INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 2023, VOL. 18, 2170007 https://doi.org/10.1080/17482631.2023.2170007 EMPIRICAL STUDIES Positive body image: a qualitative study on the successful experiences of adolescents, teachers and parents G Tort-Nasarre a,b,c, M Pollina-Pocallet d,e, Y Ferrer Suquet e , M Ortega Bravo e,f,g , M Vilafranca Cartagena h and E Artigues-Barberà b,e,i a Calaf Primary Care Center, SAP Anoia-Gerència Territorial Catalunya Central, Institut Català de la Salut (ICS), Calaf, Barcelona, Spain; b Department of Nursing and Physiotherapy, Faculty of Nursing and Physiotherapy, University of Lleida, Lleida, Spain; cAFIN, Research Group and Outreach Centre, Universitat Autònoma de Barcelona, Barcelona, Spain; dBellpuig Primary Care Center, Diputació, Lleida, Gerència Territorial Lleida, Catalan Health Institute (ICS), Barcelona, Spain; eResearch Support Unit Lleida, Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Lleida, Spain; fCappont Primary Care Center, Lleida, Gerència Territorial Lleida, Catalan Health Institute (ICS), Barcelona, Spain; gDepartment of Medicine, Faculty of Medicine, University of Lleida, Lleida, Spain; hDepartment of Nursing, Faculty of Health Science and Welfare, University of Vic-Central University of Catalonia (UVIC- UCC), Manresa, Spain; iBalafia Primary Care Center, Lleida, Gerència Territorial Lleida, Catalan Health Institute (ICS), Barcelona, Spain ABSTRACT ARTICLE HISTORY Purpose Body image encompasses body-related self-perceptions and personal attitudes. Received 28 September 2022 Dissatisfaction with body image during the early stages of adolescence is negatively related Accepted 13 January 2023 to self-esteem and other health problems. A few publications focused on positive body image KEYWORDS and directly related to the experiences and interactions of adolescents themselves. To explore Positive body image; positive body image in adolescents and describe the familial and educational factors that qualitative study; contribute to its development.Methods A qualitative study was conducted. Purposive sam­ adolescents; parents; pling was used, and 9 adolescents, 6 families, and 8 teachers participated in semi-structured educational personnel interviews, which were then theme analyzed. Results Self-care, body acceptance, confronting messages that attack body image, and the influence of social media have been identified as emerging themes in adolescents’ positive body image experiences. Therefore, the pubertal period, family values, fostering, and educational actions as well as media literacy were identified as factors promoting self-esteem and positive body image in the family and educational environment. Conclusions Their parents also expressed aspects such as those that contribute to the development of healthy self-esteem, confidence, and positive body image. Alternatively, the teachers indicated educational activities to work on self-image and self-esteem when faced with situations of concern in the classroom. Introduction confidence (Rosenberg, 1989). The quality of these Adolescence is a transitional period between child­ relationships has a key role in their psychosocial hood and adulthood, and it is divided into early ado­ development (Mota & Matos, 2014). lescence (from 10 to 14 years old) and late Body image (BI) is conceptualized as the internal adolescence (from 15 to 19 years old) (Unicef representation that someone has of their external Nations Cildren’s Fund, 2011). This period is character­ appearance (Grogan, 2016) and encompasses self- ized by significant physical, psychological and social perceptions related to the body and personal atti­ changes that affect the adolescent’s growth and can tudes, including thoughts, beliefs, feelings and beha­ pose challenges for developing and/or maintaining viours (Cash & Smolak, 2011; Sands, 2000). At the positive body image (Parent et al., 2003; Rogol et al., same time, body image is a complex phenomenon 2002). In addition, these biological, cognitive and psy­ that includes several components with gender, ethnic chosocial changes tend to be more prominent and and sociocultural influences (Cash, 2012; Cash & abrupt during adolescence in comparison to adult­ Smolak, 2011). hood (Markey, 2010) as adolescents are positioned Alternatively, body dissatisfaction is defined as to accept or reject their maturing body and partici­ a person’s negative thoughts and feelings about pate in self-care or dangerous behaviours (Sundgot- their body. It is related to negative assessments of Borgen et al., 2019). Various social agents have strong the size, shape and weight of the body, and generally interactions with adolescents, such as their family, involves a perceived discrepancy between the per­ peers, groups, educational institutions and the son’s assessment, their body and their ideal body media, which helps to construct a system of values (Grogan, 2016; Tiggemann et al., 2011). Likewise, dis­ and beliefs that are the basis for the adolescent’s self- satisfaction with body image during the early stages CONTACT E Artigues-Barberà eartigues.lleida.ics@gencat.cat Research Support Unit Lleida, Rambla Ferran, 44, Lleida 25007, Spain © 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 2 G. TORT-NASARRE ET AL. of adolescence has been related to lower self-esteem both for girls (Wertheim et al., 2011) and for boys and predicts depressive symptoms, a higher body (Ricciardelli & Cash, 2012). mass index, less physical activity, clinical eating dis­ orders, a poorer quality diet, disordered eating (i.e., diet behaviours based on trends, food and use of Aim ingredients for emotional regulation), behaviours Due to the relative scarcity of research on positive aimed at losing weight (through diets, food restric­ body image and the need to clarify the interactions tions and modification of dietary habits), which at the between some protective and risk factors related to same time foster problems with the distortion of self- this construct during adolescence, this qualitative image (Vaquero-Cristóbal et al., 2013). Also, some study aims to explore positive body image in adoles­ authors have associated certain internal factors with cents and describe the familial and educational fac­ body dissatisfaction and the concept of the body tors that contribute to its development. The specific (Heidelberger & Smith, 2018), the perception of questions that guided the investigation are: What beauty and ideals of appearance transmitted by characterizes positive body image in adolescents? society and the media (Meier & Gray, 2014), the atti­ Which factors in the familial and educational environ­ tude towards the self and towards others ment influence positive body image in adolescents? (Heidelberger & Smith, 2018) and gender differences and perspectives (Ramos Valverde et al., 2010). Other authors have identified the media together with Methods family and friends as part of the external factors that Design influence BI (Heidelberger & Smith, 2018; Ramos Valverde et al., 2010; Vaquero-Cristóbal et al., 2013). We used a qualitative descriptive design, an approach Tort-Nasarre et al. (Tort-Nasarre et al., 2021) suggest that is suited to reaching a deeper understanding of that the construct of body image in adolescents has practice in applied disciplines (Colorafi & Evans, 2016). multiple meanings and that it does not necessarily This design is especially pertinent when the goal is to involve dissatisfaction when there is a mismatch understand the participants’ perspectives and experi­ between the real and desired image. The concept of ences (Morse & Field, 1995). body image is established in a much more complex way than simply through the messages received by Participants the mass media and the pressure experienced from friends. The family and the school environment also Purposive sampling was used with the aim of recruit­ play a determining role in terms of protective factors ing good informants who meet the research objec­ when work is done to provide tools to help them tives (Moser & Korstjens, 2018). The participants were develop self-esteem, assuredness and confidence. part of three groups: students, teachers and parents There are plenty of studies on body dissatisfaction of students at a school in Bellpuig, Lleida, Catalonia, in adolescents all over the world and also in Catalonia Spain. The inclusion criteria for participants were (Pollina Pocallet et al., 2019; Pollina-Pocallet et al., being students in the Compulsory secondary educa­ 2021), however during recent decades, in the context tion, being considered by their peers as someone with of research into body image there has been a call to high self-esteem, good body image and assuredness. focus on positive body image and its links to well­ Being teachers at the school and considered by the being (Tylka et al., 2018). Positive body image has students as references. Being parents of students cho­ been conceptualized as a multidimensional construct sen by their peers as references. that represents love and respect, acceptance and The school nurse helped to recruit the participants. appreciation of individuals and feeling comfortable The recruitment process was complex as there were with their body, independently of their actual physical three groups of participants to recruit: adolescents, appearance, as well as their ability to interpret mes­ parents and teachers. To recruit the adolescents, sages in a way that protects the body (i.e., internaliz­ a questionnaire (ad hoc) was given in which the stu­ ing positive messages, rejecting or reformulating dents were asked to write the names of three class­ negative messages (Tylka & Wood-Barcalow, 2015b). mates that they thought had high self-esteem, The response to this perspective has been to develop assuredness and good self-image, and another ques­ a multidimensional conceptualization of positive body tionnaire (ad hoc) to write down the names of the image among adults (e.g., Tylka & Wood-Barcalow) three most important teachers of their school year. (Tylka & Wood-Barcalow, 2015a) but among adoles­ Both questionnaires were anonymous. 324 adoles­ cents it has still been scarcely studied (Frisén & cents responded to the questionnaires, based on the Holmqvist, 2010) even though, as mentioned pre­ list obtained a definitive list was drawn up and the viously, the formation of positive attitudes and per­ adolescents who received the most votes from ceptions of the body is important during adolescence each year group were asked to participate, as well as INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 3 the teachers who were the most highly rated. Lastly, 2020). Credibility was ensured due to the constant review the parents of the students who received the most process of the process of analysis. Transferability was votes were invited to take part in the study. Finally, 9 ensured through the detailed description of the phenom­ students, 8 teachers and 6 mothers/fathers were enon in sufficient detail to be transferable to other set­ chosen. tings and people. Dependability was ensured in this study One of the team’s researchers (MPP) invited the due to the review by each of the researchers of the candidates to participate in the study via telephone. process of analysis as well as the final product. Those who accepted were sent the informed consent Confirmability was assured through the reflective work and information sheet for the study that was collected of each researcher who made field notes during the inter­ by the same researcher. views to offer the most objectivity possible in the data collection and analysis. We completed the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong Data collection et al., 2007). This study was approved by the ethics and The data were collected using semi-structured interviews clinical research committee at the Institut d’Investigació with the students, teachers and parents. The team of IDIAP Jordi Gol under the code 20/154-P. researchers created a set of interview questions based on the existing literature and adapted to the three profiles of participants. During the interviews, the participants Results were encouraged to add additional information on their 23 participants took part in the study: 9 students experience. The interviews were carried out by three between 12 and 16 years old (77.8% female and members of the team: MPP, GTN and EAB from 22.2% male), 8 secondary school teachers who were July 2021 to March 2022. The interviews were carried references for the students (62.5% female and 37.5% out firstly via video call through Teams due to the lock­ male) and 6 parents of the students (83.3% female down situation as a result of COVID-19 and the latest ones and 16.7% male) (Table I). were carried out face-to-face with the teachers and par­ The participants are coded as follows: A1-A9: ents. During the interviews, notes were taken on the non- Adolescents, P10-P16: Parents and T17-T22: teachers. verbal communication of the participants. The interviews In the data from the interviews 2 themes and 8 lasted approximately 30–45 minutes. All the interviews sub-themes were identified. See Table II were recorded on a tablet and were transcribed. All the interviews were anonymized, assigning them an alpha­ numeric code. They were encrypted and stored in Theme 1: experiences regarding the adolescents’ a dissociated manner on a secure server at the positive body image Institution. The transcribed interviews were also returned to the participants for their approval. All the participants The adolescents express the aspects that characterize accepted the transcription. positive body image and they are summarized in the following sub-themes: doing self-care, acceptance of Data analysis one’s own body, confronting messages that attack body image and the influence of social networks. The thematic analysis method was followed (Braun & Clarke, 2006) and it was organized using Atlas-ti version Doing self-care 7. GTN and EAB carried out the data analysis. They began The majority of the adolescents talk about actions to familiarize with the data to obtain a complete view of aimed at caring for the body, such as doing sport them. Later, meaning units of the text were identified. and having a good diet: Similar expressions were put together, sub-themes and later main themes were created. In doing so, they I am well looked-after. I play tennis 5 days a week. remained faithful to the participants’ expressed perspec­ I like it a lot. I do lots and lots of sport. A3. tives (Patton, 1990). Quotes were also extracted to illus­ They value the advantages and benefits that looking trate the results, indicating the participant’s code at the after the body brings to their physical and psycholo­ end of each of these. Data saturation was reached when gical wellbeing: we detected that no relevant new information was emer­ ging (Saunders et al., 2018). I have always considered sport to be something you need, not for getting thin, but for distracting yourself and getting rid of everything that’s happened when Rigour you have a very dark and busy day, doing sport airs you out and goes really well. A6. The study complied with credibility, transferability, dependability and confirmability which ensures the trust­ In addition, they identify diets that are not appropri­ worthiness of the qualitative research (Johnson et al., ate for their development: 4 G. TORT-NASARRE ET AL. Table I. Characteristics of the participants. Adolescents Sex Academic year Number of siblings A1 Female 1st year ESO Four siblings, she is the youngest A2 Female 2nd year ESO Two siblings, she is the youngest. A3 Male 3rd year ESO Five siblings, he is the youngest A4 Female 4th year ESO Three siblings, she is the middle child A5 Female 2nd year ESO Two siblings, she is the oldest A6 Female 4th year ESO Two siblings, she is the oldest A7 Male 4th year ESO Two siblings, he is the oldest A8 Female 4th year ESO Two siblings, she is the youngest A9 Female 1st year Baccalaureate Two siblings, she is the youngest Parents Family relationship Age Marital status P10 Mother 50 Separated P11 Mother 47 Separated and with partner P12 Mother 47 Separated P13 Mother 52 Separated and with partner P14 Father 51 Married P15 Mother 56 Married P16 Mother 44 Married Teachers Age sex Studies Subject school year T17 59Female Masters Entire curriculum 6th year of primary education T18 57Female Masters Mathematics 1st year of ESO T19 43 Male Spanish Spanish language and literature 4th year ESO T20 42 Male Business Social sciences and IT 3rd and 4th year ESO T21 43Female Chemistry Technology, physics and chemistry 1st and 4th year ESO T22 45Female Translation and English 1st year ESO interpreting T23 55 Male Environmental Biology and geology 3rd year ESO sciences T24 52Female English and German English 2nd year ESO language Table II. Themes and sub-themes. Theme Sub-theme Experiences regarding the adolescents’ positive body image a. Doing self-care b. Acceptance of one’s own body c. Confronting messages that attack body image d. Influence of social networks Promoting factors in the familial and educational a. Pubertal timing environment b. Family values and actions that promote self-esteem and positive body image c. Educational actions that generate self-esteem and positive body image d. Media literacy I think that when there are people who are fine and And that if they have to do it, that they do it right by they go on diets to be thinner because they are eating and doing sports. A5. obsessed with their body, I think that it’s not good, if you eat well and do sport it’s better. A1. Acceptance of one’s own body And they give healthy advice to friends who want to The adolescents show aspects related to the accep­ get thinner and discourage risky behaviours: tance and appreciation of their own body. Many of Sometimes, when one day they aren’t feeling good, them like their body: they want to lose weight. . . then most of us say that there’s no need, that they’re fine and not to do silly I like my body, I wouldn’t change anything right now, things like stopping eating, vomiting. . . and all of that. I am how I would like to be. A1. INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 5 Others explain that you have to accept yourself as you are It is very important, because girls sometimes more physically and not put too much importance on the than boys tend to obsess more over the physique and follow certain ideals. The boys maybe don’t talk about body: it, but inside they feel it too. A4. You have to accept yourself as you are and you The teachers also observe differentiating details mustn’t put much importance on the body and try to be like another person to be better, rather that, between the boys and girls regarding a body that is sometimes, what you think is better. A4. not within the pre-established social canons: The boys that are a little beyond what is normal There are also adolescents that believe that it is more might be chubbier, you do see them as being very important how you are internally as a person: shy, very much so, maybe extremely shy more than a fat girl, alternatively, with the girls if they’re a little I put a normal amount of importance on it, not a lot outside of the common pattern I see them as some­ and not very little. The most important thing is how what disinhibited. T22. you are, your personality. A1. But on the other hand, being different to the rest of In this manner, the adolescents indicate that you have the group is challenging and a concern for many of to be secure in yourself: them. Faced with this experience, the teachers If you don’t feel well with yourself others won’t like describe the individual adaptive responses of these you either and you have to appear secure in your­ students when they feel exposed to their peers, for self. A3. example when they have to speak to an audience: good self-esteem as a protective measure: You see that they are a little embarrassed going to speak to an audience because they don’t feel confi­ I believe that you can be physically not so perfect, but dent in their body. T24. if you have good self-esteem and you like yourself, you’ll see yourself as perfect and it won’t matter to or how they hide the body to not show it to their you what other people say about you, alternatively, peers: maybe you’re fine but you have very low self-esteem, and you’ll give the slightest hurtful comment they They wear looser things, or sweatshirts when it’s hot make more importance than the 30 positive ones and they don’t even want to take off their coat (. . .) they make. A5. because either they have boobs because they’re fat or they have a belly. T24. They also highlight the relationship between accept­ The teachers mention how the process of adaptation ing the body and accepting yourself as inseparable by the group is for those who have a different physi­ aspects: cal image to the rest: I believe that if you feel good with your body, you’ll There are groups that wouldn’t accept them because also feel good with yourself because it is part of you. they are dressed differently, because they are differ­ And I think that it is important but not very, we ent and there are groups that would accept them shouldn’t give it much importance because there because they’re bringing other things as well as the are people who are obsessed with their body, and way they dress. T20. it’s not necessary. A4. Others explain the need to normalize body image and Confronting messages that attack body image. accept different canons of beauty and health: Some adolescents consider receiving messages from Normalizing that being fat or being very thin is not peers as a positive reinforcement: a very bad thing. Maybe, let’s see, being very, very fat My friends always tell me that they think I have a very might be harmful for the health, but equally we have good body. It isn’t important but I like it. When you to normalize everything, that it’s not bad that some­ receive these positive comments from your friends it one is fatter or that someone else is thinner. A1. makes you feel better and makes you like yourself more. A3. However, a few adolescents express aspects related to the appreciation or acceptance of the image of others: But the influence of friends is not always positive, they I think that you have to respect everyone. A3. also explain about messages between friends that attack the body image of others, causing upset Alternatively, there are young people who don’t fit between them: into the socially established canons of beauty. They feel the need to hide their body and adopt avoidant They go along with them because they are very thin behaviours when they are exposed to the rest of their or because they don’t have boobs, for example. . . there are kids that tell them this. A1. peers. These behaviours are determined by the opi­ nion that they themselves have of BI and they differ The teachers also highlight situations that are threa­ between boys and girls: tening for body image between peers: 6 G. TORT-NASARRE ET AL. Some girls are having a bad time due to comments everyone wants to achieve and if you don’t have that the boys are making. That they’re fat, that they a certain build you can’t manage to have it. People don’t have breasts, that they have a fat bum. That’s have become so used to the fact that if someone is what the boys say. The boys say things to the girls different, the only thing they do is bring them down and there are even girls that were considering not because they are different. A5. going to the swimming pool or not wearing a bikini because of what the boys might think about their body. T20. Theme 2: promoting factors in the familial and In the face of these threatening messages, the parents educational environment and teachers assess high self-esteem and confidence In terms of the manner in which parents and educa­ in adolescents as key factors for not letting them­ tors talk about issues related to the appearance, the selves be influenced: following sub-themes were identified: Pubertal tim­ ing, Values and actions that promote self-esteem If you have a good base and good self-esteem it doesn’t have to affect you so much either. But if and positive body image, Educational actions that you’re someone who has very fragile moments generate self-esteem and positive body image and maybe what they say affects you more. P11. Media literacy. At the same time, the adolescents identify different strategies for dealing with the negative messages Pubertal timing. In many cases, the parents and they receive from their peers such as selective educators know what it means to go through these listening: vital stages characterized by a process of physical, I’m a person who doesn’t listen to harmful criticism psychological and emotional change. They indicate very much, because it isn’t useful. You have to listen that they know about aspects of the adolescent stage: to the good ones to have good self-esteem and self- image. A6. It changes a lot, there are animal changes on physio­ logical levels, they’re animalistic the changes that defending the weaker peer: happen. T23. There were some boys who were calling another For the teachers and parents these physical changes person names. They were calling them fat and such. have an emotional impact and cause a lack of emo­ They were starting on their body weight. Us girls tional regulation: always told them to be quiet, it was all the girls against these boys. A4. it’s a stage with lots of changes, they aren’t balanced, or even helping them with strategies that they have as soon as they’re happy they’re angry, they can feel learned by experiencing similar situations: happy with themselves or not. It’s a stage of lots of imbalances and little acceptance and of rage and I went to help this person, because when they did it getting angry, being angry. Little acceptance of to me, I didn’t know how to defend myself either so rules, or of themselves, it’s like they’re a little angry I think that what’s needed when they’re doing that to with the world. . . T22. you is to stick out your chest and face them so they see you, so they can’t bring you down. A5. And it also affects self-esteem and self-knowledge: They’re really in a process of change, so what hap­ The influence of social media. The influence of pens? They don’t feel well with their mind or with social media with regards to body image is another their body because they’re in a process of change. Of of the elements that they talk about. It is worth under­ course, they don’t yet really know where to go and lining that the adolescents are fully aware of the then their self-esteem is affected. P10. effect of the messages they receive about beauty And they identify consequences related to social ideals on social media: interaction, There are lots of comments talking about the physi­ que on social media and this very much affects us It’s a topic that matters so much to them and they teenagers, who are the people who use it most. A2. really look after their image, excessively so I think rather than too much, but of course it’s their whole and their consequences when they don’t comply with world right now, the social relationships, fitting into the beauty canons broadcast by the mass media: the world, and they value it excessively. I find that there are lots of problems related to food that are I think we’ve reached a point where everyone gives it unnecessary. T21. too much importance, because everyone also focuses on it a lot and brings down other people due to the They also have lots of problems, I think, psychological appearance that society has given us of how a person problems, problems like anorexia. It’s that now, social has to be or how they have to stop being, people on media and everything like that is making it very TV, influencers. They give us an appearance that bad. P12. INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 7 They also indicate the influence of friends and the fact This accompaniment and values are received and of following a uniform pattern of dressing and thus interpreted by the children as they explain: feeling integrated into the group: They’ve never told me to stop eating, that you’re fat Friendships do a lot! It’s that for them at this stage of or to eat less. They’ve never started on me and my life, friendships are more important than parents and body. A4. being another one in the group is essential for them. T24. Physical appearance at my house is not very impor­ tant, it’s more important to be a good person. A6. I see that their external style is always a mono-topic. Nobody goes outside the norm, I don’t know any The adolescents explain how their parents teach them 1st year ESO student that has their own style, in skills and points of view in the face of negative com­ other words, they all wear the same type of T-shirt. ments that attack the physical appearance: What I see is that there is one style and nobody departs from that. T18. My Mum and Dad told me and everyone has told me you have to learn to defend yourself, you can’t lower Family values and actions that promote your head and let them bring you down because self-esteem and positive body image. Another none of us are better, nobody is better than anyone. topic that was identified in the data was the transmis­ Then at home they also helped me, they told me that I had to defend myself without lacking respect. A5. sion of values in the family environment. These values are defined as aspects that facilitate the children hav­ They are families that generate healthy relationships ing positive body image and high self-esteem. The with self-esteem and self-image. The parents express, parents highlighted the affective link, help and among the strategies that they talk about, they accompaniment: believe that it is crucial to be present in the day-to- There is an esteem link, the family link, the link that day and maintain good communication links: has to transmit values, values for making your bed, I am always very much in contact with the children. values for cooking, values for beliefs I mean. . . that’s We do lots of things together, we talk a lot, I go in what a family is, not just transmitting certain values. their room, they come in mine, I mean that at my I think that it has to transmit all of them, the more the house there are no closed doors. I think that they tell better. P10. me about lots of things, I’m sure they don’t tell me They teach them to find solutions based on parental everything, or anywhere close, but they tell me lots. P10. communication: What I always repeat to them is that if they ever see In addition, the families also talk about activities and a problem, they find themselves trapped, they find actions that they do to educate and work on the self- that they don’t know what to do, as much as it seems esteem and positive self-image of their children. Such very complicated, very difficult and very hard to as working on self-acceptance and confidence in them, that they should talk to me about it because yourself: just the fact of explaining half of the problem works and then, maybe between the two of us we can find We’ve prioritized feeling confident in yourself, or lov­ the solution that one person alone can’t find. P13. ing yourself as you are, accepting yourself and giving others the image of who you really are inside. I have Accompaniment that is guided, and they explain how always given them certain very clear parameters they put limits on their children and the reason for around what to do in lots of situations. For self- doing so, confidence and self-esteem, I think that all that makes self-esteem, feeling confident. P13. I put limits on them. Or rather you reach a point where it’s “Right, that’s it”. I’ve tried to reason everything. . . or Giving positive reinforcements: I say something, I don’t agree, I don’t see it like that, whatever. . . but if I really think that it is better for them Giving them positive reinforcements with the things and the other thing isn’t good, if necessary, in the end that you see that they can highlight and those that I’m capable of saying “that’s it, because I said so” they do not, so bringing out the good. Make them because I’m reasoning everything to you and I’m giving see what they’re worth, so they go looking for their a basis for it and you’re not paying attention to me, path towards things that can be good. P11. you’re not listening, so that’s it. P13. Looking after yourself: Teaching them to have their own style, their own opinion and not letting themselves be influenced by You have to have a good concept of yourself, you have to look after yourself. Looking after yourself others: doesn’t mean you have to be thin, that you have to At home certain values have been given, you’re clean, be all muscular. P13. you’re polite, you dress in the style you like, but you dress well and from there everyone has their own Knowing how to decide and being responsible for the style. P13. consequences: 8 G. TORT-NASARRE ET AL. You have to make a decision, you have to evaluate it and you’ll come out of it and not doing the opposite: and once you’ve evaluated it, you have to accept that “you’ll do nothing with your life”. T21. maybe it won’t please everyone and that you’ll have to be responsible for your actions. P13. giving confidence through communication: Speaking with them: to give them confidence because they talk to me about what is happening, Educational actions that generate self-esteem and and then when they explain what is happening, try­ positive body image. The teachers explain in detail ing to look for solutions within what I can do. T20. their educational aim and how this is determined by professional teaching values: respect, consideration, These teaching actions have the reward of feeling like visibility and not judging. The importance of these they help the adolescent: aspects for the development of self-esteem: There are lots of teachers who help with lots of students who don’t find themselves, who don’t see Respect, consideration, giving each student the place themselves or have a negative image of themselves, that corresponds to them, meaning that they aren’t a physical as well as mental image, we go along with invisible in the classroom, even if they aren’t always them and, at times, as well, if the thing isn’t very visible. They’re all part of that group and this is very serious sometimes they come out of this type of important for self-esteem. T17. dark hole. T23. Evaluating them: The teachers at the school carry out activities aimed at My job is also to evaluate them very positively. T18. educating the adolescents on self-esteem and emo­ tional regulation: Establishing a good channel of communication: We did an activity that was called Great and it was I talk to the students a lot when I can. Whenever about saying positive things, not about buttering I can. T24. them up or telling lies, but saying positive things about yourself, the teachers, your peers. . . well activ­ It is important to highlight that the teachers identify ities like that. T21. certain characteristics in the adolescents with low self- esteem: These teachers find themselves in situations in the classroom in which they have to work on positive A person who is insecure, introverted, people who are body image and thus avoid dissatisfaction or conflict negative and for whom it is difficult to get themselves and carry out activities aimed at this such as: up, when so many young people sometimes tell you “It’s hard for me to get up in the morning but I’ll The other day I did an activity where I put images of make the effort. T19. the kinds of girls that the boys follow and that they like and such and afterwards I put the opposite, those As a trait characteristic of the adolescent age in cur­ images of the boys that the girls follow. Then I had rent society: them stand up in front of the class and I asked: boys are you the same as these boys that come up here on They have low self-esteem, because it’s protected social media? No, so don’t ask the girls to be the same them a lot and this has made it so that any form of as these girls. It was an exercise in seeing that one effort grinds them down, makes them suffer, they get thing is day-to-day reality, and the other is how they exhausted. From this culture of effort, trying, falling want to appear. T20. and getting back up again and all that I don’t think so: they don’t have too much of it. T20. By comparing images between one and the other they see it is a visual thing and this stays with them In addition, they highlight how self-esteem is a key there. T20. element for functioning throughout life and carrying on despite having little integration of a culture of Sitting in a circle and expressing how they feel or how they feel from what the others make them feel effort: with them, of how they treat them, how they stop A person with self-esteem will carry on going. T17. treating them and comparing themselves, from now on. . . speaking about it among them all in small They describe teaching strategies when faced with groups to talk about it and how to be able to solve adolescent students with low self-esteem, this and how you make the other, with your own reactions, can make the other feel better. T20. With students with low self-esteem what I do, what I try to do is give them an important place in the class, but as important as that of any other student. T17. Media literacy Another emerging theme that the parents and tea­ giving elements because they believe in themselves chers mention is the use that the adolescents make of and encouraging them to tackle challenges: social media and how they influence BI. For the edu­ Reinforcing self-esteem, with the feeling of always cators and parents, media literacy and education is giving them encouragement and forward movement a challenge. For example, they realize the effects that INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 9 it has for young people listening depending on which influence of the school environment, an aspect that type of music that entails implicit patriarchal values: can be essential and which is covered in the current research. It’s this patriarchal culture that we have in our society that, as much as we try to fight and fight, there is always this background of social media, music. . . Experiences regarding positive body image everything that affects adolescents. This music leaves the girls on the ground. And the girls listen to this With regards to the aspects that characterize positive music and sing it and then you say it’s just lyrics, no body image, many adolescents describe doing self- no, but this gets into you and you end up feeling the care as a beneficial aspect that brings them physical same as the boys that follow it. And this very nega­ tively affects them and they don’t realize it as much and psychological wellbeing (Wood-Barcalow et al., as we try to educate, educate, educate. . . we have all 2010). In addition, it is worth pointing out that they this background. T20. are capable of detecting unhealthy habits such as unhealthy diets or excessive physical activity and giv­ Or of how they mirror the success of the youtubers: ing healthy lifestyle advice to friends when they If I have a youtuber as a model, and a youtuber detect that they are doing these practices. This rein­ making 4 videos earns a living and a very good one, forces a protective role towards body dissatisfaction why do I need to make an effort? If I’m an instagram­ associated with the development of eating disorders mer what I’m doing is uploading photos of how I dress, what I visit, the places I go, etc., with this I’m or psychological stress (Añez et al., 2018; Dhillon & earning a good living why do I need to make an Dhawan, 2011). effort, why do I have to do a degree, a training This study also highlights the association between course, it’s not worth it, so this low-effort society, high self-esteem, confidence and self-image. In this I think it also affects them. T19. regard, some participants prefer being good people Even so, both the teachers and the parents look to even though their body is not perfect, and having teach the critical analysis of the information and what confidence in yourself and being capable of not pay­ they receive on social media: ing attention to negative comments on your appear­ ance. These are aspects that are reinforced by the I’m sick of telling them not to look for information work of Holmqvist et al. (Holmqvist & Frisén, 2012) where we don’t know that the source is reliable or as protective attitudes. they might be tricked, or going to look for videos that don’t explain anything good to you, don’t look at this, In addition, another aspect to highlight is the do a search. Guiding them a bit. T23. acceptance and appreciation of their own body as inseparable aspects and ones that make up the iden­ They’re becoming aware of the manipulation of the tity (Holmqvist & Frisén, 2019). However, the study images they receive on social media: shows that there are also adolescents that hide their They see it on a tablet, remind themselves with body and adopt avoidant behaviours when they per­ a TikTok: here there are lots of filters what an embar­ ceive that they do not have the body that they would rassment, this girl with such a filter, look on Google like, seen from the perspective of the educators. The and compare. I think that it’s going to make the kids study has not identified the consequences of the open their eyes, that all that is a lie, it’s cinema, it’s a film: they’re wearing make up, it’s all. . . it’s all appreciation of the body of others. However, it is a lie. T22. possible to confirm this through the follow-up of the qualitative study on these adolescents. The influence of friends is not always positive and at times they find themselves in situations where their Discussion self-image or that of their peers feels threatened. In This study has explored positive body image in ado­ these cases it must be emphasized that the adoles­ lescents in Catalonia (Spain) as well as the perspective cents with good confidence defend the weak ones, or of parents and educators. In particular it contributes rather they acquire an attitude of selective listening data from the adolescents considered by their peers and do not let themselves be influenced by these as having high self-esteem, confidence and good comments. These abilities to face negative comments body image, the teachers who are references for may suggest aspects for development in programmes these same students and their parents, an aspect that promote health and the prevention of body that contributes to the in-depth and detailed results dissatisfaction. on positive body image at this age. In this regard, the The adolescents are fully aware of the influence of formation of positive body attitudes and perceptions social media and of how it can condition their self- is an important development task during adolescence. image and self-esteem (Burnette et al., 2017) and In particular, the influence of the education received body dissatisfaction (Calado et al., 2011; Mooney from parents and friends has been studied (Frisén & et al., 2009). The results indicate that those adoles­ Holmqvist, 2010), but there is a lack of studies on the cents with good self-esteem and confidence in 10 G. TORT-NASARRE ET AL. themselves are also more critical when faced with the not only from the school environment, but also in messages received from the mass media. Therefore, the community sphere that may have a positive helping the adolescents to understand this influence impact (better acceptance, fostering of self-esteem, in the school and family environment can be high­ expansion of perspectives on beauty ideals, normal­ lighted as a recommendation for the development of ization of concerns between parents and educators) healthy body image and self-esteem. despite the direct influence exercised by friends and social media during adolescence. Promoting factors in the familial and educational environment Limitations The parents and educators selected by the students themselves have a direct influence on the way in This study has various limitations. The first is that it which the adolescents perceive their self-image. One can only be transferable to similar social and cultural of the important things that they do to help them to contexts and adolescents or young people of the perceive a healthy self-image and self-esteem, among same age band. The sample is small and, therefore, others, is talking about these topics with them, there­ it is not representative of all adolescents with a similar fore building support bridges. In this manner, the profile. The context in which the study was carried out accompaniment of the parents and educators, when was limited to schools in a specific area in Catalonia they know the characteristics of the adolescent stage (Spain) with specific sociodemographic characteristics. and are capable of understanding it, are preventive A wider sample of participants from different educa­ measures that must be considered in programmes tional, family and social backgrounds may reinforce that educate about health. this study. It is also important to highlight that in In relation to family values, we have shown how a qualitative descriptive study it is impossible to quan­ the vast majority of parents have a good communica­ tify the experiences of the participants. Finally, our tion link with their children, a link of esteem and study only includes the perspective of adolescents, a safe environment. In addition, they impose limits families and teachers, and it is possible that when it is necessary and put in place guidelines to a qualitative discussion methodology such as a focus be followed. At the same time, the children evaluate group may provide new information on the topic. the messages received from their parents as help to Likewise, a more complete image may arise if the make them grow up. These families have healthy perspective of school nurses and healthcare workers interpersonal relationships, many parents take actions were included. aimed at working on positive self-image and self- esteem, they can affirm with these results that they may be crucial elements for the development of Conclusions healthy body image. Alternatively, they are education­ ally complex aspects that may be included in inter­ The study provides a perspective on positive body ventions such as “parent school” (Sharpe et al., 2013). image in adolescents, families and teachers in an Another aspect that is worth highlighting from the area in Catalonia (Spain). The adolescents communi­ study and which has been scarcely studied is the role cated their experiences and perspectives related to of educators (Ciao et al., 2018; Sundgot-Borgen et al., positive body image such as the actions aimed at 2018). The data from the study provide new informa­ the care of the body, the acceptance of the body tion specifically with regards to the context of the and the normalization of differences and security promotion of healthy body image. For example, with oneself. Their parents also expressed aspects these schoolteachers take actions aimed at working such as those that contribute to the development of on self-esteem and confidence, resolving situations of healthy self-esteem, confidence and positive body conflict between peers. The educational aim is based image in this crucial stage of development and on educating the adolescents. In addition, the influ­ maturation, placing emphasis on family activities and ence of social media can increasingly lead to body values. Alternatively, the teachers indicated educa­ dissatisfaction (Burnette et al., 2017), the study under­ tional activities to work on self-image and self- lines that the teachers need to place emphasis on esteem when faced with situations of concern in the media education to help the adolescents to have classroom, the fostering of a critical attitude and a critical attitude towards the negative messages media literacy on the messages received on social from social media. media. To finish, the adolescents’ successful experiences This research provides a complete description of related to body image cannot be understood without aspects relevant to positive body image addressed in considering the influence of their families and tea­ the current social and cultural context in which the chers. These results suggest inclusive interventions, adolescents are immersed. INTERNATIONAL JOURNAL OF QUALITATIVE STUDIES ON HEALTH AND WELL-BEING 11 Implications for clinical practice Committee at the XIII Family and Community Congress (2016). I received a Grant for the Promotion of Health The diversity of experiences and points of view given in Research from the Biomedical Research Institute of Lleida this study reflects the complexity of the construct of body (2018). I am Internship tutor at the University of Nursing of image that still has aspects that can be explored further. Lleida and also at the Ramon Llull University. The results cast light on certain multifactorial components Yvonne Ferrer-Suquet Graduated in Labor Relations and of body image in adolescence to be taken into account Technical Administration. I have professional experience in when designing and implementing educational pro­ labor relations and in the Social and Health fields. I have grammes for the promotion of healthy self-esteem, con­ worked in Mental Health area, in particular, in eating beha­ vior disorders and addictions. I am currently working in the fidence and body image in adolescence in order to Lleida-Pyrenees Research Support Unit from the Catalonia’s prevent eating disorders. The role of nurse as well as Health Department and the Institute for Primary Health Care teacher in the community context plays an important Research Foundation (IDIAP JGol) and at the role in the promotion of health on this topic. Inclusive Multiprofessional Teaching of Family and Community Care- programmes that are carried out by various health profes­ Lleida-ICS Unit. I collaborate on projects associated to COVID-19, ethics, or body image and self-esteem. I am a sionals may help these adolescents to prevent eating teacher in regulated training courses about bibliographic disorders. In addition, it is also important to highlight resources. that the active participation of adolescents in pro­ grammes on body image in the school setting is neces­ Marta Ortega Bravo I am a Family and Community Doctor. I have worked at the Cappont Primary Care Center, Lleida sary. Also, it is necessary to carry out interventions directly since 2007. Currentlly Coordinator of the Research Support in families or with teachers in order to make them aware Unit in Lleida of the Institute for Primary Healthcare of the importance of creating a favourable environment Research IDIAP Jordi Gol. Member of the Research Ethics for positive body image. Committee of the Arnau de Vilanova University Hospital in Lleida. I am an Associate professor of the subject of University of Lleida, as well as a tutor of pre-doctoral train­ Acknowledgements ing programs at the Doctorate School from the University of Lleida and Thesis director of the Health Doctorate at the The research team wish to thank all the participants and University of Lleida. schools that facilitated the project for their collaboration: IES Mireia Vilafranca Cartagena Graduated in nursing in 2013 Lo Pla d’Urgell (Bellpuig, Catalonia, Spain) from the University of Barcelona. Master of “nursing care: methodology and applications” by the University of Barcelona. Currently pursuing a doctorate in health sciences Disclosure statement at the University of Lleida. Hospital nurse in Sant Joan de No potential conflict of interest was reported by the author(s). Déu in Manresa, Althaia, located in the center of Catalonia. Specialized in the field of internal medicine. She works at the university of UCC-UManresa, teaching in the nursing degree. The line of research is focused on his doctorate, Funding healthy habits, Diabetes Mellitus Type 2, physical activity. He is being trained in qualitative methodology, already having The authors declare no support from any organization for contributions. the submitted work; no financial relationships with organi­ zations that might have an interest in the submitted work in Eva Artigues-Barberà I am a Health PhD and Primary Care the previous three years; and no other relationships or nurse. I collaborate with research groups and also in pro­ activities that could appear to have influenced the sub­ jects, development and dissemination of different investiga­ mitted work. tions. I am an associate professor in the Master’s Degree in Health Education at the Faculty of Nursing and Physiotherapy of the UdL and have also taught at the Notes on contributors Nursing Diploma and Degree. With a long career in Gloria Tort-Nasarre Nurse, anthropologist and doctor in Primary Care and Community intervention Programs, I pedagogy. Primary care nurse in the public health network have experience regarding school groups and universities. of Catalonia. She works in a rural primary care center and I have been trained in research methodology, gender per­ teaches the nursing degree and the master’s degree in spective, citizen participation, Health Education and group health education at the University of Lleida. Degree in interventions. Social and Cultural Anthropology from the Autonomous University of Barcelona (1995) and doctorate in pedagogy from the University of Barcelona in 2015. I have extensive ORCID experience in the world of university nursing teaching for more than 20 years, vice-dean of the Faculty of Nursing and G Tort-Nasarre http://orcid.org/0000-0001-5270-821X Physiotherapy at the University of Lleida-Igualada Campus. M Pollina-Pocallet http://orcid.org/0000-0003-3655-5836 Y Ferrer Suquet http://orcid.org/0000-0001-9278-7610 Mercè Pollina-Pocallet I do my daily work as a Pediatric M Ortega Bravo http://orcid.org/0000-0002-0765-6841 Nurse in Primary Care Centre. I have a Postgraduate in M Vilafranca Cartagena http://orcid.org/0000-0003-2953- Nutrition, Health Promotion and another one in Education 3196 and Public Health Nursing. I was a Member of the Scientific E Artigues-Barberà http://orcid.org/0000-0001-5756-696X 12 G. TORT-NASARRE ET AL. References Markey, C. N. (2010). Invited commentary: Why body image is important to adolescent development. 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