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Counseling Enrichment Sessions for Adolescents about their Body Image and Self-esteem

Amany Mohamed Saad*, Wafaa Osman Abd El Fatah, Eman Hassan Mahmoud

Community Health Nursing Department, Faculty of Nursing, Helwan University, Egypt

Abstract: Adolescence is an essential phase of human development and is characterized by significant physical changes and maturation, so the adolescents face different problems in dealing with these rapid changes which affect their satisfaction with their bodies and self-esteem. Aim: The aim of this study was to determine the effect of counseling enrichment sessions for adolescents about their body image and self-esteem. Design: A quasi-experimental design was used. Setting: The study was conducted in Zahraa Helwan preparatory secondary girls school at Wadi Hof. Sample: Purposive sample including 180 adolescent girls. Tools: A semi-structured interview questionnaire was used to collect the data and involved four parts: Part 1. Demographic characteristic data, Part 2. Anthropometric measurements. Part 3. Body Image test, and Part 4. Coopersmith Self-esteem Inventory. Results: There was a positive relation between body image and self-esteem pre and post counseling enrichment sessions which mean that, the girls' body image was affected dependently on their self-esteem. Also body image and self-esteem were improved post counseling enrichment sessions with highly statistically significant difference. Conclusion: The counseling enrichment sessions for body image and self-esteem have positive effect on adolescents. Recommendations: Therapeutic programs to guide those who have unsatisfied body image to optimize consensus, improve their mental health and self-esteem. And teachers, parents, and school nurses should receive periodically education related to the development of secondary sexual characteristics during puberty of adolescents.

Keywords: counseling, enrichment sessions, adolescents, body image and self-esteem

Received July 08, 2018; Revised August 16, 2018; Accepted September 11, 2018

Citation: Amany Mohamed Saad, Wafaa Osman Abd El Fatah, Eman Hassan Mahmoud, Counseling Enrichment Sessions for Adolescents about their Body Image and Self-esteem. American Journal of Nursing Research, 6 (6). 359-370. January 2018. doi:10.12691/ajnr-6-6-3

1. Introduction

Adolescence represents a pivotal stage in the development of positive or negative body image. Many influences exist during the teen years including transitions (puberty) that affects one’s body shape, weight status, and appearance [1]. Also it is a period of life during which many important body changes take place that are determined by pubertal development. Puberty is a very important process for adolescents. Physiological changes and body modifications lead to great vulnerability. This vulnerability is connected to the adolescent’s perceptions of the uncertainty of outcomes due to the transformation of their infant body into an adult one [2].

Adolescents' body plays a major role in shaping their body image and thoughts of his or her physical appearance in the eyes of others. Body image is formed as a result of several factors such as social upbringing, community, culture, media, family and friends [3].

In adolescence, when girls are preoccupied with gaining adolescent males' attention and being popular, controlling appearance seems crucial. The physical appearance can reflect the person’s ability to manage own life and exercise both self-control and control in the social context. Even though girls are aware that a body in accordance with the social norms has plenty of benefits in the social arena, they also learn that self-control is a necessary. So, self-regulatory behaviors such as dieting and weight control are perceived as normal behaviors [4].

A healthy body image is vital for a healthy self-esteem. It means being comfortable with own body and own perception. A poor body image can be damaging in many ways. It’s often associated with eating disorders, depression, anxiety, low self-esteem and other issues. The reality is that the adolescents don’t like, and ashamed of their bodies [5]. Body image is a big problem in our society, and can lead to depression, social anxiety and eating disorders. Body image is the dynamic perception of one’s body how it looks, feels, and moves. It is shaped by perception, emotions, physical sensations, and is not static, but can change in relation to mood, physical experience, and environment. Because adolescents experience significant physical changes in their bodies during puberty, they are likely to experience highly dynamic perceptions of body image. Body image is influenced strongly by self-esteem and self-evaluation, more so than by external evaluation by others [6].

Body image is a multidimensional construct encompassing how we perceive, think, feel, and act toward our bodies. One aspect of body image investigated is how adolescent individuals assess their own levels of attractiveness, and appearance evaluation. Appearance evaluation has important links to self-esteem, depression, and anxiety [7].

Self-esteem is the experience of being competent to cope with the basic challenges of life and being worthy of happiness. It is the sum of self-confidence and self-respect. If one does not take a positive attitude towards their body, it can lead to feelings of worthlessness and confidence levels can be hindered. It is also well established that self-esteem is a good indicator of overall well-being [8].

The strong connection between self-esteem and body image has been widely documented. For instance, a high body satisfaction contributed to self-esteem. There is consistent evidence that girls’ depressive symptoms in adolescence are predicted by body image dissatisfaction as a consequence of pubertal changes [9].

Today the role of the school nurse is taking a new role to better meet the needs of today’s children, adolescents and their families. They have expanded their skills to support young people to attain good physical, sexual and mental health, reducing health inequalities by helping them to make healthy choices and ensuring that they can balance the opportunities and risks in choices that impact their health and grow up [10].

School counselors have a role in assessment, providing interventions, addressing body image concerns as preventative measures within a school, and providing follow-up services. They also should provide parents with the appropriate knowledge about their role in the development of their children’s body images and self-esteem. As well they need to be conscious when they need to refer their students for outside help and provide necessary resources [11]. They have the unique opportunity to raise awareness about healthy body image and increase self-esteem throughout the school. School counselors are encouraged to promote healthy body images for all students [12].

1.1. Significance of the Study

Adolescence is a serious period of growth and emotional disorder. During this period self- understanding about their appearance is significant to the progress of self-esteem. Physical changes during puberty may cause them to have both positive and negative feelings towards their body which reflects on their self-esteem. Though there are many factors that influence adolescents, the most important ones are self-esteem, and body image [13]. Body image is the mental picture we have of our body; what it looks like and how we perceive it to look. Self-esteem is the true opinion we have of ourselves, and how we respect ourselves as a person [14].

Body image satisfaction and self-esteem play important roles in the development of pre-adolescents and adolescents to move into late adolescence. Body image and self-esteem become crucial factors for students' academic behaviors and success in school. To achieve this , there is a need for counseling sessions among the adolescent girls to improve body image and increase their self-esteem.

2. Aim of the Study

The study aimed to determine the effect of counseling enrichment sessions for adolescents about their body image and self-esteem.

2.1. Hypotheses

H1. Counseling enrichment sessions will improve the body image and increase self-esteem for adolescents.

H2. There will be a significant relationship between body image and self-esteem among adolescents.

2.2. Subjects and Methods

2.2.1. Design

A quasi-experimental design was used to conduct this study.

2.2.2. Setting

The study was conducted in Zahraa Helwan preparatory secondary girls school at Wadi Hof.

2.2.3. Sample

A purposive sample included 180 adolescent girls present at the previously mentioned setting and they have the following inclusion criteria:

• Available at the time of data collection

• Willing to participate in the study

• Free from any chronic diseases or psychological disorders.

2.2.4. Tools for Date Collection

A semi-structured interview questionnaire was used to collect the data (pre and post). It was designed by the researchers in simple Arabic language after reviewing the current literatures. It comprised from four parts as following:

Part 1. Demographic characteristic data such as: Age, school grade, family member, family number, room number, ....etc.

Part 2. Anthropometric measurements as: Weight, height, and body mass index (BMI).

Part 3. Body Image test: It was adapted from [15] it was modified by the researchers and consisted of 27 questions. Body image scale was to measure body perception and satisfaction in adolescents.

2.2.5. Scoring System

The items were scored by using a three- point Likert scale. The scale is ranging from yes takes three, sometimes takes two and no takes one with higher scores indicating greater positive body image.

Part 4. Coopersmith Self-esteem Inventory: It was adapted from [16]. Adolescent’s self-esteem consisted of 25 questions. The self-esteem scale is designed to measure adolescent’s general feelings about themselves.

2.2.6. Scoring System

The items were scored by using two- point Likert scale. The scale ranges from applies takes two and not applicable takes one, with higher scores indicating greater self-reported levels of self-esteem.

2.3. Content Validity

The study tools were tested for validity by a panel of 3 experts from the Faculty of Nursing (Community Health Nursing, Psychiatric & Pediatric Nursing). For judgment of clarity, relevance of sentences, comprehensiveness and appropriateness of content. According to the opinion of the expertise's minor modifications were applied on the form of rephrasing, or comprehension and changing of some questions was performed.

2.4. Reliability of the Tools

All tools used in the present study showed good reliability. It calculated as follows: Self-esteem tool Cronbach's Alpha was 0.702 and body image tool Cronbach's Alpha was 0.771.

2.5. Pilot Study

A pilot study was conducted on 10% of the adolescents and later they excluded from the main study sample, it was used to test the applicability and clarity of the tool and estimate the time needed to fill in the tools.

2.6. Ethical Considerations

Prior to collecting the data an informed oral and written consent was obtained. Adolescents also received the information on this study including the purpose, benefits of this study and data collection procedures. Adolescents who were reluctant to participate in this study, could refuse for participation at any time. Also, they were assured that the information given will be remained confidentially and used for the research purpose only.

2.7. Field Work

The actual field work for data collection has consumed 6 months, data collection done through the following steps:

- Official letter issued from the Faculty of Nursing, Helwan University, including the aim of the study and its schedule, was forwarded to the administrator of Zahraa Helwan preparatory secondary girls' school at Wadi Hof to obtain permission to visit and conduct the study.

- An informed consent was obtained from the adolescent girls to be engaged in this study.

- The aim of the study and its expected outcomes were being explained.

- The researchers were contacted with the studied adolescents before collecting data for the purpose of providing a simple explanation of the objective of the study to gain their cooperation & to assure the adolescents about the anonymity of their answers and that the information was used for scientific research only and was strictly confidential.

The counseling enrichment sessions built in four phases as the following:

1. Preparatory phase: The initial stage was done by using pretest to assess the needs and determine the baseline of knowledge and build up the counseling sessions to improve adolescents' level of knowledge about body image and self-esteem. This phase lasted for four weeks.

2. Planning phase: Based on the outcome acquired from the preparatory phase, the counseling enrichment sessions were formed after reviewing of the related literature. Detected needs and deficiencies were changed into aim to evaluate the effect of counseling enrichment sessions for adolescents. The booklet included knowledge about body image and self-esteem such as; meaning of adolescence stage, physical characteristics of adolescent girl, the most contributing factors of changes in body image, symptoms and cause, factors of changes in body image, positive and negative effects of self-esteem. The teaching methods used which were: Lectures, brainstorming and group discussions and teaching media include: Data show and booklet were made by the researchers offered to each adolescent as a reference.

3. Implementation phase: The data was collected during school day, it takes 6 months to 7 months and started on first of October to the end of April 2017, done in three visits/ week to school for a period of 6 months because it is except the one month of midterm exam and period of half term holiday (on Tuesday , Wednesday and Thursday which starts from 9.30 a.m. to 1.00 p.m.). The counseling enrichment sessions were done in 5 months of them and the adolescent girls was divided into 10 groups, each one consisted of 18 adolescents, and the counseling were applied through six theoretical sessions about body image and self-esteem. The duration of each session was about 30- 45 minutes according to presented items. It was followed by a summary of the previous session.

4. Evaluation phase: At the end of all sessions, the effect of the counseling sessions was measured immediately one time only through applying the similar tools of pre-test as a posttest to evaluate the degree of understanding of the counseling sessions.

2.8. Statistical Analysis

The collected data were organized, tabulated and statistically analyzed using the Statistical Package for Social Sciences (SPSS), version 20. For Numerical data, the range, mean and standard deviation were calculated. Qualitative data were presented as frequencies and percentages. A p-value ≤ 0.05 was considered statistically significant. Wilcoxon signed-rank test was used to compare between scores pre and post counseling enrichment sessions application. Spearman’s correlation coefficient was used to determine correlations between self-esteem and body image scores. ANOVA (f-test) was used to test model fit.

2.9. Results

Table 1a. Reveals that the present study was conducted on 180 adolescent girls. These adolescents were from different preparatory and secondary school grades. More than half (51.7%) of family members of the studied sample was (3-5) members, while minority (3.4%) of them had (9-12) members. The most common number of rooms at home was three rooms (53.3%), while the least was six rooms (1.7%). As regards ranking among sisters and brothers; 36.1% of the girls were the first, while minority (1.2%) of them was the sixth. Eleven fathers (6.1%) had primary or less education, 73 fathers (40.6%) had secondary education, while 96 fathers (53.3%) had high education. (81.1%) of girls fathers were employed, while (18.9%) were unemployed. Minority of girls mothers (7.2%) had primary or less education, (47.8%) had secondary education, while (45.0%) of them had high education. More than one third of girls mothers (35.6%) were employed, while (64.4%) were house-wives.

Table 1b. Shows that the mean age of the studied sample was 14.2 years and the mean birth rank was the second and BMI below 23.

Table 2. As regard to body weight the most common (36.1%) of them were between (35-45 kg), while the minority (13.3%) were >65 kg. Related to BMI more than half (55%) were have normal body weight and minority (2.8%) of them were obesity.

Table 3. Reveals that there were statistically significant differences in all items of self-esteem scores post counseling enrichment sessions application.

Table 4. Presents that self -esteem was dramatically improved post counseling enrichment sessions with statistically significant difference in comparison to the baseline by using chi-square test.

Table 5. Demonstrated that pre counseling sessions 66.1% of adolescents have the negative comments of colleagues effect on their body image, while post counseling 78.3% of them not have these negative comments. Also 22.8% of them pre counseling enrichment sessions feel depressed because of their body shape, while post counseling 75.0% not have this feeling.

Table 6. Shows that body image was dramatically improved post counseling enrichment sessions with highly statistically significant difference in comparison to the baseline by using chi-square test.

Table 7. Illustrates highly statistically significant reverse correlations between body image versus age and BMI, while it was a positive correlation with self -esteem pre and post counseling enrichment sessions by using correlation coefficient test. On the other hand, there were no statistically significant correlations versus birth rank and crowding index.

Table 8. Shows highly statistically significant inverse correlations between self-esteem pre and post counseling enrichment sessions versus age and BMI, by using correlation coefficient test. Also, no statistically significant correlations were found versus other variables.

Figure 1. Reveals that self -esteem was improved post counseling enrichment sessions in comparison to the baseline.

Figure 2. Displays that body image was improved post counseling enrichment sessions in comparison to the baseline.

Figure 3 and Figure 4. These figures confirms that there was a positive relation between body image and self-esteem pre and post the counseling enrichment sessions as appear post counseling enrichment sessions which improve their body image and self-esteem.

Table 1a. Distribution of the studied sample according to socio-demographic characteristics (n=180)

Table 1b. Distribution of the studied sample mean scores regarding to some variables

Table 2. Distribution of the studied sample regarding to anthropometric measurements

Table 3. Descriptive statistics for comparison between self-esteem scores pre and post counseling enrichment sessions

Table 4. Total scores of self -esteem pre and post counseling enrichment sessions

Table 5. Descriptive statistics for comparison between body image scores pre and post counseling enrichment sessions

Table 6. Total scores of body image pre and post counseling enrichment sessions

Table 7. Correlation between body image score versus socio-demographic variables pre/post counseling enrichment sessions

Table 8. Correlation between self- esteem versus socio-demographic variables (pre/post counseling enrichment sessions)

Figure 1. Total self-esteem levels pre and post counseling enrichment sessions

Figure 2. Total scores of body image pre and post counseling enrichment sessions

Figure 3. Correlation between body image versus self-esteem (pre counseling enrichment sessions)

Figure 4. Correlation between body image and self- esteem (post counseling enrichment sessions)

3. Discussion

Physiological and body changes make adolescents more interested and concentrated upon their body image. Body image is a component of self-esteem and it is a big problem in our society, and can lead to depression, social anxiety and eating disorders [6].

The present study exposed that the study was conducted on 180 adolescent girls. These adolescents were from different preparatory and secondary school grades. This is incongruent with that of [17] in Korea, who revealed that the total sample was 153 children and 19.0% of them were in the 1st grade, 16.3% were in 2nd grade, 13.7% were in 3rd grade, 26.8% of participants were in 4th grade ,15.7% were in 5th grade, and 8.5% of them were in 6th grade. Concerning to the sex, 52.3% of them were boys and 47.7% were girls.

As regard to body weight, the current study indicated that the most common weight of them was between (35 - 45kg), while the minority was >65 kg. This is as in study done by [18] in Iran, who illustrated that the mean weight of girls was 86.86 ± 9.80 kg and boys was 94.08 ± 13.61 kg.

Related to BMI the present study revealed that more than half were have normal body weight and minority of them were obesity. This is disagree with [19] in Zagazig University, which reported that more than one quarter of the students were overweight and obese ( 19.6% and 8.4% respectively).

The current findings presented that the mean age of the studied sample was 14.2 years, and the mean birth rank was the second. This because the girls in early adolescence (period from 12 to 14 years) is vulnerable and it is the ideal time for any educational intervention. This result was similar to study conducted by [2] in Italy, who stated that a total of participants were between 11 and 17 years with a mean and SD (13.33 ± 1.7).

The current study results showed that minority of fathers had primary or less education, two fifths of fathers had secondary education, while more than half of them had high education. In addition that majority of adolescent fathers were employed, while minority were unemployed. Also minority of adolescent mothers had primary or less education, more than two fifths had secondary and high education. More than one third of adolescent mothers were employed, while more than three fifths were house-wives. This is similar to study conducted by [20] in Korea, who found that the largest portion (42.8 %) of the sample reported their father’s educational level were bachelor’s degrees, followed by high school diplomas (40.3 %), post-bachelor’s degrees (8.1 %), and middle school diplomas (3.5 %). Mothers were slightly less educated as it is mother’s educational level were high school diplomas (50.5 %), bachelor’s degrees (36.4 %), post-bachelor’s degrees (4.0 %), and middle school diplomas (3.9 %).

The present study showed that pre counseling enrichment sessions the half of adolescents have negative body image, while more than third of them having positive body image with Mean ± SD of total body image (1.78± 0.41). These results clarified that most of the girls are dissatisfied with their body. But post counseling enrichment sessions the study illustrated that one fifth of adolescents have negative body image, while more than three quarters of them having positive body image with Mean ± SD of total body image (53.53 ± 4.37). This is agrees with, the research of [21], who mentioned that 86% of adolescents are dissatisfied with their bodies and want to decrease their weight. This might be explained that their body dissatisfaction could be attributed to the negative internalization of sociocultural attitudes toward appearance; in addition to that these adolescent girls have an opportunity for social comparison with media models. This finding is also in the same line with the opinion of [22], who found that early developing girls have less positive body images than boys which greatly contributes to self-esteem.

The results of current study have also demonstrated that the adolescents' body image was dramatically improved post counseling enrichment sessions with highly statistically significant difference. From researcher point of view this result implied that adolescent girls are receptive to dietary and physical activity behavioral modifications. This result achieves also the aim of this study. This is supported by finding of [23], who showed that counseling program was positive for adolescent girls to accept and improve their body image.

The results of this current study confirmed the relationships of body image and self-esteem as in Figure 3 and Figure 4, there was a positive relation between body image and self-esteem pre and post counseling enrichment sessions which means that, the adolescents' body image was affected dependently of their self-esteem, indicating that the adolescents become more embarrassed with the physical changes occurring in their bodies, so their body image declined which affected negatively their self-esteem. This result is in agreement with [24], who showed that the girls aged 11-16 having body dissatisfaction, consequently, their self-esteem was lowered. For that the present study aimed at developing the body image of the adolescents leading to improve their self-esteem, through a counseling enrichment sessions to improve their body image and self-esteem. In additional to [25], who reported that self-esteem play a role in body image effects, that mean low self-esteem is associated with body dissatisfaction in school girls. This might be due to the sociocultural influences on the girls' body image such as experimental exposure to size magazine models, and the media effect on their body concept. As well these results were in agreement with [26], who examine eating disorders and social media on body dissatisfaction. Additionally, due to the fact that we live in a media saturated world, mass media is significantly influential in regards to how people learn about body ideals as well as attractiveness according to [27].

The above mentioned results proved the second hypothesis which revealed that there will be significant relationship between body image and self-esteem among adolescents.

The current study demonstrated that pre counseling enrichment sessions more than two third of adolescents have the negative comments of colleagues effect on their body image, while post counseling enrichment sessions more than three quarters of them not have these comments. This result was similar to [28], who found conversations focusing on the value of oneself beyond appearance and building productive friendships can ultimately affect how a person feels about their weight. This might be due the importance of negative messages from peers, friends, and family and its impact on weight, positive role models, and building healthy relationships to improve body image.

The results of present study showed that pre counseling enrichment sessions more than one fifth of adolescent girls have the feel of depressed because of their body shape, while post counseling enrichment sessions three quarter of them not have this feeling. So it is vital to teaching young adolescents to critical think about their bodies and appearance. in this regard, [29] demonstrate that the need to implement methods to help individuals negative appearance shaming messages. This may be because young girls are often victims of appearance shaming and weight related critiques from others.

The current study indicated that self-esteem and body image were dramatically improved post counseling enrichment sessions with highly statistically significant difference. This finding is proved the aim as well as the first hypothesis of the current study. This result was supported by [30], who suggest that young women who are low in self-esteem or depressed, and for whom thin or appearance based self-worth are dissatisfied with their bodies.

The present study results revealed that, there was a significant correlation between body image versus age and BMI. This can be explained that the negative body image in early adolescence is linked primarily to the body weight and shape, whereas when the age increases, the sexual organs of the females grow, making them more embarrassed and consequently affecting negatively their body image and self-esteem. this result in the same line with that of a study done by [12], who suggested that it is urged to facilitate small group counseling and individual session for students struggling with body image and self-esteem issues for health and wellness, self-care and self-love.

The current study showed that pre counseling enrichment sessions nearly to three quarters of adolescents wish to have body and shape such as actors or fashion models or athletes, while the majority of them don’t wish that post counseling enrichment sessions. This is may be related to fashion and social media are interpersonally rich modalities that offer graphs, videos, animation and multimedia cues that attractive for adolescent girls wishes to be. This result is similar to [31], who explained that the differences between conventional and social media have important implications for social effects on body image concerns.

4. Conclusion

The counseling enrichment sessions for body image and self-esteem have positive effect on adolescents that help them improve their body image leading to improve self-esteem that building healthy relationship with their peer, friends and family.

5. Recommendations

1. Therapeutic programs to guide those who have unsatisfied body image to optimize consensus, mental health and self-esteem.

2. Teachers, parents, and school nurses should receive periodically education related to the development of secondary sexual characteristics during puberty of adolescents.

3. Conducting a clinical study to identify the personality dynamics of individuals who have a disorder in the body image and self-esteem.

4. Increasing adolescent and public awareness about the puberty physical changes and coping with it without affecting their self-esteem.

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