Heidi Williamson

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Body dissatisfaction is a global public health issue negatively impacting young people’s mental and physical wellbeing, underscoring an urgent need to develop early interventions. Emerging evidence suggests that microinterventions are acceptable and effective in delivering mental health interventions. Given the popularity of video games amongst young people, the gaming world holds great promise for housing body image microinterventions. As such, we developed Super U Story, a stand-alone, self-paced, narrative-based adventure video game for the popular gaming platform, Roblox, grounded in the Tripartite Influence Model of body dissatisfaction and basic tenets of positive body image. Objective: This trial evaluated the effectiveness of a purpose-built Roblox video game on US children and adolescents’ state and trait body image and related outcomes. Methods: A sample of 1059 US-based girls and boys (43.4% girls) aged 9-13 years (mean 10.9, SD 1.36) from diverse ethnic, socioeconomic, and geographic backgrounds were recruited online via a research agency into a 3-arm, web-based parallel randomized controlled trial. Participants were assigned to an intervention group, active control group (a Roblox game called Rainbow Friends 2 Story (Color Story)), or attention control group (online word search). Participants completed self-report assessments at baseline (1 week preintervention and before randomization), immediately before and after the intervention testing phase, and 1 week postintervention. Outcomes included state measures of body satisfaction (primary outcome), mood, and body functionality, and trait measures of body esteem, body appreciation, internalization of appearance ideals, and social media literacy. Data were evaluated using repeated measures ANCOVA controlling for baseline. Engagement and acceptability data were collected. Results: Relative to the active control, intervention participants showed improved state body satisfaction (F(1, 694)=5.196, P=.023, η_p^2=.007), but not in comparison to the attention control. State mood, state body functionality, internalization of appearance ideals, and social media literacy showed no significant effects. Relative to the intervention group, the active control showed improved trait body esteem (F(1, 663)=5.398, P=.020, η_p^2=.008) and body appreciation (F(1, 663)=6.078, P=.014, η_p^2=.009). Exploratory analyses found age and gender did not moderate effects. We were unable to examine dose-response effects. Acceptability scores were good. Self-report engagement data suggested participants experienced highly variable and often low-dose exposure. Conclusions: This large-scale, fully powered trial is the first to assess the effectiveness of a Roblox-based body image intervention. Overall, playing Super U Story did not cause harm; however, evidence is lacking to suggest it improved body image. Learnings are discussed, including psychoeducation as an intervention technique, ‘chocolate-covered broccoli’ phenomena (ie, losing players who recognise thinly disguised educational messages), and measuring intervention engagement. Clinical Trial: ClinicalTrials.gov NCT05669053; https://clinicaltrials.gov/study/NCT05669053

BACKGROUND Body dissatisfaction is a global public health issue negatively impacting young people’s mental and physical well-being, underscoring an urgent need to develop early interventions. Emerging evidence suggests that microinterventions are acceptable and effective in delivering mental health interventions. Given the popularity of video games among young people, gaming holds great promise for body image microinterventions. As such, we developed Super U Story, a stand-alone, self-paced, narrative-based adventure video game for the popular gaming platform Roblox grounded in the Tripartite Influence Model of body dissatisfaction and basic tenets of positive body image. OBJECTIVE This trial evaluated the effectiveness of playing a purpose-built Roblox video game once on US children and adolescents’ state and trait body image and related outcomes. Gameplay was capped at 30 minutes. METHODS Overall, 1059 US-based girls and boys (n=460, 43.4% girls) aged 9 to 13 years (mean age 10.9, SD 1.36 years) from diverse ethnic, socioeconomic, and geographic backgrounds were recruited online via a research agency into a 3-arm, online, parallel randomized controlled trial. Participants were assigned to an intervention group, active control group (a Roblox game called Rainbow Friends 2 Story [Color Story]), or attention control group (web-based word search). Participants completed self-report assessments at baseline (1 week before the intervention and before randomization), immediately before and after intervention testing, and 1 week after the intervention. Outcomes included state measures of body satisfaction (primary outcome), mood, and body functionality and trait measures of body esteem, body appreciation, internalization of appearance ideals, and social media literacy. Data were evaluated using repeated-measure analysis of covariance controlling for baseline. Engagement and acceptability data were collected. RESULTS Intervention participants showed improved state body satisfaction (F1,694=5.20; P=.02; ηp2=0.01) relative to the active control but not in comparison to the attention control. State mood, state body functionality, internalization of appearance ideals, and social media literacy showed no effects. Relative to the intervention group, the active control showed improved trait body esteem (F1,663=5.40; P=.02; ηp2=0.01) and body appreciation (F1,663=6.08; P=.01; ηp2=0.01). Exploratory analyses found that age and gender did not moderate the effects. We were unable to examine dose-response effects. Acceptability scores were good. Self-report engagement data suggested that participants experienced a highly variable and often low-dose exposure. CONCLUSIONS This large-scale, fully powered trial is the first to assess the effectiveness of a Roblox-based body image intervention, demonstrating the potential for disseminating microinterventions to children and adolescents on large and popular commercial platforms. Overall, playing Super U Story did not cause harm; however, evidence is lacking to suggest that it improved body image. Learnings are discussed, including psychoeducation as an intervention technique, “chocolate-covered broccoli” phenomena (ie, losing players who recognize thinly disguised educational messages), and measuring intervention engagement. CLINICALTRIAL ClinicalTrials.gov NCT05669053; https://clinicaltrials.gov/study/NCT05669053

Body image concerns significantly impact boys’ physical and mental health. While several reviews synthesize evidence on body image interventions for mixed-gender adolescents, a systematic review exclusively focusing on boys is currently missing. Thus, this systematic review synthesizes evidence on universal psychosocial interventions targeting body image among boys and identifies effective approaches for enhancing their body image. Searches were conducted across seven databases until February 2024. Forty-one studies were included and assessed for quality across domains such as selection bias, study design, and methods. Three studies exclusively targeted boys, while 38 involved mixed-gender groups. Multiple therapeutic approaches were used across the interventions, including media literacy, socio-cognitive approaches, combined cognitive dissonance and media literacy, positive body image, compassion and mindfulness, and other approaches, with no single approach proving universally effective. Some promise for interventions employing positive body image and embodiment techniques was noted. Few interventions showed effectiveness on boys’ body image but most benefited girls. Further, findings were inconsistent across outcomes, with lower-quality studies driving evidence of effectiveness. These findings highlight that the effectiveness of current body image interventions among boys is inconclusive, emphasizing the urgent need for improvement or development of new interventions tailored specifically to address boys’ body image concerns.

Multidisciplinary health professionals (HPs) are involved in supporting patients who have conditions that affect their appearance. With appearance-associated distress common in this group, acceptance and commitment therapy (ACT) and enhanced communication skills both show effectiveness in helping patients adjust to their conditions. Multidisciplinary HPs are perfectly placed to provide low-level psychological support as paraprofessionals. We present the real-world evaluation of a training programme, ACT Now, which was delivered via the train-the-trainer model to 149 multidisciplinary HPs in six European countries. Trainees completed a 16-item knowledge, attitude and practice survey covering psychoeducation on appearance concerns, ACT applied to the patient group and communication skills, at pre-training, post-training and at 3-or-6-month follow-up. Findings show that trainees’ confidence consistently improved in understanding specific facets of appearance concerns and ACT processes, with largely positive changes in other facets, skewed towards delivery nations in which psychologists delivered the training. Patient communication skills generally improved, though again these were more pronounced in psychologist-led countries. However, an absence of significant improvements in ACT comprehension suggests a challenge in transmitting the ACT model to HPs. Providing more initial training to non-psychologist trainers and embedding post-training skills practice for trainees may help reinforce the ACT component of the training.

Background: Body dissatisfaction is a global issue, particularly among adolescent girls and young women. Effective body image interventions exist but face barriers to scaling up, particularly in lower- and middle-income countries, such as Indonesia, where a need exists. Objective: We aimed to evaluate the acceptability and efficacy of Warna-Warni Waktu, a social media–based, fictional 6-episode video series with self-guided web-based activities for improving body image among young Indonesian adolescent girls and young women. We hypothesized that Warna-Warni Waktu would increase trait body satisfaction and mood and decrease internalization of appearance ideals and skin shade dissatisfaction relative to the waitlist control condition. We also anticipated improvements in state body satisfaction and mood immediately following each video. Methods: We conducted a web-based, 2-arm randomized controlled trial among 2000 adolescent girls and young women, aged 15 to 19 years, recruited via telephone by an Indonesian research agency. Block randomization (1:1 allocation) was performed. Participants and researchers were not concealed from the randomized arm. Participants completed self-report assessments of trait body satisfaction (primary outcome) and the internalization of appearance ideals, mood, and skin shade dissatisfaction at baseline (before randomization), time 2 (1 day after the intervention [T2]), and time 3 (1 month after the intervention [T3]). Participants also completed state body satisfaction and mood measures immediately before and after each video. Data were evaluated using linear mixed models with an intent-to-treat analysis. Intervention adherence was tracked. Acceptability data were collected. Results: There were 1847 participants. Relative to the control condition (n=923), the intervention group (n=924) showed reduced internalization of appearance ideals at T2 (F1,1758=40.56, P<.001, partial η2=0.022) and T3 (F1,1782=54.03, P<.001, partial η2=0.03) and reduced skin shade dissatisfaction at T2 (F1,1744=8.05, P=.005, partial η2=0.005). Trait body satisfaction improvements occurred in the intervention group at T3 (F1, 1781=9.02, P=.005, partial η2=0.005), which was completely mediated by the internalization change scores between baseline and T2 (indirect effect: β=.03, 95% CI 0.017-0.041; direct effect: β=.03, P=.13), consistent with the Tripartite Influence Model of body dissatisfaction. Trait mood showed no significant effects. Dependent sample t tests (2-tailed) found each video improved state body satisfaction and mood. Cumulative analyses found significant and progressive improvements in pre- and poststate body satisfaction and mood. Intervention adherence was good; participants watched an average of 5.2 (SD 1.66) videos. Acceptability scores were high for understandability, enjoyment, age appropriateness, usefulness, and likelihood to recommend. Conclusions: Warna-Warni Waktu is an effective eHealth intervention to reduce body dissatisfaction among Indonesian adolescent girls and young women. Although the effects were small, Warna-Warni Waktu is a scalable, cost-effective alternative to more intense interventions. Initially, dissemination through paid social media advertising will reach thousands of young Indonesian women. Trial Registration: ClinicalTrials.gov NCT05383807, https://clinicaltrials.gov/ct2/show/NCT05383807 ; ISRCTN Registry ISRCTN35483207, https://www.isrctn.com/ISRCTN35483207 International Registered Report Identifier (IRRID): RR2-10.2196/33596

Background: Adolescents with a condition affecting their appearance that results in a visible difference can be at risk of psychosocial distress and impaired adjustment. Evidence for the effectiveness of existing interventions in improving psychosocial outcomes is limited, and relevant treatment can be difficult to access. Young Person’s Face IT (YPF), a self-guided web-based intervention, has demonstrated potential in reducing social anxiety in adolescents with a visible difference. However, more knowledge is needed about the variables that contribute to variations in intervention effects to identify those who may benefit most from YPF. Objective: This study aimed to investigate demographic, psychosocial, and intervention-related variables as predictors of overall intervention effects after adolescents’ use of YPF. Methods: We used longitudinal data collected as part of a larger, ongoing mixed methods project and randomized controlled trial (ClinicalTrials.gov NCT03165331) investigating the effectiveness of the Norwegian version of YPF. Participants were 71 adolescents (mean age 13.98, SD 1.74 years; range 11-18 years; 43/71, 61% girls) with a wide range of visible differences. The adolescents completed primary (body esteem and social anxiety symptoms) and secondary (perceived stigmatization, life disengagement, and self-rated health satisfaction) outcome measures at baseline and postintervention measurement. The predictor variables were demographic (age and gender), psychosocial (frequency of teasing experiences related to aspects of the body and appearance as well as depressive and anxiety symptoms), and intervention-related (time spent on YPF) variables. Results: Two-thirds (47/71, 66%) of the adolescents completed all YPF sessions and spent an average of 265 (SD 125) minutes on the intervention. Backward multiple regression analyses with a 2-tailed P-value threshold of .20 revealed that several variables were retained in the final models and predicted postintervention outcome changes. Body esteem was predicted by age (P=.14) and frequency of teasing experiences (P=.09). Social anxiety symptoms were predicted by gender (P=.12), frequency of teasing experiences (P=.03), depressive and anxiety symptoms (P=.08), and time spent on YPF (P=.06). Perceived stigmatization was predicted by age (P=.09), gender (P=.09), frequency of teasing experiences (P=.19), and depressive and anxiety symptoms (P=.06). Life disengagement was predicted by gender (P=.03), depressive and anxiety symptoms (P=.001), and time spent on YPF (P=.14). Self-rated health satisfaction was predicted by age (P=.008). However, the results were limited by relatively low explained postintervention variance, ranging from 1.6% to 24.1%. Conclusions: This study suggests that adolescent boys, adolescents who experience higher levels of psychosocial distress related to their visible difference, and adolescents who spend sufficient time on YPF may obtain better overall intervention effects.

BACKGROUND Body dissatisfaction is a global issue, particularly among adolescent girls and young women. Effective body image interventions exist but face barriers to scaling up, particularly in lower- and middle-income countries, such as Indonesia, where a need exists. OBJECTIVE We aimed to evaluate the acceptability and efficacy of Warna-Warni Waktu, a social media–based, fictional 6-episode video series with self-guided web-based activities for improving body image among young Indonesian adolescent girls and young women. We hypothesized that Warna-Warni Waktu would increase trait body satisfaction and mood and decrease internalization of appearance ideals and skin shade dissatisfaction relative to the waitlist control condition. We also anticipated improvements in state body satisfaction and mood immediately following each video. METHODS We conducted a web-based, 2-arm randomized controlled trial among 2000 adolescent girls and young women, aged 15 to 19 years, recruited via telephone by an Indonesian research agency. Block randomization (1:1 allocation) was performed. Participants and researchers were not concealed from the randomized arm. Participants completed self-report assessments of trait body satisfaction (primary outcome) and the internalization of appearance ideals, mood, and skin shade dissatisfaction at baseline (before randomization), time 2 (1 day after the intervention [T2]), and time 3 (1 month after the intervention [T3]). Participants also completed state body satisfaction and mood measures immediately before and after each video. Data were evaluated using linear mixed models with an intent-to-treat analysis. Intervention adherence was tracked. Acceptability data were collected. RESULTS There were 1847 participants. Relative to the control condition (n=923), the intervention group (n=924) showed reduced internalization of appearance ideals at T2 (F1,1758=40.56, P<.001, partial η2=0.022) and T3 (F1,1782=54.03, P<.001, partial η2=0.03) and reduced skin shade dissatisfaction at T2 (F1,1744=8.05, P=.005, partial η2=0.005). Trait body satisfaction improvements occurred in the intervention group at T3 (F1, 1781=9.02, P=.005, partial η2=0.005), which was completely mediated by the internalization change scores between baseline and T2 (indirect effect: β=.03, 95% CI 0.017-0.041; direct effect: β=.03, P=.13), consistent with the Tripartite Influence Model of body dissatisfaction. Trait mood showed no significant effects. Dependent sample t tests (2-tailed) found each video improved state body satisfaction and mood. Cumulative analyses found significant and progressive improvements in pre- and poststate body satisfaction and mood. Intervention adherence was good; participants watched an average of 5.2 (SD 1.66) videos. Acceptability scores were high for understandability, enjoyment, age appropriateness, usefulness, and likelihood to recommend. CONCLUSIONS Warna-Warni Waktu is an effective eHealth intervention to reduce body dissatisfaction among Indonesian adolescent girls and young women. Although the effects were small, Warna-Warni Waktu is a scalable, cost-effective alternative to more intense interventions. Initially, dissemination through paid social media advertising will reach thousands of young Indonesian women. CLINICALTRIAL ClinicalTrials.gov NCT05383807, https://clinicaltrials.gov/ct2/show/NCT05383807 ; ISRCTN Registry ISRCTN35483207, https://www.isrctn.com/ISRCTN35483207 INTERNATIONAL REGISTERED REPORT RR2-10.2196/33596

A modest but significant number of military personnel sustained injuries during deployments resulting in an altered-appearance (e.g., limb loss and/or scarring). Civilian research indicates that appearance-altering injuries can affect psychosocial wellbeing, yet little is known about the impact of such injuries among injured personnel. This study aimed to understand the psychosocial impact of appearance-altering injuries and possible support needs among UK military personnel and veterans. Semi-structured interviews with 23 military participants who sustained appearance-altering injuries during deployments or training since 1969 were conducted. The interviews were analyzed using reflexive thematic analysis, identifying six master themes. These themes indicate that in the context of broader recovery experiences, military personnel and veterans experience a variety of psychosocial difficulties related to their changed appearance. While some of these are consistent with evidence from civilians, military-related nuances in the challenges, protective experiences, coping approaches, and preferences for support are evident. Personnel and veterans with appearance-altering injuries may require specific support for adjusting to their changed appearance and related difficulties. However, barriers to acknowledging appearance concerns were identified. Implications for support provision and future research are discussed.