The Meaning and Factors That Influence the Concept of Body Image: Systematic Review and Meta-Ethnography from the Perspectives of Adolescents

Community care nurses educate adolescents about body image, but their interventions appear to be ineffective. Body dissatisfaction predicts unhealthy behaviors among adolescents. This study aimed to understand the meanings and factors that influence the concept of body image through a systematic review and meta-ethnography of qualitative studies from the perspective of adolescents. Ten studies published from 2009–2019 were identified by a search of relevant systematic databases between September and December 2019. The review followed the seven steps of meta-ethnography developed by Noblit and Hare, including a line-of-argument. The synthesis revealed six themes: self-perception of body image; opinions of friends and colleagues; opinions of family; specific features of the school environment; expectations perceived across the mass-media; and strategies, practices, and self-management of body image. An explanatory model was developed that showed adolescents’ development of body image and the path towards its establishment. In conclusion, these results should be considered to implement strategies to promote a healthy body image in adolescents by community health and mental health nurses.


Introduction
Body image (BI) is the internal representation of one s external appearance [1] and encompasses self-perceptions related to the body and personal attitudes, including thoughts, beliefs, feelings, and behaviors [2]. It is a multidimensional representation [3] made up of four components: global subjective satisfaction (evaluation of the body); affection (feelings associated with the body); cognitions (investment in appearance and beliefs about the body); and behaviors (avoidance of situations of body exposure) [1]. Therefore, BI is a complex phenomenon that includes many components related to gender, ethnic and sociocultural factors [2,4]. Effective measures regarding BI must address individual feelings, including satisfaction/dissatisfaction; physical self-awareness; beliefs; ideas; and behaviors regarding appearance [4]. The inclusion criteria for the sample selection required that the original studies described the meaning, attribution, and experiences of BI in healthy adolescents. Moreover, data from these primary studies had to be obtained from the perspective of adolescents. The original reports must have used a qualitative approach in relation to data collection and data analysis. Studies using mixed methods were eligible for inclusion if it was possible to extract the results derived from qualitative research.
We preliminarily identified studies through searching relevant electronic databases, by using Medical Subject Headings (MeSH) terms and text words. Table 2 describes the final search strategy, which was adapted to the selected databases according to the specific language used in each one. We searched the Web of Science, PubMed, PsycINFO, CINAHL, Scopus, and the Cochrane Register. We set the publication date for the search from 2009 to 2019 and considered only peer-reviewed studies published in English. Finally, we complemented the process by searching for key authors. Using the last strategy we found several studies, but they were not incorporated as they did not meet the inclusion criteria and were not exactly focused on the subject of the review.

Selection and Summary of the Studies
The main investigator (GTN) performed the systematic literature search and was responsible for reviewing the n = 147 potential studies according to title, abstract and full text. Studies were excluded when they did not meet the inclusion criteria, did not focus sufficiently on the topic, were from specific ethnic groups, or data had not been collected from an adolescent perspective. Disagreements were resolved by discussion and by reference to the full article by another investigator (EAB). Finally, the research team (GTN, MPP, EAB) agreed on the studies (n = 10) that should be included in the synthesis. The flowchart is displayed in Figure 1.

Quality Assessment
The ten included papers were assessed for quality by the review team independently using the Critical Appraisal Skills Programme (CASP) tool [21]. None were excluded according to quality criteria.
This research did not require approval, since all the studies included in the review had already been approved by their respective ethics committee.

Synthesis
The ten studies were synthesized using Nobit and Hare′s [20] seven-stage method. In the first phase, we identified the topic of interest provided by the qualitative studies. The second phase involved selecting the studies to include in the synthesis. This phase generated a repeated process of reading the studies to identify a list of metaphors in each of them and the affiliation of disparate and common themes. We drew a map of the units

Quality Assessment
The ten included papers were assessed for quality by the review team independently using the Critical Appraisal Skills Programme (CASP) tool [21]. None were excluded according to quality criteria.
This research did not require approval, since all the studies included in the review had already been approved by their respective ethics committee.

Synthesis
The ten studies were synthesized using Nobit and Hare s [20] seven-stage method. In the first phase, we identified the topic of interest provided by the qualitative studies. The second phase involved selecting the studies to include in the synthesis. This phase generated a repeated process of reading the studies to identify a list of metaphors in each of them and the affiliation of disparate and common themes. We drew a map of the units of meaning, codes, and themes of the phenomenon under study. We used the ATLAS-TI vs.7 software (Development GmbH. Berlin. Germany) for this phase. The topics in each article were initially identified by the principal investigator (GTN), and later discussed and analyzed by the entire research team (GTN, MPP, EAB). Disagreements were resolved by rereading from top to bottom all selected articles. Once we identified the main concepts in each article, we made a search for the presence of these concepts in the rest of the documents. During this process, we ensured that each key concept took on similar meanings in all documents. Moreover, we identified those that were unique or specific to one or more studies.
We started the synthesis with the first published article [22], then worked through the studies in chronological order of publication. We performed the comparison process by identifying the themes in the first study, and then adding others as they emerged (Table 3). Table 3. Quotations from participants and authors to illustrate each theme.

Themes/Categories
Quotations from Participants Primary Studies

Interpretations of Findings Offered by Authors
Individual Factors: Self-Perception of Body Image

Emotional self
When I eat something fattening I feel bad. I feel guilty that I am already fat and after eating this, I will become fat [23].
Feeling guilty about myself I think I look pretty good. I m not like very good-looking, but quite normal.
It s not that I m ugly [24]. Self-confidence I get sad when I get chubby [9]. Feeling sad People degrade them, make them feel bad about them and that s where they get more stressed and then they eat those foods [9]. Get stressed Everybody should be able to look the way they want to, and there should not be any things that make them feel that they need to change [25]. Be yourself Hayley: Some people it could happen to and others it would never. Roisin: Like if the person is confident. Researcher: OK, so you think that helps them not be affected by it? Roisi4: Yeah cos if they are really shy and all they would probably be but if they were confident they wouldn t [26].

Be confident
Thinking self If you like yourself and you look in the mirror and like what you see in there, you re confident with people [22].

Self-confidence
My weight gain is the main concern. I like the way my face is [23]. My concern I think there are greater differences between boys than there are between girls. I think most girls want the same things, they want to be slim and Yeah, like, be good looking and slim. But I think the boys here are more into beefing up than the west-end boys are. That s what I think [27].
As I want to be It depends more on talking a lot, being clever and being knowledgeable. Then you can talk about status. I don t think it s about appearance. It s more about being visible at our meetings. This goes for both boys and girls [27].

Important values
I think most people, at least girls, have an inner wish to be thin and would love to have a body like Britney Spears. This is the goal, but then I think it varies between groups [27].
Wish to be thin

Relational Factors: Relevance of the Opinions of Friends and Colleagues of Body Image
Peer surveillance People our age are very critical of other people and how they look. Like they re very cruel and they don t think they ve got feelings and they make snap judgements about girls and give them low self-esteem [22].
To be overly critical of appearance They put pressure on you to get the body they think is right, like soccer players, skinny strong and muscley [28]. Because you get judged. Like everybody judges you, wherever you walk really ( . . . ) I think just looking attractive so that people don t talk about you and say like, 'Oh she's fat, she s ugly, her hair looks ridiculous [29].
Pressure for an ideal body Table 3. Cont.

Interpretations of Findings Offered by Authors
Peer acceptance Guys don t look at me. Nothing about me has changed but the weight gain. I feel that they are not looking at me because of the weight gain . . . .Guys don t look at me the way they used to [23].

Without acceptance
Some people in my class they are big and they get bullied a lot, but I stop that bullying [9]. Get bullied They like could be fat and everybody s mocking them so they like exercise because exercise makes you thin [26].
Fear of being mocked  [26]. My mom is mad at me because I (weigh) less than her [9].
Mother pressure [We] might talk about that I had my hair cut and [mother says] Oh, that haircut really suits you (...) or if I buy a new top she usually says 'well, that's nice [24].

Opinions about clothes
So if you see your parents going on Atkins Diet or something then you re going to be thinking 'oh should I be having carbs? Like is it not good to have carbs?' So then you just think it s normal to just cut things out of your diet [29].

Pressure from family
Opinion on parental control My parents, like, tried to make a lot of restrictions and, like, I don t listen to them anymore [30].
Parental restrictions on social media It like gives me anxiety whenever my parents are like 'okay, I m gonna just like check something' and they like actually check my computer history a lot and so like I start to like freak out like even though I ve done like nothing wrong which makes them like get a message that like I did something even though I ve done nothing. And so I'm like constantly worried about what I use [30].

Opinion on teachers
If you go to a teacher, they re going to give you the 'well it s wrong and you know what can happen' [29]. Teacher support At this school, they teach us how to like yourself and self-confidence and stuff. This is a really inclusive school and it teaches you how you shouldn t care how other people think of how you look but in other public schools . . . Our teachers in health class, like all the umm teachers help us with confidence [and] teach us to build a really thick wall so that this stuff does not get to you and I guess you are more immune to it because you know you are fine and so does your class, too [30].

Environmental Factors: Perceived Expectations Across the Mass-Media of Body Image
Celebrities A lot of the boys talk about what celebrities they like and then the girls would look up that celebrity and how they look, what they wear and everything and might copy them [26]. You would want to be as skinny as them [22]. If I'm following a female celebrity. they do all these, like, photo shoots and stuff and they look really pretty. So, sometimes, I guess that makes me not feel good? [30] Then everybody started to aspire for it. You become conscious that you have to be a size zero. Earlier you were size 1.Now you are relatively fatter [23].
Copying fashion trends from celebrities Table 3. Cont.

Mas media
Accepting compliments is so much easier than being like [30]. Pressure to get likes I feel pretty confident in myself. I mean, I might. look at somebody and be like, 'Yeah, she s really pretty' but. I m happy with who I am, like I wouldn't want to be anybody else [30].

Confident in myself
Like I know sometimes I ll look at pictures and it ll make me feel like not happy with myself cause sometimes I ll wanna look like them [30].
Comparison/unhappy with myself Buy this top and it will make you look this thin [25].
Coping fashion trends Outcomes: Strategies, Practices, and Self-Management Both self-devised diets and prescribed fad diets would be executed, normally for short periods of time [22].
Dieting and prescribed fad diets They say something like 'I m so fat, I need to get on a diet!' or something like that, and then people who are actually like more overweight might think like 'oh they re saying that and they re skinnier than me, which means that I m even worse than them' [29].
Dieting I tend to stick to whole wheat and I don t have white rice and white bread. I stay away from sugar, cheese. I don t like oily things. I think it has become a habit because I have stuck to this for quite a while. I never deny myself [23].

Healthy diet
You know the vinegar, she drinks that and it kind of stops her from eating and it actually just makes her stomach feel full [26].

Dieting and prescribed fad diets
Acting self: sport My brother, he s only 15, his team the under 17 s, they are, they have to start working in the gym now and they have to be on this diet, and my brother s friend plays for Munster and they have to be on this proper diet like they can't eat chocolate bars [26].

Sport practice
Like if you were kind of fat they wouldn t really like talk to you. They d leave you out of all the games and say picking teams for a match you d always be the last picked just because you re fat and you weren t sporty [28].
Not to be sporty Exercise as a natural part of life. Exercise as joyful and health-promoting [24].
Healthy exercise Subsequently, we developed a "line of argument" [20]. In this phase, it was possible to reorganize the results generating a new interpretation of the phenomenon explained by the data. In this way, we achieved a synthesis that was not only the sum of the individual parts of each article, but also provided a meticulous interpretation, and preserved the integrity of each study. This phase was carried out by GTN and then discussed by the full group of researchers. Finally, we obtained an explanatory model of the construct, the meaning, and the factors that contribute to developing BI in adolescence in a western context.

Description of Themes
We extracted six themes that influence the process of developing BI, according to the opinion of adolescents: (1) self-perception of BI; (2) opinions of friends and colleagues; (3) opinions of family and parents; (4) specific features of the school environment that influence BI; (5) perceived expectations of BI across the mass-media; and (6) strategies, practices, and self-management for BI. These themes are closely related to each other. Figure 2 illustrates the line-of-argument synthesis that demonstrates the key processes in understanding adolescents meaning of BI. All the manuscripts are from scientific journals and published in the English language. The studies were carried out in six countries: three in Ireland [22,26,28], two in Sweden [24,31], two in the USA [9,30], one in India [23], one in Norway [27], and another in the UK [29]. Eight of these studies use qualitative designs [22][23][24][25][26][27][28][29], and the other two use mixed methods [9,30]. Likewise, all perform thematic content analysis. As data collection method, five studies apply focus groups [22,[26][27][28][29], three use semi-structured interviews [23][24][25] and two employ focus group and individual survey [9,30].

Description of Themes
We extracted six themes that influence the process of developing BI, according to the opinion of adolescents: (1) self-perception of BI; (2) opinions of friends and colleagues; (3) opinions of family and parents; (4) specific features of the school environment that influence BI; (5) perceived expectations of BI across the mass-media; and (6) strategies, practices, and self-management for BI. These themes are closely related to each other. Figure  2 illustrates the line-of-argument synthesis that demonstrates the key processes in understanding adolescents′ meaning of BI. .

Self-Perception of BI
Six of the studies provide self-perception data that influence the desire for an ideal BI [9,22,23,26,27,31]. Adolescents explain how self-esteem, self-confidence, insecurity, acceptance, self-protection, and anxiety are part of their internal dialogue and beliefs about their BI. Some young people express concern about physical appearance, such as being too fat, gaining weight, aspiring to be prettier, putting on makeup to cover acne [22,23]. Therefore, they express a desire for a different BI. They show negative emotions, such as anger, sadness, guilt or frustration [9,22,23]. Some are aware that they must stop focusing on their body to have a healthier self-esteem. Self-confidence is crucial [24,26], as well as appreciating themselves as they are [22]. Satisfaction with BI is related to acceptance [24,27]. In two articles [9,25], adolescents gave more importance to interior happiness, intelligence, and kindness, than to physical appearance.

Relevance of the Opinions of Friends and Colleagues on BI
Eight studies examine the influence of peers on the ideal of BI [9,[22][23][24][26][27][28][29]. Participants express thoughts and emotions about the pressure of being accepted; the fear of being rejected, excluded, or judged; and the feeling of being watched, compared, or criticized for their physical appearance [9,22,[27][28][29]. Others claim that they do not compare themselves to friends and aspire to the ideal of BI that they define [23,24]. Body weight is a point of constant vigilance and criticism, jokes, teasing, and exclusion among peers. Such situations can last over time and affect mental health by producing low self-esteem, eating disorders, self-harm, and even suicide [22,28]. The motivation to be accepted drives adolescents to follow fashion trends, and change their appearance by dieting, fasting, and practicing physical exercise [26]. Consequently, adolescents copy standard models and talk about losing weight, dieting, wearing clothes that make them more attractive, and practicing sports.

Relevance of the Opinions of Family and Parents on BI
Six studies provide data related to the influence of parents on BI in terms of dissatisfaction and satisfaction [9,23,24,26,29,30]. Several adolescents comment on the importance of pressure derived from the family, specifying that it influences then via the way they dictate diet and how they model eating habits and self-confidence [29]. It was sometimes shown that mothers persuade their daughters to copy the styles and fashion imposed by celebrities [26]. Adolescents think that their parents are concerned about their health: they encourage them to a healthy, non-sedentary lifestyle and healthy eating [23]. Other studies show that parents express opinions about clothes and haircuts, and judge them according to their own ideals [24]. Other parents pressure their children to lose weight and conform to standard models [9]. Among the actions undertaken by adolescents because of the messages received by parents, we identify factors that facilitate and predispose the appearance of unhealthy behaviors or reinforce pre-existing ones.

Relevance of Specific Features of the School Environment That Influence the BI
Only two of the selected articles provide results on how the school and teachers influence adolescents beliefs about BI [29,30]. In Brunette et al. [30] some adolescents express how the school environment encourages them to learn strategies that help to mitigate the harmful aspects of negative comparison between equals, including those received through the mass media. They also mention the benefit of voluntarily participating in a school group dealing with BI. In the study of Sharpe et al. [29] some participants point to teachers as a valuable source of support and give some recommendations.

Perceived Expectations on BI across the Mass Media
Seven studies provide data on the relationship between mass-media and the perception of satisfaction or dissatisfaction with BI [9,22,23,[25][26][27]30]. Some participants comment that they are influenced by the image of certain international actresses or celebrities [22,26,27]. Some adolescents, especially girls, copy and imitate fashion, clothing, and hairstyles of celebrities to feel more comfortable with their individual appearance [23,26]. There are also mixed opinions on the role of the media in developing dissatisfaction with the weight of adolescent women [23]. Some girls convey that they are aware that com-panies use appearance and BI for commercial purposes [25].On an emotional level, the images spread by the mass media make them feel frustrated if they do not achieve the ideals [9]. Other teens instead feel uncomfortable with the messages and decided not to look at them [25]. Some participants comment that selfies are an important part of their life. They add that they need to receive likes to feel comfortable with their BI and increase their level of self-esteem [30]. 4.2.6. Strategies, Practices, and Self-Management for the Ideal BI: Diet and Physical Exercise Seven of the studies refer to the use of diet and exercise as self-management practices related to physical appearance [22][23][24][26][27][28][29]. Diet and exercise are used as strategies for weight loss [24,26], sometimes including fad diets [22]. However, some people are not conscious of such diets [23] and inadvertently engage themselves in unhealthy behaviors [26]. The goal is to become equals [28,29], mostly through diet for females and bodybuilding for males [26][27][28]. Therefore, they pretend to look like celebrities [26] and attract male attention [22,29].
Positive peer influences are manifested by congratulations, sources of encouragement, and opinions to motivate dieting, physical activity, and exercise and to counteract useless pressures [28,29]. In the same way, support and motivation by mothers represent positive influences [23]. Sports stars and dancers influence healthy behaviors [26,27]. However, some adolescents already conceive physical fitness and caring for the body as a part of health care, turning exercise into a natural and important part of life, generating joy, fun, and friendship [24]. One of the studies [29] propose different prevention strategies with early interventions on body dissatisfaction and diet. The effectiveness of the last strategy is shown in the study by Brunette et al. [30], along with self-acceptance and acceptance of differences, trust, and diversity.

Explanatory Model
The explanatory model derived from these results shows that the BI elaboration process is a dynamic, multidimensional, and complex phenomenon. It responds to internal and external stimuli experienced by the adolescent himself, and not simply social pressure, friendship, and school environment. According to this model, the reevaluation of oneself is a crucial element that influences the meaning of, and satisfaction or dissatisfaction with, BI. Beliefs and emotions reinforce an evaluation of oneself that leads one to accept or reject bodily self-image. As a result of this reevaluation, some of the adolescents diet and exercise as a self-management strategy to achieve an ideal weight or image that matches the canons of beauty. However, the resistance to accept one's body does not necessarily imply unhealthy diets or disproportionate physical exercise as strategies for weight control. Individual coping is crucial for addressing one s image and adolescent identity. We show that there are barriers and obstacles to, and also positive appreciations for, the achievement of a healthy BI in adolescence. However, there are adolescents with an efficient perceived self-efficacy and with positive appreciations about their body, even when it does not fit into the beauty canons established in Western society. All these factors should be considered in prevention programs, and promotion of a healthy BI.

Discussion
This synthesis suggests that the BI construct in adolescents has multiple meanings and that it does not necessarily imply dissatisfaction when there is a mismatch between actual and desired BI. BI is established in a much more complex way than simply through the messages received by the mass media and the pressure from friends. The family and the school environment play a decisive role as protective factors when applicable, providing tools to promote self-esteem, security, and confidence. We identified six themes from the analysis of the various studies.

1.
Self-perception of BI defines the way of thinking and feeling about oneself in relation to body image. Messages about the body can be interpreted in a distorted way [32]. Therefore addressing misperceptions about weight is not enough for the prevention and promotion of a healthy body image in adolescents [33,34]. The studies analyzed show that the problems of distortion of body image facilitate behaviors aimed at losing weight. Dissatisfaction with body image during the early stages of adolescence has been related to poorer self-esteem [7], more in adolescent girls than in boys [35].

2.
Relevance of the opinions of friends and colleagues on BI relates to the messages that adolescents receive from their friends. However, Willis et al. [36] provide results that contradict the common perception that overweight or obesity in adolescents is related to body dissatisfaction. Some of the overweight teens do not support the perception of friends or family about BI. 3.
Relevance of the opinions of family and parents on BI. Both the negative influence of friends and family members are considered barriers to a healthy BI; however, they can be facilitators when messages are received positively by the adolescent [37]. Adolescents with high levels of body dissatisfaction may also experience higher levels of depression and less positive social interactions that lead to a decrease in family connection [38]. Consequently, considering the point of view of each adolescent, it is essential to include the role of parents in health educational interventions to develop a healthy BI.

4.
Relevance of specific features of the school environment that influence BI. There are few studies which investigate the influence of school and teachers on the development of BI. Several studies show the benefits of including programs to promote a healthy BI in schools [39], thus evidencing the important role that school plays as a primary context of socialization [40].

5.
Perceived expectations of BI across the mass-media. Exposure of physical appearance in social networks is related to different factors: (1) dissatisfaction with weight; (2) drive for thinness and ideal internalization; (3) self-objectification, especially in adolescent girls [10,41]; and (4) increased concerns and beliefs related to appearance [42]. Some of them are aware of the manipulation of the media and are critical of the pressure exerted about obtaining the ideal BI [43]. Nevertheless, the influence of media on adolescent girls should also be considered. Consequently, media literacy is considered necessary [25], as well as the development of prevention strategies. The latter include promoting skills to use the internet and mass media and training adolescents to develop a healthy BI. 6. Strategies, practices, and self-management for the ideal BI. The results of the synthesis agree with the study of Pollina et al. [44] in which it is shown that body dissatisfaction predicts unhealthy behaviors among boys and girls, with different patterns between gender. This dissatisfaction also generates problems of distortion of BI. Moreover, it facilitates behaviors aimed at losing weight (i.e., diets, food restrictions, and modification of eating habits), which are patterns of eating behavior that predict obesity in the future [45].
The present synthesis also yields an explanatory model on the meaning of the BI construct and the process of its elaboration. This model can promote approaches focused on health, well-being, and social justice by emphasizing contextual factors, and not exclusively focusing on weight, BMI, and individual responsibility, as pointed out by Tylka [46]. Obtaining the desired and satisfactory BI can prevent risk behaviors related to (1) dietary habits; (2) exercise; (3) medication; (4) situations of bullying and exclusion; (5) emotional discomfort around self-esteem, self-confidence, and self-acceptance; and (6) mental health diseases, such as distortion of BI, anxiety and depression, which can last into adulthood and old age. In conclusion, in our study, we are create the basis to address a major problem in public health. The results of the present synthesis also reinforce the proposals [47,48] for exploring positive BI in adolescents more deeply.

Strengths and Limitations of the Review
The strength of the review is reflected in the systematic identification of articles, using a broad and specific search strategy and multiple databases. Furthermore, this rigor is improved by applying the CASP score.
One possible limitation is due to the nature of the methodology, which is related to the use of different qualitative designs. In this review, however, we place the focus on the substantive area provided in each study.
Future research is necessary to determine the extent to which the present results could be generalized in other social and cultural contexts. Indeed, most of the studies reviewed are from western countries or western models of societies in which family, friends, and social factors play the same role.

Implications for Practice
A model has been developed that can help health professionals and educators to reorient the focus of interventions and programs devoted to this issue.
We should make an effort to create intervention tools to provide adolescents with a distanced, critical, and reflective point of view on the inputs they receive.
To prevent problems and promote public health by providing adolescents with information, instruments, and strategies would help empower adolescents to form the most positive perspective on BI and motivate them to engage in healthy behaviors for to maximize their satisfaction with their BIs. The results reported here may also help investigators formulate intervention strategies for improving BI among pre-adolescent children.

Conclusions
The present review shows the construct, the meaning, and the key factors that influence the development of BI, according to the perspective of adolescents. The synthesis presents strategies that have a negative impact on the health of adolescents, and factors that are a protective framework for a healthy BI.
The results provide relevant information for nursing professionals who should consider the design and implementation of educational programs on BI and health promotion in childhood and adolescence. These interventions should consider multiple levels, the perspectives of adolescents and the specific needs of each subgroup: girls, boys, peers, friends, etc. In addition, our synthesis identifies protective factors for a healthy BI, such as positive school environment and teacher support, as well as the need for strategies to deal with the impact of mass media messages. These are necessary to understand the needs of adolescents and develop individualized care plans in the earlier stages of life.

Data Availability Statement:
The research team has the data under their control. The data will be available to anyone who requests it if the demand is reasonable.