The Norwegian healthy body image intervention promotes positive embodiment through improved self-esteem

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Body Image

j o u r n al ho me p ag e :w w w . e l s e v i e r . c o m / l o c a t e / b o d y i m a g e

The Norwegian healthy body image intervention promotes positive embodiment through improved self-esteem ^夽

Christine Sundgot-Borgen

^a,∗

, Andreas Stenling

^b

, Jan H. Rosenvinge

^c

, Gunn Pettersen

^d

, Oddgeir Friborg

^c

, Jorunn Sundgot-Borgen

^a

, Elin Kolle

^a

, Monica Klungland Torstveit

^e

, Kethe M.E. Svantorp-Tveiten

^a

, Solfrid Bratland-Sanda

^f

aNorwegianSchoolofSportSciences,DepartmentofSportsMedicine,Sognsveien220,N-0806Oslo,Norway

bUmeåUniversity,DepartmentofPsychology,90187Umeå,Sweden

cUiT–TheArcticUniversityofNorway,FacultyofHealthSciencesDepartmentofPsychology,9037Tromsø,Norway

dUiT-TheArcticUniversityofNorway,FacultyofHealthSciencesDepartmentofHealthandCaringSciences,N-9037Tromsø,Norway

eUniversityofAgder,FacultyofHealthandSportSciences,Postbox422,4604Kristiansand,Norway

fUniversityCollegeofSoutheastNorway,DepartmentofSports,PhysicalEducationandOutdoorStudies,P.O.Box235,N-3603Kongsberg,Norway

a r t i c l e i n f o

Articlehistory:

Received18December2019

Receivedinrevisedform28August2020 Accepted28August2020

Keywords:

Healthpromotion Embodiment Adolescence

Randomizedcontrolledstudy Mediation

a b s t r a c t

WeexaminedbothdirectandindirecteffectsoftheHealthyBodyImage(HBI)interventiononpositive embodimentamongNorwegianhighschoolstudents.Intotal,244612thgradeboys(43%)andgirls (meanage16.8years)from30schoolsparticipatedinacluster-randomizedcontrolledstudywiththe HBIinterventionandacontrolconditionasthestudyarms.Wetestedmediationmodelsusingpath analysisandfoundthatamongseveralhypothesizedmediators,onlyself-esteemmediatedapositive interventioneffectonpositiveembodimentforbothboysandgirls.Adirecteffectoftheinterventionon positiveembodimentwasonlyfoundingirls.Thestudyprovidesnovelﬁndingsindicatingthathealth promotioninterventionstoaddressapositiveembodimentshouldfocusonenhancingadolescent’sself- esteem.Serialmediationmodelingmightrevealmorecomplexexplanationsofchangemechanismsand couldfurtherevolvecurrentknowledge.

1. Introduction

Positiveembodimentis deﬁned aspositive body connection andcomfort,embodiedagencyandpassion,andattunedself-care (Piran,2016).Thisconstructdoesoverlapwithpositivebodyimage (Tylka,2019),asbothconstructsemphasizepositiveconnectionto, andappreciationof,thebody,aswellasattunedcareofthebody (Tylka &Piran, 2019).However, positive embodiment captures anevenbroaderconstructbyalsointroducingtheexperienceof agencytoactintheworldandcomfortwithbodilydesires(Piran,

夽 ThisresearchwassupportedbyTheNorwegianWoman‘sPublicHealthAsso- ciation,theNorwegianExtraFoundationforHealthandRehabilitation,andTINE SA.∗Correspondingauthor.

E-mailaddresses:[email protected]

(C.Sundgot-Borgen),[email protected](A.Stenling),[email protected] (J.H.Rosenvinge),[email protected](G.Pettersen),[email protected] (O.Friborg),[email protected](J.Sundgot-Borgen),[email protected] (E.Kolle),[email protected](M.K.Torstveit),[email protected] (K.M.E.Svantorp-Tveiten),[email protected](S.Bratland-Sanda).

2019).Holdingapositiveembodimentisimportantasitpositively associates with self-esteem, body-esteem, and life satisfaction inwomen (Chmielewski,Tolman,&Bowman,2018; Holmqvist, Frisén,&Piran,2018)andmen(Holmqvistetal.,2018),andneg- ativelyassociates withself-objectiﬁcationand eatingrestrainin woman(Holmqvistetal.,2018).Italsoservesasaprotectivefactor towardseatingdisorders(Piran,2016).Otherhealthoutcomesand behaviourssuchase.g.physicalactivityandhealthyeatinghabits havebeenpositivelyassociatedwiththerelatableconstructsbody satisfaction(Neumark-Sztainer,Paxton,Hannan,Haines,&Story, 2006), body appreciation (Andrew, Tiggemann, & Clark, 2016;

Baceviciene&Jankauskiene,2020),positivefeelingsandattitudes towardsthebodyandappearance(Kantanista,Osi ´nski,Borowiec, Tomczak,&Król-Zieli ´nska,2015;Kołoło,Guszkowska, Mazur,&

Dzielska,2012; Ramseyer,Jones,&O’Neill,2019)andqualityof life(Grifﬁthsetal.,2017;Haraldstad,Christophersen,Eide,Natvig,

&Helseth,2011).Physical,mentalandsocialchangesduringado- lescencearechallengingandcanhavealong-termimpactonbody image,andbeinganadolescentisdeﬁnedasaneatingdisorderrisk factor(Rosenvinge,2015).Hence,asacounterbalance,promoting positiveembodimentinadolescentsisthereforevitaltoestablish

https://doi.org/10.1016/j.bodyim.2020.08.014

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C.Sundgot-Borgenetal./BodyImage35(2020)84–95 85

agoodbasisforhealth(Halliwell,2015;Tylka&Piran,2019),and canbe viewedasa core issuefor publichealth (Bucchianeri &

Neumark-Sztainer,2014).

1.1. Existingevidence

Meta-analysesandsystematicreviewsshowthatpreviousuni- versalstudiesaimingtoimprovebodyimage,eitherbyreducing riskfactorsorenhanceprotectivefactors,havefocusedonmedia literacy, self-esteem, psychoeducation, or cognitive behavioral therapy (CBT)interventions.The majorityofsuchinterventions have hadan overall aimtoreduceinternalizationof unhealthy media ideals and/or improve self-esteem, by targeting speciﬁc riskorprotectivefactorsaspresentedbelow,tofacilitatepositive changesinbodyimageoutcomes(Alleva,Sheeran,Webb,Martijn,

&Miles,2015;Le,Barendregt,Hay,&Mihalopoulos,2017;Watson etal.,2016).

1.1.1. Internalizationofbodyidealsandperceivedpressurefrom media

Internalizationof body ideals hasbeendeﬁned asan estab- lished risk factor for eatingdisorders (Cafri et al., 2005; Stice, Presnell,&Spangler,2002;Thompson&Stice,2001),andseveral studieshavefoundthattargetingthethin-internalizationingirls (Agam-Bitton,Ahmad,&Golan,2018;Richardson&Paxton,2010;

Sharpe, Schober,Treasure,&Schmidt, 2013), and generalinter- nalizationin boys(Bird,Halliwell, Diedrichs, &Harcourt,2013;

McVey,Tweed, &Blackmore,2007)positivelyaffecteddifferent bodyimageoutcomes.Inaddition,eatingdisorderpreventionstud- ieshavefoundthatthereductionofthin-internalizationmediated theinterventioneffectonbothbodydissatisfactionandeatingdis- ordersymptomsinadolescentgirls(e.g.Stice,Marti,Rohde,&Shaw, 2011;Stice,Presnell,Gau,&Shaw,2007)andyoungfemales(Seidel, Presnell,&Rosenﬁeld,2009).However,onlythemediationaleffect of internalizationof thethin-body ideal, not the more current athletic body ideal, hasbeen investigated (Novella, Gosselin, &

Danowski,2015;Schaeferetal.,2015).Also,theperceivedpressure frommediaisoftentargetedalongwithinternalizationininter- ventions,buthasnotbeeninvestigatedasamediator,andshould alsobeconsideredintofuturemediationalanalyses(Schaeferetal., 2015).

1.1.2. Medialiteracy

Exposuretoappearancerelatedcontentandappearancecom- parisonin social media,predictnegativebody imageoutcomes (Andrew,Tiggemann,&Clark,2016;Rodgers,McLean,&Paxton, 2015).Medialiteracytraininghasthereforebeenacknowledged as an important technique to prevent negative consequences fromsocialmediause.Medialiteracytrainingischaracterizedby enhancingthe ability tomore critically evaluateand challenge the presentation of idealized bodies and lifestyles, and tofur- theracknowledgetheunattainabilityoftheextremebodyideal (McLean,Paxton,&Wertheim,2016;Wilksch,2019).Medialiter- acyhasextensivelybeenusedinbodyimageinterventions.One example is the school-based program from Spainwhich found thatamedialiteracyprogramreducedlevelofdisorderedeating (González, Penelo,Gutiérrez,&Raich,2011)and improvedbody satisfactioninadolescentboysandgirls(Espinoza,Penelo,&Raich, 2013).TheMediaSmartfromAustraliawasfoundtoreduceweight and shape concernin adolescent girls(Wilksch &Wade, 2009;

Wilkschetal.,2015),whilepreventinggrowthineatingdisorder risk factorsin boysand girls(Wilksch,2010; Wilksch &Wade, 2014).Still,themajorityofstudiestargetingmedialiteracyhave notmeasuredchangesinpositivebodyimageorembodimentout- comes,onlyareductioninriskfactorsforbodydissatisfactionor eatingdisorder(Wilksch,2019).In addition,although theeffect

ofbodyimageinterventionsincludingmedialiteracycontenthas beenreported,fewstudieshavetestedthemediationaleffectof medialiteracy.TheonlyexampleisthestudyofAgam-Bittonetal.

(2018)whofoundthatmedialiteracymediatedtheintervention effecton“currentbodyimage”amongafemaleadolescentsample.

1.1.3. Self-compassion

Self-compassion is described as how we relate toourselves when we experiencefailures,inadequacy,or personalsuffering (Neff,2003).Self-compassionisnotonlythoughttohaveadirect relationshipwithbodyimage,butmaybufferagainsttheeffectsof riskfactors,includingsocioculturalfactors,onbodyimage(Braun, Park, &Gorin,2016;Rodgers etal., 2017).A longitudinalstudy foundthatself-compassionwaspositivelyassociatedwithbody satisfaction and negatively associated witheating pathology in adolescentboysandgirls,whileself-compassionpredictedbody satisfaction in girls (Pullmer, Coelho, & Zaitsoff,2019). Studies targeting self-compassion in adolescent boysand girlsthrough anapp, adultfemalesthrough apodcast, andfemale university students through a writing task, were found to promote self- compassionandappearanceesteem(Rodgersetal.,2018),reduce body dissatisfaction and improve body appreciation(Albertson, Neff, & Dill-Shackleford, 2015), and promote body satisfaction (Seekis,Bradley,&Duffy,2017),respectively.Self-compassionhas been found to mediate the impact of body dissatisfaction and unfavourablesocialcomparisonsonpsychologicalqualityoflife in female college students (Duarte, Ferreira,Trindade, &Pinto- Gouveia,2015).However,self-compassionhasnotbeenevaluated asapotentialmediatorininterventionstudies.

1.1.4. Self-esteem

Self-esteem strongly relates to how adolescents experience theirbody(vandenBerg,Mond,Eisenberg,Ackard,&Neumark- Sztainer, 2010), and has been shown to correlate with body appreciationinEuropeanadolescentboysandgirls(Lemoineetal., 2018). Enhancing self-esteem couldmake students accept and appreciateindividualcharacteristicsandmoreeasilystaypositively connectedtotheirbodies,despiteunhealthyexposures(Rousseau

&Eggermont,2018).Therefore, numerousof bodyimage inter- ventionshavetargetedself-esteemandpositivelychangedbody imageoutcomes(Agam-Bittonetal.,2018;O’Dea&Abraham,2000;

Richardson,Paxton,&Thomson,2009;Sharpeetal.,2013).Still, toourknowledge,self-esteemhasonlybeentestedasapoten- tialmediatorinabodyimageinterventionbyAgam-Bittonetal.

(2018),whichfoundnointerventioneffectthroughself-esteemon bodyimageoutcomesinadolescentgirls.Moreinvestigationinto themediationaleffectonbothgendersisthereforewarranted.

1.1.5. Bodyimageﬂexibility

Bodyimageflexibilityisdescribedasone’scapacitytoexperi- encetherangeofperceptions,feelings,thoughts,andbeliefsrelated tothebody,andstillactonchosenpersonalvalues(Sandoz,Wilson, Merwin,&Kellum,2013).Theconstructpositivelyassociateswith bodyappreciation,compassion,self-care,ageneralpsychological flexibility,distress tolerance, and negatively associate withdif- ferent measuresofnegativebody image,disorderedeating,and psychologicalrigidityandaffectregulation(Rogers,Webb,&Jafari, 2018).Still,body imageflexibilityhasscarcelybeentargetedor measuredininterventionstudies.Oneself-compassionandbody image intervention forlate adolescents measuredtheeffect on bodyimageflexibility,butfoundnointerventioneffectonthismea- sure(Rogersetal.,2018;Sandoz,Webb,Rogers,&Squyres,2019).

Bodyimageﬂexibilityhasbeenfoundtomediatetherelationship betweennegativebodyimagevariablesandmaladaptivebehav- ioraloutcomes(Rogersetal.,2018),butduetothelackoffocusin

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interventionstudies,theconstructhasnotbeeninvestigatedasa potentialmediator.

Mediationanalysescancontributewiththeexplanationofhow aninterventioneffectstheoutcomethroughspecificmechanisms, suchasthosepreviouslydescribed(Hayes,2017).Improvedknowl- edgeonwhichconstructsthatshouldbetargetedinanintervention forbesteffectontheoutcomewouldlikelyenhancetheefficacyof bodyimageinterventionsinthefuture.Althoughitis acknowl- edgedthatboysaswellasgirlswouldbenefitfromimprovingtheir bodyimage,existing interventionsseemtobemoreeffectivein girlscompared toboys(Birdetal.,2013; Diedrichsetal.,2015;

Franko,Cousineau,Rodgers,&Roehrig,2013;O’Dea&Abraham, 2000;Richardsonetal.,2009;Sundgot-Borgenetal.,2019).Medi- ationalanalysesshouldbesplitongendertoinvestigatewhether therearedifferencesbetweengendersinmechanismsofchange, hence,whichconstructsthatneedstobetargetedforbestinter- ventioneffectinbothgenders.Untilnow,amongthosefewexisting studies,onlyfemalesampleshavebeenincludedorstudiesdidnot splitongendersintheiranalyses.

1.2. Thehealthybodyimageintervention

Toanswertotheexistingneedformoreknowledgeonhowto promotepositiveembodimentin adolescents,theHealthyBody Image(HBI)intervention wasdeveloped(Sundgot-Borgenetal., 2018).Thestudywasauniversal,school-based,health-promotion intervention,whichaimedtopromotepositiveembodimentinhigh schoolboysandgirlsbytargetingriskfactorsandprotectivefactors throughthreeinteractiveworkshops.

1.3. Interventiontargets

TheHBIintervention workshopsaimedto reducebodyideal internalizationthroughdiscreditingbodyideals,makingthestu- dentsbecome more media literate and use social media more constructively.We aimedtoenhancemedialiteracybyteaching thestudentsaboutmechanismsusedin socialmediathatcould affectperceptions,believesandattitudesaboutbodyappearance,to makethemmorecriticaltoinformationsourcesandchooseexpo- suresinamorebodyimagefriendlyway.Wetargetedtimespenton appearancerelatedcontentinsocialmediabyenhancingawareness ofpersonalreactionstothevolumeandtypeofcontent,discrediting unhealthyideals,andempoweringtheirchoicetochooseconstruc- tiveratherthandestructivecontent.Bytargetinginternalization andmedialiteracyelementswesimultaneouslybelievedthatthe perceivedpressurefrommediawouldbereduced.Theworkshops targetedenhancementofself-compassionbymakingthestudents understandconsequencesofunhealthybodymodiﬁcation,become moreawareof-,andtherebyengagemorewith,existingpositive inﬂuencesin theirdailylives, by using social mediain a more self-caringway, and by providing a wellness focus on lifestyle information.Theworkshopsalsofocusedonidentifyingandappre- ciatingindividualdifferenceswithinagroupbutalsobecomeaware of,andappreciate,one’sownpositivecontrollablecharacteristic notrelatedtoappearance.Thiswasbelievedtoenhancestudents’

self-esteem.Finally,bynotstrivingfortheidealizedlifestyleorbody, andbybeingmoremedialiterate,havingafoundself-esteemand beingself-caring,webelievedthatitwouldbeeasierforthestu- dentstoneglectthepressuretostriveforotherpeople’sstandards, andtomaintainone’sownindividualstandards,values,andpref- erences,andstaybodyimageﬂexible.

Inapreviouspublication,wereportedthattheHBIinterven- tion promoted positive embodiment, with a 12-months follow up-effectingirls(Sundgot-Borgenetal.,2019).It isnowneces- sarytounderstandchangemechanismswithintheinterventionto gainknowledgeonwhytheinterventioneffectedthestudents,and

therebywhichconstructsmightneedtobefocusedoninfuture implementation. Also, suchanalyses canhelp explain potential genderdifferencesinwhichtargetsoneshouldfocuson,toenhance effectonbothgenders.TheHealthyBodyImage(HBI)intervention thereforeaimedtotesthypothesesrelatedtomediationofmea- suredconstructs, thattheoreticallyaccount fortheintervention effectonthemainoutcomepositiveembodiment.

We hypothesized that the HBI intervention would promote positiveembodimentinboysandgirlsthroughreducedinternal- izationoftheathleticandthin-bodyideal,improvedmedialiteracy, healthiersocialmediause,reducedpressurefrommedia,increased self-compassion,self-esteem,andbodyimageﬂexibility.

2. Method

2.1. Samplecharacteristics

Fromtheoriginalinterventionstudy,thirtyschoolswereran- domizedina1:1ratiotoeithertheHBIinterventionorthecontrol condition,respectively. Intotal,2446male andfemalestudents consentedtoparticipateatpre-test,whiledropoutledtoatotal of1254,1278,and1080consentingstudents, respectively,who participatedatthepost-interventiontests(Fig.1).Variable spe- ciﬁcparticipationnumbersanddrop-outratesarefoundinTable1.

Nodifferences wereobservedintheoutcomevariable between dropoutsand completersineitherboysorgirls.However,more studentsinthecontrolgroup(p=.001,␾=10.61),andmoreboys (p<.001,␾=52.48)droppedout.Boyswhodroppedouthadslightly higherBMI(p=.044,d=0.15)andbodyweight(p=.010,d=0.20), whilegirlswhodroppedoutwereslightlyolder(p=.014,d=0.17).

2.2. Procedure

TheHBIinterventionincludedallNorwegianpublicandprivate highschoolsinOsloandAkershuscounty,andspeciﬁcallyinvited all12thgradeschoolclassesfollowingageneralstudyprogram.

Studentsfollowingavocationalstudyprogramwereexcluded,and nofurtherexclusioncriteriawereset.Thestudentsconsentedby respondingtoane-mailcontainingstudyinformationandaletter ofinformedconsent.Theyacceptedbypressingyestothequestion ofconsentandwereredirectedtotheonlinequestionnairepackage SurveyXact8.2offeredbyRamböll,Aarhus,Denmark.

2.3. Ethicsapprovalandconsenttoparticipate

The study met the intent and requirements of the Health ResearchActandtheHelsinkideclaration,andwasapprovedby theRegional CommitteeforMedicaland HealthResearchEthics (P-REK 2016/142).It wasenrolledin theinternationaldatabase ofcontrolledtrialswww.clinicaltrials.gov(ID:PRSNCT02901457).

Furtherdetailsarepresentedinapreviouspublication(Sundgot- Borgenetal.,2019).

2.4. Measurements

Asdescribedinthestudyprotocol(Sundgot-Borgenetal.,2018), participants completed the same standardized questionnaires onlineandoutsideschoolhoursatbaseline,post-intervention,and at3-and12-monthsfollow-up.Allbaselineassessmentswerecon- ductedpriortotherandomization.Studentswhorespondedtothe questionnairewereinthedrawforgiftcardswithavalueof500 NOK.

2.4.1. Positiveembodiment

PositiveembodimentwasmeasuredusingtheExperience of EmbodimentScale(EES)(Teall&Piran,2012).The34itemscov-

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C.Sundgot-Borgenetal./BodyImage35(2020)84–9587 Table1

DescriptiveStatisticsfortheInterventionandControlGroupsamongbothboysandgirls.

Boys Girls

Intervention Control Intervention Control

Drop-out* n M SD Drop-out n M SD P Drop-out n M SD Drop-out n M SD P

Positiveembodiment(T1) 283 131.58 20.05 136 127.46 22.83 .074 582 117.92 22.39 282 114.14 24.93 .025

Positiveembodiment(T4) 32% 192 137.15 19.59 31% 94 131.54 24.43 .054 21% 459 127.71 22.58 26% 210 116.65 26.44 <.001

Athleticinternalization(T1) 281 3.23 1.11 136 3.37 1.04 .223 582 3.02 1.10 281 2.99 1.04 .653

Athleticinternalization(T3) 4% 269 2.89 1.12 1% 135 3.18 1.12 .017 7% 540 2.70 1.05 7% 260 2.80 1.06 .215

Thininternalization(T1) 281 2.48 0.93 136 2.64 0.93 .101 582 3.28 1.07 281 3.40 1.14 .126

Thininternalization(T3) 10% 252 2.45 0.94 0% 136 2.79 0.97 .001 7% 542 2.56 1.01 6% 264 2.84 1.02 <.001

Pressurefrommedia(T1) 281 2.09 1.14 136 2.16 1.17 .570 582 3.15 1.25 281 3.27 1.28 .182

Pressurefrommedia(T3) 10% 252 2.03 1.11 0% 136 2.16 1.06 .244 7% 542 2.94 1.21 6% 264 3.21 1.21 .002

Medialiteracy(T1) 310 18.87 4.47 153 17.78 5.02 .019 611 20.91 3.85 298 20.57 4.05 .227

Medialiteracy(T3) 44% 179 19.19 4.83 43% 87 18.38 5.25 .213 30% 429 21.61 4.02 34% 198 21.21 4.20 .247

Timeonappearancecontent(T1) 320 21.70 3.71 155 21.28 3.61 .245 621 18.51 4.53 313 18.14 4.59 .233

Timeonappearancecontent(T3) 86% 46 21.15 4.35 83% 26 18.77 4.89 .036 89% 66 19.18 4.43 91% 29 16.72 4.32 .014

Self-compassion(T1) 328 3.28 0.54 174 3.24 0.61 .364 644 3.02 0.64 324 2.94 0.65 .106

Self-compassion(T3) 26% 242 3.41 0.67 27% 127 3.30 0.64 .126 19% 522 3.16 0.70 24% 247 3.04 0.71 .038

Self-esteem(T1) 276 33.13 5.46 135 32.63 6.47 .436 578 29.49 5.96 279 28.43 6.46 .017

Self-esteem(T3) 15% 234 33.57 5.88 12% 119 31.75 6.36 .008 13% 503 30.64 5.70 15% 237 29.03 6.88 .002

Bodyimageﬂexibility(T1) 342 70.30 9.01 183 68.39 11.66 .055 649 58.48 15.37 334 57.47 16.67 .356

Bodyimageﬂexibility(T3) 32% 234 73.47 12.13 33% 122 68.51 15.78 .003 21% 514 62.41 17.48 28% 241 60.49 19.38 .174

Note:T1=baseline,T3=3-monthsfollow-up,T4=12-monthsfollow-up.

*Drop-outrepresentsthedrop-outratespergroupbasedonthetotalnumberofparticipantsrespondingtothespeciﬁcvariableatT1.

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Fig.1. Schools(c*)andstudents(N),andresponserateofparticipatingstudents.RetrievedfromSundgot-Borgenetal.(2019).Thehealthybodyimage(HBI)intervention:

Effectsofaschool-basedcluster-randomizedcontrolledtrialwith12-monthsfollow-up.BodyImage,29,122-131.

eredpositiveconnectionwiththebody,agencyandfunctionality, experienceand expressionof desire,body attunement,self-care vs.harm/neglect,andsubjectivelensvs.self-objectiﬁcation.The itemshadaLikert-formatrangingfrom1(stronglydisagree)to5 (stronglyagree),andthe17negativelyframeditemswerereversed sothatthesumscorereﬂectedhigherlevelsofpositiveembod- iment.Thetotalscorerangesfrom34−170.Furtherexamination oftheinstrumenthasbeendescribedpreviously(Sundgot-Borgen etal.,2019).TheCronbach’salphaforthecurrentstudywas.93 forgirlsand.92forboys,similartootherstudieswiththerange

of.91–.94(Chmielewskietal.,2018;Holmqvistetal.,2018;Teall, 2006,2014).

2.4.2. Internalizationofbodyidealsandpressurefrommedia The Sociocultural Attitudes Towards Appearance Questionnaire-4 (SATAQ-4) (Schaefer et al., 2015) was used toassesssocietalandinterpersonalaspectsofappearanceideals.

Fromtheﬁveindividualsubscales,theThin/LowBodyFatInternal- ization,Athletic/MuscularInternalization,andPerceivedPressure from Media, were used. Participants answered on a ﬁve-point

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Likert-scalerangingfrom1(stronglydisagree)to5(stronglyagree), whereahigherscoreindicatesahigherdegreeofinternalization orperceivedpressure.Cronbach’sAlphainthepresentsamplewas forboysbetween.85and.94,andbetween.91and.95forgirls, slightlyhigherthanintheoriginalstudy(Schaeferetal.,2015).

2.4.3. Medialiteracyandsocialmediause

Anunpublishedsocialmediascalewasused,whichoriginally measuresimpressionmanagement,socialcapital,socialcompar- isonsofbodyexperienceandphysicalappearance,andsocialmedia literacy(insubmissionprocess).Thescalecontains20items,and studentsrespondonastandardLikertresponseformat(1-strongly disagree,5-stronglyagree).Forthiscurrentstudy,thetwosubscales MediaLiteracy(fouritems)andTimeSpentonBodyAppearance RelatedContentinSocialMedia(ﬁveitems)wereusedasthesecon- ceptswerespeciﬁcallytargetedintheHBIintervention.Ahigher scoreonbothsubscaleswaspreferable,asthelatterscaleitemsin thisstudywerereversed.TheCronbach’salphafortheMediaLit- eracysub-scalewas.80and.78forboysandgirlsrespectively.For thesubscaleTimeSpentonBodyAppearanceRelatedContentin SocialMedia,theCronbach’salphawas.78and.79forboysand girlsrespectively.

2.4.4. Self-compassion

TheSelf-CompassionScale–ShortForm(Raes,Pommier,Neff,

& Van Gucht, 2011) measures an individual’s ability to main- tainwarm,kind,caring, comfortingtowardsthemselves,andto maintainconnectedtothemselves,whentheyexperiencepersonal failings.The12-itemsarerespondedtoonaLikertscaleranging from1(almostnever)to5(almostalways).Allnegativeworded itemswerereversed, and amean scorewascalculated. Forthe currentsample,reportedCronbach’salphawaslowerthanforthe originaladultsample,with.57and.76forboysandgirlsrespec- tively.Thiswasslightlylowerthanpreviouslyfoundinadolescents (␣=.88)(Cunha,Xavier,&Castilho,2016).

2.4.5. Self-esteem

Self-esteemwasmeasuredbytheRosenbergSelf-EsteemScale (RSES)(Rosenberg,1965)whichisa10-itemscalethatmeasures globalself-worthbyusingbothnegativeandpositivewordeditems scoredonafour-pointLikert-scalerangingfrom1(stronglyagree) to4(stronglydisagree).Thetotalscorerangesfrom10to40where a higher score represents a higher global self-worth. Negative wordeditemswerereversed.Inthepresentstudytheinternalcon- sistencyof␣.90and.92forboysandgirlsrespectivelywasbetter thanthe␣of.86reportedintheNorwegianvalidationstudyofthe RSES(vonSoest,2005).

2.4.6. Bodyimageﬂexibility

TheBodyImageAcceptanceandActionQuestionnaire(BIAAQ) (Sandozetal.,2013)wasusedtomeasurebodyimageﬂexibility.

Thescaleconsistsof12itemsscoredonaseven-pointLikertscale rangingfrom1(nevertrue)to7(alwaystrue),andtotalscoreranges from12to84.Negativewordeditemswerereversedsothatahigher scorereﬂectsahigherdegreeofbodyimageﬂexibility.Theinternal consistencyintheoriginalstudywas␣.93(Sandozetal.,2013), whichwassimilartogirls(␣.92),andslightlyhigherthanforboys (␣.85)inoursample.

2.5. Theintervention

Theinterventionhadaninteractiveeducationalapproach,fol- lowed the elaboration likelihood model (Petty & Bri ˜no, 2012), andcontainedthree90-mininteractiveworkshops.Allworkshops werearrangedinmixed-genderclassroomsduringregularschool hours.Threeweeksintervalbetweeneachworkshopresultedina

three-monthinterventionperiod.Duringtheinterventionperiod, studentsatthecontrolschoolsfollowedtheirregularschoolcur- riculum. After the ﬁnal 12- months follow-up, control schools wereofferedonelecturewheretheprogramhighlightswerecom- pressed.TheﬁrstandninthauthorwerePh.D.studentsand led theworkshops.Botharespecializedinphysicalactivityandhealth, sportsnutrition,motivationalinterviewing,andbodyimageamong adolescents.Adetailedaccountofthecontentandtargetsofthe interventionisprovidedinpreviouspublications(Sundgot-Borgen etal.,2018,2019).

2.6. Statisticalanalyses

The analyseswereconducted inMplus version 8.3(Muthén

& Muthén, 20171998–2017). We used path analysisto exam- inedirecteffects(a,b,andc´),totalindirecteffects(i.e.,thesum of specific indirect effects), and specific indirecteffects (ab)of theinterventiononpositiveembodiment.Followingrecommen- dations intheliterature(Preacher&Hayes,2008)we reliedon non-symmetricbootstrapconfidenceintervals(CI)toassessmedi- ation.ThebootstrapCIswerebasedon10,000bootstrapsamples.

Together these bootstrap samples provide an empirical repre- sentationofthesamplingdistributionoftheindirecteffect(ab) andnon-symmetricCIsfortheindirecteffect.Evidenceofmedi- ationissupportedifthe95%CIdoesnotincludezero(Hayes&

Rockwood,2017).Wecalculatedthepartiallystandardizedindi- recteffect(abps)asaneffect-sizemeasurefortheindirecteffects (Mioˇcevi ´c,O’Rourke,MacKinnon,&Brown,2018).Thiseffect-size measurecapturesthesizeoftheindirecteffectintermsofstandard deviationsofthedependentvariableforaone-unitchangeinthe independentvariable.InthecaseofabinaryXvariable(e.g.,repre- sentinginterventionandcontrolgroup)itisthechangeinstandard deviationunitsofYbetweenthetwogroups.However,theunstan- dardizedslopecoefﬁcientsfromthepathanalysisareeffectsize measuresaswell(i.e.,simpleeffectsize;(i.e.,simpleeffectsize;

Baguley,2009),andweprimarilyrelyonthesewheninterpreting theeffects.Thepredictorwasadichotomousvariablerepresenting intervention(1)andcontrol(0)group.Themediatorswereassessed attimepoint3(T3)andtheoutcomewasassessedattimepoint4 (T4).Toonlypresentdatathatisusedinouranalyses,T1andT3data onmediationvariablesandT1andT4dataforthemainoutcome variableispresentedintheresultssection(Tables1–3).Thispar- ticularmediationsequencewaschosenbecauseitwasconsidered mostrelevantinordertoexplorelongitudinaleffects,andbecause webelievedthatskillstaughtintheinterventionneededtobeused ineverydaylifebythestudentspost-interventiontoeffectdifferent constructsovertime,reﬂectingamaturationprocess.However,for transparency,theAppendix(inSupplementarymaterial)presents resultsforthemediationsequencewheremediatorsandoutcome wereassessedatT2andT3,respectively.

Wecontrolledforbaselinescoresofthemediatorsandtheout- comeinthepathanalysis(cf.Vickers&Altman,2001).Toaccount forthenesteddatastructure(studentsnestedinclassrooms)we used the aggregated analysis method outlined by Muthén and Satorra (1995),which computesthe usualparameterestimates but adjuststhestandard errorsand goodness-of-fitmodel test- ing.Model fit wasevaluatedwithconventional fit indices such asthecomparativefitindex(CFI),theTucker-LewisIndex(TLI), thestandardizedrootmeanresidual(SRMR),andtherootmean squareerrorofapproximation(RMSEA).CFIandTLIvaluesaround 0.90andSRMRandRMSEAvaluesaround0.08indicatedacceptable modelfit(Marsh,2007).Basedondrop-outanalysesweassumed thedatatobemissingatrandom.Missingdatawerehandledby thefullinformationmaximumlikelihood(FIML)estimator(Enders, 2010), which includesallavailabledata intheanalyses.A case wasrecorded asdropout and excludedfrom theanalysesif all

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Table2

ParameterEstimatesfromthePathAnalysisinBoysandGirls.

Boys(n=551) Girls(n=1010)

95%CI 95%CI

B SE p LL UL B SE p LL UL

X→Y(c’path)

Intervention→Positiveembodiment 2.20 2.04 0.28 −1.90 6.20 5.86 1.12 <.001 3.61 7.97

X→M(apaths)

Intervention→Athleticinternalization −0.22 0.10 .027 −0.41 −0.03 −0.10 0.06 .119 −0.21 0.02

Intervention→Thininternalization −0.27 0.10 .005 −0.47 −0.08 −0.27 0.07 <.001 −0.40 −0.13

Intervention→Pressurefrommedia −0.10 0.10 .304 −0.28 0.09 −0.25 0.08 .001 −0.39 −0.09

Intervention→Medialiteracy 0.87 0.58 .136 −0.31 1.98 0.12 0.35 .734 −0.56 0.82

Intervention→Self-compassion 0.09 0.06 .127 −0.03 0.19 0.06 0.05 .213 −0.03 0.14

Intervention→Self-esteem 1.32 0.56 .017 0.25 2.41 1.21 0.41 .003 0.40 1.99

Intervention→Bodyimageﬂexibility 3.27 1.51 .030 0.41 6.29 1.47 0.83 .078 −0.20 3.03

M→Y(bpaths)

Athleticinternalization→Positiveembodiment 0.26 1.27 .839 −2.29 2.67 0.87 0.85 .307 −0.78 2.55

Thininternalization→Positiveembodiment 1.25 1.83 .496 −2.15 4.92 −1.12 0.94 .232 −3.03 0.70

Pressurefrommedia→Positiveembodiment −0.64 1.35 .636 −3.46 1.76 −0.21 0.53 .695 −1.25 0.85

Medialiteracy→Positiveembodiment 0.74 0.25 .003 0.25 1.23 0.20 0.13 .124 −0.07 0.43

Self-compassion→Positiveembodiment 3.17 2.49 .204 −1.92 7.94 1.01 1.14 .332 −1.19 3.30

Self-esteem→Positiveembodiment 0.86 0.28 .002 0.33 1.42 1.05 0.15 <.001 0.75 1.33

Bodyimageﬂexibility→Positiveembodiment 0.14 0.10 .181 −0.06 0.35 0.36 0.05 <.001 0.26 0.45 Note.Atotalof1561studentswereincludedintheanalyses.MediatorsweremeasuredatT3andtheoutcomewasmeasuredatT4.Baselinescoresofthemediatorsand outcomewerecontrolledforintheanalysis.The95%CIsarenon-symmetricalbootstrapCIs.LL=lowerlimit,UL=upperlimit.p-valuesbelow.05indicateastatistically signiﬁcanteffectandismarkedbyboldtext.

post-interventionandfollow-updataweremissing.Wespecified amultigroupmodeltoexaminegender-specificeffects.Ap-value below.05anda95%CIthatdidnotincludezeroindicatedstatisti- callysignificanteffectinthepathanalysis.

3. Results

Table1presentsdescriptive statistics ofthestudy variables.

Includedaspossiblemediatorsintheestimatedmodelswere1.

internalizationoftheathleticbody,2.internalizationofthethin body,3.perceivedpressurefrommedia,4.medialiteracy,5.time spentonbodyappearancerelatedcontentinsocialmedia,6.self- compassion,7.self-esteem,and8.bodyimageﬂexibility.However, thevariabletime spent onbody appearancerelated content in socialmediahadapproximately88%missingdataatT3andwas excludedfromtheanalysisduetotheuncertaintyintheFIMLesti- mation(Muthén&Muthén,2017).BasedontheFIMLmethod,the overallnumberofincludedparticipantsfromtheoriginalsample intothepathanalyseswas1561,with551boysand1010girls (Table2).Thisisbasedontheexclusionofparticipantswhohad nodataonT2-T4,andparticipantswithnodataongender.

3.1. Pathanalysis

ThepathanalysisisdisplayedinFig.2aforboysand2bforgirls andtheparameterestimates(i.e.,directeffects)arepresentedin Table2.Modelﬁtofthemultigroupmodelwas,␹²=607.389,df= 128,p<.001,CFI=0.907,TLI=0.855,RMSEA=0.069(90%CI[0.064, 0.075]),SRMR=0.083.Forboysthedirecteffect(c´)oftheinter- ventiononpositiveembodimentwasnotstatisticallysigniﬁcant.

Theapaths(i.e.,XIntervention/control→M_T3)indicatedthattheinter- ventionincreasedself-esteemandbodyimageﬂexibility,whereas itreducedscoresoninternalizationoftheathleticandthinbody, comparedtocontrols.Thebpaths(i.e.,M_T3→Y_T4)showedthatself- esteemandmedialiteracywerepositiveandstatisticallysigniﬁcant predictorsofpositiveembodiment(Fig.2a).

For girls the direct effect (c´) of the intervention on posi- tiveembodimentwaspositiveandstatisticallysigniﬁcant.Thea paths(i.e.,XIntervention/control→MT3)indicatedthattheintervention

increasedself-esteem,whereasitreducedscoresonthininternal- ization andpressure frommedia.The bpaths(i.e.,MT3 →YT4) showedthat self-esteem and body imageﬂexibility wereposi- tiveandstatisticallysigniﬁcantpredictorsofpositiveembodiment (Fig.2b).

Indirecteffectswerealsocalculatedbasedontheunstandard- izedcoefficientsinthepathanalysis.AsseeninTable3,therewas apositiveandstatisticallysignificanttotalindirecteffect(ab_boys= 2.16,95%CI[0.14,4.44];ab_girls=2.14,95%CI[0.78,3.58])and aspecificindirecteffectoftheinterventiononpositiveembodi- mentthroughself-esteem(ab_boys=1.14,95%CI[0.16,2.49];ab_girls

=1.26,95%CI[0.38,2.29])forboysandgirls(seeFig.2).Noneof theotherindirecteffectswerestatisticallysigniﬁcantforthismedi- ationsequence.Itshouldbementionedthatwhenweconducted theadditionalmediationsequence(T2→T3),self-esteemstillmedi- atedtheinterventioneffectforbothgenders,whileinternalization oftheathleticidealmediatedinterventioneffectingirlsonly(see Appendix(inSupplementarymaterial)).

4. Discussion

TheresultsareinlinewiththehypothesisthattheHBIinter- ventionincreasedpositiveembodimentviaenhancedself-esteem inbothadolescentboysandgirls.

4.1. Indirecteffects

Thecurrentstudyfoundasigniﬁcantmediatedpathwayinboys andgirlsviaself-esteem.Activitieswithintheinterventionsuchas enhancingthestudents’abilitytoidentifyandappreciateindividual differences,appreciateone’sownpositivecontrollablecharacteristic,anddeveloppositiveattitudesandevaluationofthemselves, seemtohaveaffectedthestudents’self-esteem.Thedevelopment ofself-esteemovertimemayhavemadeiteasierforthestudentsto becomecomfortablewiththeirindividualcharacteristicsandlower thedesiretoadoptandadheretosocialstandards.Asaresult,itmay havebecomeeasierfortheadolescentstorejectunhealthyexpo- suresandratherfocusongrowthofembodiedexperiences(Piran, 2019;Rousseau&Eggermont,2018).Additionally,improvingastu-

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Fig.2. Resultsofthemediationmodelinboys(A)andgirls(B).MediatorsweremeasuredatT3andtheoutcomewasmeasuredatT4.Baselinescoresofthemediatorsand outcomewerecontrolledforintheanalysis.Correlationsbetweenmediatorsareomittedfromthefigureofclarity.Solidlinesindicatestatisticallysignificanteffects(+or— indicatethedirectionoftheeffect),dashedlinesindicatenon-significanteffects.The95%CIsarenon-symmetricalbootstrapCIs.ab=indirecteffect,LL=lowerlimit,UL= upperlimit.*95%CIthatdoesnotincludezeroindicateastatisticallysignificanteffect.

Table3

IndirectEffectsoftheInterventiononPositiveEmbodimentinBoysandGirls.

Boys(n=551) Girls(n=1010)

95%CI 95%CI 95%CI 95%CI

ab LL UL abps LL UL ab LL UL abps LL UL

Totalindirecteffect^a 2.16* 0.14 4.44 0.10 0.01 0.21 2.14* 0.78 3.58 0.10 0.03 0.16

Intervention→Self-esteem→Positiveembodiment 1.14* 0.16 2.49 0.05 0.01 0.12 1.26* 0.38 2.29 0.06 0.02 0.10 Intervention→Bodyimageﬂexibility→Positiveembodiment 0.45 −0.20 1.56 0.02 −0.01 0.07 0.52 −0.07 1.12 0.02 −0.00 0.05 Intervention→Self-compassion→Positiveembodiment 0.27 −0.20 1.00 0.01 −0.01 0.05 0.06 −0.07 0.32 0.00 −0.00 0.01 Intervention→Athleticinternalization→Positiveembodiment −0.06 −0.64 0.62 −0.00 −0.03 0.03 −0.08 −0.32 0.09 −0.00 −0.01 0.00 Intervention→Thininternalization→Positiveembodiment −0.34 −1.60 0.63 −0.02 −0.08 0.03 0.30 −0.19 0.86 0.01 −0.01 0.04 Intervention→Pressurefrommedia→Positiveembodiment 0.06 −0.27 0.55 0.00 −0.01 0.03 0.05 −0.21 0.34 0.00 −0.01 0.02 Intervention→Medialiteracy→Positiveembodiment 0.64 −0.21 1.77 0.03 −0.01 0.09 0.02 −0.13 0.22 0.00 −0.01 0.01 Note.MediatorsweremeasuredatT3andtheoutcomewasmeasuredatT4.Baselinescoresofthemediatorsandoutcomewerecontrolledforintheanalysis.The95%CIs arenon-symmetricalbootstrapCIs.ab=indirecteffect,abps=partiallystandardizedindirecteffect,LL=lowerlimit,UL=upperlimit.

*95%CIthatdoesnotincludezeroindicatesastatisticallysigniﬁcanteffect.

aTotalindirecteffect=sumofallspeciﬁcindirecteffects.

dent’sself-esteemmighthavehadrippleeffectsonpsychological well-being,andmighthavefacilitatedhealthierexposurechoices suchaspeoplewithpositiveattitudes,positiveandconstructive socialmediacontent,healthylifestylechoicesand positiveself- communication.Thismightfurtherimprovepositiveembodiment subdomainsdescribedinthedevelopmentaltheoryofembodiment (Piran,2017).

The suggested effect on body image outcomes by targeting self-esteemhasalsobeenfoundinpreviouspreventionandpro- motionstudies(Agam-Bittonetal.,2018;O’Dea&Abraham,2000;

Richardsonetal.,2009;Sharpeetal.,2013).ThestudybyAgam- Bittonetal.(2018)istheonlystudyinadditiontothecurrent,to investigatethemediationaleffectofself-esteemonintervention outcomes(Agam-Bittonetal.,2018).Incontrasttoourﬁndings, they foundno mediational effect of self-esteem on promotion of body image.It shouldbe mentioned that Agam-Bittonet al.

onlyusedthreemonthsfollow-uptime.Incontrast,theHBIinter- ventionreportedamediationaleffectonpositiveembodimentat 12-months follow-up. This could indicatethat changes in self- esteemmightneedtoaffectpositiveembodimentoveralonger periodoftimethroughmaturation,wherea3-monthsfollow-up mightnothavebeensufﬁcientforsimilarﬁndingstobeobserved.

However,fortransparency,wealsoanalyzedtheshort-termmedi- ation sequenceand foundself-esteem atpostintervention (T2) tomediatetheinterventioneffectonpositiveembodimentat3-

monthsfollow-up (T3).The self-esteemintervention contentin Agam-Bittonetal.wasmorefocusedonexplaininganddiscussing self-esteem as a construct, while our intervention speciﬁcally taughtthestudentshowtopromotetheirownself-esteem.This contentandteachingtechniquemightbeamoreplausibleexpla- nationforthedifferentﬁndingsbetweenthestudies.

AsseeninTable1,changesinself-esteeminbothboysandgirls weresigniﬁcant,yetsmall.Also,thedirecteffectoftheinterven- tiononEESscoresingirlsindicatesthattheinterventionwasonly partlymediatedbychangesinself-esteem.Inadditiontoenhanced self-esteem,theinterventioneffectcouldbeexplained byother unmeasuredfactorssuchasreducedbodydissatisfaction,improved eatingandphysicalactivitybehaviors,andreducedcomparison, whichweretopicsalsodiscussedinourintervention.Also,mak- ingthestudents feelliketheywereof greatimportance tothe project,partofagroup,andseenandheardbybothfacilitators, mighthaveaffectedthestudents’feelingsofbelonging,acceptance, andself-worth.Theseareknownasnon-speciﬁcfactorsthatare notconstructstargetedbytheinterventionandnotmeasured,but thatmight,nevertheless,beaneffectofthetherapeuticrelationship betweenfacilitatorandstudentandmayaccountforsomeofthe interventioneffect(Donovan,Kwekkeboom,Rosenzweig,&Ward, 2009).

Notably,theinterventioneffectinthepresentstudywasalso highlygenderspeciﬁc.Asshowninapreviouspublication,only

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asmalltransientinterventioneffectwasfoundinboys,while a sustainedeffectwasfoundingirls(Sundgot-Borgenetal.,2019).

Itisnaturaltosuggestthatinadditiontoself-esteem,thereare otherfactorsthatneedtobefocusedoninfutureinterventions toimprovelong-termeffectinboys.Accordingtotheliterature, suchfactorscouldbethegenderofthefacilitator(Yager,Diedrichs,

& Drummond, 2013), chosen learning activities and methods (Wahistrom,2002),andthefactthatboystendtodescribebody imageasagirlsthing(Adams,Turner,&Bucks,2005;Hargreaves&

Tiggemann,2006),whichwouldaffectthechanceofbeingaffected byabodyimageintervention.

Forfuturestudies,itmightseemimportanttonotonlymeasure themediationaleffectofglobalself-esteem,asmeasuringspeciﬁc domainsofself-esteemcouldprovideimportantinformationon whatspeciﬁcpartsofself-esteemaninterventionneedstotarget inboysandgirlstoprovideanevenstrongereffectonembodiment (vonSoest,Wichstrøm,&Kvalem,2016).Asanexampletofurther improvetheeffectinboys,onemayspeculatewhetheraninclusion ofphysicalactivitysessionscouldhavepromotedtheathleticcom- petencedomain,whichhasbeendescribedasmoreimportantfor boys’globalself-esteemcomparedtogirls(vonSoestetal.,2016).

4.2. Non-mediatingvariables

For the primary mediation sequence, we did not observe hypothesized indirect effects of the intervention on positive embodiment through internalization of the athletic or thin bodyideal,perceivedpressurefrommedia,medialiteracy,self- compassion,orbody image ﬂexibilityin neitherboysnorgirls.

Ouradditionalanalysesoftheshort-termmediationaleffectfound thatinternalizationoftheathleticidealmediatedthe3-months interventioneffectingirlsonly.However,comparingourprimary mediationalsequence, our resultscontradicts two studieswith similarlong-termmediationsequence,whofoundthatreduction inthin-internalizationfully(Sticeetal.,2011)andpartly(Seidel etal.,2009)mediatedtheeffectofadissonance-basedinterven- tiononbodydissatisfactionandbulimicsymptoms,respectively.

Aninterestingquestionwouldbewhetherthedissonance-based approachusedin thesestudiesis superiortothepsychoeduca- tionalapproachusedintheHBIintervention,intermsofchanging participants’ level of internalization. Another important aspect that alsocould explain someof the differences betweenstudy findings is that both previous studies intervened on high-risk girls, and the outcomes were related to negative body image in contrast to ourmixed-gender universal sample witha positive embodiment outcome. Hence, methodological inequalities make further comparison difficult. When it comes to internalization ofthe athleticideal and pressure frommedia,previous studies have not investigated these as mediators such as the thin ideal, and ourfindings providenew knowledge. Based on theHBIinterventioncontent,thelackofmediationaleffectwas surprisingasinternalizationand pressurefrommediapervaded allworkshops.Based onours and previousfindings,one might hypothesis that a reduction in internalizationin general might have a stronger influence onthe level of negative body image outcomes long-term compared to positive body image related outcomes.However,morestudiesareneededtobackupthisexpla- nation.

Thelack of identifyingmedialiteracyas a mediator contra- dicts ﬁndings from Agam-Bitton et al. (2018), who found that medialiteracymediatedtheinterventioneffecton“currentbody image”amongafemaleadolescentsample.However,thechoice ofquestionstomeasuremedialiteracyinourstudyprovidesan uncertaintytowhethertrueinterventioneffectsonthisvariable couldbeassessed.Thisisbecausetheworkshopcontentwasmore focusedonstudentsbecomingcriticaltostrategiesusedbyproﬁles

andadvertisers,retouching,andhowthesetechniquesinﬂuenced attitudes,believesandemotions,asinAgam-Bittonetal.,compared towhatthestudyquestionnaireaskedabout.Anotherdifferenceto Agam-Bittonetal.(2018),wastheirmeasureofgirls-onlyintheir analyses,andCurrentBodyImageasonebodyimageoutcome.In contrasttotheEESusedinourstudy,theiroutcomedidnotcap- turethecomplexdomainofpositiveembodimentassuggestedin theliterature(Webb,Wood-Barcalow,&Tylka,2015),leavingthe twostudiestomeasuremediationeffectsfromtwodifferentout- comes.Therefore,methodologicaldifferencescouldcontributeto theexplanationofvariousﬁndings.

Althoughbothself-compassionandbodyimageﬂexibilitywere targetedthroughout all threeworkshops bydifferent activities, theseconstructsmighthavebeenlessdirectlyexplainedbythe facilitatorsanddiscussedamongthestudents.Theconstructswere rather believed to beindirectly affected through working with othermorefamiliarconstructssuchase.g.idealization,communication, comparison, lifestyle behaviours, and might not have been targeted to the extent that was intended. An additional explanationforthelackofmediationeffectscouldbethatthese constructsprotectagainstdestructiveconsequencestobodyimage threatsand poorbodyimage,but mightnot haveadirect abil- itytoimprovescoresonpositiveembodimentalone(Neff,2003;

Rogersetal.,2018).Reductionofinternalizationofboththeath- leticand thin body ideal,pressure from media,medialiteracy, self-compassion,and body image ﬂexibility,mightstill be con- sideredimportantinembodimentpromotiveinterventions.This couldpossiblybethroughenhancingconstructivecopingmecha- nismsandworkasprotectivefactorsagainstbodyimagethreats (Braunetal.,2016;Levine&Smolak,2016).However,probablynot asthemaincomponentsthatneedtobeenhancedinaninterven- tionforthespeciﬁcvariablepositiveembodimenttochangeover time.

Theparallelmodelingmadeitpossibletoanalyzewhetherany hypothesizedvariablesalonemediatedtheinterventioneffect.The truemechanisms might be more complex than this study was abletocapturethroughparallelmediationmodelling.Serialmedi- ationmodelingisoneexampleofadditionalmethodsthatcould providesupplementalinformation,indicatingwhethertheinter- ventionimpactstheoutcomethroughalongerchainofmediators.

Basedontheﬁndingsfromthecurrentstudy,self-esteemscoresare likelytoplayanimportantroleinthischainofmediators.Although ouradditionalanalysesoftheshort-termsequenceshowthatinter- nalizationoftheathleticidealmediatedinterventioneffectingirls, theremainingﬁndingsaresimilarbetweentheprimaryandaddi- tionalsequence,wherethelong-termsequenceremainthemost importantintermsofevaluatingmeaningfuleffectsoftheinter- ventionforpotentialimplementation.

4.3. Strengthsandlimitations

Thecurrentstudyistoourknowledgetheﬁrstonetoreport mediatedeffectsofaninterventiononapositiveembodimentout- comeusingamixed-gendersample.Also,theanalyseswerebased onaclusterRCTwithfourmeasurementtime-points,includingthe 12-monthsfollow-up.Allanalyseswereadjustedfornesteddata, andmodelsestimatedseveralmediatorsinboysandgirlssepa- rately.

Themainlimitationwasthehighdrop-outrateespeciallyin boysandcontrols,whichmighthaveimpactedthestatisticalpower especiallyforboysandincreasestheriskoftypeIIerror.Although FIMLisanappropriatemethodtouseonlargesamples,estimates mighthaveabiggerchanceofbiasinsmallsamples,whichwas thecaseforsomeofthevariables.Thedrop-outratealsoledto theexclusionofonehypothesizedmediator;TimeSpentonBody AppearanceRelatedContentinSocialMediafromanalyses.Lim-