Self-Efficacy Mediating the Relationship Between Health Literacy and Body Image
Co-authors: Mackenzie Bowring, Samantha Gervais, Drew Levine, Heather MacArthur, & Matthew Morr
Original photo
Originally submitted as part of the curriculum at Merrimack College | Autumn 2015
Presented at the 86th Southern States Communication Association Conference, Austin, TX | April 2016 | Program
Abstract
There has not been very much research on whether or not health literacy affects body image. It’s plausible if you know how to be healthy, ideally you would have a higher self-worth. However, this could only be true if you had the motivation and self-drive to do so, and that is where self-efficacy comes in. Self-efficacy would mediate health literacy’s relationship with body image - pushing you to use your health knowledge to make the right choices for your body. 184 undergraduate students completed a questionnaire to test health literacy level, perception of own self-efficacy, and perception of own body image. Contrary to initial thoughts, there was no mediating relationship between health literacy and body image. There was, however, a direct relationship between self-efficacy and body image.
Introduction
Body image is of high concern to college students. According to Lowery, et al. (2005), body image is the self-perception of one’s physical appearance. College students are an ideal sample because food choices can often be limited, either by what is provided or financially, and are influenced to have an ‘ideal body type.’ Garfinkel and Garner (1982), described the role that the ideal body type plays: “The media have capitalized upon and promoted this image [of thinness] and through popular programming have portrayed the successful and beautiful protagonists as thin. Thinness has thus become associated with self-control and success” (p. 106). As Wardle, Haase, and Steptoe (2006) describe, “adolescence and young adulthood are key risk times for body image problems” (p. 645). In order to fully understand the idea of body image, it is necessary to find out about how health literacy and 3 self-efficacy contribute. To achieve this, we will need to survey students and find out how health literate they are. Our findings will conclude whether or not college students have the ability to decline unhealthy temptations, and discern whether or not motivation could affect this. Self-efficacy “refers to beliefs in one's capabilities to organize and execute the courses of action required to manage prospective situations" (Bandura, 1995, p. 2), and could play a vital role in body image in students. If students have high health literacy, and they are able to overcome unhealthy temptations, ideally they would have a positive body image. Conversely, if students cannot resist unhealthy temptations, it would be feasible that these students would have a negative body image. Throughout this process, we will understand college student’s health literacy level and whether or not self-efficacy mediates its relationship with body image.
Health Literacy
Health Literacy is the knowledge that a person has about reading and understanding healthcare decisions, whether it is about nutritional value or reading pamphlets on healthcare information. According to the Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs (1999), “patients with adequate health literacy can read, understand, and act on health care information” (p. 553). Health literacy is necessary to make appropriate health decisions, as Ratzan and Parker (2000) describe, or, “’how do I keep myself well?’” (p. v). A person with high literacy can intake medical information and understand it, whether it is about a prescription medication or a diagnosis of an illness. A health literate person can receive and understand health instruction, and ideally, can apply it. However, individuals with low health literacy are unable to read nutrition labels or understand something given to them by a doctor. Low health literacy is dangerous: a study done with roughly twenty-seven hundred patients between two hospitals found that patients with an “inadequate functional health literacy were more than twice as likely to have poor self-reported health status as were subjects with adequate literacy” (Ad Hoc Committee, 1999, p. 554).
Self-Efficacy
Self-efficacy plays an important role in shaping an individual’s future. Self-efficacy reflects confidence in the ability to exert control over one's own motivation, behavior, and social environment. According to Bandura (1997), “people are proactive, aspiring organisms who have a hand in shaping their own lives and the social systems that organize, guide, and regulate the affairs of their society” (p. 131). Self-efficacy affects human wellbeing and accomplishments. Self-efficacy is immediately impacted if the individual is independent or dependent. According to Bandura (1997), “sharing the same efficacy beliefs and aspirations of families, communities, organizations, social institutions and even nations so that people can solve the problems they face and improve their lives through unified effort” (p. viii). It is known that teamwork can improve community life and society, however, ultimately one must control his or her life, but encouragement to do the right things, such as being nutritious or living healthily, makes a positive impact.
Health Literacy and Self-Efficacy. There is a connection between health literacy and self-efficacy behavior. Health literacy has been identified as a predictor of self-efficacy in the context of diabetes and HIV self care. Wolf, Davis, Osborn, Skripkauskas, Bennett, and Makoul (2007) found that in 204 HIV infected patients, lower self efficacy for taking prescribed medication had a negative correlation with health literacy. That is to say, patients who were unable to understand health information were less likely to take their medicine. Wagner, Semmler, Good, and Wardle (2009) found that low health literacy is likely to negatively affect effort in reading information and information seeking in colorectal cancer screenings, and Bohanny, Wu, Liu, Yeh, Tsay, and Wang (2011) confirmed that in Type 2 Diabetes Mellitus patience as well.
Body Image
Body image has evolved over the years, however, many agree on this definition: body image is “one’s subjective, mental appearance of his or her physical appearance” (Lowery, Robinson Kurpius, Befort, Hull Blanks, Sollenberger, Foley Nicpon, & Huser, 2005, p. 612). This is not a new concept; today’s society puts more focus on physical appearance, diet, and exercise. As students arrive to college, the stigma can become harsher. The ‘freshman fifteen,’ the idea that freshmen gain weight (about fifteen pounds) through the first year, hits full effect even before students’ arrival to campus. Graham and Jones (2002), of the Journal of American College Health, investigate the longtime college initiation ideology. The duo finds this saying casts a negative attitude about weight for women and men alike. In a study conducted by Racette, Deusinger, Strube, Highstein, and Deusinger (2005), “body weight increased in 70% of the 290 students between the beginning of their freshman year and the end of their sophomore year” (p. 247). It can often affect men by leading to excessive weight lifting, steroid abuse and other damaging body activities (Lowery et al., 2005). College students are paying too close attention to weight, and can start to develop a negative body image. The college environment is stressful enough without being constantly “assessed for physical attractiveness” (Lowery et al., 2005, p. 612), as so happens at an accelerated rate on college campuses. Expectations of physical appearance are set to an unattainable high, despite being the age that sees the biggest weight increase. In a study conducted from 1991 to 1998, 18-29 year olds saw a 69.9% obesity increase, followed by 30-39 year olds (49.5%) and 50-59 year olds (47.9%) (Mokdad, Serdula, Dietz, Bowman, Marks, & Koplan, 1999). It is important to address the issue of body image at college because it more likely to cause eating disorders than stress in college women (Levitt, 2004).
Lowery et al. (2005) found that “for both men and women, more positive physical fitness/health-related behaviors were positively related to self-esteem and body image” (p. 612). A healthier diet and exercise can lead to a feeling of productivity, which can generate a more positive outlook, due to endorphins, and can yield a positive body image.
Research Question: Does self-efficacy mediate the relationship between health literacy and body image?
Method
Participants
Undergraduate students (N=184) across a small, Northeastern Catholic college were administered a survey. The college is 51% male and 49% female, and it is 65.8% White, 6.1% Hispanic/Latino(a), and 2.9% African American/Black (Forbes, 2015). The sample consisted of 123 women and 61 men, with an average age of 19.61 (SD=.996). Of the sample, 160 (87.0%) were White, 8 (4.3%) were Hispanic/Latino(a), 7 (3.8%) were African American/Black, 4 (2.2%) were Native American, 3 (1.6%) were Asian/Pacific Islander, and 2 (1.1%) were Middle Eastern. 34 participants were Student-Athletes, where 144 were Non Student-Athletes. 12 were Commuter students and 165 were Resident students.
Participants were randomly selected. We reached participants in heavily trafficked areas around the college campus, as well as classrooms and residence halls. Participants who received the survey filled out the consent form first and then were handed a double-sided survey to fill out. As some of the questions on the survey were decently personal, the consent form and the survey were distributed as separate sheets, to ensure participant anonymity.
Measures
Health literacy. This measure consisted of six short answer questions produced by Pfizer Inc. for the Newest Vital Sign (NVS) Assessment Tool (2011). Participants were graded for a score out of 6 (1 point for a correct answer, 0 points 8 for an incorrect answer). The assessment involved interpreting a nutritional label from a container of ice cream. With only the label, participants had to calculate the number of calories, carbohydrates (e.g., “If you are allowed to eat 60 grams of carbohydrates as a snack, how much ice cream would you have?”), saturated fat, and discern whether someone with a myriad of allergies (“penicillin, peanuts, latex gloves, and bee stings”) could eat the ice cream. The mean score for health literacy was quite high (M=4.96, SD=1.29).
Self-efficacy. This measure consisted of six Likert style questions sampled from the General Self-Efficacy Scale (GSE) (Schwarzer & Jerusalem, 1995). Response options were 1 (not true at all), 2 (hardly true), 3 (moderately true), and 4 (exactly true). These options measured the participants’ self-evaluation of their capabilities. The survey evaluated problem solving (e.g., “If I am in trouble, I can usually think of a solution”) and motivation (e.g., “I can solve most problems if I invest the necessary effort”). Of the 184 participants, the average person was had moderate self-efficacy (M=3.19, SD=.459). The scale demonstrated reliability (α=.807).
Body image. This measure consisted of ten Likert style statements sampled from the Body Satisfaction Scale for Adolescents and Adults (Mendelson, Mendelson, & White, 2001). Response options were 1 (never), 2 (seldom), 3 (sometimes), 4 (often), and 5 (always). The survey evaluated body satisfaction (e.g., “I am proud of my body”) and preoccupancy of changing how the participants look (e.g., “I am preoccupied with trying to change my body weight”). The average participant had a neutral stance on his or her body image (M=3.18, SD=.669). The scale was reliable (α=.829).
Analysis
A regression analysis was run to assess the impact of the independent variable (health literacy) on the dependent variable (body image).
Results
A simple linear regression was calculated to assess health literacies predictive value on a person’s body image. Non-significant results were produced (β=,.084, p=.261). A second simple linear regression was conducted to assess self-efficacy as a predictor of body image. This regression did produce significant findings (β=.194, p=.008)
Discussion
Results from a linear regression analysis indicated no influential relationship between health literacy and body image (β=-.084, p=.261). We found that most participants scored high on the Newest Vital Sign measure (M=4.96/6). Although there was a high mean score for health literacy, it did not affect the outcome of body image. Despite our initial inference that high health literacy would influence body image, this was not the case. Thus, while not discounting the potential value of health literacy, researchers need to acknowledge that there are other factors influencing body image. Such additional factors are addressed in the following.
Body image is an important contributor to feelings of personal wellbeing, especially on college campuses where physical attractiveness is a common criterion for peer evaluation (Pipher, 1994). Some individuals have a high positive body image while others may have a low negative body image, which may lead to major concerns. Positive body image may lead to strong confidence in individuals. Negative body image may lead to mental illnesses such as depression, eating disorders, and other complications. Researchers and theorists have speculated about the relationship between body image and depression based primarily on clinical observation (Bedrosian, 1981; Emery, 1981). According to Bedrosian (1981) and Emery (1981), adolescents can become depressed or self-conscious due to changes in physical appearance as well as unrealistic and unattainable expectations of themselves.
Moreover, Beck (1967), in order to discern how influential body image can be on individuals, saw that of 975 patients, those with either no, mild, moderate, or sever depression (12%, 33%, 50%, and 66%, respectively) had a distorted body image. In fact, a patient’s “distorted picture of his physical appearance is often quite marked in depression” (Beck, 1967, p. 26). Per Cook-Cottone (2015),
“For those with eating disorders, flourishing includes mind and body attunement and effective, mindful self-care while negotiating environmental demands and supports. Within this context, positive body image may play a powerful role in the treatment of eating disorders as patients go beyond traditional therapeutic goals to nurture a health relationship with the body and others” (p. 165-166).
Attunement emphasizes an embodied awareness of the self, both external and internal. Self-efficacy extends on this level of awareness, as noted by Badura (1997), self-efficacy stresses and individual’s ability to successfully respond to stimuli and promote behavior change - in this instance, body-related issues. Acknowledging that all individuals have different self-perceptions of his or her own body is important to tackling body image issues that may lead to, or were caused by, depression. To address body image issues, especially on college campuses, findings from the current study point to self-efficacy as a positive health promotion tool.
Theoretically, self-efficacy and body image appear to be closely related. Self-efficacy is centered on the ability to succeed in completing a self-set task (Bandura, 1997). This applies when the self-set task is maintaining positive health-related behaviors. Having high self-efficacy can lead to making better dietary and exercise choices, which plausibly can lead to positive body image. Conversely, low self-efficacy can lead to poor dietary and exercise choices, which plausibly can lead to body image issues, especially if as result of mental illness. Self-efficacy is important because despite how health literate a person may be, if he or she has low self-efficacy, that knowledge will go to waste. Additionally, a unique challenge faced by college students is the lack of control over the food choices served in cafeterias.
At this sample school, all first-year students are automatically enrolled in a first-year seminar (First-Year Experience, FYE). Throughout the course, students cover many topics, including acclimation to advising to international programs. However, topics related to mental health and body image are hardly touched. This class, due to its mandatory requirement, is a perfect opportunity to teach about body image related issues or train based in self-efficacy relating to body image. As we have seen, college students are the prime age group to develop eating disorders stemming from body image related issues (Levitt, 2004). Mental illnesses and disorders need to be addressed on college campuses, and self-efficacy provides a plausible path to a solution.
Future Research & Limitations
Limitations on this research can be traced to methodological decisions made throughout the design and data collection process. The survey could be improved in a few different ways. For example, the self-efficacy questionnaire (Shwarzer & Jerusalem, 1995) only measured general self-efficacy, whereas a survey more closely aligned with the intersection of self-efficacy and body image outcomes could have provided more descript findings.
As for the health literacy measure (The Newest Vital Sign, 2011), retrial changes could be made. In another study (Shah, Bremmeyr, & Savoy-Moore, 2010), the test was administered verbally, while the participant looked at a nutritional label. However, the brevity it provided, taking about three minutes to complete (Johnson & Weiss, 2008; Shah et al., 2010), was needed for our short time period. The measure itself could have caused certain limitations, such as inaccuracy. A participant could have adequate health literacy - a 4 or greater out of 6 (Weiss, Mays, Martz, Castro, DeWalt, Pignone, Mockbee, & Hale, 2005) - but could not be able to do the unexpected arithmetic mentally, thus driving the score down. That being said, we did not restrict use of calculators, which could have inflated the score.
However, we suspect that the homogeneity of the sample could have inflated scores. In a study to conduct the national average for health literacy (Kutner, Greenberg, Jin, & Paulsen, 2006), White participants had the highest level of health literacy. Our sample, being 65.8% (n=160) White, may have drove the health literacy score up (M=4.96, SD=1.29). Kutner et al. (2006) also found that women had a better health literacy score than men. Women, being 66.8% (n=123) of the study, may have driven up the mean health literacy score. However, Kutner et al. (2006) only saw a difference of 4% between men and women only in the intermediate health literacy level.
Future research in health literacy is vital to a healthy population. With economic inequality, disadvantaged individuals do not have the means to reach an adequate health literacy level. As Kutner et al. (2006) describes, there is a large gap between those at the poverty threshold and those above 175% of the threshold. With the economic gap widening and widening, health education is as necessary as ever.
Although self-efficacy did not mediate any relationship between health literacy and body image, it did have a profound effect on body image. Further research may point itself towards self-efficacy training as a combat on body image related mental illness, such as eating disorders and depression. Despite lacking in relation to body image, health literacy had a correlation with self-efficacy. Other studies have found a relationship between health literacy and self-efficacy (Wolf et al., 2007; Wagner et al., 2009; Bohanny, Wu, Liu, Yeh, Tsay, & Wang, 2013), discerning the implications on HIV/AIDS patients, colorectal cancer screenings, and Type 2 Diabetes Mellitus, respectively. Future research should continue to explore the influence self-efficacy has on individual and societal levels of health, while also further investigating the effects of health literacy and self-efficacy as health promotion methods on college campuses.
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