ORIGINAL ARTICLE
The Body Image Scale: A Simple and Valid Tool for Assessing Body Image Dissatisfaction in Inflammatory Bowel Disease Edel McDermott, MB,* ,† Jenny Moloney, BSc,‡ Niamh Rafter, BComm,* ,† Denise Keegan, RGN,* ,† Kathryn Byrne, BSc,* ,† Glen A. Doherty, PhD,* ,† Garret Cullen, MD,* ,† Kevin Malone, MD,†,§ and Hugh E. Mulcahy, MD* ,†
Background: Body image refers to a persons’ sense of their own physical appearance. This can be negatively influenced by a number of factors including disease states and treatments. Inflammatory bowel disease (IBD) carries a distinct psychosocial and a physical burden, but body image has not been formally assessed in patients with IBD, nor is there a validated body image questionnaire. Our aim was to assess and validate a body image questionnaire for patients with IBD.
Methods: Three hundred thirty-eight ambulatory patients (median age, 36; 174 male) completed a questionnaire that included the Hopwood body image scale adapted from the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Study Group. Data from another scale, the Cash Body Image Disturbance Questionnaire, were also collected in addition to demographic and clinical data. Results: Factor analysis resulted in a single factor solution explaining 65% of the variance. Internal consistency of the body image scale was demonstrated with a Cronbach alpha of 0.93. Convergent validity was established with a correlation coefficient of 0.64 (P , 0.001) with the Cash Body Image Disturbance Questionnaire. Females (P , 0.001) and those who had undergone either stoma or nonstoma forming surgery experienced more body image dissatisfaction (P ¼ 0.002), indicating predictive validity. Reliability was confirmed with a test–retest correlation of 0.82 (P , 0.001).
Conclusions: The modified body image scale is a valid tool for assessing body image in patients with IBD. (Inflamm Bowel Dis 2014;20:286–290) Key Words: inflammatory bowel disease, Crohn’s disease, ulcerative colitis, body image, questionnaire
B
ody image refers to a person’s sense of their own physical appearance and to their perception of how others see them. A normal individual’s body image is thought to be influenced by many factors including gender, personality type, and cultural and social norms. Body image has a major influence on social interactions and relationships, and individuals with a negative body image may experience feelings of shame, embarrassment, and anxiety about their physical appearance. Body image dissatisfaction is commonly found in the general population.1 As an example, 62% of female and 38% of male European university students consider themselves “too fat.”2 High rates of body image dissatisfaction are also found in American university students,3 and the
Received for publication September 21, 2013; Accepted November 1, 2013. From the *Department of Gastroenterology, St Vincent’s University Hospital, Dublin, Ireland; †UCD School of Medicine and Medical Science, University College Dublin, Dublin, Ireland; ‡Department of Gastroenterology, St Luke’s Hospital, Kilkenny, Ireland; and §Department of Psychiatry, Psychotherapy and Mental Health Research, St Vincent’s University Hospital, Dublin, Ireland. The authors have no conflicts of interest to disclose. Reprints: Hugh E. Mulcahy, MD, Department of Gastroenterology, St Vincent’s University Hospital, Elm Park, Dublin 4, Ireland (e-mail: [email protected]). Copyright © 2013 Crohn’s & Colitis Foundation of America, Inc. DOI 10.1097/01.MIB.0000438246.68476.c4 Published online 26 December 2013.
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perceived pressure for females to be thin and for males to have a muscular physique frequently impacts on the normal individual’s emotional and interpersonal experiences and quality of life.4,5 An individual’s body image may change in response to aging, media and advertising exposure, previous life events, and both positive or negative interpersonal experiences. It may also be influenced by physical disease that results in changes in appearance or physical function.6 Body image dissatisfacton has been found in patients with rheumatological, dermatological, and renal diseases,7–9 and in patients undergoing surgery.10 However, only a single study has assessed body image in inflammatory bowel disease (IBD).11 This Australian postal questionnaire included a single specific question regarding body image impairment and provided interesting initial insights into patient concerns. Twothirds of respondents reported body image impairment as a result of their disease, and the authors emphasized the importance of body image in IBD and the need for further research. Although body image issues are clearly important to patients with IBD, study is hampered by the absence of a suitable assessment tool to collect standardized data. A number of scales have been developed to assess body image dissatisfaction in physical diseases,12,13 but none has been tested or validated in an IBD population. Our aim was to assess and validate a body image scale specifically for use with patients with IBD. Inflamm Bowel Dis Volume 20, Number 2, February 2014
Inflamm Bowel Dis Volume 20, Number 2, February 2014
Tool for Assessing Body Image Dissatisfaction
TABLE 1. Demographic and Clinical Details of 338 IBD Study Patients Gender (male/female) (%) Age, median (range), yr Disease type (Crohn’s disease/ulcerative colitis) (%)a Disease duration, median (range), yr Prior surgery (yes/no) (%) Current biologic use (yes/no) (%) Current immunomodulator use (yes/no) (%)
174 (51)/164 (49) 36 (18–83) 187 (55)/150 (45) 6.4 (0.1–37.3) 98 (29)/240 (71) 97 (29)/241 (71) 133 (39)/205 (61)
a
Data missing for 1 patient.
MATERIALS AND METHODS Three hundred eighty-seven patients attending ambulatory clinics in 1 of 2 medical centers, between July 2011 and November 2012, were invited to participate in the study. Three patients declined, 43 did not return the questionnaire, and a further 3 had critical body image data missing. The study therefore included 338 patients whose demographic and clinical details are shown in Table 1. Patients completed a self-administered questionnaire that included a modified body image scale by Hopwood et al.14 This scale was designed as a brief self-report measure in conjunction with the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Study Group. It has been tested and validated on a broad range of cancer patients, and coverage has proved acceptable to both male and female patients with a range of body image concerns.14,15 The scale is not specific to any 1 disease and focuses on the effects of both disease and treatment on body image. We therefore considered it a suitable candidate tool for use in patients with IBD in whom both the primary disease and its treatment might be expected to play a part
in overall body image dissatisfaction. In the development of the original scale, Hopwood et al14 described the process of item generation and scale construction, using “the literature, discussion with health professionals, and extensive interviews with breast cancer patients.” We assessed content validity of the scale in our IBD population with a team of multidisciplinary health care professionals involved in the care of patients with IBD. The original scale included a question “Have you been dissatisfied with the appearance of your scar?”. This question biases dissatisfaction towards those who have undergone operation, since those not having had surgery necessarily score zero. We therefore excluded this question. We also added a number of questions to Hopwood’s original scale during the content validation phase, specifically targeted towards patients with IBD. These assessed dissatisfaction related to body odor and noise, both potentially pertinent to our patient population. However, factor analysis revealed that these additional items formed a separate factor, reduced predictive ability when compared with the original scale and reduced internal reliability. These items were deemed to be measuring a different construct, and were excluded from the modified scale. Thus, the final questionnaire included 9 items (Fig. 1). Patients scored from 0 (“Not at all”) to 3 (“Very much”) on each question so the lowest possible total score was 0 and the highest 27, with higher scores indicating increasing body image dissatisfaction. Ethical approval was obtained from local Ethics Committees. Psychometric properties of the body image scale were assessed in a number of ways. Response prevalence, i.e., the frequency with which a score of 1 or more was obtained for each question, was determined. Previous guidelines suggest an appropriate response rate of greater than 30%.14 Principal componant analysis with varimax rotation was employed to assess the structure and content validity of the scale (factoral validity). Internal consistency of the baseline scores was determined using Cronbach’s alpha coefficient, with levels above 0.7 reflecting high levels of consistency. Construct validity was tested using
FIGURE 1. Modified body image scale. www.ibdjournal.org |
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FIGURE 2. Percentage of 338 patients with IBD answering each of 9 body image scale questions: “Not at all,” “A little,” “Quite a lot,” and “Very much”.
a combination of validation techniques. Convergent validity was assessed by comparing the body image scale with the Cash Body Image Disturbance Questionnaire.3 This body image tool has a different format to the body image scale, with both quantitative and qualitative components, and has been validated in patient cohorts and in healthy students.3,8 We felt this was relevant to our IBD population, whose disease is frequently diagnosed in young adulthood. The Body Image Disturbance Questionnaire was developed within a cognitive behavioral framework and focuses on the psychosocial impact of body image disturbance. We performed known group comparisons (predictive validity) by comparing body image scores in males and females, and in patients who had no previous surgery, nonstoma, or stoma forming surgery with the expectation that both gender and surgery would influence a valid body image scoring system.2,10,16 Thirty-eight patients, whose treatment remained unchanged, completed the body image scale, a median of 11 months (range, 2 wk–18 mo) apart to determine test–retest reliability. Continuous data are presented as medians and interquartile ranges. Correlations were analyzed using Spearman’s rank correlation coefficient (rs). Differences between groups were assessed using the Mann–Whitney U test and Kruskal–Wallis test as appropriate. Test–retest reliability was measured using Spearman’s rank correlation coefficient. Linear regression analysis was performed to determine factors independently associated with body image dissatisfaction. Analyses were performed using the Statistical Package for the Social Sciences (SPSS 18.0; SPSS, Chicago, Illinois).
FIGURE 3. Frequency of body image scale scores in 338 patients with IBD.
variance, indicating that the 9-item scale performed well on scale structure testing. Internal consistency of the questions was demonstrated with a Cronbach’s alpha of 0.93. Figure 3 shows the frequency of total body image scores. Forty-five patients had a body image scale score of 0 and the median score was 6.
Construct Validity Figure 4 shows the association between the modified Body Image Scale and the Body Image Disturbance Questionnaire. Convergent validity was established with a correlation coefficient of 0.64. Figure 5 shows the association between body image, gender, and previous surgery. Females tended to experience more body image dissatisfaction than males (P , 0.001), whereas patients who had undergone either nonstoma or stoma forming surgery also tended to have higher dissatisfaction scores on the Body Image Scale (P ¼ 0.002). Linear regression analysis indicated that body image was unrelated to disease type (P ¼ 0.77) and confirmed that younger age, female gender, and both
RESULTS Figure 2 shows the response prevalence to individual questions. Between 30% and 72% of patients answered “Not at all” to each of the 9 questions. As an example, 30% of patients answered “Not at all” to question 1, whereas 43%, 17%, and 10% answered “A little,” “Quite a lot,” and “Very much,” respectively. Overall, 8 of the 9 questions achieved the recommended 30% response rate with question 7 achieving a 28% positive response rate. Factor analysis resulted in a single factor solution explaining 65% of the
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FIGURE 4. Correlation between the modified body image scale and the body image disturbance questionnaire (BIDQ) in 338 patients with IBD.
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FIGURE 5. Relationship between body image, gender, and previous surgery in 338 patients with IBD.
nonstoma and stoma forming surgery were independently associated with body image dissatisfaction (Table 2). Test–retest reliability was demonstrated between body image scores performed a median of 11 months apart (range, 2 wk–18 mo) (rs, 0.82; P , 0.001 Spearman’s rank correlation coefficient).
DISCUSSION Body image dissatisfaction is experienced by many individuals in the normal population, and is increased by the physical and functional changes of chronic disease states.17 IBD frequently develops in young adults and seems to be associated with body image impairment in many patients. We sought to identify a body image tool that met specific requirements. First, the questions needed to focus on body image satisfaction, rather than psychological or cognitive behavior, to facilitate its use by gastroenterologists and provide a clear message for clinicians to understand and interpret. Second, the questionnaire needed to be appropriate for both patients with Crohn’s disease and ulcerative colitis, and to consider the effects of treatment and disease. Third, as advocated by survey
design experts,18,19 it is needed to be simple and quick to complete and have a standardized format with unambiguous questions throughout, so that it could be self-administered by patients with a range of educational abilities. Finally, validity needed to be confirmed in a large group of patients with IBD. The Body Image Scale largely fulfills the above criteria. It was developed primarily for use in research trials, and has previously been found to be a valid and succinct measure of the impact of both disease and treatment on body image.14,15 We found it easy to administer, and patients seemed to find it simple and quick to use with only 3 of 341 patients who returned the questionnaire failing to complete the body image tool adequately. We modified Hopwood’s original 10-item questionnaire by excluding the question “Have you been dissatisfied with the appearance of your scar?” as described in the methods section above. Nevertheless, factor analysis confirmed that the scale is a unitary measure of body image disturbance and the questionnaire’s internal consistency was excellent. We found a close correlation between our modified 9-item scale and the Cash Body Image Disturbance Questionnaire, thus establishing convergent validity. Overall, there was a wide range of scores in our patient population. Dissatisfaction was greater in females and those who had undergone either stoma or nonstoma forming surgery, as previously found by Muller et al11 and others,10,16 establishing predictive validity. Regression analysis indicated that body image was not associated with disease type and the scale is applicable to patients with both Crohn’s disease and ulcerative colitis. Indeed, the nonspecific nature of the questions may also allow body image comparisons in patients with other diverse medical conditions. However, it should be noted that the questionnaire is not valid in normal individuals because 4 of the 9 questions relate specifically to disease and treatment. Between 28% and 70% of patients indicated some level of body image dissatisfaction to each
TABLE 2. Linear Regression Analysis Assessing Clinical Factors Associated with Body Image Dissatisfaction in 338 Patients with IBD 95% Confidence Interval for B Variable Age at study Gender Male Female Surgery None Nonstoma surgery Stoma surgery Disease Ulcerative colitis Crohn’s disease Constant
B
Beta
t Value
Lower
Upper
P
20.09
20.19
23.68
20.14
20.04
,0.001
— 2.59
— 0.19
— 3.73
— 1.23
— 3.96
— ,0.001
— 2.44 3.76
— 0.15 0.15
— 2.74 2.71
— 0.69 1.03
— 4.20 6.49
— 0.007 0.007
— 0.22 8.93
— 0.16 —
— 0.29 7.35
— 21.27 6.54
— 1.70 11.31
— 0.77 ,0.001
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question. Question 7, “Do you avoid people because of the way you feel about your appearance?” received the lowest positive response rate at 28%. It is interesting that this is the only question that relates to patients’ interactions with others rather than personal perceptions about body image, and the low positive response rate may relate to the lack of readily noticeable signs of disease or functional changes in most patients. Finally, it should be noted that although the scale is a reliable measure of body image over time in patients with stable disease and whose treatment remains unchanged, the study did not determine if the questionnaire is capable of measuring change in body image perception in patients with IBD (responsiveness) after medical treatment, surgery, or other life events. Responsiveness has previously been demonstrated in the original development of the scale with a significant increase in the reporting of body image dissatisfaction after surgery,14 but responsiveness in patients with IBD will require a longitudinal study of patients either undergoing changes to their medical treatment or surgery. One such study is ongoing in our institution. What are the potential uses for an IBD body image scale? From a clinical point of view, it would be helpful to identify patients with body image alterations who might benefit from simple or more complex psychological interventions. In addition, from a research perspective, body image assessments might usefully be employed as secondary endpoints in medical and surgical clinical trials, providing a deeper understanding of the subtle quality of life changes that occur as a result of different interventions. Finally, it is frequently stated that IBD may lead to significant physical and psychological comorbidity. Yet the extensive data underpinning these beliefs are incomplete, insofar as no single study has integrated broad biological and psychosocial strands to assess the range of IBD comorbidities and determine their interactions. Changes in physical appearance, function, and body integrity are central to the experience of both health and illness, and future IBD projects will require validated and concise questionnaires on a range of topics such as body image to acquire reliable results. We found the modified Body Image Scale valid, quick, and simple to use and we anticipate that it may make a suitable component of future IBD clinical and research assessments.
ACKNOWLEDGMENTS The authors would like to acknowledge Boston Scientific for funding Dr. Edel McDermott as a University College Dublin
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Newman Research Fellow for this study. The authors also thank Dr. Penelope Hopwood for permission to use the body image scale and Ms. Margaret McDermott for her helpful comments during manuscript preparation.
REFERENCES
1. Grogan S. Body image and health: contemporary perspectives. J Health Psychol. 2006;11:523–530. 2. El Ansari W, Clausen SV, Mabhala A, et al. How do I look? Body image perceptions among university students from England and Denmark. Int J Environ Res Public Health. 2010;7:583–595. 3. Cash TF, Phillips KA, Santos MT, et al. Measuring “negative body image”: validation of the Body Image Disturbance Questionnaire in a nonclinical population. Body Image. 2004;1:363–372. 4. Grabe S, Ward LM, Hyde JS. The role of the media in body image concerns among women: a meta-analysis of experimental and correlational studies. Psychol Bull. 2008;134:460–476. 5. Engeln R, Sladek MR, Waldron H. Body talk among college men: content, correlates, and effects. Body Image. 2013;10:300–308. 6. Cash TF, Pruzinsky T. Body Image: A Handbook of Theory, Research, and Clinical Practice. New York, NY: Guilford Press; 2002. 7. Gutweniger S, Kopp M, Mur E, et al. Body image of women with rheumatoid arthritis. Clin Exp Rheumatol. 1999;17:413–417. 8. Bowe WP, Doyle AK, Crerand CE, et al. Body image disturbance in patients with Acne Vulgaris. J Clin Aesthet Dermatol. 2011;7:35–41. 9. Oyekcin DG, Gulpek D, Sahin EM, et al. Depression, anxiety, body image, sexual functioning, and dyadic adjustment associated with dialysis type in chronic renal failure. Int J Psychiatry Med. 2012;43:227–241. 10. Park SK, Olweny EO, Best SL, et al. Patient-reported body image and cosmesis outcomes following kidney surgery: comparison of laparoendoscopic single-site, laparoscopic, and open surgery. Eur Urol. 2011;60: 1097–1104. 11. Muller KR, Prosser R, Bampton P, et al. Female gender and surgery impair relationships, body image, and sexuality in inflammatory bowel disease: patient perceptions. Inflamm Bowel Dis. 2010;16:657–663. 12. Ahn J, Penn P, Bharucha N, et al. Body image disturbance questionnaire— Scoliosis Version: discriminant validity in AIS. Spine. 2010:62–63. 13. Heinberg LJ, Kudel I, White B, et al. Assessing body image in patients with systemic sclerosis (scleroderma): validation of the adapted satisfaction with appearance Scale. Body Image. 2007;4:79–86. 14. Hopwood P, Fletcher I, Lee A, et al. A body image scale for use with cancer patients. Eur J Cancer 2001;37:189–197. 15. Moreira H, Silva S, Marques A, et al. The Portuguese version of the body image scale (BIS)—psychometric properties in a sample of breast cancer patients. Eur J Oncol Nurs. 2009;14:111–118. 16. Whistance RN, Gilbert R, Fayers P, et al. Assessment of body image in patients undergoing surgery for colorectal cancer. Int J Colorectal Dis. 2010;25:369–374. 17. Pruzinsky T. Enhancing quality of life in medical populations: a vision for body image assessment and rehabilitation as standards of care. Body Image. 2004;1:71–81. 18. Payne SL. The Art of Asking Questions. Princeton, NJ: Princeton University Press; 1951. 19. Schaeffer NC, Presser S. The science of asking questions. Ann Rev Sociol. 2003; 29: 65–88.
The Body Image Scale: A Simple and Valid Tool for Assessing Body Image Dissatisfaction in Inflammatory Bowel Disease Edel McDermott, MB,* ,† Jenny Moloney, BSc,‡ Niamh Rafter, BComm,* ,† Denise Keegan, RGN,* ,† Kathryn Byrne, BSc,* ,† Glen A. Doherty, PhD,* ,† Garret Cullen, MD,* ,† Kevin Malone, MD,†,§ and Hugh E. Mulcahy, MD* ,†
Background: Body image refers to a persons’ sense of their own physical appearance. This can be negatively influenced by a number of factors including disease states and treatments. Inflammatory bowel disease (IBD) carries a distinct psychosocial and a physical burden, but body image has not been formally assessed in patients with IBD, nor is there a validated body image questionnaire. Our aim was to assess and validate a body image questionnaire for patients with IBD.
Methods: Three hundred thirty-eight ambulatory patients (median age, 36; 174 male) completed a questionnaire that included the Hopwood body image scale adapted from the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Study Group. Data from another scale, the Cash Body Image Disturbance Questionnaire, were also collected in addition to demographic and clinical data. Results: Factor analysis resulted in a single factor solution explaining 65% of the variance. Internal consistency of the body image scale was demonstrated with a Cronbach alpha of 0.93. Convergent validity was established with a correlation coefficient of 0.64 (P , 0.001) with the Cash Body Image Disturbance Questionnaire. Females (P , 0.001) and those who had undergone either stoma or nonstoma forming surgery experienced more body image dissatisfaction (P ¼ 0.002), indicating predictive validity. Reliability was confirmed with a test–retest correlation of 0.82 (P , 0.001).
Conclusions: The modified body image scale is a valid tool for assessing body image in patients with IBD. (Inflamm Bowel Dis 2014;20:286–290) Key Words: inflammatory bowel disease, Crohn’s disease, ulcerative colitis, body image, questionnaire
B
ody image refers to a person’s sense of their own physical appearance and to their perception of how others see them. A normal individual’s body image is thought to be influenced by many factors including gender, personality type, and cultural and social norms. Body image has a major influence on social interactions and relationships, and individuals with a negative body image may experience feelings of shame, embarrassment, and anxiety about their physical appearance. Body image dissatisfaction is commonly found in the general population.1 As an example, 62% of female and 38% of male European university students consider themselves “too fat.”2 High rates of body image dissatisfaction are also found in American university students,3 and the
Received for publication September 21, 2013; Accepted November 1, 2013. From the *Department of Gastroenterology, St Vincent’s University Hospital, Dublin, Ireland; †UCD School of Medicine and Medical Science, University College Dublin, Dublin, Ireland; ‡Department of Gastroenterology, St Luke’s Hospital, Kilkenny, Ireland; and §Department of Psychiatry, Psychotherapy and Mental Health Research, St Vincent’s University Hospital, Dublin, Ireland. The authors have no conflicts of interest to disclose. Reprints: Hugh E. Mulcahy, MD, Department of Gastroenterology, St Vincent’s University Hospital, Elm Park, Dublin 4, Ireland (e-mail: [email protected]). Copyright © 2013 Crohn’s & Colitis Foundation of America, Inc. DOI 10.1097/01.MIB.0000438246.68476.c4 Published online 26 December 2013.
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perceived pressure for females to be thin and for males to have a muscular physique frequently impacts on the normal individual’s emotional and interpersonal experiences and quality of life.4,5 An individual’s body image may change in response to aging, media and advertising exposure, previous life events, and both positive or negative interpersonal experiences. It may also be influenced by physical disease that results in changes in appearance or physical function.6 Body image dissatisfacton has been found in patients with rheumatological, dermatological, and renal diseases,7–9 and in patients undergoing surgery.10 However, only a single study has assessed body image in inflammatory bowel disease (IBD).11 This Australian postal questionnaire included a single specific question regarding body image impairment and provided interesting initial insights into patient concerns. Twothirds of respondents reported body image impairment as a result of their disease, and the authors emphasized the importance of body image in IBD and the need for further research. Although body image issues are clearly important to patients with IBD, study is hampered by the absence of a suitable assessment tool to collect standardized data. A number of scales have been developed to assess body image dissatisfaction in physical diseases,12,13 but none has been tested or validated in an IBD population. Our aim was to assess and validate a body image scale specifically for use with patients with IBD. Inflamm Bowel Dis Volume 20, Number 2, February 2014
Inflamm Bowel Dis Volume 20, Number 2, February 2014
Tool for Assessing Body Image Dissatisfaction
TABLE 1. Demographic and Clinical Details of 338 IBD Study Patients Gender (male/female) (%) Age, median (range), yr Disease type (Crohn’s disease/ulcerative colitis) (%)a Disease duration, median (range), yr Prior surgery (yes/no) (%) Current biologic use (yes/no) (%) Current immunomodulator use (yes/no) (%)
174 (51)/164 (49) 36 (18–83) 187 (55)/150 (45) 6.4 (0.1–37.3) 98 (29)/240 (71) 97 (29)/241 (71) 133 (39)/205 (61)
a
Data missing for 1 patient.
MATERIALS AND METHODS Three hundred eighty-seven patients attending ambulatory clinics in 1 of 2 medical centers, between July 2011 and November 2012, were invited to participate in the study. Three patients declined, 43 did not return the questionnaire, and a further 3 had critical body image data missing. The study therefore included 338 patients whose demographic and clinical details are shown in Table 1. Patients completed a self-administered questionnaire that included a modified body image scale by Hopwood et al.14 This scale was designed as a brief self-report measure in conjunction with the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Study Group. It has been tested and validated on a broad range of cancer patients, and coverage has proved acceptable to both male and female patients with a range of body image concerns.14,15 The scale is not specific to any 1 disease and focuses on the effects of both disease and treatment on body image. We therefore considered it a suitable candidate tool for use in patients with IBD in whom both the primary disease and its treatment might be expected to play a part
in overall body image dissatisfaction. In the development of the original scale, Hopwood et al14 described the process of item generation and scale construction, using “the literature, discussion with health professionals, and extensive interviews with breast cancer patients.” We assessed content validity of the scale in our IBD population with a team of multidisciplinary health care professionals involved in the care of patients with IBD. The original scale included a question “Have you been dissatisfied with the appearance of your scar?”. This question biases dissatisfaction towards those who have undergone operation, since those not having had surgery necessarily score zero. We therefore excluded this question. We also added a number of questions to Hopwood’s original scale during the content validation phase, specifically targeted towards patients with IBD. These assessed dissatisfaction related to body odor and noise, both potentially pertinent to our patient population. However, factor analysis revealed that these additional items formed a separate factor, reduced predictive ability when compared with the original scale and reduced internal reliability. These items were deemed to be measuring a different construct, and were excluded from the modified scale. Thus, the final questionnaire included 9 items (Fig. 1). Patients scored from 0 (“Not at all”) to 3 (“Very much”) on each question so the lowest possible total score was 0 and the highest 27, with higher scores indicating increasing body image dissatisfaction. Ethical approval was obtained from local Ethics Committees. Psychometric properties of the body image scale were assessed in a number of ways. Response prevalence, i.e., the frequency with which a score of 1 or more was obtained for each question, was determined. Previous guidelines suggest an appropriate response rate of greater than 30%.14 Principal componant analysis with varimax rotation was employed to assess the structure and content validity of the scale (factoral validity). Internal consistency of the baseline scores was determined using Cronbach’s alpha coefficient, with levels above 0.7 reflecting high levels of consistency. Construct validity was tested using
FIGURE 1. Modified body image scale. www.ibdjournal.org |
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FIGURE 2. Percentage of 338 patients with IBD answering each of 9 body image scale questions: “Not at all,” “A little,” “Quite a lot,” and “Very much”.
a combination of validation techniques. Convergent validity was assessed by comparing the body image scale with the Cash Body Image Disturbance Questionnaire.3 This body image tool has a different format to the body image scale, with both quantitative and qualitative components, and has been validated in patient cohorts and in healthy students.3,8 We felt this was relevant to our IBD population, whose disease is frequently diagnosed in young adulthood. The Body Image Disturbance Questionnaire was developed within a cognitive behavioral framework and focuses on the psychosocial impact of body image disturbance. We performed known group comparisons (predictive validity) by comparing body image scores in males and females, and in patients who had no previous surgery, nonstoma, or stoma forming surgery with the expectation that both gender and surgery would influence a valid body image scoring system.2,10,16 Thirty-eight patients, whose treatment remained unchanged, completed the body image scale, a median of 11 months (range, 2 wk–18 mo) apart to determine test–retest reliability. Continuous data are presented as medians and interquartile ranges. Correlations were analyzed using Spearman’s rank correlation coefficient (rs). Differences between groups were assessed using the Mann–Whitney U test and Kruskal–Wallis test as appropriate. Test–retest reliability was measured using Spearman’s rank correlation coefficient. Linear regression analysis was performed to determine factors independently associated with body image dissatisfaction. Analyses were performed using the Statistical Package for the Social Sciences (SPSS 18.0; SPSS, Chicago, Illinois).
FIGURE 3. Frequency of body image scale scores in 338 patients with IBD.
variance, indicating that the 9-item scale performed well on scale structure testing. Internal consistency of the questions was demonstrated with a Cronbach’s alpha of 0.93. Figure 3 shows the frequency of total body image scores. Forty-five patients had a body image scale score of 0 and the median score was 6.
Construct Validity Figure 4 shows the association between the modified Body Image Scale and the Body Image Disturbance Questionnaire. Convergent validity was established with a correlation coefficient of 0.64. Figure 5 shows the association between body image, gender, and previous surgery. Females tended to experience more body image dissatisfaction than males (P , 0.001), whereas patients who had undergone either nonstoma or stoma forming surgery also tended to have higher dissatisfaction scores on the Body Image Scale (P ¼ 0.002). Linear regression analysis indicated that body image was unrelated to disease type (P ¼ 0.77) and confirmed that younger age, female gender, and both
RESULTS Figure 2 shows the response prevalence to individual questions. Between 30% and 72% of patients answered “Not at all” to each of the 9 questions. As an example, 30% of patients answered “Not at all” to question 1, whereas 43%, 17%, and 10% answered “A little,” “Quite a lot,” and “Very much,” respectively. Overall, 8 of the 9 questions achieved the recommended 30% response rate with question 7 achieving a 28% positive response rate. Factor analysis resulted in a single factor solution explaining 65% of the
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FIGURE 4. Correlation between the modified body image scale and the body image disturbance questionnaire (BIDQ) in 338 patients with IBD.
Inflamm Bowel Dis Volume 20, Number 2, February 2014
Tool for Assessing Body Image Dissatisfaction
FIGURE 5. Relationship between body image, gender, and previous surgery in 338 patients with IBD.
nonstoma and stoma forming surgery were independently associated with body image dissatisfaction (Table 2). Test–retest reliability was demonstrated between body image scores performed a median of 11 months apart (range, 2 wk–18 mo) (rs, 0.82; P , 0.001 Spearman’s rank correlation coefficient).
DISCUSSION Body image dissatisfaction is experienced by many individuals in the normal population, and is increased by the physical and functional changes of chronic disease states.17 IBD frequently develops in young adults and seems to be associated with body image impairment in many patients. We sought to identify a body image tool that met specific requirements. First, the questions needed to focus on body image satisfaction, rather than psychological or cognitive behavior, to facilitate its use by gastroenterologists and provide a clear message for clinicians to understand and interpret. Second, the questionnaire needed to be appropriate for both patients with Crohn’s disease and ulcerative colitis, and to consider the effects of treatment and disease. Third, as advocated by survey
design experts,18,19 it is needed to be simple and quick to complete and have a standardized format with unambiguous questions throughout, so that it could be self-administered by patients with a range of educational abilities. Finally, validity needed to be confirmed in a large group of patients with IBD. The Body Image Scale largely fulfills the above criteria. It was developed primarily for use in research trials, and has previously been found to be a valid and succinct measure of the impact of both disease and treatment on body image.14,15 We found it easy to administer, and patients seemed to find it simple and quick to use with only 3 of 341 patients who returned the questionnaire failing to complete the body image tool adequately. We modified Hopwood’s original 10-item questionnaire by excluding the question “Have you been dissatisfied with the appearance of your scar?” as described in the methods section above. Nevertheless, factor analysis confirmed that the scale is a unitary measure of body image disturbance and the questionnaire’s internal consistency was excellent. We found a close correlation between our modified 9-item scale and the Cash Body Image Disturbance Questionnaire, thus establishing convergent validity. Overall, there was a wide range of scores in our patient population. Dissatisfaction was greater in females and those who had undergone either stoma or nonstoma forming surgery, as previously found by Muller et al11 and others,10,16 establishing predictive validity. Regression analysis indicated that body image was not associated with disease type and the scale is applicable to patients with both Crohn’s disease and ulcerative colitis. Indeed, the nonspecific nature of the questions may also allow body image comparisons in patients with other diverse medical conditions. However, it should be noted that the questionnaire is not valid in normal individuals because 4 of the 9 questions relate specifically to disease and treatment. Between 28% and 70% of patients indicated some level of body image dissatisfaction to each
TABLE 2. Linear Regression Analysis Assessing Clinical Factors Associated with Body Image Dissatisfaction in 338 Patients with IBD 95% Confidence Interval for B Variable Age at study Gender Male Female Surgery None Nonstoma surgery Stoma surgery Disease Ulcerative colitis Crohn’s disease Constant
B
Beta
t Value
Lower
Upper
P
20.09
20.19
23.68
20.14
20.04
,0.001
— 2.59
— 0.19
— 3.73
— 1.23
— 3.96
— ,0.001
— 2.44 3.76
— 0.15 0.15
— 2.74 2.71
— 0.69 1.03
— 4.20 6.49
— 0.007 0.007
— 0.22 8.93
— 0.16 —
— 0.29 7.35
— 21.27 6.54
— 1.70 11.31
— 0.77 ,0.001
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question. Question 7, “Do you avoid people because of the way you feel about your appearance?” received the lowest positive response rate at 28%. It is interesting that this is the only question that relates to patients’ interactions with others rather than personal perceptions about body image, and the low positive response rate may relate to the lack of readily noticeable signs of disease or functional changes in most patients. Finally, it should be noted that although the scale is a reliable measure of body image over time in patients with stable disease and whose treatment remains unchanged, the study did not determine if the questionnaire is capable of measuring change in body image perception in patients with IBD (responsiveness) after medical treatment, surgery, or other life events. Responsiveness has previously been demonstrated in the original development of the scale with a significant increase in the reporting of body image dissatisfaction after surgery,14 but responsiveness in patients with IBD will require a longitudinal study of patients either undergoing changes to their medical treatment or surgery. One such study is ongoing in our institution. What are the potential uses for an IBD body image scale? From a clinical point of view, it would be helpful to identify patients with body image alterations who might benefit from simple or more complex psychological interventions. In addition, from a research perspective, body image assessments might usefully be employed as secondary endpoints in medical and surgical clinical trials, providing a deeper understanding of the subtle quality of life changes that occur as a result of different interventions. Finally, it is frequently stated that IBD may lead to significant physical and psychological comorbidity. Yet the extensive data underpinning these beliefs are incomplete, insofar as no single study has integrated broad biological and psychosocial strands to assess the range of IBD comorbidities and determine their interactions. Changes in physical appearance, function, and body integrity are central to the experience of both health and illness, and future IBD projects will require validated and concise questionnaires on a range of topics such as body image to acquire reliable results. We found the modified Body Image Scale valid, quick, and simple to use and we anticipate that it may make a suitable component of future IBD clinical and research assessments.
ACKNOWLEDGMENTS The authors would like to acknowledge Boston Scientific for funding Dr. Edel McDermott as a University College Dublin
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Newman Research Fellow for this study. The authors also thank Dr. Penelope Hopwood for permission to use the body image scale and Ms. Margaret McDermott for her helpful comments during manuscript preparation.
REFERENCES
1. Grogan S. Body image and health: contemporary perspectives. J Health Psychol. 2006;11:523–530. 2. El Ansari W, Clausen SV, Mabhala A, et al. How do I look? Body image perceptions among university students from England and Denmark. Int J Environ Res Public Health. 2010;7:583–595. 3. Cash TF, Phillips KA, Santos MT, et al. Measuring “negative body image”: validation of the Body Image Disturbance Questionnaire in a nonclinical population. Body Image. 2004;1:363–372. 4. Grabe S, Ward LM, Hyde JS. The role of the media in body image concerns among women: a meta-analysis of experimental and correlational studies. Psychol Bull. 2008;134:460–476. 5. Engeln R, Sladek MR, Waldron H. Body talk among college men: content, correlates, and effects. Body Image. 2013;10:300–308. 6. Cash TF, Pruzinsky T. Body Image: A Handbook of Theory, Research, and Clinical Practice. New York, NY: Guilford Press; 2002. 7. Gutweniger S, Kopp M, Mur E, et al. Body image of women with rheumatoid arthritis. Clin Exp Rheumatol. 1999;17:413–417. 8. Bowe WP, Doyle AK, Crerand CE, et al. Body image disturbance in patients with Acne Vulgaris. J Clin Aesthet Dermatol. 2011;7:35–41. 9. Oyekcin DG, Gulpek D, Sahin EM, et al. Depression, anxiety, body image, sexual functioning, and dyadic adjustment associated with dialysis type in chronic renal failure. Int J Psychiatry Med. 2012;43:227–241. 10. Park SK, Olweny EO, Best SL, et al. Patient-reported body image and cosmesis outcomes following kidney surgery: comparison of laparoendoscopic single-site, laparoscopic, and open surgery. Eur Urol. 2011;60: 1097–1104. 11. Muller KR, Prosser R, Bampton P, et al. Female gender and surgery impair relationships, body image, and sexuality in inflammatory bowel disease: patient perceptions. Inflamm Bowel Dis. 2010;16:657–663. 12. Ahn J, Penn P, Bharucha N, et al. Body image disturbance questionnaire— Scoliosis Version: discriminant validity in AIS. Spine. 2010:62–63. 13. Heinberg LJ, Kudel I, White B, et al. Assessing body image in patients with systemic sclerosis (scleroderma): validation of the adapted satisfaction with appearance Scale. Body Image. 2007;4:79–86. 14. Hopwood P, Fletcher I, Lee A, et al. A body image scale for use with cancer patients. Eur J Cancer 2001;37:189–197. 15. Moreira H, Silva S, Marques A, et al. The Portuguese version of the body image scale (BIS)—psychometric properties in a sample of breast cancer patients. Eur J Oncol Nurs. 2009;14:111–118. 16. Whistance RN, Gilbert R, Fayers P, et al. Assessment of body image in patients undergoing surgery for colorectal cancer. Int J Colorectal Dis. 2010;25:369–374. 17. Pruzinsky T. Enhancing quality of life in medical populations: a vision for body image assessment and rehabilitation as standards of care. Body Image. 2004;1:71–81. 18. Payne SL. The Art of Asking Questions. Princeton, NJ: Princeton University Press; 1951. 19. Schaeffer NC, Presser S. The science of asking questions. Ann Rev Sociol. 2003; 29: 65–88.
