Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 16 nº 2 - Apr/Jun - 2019

Original Article Imprimir 

Páginas 27 a 37


Family violence and body image dissatisfaction among adolescents from the Bolsa Família Program treated at a basic health unit

Violencia familiar e insatisfacción con la imagen corporal en adolescentes del Programa Bolsa Familia atendidos en una unidad básica de salud

Violência familiar e insatisfação com a imagem corporal entre adolescentes do Programa Bolsa Família tratados numa unidade básica de saúde

Autores: Ana Maria Vieira Lourenço da Silva1; Maria Helena Hasselmann2

1. Doctora in Eating, Nutrition and Health by the State University of Rio de Janeiro (UERJ). Nutritionist of the Municipal Secretary of Health in Rio de Janeiro - Polyclinic Hélio Pellegrino - City Hall of Rio de Janeiro. Rio de Janeiro, RJ, Brazil
2. Doctorate in Collective Health by the State University of Rio de Janeiro (UERJ). Adjunct Professor of the Nutrition Institute - Department of Social Nutrition - of UERJ. Rio de Janeiro, RJ, Brazil

Correspondência:
Ana Maria Vieira Lourenço da Silva
Policlínica Hélio Pellegrino
Rua do Mattoso, nº96, Praça da Bandeira
Rio de Janeiro, RJ, Brasil. CEP: 20270133
(amvls@hotmail.com)

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How to cite this article

Keywords: Body Image; Adolescent; Domestic Violence.
Palabra Clave: Imagen Corporal; Adolescente; Violencia Doméstica.
Descritores: Imagem Corporal; Adolescente; Violência Doméstica.

Abstract:
OBJECTIVE: Investigate the relationship between physical and psychological family violence against the adolescent and dissatisfaction with body image.
METHODS: This study assessed the dissatisfaction with body image through the Body Area Scale; the psychological violence by the Scale of psychological violence against adolescents and the physical violence between parents and adolescents by the Conflict Tactics Scales Form R (CTS-1). A total of 201 adolescents aged 10 to 19 years old enrolled in a family care program at a health center in the municipality of Rio de Janeiro, Brazil, were analyzed. We conducted bivariate and multivariate analysis to estimate associations between family violence (psychological and physical violence) and dissatisfaction with body image. Associations between variables were expressed as odds ratios and their respective 95% confidence intervals were estimated via logistic regression.
RESULTS: Psychological violence was associated with dissatisfaction with body image only for female adolescents (OR = 4.2; 95% confidence interval 1.37 to 12.86).
CONCLUSION: These results suggest that it is important to implement education and health policies to inform the public on the harmful effects of psychological violence during adolescence.

Resumen:
OBJETIVO: Investigar la relación entre violencia familiar física y psicológica contra el adolescente y la insatisfacción con la imagen corporal.
MÉTODOS: Este estudio evaluó la insatisfacción con la imagen corporal por la Body Area Scale; la violencia psicológica contra el adolescente por la Escala de violencia psicológica contra los adolescentes y la violencia física entre los padres y los adolescentes por el Conflict Tactics Scales Form R (CTS-1). Fueron analizados 201 adolescentes de 10 a 19 años, inscritos en un Programa de Asistencia Familiar de un Centro de Salud en la ciudad de Rio de Janeiro, Brasil. Análisis bivariados y multivariados fueron realizados para estimar asociaciones entre violencia familiar (física y psicológica) y la insatisfacción con la imagen corporal. Las asociaciones entre las variables fueron expresadas como razones de posibilidad y sus respectivos intervalos de confianza (95%) estimadas vía regresión logística.
RESULTADOS: La violencia psicológica fue asociada a la insatisfacción con la imagen corporal solamente para adolescentes del sexo femenino (OR = 4,2; intervalo de confianza del 95%, 1,37 a 12,86).
CONCLUSIÓN: Esos resultados sugieren que es importante implementar políticas de educación y salud para informar al público sobre los efectos nocivos de la violencia psicológica durante la adolescencia.

Resumo:
OBJETIVO: Investigar a relação entre violência familiar física e psicológica contra o adolescente e a insatisfação com a imagem corporal.
MÉTODOS: Este estudo avaliou a insatisfação com a imagem corporal pela Body Area Scale; a violência psicológica contra o adolescente pela Escala de violência psicológica contra os adolescentes e a violência física entre os pais e os adolescentes pelo Conflict Tactics Scales Form R (CTS-1). Foram analisados 201 adolescentes de 10 a 19 anos, inscritos num Programa de Assistência Familiar de um Centro de Saúde na cidade do Rio de Janeiro, Brasil. Análises bivariadas e multivariadas foram realizadas para estimar associações entre violência familiar (física e psicológica) e a insatisfação com a imagem corporal. As associações entre as variáveis foram expressas como razões de chances e seus respectivos intervalos de confiança (95%) estimadas via regressão logística.
RESULTADOS: A violência psicológica foi associada à insatisfação com a imagem corporal somente para adolescentes do sexo feminino (OR = 4,2; intervalo de confiança de 95%, 1,37 a 12,86).
CONCLUSÃO: Esses resultados sugerem que é importante implementar políticas de educação e saúde para informar o público sobre os efeitos nocivos da violência psicológica durante a adolescência.

INTRODUCTION

Body image can be conceptualized as a multidimensional construct that represents how individuals think, feel and behave in relation to their physical attribute. Problems with body image may range from moderate dissatisfaction and concern for the body to deep dissatisfaction with physical appearance1.

Studies have shown a high level of dissatisfaction with body image in adolescents, being more pronounced in females. Overall, research shows that body image dissatisfaction may be linked to unhealthy weight management practices, eating disorders (anorexia, bulimia, and binge eating) and negative self-perception of weight, health, and well-being1.

The literature suggests that body dissatisfaction has a multifactorial etiology and may be the result of physical characteristics: body size versus culture, social environment (emphasis on thinness and appearance), psychological factors (low self-esteem and depression) and an ideal image differentiated body sex (thin and sexy for women and strong and muscular for men) 1. Socioeconomic factors-education, race/ethnicity, income and economic class-are also pointed as influencers of body dissatisfaction2.

With advances in the knowledge of the social determinants of health, research in the area of body image began to consider violence as another important aspect in its development. Kearney-Cooke and Striegel-Moore3 state that in the presence of violence, a negative or embarrassing feeling about the body - body dissatisfaction - may arise and favor the unhealthy or inappropriate practice of eating.

Following this same line of argument, other studies suggest a relationship between sexual abuse and eating disorders in young girls4. However, it is important to mention that other types of abuse such as psychological and physical violence are also pointed as possible determinants of body image perception5.

Therefore, unraveling the causes of body dissatisfaction is of paramount importance to minimize its consequences on the health of individuals, especially among adolescents. Exploring other types of violence will enable health professionals and the general public to better understand the relationship between family violence and possible changes in body image. This study aimed to investigate the relationship between physical and psychological family violence suffered by adolescents and dissatisfaction with body image.


METHOD

The research was conducted at a municipal health unit in Rio de Janeiro (Hélio Pellegrino Polyclinic) and involved 201 adolescents between 10 and 19 years old who received benefits from the Bolsa Família Program (PBF). These youngsters were selected through a convenience sample and have similar characteristics in terms of socioeconomic status, for example, among the prerequisites required by the program are: low family income, constant school attendance and proof of periodical follow-up health status in a health unit. These adolescents were monitored by the nutrition service of this health unit from 2008 to 2009.

Data were obtained through a pre-tested questionnaire, consisting of questions regarding outcome (body image dissatisfaction), central exposure (physical and psychological family violence) and covariates (demographic and personal information).

Dissatisfaction with body image was measured by the Portuguese version of BodyArea Scale6. The scale consists of 15 items covering the degree of dissatisfaction with the following body parts: face, hair, buttocks, hips, thighs, legs, stomach, waist, chest/chest, back/shoulders, arms, muscle tone, weight, height and all other areas. For each area, the adolescent self-rated according to a range of variation from very dissatisfied (score 1) to very satisfied (score 5). Body image was evaluated according to the average total score of all body areas7, ie, face + hair + buttocks + all areas/16 (total number of body areas) and classified as satisfactory (mean>3) and unsatisfactory (average ≤ 3)8.

Physical violence was measured by a Portuguese language version of the ConflictTacticsScales (CTS-1) instrument9. The CTS-1 is intended to measure the strategies used by family members to resolve possible disagreements and, indirectly, to capture a situation of family violence. Family relationships considered in the present study were between parents (father and mother) with adolescents. The scales of minor physical violence (items k-m) and severe physical violence (items n-s) were classified as follows: they did not occur in the relationship and occurred at least once in the relationship10. The time period investigated was 12 months before the interview.

Psychological violence was measured by a Portuguese version of the psychological violence against adolescents scale11. This scale evaluated the experiences lived by the young person who had in his relationships, a significant person denigrating his qualities, abilities, desires and emotions or exerting excessive behavioral demands. This consists of 18 closed items, with five answer options: never, rarely, sometimes, almost always and always with scores 1, 2, 3, 4 and 5, respectively. Scoring is performed by summing the scores of each item, dividing this sum by the total points each teenager could score on the questionnaire and multiplying by 100. The presence or absence of psychological violence is guided by the median of this percentage of points, ie presence of psychological violence (percentage of points ≥ median) and absence of psychological violence (percentage <median)12.

Demographic information and characteristics of adolescents were collected, such as age, gender, race/color (black and non-black), health status (good or bad), racial discrimination (present or absent), housing conditions, social network and social support, sexual maturation and nutritional status.

Housing conditions were assessed by an instrument composed of items corresponding to crowding, materials used to build the house, type of floor, electricity, water supply, sewage disposal and the way garbage is collected. Data were scored and the total score was considered as satisfactory housing conditions when ≤ 9 and unsatisfactory housing conditions when <913.

The network and social support variables were assessed by a Portuguese language version of the social support questionnaire used in the Medical Outcomes Study14. This instrument measures the perception of support availability. It is composed of five dimensions: 1) material; 2) affective; 3) positive social interaction; 4) emotional and 5) information. Each dimension comprises questions that are scored by scores ranging from 1 to 5, corresponding to the answers never, rarely, sometimes, almost always and always. By summing the scores of the questions of each dimension, the score was made by dividing by the maximum total score for each dimension and multiplied by 100. The social support measure was obtained by the average score of the five dimensions15. Social support was considered satisfactory when the average was equal to or greater than 75%. To measure the social network, the instrument presents items related to the number of friends and relatives, and the participation of adolescents in social activities15. Information on how many people the teenager can count on was distributed as 0, 1, 2, and 3 or more.

Sexual maturation was self-assessed by viewing the Tanner table with photos representing the five stages of puberal development16 and the adolescent was classified as pre puberal or puberal17.

Nutritional status was assessed according to body mass index (BMI) calculated by dividing body weight (kg) by height (m) squared. BMI was classified according to World Health Organization criteria18 and then dichotomized for logistic regression analysis of adequate weight / underweight and overweight.

All analyzes were conducted separately for male and female adolescents, considering that there are differences between genders regarding body image perception. Statistical analysis of the data proceeded as follows:

Univariate analysis, determining absolute and relative frequencies (prevalence) for categorical variables, and summary measure (mean, median, standard deviation) for numerical variables;

Bivariate analysis, considering the body image variable as outcome. For categorical variables, according to the contingency tables determined for each variable versus outcome, the Chi-square test was selected to test their association. For numerical variables, the unpaired Student's t test was used;

Univariate logistic regression analysis (gross) between exposure variables (minor physical violence, severe physical violence and psychological violence) and outcome variable (dissatisfaction with body image) and covariates of interest;

Multivariate logistic models were created for each exposure variable (minor physical violence, severe physical violence and psychological violence) and outcome variable (body image dissatisfaction), adjusted for covariates that presented p <0.20 in the crude analysis. The criterion of statistical significance for the multivariate logistic model was p <0.05;

The models were diagnosed by the Hosmer-Lemeshow test. The model was considered well-adjusted when> 0.05; and Odds ratios (OR) for each exposure variable in multivariate logistic models, in addition to the respective 95% confidence intervals and p value.

To perform the analysis, the study used Epi Info 2000 for database creation, R Studio software version 0.96.0331, and R 2.15 software with MKmisc and epicalc packages and extensions for further analysis.

Only adolescents and their legal guardians who agreed and signed the Informed Consent Form were included in the study. The research was approved and authorized by the Research Ethics Committee of the Rio de Janeiro Municipal Health Secretariat (Opinion No. 122A / 2007).


RESULTS

Table 1 shows the demographic and personal information of the adolescents studied. Regarding body image, about 20% of adolescents were dissatisfied. Female adolescents had higher body image dissatisfaction values than male adolescents but this difference was not statistically significant (p = 0.454).




Table 2 shows the frequency of each type of family violence performed by parents against adolescents. Almost half of the sample experienced psychological violence, but female adolescents were the biggest victims. Regarding other types of violence, 30% of both sexes suffered severe physical violence and about 40% suffered minor physical violence.




Based on the results obtained from the bivariate analysis (Table 3), it was observed that for male adolescents, their nutritional status was significantly associated with body image (p=0.018). Those who were overweight were 4 times more likely to be dissatisfied with their body image. For female adolescents, in addition to nutritional status (p=0.019), psychological violence (p=0.015) and housing conditions (p=0.041) are also significantly associated with dissatisfaction with body image, that is, overweight, the presence of psychological violence and inadequate housing conditions generate about 3 times more chances of dissatisfaction with body image.




Information on multivariate OR models and their respective confidence intervals is shown in Table 4. The models used the explanatory variables (types of violence), nutritional status and age for male adolescents and female adolescents were the types of violence, nutritional status and housing condition.




For male adolescents (Table 4), analyzes showed that no type of violence was significantly associated with dissatisfaction with body image (minor physical violence - p = 0.668; severe physical violence - p=0.670 and psychological violence - p=0.854). For female adolescents (Table 4), only psychological violence was significantly associated with dissatisfaction with body image (p=0.012). Thus, female adolescents who suffered psychological violence were 4.2 times more likely to be dissatisfied with body image than those who did not experience psychological violence. Although not statistically significant, associations were positive between physical violence and dissatisfaction with the body image of adolescents (minor physical violence - p=0.242 and severe physical violence - p=0.076). The more severe physical violence, the greater the dissatisfaction with body image - minor physical violence (OR = 1.8; CI = 0.67-4.80) and severe physical violence (OR = 2.5; CI = 0,91-7.01). The diagnosis of the multivariate logistic model showed, in both sexes, p value greater than 0.05 for all types of family violence (data not shown).


DISCUSSION

This study investigated the relationship between family violence by parents and dissatisfaction with body image of adolescents monitored by the Family Assistance Program. Adolescent victims of violence were expected to be more dissatisfied with their body image. This hypothesis was supported only for female adolescents victim of psychological violence, both in bivariate and multivariate analyzes.

Exposure to stressors in the early stages of life can affect body image. Murray, Byrne, and Rieger19, in their study of 533 australian adolescents, examined the relationship between stress and body image and found that female adolescents with higher stress levels had more symptoms of depression, greater body image dissatisfaction, and low self-esteem than male teenagers. When it is considered that the existence of family violence can be a stressful situation for adolescents20, body image is consequently negatively affected, which leads to the same results of the present study. Thus, female adolescents exposed to violence show greater dissatisfaction with body image.

Regarding the types of violence, studies that investigated the relationship between violence and body image in adolescents evaluated sexual violence21-23, physical violence21,23 and neglect22. Schaaf and McCanne23, researching female students, found no relationship between physical and sexual violence and body image distortions, despite the fact that young women who suffered physical abuse had higher personal expectations and greater difficulty in identifying emotions and feelings of hunger and satiety. However, when assessing 1571 adolescents in New Castle (USA), Logio21 observed that those who suffered physical and sexual violence showed altered perception of their body image for overweight, with greater evidence for female adolescents. At the same time, there was a strong correlation between adolescents with a history of abuse and the presence of eating disorders and dietary behavior. Rama Bouquet and Santos22, in a study of female adolescents who were victims of neglect and sexual abuse, observed that these adolescents presented a more negative view of the body, regardless of the type of violence. These findings identify past experiences of abuse as a risk factor for unhealthy eating practices and an unhealthy body image self-assessment.

Importantly, there are few studies on the subject5,21,22 and they employ different methodologies to assess body image and measure family violence. With regard to body image, instruments/scales can assess body image disorders according to perceptual and attitudinal aspects. Studies that express the perceptual component measure body image by the degree of accuracy with which body size is perceived, while the attitudinal one expresses affective and cognitive components24. Most of the above mentioned studies measured body image according to attitudinal aspect, despite the use of different scales/instruments. It is noteworthy that this study also assessed body image by attitudinal aspect. In family violence, there is a disagreement among researchers as to the definition of what types of behaviors or punishments should be considered as abuse and also regarding the temporality - past versus current25. Consequently, it is not always possible to compare the results found in the few existing investigations. Even so, evidence suggests that a stressful family environment generates serious problems in the development of children and adolescents26.

Despite the relative absence of studies examining the relationship between psychological violence and body image dissatisfaction in adolescents, existing research shows a link between childhood violence and body image problems in adulthood26. Violence in childhood has negative consequences and may lead to the emergence of psychopathologies in adulthood. Psychological violence has been associated with self-criticism, body image dissatisfaction, depression and low self-esteem among adults5.

Therefore, it is important to have a safe and welcoming family environment to develop a healthy body image in individuals, particularly in the case of adolescents. The body is not simply a biological machine, but a body that comprises a history of relational experiences that will aid an individual's development and ability to cope with stressful situations. It is also a means of regulating affections or solving problems of a relational/personal nature27. Eubanks et al.4, in their study of 38 undergraduates, observed that victims of physical and psychological abuse felt that their parents loved them less, gave them less support, and figured as a negative model in their lives. This shows once again how the existence of physical or psychological violence within the family can negatively affect the lives of the individuals involved. From this perspective, healthy relationships that adolescents enjoy with other family members are potentially decisive to lead to proper development and good social relationships27.

This study has certain limitations: the first concerns the sample design, which was based on a cross-section, which is not able to infer the temporality of the described associations. The second limitation concerns the type of sample. The present study used a convenience sample of individuals enrolled in the Family Assistance Program, with similar socioeconomic characteristics. Another limitation to be considered refers to the variables that may be involved in the relationship between violence and dissatisfaction with body image, which were not addressed here and which may generate body image problems, such as: shame, self-criticism, changes in humor, perfectionism, puberty, self-objectification, identification of gender roles, sexuality, anxiety and other experiences that are potential mediators in the relationship between childhood maltreatment and body image problems5. In addition, given that some maltreated children do not develop serious psychological consequences or other health problems, it is an important task for the future to identify the factors that protect these children from the negative consequences of abuse. From this point of view, it is important that other researches investigate the relationship between family violence and body image, developing longitudinal studies and considering other aspects, such as compensatory mechanisms, psychological factors and the perception of family relationships that, when favorable, help in overcoming trauma.


CONCLUSION

Despite the limitations, this was the first study on the relationship between physical and psychological violence and body image dissatisfaction in Brazilian adolescents. Based on the results of this study, it can be assumed that psychological violence is linked to dissatisfaction with body image in female adolescents. This knowledge can help underpin strategies that enable adolescents and their parents to understand the detrimental effects that an unfavorable home environment can have on an adolescent's growth and development. It should also be clear to society that violence, culturally accepted as part of the educational process, can have negative consequences for body image formation.


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