qualitative research reflective journal

Reflexive journals in qualitative research

Daniel Turner

It is common practice for researcher to keep a journal or diary during the research process, regardless of discipline or methodology. These are sometimes called reflexive diaries, self-reflexive journals, research journals or research diaries. They are all basically the same thing – a written (or verbal) record written by the researcher during the research process, detailing what they did and why.

Lincoln and Guba (1982) wrote a classic paper detailing reflexive journals as part of an auditing process for research projects, but with the very specific aim of improving the reliability of research and removing bias. Smith (1999) also describes research journals as an important part of ‘enhancing ethical and methodologic rigour’, but there much more to them than this, regardless of the rather positivistic terminology.

Qualitative research projects are complex to design, manage and analyse, and can take many years to complete. Keeping a personal record of the process, key decisions and feelings offers the researcher the opportunity to learn from the research process (Thorpe 2010) and better remember how things came to pass. When writing up, this log can become as a vital a source of data as a participant interview.

There are lots of papers and textbooks that give examples of what research journals look like (eg Silverman 2013 has several from former students), however few detail what they should contain, or how to keep them.

Lincoln and Guba (1982), offers one of the few good published guidelines for what should actually be in a reflexive journal. They define it as “analogous to the anthropologists field journals and is the major means for an inquirer to perform a running check on the biases, which he (sic) carried with him into the context”. The paper lists 4 major things to record in the diary:

1. A log of evolving perceptions

2. A log of day-to-day procedures

3. A log of methodological decision points

4. A log of day-to-day personal introspections

But as Janesick (1998) notes, another important role is to “refine the understanding of the responses of participants in the study, much like a physician or health care worker might do”. In other words, to also record the researchers own observations about the participants and their lives, when doing interviews, focus groups or ethnography, that will enrich and give context to other more ‘formal’ methods of data collection. She defines a different set of 4 roles for research journals which are more focused towards typical qualitative projects and philosophies:

1. Refine the understanding of the role of the researcher through reflection and writing, much like an artist might do;

2. Refine the understanding of the responses of participants in the study, much like a physician or health care worker might do;

3. Use a journal as an interactive tool of communication between the researcher and participants in the study, as a type of interdisciplinary triangulation of data;

4. View journal writing as a type of connoisseurship by which individuals become connoisseurs of their own thinking and reflection patterns, and indeed their own understanding of their work as qualitative researchers.

Reflexive diaries can also be used by those performing research that contains ethnographic methods, and diaries or journals are very commonly used in ethnography. See for example Barry and O’Callaghan (2009), using diaries to record the experiences of student therapists in a hospital setting. Reflexive journals can also be used in autoethnography, or other qualitative research that focuses on the researcher as the participant or main focus of the study or context.

But it’s important to not confuse these with diaries or journals which are given to participants as data collection of the lives and experiences of respondents. There is much more written in the literature on this topic, see our own post on participant diaries , and Janesick (1998) has written about distinguishing and triangulating these in her article.

So what does a reflective journal look like? Many people prefer to write a physical diary, in a paper journal or notebook (eg Nadin and Cassell 2006), or you can just use any standard word-processor like Word. There are advantages to having it digitally: it does make it easier to search, and easier to back up (by saving it in multiple places). Vicary, Young and Hicks (2016) recommend writing a research diary directly in qualitative data analysis software (CAQDAS), in their case using Nvivo 10, but any qualitative software has the same basic capability.

The latest version of Quirkos (2.3) contains a new feature which can help with a reflexive journal. For the live collaboration in Quirkos cloud, we added a chat feature so that people can communicate, either in real time, or when working sequentially on their project. But we also added this feature to the offline version as well, not just to keep feature parity, but to give a space to write project wide notes. While you can attach memos to sections of text, and use a source property to have notes attached to a section of text, there wasn’t an designated to write generally in the project file.

Banner - Qualitative analysis made simple with Quirkos

Previously we’ve suggested that people created a blank source and write in there, which gives the advantage that you can treat it like any other data source – coding it and including (or excluding) it from search and query results. However, the chat function works as a great journaling system Even though you are just ‘talking’ to yourself, each entry has a date and time stamp, and you can scroll up and down the list and remove specific entries if needs be. It’s also right there, in the same window you are using to analyse, which makes it very easy to keep quick comments as you work.

If you want to see how intuitive and simple Quirkos makes qualitative analysis, you can try either it with Cloud storage or offline storage for free, for Windows, Mac or Linux . You can also get a good idea of what it’s like to work with Quirkos by watching a short tutorial video right here:

Barry, P., O’Callaghan, 2009, Reflexive Journal Writing: A Tool for Music Therapy Student Clinical Practice Development, Nordic Journal of Music Therapy, 17(1) https://www.tandfonline.com/doi/abs/10.1080/08098130809478196

Janesick, V., 1998, Journal Writing as a Qualitative Research Technique: History, Issues, and Reflections, https://files.eric.ed.gov/fulltext/ED420702.pdf

Lincoln, Y., Guba, E., 1982, ESTABLISHING DEPENDABILITY AND CONFIRMABILITY IN NATURALISTIC INQUIRY THROUGH AN AUDIT, https://files.eric.ed.gov/fulltext/ED216019.pdf

Nadin, S., Cassell, C., 2006, The use of a research diary as a tool for reflexive practice: Some reflections from management research, Qualitative Research in Accounting & Management 3:208-217, https://www.researchgate.net/publication/227430125_The_use_of_a_research_diary_as_a_tool_for_reflexive_practice_Some_reflections_from_management_research

Silverman, D., 2013, Doing Qualitative Research, Sage, London

Smith, B., 1999, Ethical and methodologic benefits of using a reflexive journal in hermeneutic-phenomenologic research., Image Journal of Nursing Scholarship. 1999;31(4):359-63.

Thorpe, K. (2010) Reflective learning journals: From concept to practice Reflective Practice; International and multidisciplinary perspectives Vo 5 Issue 3 pp 327-343

Vicary, Young and Hicks, 2016, A reflective journal as learning process and contribution to quality and validity in Interpretative Phenomenological Analysis, Qualitative Social Work, 16(4), 550–565. https://www.research.manchester.ac.uk/portal/files/27234596/POST-PEER-REVIEW-NON-PUBLISHERS.PDF

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Reflectivity in Research Practice: An Overview of Different Perspectives

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Examining the world through qualitative inquiry

Reflective journals in qualitative inquiry

This week’s guest blogger is Kyu Ha Choi, who is a Ph.D. candidate in the Sport Management and Policy program in the Department of Kinesiology at the University of Georgia, Athens, GA, USA. His research focuses on sport event management with emphasis on the development of sport along with qualitative research methods.

Screencast on reflective journals in qualitative research

I initially had three questions that pertain to the concept of reflective journals in relation to qualitative research. Those three questions were: (1) what is the reflective journal in qualitative research? (2) why do we implement reflective journals in our research? and (3) what are the outcomes of employing reflective journals in research? In response to these questions, the objectives of this essay are to understand the concept of reflective journals within qualitative research and to understand why reflective journals are implemented in qualitative research. This essay has been written for any researcher, but especially novice researchers who are not very familiar with or have a limited knowledge of reflective journals in qualitative research and how they might incorporate them in their research. This essay will help researchers learn about the possible outcomes of employing reflective journals and outline some challenging issues of using reflective journals in research.

The reflective journal in qualitative research is a written record by the researchers themselves and is written throughout the research process. A reflective journal includes the details of what the researchers did, thought, and felt while analyzing the data. Then, the rationale behind those thoughts and percepts are recorded. According to Russell and Kelly (2002), keeping self-reflective journals during the analysis process is a strategy that facilitates reflexivity by using the researchers’ journals to examine “personal assumptions and goals” and to clarify “individual belief systems and subjectivities” (p. 2). By doing so, keeping reflective journals consciously acknowledges the values and experiences of the researchers rather than attempting to control their values through methods. In other words, the reflective practice encourages researchers to talk about the presuppositions, experiences, and actions and rationales behind them during the research process. In this regard, reflective journals are increasingly becoming visible within qualitative research.

As for the attributes of reflective writing, the fact that the reflective journal is written in the first-person point of view makes the writing fundamentally subjective. Through writing in the first-person point of view, the centrality of the researcher is acknowledged. Also, self-awareness and an internal dialogue that help in analyzing important issues in the research are supported. In this regard, Jasper (2005) noted that “the purpose of reflective writing is learning which will precipitate some form of action or change in behaviour… is to facilitate the researcher’s discovery and provide a verifiable audit-trail of the research process.” (p. 250) Reflective writing also develops critical thinking by enhancing higher-level conceptual skills. This development is supported because writing down ideas urges the author or researcher to develop and rationalize, which motivate the author to acquire new knowledge that is associated with the research. Finally, reflective writing, along with critical thinking, enables researchers to broaden their perspectives and discover new thoughts and research practices.

Reflective journals as data mainly fall into two categories. First, the products of reflective writing can be used as primary data. Autobiographies, journals, and logs are examples of the case in which reflective writing is employed as the primary data. Reflective writing as the primary data source is well-established in qualitative research, especially in the field of nursing and education. This essay focuses on reflective journals as the secondary data category, including field notes with reflection-on-action that includes insights and references to other data sources. Smith (1999) highlighted in his study that written reflections on one’s own feelings create an audit trail of one’s reasoning, thus contributing to the trustworthiness of the findings by supporting the researcher’s subjectivity.

One of the main reasons why the qualitative researcher maintains a reflective journal is to achieve a rigorous research process. Issues of rigor in qualitative research refer to the trustworthiness of the study (Guba & Lincoln, 1985), and some attributes of rigor include credibility, dependability, and transferability. According to Jasper (2005), reflective journal writing allows researchers to own centrality of their research process, which contributes to the legitimacy of the knowledge claims. Also, reflective journal writing provides an audit trail which clearly indicates the procedural steps that enhance the transparency of process. Moreover, a reflective journal is particularly useful when things did not happen as planned and as one’s thinking changes.

The primary purpose of using reflective journals is to enable researchers to explicitly map their role as researchers. By allowing the subjectivity of the researchers, reflective journals record one’s experiences, thoughts, opinions, and feelings and make them an acknowledged part within the data analysis and interpretation processes. By doing so, researchers can make a vague and unorganized research process more visible not only for themselves but also for their readers. Also, use of reflective journals affects the research process by changing the research design or approach if necessary. Last, but not least, as previously mentioned, use of reflective journals provides an audit trail of the research design, which enhances the transparency of the research process.

Despite the positive potential outcomes from using reflective journals, several challenging issues are associated with reflective journal writing. One potential issue is on ethical grounds in which confidentiality is hard to account for when reflective writing is practiced poorly. Another noticeable issue is hindsight bias. The practice of reflective journal writing may cause hindsight bias which happens when researchers know the outcome of their research in advance and consequently judge that outcome as more likely if they had not known that outcome knowledge (Rehm & Gadenne, 2013). As a result, researchers must overcome several issues in order to conduct a rigorous and reliable reflective journal writing that contributes positively to the research process.

Use of the reflective journal may seem a bit bothersome and time-consuming to some researchers. However, this practice certainly helps qualitative researchers to have a central role in a research process and enhances the transparency of the research process. I am certain that reflective journals are worthy of the required time, and we should make reflective journaling a priority in any type of research.

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Hannigan, B. (2001). A discussion of the strengths and weaknesses of ‘reflection’ in nursing practice and education. Journal of Clinical Nursing , 10 (2), 278-283.

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Rehm, J. T., & Gadenne, V. (2013). Intuitive predictions and professional forecasts: Cognitive processes and social consequences (Vol. 20). Elsevier.

Russell, G. M., & Kelly, N. H. (2002, September). Research as interacting dialogic processes: Implications for reflexivity. In Forum Qualitative Sozialforschung/Forum: Qualitative Social Research (Vol. 3, No. 3).

Smith, B. A. (1999). Ethical and methodologic benefits of using a reflexive journal in hermeneutic‐phenomenologic research. Image: The Journal of Nursing Scholarship , 31 (4), 359-363.

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Kathy Roulston is a professor in the Qualitative Research program in the Department of Lifelong Education, Administration and Policy at the University of Georgia, Athens, GA, USA. She teaches qualitative research methods, and has written on qualitative interviewing. https://orcid.org/0000-0002-9429-2694 Kathryn J. Roulston on ResearchGate My books include: Interviewing: A guide to theory and practice, see: https://us.sagepub.com/en-us/nam/interviewing/book272521 Interactional studies of qualitative interviews. See: https://benjamins.com/catalog/z.220 View all posts by qualpage

Using the Research Journal during Qualitative Data Collection in a Cross-Cultural Context

This article shows how a research journal can be used as a tool to reflect on issues arising during the phase of data collection. Especially in cross-cultural comparative research, unexpected cultural issues are likely to arise. The most critical is the phase of data collection, where decisions have to be made quickly. This article demonstrates how to establish and maintain a research journal during cross-cultural face-to-face interviewing with entrepreneurs. It provides ten suggestions for “what” and “why” to take notes on during five phases of data collection. Furthermore, the article elaborates on how a research journal could be used to deal with emotions as well as methodological and ethical issues that may arise.

Introduction

In sociological research, there is a long tradition of providing accounts of the research process ( Quilgars et al. 2009 ). Unfortunately, in entrepreneurship journal articles, researchers hardly mention issues that arise during the actual phase of data collection. Gómez and Kuronen (2011) refer to this phase as the “grass-root level”, where the work is actually done and decisions are made. Especially in cross-cultural comparative entrepreneurship research, this is the level where most unexpected cultural issues and differences arise. Reflective data is often omitted from the final written report because the researcher may seek to conceal and suppress certain relevant, and at times, personal aspects during research. These missing voids affect the findings and their reading, even if the reader is unaware of its existence or influence ( Weiner-Levy and Popper-Giveon 2013 ). If present, reflections are mainly on practical issues and research design, such as whether or not to hire a translator (see for example Williamson et al. 2011 ) and not on the phase of interviewing itself.

So far, little is written about the role of the research journal as a learning tool and how to establish and maintain it ( Engin 2011 ). For these reasons, the complexity of comparative research on entrepreneurship requires greater attention, particularly when the study is conducted by a single researcher. This article aims to explain how a journal can be used to reflect on issues arising during the phase of data collection. This article is based on a case study and uses practical examples from conducting interviews with entrepreneurs in various countries. Entrepreneurship researchers may benefit from using a research journal and improve the transparency and quality of cross-cultural interview studies in entrepreneurship research.

In cross-cultural qualitative research (which can be multicultural, multilingual, multinational, or multiregional), the main aim is to study entrepreneurs in different cultural settings. This research often takes place at the level of local practices, entrepreneur’s everyday life, and experiences. A major advantage of the in-depth qualitative cross-national approach is that it enables the researcher to analyze the entrepreneurial phenomena “from inside”, in their cultural and social context, in actual local practices, and in entrepreneur’s everyday life. This is more difficult, if not impossible, in large-scale multi-national comparisons ( Gómez and Kuronen 2011 ).

Comparative research methods have long been used in cross-cultural studies to identify, analyze, and explain similarities and differences among entrepreneurs. These methods serve as a means of gaining a better understanding of different structures and institutions influencing entrepreneurship. More recently, as greater emphasis has been placed on contextualization. Cross-national comparison, which has been encouraged by (European) government and research funding bodies to monitor, report, and evaluate developments, has coincided with the growth of interdisciplinary and international collaboration and networking in entrepreneurship research ( Hantrais 2008 ).

Yet, relatively few entrepreneurship researchers feel they are well equipped to conduct studies that to cross national boundaries. In case they do, it is most common to have a multi-national team of researchers with local researchers collecting data from their home country and in their native language ( Hantrais 2008 ; Mangen 1999 ). Although teamwork in cross-cultural research benefits from theoretical, methodological, and practical discussions between researchers, Agar (1980) argues that the feeling of being “the professional stranger” is missing. By contrast, solo-researchers conducting cross-cultural comparative research by themselves are able to see things from a different perspective when in a foreign culture and society, but also in one’s own country after taking distance from it. Especially in this type of research setting, reflection is important.

I will start this article by elaborating on the importance of reflection and keeping a journal as a tool do to so. I will then demonstrate how to establish and maintain such a journal during five phases of cross-cultural face-to-face interviewing with entrepreneurs. I provide ten suggestions of “what” and “why” to take notes on during these five phases. Furthermore, I elaborate on how a research journal could be used to deal with emotions during the phase of data collection. Lastly, crucial issues such as compliance to the study protocol and ethical issues will be addressed.

The Importance of Reflection

Reflexivity emphasizes an awareness of the researcher’s own presence in the research process, with the aim of improving the quality of the research. Over the past few years, a researcher’s positionality, his identity, conceptions, origin, and gender have been considered factors likely to influence the choice of research topic, field work, data analysis, and presentation ( Weiner-Levy and Popper-Giveon 2013 ). Gokah (2006) argues, based on his own experiences, how (naïve) researchers are likely to be confronted with field realities that may threaten their well-being or research work. Borg (2001) notes that emotions too are an undeniable part of the human researcher’s work. Usually, reflexivity in the literature is discussed as an individual activity. Furthermore, thinking reflexively is often portrayed as an afterthought in qualitative analysis, an exercise to conduct once the data has been collected and the results have been written up ( Browne 2013 ). Reflective data, however, may show relevant findings that would otherwise have been missed ( Weiner-Levy and Popper-Giveon 2013 ).

The Research Journal as a Tool for Reflection

Reflection by solo researchers is often done in written forms such as journals (or diaries) and case records ( Boutilier and Mason 2012 ).The case record is based on a problematic situation and includes a factual description of an event and reflection on the nature of the situation, the action taken, the alternatives considered, and the possible outcomes ( Kottkamp 1990 ). Journal writing expands the scope of such reflection beyond problematic situations. In addition to a case record, it contains a critical analysis of the (political) context in which actions unfold, the researchers’ knowledge, skills, expertise, values, assumptions, and the emotions evoked by the research. The research journal is a tool for observing, questioning, critiquing, synthesizing, and acting. The specific elements it may contain are: (1) data obtained by observation, interviews, and informal conversations; (2) additional items such as photographs and letters; (3) contextual information; (4) reflections; and (5) ideas and plans for subsequent research steps ( Altrichter and Holly 2005 ).

By integrating these elements and using the journal throughout the research, it becomes a tool for reflection in the midst of making choices, which is also referred to as reflection-in-action ( Boutilier and Mason 2012 , 200). Newbury ( 2001 , 3) argues that the research journal can be seen as “a melting pot for all of the different ingredients of a research project – prior experience, observations, readings, ideas – and a means of capturing the resulting interplay of elements”. Browne (2013) shows that it may also become a tool to air grievances, to rationalize decision making processes at times of great uncertainty, and an opportunity for researchers to be open and honest about their personal transformation during the fieldwork process. The research journal can assist the researcher in acknowledging these emotions, expressing them, and particularly where these emotions threaten the progress of the research, analyzing and reacting to them. It may contain conversations, poetry, drawings, and songs that may assist in making feelings and thoughts more clear ( Boutilier and Mason 2012 ). After introducing the case study in the next section, this article continues by demonstrating how to establish and maintain a research journal.

A Case Study Approach

I use examples from my own research about the work-life balance of independent professionals, who are highly skilled solo independent professionals and engaged in service activities ( Leighton and Brown 2013 ; Rapelli 2012 ). This explorative comparative case study, conducted in three European countries as a solo researcher, was designed to understand, in-depth, how social support increases the independent professionals’ abilities for work-life balance. Data was collected by a semi-structured questionnaire based on the capability approach adjusted to work-life balance ( Hobson 2014 ) and literature on social support and work-life balance. I interviewed 50 entrepreneurs in total in The Netherlands ( N =16), Spain ( N =17), and Sweden ( N =17) and worked and lived in each country for minimum of three months. In each country, I approached the owners of several co-working spaces to invite independent professionals to participate in the research. Next, the interviewees were asked to forward our invitation to colleagues who worked from home via the snowball method. A pro of this method is that it allowed us to ensure variation in the sample, for example in location of the work place, occupation, gender, and parental status. Data was collected through audio taped interviews, lasting approximately one hour. The interviews took place between January and August 2015 at co-working spaces, cafés, or at homes in Rotterdam, Valencia, and Malmö. In the next section, I will elaborate on how I established and maintained a research journal during this research project.

Establishing and Maintaining a Research Journal

During my research project, I kept a digital journal in Microsoft Word and Excel in a folder on my laptop. The Word document contained the methodological steps taken to gather my data, including key persons and organizations. In an Excel file, I recorded the important contact details of participants during the period of fieldwork. The Excel file contained three sheets with one for each country. The columns contained information such as date of the interview, email address, web page, telephone number, age, family situation, and work location. Later, I added numerical data from the exercises I did with participants, but also, for example, descriptive data about the setting in which we met. I updated this file as soon as I got home after the interview or, for example, when I received a confirmation email from participants. Besides a digital, practical journal, I bought a small notebook which I always carried with me in my bag, because I noticed that ideas often come at moments you do not expect them. In this small notebook I would write down patterns I discovered across the interviews, but also ideas on persons to contact, suggested books to read, or websites to check. During the interviews, I used a printed out a topic list on which I scribbled down answers or ideas. Because I obviously needed to focus on the participant and the conversation, I would work out these ideas in my note book directly after the interview.

Using the Research Journal During the Various Phases of Data Collection

In this paragraph, I will illustrate what I wrote down in my research journal and why this was useful during five phases: before data collection, while contacting participants, after the first interviews, during interviews, and after the interviews are conducted. This description results in a flow chart at the end of this paragraph ( Figure 1 ), showing five phases and ten suggestions for keeping a research journal.

Before Data Collection

Before I started to collect data, I wrote down in my journal how I perceived the world at that point of time and how I could understand the work-life balance of the entrepreneurs under study. For example, an important assumption in my research was that the national context would influence the entrepreneur’s abilities to achieve work-life balance. A reflexive position statement was a valuable start, since it served as a starting point to come back to and it allowed me to compare it to my stance afterwards.

Contacting Participants

During the phase of contacting participants, I felt low in energy because I was simultaneously settling down in a new country and meeting new people. Meeting so many new people and contacting possible participants meant having to introduce myself and constantly taking part in small talk, so the first week or two, I was too tired to work. Finding participants took a lot of time as well, which made me feel very unproductive. I used my journal to set priorities and remind myself of what I had to accomplish during my stay abroad. I struggled with my perfectionism – wanting to do more and better. Writing in my journal made me become aware of my thoughts, taught me to focus, as well as work according to my given energy level. The results confirmed my belief that individuals cannot be studied separate from their (national) context. Furthermore, I found out that it is not only national context, but also work characteristics that influence work-life balance experiences.

After the First Interviews

In the phase of the first explorative interviews, I used my journal to write down (cultural) customs and the participant’s expectations regarding timing and relational aspects. When I scheduled most of my interviews and I was ready to meet participants, I noticed that timing is important to take into account. In the Netherlands, for example, it is seen as polite to show up a little early for your appointment. When I arrived 10 min before my interview appointment in Spain, I unintendedly stressed the participant. She opened the door by saying “I should have known, since you’re Dutch. I thought we would meet at 11.00 and I need some time to clean up, collect my stuff, and make some coffee. Just sit down there, will you?”. I got the impression she felt rushed, which was not a good start to the interview. In Sweden, I found out that it is common to take of your shoes off before entering someone’s home. These taken for granted customs might cause moments of confusion if not taken into account. I used my journal to prevent myself from making the same mistakes again and making participants feel uncomfortable.

Regarding relational aspects, I made notes on the effects of bringing gifts for participants as I brought Dutch caramel waffles as a small gift for the participants. Although the gifts were very much appreciated, I did not feel as if a gift was necessary. Participants were most often happy to share their stories and to benefit from a moment of reflection. Because I travelled by plane, I could not bring caramel waffles for everyone and had to buy local chocolates instead. Because these were not Dutch, I felt they were less appreciated and therefore I stopped bringing them. Because I took notes on relational aspects in my Excel file, I found out that the gift only contributed if authentically given.

In the same phase of the first explorative interviews, I took notes on my interview techniques. Reflecting on my techniques afterwards allowed me to see what went well and what did not. In the beginning, I noticed that I sometimes posed more questions at the same time. I found that especially non-native speakers would only answer the last question they heard. Furthermore, the Spanish entrepreneurs would answer negative questions different from what I expected (i. e. with “yes” where I would have expected “no” in the Netherlands).

During Interviews

The research journal appeared to be especially helpful during the actual interview phase. First, I took notes on context such as the interview and work location. The interview location was chosen by the participants, which often provided me with background information on where and how they worked. I always took notes on these workspaces on my topic list. Workspaces could be separate offices or the kitchen table, which, for example, gave me a sense of whether participants were organized or messy. Another example is the presence of pets. After I noticed that a participant held her cat during the entire interview, I started to realize that pets could play an important role in the work-life balance of self-employed workers. Dogs, for example, provide temporal structure because the owners need to walk them at fixed times. After the interview, I transferred my notes on the work location and the presence of pets to a table in Excel, which allowed me to clearly see relationships between their work context and work-life balance.

I took notes on language issues such as the interviewee’s use of dictionaries or a translator. At the beginning of the interview, I noticed that participants often apologized for their level of English. Some of them made use of Google translate if they could not find the right word. Most of the times I could offer a suggestion – in English or Spanish – for the word I thought they meant. In one case, the participant felt he needed someone to translate, who in this case was the owner of the co-working space he was working at as well. Halfway through the interview, we decided that we could suffice without a translator. I marked this moment on my topic list. When I analyzed the interview, I could see that the participant talked much more freely about his personal experiences. This was probably related to anonymity issues. Reflecting on this practical issue reassured me in my decisions to do all the interviews myself, without the help of a translator.

During the interviews I noted long pauses, gaps, and contradictions. Pauses most often meant that participants were thinking, but sometimes they were thinking about the meaning of the question, instead of the answer. Long pauses or gaps might indicate difficulties with interpretation, resulting in short or irrelevant answers. Afterwards, reflecting on these notes of long pauses, I noticed that they occurred after the use of abstract concepts. Terms such as “work-life balance” and “autonomy” were too abstract for participants, regardless of me explaining what I meant by these terms at the beginning of the interview. Concepts might have different meanings or connotations across cultures, because of which I decided not to use them at all but stick to the language respondents used themselves. My research journal entries helped me to avoid misunderstandings.

Cultural differences in body language sometimes made me feel uncomfortable. In Spain, for example, it is common to kiss someone when you first meet them. Furthermore, during the interviews participants sometimes touched me, in a friendly manner, on the arm when they were emotional or wanted to thank me. A few times, male respondents flirted with me or made ambiguous remarks. Because I did not expect these remarks and did not know how to respond to them in the moment, I mostly ignored them until the interview was over. When the interview was concluded I would sit down and write how I felt and why. Later, when I compared my notes to the transcription, I found out that body language and ambiguous remarks were most often made when we discussed difficult issues or emotions. With the help of my journal, I found out that body language sometimes is used to distract the attention from key issues.

In Spain, I especially felt I had to interrupt respondents to prevent them from floating away from the key issue. This was challenging, as the Spanish participants often used expressive body language and hand gestures while telling their stories. In the beginning I would just observe them and make notes on my topic list, but later I tried to mirror them and use more body language myself. Although this felt as a barrier in the beginning, later I noticed that it feels more comfortable if both interlocutors have similar communication styles. In Sweden, on the contrary, one respondent told me that he felt uncomfortable talking about himself all the time, until he realized that he was the object of study. After taking note of this, I explained to all Swedish participants that I was mostly interested in their daily experiences and feelings. Thanks to my notes, I also found out that younger participants were more likely to share their personal experiences with me than older participants. The latter sometimes made remarks like “you will understand when you have children yourself” or “it’s much more difficult to make real good friends after your thirties, you will see”. Reviewing my notes helped me to prepare for similar situations in the future. For example, I would then start talking about common contacts, networks, or interests first. Another strategy was to tell them that I had run my own business too. The effect was that participants would think that “I knew what I was talking about”. In short, body language often signals difficult issues or emotions and is sometimes used to distract from key issues. Encouragements or interruptions may be helpful in making participants feel more at ease or remaining on topic, but the researcher might risk missing out on relevant stories.

There were more moments I had to pretend I knew what the participant was talking about in order to keep them talking. My research journal notes showed me my limited knowledge of the country context the participants were living in and the importance of comparative analysis to detect contextual influences. I had assumed beforehand that culture would influence the participant’s experiences of work-life balance. However, I noticed that I could not ask respondents directly about culture, simply because they had no reference point. Similarly, unless they had lived in another country before, they were unaware of work-life arrangements in other countries and therefore could hardly judge their own system. Furthermore, participants would only talk about government support if I explicitly asked about it. Apparently, this was not a pressing issue in individuals’ experiences. Participants would only bring up issues they were not satisfied with (such as tax systems).

My notes also showed me my own limited awareness of current political debates, business forms, and registration and tax payment systems. I did not experience this lack of knowledge as an obstacle during the interviews, but I was aware of having to pretend I knew. During the interview, I would note in my journal to check certain websites or to ask someone later. Making notes on my lack of knowledge on a topic allowed me to pretend as if I knew and keep participants talking.

After Interviews

During the last phase of data collection, and also immediately after the interviews, I would sit down in a café, read the notes I made in my notebook, and try to discover patterns. I distanced myself from the individual interviews and analyzed the information across occupations, gender, parents, and non-parents, and so on. I supplemented these ideas with my personal observations as a Dutch researcher working and living in a foreign country, which I had made throughout the whole interviewing phase. Because I went back and forth between analyzing within and between countries, I also needed to put my work away for a while to distance myself from the data. Because I worked and lived in the countries myself too, I noticed that I got adjusted to the context. I started to take things for granted myself. Taking notes on the context was especially difficult in the Netherlands, where I was not the “professional stranger” as termed by Agar (1980) . However, cross-cultural differences came up after constant comparisons between countries. My research journal allowed me to discover patterns across individuals and countries and to adjust interview questions if necessary ( Figure 1 ).

Flow chart showing what and why to enter in a research journal during the various phases of data collection.

Journaling Emotions

Besides improving the quality of data collection, maintaining a research journal provides the opportunity to record the emotional highs and lows of the process ( Engin 2011 ). Browne (2013) argues that fear, worry, anxiety, loneliness, and apprehension ultimately inform many of the major choices made in the field. Although these issues might be more severe in an insecure and volatile research context, they were present in my research period abroad too.

At some point during the interviewing phase, I felt lonely. When I read Browne’s (2013) description on how he developed an evening routine revolving around Skype by calling friends and family and catching up on other people’s lives, I felt very relieved. I was not the only one Skyping and texting my friends regularly, while I felt like I should go out every night to enjoy this adventure to the maximum. A feeling of loneliness is not necessarily caused by being alone, but can also be experienced when surrounded by new colleagues, a flat mate, and entrepreneurial participants in an unknown city. I especially missed friends, family, and colleagues who knew me and with whom I could talk about something other than work in my mother tongue.

At times, feelings of loneliness prevented me from being focused on what I was doing in the moment. I struggled with whether or not to invest in new relationships as I knew that I would “only” stay for a few months. This became especially apt after six months, towards the end of my research period. I was aware of cultural differences too, in the sense that it was more difficult to start social relationships in Sweden than in Spain. Reflections on my own journal entries made me decide to focus on a few persons I felt connected with. Although I felt supported by relatives via Skype and email, I stopped communicating with them in order to be able to focus my attention on the people around me.

Being away from home also meant that I did not work at an office surrounded by colleagues. On one hand, I experienced a feeling of freedom as I did not have to attend department meetings and nobody would ask if I did not work for a day. On the other hand, I missed being able to check whether I was doing the right thing and making the right decisions. I started to write down in my journal how and why I was doing this project.

My journal also taught me to tap into my intrinsic motivation. For example, I wrote that participants were often surprised by their own answers. After the interview, participants told me how this interview had made work-life related issues more clear to them. Realizing that I could contribute to improving one’s quality of life made me feel better than publishing as much articles as possible on it. I learned that I felt most fulfilled by being able to offer a moment of reflection to participants. This motivated me even more to focus on the quality of the work I was doing.

To conclude, besides using the research journal for improving the quality of data collection, it could help you to deal with emotions. I suggest to: (1) take notes on feelings of loneliness because it helps you to focus on being “here and now” and to connect with people around you; and (2) to take notes on how and why you are doing this project because it helps you to tap into your intrinsic motivation, especially if you are conducting this research alone.

Methodological Considerations

Regardless of their philosophical background, qualitative researchers have distinct criteria by which to ensure and judge the trustworthiness of findings. The qualitative data collection and analysis is based on a research protocol. The protocol is an explicit guide on all aspects of the proposed methodology. However, in the phase of qualitative data collection, unexpected issues may arise that are not mentioned in the protocol. Here, it becomes extra important to ensure the rigor of qualitative research.

Rigorous data analysis may be achieved through providing the reader with an explanation about the process by which the raw data is collected, transformed, and organized into the research report ( Tracey 2010 ). Furthermore, Tracey (2010) argues that qualitative research should be characterized by sincerity. Sincerity means that “the research is marked by honesty and transparency about the researcher’s biases, goals, and foibles as well as about how these played a role in the methods, joys, and mistakes of the research” ( 2010 , 841). It can be achieved by: (1) transparency about the methods and challenges; and (2) self-reflexivity about subjective values, biases, and inclinations. Transparency requires a case record or an “audit trail” which provides “clear documentation of all research decisions and activities” throughout the account or in the appendices ( Creswell and Miller 2000 , 28). An account of self-reflexivity is seldom provided, but could be based on the research journal. Whereas the research protocol is written before the phase of data collection, research journal entries are made unexpectedly and not separated and structured such as a research protocol. A research journal includes different types of entries such as data, additional items, contextual information, reflection, and ideas ( Altrichter and Holly 2005 ). This may raise the question whether reflection impacts on replicability of the protocol and the transferability of the results.

As I have shown before, the research journal can be used for reflection-in-action ( Boutilier and Mason 2012 ). The research journal allows the researcher to reflect on these issues in the midst of making choices. Instead of ignoring or going over issues because they were not in the protocol, the researcher reports on unexpected issues without wanting to improve the status of the data. Using a research journal allows the researcher to remember these issues and reduces the chances of the researcher sweeping issues under the carpet.

Furthermore, the research journal may contain notes on methodological issues or ideas on alternative methods and procedures. More specifically, researchers may reflect on the conditions under which they used particular research methods, possible biases, the role of the researcher, and what decisions they made about the future course of the research and why. These reflections may help to develop the quality of the research project, the competence of the researcher and future research ( Altrichter and Holly 2005 ). Rather than a replacement of the protocol, the research journal may be seen as a valuable addition to ensure sincerity and rigor. In the next paragraph, ethical considerations will be discussed.

Ethical Considerations

Being reflexive, or holding up research activities to ethical scrutiny, is an important part of research ethics ( Israel and Hay 2006 ). Ethical decision-making is influenced by ethical frameworks, professional guidelines, and ethical and legal regulation ( Wiles 2012 ). This becomes clear when a researcher submits a research manuscript and is asked to declare that the independence of research is clear and any conflicts of interest or partiality must be explicit. The most common aspects of ethical frameworks are respect for people’s autonomy, beneficence, non-maleficence, and justice. Respect for autonomy relates to issues of voluntariness, informed consent, confidentiality, and anonymity. Beneficence concerns the responsibility to do good, non-maleficence concerns the responsibility to avoid harm, and justice concerns the importance of the benefits and burdens of research being distributed equally ( Israel and Hay 2006 ).

Some of these ethical issues can be considered prior to the research commencing, but many are emergent and become apparent only as the research proceeds, mainly during the phase of data collection. Furthermore, researchers may have a “gut feeling” about the morally right course of action when they encounter issues. This is why Wiles (2012) argues that ethical issues should be approached from a situational relativist perspective. This means that the ethical issues should be managed when they emerge in research, rather than solely adhere to a set of principles or rules. From this perspective, ethical frameworks do not determine decision-making but rather provide researchers with a means of thinking systematically about moral behavior in research. In addition, a journal may help researchers to think about, evaluate, and justify these issues and their “gut feelings”.

By writing down issues in a research journal during the phase of data collection, researchers are able to manage them in considered and reflexive ways ( Israel and Hay 2006 ). For example, researchers might write and reflect on why one guideline might need to be chosen over another ( Israel and Hay 2006 ; Hammersley and Traianou 2012 ). During my research project, I reflected on whether I should be honest and tell participants I did not know which policies they were talking about, or whether I could lie and tell them I knew in order to keep them talking. Because it would not harm the participants, I decided I would pretend I knew. Reflexivity may also help to maintain the ethics of the power relationship between researcher and the researched. Reflexivity is likely to situate the researcher as non-exploitative and compassionate toward the research subjects ( Pillow 2003 ). Being self-reflective helps the researcher to identify questions and content that he or she tends to emphasize or shy away from. It increases awareness of one’s own reactions to interviews, thoughts, emotions, and triggers ( Berger 2015 ). To conclude, the research journal may function as a tool for honesty and awareness of ethical issues and to reflect on them, but also a log if consent from ethical committees is required afterwards ( Pillow 2003 ).

Conclusions

In this article I have argued that keeping a research journal is a suitable method to reflect on issues arising during the phase of data collection. This is important especially if there are no colleague researchers within reach to discuss issues with, because unexpected issues may arise and decisions have to be made quickly in the phase of data collection.

I used examples from my own research project to show how a research journal may effectively help one to reflect on issues during face-to-face interviews with entrepreneurs in three different countries. I would like to encourage qualitative entrepreneurship researchers to establish a journal on your laptop, on printed-out topic lists, and in a notebook that can always be kept in your bag. A research journal should always be at hand and ready to use, since ideas often come at unexpected moments. Smartphones or tablets could serve this purpose very well too. Based on a case study, I provided ten suggestions for what and why to write down in a research journal during five phases of data collection: before you start, while contacting participants, after the first interviews, during interviews, and after the interviews are conducted.

Besides improving the quality of data collection, maintaining a research journal also provides researchers with the opportunity to deal with emotions. I suggest to: (1) take notes on feelings of loneliness because it helps you to focus on being “here and now” and to connect with people around you; and (2) take notes on how and why you are doing this project because it helps you to tap into your intrinsic motivation, especially if you are conducting this research alone.

Researchers may increase the rigor of qualitative research by providing the reader with an explanation about the methodological process ( Tracey 2010 ). The research journal may be seen as a valuable addition to the research protocol, because it allows researchers to reflect on arising issues which are not included in the protocol and require immediate decision making. Besides methodological choices, researchers in the field need to deal with ethical considerations. Keeping a research journal stimulates researchers to note down their thoughts and considerations. These notes are likely to provide clarity and stimulate researchers to be honest and compassionate toward the research participants. Lastly, the research journal may function as a log if consent from ethical committees is required afterwards ( Pillow 2003 ).

To conclude, the journal helps researchers to reflect on unexpected issues, emotional challenges, and methodological and ethical issues at the “grass-root level of qualitative research”, which undoubtedly will arise in a cross-cultural context. Although in this case study cross-cultural refers to cross-national, entrepreneurship researchers conducting face-to-face interviews in local or regional multicultural and multilingual settings can benefit from keeping journals too. The research journal may be seen as a valuable addition to the research protocol, which will improve the rigor and sincerity of qualitative entrepreneurship research.

Funding statement: Netherlands Organization for Scientific Research (NWO) (Grant/Award Number: “4010002.006”).

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Journal and Issue

Articles in the same issue.

Research Design Review

A discussion of qualitative & quantitative research design, reflections from the field: questions to stimulate reflexivity among qualitative researchers.

The outcomes from a qualitative study are only as good as the data the researcher returns from the field. And one of the biggest threats to the quality of the research data is the ever-present yet rarely examined assumptions and prejudices inadvertently contributed by the researcher.

This is why personal reflection is an important part of qualitative research design. To motivate and capture this reflection, the earlier RDR article discusses the use of a reflexive journal or diary by which the researcher provides a subjective account of each research event with details of the influences that may have affected results. The journal “sensitizes the [researcher] to his or her prejudices and subjectivities, while more fully informing the researcher on the impact of these influences on the credibility of the research outcomes.”

But what exactly are the particular questions the researcher should be addressing in this journal? That is, what exactly is the researcher reflecting on ? A reflexive exercise that is totally open and non-directional can be good, but it is also useful to consider particular questions that help stimulate reflective thoughts. Here are a few key questions for the researcher’s reflexive journal:

Broad Takeaways from the Research Event (e.g., the IDI, the focus group, the observation)

What do I think I “know” from this/these participants?
How do I think I “know” it?
Will this knowledge change the course of the research, in terms of objectives, methods, line of inquiry; and, if so, how?

Specific Reflections on the Experience

What assumptions did I make about the participant(s)?
What assumptions did I make about comments/responses to my questions?
How did these assumptions affect or shape: the questions I asked, the interjections I made, my listening skills, and/or my behavior?
How did my personal values, beliefs, life story, and/or social/economic status affect or shape: the questions I asked, the interjections I made, my listening skills, and/or my behavior?
To what degree did my emotions or feelings for the participant(s) affect or shape: the questions I asked, the interjections I made, my listening skills, and/or my behavior?
How will my emotions or feelings for the participant(s) affect the analytical process and my ability to draw valid interpretations from the data?
How did the physical setting/location of the research event alter how I related to the participant(s), and how the participant(s) related to me?
How did the physical setting/location impact data collection?
What were the logistical issues (e.g., in gaining access) that contributed to the “success” or weakness of the outcomes?

¹Compared to quantitative research.

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19 comments

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In school, I was trained to see reflexivity as an important part of the research process. Yet, as a researcher in business, it’s not something that we ever really have time for – I think because it’s not seen as directly useful for the bottom line or the design of products or experiences (even though such reflections can shape research design and analysis, and therefore results.)

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Reflexivity is definitely integral to community research, and inherent in approaches such as community based participatory research (CBPR). Interesting comment in above article about ’emotional connections’. Perhaps an unavoidable symptom of the blurred boundaries that emerge in this type of research. Is this an ethical issue? Read what some researchers have said about their experience of ethics in CBPR at http://cbprethics.wordpress.com .

Reblogged this on Qualitative PhD Research and commented: I wonder – how soon do Doctoral Researchers start practicing reflexivity? Is it something that your Supervisor flagged as important? Do researchers ‘dipping their toes’ in qualitative research take on reflexive practice?

Medical students’ experience and learning outcomes of overseas community involvement project: a qualitative study

Gayathri Devi Nadarajan 1 , 2 ,
Kumaran Rasappan 3 ,
Jonathan Shen You Ng 4 ,
Melvin Lim Junchen 4 &
Sungwon Yoon 5

BMC Medical Education volume 24 , Article number: 854 ( 2024 ) Cite this article

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Metrics details

Medical students in Singapore engage in short term medical missions, locally known as Overseas Community Involvement Projects (OCIPs). Little is known about the learning outcomes of an OCIP and how this complements their medical education back home. Understanding this can help the medical educators structure the OCIP to optimise its learning value.

This study aims to gain an in-depth understanding of the experiences and learning outcomes of the medical students who participated in the OCIP.

This was a qualitative study involving Singaporean students from one medical school travelling to Nepal. Data was collected from reflective journals, overall group reflections and two focus group discussions. The data was thematically analysed using the Accreditation Council for Graduate Medical (ACGME) core competencies for medical professionals.

The data could be classified under various themes within the six domains of the ACGME framework. The study revealed themes of: humanism, socioeconomic and cultural determinants of health under the domain of patient care, application of medical knowledge, investigating and evaluating the needs of a population and feedback to drive improvement under the domain of practice-based learning and improvement, use of non-verbal cues and communicating across language barriers under the domain of interpersonal and communication skills, healthcare systems and delivery, resourcefulness and adaptability, health equity and accessibility under the domain of systems-based practice, ethics, role-modelling, teamwork and leadership skills, interprofessional skills and resilience under the domain of professionalism. Understanding the students’ motivations, utilising reflections, and following the patients’ journey facilitated attainment of these outcomes.

Conclusions

This OCIP experience translated to learning outcomes aligned with the ACGME framework. There is great potential for the experiential learning from a well-structured OCIP to help with personal and professional development and global health education.

Peer Review reports

Introduction

Globalisation provides opportunities and challenges to medical education. There is an increasing interest in overseas service trips and global health education where medical students engage in Overseas Community Involvement Project (OCIP). These trips involve medical students, usually from high income regions, travelling to a lower resource setting. The trips, ranging from 1 week to 3 weeks in duration, are student-led, supervised by a physician mentor who may not necessarily accompany them. Such trips were more common prior to the COVID-19 pandemic related travel restrictions. Currently, it is picking up pace once again as the world is steadily recovering from the pandemic.

As this overseas service activity begins to resume, it is time to re-think how it can be approached. These trips raise ethical issues such as sustainability of student involvement or a lack of follow-up of patients after a diagnosis of a chronic illness during the trip [ 1 , 2 , 3 , 4 ]. In addition, when students volunteer, significant resources are dedicated to this activity including time, money and even utilisation of the receiving countries’ scarce resources. Safety of all involved is also an issue as there are no regulations about personal protective equipment or operating protocols should the students encounter an infectious disease outbreak. Hence, it is now more important than ever to be clear on the risks and benefits of such trips.

If the risks and benefits are well taken into consideration when planning an OCIP, these trips may have the potential to benefit the community in low-income settings through collaborative partnerships [ 5 , 6 ]. For the students, the OCIP may serve as an educational tool or pedagogy in medical education. The experience can be very rich and may stimulate learning of important but often neglected topics within medical education which are also challenging to teach such as health systems and socioeconomic and cultural determinants of health [ 7 , 8 , 9 ]. The OCIP also provides students with early exposure to community health [ 10 ] and may potentially be a valuable source of experiential learning.

While a few studies [ 11 , 12 , 13 ] described the benefits and issues around volunteerisms in global health, very little medical education research has been conducted to demonstrate the possible learning outcomes of an OCIP. Specifically, there is a gap in understanding how the OCIP experience relates to medical education competencies. Furthermore, the literature on the experience of Asian medical students volunteering in overseas community projects is sparse. As global health issues are increasingly incorporated into medical education with growing interest in OCIP, it is important to understand what Asian medical students learn and how this complements their medical education back home. This in turn can help the medical educators structure the OCIP to optimise its learning value. Therefore, the aim of this study is to gain an in-depth understanding of the experiences and learning outcomes of the medical students who participated in the OCIP.

Study design

A qualitative study design was chosen as the study requires an in-depth understanding of students’ experiences.

Setting and participants

This study was based in one medical school in Singapore, a metropolitan city state. Each of the three medical schools in Singapore have multiple OCIPs which are student-led with physician oversight. Such OCIPs have been in existence in each of these schools since their setup and is voluntary. It is currently not part of the medical curriculum but is available for anyone to join in medical school. The term OCIP is used rather than short term experiences in global health (STEGH) because the objective of such trips is to provide service to an underserved community rather than a ‘global health experience’. The OCIP group usually revisits the same location to ensure continuity of care. The OCIP activities typically include screening camps, health education or training to equip the community with a certain set of skills. Project Aasha is an annual OCIP where participants spend two weeks in the rural, mountainous region of Nepal. Landlocked between India and China in Asia, Nepal has a population of about 30 million, spread across the valley of Kathmandu (its capital) and unique terrains comprising of the world’s highest mountains and terai (lowland region). Though healthcare is heavily subsidised for the poor, the challenging terrains affects accessibility, and the poor health literacy and volatile politics makes implementation of policies difficult. Hence, universal health coverage and equitable health provision is still a struggle. The trip was based in Bung village in the Himalaya mountains in North-eastern Nepal at an elevation of 1800 m and Biratnagar city, a terai in Eastern Nepal. The health service consisted of first aid training and women’s health education for school students, health screening and cataract surgery for the villagers. This trip rooted from the local community leaders approaching the physician mentor of Project Aasha. They were concerned of the general poor state of health of the villagers- where many of them do not continue with follow up care for their chronic conditions, there was poor health literacy and there was a major concern about injuries and the lack of first aid knowledge as the nearest hospital was a day’s walk away. Following contact with the community leader, and prior to this trip, Project Aasha members did a separate trip for a needs analysis (by performing a door-to-door survey) and also proceeded to apply for permits to allow the team to practice in the village of Bung.

The OCIP team consisted of a physiotherapy group (four students and a mentor) an ultrasonographer, five doctors (from specialties of Ophthalmology, Emergency Medicine, Orthopaedics and Surgery), fourteen medical students and two Nepalese student translators. Pre-trip, the students were involved in researching about the community they would be visiting in Nepal, preparing the logistics for the team’s stay, trip itinerary, medical equipment, medications and training materials for the community. There was also a sharing session in which the teams that had previously went to Nepal shared their experiences. Once in Nepal, the team reached their destination by jeep on partially built gravel roads and trekking through the mountainous terrain. The team took the same route that the villagers would take to reach secondary and tertiary healthcare facilities. This gave them the opportunity to meet the various stakeholders in the clinics and hospitals, with the aim of understanding the local health system. The mentors accompanying the students utilised reflections [ 14 ] to consolidate students’ daily experiences. Reflective learning, where a deliberate attempt is made to share and reflect on one’s experiences from the day [ 15 ] is key to Project Aasha as it helps shape the experiences into learning moments. Participants for this study were 14 medical students who took part in the trip.

Data collection

At the start, the students were asked to share verbally within the group and in a reflective log on their motivations to participate in the OCIP. On each of the four service days, they were also asked to fill a personal daily reflective log. The end of each service day consisted of a daily debrief, where operational issues of the day will be discussed followed by a group reflective session, where the supervising seniors (doctors and physiotherapists in this trip) also shared their reflections. The reflective log asked all the students to pen down their experience and learning points for the day while the group reflective session asked some of them to share their experiences from the day. This was recorded and transcribed verbatim. At the end of the trip, two focus group discussions (FGD) were conducted on-site where the students were asked to share their overall experience from the trip and what they have learnt. They were audio-recorded and transcribed verbatim. Hence, the data collection comprised three different sources- reflective journals, overall group reflections and the two FGDs.

Data analysis

The transcribed data and written materials were thematically analysed by two coders (GN, MN). GN and MN are both medical doctors with public health training. Disagreements were resolved by a third coder (SY) who is an academic faculty member with expertise in global health and health services research through iterative meetings. Following the initial thematic analysis, compiled themes and sub-themes were subsequently mapped onto the ‘Accreditation Council for Graduate Medical (ACGME) core competencies for medical professionals’ since it is a commonly used framework to measure the competencies of the medical doctors in Singapore. Themes and sub-themes that did not fall within the ACGME categories but emerged from data were also compiled. Therefore, our analysis involved both inductive and deductive approaches. To bolster the strength of our qualitative analysis, we employed data triangulation by incorporating multiple data sources including on-site reflective journals, recorded group reflections and focus groups. These sources allowed us to capture comprehensive exploration of students’ experiences. The analysis involved two independent coders, each responsible for examining the three sources of data. By comparing interpretations of the coding, we assessed the extent of convergence across various data and between coders while also identifying any divergences. This approach ensured a rigorous examination of the experiences and learning outcomes. Through analysis, a conceptual diagram for the learning outcomes from OCIP was generated.

The study was declared to have exempt status and ethical waiver by the SingHealth Centralised Institutional Review Board (Ref no. 2018/3226).

Table 1 shows the characteristics of participants and their motivations to join the trip. There was a balanced number of male and female participants from both year one and two of the same medical school, with an average age of 20 years old. Approximately three quarters (75%) did not have a prior OCIP experience. The majority of students (50%) stated that the experience of healthcare in a low resource setting was the main motivation to join the trip, followed by the experience of healthcare within a different culture, learning how to plan for medical mission trips, wanting to join a sustainable OCIP project and an interest in serving an underserved population.

Learning points during the preparation phase of the trip

Table 2 shows what participants learnt during the pre-trip preparation phase. Three themes were identified – organisational skills, teaching skills and the ability to take into context the culture of the recipient community when developing health education materials. As this is a student-led trip, the students organised all aspects of the trip for the team as well as for the Nepalese community. Consequently, many reflected on acquisition of organisational skills during the preparation phase.

The students also prepared teaching materials for first aid, hand hygiene and women’s health under the physician’s guidance. The initial teaching materials were adopted from the internet, which lacked localisation and thus appeared to be unsuitable for the villagers. For example, for menstrual hygiene, the menstrual cup was seen to be too invasive and culturally inappropriate, and the sanitary napkins were viewed as environmentally unfriendly as compared to using a cloth. Through feedback from the physicians as well as sharing from their predecessors who had visited the village the year before, they learnt to tailor the teaching materials accordingly to the local culture, beliefs and practices.

OCIP experience and learning outcomes according to ACGME framework

Participants’ experiences and reflections engendered various themes under the six domains of the ACGME framework. These quotes for the themes are summarised in Table 3 .

Patient care (PC)

Their reflections depicted the experience of humanism . Besides attending to the patients, the students observed how the doctors, translators and physiotherapists interacted with the patients. This allowed them to appreciate different facets of patient care such as understanding patients’ unique concerns besides the medical complaints and seeing them as an individual rather than a collection of symptoms and signs. Socioeconomic and cultural determinants of health were another two emerging themes of this domain. As one student reflected, “an elderly couple with social issues that greatly outweighed their medical ones, leading me to rethink how to we treat patients”. Seeing them in-situ within their villages and communities allowed the students to appreciate how their lifestyle, habitat and beliefs could influence their presenting medical complaints and health behaviors. For example, students noticed that despite medical advances and awareness, villagers preferred to follow the practice of being isolated during the menstrual cycle or deliver at home instead of using a birthing center due to their own cultural beliefs.

Medical knowledge (MK)

Besides clerking for the patients, the students took on the roles of a pharmacist and a triage nurse which helped them improve the understanding of the patient’s healthcare journey and narratives. Students also worked closely with the doctors who would supervise all the cases they saw. This opportunity allowed them to “use medical knowledge to correlate the clinical presentation with the disease” and apply their medical knowledge in a safe, protected environment.

Practice based learning and improvement (PBLI)

Interactions with the stakeholders especially enabled the students to appreciate the role of PBLI in striving for quality care for the villagers. As this OCIP doesn’t involve any NGOs, the students had the chance to directly interact with the village leaders and clinic leads to understand the healthcare issues in the village and brainstorm on solutions. Through conversations with these stakeholders, they were able to “understand the situation better and design programmes that will benefit the communities the most.” In this process, they learnt how best to investigate and evaluate the needs of the population and the importance of regular feedback to improve the system .

Interpersonal and communication skills

During the OCIP, the patients mainly spoke the Nepali language which indeed created a challenging language barrier . When the students had to work around this barrier, it allowed them to appreciate the importance of non-verbal communication as well as accuracy in understanding the patients’ narrative when taking a history from them. As one student described, students learned “how to make patients feel engaged and connected to you even though I was speaking through a translator.” During the daily reflections sharing, the physicians shared their communication challenges back in multiracial Singapore where knowing English alone is insufficient as each of the elderly patients speak their ethnic dialect. This reflection allowed the students to relate the experience to the situation In Singapore and reflect on how they would communicate across language barriers .

Systems based practice (SBP)

This OCIP was designed in a way that the team has to trek through the mountains from the nearest town to reach the villages for medical service provision and training. This follows the villagers’ journey should they need to travel to a tertiary hospital as the roads are not conducive for vehicular travel. The experience made the students realize how such a system can especially impact the speed of treatment in times of emergencies. During reflections, the physicians also shared that although Singapore is a developed country, for an elderly or disabled patient, their frequents trips to the hospital for multiple medical appointments is comparable. Hence, an ideal situation may be to have a strong primary healthcare facility near their homes, staffed by health professionals who have built a good rapport with the villagers and can manage common chronic conditions. It was commonly reflected that such experiences and sharing enabled them to understand healthcare delivery in low resource settings and relate it back to practice at home. Many reflected on health inequity as they saw how those living in the mountains were disadvantaged due to inaccessibility by virtue of the terrain or when they were unable to afford transport via helicopter to reach a tertiary hospital when time critical care is needed. In addition, the health post at these mountainous villages were often left unattended unlike those along more popular trekking routes like the Everest Base Camp trek or in the city. This created an unreliable system and affected the confidence the villagers have on the healthcare providers. Birthing centres were also present, but they were located on the top of a hill which was challenging for pregnant ladies to travel to. Hence people defaulted antenatal follow-ups and delivered at home. Such experiences brought about reflections on healthcare systems, accessibility and delivery. Specifically, students highlighted the importance of “understanding the bigger picture of the healthcare system in the management of patients.”

Professionalism

Many themes emerged under the domain of professionalism, such as the ethics around such short-term mission trips as well as role modelling when the students saw how the local doctors worked hard for the underprivileged population. Students reflected that healthcare is all “about heart” and they should “always reach out to those in need of greater help.” Experiencing healthcare in a low-income setting also brought about a sense of gratitude . Concurrently, organizing and conducting the trip together with different healthcare professionals provided the platform for the development of teamwork, leadership and interprofessional skills . Lastly, through their experience and reflections, the students reflected on their self-resilience as well as the resilience of the Nepalese people in managing with the minimum. Students observed that witnessing how Nepalese people navigate challenges despite limitations in healthcare infrastructure provided them with “a better insight into what it means to be resilient and how to cope with difficult situations.”

The ACGME framework is broad enough to encompass the various themes from the students’ reflections. Interestingly, these themes refer to the soft or non-technical skills (NTS) in the medical curriculum. These themes also fall within the domains of global health education (socioeconomic and cultural determinants of health, PBLI, SBP), personal (teamwork & leadership skills, resilience) and professional (humanism, MK, ICS, interprofessional skills) development. Teaching the NTS is challenging and may sometimes be perceived as less important by the students. Hence, we propose an alternative conceptual model (Fig. 1 ) to highlight learning outcomes from OCIPs. It aims to help the facilitator and learner in reflecting on their experiences, converting them into learning moments and effectively consolidating learning outcomes in an OCIP. Our framework takes the form of a pyramid, with “Personal Development” forming its base, “Professional Development” building upon that foundation and ultimately capped with “Global Health Awareness”. It is structured as such because it is imperative for the learner to develop personal competencies and attributes to be in a comfortable zone, to glean the higher-order professional and global health skills offered by an OCIP experience. For example, without addressing personal competencies such as teamwork or adaptability to the challenging environment, students may struggle to progress to the next stage of learning professional competencies. Only by adequately addressing these two foundational skills, can students develop a deeper appreciation for global health principles, such as social determinants of health. Understanding the students’ motivations pre-trip can set the learners’ agendas and shape the experiential learning outcomes. Lastly, reflections during the trip and a healthcare journey approach can meaningfully contribute to reaching these outcomes.

Framework for OCIP learning outcomes

This study sought to understand Singaporean medical students experience and learning outcomes of the OCIP. While findings from this study echo the benefits of global health experience published elsewhere [ 8 , 10 , 16 ], this is the first study to show how the OCIP experience could translate to various facets of ACGME domains. Our results demonstrate that OCIP is relevant to undergraduate medical education and could be a pedagogical tool for acquiring ACGME competencies as well as skills relevant to their personal, professional development and global health understanding.

The OCIP provides the opportunity to utilize both experiential learning [ 17 , 18 ] and reflections, which are powerful pedagogical tools in medical education and part of the Kolb’s learning cycle. It provides the space to experience medicine in a more relaxed setting. The dedicated sharing time allows them to reflect and conceptualise the experience and eventually test out what they have learnt the following day [ 17 ]. The experience, reflection, abstract conceptualisation and experimentation are all part of the Kolb’s cycle.

The OCIP also contributes to the transformative learning process [ 19 ]. The students had certain assumptions at the start of the OCIP, which were challenged during the trip. Some of the self and group reflections evoked deep discussions which brought about a change in their perspectives. This is similar to studies which show that critical reflection of experiences serve as a pedagogical approach to learn complex concepts [ 20 , 21 ]. For example, a successful physician is seen as one who can diagnose a patient’s problem and prescribe the appropriate management. However, in the low-resource setting, there was the realization that such skill would not suffice in the optimal long-term management, due to the scarcity of treatment or the inability of villagers to travel regularly to tertiary hospital for continued treatment. Thus, a “health systems” thinking process would be required to address the patient’s problems. Upstream problems (e.g., sanitation, diet) need to be addressed and active effort needs to be made for effective health education and preventative health. Allied healthcare may need to be stationed at the village health posts. The physician should be able to effectively communicate a diagnosis to the villagers and help them understand the impact of illness and treatment noncompliance on their lives such that they follow up on their treatment. And most importantly there should be a system to ensure continuity of care after the departure of overseas physicians. From this experience, it became evident that a successful physician should possess strong leadership skills and ability to bring all of these together.

Such an experience showed the students that a successful physician also needs to have NTS. The Lancet Commissions have proposed a new approach in medical education that focuses on teaching NTS to address health inequity [ 22 ]. These topics are also important to develop a future generation of doctors who are community and socially responsible [ 20 , 23 ]. However, these are challenging topics to teach. The OCIP experience generated the importance of NTS - such as PC, ICS, SBP and professionalism. A well designed OCIP can facilitate the learning of these challenging concepts [ 24 ].

Findings from this study can pave the way for adoption of more relevant competencies to measure the impact of an OCIP. For example, cultural competence or humility has been one of the commonly used learning outcomes. However, the limitations of using this term as a learning outcome are being recognised, as it has not succeeded in reducing health disparities. In response, some have proposed a transnational [ 23 , 24 ] approach to medical education and a global health curriculum to complement OCIPs. The transnational approach comprises both of medical and social competencies that allow the physician to manage patients in various settings. Some of the learning themes identified in this study fall within the transnational framework [ 24 ] and hence, these outcomes (e.g., health systems understanding) may be used to measure the educational effectiveness of an OCIP. Adopting a transnational approach may potentially result in incorporating new competencies into medical education to cultivate socially responsible physicians.

Our findings underscore the need to develop a curriculum for physicians leading OCIPs on how to facilitate the experiential learning through reflections [ 20 ]. A curriculum covering topics relevant to the practical and medical education aspects of an OCIP is much needed [ 4 ]. Although there are existing guidelines on global health ethics [ 2 ], infectious diseases, tropical and travel medicine, currently, there is no guideline on how to facilitate the experiential learning process of medical students during an OCIP. Our findings serve to act as an impetus to develop a more structured approach to OCIPs to ensure that its educational benefits are appropriately assessed.

This study has a few limitations. The study was based on a single OCIP group in Singapore which may limit the transferability of the findings. The physician leads of the OCIP group utilized reflections to facilitate learnings from the OCIP experience and hence there is uncertainty if similar learning outcomes will be achieved if an OCIP didn’t consist of reflective practice. This study explored the OCIP’s benefits solely from the perspectives of the medical student volunteers, leaving the viewpoints of local translators or local population unaccounted for. Further research work is warranted to include the perspectives of the community receiving help [ 25 ] to understand the OCIP’s experiential learning in a more holistic manner.

The rich experience of an OCIP can provide valuable lessons that classroom or bedside teaching may not achieve. In today’s globalized world, as patient care becomes more complex, it is essential to be an all-rounded physician. The experiential learning from OCIPs can facilitate this development. Future steps should focus on how to make such trips more impactful and relevant for the community it serves and to develop a pre-trip checklist of competencies that encompasses the essential NTS required for such trips.

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Data availability

All relevant data are within the manuscript.

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Acknowledgements

We would like to thank the Project Aasha students who participated in this study.

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Gayathri Devi Nadarajan (GDN) and Sungwoon Yoon (SY) conceptualised the article, contributed to article sections, and reviewed and revised manuscript based on suggestions from the other authors. GDN, SY and Melvin Lim Junchen (ML) undertook the thematic analysis and contributed to the result section. Kumaran Rasappan and Jonathan Shen You Ng contributed to the article sections. All the authors have read and approved the final manuscript. GDN takes full responsibility for the article.

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Nadarajan, G.D., Rasappan, K., Ng, J.S.Y. et al. Medical students’ experience and learning outcomes of overseas community involvement project: a qualitative study. BMC Med Educ 24 , 854 (2024). https://doi.org/10.1186/s12909-024-05560-6

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#ForYou? the impact of pro-ana TikTok content on body image dissatisfaction and internalisation of societal beauty standards

Roles Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing

Affiliation Faculty of Business, School of Psychology, Justice and Behavioural Science, Charles Sturt University, Wagga Wagga, New South Wales, Australia

Roles Conceptualization, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Madison R. Blackburn,
Rachel C. Hogg

Published: August 7, 2024
https://doi.org/10.1371/journal.pone.0307597
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Videos glamourising disordered eating practices and body image concerns readily circulate on TikTok. Minimal empirical research has investigated the impact of TikTok content on body image and eating behaviour. The present study aimed to fill this gap in current research by examining the influence of pro-anorexia TikTok content on young women’s body image and degree of internalisation of beauty standards, whilst also exploring the impact of daily time spent on TikTok and the development of disordered eating behaviours. An experimental and cross-sectional design was used to explore body image and internalisation of beauty standards in relation to pro-anorexia TikTok content. Time spent on TikTok was examined in relation to the risk of developing orthorexia nervosa. A sample of 273 female-identifying persons aged 18–28 years were exposed to either pro-anorexia or neutral TikTok content. Pre- and post-test measures of body image and internalisation of beauty standards were obtained. Participants were divided into four groups based on average daily time spent on TikTok. Women exposed to pro-anorexia content displayed the greatest decrease in body image satisfaction and an increase in internalisation of societal beauty standards. Women exposed to neutral content also reported a decrease in body image satisfaction. Participants categorised as high and extreme daily TikTok users reported greater average disordered eating behaviour on the EAT-26 than participants with low and moderate use, however this finding was not statistically significant in relation to orthorexic behaviours. This research has implications for the mental health of young female TikTok users, with exposure to pro-anorexia content having immediate consequences for internalisation and body image dissatisfaction, potentially increasing one’s risk of developing disordered eating beliefs and behaviours.

Citation: Blackburn MR, Hogg RC (2024) #ForYou? the impact of pro-ana TikTok content on body image dissatisfaction and internalisation of societal beauty standards. PLoS ONE 19(8): e0307597. https://doi.org/10.1371/journal.pone.0307597

Editor: Barbara Guidi, University of Pisa, ITALY

Received: November 2, 2023; Accepted: July 8, 2024; Published: August 7, 2024

Copyright: © 2024 Blackburn, Hogg. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data for this study can be found on Figshare via the following link: https://doi.org/10.6084/m9.figshare.25756800.v1 .

Funding: We acknowledge the financial support provided by Charles Sturt University.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Social media is a self-presentation device, a mode of entertainment, and a means of connecting with others [ 1 ], allowing for performance and the performance of identity [ 2 ], with social rewards built into its systems. Five to six years of the average human lifespan are now spent on social media sites [ 3 ] and visual platforms such as Instagram and TikTok increasingly dominate the cultural landscape of social media. Such visually oriented platforms are associated with higher levels of dysfunction in body image [ 4 ], while the COVID-19 pandemic has seen a rise in disordered eating behaviour [ 5 ]. Despite this, the field lacks a clear theoretical framework for understanding how social media usage heightens body image issues [ 6 ] and little research has specifically examined the impacts of TikTok based content. In this research, we sought to explore the impact of pro-anorexia TikTok content on body image satisfaction and internalisation of beauty standards for young women. The forthcoming sections of this literature review will highlight the features of social media content that may be particularly pernicious for young female users and will explore disordered eating and orthorexia in a social media context, concluding with a theoretical analysis of the relationship between social media and body image and internalisation of beauty standards, respectively.

Social media offers instant, quantifiable feedback coupled with idealised online imagery that may intersect with the value adolescents attribute to peer relationships and the sociocultural gender socialisation processes germane to this period of development, creating the “perfect storm” for young social media users, especially females [ 6 ]. In a study of 85 young, largely female eating disorder patients, a rise in awareness of online sites emphasizing thinness as beauty was evident from 2017 to 2020, with 60% of participants indicating that they knew of pro-ana websites and 22% of participants admitting to visiting them [ 7 ]. Research suggests that social media may also trigger those with extant eating disorders while simultaneously influencing healthy individuals to engage in disordered eating behaviour [ 8 ].

“Pro” eating disorder communities, hereafter referred to as “pro-ana” (pro-anorexia) communities, are a particular concern in a social media context. These communities encourage disordered eating, normalise disordered behaviours, and provide a means of connection for individuals who endorse anti-recovery from eating disorders [ 8 ]. Weight-loss tips, excessive exercise routines, and images of emaciated figures are routinely shared in these online communities [ 9 ], with extant research highlighting the association between viewing eating disorder content online and offline eating disorder behaviour [ 8 ]. Women who view pro-ana websites display increased eating disturbances, lowered body satisfaction, an increased drive for thinness, and higher levels of perfectionism when compared to women who have not viewed pro-ana content [ 10 , 11 ]. In research on adolescent girls, Stice [ 12 ] investigated the influence of exposure to media portraying the “thin-ideal” and found that perceived pressure to be thin was a predictor of increased body image dissatisfaction, which in turn led to increases in disordered eating behaviour. In similar research, Green [ 10 ] found that individuals with diagnosed eating disorders reported worsening symptoms after just 10-minutes of exposure to pro-ana content on the online platform, Tumblr.

Disordered eating #ForYou

The most downloaded social application (app) of 2021, TikTok is a social media platform that allows short-form video creation and sharing within a social media context [ 13 ]. Since its launch in 2017, TikTok has had over two billion downloads and has an estimated one billion users, the vast majority of which are children and teenagers [ 14 ]. Unlike other social media platforms where users have greater autonomy over the content generated on their homepage newsfeed, TikTok’s algorithm records data from single users and proposes videos designed to catch a user’s attention specifically, by creating a personalised “For You” page [ 15 ]. This feed will suggest videos from any creator on the platform, not just followed accounts. As such, if a user ‘interacts’ with a video, such as liking, sharing, commenting, or searching for related content, the algorithm will continue to produce similar videos on their “For You” page. The speed with which TikTok content can be created and consumed online may also be key to its impact. Any given social media user could watch more than a thousand videos on TikTok in an hour, creating a reinforcing effect that may have more impact than longer form content from a single creator [ 2 ].

Whilst the popularity of TikTok’s “For You” page has prompted global leaders in social media to build their own recommended content features, this feature remains most pronounced on TikTok. The “For You” page is the homepage of TikTok where users spend the majority of their time, compared to other social media platforms where homepages consist of a curation of content from followed accounts. Instagram’s explore page continues to emphasise established influencer culture and promote accounts of public figures or influencers with large followings. Contrastingly, TikTok’s unique algorithm makes content discoverability an even playing field, as any user’s content has the potential to reach a vast audience regardless of follower count or celebrity status. TikTok users therefore have less control over their homepage newsfeed compared to other social media platforms where users elect who they follow.

Unlike other social media platforms that implicitly showcase body ideals, TikTok contains explicit eating disorder content [ 16 ], while the “For You” page means that simply interacting with health and fitness videos can lead to unintended exposure to disordered eating content. Even seemingly benign “fitspiration” content may have psychological consequences for viewers. Beyond explicit pro-ana content, #GymTok and #FoodTok are two popular areas of content that provide a forum for users to create and consume content around their and others’ daily eating routines, weight loss transformations, and workout routines [ 2 ]. TikTok also frequently features content promoting clean eating, detox cleanses, and limited ingredient diets reflective of the current “food as medicine” movement of western culture [ 17 ], otherwise known as orthorexia. Despite efforts to ban such pro-ana related content, some videos easily circumvent controls [ 18 ], in part because many TikTok creators are non-public figures who are not liable to the backlash or cancellation that a public figure might receive for circulating socially irresponsible content.

Orthorexia: The rise of ‘healthy’ eating pathologies

Psychological analyses of eating disorders have historically focused on restrictive eating and the binge-purge cycle, however, more recently “positive” interests in nutrition have been examined. Orthorexia nervosa is characterised by a restrictive diet, ritualized patterns of eating, and rigid avoidance of foods deemed unhealthy or impure that consumes an individual’s focus [ 19 ]. Despite frequent observation of this distinct behavioural pattern by clinicians, orthorexia has received limited empirical attention and is not formally recognised as a psychiatric disorder [ 19 ]. Orthorexia and anorexia nervosa share traits of perfectionism, high trait anxiety, a high need to exert control, plus the potential for significant weight loss [ 19 ]. Termed ‘the disorder that cannot be diagnosed’ due to limited consensus around its features and the line between healthy and pathological eating practices, orthorexia mirrors the narrative of neoliberal self-improvement culture, wherein the body is treated as a site of performance and transformation.

Orthorexic restrictions and obsessions are routinely interpreted as signs of morality, health consciousness, and wellness [ 20 , 21 ]. Social media wellness influencers have played a significant role in normalising “clean [disordered] eating”. As one example, Turner and Lefevre [ 22 ] conducted an online survey of social media users following health food accounts and found that higher Instagram use was associated with a greater tendency towards orthorexia, with the prevalence of orthorexia among the study population at 49%, substantially higher than the general population (<1%). Similar health and food-related content on TikTok may provoke orthorexic tendencies among TikTok users, however, limited research has investigated orthorexic eating behaviour in the context of TikTok. The current study aims to bridge this gap in the literature around TikTok use and orthorexic tendencies. Disordered eating behaviour in the present study was measured by two separate but related constructs. ‘Restrictive’ disordered eating relates to dieting, oral control, and bulimic symptoms, whilst ‘healthy’ disordered eating constitutes orthorexic-like preoccupation with health food.

Theoretical analysis of body image and social media

An established risk factor in the development and maintenance of disordered eating behaviour is negative body image. Body image is a multidimensional construct that represents an individual’s perceptions and attitudes about their physical-self and encompasses an evaluative function through which individuals compare perceptions of their actual “self” to “ideal” images [ 23 ]. This comparison may produce feelings of dissatisfaction about one’s own body image if a significant discrepancy exists between the actual and ideal self-image [ 23 ]. Body image is not necessarily congruent with actual physique, with research demonstrating that women categorised as having a healthy body mass index (BMI) nonetheless report dissatisfaction with their weight and engage in restrictive dietary behaviours to reduce their weight [ 24 ]. In addition, body image dissatisfaction is considered normative in Western society, particularly among adolescent women [ 25 ]. This may be attributable to the constant flow of media that exposes women to unrealistic images of thinness idealized within society [ 26 ].

One theoretical framework for understanding social media’s relationship with body image is the Social Comparison Theory, proposed by Festinger [ 27 ] who suggests that people naturally evaluate themselves in comparison to others via upward or downward social comparisons. Research supports the notion that women who frequently engage in maladaptive upward appearance-related social comparisons are more likely to experience body image dissatisfaction and disordered eating [ 25 , 28 ], while visual exposure to thin bodies may detrimentally modulate one’s level of body image satisfaction [ 29 – 31 ]. In their study of undergraduate females, Engeln-Maddox [ 29 ] found that participants made upward social comparisons to images of thin models which were strongly associated with decreases in body image satisfaction and internalisation of thinness. Similarly, Tiggemann [ 32 ] found that adolescents who spent more time watching television featuring attractive actors and actresses reported an increased desire for thinness, theorised to be a result of increased social comparison to attractive media personalities.

The Transactional Model [ 33 ] extends Social Comparison Theory by emphasising the multifaceted and complex nature of social media influences on body image. This model acknowledges that individual differences may predispose a person to utilise social media for gratification, and highlights that as time spent on social media increases, so too does body image dissatisfaction [ 33 ]. In line with this, a recent review of literature by Frieiro Padín and colleagues [ 34 ] indicated that time spent on social media was strongly correlated with eating disorder psychopathologies, as well as heightened body image concerns, internalisation of the thin ideal, and lower levels of self-esteem. Time on social media also correlated with heightened body image concerns to a far greater extent than general internet usage [ 35 , 36 ].

Body image ideals are not static. The traditional ideal of rib-protruding bodies from the 90s, known colloquially as “heroin chic”, have recently shifted to a celebration of the “slim-thicc” figure, consisting of a cinched, flat waist with curvy hips, ample breasts, and large behinds [ 37 ]. The “slim-thicc” aesthetic allows women to be bigger than previous body ideals, yet this figure is arguably more unattainable than the thin-ideal as surgical intervention is commonly needed to achieve it, depending on genetics and body type. The idealisation of the “slim-thicc” figure is highlighted by the “Brazilian butt lift” (BBL), a potentially life-threatening procedure that is nonetheless the fastest growing category of plastic surgery, doubling in growth over the past five years, despite the life-threatening potential of the procedure [ 38 ]. Research suggests that the slim-thicc ideal is no less damaging nor threatening of body image than the thin-ideal. Indeed, in experimental research on body ideals, McComb and Mills [ 39 ] found that the greatest body dissatisfaction levels in female undergraduate students were observed among those exposed to imagery of the slim-thicc physique, relative to that exhibited by those exposed to the thin-ideal and fit-ideal physique, as well as the control condition.

Recent body ideals have also favoured muscular thin presentations, considered to represent health and fitness as evident in the “#fitspiration” Instagram hashtag that features over 65 million images [ 40 ]. Fitspiration has the potential to positively influence women’s health and wellbeing by promoting exercise engagement and healthy eating, yet various content analyses of fitspiration images highlight aspects of fitspiration that warrant concern [see 40 , 41 ]. Notably, fitspiration typically showcases only one body type and women whose bodies do not meet this standard may experience body dissatisfaction [ 40 ], while the gamification of exercise, such as receiving likes for every ten sit-ups, segues with the intensive self-control and competitiveness that often underpins eating disorders and eating disorder communities [ 1 ].

In recent experimental research, Pryde and Prichard [ 42 ] examined the effect of exposure to fitspiration TikTok content on the body dissatisfaction, appearance comparison, and mood of young Australian women. Viewing fitspiration TikTok videos led to increased negative mood and increased appearance comparison but did not impact body dissatisfaction. This finding contradicts previous research and may be due to fitspiration content showcasing body functionality rather than aesthetic, which may lead to positive outcomes for viewers. The fitspiration content used by Pryde and Prichard [ 42 ] did not contain the harmful themes regularly found in other forms of fitspiration content. Appearance comparison was significant in the relationship between TikTok content and body dissatisfaction and mood, suggesting that this may be a key mechanism through which fitspiration content leads to negative body image outcomes and supporting the notion that fitspiration promotes a focus on appearance rather than health.

Body image dissatisfaction among women is associated with co-morbid psychological disturbances and the development of disordered eating behaviours [ 43 , 44 ]. A large body of research indicates that higher levels of both general and appearance-related social comparison are associated with disordered eating in undergraduate populations [ 10 , 28 , 45 – 48 ]. As one example, Lindner et al. [ 46 ] investigated the impact of the female-to-male ratio of college campuses on female students’ engagement in social comparison and eating pathology. Their findings lend support to the Social Comparison Theory, indicating that the highest levels of eating pathology and social comparison were found among women attending colleges with predominantly female undergraduate populations. A strong relationship was also found between eating pathology and engagement in appearance-related social comparisons independent of actual weight. Lindner et al. [ 46 ] surmised that these results suggest social comparison and eating pathology behaviours are due to students’ perceptual distortions of their own bodies, potentially fostered by pressures exerted from peers to be thin.

Similarly, Corning et al. [ 45 ] investigated the social comparison behaviours of women with eating disorder symptoms and their asymptomatic peers. Results illustrated that a greater tendency to engage in everyday social comparison predicted the presence of eating disorder symptoms, while women with eating disorder symptoms made significantly more social comparisons of their own bodies. Such findings are supported by subsequent research, with Hamel et al. [ 28 ] finding that adolescents with a diagnosed eating disorder engaged in significantly more body-related social comparison than adolescents diagnosed with a depressive disorder or no diagnosis. Body-related social comparison was also significantly positively correlated with disordered eating behaviours. While extant research has focused upon social comparison as it has occurred through traditional media outlets, less research has investigated the facilitation of social comparison through social media platforms, particularly contemporary platforms such as TikTok.

Theoretical analysis of internalisation processes and social media

The extent to which one’s body image is impacted by images and messages conveyed by the media is determined by the degree to which these images and messages are internalised. Some may argue that social media platforms are distinct from what occurs in “real” life, creating fewer opportunities for internalisation to occur. Yet as Pierce [ 2 ] argues, platforms such as TikTok create their own realities, allowing users to explore their identities, form relationships, engage with culture and world events, and even develop new patterns of speech and writing. TikTok trends commonly infiltrate society, underscoring the impact of social media on life beyond the online world and thus a sociocultural analysis of TikTok is warranted. Sociocultural theories suggest that society portrays thinness as the ideal body shape for women, resulting in an internationalisation of the “thin is good” assumption for women. This in turn results in lowered body image satisfaction and other negative outcomes [ 43 ]. The significance of social influences, including the role of family, peers, and the media, is emphasised by sociocultural theory, with individuals more likely to internalise the thin ideal when they encounter pressuring messages that they are not thin enough from social influences [ 48 ]. Within this theoretical approach, an individual’s degree of thin ideal internalisation is theorised to depend on their acceptance of socially defined ideals of attractiveness and is reflected in their engagement in behaviours that adhere to these socially defined ideals [ 49 ].

Building on this, the tripartite influence model suggests that disordered eating behaviours arise due to pressure from social agents, specifically media, family, and peers. This pressure centres on conforming to appearance ideals and may lead to engagement in social comparison and the internalisation of thin ideals [ 48 ]. This is relevant in a digital context given social media provides endless opportunities for individuals to practice social comparison and for many users, social comparison on TikTok is peer-based as well as media-based. According to the tripartite model, social comparisons have been consistently associated with a higher degree of thin ideal internalisation, self-objectification, drive for thinness, and weight dissatisfaction [ 50 ]. Furthermore, and in contrast to traditional media where social agents are mainly models, celebrities, and movie stars, social agents on social media can include peers, friends, family, and individuals who have a relationship with the individual. Social media content generated by “everyday” people, rather than super models or movie stars, may result in comparisons that are more horizontal in nature. This is particularly evident on TikTok where content creators are rarely famous before creating a TikTok account, often remain micro-influencers after achieving some notoriety, and are usually around the same age as those viewing their content.

Pressure to be thin from alike peers may have a particularly pronounced impact on one’s degree of internalisation of the thinness ideal. Indeed, Stice et al. [ 51 ] found that after listening to young thin women complain about “feeling fat”, their adolescent participant sample reported increased body image dissatisfaction, suggesting that pressure from peers perpetuates the thinness ideal, leading to internalisation of the ideal and subsequent body dissatisfaction. Similarly, it was found that adolescent females were more likely to engage in weight loss behaviour if a high portion of peers with a similar BMI were also engaging in these behaviours, illustrating that appearance pressure exerted by alike peers may result in thin-ideal internalisation and engagement in weight loss behaviours to control body weight and shape [ 52 ]. Such findings raise questions around whether those most similar to us have the greatest impact upon thin-ideal internalisation, body image dissatisfaction, and disordered eating behaviours.

In further support for the tripartite influence model, research by Thompson et al. [ 48 ] indicates that the ideals promoted through social media trends are internalized despite being unattainable, resulting in body image dissatisfaction and disordered eating behaviour. Similarly, Mingoia et al. [ 53 ] found a positive association between the use of social networking sites and thin ideal internalisation in women, indicating that greater use of social networking sites was linked to significantly higher internalisation of the thin ideal. Interestingly, the use of appearance-related features (e.g., posting or viewing photographs or videos) was more strongly related with internalisation than the broad use of social networking sites (e.g., writing status’, messaging features) [ 53 ]. Correlational and experimental research alike has demonstrated that thin ideal internalisation is related to body image dissatisfaction and leads to expressions of disordered eating such as restrictive dieting and binge-purge symptoms [ 31 , 48 , 54 , 55 ]. Subsequent expressions of disordered eating may be seen as an attempt to control weight and body shape to conform to societal beauty standards of thinness [ 51 ].

This sociocultural perspective is exemplified by Grabe et al’s. [ 54 ] meta-analysis of research on the associations between media exposure to women’s body dissatisfaction, internalisation of the thin ideal, and eating behaviours and beliefs, illustrating that exposure to media images propagating the thin ideal is related to and indeed, may lead to body image concerns and increased endorsement of disordered eating behaviours in women. Similarly, Groesz et al. [ 55 ] conducted a meta-analysis to examine experimental manipulations of the thin beauty ideal. They found that body image was significantly more negative after viewing thin media images than after viewing images of average size models, plus size models, or inanimate objects. This effect size was stronger for participants who were more vulnerable to activation of the thinness schema. Groesz et al. [ 55 ] conclude that their results align with the sociocultural theory perspective that media promulgates a thin ideal that in turn provokes body dissatisfaction.

Current research

Existing research has established the relationship between body image dissatisfaction and disordered eating behaviours and social media platforms such as Instagram and Twitter. The unique implications of the TikTok ‘For You Page’, as well as the dominance of peer-created and explicit disordered eating content on TikTok suggests that the influence of this platform warrants specific consideration. This study adds to extant literature by utilising an experimental design to examine the influence of exposure to pro-ana TikTok content on body image and internalisation of societal beauty standards. A cross-sectional design was used to investigate the effect of daily TikTok and the development of disordered eating behaviours. Although body image disturbance and eating disorders are not limited to women, varying sociocultural factors have been implicated in the development of disordered eating behaviour in men and women [ 45 ], while issues facing trans people warrant specific consideration beyond the scope of this study, therefore the present sample contains only female-identifying participants.

Aims and hypotheses.

The current study aimed to investigate the impact of pro-ana TikTok content on young women’s body image satisfaction and internalisation of beauty standards, as well as exploring daily TikTok use and the development of disordered eating behaviour. First, in line with the cross-sectional component of the study, it was hypothesized that women who spend greater time on TikTok per day would report significantly more disordered eating behaviour than women who spend low amounts of time on TikTok per day. Second, it was hypothesized that women in the pro-ana TikTok group would report a significant decrease in body image satisfaction state following exposure to the pro-ana content compared to women in the control group. Third, it was hypothesized that women in the pro-ana Tik Tok group would report increased internalisation of societal beauty standards following exposure to pro-ana TikTok content compared to women in the control group.

Participants

Participants in the current study included 273 women aged between 18 to 28 years sourced from the general population of TikTok users. The predominant country of residence of the sample was Australia, with 15 participants indicating they currently reside outside of Australia. Of the remaining data relating to the two conditions of the study, 126 participants were randomly allocated into the experimental condition, and 147 participants were randomly allocated into the control condition. Snowball sampling was used to recruit participants through social media, online survey sharing platforms, and word-of-mouth, with first-year University students targeted for recruitment by offering class credit in return for participation. Participants could withdraw their consent at any time by exiting the study prior to completion of the survey.

The current study employed a questionnaire set that included a demographic questionnaire, and five scales measuring disordered eating behaviour, body satisfaction, and internalisation of societal beauty standards, as well as perfectionism, the latter of which was not examined in the present study.

Demographic questionnaire.

The demographic questionnaire required participants to answer a series of questions relating to their gender, age, relationship status, ethnicity, country of residence, TikTok usage, and exercise routine. A screening question redirected non-female-identifying persons from the study. Responses to the TikTok usage items were examined cross-sectionally with responses on the EAT-26 and ORTO15 used to examine the influence of daily TikTok use and the presentation of disordered eating behaviours.

Eating attitudes test.

The Eating Attitudes Test (EAT-26, [ 56 ]) is a short form of the original 40-item EAT scale [ 57 ] which measures symptoms and concerns characteristic of eating disorders. The 26-item short-form version of the EAT was utilised in the present study due to its established reliability and validity, and strong correlation with the EAT-40 [ 56 ].

Responses to the 26-items are self-reported using a 6-point Likert scale ranging from Always (3) to Never (0) [ 56 ]. The EAT-26 consists of three subscales including dieting, bulimia and food preoccupation, and oral control. Five behavioural questions are included in Part C of the EAT-26 to determine the presence and frequency of extreme weight-control behaviours including binge eating, self-induced vomiting, laxative usage, and excessive exercise [ 56 ]. Higher scores indicate greater disordered eating behaviour, and those with a total score of 20 or greater are, in clinical contexts, typically highlighted as requiring further assessment and advice of a mental health professional [ 56 ].

Internal consistency of the EAT-26 was established in initial psychometric studies which reported a Cronbach’s alpha of.85 [ 58 ]. For the current study, the Cronbach’s alpha = .91. Previous research has also demonstrated that the EAT-26 has strong test-retest reliability (e.g., 0.84) [ 59 ], as well as acceptable criterion-related validity for differentiating between eating disorder populations and non-disordered populations [ 56 ]. In the current study, the EAT-26 was used to measure disordered eating behaviour, and the cut-off score of 20 and above was adopted to categorise increased disordered eating behaviour. Given how this construct is measured, from this point forward the present study will refer to EAT-26 responses as ‘restrictive’ type disordered eating.

The ORTO-15 is a 15-item screening measure that assesses orthorexia nervosa risk through questions regarding the perceived effects of eating healthy food (e.g. “Do you think that consuming healthy food may improve your appearance?”), eating habits (e.g. “At present, are you alone when having meals?”), and the extent to which concerns about food influence daily life (e.g. “Does the thought of food worry you for more than three hours a day?”) [ 19 ]. Responses are self-reported using a 4-point Likert scale ranging from always , often , sometimes , or never . Individual items are coded and summed to derive a total score. Donini et al. [ 60 ] established a cut off total score of 40; scores below 40 indicate orthorexia behaviours, whilst scores 40 or above reflect normal eating behaviour. This cut off score was determined by Donini et al. [ 60 ] as their results revealed the ORTO-15 demonstrated good predictive capability at the threshold of 40 compared to other potential threshold values.

Although the ORTO-15 is the most widely accepted screening tool to assess orthorexia risk, it is still only partially validated [ 61 ], and inconsistencies of the measures’ reliability and validity exist in current literature. For example, Roncero et al. [ 62 ] estimated that the reliability of the ORTO-15 using Cronbach’s alpha was between 0.20 and 0.23, however, after removing certain items, the reliability coefficients were between 0.74 and 0.83. Contrastingly, Costa and colleagues’ [ 63 ] review of current literature surrounding orthorexia suggested adequate internal consistency (Cronbach’s alpha = 0.83 to 0.91) with all 15-items.

In the present study, a reliability analysis revealed unacceptable reliability for the ORTO-15 (α = .24). Principal components factor analysis identified two factors within the ORTO-15, one relating to dieting and the other to preoccupation with health food. Separate reliability analyses were performed on the items that comprised these two factors and the diet-related items did not have acceptable reliability (α = -.40), whilst the health food-related items bordered on acceptable reliability at α = .63. Consequently, only the health food-related items were retained in the current study following consideration of Pallant’s [ 64 ] assertion that Cronbach alpha values are sensitive to the number of items on a scale and it is therefore common to obtain low values on scales with less than ten items. Pallant [ 64 ] notes that in cases such as this, it is appropriate to report the inter-item correlation of the items, while Briggs and Cheek [ 65 ] advise an optimal range for the inter-item correlation between.2 to.4, with the health food-related items in the current study obtaining an inter-item correlation of.25. Throughout this study, the construct measured by these ORTO-15 items will be referred to as ‘healthy’ type disordered eating to reflect this obsessive health food preoccupation and differentiate between the two disordered eating dependent variables measured in the current study.

Body image states scale.

The Body Image States Scale (BISS) by Cash and colleagues [ 66 ] is a six-item measure of momentary evaluative and affective experiences of one’s own physical appearance. The BISS evaluates the following aspects of current body experience: dissatisfaction-satisfaction with overall physical appearance; dissatisfaction-satisfaction with one’s body size and shape; dissatisfaction-satisfaction with one’s weight; feelings of physical attractiveness-unattractiveness; current feelings about one’s looks relative to how one usually feels; and evaluation of one’s appearance relative to how the average person looks [ 66 ]. Participants responded to these items using a 9-point Likert-type scale which is presented in a negative-to-positive direction for half of the items, and a positive-to-negative direction for the other half [ 66 ]. Respondents were instructed to select the statement that best captured how they felt “ right now at this very moment ”. A total BISS score was calculated by reverse-scoring the three positive-to-negative items, summing the six-items, and finding the mean, with higher total BISS scores indicating more favourable body image states.

During the development and implementation of the BISS, Cash and colleagues [ 66 ] report acceptable internal consistency and moderate stability over time, an anticipated outcome due to the nature of the BISS as a state assessment tool. The BISS was also appropriately correlated with a range of trait measures of body image, highlighting its convergent validity [ 66 ]. Cash and colleagues [ 66 ] also report that the BISS is sensitive to reactions in positive and negative situational contexts and has good construct validity. An acceptable Cronbach’s alpha coefficient of.88 was obtained in the current study.

Sociocultural Attitudes Towards Appearance Questionnaire—4.

The Sociocultural Attitudes Towards Appearance Questionnaire– 4 (SATAQ-4) [ 67 ] is a 22-item self-report questionnaire that assesses the influence of interpersonal and sociocultural appearance ideals on one’s body image, eating disturbance, and self-esteem. Ratings are captured on a 5-point Likert scale which asks participants to specify their level of agreement with each statement by choosing from 1 ( definitely disagree ) through to 5 ( definitely agree ), with higher scores indicative of greater pressure to conform to, or greater internalisation of, interpersonal and sociocultural appearance ideals [ 67 ]. The five subscales of the SATAQ-4 measure: internalisation of thin/low body fat ideals, internalisation of muscular/athletic ideals, influence of pressures from family, influence of pressure from peers, and influence of pressures from the media [ 67 ]. For the purposes of the present study, the questions from the media pressure subscale were modified to enquire specifically about social media rather than traditional forms of media.

Across all samples in Schaefer et al’s. [ 67 ] study, the internal consistency of the five SATAQ-4 subscales is considered acceptable to excellent, with Cronbach’s alpha scores between 0.75 and 0.95. These subscales also displayed good convergent validity with other measures of body satisfaction, eating disorder risk, and self-esteem [ 67 ]. Pearson product-moment correlations between the SATAQ-4 subscales and convergent measures revealed medium to large positive associations with eating disorder symptomology, medium negative associations with body satisfaction, and small negative associations with self-esteem [ 67 ]. A Cronbach’s alpha of.87 was obtained in the present study, demonstrating acceptable internal consistency.

Ethical approval for the present study was granted by the Charles Sturt University Human Research Ethics Committee (Approval number H21155) prior to data collection. Participants were directed to the study via an online link to QuestionPro where they were provided an explanation of the study, their rights, and contact details of relevant support services if they were to become distressed. Participants gave informed consent by clicking on a link that read, “I consent to participate” at the beginning of the survey and then again through the submission of their completed survey. Any incomplete responses were not included in the dataset. Data collection commenced on the 30 th of July 2021 and ceased on the 1st of October 2021. In line with the cross-sectional and descriptive aspects of the research, participants were asked demographic questions about their gender, age, relationship status, ethnicity, country of residence, TikTok usage, and exercise habits. Participants then completed the experimental set in the following order: BISS (pre-test), SATAQ-4 (pre-test), EAT-26, ORTO-15, Experimental intervention (control or experimental TikTok video condition), SATAQ-4 (post-test), BISS (post-test), and debrief. All questionnaires presented to each participant were identical. Measures were not randomised to ensure that body image and internalisation were assessed at both pre- and post-test to evaluate the experimental manipulation.

Participants were randomly allocated to one of two conditions: experimental (pro-ana TikTok video) or control (“normal” TikTok video). Participants allocated to the experimental condition watched a compilation of TikTok videos containing explicit disordered eating messages such as young women restricting their food, displaying gallows humour about their disordered eating behaviour, starving themselves, and providing weight loss tips such as eating ice cubes and chewing gum to curve hunger. Participants in the experimental condition were also exposed to more implicit body image ideals typical of fitspiration-style content. This included thin women displaying their abdomens, cinched waists, dancing in two-piece swimwear, along with workout and juice cleanse videos promising fast weight loss. Participants in the control condition viewed a compilation of TikTok videos containing scenes relating to nature, cooking and recipes, animals, and comedy. After viewing the 7- to 8-minute TikTok video, all participants completed measures of internalisation and body satisfaction again to assess the influence of either the pro-ana TikTok video or the normal TikTok video. The debrief statement made explicit to participants the rationale of the study and explained the non-normative content of the videos shown to the experimental group. A small financial incentive was offered via a prize draw of five vouchers.

Statistical analysis

The data from QuestionPro was collated and analysed using IBM SPSS Statistics software, Version 28. All measures and manipulations in the study have been disclosed, alongside the method of determining the final sample size. No data collection was conducted following analysis of the data. Data for this study is available via the Figshare data repository and can be accessed at https://doi.org/10.6084/m9.figshare.25756800.v1 . This study was not preregistered. Sample size was determined before any data analysis. A priori power analyses were conducted using G*Power to determine the minimum sample sizes required to test the study hypotheses. Results indicated the required sample sizes to achieve 90% power for detecting medium effects, with a significance criterion of α = 0.05, were: N = 108 for the mixed between-within subjects ANOVAs and N = 232 for the one-way between groups ANOVAs. According to these recommendations, adequate statistical power was achieved. All univariate and multivariate assumptions were checked and found to be met. All scales and independent variables were normally distributed.

The analysis of the current study including data screening processes, descriptive statistics, and hypothesis testing will be presented in this section. Hypothesis testing began with two separate mixed between-within subjects analysis of variance models (ANOVAs) to examine the impact of the experimental manipulation on the independent variables of body image and internalisation of appearance ideals and pressure. Finally, the effect of time spent using TikTok daily on restrictive and ‘healthy’ disordered eating behaviour was explored cross-sectionally using two separate one-way between-subjects ANOVAs.

Data screening

Prior to statistical analysis, data were screened for entry errors and missing data. Of the 838 participants who initially consented to participate in the survey, 555 responses were insufficiently complete for data analysis. As participants were permitted to withdraw their consent by exiting the online survey, these results were excluded from all subsequent analyses. Of those that did not complete the study, the majority withdrew during the BISS (pre-test) and the ORTO-15, suggesting that these participants potentially experienced discomfort or distress when asked to reflect on their appearance and their eating behaviours. Of the completed responses, nine were excluded due to not meeting the study’s stated age eligibility and another case was excluded due to disclosure of a previous eating disorder diagnosis. The remaining data set comprised of 273 participants.

Descriptive statistics

Demographic characteristics..

In the current sample, 50% of participants reported being currently single and most participants (83%) were Caucasian, with 71% of participants indicating that they spent up to two hours per day using TikTok. Further demographic information is provided in Table 1 .

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https://doi.org/10.1371/journal.pone.0307597.t001

#ForYou: TikTok consumption demographics.

Participants in the current study reported that entertainment (75%), fashion (59%), beauty/skincare (54%), cooking/recipes (51%) and life hacks/advice (51%) content frequently occurred on their For You page. Largely in keeping with this, participants reported experiencing the most enjoyment from viewing entertainment (84%), life hacks/advice (57%), home renovation (56%), recipes/cooking (56%), and fashion (54%) content on their For You page.

In the current sample, 64% of participants reported being exposed to disordered eating content via their For You page. Only 15% of participants had not been exposed to any negative content themes. Further descriptive For You page content information is displayed below in Table 2 .

https://doi.org/10.1371/journal.pone.0307597.t002

Notably, 43% of the participant sample were frequently exposed to fitness and sports related content and the same percentage of the sample enjoyed seeing this content, suggesting that content broadly aligned with #fitspiration was consumed and appreciated by nearly half of participants. Concerningly, 40–60% of participants had been exposed to negative TikTok content via the For You Page, with content ranging from self-harm and suicidality to violence and illegal activity. No data was collected on the specifics of this content, however, and it is possible that some “negative” content may be framed from a proactive, preventative perspective, and this warrants further consideration.

Hypothesis testing: Cross-sectional analysis

Hypothesis 1: daily tiktok use and disordered eating behaviour..

To test the cross-sectional analysis of this study, two separate one-way between-groups ANOVAs were conducted to explore the impact of daily amount of TikTok use on ‘healthy’ disordered eating and restrictive disordered eating behaviour. This was necessary as time on TikTok was measured categorically. Participants were divided into four groups according to their average daily time spent using TikTok (Low use group: 1 hour or less; Moderate use group: 1–2 hours; High use group: 2–3 hours; Extreme use group: 3+ hours). Homogeneity of variance could be assumed for each ANOVA as indicated by non-significant Levene’s Test Statistics.

There was no statistically significant difference at the p < .05 level in ORTO15 scores for the four TikTok usage groups: F (3, 269) = .38, p = .78, indicating that ‘healthy’ disordered eating did not significantly differ across women who use TikTok for different periods of time per day. The effect size, calculated using eta squared, was.004, which is considered small in Cohen’s [ 68 ] terms. This small effect size is congruent with the non-significant finding.

The second ANOVA measuring differences among EAT-26 scores across the four TikTok usage groups also yielded a non-significant result: F (3, 269) = 1.21, p = .31. Eta squared was calculated as.01, representing a small effect size [ 68 ] consistent with this non-significant result. The means and standard deviations of the four TikTok usage groups across dependent variables of ‘healthy’ and restrictive disordered eating, as measured by the ORTO15 and the EAT-26 respectively, are displayed in Table 3 .

https://doi.org/10.1371/journal.pone.0307597.t003

Hypothesis testing: Experimental analyses

Hypothesis 2: body image satisfaction across groups from pre-test to post-test..

To evaluate the effect of the experimental intervention on body image, a 2 x 2 mixed between-within subjects ANOVA was conducted with condition (experimental vs control) as the between subjects factor and time (pre-manipulation vs post-manipulation) as the within subjects factor. All assumptions were upheld, including homogeneity of variance-covariance as indicated by Box’s M ( p >.001) and Levene’s ( p >.05) tests [ 64 ].

The interaction between condition and time was significant, Wilks’ Lambda = .98, F (1, 271) = 6.83, p = .009, partial eta squared = .03, demonstrating that the change in body image scores from pre-manipulation to post-manipulation was significantly different for the two groups. The body image satisfaction scores for women in both conditions decreased from pre-manipulation to post-manipulation. As anticipated, participants in the experimental condition reported a greater decrease in body image satisfaction than women in the control condition (see Table 4 ). This interaction effect is displayed in Fig 1 .

https://doi.org/10.1371/journal.pone.0307597.g001

https://doi.org/10.1371/journal.pone.0307597.t004

Although not consequential to the testing of the experimental manipulation, statistically significant main effects were also found for time, Wilks’ Lambda = .89, F (1, 271) = 32.99, p = < .001, partial eta squared = .109 and condition, F (1, 271) = 4.42, p = .036, partial eta squared = .016. The means and standard deviations of these main effects are displayed in Table 4 .

Hypothesis 3: Internalisation of societal beauty standards across groups from pre-test to post-test.

A second 2 x 2 mixed between-within subjects ANOVA was conducted to investigate the effect of the experimental manipulation on participants’ internalisation scores. All assumptions for the mixed model ANOVA were met with no violations.

A statistically significant interaction was found between group condition and time, Wilks’ Lambda = .97, F (1, 271) = 8.16, p = .005, partial eta squared = .029. This significant interaction highlights that the change in degree of internalisation at pre-manipulation and post-manipulation is not the same for the two conditions. Interestingly, the internalisation scores for women in the control group decreased from pre-manipulation to post-manipulation, whilst as anticipated, internalisation scores for women in the experimental group increased following exposure to the manipulation (see Table 5 ). This interaction is displayed in Fig 2 .

https://doi.org/10.1371/journal.pone.0307597.g002

https://doi.org/10.1371/journal.pone.0307597.t005

No statistically significant main effects were found for time, Wilks’ Lambda = .987, F (1, 271) = 3.59, p = .059, partial eta squared = .013 or condition, F (1, 271) = 2.65, p = .104, partial eta squared = .010. The means and standard deviations of internalisation scores for each condition at pre-manipulation and post-manipulation are displayed below in Table 5 .

The current study investigated the effect of TikTok content on women’s body image satisfaction and degree of internalisation of appearance ideals, and whether greater TikTok use contributed to increased disordered eating behaviour. In support of the hypotheses, exposure to pro-ana TikTok content significantly decreased participants’ body image satisfaction and increased participants’ degree of internalisation of appearance ideals. The hypothesis that greater daily TikTok use would contribute to increased disordered eating behaviour was not supported, as no statistically significant differences in restrictive disordered eating or ‘healthy’ disordered eating were found between the low, moderate, high, and extreme daily TikTok use groups.

Cross-sectional findings

Daily tiktok use and disordered eating behaviour..

Contrary to expectations, differences among groups on measures of restrictive disordered eating and ‘healthy’ disordered eating did not reach statistical significance. The proposed hypothesis that greater daily TikTok usage would be associated with disordered eating behaviour and attitudes was therefore unsupported. Despite lacking statistical support, participants categorised in the ‘high’ and ‘extreme’ daily TikTok use groups reported an average EAT-26 score of 18.16 and 19.09, respectively. Considering that an EAT-26 cut-off of ≥ 20 indicates potential clinical psychopathology, this mean score illustrates that exposure to TikTok content for two or more hours per day may contribute to a clinical degree of restrictive disordered eating.

The failure of the present study to detect any significant differences in disordered eating behaviours among participants with different TikTok daily usage does not align with the Transactional Model [ 33 ]. According to this model, risk factors such as low self-esteem and high thin ideal internalisation may predispose an individual to seek gratification via social media, resulting in body dissatisfaction and negative affect. The Transactional Model therefore proposes that a positive correlation exists between time spent on social media and body image dissatisfaction. Our findings also do not align with the conclusions Frieiro Padín et al. [ 34 ] drew from their review of the literature, in which a strong connection was identified between time on social media and heightened body image concerns and internalisation of the thin ideal, as well as eating disorder psychopathologies, though a distinction in outcome measures must be noted.

Based on the aforementioned sociocultural theory and previous research [see 28 , 43 , 48 ], it was assumed that increased body dissatisfaction as a result of increased time spent on social media (as stipulated by the Transactional Model), would lead to greater disordered eating behaviour. However, this was not supported statistically in the data. As postulated by Culbert et al. [ 69 ], disordered eating behaviour may instead only be a risk of media exposure if individuals are prone to endorse thin-ideals. Individuals in the present study that reported ‘high’ and ‘extreme’ daily TikTok use may have felt satisfied with their bodies and experienced lower thin-ideal internalisation. This could have potentially buffered the negative effect of greater TikTok content exposure and accounted for the lack of significant differences in disordered eating behaviour between groups. The quantity of TikTok consumption remains a pertinent question for disordered eating behaviour. As per the present study’s brief experimental manipulation, findings suggest that high frequency of daily TikTok use does not necessarily contribute to greater disordered eating behaviour than short exposures to this content.

Content presented to the pro-ana TikTok group included a mix of explicit and implicit pro- eating disorder messages as well as fitspiration content. Fitspiration content presented in the current study included workout videos to achieve a “smaller waist” and “toned abs” where female creators with slim, toned physiques sporting activewear took viewers through a series of exercises, advising viewers that they would “see results in a week”. In the present study, diet-related fitspiration content presented included the concoction of juices to “get rid of belly fat” and advice on the best “diet for a small waist” which requires avoidance of all meat, dairy, junk food, soda, and above all, to make “no excuses”. Fitspiration style content in the current study totalled one-minute, compared to disordered eating themes which totalled six minutes. The integration of these various types of content, although reflective of the For You function in TikTok, impeded our ability to determine the singular impact of fitspiration or disordered eating content, respectively, on body image and internalisation of societal beauty standards, but did reflect social media as it is consumed beyond experimental research settings.

Experimental findings

Tiktok and body image states..

The hypothesis that women exposed to pro-ana TikTok content would experience a significant decrease in body image compared to women who viewed the control TikTok content was supported. The present study found a significant interaction effect of body image between group condition (control vs experimental) and time period (pre-manipulation vs post-manipulation), as well as significant main effects. It is important to note that the statistic of interest in evaluating the success of the experimental manipulation is the interaction effect, thus main effects must be interpreted secondarily and with caution [ 64 ]. Women in the experimental group reported significantly lower body image satisfaction after exposure to the pro-ana TikTok content and compared to women who viewed the control content. This finding corroborates Festinger’s [ 27 ] Social Comparison Theory that posits people naturally evaluate themselves in comparison to others. Exposure to the pro-ana TikTok content, consisting of various thin bodies and messaging around weight loss, may have provided the opportunity for women to engage in maladaptive upward social comparisons, resulting in reduced body image satisfaction. The present study upholds previous findings of Engeln-Maddox, Tiggemann, McComb and Mills, and Gibson [ 29 , 32 , 39 , 70 ] who suggest that visual exposure to thin bodies may adversely affect one’s level of body image satisfaction and extends this research by replicating this finding in the context of a contemporary media platform, TikTok, and by utilising an experimental design.

Contradicting the present study and previous research, Pryde and Prichard [ 42 ] found no significant increase in young women’s body dissatisfaction following exposure to fitspiration TikTok content. A potential explanation for this finding is that the performance of physical movements captured in fitspiration videos may shift the focus of viewers from aesthetics to functionality, highlighting physical competencies and capabilities which has been shown to improve body image satisfaction in young women [ 71 ]. Pryde and Prichard’s [ 42 ] fitspiration content did not include typically occurring harmful themes as the present study did, potentially reducing the negative implications for body image satisfaction of exposure to such content in real world contexts.

Interestingly, women in the control group also reported a statistically significant decrease in body image satisfaction after viewing the neutral TikTok content, a finding that underscores the possible complexity of social media’s influence on body image, as identified in research by Huülsing [ 72 ]. This is an unexpected finding, as the TikTok content displayed to the control group was selected specifically to be unrelated to appearance ideals and pressures. One possible reason for this result is the repetition of administration of the BISS within a short time period. Completing the BISS twice may have caused participants to focus more attention on their body appearance than usual, resulting in more critical appraisals regardless of the experimental stimuli to which they were exposed. This notion aligns with previous research that found focusing on the appearance of body was associated with lower body image satisfaction, whereas focus on the function of the body was associated with more positive body image states [ 71 ].

One potential explanation for this finding is that the control group stimuli was contaminated and produced an unintentional effect on body image scores. Two-minutes of footage within the seven-minute control group TikTok compilation presented the human body including legs, arms, and hands. Although this body-related content was neutral in nature, it may be that even ‘harmless’ representations of the human body are sufficient to elicit a social comparison response in participants or in some capacity, reinforce the #fitspiration motifs commonly depicted on TikTok [ 1 ], therefore impacting body image scores at post-manipulation. This possible explanation has implications for TikTok use and women’s body image, as it suggests that viewing even benign content of human bodies for less than 10-minutes can have an immediate detrimental impact on body image states, even when this content is unrelated to body dissatisfaction, thinness, or weight loss. Furthermore, although a statistically significant body image decrease was detected in the control group, this finding must be interpreted with caution due to the significant interaction effect obtained.

TikTok and internalisation of societal beauty standards.

In accordance with the hypothesis, women in the experimental group reported a significant increase in their degree of internalisation of appearance ideals following exposure to pro-ana TikTok content. Women in the experimental group also reported significantly greater internalisation of appearance ideals than women in the control group. Conversely to the experimental group, internalisation scores of the control group decreased after viewing the neutral TikTok content. These findings are in line with the sociocultural theory, as women reported increased internalisation of societal beauty standards following exposure to media content explicitly and implicitly portraying the thinness ideal. The present study supports Mingoia et al’s. [ 53 ] meta-analysis, which yielded a positive association between social networking site use and the extent of internalisation of the thin ideal and furthers this notion by replicating the finding with TikTok specifically and utilising an experimental design.

In the current study, participants were subject to a single brief exposure of pro-ana TikTok content, whereas most of the sample indicated that their TikTok use was up to two hours per day. This suggests that the degree of internalisation of appearance ideals in participants lives outside of the experiment are likely to be much greater. Mingoia et al. [ 53 ] also found that the use of appearance-related features on social networking sites, such as posting and viewing photos and videos, demonstrated a stronger relationship with the internalisation of the thin ideal than the use of social networking features that were not appearance-related, such as messaging and writing status updates. As TikTok is a video sharing app and most of its content generally features full-body-length camera shots rather than a face or head shot, this finding suggests that TikTok users could potentially internalise body-related societal standards to a greater extent than users of other social media apps that typically feature head shots.

The finding that women internalised societal beauty standards to a greater degree after being exposed to pro-ana TikTok content corroborates the sociocultural theory’s emphasis of the significance of social influences in internalisation. TikTok users may be exposed to all three social influences (i.e., media, peers, and family) simultaneously on a single platform which may encourage internalisation of appearance-ideals in a more profound manner than any of these three influences in isolation. One point of difference between TikTok and other social media apps is that much content on the app is generated by “ordinary” individuals, rather than supermodels or celebrities. This enables blatantly insidious and diet-related content to circulate the app with less policing and scrutiny compared to content produced by an influencer or celebrity who may be more likely to be criticised or cancelled for socially irresponsible messaging and also provides the opportunity for more horizontal social comparisons and peer-to-peer style interactions rather than upward social comparisons.

Indeed, in their study of American teens, Mueller et al. [ 52 ] identified that girls were especially likely to engage in weight loss behaviour if a high proportion of girls with a similar BMI were also engaging in weight loss behaviours. This indicates that internalisation was strongest when appearance-ideals were promoted by alike peers. Due to the fact that much pro-ana TikTok content is created by young women, Mueller et al’s. [ 52 ] finding has problematic implications for the young female users of TikTok, in that harmful diet-related messages could be internalised to a greater extent on TikTok than on other platforms and potentially lead to body image disturbances, disordered eating behaviour, and other negative outcomes among young women.

General discussion

The findings of the current study are important but must also be understood within the broader context of participant’s daily lives beyond their participation in this study. Everyday female-identifying individuals are exposed to a multitude of different sources of information from which body image related stimuli can be drawn. The present study’s experiment was not conducted in a controlled environment due to its online nature, therefore researchers did not have the ability to assess and control for other pieces of body image-related information that participants might have consumed prior to participation that may have been salient for their body image. Further research is required to identify how sustained a change in body image states as measured by the BISS may be over time.

The findings of this study provide some insights into how social media influences disordered eating behaviour and mental health; a theoretical gap in the literature that Choukas-Bradley et al. [ 6 ] highlight as holding back research in this domain. In particular, the findings of the current study indicate that short periods of exposure to disordered TikTok content have an effect, while the high-range EAT-26 scores observed for those who engaged with TikTok for two or more hours a day also raise questions about the duration of exposure. Nonetheless, our findings demonstrate that short exposure periods are sufficient to have a negative effect on body image and internalisation of the thin ideal.

One point that may be readily overlooked in developing a theoretical framework around social media’s influence is that the narrative arc of TikTok videos is such that users are exposed to many short stories in quick succession, which may have a different effect to longer form content from a single content creator. As Pierce [ 2 ] notes, the speed of exposure to overlapping, but separate narratives depicted in successive videos, is an important feature of TikTok content and may contribute to the influence of such platforms on disordered eating and body attitudes. Each piece of content serves as a standalone narrative but may also overlap and interact with the viewer’s experience of the next video they watch to build a cumulative, normalised narrative of disordered body- and eating-practices.

In the current study, participants who engaged with TikTok for two-three hours a day were classified as high users, and those who used TikTok for three or more hours were classed as extreme. These rates of usage may, however, be quite normative, with Santarossa and Woodruff [ 73 ] citing three-four hours a day on social media as normative for their sample of young adults, though notably participants in the current study were only questioned about their TikTok usage, not their general use of social media.

While we examined the effect of pro-ana content in this study, that some changes were observed in the control group as well as the experimental group indicates that the social media environment, characterised as it is by idealisation, instant feedback, and readily available social comparison [ 6 ], may play a general role in diminishing positive body image attitudes and healthy aspirations. This is supported by Tiggemann and Slater’s [ 35 , 36 ] research in which social media usage was found to correlate positively with higher levels of body image concerns, in contrast to time spent on the internet more generally, and this may be particularly true for visually oriented platforms that sensitize viewers to their own appearance and that of others. As noted previously, of the visually-oriented social media platforms, predominantly TikTok and Instagram, videos are commonly framed on TikTok so that the subject’s whole body is visible, particularly in dance videos and in #GymTok content, where on Instagram, cameo style head-shot videos appear more likely to feature, which further suggests that TikTok may provide more body-related stimuli than other platforms, even when the intention of the content does not relate to body-image or #fitspiration.

Importantly, the algorithm on TikTok functions in such a way that those who actively seek out body positivity content may also be exposed to nefarious body-related content such as body checking, a competitive, self-surveillance type of content where users are encouraged to test out their weight by attempting to drink from a glass of water while their arm encircles another’s waist. As McGuigan [ 74 ] reports, watching just one body checking video may result in hundreds more filtering through a user’s For You page, with those actively attempting to seek out positive body image content likely to be inadvertently exposed to disordered content due to the configuration of the algorithm. This function of the For You page is demonstrated in the current study, with 64% of participants reporting having seen disordered eating content on their For You page, higher than any other kind of harmful content, including suicide and bullying. The current study did not assess participants’ consumption of #FoodTok, #GymTok, and #Fitspiration. Engagement with these dimensions of TikTok and the type of content that participants seek out via the search function warrant consideration in future research.

The TikTok algorithm underscores Logrieco et al’s. [ 18 ] findings that even anti-anorexia content can be problematic, especially given complexities in determining and controlling what is performatively problematic, including videos discussing recovery and positive body attitudes that may somewhat paradoxically further body policing and competition among users and consumers of social media content. Furthermore, as Logrieco et al. [ 18 ] highlight, TikTok is replete in both pro-ana and much more implicit body-related content that may be harmful to viewers, not to mention those creating the content, whose experiences also warrant consideration.

Theoretical and practical implications

The present study bridged an important gap in the literature by utilising both experimental and cross-sectional designs to examine the influence of pro-ana TikTok content on users’ body image satisfaction, internalisation of body ideals, and disordered eating behaviours. While the negative impact of social media on body image and eating behaviours has been established in relation to platforms such as Instagram and Twitter, TikTok’s rapid emergence and unique algorithm warrant independent analysis.

The present findings have important theoretical implications for the understanding of sociocultural influences of orthorexia nervosa development. Notably, this study is one of the first to highlight the association between orthorexia nervosa and the tripartite model of disordered eating using an experimental design. The results illustrate that the internalisation of sociocultural appearance ideals predicts the development of ‘healthy’ disordered eating, as suggested by the tripartite theory. Western culture ideals do seem to influence the expression of orthorexic tendencies, thus caution should be exercised by women when interacting with appearance-related TikTok content.

Unlike explicit pro-ana content, which is open to condemnation, the moral and health-related discourses underpinning much body-related content in which thinness and health are espoused as goodness, reflects a new trend in diet culture masquerading as wellness culture [ 20 , 21 ]. Questions are raised around the ethics of social media algorithms when the technologically fostered link between recovery-focused content and disordered-content on TikTok is laid bare, particularly considering that extant research has found individuals with experience of eating disorders often seek out support, safety, and connection online [ 49 ] and in doing so on a platform like TikTok, may be exposed to more disordered eating content than the average user. Given visual social media platforms are associated with higher levels of dysfunction in relation to body image [ 4 ], the policy and ethics of such platforms warrant scrutiny from a variety of stakeholders in management, marketing, technology regulation, with psychology playing an important role in the marketing of these platforms. As traditional journalistic platforms have been subjected to scrutiny and reform, so too must a climate of accountability be established within the social media nexus.

The widespread growth of social media may warrant greater concern than traditional forms of mass media, not only because of the full-time accessibility and diverse range of platforms, but also due to the prevalence of peer-to-peer interactions. According to the social comparison theory, comparison of oneself to others has traditionally considered more removed, higher status influences (e.g., celebrities, actors/actresses, supermodels) as a greater source of pressure than those in the individuals’ natural environment (e.g., family and peers). Re-examination of this theoretical perspective is warranted considering the contemporary challenges of social media and the perpetuation of body image messages from alike peers. Furthermore, a diverse range of “content” may trigger disordered body- and eating-related attitudes, including #fitspiration and #GymTok, which poses challenges for social media platforms in regulating content. The inclusion of orthorexia in the milieu highlights the disordered nature of seemingly benign health practices and social media content.

That TikTok content containing explicit and implicit pro-ana themes may readily remain on the app uncensored exemplifies the importance of protective strategies to build resilience at the individual level. One such protective strategy is shifting focus from body appearance to functionality. Alleva and colleagues [ 71 ] investigated the Expand Your Horizon programme, designed to improve body image by training women to focus on body functionality. They report that women who engaged with the Expand Your Horizon programme experienced greater satisfaction with body image and functionality, body appreciation, and reduced self-objectification compared to women who did not engage with the program. Health professionals involved in the care of women with eating disorders and other mental health issues should also be educated to ensure they are knowledgeable about the social media content their clients may be exposed to, equipping them with skills to engage in conversations about the potential detrimental impacts of viewing pro-ana and other harmful TikTok content [ 53 ].

The administration of such programs in schools, universities, community groups, and clinical settings could prove effectual in the prevention of disordered eating and body image disturbance development and may reduce symptom severity of a pre-established disorder. Such programs must be developed with great care, however, given the propensity for even anti-anorexia content to have a negative effect on those consuming it [ 18 ]. The development of self-compassion may also build resilience in women, with research confirming that self-compassion can be effectively taught [ 75 ]. Subsequently, programs have been developed such as Compassion Focused Therapy (CFT) in which clients are trained to develop more compassionate self-talk during negative thought processes and to foster more constructive thought patterns [ 76 ]. The value of CFT has been established in the literature with both clinical and non-clinical samples and has promising outcomes particularly for those high in self-criticism [ 77 ].

Young women should be provided with media literacy tools that can assist in advancing critical evaluations of the online world. Digital manipulation of advertising and celebrity images is well known to many people, however, this awareness may be lacking regarding social media images, as they are generally disseminated within one’s peer network rather than outside of it [ 33 ]. Media literacy interventions may educate women about how social media perpetuates appearance-ideals that are often unrealistic and unattainable [ 53 ]. As an example, Posavac et al. [ 78 ] revealed that a single media literacy intervention resulted in a reduction in women’s social comparison to body ideals portrayed in the media.

Such interventions might be extended to female-identifying TikTok users to educate them on the manipulation of videos to produce idealised portrayals of the self. Media literacy should be commenced from an early age by teaching children, adolescents, and adults to understand the influence of implicit messages conveyed through social media and to create media content that is responsible and psychologically safe for others [ 79 ]. Increased understanding of messages portrayed by social media content may prevent thin-ideal endorsement and internet misuse. Notably, however, the most effective approach would be to address the problem at its source and increase the regulation of social media companies, rather than upskill users in how to respond to harmful online environments, which creates further labour for the individual while allowing organisations to continue to produce harmful but easily monetizable content.

Limitations and future directions

To meet the requirements to run multivariate analyses, the continuous data of body image and internalisation scores were dichotomised using a median split to create ‘low’ and ‘high’ groups for each variable. Although dichotomisation was necessary to perform appropriate analyses and power analyses deemed the sample size as adequate following performance of the median split, dichotomising these variables may have contributed to a loss of statistical power to detect true effects.

Limitations are implicated in the use of the ORTO-15 in the present study. The ORTO-15 does not account for different lifestyle factors that may alter a participants’ response, such as dietary restrictions, food intolerances, or medical dietary guidelines. The discrepancies in literature surrounding the psychometric properties of the ORTO-15 may be attributable to the lack of established diagnostic criteria of orthorexia nervosa, cultural differences in expressions of eating disorders, and difficulty comparing research results in determining orthorexia nervosa diagnoses due to inconsistencies in testing questions and cut-off values [ 61 ]. Due to unacceptable reliability in the present study, a factor analysis was performed which identified a factor relating to health food preoccupation. This identified factor was used as the ORTO-15 measure and data from these 5-items were used in analyses and referred to throughout the present study as ‘healthy’ disordered eating. Using the 5-items related to ‘healthy’ disordered eating rather than the complete 15-item scale may not have accurately assessed participants’ degree of orthorexic tendencies. Despite these limitations, the ORTO-15 is the only accepted measure of orthorexic tendencies available [ 63 ]. Additionally, more limitations would likely have been encountered by using the full 15-item measure lacking reliability, compared to utilising the 5-item factor with acceptable reliability.

Future studies of TikTok and disordered eating behaviour should incorporate a measure of social comparison to verify whether social comparison is the vehicle through which women experience decreased body image satisfaction after viewing TikTok content. Future research should also examine the influence of TikTok content creation on body image, internalisation of thinness, and disordered eating behaviour and explore the association between what individuals consume on TikTok and the social media content that they produce. This research should be conducted using more diverse samples of women, including transgender women, to determine whether the findings of the present study are relevant for this population given the unique challenges regarding body image and societal beauty standards that they may experience.

Longitudinal studies are also warranted to examine the effect of exposure to pro-ana TikTok content over time, and to assess the effects of pro-ana TikTok content on body image satisfaction and eating disorder symptomology over time. Further research on orthorexia nervosa is needed to establish a more reliable measure of orthorexic tendencies and this would enable future investigation of the impact of pro-ana TikTok content on the development of orthorexia nervosa, as well as individual differences as predisposing factors in the development of orthorexic tendencies. Finally, future research should examine the efficacy of media literacy and self-compassion intervention programs as a protective factor specifically in the TikTok context, where disordered eating messages are more explicit in nature than traditional media and other social media platforms.

The findings of the current study support the notion that pro-ana TikTok content decreases body image satisfaction and increases internalisation of societal beauty standards in young women. This research is timely given reliance on social media for social interaction, particularly for young adults. Our findings indicate that female-identifying TikTok users may experience psychological harm even when explicit pro-ana content is not sought out and even when their TikTok use is time-limited in nature. The findings of this study suggest cultural and organisation change is needed. There is a need for more stringent controls and regulations from TikTok in relation to pro-ana content as well as more subtle forms of disordered eating- and body-related content. Prohibiting or restricting access to pro-ana content on TikTok may reduce the development of disordered eating and the longevity and severity of established eating disorder symptomatology among young women in the TikTok community. There are current steps being taken to delete dangerous content, including blocking searches such as “#anorexia”, however, there are various ways users circumvent these controls and further regulation is required. Unless effective controls are implemented within the platform to prevent the circulation of pro-ana content, female-identifying TikTok users may continue to experience immediate detrimental consequences for body image satisfaction, thin-ideal internalisation, and may experience an increased risk of developing disordered eating behaviours.

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Full article: A practical guide to reflexivity in qualitative research
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(PDF) Reflectivity in Research Practice: An Overview of Different
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Full article: Reflective journals as a research tool: The case of
Reflective journals in teacher education. Journals written by participants or researchers in practical settings constitute a source of narrative research (Connelly & Clandinin, Citation 1990).Reflective journals comprise an important part of documenting the practice of different professions, such as nursing, and in fields such as musical education, business administration, psychology and ...

Reflexive journals in qualitative research

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Reflectivity in Research Practice: An Overview of Different Perspectives

Reflective journals in qualitative inquiry

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Using the Research Journal during Qualitative Data Collection in a Cross-Cultural Context

Introduction

The Importance of Reflection

The Research Journal as a Tool for Reflection

A Case Study Approach

Establishing and Maintaining a Research Journal

Using the Research Journal During the Various Phases of Data Collection

Before Data Collection

Contacting Participants

After the First Interviews

During Interviews

After Interviews

Journaling Emotions

Methodological Considerations

Ethical Considerations

Conclusions

Supplementary Materials

Journal and Issue

Research Design Review

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Medical students’ experience and learning outcomes of overseas community involvement project: a qualitative study

Conclusions

Introduction

Study design

Setting and participants

Data collection

Data analysis

Learning points during the preparation phase of the trip

OCIP experience and learning outcomes according to ACGME framework

Patient care (PC)

Medical knowledge (MK)

Practice based learning and improvement (PBLI)

Interpersonal and communication skills

Systems based practice (SBP)

Professionalism

Data availability

Acknowledgements

Author information

Contributions

Corresponding author

Ethics declarations

Consent for publication

Competing interests

Additional information

Electronic supplementary material

Supplementary Material 1

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BMC Medical Education

#ForYou? the impact of pro-ana TikTok content on body image dissatisfaction and internalisation of societal beauty standards

Introduction

Disordered eating #ForYou

Orthorexia: The rise of ‘healthy’ eating pathologies

Theoretical analysis of body image and social media

Theoretical analysis of internalisation processes and social media

Current research

Aims and hypotheses.

Participants

Demographic questionnaire.

Eating attitudes test.

Body image states scale.

Sociocultural Attitudes Towards Appearance Questionnaire—4.

Statistical analysis

Data screening

Descriptive statistics

#ForYou: TikTok consumption demographics.

Hypothesis testing: Cross-sectional analysis

Hypothesis testing: Experimental analyses

Hypothesis 3: Internalisation of societal beauty standards across groups from pre-test to post-test.

Cross-sectional findings