Qualitative findings in a long-term disordered eating prevention programme follow-up with school-going girls

Abstract

The assessment of eating disorder prevention-programmes has mainly been addressed quantitatively excluding complexity that may improve prevention. We compared perceptions of eating, female and male aesthetic-models, media influences, prevention-programmes and emerging topics among 12 young females who received a media literacy programme (N = 4), media literacy plus nutrition awareness programme (N = 4) or were assigned to a control condition (N = 4). Interpretative Phenomenological Analysis highlighted ego-syntonic eating-patterns and signs of internalization of the thin ideal. Findings provide invaluable and rich information to improve future iterations of the programme.

Keywords

adolescent girls disordered eating media literacy prevention programme qualitative research

The multifactorial aetiology of Eating Disorders (ED) (Fairburn and Brownell, 2002; Garfinkel and Garner, 1982; Rojo et al., 2006; Sinton and Taylor, 2010) and its relation to other health problems requires an interdisciplinary and integrative approach, not only regarding the pathogenesis and explanatory theoretical models of these disorders, but also in the field of treatment and prevention.

Over the last 15 years, it has become accepted by health disciplines the use of qualitative methods in order to regard healthcare from the viewpoint of the patient (Biggerstaff and Thompson, 2008; Henwood and Pidgeon, 1992; Smith, 1996). Additionally, an important way of measuring the quality of health services is by studying patients’ experiences (Pettersen et al., 2010; Ribeiro and Blay, 2009). In this light, several ED treatment unit services have recently introduced qualitative methods to their assessments in order to gain a better understanding of the nature of the improvement and difficulties within the therapeutic process (Arkell and Robinson, 2008; Goddard et al., 2011; Kyriacou et al., 2009; Macdonald et al., 2011; Pettersen et al., 2010; Pretorius et al., 2010).

In the ED prevention field, significant progress has been made over the last decade regarding the reduction of ED risk factors and ED onset emergence, particularly with programmes targeting older adolescents and college-age women (Sinton and Taylor, 2010; Stice et al., 2006; 2008; Taylor et al., 2006). However, Sinton and Taylor (2010) pointed out that much remains to be done in order to improve effective programmes for younger groups. In this sense, González and colleagues (2011) have found promising results in a 30-month follow-up of a media literacy-based programme conducted in two versions. They revealed that both can be effective interventions reducing long-term, self-reported disordered eating attitudes and internalization of the aesthetic body ideal in a universal mixed-sex school-going adolescent population.

Nevertheless, most ED prevention programmes historically have addressed their effectiveness evaluation from a quantitative point of view. As a result, little is known about the role and impact of participants’ perception of prevention programmes and whether they experience such programmes as helpful and significant to their lives. Qualitative methods could introduce a deeper perspective (Flick, 2009; Neumark-Sztainer et al., 2006) to the prevention programme assessment, increasing our understanding of the risk factor interaction, the prevention process and its practice.

The aim of this study was to describe perceptions and attitudes of a sample of female participants who took part in a quasi-experimental, 30-month disordered eating prevention programme follow-up conducted in two versions.

Method

Participants

The initial sample consisted of 254 girls belonging to seven state or state-subsidized schools in the city of Terrassa (Catalonia, Spain). Three participants were excluded due to incomplete information, thereby 251 girls with a mean age of 13.4 years (SD = 0.4) were included in the pre-test. Depending on the type of school, participants were assigned to one of three possible conditions: Media Literacy (ML), Media literacy and Nutrition knowledge (ML + NUT) or non-treatment control condition (CON).

In the 30-month follow-up, 184 girls (73.3% of the original sample) remained; drop-out was due to absence on the day of assessment, incomplete assessment, or change of school. From this sample, 12 girls from the three different experimental conditions (four of each) were also selected considering the type of school, the highest and lowest previous scores on self-reported eating attitudes and internalization of idealized aesthetic models in order to widen the range and variability of responses (Flick, 2009; Patton, 2002). Therefore, within each of the three groups, two participants were recruited from a state school and two from a state- subsidized school, each of them with the first, second or third highest or lowest scores on the aforesaid constructs for each type of school.

Disordered eating prevention programme

‘Eating, feminine aesthetic beauty model and the mass media: How to train critical students in secondary school’ (Raich et al., 2008).

This programme was designed to be applied to the adolescent population. The theoretical underpinnings stem from Bandura’s Social Cognitive Model (Bandura, 1986) and Media Literacy perspective (Levine and Smolak, 2006), including two components: a) the Nutrition Knowledge (NUT) component, aimed at correcting false beliefs on nutrition by providing knowledge about balanced eating and analysing menus; and b) the Media Literacy (ML) component aimed at criticizing the prevailing aesthetic model, by making a historical and cross-cultural comparison and criticizing the female model of beauty presented in the media. Activism activities involve critical analysis of advertisements: learning about writing letters of complaint to the media interspersed with a presentation of ‘how to deal with media messages’.

The format is interactive and focused on the participants, with a PowerPoint multimedia display. It involves three sessions combined with two activities and with tasks between sessions. Participants assigned to the ML+NUT and ML conditions received the programme session once a week, over five and fours weeks respectively, presented by some of the authors of the programme, while control participants had normal classes.

Semi-structured qualitative interview

The main themes for the semi-structured qualitative interview were developed in the authors’ unit. Once defined, the topic guides were sent independently to four external expert judges in eating disorders, youth, prevention of weight-related problems in youth and qualitative methodologies respectively. Corrections and suggestions were included in order to better explore adolescents’ perceptions and attitudes of eating, female and male aesthetic models, fashion, media influences, self-care prevention programmes and emerging topics related to youth.

Procedure

The quasi-experimental design with a prospective follow-up including the qualitative part was welcomed by the Ethics Committee of our institution and was approved and mediated by the Terrassa Municipal Institute of Health and Social Welfare. Taking into account the aforementioned criteria, the participants pre-selected for each condition were informed of the study and invited to participate. When a girl refused (four cases) or was absent on the day of interview (three cases), we contacted another student from the previous list of possible participants. After obtaining informed consent from the parents or guardian in charge of the participant, interviews were conducted in a quiet room at school and lasted between 50–70 minutes. All interviews were digitally recorded (with participants’ consent) and transcribed.

Analysis

The thematic analysis of verbatim transcripts was conducted using Interpretative Phenomenological Analysis (IPA) (Smith and Osborn, 2004). IPA aims to explore in detail participants’ perception, meaning their ideographic subjective experiences, and the personal and social cognitions associated to such experiences, which are only accessible through an interpretative process (Biggerstaff and Thompson, 2008; Smith et al., 1995). In this regard, IPA explores semantic meanings within inner social cognition worlds, rather than political and social aspects within the semiotic analysis involved in different qualitative methods such as Discourse Analysis (Verón, 1993). Therefore, IPA seems to be particularly suited to studies of bio-psycho-social theories that are widely adopted by health care professionals (Biggerstaff and Thompson, 2008; Smith, 1996; 2004; Willing, 2001).

Each verbatim transcription was compared with the audio recorded interview to check the accuracy of the text by the first author. Twelve transcriptions were repeatedly read in order to identify tentative labels clustering similar units of meaning into coding themes. Related themes were condensed, resulting in a set of themes and sub-themes. The analysis was conducted primarily by the first author; the second and third author reviewed the transcripts checking the precision of coding process. Joint discussions were held between authors, and the labels and clusters of themes were modified several times until a consensus was reached on a final table of higher and lower order themes from qualitative interviews.

Results

Thirteen high-order themes were identified from the responses of the participants interviewed from the three different experimental conditions, as shown in Table 1.

Table 1.

Overview of higher and lower order themes from qualitative interviews.

Higher-order themes	Lower-order themes
Eating and nutrition	Nutrition: variety and quantity
Healthy diet	Proper variety and quantity
	Balance versus Forbidden food
	Difficult applicability
	Cheap-young people-fattening-food
Eating preferences	Eating as a social event
	Pleasure of eating
	Risky eating patterns
	Maternal regulation
Eating and gender	Cooking as a women’s role
	Eating concerns
	Amount of food
Fashion	New social trend
	Social belonging
	Social status
	Personal identity and limits in self-definition
	Ways of transmission
	Social pressure to be thin
	Attitudes toward fashion
	Fashionable possessions
	Fashionable food
	Fashionable attitudes
	Fashionable body
Female ideal of beauty	Thin, young and curvy body
	Critical attitudes
	Perceived expectations of the body from the opposite sex in social interaction
Male ideal of beauty	Thin and muscular
	Gender and aging
	Physical appearance v/s inside of the person
Models of beauty, media and daily life	Building an unrealistic model of beauty
	Ways in which people find out about fashionable possessions
	Media’s negative effect
	Effect of the perceived expectations of the body from the opposite sex
	Effect of good-looking normal people on the street
Models of beauty and body satisfaction	Individual accountability for failure
	Economic interests
	Effect of the perceived expectations of the body from the opposite sex
	Levels of internalisation of the unrealistic model
	Thin body preoccupation
	Negative affect
	Social pressure to be thin
Beauty and health	Thinness
	Active lifestyle as a mediator
Important issues for the youth of today	Physical appearance
	Fashion and fashionable possessions
	Identity seeking
	Study as a way to get social status
	Having money and a good future
	Having close and intimate friendships
Prevention/ self-care	Taking care
	Sex, drugs and alcohol
Weight-related problem prevention and the Prevention Programme	Changing advertising policies to promote a range of body sizes
	Person as a whole
	Adolescence and vulnerability
	Good social network as a protective factor
	Internalisation ideal in society and peer
	Positive evaluation of the ML programme in ideal and it’s transmission
	Positive evaluation of the ML programme in nutrition
	Areas that should be worked on in a prevention programme
	Criticism of questionnaires
	Criticism of weighing and measuring

Eating and nutrition

When defining eating and nutrition, all participants related eating with the idea of ‘necessity’. ML and ML+NUT groups mentioned the importance of ‘variety in eating’, but ML+NUT also mentioned ‘proper quantities’.

Healthy diet

Ten of the participants pointed out that this means ‘eating the proper quantities and eating a variety’. However, seven (ML, ML+NUT and Control group) considered the healthy diet to be an ideal, highlighting the difficulty of applying this ideal in the daily life of an adolescent. According to four participants (ML, Control group) it seems to be easier or more attractive to eat sweets, fried foods and McDonald’s food, which are seen as unhealthy foods and typical for young people as fattening food is the cheapest option. Additionally, two participants from the ML+NUT-group introduced the notion of balance when defining the unhealthy diet as having the following foods every day: chips, fried egg, nuggets, fast food, lots of pastries, sweets, and so on.

Eating preferences

Seven from the ML and ML+NUT groups saw eating as a social event (family and friends). Three participants from the ML+NUT-group also understood eating as a pleasure. Three participants from the Control group did not mention the social function or the pleasure. Nevertheless, one participant showed a risky eating pattern in unique eating preferences: eating alone interspersed with other activities: ‘During the week I eat in my room, next to the piano. It makes me feel good. While I eat, I usually do things, like an essay or sometimes I play the piano’. Nevertheless, four of the Control group noted a lack of schedules, food variety and social norms to regulate eating in the absence of their mother: ‘I eat what I find at home. In the morning I was in a hurry, and I only had a glass of milk for breakfast and then I came home starving. I’m used to it.’ ‘Mothers force you to eat healthily even if you don’t like it’. In this sense, healthy eating is regulated by the presence of their mother (with no personal accountability of the good practices related to eating).

Eating and gender

All the participants related female gender to eating, particularly cooking (as an everyday role). Only two of the ML group talked about men doing the holiday cooking. They also mentioned that women are more concerned about what they should or should not eat. One participant from the ML+NUT-group pointed out that men are supposed to eat more than women.

Fashion

All participants defined fashion as a new social trend followed by a social group, highlighting the social pressure to follow it. However, eight (ML, ML+NUT-group) added that a trend communicates social belonging, social status and a complex identity process: ‘Tight trousers are widely used, but I don’t like them. Now it’s fashionable and if you wear trousers, they’ll say that you are old-fashioned because of what you wear’. Fashion regulates what people wear, their ‘cool possessions’, attitudes, behaviours and ‘the kind of trendy body they should have’, ‘no one wants to be chubby’. The participants were vocal about fashion and fashionable goods coming from the media, especially from TV. While two (ML) said that the pressure to buy, have or even desire fashionable possessions could be influenced by celebrities’ possessions, two from the ML group added that shops and billboards allow people to find out about fashion too. The Control group did not mention this topic.

Regarding attitudes towards fashion: six (ML, Control group) showed negative or discrepant attitudes (whether to follow the new and changeable trend or not), while four (ML, ML+NUT group) showed positive attitudes towards fashion (just in the right dose, ‘not too much’).

Cool and fashionable goods, attitudes and behaviours for young people were defined by participants as: skinny jeans, skirts, shirts with tights or leggings, retro jackets (Vespa), low-waist trousers, low trousers and Pull and Bear long t-shirts for guys to show their underwear), wearing brands, being thin, having different hairstyles, wearing accessories such as scarves, necklaces, piercings, tattoos, getting along with people, drinking, smoking and being on a diet. Using technological devices (computer, mp3 player) and staying out until late are in fashion as well. Four (ML, ML+NUT) said that food could be fashionable, ranging from light products and fruits to Waffles and McDonald’s food. Although two (Control group) said fashion is especially followed by youths, and even parental attitudes such as monitoring could be regulated by this social trend.

Female ideal of beauty

All participants associated the current female model with youth and thinness. They defined the female ideal of beauty as a thin and curvy girl. Eight (ML, ML+NUT) added the idea of dressing well, wearing accessories and wearing well applied makeup. The Control group added the idea of having a strong and sweet character as part of the ideal of beauty that ‘changes over time’.

All intervention groups showed critical attitudes toward the prevailing aesthetic model and the overrating of physical appearance over other values such as ‘intelligence or the inside of the person’; ‘More and more people are focused on the physical appearance and not on the personality’. They perceived the opposite sex’s expectation of a ‘beautiful sexy girl’ to be related to an ultra-thin and curvy perfect body: ‘Boys like them thin, with curves, tits, ass and everything. . . And if she is blonde, even better’.

Male ideal of beauty

All participants associated the current male model with thinness and muscularity: ‘Men now are not allowed to be fat . . . They want to be slimmer and go to the gym to get a nice physique, muscles and everything’. Eight (ML, Control group) had the perception of a change in the male model of beauty though all the time being more slender and muscular than before. Two (Control group) pointed out that the male ideal of beauty is also young, but compared to women, men can be considered attractive even if they are not that young. All intervention groups noted a masculinity change. Nowadays men are seen as sexual and beauty objects as well as having to have the ‘right measurements and proportions, and a good-looking face’. However ‘they don’t represent maturity, stability, security anymore.’ ‘Physical appearance is more appreciated than the inside of the person, for sure . . . .’”

Models of beauty, beauty and daily life

All participants pointed out the negative effects of the constant exposure to media that is full of stereotypical idealized models of girls’ body image, making appearance-related self-discrepancies more salient.

In this light, nine (ML, ML+NUT, Control group) highlighted the different strategies used to build an idealized model of beauty: retouched images, make-up techniques, the absence of larger sized clothes in shops and the social discrimination against those who are different (overweight people).

Seven participants (ML, ML+NUT, Control group) mentioned the ways in which people find out what is fashionable (including goods and bodies) that could trigger appearance-related self-discrepancies: media, TV, adverts, teenage magazines, shops, billboards and celebrities: ‘I think this ideal of beauty, or this model of beauty, comes from TV . . . celebrities, almost everything comes from celebrities’. Other ways of finding out about fashion mentioned by participants are: life and social situations (gym class-shower: one [Control group]; good-looking people on the street: six [ML+NUT, Control group]; opposite sex interaction and the perception that guys prefer the idealised model of beauty: six [ML, ML+NUT group]): ‘And series and movies, and the accumulation of all those things count . . . Because girls, they try to be like them and the boys say: ‘Wow she is hot, beautiful, fine, etc. Guys focus on the physical appearance.”’

Girls were seen to be in a more vulnerable situation regarding the influences of the media than boys by 10 participants. Besides, two (ML+NUT) saw this condition as a risk for dieting, or stopping eating in order to achieve the ideal, ‘trying to please boys’. In fact, one participant from the Control group indicated dieting and excessive physical activity as normal behaviour in order to lose weight ‘but not taking diet pills as some girls do’.

Models of beauty and body satisfaction

Four (ML, ML+NUT group) highlighted the detrimental effect of adverts on people’s body image in the individual accountability for the failure of the product or not having the perfect body, as a willpower attribution (ML). Two from the ML+NUT group added there are economic interests behind the unrealistic messages disseminated though the media, highlighting the misleading resources and visual techniques used by the media in order to sell products. Another two (ML+NUT group) noted that because of the prevention programme, appearance-related self-discrepancies become less salient with portrayed images through the media but stronger with good-looking people on the street.

Five participants from intervention groups showed signs of internalization of the unrealistic thin model of beauty, which has a negative effect on their body image, triggering comparison processes: ‘They put very beautiful girls in adverts. You’d like to be like them’; ‘because these super models and girls coming out on TV are increasingly thinner. You can see their bodies and then the top models are even thinner. You notice that. It is not cool. If you are a little chubby you notice that and you say: if they are calling that super thin girl fat, what can I expect for me then?’

The entire Control group showed strong signs of internalization of the unrealistic thin model of beauty: ‘I don’t like the way I am . . . society influences us too much . . . people, fashion, designs, even the companies. We see this stereotype, you know, and we follow it.’ This is associated with weight-related self-discrepancies, extreme negative self-evaluation of appearance, negative affect and personal suffering: ‘I don’t like myself, I look fat. I’d like to be different, not just skin and bone, but thinner’; ‘When you stand in front of the mirror and you don’t like what you see, it’s a bit traumatic. Sometimes I wake up and say what a face I have, but then I let it go . . .’”; ‘You get mad when you see a super thin girl who can eat everything and you can’t . . . why do I get fat and she doesn’t . . . I don’t like being this fat.’

Two participants from the Control group indicated the body-focused negative affect is reinforced by their immediate social environment that ‘cares about it’. The ML+NUT-group proposed ways to solve people’s unease with their body or protective factors: friends and boyfriends as a social support that could reinforce a good physical appearance (as part of body image) and having an active lifestyle.

Beauty and health

For eight in the ML and Control group, beauty appearance seems to be more important than health, and beauty seems to be associated to a healthy lifestyle and thinness.

However, four (ML, ML+NUT group) pointed out that beauty and health do not have to be necessary related.

Important issues for the current youth

For all participants, physical appearance is an important issue: ‘We talk a lot about beauty and this is more or less the most important thing’; ‘Everyone is aware of image’. It is a way of coming into contact with the opposite sex, six (ML+NUT, Control group); important for the media, 12; and even to get a job, two (Control group). One (ML group) explained that while a good-looking and toned physical appearance is an important goal to achieve for girls, sex seems to be an issue for boys.

More important issues for youths today are: 1) studying, getting good grades and passing the year: ‘It’s very stressful having to decide’; ‘Getting the grades makes me worry a lot’ (12); ‘Having money and a good future are a very important issue’. 2) getting fashionable and cool possessions, being well-dressed (brands) (12): ‘I prefer to study and afterwards get a good job, because I don’t want to be a waitress or something like that’. In this sense, having material possessions is a way of gaining social status, belonging to a group and feeling more popular: ‘Be well-dressed, not tacky, not dressed the way your mother wants you to; if you don’t have a mobile and you go with those shoes, you won’t be invited to the party, but people who are dressed more or less like you do, might be invited.’ There are important values at this age, but not ‘when you get older’ (two Control group).

Clothing, piercing and tattoos as forms of identity seeking, expressing the necessity of being different from adults and peers but belonging to the group at the same time (eight ML, ML+NUT group). Getting along with people and the entertainment world (12): ‘Pulling and going out at night with friends to forget your worries’; ‘drinking when you go out’; ‘going to the cinema, watching music videos, listening to music’ and the ‘technology world are important things to us’; ‘We don’t care about politicians but football is really important’; ‘But having good friends, having close and intimate friendships is an important thing too’ (two ML+NUT group).

Prevention and self-care

All participants related prevention to the idea of being careful. They linked the concept mostly to sex life, alcohol consumption and drugs. Six (ML, Control group) also associated prevention with having a healthy and balanced lifestyle, eating well and practising physical activity. One participant (ML+NUT group) pointed out that prevention talks alone are ineffective strategies.

Weight-related problem prevention and the prevention programme

Four (ML, ML+NUT group) highlighted the importance of changing the advertising policy, promoting a range of different body sizes regarding the consequences of exposure to ultra-thin models: ‘They should show less of those ads promoting thinness’;. ‘It is ok if you have some of those but show less of them, putting on different kinds of girls, putting plumper girls on who also have rights’; ‘In the workshops we talked about people who are not perfect; that is why the advertising policy must change’.

As a prevention strategy, eight (ML, ML+NUT group) pointed out the importance of the whole person rather than just giving importance to their physical appearance. Three (ML+NUT) expressed their perception of adolescence as a vulnerable period. Nine of the participants saw the social environment as a protective factor and a need for social support. They expressed the necessity of ‘having someone to talk to’ (good friends, boyfriend): ‘Someone to tell the truth’; ‘Have someone to talk to and help you to cope with life’s difficulties’. Being Christian was also mentioned by one participant (Control group).

The unrealistic model of beauty and the importance of physical appearance are seen as something that is powerful and integrated in society and peers for 11 participants. They highlighted comparison between peers and social criticism as potential triggers of appearance-related self-discrepancies and negative affect: ‘Nowadays everyone criticises everyone, and you think that it is true; it could affect you psychologically’; ‘It happens a lot, no one laughs about good-looking people, but they laugh about overweight people . . . guys especially discriminate against chubby girls’.

‘Loving yourself’ (good self-esteem) was mentioned by eight (ML, ML+NUT, Control group) as a protective factor for feeling bad about your body and start dieting (endorsed by one ML+NUT). Seven (ML, ML+NUT group) showed a positive evaluation of the ML approach: criticism of media messages, models and the techniques used to sell us their products even if they are not true, pointing out the economic interests behind misleading messages regardless of the effect on the person who receives it: ‘Mainly I remember that the models portrayed had all been retouched. Everyone in the adverts has been retouched and they are not really true’; ‘I used to believe ads before, but not now. Adverts don’t influence me as much as before. They try all sorts of ways to sell a product, regardless of the effect on the person who receives it. Selling the product is what truly matters.’ Additionally two (ML+NUT group) showed a positive evaluation of the media literacy approach applied to the harmful effects of dieting: ‘The slides we watched in year nine were useful because there were people who had their eyes opened and said oops! The yo-yo effect of diets or things like that . . .’. One girl (ML group) said that the programme helped to develop critical thinking that changed buying habits. She also made a positive evaluation of the programme seeing it as an opportunity to discover models of beauty through different cultures.

Areas that should be worked on in prevention programmes (Control group) are parent monitoring, good self-esteem, a healthy and active lifestyle, using visual techniques, media literacy, negative and positive peer-influence and teasing resilience.

The ML group pointed out that information should be continuously spread and followed up: ‘With the workshop, my friends and I thought about it, we talked about it, it was really cool, but it doesn’t always stay in your mind . . . Physical appearance is indeed an important value in this society’. The ML+NUT group said that sex life, drugs, alcohol and tobacco consumption could be possible topics to be included in the prevention programme. Six (ML, Control group) criticized the questionnaires we used, saying they were too long and non-effective (as participants could avoid acknowledging their symptoms on questionnaire responses).

Limitations and future research

Although the number of participants who took part in this study was low, sampling in qualitative research is a way of managing diversity (Flick, 2009). In this light, the variety and variability of the studied phenomenon can be captured empirically, so samples are usually small to support exploration of the data. Additionally, despite the fact that this study only considered female participants, several gender differences found by the participants should be compared and contrasted with male referents. This could be an interesting area to consider for future research.

Discussion

The aim of this study was to describe the perception and attitudes of a sample of females who received two versions of a disordered eating prevention programme and a non-treatment Control group. Key findings suggest that there were more similarities than differences between the two versions of the programme, except in relation to the harmful effects of commercial diets and accurate notions of nutrition. However, social function or pleasure were not mentioned when defining eating and nutrition. Special attention was given to disordered eating attitudes and to signs of internalization of the unrealistic thin model of beauty with negative effects on the girls’ self-image.

In this regard, the qualitative approach provides invaluable richness and complexity to the review and enhancement of the programme by considering risk-factor interaction processes (Jacobi and Fittig, 2010) as potential triggers of appearance-related self-discrepancies, especially the adolescents’ immediate social environment and its roles in the development of multiple attitudes to the idealized ideal of beauty (Ahern et al., 2011). Besides, the consumer culture’s influence on adolescents’ self-definition and its role in the comparison process related to the influences of the immediate social environment is notable as a new feature in ED prevention (Dittman, 2008; Kyung and Roedder, 2010; Thompson et al., 1998). It enables a deeper understanding of how physical appearance, fashion and material possessions are widely valued by our participants. Even expectations of a good professional and social future are related to economic success. In this sense, the perfect body could be another product to achieve. Social situations, perceived male appearance expectations, gender roles and social belonging were also highlighted. Therefore, these aforesaid areas should be explored in future research as possible factors that could be included in the current debate on the aetiological models of ED and also as possible content of future prevention programmes. Finally, participants support the importance of continuing to work using the ML approach, which along with the incorporation of these new contents and preventive agents (such as family, peers, dating partners and various significant adults). Those elements highlighted by the participants and their interactions could offer us a better understanding of the development of weight and shape concern processes in order to better adapt prevention programmes to the necessities of middle adolescents.

Footnotes

Acknowledgements

The preparation of this article was partially supported by grants from the Spanish Ministry of Science and Education (SEJ2005-07099), Fundación Mapfre, the Catalan Agency for the Management of University AGAUR (2009-SGR-1450; 2010-BE1-00848) and the Catalan Youth Agency (ASC/2729/2008). Appreciation is expressed to Mireia Romero, the participating schools, and especially to the girls interviewed.

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