body image in the philippines essay

Corpus ID: 149011871

The Word of the Body: Depictions of Positive Body Image In Philippine Young Adult Literature

Gabriela Lee
Published 3 July 2017
Philippine Humanities Review

One Citation

Big, bakla, and beautiful: transformations on a manila pageant stage, 26 references, meant to be huge: obesity and body image in young adult novels, perceptions of body size and obesity: a selected review of the literature, culture versus biology: children's attitudes toward thinness and fatness., influence of media on body image satisfaction among adolescents, peer victimization and pediatric obesity: a review of the literature., learning curves: body image and female sexuality in young adult literature. scarecrow studies in young adult literature #35., unbearable weight: feminism, western culture, and the body, the ucla body project ii: breast and body dissatisfaction among african, asian, european, and hispanic american college women, correlates of body image satisfaction among economically depressed urban filipino women, reviving ophelia: saving the selves of adolescent girls, related papers.

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Is Body Shaming Part of Our Filipino Culture?

Any girl who grew up in a Filipino household knows a thing or two about being body shamed by family members or relatives. Whether it's being called names ( taba , payatot ) or getting called out for your size or shape (" ang laki laki mo na ," " para ka nang toothpick"), our parents, titos and titas , and lolos and lolas have contributed to it in one way or another. It's not that they hate us or deliberately want us to feel bad about ourselves. It's just that it's sadly become part of our culture.

Filipino-American Erica Dawn Waters (aka @erica_dawn_w ) is just one of the many who have endured "comments" like these until she couldn't take it anymore and told her relatives about it. Read part of her story below, which we are reposting with permission. She originally posted this on her blog, ericadawnw.com .

"Let me start off by saying I am a fiercely proud mixed-race, Filipino-American woman. Growing up, I had the wonderful and rare opportunity to live in the Philippines for six years-I learned Tagalog, immersed myself in the culture, enjoyed the endless delicacies and most importantly, developed a very close bond with my family on my mom's side. I am lucky to call both the Philippines and the United States my home.

5 Reasons Why It's Not Okay to Body Shame Yourself or Anyone Else

"If there's one thing I can attest to during my six-year stay in the Philippines, it's that Filipinos have earned their reputation of being some of the most friendly people in the world. And it's true, we are! However, no culture comes without blemishes, and the Philippines is no exception. I want to highlight one of our societal flaws that no one seems to talk about: blatant body shaming.

"Although I do not live there anymore, I try and visit as much as I can-because as any true Filipino, family-time is important to me. Every trip starts off the same way: After a 14+ hour flight, I am greeted by my cousins, aunts and uncles. Their first words to me are tumaba ka 'you got fat' as they simultaneously squeeze my 'arm fat.' My excitement for coming home instantly fades, and I immediately want to hop on the next America-bound flight-I know that this is just the beginning of a summer filled with unsolicited commentary pertaining to my body.

"At least I have someone who goes through this with me-my beautiful, older sister. Keep in mind, my sister and I are pretty healthy gals, but whenever we set foot in our island home, we are immediately pinned as fat or chubby. Why? Because Filipino's definition of beauty can best be described as: stick-thin. My sister and I just aren't built that way.

These comments are not meant to be insulting; unfortunately it's normal in Filipino society to comment on other people's physical appearances-good or bad. So, really anyone who doesn't fit within this society's beauty standards has to deal with this nonsense.

"My sister and I have grown accustomed to this practice, so we usually brush off the comments and try our hardest not to be fazed. But as much as we didn't want to be, we were fazed, we were very fazed-to the point where we used to put our bodies through hellish and unhealthy diets to try and avoid unwanted remarks about 'how fat we are' during our next visit. Yet, no matter how much we refrained from midnight snacking or how many miles we ran, we were still categorized as 'fat' the moment we stepped off the airplane.

I didn't realize it at the time, but this was a textbook case of body shaming on an entire cultural level.

"One summer, my sister and I had reached our breaking point. After a much needed, cousins-only staycation, a family member asked my sister why she's 'so big' for about the 100th time that month-as if her bone structure was her fault. She snapped, and rightly so! She wasn't going to take this treatment anymore, especially not from family.

5 Fat-Shaming Summer Memes That are Now Body-Positive

"This big blow up turned into a constructive conversation where I finally explained the negative emotional and physical effects these comments have had on my sister and me over the years. Interestingly enough, we got two very distinct responses during this chat. The first came from the older generation of our aunts and uncles who defended this behavior because it's so widely accepted.

They basically told us that because we are in the Philippines, we should conform to Filipino norms, and quit being so 'sensitive.'"

It was a good thing that Erica's cousins, who had also felt the same way about their relatives, had her back and supported what she had to say. Read about it and the rest of the story in Erica's blog post entitled, "Let's Talk About Body Shaming in the Philippines."

What are your thoughts on the issue? Sound off below or tweet us @candymagdotcom to join the conversation.

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Body image: A better perspective

Many people think of body image as a women’s issue or a young person’s issue. in actuality, we all have a perceived body image that affects so many aspects of our lives — including the opportunities we seek. .

What exactly is body image, and how can we cultivate a better, more healthy image so that we get the most out of life? To learn more, we talked to Dr. Kristine Luce , p sychologist and clinical associate professor in psychiatry and behavioral sciences at Stanford University School of Medicine.

Your body image is defined by your personal perception.

Dr. Luce defines body image as how a person thinks of, feels about and perceives their own body, and how a person imagines others perceive their body.

“Body image is an aspect of identity. Most people tend to self-identify by segmenting their lives into different roles. For example, a person may self-identify according to their profession, relationships, hobbies, etc. Body image is one aspect of a person’s complete identity, and within it a person can hold many perceptions, even contradicting perceptions.”

Although body image is commonly understood as having to do with weight and shape, the term actually encompasses all aspects of a person’s perceived physical appearance — including age, facial attributes and gender.

Body image exists on a continuum.

Dr. Luce views body image along a continuum, with “positive body image” on one end, “negative body image” on the other and the middle composed of varying aspects of both.

Dr. Luce describes a positive body image as a healthy self-image, in which a person has self-compassion and appreciation for their body. They recognize the amazing functions of their body and don’t let how they feel about their appearance limit how they live their life. On the other end of the spectrum, a person with a negative body image tends to be strongly self-critical and less attuned to the beneficial capabilities and functions of their bodies.

Most people, however, do not fall on one extreme or the other. The vast majority of people have varying degrees of appreciation and criticism for their bodies. Terms like “positive” and “negative” tend to be inadequate for fully capturing a person’s felt experience, which is generally more nuanced than binary. For example, when speaking about body image, a person may “fragment” and speak about parts of their bodies they like, and parts that they don’t like. Others might describe feeling positive about their bodies overall, but still want to change certain physical aspects.

A person’s body image is dynamic and ever changing throughout the lifespan. People tend to move along a continuum of how they perceive themselves at various stages of life, such as when they age or gain or lose weight.

Many factors contribute to a person’s body image.

Dr. Luce explains that we are constantly inundated with body image messages from many different sources, including history, economics, religion, family of origin and the media, which is the most prevalent.

Luce describes a series of studies conducted in Fiji before western TV was brought to the island. At that time there were no known cases of eating disorders in Fiji. The studies revealed that the first cases of eating and body image disorders emerged after western TV was brought to their culture, indicating that media presence was at least a contributing factor in how people perceived their bodies.

“Culture has long influenced body image by defining and dictating what is attractive. The media is a strong force that can shape and influence culture, for better or for worse.”

Other societal factors, including economic history and religion, can also contribute to one’s body image. Luce mentions that a higher body weight used to be a sign of fertility and wealth when resources were more scarce, but as resources have become more accessible, thinness or fitness is seen as a symbol of wealth because it indicates more time for self-care. For some religious groups, a thinner appearance could indicate a greater ability for fasting, which is associated with the virtue of self-control and used as a measure of spiritual virtue.

Finally, an individual’s personal history and upbringing can influence the way they perceive themselves and their bodies. For example, if someone is raised in a household or social environment in which a person’s value is very closely tied to their physical appearance, a person may begin to perceive their bodies as a measure of their self-worth.

With the constant onslaught of information we are receiving about how we think we should look, Dr. Luce assures us it is understandable if we feel pressure to look a certain way.

Body image can impact the choices we make in our lives.

Put simply, overconcern about appearance can limit what opportunities a person seeks. Dr. Luce gives several examples of this phenomenon, termed “self-handicapping” in social psychology. Self-handicapping is a cognitive strategy in which people avoid an opportunity to protect their self-esteem against the possibility of failure. For example, if a person makes the assumption that they will be discriminated against because of their appearance, they may not go for a promotion.

“Research on this subject shows that a strong enough limiting self-belief can restrict access and experiences throughout the lifespan. This is based on an assumption that may or may not be true.”

Other common examples of self-handicapping due to body image include postponing dating until reaching a particular appearance or avoiding visiting the doctor until reaching a desired weight. According to Luce, these are paradoxical approaches that rarely work, and often bring us further from our desired outcomes.

“When you think about it, most people want to look a certain way for more access in life, whether it be jobs, partners, health or something else. By avoiding promotions, dating and doctor visits due to body image concerns, our access to our desired outcomes becomes more and more limited. On the other hand, people who feel positively in their bodies are more likely to seek out opportunities in all of these areas.”

Negative body image persists throughout different demographic groups.

According to Luce, there used to be evidence that negative body image occurred more for women than for men, and more for white women than for other ethnic groups — but the gap has narrowed over time.

“In the last 20 to 30 years, there has been a proliferation of body image marketing to every ethnic group and gender. Now you can find body image advertising that targets everybody, thus increasing body image concerns and eating disorders across all types of people. I call it, ‘equal opportunity in the direction we were not hoping for.’”

Research conducted in the 1980s showed it was rare for people to feel positive in their bodies, which is a feeling that still persists, according to a 2018 poll .

There are many strategies for cultivating a more positive body image.

Dr. Luce encourages her patients to act according to their values rather than their negative self-beliefs. An example of this would be encouraging someone to go to the beach, if that is what they enjoy, even though they might also feel uncomfortable in a bathing suit. This is called a “cognitive dissonance intervention,” based on the theory that increasing the tension (or dissonance) between a person’s thoughts and actions will eventually create a new belief. Dissonance interventions are really about being aware of one’s values, living in alignment with them and not letting one’s beliefs limit opportunities in life.

“Sometimes the discomfort gets better at first, and sometimes it takes a while. But feeling the warmth of the sun or the coolness of the water can make the volume of those negative thoughts turn down, or at least fade them into the background.”

Another intervention, applied on a more macro scale, is counter-attitudinal marketing, which features people of various body sizes, shapes and ethnicities in advertisements.

“I used to have a lot of optimism around counter-advertising and counter-marketing as a strategy for improving body image across culture. I still believe it can work for people who are open to it.”

However, counter-attitudinal ads represent a very small percentage of mass media and social media images. The vast majority of media displays are not representative of the average body type: many are altered by image editing applications like Photoshop and filters, and some even represent an unhealthy body image. By understanding this fact, and being selective of our media exposure, we can begin to combat some of the negative effects of body image marketing. Luce acknowledges this is not an easy feat:

“Negative body image beliefs are deeply entrenched for some people and changing these thoughts, for some, can be very challenging.”

Luce goes on to describe how undoing a belief can be harder than building a new one, especially when we are exposed to so many media images and messages that are constantly reinforcing certain ideas.

Dr. Luce also encourages us to think about the way we speak about bodies and how this might affect body image for ourselves and our communities.

“We can all refuse to engage in conversations about other people’s bodies. By choosing to not engage in appearance-based conversations, we can influence the world by modeling our values.”

A similar strategy is reconsidering our appearance-based decisions as a message to the world. Dr. Luce admits that she doesn’t color her hair because she doesn’t want to give into the pressures around ageism. However, she acknowledges this type of action can be challenging because ageism and appearance-based discrimination exists in many fields.

“I am a psychologist in academia, so looking ‘old and wise’ is still valued. I recognize there are many people who feel they have to look a certain way to keep their jobs.”

Although we may not all be able to take such a strong action, everybody can do something to show the perception of feeling comfortable in the body they have. By choosing an alternative action that goes against societal pressures around body image, we can make changes that influence ourselves and the world around us.

Dr. Luce closes with a note of encouragement. “Body image is not static. Throughout life we move along a continuum of how we perceive ourselves. Regardless of how we feel about it at any given moment, we can have a full and meaningful life in the bodies we have.”

Mia Primeau July 2020

Select resources: Stanford Health Image Body Program The Body Positive Stanford Research Project Stanford Children’s Health: Boost Your Teen Daughter’s Body Image National Eating Disorders: The Body Project

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http://orcid.org/0000-0002-3383-6336 Zypher Jude G Regencia 1 , 2 ,
http://orcid.org/0000-0002-5497-5140 Jean-Philippe Gouin 3 ,
http://orcid.org/0000-0003-4757-8072 Mary Ann J Ladia 1 , 2 ,
http://orcid.org/0000-0002-0631-6298 Jaime C Montoya 4 ,
http://orcid.org/0000-0002-3888-8880 Emmanuel S Baja 1 , 2
1 Department of Clinical Epidemiology, College of Medicine , University of the Philippines Manila , Manila , Philippines
2 Institute of Clinical Epidemiology , National Institutes of Health, University of the Philippines Manila , Manila , Philippines
3 Department of Psychology, Faculty of Arts and Science , Concordia University , Montreal , Quebec , Canada
4 Department of Medicine, College of Medicine , University of the Philippines Manila , Manila , Philippines
Correspondence to Zypher Jude G Regencia; zgregencia{at}up.edu.ph

Introduction The rampant distribution of idealised images on the internet may lead the general public to improve their body appearance in a way that is sometimes excessive, compulsive or detrimental to other aspects of their lives. There is a decreasing appreciation of body image among emerging adults and an increasing trend on skin-lightening practices linked with psychological distress. This protocol describes the mixed-method approach to assess the relationships among body image perception, skin-lightening practices and mental well-being of Filipino emerging adults and determine the factors that influence them.

Methods and analysis An explanatory sequential mixed-method approach will be used. A cross-sectional study design will involve an online self-administered questionnaire of 1258 participants, while a case study design will involve in-depth interviews with 25 participants. Data analysis will use generalised linear models and structural equation modelling with a Bayesian network for the quantitative data. Moreover, the qualitative data will use an inductive approach in thematic analysis. A contiguous narrative approach will integrate the quantitative and qualitative data.

Ethics and dissemination The University of the Philippines Manila Review Ethics Board has approved this protocol (UPMREB 2022-0407-01). The study results will be disseminated through peer-reviewed articles and conference presentations.

MENTAL HEALTH
EPIDEMIOLOGY
Anxiety disorders
Depression & mood disorders
PUBLIC HEALTH

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2022-068561

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Strengths and limitations of this study

The mixed-methods approach will allow the researchers to capture the complexity of human phenomena, such as the main interests of this research—body image perception and skin-lightening practices.

The use of a mixed-method approach will allow for greater validity by seeking corroboration between the gathered quantitative and qualitative data.

The case study design may be used at various points of the research project, and the ability to explore deeper causes of particular phenomena will be achieved.

This study is only limited to Filipino emerging adults residing in the Philippines. It may also be limited to the study population with internet access since the survey will only be available online. Therefore, it may not capture the intended study population who do not have internet access.

The use of a cross-sectional study design in the quantitative part will not examine the temporal relationships between body image perception, skin-lightening practices and mental health status.

Introduction

Mental health concerns and body images.

Emerging adulthood represents a developmental period that follows adolescence and precedes adulthood. Various changes regarding their body will be experienced in this developmental period. These changes put the emerging adults at risk of being dissatisfied with their body appearance. 1 2 Factors including the timing of puberty, body mass index changes, sexual experiences and sexual maturation affect how emerging adults perceive themselves and their bodies. 3 4 Among emerging adults, there is an increasing trend of observations on body dissatisfaction linked with depression 5–7 and psychological distress. 8 Three essential factors became the basis for the later development of eating dysfunction due to body dissatisfaction: peers, parents and media, according to the Tripartite Influence Model. It is one of the most influential models depicting the development of eating problems. 9 The model includes two intervening factors that connect the influences to disturbed body image and eating problems: the internalisation of the societal standard of appearance and increased tendencies to compare appearances. 10 Patterned from the Tripartite Influence Model, in a previous study, results showed Filipino males had more significant dysfunction in eating attitudes compared with Europeans, while control over eating and bulimic eating behaviour was prominent in Filipino females. 11 These behaviours are eminent in non-Western culture due to the fear of getting fat. 12 13 However, contrary to these previous results, positive body image was also linked with better overall well-being and quality of life. 8 14 15 Measurements such as body appreciation and body esteem are positively associated with mental well-being. 16 17

Global skin-lightening practices

Skin-lightening practices became a trend among emerging adults to modify one’s skin tone. Skin-lightening practices are an understudied field in public health; therefore, there is an accentuated need for more epidemiologic research, particularly in under-represented countries. 18 The global phenomenon of using skin-lightening products (SLPs) is rooted in the perception that lighter skin tones may result in more opportunities in life. 19 SLP use among and between some ethnic/racial groups in Asia and Africa increased due to this perception. 20 21 A lighter skin tone is seen as a symbol of beauty, attractiveness and desirability in the African region. 19 Skin lightening is driven by a variety of factors, including psychological, cultural, sociopolitical and historical factors. 22–25 Many international cosmetic companies have used these driving factors to capitalise on this market. Companies manufacturing SLPs used different marketing strategies, such as internet marketing and social media public relations. The cultural phenomenon of skin lightening has become widespread in Asia, and it may affect the mental well-being of SLPs consumers. 26 27 In addition, some people use SLPs to manage and treat conditions relating to dermatology, including hyperpigmentation, melasma, age-induced darkening and acne. 27 28 Homemade formulations using household items combined with SLPs are now rampant among consumers. However, the unregulated and unsupervised mixing of SLPs with household items may bring dangerous effects, such as ochronosis (blue-black hyperpigmentation in the skin). 28

Skin-lightening practices and mental health concerns

Studies examining the association between using SLPs and mental health problems are a relatively new field of study. However, it has been recently observed that SLPs use is significantly associated with body image disturbances and previous exposure to trauma. 29–31 Research focused on skin-lightening practices also identified psychological correlates among Asian and African populations. There are related psychological problems that have been highlighted and are categorised as (1) self-esteem-related factors, 14 26 32 (2) body image-related factors 14 33 34 and (3) other potential psychological factors, such as the history of trauma and depressive symptoms. 31 35 In the Philippines, the Filipino’s psychological state due to American colonialism contributes to the success of the rampant SLP use. 36 In a more recent period, SLP use may also be attributed to the tendency to conform to popular culture. 36 A recent study among young Filipino men pointed out that their body modification practices, particularly the use of SLPs, are mediated by the influence of peers, employers and global pop culture. 37

Exposure to media and its influence

Global pop culture consisting of the media and social media and peer pressures may influence how emerging adults see themselves. 38 39 The emerging adult’s perception of their appearance can become distorted, leading them to engage in risky behaviours when they feel they do not measure up to the impossible goal set. The media’s effect on body image perception can cause body image issues, leading to greater risk for poor mental health conditions, eating disorders, drug and alcohol use, cutting and sexual risk behaviours. 40 Media also plays an essential role in encouraging consumers to buy and use SLPs. 25 In addition, the media portrays the lightness of the skin tone as an epitome and a standard for beauty in some cultures. 41 42 Body image, beauty and fair skin tone are the main concepts of information dissemination and product advertisements portrayed in television, magazines, newspapers and on social media platforms, including Facebook, Twitter, Instagram and TikTok. 23 27 43–45

Mental health landscape in the Philippines

The Philippines has recently passed the first law concerning the mental health of Filipinos, the Mental Health Act (Republic Act no. 11036). The Act seeks to establish access to comprehensive and integrated mental health services while protecting the rights of people with mental disorders and their family members. 46 However, mental health programmes in the Philippines remain poorly funded by the government. It is estimated that only 3–5% of the total health budget is spent on mental health, while 70% is spent on hospital care. 47 The Philippine Statistics Authority reported that mental illness in the Philippines is the third most prevalent form of morbidity. In addition, 6 million Filipinos are estimated to live with depression and/or anxiety, making the Philippines the country with the third-highest rate of mental health problems in the Western Pacific Region. 48 The scarcity of epidemiologic evidence on mental health disorders in the Philippines is evident. These estimations do not represent the numbers of Filipinos living with mental health problems as state-funded country-wide mental health screening activities and programmes are not in place. 46

Background of the study

This study was conceptualised from a growing number of theoretical and empirical studies on body image perception, skin-lightening practices and the mental well-being of both men and women. The interplay of body image and skin-lightening practices is anchored on the history of racism and modern world globalisation in the contemporary context where social media dictate a hegemonised body image and skin colour, thus, affecting a person’s mental health status. However, the interaction between body image perception and skin-lightening practices among Filipino emerging adults and its overall effect on the psychological distress of emerging adults remains understudied. Therefore, inclusive and extensive research examining various factors as patterned from the Tripartite Influence Model 9 concerning this burgeoning field is crucial in these social-media-induced trying times when mental health is greatly affected.

General aim

This study aims to assess the effect of body image perception on the mental health of Filipino emerging adults as mediated by skin-lightening practices and determine the factors that influence them.

Specific aims

To describe the Filipino emerging adults’ sociodemographic characteristics, stratified by their levels of depression, anxiety and stress.

To describe the body image perception of Filipino emerging adults, stratified by their depression, anxiety and stress.

To describe the skin-lightening practices of Filipino emerging adults, including their knowledge, perception and use of SLPs, stratified by their depression, anxiety and stress.

To estimate the effect of body image perception, skin-lightening practices and levels of media exposure on levels of depression, anxiety and stress among Filipino emerging adults.

To investigate the relationships among body image perception, skin-lightening practices and the levels of depression, anxiety and stress of Filipino emerging adults by testing a structural model.

To qualitatively identify the factors that contribute to or protect Filipino emerging adults from depression, anxiety, stress, body image concerns and skin-lightening practices.

To contextualise and expound the quantitative survey data results about the effect of body image perception and skin-lightening practices on levels of depression, anxiety and stress of Filipino emerging adults using the qualitative findings.

Methods and analysis

Study design.

This study will use a mixed-method approach, specifically the explanatory sequential design, to address the study’s objectives due to complex interactions among body image perception, skin-lightening practices and mental well-being and gain a comprehensive and in-depth overview of this topic. 49 We expect that qualitative and quantitative methods will capture the complexity of body image concerns and skin-lightening practices. 50 51 This approach will also allow us to better understand and interpret the quantitative findings using the findings from the qualitative part of the study. 50 52 53 This mixed-method approach includes (1) a Quantitative Part: a cross-sectional study involving an online questionnaire among the intended study population; and (2) a Qualitative Part: a case study involving in-depth interviews of selected participants from the quantitative part of the study.

Population and sampling technique

Study population.

This study will focus on Filipino emerging adults as the sample population. The inclusion and exclusion criteria are as follows:

Inclusion criteria

18–29 years old.

Filipino residing anywhere in the Philippines.

Male or female (sex-assigned-at birth) and all genders.

Can understand English.

Have internet access.

Exclusion criteria

Refused to provide a signed informed consent form.

Clinically diagnosed with depression or anxiety.

Sample size calculation, sampling technique and recruitment plan

For the online questionnaire, using the Error Function, Lower-Bound Sample Size and the Normal distribution Cumulative Distribution Function formulas for sample size calculation of structural equation models with a priori variables previously described, 54 55 a total minimum sample size of 1258 Filipino emerging adults will be required. An anticipated effect size of 0.10, a desired statistical power level of 80%, three latent variables, 18 observed variables and an α-level of 0.05 were used to calculate the sample size. In addition, non-probability convenience sampling will be employed for this nationwide survey among the target study population. The study will occur from October 2022 to April 2023. The participants will be recruited using different online platforms to answer the online questionnaire voluntarily. These platforms will include the Top four social media: Facebook, Twitter, Instagram and Tiktok. In addition, there will be indicators in the questionnaire to screen for valid data, such as a time recording of the response rate and an attention checker between sections of the questionnaire.

In qualitative studies, the sample size is based on the number of participants needed to achieve concept saturation, the point in the data collection when little or no relevant information emerges, and collecting more data will not add new understandings to identified concepts. 56 57 Studies showed that as few as 12 participants could be sufficient to explore shared experiences within a group, 58 with 25 informants achieving 99% saturation of concepts. 59 This study will use at least 25 informants as theoretical samples to investigate body image perception and skin-lightening practices. The initial 15 informants will include those that have severe/extreme levels of depression (five informants), anxiety (five informants) and stress (five informants) as measured during the quantitative survey. The remaining 10 informants will include those with no body image concerns (five informants) and those practicing skin lightening (five informants). Random sampling will be employed to select participants for the in-depth interview using the previously described criteria. In addition, to minimise selection bias, randomisation will be used for those chosen based on their outcome scores in the questionnaire (eg, extremely depressed, extremely anxious and extremely stressed informants), no body image concerns and practicing skin-lightening regimens. In addition, recruitment will be done by selecting the respondents who answered the online questionnaire. If the selected in-depth interviewees are uncontactable via the cellphone number or email address the informants provided, fail or decline to join; they will be replaced randomly by information-rich cases. Moreover, power dynamics will not be used to recruit respondents. The research objectives, methods, risks, benefits, voluntary participation, withdrawal and respondents’ rights will be discussed with the participants in the consent form before conducting the in-depth interview.

Data collection procedure

Quantitative part: cross-sectional survey.

The study will involve creating and distributing a self-administered online questionnaire. The questionnaire will comprise sections of demographic data (age, sex, sexual orientation), socioeconomic status (average monthly household income, occupation, highest educational attainment, urban/rural residence), the levels of media exposure (television, movie, social media and internet), relationship status (single, in a relationship), exposure assessment (body image perception and skin-lightening practices) and outcome measurements (levels of depression, anxiety and stress). The online questionnaire will be distributed in English using the Qualtrics XM platform. All questions in the survey are forced choices. Informed consent detailing the purpose, risks, benefits, methods and other ethical considerations will be presented before the participants can answer the online questionnaire. Before online release, the questionnaire shall undergo pilot pre-testing among 20 Filipino emerging adults not involved with the study. It aims to measure total test-taking time, respondent satisfaction and understandability of questions. The survey form shall be edited according to the pilot test participants’ responses.

Exposures assessment

Body image perception will be the primary exposure, and skin-lightening practice is the mediator of this study. The concept of body image perception and skin-lightening practice will be considered latent variables in the hypothesised structural model. Three observed indicators will be used to build a measurement model around body image perception: Body Appreciation Scale (BAS-2), 60 Body Esteem Scale (BES) 61 and Positive Rational Acceptance Scale (PRAS). 62 The BAS and BES measure how a person accepts each body feature, while PRAS assesses how a person responds to threats to these body features. Together, these three scales measure one’s positive body image perception. In addition, three observed indicators will also be used for the skin-lightening practice latent variable: Knowledge (K), Perception (P) and Use (U).

Research has already advanced the understanding of measuring body image perception, which gives a wide range of body image scales such as the BAS. BAS is a well-validated measure of positive body image. It represents intentional choices to accept body image regardless of its imperfections or size, respect the body by taking care of needs through engagement in health-seeking behaviours and safeguard the body by enduring the influence of narrow beauty standards promoted in the media. 63 For each item, the following response scale will be used: 1=Never, 2=Seldom, 3=Sometimes, 4=Often and 5=Always. 60 Previous research found a unidimensional factor structure, strong internal consistency (Cronbach’s α = 0.97), construct validity and test–retest reliability (r = 0.90) in community and college samples of men and women. In this study, the BAS-2 will be used, which was improved by rewording certain BAS items to remove sex-specific versions and body dissatisfaction-based language. Additional items based on positive body image research were also developed, making it a more psychometrically sound positive body image measure applicable for research. 60 Additionally, the internal consistency of the BAS-2 was excellent (Cronbach’s α=0.954, McDonald’s ω=0.956). 64

BES for adolescents and adults is widely used to assess cognitive and affective features of body image perception. 61 BES was designed for both men and women young adults and validated among college students. 65 The scale represents distinct dimensions for men and women. 66 This study will employ 19 out of the original 35 BES items. The 19 items were selected to include all items about the ‘physical condition’ and ‘weight concern/upper body strength’ factors. The ‘sexual attractiveness’ items were excluded, which had the majority of ‘physical attractiveness’ items for men. 67

Lastly, another well-accepted body image perception scale measures positive rational acceptance coping. PRAS has been conceptualised and designed as an adaptive affect regulation mechanism when the body is exposed to body image challenges. 62 Generally, PRAS involves positive self-talk, such as reminding oneself of the transience of experiencing body image concerns in the aftermath of a threat, and is positively associated, although weakly, with more general adaptive emotional regulation strategies. 68 Participants will be asked to complete an 11-item PRAS of the body image coping strategies inventory (BICSI). 62 Scores on the BICSI have been shown to have adequate factorial and construct validity and internal consistency. Cronbach’s α for PRAS scores was 0.85 (95% CI: 0.83 to 0.87). 62

The questionnaire on skin-lightening practices will be adapted from a previous study conducted in Southeast Asia, including Indonesia, Malaysia, Myanmar, Thailand and Vietnam. 69 Knowledge of the use of SLPs will be assessed with two questions, (a) the awareness that SLPs can harm the skin; and (b) knowing the active ingredients in SLPs. 27 Perceptions about a lighter skin tone and the use of SLPs will be assessed with eight items. Response options will be 1=strongly agree, 2=agree, 3=disagree, to 4=strongly disagree (Cronbach’s α=0.78). Furthermore, SLP use will be assessed with two questions: ‘Have you ever used SLPs?’ and ‘How often have you used SLPs in the past year?’ in which response options will be yes or no and will range from 0=never to 4=at least once per 3 months, respectively. 70

Outcome measurements

The validated Depression Anxiety Stress Scales-21 (DASS-21) will be used to assess the psychological distress of the respondents. DASS-21 was developed to measure the emotional states of depression, anxiety and stress. 71 DASS-21 has been previously used in American, 72 European 73 and Asian 74–78 populations. DASS-21 contains three subscales with seven items each to measure levels of depression, anxiety and stress. DASS-21 scores will be calculated based on previous studies. 79–81 The total score will be summed up in which higher scores indicate more negative experiences in the past week. For descriptive analysis, the total depression subscale will be divided into normal (0–9), mild depression (10–12), moderate depression (13–20), severe depression (21–27) and extremely severe depression symptoms (28–42). In addition, the total anxiety subscale score will be divided into normal (0–6), mild anxiety (7–9), moderate anxiety (10–14), severe anxiety (15–19) and extremely severe anxiety symptoms (20–42). Moreover, the total stress subscale score will be divided into normal (0–10), mild stress (11–18), moderate stress (19–26), severe stress (27–34) and extremely severe stress (35–42). 82

Sociodemographic variables and levels of media exposure

Based on previous literatures, the sociodemographic variables will be ascertained and selected a priori . These variables include age, 83–87 sex at birth, 88–90 sexual orientation, 91–93 household income, 90 94 working status, 90 95 highest educational attainment, 90 95 relationship status 96 97 and type of residence. 98 99

Additionally, the level of media exposure will also be ascertained using a questionnaire adapted from a study done in the Philippines with a few modifications. 100 The instrument will include questions on the influence of movies, television, the internet and social media platforms on the participants’ body image perception and skin-lightening practices. Some examples of the questions included in this section are: ‘I watch more than nine movies in a month’, ‘I immediately try any new product that I saw in a commercial’, ‘I feel handsome or beautiful when my solo picture gets a lot of likes or comments’ and ‘I compare my appearance with the photos of my Facebook friends, Instagram/Twitter mutuals, TikTok videos and other photo posts on social media’. Questions will be answered as never, sometimes, often and always.

Qualitative part: case study

Concept notes will be developed focusing on the extraneous factors affecting the participants’ body image perception, skin-lightening practices and psychological distress. Some salient topics will include current stressors (eg, personal, familial, social), emotional reactions to these stressors and facilitators that enable the participants to achieve their current motivations to modify their bodies and/or lighten their skin.

The researchers will facilitate the in-depth face-to-face interview or via various online video conferencing software such as Google Meet, Skype or Zoom. All the in-depth interviews will be recorded and transcribed for analysis. Online supplemental file 1 shows the in-depth interview guide and discussion questions.

Supplemental material

Data processing and analysis.

Descriptive statistics will be calculated and presented in frequencies and percentages for categorical variables and mean, SD and range for continuous variables to answer Specific Aim Nos. 1–3. Differences in the sociodemographic characteristics between participants will be assessed using t-tests (for continuous variables) and χ 2 or Fisher’s exact tests (for categorical variables). In addition, effect estimates will be calculated to assess the relations among body image perception, skin-lightening practices, mental health status, levels of media exposure and sociodemographic variables to answer Specific Aim No. 4. Moreover, associations between exposures (body image perception and/or skin-lightening practices) and mental health status will be estimated using generalised linear models. Depending on how common the mental health outcomes are, generalised linear models with either a Poisson distribution and log link function with a robust variance estimator or a binomial distribution and logit link function will be used to estimate either the crude and adjusted prevalence ratios (PRs) or crude and adjusted odds ratios (ORs) with 95% CI, respectively. 101–104 All regression analyses will be done in R software, and p values ≤0.05 will be considered statistically significant.

For Specific Aim No. 5, proposed structural and measurement models will be used based on the literature review ( figure 1 ). The specified model was built from reviewing previous literature on body image perception and skin-lightening practices regarding their expected relationships among the key constructs and health outcomes. Structural equation modelling (SEM) will be used to estimate and test the direct and indirect effects of the latent exposure variables (body image perception and skin-lightening practices) on the latent mental health status variable. This study will focus on the structural and measurement models.

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Structural model for the exposure, mediator and outcome variables. A, anxiety; BA, body appreciation; BE, body esteem; D, depression; EA, education attainment; HI, household income; K, knowledge; P, perception; PRA, positive rational acceptance; R, type of residence; RS, relationship status; S, stress; SO, sexual orientation; U, use; WS, working status.

The responses in the structural model in figure 1 are specified as ordered categorical (ordinal) variables. The default estimator for responses such as these is a robust weighted least squares estimator. 105 This estimation specifies a series of probit regression equations for each factor indicator on the related factor. The distribution of all observed variables will be specified in the estimation procedure. All specified models will be estimated using traditional Maximum Likelihood Estimation (MLE) and Bayesian estimation. In the MLE specification, variances of the factors will be assumed to be standard normally distributed, that is, with a variance of 1 and a mean of 0. The MLE method estimates parameters and their SE and fit indices using a normal distribution for all parameter models based on an elements matrix derived from the asymptotic variances of the thresholds and latent correlation estimates. 106 107 Results will be presented as standardised loadings, interpreted as probit regression coefficients. 105 All analyses will be done in R software.

This part of the data analysis will answer Specific Aim No. 6. One researcher will transcribe the interview, while two other researchers will validate the transcription by checking the transcript vis-à-vis the interview recordings. After transcribing the interviews, the data transcripts will be analysed using NVivo 1.6.2 software 108 by three research team members independently using the inductive logic approach in thematic analysis: familiarising with the data, generating initial codes, searching for themes, reviewing the themes, defining and naming the themes and producing the report. 109

Data familiarisation will consist of reading and re-reading the data while noting initial ideas. Additionally, coding interesting features of the data will follow systematically across the entire dataset while collating data relevant to each code. Moreover, the open coding of the data will be performed to describe the data into concepts and themes, which will be further categorised to identify distinct concepts and themes. 110

Data analysis of the interviews will be carried out according to the steps described by previous literature using a coding technique wherein the early data analysis is a critical step in the overall interpretation of the case studies. 111 The researchers will begin by coding each line of each participant’s transcript. Similar codes will then be grouped to form subcategories, and within these subcategories, categories will be identified. The primary researcher will then group the categories to develop a theory related to key informants’ experiences of body image perception, skin-lightening practices and mental health status. The data collection process will continue until each category is saturated and no new data emerges.

There will be comparisons and contrasts of the analyses conducted to develop a thematic map as discussed by the three researchers. The final thematic map of the analysis will be generated after checking if the identified themes work in relation to the extracts and the entire dataset. In addition, the selection of clear, persuasive extract examples that connect the analysis to the research question and literature will be reviewed before producing a scholarly report on the investigation. Additionally, the themes and sub-themes generated will be assessed and discussed in relevance to the study’s objectives. Furthermore, gathering and analysing the data will continue until saturation is reached. Finally, pseudonyms will be used to present quotes from the qualitative data.

Data integration from quantitative and qualitative findings

Specific Aim No. 7 will be answered using a contiguous narrative approach. It will be implemented to report and integrate the mixed-method results, reporting results of the quantitative strand followed by results of the qualitative strand in different subsections. Data triangulation will integrate the two separate data sources by examining the various aspects of the research and comparing them for convergence. Qualitative and quantitative data integration at the interpretation and reporting level will occur through joint displays. 112 113 When integrating through joint displays, the researchers will bring the data together visually to draw out new insights beyond the information gained from the different quantitative and qualitative results. This integration can occur through organising related data in a figure, table, matrix or graph. 114–116 Two researchers will be involved in the quantitative and qualitative data triangulation. Should there be disagreements, again the primary researcher together with the multidisciplinary research team will resolve the issue. Figure 2 shows the study’s implementation matrix of the explanatory sequential design.

Implementation matrix for the proposed explanatory sequential mixed-method study.

Data management plan

The primary researcher will be responsible for overall quality assurance undertaking specific activities to ensure quality control. Quality will be assured through routine monitoring of data collection procedures and periodic cross-checks against the approved protocol. Transcribed interviews and the online questionnaire will be used to record data for each participant in the study. The primary researcher will ensure the data’s accuracy, completeness, legibility and timeliness. Data captured from the online questionnaire or in-depth interviews should be consistent, clarified and corrected.

Handling missing data

All responses in the questionnaire using the Qualtrics XM will be forced. In self-report measures, data can be missing at either the item or variable level. Item level missingness occurs when subjects omit one or more items within a multi-item instrument that measures an abstract concept or variable. Variable level missingness occurs when all items on a multi-item instrument are missing. The survey forms with missing data for any variables used in the analysis will be removed. Rough guidelines for this approach suggest that if less than 10% of study participants have missing data for one or more of the analysis variables, the study results should not be significantly affected. 117 118 Multiple imputations will be used to analyse incomplete or missing data. If more than 40% of observations have missing values, then variables with the most missing values should be removed from the analyses. 117 118

Participant and public involvement statement

The participants and the public were not involved in the design and implementation of the protocol.

Ethical considerations and disseminations

Ethical considerations.

The study shall abide by the Principles of the Declaration of Helsinki (2013). It will be conducted along with the Guidelines of the International Conference on Harmonization-Good Clinical Practice (ICH-GCP), E6 (R2) and other ICH-GCP 6 (as amended); Philippine National Ethical Guidelines for Health and Health-Related Research (NEGHHRR) of 2017. Furthermore, this study protocol was granted ethical clearance from the University of the Philippines Manila Research Ethics Board (UPMREB 2022-0407-01).

All digital data will be stored in a cloud drive accessible only to the researchers. In addition, subject confidentiality will be upheld by assigning control numbers and not requiring participants to divulge their name, address and other identifying factors unnecessary for analysis. After the study, the personal data gathered from the participants will be deleted from the system and will be wiped out from the cloud drive where the data is stored. Participants may access the study results on sending a considerable request to the primary researcher. The data provided in this informed consent form are all valid during the duration of the study, which is 6 months but will be stored for up to 3 years.

Dissemination

The results will be disseminated through conference presentations, peer-reviewed journals and stakeholder activities.

The need to demonstrate more evidence

The topic of mental health has received a remarkable increase in global attention. Over time, trends showed an increasing number of people suffering from mental health disorders. 119–121 The worldwide rise in the incidence of mental health disorders prompted researchers to investigate more on this phenomenon. Growing evidence suggests that a positive body image is connected to improved social, psychological and emotional health, including physical health. 122–125 Reports have also suggested an association between a pattern of better mental health status and using SLPs. 19 126 127

The explanation speculated behind the determinants of skin-lightening practices suggests that symptoms of good mental health are linked with deficits in self-esteem or body image. 19 Many people in some populations are now more likely than ever to lighten their skin to fit into society’s definition of beauty. 128 People who use SLPs feel like they belong in a community where beauty standards must be accepted. 129 In addition, using SLPs may also be viewed as a coping mechanism for some people. 69 130 131 The biological and psychosocial phenomenon of skin lightening involves the observed interaction among three essential factors: motivation to engage in skin lightening, the different practices of skin lightening and its related effects and the prevention and treatment processes. 132

Little is known, however, about the interaction of various factors relating to body image concerns and skin-lightening practices and their effect on mental health status. In the Philippines, this emerging scientific field of research is not fully explored. For example, previous local studies only dealt with body image and mental health, 100 133–136 or skin-lightening practices, 137 138 but not the combination. Furthermore, these local studies on body image and mental health mainly tackled body dissatisfaction and depression, 100 133–136 contrary to our study which will deal with positive body image. In addition, local studies on skin-lightening practices specifically discussed how colonialism affected how Filipinos think about skin colour. 137 138

The link between body image perception, skin-lightening practices and the mental health status of Filipino emerging adults is not fully understood. This study will explore other factors contributing to the prevalence of mental health disorders brought about by the overall interaction, direct and indirect effects of body image perception and skin-lightening practices.

Study significance

This study focuses on the overall interplay of body image perception and skin-lightening practices and their effect on the mental health status of Filipino emerging adults. On an individual level, this study may increase the awareness of Filipino emerging adults as to the effect of body image perception and skin-lightening practices on their mental health status. Furthermore, this study may help them understand how the interplay of body image perception and skin-lightening practices and their effects on mental health status is affected by various factors culturally sensitive to Filipinos. On a societal level, explicit action is needed to build and promote positive body image perception to support reasonable mental health concerns. This study could be a first step toward providing evidence on effectively regulating body image concerns and practicing safe skin-lightening practices. In addition, the results of this study may give the Education Department at secondary and tertiary levels the foundation and basis to include and promote positive body image perception, safe skin-lightening practices and mental health status in their current curricula. Furthermore, the Education Department may include it through the inculcation of body and skin tone diversity in the early education learning stages of the students.

Study limitations

This study is only limited to Filipino emerging adults residing in the Philippines. In addition, it may also be limited to the study population with internet access since the questionnaire will be available online. Therefore, this study may not capture the intended study population who do not have access to the internet.

Ethics statements

Patient consent for publication.

Not applicable.

Acknowledgments

The authors would like to thank Dr Margaret Gamalo for her valuable technical inputs, support and guidance in the development of this protocol. Her contributions enhanced the scientific vigour of this protocol. In addition, Mr Regencia would like to thank the Accelerated Science and Technology Human Resource Development Program (ASTHRDP) of the Department of Science and Technology - Science Education Institute (DOST-SEI) for the scholarship grant provided.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Data supplement 1

Collaborators Dr Margaret Gamalo (Executive Director - Biostatistics Global Product Development, I&I Statistics Global Biometrics & Data Management, Pfizer Innovative Health)

Contributors All persons listed as authors have met the International Committee of Medical Journal Editors (ICMJE) authorship criteria. All authors have made significant contributions and revisions to the final manuscript and have provided complete consent for publication. Each author is responsible for the content and has read and approved the final manuscript. No author has any conflict of interest and/or disclosure to state for this manuscript. This includes financial, institutional, consultant and other relationships. ZJGR conceived the study with guidance from ESB. ZJGR conceptualised and designed the protocol. ESB, MAJL, J-PG and JCM contributed to the introduction, methods and analysis, strengths and limitations and discussion. All authors reviewed and approved the manuscript.

Funding The Department of Science and Technology will fund the project under a scholarship grant from the Accelerated Science and Technology Human Resource Development Program of the Science Education Institute.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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Body Image Perception and its Relationship to Self-Esteem among the Students of ETTMNHS

Jonalyn Francisco
Eas Angelo A. Reveral
Martin Joseph A. Santera

INTRODUCTION

Physical appearance is one of the characteristics noticed by others and has an important impact on social interaction. The study showed body image is a major factor why some women/men have poor self-esteem (Popkins, 2001). If you have a poor body image, it means you will link with other concern of childhood, such as low self-esteem, depression, and an eating disorder. In this study, the researcher wants to determine the perception of body image and its relation to self-esteem. As of now, there is a limited study about the correlation of body image and self-esteem in the public schools of the Philippines.

To determine the student's perception about the body image and its relation to self-esteem, this descriptive research made use of the Body Image Questionnaire and Self-Esteem Questionnaire to test their perception. The respondents are fifty-six (56) Grade 11 selected via stratified sampling.

According to the result of the data, the correlation between body image and self-esteem is 0.17963. It means there has a little correlation about body image and self-esteem.The SD for body image is 0.20 and for self-esteem is also 0.20.

DISCUSSIONS

The result from the Body Image Questionnaire and Self-Esteem Questionnaire revealed that there is a little correlation about body image and self-esteem. That means the majority of the respondents’ self-esteem was not affected by their physical appearance. However, only a minority of the respondents' self-esteem was affected because of their physical appearance.

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Figures and Tables

Introduction.

Acne vulgaris (AV) is one of the most common disorders managed by dermatologists around the world. It is a chronic inflammatory skin condition involving the pilosebaceous unit that is commonly seen in adolescents and young adults. Majority of patients are in the teenage years but acne may persist into adulthood.[1] Although it is non-life-threatening with no mortality associated, patients may experience significant psychological morbidity[1] as manifested by embarrassment, impaired self-image, low self-esteem, self-consciousness, frustration, and anger.[2]

Dysmorphia is defined by the Cambridge dictionary as a “condition in which part of the body is a different shape from normal” and also used to refer to conditions in which a person has false belief that something is wrong with a certain body part.[3] This can refer to certain phenomena such as “body dysmorphia”, which is a preoccupation on flaws that are unnoticeable to others.[4] Although not considered as psychiatric disorders on their own,[5] body dysmorphia is highly associated with Body Dysmorphic Disorder (BDD),[6,7] which is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as having excessive preoccupation with perceived defects or flaws believed to be ugly, unattractive, abnormal, or deformed that are not observable or appear only slightly to others; manifested by excessive repetitive behaviors such as mirror checking, excessive grooming, skin picking, and reassurance-seeking result to clinically significant distress or impairment in social, occupational, or other important areas of functioning.[4]

AV and its impact on one’s quality of life may not always be proportional to its severity as its extent to cause disability is an interplay of personal, social and occupational factors,[8] which means that a patient with multiple inflammatory lesions may report less psychosocial distress when compared to a patient who has mild acne and hides in shame until lesions resolve.[9] An extreme case of such is depicted in BDD which is also associated with comorbid psychiatric conditions such as major depressive disorder, social anxiety disorder, obsessive-compulsive disorder and substance-related disorders.[4] A study among Filipino patients with AV revealed that adolescent patients were 10 times more likely to be at risk for anxiety and depression, which is crucial as perceived flaws in physical appearance at such a stage may have a significant impact on self-image, consequently leading to decreased self-esteem, body image problems, and social withdrawal.[10] In a study by Bowe, Leyden, Crerand, Sarwer & Margolis,[9] 36.1% of patients with mild to barely detectable acne reported the same BDD symptoms as those with moderate to severe acne. Studies suggest that treatment rarely improves overall severity of BDD and that although acne may improve, such a preoccupation may shift to another feature such as the nose or hair[9, 11] or may result in a higher degree of dissatisfaction with subsequent increase in BDD symptoms.[12] BDD is seen in 2% of the general population[13] with the highest prevalence in rhinoplasty setting (20%), general cosmetic surgery (13.2%) and dermatological settings (11.3%).[14]

Over the years, there has been an increasing popularity of social media use among adolescents and young adults[15] making it an integral part of their social life. In Digital 2020: Global Digital Overview, the average social media use in the Philippines is 3 hours and 53 minutes, which is significantly higher compared to the global average of 2 hours and 24 minutes.[16]

Social media is defined as “an online platform which people use to build social networks or social relations with other people who share similar personal or career interests, activities, backgrounds, or real-life connections."[17] It is a web-based form of communication allowing conversations and information sharing among its users in the form of blogs, micro-blogs, social networking sites, video-sharing and photo-sharing sites such as Facebook, Twitter, YouTube, Instagram and TikTok, among others. With today’s era of technology and social media, it is the current young generation that has not experienced life without digital technology making them invested in their online identities.[18] It has been suggested that social media, especially those focused on visual content such as Snapchat and Instagram[15] play a role in encouraging negative belief of the body image by promoting universal standards[19] and is associated with increased body dissatisfaction and disordered eating.[20] Specifically, “selfies” or photographs taken by oneself focusing on the face posted on social media have been discussed for a possible correlation with body dysmorphia.[21] The use of selfies increased remarkably since 2012, leading to different areas of interest in terms of research,[22] particularly on the obsessive taking of selfies. Alongside its increase in popularity is an increase in number of cosmetic procedures including facelifts, eyelid surgeries, liposuction and facial rejuvenation in the United States, as presented by stats from the American Society of Plastic Surgeons, with “looking better in selfies on Instagram, Snapchat, and Facebook” noted as incentives for patients to seek such procedures.[23] With selfies, distress may result due to discrepancy of the real image taken and the ideal photo imagined, readily compared with their peers.[15,21]

The main objective of this study was to compare the body dysmorphic symptoms and selfie behavior between patients with mild AV versus those without AV. The results will highlight other possible factors influencing the disease course of AV, focusing on psychological factors (for example, body dysmorphia, selfie behavior) and help dermatologists address an unseen problem among these patients.

Methodology

This is a descriptive cross-sectional study on patients with mild AV and those without AV seen through a tertiary hospital’s teledermatology platform from April to June 2022. The Research Ethics Committee has approved of this study.

Patients aged 18-28 years old diagnosed with mild AV by their primary physician and those with no evidence of AV for the control group were included in the study. Patients with the following were excluded: presence of atrophic or dystrophic scars on the face; disfigurement of the face other than acne lesions; inability to read and understand English; and those with known psychological disorders diagnosed by a psychologist or a psychiatrist.

BDD symptoms screening

The Body Dysmorphic Disorder Questionnaire-Dermatology Version (BDDQ-DV) is a modified version of the Body Dysmorphic Disorder Questionnaire with 100% sensitivity and 93% specificity.[24] This is a brief self-report measure assessing the individual’s appearance concerns and their impact on functioning developed by Dufresne, Phillips & Vittorio.[24] It uses a Likert scale from 1 to 5 indicating the range of severity of two items. To screen positive in BDDQ-DV, patients must report the presence of preoccupation as well as at least a moderate score of 3 or higher distress or impairment in functioning.[25]

The Dysmorphic Concern Questionnaire (DCQ) is a 7-item questionnaire focused on BDD, particularly with concerns on physical appearance and past attempts to deal with the issue. Items are answered on a 4-point scale, with answers ranging from 0 to 3 points. This has been validated as a screening questionnaire for patients who present for cosmetic and non-cosmetic treatments as well. A cut-off score at ≥14 has provided a sensitivity and specificity of 72% and 90.7%, respectively.[25] For the present study, the computed Cronbach’s alpha for DCQ was satisfactory at 0.87.

Selfie behavior

The Selfitis Behavior Scale (SBS) was developed by Balakrishnan and Griffiths in 2017. This is a 20-item scale designed to measure an individual’s selfie behavior through 6 categories[26]: environmental enhancement (eg, “Taking selfies gives me a good feeling to better enjoy my environment”), social competition (eg, “Sharing my selfies creates a healthy competition with my friends and colleagues”), attention seeking (eg, “I gain enormous attention by sharing my selfies on social media”), mood modification (eg, “I am able to reduce my stress level by taking selfies”), self-confidence (eg, “I feel confident when I take a selfie”) and subjective conformity (eg, “I gain more acceptance among my peer group when I take a selfie and share it on social media”). SBS uses a 5-point Likert scale ranging from (1) Strongly Disagree to (5) Strongly Agree and is summed up to get the scores. Higher scores indicate a higher selfie behavior.[26] Joy & Sam (2019) indicated borderline for scores 0-33, acute for 34-67 and chronic for 68-100. The validity and reliability are 0.60 and 0.86, respectively.[27] For the current study, the computed Cronbach’s alpha for SBS was satisfactory at 0.95.

Eligible patients seeking treatment at the University of Santo Tomas Hospital Dermatology Department Teledermatology with mild AV diagnosed by his/her attending physician and those without evidence of AV seeking consult for other concerns not involving the face were recruited for this study. The informed consent form was given as a secure Google form that was sent to the patient via e-mail. The study objectives and procedures were explained to the patient through a phone call. Once the patient had given their consent, the primary physician forwarded the consultation photos of these patients to the primary investigator wherein the absence of AV or acne severity was re-evaluated based on the Allen and Smith grading system. Once finalized to have mild AV or without evidence of acne, a second Google form containing questionnaires was sent to the patient. A total of 217 patients were invited to participate in this cross-sectional study. Ten were excluded due to the presence of psychological disorder diagnosed by a psychologist or psychiatrist. A total of 107 patients were included in the mild AV group and 100 in the control group. This study population was composed of new and consecutive patients aged 18-28 years old seen through the teledermatology platform of USTH Dermatology from April to June 2022.

Table 1 summarizes the demographic characteristics of patients. The median age was 23 and 25 for the mild AV group and control group, respectively. The former group was significantly younger than the latter. Majority of the respondents were females (73%) for both groups. Most patients were in college level/graduate (39%) and postgraduate (36%). Educational attainment significantly differed between the two groups with a higher proportion of patients with mild AV in high school level/graduate and a higher proportion of patients in the control group in postgraduate level. More than 90% of patients reported using Facebook and Instagram. There was no significant difference between the groups in terms of social media platforms used except for Tiktok, which had a significantly higher proportion of patients with mild AV. The median duration of social media use among all patients was 6 hours per day ranging from 1-20 hours per day. For both groups, the top three reasons for social media use were communication (97%), information (94%) and entertainment (91%).

The most commonly used treatment in patients with mild AV were topical medications (79%) with only 1% using it without prescription. Majority of the patients with mild AV did not use systemic isotretinoin.

Among all patients, 21% presented with BDD symptoms, with a significantly higher proportion seen in patients with mild AV (31%) based on BDDQ-DV (Table 2). Using the DCQ with a cut-off score of 11, 14% were positive for BDD symptoms, which was significantly higher in patients with mild AV. With a higher DCQ cut-off of 14, only 5% were positive for BDD symptoms among all patients, which was still significantly higher in the mild AV group.

Table 3 summarizes concerns regarding specific body parts reported by 181 patients. Among those with mild AV, acne (31%) was the top concern followed by skin discoloration (25%), weight (18%) and perception of facial disproportion, particularly the nose and teeth (17%). Among the control group, top concerns included perception of facial disproportion (28%), weight (18%) and scars (16%).

Table 4 summarizes the effect of preoccupation with appearance as reported by 95 patients. Among those with mild AV, majority (47%) reported impairment in self-confidence and self-esteem, which was significantly higher than the control group. A significantly higher proportion of patients without mild AV noted a negative impact on relationship than those with mild AV.

Table 5 summarizes how these defects have significantly interfered with their social lives as reported by 47 patients. Most cited were isolation/hiding (23%) and becoming shy (21%). Only anxiety/worry significantly differed between the two groups, with a higher proportion seen in patients with mild AV.

Most patients had “acute selfie behavior” with no significant difference between the two groups (Table 6).

Among the different BDD screening tools, BDDQ-DV and DCQ are validated scales[24, 25] that have been used in dermatology settings – both in clinics and research. The former has a sensitivity and specificity of 100% and 93%, respectively, while the latter has 72% and 90.7%. As there are currently no studies on the Filipino population using either of the scales, this research utilized both.

The presence of BDD symptoms using the BDDQ-DV in this study was significantly higher in the mild AV group (31%) compared to the control group (10%). These results were higher when compared to findings by Bowe, et al.[9] who reported 14.1% of BDD in patients with mild AV using a more stringent score of 0 in the Allen and Smith acne severity scale; likewise, this increased to 21.1% with less stringent criteria of a score of 0-2 and not taking into consideration the presence of post-inflammatory macules and scars. The present study used a score of 0-2 similar to Bowe’s less stringent criteria. Even so, a higher percentage of patients with BDD symptoms were reported in this study. Likewise, prevalence of BDD symptoms in the present study was also higher compared to findings by Marron, et al.[13] who reported a prevalence of 10.6% of BDD in patients with mild AV. Other reports diagnosed BDD using the Structured Clinical Interview for DSM-5 criteria (SCID) and recorded a prevalence of BDD in general dermatology patients of 14.4% in the USA, 6.7% in Brazil and 8.8% in Turkey, specifically in patients with mild AV for the latter.[9, 28] These variations may be a result of cultural and racial differences among countries, especially in terms of concerns regarding physical appearances.[9] In the Philippines, based on HERDIN plus advanced search, only one study has researched on BDD among Filipino patients. This study revealed a lower (4%) than expected occurrence of BDD in a cosmetic surgery setting, wherein Body Image Disturbance Questionnaire (BIDQ) was used followed by a clinical interview to diagnose BDD[29]. So far, no local study has explored BDD in the dermatology setting, particularly in patients with AV.

On the other hand, the DCQ revealed the presence of BDD symptoms that was also significantly higher in the mild AV group (22%) compared to the control group (6%) using a cut-off score of ≥11. Using a cut-off score of ≥14, the prevalence rate of 22% from the mild AV group dropped more than two-fold to 9%, which was still significantly higher than the control group. Different cut-off values were used by various studies, with a score of ≥14 having 72% and 90.7% sensitivity and specificity, respectively.[25] Comparable to the present study’s results, Stangier, et al.[30] used DCQ among 156 female dermatological outpatients and yielded 21.1% to have significant dysmorphic concerns using a cut-off value of ≥11. This had a two-fold decrease upon increasing the cut-off value to ≥14, which was also observed in the present study. Likewise, Schut, et al.(28) reported BDD symptoms in 10.5% of dermatology patients and only 2.1% in their control group using the DCQ with a cut-off score of ≥14.

Both scales used in this study were consistent in showing that BDD symptoms are commonly observed in patients with mild AV. Hence, even patients with negligible lesions of AV can have psychological distress severe enough to cause impairment, similar to patients diagnosed with BDD.[9] Patients in this study who had scores suggestive of BDD were counseled and referred accordingly.

It is important to keep in mind that BDDQ-DV and DCQ scales should not be used alone for the diagnosis of BDD, but rather as screening tools to identify patients that may be at risk of developing such and other comorbidities associated with BDD. A structured clinical interview done by trained psychologists or psychiatrists is warranted to confirm the diagnosis of BDD satisfying the diagnostic criteria presented in the DSM-5.

Another finding in this study is that majority of mild AV patients did not use systemic isotretinoin. In relation to the high rate of BDD symptoms in this study, this does not support previous findings that isotretinoin use was commonly sought upon by patients with BDD.[9] The low rate of isotretinoin users in this study may reflect a lower socioeconomic status among Filipino patients seen in the institution’s free teledermatology consultation setting.

A component of the BDDQ-DV includes open-ended questions on patients’ specific concerns of appearance that preoccupy them and how these affect and interfere with their lives. In this study, patients with mild AV were mainly concerned and preoccupied with acne followed by skin color and discoloration, and weight. This was consistent with previous reports[9] wherein acne was one of the most prevalent concerns of patients with BDD together with other skin concerns, hair and nose. This is an important consideration because upon improvement of acne lesions, patients with BDD may have their concerns shifted to another body part that may cause the same level of impairment.[9] The control group was mainly concerned about perception of facial disproportion on the nose, teeth and mouth, followed by weight and presence of scars.

These preoccupations led to impaired confidence and self-esteem which was significantly higher in patients with mild AV while it mainly led to anxiety and overthinking in the control group. In terms of interference in social lives, those with mild AV usually hide their perceived defects and isolate themselves while those without AV reported a tendency to become shy and anxious. These findings were consistent with previous studies which identified AV’ negative implication on self-image, self-esteem, shame, embarrassment, self-consciousness, and feelings of being judged; consequently, leading to avoidance behaviors.[2] These concerns and preoccupations may appear minor, but in the context of BDD, such a manifestation can result in repetitive behavior and can cause significant impairment in a person’s life functioning.[31] Other negative effects of appearance-related concerns include hiding and missing out on opportunities, which in more severe cases, patients are unable to leave their homes or engage with others to fulfill important social responsibilities.[31, 32] Interestingly, only a small portion of patients in this study reported avoidance of posting on social media as this was thought of as a means for patients with AV to compensate and alter their minimal physical defects.

The importance of screening for BDD has been highlighted by literature mainly because of its association with different comorbidities including higher rates of suicidal ideation (46%) and suicide attempt (18%) than the general population.[32] Surveys from the American Society for Dermatologic Surgery (ASDS) and American Society for Aesthetic Plastic Surgery (ASPS) found that 61% and 85% of dermatologists and surgeons, respectively, only recognized BDD post-procedure.[32] With familiarity of the typical presentation of BDD symptoms, earlier and appropriate referrals can be done. Likewise, it is important for physicians to understand that such patients will usually seek out reassurance from professionals, have poor insight into their disorder, and may respond negatively to psychiatric referrals, hindering treatment.[31, 32] In dermatology, when encountering patients with even little objective signs of skin disease, as in mild AV, a high degree of psychological distress can be explained by the presence of BDD.[28] Although depression, anxiety and overall psychiatric morbidity have improved upon successful treatment of AV, it was found that only 9.8% of dermatologic patients with BDD noted improvement after treatment and that subsequent treatments may increase symptomatology, demoralization and persistence of BDD.[2] This may likewise prevent economic costs associated with unnecessary and even harmful treatment procedures constantly sought after by these patients.[30]

In terms of social media platform, the most commonly used among all patients were Facebook (95%), Instagram (90%), Youtube (72%), Twitter (61%) and Tiktok (52%), which was comparable to findings by local research done by Fernandez[33] with Facebook (98.67%), Instagram (81.78%), Youtube (64.89%), Twitter (52.89%) and Tiktok (33.78%) as the most commonly used platforms. In this study, there was no significant difference between groups in terms of social media platforms used except for TikTok, which can be due to its recent rise in popularity as the fastest growing social media platform in the world.[34] At the same time, since TikTok has been a huge source of acne-related posts [34] to which adolescents and young adults can have easy access, this can explain higher usage from the mild AV group compared to the control group.

A median of 6 hours of using social media was reported in this study, with no significant difference between groups. This is higher than the previous report of an average of 3 hours 53 minutes among Filipino users,[16] but this can be due to increased usage of the internet during the worldwide COVID-19 pandemic. Findings by Alsaidan, et al.[19] among a community of social media users suggested that BDD was significantly higher among those who spent longer duration on Snapchat and Instagram.

Using the SBS, most patients had “acute selfie behavior” with no significant difference between the two groups. A classification of “acute” indicated that they take selfies at least three times a day and post them online as compared to “borderline” who do the same but do not post them online; while “chronic” indicates uncontrollable urge and being compelled to post selfies more than six times a day.[15] Interestingly, no significant change existed between the mild AV and control group in terms of selfie behavior. It is important to note that having an “acute selfie behavior” does not denote a behavioral or compulsive behavior.[35] The concept of selfie behavior is still a novel concept with limited literature exploring its role in different psychological aspects.[15, 35]

In this study, most of the patients reported low self-esteem and impaired self-confidence, which were significantly higher in patients with mild AV. In previous reports,[36] it was mentioned that one of the motives for taking selfies was to increase self-esteem and seek self-reassurance. This was not reflected in the present study. Rather, Reyes, et al.[35] reported an association between narcissism and selfie behavior among Filipino adolescents and young adults wherein highly narcissistic individuals engage in greater selfie behavior.

Using either the BDDQ-DV or DCQ, BDD symptoms were significantly more prevalent in patients with mild AV despite having lesions that are negligible and clinically not apparent. This highlights the importance of dermatologists' knowledge and awareness that BDD may cause distress and impairment and should be taken into consideration for management. Social media behavior, particularly in terms of selfie behavior, was consistent in both groups; in contrary to the previous assumption that patients with mild AV will either have higher selfie activity to compensate and alter their perceived physical defects or lower selfie activity to hide and isolate themselves.

LIMITATIONS AND RECOMMENDATIONS

This study’s limitations include its cross-sectional design which does not present causal nature of the relationship among AV, BDD symptoms, and social media use; hence further analytical studies are recommended. The screening tests used in this study can also be validated for the Filipino population and evaluated through a standard structured clinical interview in diagnosing BDD for more accurate prevalence rate of BDD among Filipino patients.

DISCLOSURE AND CONFLICT OF INTEREST

This study is investigator-initiated and not industry funded or company sponsored. There is no potential conflict of interest.

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Table 1. Demographic characteristics of patients: with vs. without mild AV



Age (in years), median	24 [IQR: 21-26]	23 [IQR: 20-25]	25 [IQR: 24-27]	<0.00001 a
Sex
Male	56 (27)	27 (25)	29 (29)	0.542 b
Female	151 (73)	80 (75)	71 (71)	0.542 b
Educational attainment
No education	0	0	0	<0.0001 c
Elementary level/ Graduate	1 (1)	1 (1)	0
High school level/ graduate	44 (21)	32 (30)	12 (12)
Technical/ vocational	7 (3)	5 (5)	2 (2)
College level/graduate	81 (39)	48 (45)	33 (33)
Postgraduate	74 (36)	21 (20)	53 (53)
Social media platforms used, %yes
Facebook	196 (95)	102 (95)	94 (94)	0.671 b
Instagram	187 (90)	95 (89)	92 (92)	0.434 b
Twitter	126 (61)	67 (62)	59 (59)	0.594 b
Tiktok	108 (52)	69 (64)	39 (39)	<0.0001 b
Youtube	149 (72)	78 (73)	71 (71)	0.761 b
LinkedIn	1 (1)	1 (1)	0	1.000 c
Netflix	1 (1)	1 (1)	0	1.000 c
Time spent on social media (hours/day), median	6 [IQR: 4-8]	6 [IQR: 4-8]	5 [IQR: 4-8]	0.2037 a
Reason for social media use, %yes
Communication	201 (97)	103 (96)	98 (98)	0.684 c
Information	195 (94)	102 (95)	93 (93)	0.474 b
Network	141 (68)	70 (65)	71 (71)	0.389 b
Posting pictures	94 (45)	38 (36)	56 (56)	0.003 b
Posting selfies	44 (21)	22 (21)	22 (22)	0.800 b
Entertainment	188 (91)	96 (90)	92 (92)	0.570 b
Business	50 (24)	25 (23)	25 (25)	0.784 b
For school	3 (1)	2 (2)	1 (1)	1.000 c

a Mann Whitney U test was used; b Chi square test was used; c Fisher’s exact test was used

Table 2. The proportion of BDD: with vs. without mild AV (n=207)



BDDQ-DV
With	43 (21)	33 (31)	10 (10)	<0.0001 a
Without	164 (79)	74 (69)	90 (90)	<0.0001 a
DCQ
≥11	29 (14)	23 (22)	6 (6)	0.001a
<11	178 (86)	84 (78)	94 (94)	0.001a
DCQ
≥14	11 (5)	10 (9)	1 (1)	0.007 a
<14	196 (95)	97 (91)	99 (9)

a Chi square test was used;

Table 3 . Specific body parts wherein patients are concerned about (n=181)



Acne	56 (31)	56 (57)	0	<0.0001 a
Skin color/ discoloration	45 (25)	37 (37)	8 (10)	<0.0001 b
Weight	30 (18)	15 (15)	15 (18)	0.572 b
Perception of facial disproportion (nose, teeth, mouth)	30 (17)	7 (7)	23 (28)	<0.0001 b
Perception of body disproportion (trunk, limbs, breast)	17 (9)	8 (8)	9 (11)	0.506 b
Health implications	3 (2)	2 (2)	1 (1)	1.000 a
Unwanted hair	4 (2)	3 (3)	1 (1)	0.628 a
Hair loss/ receding hair line	3 (2)	2 (2)	1 (1)	1.000 a
Scars	13 (7)	0	13 (16)	<0.0001 b
Back acne	5 (3)	0	5 (6)	0.018 a

a Fisher’s exact test was used; b Chi square test was used

Table 5. Effect of preoccupation with appearance in the patient’s life (n=95)



Impaired social interactions	10 (11)	10 (14)	0	0.110 a
Avoids posting on social media/ shy to take photos	4 (4)	2 (3)	2 (9)	0.228 a
Impaired confidence and self-esteem	36 (38)	34 (47)	2 (9)	0.001 b
Health implications (not eating, trouble sleeping)	2 (2)	2 (3)	0	1.000 a
Hides imperfections (masks, makeup, clothes)	5 (5)	5 (7)	0	0.587 a
Anxiety/ overthinking/ insecurities	20 (21)	14 (19)	6 (27)	0.414 b
Unable to do usual hobbies	1 (1)	1 (1)	0	1.000 a
Negative emotions towards others	1 (1)	0	1 (5)	0.232 a
Avoidance/hide	2 (2)	0	2 (9)	0.052 a
Negative impact on relationship	3 (3)	0	3 (14)	0.011 a
Restraints on wearing particular clothes	1 (1)	0	1 (5)	0.232 a

Table 5. How defect significantly interfered with social life (n=47)



Lack of energy/motivation to socialize	7 (15)	7 (18)	0	0.318 a
Embarrassment	2 (4)	2 (5)	0	1.000 a
Isolation/hiding	11 (23)	11 (29)	0	0.092 a
Bad remarks from others	2 (4)	2 (5)	0	1.000 a
Became shy	10 (21)	7 (18)	3 (33)	0.377 a
Low self-esteem	5 (11)	5 (13)	0	0.567 a
Missing/ declined opportunities	4 (9)	3 (8)	1 (11)	1.000 a
Anxiety/ worry	3 (6)	0	3 (33)	0.005* a

a Fisher’s exact test was used

Table 6. Selfie behavior: with vs. without mild AV (n=207)



Selfie behavior
Borderline	23 (11)	15 (14)	8 (8)	0.388 a
Acute	146 (71)	73 (68)	73 (73)
Chronic	38 (18)	19 (18)	19 (19)

a Chi square test was used

Citation for this article:

July 18, 2023

Beauty standards have been a prominent aspect of society for centuries, with each culture having its ideals of beauty. In the Philippines, certain beauty standards have been shaped by various factors such as colonisation , globalisation , and media influences . Beauty ideals in the Philippines are deeply rooted in the country’s colonial past. Western standards of beauty particularly arose during the Spanish and American colonial periods. These standards prioritise lightness of skin, a tall stature, and a pointy nose as markers of attractiveness.

They have been perpetuated by media influences that often promote the use of skin-lightening products and feature celebrities with Caucasian-looking complexions. In recent years, there has been a shift towards more diverse beauty standards in the Philippines, with a growing appreciation for features such as fuller figures and darker skin tones. However, it is important to note that these newer standards are still not fully accepted in the mainstream media and can vary among different regions of the Philippines.

Another aspect that has played a significant role in shaping beauty standards in the Philippines is globalisation . Widespread access to the internet and social media have further exposed Filipinos to Western beauty standards, leading many to desire features such as a sharp nose, thinner lips, and smaller jawlines. It is essential to recognise the impact of beauty standards on individuals and society as a whole. These standards of beauty often carry societal implications, as they are associated with attractiveness, greater wealth, and higher intelligence. Conversely, these standards can create a sense of inadequacy and perpetuate discrimination against those who do not conform to them.

The pressure to fit into certain beauty standards can have negative effects on one’s self-esteem and mental health, especially for those who do not fit the prevailing beauty ideals. In addition, the perpetuation of certain beauty standards can also contribute to discrimination and inequality , as those who do not meet these ideals may face exclusion or marginalisation in various aspects of society. In conclusion, Philippine beauty standards have evolved due to various cultural, historical, and global factors.

While there have been shifts towards more diverse standards, it is important to continue promoting acceptance and celebration of all types of beauty. This can be achieved through media representation that reflects the diverse beauty of Filipinos and encourages self-love and acceptance . Additionally, education and awareness-raising efforts can also help combat the harmful effects of unrealistic beauty standards. Ultimately, embracing beauty in all its forms can lead to a more inclusive and accepting society that values diversity and individuality. Society must recognise that beauty standards are not absolute and should not be used as a basis for judging individuals or groups. Instead, we should appreciate and celebrate the unique features that make each person beautiful in their way. We are all beautiful just the way we are without the need to impress or satisfy other people’s preferences.

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“Classroom to Career”: The Pains of Going into the Real World

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