-compassion approaches seek to alter the way in which individuals cope with the distress associated with negative body image [
Self-compassion interventions are gaining empirical support in alleviating body image concerns. Self-compassion meditation and single-session self-compassion writing tasks can reduce women’s body dissatisfaction and body shame and improve self-compassion and body appreciation [
Self-guided, mobile-based body image programs have been developed and evaluated in light of technological advancements [
Emerging adulthood often marks the onset of body image concerns [
The sample consisted of 310 female (age: mean 21.12, SD 2.07 years) and male (age: mean 22.68, SD 2.10 years) adults aged between 18 to 30 years, recruited from the department of psychology’s research participant pool and the research recruitment platform of the National University of Singapore. A poster advertisement was uploaded on the respective recruitment platforms, wherein interested students were able to directly access a web-based link to participate in the study. Participants received either course credits or a reimbursement of SGD $ 15 (US $10.63). A power analysis with G*power 3.1 [
This 9-day program adopted cognitive dissonance and self-compassion approaches designed around the following 3 topics: media literacy, appearance comparison, and self-compassion. At the start of each 3-day period, the participants underwent a 5-minute content learning and dissonance-based or self-compassion activity related to the topic (
Daily body image and self-compassion–focused messages were sent through the app to participants thrice a day, messages modeled after the
Topic 1: appearance ideal and media literacy
Introduce the concepts of body image and appearance ideals
Highlight how the media influences our appearance ideals and raise awareness of media manipulations
Elicit discrepancies between participants’ existing beliefs and behaviors about media influences
Develop participants’ skills in identifying media influences on appearance ideals
Topic 2: appearance comparison
Introduce the concept of appearance comparison
Highlight areas of common appearance comparisons for female and male participants
Highlight disadvantages and consequences of appearance comparison
Elicit discrepancies between participants’ existing beliefs and behaviors about appearance ideals and comparison
Develop participants’ ability to manage situations when appearance comparison arises
Topic 3: self-compassion
Introduce the concepts of self-compassion and appearance rumination
Highlight the disadvantages and consequences of appearance rumination
Introduce skills to develop participants’ ability to engage in self-compassion to manage negative thoughts and feelings about their body
Body image and self-compassion–focused intervention messages.
Intervention messages | Examples |
Body image |
Did you know, media images are often edited after a photoshoot? For example, complexions are cleaned, eyelines are softened, thighs and stomachs are thinned. Hence, it is not wise to match yourself to these appearance ideals. Can you think of other ways in which media images are edited? |
Mindfulness |
I hope you have not been too hard on yourself this week. Every time you catch yourself being judgmental or critical about yourself or your body Gently acknowledge and hold the thought in your mind. Breathe slowly, and allow yourself to notice the emotional pain or sensations. Remember, it is perfectly ok for your mind to wander. Simply notice it and gently guide your attention back to your body. Slowly, give yourself compassion by reframing the inner dialogue into something encouraging and supportive. Remember, you can always think of how a wise, nurturing friend, parent, teacher or mentor would say to encourage and support you. |
Common humanity |
Sometimes, our self-critical voice can be so common that we do not even notice when it is present. Many others have felt this way before too. Have you ever noticed what you say to yourself when you are feeling bad about yourself? Let’s try to soften this self-critical voice with compassion. |
Self-kindness |
Be kind to yourself and your body. Do not say things about your body and self that you would not say to a friend. |
Behavioral tips |
Try not to check yourself on reflective surfaces when you are up and around! Enjoy your surroundings! :) |
Affirmations |
Hey! You are a limited edition and one of a kind! Appreciate all the good things that you and your body can do! :) |
Flow of Body Image Program.
Participants in the active waitlist control group engaged in a self-guided learning program on cooperation. The active waitlist control group was chosen instead of a waitlist control as it serves as an attention control to create similar experiences for participants in both groups to control for nonspecific factors that may influence the study outcomes [
Ethics approval for this study was obtained from the National University of Singapore’s institutional review board (NUS-IRB-2021-85), and it was preregistered with ClinicalTrials.gov (registration number: NCT04977973). The methods and results described complied with the CONSORT (Consolidated Standards of Reporting Trials; 2010) guidelines for reporting RCTs (
Screenshots of the body image program.
Participants first read the Participation Information Sheet on Qualtrics. After providing informed consent, participants completed measures on body image, body image risk factors, and self-compassion to obtain baseline ratings. Thereafter, participants were randomized to 1 of 2 conditions, intervention or active waitlist control, using simple randomization procedures. In this study, blinding of participants was marginally feasible as the content of the intervention programs that the participants engaged in were different in nature. However, participants were not outwardly informed of the real function of each intervention condition or of the real nature of the study being to evaluate the effectiveness of the body image program. The title of the study made known to participants was kept general (
Next, the participants downloaded the mobile app and were guided on how to navigate the app. Participants in the intervention group underwent 9 days of body image training, while participants in the active waitlist control group underwent 9 days of the cooperation learning program. The anticipated time participants spent on each program was comparable (<5 minutes per day).
Participants filled out the same questionnaires upon program completion (postintervention measure) and after 4 weeks (follow-up measure). The feedback questionnaire was administered only after the intervention.
After the 6-week data collection period, participants were debriefed about the purpose and real intent of the study. Participants in the active waitlist control group were given access to the body image program.
Body Image Ideals Questionnaire (BIQ [
The Body Appreciation Scale-2 [
The Sociocultural Attitudes Toward Appearance Questionnaire-4 Revised [
Self-Compassion Scale-Short Form [
App Engagement Scale [
Statistical analyses were conducted using SPSS (version 26.0; IBM Corp). As previous research has found that female and male participants’ body image are dissimilar and that they respond differently to intervention programs [
An analysis of covariance (ANCOVA) examined if changes in outcome measures after intervention and at follow-up were significantly different in the intervention group compared with the active waitlist control group. ANCOVA is the recommended analysis for the inferential test of intervention effects [
A total of 313 participants completed questionnaires at baseline, 296 (94.57%) participants completed questionnaires after the intervention, and 291 (92.97%) participants completed questionnaires at follow-up (
CONSORT (Consolidated Standards of Reporting Trials) flow diagram. ITT: intention-to-treat.
The intervention and active waitlist control groups did not differ significantly on demographic variables and most outcome measures at baseline (
Intent-to-treat analyses were conducted for participants who were lost to follow-up by carrying forward their last reported scores. Missing scores for AES were substituted with the mean score. Independent 2-tailed
Descriptive statistics for demographic variable of sex by condition.
Demographic variable | Intervention condition (n=149), n (%) | Active waitlist control condition (n=161), n (%) | |||
|
.32 | ||||
|
Female | 98 (65.8) | 115 (71) |
|
|
|
Male | 51 (34.2) | 46 (29) |
|
Descriptive statistics of baseline demographic and outcome variables by condition for female participants (N=213).
Variable | Intervention condition | Active waitlist control condition | |||
Age (years), mean (SD) | 21.05 (1.96) | 21.18 (2.17) | .65 | ||
BMI (kg/m2), mean (SD) | 20.20 (2.59) | 20.85 (3.32) | .14 | ||
|
.13 | ||||
|
Chinese | 94 (95.9) | 102 (88.7) |
|
|
|
Malay | 0 (0) | 1 (0.9) |
|
|
|
Indian | 1 (1) | 8 (7) |
|
|
|
Others | 3 (3.1) | 4 (3.5) |
|
|
BIQa score, mean (SD) | 2.14 (1.21) | 2.10 (1.17) | .80 | ||
BASb score, mean (SD) | 3.44 (0.77) | 3.50 (0.75) | .54 | ||
SCS-SFc score, mean (SD) | 2.88 (0.63) | 2.98 (0.55) | .23 | ||
SATAQ-4Rd: Internalisation Thin/Low Body Fat score, mean (SD) | 3.15 (0.86) | 3.03 (0.89) | .32 | ||
SATAQ-4R: peer pressure score, mean (SD) | 2.23 (1.00) | 2.14 (0.98) | .50 | ||
SATAQ-4R: media pressure score, mean (SD) | 3.26 (1.04) | 3.18 (1.23) | .61 |
aBIQ: Body Image Ideals Questionnaire.
bBAS-2: Body Appreciation Scale-2.
cSCS-SF: Self-Compassion Scale-Short Form.
dSATAQ-4R: Sociocultural Attitudes Toward Appearance Questionnaire-4 Revised.
Descriptive statistics of baseline demographic and outcome variables by condition for male participants (N=97).
Variable | Intervention condition | Active waitlist condition | |||
Age (years), mean (SD) | 23.06 (2.33) | 22.26 (1.76) | .06 | ||
BMI (kg/m2), mean (SD) | 22.19 (3.59) | 22.79 (3.17) | .39 | ||
|
.07 | ||||
|
Chinese | 50 (98) | 39 (84.8) |
|
|
|
Malay | 0 (0) | 1 (2.2) |
|
|
|
Indian | 0 (0) | 5 (10.9) |
|
|
|
Others | 1 (2) | 1 (2.2) |
|
|
BIQa score, mean (SD) | 2.12 (1.17) | 1.59 (1.12) | .03b | ||
BASc score, mean (SD) | 3.45 (0.73) | 3.55 (0.68) | .48 | ||
SCS-SFd score, mean (SD) | 3.01 (0.52) | 3.05 (0.49) | .67 | ||
SATAQ-4Re: muscularity internalization score, mean (SD) | 3.44 (0.74) | 3.17 (0.82) | .32 | ||
SATAQ-4R: peer pressure score, mean (SD) | 2.79 (1.14) | 2.78 (1.10) | .94 | ||
SATAQ-4R: media pressure score, mean (SD) | 2.70 (1.10) | 2.71 (1.05) | .96 |
aBIQ: Body Image Ideals Questionnaire.
b
cBAS-2: Body Appreciation Scale-2.
dSCS-SF: Self-Compassion Scale-Short Form.
eSATAQ-4R: Sociocultural Attitudes Toward Appearance Questionnaire-4 Revised.
Most outcome variables met the assumption tests for ANCOVA. The homogeneity of variance assumption was violated for a small number of outcome measures. However, because of the robustness of ANCOVA when sample sizes in each group are relatively equal [
On body image measures, the intervention group reported significantly lower body dissatisfaction, and significantly higher body appreciation, after the intervention and at follow-up, compared with the active waitlist control group. The effect sizes were between moderate to large at both postintervention and follow-up. On thin-ideal internalization, the intervention group reported significantly lower internalization of thin-ideal scores after the intervention and at follow-up, compared with the active waitlist control group, with small to moderate effect sizes after the intervention and at follow-up. Significant score reductions were found on measures of peer and media pressure after the intervention in the intervention group, compared with the active waitlist control group, with small to moderate effect sizes. At follow-up, a significant difference was only found for reduction in media pressure, and no significant difference was found for peer pressure. Finally, significant differences were found for the self-compassion measure after the intervention and at follow-up, compared with the active waitlist control group (
Means (SDs), univariate F test values, and effect sizes for outcome variables in female participants.
Variable | Scale range | Baseline, mean (SD) | After the intervention | Follow-up | ||||||||||
|
|
Intervention | Control | Intervention, mean (SD) | Control, mean (SD) | Effect sizea | Intervention, mean (SD) | Control, mean (SD) | Effect sizea | |||||
Body Image Ideals Questionnairescoreb | −3 to 9 | 2.14 (1.21) | 2.10 (1.17) | 1.30 (0.99) | 1.94 (1.20) | 26.02c (1) |
|
0.11 | 1.42 (0.09) | 1.91 (0.087) | 17.48c (1) |
|
0.077 | |
Body Appreciation Scale-2 scoree | 1 to 5 | 3.44 (0.77) | 3.50 (0.75) | 3.79 (0.48) | 3.57 (0.44) | 37.80c (1) |
|
0.27 | 3.73 (0.05) | 3.60 (0.045) | 38.00c (1) |
|
0.27 | |
Self-Compassion Scale-Short Form scoree | 1 to 5 | 2.88 (0.63) | 2.98 (0.55) | 3.28 (0.04) | 3.09 (0.041) | 10.82f (1) |
|
0.049 | 3.20 (0.47) | 3.05 (0.043) | 5.92g (1) |
|
0.027 | |
SATAQ-4Rh: Internalisation Thin/Low Body Fatb score | 1 to 5 | 3.15 (0.86) | 3.03 (0.89) | 2.77 (0.85) | 3.03 (0.92) | 18.49c (1) |
|
0.081 | 2.79 (0.06) | 3.00 (0.053) | 7.21f (1) |
|
0.033 | |
SATAQ-4R: peer pressureb score | 1 to 5 | 2.23 (1.00) | 2.14 (0.98) | 2.00 (0.07) | 2.28 (0.065) | 9.73f (1) |
|
0.044 | 2.12 (0.08) | 2.30 (0.073) | 2.93 (1) | .09 | 0.014 | |
SATAQ-4R: Media pressureb score | 1 to 5 | 3.26 (1.04) | 3.18 (1.23) | 2.77 (0.09) | 3.27 (0.080) | 18.08c (1) |
|
0.079 | 2.80 (0.09) | 3.12 (0.085) | 6.49a (1) |
|
0.031 |
aEffect sizes of 0.01=small, 0.06=moderate, and 0.14=large [
bLower scores are more desirable.
c
dItalicized values indicate a significant
eHigher scores are more desirable.
f
g
hSATAQ-4R: Sociocultural Attitudes Toward Appearance Questionnaire-4 Revised.
Male participants in the intervention group reported significantly lower scores on body dissatisfaction after the intervention, compared with the active waitlist control group, with a large effect size. Male participants in the intervention group also reported significantly higher scores for body appreciation and self-compassion after the intervention, compared with the active waitlist control group, with effect sizes ranging from small to moderate. No intervention effects were found after the intervention for muscularity internalization, peer pressure, and media pressure, and at follow-up for all measures (
Means (SDs), univariate F values, and effect sizes for outcome variables in male participants.
Variable | Scale range | Baseline, mean (SD) | After the intervention | Follow-up | ||||||||||
|
|
Intervention | Control | Intervention, mean (SD) | Control, mean (SD) | Effect sizea | Intervention, mean (SD) | Control, mean (SD) | Effect sizea | |||||
Body Image Ideals Questionnaireb | −3 to 9 | 2.12 (1.17) | 1.59 (1.12) | 1.24 (0.95) | 1.53 (1.20) | 16.07c (1) |
|
0.15 | 1.69 (1.23) | 1.32 (1.24) | 0.69 (1) | .41 | 0.007 | |
Body Appreciation Scale-2e | 1 to 5 | 3.45 (0.73) | 3.55 (0.68) | 3.83 (0.065) | 3.61 (0.068) | 5.71f (1) |
|
0.057 | 3.75 (0.07) | 3.60 (0.073) | 20.32 (1) | .13 | 0.024 | |
Self-Compassion Scale-Short Forme | 1 to 5 | 3.00 (0.60) | 3.15 (0.64) | 3.33 (0.054) | 3.17 (0.057) | 4.039f (1) |
|
0.041 | 3.24 (0.06) | 3.12 (0.060) | 10.79 (1) | .18 | 0.019 | |
SATAQ-4Rg: Muscularity internalisationb | 1 to 5 | 3.44 (0.74) | 3.28 (0.81) | 3.17 (0.092) | 3.20 (0.097) | .070 (1) | .79 | 0.001 | 3.27 (0.09) | 3.25 (0.093) | 0.018 (1) | .89 | 0.000 | |
SATAQ-4R: Peer pressureb | 1 to 5 | 2.79 (1.14) | 2.78 (1.10) | 2.57 (0.12) | 2.85 (0.12) | 2.72 (1) | .10 | 0.028 | 2.48 (0.10) | 2.63 (0.11) | 0.99 (1) | .32 | 0.01 | |
SATAQ-4R: Media pressureb | 1 to 5 | 2.70 (1.10) | 2.71 (1.05) | 2.54 (0.13) | 2.62 (0.13) | 0.17 (1) | .68 | 0.002 | 2.78 (0.12) | 2.65 (0.12) | 0.61 (1) | .44 | 0.006 |
aEffect sizes of 0.01=small, 0.06=moderate, and 0.14=large [
bLower scores are more desirable.
c
dItalicized values indicate a significant
eHigher scores are more desirable.
f
gSATAQ-4R: Sociocultural Attitudes Toward Appearance Questionnaire-4 Revised.
This RCT evaluated the effectiveness of a self-guided mHealth app in improving body image and self-compassion in a sample of Asian university students. Our study extended the findings of previous studies by showing that cognitive dissonance and self-compassion approaches delivered on a mobile-based platform can be beneficial in improving body image and self-compassion in young adults.
Our hypotheses for female participants were largely supported. Except for peer pressure whereby intervention effects were not found at follow-up, the intervention group reported significant improvements on body image, body image risk factors, and self-compassion at both postintervention and follow-up, compared with the active waitlist control group. Consistent with past research on longer web-based or face-to-face interventions, our findings showed that a 9-day mobile-based program using cognitive dissonance and self-compassion approaches can reduce body dissatisfaction and its risk factors, improve body appreciation, and improve self-compassion after the intervention and at follow-up in female adults [
Our hypotheses for male participants were partially supported. Unlike findings from
Overall, our findings provide preliminary support for the use of cognitive dissonance and self-compassion approaches on an mHealth app to reduce body image concerns and improve self-compassion in students. On the basis of the cognitive dissonance theory and the dual pathway model [
Consistent with
Although significant improvements in self-compassion were found for male participants after the intervention, the effect was weaker, and not significant at follow-up. As self-compassion has been identified as a crucial factor in reducing body dissatisfaction and enhancing body appreciation in female and male participants [
Sex differences in self-compassion may explain the lack of follow-up effects for self-compassion in male participants. A meta-analysis conducted by Yarnell et al [
Several reasons are conceivable why peer pressure did not reveal differential effects for male participants and for female participants at follow-up. During this developmental phase as a young adult, interpersonal relationships are crucial for female and male participants [
The lack of significant reduction in the internalization of muscularity after the intervention and at follow-up may be accounted for by at least 2 possible reasons. First, adaptations made to our mixed-sex body image program to incorporate male body image concerns may be insufficient in addressing muscular-ideal internalization in a targeted manner. For example, the terminology being changed to “ideal appearances” and insufficient examples for male participants may have led to an inadequate understanding of concerns related to muscular-ideal internalization, thus watering down the intervention effects for male participants. Second, male participants may be less engaged in the body image program than female participants, because of the lack of masculine points of reference [
Finally, the lack of group differences on media pressure for male participants was unexpected, as media literacy was previously found to be effective in reducing pressures from media influences [
First, some causal conclusions can be drawn [
This study has some limitations. First, student participants may limit the generalizability of findings, as university students and the public may differ in factors such as level of education [
The sample size for male participants in our study was small despite additional recruitment efforts and thus was likely underpowered. Moreover, in view of sex differences in body image, more research is required to better understand ways to increase the effectiveness of mobile-based body image programs for male participants in a mixed-sex format and address muscularity concerns. To capture male participants’ body image concerns more accurately, male-specific measures such as Male Body Attitudes Scale [
Finally, in light of increasing studies which found self-compassion to mediate the effects of body image interventions, future studies can examine self-compassion as a mechanism of change. It would also be beneficial to obtain qualitative feedback from participants on elements of the body image program, such as their perception of the tone or number of intervention messages, to evaluate the effectiveness of the program.
Overall, this RCT provides preliminary but encouraging support for the effectiveness of a self-guided mHealth body image app using cognitive dissonance and self-compassion approaches for university students. Mobile-based well-being programs are cost-effective and accessible and can thus be widely disseminated to benefit the masses. Future research should seek to further enhance the program’s effectiveness with the wider young adult population.
CONSORT-eHEALTH checklist (V 1.6.1).
App Engagement Scale
analysis of covariance
Body Image Ideals Questionnaire
Consolidated Standards of Reporting Trials
mobile health
randomized controlled trial
The authors would like to thank Intellect Pte Ltd for providing the mobile phone app for the programs in this study, Mr Lee Sze Chi for his advice on statistical analysis, and Ms Rachel Low for her assistance in data collection. The authors would also like to thank all participants for the time and effort that they put into our study.
The main author (WYO) and coauthor (OS) were responsible for the study conceptualization and methodology, designing of the body image mobile phone app program, data curation and formal analysis, and the writing and editing of the protocol and manuscript. The coauthor (OS) also provided supervision of the overall study and procured funding for the study.
The study was partly funded by Intellect Pte Ltd. The study design, data management, interpretation, analysis, and reporting and the decision to publish the study are entirely independent of Intellect Pte Ltd. OS had a research collaboration with Intellect Pte Ltd at the time of the data collection and has since joined Intellect Pte Ltd as their clinical director.