Factors Associated With Body Image Satisfaction Among Palestinian University Female Students, Cross-Sectional Study

Eating disorders and body dysmorphic disorder are linked to poor body image. People with these diseases commonly lack the ability to objectively assess body shape, size, or attractiveness. This study aimed to investigate the relationship between body image, eating disorders, lifestyle, social pressure, and social media engagements in female university students in Palestine. Method: A sample of 905 female undergraduate students from Palestinian universities was included in the study. Arabic validated Body Appreciation Scale (BAS-2) was used to measure body satisfaction. Early screening of eating disorders was conducted using the Arabic validated A-SCOFF tool. One-way ANOVA, independent t-test, Chi-square, Spearman rho correlation test, and simple linear regression tests were used to evaluate the relationships between study variables.

associated with higher body satisfaction. These ndings can be useful for raising awareness toward body image among this age group.

Background
The term "Body Image" was identi ed about a century ago as the mental picture of our bodies in our minds (Roosen & Mills, 2014). In other words, body image is how people see themselves when looking at their re ection in the mirror. It is also their ideas on their weight, height, body shape, and age. A positive body image is very important to maintain physical and mental health (Sreedharan & Antony, 2012). Studies suggested that body image is in uenced by biological, psychological, historical, individual, cultural, and social factors. Body image is linked to the development of eating disorders and body dysmorphic disorder. The inability to objectively view body shape, size, or appearance is common among people with these disorders. One of the main risk factors of eating disorders is the negative judgment of body shape, size, or appearance known as body dissatisfaction. Body dissatisfaction is associated with unhealthy behaviors such as binge eating, excessive exercise, self-induced vomiting, and caloric restriction (Roosen & Mills, 2014). Studies showed that eating disorders risk is high among Arab young female adults. The percentage of female university students with eating disorders risk was reported to be 28.6% in Palestine (Saleh et al., 2018), 35.4% in Saudi Arabia (Taha et al., 2018), and 24% in UAE (Thomas et al., 2010). Moreover, it was reported that half of university female students in Palestine had binge eating disorder symptoms (Badrasawi & Zidan, 2019). While one-third of Emirati university students were found to have moderate to severe binge eating disorder (Schulte, 2016). Receiving pressure to be thin might lead to negative impacts on feelings, thoughts, and behaviors regarding body weight which raises from the belief that one is not meeting the sociocultural standard of the ideal body (Shentow-Bewsh et al., 2016). Besides, media have an important role in one's life, environment, and social interactions. The over ow of information through media in uences people's physical as well as mental growth. Media images play a role in the cultural standardizing of beauty and body ideals. Youths are surrounded by various technology tools, which makes them the most affected by media (Sreedharan & Antony, 2012). After much researches on traditional media effects, investigations about social media's effect on body image were conducted due to their growing popularity (Fardouly & Vartanian, 2016). A systematic review found that social media image-related content exposure and engagement are related to higher body dissatisfaction and disordered eating behaviors (Rounsefell et al., 2020). Moreover, a literature review reported that the use of social media was associated with symptoms of eating disorders, body dissatisfaction, desiring to be thin, and disordered eating in Arabic studies (Melisse et al., 2020). Our study purpose is to investigate the relationship between body image, eating disorders, social pressure, social media engagement, and lifestyle in female university students in Palestine.

Study design
This cross-sectional study was conducted through an online structured questionnaire that was made on Google Forms and shared via Facebook Palestinian university students' o cial pages. Also, researchers contacted university instructors to share the questionnaire with their students. Palestinian female students from universities all over West Bank, Palestine who are social media users were included in the study. A statement in the introduction of the questionnaire clari ed that participation in the study was voluntary. Data collection was done in March 2021 (6/3-21/3). Accepting responses was stopped once the calculated sample size was reached. The total number of responses was 941.

Study population
Inclusion criteria were undergraduate female social media users under 30 years old. Graduated and postgraduate students were excluded. Duplicated data were removed. One pregnant and one student who reported not using social media were excluded. 905 students were included in the study.

Sample size calculation and sampling method
The participants were recruited by simple random sampling. The sample size was determined using proportions: difference between two independent proportions, for a nite population. Sample size calculations using G power software with an alpha of 0.05 (two-sided) and 90% power, allocation ratio 1. A minimum of 846 participants was needed to determine the difference between the two groups (differences in body satisfaction among participants with disordered eating and participants without). After considering 10% drop out (missing data, invalid data or met the exclusion criteria), the sample size was increases to 930 participants.

Collected data
Female students from different universities in the west bank were asked to ll an online Arabic language questionnaire. The questionnaire included 7 sections (socio-demographics, medical history and lifestyle, social media engagement, social pressure, body image satisfaction tool, and disordered eating screening measurement). The collected socio-demographic data were age, weight, height, academic year, major, living place, living condition, marital status, family income, personal income, working status, and university fee payment. Medical history and lifestyle questions were about the presence of chronic disease, taking medications, having surgery, smoking, sleeping hours, using phone hours, physical activity, dieting, and eating while watching TV or using the phone. While in social media engagement sections participants were asked about the most used social media platform (Facebook, Instagram, Snapchat, other), following models and celebrities accounts, engaging with their accounts (like, comment, share), and following their nutritional advice. The social pressure section included 3 questions: does your family criticize or make fun of your body shape?, do your friends criticize or make fun of your body shape?, and do you criticize or make fun of your body shape?.

Study instruments
Body image satisfaction was evaluated using the Arabic translated version of the Body Appreciation Scale (BAS-2). BAS-2 is a 10-item questionnaire with a 5-point Likert scale where 1 = never, and 5 = always. The overall BAS-2 score is calculated by the average of the 10 items score. The higher the overall score the higher body appreciation is. The validity of this tool has been approved for Arabic culture respondents (Vally et al., 2018). In this study, Cronbach's alpha of this test was .934 showing high reliability.
The prevalence of eating disorders among the sample was measured using A-SCOFF which is the Arabic translated version of the tool SCOFF. SCOFF is an early screening tool composed of 5 questions with yes/no answers. 2 or more yes answers give a positive result of A-SCOFF. The validity of A-SCOF for Arabic culture respondents has been approved (Aoun et al., 2015). The reliability of this tool was tested in this study the Cronbach's alpha was .420.

Data analysis
Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 23. Means and standard deviations of sample characteristics variables were calculated. One-way ANOVA, independent ttest, and Chi-square tests were applied to evaluate the relationships between study variables. Spearman rho correlation test and simple linear regression test were conducted to evaluate the relationship between BAS-2 scores and BMI and daily phone hours.

Students' socio-demographics, medical history and life style
The total number of participants was 905 female students from 9 different universities around West Bank, Palestine. The Age of students ranged from 17 to 30 years old (mean= 20.16 ± 1.55). More details about the socio-demographics of participants are shown in Table 1. The majority of students 790 (87.3%) did not suffer from any chronic health problem. While 115 (12.7%) reported that they had a chronic health problem including allergies, stomach problems, irritable bowel syndrome, and others. 73 students (8.1%) reported that they used medication regularly and 832 of them (91.9%) did not. Moreover, 140 students (15.5%) had medical surgery, while 765 students (84.5%) did not have surgery. Students' lifestyle habits are shown in Table 2.

Students' social media engagement & social pressure
The most popular social media platform among students was Instagram, 48.8% of them reported that they use it the most. Then, Facebook with 37.7% of students using it the most. 9.2% of students reported that they use other social media platforms the most including WhatsApp, YouTube, TikTok, and others. Table 3 shows more detailed information about students' social media engagement. The social pressure on students' was evaluated by receiving criticisms or mockery on their body shape. 24.5% of students (222) receive them from their families, 15.1% of them (137) from their friends, and 39.1% of them (354) criticize or mock their body shape.

Body Satisfaction and eating disorders
The mean score of BAS-2 of students was 4.22 ± 0.74 (Range= 1. 2 -5). A-SCOF test revealed that 40.3% (365) of the sample had positive results while 59.7% (540) had a negative result. Independent t-test showed that body satisfaction and A-SCOF results were signi cantly related (p<.001). As expected, students with negative A-SCOF results had signi cantly higher body satisfaction scores (4.42 ± .62) than those with a positive result indicating a presence of an eating disorder (3.92 ± .82).

Body Satisfaction and BMI
A signi cant relationship was found between BMI and body satisfaction (p<.001). Those who have normal or underweight had higher body satisfaction scores than those who are overweight or obese.
Besides, overweight students had signi cantly higher body satisfaction levels than obese students.
A correlation test was conducted between body satisfaction score and BMI. Body satisfaction score was signi cantly correlated with BMI (P<.001). Pearson's correlation coe cient was -.183. Moreover, univariate analysis showed that BMI was signi cantly related to body satisfaction score (r= .034, p<.001) ( Table 4).

Body satisfaction, social media, & social pressure
No signi cant relationship was found between the most used social media platform and body satisfaction in students. There was a difference in body satisfaction scores between those who engage with models or celebrities' accounts and those who do not. However, this difference was not statistically signi cant. While following models or celebrities on those platforms was signi cantly negatively related to body satisfaction (p<.01). Similarly, following their nutritional advice was signi cantly negatively related to body satisfaction (p<.05). Moreover, family, friends, and personal criticizing or mocking body shape were signi cantly negatively related to body satisfaction (p<.001) ( Table 5).

Body Satisfaction, socio-demographics & lifestyle
A signi cant relationship was found between students' majors and body satisfaction scores. As Table 6 shows, students who major in human sciences and arts had signi cantly lower body satisfaction scores than other students (p<.05). Moreover, students' living nature was signi cantly related to their body satisfaction (p<.05). Those who live with their families had signi cantly higher body satisfaction scores than those who live in student housing or with their relatives.No signi cant relationship was found between medical history and the body satisfaction of students.
For lifestyle variables, Smoking was signi cantly related to body satisfaction (p<.05). Non-and irregular smokers had higher body satisfaction levels than smokers. There was a signi cant relationship between physical activity and body satisfaction (p<.05). Students who are not physically active had lower body satisfaction levels than those who are regularly and irregularly active. Moreover, following a diet had a signi cant relationship with body satisfaction (p<.001). Students who have been on a diet had signi cantly lower body satisfaction scores. In addition, the reason for diet was also signi cantly related to the body satisfaction of students (p<.001). Those who have been on a diet for other reasons had signi cantly higher scores than those who dieted to lose weight or for therapeutic reasons. However, no signi cant difference was found between those who dieted for other reasons and for gaining weight. And no signi cant difference was found between those who dieted to lose, or gain weight, or for therapeutic reasons. Eating while being on screens was signi cantly negatively related to body satisfaction (p<.05).
A correlation test was done between body satisfaction score and daily phone hours. Daily phone hours were signi cantly related to body satisfaction (p<.01). Pearson's correlation coe cient was -.103. Table 7 shows that univaraite analysis found a signi cant relationship between body satisfaction score and daily phone hours (r= .011, p<.01).

Discussion
A representative sample of Palestinian female university students from different universities in West Bank, Palestine was included in this study. The mean body satisfaction scale BAS-2 score was 4.22 ± 0.74, which re ects a high degree of satisfaction among students. In contrast, high body dissatisfaction prevalence was found among Jordanian women in a study. 66% of Jordanian women wanted to lose weight and 13.7% wanted to gain weight (Madanat et al., 2011). Similarly, a study found that 87% of Saudi women attending tness centers were dissatis ed with their body shape (Albawardi et al., 2021). This difference might be caused by the difference in age group, as the Jordanian study reported that older women desired more weight change (Madanat et al., 2011), and older Saudi women had higher body dissatisfaction (Albawardi et al., 2021).

Body image and eating disorders
A-SCOF test revealed that 40.3% of students had a positive result that indicates a presence of an eating disorder. As expected, students with positive results had signi cantly lower body satisfaction scores (3.92 ± .82) than those who had negative A-SCOF results (4.42 ± .62) (p < .001). Similarly, body dissatisfaction was associated with disordered eating behaviors in female undergraduate students in the

Body image and BMI
A signi cant relationship was found between BMI and body satisfaction (p < .001). Normal and underweight students had higher body satisfaction scores than overweight and obese students. And overweight students had higher body satisfaction levels than obese ones. This was also seen in Saudi women, where those with higher BMI had a signi cantly higher level of body image dissatisfaction (Albawardi et al., 2021;Aljadani, 2019). Likewise, Emirati studies reported that higher BMI was signi cantly related to higher body dissatisfaction for both women and men (Alharballeh & Dodeen, 2021;Radwan et al., 2019). Moreover, body satisfaction was signi cantly negatively correlated with BMI (r = .034, P-value < .001). This correlation was smaller than the correlation between BMI and women body image dissatisfaction found by a Saudi study (r = .135, P-value > 0.01) (Aljadani, 2019).

Body image and social media
The most used social media platform by students was Instagram (48.8%) followed by Facebook (37.7%). However, no signi cant relationship was found between the most used social media platform and body satisfaction among students in this study. A recent study found that spending 7 minutes on Instagram had a more negative effect on the body image of undergraduate females than Facebook. This was explained by the more image-focused content on Instagram (Engeln et al., 2020). However, the comparison in our study was between the overall usage of the different social media platforms rather than the effect of scrolling on them for a short time. Additionally, there could be a similar pattern of content on Facebook and Instagram exposed to our sample.
68.6% of students follow either models or celebrities on social media. Following models or celebrities was signi cantly negatively related to body satisfaction (p < .001). This agrees with the results if a study stated that following appearance-focused Instagram account was signi cantly related to body image concerns among young women living in Australia (Cohen et al., 2017). A study revealed that exposure to Instagram pictures of attractive celebrities and peers had a signi cantly greater negative effect on the body image of female university students compared to travel pictures. The study reported that appearance comparison was the reason behind this effect (Brown & Tiggemann, 2016). Similarly, a study found that female university students Facebook users had a signi cantly lower rate of their body image after comparing themselves with celebrities than comparing themselves with friends or peers (Fardouly & Vartanian, 2015). Perhaps this explanation leads us to another observation among our sample where lower body satisfaction was signi cantly related to following models or celebrities' nutritional advice (p < .05). Thus, students might follow such advice believing that they could have the similar body shape of models and celebrities they are comparing themselves with.
However, no signi cant relationship was found between engagement by like/share/comment on models or celebrities' posts and body satisfaction. A study found that rather than the engagement with Instagram pictures; appearance comparisons negatively affected body image in female university students in the US (Hendrickse et al., 2017). Hence that, harmful comparing behavior may occur no matter social media users engage actively or passively with what they are exposed to.

Body image and social pressure
In this study, 24.5% and 15.1% of students received criticizing or mocking from their families and friends, respectively. Those family and friends' comments were signi cantly negatively related to body satisfaction (p < .001). A study in Emirati young women reported that many of them are being pressured by their families or friends about their body weight. This pressure was not only on obese or overweight women but some underweight women as well (Trainer, 2010). Another study reported that students living in the UAE were more in uenced by family and friends' attitudes than media on their body image perception (Sreedharan & Antony, 2012). Moreover, the family in uence was signi cantly related to disordered eating behaviors among Emirati university students. Besides, this study found that disordered eating behaviors were correlated with body image concerns (Radwan et al., 2018). A study on undergraduate females in the US reported that family in uence was related to both body image dissatisfaction and bulimic symptoms (Kluck, 2010). Hence that family pressure may cause body image concerns that turn into behaviors. 39.1% of students in this study criticize or mock their body shape. Personal criticizing or mocking body shape was also signi cantly negatively related to body satisfaction (p < .001). Which agrees with previous studies, a meta-analysis found that negative self-talk on the body known as "Fat talk" was linked to body dissatisfaction in women. Moreover, it was suggested that this kind of self-talk is a risk factor to body dissatisfaction rather than a consequence of it (Mills & Fuller-Tyszkiewicz, 2017).

Body image and lifestyle
Physical activity and body satisfaction were signi cantly related (p < .05). Those who are not physically active had lower body satisfaction levels than students who are regularly and irregularly active. Similarly, More body-satis ed women were more physically active than those who were dissatis ed with their bodies in Saudi (Albawardi et al., 2021) and Emirati studies (Radwan et al., 2019).
Dieting was also signi cantly related to body satisfaction (p < .001). Students who have been on a diet had signi cantly lower body satisfaction scores. The reason for dieting was also signi cantly related to body satisfaction among students. Those who have been on a diet to lose weight or for therapeutic reasons had signi cantly lower body satisfaction scores than those who dieted for "other reasons". Similar to our ndings, a Saudi study reported that weight loss attempts were signi cantly associated with higher body dissatisfaction among women (Albawardi et al., 2021). Also an Emeriti study found that the percentage of body dissatis ed female university students and had been on a diet were higher than those who are satis ed with their bodies. Moreover, the percentage of students who wanted to lose weight and have been on a diet was higher than those who wanted to gain weight and dieted (Radwan et al., 2019).

Strengths And Limitations
The study has successfully evaluated different factors related to body image satisfaction in a representative sample of a vulnerable age group. One of the limitations of the study is that it did not compare between social media users and non-users that might give a wider perspective. In addition, it could not investigate if there is any positive effect of social media on body image. Future research should consider studying different aspects of social media effects on body image and involve those who do not use it.