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Attitudes of clinical and non clinical samples towards plastic surgery and their relationship with self-awareness and body image

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https://www.eduzhai.net International Journal of Applied Psychology 2019, 9(2): 62-73 DOI: 10.5923/j.ijap.20190902.03 Attitude towards Plastic Surgeries and Relation to Self-Awareness and Body Image among Clinical and Non-Clinical Sample Sawzan S. Basyouni Associate Professor of Mental Health and Psychological Counseling, College of Education, Umm al-Qura University, Mecca, Saudi Arabia Abstract The present study aims to investigate the relationship between attitude towards plastic surgeries, self-awareness, and body image. The sample comprised a clinical sample of (30) referrals to Obajy for Plastic Surgery in Jeddah and King Abdullah Medical City in Mecca (who have undergone plastic surgery) and a non-clinical sample of (30) students and faculty members at the College of Education (who have not undergone plastic surgery). To achieve the study objective, the scales of the attitude towards plastic surgeries, self-awareness, and body image were applied to the participants. The results showed that there was a positive significant correlation between the total score of the scale of the attitude towards plastic surgeries and the total score of the scales of self-awareness and body image. In addition, there was a statistically significant difference between the average score of the clinical and non-clinical participants for the three scales in favor of the non-clinical participants. The study recommended developing counseling and therapeutic programs for those who are dissatisfied with their body image and those who lack self-awareness to achieve mental health and adjustment. Keywords Attitude towards plastic surgeries, Self-awareness, Body image 1. Introduction Plastic surgeries are one of the most important social phenomena in the Saudi community. Because it is a means of change or imitation, several men and women have recently become obsessed with it. In addition, it is a strong passion in our modern life. We currently live in "the age of image". The image has become an inevitable aspect of life and people, especially the young who have become preoccupied with face and body shape. Those who are dissatisfied with their face or a part of it, dream about changing it or they actually see a plastic surgeon. Consequently, the popularity of plastic surgeries has exceeded all expectations. They have captured the attention of all social segments in varying proportions. Thus, it is of primary importance to highlight plastic surgeries and the attitude towards them. In addition, beauty is an essential requirement for the female who is strongly passionate about improving her appearance and showing off her beauty. Therefore, the culture of plastic surgery has become more prevalent. Al-Otaibi (2009) indicated that (93%) of Saudi university * Corresponding author: sawzanbasyouni@yahoo.com (Sawzan S. Basyouni) Published online at https://www.eduzhai.net Copyright © 2019 The Author(s). Published by Scientific & Academic Publishing This work is licensed under the Creative Commons Attribution International License (CC BY). http://creativecommons.org/licenses/by/4.0/ students tend to undergo plastic surgeries. The plastic surgery has been a remarkable development and science that has its origins and rules. Furthermore, it is an important branch of general surgery. Currently, various media campaigns promote plastic surgery. Free forums involve a large number of doctors who motivate both the sick and the healthy to change facial gestures, refresh the face and undergo fat removal procedures (Farajallah and Farajallah, 2011). Rafferty (2016) (as cited in Saleh, 2017) reports that 1,600,000 plastic surgeries were done in the United States in 2016 and approximately 240,000 adolescents (aged 13-19) have undergone them. The proliferation of plastic surgery among males and females is based on the increased awareness, relevant culture, as well as the growing focus of media on relevant issues. Mass media, including the radio, TV, newspapers, and Internet, especially the satellite channels dedicating programs to beauty and plastic surgery, directly contribute to the increasing the demand for these surgeries. Psychological studies indicate that adolescents and young people undergo plastic surgery the most. The American Society for Aesthetic Plastic Surgery (ISAPS) asserts that Saudi Arabia predominates in the number of plastic surgeries done in its centers and hospitals. In 2016, 95 thousand out of 12 million plastic surgeries were done in Saudi Arabia. Therefore, it is ranked first in the Arab region, and third worldwide in terms of the number of plastic surgeries, International Journal of Applied Psychology 2019, 9(2): 62-73 63 followed by the UAE, Lebanon, Egypt, and Iraq, respectively (Saleh, 2017). According to the statistics published by the Saudi Ministry of Health in "Your Health Electronic newspaper" (2012), plastic surgery annually increases by 15% in Saudi Arabia. Plastic surgery consultant at ISAPS and faculty member at the College of Medicine, King Saud University, Dr. Khalid Al-Zahrani states that plastic surgery has been constantly increasing by 25% in Saudi Arabia compared to its rate in 2017. In addition, the proportion of young men and women who underwent these surgeries was rated 56% (Al-Aqeel, 2014; Haqqad, 2018). Accordingly, ISAPS warns that plastic surgery among adolescents, particularly those aged (14-18) has been on the rise (Saleh, 2017). Accordingly, it is necessary to address the attitude of university students towards plastic surgery and the relation to some variables. In addition, psychologists report that some plastic surgery seekers lack self-confidence. Thus, they urge the treating doctor to diagnose their psychological state properly and thoroughly because their psychological problems may stimulate them to undergo these surgeries. Others suffer from neither psychotic disorder nor physical deformity (Henderson-King and Henderson-King, 2005; Frederick et al., 2007). Farshidfar, Dastjerdi, and Shahabizadeh (2013) indicate that adolescents have self-dissatisfaction and conceive an unreal body image. Gardner (2015) defines the characteristics of teens seeking plastic surgery, as follows: - Lack of self-confidence. - Cognitive deformity in the body image. - Low emotional maturity. - Declining capacity to face psychological stress. Mianroodi, Eslami and Khanjani (2012) conclude that the adolescents who have undergone plastic surgery had low self-esteem and were dissatisfied with their body image before the surgery because of some outer physical characteristics. Honigman, Phillips and Castle (2004) and Khazir, Therah and Mohmood (2016) show that the adolescents who undergo plastic surgeries suffer from body dysmorphic disorder that causes depression, anxiety, and a desire to change the shape. Hewitt (2009) reports that the adolescents who tend to undergo plastic surgery suffer from bad emotional self-regulation so they were dissatisfied with a specific body part or their entire body. Al-Mutairi (2014) reveals a statistically insignificant inverse relation between control concept and attitude towards plastic surgery and recommends the application of the study tools to a larger clinical sample with different variables. Self-awareness means that the individual is aware of himself/herself and the surrounding world, realizes the relationships that connect the things and phenomena around him/her. That is, s/he deepens the quality of feelings and the essence of existence. Eventually, such awareness creates self-esteem (Amer & Muhammad, 2008; Abu Jado, 2004). It contributes to the achievement of success, progress, and excellence. It helps the individual identify his/her self properly through realizing his capabilities, potentials, strengths and weaknesses, as well as ability to make the right decisions which create the state of harmony and interaction (Al-Najjar, 2018). In addition, the lack of self-awareness reduces the individual's ability to grow and develop as a normal person who promotes himself/herself. Hence, the primary objective of self-awareness is to protect the individual from the harmful negative influences and to reinforce his/her ethics and behaviors through raising awareness to distinguish the right and the wrong (Qasem and Al-Katabi, 2017). Accordingly, self-awareness is important because it helps the individual identify the method that enables him/her to reinforce the desired behaviors assisting him/her maintain values and habits in a more positive way. This enhances the ability to control himself/herself to understand life matters, so he/she is able to select deliberately what helps address the situations properly. Body image is one of the variables that affect the individual's behavior and have a significant role in self-assessment and interactions with the body. In addition, it is a positive or negative mental image created of the body, and it appears in a number of accompanying behavioral tendencies (Al-Desoky, 2006). Negative body image affects the social and physical competence and causes some symptoms of anxiety, low self-esteem, and alienation and social concerns. In addition, dissatisfaction with the body also causes various psychological and psychophysical problems, which create a disturbance of the body image. This problem arises when the body shape is not consistent with the model shape the individual conceives (Al-Qadi, 2009; Allen and Unwing, 2003). To conclude, body image is important and substantial feature in which people are concerned. This is asserted by the view of the social effects of the appearance, the internal view that reflects the personal attitude of the appearance, or the real appearance of the individual. Difference between the internal and the external views is of great importance because people do not perceive themselves as the others. The psychological and social aspects of individuals, who intend to undergo plastic surgery, have been addressed by various studies. For example, Zahra, Reza, and Fateme (2012) and Honigman et al. (2004) show that body image reduces self-confidence and creates dissatisfaction, anxiety, and low self-esteem. People tend to undergo plastic surgery to get psychological well-being, self-enjoyment, and self-relief. Because of her contact with university students and faculty members, the author argues that most of their educational, psychological, social problems occur due to lack of self- awareness and body dysmorphic disorder. Consequently, it is important to investigate the relationship between these two variables and the attitude towards plastic surgery. 64 Sawzan S. Basyouni: Attitude towards Plastic Surgeries and Relation to Self-Awareness and Body Image among Clinical and Non-Clinical Sample However, no study, to the author's knowledge, has addressed the relationship between the attitude towards plastic surgeries and self-awareness and body image among clinical and non-clinical samples. Therefore, a study shall investigate this relation. 2. Statement of the Problem The problem of the present study involves the lack of self-awareness among some university students and faculty members, which may create low self-concept and lack of self-confidence. In addition, they have dysmorphic disorder, so they frequently attempt to change their appearance, especially with the massive changes which create dissatisfaction with their appearance. One of these attempts is their attitude towards plastic surgery. Thus, it is essential to address the relationship between the attitude towards plastic surgeries and self-awareness and body image. The problem of the study is formulated in the following major question: Is there a relation between the attitude towards plastic surgeries and self-awareness and body image among clinical and non-clinical samples? It is subdivided into the following minor ones: 1. Is there a correlation between the attitude towards plastic surgeries and self-awareness and body image among the clinical and non-clinical participants? 2. Is there a difference between the clinical participants who have undergone plastic surgeries and the non-clinical ones who have not undergone plastic surgeries in the scale of attitude towards plastic surgery? 3. Is there a difference between the clinical participants who have undergone plastic surgeries and the non-clinical ones who have not undergone plastic surgeries in the scale of self-awareness? 4. Is there a difference between the clinical participants who have undergone plastic surgeries and the non-clinical ones who have not undergone plastic surgeries in the scale of body image? 2.1. Objectives The study aims to investigate 1. The correlation between the attitude towards plastic surgeries and self-awareness and body image among the clinical and non-clinical participants. 2. The difference between the clinical participants who have undergone plastic surgeries and the non-clinical ones who have not undergone plastic surgeries in the scale of attitude towards plastic surgery. 3. The difference between the clinical participants who have undergone plastic surgeries and the non-clinical ones who have not undergone plastic surgeries in the scale of self-awareness. 4. The difference between the clinical participants who have undergone plastic surgeries and the non-clinical ones who have not undergone plastic surgeries in the scale of body image. 2.2. Significance It is a significant study because: 1. It addresses plastic surgery which is an important topic in the field of mental health despite its recent prevalence. 2. It is one of the few studies that have utilized two different samples to increase the verification of the results because most studies were applied to either a clinical or a non-clinical sample. 3. It designs a scale of the attitude towards plastic surgeries to evaluate the participants' attitude towards them. 2.3. Limitations The study is limited to: Spatial and human limitations: A clinical sample of referrals to Obajy for Plastic Surgery in Jeddah and King Abdullah Medical City in Mecca (who have undergone plastic surgery including nose reconstruction, face-lift, fillers injections, lip enhancement and lifting or reshaping any part of the body) and a non-clinical sample of students and faculty members at the College of Education, Umm Al-Qura University (who have not undergone plastic surgery), aged (20-35) years. Temporal Limitations: The first semester of the academic year 2018/2019. Objective Limitations: - Domains of the attitude towards plastic surgery: Mental, behavioral, and emotional domains. - Domains of self-awareness: Private self-awareness, public self-awareness, and social anxiety. 2.4. Hypotheses The study seeks to verify the validity of the following hypotheses: 1. There is a positive correlation between the attitude towards plastic surgeries and self-awareness and body image among the clinical and non-clinical participants. 2. There is no statistically significant difference between the average score of the clinical participants (who have undergone plastic surgeries) and the non-clinical participants (who have not undergone plastic surgeries) in the scale of attitude towards plastic surgery. 3. There is no statistically significant difference between the average score of the clinical participants (who have undergone plastic surgeries) and the non-clinical participants (who have not undergone plastic surgeries) in the scale of self-awareness. 4. There is no statistically significant difference between the average score of the clinical participants (who International Journal of Applied Psychology 2019, 9(2): 62-73 65 have undergone plastic surgeries) and the non-clinical participants (who have not undergone plastic surgeries) in the scale of body image. 3. Definition of Terms Aattitude towards plastic surgery It is procedurally defined as the participants' relatively constant attitude towards plastic surgery, whether positive or negative, acceptable or unacceptable. It is the degree of their mental readiness to undergo plastic surgery. It is identified by the participants' total scores on the items of the scale of attitude towards plastic surgery and measured by the participants' total score in the three domains of the scale (i.e. mental, behavioral, and emotional domains). Self-awareness It is procedurally defined as the participants' accurate and comprehensive awareness of their characteristics, emotions, beliefs, attitudes, strengths, and weaknesses employed in decision-making, solving problems, as well as observing their motivations, attitudes, and thoughts. It is identified by the score of the participants on the scale of self-awareness adopted by the author. Body image It is procedurally defined, as the participant's mental image of his/her own body, whether the external appearance or the internal parts, in addition to his /her positive and negative feelings and attitudes. It is constantly developed and identified by the score of the participants on the scale of body image adopted by the author. 4. Theoretical Framework and Literature Review I. Plastic surgeries and attitude towards them Plastic surgery is a type of surgeries which correct congenital defects, such as exodontias, rectifying the shape of the deformed organs like cleft lip repair, or treating the deformities, including burns and wounds, caused by various accidents (Kanaan, 2000). Al-Fozan (2008) defines it as a surgical procedure that improves the shape or function of the visible body organs. Al-Najjar (2016) argues that it is a procedure that aims to increase or decrease the shape of the organ. The author defines the plastic surgery as the medical procedures which plastic surgeons perform on the Saudi woman's body to change or rectify it, whether for therapeutic or aesthetic need. According to Gerber (2006), plastic surgeons classify plastic surgeries into two types: 1. Reconstructive surgery: It is performed to treat the form and function of the deformed organ. The surgeon is keen to restore the primary shape of the organs with no apparent impact. It comprises the following three types: 1.1. Corrective plastic surgery treats congenital defects. 1.2. Prosthesis: Prosthetic implant is an artificial device that replaces a missing body part, which may be lost through trauma or disease. 1.3. Constructive plastic surgery is associated with the building and normal development of the body. 2. Cosmetic surgery improves and beautifies the appearance, such as changing the skin's color. Makki (2013) indicated that plastic surgery has become an obsession for all ages. Paying attention to appearance has become a requirement not only for the woman but for the society, as well. The attitude is the tendencies that stimulate the individual to have a specific behavioral response to people, concepts, events, situations, or things that constitute a complex system in which various variables interact (Abu Jado, 2008). Al-Dahiri (2008) identified the elements of attitude as follows: - Cognitive elements (belief or disbelief): They are associated with the individual's information on attitude. Some beliefs in our everyday life are not based on the objective facts and observation, but a person sometimes has two contradictory opinions on the same subject. - Emotional elements (preference and lack of preference): They represent the emotional aspects associated with something and whether they please the individual or not. - Behavioral elements: The attitude involves the readiness to response in a behavioral form of and the way the person handles the attitude in a definite situation. Alwan and Hamad (2008) mentioned a set of the attitude's characteristics. They argue that the attitude is hypothetical, acquired, and linear. The author concludes that the attitude towards plastic surgery involves the three above-mentioned characteristics. She assumes that the participants' attitude is acquired from life experiences. In addition, their views on undergoing plastic surgery differ according to its importance or their desire. Farahat (as cited in Al-Baridi, 201) reported that (83%) of the Saudi females undergo plastic surgery and Jeddah has (400) plastic surgery clinics reflecting the awareness of the Saudi woman and her interest in plastic surgery. Steffanie, Sarwen, and Cash (2009) and Brown et al. (2007) argued that exposure to media is an indicator of accepting the plastic surgery and the attitude towards undergoing it in the future. The author claims that plastic surgery photos that media show motivated the individuals to undergo it, form a positive attitude towards it, and increase awareness of its necessity. In addition, medical developments have simplified its procedures. Utilizing the easiest instruments and techniques has resulted in rapid recovery. Thus, the surgery has 66 Sawzan S. Basyouni: Attitude towards Plastic Surgeries and Relation to Self-Awareness and Body Image among Clinical and Non-Clinical Sample prevailed tremendously. Reconstr (2007) claimed that plastic surgery positively affects the individuals. It enhances social performance and quality of life, reduces neuroticism, improves body image, and restores self-confidence. II. Self-awareness There are several views on the concept of self-awareness and its functions, such as the theories of Duval and Wiclund (1972), Diener (1979), and Buss (1980). Self-awareness is defined as the individual's perception of his/her strengths and challenges, as well as accepting reality and future prospects (Hippe, 2004). Goleman claimed that the individuals have different patterns of self-awareness: 1. Self-awareness individuals: They know their mood. They are spontaneous and self-confident, and have good mental health and positive appearance. When they have a bad mood, thoughts or fantasy will not occupy their minds because they rapidly get rid of them. 2. Borderline individuals: They are overwhelmed by their emotions and unaware of their state. They cannot control their mood; they are temperamental and rarely get rid of their bad mood. 3. Self-acceptance: They have a clear vision of their emotions, but they are moody and never attempt to change them (Goleman, 2000; Goleman, 2004; Hasan, 2013). According to Sultan (2015) and Hamid (2007), self-awareness, as a psychological concept, comprises three domains: 1. Private self-awareness involves a focus on the hidden aspects of the personality. People with high private self-awareness are more attentive to their cognitive processes and feelings. They are also more compatible with themselves in daily activities. On the contrary, low private self-awareness results from the motive of self-defense which is stronger than self-concept. 2. Public self-awareness: People with this type are concerned with their social connections and appearance as well as the impression the others make about them. They also care about others' opinions on them. 3. Social Anxiety: It appears if the individual feels shy, confused, and disturbed in the presence of others. This negatively affects his/her interaction with them. The author benefited from the three domains of self-awareness when selecting the appropriate scale. III. Body Image Like other psychological disorders, several theories have addressed body image. For example, the biomedical theory associates body image with the cerebral cortex. While the School of Psychoanalysis has asserted the sexual experiences in early childhood, the Behavioral School has focused on the behavioral determinants that come from the environment and affect the image, and the Humanistic School has linked body image with self-awareness. The social theory has focused on the social levels of beauty (Al-Ashram, 2008; Al-Desoky, 2008; Al-Jubouri and Hafez, 2007). The author argues that it is necessary to take into account the comprehensive theory that combines the above-mentioned theories because the study addresses a person with integrated biological, psychological, and social aspects. Body image is a multifaceted psychological experience of the embodiment that encompasses evaluative thoughts, beliefs, feelings, and behaviors related to one’s own physical appearance (Hrabosky et al., 2009). Body image encompasses three elements: - Cognitive element: It refers to one's perception of the body size. - Subjective element: It refers to a number of aspects, such as satisfaction, interest, and concern about body image. - Behavioral element: It focuses on avoiding situations that cause the individual discomfort, distress, and annoyance due to physical appearance (Al-Desoky, 2006). Body image is dynamic and inconstant due to its interaction with several factors, such as: - Age group: Body image in the twenties is not similar to that in the forties. - Others' opinions and comments: The comments of parents, colleagues, and partner. - Common social values: The matter is associated with the size and shape of the desired body, where fitness has become a symbol of excitement and success. - One's attitude towards himself/herself and self-esteem. - Marital status: Married women have a positive feeling towards their bodies compared to single ones (Abaza, 2014; Al-Nubi, 2010; Abu Hindi, 2004). Many studies addressed the relationship between the attitude towards plastic surgery, self-awareness, and body image. For example, Khazir et al. (2016) explored the positive attitude among a sample of female university students towards plastic surgery, body image disturbance, self-confidence, and dissatisfaction with the body after the intervention. The results showed that the scores of positive attitude, body image disturbance, and dissatisfaction with the body among the intervention participants were lower than the scores of the control participants. Moreover, self-esteem was significantly higher among the intervention participants. Al-Mutairi (2014) examined the relationship between the attitude towards plastic surgery, locus of control, and self-awareness among clinical and non-clinical samples. The results indicated statistically significant differences in the attitude towards plastic surgery between the two groups in favor of the clinical participants. In addition, there were statistically significant differences in self-awareness International Journal of Applied Psychology 2019, 9(2): 62-73 67 between the two groups in favor of the non-clinical participants. Carolina (2013) examined adolescents' attitudes towards plastic surgery, as well as the relationships between these attitudes, body appreciation, and body ideal internalization. The results showed that the body ideal internalization was associated with more favorable plastic surgery approaches. In addition, girls who frequently read fashion blogs reported higher thin ideal internalization and demonstrated a slight tendency of more plastic surgery consideration. Zahra et al. (2012) investigated the relationship between body image, self-esteem, and conformity with plastic surgery. The results showed that women were more likely than men to undergo plastic surgery. The persons described to have a physical attraction had the most plastic surgery. Positive body image and conformity predicted acceptance of plastic surgery. Additionally, self-esteem and body image indirectly affected plastic surgery. von Soest et al. (2006) investigated psychological and social factors that are expected to predict the motivation to undergo plastic surgery. It was hypothesized that body image, self-esteem, acceptance of plastic surgery in the individual's environment, and self-control are related to motivation to have plastic surgery. Social acceptance of plastic surgery and body image were the strongest predictors of plastic surgery motivation. Pecorari et al. (2006) showed a relationship between self-esteem and body image among the females seeking rhinoplasty. In addition, self-esteem among those who focused on how the others saw them was low. Whereas, the results showed no body image disturbance among the participants. Honigman et al. (2004) explored the psychosocial effects of patients seeking plastic surgery. The results demonstrated high self-confidence, self-esteem, and positive body image after the elective plastic surgery among some participants. It was unsatisfactory for the other participants who encountered several problems, such as depression, social isolation, family dysfunction, and self-destructive behaviors. Alagöz et al. (2003) highlighted the characteristics of the individual seeking plastic surgery through the evaluation of self-esteem and body image. The results showed a minor disturbance in the body imaging scale and a slight increase in the self-esteem of the participants. Cults- Read (2002) examined the relationship between self‐presentational motives and physical activity in a population of plastic surgery participants. The results revealed statistically significant differences in self‐presentational concern and public self‐awareness between those who elected the treatment for appearance motives and those who elected treatment for health‐based motives. In addition, greater self‐presentational concerns and greater public self‐awareness were associated with having appearance‐related motives for treatment and with being a less frequent exerciser. The author concludes that the results of the pieces of literature are inconsistent because the studies were applied to different cultures, such as the Iranian, Norwegian, and Arabic. This inconsistency motivated the author to investigate the relationship between self-awareness and body image because it is an important psychological domain in the attitude towards plastic surgery. 5. Methodology 5.1. Method The present study adopted the descriptive correlational approach to investigate the relationship between the attitude towards plastic surgery, self-awareness, and body image among clinical and non-clinical samples. 5.2. Sample The sample comprised a clinical sample of (30) referrals to Obajy for Plastic Surgery in Jeddah and King Abdullah Medical City in Mecca. They have undergone plastic surgery, including nose reconstruction, face-lift, fillers injections, lip enhancement and lifting or reshaping any part of the body. It also compromised a randomly selected non-clinical sample of (30) students and faculty members aged (20 - 35) at the College of Education in Umm Al-Qura University (who have not undergone plastic surgery). Equivalence between the two groups The author conducted equivalence between the group that has undergone the surgery one week earlier and the group that has not undergone the surgery. The author aimed to identify a group with a high attitude towards undergoing plastic surgery. However, the other group, despite its higher attitude towards plastic surgery does not undergo it due to special circumstances. Table (1). Arithmetic mean, standard deviation, and T- value between the two groups Sample Clinical Non-clinical Variable Attitude towards plastic surgery Number 30 30 Arithmetic Means 90.75 91.45 Standard Deviation 6.31 7.81 TValue Significance 0375 Insignificant Table (1) shows that there are no statistically significant differences between the two groups in the attitude towards plastic surgery. 68 Sawzan S. Basyouni: Attitude towards Plastic Surgeries and Relation to Self-Awareness and Body Image among Clinical and Non-Clinical Sample 5.3. Tools 1. The scale of attitude towards plastic surgery (designed by the author) To design the scale of attitude towards plastic surgery, the author adopted the following steps: 1.1. Defining the scale's objective (3) for "always", (2) for "occasionally" and (1) for "rarely". The negative items are graded, as follows: (1) for "always", (2) for "occasionally", and (3) for "rarely". Thus, the total score of the scale is (120-140), and the high score reveals a positive attitude towards plastic surgery, while the low score suggests a negative attitude (i.e. refusal of) towards plastic surgery. The scale aims to evaluate the attitude of the clinical and non-clinical participants towards plastic surgery; i.e. their response and willingness to accept or reject plastic surgery. 1.2. Defining the scale domains After reviewing the literature relevant to the attitude, as well as some scales relevant to the attitude, in general, and the attitude towards plastic surgery, in particular, such as (Al-Aqeel, 2014), the author defined the three domains of the scale (i.e. mental, behavioral, and emotional domains). 1.3. Preparing the preliminary form of the scale After defining the scale's objective, domains, and items, the three domains comprising (40) items (10 for the mental domain, 15 for the behavioral domain and 15 for the emotional domain) were formulated. 1.4. Method of grading and estimating the total score The items, which followed the Three-Point Likert Scale, were formulated. The positive items are graded, as follows: 1.5. Validity and reliability of the scale - Reviewer's validity: To estimate the validity of the scale, its preliminary form was reviewed by (10) reviewers specialized in Psychology and Mental Health to give opinions and make notes. Accordingly, the scale was modified to comprise (40) items after deleting (4) items and adding (4) new items in order to avoid inappropriateness and frequency. - Pilot-test: After modifying the scale, it was applied to a random pilot sample of (60) women who have undergone plastic surgery and university students to estimate the validity and reliability of the scale, as follows: - Internal validity The internal validity was estimated by calculating Pearson correlation coefficients between the score of each item and the total score of the scale, and between each domain and the total score of the scale. Table (2). Correlation coefficients between the score of each item and the total score of the scale of the attitude towards plastic surgery No. Correlation score No. Correlation score No. Correlation score No. Correlation score 1 0.41 11 0.42 21 0.50 31 051 2 * 0.42 12 0.44 22 0.44 32 048 3 0.39 13 0.66 23 0.48 33 049 4 0.44 14 0.44 24 0.46 34 039 5 0.57 15 0.39 25 0.55 35 051 6 0.46 16 0.48 26 0.45 36 047 7 0.55 17 0.55 27 0.60 37 039 8 0.56 18 0.51 28 0.52 38 041 9 0.49 19 0.50 29 0.49 39 053 10 0.50 20 0.48 30 0.59 40 057 Table (2) shows that all correlation coefficients are significant at the level of (0.01). Hence, the scale is highly reliable. Table (3). Correlation coefficients between the domain and the total score of the scale Domains Mental Behavioral Emotional Correlation coefficient 0.76 0.87 0.82 Significance level 0.01 0.01 0.01 All correlation coefficients are statistically significant at the level of (0.01). Thus, the scale has internal validity. - Reliability The scale’s reliability was calculated using Cronbach's alpha (α). It rated (0.872) suggesting that the scale is highly reliable. 1.6. Final form of the scale of the attitude towards plastic surgery After calculating the validity and reliability of the scale, its final form comprised (3) domains and (40) positive and negative items. 2. Self-awareness Scale (Al-Anazy, 2006) The scale consists of (22) items following the Five-Point Likert Scale with some negative items. It measures the three domains of self-awareness (i.e. private self-awareness, public self-awareness and social anxiety). - Validity Al-Anazy (2006) calculated the validity of the scale by analyzing the main domains and factors. The factors for the International Journal of Applied Psychology 2019, 9(2): 62-73 69 total sample - males and females - were divided into three rates: (19.29%, 11.32%, and 9.80%) of the total variance, respectively. Statistical strength varied from the first, the second, and the third factors. - Reliability of the modified scale The scale’s reliability was calculated using Cronbach's alpha (α). It rated (0.77) among the females and (0.76) among the males. The internal validity was estimated by calculating the correlation coefficients between the score of each item and the total score of the domain, and between each domain and the total score of the scale. Table (4). Correlation coefficients of the items of self-awareness scale with the total score of the domain Private self-awareness Item Correlation coefficient 6 0.611 12 0.669 14 0.512 17 0.662 Public self-awareness Item Correlation coefficient 5 0.707 10 0.797 16 0.661 20 0.889 Social anxiety Item Correlation coefficient 3 0.840 9 0.862 15 0.864 22 0.871 Table (4) indicates that (10) items were deleted: (5) in private self-awareness, (3) in public self-awareness, and (2) in social anxiety. All the other correlation coefficients are significant at the level of (0.01), so it has a good degree. Table (5). Correlation coefficients of the domains of self-awareness scale with the total score Domain Private self-awareness Public self-awareness Social anxiety Total score Correlation coefficients 0.727 0.719 0.779 0.851 Table (5) shows the correlation coefficients between the domains of the scale and the total score. They rated (0.779-0.719). The total score of the scale rated (0.85) which is a high value suggesting that the scale has a high degree of internal validity. - Reliability The scale’s reliability was verified using Cronbach's alpha (α). Table (6). Cronbach's alpha (α) coefficient of self-awareness scale Domain N Self-awareness scale 231 Items Number 12 Cronbach's alpha (α) 0.719 The results of the table show that the reliability of the scale is moderate indicating that the domain is reliable and valid for the test. The scale’s psychometric characteristics - Reviewer's validity: To estimate the validity of the scale, its preliminary form was reviewed by (10) reviewers specialized in Psychology and Mental Health to give opinion and make notes. Accordingly, the scale was modified. - Pilot-test: After modifying the scale, it was applied to the same pilot sample. - Internal validity: Pearson correlation coefficients were calculated between the score of each item and the total score of the scale. Table (7). Correlation coefficients between each item and the total score of self-awareness scale No. Correlation Degree No. Correlation Degree No. Correlation Degree 1 0.51 5 0.55 9 0.52 2 0.60 6 0.59 10 0.48 3 0.59 7 0.61 11 0.43 4 0.44 8 0.49 12 0.60 All correlation coefficients are statistically significant at the level of (0.01), so the scale has internal validity. - Reliability The scale’s reliability was calculated using Cronbach's alpha (α). The reliability coefficient of the scale rated (0.797) indicating that the scale is highly reliable. 3. Body image scale (Shakeer, 2015) The scale comprises (26) items. (3) stands for totally agree, (2) stands for undecided, and (1) stands for disagree. The total score ranges from (26) to (78), where the high score indicates deformity and disturbance of body image. To calculate the validity and reliability of the scale, it was applied to (320) male and female participants aged (15-45). Validity and reliability - Face validity: It was verified within the development of the scale and was reviewed by some professors of psychology, psychiatry, and medicine who approved its validity. - -Discrimination validity: It was verified through making a comparison between the higher and the lower levels of males and females' scores at the level of (0.01). That is, there are statistically significant differences. - Reliability:  Test-retest: Retesting was after a three-week interval. The correlation coefficient rated (0.61) for the College of Education's students and (0.51, 0.59, and 0.60) for the participants with rheumatic heart disease, skin mutilation, and neuropathy. It was significant at the level of (0.01).  Split-half method: It was verified by calculating the correlation coefficients between the odd and even items and compensation in the test using the Spearman equation. The correlation coefficient rated (0.92) suggesting that the scale is highly reliable and valid. The scale’s psychometric characteristics - Reviewer's validity: To estimate the validity of the scale, its preliminary form was reviewed by (10) reviewers specialized in Psychology and Mental Health to give opinion and make notes. They totally agreed on the scale (100%). 70 Sawzan S. Basyouni: Attitude towards Plastic Surgeries and Relation to Self-Awareness and Body Image among Clinical and Non-Clinical Sample - Pilot-test: The scale was applied to the same pilot sample. - Internal validity: The Pearson correlation coefficients were calculated between the score of each item and the total score of the scale. Table (8). Correlation coefficients between the score of the items and the total score of the scale - Reliability of body image scale The reliability was calculated by re-testing the scale using Pearson equation rating (0.88) and statistically significant at the level of (0.01), and split-half method rating (0.92) and statistically significant at the level of (0.01). Thus, the scale is highly reliable. Body image scale Correlation coefficient No. Correlation coefficient No. Correlation coefficient 1 0.46 11 0.52 21 0.50 2 0.48 12 0.64 22 0.44 3 0.37 13 0.60 23 0.48 4 0.44 14 0.41 24 0.46 5 0.51 15 0.40 25 0.55 6 0.48 16 0.48 26 0.44 7 0.51 17 0.51 8 0.50 18 0.45 9 0.43 19 0.66 10 0.51 20 0.45 6. Results and Discussion 1. To answer the first question and verify the first hypothesis, the correlation coefficient was estimated between the total score of the scale of the attitude towards plastic surgeries and the total score of the scales of self-awareness and body image among the participants. This result verifies the first hypothesis and shows a strong correlation among the variables. That is, the higher the attitude towards plastic surgery among the participants is, the higher their self-awareness is and the more they are satisfied with the other body organs and physical appearance. Table (8) indicates that all correlation coefficients are statistically significant at the level of (0.01), so the scale is highly valid. Table (9). Correlation coefficient between the total score of the scale of the attitude towards plastic surgery and the total score of the scales of self-awareness and body image among the participants Variable Total score of the scale of the attitude towards plastic surgery N=60 Total score of self-awareness scale Pearson correlation coefficient Statistical significance 0.746 0.01 Total score of body image scale Pearson correlation coefficient Statistical significance 0.678 0.01 Table (9) shows that there is a positive significant correlation between the total score of the scale of the attitude towards plastic surgery and the total score of the scales of self-awareness and body image. The correlation coefficients rated (0.746) and (0.678), respectively, which is statistically significant at (0.01). The author attributed the result to the following reasons: - The clinical and non-clinical participants have a positive attitude towards plastic surgery. The clinical participants have already gone to plastic surgery clinics and underwent plastic surgery. In addition, the non-clinical participants had a positive attitude because of their desire to be good looking and to keep up with modern developments. Moreover, the female constantly gives concern to her look and beauty and seeks the best in plastic surgery. - The person who has a positive concept of physical appearance and a good concept of the body image properly establishes social relations within the framework of the social interaction, including interpersonal skills, social interaction, participation, social behavior, emotional expression, and vice versa. On the contrary, the person does not establish social relationships and positively develops social skills if s/he has a negative self-concept. The two variables affect the person, so s/he seeks plastic surgery as a means to improve the appearance and body. - The individuals who are self-aware of their potentials, abilities, tendencies, aspirations, and attitudes seek to improve their appearance through plastic surgery. The better his/her appearance is, the more positive he/she becomes. - The females frequently care about their physical appearance because they know that others look at them. They also establish their self-awareness when they interact with others. In addition, their perception of others' view on their appearance influences their self-awareness. - The woman, throughout the life cycle, gives concern to body image because it involves social acceptance, increased self-confidence and self-esteem, and causes less annoyance of her appearance. - The individuals with self-awareness are highly able to identify and express their characteristics in a manner that is consistent with their ideas and tendencies. Consequently, they see that plastic surgery provides them with more personal and emotional adjustment. - Plastic surgery improves physical appearance and protects individuals from body image disturbances, which result in psychological disorders and International Journal of Applied Psychology 2019, 9(2): 62-73 71 disappointment. This indicates that the body image significant influences the individuals' attitude towards plastic surgery. - The high demand for plastic surgery among the participants associated with their body image reveals their positive attitude towards it, increases their self-confidence as well as self-esteem, and is influenced by various psychological and social factors. The result matches the results of Al-Mutairi (2014) and Mianroodi et al. (2012) showing a correlation between the attitude towards plastic surgery, self-awareness, self-esteem and self-respect. It matches the results of Pecorari et al. (2010) and Carolina (2013) suggesting a relationship between the attitude towards plastic surgery, body image, and motivation to undergo the surgery. Furthermore, matches the results of Khazir et al. (2016), Farshidfar et al. (2013), Mianroodi et al. (2012), Zahra et al. (2012), Hewitt (2009), von Soest et al. (2006), and Honigman et al. (2004) which showed a correlation between the attitude towards plastic surgery, self-awareness, and body image. 2. To answer the second question and verify the second hypothesis, t-test of the independent groups was utilized to estimate the significance of difference between the average scores of the clinical and non-clinical participants in the scale of attitude towards plastic surgery. Table (10). Significance of the difference between the average scores of the clinical and non-clinical participants in the scale of attitude towards plastic surgery Variable Clinical=30 M SD Non-clinical=30 T-Value Significance M SD Scale of attitude towards 65.72 5.28 91.45 7.81 17.145 Significant plastic surgery Table (10) shows a statistically significant difference between the average score of the clinical and non-clinical participants in the scale of attitude towards plastic surgery in favor of the non-clinical participants, suggesting that the non-clinical participants had a higher positive attitude than the clinical participants did. 3. To answer the third question and verify the third hypothesis, t-test of the independent groups was utilized to estimate the significance of difference between the average scores of the clinical and non-clinical participants in the scale of self-awareness. Table (11). Significance of the difference between the average scores of the clinical and non-clinical participants in the scale of self-awareness Variable Scale of self- awareness Clinical =30 M SD 40.72 3.28 Non-clinical =30 M SD 47.47 4.21 T-Value 6.81 Significance Significant Table (11) shows a statistically significant difference between the average score of the clinical and non-clinical participants in the scale of self-awareness in favor of the non-clinical participants, suggesting that the non-clinical participants had a higher self-awareness than the clinical participants did. 4. To answer the fourth question and verify the fourth hypothesis, t-test of the independent groups was utilized to estimate the significance of difference between the average scores of the clinical and non-clinical participants in the scale of body image. Table (12). Significance of the differences between the average scores of the clinical and non-clinical participants in the scale of body image Variable Post-test of body image scale Clinical=30 M SD 60.72 4.52 Non-clinical=30 M SD 71.38 6.22 T-Value 10.639 Significance Significant Table (12) shows a statistically significant difference between the average score of the clinical and non-clinical participants in the scale of body image in favor of the non-clinical participants, suggesting that the non-clinical participants had a better body image than the clinical participants did. These results are attributed to the individual’s desire to become distinct and to have good-looking, so there is a positive attitude towards plastic surgery. People believe that these surgeries are the way to have a better body image, a feeling of acceptance, happiness and psychological satisfaction. Accordingly, the demand for plastic surgery increased, self-awareness became higher, and body image got better despite of the risks of the surgery. Currently, beauty is a substantial requirement for the female who is strongly passionate about improving her appearance and showing off her beauty, so the culture of plastic surgery has become more prevalent. It represents one of the most prominent alternatives that females use to improve their physical appearance and highlight their beauty. Furthermore, females from different age group become obsessed with plastic surgery despite the financial cost and the health risk. The increased self-awareness involves not only identifying the individual’s strengths, weaknesses and internal feelings, but also becoming aware of the others and realizing the impact of physical appearance and actions. It thus results in a psychological status of social anxiety when being among others. In this respect, the role of social media, mass media, and globalization cannot be denied. The promotion for the superiority of female physical beauty over her social and integrated position results in her increased tendency to imitate beauty icons. In addition, the promotion for cheap cosmetic surgeries contributes to increasing female dissatisfaction with her body image and consequently her willingness to undergo such surgeries. Participants of the clinical sample, who underwent some simple cosmetic procedures such as nose reconstruction, face-lift, fillers injections, lip enhancement or lifting or reshaping any part of the body, have a positive attitude towards plastic surgeries and are willing to improve their body image constantly, as they are dissatisfied with their physical appearance. Al-Otaibi (2009) asserted that (93%) of Saudi university students tended to undergo plastic surgery. Furthermore, Saudi specialists cosmetic asserted the annual increase of plastic surgery in Saudi Arabia which predominated in the

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