The Journal of School Nursing
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DOI: 10.1177/1059840520933341
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This cross-sectional study was carried out to investigate the self-perception of primary school students aged 10–14 and their attitudes toward obese children (n = 693). There was a weak, positive, and highly significant correlation between the mean scores for the overall Attitude Toward Obese Children Scale, the Self-Perception Profile for Children Scale, and the Acceptance of Obese Peers subscale (p = .000). There was a weak, positive, and highly significant correlation between all the subscales except for the Rejection of Obese Peer and Social Acceptance and Athletic Competence subscales (p < .01). Selfperception in adolescence is effective throughout life in terms of community mental health. Therefore, it is of great importance to carry out education and awareness-raising studies in schools to gain students positive attitudes and behavior toward individuals with different characteristics.
self-perception, obesity, adolescence, school health nursing
Physical appearance is one of the most sensitive issues for adolescents (Kornilaki, 2015). Displaying negative attitudes toward overweight, one of the physical appearance–related issues among children and adolescents, starts from preschool period and continues during adulthood (Pont et al., 2017; Smith et al., 2020; Stevens et al., 2017). Obese children are exposed to negative behaviors such as physical (kicking, hustling, etc.), verbal (teasing, name-calling, derogatory remarks), or relational (being ignored or avoided, social exclusion, being targets of rumors) than are their normalweight peers (Di Pasquale & Celsi, 2017; Pont et al., 2017). Puhl and Latner (2007) defined negative attitudes toward obese individuals as weight-related stereotypes such as prejudice, uniformity, rejection, exclusion, and weight bias. Young people who were exposed to negative weightrelated attitudes (weight bias) failed to acquire normal social competence (Pont et al., 2017; Puhl & Latner, 2007).
In recent studies that support this result, obese children are exposed to rejection, social isolation, humiliation, and hostility during the adoption and development of social skills (Kovalskys et al., 2016; Pereda-Pereda et al., 2019; Puhl et al., 2011), and that they are not preferred by their peers (Koroni et al., 2009; Pereda-Pereda et al., 2019; Puhl & Latner, 2007). Obese children’s vulnerability to negative attitudes and stigma comes not only from their peers but also from other sources such as parents, relatives, educators, school administrators, and health professionals (Almenara &Ježek, 2015; Koroni et al., 2009; Lynagh et al., 2015; Pereda-Pereda et al., 2019; Pont et al., 2017). As a result of such negative attitudes, obese children develop low selfesteem, feel embarrassed, are exposed to mocking behavior more (Kornilaki, 2015; Pont et al., 2017; Puhl et al., 2011; Rentz-Fernandes et al., 2017), and cannot adapt to school life completely (Pereda-Pereda et al., 2019). Obese children suffer from anxiety and depression more severely than do their normal-weight peers (Rentz-Fernandes et al., 2017). Social messages about the importance of being thin and negative messages about being obese create enormous pressure on obese children/adolescents, which prevents them from developing positive body image. Negative messages can also trigger the development of negative attitudes toward these children (Kantanista et al., 2017; Kornilaki, 2015). Negative attitudes and messages bring about social isolation of obese children (Pont et al., 2017).
Today, the prevalence of obesity, irrespective of age, sex, or ethnicity, is increasing all over the world (Abarca-Gómez et al., 2017; The State of Childhood Obesity, 2016). As in the other parts of the world, the incidence of obesity is increasing in Turkey (Turkish Childhood Obesity Research, 2016). With this increase, negative attitudes toward obese children have begun to emerge. Unfortunately, in Turkey, culturally, a child’s being overweight until they are 3–4 years old is preferred because it is considered as the sign of being healthy. However, as the child grows older, they are exposed to negative attitudes in family, school, and social and work environment. While there are several studies questioning obese children’s self-perception and exposure to teasing, there are no studies reporting the attitudes of nonobese children toward obese children in Turkey. Therefore, this cross-sectional study was aimed at investigating 10- to 14-year-old elementary school students’ self-perceptions and attitudes toward obese children. The results of this study are expected to fill the gap in the literature to identify Turkish students’ attitudes toward obesity and to compare them with those of other countries. Therefore, the main question of this study is “Is there a relationship between primary school students’ scores for attitudes toward obese children and their self-perception scores?”
This cross-sectional study was carried out to investigate selfperception of students aged 10–14 and their attitudes toward obese children between February 2019 and May 2019. The ethics committee permission of the study was obtained from The Izmir Katip Celebi University Non-Interventional Clinical Research Ethics Committee (decision number: 2018/ 382).
Four primary schools were randomly selected to be included in this cross-sectional study. While two of them were in an urban area, the other two were in a rural area. The study sample comprised 693 (344 girls, 349 boys) fifth, sixth, seventh, and eighth grade students attending these four schools. The sample size was calculated to include at least 620 students using the G*power Version 3.1 power analysis program (power: 80%, effect size: 0.2, and confidence level: 95%; https://stats.idre.ucla.edu/other/gpower/). Considering the possibility of losses during the study, 10% more students were included in the sample. All the fifth, sixth, seventh, and eighth grade students in the four schools were included in the study population. Researchers attempted to reach the students who were absent on the data collection day on other days. However, they still could not reach some students. Moreover, some students’ parents did not sign the informed consent form, and some other students did not want to participate in the study (n = 56).
Sociodemographic Characteristics Questionnaire. The questionnaire included items identifying the participating students’ sociodemographic characteristics.
Stimuli. In order for the participants to list their preferences of friends, figures of eight boys and eight girls (about 12 years old) with different physical characteristics (thin, obese, healthy, sporty, short, tall, wheelchaired, and crutched) were chosen based on the literature (Koroni et al., 2009; Latner et al., 2005) after expert opinion was obtained from academicians (two pediatric nurses, one pediatrician, two public health nurses, and one child psychiatrist) and experts working in the field (two school nurses, three counselors providing guidance and psychological support, four teachers, two pediatric nurses, and one dietician). Of the pictures, those with boy figures were given to the boy participants and those with the girl figures were given to the girl participants, and they were asked to sort their preferences of friends in these figures from 1 (the most preferred) to 8 (the least preferred).
Scale for Attitudes Toward Obese Children (SFATOC). The scale has two subscales (Rejection of Obese Peers and Acceptance of Obese Peers), and 16 items rated on a 6-point Likert-type scale (Celik et al., 2015). In the scale, the children are asked to state how much they agree with the statements indicating one’s attitudes toward obese peers. While the lowest possible score to be obtained from the overall scale is 0, the highest possible score is 80. The higher the score obtained from the overall scale is the more positive the attitude displayed toward obese children is. The Cronbach’s a value of the scale was .76 and .84 in the original and present studies, respectively.
Self-Perception Profile for Children (SPPC). The scale developed by Harter (1985) was adapted to Turkish by Sekercioğlu and Koç (2017). The scale has six subscales: Competence in Scholastics, Social Acceptance, Athletic Competence, Physical Appearance, Behavioral Conduct, and Global Self-Worth. The minimum and maximum possible scores to be obtained from the overall scale are 36 and 144, respectively. As the score obtained from the scale increases, so does selfperception. The Cronbach’s a value for the subscales that ranged between .71 and .86 in Harter’s study ranged between .69 and .77 in the present study. Permission to use the scale in the present study was obtained from its authors via email.
Anthropometric measurements. The participating students’ height and weight measurements were carried out in line with the international standards (World Health Organization [WHO], 2016). Body mass index (BMI) was calculated by dividing body weight by body height squared (kg/m2 ). BMI percentiles were based on the reference data for 5–19 agegroup children released by the WHO in 2007 (Turkish Childhood Obesity Research, 2016). Based on this classification, of the participating students, 7.6% were underweight (in the 5th percentile), 50.9% were in the normal-weight range (from the 5th percentile to the 85th percentile), 16.6% were at-risk of overweight (from the 85th to the 95th percentile), and 16.7% were overweight (in the 95th percentile or greater).
The study data were collected between February 2019 and May 2019 on the days and hours allocated by the school administrators. Before the data collection, a consent form was sent to the parents. Data were collected from the children whose families gave their consent. Anthropometric measurements were performed by the first researcher in places (indoor sports hall, classroom, sports room, and meeting room) allocated by the school administrations. Separate rooms were used for female and male students in the measurement areas. In the places, where no separate rooms were available, the room was divided into two parts using a folding screen. The data collection instruments were handed out to the participating students after their anthropometric measurements were made. The researcher answered any questions asked by the participating students to clarify the items in the questionnaires.
They were told that there were no right or wrong answers to the questions and asked to give honest answers to the questions. The participants were given a class hour to reply to the questions in the scales. At the end of the data collection process, 20-min trainings on respect for differences, nonmocking, and prevention of stigmatization/discrimination were given to the students in their classrooms or in the meeting room in the schools where the study was carried out.
To administer the scales in the study, permission was obtained from the authors via email. The students were informed about the purpose of the study and asked not to write any personally identifiable information on the questionnaires. They were also told that the data collected from them would be kept confidential and would not be disclosed to third parties such as school management/teachers. The study data were collected on a voluntary basis by asking the participants the questions directly.
In the study, the Statistical Package for Social Sciences Version 25.0 was used. Kolmogorov–Smirnov test results indicated that SPPC and SFATOC scores had a normal distribution (p > .05). The correlation analysis was performed to determine the relationships between the scales’ scores. At the 95% confidence interval, p < .05 was considered significant.
The mean age of the students participating in the study was 12.27 + 1.20. Of them, 50.4% (n = 349) were boys, 78% were from the urban areas, and 22% were from the rural areas. The rate of overweight and obesity was higher in boys than in girls (p = .01). There was no difference between BMI percentile values according to the participants’ ages (p = .10; Table 1). The scores that the participants obtained from the SFATOC are shown in Table 2. The mean scores of the participating students obtained from the SFATOC were not affected by their age, sex, and BMI percentile values (p > .05).
The mean score obtained from the overall SFATOC by the participants from the urban area was higher than that obtained by the participants from the rural area (p = .001). The former participants also obtained a higher mean score from the Rejection of Obese Peers subscale of the SFATOC than did the latter participants (p = .000). However, there was not a significant difference between their mean scores for the Acceptance of Obese Peers subscale of the SFATOC (Table 2).
The mean score from the overall SPPC was 105.46 + 17.26. The mean score the boy participants reported from the Athletic Competence subscale was a bit higher than was that reported by the girl students (p = .01). However, the girl participants obtained a higher score from the Behavioral Conduct than that obtained by the boy participants (p = .006). On the other hand, the mean scores they obtained from the other subscales of the SPPC were not affected by the gender and BMI variables (p > .05). The mean score obtained from the overall SPPC by the participants from the rural area was higher than that obtained by the participants from the urban area (p = .009). The participants from the rural area also obtained higher mean scores from the Competence in Scholastics (p = .004), Physical Appearance (p = .04), and Global Self-Worth (.04) subscales of the SPPC than did the participants from the urban area (Table 2).
The mean scores the participating students obtained from the SFATOC and its Acceptance of Obese Peers subscale were correlated with their mean scores for the SPPC and its subscales (p = .000). Except for the Rejection of Obese Peers, Social Acceptance, and Athletic Competence subscales, there was a correlation between all the other subscales (p < .01; Table 3).
In terms of physical characteristics, while 29.8%, 24%, and 22.3% of the boys place the strong, healthy, and sporty looking figures, respectively, in the first place in the list, 30.3%, 24.8%, and 17.4% of the girls placed the sporty, healthy, and strong looking figures, respectively, in the first place in the list (Figure 1). While 41.7% of the boys placed the obese looking figure in the eighth place in the list, 64.5% of the girls placed the obese looking figure in the last place in the list.
The prevalence of obesity is a major public health problem for each age-group (The State of Childhood Obesity, 2016; WHO, 2016) and is increasing among children both in Turkey and in the other countries of the world (Turkish Childhood Obesity Research, 2016). This increase in the prevalence of obesity brings about social and psychosocial well-being problems in addition to physical problems (Y. K. Wu & Berry, 2018). While the different dimensions of obesity (its effect on school success, absenteeism, self-esteem, etc.) in primary school students have been investigated in a great number of studies in the literature, there is no study investigating the attitudes and self-perception of nonobese children in Turkey. In the present study, self-perceptions of elementary school students aged 10–14 years and their attitudes toward obese children were investigated.
In the current study, approximately one of every five participants was in the obese group, and the prevalence of being overweight and obese was higher in boys than that in girls. The result that the prevalence of obesity is higher in boys has been reported in previous studies (Balluck et al., 2016; Rentz-Fernandes et al., 2017; Savashan et al., 2015) and related reports as well (Turkish Childhood Obesity Research, 2016; WHO, 2016). Contrary to studies indicating that boys displayed negative attitudes more (Hansson et al., 2009) and that attitudes displayed toward obese students by children who had been overweight/obese at any time in their life were the same as those displayed by obese children (Akcelik, 2019), in the present study, the participating students’ attitudes toward obese children were not affected by age, sex, and BMI. The attitudes displayed by obese children toward other obese children were not affected by BMI. It was reported that male students displayed negative attitudes toward obese students more (Hansson et al., 2009) and that attitudes displayed toward obese children by children who had been overweight/obese at any time in their life were the same as those displayed by nonobese children (Akçelik, 2019). Contrary to these studies, the attitudes displayed by the students toward obese children in the present study were not affected by age, gender, and BMI. The attitudes displayed by obese children toward other obese children were not affected by BMI either. In the present study, the findings of the objective data obtained from the actual weights of the students were interpreted. However, there are studies focusing on the perceived weight in determining the obesityinduced stigma (Kornilaki, 2015; Latner et al., 2005). In this context, in future studies, female and male students’ attitudes toward obesity can be determined by examining their subjective body perceptions.
The mean score the participants obtained from the SFATOC was above the average, which indicated that they displayed moderately positive attitudes. In another study (Ozturk et al., 2017), as in this study, both the boys and the girls displayed positive attitudes toward their obese peers. The results showing positive attitudes were the reflection of the students’ responses to the SFATOC. This may have occurred as a result of a partial effect of the students’ tendency to give honest responses to the questions in the scale. For instance, the fact that these students put obese children in the last place in their friend preferences gives a hint about their actual attitudes toward obese children.
In the present study, another interesting finding was that the participants from the urban area displayed a more positive attitude toward obese children than did the participants from the rural area. However, our search for studies comparing attitudes of children and adolescents living in urban areas toward obese children with those of children and adolescents living in rural areas indicated a gap in the literature. It is recommended that the samples of studies to be carried out in the future should include children and adolescents living in rural and urban areas of different countries. Adolescence is a period during which students are very sensitive in terms of physical characteristics. Among adolescents who are criticized, judged, or excluded by their peers due to their physical characteristics, their self-perception along with their body image is negatively affected (Kornilaki, 2015; McCullough et al., 2009; Rentz-Fernandes et al., 2017). In the current study, the participating students’ self-perception was above the average. While the boy participants had higher levels of self-perception of athletic competence, the girl participants had higher levels of self-perception of behavioral conduct. In several studies (Çoknaz et al., 2019; Kornilaki, 2015; McCullough et al., 2009; X. Wu et al., 2016), self-perception of obese children is lower than is that of nonobese children. Contrary to these results, in the present study, there was no difference between the obese and nonobese participants in terms of self-perception. It is recommended that studies to be conducted in the future should focus on self-perception of obese children.
The mean scores the participants from the rural area obtained from the subscales such as Competence in Scholastics, Physical Appearance, and Global Self-Worth were higher than were those of the participants from the urban area. This situation may have stemmed from the fact that the families’ levels of socioeconomic characteristics such as education and income differed according to the area where the schools were located. In addition, living conditions in the rural areas are different from those in the urban areas. In rural areas, children are given more responsibilities, due to cultural factors and large family structure, which gives children an opportunity to increase their self-confidence (Tosun, 2018). In the present study, the participants displayed more positive attitudes toward obese students as their selfperception increased. The most striking relationship was that the participants who displayed a positive attitude toward Acceptance of Obese Peers had higher perceptions of Competence in Scholastics. In the literature, the results of the present study were not compared with those of other studies due to the low number of studies examining the relationship between students’ attitudes toward obese and their selfperception. It is recommended that studies to be conducted in the future should investigate attitudes toward obesity and self-perception according to age groups and gender.
Given the friend figure preferences used to measure students’ attitudes toward obese peers, both the boys and the girls preferred the strong, healthy, and sporty looking figure in the first place. The number of the girls who placed obese children in the last place in the list was higher than was that of the boys. Although the students chose positive behaviors while responding to the items in the scale, they displayed a different attitude toward the figures they would prefer in their daily lives. Another striking result of the present study is that approximately one of every three girls and one of every five boys put the obese child figure in the eighth (last) place in the list. This result is consistent with those of previous studies (Hansson et al., 2009; Koroni et al., 2009; Latner et al., 2005; Pereda-Pereda et al., 2019). Prejudice against obese and underweight students is more common (Hansson et al., 2009). According to the study of Latner et al. (2005) which revealed changes in attitudes toward obese children within a period of 40 years, the greatest prejudice was against obese children, and this prejudice gradually increased over the years. In a similar study conducted in Greece by Koroni et al. (2009), the healthy child took the first place in the list, and 56.4% of the students placed the obese child in the last place or second to the last place (Koroni et al., 2009). Boys put the students with physical disabilities in a lower place in the list than did girls (Koroni et al., 2009; Latner & Stunkard, 2003). While boys did not seem to like children with physical disabilities, girls did not seem to like obese children or children with a scar on the face (Koroni et al., 2009). In another study conducted with children aged 10–13 years, while nonobese children were preferred most, obese children were preferred least (Puhl & Latner, 2007). According to students aged 8–12 years, the least preferred figure to be with in social and recreational activities according to the body structure was the obese child figure (Pereda-Pereda et al., 2019). On the other hand, of the obese children, while the girls preferred children with slimmer figures, the boys preferred the figure that looked a bit stronger than them (Balluck et al., 2016). All these results show that students attach importance to physical appearance, which suggests that body image can be influenced by cultural factors such as beliefs and values related to beauty and attractiveness.
The present study had some limitations. Because it is not a national study, its sample is not the representative of the entire adolescent population of Turkey. SPPC is widely used in many studies. In the data collection process of the present, it was observed that the students had difficulty in understanding the items in the tool. Therefore, frequently, explanations were made during the data collection process, and if the students had any questions, their questions were answered. In this context, it was considered that the SPPC was less self-explanatory.
The results of the present study, aimed at drawing attention to weight bias that may negatively affect the self-perception of adolescents who are in a critical period of their lives, show that negative attitudes toward overweight children are highly prevalent among Turkish students.
Therefore, preventive measures aimed at reducing obesity effectively and encouraging the acceptance of individuals with different characteristics should be designed and implemented. Attempts should be aimed at increasing and spreading positive peer interactions. Efforts should be made to assess students’ perceptions in both urban and rural areas to clarify any difference. Schools are the most suitable environments to achieve this purpose. Thus, such attempts can encourage not only parents but also teachers, health care professionals, and other children to develop positive perspectives.
Causes and consequences of weight bias should be investigated in detail. In future studies, how different variables (sociocultural, familial characteristics, etc.) affect attitudes toward obesity can be investigated. In addition, it is recommended to conduct studies to investigate the effectiveness of programs to be implemented in schools to reduce negative attitudes toward obesity.
The authors would like to thank the students who participated in the study.
Both authors contributed equally to the conception of the study, acquisition and interpretation of data, manuscript drafts and subsequent revisions, and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Medine Yilmaz gave final approval on the text.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Medine Yilmaz, RN, PhD https://orcid.org/0000-0001-9409-6282
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Hulya Ciloglu, RN, MSc, is a manager nurse at Cigli State Hospital, Izmir, Turkey.
Medine Yilmaz, RN, PhD, is a professor at the Department of Public Health Nursing, Faculty of Health Sciences, Izmir Katip Celebi University, Cigli, Izmir, Turkey.
1 Cigli State Hospital, Izmir, Turkey
2 Department of Public Health Nursing, Faculty of Health Sciences, Izmir Katip Celebi University, Izmir, Turkey
Corresponding Author:Medine Yilmaz, RN, PhD, Department of Public Health Nursing, Faculty of Health Sciences, Izmir Katip Celebi University, Cigli, Izmir 35620, Turkey.Email: medine.caliskanyilmaz@gmail.com
