Sung et al.

BMC Nursing (2023) 22:481 BMC Nursing

https://doi.org/10.1186/s12912-023-01649-3

RESEARCH Open Access

BodyThink program-based body image

education improves Korean adolescents’
attitudes toward cosmetic surgery:
randomized controlled trial
Hyeonhwa Sung1†, A Young Han1,2† and Geun Hee Seol1,3*

Abstract
Background The aims of this study were to modify the widely used BodyThink program to suit the circumstances of
Korean schools and determine its effects on body esteem, body image, appearance stress, depression, and attitudes
toward cosmetic surgery.
Methods Participants were 184 third-grade students from two middle schools in Korea, who were randomly
assigned to a control or intervention group. Two of the participants dropped out; hence, data from 182 students were
analyzed. The control group received the existing curriculum for 4 sessions, and the experimental group was provided
with 4 sessions of the revised BodyThink program. Before and after the intervention, all participants completed
questionnaires.
Results In the BodyThink group, improved body image, decreased depression, and positive improvements in
attitudes toward cosmetic plastic surgery were observed after the intervention.
Discussion These results suggest that school health nurses can utilize interventions based on BodyThink program in
their curricula to improve the physical and emotional health of adolescents.
Trial registration This study has been retrospectively registered with the Clinical Research information Service (CRIS)
in Korea on October 5, 2023 (KCT0008839).
Keywords Body image, Depression, Cosmetic surgery, Adolescent

†
Hyeonhwa Sung and A Young Han contributed equally to this work.
*Correspondence:
Geun Hee Seol
[email protected]
1
Department of Basic Nursing Science, College of Nursing, Korea
University, Seoul, Republic of Korea
2
Department of Nursing, College of Life Science and Industry, Sunchon
National University, Suncheon, Republic of Korea
3
BK21 FOUR Program of Transdisciplinary Major in Learning Health
Systems, Graduate School, Korea University, Seoul, Republic of Korea

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Sung et al. BMC Nursing (2023) 22:481 Page 2 of 10

Background is essential to guide adolescents toward a healthy body

Body image formation during adolescence plays an image rather than view their excessive interest in their
important role in self-perception, self-esteem, and overall appearance as a minor problem [13]. To date, educational
quality of life [1]. The transition to adolescence sees chil- programs aimed at improving body image have been
dren become more aware of their physical appearance, deployed based on a variety of topics and approaches
including their height, weight, and facial features, and both domestically and internationally. Among them, the
increasingly compare themselves to social standards and BodyThink program, which was developed by the British
peer groups. Body image is closely related to self-esteem Eating Disorders Association with the aim of improving
in adolescence. A more positive body image is associated body image and self-esteem and cultivating the ability to
with a higher tendency for positive rational acceptance, critically view images in the mass media, has been shown
whereas a negative body image is associated with a ten- to improve body image and self-esteem in Australian
dency for maladaptive coping, including binge eating [2]. youth [14]. The purpose of the present study was to apply
Body image formation in adolescents is greatly influ- the BodyThink program to Korean adolescents and deter-
enced by peers and social media. They may compare mine its effects on body esteem, body image, appearance
themselves to friends, celebrities, and influential peo- stress, depression and cosmetic surgery attitude. The
ple, which can affect how they perceive their bodies [3]. results of this study are expected to be helpful in pro-
Media, including magazines, television, and social media viding effective information on how to promote healthy
platforms, often portray unrealistic beauty standards. body image to school and community nurses in charge of
Social media use by adolescents can lead to long-term the physical and emotional health of adolescents.
exposure to such images, which can create perceptions
of ideal bodies and cause dissatisfaction with their own Methods
bodies [4]. Participants
According to the Korean Youth Health Behavior Sur- Participants were 184 third-grade students from two
vey, one in four Korean female students with a body middle schools in Gyeonggi-do, South Korea. The study
mass index within the normal range had a distorted body was conducted with the approval of the school principal,
image and perceived themselves as overweight [5]. This and classroom units were randomly assigned to interven-
means that female Korean teenagers show a level of dis- tion or control groups. In brief, an author of this study,
satisfaction with their body image that is not in line with AH, randomly assigned each class to the control or inter-
their actual appearance. In particular, Korean teenagers vention group using a random number table in Microsoft
are widely exposed to media genres such as K-pop and Excel, and notified the researcher HS, who conducted the
K-dramas that promote specific beauty standards [6]. actual classes, of the results of the assignment. To reduce
In addition to the cultural trend of viewing appearance contamination effects from intergroup communication,
as a means for social success, Koreans adolescents have classes were conducted without informing participat-
long considered cosmetic surgery to be an easy way to ing students whether they were assigned to the control
improve their appearance [7]. or intervention group. In addition, the purpose of the
Plastic surgery involves reconstructing or modify- research and the meaning of participating in the research
ing parts of the human body. Reconstructive surgery were explained at each session, and the participants were
aims to rebuild or improve the function of a part of the instructed not to share class content. Participants were
body, such as removal of burns or micro-scars, whereas eligible for selection if both they and their parents agreed
cosmetic surgery aims to improve the appearance of the to participate in the study, and if they did not have dis-
body even in the absence of physical or medical problems abilities in hearing, vision, or literacy. Students who
[8]. Cosmetic surgery has recently become increasingly were receiving hospital treatment or counseling for body
popular as a means of pursuing beauty by people who are image-related diseases, students with physical or emo-
dissatisfied with their appearance [9]. Korea ranks first tional disabilities, and students who had completed body
in the world in terms of cosmetic procedures per capita, image promotion education were excluded.
with 13.5 procedures per 1,000 people [10], and ranks 5th G*power 3.1 was used to determine the number of
according to the estimated number of plastic surgeons subjects needed to achieve a power of 80%, significance
per 1,000 population. This excessive interest in cosmetic level of 0.05, and effect size of 0.4, where these levels
surgery is having a great influence on adolescent students were set based on previous research [15]. Assuming a
[11]. 15% dropout rate, a total of 184 students were selected
Negative body image during adolescence can give rise as the sample size. A total of 92 students were enrolled
to physical and psychological problems such as eating in the experimental group and 92 in the control group, of
disorders and bullying, and can continue into adulthood, which 2 students dropped out in the experimental group.
causing problems throughout life [12]. For this reason, it
Sung et al. BMC Nursing (2023) 22:481 Page 3 of 10

Hence, the final analysis included 90 students in the Appearance stress instruments
experimental group and 92 in the control group (Fig. 1). Appearance stress refers to the psychological pressure
felt about one’s overall appearance, and was measured
Body esteem instruments using the instrument developed by Yang [19]. A total of
Body esteem refers to an individual’s subjective percep- 19 questions are measured on a 5-point Likert scale, with
tion and evaluation of his or her own body. Body esteem higher scores indicating higher appearance stress. Cron-
was assessed using the scale developed by Mendelson, bach’s alpha value was 0.95 in the present study and 0.92
Andrews, Balfour, and Buchoiz (1997) for adolescents in the work of Yang (1993).
and adults, adapted by Lee [16, 17]. This scale consists
of 23 questions on a 4-point Likert scale, with a higher Depression instruments
score indicating higher body esteem. Questions 4, 7, 9, The Center for Epidemiological Studies-Depression
11, 13, 17, 18, 19, and 21, which have negative connota- (CES-D) scale Korean version was used to measure
tions, were reverse calculated. Cronbach’s α coefficient depression [20]. The CES-D scale developed by the
was found to be 0.90 in the present study, similar to the American Institute of Mental Health (1971) was trans-
value of 0.92 obtained by Lee (2001). lated into Korean by Noh (1992) and revised to 26 ques-
tions by adding 4 questions to ensure reliability. The
Body image instruments Korean version of CES-D uses a 4-point Likert scale to
Body image refers to an individual’s satisfaction with the evaluate the frequency of recently experienced depressive
shape and function of each part of his or her body. Body symptoms, with higher scores indicating higher levels of
image was assessed using the body cathexis scale devel- depression. Questions 4, 8, 12, and 16 were back-calcu-
oped by Secord and Jourard [18]. This scale consists of lated. This tool has been used several times in Korean
46 questions on a 5-point Likert scale, with higher scores adolescents. Cronbach’s α coefficient was found to be
indicating higher satisfaction with one’s body. Cronbach’s 0.91 in the present study, and 0.89 in the study by Cho
α coefficient was found to be 0.95 in the present study, and Kim (1993).
compared to 0.83 in the study of Secord and Jourard
(1953).

Fig. 1 Flow diagram of the study and number of participants at each stage
Sung et al. BMC Nursing (2023) 22:481 Page 4 of 10

Cosmetic surgery attitude instruments and post-data was collected immediately after the fourth
Cosmetic surgery attitude, which refers to an individ- training session.
ual’s attitudes toward cosmetic surgery, was assessed
using the scale developed by Jeon & Lee [21]. This scale Ethical considerations
consists of 19 questions on a 4-point Likert scale, with All procedures in this study were conducted with the
higher scores indicating a more active intention toward approval of the Korea University Institutional Review
cosmetic surgery. This tool consists of 5 sub-categories Board (Code: KUIRB-2023-0141-01). Registration for this
comprising 4 questions about secrecy regarding cosmetic study as a CRIS clinical trial has been completed (Code:
surgery, 4 questions about the value of cosmetic surgery, KCT0008839). Considering the characteristics of middle
5 questions about conformity regarding cosmetic sur- school students, the study was conducted with the con-
gery, 4 questions about payment for cosmetic surgery, sent of the school principal, parents, and the students
and 3 questions about risk tolerance for cosmetic surgery. themselves prior to data collection. A study description
Cronbach’s α in Jeon’s (2002) study was 0.63 for secrecy and consent form specifying the purpose of the study,
regarding cosmetic surgery, 0.75 for value of cosmetic research content and procedures, confidentiality of data,
surgery, 0.84 for conformity regarding cosmetic surgery, disposal after completion of the study, and possibility of
0.75 for payment for cosmetic surgery, and 0.79 for risk cancellation at any time during participation were sent
tolerance for cosmetic surgery, and the corresponding home, and written consent was obtained.
values obtained in the present study were 0.86, 0.87, 0.78,
0.86, and 0.90, respectively. Statistical analyses
Data were expressed as numbers and percentages or
Revised BodyThink program means and standard deviations. The collected data were
The BodyThink program applied in this study maintained subjected to a two-sided test at a significance level of
the same topics and activities as the previously deployed 0.05 using SPSS 28.0. After verifying the normality of the
BodyThink program [14], but several parts were modified data and homogeneity between groups, the independent
to make it applicable to a Korean context (Table 1). For t-test, Mann-Whitney U test, paired t-test, and Wilcoxon
example, the existing program lasted 50 min per session, Signed-Rank test were used to compare the differences
but in the present study sessions were 45 min, the regular in the effectiveness of the intervention program between
class time in Korean schools. The intervention consisted and within the experimental and control groups. The
of 4 sessions, the same as in the existing program. Some possibility of gender differences was considered, but
video materials were changed to feature Korean culture because the analysis of the results of this study did not
and Korean people. To increase intervention fidelity in show significant differences between genders, the data
our study, we implemented three strategies. First, the were analyzed based on the control group and experi-
topics and activities of the revised program were verified mental group [22].
for content validity through consultation with two nurs-
ing professors. Second, a syllabus was created for each Results
session regarding the educational content provided to Participant characteristics
the control and intervention groups, and the classes were Of the 182 participants, 105 (57.7%) were boys, and the
conducted according to the protocol. Third, to increase average age was 14.47 years old. The average BMI of
the internal validity of the study, the author of the present the participants was 21.32 kg/m2, and 95 (52.2%) were
study, a middle school health nurse (HS), delivered the within the normal range. Ninety-four (51.7%) partici-
program to all students. pants preferred sweet tastes. Among all participants, the
average scores for the dependent variables were as fol-
Intervention lows: body esteem, 2.50 ± 0.52 (out of 4.00) points; body
The intervention was conducted after school for 4 weeks, image, 3.39 ± 0.76 (out of 5.00) points; appearance stress,
once a week from May to June 2023. The control group 2.28 ± 0.88 (out of 4.93) points; depression, 1.88 ± 0.51
was given four sessions of healthy body image education (out of 3.65) points, and cosmetic surgery attitude,
linked to the existing curriculum. For example, it cov- 1.55 ± 0.56 (out of 3.16) points. There was no significant
ered topics such as the characteristics of physical devel- difference in the baseline scores of the participants’ gen-
opment during adolescence, establishment of a desirable eral characteristics, body esteem, body image, appear-
body image, health promotion culture, and health threat ance stress, depression, and cosmetic surgery attitude
culture. The experimental group was provided with 4 ses- between the control and experimental groups, ensuring
sions of the revised BodyThink program. The interven- homogeneity (Table 2).
tions for each group are detailed in Table 1. Pre-data were
collected immediately before the first training session,
Sung et al. BMC Nursing (2023) 22:481 Page 5 of 10

Table 1 Intervention programs for the control and experimental groups

Sessions Control group Experimental group
1st Aims • Understand the characteristics of physical development dur- • Understand the characteristics of physical development
ing adolescence during adolescence
• Accepting one’s physical changes positively • Understand body image and self-esteem and identify
influencing factors
Development 1. Growth surge 1. Physical development during adolescence
• Concept and influencing factors of the growth surge during • Concept and influencing factors of the growth surge during
adolescence adolescence
• Gender differences in the growth surge • Expressing changes in one’s secondary sexual characteristics
2. Secondary sexual characteristics 2. Body image and self-esteem
• Explain secondary sexual characteristics according to gender • Explain definition of physical appearance
• Think about your own physical changes • Explain definition of self-esteem
3. Forming a positive body image 3. Watch and discuss Real Beauty Sketch
• Efforts to form a positive body image • Discuss factors that affect body image and self-esteem
• Attitude guidance to form a positive body image • Presentation on ways to improve body image and
self-esteem
Summary • Summary of the growth surge, secondary growth, sexual • Summary of the meaning of physical development charac-
maturity, and physical changes teristics, body image, and self-esteem during adolescence
2nd Aims • Understanding eating disorders caused by body image • Establishing one’s standards for beauty and presenting a
distortion desirable body image
• Establishing one’s standards for beauty and presenting a • Reduce internalization of ideal media appearances and
desirable body image body comparisons
Development 1. Body image distortion 1. Improve media literacy
• Teaching materials: News related to adolescent eating • Teaching material: Killing Us Softly III video
disorders • Explain the definition of media literacy
• Learn about the problems of anorexia • Discuss the impact of media images on the public after
• Learn about the problems of bulimia watching the video
• Calculate one’s BMI and think about ways to maintain an • Think critically about appearance stereotypes produced by
appropriate weight media such as movies, dramas, and advertisements
2. Establishing a desirable body image • Establishing your own standards for viewing appearance
• Setting your own standards for healthy beauty images produced by the media
• Identifying ineffective weight management
Summary • Summary of characteristics of eating disorders that may ap- • Summary of definition of media literacy and establishment
pear during adolescence one’s ideal appearance standards
3rd Aims • Explain how cultural elements such as beliefs, normative • Understand the qualities you value in others
practices, and media affect health • Overcoming negative experiences related to appearance
Development 1. Health and culture 1. Improved self-esteem and recovery from appearance-
• Explain the concepts of beliefs, practices, norms, and media related injuries
• Explain the concepts of health beliefs, health practices, • Talk about the effects of teasing one’s appearance
health norms, and health media with examples • Participate in role-playing about appearance-related teasing
2. Health promotion culture • Think about ways to deal with appearance-related teasing
• Describe a culture that pursues extension of life expectancy • Write and exchange letters complimenting each other on
and well-being appearance, personality, etc.
• Describe healthy leisure, healthy company dinners, and • Read the letters and share your impressions
healthy foods 2. Understanding others
• Explain that efforts are needed to maintain and promote a • Sharing opinions on what makes people beautiful
health culture
Summary • Summary of the impact of culture on health and health • Summary of the effects of appearance-related teasing and
promotion culture countermeasures
Sung et al. BMC Nursing (2023) 22:481 Page 6 of 10

Table 1 (continued)
Sessions Control group Experimental group
4th Aims • Identify health risk cultures such as fad imitation and suggest • Understand the reality and risks of youth cosmetic surgery
improvements • Reinforce behaviors that positively impact body image and
self-esteem
Development 1. Health risk culture 1. The dangers of adolescent cosmetic surgery and the
• Explain the concepts of fashion imitation culture, appear- beauty of choosing oneself
ance-oriented culture, safety insensitivity, and addiction • Explain the reality and risks of youth cosmetic surgery
culture • Watch and discuss the Choose Beautiful video
• Explain the seriousness of the culture of indiscriminate • Watch and discuss the video of a girl who was teased for
imitation of trends and emphasis on appearance due to the having a rare disease, but became a top model
influence of consumer culture and media • Complete individual activity sheet ‘What can I do to con-
• Explain the health threats of addiction culture and insensitiv- tinue to help my body?’
ity to safety
• Think about ways to improve health risk culture in daily life
Summary • Summarize the impact of health risk culture on health • Summary of the effects of appearance-related teasing and
countermeasures

Table 2 General characteristics of study participants

Variables Total (n = 182) Control (n = 92) Experimental (n = 90) t/x2 P
Gender
Male 105 (57.7) 53 (57.6) 52 (57.8) 0.001 0.982
Female 77 (42.3) 39 (42.4) 38 (42.2)
Age (years) 14.47 ± 0.51 14.43 ± 0.52 14.50 ± 0.50 -0.951 0.342
Height (cm) 166.47 ± 8.07 166.62 ± 8.46 166.32 ± 7.70 -0.032 0.974
Weight (kg) 59.52 ± 13.83 59.90 ± 15.16 59.14 ± 12.41 -0.410 0.682
BMI (kg/m2) 21.32 ± 3.77 21.35 ± 3.87 21.30 ± 3.70 -0.051 0.960
< 18.5 36 (19.8) 19 (20.7) 17 (18.9) -0.198 0.843
18.5–22.9 95 (52.2) 47 (51.1) 48 (53.3)
23-24.9 23 (12.6) 10 (10.9) 13 (14.4)
> 25 28 (15.4) 16 (17.4) 12 (13.3)
Siblings
Only child 37 (20.3) 17 (18.5) 20 (22.2) 0.625 0.533
With siblings 145 (79.7) 75 (81.5) 70 (77.8)
Preferred flavor
Salty 42 (23.1) 23 (25.0) 19 (21.1) -1.403 0.163
Sweet 94 (51.7) 49 (53.3) 45 (50.0)
Sour 10 (5.5) 6 (6.5) 4 (4.4)
Spicy 35 (19.2) 14 (15.2) 21 (23.3)
Bitter 1 (0.6) 0 (0) 1 (1.1)
Body esteem 2.50 ± 0.52 2.55 ± 0.54 2.45 ± 0.51 -1.270 0.204
Body image 3.39 ± 0.76 3.39 ± 0.75 3.39 ± 0.69 -0.037 0.971
Appearance stress 2.28 ± 0.88 2.20 ± 0.85 2.36 ± 0.90 -1.271 0.204
Depression 1.88 ± 0.51 1.89 ± 0.55 1.86 ± 0.47 -0.092 0.927
Cosmetic surgery attitude 1.55 ± 0.56 1.51 ± 0.54 1.59 ± 0.58 -1.071 0.284
Secrecy regarding cosmetic surgery 1.81 ± 0.85 1.68 ± 0.82 1.94 ± 0.87 -1.988 0.052
Value of cosmetic surgery 1.67 ± 0.76 1.61 ± 0.72 1.72 ± 0.80 -0.847 0.397
Conformity regarding cosmetic surgery 1.53 ± 0.61 1.48 ± 0.56 1.58 ± 0.65 -0.619 0.536
Payment for cosmetic surgery 1.42 ± 0.64 1.43 ± 0.62 1.42 ± 0.67 -0.462 0.644
Risk tolerance for cosmetic surgery 1.31 ± 0.56 1.33 ± 0.59 1.30 ± 0.53 -0.140 0.889
Note. Mean ± SD or n (%)

Effects of intervention on body esteem and body image group changed only slightly, with a score difference of
The body esteem scores of both the control and 0.02 ± 0.39 between before and after training, whereas
experimental groups increased slightly after train- the experimental group’s score increased significantly
ing, with no statistically significant difference between from 3.39 ± 0.69 before training to 3.55 ± 0.72 after
the two groups. The body image score of the control training (p < 0.05, Table 3). After training, there was no
Sung et al. BMC Nursing (2023) 22:481 Page 7 of 10

Table 3 Outcome variables of BodyThink program of study Effects of the intervention on cosmetic surgery attitude
participants After the intervention, there was a significant differ-
Variables Control Experi- Z* P* ence in the change in cosmetic surgery attitude scores
(n = 92) mental
(n = 90)
between the control and experimental groups (0.03 ± 0.38
Body esteem vs. -0.19 ± 0.41, p < 0.001). Compared to baseline, the cos-
Pre 2.55 ± 0.54 2.45 ± 0.51 metic surgery attitude score of the control group did not
Post 2.59 ± 0.53 2.49 ± 0.51 differ significantly after the intervention, whereas the
Difference 0.04 ± 0.28 0.04 ± 0.36 -0.276 0.782 score of the experimental group after training was signifi-
P† 0.059 0.226 cantly lower (1.59 ± 0.58 vs. 1.40 ± 0.52, p < 0.001, Table 3).
Body image The change in score between before and after the inter-
Pre 3.39 ± 0.75 3.39 ± 0.69 vention in the cosmetic surgery attitude subcategories
Post 3.42 ± 0.84 3.55 ± 0.72 differed significantly between the control and experimen-
Difference 0.02 ± 0.39 0.16 ± 0.56 -1.509 0.131 tal groups (Fig. 2). The cosmetic surgery secrecy score,
P** 0.824 0.028 which indicates a person’s desire to hide having under-
Appearance stress gone cosmetic surgery, of the control group changed
Pre 2.20 ± 0.85 2.36 ± 0.90 very little whereas the score for the experimental group
Post 2.15 ± 0.89 2.29 ± 0.91 decreased, with the difference between the groups being
Difference -0.05 ± 0.44 -0.07 ± 0.55 -0.217 0.828 significant (0.01 ± 0.06 vs. -0.38 ± 0.08, p < 0.001). The
P** 0.455 0.297 change in cosmetic surgery value score, which indicates
Depression the desire to improve one’s appearance through cosmetic
Pre 1.89 ± 0.55 1.86 ± 0.47 surgery, also decreased significantly in the experimen-
Post 1.82 ± 0.50 1.80 ± 0.53 tal group compared to the control group (0.07 ± 0.06 vs.
Difference -0.07 ± 0.39 -0.05 ± 0.43 -1.011 0.312 -0.21 ± 0.05, p < 0.01). The change in cosmetic surgery
P** 0.288 0.046 conformity score, which refers to the psychological
Cosmetic surgery pressure to imitate the appearance or opinions of oth-
attitude
ers, showed no difference in the control group, while
Pre 1.51 ± 0.54 1.59 ± 0.58
the experimental group showed a significant change,
Post 1.54 ± 0.64 1.40 ± 0.52
decreasing by 0.16 from before to after the interven-
Difference 0.03 ± 0.38 -0.19 ± 0.41 -3.851 < 0.001
tion (p < 0.01). The change in cosmetic surgery payment
P** 0.830 < 0.001
score, which indicates willingness to pay for cosmetic
Note. Mean ± SD, *Mann-Whitney U test, **
Wilcoxon Signed-Rank test, †paired
t-test surgery, also significantly decreased in the experimen-
tal group compared to the control group (0.01 ± 0.05 vs.
statistically significant difference in body image between -0.16 ± 0.06, p < 0.05). These results show that the Body-
the two groups. These results show that the BodyThink Think program has a positive effect on the formation of
program can help improve adolescents’ body image. adolescents’ attitudes toward cosmetic surgery.

Effects of intervention on appearance stress and Discussion

depression The purpose of the current study was to evaluate the
The appearance stress scores of both the control and effects of the revised BodyThink program on overall body
experimental groups were slightly lower after training image in Korean middle school students. The results
compared to baseline, and there was no statistically sig- showed that the revised BodyThink program can improve
nificant difference between the two groups. The depres- body image, reduce depression, and make positive
sion score of the control group decreased slightly from improvements in cosmetic surgery attitudes in Korean
1.89 ± 0.55 before training to 1.82 ± 0.50 after training, adolescents.
but the difference was not statistically significant. How- Educational interventions to improve body image have
ever, the score of the experimental group decreased sig- been applied on a variety of topics and through a variety
nificantly from 1.86 ± 0.47 to 1.80 ± 0.53 (p < 0.05, Table 3). of media. Interventions have been based on an ecological
After the intervention, the depression scores of the two systems perspective [23], acceptance and commitment
groups did not differ significantly. These results show that therapy [24], a peer education program [25], emotion reg-
the BodyThink program has a positive effect on depres- ulation [26] and a health belief model [27]. Approaches
sion in adolescents. such as school-based interventions [28], internet-based
interventions [29] and application-based interventions
are being actively deployed [27, 30]. Systematic reviews
have shown that interventions that include topics such as
Sung et al. BMC Nursing (2023) 22:481 Page 8 of 10

Fig. 2 Effect of the BodyThink program on cosmetic surgery attitude subcategories

(A) Effect of the BodyThink program on secrecy regarding cosmetic surgery. (B) Effect of the BodyThink program on value of cosmetic surgery. (C) Effect
of the BodyThink program on conformity regarding cosmetic surgery. (D) Effect of the BodyThink program on payment for cosmetic surgery. Data are
expressed as mean ± SEM. *p < 0.01, **p < 0.05 compared with the control group. ##p < 0.01, ###p < 0.001 compared with the same group before training

media literacy, cognitive dissonance, and healthy weight content related to media literacy and self-esteem in the
information are the most promising approaches for BodyThink program makes it particularly suitable for this
improving body image perceptions in adolescents [31, population [33].
32]. The present results suggest a relationship between
In our study, the BodyThink program was found to improving body image and positive changes in cosmetic
have positive effects on body image satisfaction. This can surgery attitudes. A previous study showed that young peo-
be attributed to the emphasis of the BodyThink program ple have a higher level of media involvement than other age
on cultivating media literacy to enable adolescents to groups, and that the higher the level of media involvement,
critically view media images based on their understand- the higher the desire for cosmetic surgery, value attributed
ing of body image and self-esteem [14]. Given that young to cosmetic surgery, and attitudes toward risk tolerance [34].
people consume large volumes of media and are highly Eastern cultures, such as that of Korea, tend to pursue West-
affected by self-esteem issues, the preponderance of ern face and body shapes as beauty standards, emphasizing
Sung et al. BMC Nursing (2023) 22:481 Page 9 of 10

certain features such as double eyelids, V-shaped faces, and Conclusion

voluptuous breasts [35]. Adolescents may encounter psy- Body dissatisfaction is a growing public health problem
chological difficulties such as low self-esteem, appearance among Korean adolescents. In this study, we confirmed
stress, and depression if they feel that they must change that the BodyThink program, which was modified to suit
their appearance to be accepted or valued by their peers the circumstances of Korean schools, has a positive effect
or society [4]. Additionally, adolescents are more likely to on adolescents’ attitudes toward cosmetic surgery. Middle
make decisions about cosmetic plastic surgery without suf- school is a critical time in which adolescents form attitudes
ficient information about the associated health risks, such and behaviors related to body image. Positive interventions
as complications or infections [36]. Therefore, education at this stage can have a long-term impact on how individu-
to promote body image can help to free adolescents from als perceive themselves and others, potentially promoting a
social pressures and media portrayals of beauty and help healthy body image and reducing appearance-related stress
mitigate these physical and mental health risks in adoles- throughout their lives. Therefore, the present results sug-
cents. Depression has been identified as a major predictor of gest that the BodyThink program should be expanded or
acceptance of cosmetic surgery among Korean women [37]. integrated into school curricula to benefit greater numbers
In the present study, the decrease in depression scores in of students. Additionally, the BodyThink program has the
students who participated in the BodyThink program may potential to be applied to other rehabilitation populations
be related to the positive change in cosmetic plastic surgery who experience body image changes during the course of a
attitudes. chronic illness.
Recently, Korean teenagers have developed a tendency
Abbreviations
to indulge in sweet foods while imitating ‘mukbang’ influ- CES-D Center for Epidemiological Studies-Depression
encers on social networks [38]. In our study, we attempted a
subgroup analysis based on preferred taste. Although there Author contributions
GHS: Funding acquisition, Project administration, Conceptualization,
were no between-group differences according to taste pref- Investigation, Supervision, Methodology, Formal analysis, Visualization, Writing
erences (data not shown), extreme stress regarding appear- – review & editing. HS: Conceptualization, Investigation, Formal analysis,
ance often manifests itself as abnormal eating behavior [39]. Visualization, Writing – original draft. AYH: Formal analysis, Visualization,
Writing – original draft. All authors approved the final version.
For example, affected individuals eat a large amount of food
in a short period of time and engage in purging behavior or Funding
consciously not eating. Therefore, we believe that the rela- This work was supported by the National Research Foundation of Korea (NRF)
grant funded by the Korea government (MSIT) (No. 2021R1A2C2004118) and
tionship between eating behavior and body image is worthy the Institute of Nursing Research, Korea University Grant. This manuscript is a
of study. revision of HS’s master’s thesis from Korea University.
The students who participated in the present study
Data availability
showed high levels of treatment adherence and low levels of Data are usable on request from the corresponding author on reasonable
dropout, possibly due to the adjustment of topics and ses- request.
sions to suit the circumstances of Korean schools. The key
to behavior change in education is to change the environ- Declarations
ment or process to make it easier to adopt a new practice
Ethics approval and consent to participate
or procedure than a once-and-done strategy [40]. Therefore, All procedures in this study were conducted with the approval of the Korea
providing evidence-based, multifaceted interventions in the University Institutional Review Board (Code: KUIRB-2023-0141-01). Informed
school curriculum will be an effective educational method consent was obtained from all the participants and legal guardians for the study.
All methods were carried out in accordance with declaration of Helsinki.
to improve the physical and psychological health of adoles-
cents [41]. Consent for publication
This study had several limitations. First, because the Not applicable.

intervention program was applied in two middle schools Conflict of interest

in Korea, research on more diverse institutions and ages is The authors confirm that there are no conflicts of interest.
needed to increase the external validity of the educational
effect. Second, because one researcher conducted all of Received: 19 October 2023 / Accepted: 11 December 2023

the training, it is necessary to verify the program’s accept-

ability to existing school nurses and school institutions.
Third, the present study measured the results immediately
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