Elsevier

Body Image

Volume 36, March 2021, Pages 34-44
Body Image

‘Everybody’s Different: The Appearance Game’. A randomised controlled trial evaluating an appearance-related board game intervention with children aged 9–11 years

https://doi.org/10.1016/j.bodyim.2020.09.010Get rights and content

Abstract

This study evaluated the effectiveness of an educational board game aimed at increasing knowledge of appearance-related issues, positive body image, media literacy, and acceptance of appearance diversity with British school children. Two hundred and fifty-nine children, aged 9–11 (Mage = 10.26), from three primary schools in South-West England participated in a two-arm matched cluster randomised controlled trial. Outcome measures were collected pre-, post- and at two-week follow-up. Knowledge of appearance-related issues significantly increased in the intervention group, compared to the control group post-intervention, but was not maintained at follow-up. There were no significant differences between groups for body appreciation, media literacy or acceptance of visible difference. Of the intervention arm, 78 % (n=117) they would like to play again and 85.3 % (n=128) thought other children would like to play. Qualitative data suggests participants learned the key messages of the game. The findings suggest ‘Everybody’s Different: The Appearance Game’ is an enjoyable way to increase knowledge of appearance-related issues. In future, researchers should consider how to increase body appreciation, media literacy and acceptance of appearance diversity, for example by increasing the dosage of the game or using it in conjunction with discussions and lessons surrounding appearance diversity and appearance-altering conditions.

Introduction

Body concerns are becoming increasingly prevalent in children and young people (Tatangelo & Ricciardelli, 2017). Evidence suggests that body image disturbance can occur before puberty (Schuck, Munsch, & Schneider, 2018), with some estimating that around half of children aged between 6 and 12 years old experience some dissatisfaction with their appearance (Smolak, 2011). Although research has historically focussed on body image in girls and women, for whom body image concerns are considered to be more prevalent (O’Dea, 2005), it is now recognised that body image is also a relevant issue for boys and men (De Jesus et al., 2015). Appearance dissatisfaction is associated with numerous negative health and psychosocial consequences, including depression, low self-esteem, disordered eating, decreased physical activity, risky health behaviours such as smoking and high-risk drinking, and poor academic engagement in adolescence (Bornioli, Lewis-Smith, Smith, Slater, & Bray, 2019; Halliwell, Diedrichs, & Orbach, 2014; Neumark-Sztainer, Paxton, Hannan, Haines, & Story, 2006; Paxton, Neumark-Sztainer, Hannan, & Eisenberg, 2006). Therefore, promoting a healthy body image in pre-adolescent children is an important priority for its potential to improve numerous aspects of quality of life (Bird, Halliwell, Diedrichs, & Harcourt, 2013).

In conjunction with this, social media now form a central part of the lives of many children and young people, with approximately 93 % of children aged 8–11 years spending around 13.5 h per week online (Ofcom, 2018). However, as with mainstream media, social media content can perpetuate body concerns by encouraging appearance-related social comparisons, which can occur in children as young as eight years old (Fardouly & Vartanian, 2016; Holt & Ricciardelli, 2002). For these reasons, appearance-related media literacy forms an important part of body image interventions, in order to encourage children to think critically about how appearance is portrayed in mainstream and social media (Potter, 2013).

School-based body image interventions can provide a practical way of targeting large numbers of children and have the potential to be integrated within the curriculum (Halliwell et al., 2016; Yager, Diedrichs, Ricciardelli, & Halliwell, 2013). In recognition of the importance of body image, some governments are starting to acknowledge body dissatisfaction as a public health issue in children, which needs to be addressed at school (Yager et al., 2013). For example, the UK Government Equalities Office (2015) has initiated a Body Confidence Campaign that recommends body image issues should be incorporated into the UK National Curriculum.

Body image interventions tend to focus primarily on perceptions of one’s own appearance, and the impact that this can have on physical and psychosocial wellbeing. However, one’s own appearance-related attitudes and behaviours towards others can also have consequences. For example, in addition to the appearance-related pressures facing all young people, those who are born with, or acquire, conditions that alter their appearance away from what is considered to be ‘the norm’ can face additional concerns about their own appearance, and experience challenges relating to how society perceives them (Rumsey & Harcourt, 2004). Examples of these conditions, known collectively as ‘visible differences’, include cleft lip and/or palate or other craniofacial conditions, birthmarks, burn scars, and skin conditions such as eczema or psoriasis. Approximately one million people in the UK live with an appearance-altering condition (Partridge & Julian, 2008), with around 86,000 of these being children and young people (Changing Faces, 2018).

Unfortunately, there is considerable stigma surrounding appearance-altering conditions within society (Stock, Whale, Jenkinson, Rumsey, & Fox, 2013; Strauss et al., 2007). Those with visible differences can encounter staring, pointing and unwanted comments or questions in public places, which may make it difficult for them to partake in everyday activities (Rumsey & Harcourt, 2012). Similarly, children and young people with a visible difference may be subject to teasing or bullying, which can make it difficult to form peer relationships and negatively impact their academic engagement and achievement (Stock et al., 2013; Strauss et al., 2007). Additionally, research shows that individuals with appearance-altering conditions are often negatively stereotyped. For example, they may be assumed to lack intelligence or capability to perform certain job roles, which can negatively impact their career prospects and aspirations (Richman, 1978; Stock et al., 2013). The way that people with appearance-altering conditions are portrayed in the media reinforces these negative attitudes (Stock et al., 2013; Wardle, Boyce, & Barron, 2009). For example, individuals with visible differences are often portrayed as ‘bad’ or ‘evil’ characters in books, television, and film (Rumsey & Harcourt, 2012). Due to these experiences and societal prejudices, social anxiety and fear of negative evaluation from their peers and the public is common in people with appearance-altering conditions (Rumsey & Harcourt, 2012). To reduce this stigma, and increase acceptance of appearance diversity, the inclusion of content focussed on appearance-altering conditions could be included in media literacy programmes.

While some interventions have been developed to help young people with visible differences cope with the psychosocial aspects of looking ‘different’ (e.g., Williamson, Griffiths, & Harcourt, 2015), it is also important to focus on changing the prejudicial attitudes and behaviours of society (Thompson & Kent, 2001). This requires the development of effective population level interventions in order to increase knowledge, understanding, and acceptance of diversity of appearance. In addition to interventions for the adult population, targeting children and young people may be beneficial in order to influence societal attitudes as they are still developing.

At present, a number of school-based body image interventions have been developed and found effective at reducing negative body image, increasing media literacy, and preventing disordered eating (e.g., Becker & Stice, 2011; Bird et al., 2013; Diedrichs et al., 2015; Halliwell et al., 2016; Wilksch, O’shea, & Wade, 2018; Yager et al., 2013). The majority, however, are designed for secondary schools (11 years old and above). Additionally, these interventions typically do not include content about appearance diversity and appearance-altering conditions. Given that body image concerns develop at a young age, as children become more aware of appearance differences, it is important to develop interventions targeting these issues in ways that are interesting and engaging for younger children.

In addition, over the past decade, focus in the field has shifted towards the promotion of positive body image rather than on reducing the presence of negative body image (Halliwell, 2015). Positive body image relates to having a favourable and respectful attitude towards one’s body, regardless of whether it meets societal appearance ideals (Halliwell, 2015). Menzel and Levine (2011) characterise positive body image as having three central components, which are (a) appreciating the body and its functionality, (b) being attuned to the needs of the body, and (c) protecting oneself from negative messages relating to appearance. In particular, positive body image is seen as a valuable target of interventions because it is associated with increased psychological and physical wellbeing and may be protective against exposure to appearance-ideal media imagery (Tylka & Wood-Barcalow, 2015a). Moreover, positive body image is a malleable construct, which can be fostered through interventions both in childhood and adulthood (Guest et al., 2019; Tylka & Wood-Barcalow, 2015b). For example, interventions that involve focussing on body functionality, practising self-compassion, and carrying out self-affirmation exercises have been found to increase aspects of positive body image (Alleva, Diedrichs, Halliwell, Martijn et al., 2018; Alleva, Diedrichs, Halliwell, Peters et al., 2018; Duncan, Al-Nakeeb, & Nevill, 2009; Halliwell, Jarman, McNamara, Risdon, & Jankowski, 2015; Toole & Craighead, 2016).

To summarise the foregoing discussion, body concerns are prevalent among young people and can have serious consequences; improving body image among young people is a priority, and body image programmes within schools may be helpful. Further, young people with a visible difference may be particularly vulnerable to developing body concerns and experiencing appearance pressures from their immediate and broader social environment. Taking this into account, in this study, we developed an educational board game aiming to promote positive body image, increase knowledge of appearance-related issues, increase acceptance of diversity of appearance, and encourage group discussion and critical thinking about the role that appearance plays in the media, such as using beauty ideals to sell products. In particular, the positive body image-related content included appreciation, acceptance, and respect of the body, body functionality, broad conceptualisations of beauty, and bodily-self-care. This was included in the intervention through psychoeducational information and activity and question cards that encourage players to practise these aspects of positive body image, for example by thinking about their own body functionality, how they might care for their body, or what they appreciate about their bodies.

The game topics are relatively complex and lend themselves to discussion-based activities, therefore we decided that it was suitable to design a game for older primary school children (9–11 years old). The game, ‘Everybody’s Different: The Appearance Game’ (www.appearancegame.com), was developed in collaboration with a UK-based educational board game company. Previous research has shown that board games can be an effective way of facilitating learning and increasing interest in topics including nutrition and healthy eating in children of primary school age, and are suitable to play in a classroom setting (Amaro et al., 2006; Yien, Hung, Hwang, & Lin, 2011).

To ensure that the board game is a useful and effective intervention, we aimed to evaluate its effectiveness by conducting a cluster randomised controlled trial with primary school children aged 9–11 years. We hypothesised that playing ‘Everybody’s Different: The Appearance Game’ (compared to playing an educational board game about anatomy) would (a) increase knowledge of appearance-related issues, (b) increase positive body image, (c) increase appearance-related media literacy, (d) reduce negative perceptions of visible differences and (e) be an enjoyable intervention for children aged 9–11 years.

Section snippets

Participants

Emails were sent to the headteachers of 11 primary schools in the South-West of England, inviting them to take part. The emails described the opportunity to be involved in an “exciting study to evaluate ‘Everybody’s Different: The Appearance Game’, a new educational board game”. If interested in taking part, the headteachers passed information about the research on to the Year Five and Six class teachers at their school and asked them to attend a face-to-face meeting with the research team. In

Results

Data entry checks were performed to ensure coding fidelity and data veracity. Data validity checks were undertaken, and scale data was examined for the presence of any unduly inferential observations. Outcome measures were checked for excessive skewness and for any floor or ceiling effects and Normal Quantile-Quantile plots were used to assess deviations from normality. The values for skewness and kurtosis fell within an acceptable range for a sample size of 200 or more (Tabachnick, Fidell, &

Discussion

The findings from the current study suggest that a short exposure of 40 min to an educational board game relating to positive body image, diversity of appearance, and appearance-related media literacy, can significantly increase knowledge of board game content relating to appearance-related issues in a group of school children aged 9–11 years. The game was also reported to be enjoyable by the majority of participants, and findings from the qualitative content analysis suggest that the children

Conclusion

In summary, findings from the present study suggest that ‘Everybody’s Different: The Appearance Game’ is an enjoyable intervention about appearance-related issues for primary school children aged 9–11 years. Findings suggest that a one-off, inexpensive board game increased knowledge of appearance-related issues; however, the game did not significantly increase body appreciation, media literacy or change perceptions of visible difference. Given that media literacy and positive body image are

Funding information

This work was conducted within a programme of work at the Centre for Appearance Research, funded by the Vocational Training Charitable Trust Foundation (VTCTF), United Kingdom.

CRediT authorship contribution statement

E. Guest: Conceptualization, Methodology, Formal analysis, Investigation, Resources, Data curation, Writing - original draft, Writing - review & editing, Visualization, Project administration. H. Jarman: Conceptualization, Resources, Writing - original draft. N. Sharratt: Conceptualization, Resources, Writing - original draft. H. Williamson: Conceptualization, Resources, Writing - original draft. P. White: Conceptualization, Formal analysis, Writing - original draft, Writing - review & editing.

Declaration of Competing Interest

None.

Acknowledgements

We would like to thank the three primary schools that took part in this study, Focus Games for helping develop ‘Everybody’s Different: The Appearance Game’, and Georgia Treneman-Evans, Arabella Macrae, Beth Herring, Harriet Smith, Abigail Woodley, Bruna Costa and Jade Parnell for their help with data collection during the project.

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