Effectiveness of a Self-guided Mobile Phone Application in Improving the Way we See Ourselves and Our Bodies
Condition: Body Image
Study type: Interventional

Summary: 
      Body image concerns are pervasive and can impact multiple aspects of a person's life.
      Individuals with negative body image tend to have negative thoughts and feelings about their
      bodies, often resulting in unhealthy behaviours. Negative body image is also associated with
      mental and physical health conditions. Thus, prevention efforts are crucial to alleviating
      body image concerns in young adults as they are considered high-risk populations.

      This study is a randomised controlled trial that aims to evaluate the effectiveness of a
      self-guided body image program on a mobile-based application for young adults.

      Hypothesis 1a: The intervention group will improve significantly on measures of body image at
      post-intervention and follow-up, as compared to the control group.

      Hypothesis 1b: The intervention group will reduce significantly on measures of
      appearance-ideal internalization, media and peer pressures at post-intervention and
      follow-up, as compared to the control group.

      Hypothesis 2: The intervention group will improve significantly on the measure of
      self-compassion at post intervention and follow-up, as compared to the control group.
    

Detailed description: 
      Procedure:

      Participants will begin by reading the Participant Information Sheet (PIS) online. Once they
      have indicated consent on the online Consent Form, participants will proceed to complete a
      set of questionnaire on an online survey platform (Qualtrics) to obtain baseline ratings. The
      online questionnaire consists of four measures on body image, body image risk factors and
      self-compassion. Participants will also report demographic information such as gender and
      age.

      Next, participants will download the phone application and be guided to navigate the
      application. The phone application for the programs in this study is provided by Intellect
      Pte Ltd, a Singaporean technology start-up company that collaborates with the supervisor of
      this project (OS). All participants will be randomized to one of two conditions- intervention
      or active wait-list control-using simple randomisation procedures. Participants in the
      intervention condition will participate in 9 days of body image program, while participants
      in the active wait-list control condition will participate in 9 days of cooperation learning
      program. In both programs, participants will engage in content learning and short activities
      daily on the phone application. The anticipated time participants will spend on each programs
      is comparable, of about less than five minutes per day.

      Participants will be asked to complete the same set of online questionnaires immediately
      after completing the program (post-intervention measure), and four weeks after completing the
      program (follow-up measure). The feedback questionnaire will be administered only
      post-intervention. Participants will receive either course credit or a small monetary
      reimbursement after completing the program and questionnaire at post-intervention and at the
      four weeks follow-up.

      At the end of the six weeks data collection period, all participants will be debriefed about
      the purpose of the study. Participants in the active wait-list control condition will be
      given access to the body image program.

      Outcome Measures:

      Body image measures:

      Body Image Ideals Questionnaire (BIQ) is a 22-item scale that assesses body image
      satisfaction-dissatisfaction by measuring the degree of congruence or discrepancy of one's
      perceived and idealized physical attributes. On a scale from 0 (Exactly as I am) to 3 (Very
      unlike me), participants rate the degree they resemble their physical ideal on 11 physical
      attributes. Next, participants rate the importance that they attain their ideal on each
      physical attribute. The cross-products of the discrepancy and importance ratings for each
      physical attribute will be obtained and a composite BIQ score will be computed. Higher scores
      indicate a greater disparity between one's perceived and ideal physical attributes,
      suggesting higher levels of body dissatisfaction. BIQ has good internal consistency, with
      Cronbach's α of 0.81 for males and 0.76 for females.

      Body Appreciation Scale-2 (BAS-2) is a 10-item scale that assesses individuals' positive
      attitudes toward their bodies. Items are scored on a scale from 1 (Never) to 5 (Always).
      Scores on all items are averaged with higher scores indicating greater body appreciation.
      BAS-2 has excellent internal consistency, with Cronbach's α of 0.96 for males and 0.97 for
      females.

      Risk factor measures:

      Sociocultural Attitudes Toward Appearance Questionnaire-4 Revised (SATAQ-4R) measures
      internalization ideals and appearance-related sociocultural pressures. The seven subscales
      consist of 31 items for females and 28 items for males on a scale from 1 (definitely
      disagree) to 5 (Definitely agree). Higher scores on each subscale indicate higher levels of
      internalisation and sociocultural pressures. The internal consistency of the subscales are
      good, with Cronbach's α of 0.82 or higher in a sample of university females and Cronbach's α
      of 0.75 or higher in a sample of university males.

      Self-compassion measure:

      Self-Compassion Scale-Short Form (SCS-SF) is a 12-item scale that measures self-compassion on
      six subscales. Each item is scored from 1 (Almost never) to 5 (Almost always). A total
      self-compassion score is a grand mean of all six subscale means, with higher scores
      indicating higher levels of self-compassion. The internal consistency of the scale is
      excellent, with Cronbach's α of 0.86.

      Feedback questionnaire:

      App Engagement Scale is a 7-item scale that measures participants' engagement on the phone
      application form 1 (Definitely disagree) to 5 (Definitely agree). A total score is derived by
      adding scores from each item. The internal reliability of the scale is good, with Cronbach's
      α of 0.84.

      Power analysis and sample size:

      Most studies that examined mobile and internet-based body image and eating disorder programs
      reported intervention effects of small to moderate effect sizes. Using G*power, a small
      effect size of Cohen's f = 0.1, and alpha = 0.05, an estimated sample size of 214
      participants are required to achieve a power of at least 0.90. Taking into consideration a
      potential attrition rate of 30% in app-based interventions, 280 participants are required.

      Statistical analyses:

      Statistical analyses will be done using SPSS Version 26.0. All analysis will be conducted
      using two-tailed test with a level of significance at p < .05.

      Data will first be visually inspected using scatterplots, histograms and boxplots to examine
      the distribution of data and identify significant outliers. Data further than three standard
      deviations from the mean will be identified as significant outliers. Further analyses will be
      conducted with and without the outliers to determine if outliers influence the results
      significantly. If outliers influence results significantly, they will be managed using the
      Winsorizing method, where outliers will be replaced with the next closest non-outlying data
      point.

      A one-way Analysis of Variance (ANOVA) will examine baseline differences between the two
      conditions on all demographic and dependent variables. If no significant differences are
      observed at baseline between the two conditions, two-way 2 (condition) X 3 (time) mixed
      factorial repeated measures ANOVA will be conducted to determine if there are significant
      changes over time in the intervention and active wait-list control conditions. Any
      significant interaction terms (condition x time) will be examined using simple slope
      analysis. Tests of statistical assumptions such as Mauchly's Test of Sphericity and Levene's
      test for homogeneity of variances will be carried out before the main analyses.

      If significant differences are observed at baseline between the two conditions, Analysis of
      Covariance (ANCOVA) will be conducted, controlling for baseline values. Tests of statistical
      assumption for ANCOVA such as independence between covariate and independent variable
      (condition), and homogeneity of regression slopes will be carried out.

      For both analyses, if participants in the intervention condition improved significantly on
      the outcome measures at post-intervention and follow-up compared to participants in the
      active wait-list control condition, it provides evidence that the intervention is effective
      in improving body image and self-compassion in university students.

      Intent-to-treat analysis will be carried out to address the loss of participants' data due to
      attrition, by carrying forward the participants' last reported score. Analyses using one-way
      ANOVA on demographic and dependent variables will be done to determine if there are any
      significant differences between participants who dropped out and participants who did not.
      Any significant differences detected can inform of attrition-related biases in the study.
    

Intervention name(s): Self-guided programme on body image; Self-guided programme on cooperation
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Participants will download the application from the App store or Google Play store for free. In both programs, participants engage in content learning and short activities daily on the phone application. The anticipated time participants will spend on each program is comparable, of about less than five minutes per day.
Participants complete the same set of questionnaires immediately after completing the program (post-intervention measure), and again at 4 weeks after completing the program (follow-up measure).
At the end of the six weeks data collection period, all participants will be debriefed about the purpose of the study. Participants in the active wait-list control condition will be given access to the body image program.; Participants will download the application from the App store or Google Play store for free. In both programs, participants engage in content learning and short activities daily on the phone application. The anticipated time participants will spend on each program is comparable, of about less than five minutes per day.
Participants complete the same set of questionnaires immediately after completing the program (post-intervention measure), and again at 4 weeks after completing the program (follow-up measure).
At the end of the six weeks data collection period, all participants will be debriefed about the purpose of the study. Participants in the active wait-list control condition will be given access to the body image program.
Allocation: Randomized
Intervention model: Factorial Assignment
Masking: Single (Participant)
Primary purpose: Supportive Care