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Abstract

Engagement in health-promoting behaviors has been argued to be dependent on psychological factors in addition to simply having knowledge or access to resources. We systematically reviewed the evidence for the association between body (dis)satisfaction and health screening behaviors using six electronic databases and supplementary manual searches in the current study. To be included in the review, studies had to be empirical, in any language, and examined the potential link between body (dis)satisfaction and health screening. Findings from the final 16 quantitative and 12 qualitative studies generally suggest that people who were more satisfied or less dissatisfied with their bodies were more likely to engage in health screening. This review also highlighted key gaps in the literature such as the limited studies that included men as participants and the lack of examination of the underlying mechanisms and contingencies of the relationship between body (dis)satisfaction and health screening behaviors.

Keywords

body dissatisfaction body image body satisfaction health screening medical screening

Introduction

Health screening, which is a process aimed at identifying individuals who are at a higher risk of contracting or developing a specific disease to benefit from early intervention or treatment (World Health Organization, 2020), has been shown to lower disease mortality and reduce premature deaths (Stang and Jöckel, 2018). Despite national efforts in England and the United States to encourage participation in frequent health screenings, the engagement rate remains low (Harte et al., 2018; Smith et al., 2019). Given that raising awareness of the importance of screening and increasing their accessibility is insufficient to promote engagement, some researchers have turned their attention to the psychological predictors of health screening behaviors such as one’s evaluation of their body image (Ridolfi and Crowther, 2013). One evaluative component of body image is body dissatisfaction, which refers to one’s “negative thoughts and feelings about his or her own body” (Grogan, 2017: 4), and includes evaluations of (dis)satisfaction related to body size, shape, overall appearance, and body parts/areas. Because health screenings require the exposure of the physical body or the exposure of bodily information (McBride et al., 2019), such situations may heighten the salience of bodily-related concerns and fear of negative appearance-based evaluations (Cash et al., 2004) among those with more body dissatisfaction.

Indeed, studies have shown that individuals who are more satisfied with their body shape (Ludman et al., 2010) and appearance (Samah and Ahmadian, 2014) were more likely to engage in health screening. From their review of the literature on body image and cancer screening among women, Ridolfi and Crowther (2013) proposed that the association between body image evaluation and cancer screening behaviors may be explained by feelings of body shame and motivation to avoid the exposure of one’s body to oneself and others. These may represent strategies aimed to protect oneself from possible drops of their already impoverished evaluation of their body. Health screening behaviors require individuals to perform visual or tactile self-examinations of their body or have another person closely examine their body during clinical examinations. Thus, individuals with more body dissatisfaction may engage in fewer self-examinations to minimize confrontation with their source of dissatisfaction or shame, that is, their body, or avoid or delay clinical examinations to prevent negative evaluations from healthcare professionals (Mensinger et al., 2018; Swami and Furnham, 2018).

Nevertheless, findings on the association between body (dis)satisfaction and screening have been mixed. Andrew et al. (2016) found that body areas dissatisfaction predicted skin cancer screening but not breast cancer screening among female university students in Australia. Adams et al. (1993) found that adult women aged 40–65 years who evaluated their body more positively were more likely to have a past pelvic examination. However, this association was not found in a sample of breast cancer survivors (Katz et al., 2009). These findings suggest that the effect of body (dis)satisfaction may vary by the type of screening behaviors, as well as the age or health experiences of the participants. Indeed, Ridolfi and Crowther’s (2013) review of the literature has highlighted the roles of age, self-efficacy, subjective norms, risk perception, and health anxiety as potential attenuators of body dissatisfaction effects.

To the best of our knowledge, the only published review on the association between body image evaluation and screening behaviors (Ridolfi and Crowther, 2013) focused on cancer screening and women samples. A more thorough understanding of this association is essential, given the experience of body dissatisfaction across genders and ages (Frederick et al., 2007; Runfola et al., 2013), the lower uptake of screening among men (Davis et al., 2012), and evidence suggesting the relevance of body dissatisfaction in men’s health screening behaviors that are not cancer-specific (Ramseyer Winter et al., 2020).

Hence, the aim of this systematic review was to summarize the existing evidence on the role of body (dis)satisfaction in health screening behaviors following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA; Page et al., 2021) guidelines (Table S1). To this end, we searched for relevant studies to address the broad question of whether body (dis)satisfaction is associated with any health screening behaviors among individuals of any gender and age. We included studies that tested interventions as well as quantitative and qualitative observational studies.

Method

The protocol of this systematic review was registered with PROSPERO (CRD42021229840). The original protocol involved the broader construct of body image. However, because body image is multidimensional, the mechanisms that underlie its associations with health behaviors likely vary according to the different dimensions (Ramseyer Winter et al., 2020). Given our aim of searching for studies involving any health screening behavior, we decided to focus on one aspect of body image, that is, body (dis)satisfaction, and amended our original protocol accordingly.

Eligibility criteria

All quantitative and qualitative studies that were published up to 31 December 2021 and explored the possible association between body (dis)satisfaction and health screening were included. No language restriction was imposed. These steps were taken to ensure the records obtained were up to date at the time of search and to minimize selection bias due to the language of the journals. We excluded gray literature, conference proceedings, theses, non-peer-reviewed monographs, books and book chapters, study protocols, and studies that reported on body image or health screening tool development or validation. We focused the literature search on high-quality, peer-reviewed studies to reduce the risk of bias and ensure the reliability and rigor of studies included in our review.

Information sources and search strategy

We searched for peer-reviewed articles on the following databases: Ovid MEDLINE, PubMed, PsycINFO, EMBASE, and CINAHL+. The following combination of Medical Subject Heading (MeSH) terms and keywords was used: (“body image” OR “body dissatisfaction” OR “body satisfaction”) AND (“screening” OR “medical screening” OR “health screening” OR “medical examination” OR “physical examination” OR “screening test” OR “health check” OR “check up” OR” health examination” OR “health assessment” OR “clinical examination”). We then hand-searched the reference lists of the included articles for potentially relevant studies (see Table S2 for the complete search strategy).

Study selection

We imported the articles from the literature search to Covidence (Veritas Health Innovation, n.d.). After deleting duplicated records, we began a two-stage screening process. First, two reviewers (Authors 2 and 3) independently screened the titles and abstracts of all potential articles according to the eligibility criteria. Full texts were then retrieved for the articles that could not be excluded based on title or abstract, and further screened following the same criteria. A third reviewer (Author 4) resolved any conflict in the agreement between the two reviewers.

Data extraction and synthesis

The following data were extracted from each finalized article: citation, study design, country, target population, gender of study participants, age, sample size, body (dis)satisfaction measures, health screening behavior assessed, and main findings.

Quality assessment

The quality of the quantitative studies was assessed independently by two reviewers (Authors 2 and 4) using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies checklist (National Institutes of Health Quality, 2014). The overall quality was rated as poor (0–4), fair (5–7), or good (8–14). The qualitative studies were classified as “high,” “medium,” or “low” quality based on Critical Appraisal Skills Programme (2021; CASP) quality-assessment tool for qualitative studies. As the CASP checklist does not provide scores, we followed Bohren et al.’s (2014) approach to categorize the qualitative studies into “high,” “medium,” or “low” quality based on the evaluation of the two reviewers. A third reviewer (Author 1) acted as a conflict resolver.

Results

Study selection

We identified 2799 records through electronic database searches. After removing 1153 duplicates and screening by title and abstract, the full texts of 38 articles, which were all in English, were assessed for eligibility. Twenty-three full texts were excluded. Of these, 19 did not examine the association between body image and health screening and four were conference abstracts (Table S3). We found 15 articles via manual search and excluded two for duplicated reporting (Ahmadian et al., 2016; Wang et al., 2017). Hence, a final total of 28 unique studies was included in this review (see Figure 1).

Figure 1.

PRISMA 2020 flow chart showing the study selection process.

Study characteristics

Design of the studies

Of the 28 studies (See Table 1), 16 used quantitative methodologies, all of which relied on cross-sectional designs. The remaining 12 studies used qualitative methodologies, which mostly relied on loosely-structured or semi-structured interviews (Ellingson, 2003; Lende and Lachiondo, 2009; McBride et al., 2019; Russell and Carryer, 2013; Wang et al., 2018).

Table 1.

Studies included in the review (n = 28).

Study	Study design	Population/country	Age range (years)	Body (dis)satisfaction and other body image measures	Health screening behavior	Main findings
Quantitative studies (n = 16)
Samah and Ahmadian (2014)	Cross-sectional quantitative	842 female university students Malaysia	17–52 (M = 22.5, SD = 4.8)	MBSRQ-AS: AES, AOS, BASS, OPS, SWS	Breast self-examination	Only appearance evaluation (satisfaction with overall appearance) and not body areas satisfaction significantly predicted more breast self-examination behaviors in the past year, and intention to practice in the next year.
Adams et al. (1993)	Cross-sectional quantitative	291 women USA	40–65 (M = 51.9, SD = 7.3)	Single-item measure^a	Pelvic examination	Significantly more percentage of women with positive opinions (69%) about their appearance reported annual pelvic examinations in the past 2 years, compared to those with negative opinions (55%).
Andrew et al. (2016)	Cross-sectional quantitative	256 female university students Australia	18–29 (M = 20.1, SD = 3.1)	BAS MBSRQ-AS: BASS	Breast examination, skin examination, pap test	Lower body dissatisfaction and higher body appreciation were associated with more frequent skin cancer screening but not breast cancer screening and getting a pap test when required.
Chait et al. (2009)	Cross-sectional quantitative	93 women USA	28–82 (M = 56.9, SD = 9.6).	MBSRQ-AS: AES, AOS, BASS, with additional item assessing satisfaction with breast.	Breast and skin cancer self-examination	Breast self-examination was not associated with body image indicators. More satisfaction with appearance and body areas were related to more skin self-examination behavior in the past year. However, only satisfaction with appearance remained significant after including both as predictors in the same model.
DeMaria et al. (2011)	Cross-sectional quantitative	450 female university students USA	18–24 (M = 20.6, SD = 1.3)	FGSIS BPSS-R	Gynecological screening	When examined together, only genital self-image but not body areas satisfaction positively predicted 24-month gynecological screening.
Gillen and Markey (2014)	Cross-sectional quantitative	277 undergraduate students (155 sexually active) USA	18–25 (M = 19.3, SD = 1.4)	MBSRQ-AS: AES, AOS	HIV screening	Among sexually active students, appearance orientation and appearance evaluation did not significantly predict HIV screening.
Hibbert et al. (2020)	Cross-sectional quantitative	500 transgender people (147 trans men, 88 trans women, 244 non-binary, 21 others) UK	18–71 (M = 27.1, SD = 9.6)	OBCS	HIV screening	People who were more dissatisfied with their body were less likely to have ever been tested for HIV.
Jensen and Moriarty (2008)	Cross-sectional quantitative	218 college students (53.2% women) USA	18–26 (M = 19.5, SD = 2.7)	Single-item measure^b	Skin self-examination	Discomfort with body was marginally associated with skin self-examination performance in the past year among women but not men.
Katz et al. (2009)	Cross-sectional quantitative	245 female long-term unilateral breast cancer survivors USA	>30 Breast examination: M = 61.9 Pelvic examination: M = 63.9	SCS	Clinical breast examination, mammography, pelvic examination	Body satisfaction was not related to the frequency of breast cancer screening and pelvic examinations in the past year.
Kwan and Lee (2018)	Cross-sectional quantitative	444 men who have sex with men Hong Kong	>18 (Md = 25, IQR = 22–31)	Single-item measure^c	HIV screening	Compared to those who have never tested for HIV, those who have ever tested were more likely to perceive themselves as “average or attractive” than “not attractive at all or unattractive.”
Ludman et al. (2010)	Cross-sectional quantitative	5260 women USA	Mammogram: 51–65 Pap test: 40–65	Single-item on body shape satisfaction from EDI-3	Mammogram, pap test	Body shape satisfaction was positively associated with obtaining pap tests in 3 years but not with obtaining mammograms in 2 years.
Luszczynska et al. (2012)	Cross-sectional quantitative	424 women Poland	18–65 (M = 35.9, SD = 13.9)	MBSRQ-AS: Two items from AES and one from BASS.	Cervical cancer screening	Satisfaction with body weight and appearance was positively associated with regular cervical cancer screening in the past 3 years and intention to screen in the next year.
Ramseyer Winter et al. (2020)	Cross-sectional quantitative	243 men who have used a hook-up app/website in the past month USA	22–65 (M = 32.4, SD = 8.2)	BAS-2 BISCS	HIV and other STIs screening	Higher body image self-consciousness was related to a lower likelihood of ever being screened for HIV and other STIs. Body appreciation was not a significant predictor of screening.
Risica et al. (2008)	Cross-sectional quantitative	1248 women, 878 men USA	36–65	Single-item measure^d	Skin self-examination	Higher body satisfaction was associated with more skin self-examination in the past 2 months. This association was stronger among women than men.
Swami and Furnham (2018)	Cross-sectional quantitative	284 women UK	18–76 (M = 38.1, SD = 11.6)	BSDS EDI-3: Body Dissatisfaction subscale	Breast self-examination	Greater breast size dissatisfaction was significantly associated with less frequent breast self-examination behaviors.
Wang et al. (2020)	Cross-sectional quantitative	208 self-identified lesbians Taiwan	>20 Butch-identified: M = 29.5, SD = 7.1 Femme-identified: M = 29.2, SD = 7.2	Single-item measures^e	Breast self-examination, mammogram	Among femme-identified lesbians, more concern about appearance was associated with less breast self-examination and mammograms. Among butch-identified lesbians, more concern about appearance and more negative views about their breasts were associated with lower breast self-examination.
Qualitative studies (n = 12)
Clark et al. (2003)	Focus group discussion	14 women who partner with women and 14 women who partner with men, are not legally married and without a history of breast, cervical, and colorectal cancer. USA	40–75 (M = 53.2)	—	Breast, cervical, and colorectal cancer screenings	Barriers to screening included previous negative healthcare experiences and feeling of being blamed for being an inconvenience due the shape and size of their bodies.
Ellingson (2003)	Loosely-structured interviews Autobiographical journal	7 European American college-educated women. USA	37–52	—	Breast cancer screening	Barriers to screening included difficulty looking at own image without getting distracted by “flaws,” discomfort with exposing breasts to self, and discomfort with self-touching because it feels too sexual.
Fish and Wilkinson (2003)	Open-ended items in a self-administered questionnaire	218 lesbians who reportedly never practised breast self-examination. UK	—	—	Breast cancer screening	15 (7%) of the 229 explanations given for not self-examining breasts were related to feelings of discomfort and embarrassment with their bodies.
Lende and Lachiondo (2009)	Semi-structured interview	15 African American women affiliated with a local breast cancer services program. USA	45–73 (M = 56, SD = 9.7)	—	Breast cancer screening	Reasons for not screening included discomfort with self-touching of breasts because it feels inappropriate or too sexual, discomfort with body, and previous negative healthcare experiences.
McBride et al. (2019)	Semi-structured interview	19 self-identified obese women Australia	47–75 (M = 57)	—	Breast cancer screening	Screening reminds women of their dislike or discomfort with their body. Other barriers included discomfort with exposing breast to others, feelings of self-consciousness and embarrassment about appearance, and previous negative healthcare experiences.
Nguyen-Truong et al. (2018)	Focus group discussion	40 self-identified Vietnamese/Vietnamese American women USA	⩾21 (M = 46.5, SD = 12.9)	—	Breast cancer screening	Concerns about body image were reported in connection with surgical treatment of breast cancer, but not with screening.
Oscarsson et al. (2008)	Interview	14 adult women who chose not to attend a cervical cancer screening program in the last 5 years Sweden	33–64 (Md = 50)	—	Cervical cancer screening	Barriers to screening included shame and embarrassment with body, and discomfort with exposing body to others.
Russell and Carryer (2013)	Semi-structured interview	8 women who self-identified as obese/overweight New Zealand	—	—	Pap test, pelvic examinations	A key barrier to screening was the feeling of being stigmatized by healthcare providers in the past due to their larger bodies.
Thomas (2004)	Blank journal with a list of topics and follow-up interview	12 African American college graduate women USA	42–63 (Md = 56)	—	Breast cancer screening	Barriers to screening included negative feelings about breast’s appearance or size, discomfort with exposing breasts during mammography or clinical examination, and discomfort with touching own breasts.
Thomas and Usher (2009)	A notebook/tape recorder to record life events and stories, and follow-up interview	36 women USA	42–69	—	Breast cancer screening	Barriers included feelings about breasts that are shaped by adolescent experiences such as teasing, media/societal influence, and family norms and values.
Wang et al. (2018)	Semi-structured interview	37 self-identified lesbians Taiwan	21–57 (M = 32.4, SD = 8.5)	–	Breast cancer screening	Discomfort with breasts stemming from gender identity were cited as barriers to screening among butch-identified lesbians but not femme-identified lesbians. Other barriers included previous negative experiences with healthcare providers and other patients, and a fear of judgment from others.
Wakewich et al. (2016)	Focus group discussion	69 women from First Nations communities Canada	Mostly aged 25–49	–	Cervical cancer screening	Feelings of shame related to body and sexuality stemming from experiences of sexual abuse acted as a barrier to screening.

The MBSRQ-AS: Multidimensional Body-Self Relations Questionnaire-Appearance Scales (Brown et al., 1990; Cash, 2000) consists of five subscales, which include the AES: appearance evaluation scale, AOS: appearance orientation scale, BASS: body areas satisfaction scale, OPS: overweight preoccupation scale, and SWS: self-classified weight scale, BAS: Body Appreciation Scale (Avalos et al., 2005), FGSIS: Female Genital Self-Image Scale (Herbenick and Reece, 2010), BPSS-R: Body Parts Satisfaction Scale-Revised (Petrie et al., 2002), OBCS: Objectified Body Consciousness Scale (Lindberg et al., 2006), SCS: Self-Concept Scale (Polivy, 1977), EDI-3: Eating Disorders Inventory-3 (Garner, 2004), BAS-2: Body Appreciation Scale-2 (Tylka and Wood-Barcalow, 2015), BISCS: Body Image Self-Consciousness Scale (Wiederman, 2000), BSDS: Breast Size Dissatisfaction Scale (Swami et al., 2014); HIV: Human Immunodeficiency Virus; STI: Sexually Transmitted Infections. The main findings from the qualitative studies were inferred from the focus group discussions, interviews, open-ended questionnaire responses, and journal entries.

Choice from 5 response options to rate their appearance, which was collapsed into two groups: positive versus negative opinions about appearance.

Agreement to “In general, looking at my body makes me feel uncomfortable” rated on a 7-point scale.

Self-perceived attractiveness of appearance measured on a 4-point scale (not attractive at all, unattractive, average, attractive), which was later collapsed into two groups: not attractive at all-unattractive versus average-attractive.

Agreement to “I like the way my body looks” rated on a 4-point scale.

Agreement to “I worry about my appearance being judged by other women,” “I feel embarrassed about my own breasts,” and “I feel uncomfortable when I think of my own breasts” rated on a 5-point scale.

Samples

Most studies were conducted in the United States (n = 15; Adams et al., 1993; Chait et al., 2009; Clark et al., 2003; DeMaria et al., 2011; Ellingson, 2003; Gillen and Markey, 2014; Jensen and Moriarty, 2008; Katz et al., 2009; Lende and Lachiondo, 2009; Ludman et al., 2010; Nguyen-Truong et al., 2018; Ramseyer Winter et al., 2020; Risica et al., 2008; Thomas, 2004; Thomas and Usher, 2009), followed by the United Kingdom (n = 3; Fish and Wilkinson, 2003; Hibbert et al., 2020; Swami and Furnham, 2018). Only six studies did not examine women exclusively (Gillen and Markey, 2014; Hibbert et al., 2020; Jensen and Moriarty, 2008; Kwan and Lee, 2018; Ramseyer Winter et al., 2020; Risica et al., 2008). The sample size of the studies ranged from 93 to 5260 for quantitative studies and 7 to 218 for qualitative studies.

Quality assessment of studies

Of the quantitative studies, four (Hibbert et al., 2020; Katz et al., 2009; Luszczynska et al., 2012; Ramseyer Winter et al., 2020) were rated to be of good quality, 11 of fair quality (Andrew et al., 2016; Clark et al., 2009; DeMaria et al., 2011; Gillen and Markey, 2014; Jensen and Moriarty, 2008; Kwan and Lee, 2018; Ludman et al., 2010; Risica et al. 2008; Samah and Ahmadian, 2014; Swami and Furnham 2018; Wang et al., 2018), and one (Adams et al., 1993) of poor quality (see Table S4a). There was a 75% agreement rate in quality assessment between the reviewers.

Five qualitative (Clark et al., 2003; Lende and Lachiondo, 2009; Thomas, 2004; Wakewich et al., 2016; Wang et al., 2018) were rated to be of high quality, and only two (Ellingson, 2003; Russell and Carryer, 2013) were rated to be of poor quality. The remaining studies were of medium quality (Fish and Wilkinson, 2003; McBride et al, 2019; Nguyen-Truong et al, 2018; Oscarsson et al, 2008; Thomas and Usher, 2009; see Table S4b).

Assessment of body (dis)satisfaction

As shown in Table 1, ten measures were used to assess different aspects of body (dis)satisfaction in 11 studies while five studies (Adams et al., 1993; Jensen and Moriarty, 2008; Kwan and Lee, 2018; Risica et al., 2008; Wang et al., 2020) used self-developed single-item measures. The most used measure was the Multidimensional Body–Self Relations Questionnaire–Appearance Scales (MBSRQ-AS; Brown et al., 1990; Cash, 2000). One study used the complete MBSRQ-AS, which includes subscales that examine other dimensions of body image (Samah and Ahmadian, 2014), three used selected subscales (Andrew et al., 2016; Chait et al., 2009; Gillen and Markey, 2014), while one used only three items from MBSRQ-AS (Luszczynska et al., 2012). The body dissatisfaction subscale of the Eating Disorders Inventory-3 (Garner, 2004) was used in two studies. One used the entire subscale (Swami and Furnham, 2018) while another utilized an item from this subscale to capture body shape dissatisfaction (Ludman et al., 2010).

The most commonly assessed aspects of body (dis)satisfaction were satisfaction with overall physical appearance (n = 7; Adams et al., 1993; Chait et al., 2009; Gillen and Markey, 2014; Kwan and Lee, 2018; Luszczynska et al., 2012; Risica et al., 2008; Samah and Ahmadian, 2014) and overall body areas (n = 6; Andrew et al., 2016; Chait et al., 2009; DeMaria et al., 2011; Katz et al., 2009; Samah and Ahmadian, 2014; Swami and Furnham, 2018). Few studies examined (dis)satisfaction with specific body areas such as breasts (Chait et al., 2009; Swami and Furnham, 2018; Wang et al., 2020) and genitals (DeMaria et al., 2011). Other dimensions of body image that are not specific to body (dis)satisfaction, such as body appreciation (Andrew et al., 2016; Ramseyer Winter et al., 2020), appearance orientation (the extent to which one invests in their appearance; Chait et al., 2009; Gillen and Markey, 2014; Samah and Ahmadian, 2014), evaluation concerning body weight, size, or shape (Ludman et al., 2010; Samah and Ahmadian, 2014), feelings about how one’s body appears to others (Ramseyer Winter et al., 2020; Wang et al., 2020), and negative feelings when looking at one’s body (Jensen and Moriarty, 2008), were also examined. Hibbert et al. (2020) examined objectified body consciousness (McKinley and Hyde, 1996), which encapsulates elements of appearance evaluation, concerns about how one appears to others, and internalization of cultural standards of bodies.

Health screening behaviors assessed

The 28 studies included in this review assessed health screening behaviors that concern breast, cervical, skin, and colorectal cancers; Human Immunodeficiency Virus (HIV); other sexually transmitted infections (STIs); and gynecological examinations not specific to cervical cancer screening such as pelvic examinations. We combined cervical cancer screening and pelvic examinations in our reporting as some studies did not specify whether these gynecological examinations performed were specific to cervical cancer screening.

Breast cancer screening was the most assessed behavior (n = 16). Five studies captured breast self-examinations only (Chait et al., 2009; Ellingson, 2003; Fish and Wilkinson, 2003; Samah and Ahmadian, 2014; Swami and Furnham, 2018), five captured clinical examinations only (Clark et al., 2003; Katz et al., 2009; Ludman et al., 2010; McBride et al., 2019; Thomas and Usher, 2009), while six captured both (Andrew et al., 2016; Lende and Lachiondo, 2009; Nguyen-Truong et al., 2018; Thomas, 2004; Wang et al., 2018, 2020).

The second most assessed behavior was cervical cancer screening and other gynecological exams (n = 10; Adams et al., 1993; Andrew et al., 2016; Clark et al., 2003; DeMaria et al., 2011; Katz et al., 2009; Ludman et al., 2010; Luszczynska et al., 2012; Oscarsson et al., 2008; Russell and Carryer, 2013; Wakewich et al., 2020), which were solely clinical examinations. Four studies examined skin cancer screening, whereby three captured self-examinations only (Chait et al., 2009; Jensen and Moriarty, 2008; Risica et al., 2008) while the other combined self- and clinical examinations into one measure (Andrew et al., 2016). Four studies reported on HIV screening (Gillen and Markey, 2014; Hibbert et al., 2020; Kwan and Lee, 2018; Ramseyer Winter et al., 2020). Colorectal cancer (Clark et al., 2003) and other STIs screening (Ramseyer Winter et al., 2020) were the least assessed. The measures for HIV and other STIs screening did not differentiate between self and clinical examinations.

Association between body (dis)satisfaction and health screening

Breast cancer screening

Three out of the seven quantitative studies reviewed found significant associations between body (dis)satisfaction and breast screening behaviors. Of the three, two featured body dissatisfaction effects that were breast-specific: Women who were more dissatisfied (Swami and Furnham, 2018) or more embarrassed and uncomfortable with their breasts (Wang et al., 2020) were less likely to engage in self-examinations. The role of breast dissatisfaction as a barrier to screening was also highlighted in qualitative studies. Women tend to report discomfort in exposing and touching their breasts during examinations due to the high sexual or negative feelings that they attach to their breasts (Ellingson, 2003; Lende and Lachiondo, 2009; Thomas and Usher, 2009; Wang et al., 2018). Many of these feelings may have been shaped by socioculturally-cultivated norms and values (Lende and Lachiondo, 2009; Oscarsson et al., 2008; Thomas, 2004; Thomas and Usher, 2009; Wang et al., 2018), and adolescent experiences (Lende and Lachiondo, 2009; Thomas and Usher, 2009). Butch-identified lesbians, who prefer appearing more masculine, also report feelings of discomfort stemming from their gender identity and the disconnect that they feel between their body and breasts as reasons for avoiding clinical examinations (Fish and Wilkinson, 2003; Wang et al., 2018). The third quantitative study that found body (dis)satisfaction effects revealed that women who were less satisfied with their appearance reported fewer past behaviors and future intentions of breast self-examination (Samah and Ahmadian, 2014). Indeed, qualitative findings suggest that women with more body dissatisfaction may find it difficult to examine their body closely as it reminds them of their discomfort with and disliking of their body (Ellingson, 2003; McBride et al., 2019). Additionally, their fear of their appearance being judged by others may also exacerbate their avoidance of clinical examinations (Clark et al., 2003; Wang et al., 2018, 2020).

(Dis)satisfaction with other bodily attributes, such as overall body areas (Andrew et al., 2016; Chait et al., 2009; Katz et al., 2009; Samah and Ahmadian, 2014) and body shape (Ludman et al., 2010); and other body image indicators, such as the degree of investment in one’s appearance (Chait et al., 2009; Samah and Ahmadian, 2014) and weight-related concerns or perceptions (Samah and Ahmadian, 2014), did not predict breast cancer screening. Of the four quantitative studies that did not find any significant associations, most involved older participants (at least or on average 50 years old) and were not specific to self-examinations.

Cervical cancer screening and other gynecological examinations

Four out of the six quantitative studies that examined cervical cancer screening behaviors or other gynecological examinations found significant associations. More satisfaction with body shape (Ludman et al., 2010), body weight and appearance (Luszczynska et al., 2012), and genitals (DeMaria et al., 2011); and having a more positive opinion about one’s own appearance (Adams et al., 1993) were linked to more screening behaviors among American and Polish women. Among young Australian women, however, the frequency of pap tests did not vary by body areas satisfaction or appreciation (Andrew et al., 2016). Body areas satisfaction also did not predict past screening behaviors among breast cancer survivors (Katz et al., 2009).

Findings from qualitative studies suggest that some women avoid cervical cancer screening due to their reluctance to expose their body to another person. This reluctance is driven by negative feelings toward their body, which may stem from childhood physical abuse, a history of eating disorders, or aging (Oscarsson et al., 2008; Wakewich et al., 2016). Women, especially those who are obese, also avoid gynecological examinations because of their past negative experiences with healthcare providers that concern their physical appearance. These include comments or nonverbal behaviors that make patients feel like they are an inconvenience (Clark et al., 2003; Russell and Carryer, 2013), which eventually gets internalized as guilt and shame by some women (Clark et al., 2003).

Skin cancer screening

All four studies that examined skin cancer screening relied on quantitative methods. Higher satisfaction with overall body areas (Andrew et al., 2016; Chait et al., 2009), satisfaction with physical appearance (Chait et al., 2009; Risica et al., 2008), and body appreciation (Andrew et al., 2016) were linked to more frequent skin cancer screening in the past. Less discomfort with one’s body marginally predicted engagement in skin self-examination within the past year among women (Jensen and Moriarty, 2008). Both studies that included men and women in their sample found stronger correlations among women (Jensen and Moriarty, 2008; Risica et al., 2008).

HIV and STI screening

Three of four quantitative studies showed that body (dis)satisfaction was associated with ever having HIV and STI tests. Screening behaviors were more prevalent among transgender men and women with lower body dissatisfaction (Hibbert et al., 2020), men who have sex with men who perceived themselves to have an attractive appearance or a fit body (Kwan and Lee, 2018), and less bodily self-conscious men who “hook up” (Ramseyer Winter et al., 2020). Screening behavior did not vary by the degree to which men appreciated their body (Ramseyer Winter et al., 2020) and the degree to which undergraduate men and women were satisfied with or invested in their appearance (Gillen and Markey, 2014).

Colorectal cancer screening

Only one qualitative study reported body dissatisfaction concerns related to colorectal screening. Clark et al. (2003) found that women avoided screening because they felt blamed for their body shape or size and felt embarrassed about the preparation for the procedure.

Discussion

The current review collated existing findings from 16 quantitative and 12 qualitative studies on the association between body (dis)satisfaction and health screening behaviors. While the abovementioned association does not appear consistent across studies—likely because of the variability in the body (dis)satisfaction measures used, screening behaviors captured, and population characteristics—some key patterns were evident from the current review.

First, not all aspects of body (dis)satisfaction were related to health screening. Screening behaviors were most consistently shown to be associated with one’s satisfaction with physical appearance (Adams et al., 1993; Chait et al., 2009; Kwan and Lee, 2018; Luszczynska et al., 2012; Risica et al., 2008; Samah and Ahmadian, 2014) and not their overall satisfaction with body areas (Andrew et al., 2016; Chait et al., 2009; DeMaria et al., 2011; Katz et al., 2009; Samah and Ahmadian, 2014; Swami and Furnham, 2018). Skin cancer screening, which was mostly measured as self-examination, is the only screening behavior that was consistently associated with various measures of body (dis)satisfaction (Andrew et al., 2016; Chait et al., 2009; Jensen and Moriarty, 2008; Risica et al., 2008). As suggested by Andrew et al. and Chait et al., overall body dissatisfaction and skin cancer self-examination may be more closely linked because it relies on one’s visual inspection of all body parts rather than a confined area. In support, our review suggests that screenings that require the inspection of a specific body area may be better predicted by one’s dissatisfaction with that body area rather than overall body dissatisfaction: Women who were more satisfied with their genitals attended more gynecological examinations (DeMaria et al., 2011) and women who were more satisfied with their breast size self-examined their breasts more frequently (Swami and Furnham, 2018).

Second, current findings highlight the role of potential moderating variables in the association between body (dis)satisfaction and screening behaviors. The quantitative studies that found significant associations between body dissatisfaction and breast examinations were generally conducted with younger participants. Older women may be more likely to include clinical breast cancer screening as part of their routine medical check-ups than younger women, given the higher risk of breast cancer with age (Siegel et al., 2022). The opposite pattern was found in cervical cancer and gynecological screening. Following the same argument, younger women may be more motivated to seek routine pap tests regardless of their feelings about their body because of the higher prevalence of human papillomavirus infections among young adults (Sargent et al., 2008). Taken together, these findings suggest that increases in screening behavior due to age-related needs, risks, or norms could weaken the effects of body dissatisfaction (Ridolfi and Crowther, 2013).

Only two of the four studies conducted with more than one gender examined how the correlation between body dissatisfaction and screening behavior varied by gender (Jensen and Moriarty, 2008; Risica et al., 2008). Both found a stronger correlation for women than men, which may be driven by women’s stronger prioritization of appearance (Quittkat et al., 2019) or higher uptake of screening (Davis et al., 2012). Our finding that body (dis)satisfaction was shown to be a more consistent predictor of breast self-examinations than clinical examinations suggests the role of examination type as a potential moderator. The effect of body (dis)satisfaction effect may be weaker in clinical examinations as they tend to be performed as routine checks and do not require one to confront their own body. However, we refrain from forming conclusions based on these limited studies and urge future researchers to further test the potential role of age, gender, and examination type as moderators of the association between body (dis)satisfaction and health screening behaviors.

None of the quantitative studies directly tested the possible mechanisms or mediating pathways underlying the body dissatisfaction and screening association. Nevertheless, qualitative findings suggest a few possible pathways. People who view their body more negatively may be more likely to encounter or recall negative interpersonal experiences such as stigmatization from service providers (Russell and Carryer, 2013) or other patients (Wang et al., 2018) when seeking healthcare. Over time, these feelings may develop into a generalized fear of negative evaluation from others (Cash et al., 2004) or feelings of stress related to healthcare encounters, which in turn predicts higher healthcare avoidance (Mensinger et al., 2018). Moreover, people who are less satisfied with their appearance may not want to confront their source of dissatisfaction, which may develop into a motivation to avoid their body. This motivation may manifest behaviorally as avoidance of body exposure (Ridolfi and Crowther, 2013), which could explain the link between body dissatisfaction and screening behaviors that require close examination of their body. Additionally, the avoidance motivation may manifest cognitively as reduced attention to bodily health and functioning (Fish and Wilkinson, 2003), which could explain the link between body dissatisfaction and screening behaviors that do not require bodily exposure such as HIV screening. Future work should empirically examine these potential mechanisms using longitudinal observational designs or experimental methods.

Among the quantitative studies included in this review, only five tested other dimensions of body image in addition to body (dis)satisfaction. Weight-related concerns and investment in appearance did not emerge as significant predictors of health screening (Chait et al., 2009; Gillen and Markey, 2014; Samah and Ahmadian, 2014). Two studies (Andrew et al., 2016; Ramseyer Winter et al., 2020) examined the role of body appreciation, which captures the degree to which one loves, accepts, appreciates, and respects their body’s unique beauty and functionality (Tylka and Wood-Barcalow, 2015), and findings were mixed. However, it is important to note that conclusions on the role of these other dimensions of body image cannot be made given that this was not the purpose of this review and we have not fully captured the studies that have examined body image constructs other than body dissatisfaction.

Implications

Overall, the current review extends on Ridolfi and Crowther’s (2013) findings by demonstrating the relevance of body (dis)satisfaction on screening behaviors beyond cancer screenings and among men. Our findings suggest the possible superior roles of the dissatisfaction with one’s overall appearance and body areas that are specific to the health screening as predictors, elaborated on the potential mechanisms underlying the body dissatisfaction and health screening association, and highlight the lack of experimental studies.

Our review also provides further evidence to support the incorporation of body image promotion goals in health interventions such as public health campaigns. Rather than highlighting the deadliness of diseases, which may increase avoidance of screening behaviors due to fear of illness detection (Ellingson, 2003; McBride et al., 2019), it may be more beneficial to incorporate messages or tasks that promote satisfaction with one’s appearance or a healthy relationship with one’s body, while promoting health literacy (Baccolini et al., 2022). More importantly, healthcare providers need to create a safe, stigma-free, and accepting environment for patients. Good provider-patient relationships need to be cultivated as healthcare provider recommendation is a key predictor of preventive health behaviors such as cancer screening (Rollet et al., 2021) and vaccine uptake (Oh et al., 2021). Healthcare-related policymakers and stakeholders could provide sensitivity and communication training to practitioners, which could be reinforced through service evaluations and improvements.

Limitations

Some limitations in the published literature are evident. First, the studies were predominantly done with women and people of Western cultures, which may challenge the generalizability of the findings. For instance, body dissatisfaction may not be a meaningful predictor of screening behaviors among populations with lower health literacy or poorer healthcare access. All studies relied on cross-sectional designs and examined physical health screening behaviors that were mostly related to cancer. There was a lack of standardization in body dissatisfaction and health screening measures. Future studies should account for the multiple aspects of body (dis)satisfaction (i.e. overall appearance and body areas to be screened) as well as the multidimensional nature of body image (i.e. capturing both negative and positive body image) using validated measures, utilize more comprehensive measures of health screening behaviors, and examine other screening behaviors such as psychological or mental health screening.

Moreover, our search was restricted to peer-reviewed journals, and grey literature was excluded from the search. Although efforts were made to search for related articles manually, it is possible that some publications were missed. Our choice of keywords may have also limited our search results. For instance, we did not include more specific terms such as pap smear or prostate exam for medical screening and terms such as body shame and ideal body for body dissatisfaction. Nevertheless, our search strategy was based on similar keywords used in other reviews that concerned health screening (Hoffmann and Del Mar, 2017) and body dissatisfaction (McComb and Mills, 2020), and a preliminary search to verify our keywords.

Conclusion

In conclusion, the current review showed a relatively consistent relationship between several aspects of body (dis)satisfaction and physical health self- and clinical screening behaviors. People who were more dissatisfied with their physical appearance or specific body parts were less likely to engage in self- and clinical-examinations for screening purposes. Findings suggest that more research is required to understand which aspects of body (dis)satisfaction better predict the different forms of health screening, in which context, and through which underlying mechanisms.

Supplemental Material

sj-docx-1-hpq-10.1177_13591053231189413 – Supplemental material for Body (dis)satisfaction and health screening behaviors: A systematic review of observational studies

Supplemental material, sj-docx-1-hpq-10.1177_13591053231189413 for Body (dis)satisfaction and health screening behaviors: A systematic review of observational studies by Pei Hwa Goh, Hoi Yan Loh, Ker Rou Chung and Amutha Ramadas in Journal of Health Psychology

Supplemental Material

sj-docx-2-hpq-10.1177_13591053231189413 – Supplemental material for Body (dis)satisfaction and health screening behaviors: A systematic review of observational studies

Supplemental material, sj-docx-2-hpq-10.1177_13591053231189413 for Body (dis)satisfaction and health screening behaviors: A systematic review of observational studies by Pei Hwa Goh, Hoi Yan Loh, Ker Rou Chung and Amutha Ramadas in Journal of Health Psychology

Supplemental Material

sj-docx-3-hpq-10.1177_13591053231189413 – Supplemental material for Body (dis)satisfaction and health screening behaviors: A systematic review of observational studies

Supplemental material, sj-docx-3-hpq-10.1177_13591053231189413 for Body (dis)satisfaction and health screening behaviors: A systematic review of observational studies by Pei Hwa Goh, Hoi Yan Loh, Ker Rou Chung and Amutha Ramadas in Journal of Health Psychology

Supplemental Material

sj-docx-4-hpq-10.1177_13591053231189413 – Supplemental material for Body (dis)satisfaction and health screening behaviors: A systematic review of observational studies

Supplemental material, sj-docx-4-hpq-10.1177_13591053231189413 for Body (dis)satisfaction and health screening behaviors: A systematic review of observational studies by Pei Hwa Goh, Hoi Yan Loh, Ker Rou Chung and Amutha Ramadas in Journal of Health Psychology

Supplemental Material

sj-docx-5-hpq-10.1177_13591053231189413 – Supplemental material for Body (dis)satisfaction and health screening behaviors: A systematic review of observational studies

Supplemental material, sj-docx-5-hpq-10.1177_13591053231189413 for Body (dis)satisfaction and health screening behaviors: A systematic review of observational studies by Pei Hwa Goh, Hoi Yan Loh, Ker Rou Chung and Amutha Ramadas in Journal of Health Psychology

Footnotes

Data sharing statement

All data generated or analysed during this systematic review are included in their entirety in this published article itself. Supplemental Material describing the analyses are available via the Sage Journals platform.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Ethics approval

This study did not involve primary data collection and was thus exempt from ethical review.

Pre-registration

The protocol of this systematic review was registered with PROSPERO (CRD42021229840). We amended the original protocol to focus on body (dis)satisfaction instead of the broader construct of body image.

ORCID iDs

Pei Hwa Goh

Hoi Yan Loh

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