REGULAR ARTICLE

An Evaluation of A Body Image Intervention Based

On Risk Factors for Body Dissatisfaction: A Controlled
Study with Adolescent Girls
ABSTRACT
Shanel M. Richardson, BBSc Objective: In this research we aimed to
(Hons) evaluate the efficacy of a theoretically
Susan J. Paxton, PhD* derived school-based body image inter-
vention for young adolescent girls.
Method: Participants were 194, fe-
male Grade 7 students from two Cath-
olic Secondary Schools in Melbourne,
Australia. One school was allocated to
the intervention group and the other
school was allocated to the control
Results: The intervention group
reported significantly more positive out-
comes than the control group on meas-
ures of intervention topic knowledge, risk
factors for body dissatisfaction, body
image, dietary restraint and self-esteem,
at post-intervention and follow-up.
Discussion: This study provides sup-
port for the efficacy of a theoretically
derived school-based body image inter-
vention with adolescent girls. V
C 2009 by

group. The intervention group partici- Wiley Periodicals, Inc.

pated in three 50-min body image
intervention sessions, while the control Keywords: body image; risk factors;
group received their usual classes. All prevention; intervention; evaluation
participants completed baseline, post-
intervention and 3-month follow-up
questionnaires. (Int J Eat Disord 2010; 43:112–122)

Introduction From an etiologic perspective, a reduction in

This study aimed to evaluate the efficacy of a theo-
retically derived school-based body image interven-
tion for young adolescent girls, Happy Being Me.
Interventions to prevent and reduce body dissatis-
faction are of great importance as body dissatisfac-
tion is reported by up to 70% of adolescent girls,1 is
a predictor of extreme weight control behaviors,
lower levels of physical activity, depressed mood,
and low self-esteem2,3 and is a risk factor for the de-
velopment of eating disorders.4,5
Numerous evaluations of school-based programs
aimed at reducing body dissatisfaction have been
conducted over the past two decades.6 Many of the
initial interventions achieved limited success,7
which theorists’ claimed could be largely attributed
to a failure to consider etiologic theory.2,7,8 An
incorporation of etiologic theory into interventions
is now occurring,9,10 and this study is an evaluation
of such an approach.
Accepted 11 February 2009
*Correspondence to: Susan Paxton, School of Psychological
Science, La Trobe University, Bundoora, Melbourne, Australia
3086. E-mail: susan.paxton@latrobe.edu.a
School of Psychological Science, La Trobe University,
Melbourne, Australia
Published online 6 April 2009 in Wiley InterScience
(www.interscience.wiley.com). DOI: 10.1002/eat.20682
V
C 2009 Wiley Periodicals, Inc.
causal risk factors for a problem is likely to have
the effect of reducing the frequency and intensity
of the problem because it breaks the developmen-
tal sequence.4,11 Likely causal risk factors for body
dissatisfaction in adolescent girls have been pro-
posed theoretically and explored empirically. Risk
factors for which there is particularly strong sup-
port include internalization of the thin body ideal,
body comparison, appearance conversations and
appearance teasing9,12–14 and consequently these
factors formed the focus of our intervention. The
personality and temperament factors self-esteem
and perfectionism have also been identified as pos-
sible causal risk factors.15,16 However, in this inter-
vention we focused our attention on socio-environ-
mental factors that could be targeted in a brief
school-based intervention.
It has been proposed that internalization of the
thin ideal occurs when an individual accepts the
thin media ideal and evaluates her body in relation
to this ideal.17 It has been argued that if the individ-
ual does not live up to the ideal body dissatisfac-
tion results.18 Cross-sectional and longitudinal
research provide support for internalization of the
thin ideal as a risk factor for body dissatisfac-
tion.12,14,19 Thus, we aimed to reduce internaliza-
tion of the thin ideal as a means of reducing body
dissatisfaction.

112 International Journal of Eating Disorders 43:2 112–122 2010


Body comparison is the tendency for a person to
evaluate his or her appearance by making a com-
parison with the appearance of another.20 Research
supports the proposal that a high level of body
comparison is a risk factor for body dissatisfaction
in adolescent girls.12,14,21–23 Thus, it is proposed
that reducing body comparison will result in a
reduction in body dissatisfaction. Adolescent girls
frequently engage in body comparisons with mem-
bers of their social environment such as friends,
peers and family members, in addition to media
images.23–25 Consequently, we proposed that an
intervention directed at change in this behavior
delivered within the immediate school environ-
ment could be particularly helpful in reducing
body dissatisfaction.
Research also suggests that frequent appearance
conservations or ‘‘fat-talk’’ is a causal risk factor for
body dissatisfaction.12,25,26 It has been argued that
appearance conversations encourage the creation
of appearance ideals and reinforce the importance
placed on appearance27 and research indicates that
adolescent girls regularly engage in appearance
conversations.27,28 Therefore, we proposed that it is
likely that reducing appearance conversations
within a girl’s peer group will contribute to the
reduction of body dissatisfaction.
Appearance teasing, which occurs frequently in
peer environments13,29–31 is also empirically sup-
ported as a risk factor for body dissatisfaction in
adolescent girls19,30 and has been demonstrated to
be a prospective risk factor for bulimic symptoms
in Grade 7 girls.32 Thus, we proposed that an inter-
vention designed to reduce appearance teasing
would also be likely to reduce body dissatisfaction.
In addition to considering risk factor research in
the development of Happy Being Me, other empiri-
cal findings were taken into account. First, previous
research had identified body image prevention
messages that girls themselves believe to be most
persuasive.33 These messages, reflecting on inter-
nalization of the thin ideal, body comparison and
appearance conversation, (i.e., ‘media images are
not real,’ ‘appearance does not equal how valuable
you are,’ ‘the ideal body changes through history
and between cultures,’ ‘don’t fall into the compari-
son trap,’ and ‘fat-talk’) were incorporated into the
content of Happy Being Me.
Second, research indicates that program content
is not the only important component of an inter-
vention; presentation style, choice of participants
and intervention setting also need to be consid-
ered.6,7,34 In regard to the presentation style, inter-
active rather than didactic interventions have been
International Journal of Eating Disorders 43:2 112–122 2010
AN EVALUATION OF A BODY IMAGE INTERVENTION
found to be more successful in changing attitudes
and behaviors.7 Viewed in light of the Elaboration
Likelihood Model of persuasive communication,35
the greater effectiveness of an interactive style is
likely to be the case as interactive interventions
allow participants to expand and elaborate on the
content by expressing opinions, engaging in discus-
sions and challenging information. Thus, an inter-
active intervention style was adopted in this inter-
vention. In addition, because adolescent friends act
as a source of influence on each other,36 the activ-
ities in the intervention were designed to focus on
participants exploring risk factors together.
In relation to participants, young adolescents
were selected because promising results have been
found for interventions with older adolescents,37–39
but interventions with younger adolescents have
been less favorable.40–45 Also, body dissatisfaction
is less evident in younger adolescent girls12 and
consequently there is still the opportunity for pri-
mary prevention. More specifically, Grade 7 stu-
dents were selected (approximate age 11–13 years),
because puberty, which has been found to have an
impact on the development of disordered eating
behavior,46 is likely to be occurring at this age,47
suggesting that this may be a vulnerable time for
these adolescents. Furthermore, within the state of
Victoria, Australia (where the study was com-
pleted), Grade 7 is generally the first year of high
school and a time in which girls frequently make
new friendships and establish new group norms. It
was hoped that delivering an intervention that
emphasized the peer environment would lead to
students developing attitudes and behaviors that
foster positive body image among peer groups.
Finally, schools were chosen as the setting as
they provide an effective way of targeting the
desired population. The school is an ecologically
valid setting for an intervention7 and, in addition,
the classroom provides the opportunity for peer
discussion, as well as group and individual work.
In summary, this study aimed to evaluate the ef-
ficacy of a theoretically derived school-based body
image intervention for young adolescent girls,
Happy Being Me. We hypothesized that the inter-
vention group would report more positive out-
comes on measures of intervention topic knowl-
edge, internalization of the thin ideal, body com-
parison, appearance conversations, appearance
teasing and body image, when compared to the
control group. Exploratory analyses were also con-
ducted to assess if Happy Being Me had any impact
on eating disorder symptoms and self-esteem.
113
RICHARDSON AND PAXTON
Method
Participants
Participants were 194, female Grade 7 students from
two Catholic Secondary schools located in medium
socio-economic areas in Melbourne, Australia. The
school that was available to receive the intervention in
the first half of 2007 was allocated to the intervention
group (n 5 104), while the other school was allocated to
the control group (n 5 90). Thus, group allocation was
not random. The mean age of participants was 12 years
and 4 months (SD 5 4.13 months). The mean BMI of par-
ticipants was 19.70 (SD 5 3.70). Participants were born in
a variety of counties, with the most common being Aus-
tralia (89.7%), the Philippines (1.5%), France (1%), and
Malaysia (1%).
Assessment Instruments
Intervention Topic Knowledge. Knowledge of the inter-
vention topics was assessed using five items designed for
this study (i.e., ‘Models in fashion magazines . . . are
made to look glamorous and successful using fashiona-
ble clothes, lighting and make-up,’ ‘Many fashion maga-
zine images of female models have been changed using
computer techniques,’ ‘The ideal body shape differs
between cultures’ ‘The ideal body shape has changed
throughout history,’ and ‘The comparison trap is where
people pick out things that they don’t like about their
appearance and compare those things with other people
that they consider better on those things’) rated on a 5-
point scale ranging from ‘strongly agree’ (1) to ‘strongly
disagree’(5). The scale had adequate internal consistency
(Cronbach’s alpha 5 0.54) and a medium significant pos-
itive correlation was found for the control group from T1
to T2 (r (90) 5 0.44, p \ .01) suggesting adequate test-
retest reliability.
Risk Factors for Body Dissatisfaction. Internalization of
the thin ideal was assessed using the Sociocultural Atti-
tudes Toward Appearance Questionnaire Internalization
subscale.48 This subscale has 14 items (e.g., ‘I believe that
clothes look better on thin models’) rated on a 5-point scale
ranging from ‘strongly disagree’ (1) to ‘strongly agree’ (5). It
has been shown to produce reliable and valid scores in
samples of adolescent girls12,20 and it showed good internal
consistency in this study (Cronbach’s alpha 5 0.89).
Body comparison was assessed using the 5-item Physi-
cal Appearance Comparison Scale.49 Items (e.g., ‘At par-
ties or other social events, I compare my physical appear-
ance to the physical appearance of others’) are rated on a
5-point scale ranging from ‘never’ (1) to ‘always’(5). This
scale has been shown to produce reliable and valid scores
in adolescent samples.20,50 However, in the current study
one item (i.e., ‘Comparing your looks to the looks of
114
others is a bad way to determine if you are attractive or
unattractive’) produced a very low item total correlation
at each time point (range 5 0.01–0.11) and therefore it
was not included in the scale. The consequent internal
consistency was satisfactory (Cronbach’s alpha 5 0.85).
Appearance conversations were assessed using the 5-
item Appearance Conversation Scale.19 Items (e.g., ‘My
friends and I talk about how our bodies look in our
clothes’) are rated on a 5-point scale ranging from ‘never’
(1) to ‘very often’ (5). The scale has been shown to pro-
duce reliable and valid scores in samples of adolescent
girls12,19 and good internal consistency was found in this
study (Cronbach’s alpha 5 0.86).
Appearance teasing was assessed using the 6-item
Weight Teasing subscale of the Perception of Teasing
Scale.51 This subscale was adapted to be relevant to per-
ceived teasing over the previous 2 weeks, rather than over
the participant’s lifetime. Items (e.g., ‘People made fun of
you because you were heavy’) are rated on a 5-point scale
ranging from ‘never’ (1) to ‘very often’ (5). The subscale
has been shown to produce reliable and valid scores in
samples of adolescent girls20,52 and internal consistency
was high in this study (Cronbach’s alpha 5 0.91).
Body Image and Eating Disorder Symptoms. Body sat-
isfaction was assessed using an extended version of the
Body Satisfaction Visual Analogue Scale.50 While the orig-
inal scale consists of 1 item (‘Feel satisfied with your
body’), the extend version has four additional items (i.e.,
‘Feel satisfied with your weight,’ ‘Feel comfortable with
your body shape,’ ‘Feel satisfied with your appearance,’
‘Feel like an attractive person’). Participants respond
‘how they feel right now’ by marking a 100-mm horizon-
tal line anchored by ‘not at all’ and ‘very much so’. Indi-
vidual responses were measured to the nearest milli-
metre producing a numerical score on a 100-point scale.
Numerical scores from all items were summed to create
a scale total. The original scale has been shown to pro-
duce reliable and valid scores in samples of adoles-
cents.21 Internal consistency was high in the current
study (Cronbach’s alpha 5 0.91).
Body dissatisfaction was assessed using the 9-item
Body Dissatisfaction subscale of the Eating Disorder In-
ventory.53 It includes items such as ‘I think my hips are
too big’ that are rated on a 6-point scale ranging from
‘never’ (1) to ‘always’ (6). In line with the scoring recom-
mended for non-clinical samples54 the non-transformed
scoring system was used. This subscale has been shown
to produce reliable and valid scores in samples of adoles-
cent girls19,55 and internal consistency was high in this
study (Cronbach’s alpha 5 0.92).
Dietary restraint was assessed using the Eating Disor-
der Examination Questionnaire Restraint subscale.56 This
subscale consists of five items (e.g., ‘On how many days
International Journal of Eating Disorders 43:2 112–122 2010

TABLE 1. An outline of the aims, content, and processes involved in Happy Being Me
Aims
Session One
To increase media literacy
To reduce internalisation of the thin-ideal
Session Two
To educate on appearance conversations
To highlight the impact of fat-talk and appearance
teasing
To develop skills for situations involving fat-talk or
teasing
To reduce fat-talk and appearance teasing
Session Three
To educate on body comparison
To increase skills at identifying body comparisons
To highlight the consequences of body
comparisons
To develop skills in avoiding body comparisons
To revisit the media’s manipulation of images
To highlight positive qualities that are not
associated with appearance
To review the program
out of the past 28 days have you been deliberately trying
to limit the amount of food you eat to influence your
weight or shape’) that are rated on a 7-point scale rang-
ing from ‘no days’ (0) to ‘every day’ (6). The scale has
been shown to produce reliable and valid scores in sam-
ples of adolescent girls44 and internal consistency was
satisfactory in this study (Cronbach’s alpha 5 0.83).
Bulimic symptoms (e.g., binging, purging) were
assessed with the Eating Disorder Inventory Bulimia sub-
scale.53 This subscale consists of seven items (e.g., ‘I stuff
myself with food’) rated on a 6-point scale ranging from
‘never’ (1) to ‘always’(6). As in the case of the Body Dis-
satisfaction subscale, the untransformed scoring system
was used.54 This subscale has been shown to produce
reliable and valid scores in samples of adolescent
girls20,57 and internal consistency was adequate in the
current study (Cronbach’s alpha 5 0.77).
Self-esteem. Self-esteem was assessed using the 10-
item Rosenberg Self-Esteem Scale.58 Items (e.g., ‘At times
I am no good at all’) are rated on a 4-point scale ranging
from ‘strongly agree’(1) to ‘strongly disagree’ (4). This
widely used scale has been shown to produce reliable
and valid scores in samples of adolescent girls15,26,59 and
internal consistency was satisfactory in this study (Cron-
bach’s alpha 5 0.86).
International Journal of Eating Disorders 43:2 112–122 2010
AN EVALUATION OF A BODY IMAGE INTERVENTION
Content Processes
The different techniques that can be used by the media Group worksheets and class
to manipulate images (Media images are not real) discussion
The media’s emphasis on attractiveness as a measure of Class activity and discussion
success
Appearance does not equal how valuable you are Individual brainstorming and
class discussion
The ‘ideal body’ differs across time and between cultures Handouts, homework reading
and class discussion
Exploration of the impact of fat-talk and teasing Didactic presentation, individual
brainstorming and class role
plays
Exploration of strategies that could be used during Group worksheets and role plays
situations that involve fat-talk or appearance teasing
Introduction to body comparison and its negative Slide show presentation and
consequences individual worksheets
Exploration of strategies that could be used instead of Small group activity and class
body comparisons (Do not fall into the comparison discussion
trap)
Media’s manipulation of images Film clip presentation and class
discussion
Emphasis on positive qualities that are not to do with Individual worksheets and
appearance activities in pairs
Review sessions Slide show presentation and class
discussion
Feedback on Happy Being Me. Intervention partici-
pants used a 5-point scale, ranging from ‘strongly dis-
agree’ (1) to ‘strongly agree’ (5), to provide feedback on
relevance, interest, enjoyment, comfort and honesty of
expression in Happy Being Me sessions. Participants also
had the option of providing written feedback on their fa-
vorite thing, least favorite thing, what they would change,
and anything additional.
Happy Being Me Program
Table 1 outlines the aims, content and processes
involved in Happy Being Me. Durkin60 developed the ini-
tial aspects of the program, which have been extended
upon by the authors. The program aims to educate par-
ticipants about the negative consequences of internaliza-
tion of the thin ideal, body comparisons, appearance
conversations and appearance teasing. It also aims to
empower participants to develop strategies they can use
to combat these risk factors. Happy Being Me is an inter-
active, participant focused, 3-session program, with each
session running for approximately one school lesson (i.e.,
50 min). Happy Being Me is a selective intervention
because it is designed specifically for the high risk group
of adolescent girls at an age when severe body dissatis-
faction has not typically become established.
115
RICHARDSON AND PAXTON
Procedure
Ethics approval was gained from La Trobe University
and the Catholic Education Office. Pilot testing was con-
ducted and the results of the pilot were used to improve
the questionnaire and the intervention. After active
informed consent was obtained from participants and a
parent or guardian, participants completed the baseline
questionnaire (T1) in a classroom setting. Participants in
the intervention group then participated in Happy Being
Me, which was facilitated by the first author. Participants
took part in Happy Being Me during their usual health
lessons; there were four classes of intervention partici-
pants. After the program was completed, all participants
completed the time 2 (T2) questionnaire. All participants
were re-assessed three months later (T3). Once all the
data had been collected for the study, the control group
participated in Happy Being Me.
Statistical Analyses
To compare the intervention and the control groups
on T2 outcome scores after controlling for T1 scores,
analysis of covariance (ANCOVA) analyses were con-
ducted for each T2 outcome variable in which the T1
score for the relevant variable was entered as the covari-
ate. ANCOVA is one of the statistical techniques recom-
mended by Stice and Shaw7 to analyse intervention
effects. Similarly, in order to compare the intervention
and control groups on T3 outcome scores, ANCOVAs
were conducted for T3 scores in which the T1 score for
the relevant variable was entered as the covariate. Most
variables met the assumptions of ANCOVA. However,
transformations were used to improve the normality of
appearance conversations, dietary restraint and bulimic
symptom scores prior to analyses. The assumption of ho-
mogeneity of the regression slope required for ANCOVA
was violated for T3 body dissatisfaction and T3 bulimic
symptoms. Consequently, to examine differences
between groups on these variables, ANOVAs were per-
formed using difference scores (i.e., T1–T3), because
such an approach is recommended as an alternative to
ANCOVA.61 The alpha level was set at p \ 0.05 for all
analyses.
Intention to treat analyses have been presented, which
were performed using maximum likelihood imputation
to deal with missing data. This technique is a conserva-
tive way to analyze the data, thus helping to prevent the
over-estimation of the efficacy of the intervention. Nota-
bly, the same significant differences were found when
completers’ analyses were utilized.
Quantitative feedback was analyzed by calculating per-
centages for each response. For qualitative feedback, the
first author reviewed all responses and identified com-
mon themes. Responses were then grouped according to
these themes. An independent rater was provided with
116
the themes and a random selection of responses, and
was asked to categorize the responses according to the
themes. Inter-rater reliability between the two raters was
high (above 92%).
Results
Participant Characteristics
All 194 participants completed T1 and T2 and
188 participants (96.91%) completed the T3 ques-
tionnaires. One intervention participant failed to
complete the Feedback on the Happy Being Me sec-
tion of the T2 questionnaire. Consequently this
participant’s data was treated as missing during
analyses related to Feedback about Happy Being
Me. Analyses indicated that there were no signifi-
cant differences between participants who
returned every questionnaire compared to partici-
pants who did not. Analyses were conducted to
assess if there were any differences between groups
(intervention vs. control) at T1. No significant dif-
ferences were found.
Examination of the Effects of the Intervention
Comparisons of intervention and control group
knowledge, risk factor, body image, eating disorder
symptom and self-esteem scores at T2 and T3
revealed that the intervention group reported sig-
nificantly higher intervention topic knowledge,
lower internalization of the thin ideal, lower body
comparison, lower appearance conversation,
higher body satisfaction, lower body dissatisfac-
tion, lower dietary restraint, and higher self-esteem
scores, at T2 and T3, when compared to the control
group (Table 2). Effects sizes were large for knowl-
edge at T2 and T3, moderate-large for body satis-
faction at T2 and T3 and for body dissatisfaction at
T2, moderate for self-esteem at T2 and T3, dietary
restraint at T2 and body dissatisfaction at T3, and
small-moderate for internalization of the thin ideal,
body comparison and appearance conversations at
T2 and T3, and for dietary restraint at T3. No signif-
icant differences were found between the interven-
tion and control groups for appearance teasing or
bulimic symptoms at T2 or T3. Notably, at no point
did the control group report significantly more pos-
itive outcomes than the intervention group.
Feedback about Happy Being Me
Table 3 presents intervention participants’ feed-
back on the sessions. The majority agreed or
strongly agreed that they found Happy Being Me
International Journal of Eating Disorders 43:2 112–122 2010
 AN EVALUATION OF A BODY IMAGE INTERVENTION

interesting and enjoyable, felt comfortable during

0.326
0.040
0.058
0.036
0.006
0.113
0.068
0.044
0.005
0.067
ES
the sessions and honestly expressed their opinions.
Although participants were more likely to agree or

91.99***

29.15***

13.74***
strongly agree that they found Happy Being Me rel-

7.80**

7.10**

8.51**
11.42**

14.07**
1.15

0.89
F
evant, when compared to participants who dis-
agreed or strongly disagreed, neutral was the most

290.83 (134.66)
common response to this question.
33.41 (10.74)

26.26 (10.67)
17.78 (2.79)

8.17 (3.62)
10.02 (4.14)
6.82 (1.89)

3.73 (5.29)
10.52 (4.52)
31.36 (5.65)
Table 4 presents the three most common themes
Control
T3

reported by participants related to their favorite

thing, least favorite thing, what they would change
386.07 (97.17)
and any additional comments. Over 48% of partici-
pants identified activities related to the media’s
Intervention

21.80 (2.99)
28.27 (8.60)
6.45 (2.65)
8.26 (3.50)
6.44 (1.10)

19.64 (8.54)
1.19 (2.29)
9.76 (3.80)
34.30 (5.26)
manipulation of images as their favorite thing
about the sessions, whereas 38.33% of participants
indicated that the program was a positive experi-
ence in their additional comments. Furthermore,
0.360
0.030
0.044
0.045
0.006
0.113
0.090
0.078
0.001
0.073

22.33% of participants reported that they did not

ES

have a ‘least favorite thing’ and 38.83% of partici-

pants reported that they would not change any part
104.86***

24.26***
18.93***
15.58***

15.06***
8.54**
9.07**

0.036
5.74*

of the program.
1.10
F

280.35 (127.47)
34.70 (10.43)

26.67 (10.08)
17.61 (2.82)

8.45 (3.35)
10.16 (4.11)
7.12 (2.75)

3.83 (5.03)
10.70 (4.41)
30.72 (5.04)
Control
T2

Discussion
This study aimed to evaluate the efficacy of a theo-
365.51 (114.18)

retically derived school-based body image inter-

Intervention

21.85 (2.91)
29.82 (9.09)
6.89 (3.09)
8.36 (3.31)
6.59 (1.38)

21.09 (9.94)
1.05 (1.74)
9.87 (3.38)
33.49 (5.07)

vention, Happy Being Me. Findings suggest that

Happy Being Me had a positive impact at post-
Means (standard deviations) univariate F values and effect sizes

intervention and 3-month follow-up on all but one

of the areas addressed during the intervention (i.e.,
281.43 (125.20)

intervention topic knowledge, internalization of the

35.61 (11.09)

26.52 (10.88)
17.31 (2.73)

8.89 (4.11)
10.43 (4.38)
7.21 (2.46)

5.06 (6.66)
11.72 (5.01)
29.96 (5.12)
Control

thin ideal, body comparison, appearance conversa-

tions, body satisfaction, and body dissatisfaction).
In addition, the program had a positive impact on
dietary restraint and self-esteem, topics that were
T1

Note. Effect sizes of 0.01 5 small; 0.06 5 moderate; 0.14 5 large.

322.18 (119.21)

not specifically addressed. There was no evidence

32.01 (10.60)

24.19 (10.73)
Intervention

17.93 (3.23)

7.84 (3.60)
9.34 (3.84)
6.77 (1.71)

2.40 (3.97)
10.45 (3.47)
31.14 (5.58)

that the program had any iatrogenic effects. Fur-

thermore, participant feedback about Happy Being
Me was favorable.
These findings compare favorably with other
Scale Range

body image interventions for adolescents. Although

0–500
14–70

10–40
7–35

5–20
5–25
6–30

9–54
0–30
7–42

most studies report the desired impact on interven-

tion topic knowledge, a positive impact on other
*p \ 0.05; **p \ 0.01; ***p \ 0.001.
Higher scores are more desirable.
Lower scores are more desirable.

variables occurs less consistently. For instance,

when looking at studies that have included a
Internalisation of the thin idealb
a
Intervention topic knowledge

control group and a follow-up period, some have

Appearance conversationsb

found improvements on the risk factors addressed

in the current study,38,39,62 but a number have
Body dissatisfactionb
Appearance teasingb

Bulimic symptomsb
Body comparisonb

not.10,43,63–66 Similarly, while some studies have

Body satisfactiona

Dietary restraintb

found that an intervention for adolescents had a

Self-esteema
TABLE 2.

positive impact on body image,38,39,64,66 some have

failed to find this effect at follow-up,42,43,67 while
b
a

others have found no effect.40,41,44,45,62,65,66,68–70

International Journal of Eating Disorders 43:2 112–122 2010 117

RICHARDSON AND PAXTON

TABLE 3. Intervention participants’ feedback on Happy Being Me reported in frequencies (percentages) (N 5 103)
Strongly Disagree Disagree Neutral Agree Strongly Agree

I felt comfortable discussing the issues in a group with my classmates 7 (6.80) 4 (3.88) 23 (22.33) 29 (28.16) 40 (38.83)
I felt that I could be honest about my opinions 3 (2.91) 4 (3.88) 20 (19.42) 31 (30.10) 45 (43.69)
I felt the sessions were relevant to me 15 (14.56) 11 (10.68) 38 (36.89) 19 (18.45) 20 (19.42)
I felt that the sessions were interesting 4 (3.88) 4 (3.88) 16 (15.54) 34 (33.01) 45 (43.69)
I felt that the sessions were enjoyable 4 (3.88) 3 (2.91) 21 (20.39) 30 (29.13) 45 (43.69)

TABLE 4. Frequencies (percentages) and examples of the three most common themes reported by participants
in relation to their favourite thing, least favourite thing, what they would change and any additional
comments related to Happy Being Me (N 5 103)
Favourite thing
Theme: Activities related to the media’s manipulation of images 50 (48.54)
‘‘Being about to notice what the media really does to you. And what the media do with people with acne- they delete it.’’ ‘‘Watching
the film . . .it shows that you don’t have to be pretty and that most models aren’t as beautiful and thin as they look. . .they are just
like us.’’
Theme: Discussions 32 (31.07)
e.g., ‘‘I enjoyed all the open discussions.’’ ‘‘Having a discussion that is open to everyone no matter what they say.’’
Theme: Participating in role plays 8 (7.77)
e.g., ‘‘My favourite thing was the part where we got to go up on stage and perform.’’ ‘‘Where we did role plays.’’
Least favourite thing 23 (22.33)
Theme: I didn’t have a least favourite thing
e.g., ‘‘I didn’t have one. I thought they were all interesting and fun.’’ ‘‘None it was all good.’’
Theme: Re-arranging the room for activities 16 (15.53)
e.g., ‘‘When we sat in a big circle because we had to move everything after.’’ ‘‘Putting the tables back in place’’
Theme: Participating in the research 13 (12.62)
e.g., ‘‘Filling in all the questionnaires.’’ ‘‘The questionnaires because they’re boring’’
What they would change 31 (30.10)
Theme: I wouldn’t change anything
e.g., ‘‘Nothing, it was all fantastic.’’ ‘‘Nothing at all. They were very enjoyable.’’
Theme: More interactive or more games 18 (17.48)
e.g., ‘‘I’d make more games.’’ ‘‘Maybe to have more activities that involves things that you have to interact with other people.’’
Theme: Room arrangement 9 (8.74)
e.g., ‘‘Leave the tables where they are.’’ ‘‘Not moving the tables. Everything else was fun.’’
Additional comments 40 (38.83)
Theme: The program was a positive experience
e.g., ‘‘It was a good program that made me realise that I am special and that it’s not the most important thing to be good looking.’’
‘‘I really enjoyed the sessions and felt like they really helped me.’’
Theme: Feedback about improving the program 15 (14.56)
e.g., ‘‘Just to maybe do more group activities (like the acting).’’ ‘‘I think you should do more on girls/women role models because that
was good.’’
Theme: I don’t have any additional feedback 11 (10.68)
e.g., ‘‘Nothing really.’’ ‘‘No not anything’’

Also, while some research has found an improve-
ment in eating disorder symptoms,37–39,62,65,71 a
number of studies have not.69,72,73 Furthermore,
while an effect on self-esteem has been found,67
this is unusual.10,40,41,64,66,69,73 Moreover the results
of this study are very promising given the limited
success of body image interventions with young
adolescents.40–42,44,45 Notably, the present study did
not have as long a follow-up as some of the above-
mentioned studies and it is not clear whether
changes evident at 3-months would diminish over
a longer period.
This program aimed to reduce causal risk factors
for body dissatisfaction in an attempt to reduce
body dissatisfaction itself. Thus we can speculate
that this process contributed to the positive out-
comes. Dissonance reduction may also have been a
contributing process because socratic questioning
was used in an attempt to create dissonance
between the belief that success, happiness and like-
ability is related to conforming to the appearance
ideal and the girls’ own ideas about why they
appreciate other females. Future research evaluat-
ing Happy Being Me is required to clarify the mech-
anisms that contributed to the changes observed.
The results indicate that Happy Being Me did not
have the desired impact on appearance teasing.
This may have been because participants did not
generalize the activities on intervening if witness-
ing appearance teasing, to a need to reduce any
appearance teasing they direct towards peers. Also,
it may be that appearance teasing is such an
engrained behavior with adolescent girls that a sin-
gle session on the topic was not enough to have an

118 International Journal of Eating Disorders 43:2 112–122 2010


impact. Conversely, it may have been that the rates
of appearance teasing were already low, producing
a floor effect. This final suggestion is supported by
the results, as both groups demonstrated means no
higher than 7.21, when the possible range for this
scale was 6–30. However, this floor effect may be
partly explained by the questionnaire utilized that
relates to extreme forms of weight based teasing
(e.g, ‘People called you . . . fatso,’ ‘People snickered
about your heaviness,’ ‘People pointed at you
because you were overweight’) and the results may
have been different if the questionnaire related to
less severe weight based comments that are per-
ceived as hurtful (e.g., ‘Those jeans are a bit tight
around your waist,’ ‘You look heavy in that photo’
etc.). Further investigation on this issue would be
worthwhile.
Although significant differences were found for
body dissatisfaction the results of the study indi-
cate that the program did not have an impact on
bulimic symptoms within the time frame assessed.
There are a number of possible explanations. There
may be a flaw in models of bulimia nervosa which
indicate that body dissatisfaction predicts growth
in dieting and negative affect, which in turn predict
growth in bulimic symptoms.18,74 However, caution
should be exercised when making claims about eti-
ologic theory from prevention interventions.75 It
may have been that the impact on body dissatisfac-
tion was not large enough to translate into an effect
on bulimic symptoms or that the time frame
assessed was not long enough for this to occur.
Also, as with appearance teasing, a lack of impact
may have been the result of a floor effect, as both
groups demonstrated means no higher than 11.72,
when the possible range for the scale was 7–42.
Such low scores are consistent with the literature,
as relatively few girls develop bulimia nervosa in
early adolescence.76 It was not anticipated that
Happy Being Me would have an impact on eating
disorder symptoms because the intervention was
selective and thus not aimed at girls already dis-
playing symptoms. However, it would be worth-
while for future evaluations to conduct clinical
assessments of eating disorders and to investigate
if the program prevents the development of eating
disorders over time. Such evaluations are beginning
to emerge for other interventions.37
Currently the body image intervention with the
strongest empirical support is a dissonance-based
program developed and evaluated by Stice
et al.17,38,39,62 To date dissonance based interven-
tions have not been widely used with young adoles-
cent girls. However, given the success of disso-
nance-based approaches with older adolescent and
International Journal of Eating Disorders 43:2 112–122 2010
AN EVALUATION OF A BODY IMAGE INTERVENTION
young adult samples the dissonance based inter-
vention would be an appropriate comparison
group for future evaluations of the effectiveness of
Happy Being Me.
Although the findings overall were positive, a
number of limitations impact on the conclusions
that can be drawn from our study. First, the study
evaluated the program’s efficacy and not its effec-
tiveness in that it evaluated the facilitation of
Happy Being Me by the first author who is knowl-
edgeable about body image issues. It is not known
if the intervention would produce similar results if
less experienced teaching or other school staff
facilitated the program. However, previous research
would suggest that the results would be less desira-
ble as eating disorder prevention programs deliv-
ered by trained interventionists have been found to
be more effective than those provided by endoge-
nous providers (e.g., teachers).6
A second limitation of this study was that it
involved girls alone. It has been argued that males
should also be included in body image interven-
tions because they too experience body dissatisfac-
tion.9,77 Males also play a role in the peer environ-
ment of girls and may play a part in perpetuating
the thin ideal.78 At a practical level, coeducational
interventions may be more desirable because most
schools are coeducational. On the other hand, pro-
gram content is directed towards altering risk fac-
tors that have specifically been observed in girls
and adapting the program to make it more suitable
for boys may reduce the effectiveness of the pro-
gram for girls. Future research needs to explore
these issues.
Third, when the intervention and control groups
come from different schools it increases the likeli-
hood of T1 differences, and that participants from
one group will be exposed to something other than
the intervention to which the other group is not
exposed. Although a design in which participants
come from different schools limits any flow-on
effects between intervention and control partici-
pants,79 future research would benefit from involv-
ing intervention and control participants from the
same school.
A fourth limitation of our study was non-random
allocation to groups, which may have introduced a
sampling bias. Efforts were made to control for any
group differences by using T1 variables as covari-
ates, but any replication of this research would be
strengthened by random allocation.
A fifth limitation relates to the assessment instru-
ments. The scale assessing Intervention Topic
Knowledge only contained five items and thus has
119
RICHARDSON AND PAXTON
relatively shallow content validity given the breadth
of information addressed in the intervention. Also
the internal consistency and test-retest reliability of
this scale was adequate, but not high. Furthermore,
the Restraint Scale of the Eating Disorder Examina-
tion Questionnaire may not be the best measure of
eating disorder symptoms given that an experi-
mental study has found that the scale did not sig-
nificantly correlate with an objective measure of
caloric intake.80 As discussed above, future evalua-
tion of the program would benefit from clinical
assessment of eating disorders. Notably, strong psy-
chometric properties were demonstrated for all
other instruments.
Finally, in addition to a medium term follow-up,
longer term follow-ups would be valuable to iden-
tify whether between group differences continue or
how long between group differences last. This
would indicate when it would be most effective to
introduce a further developmentally appropriate
intervention to meet new body image challenges
and reinforce earlier messages.
Despite shortcomings, the current research pro-
vides support for the efficacy of Happy Being Me, a
program that has incorporated the recommenda-
tion of basing interventions on etiologic theory.
This program has the advantage of being easy to fit
into school curricula because it is brief, but also
because it has the capacity to be incorporated into
other components of curriculum, such as anti-bul-
lying policy or peer support groups. Neumark-
Sztainer et al.81 have argued that efforts to change
the environment are critical if we are to move for-
ward in the eating disorder prevention field. Happy
Being Me is a step towards such an approach as it
assists adolescents to make changes to their peer
environment. Finally, a manualized version of the
program has been developed, which could assist
with training people in its facilitation. In conclu-
sion, this study provides support for the efficacy of
Happy Being Me as a theoretically derived school-
based body image intervention for adolescent girls.
The authors thank the school staff and students that
were involved in the evaluation of Happy Being Me. The
authors also thank Dr. Sarah Durkin who began the de-
velopment of what is now Happy Being Me.
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