INTRODUCTION

Body image dissatisfaction is closely linked to eating disorders, because it is a variable that can predict, maintain, or regulate such disorders.^{1, 2}

Body image is the mental representation that a person makes of his or her own body, involving feelings, attitudes and behaviors.³ Dissatisfaction with this body image arises from the belief that some parts of the body, related to shape and weight,are unacceptable because those are considered disproportionate.⁴ Because of the discomfort this dissatisfaction causes, people tend to engage in conducts that can compromise their health, such as prolonged fasting, restrictive dieting, compulsive exercise, laxative use, etc., in order to change their perceived image. These risk behaviors are the antecedent of eating disorders.⁵

Several instruments have been used to measure body image dissatisfaction, however the best known is the Figure Rating Scale (FCS), developed by Stunkard, Sorensen, & Schulsinger (1993), which consists of nine silhouettes of different sizes, from which participants choose the figure they identify with and the one they would like to have, that is, the perceived figure and the desired figure. Based on these discrepancies, the presence of dissatisfaction is obtained, which can be: positive dissatisfaction (having a thinner figure) or negative dissatisfaction (having a more robust figure).⁶

Body image dissatisfaction has been studied mainly in the female population of high socioeconomic strata and more urbanized regions, because they are the group that has reported the highest prevalence of eating disorders,⁷ however, due to the current acculturation process characterized by transformations and mutual influences between the different contexts,. together with the rise of mass media, concern about body weight and shape is no longer an exclusive phenomenon of developed countries or urbanized areas: the trend shows its expansion towards other social sectors.^9,10

The aim of this paper is to review the researches that have studied the presence of body image dissatisfaction in population from rural areas, describing both its methodology and the results obtained.

METHODS

The review included articles published in PubMed, Google Scholar and Scopus. Keyword groups were used, such as: "body image dissatisfaction", "rural population ", “eating disorders". The search was limited to those primary studies that complied the following inclusion criteria; original articles published in English or Spanish that, among their results, measure body image dissatisfaction among the participants in their sample, of any gender and age as long as they belong to a rural area; studies with any methodology (qualitative or quantitative) only if the sample size was n>or=10. Studies were excluded that, despite containing the search terms, did not provide significant information on the topic and/or did not address the topic of interest, for example, studies conducted on populations in urban areas or studies that did not specify the place of application. Based on the criteria and available resources, the search for primary studies was conducted.

The review, classification and synthesis of the selected works was carried out through the elaboration of a matrix that included: name of the author, date of publication and country, the objective of the research, the size of the sample studied, the instrument to measure the variable of interest, and the results of the study. Finally, the analysis of the data was carried out.

RESULTS

According to the search carried out, 158 works related to the subject were found. From these, 126 were discarded because the study population was from an urban area or without specifying the rurality criterion. Likewise, three were discarded because they were systematic review studies, and two more because they were case studies. Once reviewed, 27 papers were selected that met the above-mentioned inclusion criteria.

Characteristics of the studies

The selected studies have diverse origins, with the majority of the work being carried out in the United States of America^11-16, Mexico, ^17-26 and Africa.^27-31 To a lesser extent, works from Australia, ³² Canada, ³³ Spain, ³⁴ China, ³⁵ Chile, ³⁶and India.³⁷ The study sample, in the majority of the works (52% of the total), was made up of only women, mainly in reproductive age, with ages ranging from 18 to 50 years. In thirteen works (48%) the participants were both sex, whose age range was from 8 to 21 years; children and adolescent students. The sample size was also variable, with the smallest size being 18 participants³⁴ and 1,504 being the largest sample size.²¹

In terms of methodology, these are descriptive, comparative and cross-sectional studies. Of the total, 74% were quantitative studies, 7% qualitative, and 19% with mixed methodology.

Variable: body image dissatisfaction

For body image dissatisfaction measurement, the most commonly used instrument was the Figure Rating Scale (FRS), either for adults, adolescents or children, reported in 14 studies (52% of the total); the second most frequently reported instrument was the Body Shape Questionnaire (BSQ), used in three studies (11%) and the third one was the in-depth interview used in two studies (9%); other instruments used were the Body Dissatisfaction Scale (BDS), the Adolescent Body Image Satisfaction Scale (ABISS), the Eating Attitudes Scale-26 (EAT-26), the Eating Disorder Inventory-2 (EDI-2), the IMAGE questionnaire, Personal Satisfaction and Self- Satisfaction Scale, and the Questionnaire adapted from Personal Wellness Profile (PWP), which represent the remaining 37% of the body image dissatisfaction scales.

Although the presence of body dissatisfaction in the study sample was identified in all of the studies reviewed, the presentation of the results is variable, being grouped mainly in three forms: 1) dissatisfaction in general; 2) dissatisfaction with tendency to thinness; 3) dissatisfaction with tendency to thinness as well as dissatisfaction with desires for a more robust figure. Table 1 shows the number of studies that report body dissatisfaction, according to the classification mentioned above.

Table 1.

Frequency of studies according to the results they report.

In most of the studies found, the percentage of the study sample that presented body dissatisfaction ranged from 50% to 85% of the participants. Only in four studies,^13,21,34,35 dissatisfaction occurred in less than 50% of the sample, in percentages ranging from 20% to 45%.

Regarding gender, in works that included both sexes, women reported higher levels of dissatisfaction with body image; except for two studies^24,37 in which it was men who reported higher levels of dissatisfaction.

DISCUSSION

Rurality is more than just municipalities with less than 5,000 inhabitants; it is also related to a way of perceiving, behaving and building a reality.³⁸ Characteristics such as tradition, conservatism, family as a fundamental value, have been considered, mainly, as typical of a rural context,³⁹ in contrast to aspects such as competitiveness, sexual liberation, success, consumerism, traditionally attributed to more urbanized contexts.⁴⁰ However, in recent years there has been a homogenization of contexts, where rural regions have adopted ways of thinking and lifestyles of urban populations due to, among other things, the influence of the media and globalization.³⁸

As part of these phenomena, which used to occur regularly in urban areas and can now be visualized in rural areas, body dissatisfaction stands out. Based on the studies reviewed, it is possible to point out the existence of such dissatisfaction also in the rural population, mainly with a tendency to thinness. For example, in the research carried out in rural communities, the majority of women expressed a greater desire for a slim, thin figure, without this coinciding with their current figure. In this regard, the researchers report that "dislike of the body", expressed by the interviewees and related more to an aesthetic motive than to health, is increasing in rural communities, and therefore invites reflection on how medical, family, community and media discourses have influenced their social representations of the body.²⁵

When results are compared, in relation to the level of body image dissatisfaction, with those obtained in populations from urban areas, it can be seen that there is no significant variation and that the tendency to thinness is shared by both contexts, for example, in a study carried out in three Chinese communities, one of them rural, it was found that the participants from the three communities had a desire for a slimmer figure in addition to sharing the concern about the consumption of fats, which is why the researchers mention that those are phenomena more related to modernity than to ethnicity.³⁵

An important aspect to consider is the inclusion of both genders in the study samples, allowing the possibility of finding that body dissatisfaction is a phenomenon shared by men, who may even be presenting a higher level of dissatisfaction than women, ^24,37 a similar situation presented in urbanized areas.^41,42

The inclusion of men in the study samples becomes even more important when considering that body dissatisfaction is a risk factor for eating disorders, a growing public health problem: according to data from the Center for Health and Social Care (NHS) in the United Kingdom, between 2005 and 2014 the number of hospital admissions due to eating disorders in men aged 10-24 increased by 20%..

Thanks to the media, the aesthetic ideal prevailing in urbanized contexts has also permeated the rural population, maintaining the same prototype to be achieved: an ideal figure regularly associated with thinness in women; and in the case of men, a muscular and athletic torso.⁴³ However, some women in rural regions still maintain the perception of a "robust" body as a desirable body because they consider it to be "healthy", yet this vision is mainly present among older women.^{26, 28}

In this sense, Guzmán-Saldaña et al.²⁶ mention that in the case of body image it is necessary to analyze the life cycle of people, because the perception of the body varies depending on age and marital status, among other factors. Adolescence, for example, is a stage that is especially sensitive to social rejection and isolation, mainly if young people present certain physical characteristics such as overweight, a situation that can put pressure on them to the point of exaggerating the subjective assessment of their physical appearance.⁴⁴ In the case of the studies reviewed, participants with overweight or obesity scored higher than people with normal weight, yet dissatisfaction was present in both people with obesity and people with normal weight.

The instrument used by most studies to measure the level of body dissatisfaction was the Figure Rating Scale (FRS). This one, although it has had detractors arguing that the figures do not represent the totality of shapes and bodies, ²⁰ has proven to be valid and reliable for children, adolescents or adults.⁴⁵ Finally, it should be mentioned that most of the works reviewed highlight the importance of continuing to study the presence of body dissatisfaction in rural populations, mainly due to the increase in the prevalence of eating disorders in this context: in a descriptive study, the prevalence of eating disorders was measured in a sample of 469 adolescents in school in two time periods (2008 and 2012): for the first period the prevalence was 6% and for the second period it was 9.5%. Although the trend remained stable, what the authors called a "ruralization of the disorder" attracted attention, due to the high prevalence found in this context.⁴⁶

CONCLUSIONS

The study of body image dissatisfaction has focused mainly on the urban population, but the works reviewed here show that both men and women of different ages and from rural context also manifest a desire to conform to the prevailing social aesthetic ideals, with all the health risks that this implies. Although more research is needed on this type of population, considering also the criterion of rurality which, due to the cultural transition, may be changing at present. It is important to consider the contributions of the works presented here pointing out the need to implement intervention strategies aimed equally at rural populations.

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Author notes

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