Introduction

Adolescence is a high-risk period for the occurrence of body image concerns and is also a critical period to carry out body image dissatisfaction interventions (Rodgers et al., 2015). Body image dissatisfaction is a common body image cognitive concern, which has a profound impact on physical and mental health (Bucchianeri and Neumark-Sztainer, 2014; Griffiths et al., 2017). Children are more likely to experience body image dissatisfaction due to their characteristics of physical, cognitive, and emotional (Dion et al., 2014). There were 40 to 50% of Australian adolescents with body image dissatisfaction (McCabe and Ricciardelli, 2003), 60.4% of Brazilian individuals with body image dissatisfaction (Petroski et al., 2012), 50 to 60% of Korean adolescent girls with body image dissatisfaction (Jung and Sohn, 2015). Fu et al. (2014) reported that ~77.1% of adolescents experience body image dissatisfaction. These studies showed that the prevalence of body image dissatisfaction among children has been more common. Body image dissatisfaction is strongly associated with low self-esteem, depression, eating disorders, and risky health behaviors (Bornioli et al., 2019; Bornioli et al., 2020; Chen et al., 2023; Micali et al., 2015). Rodgers et al. (2023) reported body image dissatisfaction is more prevalent among children and can lead to adverse health outcomes. Therefore, there is a need to develop acceptable and effective body image dissatisfaction interventions for children.

The main influencing factors on body image dissatisfaction include biological factors (Holsen et al., 2012), sociocultural factors (Thompson et al., 1999a) and psychological factors (Allen and Walter, 2016). The three-factor model of body image dissatisfaction is a major sociocultural theory that aims to explain the influence of social and cultural factors on body image. The theory posits that appearance-related pressures from peers, parents, and the media lead adolescent girls to internalize the ideal of a slender body image and engage in social appearance comparisons, which, in turn, influence their body image cognitive processes (Thompson et al., 1999b). To date, the three-factor model has received extensive empirical support (Barnhart et al., 2023; Hazzard et al., 2019). From an etiological perspective, reducing causal risk factors for problems may reduce the frequency and intensity of their occurrence. Theoretically, it is feasible to develop intervention programs for body image dissatisfaction based on risk factors such as appearance comparisons, appearance comments, and social media.

Schools are important places for students to learn, live, and provide the potential for ongoing interactions (Levine and Smolak, 2006). Many school-based body image dissatisfaction interventions have achieved varying degrees of intervention effectiveness (Paxton, 2002). For example, school-based interventions for students in Australia and the UK have achieved positive results in improving their body image dissatisfaction (e.g., Dove Considence Me: Five Session (Diedrichs et al., 2021), Goodform (Doley et al., 2020), Digital Bodies (Bell et al., 2021a)). In comparison to Western countries, the implementation of school-based interventions in China offers distinct institutional advantages and greater cultural adaptability. On one hand, as children’s mental health issues become more and more concerned in China, both national and local governments have begun to intensify policy support for mental health education. On the other hand, schools are the core setting of children’s daily life in China, making it convenient to conduct group-based health interventions, and with high student compliance, which benefits the implementation and promotion of body image dissatisfaction curricula.

School-based interventions are an effective means of improving the negative impacts of appearance comparisons, appearance comments, and social media on body image (Chua et al., 2019; Yager et al., 2013). In the studies of school-based intervention, critical media literacy and cognitive dissonance theory are often used to encourage students to correct inappropriate sociocultural factors and practice behaviors to protect themselves from these factors (Lewis-Smith et al., 2019). Meanwhile, a variety of methods, including psychological education (Baranowski and Hetherington, 2001), media literacy (Richardson et al., 2009), and cognitive behavioral therapy, have been applied to school-based interventions (Stice et al., 2006). The interventions based on these approaches have been shown to be more effective to improve body image dissatisfaction, its risk factors, and eating disorder symptoms (Chua et al., 2019).

Intervention studies on children’s body image dissatisfaction in China have rarely been reported, and there is a lack of effective intervention design for body image dissatisfaction. The present study aimed to develop an intervention program to provide feasible guideline for researchers in further extensive intervention researches on children’s body image dissatisfaction.

Methods

Literature research method

Search strategy

The articles on body image dissatisfaction intervention from publication to July 2023 were searched in the China National Knowledge Infrastructure (CNKI) database, Chinese Scientific and Technological Journal Database (VIP database), WANFANG Database, PubMed, Web of Science, Medline, and Cochrane Library. Search terms: “children or adolescents” and “body image or body dissatisfaction or eating disorder or disordered eating” and “intervention or prevention programs” and “school-based”.

Inclusion and exclusion criteria of literature

Inclusion criteria: (1) Research subjects: Children and adolescents; (2) Intervention: School-based intervention or combined with mental health education; (3) Control measures: Regular curriculum teaching or no intervention; (4) Outcome indicators: Body image or body image dissatisfaction; (5) Type of the study: Randomized controlled intervention, or self-administered before-and-after controlled studies, etc.; (6) Languages: Chinese or English.

Exclusion criteria: (1) Duplicate publication of literature; (2) Full text not available.

Literature screening and extraction

Two graduate students independently screened the literature by reading the title, abstract, and full-text content according to the inclusion and exclusion criteria. In this study, 1418 articles were initially retrieved, 751 articles with consistent titles and contents were excluded, 389 articles that were obviously unrelated to this study were excluded after reading the titles and abstracts, and 258 articles that did not meet the inclusion criteria were excluded after reading the full text. A total of 20 articles were included in this study, 19 of which were in English and 1 was in Chinese. As shown in the flow chart of the retrieval process (Fig. 1). This study developed a preliminary protocol for body image dissatisfaction intervention program through a literature search and group discussion

Fig. 1
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Flowchart of literature screening and extraction.

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Delphi method

The preliminary protocol of body image dissatisfaction intervention program was revised through two rounds of expert consultation via E-mail.

Selection of consultation experts

A total of 12 consultation experts were invited according to the following criteria: (1) Three years or more of research experience in the field of child and adolescent health, health promotion or sports health; (2) Undergraduate degree or above and intermediate or higher professional titles; (3) Familiarize oneself with the knowledge and development trend on children’s body image; (4) Voluntary cooperation with this research. In this study, the consultation experts aged 29–58 years old, including 4 females and 8 males, 9 PhDs and 3 masters, 10 senior and 2 associate senior professional titles, and with working experience of 3–33 years. See Table 1.

Table 1 Demographic information of consultation experts.
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Contents of expert consultation

The contents of expert consultation include four parts: (1) Background, purpose and significance of the study and requirements for filling in the form; (2) Demographic information of the experts (ages, working years, degree, professional titles, research fields, etc.); (3) Expert evaluation experience, including the degree of familiarity and judgment; (4) Each expert was scored using the 5-point Likert scale (Li et al., 2022),

and importance and feasibility of body image dissatisfaction intervention program is assessed in five levels: very important, important, average, unimportant, and very unimportant, and accordingly assigned a score of 5, 4, 3, 2, and 1. The experts may also provide specific improvement suggestions.

Consultation process

This study conducted two rounds of expert consultation via E-mail. The results of the first expert consultation were summarized and statistically analyzed to revise the body image dissatisfaction intervention program. The revised body image dissatisfaction intervention program was again sent to experts for consultation. According to the results of the second expert consultation, the body image dissatisfaction intervention program was again improved.

Statistical methods

IBM SPSS 23.0 software was used to analyze the data. Categorical data were described using frequencies and percentages (%), while quantitative data were described using means ± standard deviations (x ± s). The effective response rate, coefficients of sense (Cs), coefficient of adjudication (Ca), and coefficient of reliability (Cr) were calculated. The degree of expert consensus was measured using the coefficient of variation (CV) and Kendall’s concordance coefficient (Kendall’s W), with P < 0.05 indicating statistical significance.

Results

Theoretical system of body image dissatisfaction intervention program based on the three-factor model

Body image dissatisfaction intervention program based on the three-factor model includes a three-grade indicator system. The grade 1 indicators include four dimensions: “1. Understanding body image dissatisfaction”, “2. Positively facing the comparison of appearance”, “3. Positively responding to appearance comments” and “4. Positively responding to social media”. The grade 2 indicators includes three dimensions: health education, video intervention, and intervention form and duration, however, “1. Recognizing body image dissatisfaction” only includes health education and intervention form and duration. The indicator system is described in detail in the following Table 2.

Table 2 Theoretical system of children’s body image dissatisfaction intervention program based on the three-factor model.
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Degree of experts’ reliability and concordance

A total of 12 experts responded to the first round of expert consultation, and 11 participated in the second round of expert consultation, indicating a high level of expert engagement. The experts’ coefficient of reliability (Cr) is the related to coefficient of sense (Cs) and adjudication (Ca), which is calculated as Cr = (Ca + Cs)/2. Cr ≥ 0.70 means that the degree of reliability is high (Wang et al., 2020), which indicates that the experts have solid theoretical foundations and practical levels. In this study, the experts’ Cr values of the two rounds were 0.81 and 0.84, respectively, indicating that the results of the expert consultation were reliable. The high Cr values (0.81 and 0.84) demonstrated that the experts shared a common understanding of the intervention’s theoretical foundations and its practical implications, which was crucial for ensuring that the proposed intervention was both theoretically sound and actionable in real-world settings. See Table 3.

Table 3 Coefficients of experts’ sense, adjudication and reliability.
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The coefficient of variation (CV) and Kendall’s concordance coefficient show the consistency of experts’ opinions. The lower the CV value, the higher the degree of experts’ concordance. Generally, a CV < 0.25 indicates good experts’ concordance (He and Yang, 2018). In the two rounds of expert consultation, the CV values of importance score and feasibility score were <0.25. In this study, Kendall’s W values for importance and feasibility were 0.17 and 0.20, respectively, in the first round (P < 0.05), and 0.12 and 0.15 in the second round (P < 0.05), indicating that the experts’ opinions were basically consistent. As shown in Table 4.

Table 4 Coordination degree of experts’ opinions.
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Results of the first round of expert consultation

In the first round of expert consultation, the importance scores of grade 1 items of “1. Understanding body image dissatisfaction”, “2. Positively facing appearance comparisons”, “3. Positively responding to appearance comments”, and “4. Positively responding to social media” were 4.92, 5.00, 4.75, 4.50, and their feasibility scores were 4.92, 4.83, 4.67, 4.33, respectively. The importance scores of grade 2 items were 4.42 or greater, and their feasibility scores were 4.08 or greater. Importance scores of grade 3 items were 4.42 or greater and their feasibility scores were 4.08 or greater. The experts were overall very positive about the importance and feasibility of the theoretical framework of the body image dissatisfaction intervention program in the first round of the correspondence evaluation. See Table 5 for details.

Table 5 Results of the first round of expert consultation.
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The comments from the first round of expert consultation: (1) In grade 2 items, “Intervention subjects”, “Intervention forms”, and “Frequency and duration of intervention” should be added; According to the added grade 2 items, the corresponding grade 3 items should be improved, for example, “Children aged 8–12”, “School-based Classroom health education, and Classroom interaction”, “Once per week, 45 min per time” were added. (2) “1. Understanding body image dissatisfaction” should be revised to “Positively understanding body image dissatisfaction”; “Health education for body image dissatisfaction” should be revised to “Health education contents for body image dissatisfaction”. (3) The grade 3 items should be supplemented with more specific content and examples. In response to the first round of expert consultation, the revisions were made, followed by a second round of expert consultation.

Results of the second round of expert consultation

In the second round of expert consultation, the importance scores of “Positively understanding body image dissatisfaction”, “Positively facing appearance comparison”, “Positively responding to appearance comments”, and “Positively responding to social media” were 5,00, 5.00, 4.73, 4.82, and their feasibility scores were 5.00, 4.82, 4.55, 4.55, respectively. The importance scores of grade 2 items were 4.64 or greater and their feasibility scores were 4.18 or greater. The importance scores of grade 3 items were 4.64 or greater and their feasibility scores were 4.36 or greater. The results of the second round of expert consultation showed that the importance and feasibility of the body image dissatisfaction intervention program were better than those in the first round, which indicates that the body image dissatisfaction intervention program was more recognized. However, the experts suggested integrating “Forms of intervention” into “Forms and duration of intervention”, and revising corresponding grade 3 items. See for Table 6 details. The specific content and examples are shown in Table 7.

Table 6 Results of the second round of expert consultation.
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Table 7 Body image dissatisfaction intervention program based on three factors model for Chinese children.
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Based on the suggestions of the second round of expert consultation, we have revised determined the final body image dissatisfaction intervention program after the discussion with the research team, which is shown in Table 7.

Discussion

More and more evidence shows that body image dissatisfaction occurs in early adolescence, and it is necessary to develop body image dissatisfaction intervention program for children (Neumark-Sztainer et al., 2006). The three-factor model of body image dissatisfaction suggests that appearance comparisons, appearance comments, and social media are important risk factors for body image dissatisfaction, thus these factors have become the focus of developing body image dissatisfaction intervention programs (Thompson et al., 1999). In this study, the children’s body image dissatisfaction intervention program was developed from four dimensions, including “positively understanding body image dissatisfaction”, “positively facing appearance comparison”, “positively responding to appearance comments”, and “positively responding to social media information”, and each dimension contains a three-grade indicator.

A total of 12 experts were invited to conduct two rounds of expert consultation on children’s body image dissatisfaction intervention program. In order to avoid response bias, we performed the following procedure. Firstly, during the Delphi process, we provided a detailed introduction and explanation of the indicator system to ensure that experts fully understood the project’s objectives, contents, and intervention procedures. Secondly, the experts were selected based on their expertise in areas closely related to the intervention contents, such as health promotion, children and adolescent health, and physical activity, enabling consensus. Finally, we ensured the transparency and traceability of the iterative feedback process by establishing an item revision tracking document and a feedback explanation mechanism. The coefficients of reliability (Cr) of the two rounds of expert consultation were 0.81 and 0.84. The Cr ≥ 0.70 shows the degree of experts’ authority was high (He and Yang, 2018), which indicated that the experts had a solid theoretical foundation and clinical practice in this study area. The coefficient of variation (CV) and Kendall’s concordance coefficient (Kendall’s W) reflected the degree of experts’ homogeneity. The CV values of two rounds of expert consultation were <0.25 and the Kendall’s W values for importance and feasibility were 0.17 and 0.20, respectively, in the first round (P < 0.05), and 0.12 and 0.15 in the second round (P < 0.05), which indicated that the degree of experts’ homogeneity was good. In this study, the importance and feasibility scores of each item in the expert assessment were greater than 4.0, indicating that the content validity of the body image dissatisfaction intervention program was excellent.

In practice, most children have limited knowledge on body image, such as the harm of body image dissatisfaction to their physical and mental health, and positive behaviors of changing body image dissatisfaction. At the same time, they do not yet have a clear understanding of their own physical and mental development characteristics, such as the rapid growth in height, accumulation of fat in the buttocks, changes in voice, protrusion of male Adam’s apple, and development of female breasts, etc., which are common body image concerns during the process of children’s growth and development. Wang et al. (2022) found that the children at different developmental stages paid different attention to different parts of their bodies. Therefore, the first part of the body image dissatisfaction intervention program, “positively understanding of body image dissatisfaction”, is 45-min school-based classroom health education conducted through PPT lectures and classroom interactions, which introduced children to the basic knowledge on body image dissatisfaction, adverse effects of body image dissatisfaction on children, common poor behaviors of changing body image and their dangers, and the characteristics of children’s physical and mental development. The importance and feasibility scores of the second round of expert consultation in this part were 5.0, and the coefficient of variation was 0%, so the experts highly recognized the setting of this part.

Appearance comparison is defined as assessing one ‘s appearance by comparing one’s appearance with that of others (Schutz et al., 2002). At the same time, social comparison and cultural standards of body image internalization are also important criteria for children to evaluate their bodies (Franzoi and Klaiber, 2007). Therefore, the second part of the body image dissatisfaction intervention program was to positively face appearance comparison, and the school-based classroom health education and video intervention were used to promote children’s positive understanding of the common behaviors of appearance comparisons, adverse effects of negative appearance comparisons on children, appearance diversity, and behaviors of preventing negative appearance comparisons. The second rounds of experts evaluated this part with an importance score of 5.0 and a coefficient of variation of 0%, and feasibility score of 4.82 and a coefficient of variation of 8.5%, which shows that the correspondence experts highly recognized the setting of the content of this part.

Appearance comments may reproduce and reinforce sociocultural messages related to appearance in both direct and indirect ways (Bell et al., 2021b). Children become more concerned about their appearance and are sensitive to their external flaws or weaknesses, thus the teases of appearance by their peers further deepen adolescents’ awareness of their imperfections (Eisenberg et al., 2006). Negative comments about appearance stem from the standard of the perfect body, compare themselves to the standard of the perfect body, resulting in a more negative body image. The findings show that the experience of being teased by peers about their appearance is positively associated with body image dissatisfaction in children (Lawler and Nixon, 2010; Michael et al., 2013). Smolak (2004) discussed how parental comments about dressing style, appearance, weight, food, and diet might influence their children’s body image. Negative parental appearance talk serves as negative feedback that conveys criticism and blame to children about their weight and body shape, eating habits, and health, causing adolescents to perceive pressure from their parents, which eventually develops into body image dissatisfaction (Sharpe et al., 2013). Therefore, the third part of the body image dissatisfaction intervention program is to positively respond to appearance comments, which provides children with health education and video interventions on the common behaviors of appearance comments, adverse effects of negative appearance comments on children, positive understanding of appearance comments, and behaviors of preventing negative appearance comments. The results of the second round of expert consultation showed that the importance score was 4.73 with a coefficient of variation of 13.74%, and the feasibility score was 4.55 with a coefficient of variation of 11.43%, and these indicated that the experts were more favorable to this part as well.

The breadth and depth of mass media’s influence on children continue to expand, and more and more children are exposed to the media’s prevalent “unrealistic ideal body image” standard, whereby females are expected to be slim and males are expected to be well-muscled (Benowitz-Fredericks et al., 2012; Ren et al., 2018; Stanford and McCabe, 2005). In the past decade, there has been a dramatic increase in social media exposure, which is associated with the increase of body image dissatisfaction (De Vries et al., 2015). Therefore, the fourth part of the body image dissatisfaction intervention program is to positively respond to social media, and to introduce children to positive understanding of common social media communication, the adverse effects of negative social media communication on children, social media communication on body image, behaviors of preventing negative social media communication through health education and video interventions. The results of the second round of expert consultation showed that this part had an importance rating of 4.82 with a coefficient of variation of 8.51%, and a feasibility rating of 4.55 with a coefficient of variation of 20.44%, which indicates that the experts were also more receptive to this dimension.

Schools are important places for students to learn and live, and Yager et al. (2013) have shown that single- or multi-session classroom interventions can be effective in alleviating students’ psychological distress. Video micro-interventions have the advantage of being low-cost, easily accessible, and having the potential for broad coverage and updating, and can not only be used as stand-alone interventions, but also as an adjunct to traditional interventions (Matheson et al., 2020). Therefore, school-based classroom health education or video interventions can be conducted separately or concurrently during the course of the intervention. The classroom health education intervention is recommended to be conducted in the form of pre-class review, classroom interaction, and role-playing, with specific content points listed. It is recommended to be conducted once per week for 45 min. This study program has given the construction ideas of video intervention, including the construction of common body image dissatisfaction scene, the impact of body image dissatisfaction on the children, the positive behaviors of responding to body image dissatisfaction, etc. It is recommended that each video be 2–3 min, 1 time per week. Based on our results, we suggest that school-based programs focus on enhancing children’s understanding of body image issues and promoting positive coping strategies for dealing with societal pressures related to appearance. Moreover, it is recommended that body image education into the school curriculum to foster a more supportive and inclusive environment for children.

The following limitations exist in this study. Firstly, the study may be subject to selection bias. The body image dissatisfaction intervention program was constructed based on a three-factor theoretical model and expert consultation, there was a certain degree of subjectivity among the researchers and the consultation experts. It cannot fully represent the broader group of children. Secondly, the body image dissatisfaction intervention program was developed for Chinese children and the intervention’s effectiveness may vary in different regions or populations. Finally, in this study, the Kendall’s W value was relatively low, indicating considerable variation in the rankings provided by the experts, which may lead to weak consistency. The low Kendall’s W value could be attributed to differences in the experts’ backgrounds, varying assessment criteria, or discrepancies in their understanding of the research subject. Future studies could improve consistency by increasing the number of experts, refining the assessment tools, or standardizing the scoring process.

Conclusion

An intervention program for children’s body image dissatisfaction was developed through literature research and two rounds of expert consultation. The intervention program includes four dimensions: positively understanding body image dissatisfaction, positively facing appearance comparison, positively responding to appearance comments, and positively responding to social media, each of which contains a three-grade index, and provides clear intervention contents, intervention subjects and intervention forms. The consultation experts gave high recognition to this intervention program. This is the first study to construct a multidimensional school-based intervention program for body image dissatisfaction using the Delphi method in China, filling the gap in research on body image dissatisfaction interventions for Chinese children. The intervention helps children develop a positive body image cognition, understand common risky behaviors and adverse effects associated with body image dissatisfaction, thereby reduce the occurrence of body image dissatisfaction, and preventing children from evolving into more severe mental health issues, such as eating disorders, anxiety, and depression. This study not only offers researchers clear guidance for the effective implementation of body image dissatisfaction interventions, but also provides valuable references for Chinese authorities in the formulation and implementation of children’s body image on mental health education.